Retrospective analysis of fixed dose rate infusion of gemcitabine and S-1 combination therapy (FGS) as salvage chemotherapy in patients with gemcitabine-refractory advanced pancreatic cancer: inflammation-based prognostic score predicts survival

The application of the Glasgow prognostic score to predict the survival in patients with metastatic pancreatic carcinoma

Objectives:

Thither is a more pressing effort to think about chemotherapy (CTx) in second-line and beyond in patients with metastatic pancreatic cancer (mPC). The current work aimed to evaluate the value of the Glasgow prognostic score (GPS) and modified Glasgow prognostic score (mGPS) to predict the survival in patients receiving second-line CTx protocol.

Material and Methods:

We retrospectively reviewed the patients’ medical files with mPC who received second-line CTx protocol between September 2013 and December 2017. The GPS/mGPS graded from 0 to 2 based on C-reactive protein and serum albumin.

Results:

One hundred and sixty-nine patients with mPC were eligible. Survival of patients with Score 0 (GPS/mGPS) was better than that of Score 1 (GPS/mGPS) or Score 2 (GPS/mGPS), which was statistically significant (P < 0.001). Of 78 patients who died, only 16 patients belonged to Score 0 (GPS/mGPS), compared to 30 patients belonged to Score 1 (GPS/mGPS) and 32 patients belonged to Score 2 (GPS/mGPS). Univariate analysis showed that high GPS/mGPS (P < 0.000) as well as poor Eastern Cooperative Oncology Group Performance Status (P < 0.000) and metastasis either to the liver (P < 0.01) or lung (P < 0.04) were linked with worse prognosis. A statistically significant association was detected between the two scores. Cohen’s Kappa coefficient (k) was 0.9, SD = 0.03; 95% CI (0.787–0.922; P < 0.001).

Conclusion:

Our data suggested that GPS/mGPS is an easy and applicable index that may be used in daily practice and may help in the prognostic stratification of mPC patients to avert overtreatment in frail patients and raise the best supportive treatment concept.

Role of systemic inflammation in functional recovery, dysphagia, and 1-y mortality in heart failure: A prospective cohort study

OBJECTIVES

This study evaluated the relationship between systemic inflammation and clinical outcomes in people hospitalized with acute heart failure (AHF).

METHODS

We prospectively enrolled people newly hospitalized with AHF after excluding those with concomitant infectious or inflammatory diseases. Systemic inflammation was evaluated using the modified Glasgow Prognostic Score (mGPS) at hospitalization, and participants were classified into low-grade and high-grade inflammation groups (mGPS 0-1 and 2, respectively). The primary outcome measure was functional recovery, evaluated using the Barthel Index gain. Secondary outcome measures were dysphagia at discharge and all-cause 1-y mortality after discharge. Multivariable analyses and Kaplan-Meier estimates were used to determine the association between systemic inflammation and study outcomes.

RESULTS

A total of 184 participants (mean age, 79.1 y; 48.4% female, 51.6% male) were included; 148 (80.4%) and 36 (19.6%), respectively, had low-grade and high-grade inflammation. Participants with high-grade inflammation were significantly older, had lower body mass index and muscle strength, and had lower nutrient intake, swallowing status, and Barthel Index than those with low-grade inflammation. In multivariable analyses, mGPS was significantly associated with Barthel Index gain (β = -0.229, P = 0.004) and Food Intake Level Scale (odds ratio = 5.067, P = 0.034) at discharge; mGPS was associated with 1-y mortality after discharge (P = 0.003).

CONCLUSIONS

Baseline systemic inflammation was negatively associated with improvements in physical function and dysphagia and with 1-y survival in people with AHF. These findings highlight the importance of focusing on the assessment of systemic inflammation to accurately predict the functional prognosis of people with AHF.

Prognostic and clinical significance of modified glasgow prognostic score in pancreatic cancer: a meta-analysis of 4,629 patients

In this study, we evaluated the association of modified Glasgow Prognostic Score (mGPS) with prognosis in pancreatic cancer (PC) by performing a meta-analysis. Potentially eligible studies were shortlisted by searching PubMed, Embase, Web of Science, Scopus, and the Cochrane Library. A total of 4,629 patients with PC from 25 studies were finally included in this meta-analysis. Meta-analyses were performed using a random-effects model or fixed-effect model according to heterogeneity. We pooled the hazard ratios (HRs) with 95% confidence intervals (CIs) to estimate the association between mGPS and overall survival (OS). The results showed that elevated mGPS correlated with poor OS in patients with PC (HR=1.92, 95% CI=1.60–2.30, p<0.002). In addition, subgroup analysis indicated that increased mGPS remained a significant prognostic factor irrespective of the study design, region, disease status, treatment, survival analysis, cancer type, study center, or the Newcastle-Ottawa Scale (NOS) score (all p<0.05). There was a significant correlation between higher mGPS and male gender (Odds ratio [OR]=1.30, 95% CI=1.01–1.67, p=0.038). Elevated pretreatment mGPS is a marker of poor prognosis in patients with PC. As an easily available and cost-effective inflammatory parameter, mGPS can serve as a promising tool for prognostication in PC.

Prognostic Significance of the Modified Glasgow Prognostic Score in Patients With Pancreatic Cancer: A Meta-Analysis

BACKGROUND

The prognostic value of the modified Glasgow prognostic score (mGPS) in patients with pancreatic cancer is controversial, based on previous studies. Therefore, this meta-analysis aimed to explore the relationship between mGPS and prognosis in pancreatic cancer.

METHODS

The databases PubMed, Web of Science, Embase, and the Cochrane Library were searched to identify eligible studies. Hazard ratios (HRs) and 95% confidence intervals (CIs) were used to estimate the associations between mGPS score and survival outcomes.

RESULTS

A total of 26 studies with 5198 patients were included in this meta-analysis. In a pooled analysis, elevated mGPS predicted poorer overall survival (OS; HR = 1.98, 95% CI, 1.65-2.37, P < .001). In addition, elevated mGPS was also significantly associated with worse progression-free survival (PFS), disease-free survival (DFS), and cancer-specific survival (CSS; HR = 1.95, 95% CI, 1.36-2.80, P < .001). Subgroup analyses confirmed a significant association between mGPS and survival outcomes.

CONCLUSIONS

Our meta-analysis demonstrated that high mGPS was correlated to worse OS, PFS, DFS, and CSS in patients with pancreatic cancer. Therefore, mGPS could be employed as an effective prognostic factor for pancreatic cancer in clinical practice.

Modified FOLFIRINOX as a second-line therapy following gemcitabine plus nab-paclitaxel therapy in metastatic pancreatic cancer

Background

There is no established second-line treatment after failure of gemcitabine plus nab-paclitaxel (GnP) therapy for metastatic pancreatic cancer (MPC). The purpose of this study was to evaluate the efficacy and tolerability of the modified FOLFIRINOX (mFFX) as a second-line therapy for MPC and to investigate prognostic factors for survival.

Methods

From 2015 to 2019, we retrospectively reviewed the medical records of consecutive patients receiving mFFX for MPC after failure of GnP therapy. Patients were treated every 2 weeks with mFFX (intravenous oxaliplatin 85 mg/m², intravenous irinotecan 150 mg/m², and continuous infusion of 5-fluorouracil 2400 mg/m² for 46 h without bolus infusion).

Results

In total, 104 patients received mFFX. The median overall survival (OS) was 7.0 months (95% confidence interval [CI]: 6.2–9.8) and the progression-free survival (PFS) 3.9 months (95% CI 2.8–5.0). The objective response rate was 10.6% and the disease control rate 56.7%. The median relative dose intensities of oxaliplatin, irinotecan, and infusional 5-FU were 80.0% (range 21.5–100%), 77.2% (range 38.1–100%), and 85.9% (range 36.9–100%), respectively. Grade 3–4 toxicities were reported in 57 patients (54.8%), including neutropenia, leukopenia, anemia, febrile neutropenia, and peripheral sensory neuropathy. Glasgow prognostic score and carcinoembryonic antigen level were independently associated with survival. Our prognostic model using these parameters could classify the patients into good (n = 38), intermediate (n = 47), and poor (n = 19) prognostic groups. The median OS and PFS time was 14.7 (95% CI 7.6–16.3) and 7.6 months (95% CI 4.1–10.5) for the good prognostic factors, 6.5 (95% CI 5.5–10.0) and 3.6 months (95% CI 2.7–4.8) for the intermediate prognostic factors and 5.0 (95% CI 2.9–6.6) and 1.7 months (95% CI 0.9–4.3) for the poor prognostic factors, respectively.

Conclusions

The mFFX showed to be a tolerable second-line treatment for MPC after GnP failure. Our prognostic model might be useful for deciding whether mFFX is indicated in this setting.

The prevalence of cancer associated systemic inflammation: Implications of prognostic studies using the Glasgow Prognostic Score

The prognostic importance of SIR in patients with cancer is widely recognised. More recently it has become clear that the systemic inflammatory response is an important etiologic factor in the development of cancer cachexia. Two recent meta-analysis carried out in 2017 and 2018 were interrogated and the number of patients with specific cancer types were identified. The percentage of patients with operable cancer (n>28,000) who were systemically inflamed varied from 21% to 38%. The percentage of patients with inoperable cancer (n>12,000) who were systemically inflamed varied from 29% to 79%. Overall, the percentage of patients (n>40,000) who were systemically inflamed varied from 28% to 63% according to tumour type. The most commonly studied cancer was colorectal cancer (n∼10,000 patients) and 40% were systemically inflamed.

Predicting mortality and adverse events in patients with advanced pancreatic cancer treated with palliative gemcitabine-based chemotherapy in a multicentre phase III randomized clinical trial: the APC-SAKK risk scores

Background

The prognosis of advanced pancreatic cancer (APC) is poor and differs considerably among patients. Therefore, it is clinically relevant to identify patients with APC who are more likely to benefit from palliative chemotherapy with reduced risk of toxicity. To date, there is no prognostic score universally recommended to help clinicians in planning the therapeutic management.

Methods

Using individual patient data from 319 cases of APC treated with gemcitabine-based chemotherapy and enrolled in the SAKK 44/00-CECOG/PAN.1.3.001 randomized trial, several baseline variables, including inflammatory markers, were analysed post hoc as predictors of mortality and/or grade 3 or 4 chemotherapy-related toxicity and separate risk scores were developed.

Results

Median survival of the study patients was 7.9 months (interquartile range 3.7-13.3 months). Independent predictors of mortality included increased Aspartate transaminase (ASAT), low performance status, increased derived neutrophil to lymphocyte ratio, increased Carbohydrate Antigen 19-9 (CA 19-9), low haemoglobin, presence of pain, presence of metastasis and increased alkaline phosphatase (ALP). During the study, 117 patients experienced at least one grade 3 or 4 adverse event. Independent predictors of toxicity included white blood cells, ALP, renal function and bilirubin levels at baseline. Both models displayed moderate levels of discrimination (C-statistic 0.68 and 0.64 for mortality and toxicity, respectively) and adequate calibration.

Conclusions

We developed simple-to-use prognostic scores for mortality and severe toxicity for patients with APC. These scores can be useful in daily practice to identify patients with increased risk of death or toxicity and to plan the most appropriate therapeutic strategy to improve survival and quality of life. Further prospective studies to validate such scores are needed.

Systemic Inflammation in the Recovery Stage of Stroke: Its Association with Sarcopenia and Poor Functional Rehabilitation Outcomes

Objective

The aim of our study was to investigate how systemic inflammation relates to sarcopenia and its impact on functional outcomes in the recovery stages of stroke.

Methods

A retrospective cohort study was performed in consecutive patients admitted to convalescent rehabilitation wards following stroke. Patients with acute or chronic high-grade inflammatory diseases were excluded. Systemic inflammation was evaluated using the modified Glasgow Prognostic Score (mGPS). Sarcopenia was defined as a loss of skeletal muscle mass and decreased muscle strength, with the cut-off values set by the Asian Working Group for Sarcopenia. The primary outcome was the motor domain of the Functional Independence Measure (FIM-motor). Univariate and multivariate analyses were used to determine whether mGPS was associated with sarcopenia and FIM-motor at discharge.

Results

The study included 204 patients (mean age 74.1 years, 109 men). mGPS scores of 0, 1, and 2 were assigned to 149 (73.0%), 40 (19.6%), and 13 (6.4%) patients, respectively. Sarcopenia was diagnosed in 81 (39.7%) patients and was independently associated with stroke history (odds ratio [OR] 1.890, P=0.027), premorbid modified Rankin scale (OR 1.520, P=0.040), body mass index (OR 0.858, P=0.022), and mGPS score (OR 1.380, P=0.021). Furthermore, the mGPS score was independently associated with sarcopenia (OR 1.380, P=0.021) and FIM-motor at discharge (β=-0.131, P=0.031).

Conclusion

Systemic inflammation is closely associated with sarcopenia and poor functional outcomes in the recovery stage of stroke. Early detection of systemic inflammation and sarcopenia can help promote both adequate exercise and nutritional support to restore muscle mass and improve post-stroke functional recovery.

Post-progression survival following second-line chemotherapy in patients with advanced pancreatic cancer previously treated with gemcitabine: a meta-analysis

Background Post-progression survival (PPS) could be a confounding element in interpreting data from clinical trials of second-line chemotherapy in patients with advanced pancreatic cancer (PC) previously treated with gemcitabine (GEM) because a recent meta-analysis of oxaliplatin combination therapy showed statistical heterogeneity for overall survival (OS) but not for progression-free survival (PFS). This study aimed to improve the understanding of the impact of PPS on OS in this setting. Methods Databases were searched to identify randomized controlled trials (RCTs) in the salvage setting. We evaluated relationships between OS and PFS, PPS, and other variables. Results Totally, 17 RCTs with 3253 patients were identified. Median OS was strongly and moderately associated with median PPS and PFS, respectively (r = 0.913; p < 0.001 and 0.780; p < 0.001, respectively). The proportion of patients with good performance status was significantly associated with both PPS and PFS (r = 0.574, p < 0.001 and 0.492, p < 0.001, respectively). The induction rate of subsequent chemotherapy was related to the duration of PPS and OS (r = 0.640, p < 0.001 and 0.647, p < 0.001, respectively). Median PPS and OS were significantly longer in recent trials than those in older trials (3.55 versus 2.78 months, p < 0.001 and 6.29 versus 5.02 months, p < 0.001). Conclusions Median PPS was strongly correlated with median OS. Given the recently increased opportunity for subsequent chemotherapy and supportive care, PPS may serve as an important element to clarify problems in this setting.

Efficacy of different chemotherapy regimens in treatment of advanced or metastatic pancreatic cancer: A network meta-analysis

We performed a network meta-analysis (NMA) to compare the short- and long-term efficacy of Gemcitabine, Gemcitabine + S-1 (tegafur), Gemcitabine + nab-paclitaxel, Gemcitabine + Capecitabine, Gemcitabine + Cisplatin, FOLFIRINOX (oxaliplatin + irinotecan + fluorouracil + leucovorin), Gemcitabine + oxaliplatin, Gemcitabine + irinotecan, Gemcitabine + Exatecan, Gemcitabine + pemetrexed, Gemcitabine + 5-FU, and S-1 in treating advanced or metastatic pancreatic cancer (PC). The odds radios (OR) or weighted mean difference (WMD) and surface under the cumulative ranking curves (SUCRA) were evaluated by a combination of direct evidence and indirect evidence. In total twenty studies were included in this paper. For short-term efficacy, the overall response rate (ORR) was lower for patients treated with Gemcitabine compared with Gemcitabine + S-1, Gemcitabine + Cisplatin, Gemcitabine + irinotecan and S-1. The ORR for FOLFIRINOX was higher compared with Gemcitabine, Gemcitabine + Capecitabine and Gemcitabine + Cisplatin. The disease control rate (DCR) for Gemcitabine was lower compared with Gemcitabine + S-1, Gemcitabine + Cisplatin, and FOLFIRINOX. For long-term efficacy, the 12-month overall survival (OS) rate for FOLFIRINOX was higher compared with Gemcitabine, Gemcitabine + Capecitabine, Gemcitabine + Cisplatin, Gemcitabine + irinotecan, Gemcitabine + Exatecan, and Gemcitabine + pemetrexed. The SUCRA revealed that FOLFIRINOX was relatively better in both short- and long-term efficacy, while Gemcitabine was relatively poorer. In both short- and long-term efficacy, FOLFIRINOX had the best short- and long-term efficacy among the 12 chemotherapy regimens while efficacy of Gemcitabine was relatively poorer in the treatment of advanced or metastatic PC.

Phase II study of fixed dose-rate gemcitabine plus S-1 as a second-line treatment for advanced biliary tract cancer

PURPOSE

Gemcitabine plus platinum is considered standard first-line chemotherapy for patients with advanced biliary tract cancer. However, no standard second-line therapy has been established for this disease. According to reports, S-1 exerts anti-tumor effects on advanced biliary tract cancer and gemcitabine is more effective via fixed dose-rate administration. We evaluated the efficacy and safety of a combination of fixed dose-rate gemcitabine and S-1 after failure of gemcitabine or gemcitabine plus cisplatin therapy.

METHODS

This single-arm phase II study (clinical trial number: UMIN000005918) set the response rate as the primary endpoint and used a MiniMax two-stage design with a null hypothesis < 7% and alternative hypothesis ≥ 25%. Thirty-five patients were needed to yield a power of 90% and α value of 0.05. Patients received gemcitabine (1000 mg/m², div, 100-min period, day 1) and S-1 (40 mg/m² twice daily, oral, days 1-7), every 2 weeks until disease progression or intolerable adverse events were observed.

RESULTS

Forty-one patients were enrolled, and 3 of 23 first-stage patients responded. The overall response rate was 9.8% [95% confidence interval (CI): 2.7-19.2%]. The median overall and progression-free survival were 7.0 [95% CI: 5.3-8.6] and 2.6 months (95% CI: 1.6-3.5), respectively. The most common grade 3-4 adverse events were leukopenia (19.5%), neutropenia (19.5%), anemia (14.6%), thrombocytopenia (7.3%), and anorexia (4.8%).

CONCLUSION

Second-line fixed dose-rate gemcitabine plus S-1 was not sufficiently effective and tolerable in patients with advanced biliary tract cancer refractory to gemcitabine or gemcitabine plus cisplatin.

Biliary drainage improves the predictive value of modified Glasgow Prognostic Scores in inoperable pancreatic cancer

Objective

To assess the influence of biliary drainage to cholangitis on modified Glasgow Prognostic Score (mGPS) in patients with pancreatic cancer.

Methods

mGPS was calculated before and after biliary drainage in 47 consecutive patients with inoperable pancreatic cancer who were receiving chemotherapy. Biliary drainage was indicated for malignant obstructive jaundice that prevented the administration of chemotherapy. To elucidate mGPS values, serum levels of CRP and albumin were measured at the time of diagnosis (before biliary drainage). Overall survival was evaluated and risk factors, which contribute to overall survival, were examined.

Results

Biliary drainage was performed in 15 patients. Using values obtained before biliary drainage, there were no significant differences in median survival time between patients with a mGPS of 0 and those with a mGPS of 1 or 2 (10.7 vs. 9.4 months; p = 0.757). However, using values obtained after biliary drainage, median survival time was significantly higher in patients with a mGPS of 0 than in those with a mGPS of 1 or 2 (11.4 vs. 4.7 months; p = 0.002). Multivariate analysis revealed that a mGPS of 1 or 2 (HR: 3.38; 95% CI: 1.35–8.46, p = 0.009), a carbohydrate antigen 19–9 >1000 U/mL (2.52; 1.22–5.23, p = 0.013), a performance status of 2 (7.68; 2.72–21.28, p = 0.001), carcinoembryonic antigen level >10 ng/mL (2.29; 1.13–4.61, p = 0.021) were independently associated with overall survival.

Conclusion

mGPS values obtained after biliary drainage appear to be a more reliable indicator of overall survival in patients with inoperable pancreatic cancer.