Preoperative but not postoperative systemic inflammatory response correlates with survival in colorectal cancer

A Narrative Literature Review on Sepsis: A Primary Manifestation of Colorectal Neoplasm

Sepsis and colorectal cancer (CRC) exhibit a complex relationship that warrants further exploration. This review delves into the interplay of factors between sepsis and CRC, uncovering shared pathophysiological traits and potential bacterial associations. Understanding these connections could pave the way for earlier diagnosis, improved management, and enhanced outcomes in CRC patients. The role of immune system dysfunction, hypoalbuminemia, and specific microbial imbalances, such as Streptococcus bovis and Clostridium septicum, are discussed. Recognizing sepsis in CRC patients is crucial for timely intervention, and tailored approaches encompassing antibiotic therapy, source control measures, and cancer treatment are essential for comprehensive care. Monitoring biomarkers and ratios can provide valuable insights into complications and overall health outcomes. A multidisciplinary approach involving various specialists is necessary to address the global burden of CRC and its association with sepsis while exploring novel interventions, such as fecal microbiota transplantation and personalized care. We conducted a thorough search using reputable databases such as PubMed, Scopus, and Google Scholar to investigate the connection between sepsis and CRC. We refined our search terms, utilized sidebar filters, and examined references in selected articles. This meticulous process helped us create a comprehensive literature review and gain valuable insights into this relationship.

Prognostic Value of Post-Operative C-Reactive Protein-Based Inflammatory Biomarkers in Colorectal Cancer Patients: Systematic Review and Meta-Analysis

Post-operative inflammation in cancer patients can be modulated by drugs and diets, but evidence on its prognostic role, which would be crucial for personalized treatment and surveillance schemes, remains rather limited. We aimed to systematically review and meta-analyse studies on the prognostic value of post-operative C-reactive protein (CRP)-based inflammatory biomarkers among patients with colorectal cancer (CRC) (PROSPERO#: CRD42022293832). PubMed, Web of Science and Cochrane databases were searched until February 2023. Studies reporting associations between post-operative CRP, Glasgow Prognostic Score (GPS) or modified Glasgow Prognostic Score (mGPS) with overall survival (OS), CRC-specific survival (CSS) and recurrence-free survival (RFS) were included. Hazard ratios (HRs) with 95% confidence intervals (CIs) for the predictor-outcome associations were pooled using R-software, version 4.2. Sixteen studies (n = 6079) were included in the meta-analyses. Elevated post-operative CRP was a predictor of poor OS, CSS and RFS compared with low CRP levels [HR (95% CI): 1.72 (1.32-2.25); 1.63 (1.30-2.05); 2.23 (1.44-3.47), respectively]. A unit increase in post-operative GPS predicted poor OS [HR (95% Cl): 1.31 (1.14-1.51)]. Moreover, a unit increase in post-operative mGPS was associated with poor OS and CSS [HR (95% Cl): 1.93 (1.37-2.72); 3.16 (1.48-6.76), respectively]. Post-operative CRP-based inflammatory biomarkers have a significant prognostic role for patients with CRC. Prognostic value of these easy-to-obtain routine measurements thereby seems to outperform most of the much more complex blood- or tissue-based predictors in the current focus of multi-omics-based research. Future studies should validate our findings, establish optimal time for biomarker assessment and determine clinically useful cut-off values of these biomarkers for post-operative risk-stratification and treatment-response monitoring.

The Role of Perioperative C-Reactive Protein in Predicting the Prognosis of Epithelial Ovarian Carcinoma

Background

Increasing epidemiological evidence supported that chronic inflammatory factors might be involved in the carcinogenesis and progression of various cancers. The present study tried to investigate the prognostic value of perioperative C-reactive protein (CRP) in prognosis of patients with epithelial ovarian carcinoma (EOC) from a tertiary university teaching hospital.

Methods

The cutoff value of CRP was calculated according to receiver operating characteristic (ROC) curve. Variables were compared using Chi-square test. Progress-free survival (PFS) and overall survival (OS) time were assessed by Kaplan-Meier (KM) survival analysis and Log rank test based on serum CRP level. Univariate and multivariate Cox regression analyses were applied for assessing the relationship between clinicopathological parameters and survival.

Results

Higher perioperative CRP levels (preoperative ≥5.15 mg/L and postoperative ≥72.45 mg/L) were significantly associated with serous tumor, high-grade, advanced stage, elevated preoperative CA125, suboptimal surgery, chemotherapy resistance, recurrence and death in EOC (P < 0.01). KM analysis suggested patients with elevated preoperative, postoperative and perioperative CRP had shorter survival (P < 0.01). Elevated perioperative CRP was an independent risk factor for PFS (HR 1.510, 95% CI 1.124-2.028; P = 0.006) and OS (HR 1.580, 95% CI 1.109-2.251; P = 0.011). Similar results were obtained for elevated preoperative CRP. Subgroup analysis further suggested that elevated perioperative CRP was also an independent risk factor for prognosis in advanced stage and serous EOC.

Conclusion

Elevated perioperative CRP was an independent risk factor for poorer prognosis of EOC, particularly in advanced stage and serous patients.

Macroscopic Inflammation Status of Resected Gallbladder Predicts Therapeutic Outcome After Radical Resection for Gallbladder Carcinoma

Objective

Gallbladder carcinoma (GBC) is one of the digestive cancers with poor prognosis, for which surgical resection is the only potentially curative therapy. Prognostic value of macroscopic inflammatory status of the resected gallbladder in patient with GBC has not been fully investigated. We retrospectively investigated the relation between macroscopic inflammatory status and disease-free as well as overall survival after radical resection for GBC.

Method

The subjects were 44 patients who underwent radical resection for GBC between January 2004 and April 2011 at Jikei University Hospital. We retrospectively investigated the relationship between clinicopathologic variables, including macroscopic inflammatory status and disease-free as well as overall survival.

Results

In univariate analysis, disease-free survival was poor in patients with Tumor-Nodes-Metastasis (TNM) stage ≥III (P &lt; 0.0001) and positive vascular invasion (P = 0.0001). Patients with macroscopic chronic inflammation tended to have poor disease-free survival than those with normal type (P = 0.0930). Overall survival was poor in patients with TNM stage ≥III (P &lt; 0.0001), presence of intraoperative blood transfusion (P = 0.0125), positive vascular invasion (P = 0.0055), and macroscopic chronic inflammation (P = 0.0281). In multivariate analysis, TNM stage ≥III (P &lt; 0.0114) and macroscopic chronic inflammation (P = 0.0350) were independent predictors of disease-free survival. For overall survival, TNM stage ≥III (P = 0.0054) and macroscopic chronic inflammation (P = 0.0124) were the independent predictors. Moreover, macroscopic chronic inflammation correlated with the presence of gallstones.

Conclusion

The macroscopic Inflammation status of resected gallbladder cancer correlates with oncologic outcome in patients with GBC treated by radical resection.

Preoperative physical activity predicts postoperative functional recovery in gastrointestinal cancer patients

PURPOSE

The present study aimed to investigate the association between preoperative physical activity (PA) and postoperative functional recovery in gastrointestinal cancer patients.

MATERIALS AND METHODS

In this prospective study, we included 101 patients who underwent colorectal or gastric cancer surgery. Primary outcome was 6-minute walk distance (6MWD) decline ratio ((postoperative 6MWD value - preoperative 6MWD value)/preoperative 6MWD value × 100 (%)), which was determined as postoperative functional recovery. Patients were divided into two groups according to the median of 6MWD decline ratio: above the median (non-decline group) and below the median (decline group). The International Physical Activity Questionnaire (IPAQ-SV) (the usual seven-day short version) was used to assess preoperative PA and sedentary time. Multivariate logistic regression analysis was performed to identify predictive factors of postoperative functional recovery.

RESULTS

Preoperative PA (odds ratio (OR): 3.812; 95% confidence interval (CI): 1.326-10.956; p = 0.01), 6MWD (OR: 1.006; 95% CI: 1.002-1.011; p < 0.01), C-reactive protein (OR: 4.138; 95% CI: 1.383-12.377; p = 0.01), and combined resection (OR: 3.425; 95% CI: 1.101-10.649; p = 0.03) were associated with postoperative functional recovery.

CONCLUSIONS

Preoperative PA is a predictor of postoperative functional recovery in patients who undergoing gastrointestinal cancer surgery.Implications for rehabilitationThe association between preoperative physical activity (PA) and postoperative functional recovery has been unclear in gastrointestinal cancer patients.We indicated that preoperative PA predicts postoperative functional recovery.Patients who low preoperative PA need to be monitored carefully in the postoperative course.Patients with low preoperative PA may need enhanced postoperative rehabilitation to reduce postoperative functional decline.

Preoperative inflammation is an independent factor of worse prognosis after colorectal cancer surgery

BACKGROUND

We know that inflammation is related to colorectal cancer prognosis and to the onset of postoperative infections.

OBJECTIVE

This study aimed to understand the relationship between preoperative inflammation and the prognosis of colorectal cancer and to elucidate whether the impact of inflammation on cancer prognosis was related to an increased risk of surgical infection or was independent of it.

METHODS

Patients who underwent elective colorectal cancer surgery between November 2011 and April 2014 were included in a prospective database (IMACORS). Preoperative c reactive protein was collected for each patient. Patients were followed up according to the French national guidelines. A cut-off of preoperative CRP of 5mg/L was chosen. Clinical characteristics were compared according to CRP using Chi² and Mann-Whitney tests. The Overall Survival (OS) and Disease-Free-Survival (DFS) were compared by Kaplan-Meier curves. A Cox proportional hazards regression model was applied to perform a multivariate analysis of OS and DFS's predictors.

RESULTS

A total of 254 patients were included. The median age was 68 years old. The median follow up was 41.8 months. The overall median preoperative CRP was 5mg/L. Preoperative CRP was significantly associated with N status; CRP being significantly higher among patients with colonic cancer and with patients who didn't receive a neoadjuvant treatment. Multivariate analyse revealed that preoperative CRP is an independent prognostic factor of OS and DFS respectively (HR=2.34 (1.26-4.31), P=0.006 and HR=1.83 (1.15-2.90), P=0.01).

CONCLUSION

Preoperative inflammation measured by CRP is independently related with overall and disease-free survival of colorectal cancer.

Effects of body composition profiles on oncological outcomes and postoperative intraabdominal infection following colorectal cancer surgery

BACKGROUND

Anthropometric data as prognostic factors of colorectal cancer are promising but contradictory. The aim of this study was to assess the preoperative body composition profiles as predictive factors for postoperative, oncologic, and inflammation outcomes.

OBJECTIVES

We sought to assess the impact of body composition profiles on short- and long-term outcomes and on postoperative inflammatory response in a clinical setting for patients following curative intent surgery for colorectal cancer.

SETTING

University hopsital METHODS: We analyzed 122 patients from a prospective cohort (IMACORS) with colorectal cancer undergoing curative-intent surgery from 2011 to 2014. Musculature, total, visceral, and subcutaneous adiposity were measured from a preoperative CT scan and outcomes were compared between profiles.

RESULTS

Preoperative myopenia was an independent predictive factor of recurrence (HR = 3.3 95% CI = 1.6-6.9; P = .002) while subcutaneous adiposity was a protective factor (HR = .4 95% CI = .2-.9; P = .03). No anthropometric measurement was predictive of overall survival and postoperative intra abdominal infection was not determined by body composition profiles. Preoperative and D4 CRP levels were significantly higher in patients with subcutaneous adiposity.

CONCLUSIONS

Myopenia and subcutaneous adiposity seemed to have independent and opposite prognostic effects on recurrence. Muscle mass loss may represent a modifiable risk factor while the amount of subcutaneous adipose tissue reflects an energetic storage favorable to face this pathologic process.

Does postoperative inflammation or sepsis generate neutrophil extracellular traps that influence colorectal cancer progression? A systematic review

BACKGROUND

Colorectal cancer is the third most common cancer worldwide. Almost half of those that have a potentially curative resection go on to develop metastatic disease. A recognized risk for recurrence is perioperative systemic inflammation and sepsis. Neutrophil extracellular traps have been implicated as promotors of tumor progression. We aimed to examine the evidence in the literature for an association between neutrophil extracellular traps and postoperative metastasis in colorectal cancer.

MATERIALS AND METHODS

Studies published between 2000 and December 2018 that examined the role of neutrophil extracellular traps in sepsis and inflammation in colorectal cancer and in relation to tumor-related outcomes were identified through a database search of Cochrane, CINAHL, and MEDLINE. Quality and bias assessment was carried out by 2 reviewers.

RESULTS

Of 8,940 screened and of the 30 studies included, 21 were observational, 5 were in vivo experimental, 1 was in vitro, and 3 used a combination of these approaches.

CONCLUSION

There is clear evidence from the literature that presence of a preoperative systemic inflammatory response predicts cancer recurrence following potentially curative resection, but the evidence for association of sepsis and progression is lacking. There is robust experimental evidence in murine models showing that neutrophil extracellular traps are present in sepsis and are associated with cancer progression. Some human observational studies corroborate the prognostic significance of neutrophil extracellular traps in progression of colorectal cancer. Further human studies are needed to translate the experimental evidence and to definitively associate sepsis and neutrophil extracellular traps with poor colorectal cancer-specific outcomes.

The Pre-Treatment C-Reactive Protein Represents a Prognostic Factor in Patients with Oral and Oropharyngeal Cancer Treated with Radiotherapy

The purpose of the present study was to evaluate the prognostic significance of the pre- treatment C-reactive protein (CRP) level in a cohort of 503 patients with oral and oropharyngeal cancer treated at a tertiary academic center between 2000 and 2017. Cancer-specific survival (CSS), overall survival (OS) and loco-regional control (LC) were calculated using Kaplan-Meier analysis. To evaluate the prognostic value of the CRP level for the clinical endpoints, univariate and multivariate Cox regression models were applied. The median follow-up period was 61 months. Patients were divided into elevated CRP (≥5 mg/L) and normal CRP groups, according to pre-treatment plasma levels. An increased CRP level was significantly associated with shorter CSS (p < 0.001, log-rank test), as well as with shorter OS (p < 0.001, log-rank test) and loco-regional control (p = 0.001, log-rank test). In addition, multivariate analysis identified CRP as an independent predictor for CSS (hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.08-2.35; p = 0.020) as well as for OS (HR 1.62, 95%CI 1.17-2.24; p = 0.004) and LC (HR 1.50, 95%CI 1.06-2.14; p = 0.023). In subgroup analysis, Kaplan Meier curves revealed that an elevated pre-treatment CRP level was a consistent prognostic factor for poor CSS (p = 0.003, log-rank test), OS (p = 0.001, log-rank test), and LC (p = 0.028, log-rank test) in patients treated with definitive (chemo-) radiotherapy, whereas a significant association in patients undergoing surgery and postoperative radiotherapy was not detected. The pre-treatment CRP level seems to represent a prognostic factor for CSS, OS, and LC in patients with oral and oropharyngeal cancer, particularly in those treated with definitive (chemo-) radiotherapy. Additional large-scale prospective studies are warranted to confirm and extend our findings.

The pretreatment erythrocyte sedimentation rate predicts survival outcomes after surgery and adjuvant radiotherapy for extremity soft tissue sarcoma

Background

Systemic inflammation plays a critical role in cancer progression and oncologic outcomes in cancer patients. We investigated whether preoperative inflammatory biomarkers, including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and neutrophil to lymphocyte ratio (NLR), could be surrogate biomarkers for predicting overall survival (OS) in soft tissue sarcoma (STS) patients treated with surgery and postoperative radiotherapy.

Methods

A series of 99 patients who presented with localized extremity STS were retrospectively reviewed. The preoperative CRP levels, ESR, and NLR were evaluated for associations with OS, disease-free survival (DFS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS). Cutoff values for CRP, ESR, and NLR were derived from receiver-operating characteristic curve analysis.

Results

Elevated CRP (> 0.14 mg/dL), ESR (> 15 mm/h), and NLR (> 1.95) levels were seen in 33, 44, and 45 patients, respectively. Of these three inflammatory biomarkers, elevated CRP and ESR were associated with a poorer OS (CRP: P = 0.050; ESR: P = 0.001), DFS (CRP: P = 0.023; ESR: P = 0.003), and DMFS (CRP: P = 0.015; ESR: P = 0.001). By multivariate analysis, an elevated ESR was found to be an independent prognostic factor for OS (HR 3.580, P = 0.025) and DMFS (HR 3.850, P = 0.036) after adjustment for other established prognostic factors.

Conclusions

The preoperative ESR level is a simple and useful surrogate biomarker for predicting survival outcomes in STS patients and might improve the identification of high-risk patients of tumor relapse in clinical practice.

C-reactive protein is a significant predictor of improved survival in patients with advanced non-small cell lung cancer

This study tries to evaluate the associations between circulating C-reactive protein (CRP) and the overall survival of patients with non-small cell lung cancer (NSCLC).One hundred ninety-two patients with advanced NSCLC who treated with chemotherapy were enrolled in this study. The cut-off value of CRP concentration was 5.0 mg/L. The patients were divided into low, intermediate and high 3 groups respectively according to the baseline level of CRP before the treatment. Kaplan-Meier analysis and Cox proportional-hazard models were used to evaluate the relationship between the CRP and overall survival time of patients.After adjusting for age, gender, smoking history, pathologic type, CRP was a significant independent impact which predicts the survival prognosis of patients with NSCLC. For all patients, the hazard ratio with high CRP levels for NSCLC-specific survival was 1.83 [95%confidenceinterval (CI) = 0.96, 3.48] compared with low CRP levels. The level of CRP was significantly correlated with survival time (hazard ratio = 1.77; 95% CI = 0.73, 4.26) for the patient with first-line chemotherapy. Patients with high level of circulating CRP also responded poorly to chemotherapy.A high level of circulating CRP was associated with a poor response and worse survival in patients with NSCLC.

The Combination of Seven Preoperative Markers for Predicting Patients with Gastric Cancer to Be Either Stage IV or Non-Stage IV

To assess whether preoperative markers could predict the stage of patients with gastric cancer. We analyzed retrospectively the preoperative indicators between stage IV and non-stage IV gastric cancer at the Gastrointestinal Surgery of Nanjing Drum Tower Hospital. A total of 500 patients with gastric cancer were screened. Of all the variables, alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 125, carbohydrate antigen (CA) 199, carbohydrate antigen (CA) 724, carbohydrate antigen (CA) 242, thrombin time (TT), prothrombin time (PT), activated partial thromboplastin time (APTT), blood platelet count (PLT), white blood cell (WBC) count, C-reactive protein (CRP), neutrophil count (NC), lymphocyte count (LC), neutrophil-lymphocyte ratio (NLR), hemoglobin (HB), aspartate aminotransferase (AST), and ascites were found to have statistical differences between the two groups. Then, Stepwise Discriminant Analysis was conducted to establish a prediction model including 7 indexes (CA724, CA242, TT, PLT, CRP, AST, and ascites). According to the model, 90.6% of original grouped cases were correctly classified and 90.6% of cross-validated grouped cases were correctly classified. We built a discriminant including CA724, CA242, TT, PLT, CRP, AST, and ascites for predicting patients with gastric cancer to be either stage IV or non-stage IV. According to this discriminant, 90.6% of patients could be correctly predicted.

Long-Term Follow-Up of Patients Undergoing Resection of TNM Stage I Colorectal Cancer: An Analysis of Tumour and Host Determinants of Outcome

BACKGROUND

Screening for colorectal cancer improves cancer-specific survival (CSS) through the detection of early-stage disease; however, its impact on overall survival (OS) is unclear. The present study examined tumour and host determinants of outcome in TNM Stage I disease.

METHODS

All patients with pathologically confirmed TNM Stage I disease across 4 hospitals in the North of Glasgow between 2000 and 2008 were included. The preoperative modified Glasgow Prognostic Score (mGPS) was used as a marker of the host systemic inflammatory response (SIR).

RESULTS

There were 191 patients identified, 105 (55 %) were males, 91 (48 %) were over the age of 75 years and 7 (4 %) patients underwent an emergency operation. In those with a preoperative CRP result (n = 150), 35 (24 %) patients had evidence of an elevated mGPS. Median follow-up of survivors was 116 months (minimum 72 months) during which 88 (46 %) patients died; 7 (8 %) had postoperative deaths, 15 (17 %) had cancer-related deaths and 66 (75 %) had non-cancer-related deaths. 5-year CSS was 95 % and OS was 76 %. On univariate analysis, advancing age (p < 0.001), emergency presentation (p = 0.008), and an elevated mGPS (p = 0.012) were associated with reduced OS. On multivariate analysis, only age (HR = 3.611, 95 % CI 2.049-6.365, p < 0.001) and the presence of an elevated mGPS (HR = 2.173, 95 % CI 1.204-3.921, p = 0.010) retained significance.

CONCLUSIONS

In patients undergoing resection for TNM Stage I colorectal cancer, an elevated mGPS was an objective independent marker of poorer OS. These patients may benefit from a targeted intervention.

Elevated serum C-reactive protein level predicts a poor prognosis for recurrent gastric cancer

BACKGROUNDS

High serum C-reactive protein (CRP) was found to be associated with poor prognosis in kinds of solid tumors, however, its role in the recurrent gastric cancer (RGC) is unknown. The present study aimed to explore the prognostic value of serum CRP in RGC patients.

METHODS

A total 72 RGC patients who underwent radical surgery from January 2005 to May 2008 were enrolled. The clinical, pathological and survival information were collected. The serum CRP level was measured when the recurrence was confirmed, and the association between serum CRP and clinicopathological characters was analyzed. The prognostic value of serum CRP for RGC was investigated.

RESULTS

The serum CRP was elevated in 39 patients (H-CRP), while 33 patients were within the normal range (N-CRP).The elevated CRP was associated with Lymph node metastasis (p = 0.003) and tumor size (p = 0.004). The median survival time after recurrence was significantly worse in the H-CRP group than N-CRP group (6.5 months vs. 11.5 months, p = 0.012). Multivariate analyses identified that elevated CRP level (HR=2.325, p < 0.001), time to recurrence (HR = 0.466, p=0.033), and the follow-up treatment (HR = 2.650, p=0.001) were independent prognostic factors.

CONCLUSIONS

High serum CRP level was associated with aggressive pathological features, was an independent poor prognostic factors for RGC, which might be a potential prognostic marker for RGC patients.

Prognostic value of C-reactive protein in patients with colorectal cancer: Meta-analysis

AIM: To evaluate the association between prognosis and C-reactive protein (CRP) in patients with colorectal cancer.

METHODS: We systematically searched the relevant studies assessing prognostic value of C-reactive protein in patients with colorectal cancer in PubMed and Embase database (up to May 2015). This meta-analysis was completed with hazard ratio (HR) and 95% confidence intervals (CI) as effect measures, using Stata12.0 software. Subgroup and sensitivity analyses were also performed.

RESULTS: Twenty-one eligible studies were included in the present meta-analysis, including 4242 patients with colorectal cancer. Our results showed that elevated CRP was associated with poor survival in patients with colorectal cancer (overall survival: HR = 1.89, 95%CI: 1.52-2.35, P < 0.001; cancer-specific survival: HR = 2.08, 95%CI: 1.42-3.04, P < 0.001; disease-free survival: HR = 1.44, 95%CI: 1.25-1.67, P < 0.001). The subgroup analyses based on the sampling time, sample size and study region obtained similar results. Moreover, sensitivity analyses confirmed the stability of our results.

CONCLUSION: Our meta-analysis indicates that CRP is significantly associated with a poor prognosis for patients with colorectal cancer.

Immunological markers predict the prognosis of patients with squamous non-small cell lung cancer

Lung cancer has become the leading cause of cancer-related death worldwide. However, treatment failures still represent enormous challenges, and it is doubtful whether standard treatment modalities could continuously achieve substantial improvements. As one of the novel therapy strategies, PD-L1 has been shown the function of down-regulating T cell activation through receptor PD-1. Moreover, prognosis of cancer patients is based not only on tumor-related factors but also on host-related factors, particularly systemic inflammatory response. Significantly, squamous non-small cell lung cancer (NSCLC) revealed to be divergent clinical and molecular phenotypes compared with non-squamous NSCLC. Monocyte ratio, neutrophils to lymphocytes ratio, PD-L1 immunostaining score and PD-1-positive stained tumor-infiltrating lymphocyte counts were assessed by Fisher's linear discriminant analysis to discriminate whether overall survival (OS) would exceeding 5 years. Finally, a prediction model was established for OS based on these immunological markers. Furthermore, this prediction model was validated in a second set of squamous NSCLC patients. The model offers a novel tool for survival prediction and could have important clinical implications for patients with squamous NSCLC, thus providing a framework for future individualized therapy.

Impact of Preoperative Neutrophil to Lymphocyte Ratio and Postoperative Infectious Complications on Survival After Curative Gastrectomy for Gastric Cancer: A Single Institutional Cohort Study

Although postoperative complications are associated with a poor long-term prognosis after resection of several solid tumors via an undetermined mechanism, there are few related reports in gastric cancer patients. Preoperative elevated neutrophil to lymphocyte ratio (NLR) reflects a systemic inflammatory response and is a predictor of poor survival in gastric cancer. The relationship between preoperative NLR and postoperative complications and the impact of these 2 factors on survival in gastric cancer remains unclear. Our aim is to examine the association between postoperative complications and survival, and preoperative NLR in patients undergoing curative resection for gastric cancer. We enrolled a total of 404 consecutive patients with gastric cancer undergoing curative gastrectomy between January 1, 2000 and December 31, 2011. Multivariable analyses were performed to correlate preoperative and operative variables with postoperative complications and to correlate complications with long-term survival after gastrectomy. Postoperative infectious and noninfectious complication rates were 17.6% and 7.9%, respectively. Preoperative NLR independently predicted the development of postoperative infectious complication, but not the development of postoperative noninfectious complications after gastrectomy. Both elevated NLR and postoperative infectious complication were independently associated with long-term survival. Also, patients with both elevated NLR and the development of postoperative infectious complication had the worst long-term survival. NLR independently predicted the development of postoperative infectious complication and lower survival after gastrectomy. Elevated NLR could trigger postoperative infectious complication and increase the risk of recurrence in patients with postoperative infectious complication after gastrectomy.

Prognostic value of monocyte and neutrophils to lymphocytes ratio in patients with metastatic soft tissue sarcoma

Metastatic soft tissue sarcomas (STS) represent enormous challenges to improve the low survival rate, which is almost the same as past 2 decades ago. Prognosis of cancer patients are based not only on tumor-related factors but also on host-related factors, particularly systemic inflammatory response. We evaluated the association among possible risk factors and survival for metastatic STS by reviewed a single-institution nearly 50-year experience. We found that both monocyte ratio and NLR ratio were significant prognostic predictors for OS and PFS of metastatic STS. And patients with monocyte ratio or NLR ratio > 1 should be screened out as candidates for more intensive or aggressive multimodality treatments and more aggressive follow-up. For this reason, this result could serve as a basis for future prospective study.

C-Reactive Protein Is an Important Biomarker for Prognosis Tumor Recurrence and Treatment Response in Adult Solid Tumors: A Systematic Review

PURPOSE

A systematic literature review was done to determine the relationship between elevated CRP and prognosis in people with solid tumors. C-reactive protein (CRP) is a serum acute phase reactant and a well-established inflammatory marker. We also examined the role of CRP to predict treatment response and tumor recurrence.

METHODS

MeSH (Medical Subject Heading) terms were used to search multiple electronic databases (PubMed, EMBASE, Web of Science, SCOPUS, EBM-Cochrane). Two independent reviewers selected research papers. We also included a quality Assessment (QA) score. Reports with QA scores <50% were excluded. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) methodology was utilized for this review (S1 PRISMA Checklist).

RESULTS

271 articles were identified for final review. There were 45% prospective studies and 52% retrospective. 264 had intermediate QA score (≥50% but <80%); Seven were adequate (80% -100%); A high CRP was predictive of prognosis in 90% (245/271) of studies-80% of the 245 studies by multivariate analysis, 20% by univariate analysis. Many (52%) of the articles were about gastrointestinal malignancies (GI) or kidney malignancies. A high CRP was prognostic in 90% (127 of 141) of the reports in those groups of tumors. CRP was also prognostic in most reports in other solid tumors primary sites.

CONCLUSIONS

A high CRP was associated with higher mortality in 90% of reports in people with solid tumors primary sites. This was particularly notable in GI malignancies and kidney malignancies. In other solid tumors (lung, pancreas, hepatocellular cancer, and bladder) an elevated CRP also predicted prognosis. In addition there is also evidence to support the use of CRP to help decide treatment response and identify tumor recurrence. Better designed large scale studies should be conducted to examine these issues more comprehensively.

Impact of preoperative serum albumin on 30-day mortality following surgery for colorectal cancer: a population-based cohort study

Objective

Surgery is the only potentially curable treatment for colorectal cancer (CRC), but it is hampered by high mortality. Human serum albumin (HSA) below 35 g/L is associated with poor overall prognosis in patients with CRC, but evidence regarding the impact on postoperative mortality is sparse.

Methods

We performed a population-based cohort study including patients undergoing CRC surgery in North and Central Denmark (1997–2011). We categorised patients according to HSA concentration measured 1–30 days prior to surgery date. We used the Kaplan-Meier method to compute 30-day mortality and Cox regression model to compute HRs as measures of the relative risk of death, controlling for potential confounders. We further stratified patients by preoperative conditions, including cancer stage, comorbidity level, and C reactive protein concentration.

Results

Of the 9339 patients undergoing first-time CRC surgery with preoperative HSA measurement, 26.4% (n=2464) had HSA below 35 g/L. 30-day mortality increased from 4.9% among patients with HSA 36–40 g/L to 26.9% among patients with HSA equal to or below 25 g/L, compared with 2.0% among patients with HSA above 40 g/L. The corresponding adjusted HRs increased from 1.75 (95% CI 1.25 to 2.45) among patients with HSA 36–40 g/L to 7.59 (95% CI 4.95 to 11.64) among patients with HSA equal to or below 25 g/L, compared with patients with HSA above 40 g/L. The negative impact associated with a decrement of HSA was found in all subgroups.

Conclusions

A decrement in preoperative HSA concentration was associated with substantial concentration-dependent increased 30-day mortality following CRC surgery.

Prognostic significance of preoperative peripheral blood monocyte ratio in patients with hepatocellular carcinoma

BACKGROUND

Leukocyte subsets in peripheral blood, which include neutrophils, lymphocytes, and monocytes, have not been well established as prognostic factors in patients with hepatocellular carcinoma (HCC).

METHODS

Consecutive patients who underwent curative hepatic resection for HCC at the National Cancer Center, Republic of Korea, from 2001 to 2008 were enrolled in this retrospective study. Clinicopathologic factors, cancer-specific survival (CSS), and disease-free survival (DFS) were analyzed with respect to preoperative lymphocyte subsets, especially monocyte ratio.

RESULTS

The 603 patients had a median follow-up of 40.0 months and a 5-year overall survival rate of 67.7 %. In univariate analysis of survivals, preoperative lymphocyte ratio ≤35 % and monocyte ratio >7 % were significantly poor prognostic factors. In multivariate analysis, preoperative monocyte ratio >7 %, satellite nodule, and microvascular invasion were independent risk factors for CSS and DFS (hazard ratio of monocyte ratio >7 % = 1.77, p = 0.02 and 1.57, p = 0.006, respectively). Considering monocyte ratio with preoperative α-fetoprotein level, patients with both abnormal α-fetoprotein levels (>12 ng/mL) and monocyte ratio >7 % showed significantly worse CSS and DFS than other groups (p < 0.001). Cirrhotic patients with monocyte ratio >7 % showed significantly poor CSS and DFS compared with non-cirrhotic patients (p = 0.033 and <0.001, respectively).

CONCLUSIONS

A preoperative monocyte ratio >7 % of peripheral blood is an independent risk factor for CSS and DFS after hepatic resection for HCC. Preoperative monocyte ratio might be considered as a novel biomarker for HCC.

Polymorphisms in C-reactive protein and Glypican-5 are associated with lung cancer risk and Gartrokine-1 influences Cisplatin-based chemotherapy response in a Chinese Han population

The role of genetics in progression of cancer is an established fact, and susceptibility risk and difference in outcome to chemotherapy may be caused by the variation in low-penetrance alleles of risk genes. We selected seven genes (CRP, GPC5, ACTA2, AGPHD1, SEC14L5, RBMS3, and GKN1) that previously reported link to lung cancer (LC) and genotyped single nucleotide polymorphisms (SNPs) of these genes in a case-control study. A protective allele "C" was found in rs2808630 of the C-reactive protein (CRP). Model association analysis found genotypes "T/C" and "C/C" in the dominant model and genotype "T/C" in the overdominant model of rs2808630 associated with reduced LC risk. Gender-specific analysis in each model showed that genotypes "T/T" and "C/C" in rs2352028 of the Glypican 5 (GPC5) were associated with increased LC risk in males. Logistic regression analysis showed "C/T" genotype carriers of rs4254535 in the Gastrokine 1 (GKN1) had less likelihood to have chemotherapy response. Our results suggest a potential association between CRP and GPC5 variants with LC risk; variation in GKN1 is associated with chemotherapy response in the Chinese Han population.

Postoperative intra-abdominal infection and colorectal cancer recurrence: a prospective matched cohort study of inflammatory and angiogenic responses as mechanisms involved in this association

BACKGROUND

Anastomotic leakage is associated with higher rates of recurrence after surgery for colorectal cancer. However, the mechanisms responsible are unknown. The aim was to investigate the inflammatory and angiogenic responses in patients undergoing surgery for colorectal cancer who had postoperative intra-abdominal infection, and to compare the results with patients without complications.

METHODS

Consecutive patients undergoing surgery for colorectal cancer with curative intent were included. Patients who had an anastomotic leak or intra-abdominal abscess were included in the infection group and matched with patients who had an uncomplicated postoperative course. IL-6 and VEGF were measured in serum and peritoneal fluid.

RESULTS

Serum concentration of IL-6 was higher in the infection group (n = 30) compared with the control group (n = 30) on day 4 (infection: 42.3 [27.6-1473.2] versus control: 0.6 [0.6-17.1] pg/ml; p = 0.008). IL-6 in peritoneal fluid was higher in the infection group at 48 h and day 4 (infection: 1000.2 [995.4-1574.0] versus control: 90.3 [35.2.6-106.1] pg/ml; p = 0.001). Serum VEGF was higher in the infection group on day 4 (infection: 1128.6 [427.3-10000.0] versus control: 438.3 [214.1-677.6] pg/ml; p = 0.001). Peritoneal VEGF concentration was higher in the infection group at 48 h and day 4 (infection: 10000.0 [2563.0-10000.0] versus control: 477.8 [313.5-814.4] pg/ml; p = 0.001). Two-year recurrence rate was higher in patients with infection (infection: 30% versus control: 4%; p = 0.001).

CONCLUSIONS

Intra-abdominal infection increases IL-6 and VEGF after surgery for colorectal cancer. Amplification of inflammation and angiogenesis might be one of the mechanisms responsible for the higher recurrence rate observed in patients with anastomotic leakage or intra-abdominal abscess.

From genotype to functional phenotype: unraveling the metabolomic features of colorectal cancer

Much effort in recent years has been expended in defining the genomic and epigenetic alterations that characterize colorectal adenocarcinoma and its subtypes. However, little is known about the functional ramifications related to various subtypes. Metabolomics, the study of small molecule intermediates in disease, provides a snapshot of the functional phenotype of colorectal cancer. Data, thus far, have characterized some of the metabolic perturbations that accompany colorectal cancer. However, further studies will be required to identify biologically meaningful metabolic subsets, including those corresponding to specific genetic aberrations. Moreover, further studies are necessary to distinguish changes due to tumor and the host response to tumor.

Postoperative complications influence prognosis and recurrence patterns in periampullary cancer

BACKGROUND

The present study was performed to elucidate the influence of postoperative complications on the prognosis and recurrence patterns of periampullary cancer after pancreaticoduodenectomy (PD).

METHODS

Clinical data were reviewed from 200 consecutive patients who had periampullary cancer and underwent PD between October 2003 and July 2010, and survival outcomes and recurrence patterns were analyzed. Postoperative complications were classified according to a modification of Clavien's classification.

RESULTS

Overall, 86 major complications of grade II or higher occurred in 71 patients. The patients were classified into two groups according to the presence of postoperative complications of grade II or higher: group Cx-, absence of complications (n = 129); and group Cx+, presence of complications (n = 71). There were no differences in gender, mean age, tumor node metastasis stage, biliary drainage, type of resection, and radicality between the two groups (P > 0.05). The 3-year overall and disease-free survival rates of the group Cx+ patients (31.0 and 22.3 %, respectively) were significantly lower than those of the group Cx- patients (49.0 and 40.0 %; P = 0.003 and 0.002, respectively). The multivariate analysis showed that postoperative complications (P = 0.001; RR = 1.887; 95 % confidence interval [CI] 1.278-2.785), a T stage of T3 or T4 (P = 0.001; RR = 2.503; 95 % CI 1.441-4.346), positive node metastasis (P = 0.001; RR = 2.093; 95 % CI, 1.378-3.179), R1 or R2 resection (P = 0.023; RR = 1.863; 95 % CI 1.090-3.187), and angiolymphatic invasion (P = 0.013; RR = 1.676; 95 % CI 1.117-2.513) were independent prognostic factors for disease-free survival. Regarding recurrence patterns, group Cx+ patients exhibited more distant recurrences than did group Cx- patients (P = 0.025).

CONCLUSIONS

Postoperative complications affect prognosis and recurrence patterns in patients with periampullary cancer after PD.

Validation of the prognostic relevance of plasma C-reactive protein levels in soft-tissue sarcoma patients

BACKGROUND

The concept of the involvement of systemic inflammation in cancer progression and metastases has gained attraction within the past decade. C-reactive protein (CRP), a non-specific blood-based marker of the systemic inflammatory response, has been associated with decreased survival in several cancer types. The aim of the present study was to validate the prognostic value of pre-operative plasma CRP levels on clinical outcome in a large cohort of soft-tissue sarcoma (STS) patients.

METHODS

Three hundred and four STS patients, operated between 1998 and 2010, were retrospectively evaluated. CRP levels and the impact on cancer-specific survival (CSS), disease-free survival (DFS) and overall survival (OS) were assessed using Kaplan-Meier curves and univariate as well as multivariate Cox proportional models. Additionally, we developed a nomogram by supplementing the plasma CRP level to the well-established Kattan nomogram and evaluated the improvement of predictive accuracy of this novel nomogram by applying calibration and Harrell's concordance index (c-index).

RESULTS

An elevated plasma CRP level was significantly associated with established prognostic factors, including age, tumour grade, size and depth (P<0.05). In multivariate analysis, increased CRP levels were significantly associated with a poor outcome for CSS (HR=2.05; 95% CI=1.13-3.74; P=0.019) and DFS (HR=1.88; 95% CI=1.07-3.34; P=0.029). The estimated c-index was 0.74 using the original Kattan nomogram and 0.77 when the plasma CRP level was added.

CONCLUSION

An elevated pre-operative CRP level represents an independent prognostic factor that predicts poor prognosis and improves the predictive ability of the Kattan nomogram in STS patients. Our data suggest to further prospectively validate its potential utility for individual risk stratification and clinical management of STS patients.

Elevated serum C-reactive protein as a prognostic marker in small cell lung cancer

PURPOSE

Elevated C-reactive protein (CRP) is associated with poor prognosis in several tumor types. The purpose of this study was to investigate serum CRP as a prognostic marker in small cell lung cancer (SCLC).

MATERIALS AND METHODS

The pretreatment serum CRP level was measured in 157 newly diagnosed SCLC patients, and correlation between serum CRP level and other clinical parameters was analyzed. Multivariate analyses were performed to find prognostic markers using Cox's proportional hazards model.

RESULTS

The initial CRP concentration was within the normal range in 72 (45.9%) patients and elevated in 85 (54.1%) patients. There was a significant correlation between serum CRP level and the extent of disease (p<0.001), weight loss (p=0.029) and chest radiation (p=0.001). Median overall survival (OS) in the normal CRP group was significantly longer than with the high CRP group (22.5 months vs. 11.2 months, p<0.001). Extent of disease (p<0.001), age (p=0.025), and performance status (p<0.001) were additional prognostic factors on univariate analysis. On multivariate analysis, elevated serum CRP level was an independent prognostic factor for poor survival (HR=1.8; p=0.014), regardless of the extent of disease (HR=3.7; p<0.001) and performance status (HR=2.2; p<0.001).

CONCLUSION

High level of CRP was an independent poor prognostic serum marker in addition to previously well-known prognosticators in patients with SCLC.

Prognostic value of pre-treatment circulating monocyte count in patients with cervical cancer: comparison with SCC-Ag level

OBJECTIVE

Higher level of circulating monocyte has been reported to be related with higher cancer incidence and mortality. We investigated the role of pre-treatment circulating monocyte count for cancer specific survival in cervical squamous cell carcinoma patients comparing with pre-treatment squamous cell carcinoma-related antigen (SCC-Ag) level.

METHODS

We retrospectively enrolled patients with squamous cell carcinoma of the cervix (FIGO stage IB to IVA) who had complete blood cell counts with differential cell count and serum SCC-Ag level within 2 weeks before starting initial treatment and were treated at Samsung Medical Center, Seoul, Korea, from 1996 to 2007.

RESULTS

The 788 patients in our study group had a median follow-up of 53.4 months and a five-year survival rate of 87.8%. The median value for pre-treatment circulating monocyte count was 349/μl (21-1463), and the median concentration of SCC-Ag was 1.6 ng/ml (0.1-362.0). In multivariable analysis, the pre-treatment circulating monocyte count was an independent prognostic factor for progression-free survival and overall survival in locally advanced disease (P=0.007 and P=0.038) but not in case of SCC-Ag for overall survival. The combined index of monocyte count and SCC-Ag level could enhance the prognostic value of SCC-Ag alone in patients with locally advanced cervical squamous cell carcinoma.

CONCLUSIONS

A higher pre-treatment circulating monocyte count is independently associated with poor prognosis in patients with locally advanced cervical squamous cell carcinoma. The pre-treatment circulating monocyte count may be considered as an adjunctive biomarker with SCC-Ag.

C-reactive protein concentration is associated with prognosis in patients suffering from peritoneal carcinomatosis of colorectal origin

PURPOSE

Only a limited number of patients with peritoneal carcinomatosis (PC) of colorectal origin benefit from palliative chemotherapy. Identification of prognostic factors may aid in patient selection. The plasma concentration of C-reactive protein (CRP) is increasingly recognized as prognostic factor in a variety of malignancies. However, its value in peritoneal PC of colorectal origin is currently unknown. The aim of the present study was to investigate the association of plasma CRP concentrations with survival in patients suffering from PC of colorectal origin who receive palliative chemotherapy.

METHODS

Fifty patients with colorectal PC were identified from the Eindhoven Cancer Registry. Relevant data were retrieved from their clinical records. The most discriminatory CRP concentration was identified and patients were stratified accordingly, resulting in a group with low and a group with high CRP concentrations. Further comparisons were made between these groups.

RESULTS

A CRP concentration <35 mg/L was associated with a better prognosis (median survival 22.4 months) than a CRP concentration ≥35 mg/L (7.9 months) (p = 0.0002). CRP concentrations were inversely related to albumin concentrations which could predict survival at a cut-off value of 35 g/L (median survival 7.2 vs. 12.9 months, p = 0.01). High CRP concentrations were related to a decreased resectability rate of the primary tumor.

CONCLUSION

Elevated CRP plasma concentrations are associated with decreased survival in patients with colorectal PC. This reflects the importance of inflammation in cancer survival. Further research is warranted to assess the clinical applicability of the current findings.

Preoperative inflammation is a prognostic factor for gallbladder carcinoma

BACKGROUND

Inflammation frequently accompanies gallbladder carcinoma (GBC), but its impact on outcome is unclear. The present study investigated the impact of concomitant inflammation on survival of patients with GBC.

METHODS

All patients undergoing surgery for GBC between October 2003 and May 2009 were identified retrospectively from a prospectively collected database. Patients were classified according to whether preoperative inflammation was present (65 patients) or not (23).

RESULTS

A total of 88 patients were enrolled. There were no differences in sex, mean age, tumour node metastasis (TNM) stage and radicality of resection between the two groups. The overall 3-year survival rate was lower in patients with preoperative inflammation than in those without (33 versus 73 per cent; P = 0·001). In univariable analysis, preoperative inflammation, T, N and M category, TNM stage, radicality of surgery and tumour differentiation were significant prognostic factors. The presence of preoperative inflammation (hazard ratio (HR) 2·38, 95 per cent confidence interval 1·04 to 5·43), lymph node metastases (HR 5·23, 1·05 to 26·09) and R1 or R2 resection (HR 3·77, 1·47 to 9·72) were independent prognostic factors for poor survival.

CONCLUSION

The presence of preoperative inflammation is an independent prognostic factor for poor survival in patients with GBC.

The effects of obesity and obesity-related conditions on colorectal cancer prognosis

BACKGROUND

Colorectal cancer is the second-leading cause of cancer death in the United States among men and women combined. Refinements in screening, staging, and treatment strategies have improved survival from this disease, with over 65% of patients diagnosed with colorectal cancer surviving over 5 years after diagnosis. In the prognosis of colorectal cancer, clinicopathological factors are important. However, modifiable prognostic factors are emerging as significant contributors to cancer outcomes, including obesity and obesity-related inflammation and metabolic conditions.

METHODS

This report reviews the literature on obesity and obesity-related inflammation and metabolic disturbances and colorectal cancer outcomes (recurrence, disease-free survival, and/or mortality). A PubMed search was conducted of all English-language papers published between August 2003 and 2009 and cited in MEDLINE.

RESULTS

Primary research papers were reviewed for colorectal cancer outcomes related to obesity, inflammation, or metabolic conditions. An association between body size and colorectal cancer recurrence and possibly survival was found; however, reports have been inconsistent. These inconsistent findings may be due to the complex interaction between adiposity, physical inactivity, and dietary intake. Circulating prognostic markers such as C-reactive protein, insulin-like growth factor, and insulin, alone or in combination, have been associated with prognosis in observational studies and should be evaluated in randomized trials and considered for incorporation into surveillance.

CONCLUSIONS

The literature suggests that obesity and obesity-related inflammation and metabolic conditions contribute to the prognosis of colorectal cancer; however, comprehensive large scale trials are needed. Interventions to reduce weight and control inflammation and metabolic conditions, such as diabetes, need to be evaluated and rapidly translated to behavior guidelines for patients.

Preoperative systemic inflammation predicts postoperative infectious complications in patients undergoing curative resection for colorectal cancer

The presence of systemic inflammation before surgery, as evidenced by the glasgow prognostic score (mGPS), predicts poor long-term survival in colorectal cancer. The aim was to examine the relationship between the preoperative mGPS and the development of postoperative complications in patients undergoing potentially curative resection for colorectal cancer. Patients (n=455) who underwent potentially curative resections between 2003 and 2007 were assessed consecutively, and details were recorded in a database. The majority of patients presented for elective surgery (85%) were over the age of 65 years (70%), were male (58%), were deprived (53%), and had TNM stage I/II disease (61%), had preoperative haemoglobin (56%), white cell count (87%) and mGPS 0 (58%) in the normal range. After surgery, 86 (19%) patients developed a postoperative complication; 70 (81%) of which were infectious complications. On multivariate analysis, peritoneal soiling (P<0.01), elevated preoperative white cell count (P<0.05) and mGPS (P<0.01) were independently associated with increased risk of developing a postoperative infection. In elective patients, only the mGPS (OR=1.75, 95% CI=1.17–2.63, P=0.007) was significantly associated with increased risk of developing a postoperative infection. Preoperative elevated mGPS predicts increased postoperative infectious complications in patients undergoing potentially curative resection for colorectal cancer.

Preoperative resolution of jaundice following biliary stenting predicts more favourable early survival in resected pancreatic ductal adenocarcinoma

INTRODUCTION

Despite the widespread use of endoscopic biliary stenting in patients presenting with potentially resectable pancreatic cancer, there is no general consensus regarding whether this represents a superior management approach over expeditious surgical intervention. The objective of this study was to investigate the influence of preoperative biliary stenting and resolution of jaundice on subsequent postoperative survival following resection for pancreatic cancer.

METHODS

155 patients undergoing partial pancreatoduodenectomy for pancreatic ductal adenocarcinoma between January 1997 and August 2007 were identified from a prospectively maintained database.

RESULTS

There was no survival difference when comparing patients undergoing preoperative biliary drainage (n = 130) with those who did not (n = 25) (log rank, P = 0.981). When analysing individual prognostic factors as continuous variables in univariate Cox analysis, lower albumin levels (P = 0.016), elevated alkaline phosphatase levels (P = 0.011) and elevated CRP levels (P = 0.021) were associated with poorer overall survival. Multivariable Cox regression demonstrated that both albumin (P = 0.008) and CRP (P = 0.038) remained significant independent predictors of overall survival alongside lymph node ratio (P = 0.018). Although preoperative bilirubin levels were not associated with overall survival when analysed as a continuous variable (Cox, P = 0.786), the presence of jaundice (i.e., bilirubin >35 micromol/l) at the time of surgery was a significant adverse predictor of early survival in patients undergoing preoperative biliary drainage (Breslow-Gehan-Wilcoxon, P = 0.013) and remained a significant predictor of early survival when included in a further Cox analysis with censoring of cases who survived beyond 6 months (Cox, P = 0.017).

CONCLUSION

These results suggest that the presence of jaundice at the time of resection has an adverse impact on early, but not overall, postoperative survival in pancreatic cancer patients undergoing preoperative biliary drainage.

Inflammation and CYP3A4-mediated drug metabolism in advanced cancer: impact and implications for chemotherapeutic drug dosing

BACKGROUND

The inability to accurately predict treatment outcomes for cancer patients in terms of tumour response and anticancer drug toxicity is a severe limitation inherent in current approaches to chemotherapy. Many anticancer drugs are metabolically cleared by cytochrome P450 3A4 (CYP3A4), the predominant CYP expressed in liver. CYP3A4 expression exhibits marked interindividual variation and is repressed in acute inflammatory states.

OBJECTIVES

(1) To review the relevance of CYP3A4 variability to drug metabolism in the setting of cancer and to understand how inflammation associated with malignancy contributes to both this variability and to adverse treatment outcomes. (2) To examine the relationship between tumour-induced inflammation and repression of CYP3A4 and to explore methods of dosing of anticancer drugs in the setting of advanced cancer.

METHODS

Review of relevant literature covering both human and animal studies as well as in vitro mechanistic studies.

RESULTS/CONCLUSIONS

Interindividual variability in CYP3A4 expression is a major confounding factor for effective cancer treatment and methods to predict CYP3A4-mediated drug clearance may have clinical utility in this setting. Although acute inflammation has long been recognised to repress drug metabolism, it is now becoming apparent that cancer patients exhibiting clinical and laboratory features of an inflammatory response have reduced expression of CYP3A4 and possibly other genes relevant to anticancer drug disposition.