Association of C-reactive protein levels and long-term survival after neoadjuvant therapy and esophagectomy for esophageal cancer

Efficacy and survival of nivolumab treatment for recurrent/unresectable esophageal squamous-cell carcinoma: real-world clinical data from a large multi-institutional cohort

BACKGROUND

Real-world clinical outcomes of and prognostic factors for nivolumab treatment for esophageal squamous-cell carcinoma (ESCC) remain unclear. This study aimed to evaluate real-world outcomes of nivolumab monotherapy in association with relevant clinical parameters in recurrent/unresectable advanced ESCC patients.

METHODS

This population-based multicenter cohort study included a total of 282 patients from 15 institutions with recurrent/unresectable advanced ESCC who received nivolumab as a second-line or later therapy between 2014 and 2022. Data, including the best overall response, progression-free survival (PFS), and overall survival (OS), were retrospectively collected from these patients.

RESULTS

Objective response and disease control rates were 17.0% and 47.9%, respectively. The clinical response to nivolumab treatment significantly correlated with development of overall immune-related adverse events (P < .0001), including rash (P < .0001), hypothyroidism (P = .03), and interstitial pneumonia (P = .004). Organ-specific best response rates were 20.6% in lymph nodes, 17.4% in lungs, 15.4% in pleural dissemination, and 13.6% in primary lesions. In terms of patient survival, the median OS and PFS was 10.9 and 2.4 months, respectively. Univariate analysis of OS revealed that performance status (PS; P < .0001), number of metastatic organs (P = .019), C-reactive protein-to-albumin ratio (CAR; P < .0001), neutrophil-lymphocyte ratio (P = .001), and PMI (P = .024) were significant. Multivariate analysis further identified CAR [hazard ratio (HR) = 1.61, 95% confidence interval (CI) 1.15-2.25, P = .0053)] in addition to PS (HR = 1.65, 95% CI 1.23-2.22, P = .0008) as independent prognostic parameters.

CONCLUSIONS

CAR and PS before nivolumab treatment are useful in predicting long-term survival in recurrent/unresectable advanced ESCC patients with second-line or later nivolumab treatment.

TRIAL REGISTRATION

UMIN000040462.

Prognostic Value of Inflammation Biomarkers in Penile Squamous Cell Carcinoma Patients Without Distant Metastasis

BACKGROUND

To investigate the value of the presurgical inflammatory biomarkers including C-reactive protein (CRP), albumin (ALB), C-reactive protein to albumin ratio (CAR), Glasgow prognostic score (GPS), the modified GPS (mGPS), and the high-sensitivity modified GPS (Hs-mGPS) in penile squamous cell carcinoma (PSCC) without distant metastasis and develop a tool to predict the overall survival (OS) of PSCC patients.

METHODS

We retrospectively enrolled 271 PSCC patients without distant metastasis from 2006 to 2021. Patients were divided into 2 cohorts by a 7:3 ratio-a training cohort (n = 191) and a validation cohort (n = 80). We performed cox regression analyses on the training cohort and constructed a nomogram to predict OS over 1, 3, and 5 years. Data from the validation cohort was used to validate the nomogram's predictive power.

RESULTS

According to Kaplan-Meier analysis, elevated CRP (P < .001), hypoalbuminemia (P = .008), higher CAR (P < .001), higher GPS score (P < .001), higher mGPS score (P < .001), and higher Hs-mGPS score (P = .015) were associated with a decreased overall survival. GPS score, along with age, pathology N stage, and grade, was found to be an independent risk factor for poor prognosis in the multivariate analysis. We constructed a nomogram based on the prespecified variables predicting 1-, 3- and 5-year OS. The C-indexes of the nomogram in the training and validation cohorts were 0.871 and 0.869, respectively. The decision curve analysis showed that the nomogram had a larger net benefit. The Kaplan-Meier curves showed significant differences between the risk groups categorized according to the nomogram (P < .001).

CONCLUSIONS

Inflammation biomarkers of systemic inflammation and nutritional status play an important role in individual OS predictions for PSCC patients without distant monitoring. The establishment of the nomogram provided a tool to predict the survival of 1-, 3-, and 5-year OS in PSCC patients without distant metastasis.

C-reactive protein to prealbumin ratio: a useful inflammatory and nutritional index for predicting prognosis after curative resection in esophageal squamous cell carcinoma patients

PURPOSE

Although C-reactive protein to prealbumin ratio (CPR) can predict the outcomes of several types of cancer surgeries, little is known about the implication of CPR in patients undergoing esophagectomy for esophageal squamous cell carcinoma (ESCC).

METHODS

Between 2009 and 2018, 682 consecutive ESCC patients who underwent curative esophagectomy were enrolled. The clinicopathological factors and prognoses were compared between the groups stratified by preoperative CPR levels. A logistic regression model was used to determine the risk factors of postoperative pneumonia. Survival curves were constructed using the Kaplan-Meier method and compared using the log-rank test. The Cox proportional hazards model was used to elucidate prognostic factors.

RESULTS

There were more elderly patients, more males, and more advanced clinical T and N categories in the high CPR group than in the low CPR group. Also, the incidence of postoperative pneumonia was significantly higher in the high CPR group than in the low CPR group (32.4% vs. 20.3%, p < 0.01). In multivariate analyses, high CPR was one of the independent predictive factors for postoperative pneumonia (OR, 1.71; 95% CI, 1.15-2.54; p < 0.03). Moreover, high CPR was an independent prognostic factor for overall, cancer-specific, and recurrence-free survivals (HR 1.62; 95% CI 1.18-2.23; p < 0.01, HR 1.57; 95% CI 1.08-2.32; p = 0.02, HR 1.42; 95% CI 1.06-1.90; p = 0.02).

CONCLUSION

Preoperative CPR was found to be a useful inflammatory and nutritional indicator for predicting the occurrence of pneumonia and prognosis in patients with ESCC undergoing esophagectomy.

Real-World Efficacy Data and Predictive Clinical Parameters for Treatment Outcomes in Advanced Esophageal Squamous Cell Carcinoma Treated with Immune Checkpoint Inhibitors

PURPOSE

This study aimed to evaluate the real-world efficacy of immune checkpoint inhibitors (ICIs), and to identify clinicolaboratory factors to predict treatment outcomes in patients with advanced esophageal squamous cell carcinoma (ESCC) receiving ICIs.

MATERIALS AND METHODS

Sixty patients with metastatic or unresectable ESCC treated with nivolumab (n=48) or pembrolizumab (n=12) as ≥ second-line treatment between 2016 and 2019 at Asan Medical Center were included.

RESULTS

The median age of the patients was 68 years (range, 52 to 76 years), and 93.3% were male. Most patients had metastatic disease (81.7%) and had been previously treated with fluoropyrimidines, platinum, and taxane. In 53 patients with measurable disease, the overall response rate and disease control rate were 15.1% and 35.8%, respectively. With a median follow-up duration of 16.0 months, the median progression-free survival (PFS) and overall survival (OS) were 1.9 months (95% confidence interval [CI], 1.54 to 2.19) and 6.4 months (95% CI, 4.77 to 8.11), respectively. After multivariate analysis, recent use of antibiotics, low prognostic nutrition index (< 35.93), high Glasgow Prognosis Score (≥ 1) at baseline, and ≥ 1.4-fold increase in neutrophil-to-lymphocyte ratio after one cycle from baseline were significantly unfavorable factors for both PFS and OS. Younger age (< 65 years) was a significant factor for unfavorable PFS and hyponatremia (< 135 mmol/L) for unfavorable OS.

CONCLUSION

The use of ICIs after the failure of chemotherapy showed comparable efficacy in patients with advanced ESCC in real practice; this may be associated with host immune-nutritional status, which could be predicted by clinical and routine laboratory factors.

C-Reactive Protein and C-Reactive Protein-Based Scores to Predict Survival in Esophageal and Junctional Adenocarcinoma: Systematic Review and Meta-Analysis

BACKGROUND

Esophageal adenocarcinoma (EAC) has a poor prognosis; predictive markers of prognosis would facilitate advances in personalized therapy. C-reactive protein (CRP) and CRP-based scores are increasingly recommended across oncology; however, their role and value in EAC is unclear. This systematic review and meta-analysis examined CRP cut-point and scores and how they may best be applied in predicting survival in EAC.

METHODS

A systematic literature search was conducted in EMBASE, Medline, Web of Science, Cochrane, Scopus and CINAHL databases, from inception to 1st October 2020. Studies reporting data from adults with EAC including adenocarcinoma of the gastro-esophageal junction (AEG), pre-treatment CRP or CRP-based score and Hazard Ratio (HR) for survival were included. QUIPS tool assessed risk of bias. Meta-analysis was undertaken.

RESULTS

A total of 819 records were screened. Eight papers were included, with data for 1475 people. CRP cut-points ranged from 2.8 to 10 mg/L. The Glasgow Prognostic Score (GPS) and modified GPS were the most commonly reported scores. On meta-analysis, elevated preoperative GPS/mGPS was significantly associated with worse overall survival (hazards ratio [HR] 1.81, 95% confidence interval [CI] 1.25-2.62, p = 0.002); results were similar in subgroup analyses of multimodal treatment, M0 disease, and R0 resection.

CONCLUSIONS

This is the first review to evaluate comprehensively the evidence for CRP and CRP-based scores in EAC. Meta-analysis demonstrated that elevated preoperative GPS or mGPS was significantly associated with reduced overall survival in EAC, including AEG. There is insufficient evidence to support use of CRP alone. Future studies should examine GPS/mGPS in EAC prospectively, alone and combined with other prognostic markers.

Meta-analysis of prognostic factors of overall survival in patients undergoing oesophagectomy for oesophageal cancer

INTRODUCTION

Currently, the American Joint Commission on Cancer (AJCC) staging system is used for prognostication for oesophageal cancer. However, several prognostically important factors have been reported but not incorporated. This meta-analysis aimed to characterize the impact of preoperative, operative, and oncological factors on the prognosis of patients undergoing curative resection for oesophageal cancer.

METHODS

This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling to determine pooled univariable hazard ratios (HRs). The study was prospectively registered with the PROSPERO database (Registration: CRD42018157966).

RESULTS

One-hundred and seventy-one articles including 73,629 patients were assessed quantitatively. Of the 122 factors associated with survival, 39 were significant on pooled analysis. Of these. the strongly associated prognostic factors were 'pathological' T stage (HR: 2.07, CI95%: 1.77-2.43, P < 0.001), 'pathological' N stage (HR: 2.24, CI95%: 1.95-2.59, P < 0.001), perineural invasion (HR: 1.54, CI95%: 1.36-1.74, P < 0.001), circumferential resection margin (HR: 2.17, CI95%: 1.82-2.59, P < 0.001), poor tumor grade (HR: 1.53, CI95%: 1.34-1.74, P < 0.001), and high neutrophil:lymphocyte ratio (HR: 1.47, CI95%: 1.30-1.66, P < 0.001).

CONCLUSION

Several tumor biological variables not included in the AJCC 8th edition classification can impact on overall survival. Incorporation and validation of these factors into prognostic models and next edition of the AJCC system will enable personalized approach to prognostication and treatment.

Gustave Roussy Immune Score (GRIm-Score) is a prognostic marker in patients with resectable esophageal squamous cell carcinoma

Background: The Gustave Roussy Immune Score (GRIm-Score) was initially reported to select patients for immunotherapy. Therefore, the purpose of the current retrospective study was to determine whether GRIm-Score, a novel nutritional and inflammatory-based prognostic score, is a useful prognostic marker in patients with esophageal squamous cell carcinoma (ESCC) undergoing surgical resection. Methods: A retrospective single institutional study including 372 ESCC patients undergoing surgical resection was performed. The GRIm-Score was simply calculated by lactate dehydrogenase (LDH), neutrophil lymphocyte ratio (NLR) and albumin (ALB). The cancer-specific survival (CSS) was analyzed for the current study with Cox regression analyses with forward stepwise and Kaplan-Meier methods. Results: There were 284 (76.3%) men and 88 (23.7%) women with the mean age of 59.3 ± 8.0 years (range: 36-80 years). Patient with a high GRIm-Score had poor CSS (10.3% vs. 35.0%, P < 0.001). The GRIm-Score, in multivariate analyses, instead of NLR, LDH or ALB, was an independent prognostic factor for CSS (P = 0.004). Conclusion: The GRIm-Score was an independent prognostic marker in patients with ESCC undergoing surgical resection. Our study is also the first study to discuss the prognostic value of GRIm-Score in patients with resectable ESCC.

Preoperative serum C-reactive protein levels and postoperative survival in patients with esophageal squamous cell carcinoma: a propensity score matching analysis

Objectives

This study tested the relationship between preoperative serum C-reactive protein (CRP) levels and cancer-specific prognosis in patients with esophageal squamous cell carcinoma who have undergone curative resection.

Methods

We conducted a retrospective study on 961 patients with esophageal squamous cell cancer who underwent curative esophagectomy from 2006 to 2012 at the Sun Yat-sen University Cancer Center. Preoperative serum CRP levels were determined, and a cutoff value of 5.0 mg/mL was established. Propensity score matching (PSM) was performed to reduce the selection bias between patients with low CRP (≤ 5.0 mg/mL) and those with high CRP (> 5.0 mg/mL) levels based on age, tumor-lymph node-metastasis (TNM) stage, and tumor grade. The prognostic value of preoperative CRP levels was determined using life table, Kaplan–Meier, and Cox proportional hazards analyzes.

Results

In the unmatched cohort, the 3-year and 5-year survival rates were 57 and 53%, respectively, in patients with high preoperative CRP levels (> 5.0 mg/mL) and 68 and 56%, respectively, in those with low preoperative CRP levels (≤ 5.0 mg/mL). The difference in the survival rates of the 2 groups was significant (p = 0.004). Univariate survival analysis revealed that the preoperative CRP levels, TNM stage, tumor grade, drinking history, and anastomosis method were prognostic factors for overall survival (OS). Before conducting PSM, the low-CRP group had a lower age (p = 0.001), lower histological grade (p = 0.086), and lower TNM stage (p = 0.254).

After PSM, 176 patients with low CRP levels and 176 of those with high CRP levels were enrolled in the analysis. In the matched cohort, the 3-year and 5-year survival rates were 56 and 50%, respectively, in patients with high preoperative CRP levels (> 5.0 mg/mL) and 68 and 56%, respectively, in those with low preoperative CRP levels (≤ 5.0 mg/mL). The difference in the survival rates between the low- and high-CRP groups was significant (p = 0.044). Multivariate analysis of the matched patients revealed that the TNM stage and preoperative CRP level were independent prognostic factors for OS.

Conclusions

A high preoperative CRP level (> 5.0 mg/mL) predicts worse survival prognosis in patients who have undergone curative resection for esophageal squamous cell cancer.

C-Reactive Protein to Prealbumin Ratio (CPR): A Novel Inflammatory-Nutritional Prognostic Factor for Predicting Cancer-Specific Survival (CSS) and Overall Survival (OS) in Patients with Resectable Esophageal Squamous Cell Carcinoma

Background

The inflammation and nutrition play an important role in prognosis. A novel index combined with inflammatory and nutritional biomarkers, named C-reactive protein (CRP) to prealbumin (PALB) ratio (CPR), was initially reported to predict the prognosis in resectable esophageal squamous cell carcinoma (ESCC).

Patients and Methods

A retrospective study was conducted including 346 resectable ESCC patients. The X-tile program was used to confirm the optimal cut-off value. The Kaplan-Meier methods and Cox regression analyses were performed to analyze the cancer-specific survival (CSS) and overall survival (OS).

Results

The optimum cut-off point was 0.03 for CPR. Patients with a high level of CPR (> 0.03) were associated with poor CSS (12.0% vs. 43.0%, P<0.001) and OS (11.2% vs. 40.7%, P<0.001). Multivariate analyses revealed that CPR was an independent predictor in resectable ESCC patients (CSS, P=0.008; OS, P=0.007).

Conclusion

This study, to the best of our knowledge, is the first to investigate prognostic role of CPR in patients with ESCC. Our retrospective observations indicate that CPR, with the optimal cut-off value of 0.03, is a useful potential predictor in resectable ESCC patients.

Esophageal cancer lymph node metastasis-associated gene signature optimizes overall survival prediction of esophageal cancer

Esophageal cancer (EC) is characteristic of early regional lymph node metastasis (LNM) and most patients with metastasis have a poor prognosis. However, the current diagnostic techniques do not enable precise differentiation of EC LNM, prognostic stratification, and individual survival estimation. To identify potential molecular biomarkers for EC patients with LNM, we explored differently expressed genes in The Cancer Genome Atlas database between 77 non-LNM cases and 88 LNM cases by limma package R. Then, according to univariate and multivariate Cox regression analyses, we constructed an 8-messenger RNA (mRNA) prognostic signature model, which could predict the outcome in a more exact way. The area under the curve of the risk score is significantly higher than other clinical information, indicating that the 8-mRNA-based risk score is a good indicator for prognosis. Then, combined with other individual risk factors, such as age, sex, T stage, M stage, etc, we could precisely calculate the individual 1-, 3-, and 5-year survival rates. The Gene Set Enrichment Analysis, Gene Ontology, and Kyoto Encyclopedia of Genes and Genomes analysis indicate that the risk model is mainly associated with cancer-related pathways, such as cell division, cellular meiosis, and cell cycle regulation. In summary, the 8-mRNA-based risk score model that we developed successfully predicts the survival of EC. It is independent of clinical information and performing better than other clinical information for prognosis.

A novel inflammation-based prognostic score for patients with esophageal squamous cell carcinoma: the c-reactive protein/prognostic nutritional index ratio

Background

Inflammation plays a critical role in cancer prognosis. In the current study, we proposed a novel inflammation-based prognostic score, named c-reactive protein/prognostic nutritional index ratio (CRP/PNI ratio), for predicting the prognosis for patients with resectable esophageal squamous cell carcinoma (ESCC).

Results

The optimal cut-off value was 0.10 for CRP/PNI ratio according to the ROC curve. Patients with CRP/PNI ratio ≤0.10 had a significantly better 5-year CSS compared to CRP/PNI ratio >0.10 (44.5% vs. 15.7%, P<0.001). On multivariate analyses, we revealed that CRP/PNI ratio was a significant predictive factor of CSS (P=0.009). A nomogram could be more accuracy for CSS. The Harrell's c-index for CSS prediction was 0.688.

Materials and Methods

A total of 308 patients with resectable ESCC were enrolled in this retrospective study. The optimal cuf-off value for CRP/PNI ratio was calculated by a receiver operating characteristic (ROC) curve. Kaplan-Meier methods were used to analyse the cancer-specific survival (CSS). Univariate and multivariate analyses were evaluated for CSS. A nomogram was also established to predict the prognosis for CSS.

Conclusion

The CRP/PNI ratio is a novel and useful prognostic score for CSS in patients with resectable ESCC.

Role of Postoperative C-Reactive Protein Levels in Predicting Prognosis After Surgical Treatment of Esophageal Cancer

BACKGROUND

Elevated preoperative serum C-reactive protein (CRP) levels are reportedly associated with a poor prognosis for patients with various types of malignant tumors. However, the impact of postoperative CRP levels on the prognosis of patients with esophageal cancer remains unknown. The present study aims to clarify the prognostic significance of postoperative CRP levels on the survival of patients with esophageal cancer.

METHODS

We reviewed the records of consecutive 202 patients with thoracic esophageal squamous cell carcinoma who underwent transthoracic esophagectomy. We measured serum CRP levels on postoperative days (PODs) 1, 2, 3, 5 and 7 and evaluated the relationships between postoperative CRP levels and survival.

RESULTS

The findings of Cox regression analyses suggested that elevated CRP levels on POD 3, 5 and 7 were associated with poor recurrence-free survival (RFS). We divided CRP levels on POD 7 into three tertiles and found that RFS could be clearly stratified, being the poorest (p < 0.001) in the highest tertile (high CRP). The trend was similar even in patients with or without infectious complications and with or without advanced pathological stage. Multivariate analysis showed that pathologically advanced stage (Hazard ratio [HR], 5.14; 95% confidence interval [CI] 2.67-9.87; p < 0.001) and high CRP (HR, 2.27; 95% CI 1.3-3.96; p = 0.004) were independent predictors of RFS.

CONCLUSION

Postoperative CRP levels could predict the prognosis of patients with esophageal cancer. We propose that the clinical course of postoperative CRP level should be carefully monitored as a predictor of survival.

A novel inflammation-based prognostic index for patients with esophageal squamous cell carcinoma: neutrophil lymphocyte ratio/albumin ratio

Background

We initially proposed a novel inflammation-based prognostic index, named neutrophil lymphocyte ratio/albumin ratio (NLR/Alb), for predicting the postoperative survival in esophageal squamous cell carcinoma (ESCC).

Materials and methods

A retrospective study of 329 cases with resectable ESCC was included. The optimal cut-off values were evaluated by X-tile program. The 5-year cancer-specific survival (CSS) was calculated by Kaplan–Meier method. Cox regression analyses were performed to evaluate the prognostic factors.

Results

The optimal cut-off value was 0.1 for NLR/Alb according to the X-tile program. There was a significantly better 5-year CSS in patients with NLR/Alb ≤ 0.1 than patients with NLR/Alb > 0.1 (39.1% vs. 11.0%, P < 0.001). According to multivariate analyses, NLR/Alb (P = 0.001) was an independent prognostic factor.

Conclusions

The NLR/Alb is a novel and usefull predictive factor in patients with ESCC.

The Surgical Apgar Score Predicts Not Only Short-Term Complications But Also Long-Term Prognosis After Esophagectomy

BACKGROUND

The surgical Apgar score (SAS) quantifies three intraoperative factors and predicts postoperative complications, but few reports describe its usefulness in esophagectomy, and no studies to date show its correlation with long-term prognosis after esophagectomy.

METHODS

This study investigated 400 cases in which esophagectomy was performed on esophageal malignant tumors at the authors' hospital from January 2007 to January 2017. In this study, SAS was defined as the sum of the scores of three parameters, namely, estimated blood loss, lowest mean arterial pressure, and lowest heart rate, with values extracted from medical records. Postoperative complications classified as Clavien-Dindo grade 3 or higher were also extracted. The study retrospectively compared the relationship of SAS to postoperative complications and survival.

RESULTS

Univariate analysis showed that postoperative complications were significantly associated with hypertension (p = 0.017), thoracotomy (p = 0.012), and SAS ≤ 5 (p < 0.0001), and multivariate analysis showed that hypertension (p = 0.049) and SAS ≤ 5 (p < 0.0001) were significant predictive factors for complications. In the prognostic analysis, log-rank analysis showed that patients with an SAS ≤ 5 had a significantly poorer prognosis than those with a SAS > 5 (p = 0.043), especially for complications classified as clinical stage 2 or higher (p = 0.027). In the multivariate analysis, SAS ≤ 5 was identified as a significantly poor prognostic factor for complications classified as clinical stage 2 or higher (p = 0.029).

CONCLUSION

In this study, SAS was useful not only for predicting short-term complications, but also as a long-term prognostic factor after esophagectomy.

Combination of c-reactive protein and squamous cell carcinoma antigen in predicting postoperative prognosis for patients with squamous cell carcinoma of the esophagus

Background

We initially proposed a useful and novel prognostic model, named CCS [Combination of c-reactive protein (CRP) and squamous cell carcinoma antigen (SCC)], for predicting the postoperative survival in patients with esophageal squamous cell carcinoma (ESCC).

Methods

Two hundred and fifty-two patients with resectable ESCC were included in this retrospective study. A logistic regression was performed and yielded a logistic equation. The CCS was calculated by the combined CRP and SCC. The optimal cut-off value for CCS was evaluated by X-tile program. Univariate and multivariate analyses were used to evaluate the predictive factors. In addition, a novel nomogram model was also performed to predict the prognosis for patients with ESCC.

Results

In the current study, CCS was calculated as CRP+6.33 SCC according to the logistic equation. The optimal cut-off value was 15.8 for CCS according to the X-tile program. Kaplan-Meier analyses demonstrated that high CCS group had a significantly poor 5-year cancer-specific survival (CSS) than low CCS group (10.3% vs. 47.3%, P <0.001). According to multivariate analyses, CCS (P =0.004), but not CRP (P =0.466) or SCC (P =0.926), was an independent prognostic factor. A nomogram could be more accuracy for CSS (Harrell's c-index: 0.70).

Conclusion

The CCS is a usefull and independent predictive factor in patients with ESCC.

Significance of blood neutrophil-to-lymphocyte ratio for prognostic stratification of patients with gastroesophageal junction adenocarcinoma in the era of the 8th edition of the American Joint Committee on Cancer (AJCC8) staging

The prognosis of patients with gastroesophageal junction (GOJ) adenocarcinoma depends mainly on the clinical staging, as described by the new AJCC8 (American Joint Committee on Cancer 8th edition). Evidence suggests that peripheral blood neutrophil-to-lymphocyte ratio (NLR) may be of prognostic significance in patients with upper gastrointestinal cancers. We examined the prognostic significance of NLR in the era of the new AJCC8 staging system. In this single-centre cohort study, retrospective data on patients with operable GOJ adenocarcinoma treated with perioperative chemotherapy were analysed. The prognostic significance of baseline NLR in combination with AJCC8 clinical staging and other patient characteristics was examined for both time-to-progression (TTP) and overall survival (OS). Of 316 patients, 245 (77.5%) underwent radical surgery. Fifty-one patients (16.2%) developed unresectable disease due to early disease progression. NLR was the only baseline factor independently associated with the development of early disease progression. AJCC8 clinical staging was significantly associated with TTP and OS. In addition, NLR ≥ 3 was predictive of poorer TTP (p = 0.001) and OS (p = 0.002), confirmed in multivariate Cox-regression analysis. NLR ≥ 3 was prognostic, especially in patients with clinical stage III for TTP (p = 0.006) and OS (p = 0.025) and in patients with clinical stage IVA for OS (p = 0.017). NLR significantly improved the prognostic classification of patients by different AJCC8 clinical stages, with a c-index improved from 0.554 to 0.592 (p < 0.001). NLR was confirmed to be an independent prognostic factor in this cohort and could be used in combination with AJCC8 clinical staging to improve the baseline prognostic stratification of patients with newly diagnosed resectable GOJ adenocarcinoma.

Impact of Neoadjuvant Chemoradiation on Short-Term Outcomes for Esophageal Squamous Cell Carcinoma Patients: A Meta-analysis

BACKGROUND

Neoadjuvant chemoradiation (NCRT) has emerged as a component of the standard treatment for esophageal squamous cell carcinoma (SCC). The primary benefit of NCRT is an improvement in long-term survival; however, the impact of NCRT on short-term outcomes is unclear.

METHODS

A comprehensive electronic literature search was performed via the MEDLINE (PubMed), Cochrane Library, and Google Scholar databases through November 2015 for the inclusion of randomized controlled trials (RCTs) that evaluated short-term outcomes of patients administered NCRT followed by surgery compared with surgery alone for resectable esophageal SCC. The main outcome measures were postoperative mortality and morbidity. A meta-analysis was performed using random-effects models to calculate odds ratios (ORs) with 95 % confidence intervals (CIs).

RESULTS

Eight RCTs were included, for a total of 1058 patients. Meta-analysis of the overall postoperative mortality and cardiopulmonary complication rates showed that there was a significant increase for patients administered NCRT followed by surgery compared with surgery alone (OR 1.87, 95 % CI 1.07-3.28, p = 0.03, number of patients needed to harm = 33.3; and OR 2.12, 95 % CI 1.03-4.35, p = 0.04, respectively). Dropout before surgery was higher for patients in the NCRT followed by surgery group compared with patients in the surgery-alone group. NCRT has no statistically impact on anastomosis and other complications compared with surgery alone.

CONCLUSIONS

NCRT for esophageal SCC significantly increases postoperative mortality and cardiopulmonary complications.

Association between the inflammatory biomarker, C-reactive protein, and the response to radiochemotherapy in patients with esophageal cancer

Locally advanced esophageal cancer has been treated by a multimodality regimen encompassing combined radiochemotherapy (RCT). The tumor response to neoadjuvant RCT is a major determinant of further therapeutic strategies, whether surgery or a continuation of RCT, and therefore, also of the patient's overall prognosis. The present study included patients with histologically proven squamous cell esophageal carcinoma. The C-reactive protein (CRP) level was measured prior to and following the completion of neoadjuvant RCT. Only CRP measurements taken within 2 weeks of the start of RCT were analyzed. Further measurements were then taken at 6, 12, 18, 24, 30, 36 and 40 weeks following RCT. CRP levels were high prior to treatment; however, eventually decreased and normalized following the therapy. In univariate analysis, pre-therapeutic CRP levels had a significant influence on the response rate (P=0.033), whilst post-therapeutic CRP levels had no significant influence (P=0.383). Pre-therapeutic CRP levels, however, not post-therapeutic CRP levels were significantly correlated with the response rate (P=0.045 and P=0.444, respectively), and no association was observed between CRP levels and survival. This preliminary data indicated that the pre-therapeutic serum CRP level is a possible indicator of treatment response to RCT.

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.

The combination of preoperative serum C-reactive protein and carcinoembryonic antigen is a useful prognostic factor in patients with esophageal squamous cell carcinoma: a combined ROC analysis

Background

The prognostic value of inflammatory index in esophageal cancer (EC) has not been established. In the present study, therefore, we initially evaluated a novel prognostic system, named the COCC (COmbination of C-reactive protein [CRP] and carcinoembryonic antigen [CEA]), for making a prognosis in patients with esophageal squamous cell carcinoma (ESCC).

Methods

A total of 327 patients with ESCC between January 2006 and December 2008 were included in this retrospective study. The COCC was calculated by combined CRP and CEA according to the logistic equation. The Kaplan–Meier method was used to calculate the cancer-specific survival (CSS), and the difference was assessed by the log-rank test. Cox regression analyses were performed to evaluate the prognostic factors.

Results

In our study, COCC was defined as CRP +0.71 CEA according to the logistic equation. Receiver operating characteristic curves for CSS prediction were plotted to verify the optimum cutoff points for CRP, CEA, and COCC, which were 9.8 mg/L, 4.2 ng/mL, and 8.0, respectively. Patients with COCC ≤8.0 had a significantly better CSS than patients with COCC >8.0 (53.1% vs 15.3%, P<0.001). Multivariate analysis revealed that COCC was an independent prognostic factor in patients with ESCC (P=0.006). In addition, the area under the curve (AUC) was 0.722 for COCC, 0.645 for CRP, and 0.618 for CEA, indicating that COCC was superior to CRP or CEA for CSS prediction.

Conclusion

The COCC is an independent prognostic factor in patients with ESCC. We conclude that COCC was superior to CRP or CEA as a more precise prognostic factor in patients with ESCC.

Prognostic role of serum C-reactive protein in esophageal cancer: a systematic review and meta-analysis

Background

Recent studies have shown that C-reactive protein (CRP) is a useful predictive factor in several cancers; however, its role in esophageal cancer (EC) is controversial.

Methods

A systematic literature search was performed using Medline, PubMed, and Web of Science to analyze the prognostic value of serum CRP in patients with EC. A meta-analysis was performed to assess the association between serum CRP and overall survival (OS) in patients with EC.

Results

A total of eight studies involving 1,471 patients were included in our study. Our pooled results demonstrated that a high level of serum CRP was associated with poor OS (hazard ratio [HR]: 1.40, 95% confidence interval [CI]: 1.25–1.57, I²=81.3%, P<0.0001). Subgroup analyses were performed in further investigations. When the patients were segregated according to treatment, pathological type, and cut-off level, high levels of serum CRP were found to be significantly correlated with OS.

Conclusion

Our meta-analysis revealed that high levels of serum CRP were significantly associated with poor OS in patients with EC.

Systematic review and meta-analysis of tumor biomarkers in predicting prognosis in esophageal cancer

BACKGROUND

Esophageal cancer (EC) is a frequently occurring cancer with poor prognosis despite combined therapeutic strategies. Many biomarkers have been proposed as predictors of adverse events. We sought to assess the prognostic value of biomarkers in predicting the overall survival of esophageal cancer and to help guide personalized cancer treatment to give patients the best chance at remission.

METHODS

We conducted a systematic review and meta-analysis of the published literature to summarize evidence for the discriminatory ability of prognostic biomarkers for esophageal cancer. Relevant literature was identified using the PubMed database on April 11, 2012, and conformed to the REMARK criteria. The primary endpoint was overall survival and data were synthesized with hazard ratios (HRs).

RESULTS

We included 109 studies, exploring 13 different biomarkers, which were subjected to quantitative meta-analysis. Promising markers that emerged for the prediction of overall survival in esophageal squamous cell cancer included VEGF (18 eligible studies, n=1476, HR=1.85, 95% CI, 1.55-2.21), cyclin D1 (12 eligible studies, n=1476, HR=1.82, 95% CI, 1.50-2.20), Ki-67 (3 eligible studies, n=308, HR=1.11, 95% CI, 0.70-1.78) and squamous cell carcinoma antigen (5 eligible studies, n=700, HR=1.28, 95% CI, 0.97-1.69); prognostic markers for esophageal adenocarcinoma included COX-2 (2 eligible studies, n=235, HR=3.06, 95% CI, 2.01-4.65) and HER-2 (3 eligible studies, n=291, HR=2.15, 95% CI, 1.39-3.33); prognostic markers for uncategorized ECs included p21 (9 eligible studies, n=858, HR=1.27, 95% CI, 0.75-2.16), p53 (31 eligible studies, n=2851, HR=1.34, 95% CI, 1.21-1.48), CRP (8 eligible studies, n=1382, HR=2.65, 95% CI, 1.64-4.27) and hemoglobin (5 eligible studies, n=544, HR=0.91, 95% CI, 0.83-1.00).

CONCLUSIONS

Although some modest bias cannot be excluded, this review supports the involvement of biomarkers to be associated with EC overall survival.

Combination of neutrophil lymphocyte ratio and platelet lymphocyte ratio is a useful predictor of postoperative survival in patients with esophageal squamous cell carcinoma

Background

Recent studies have shown that the presence of systemic inflammation correlates with poor survival in various types of cancers. This study investigated the usefulness of a novel inflammation-based prognostic system, using the combination of neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR), collectively named the CNP, for predicting survival in patients with esophageal squamous cell carcinoma (ESCC).

Materials and methods

The CNP was calculated on the basis of data obtained on the day of admission: patients with both elevated NLR (>3.45) and PLR (>166.5) were allocated a score of 2, and patients showing one or neither were allocated a score of 1 or 0, respectively.

Results

The CNP was associated with tumor length (P<0.001), differentiation (P=0.021), depth of invasion (P<0.001), and nodal metastasis (P<0.001). No significant differences were found between the CNP and morbidity. However, significant differences were found between the CNP and mortality (P,0.001). The overall survival in the CNP 0, CNP 1, and CNP 2 groups were 63.4%, 50.0%, and 20.2%, respectively (CNP 0 versus CNP 1, P=0.014; CNP 1 versus CNP 2, P<0.001). Multivariate analyses showed that CNP was a significant predictor of overall survival. CNP 1–2 had a hazard ratio (HR) of 1.964 (95% confidence interval [CI]: 1.371–2.814, P<0.001) for overall survival. CNP (HR =1.964, P<0.001) is superior to NLR (HR =1.310, P=0.053) or PLR (HR =1.751, P<0.001) as a predictive factor.

Conclusion

The CNP is considered a useful predictor of postoperative survival in patients with ESCC. The CNP is superior to NLR or PLR as a predictive factor in patients with ESCC.

Preoperative level of serum amyloid A is superior to C-reactive protein in the prognosis of esophageal squamous cell carcinoma

Preoperative elevations in the levels of serum amyloid A (SAA) or C-reactive protein (CRP) have been reported to be prognostic indicators in several malignancies. The aim of this study is to evaluate the serum levels of SAA and CRP in the prognosis of esophageal squamous cell carcinoma (ESCC). In total, 252 patients with ESCC who had undergone surgery with curative-intent were retrospectively recruited. The specificity, sensitivity, and prognostic value of SAA or CRP levels were measured as the area under the receiver operating characteristic (ROC) curve (AUC). The clinical value of SAA and CRP levels as prognostic indicators was evaluated using Cox's proportional hazards model. The 1-, 3-, and 5-year overall survival (OS) rates for the entire cohort of patients with ESCC were 71.0%, 61.0%, and 43.0%, respectively. The correlation between the levels of SAA and CRP was significant (r(2) = 0. 685, P < 0.001). The ROC analysis showed that the levels of CRP were associated with a significantly lower overall accuracy than were the SAA levels (AUC, 0.615 vs. 0.880; P < 0.001). For the complete cohort, the median OS was 52.0 months longer in patients with low preoperative serum levels of SAA (72.0 months) compared with patients who had high SAA levels (20.0 months, P < 0.001). The median OS among patients with low CRP levels was also longer compared with the patients who had high CRP levels (72.0 vs. 51.0 months, respectively; P < 0.001). Subgroup analyses showed that the preoperative elevated levels of SAA could find significant differences in OS for stage I, stage II, and stage III (P < 0.001, P = 0.001, and P < 0.001, respectively), whereas the increased levels of CRP could only find a difference in OS for stage II cancers. After a multivariate analysis, preoperative elevated level of SAA was found to be an independently and significant prognostic factor (P < 0.001). Our study indicates that the preoperative levels of SAA and CRP can act as prognostic factors, and that elevated levels of these proteins are associated with negative effects on the survival of patients with ESCC. SAA showed a higher prognostic value than CRP in both cohort and subgroup analysis.

Soluble interleukin-6 receptor is a serum biomarker for the response of esophageal carcinoma to neoadjuvant chemoradiotherapy

Preoperative chemoradiotherapy has been shown to improve the outcome of patients with esophageal cancer, but because response to this therapy varies, it is desirable to identify in advance individuals who would be unlikely to benefit, in order to avoid unnecessary adverse drug effects. The serum profiles of 84 cytokines and related proteins were determined in 37 patients with esophageal squamous cell carcinoma who received identical neoadjuvant preoperative chemoradiotherapy regimens and underwent surgical resection. Histological response to this therapy was assessed in surgically resected specimens. The serum soluble interleukin-6 receptor (sIL6R) level was significantly higher in 30 patients who failed to achieve a histological complete response (P = 0.005). Multivariate analysis revealed that the increased level of sIL6R was one of several significant independent predictors of an unfavorable outcome (hazard ratio, 2.87; P = 0.017). The increased level of this cytokine in patients who did not obtain a complete response was reproducibly observed in an independent cohort of 34 patients. Esophageal squamous cell carcinoma patients with an increased serum level of sIL6R are predicted to respond poorly to preoperative chemoradiotherapy, therefore, their exclusion from this treatment may be considered. Persistent systemic inflammation is implicated as a possible mechanism of resistance to this therapy.

Comparative evaluation of serum C-reactive protein (CRP) levels in the different histological subtypes of esophageal cancer (squamous cell carcinoma and adenocarcinoma of esophagus)

Elevated C-reactive protein (CRP) levels have been found in patients with several malignancies. The aim of the present study was to analyze the diagnostic and prognostic values of CRP levels measurement in esophageal cancer (EC) patients in relation to its different histological subtypes (squamous cell carcinoma-ESCC and adenocarcinoma-AC of esophagus) and compared them with classic tumor markers-carcinoembryonic antigen (CEA) and squamous cell cancer antigen (SCC-Ag). The diagnostic sensitivity, specificity, and the areas under receiver operating characteristic curves (AUC) for all the proteins tested were defined. Serum CRP levels were statistically higher in EC, ESCC, and AC patients compared to healthy subjects and significantly increased in EC and ESCC patients with the presence of lymph node and distant metastases. The percentage of elevated CRP results in all the analyzed subgroups (EC, ESCC, and AC) was higher than CEA and SCC-Ag, similarly as AUC for CRP in comparison to SCC-Ag. Serum CRP level was a significant predictor of EC and ESCC patients' survival in univariate analysis. In conclusion, these results indicate that CRP can be used as an adjunct in evaluating the tumor markers-CEA and SCC-Ag and may improve the clinical diagnosis and follow-up of EC patients, especially for ESCC subgroup.

Pretreatment serum C-reactive protein levels predict benefit from multimodality treatment including radical surgery in malignant pleural mesothelioma: a retrospective multicenter analysis

OBJECTIVE

To evaluate the prognostic and predictive relevance of pretreatment serum C-reactive protein (CRP) in malignant pleural mesothelioma (MPM) patients.

BACKGROUND

MPM is a rare but aggressive disease with poor treatment outcome. Therapeutic decision is challenging, and predictive biomarkers for better treatment stratification are urgently needed.

METHODS

Clinical data, including survival and pretreatment CRP levels, were retrospectively collected from 115 patients with histologically proven MPM. Patients with any evidence for infectious disease were excluded. The association between CRP levels and survival was analyzed using Cox models adjusted for clinical and pathological factors.

RESULTS

Median pretreatment CRP of all patients was 1.19 mg/dL (range: 0.00-22.62 mg/dL). Patients with elevated CRP levels (≥1 mg/dL; n = 62, 53.9%) had a significantly shorter overall survival compared with those with normal CRP (hazard ratio [HR] 2.81, 95% confidence interval [CI] 1.82-4.33; P < 0.001). In multivariate survival analyses, elevated CRP was confirmed as an independent prognostic factor in MPM (HR 2.07, 95% CI 1.23-3.46; P = 0.01). Most interestingly, we observed a significant interaction between CRP and treatment modality (P < 0.001). Among patients with normal CRP levels, radical tumor resection within multimodality therapy was associated with distinctly prolonged overall survival when compared with treatment protocols without surgery (HR 7.26, 95% CI 3.40-15.49; P < 0.001). In contrast among patients with elevated CRP, no survival benefit was achieved by radical surgery within multimodality approaches (HR 0.911, 95% CI 0.53-1.58; P = 0.74).

CONCLUSIONS

Our results suggest that multimodality regimens including radical resection increase survival selectively in MPM patients with normal pretreatment serum CRP levels.

Inflammation-based prognostic score predicts survival in patients with advanced gastric cancer receiving biweekly docetaxel and s-1 combination chemotherapy

OBJECTIVES

This study was conducted to determine the prognostic value of the Glasgow Prognostic Score (GPS), an inflammation-based prognostic score composed of C-reactive protein and albumin, for patients with advanced cancer.

METHODS

A total of 83 advanced gastric cancer patients receiving biweekly docetaxel/S-1 treatment (DS) were included in the study. To identify the value of GPS as prognostic factor for disease-specific survival (DSS) and progression-free survival (PFS), univariate and multivariate analyses were performed.

RESULTS

Unresectable tumors were observed in 78 patients and recurrent tumors were detected in 5 patients. Of these, 12 patients underwent gastrectomy. There were significant correlations between the GPS and the neutrophil/lymphocyte ratio. Univariate analysis revealed that the GPS, Eastern Cooperative Oncology Group performance status and gastrectomy after DS treatment significantly affected prognosis. Multivariate analysis showed that the GPS, age and gastrectomy independently influenced DSS, and that the GPS and gastrectomy also influenced PFS. Multivariate analysis restricted to patients without gastrectomy showed that the GPS and age independently affected DSS, and that the GPS influenced PFS.

CONCLUSION

In the low GPS group, it may be possible to obtain favorable outcomes by chemotherapy in advanced gastric cancer patients. However, a well-designed prospective trial in a large patient cohort is required to corroborate the prognostic value of the GPS.

Prognostic value of an inflammation-based score in patients undergoing pre-operative chemotherapy followed by surgery for esophageal cancer

Recent studies have shown that the presence of systemic inflammation is associated with poor outcome in patients with malignancy. However, whether systemic inflammation affects the response to pre-operative therapy and survival of patients undergoing multimodal treatment for esophageal cancer is not clear. We studied 152 patients who underwent pre-operative chemotherapy followed by surgery for esophageal cancer. The correlation between various clinicopathological factors, including hematological markers of systemic inflammatory response, and survival or response to chemotherapy was examined. Among various hematological factors, leucocyte count, hemoglobin level, albumin level, neutrophil-lymphocyte ratio and CEA, but not serum concentration of C-reactive protein, were significantly associated with survival. Multivariate analysis revealed that the clinical response to chemotherapy, number of metastatic lymph nodes, operative complications and systemic inflammation score (SI score), comprising leucocyte count, albumin and hemoglobin levels, were independent prognostic factors, and identified the SI score as the most significant prognostic factor. There was no significant relationship between hematological markers of systemic inflammation, including the SI score, and the response to chemotherapy. In conclusion, in patients scheduled for chemotherapy followed by surgery for esophageal cancer, systemic inflammation, reflected by SI, predicts poor outcome, but not the response to chemotherapy.

C-reactive protein levels: a prognostic marker for patients with head and neck cancer?

Background

Recent advances in understanding complex tumor interactions have led to the discovery of an association between inflammation and cancer, in particular for colon and lung cancer, but only a very few have dealt with oral cancer. Therefore, the aim of the current study was to investigate the significance of preoperative C-reactive protein (CRP) levels as a parameter for development of lymph node metastases or recurrence.

Materials and methods

In 278 patients with oral cancer, preoperative CRP levels were compared with development of recurrence and metastasis.

Results

In 27 patients from the normal CRP group, and in 21 patients from the elevated CRP group, local recurrence was observed. Concerning lymph node metastases, 37 patients were in the normal group and 9 patients in the elevated CRP group. No significant correlation could be found between elevated CRP levels and metastasis (p = 0.468) or recurrence (p = 0.137).

Conclusion

Our findings do not appear to support a correlation between preoperative CRP levels and development of recurrence or metastases. In further studies, CRP levels in precancerous lesions and in Human Papilloma Virus (HPV) positive patients with oral squamous cell carcinoma (SCC) should be studied.