The Influence of Body Mass Index on Overall Survival Following Surgical Resection of Non-Small Cell Lung Cancer

A prediction model based on high serum SH2B1 in patients with non-small cell lung cancer

BACKGROUND

Identifying a specific biomarker will facilitate the diagnosis and prediction of non-small cell lung cancer (NSCLC). The aim of this study was to investigate the serum SH2B1 in patients with NSCLC and healthy volunteers and establish a novel prediction model.

METHODS

A total 103 NSCLC patients and 108 healthy volunteers were selected from December 2019 to December 2020. Their serum and important clinical data were collected. Serum SH2B1 concentration was determined by ELISA. A novel prediction model for NSCLC was established according to these significant factors.

RESULTS

Multivariate logistic regression analysis indicated that the chronic pulmonary diseases; NLR ≥ 2.07; hemoglobin level ≥ 136.56 g/L; albumin level ≥ 42.59 g/L and serum SH2B1 concentration ≥615.28 pg/mL were considered as statistically significant difference (p < 0.05). A comprehensive nomogram was established based on serum SH2B1 concentration combined with significant clinical indicators to predict an individual's probability of NSCLC.

CONCLUSION

The serum SH2B1 concentration ≥ 615.28 pg/mL is a significant predictive factor for NSCLC. Significantly, the prediction model based on serum SH2B1 has good stability and accuracy, which provides new insights of prediction assessment for NSCLC.

Thiazolidinedione enhances the efficacy of anti-PD-1 monoclonal antibody in murine melanoma

Several clinical studies observed a surprising beneficial effect of obesity on enhancing immunotherapy responsiveness in patients with melanoma, highlighting an as-yet insufficiently understood relationship between metabolism and immunogenicity. Here, we demonstrate that the thiazolidinedione (TZD) rosiglitazone, a drug commonly used to treat diabetes by sequestering fatty acids in metabolically inert subcutaneous adipose tissue, improved sensitivity to anti-programmed cell death protein 1 (PD-1) treatment in YUMMER1.7 tumor-bearing mice, an initially immunotherapy-sensitive murine melanoma model. We observed a transition from high to intermediate PD-1 expression in tumor-infiltrating CD8+ T cells. Moreover, TZD inhibited PD-1 expression in mouse and human T cells treated in vitro. In addition to its direct impact on immune cells, TZD also decreased circulating insulin concentrations, while insulin induced T cell exhaustion in culture. In TZD-treated mice, we observed higher fatty acid concentrations in the tumor microenvironment, with fatty acids protecting against exhaustion in culture. Together, these data are consistent with an indirect mechanism of TZD inhibiting T cell exhaustion. Finally, we analyzed imaging data from patients with melanoma before and after anti-PD-1 treatment, confirming the beneficial effect of increased subcutaneous fat on anti-PD-1 responsiveness in patients. We also found that the expression of peroxisome proliferator-activated receptor gamma (PPARγ), the canonical activator of lipid uptake and adipogenesis activated by TZD, correlated with overall survival time. Taken together, these data identify a new adjuvant to enhance immunotherapy efficacy in YUMMER1.7 melanoma mice, and discover a new metabolism-based prognostic marker in human melanoma.NEW & NOTEWORTHY Zhang et al. demonstrate that the diabetes drug rosiglitazone improves the efficacy of immunotherapy in mouse melanoma. This effect is both direct and indirect: TZD directly reduces PD-1 expression in CD8+ T cells (i.e., reduces exhaustion), and indirectly reduces exhaustion by lowering insulin levels and increasing local fat. Finally, they demonstrate that hallmarks of TZD action (such as PPARγ expression and subcutaneous fat content) correlate with improved immunotherapy efficacy in humans with melanoma.

Cardiorespiratory fitness and BMI measured in youth and 5-year mortality after site-specific cancer diagnoses in men-A population-based cohort study with register linkage

BACKGROUND

Our aim was to assess associations between cardiorespiratory fitness (CRF) and body mass index (BMI) in youth and 5-year mortality after site-specific cancer diagnoses in men.

METHODS

Men with cancer from a population who underwent military conscription at ages 16-25 during 1968-2005 in Sweden were included. CRF was assessed as maximal aerobic workload on a cycle ergometer test and was classified as low, moderate, or high. BMI (kg/m2 ) was classified as underweight (<18.5), normal weight (18.5-24.9), overweight (25-29.9), or obesity (>30). Conscription data were linked with register data on cancer diagnosis and mortality. Analyses included CRF, BMI, date of diagnosis, and age, year, and center for conscription.

RESULTS

A total of 84,621 cancer cases were included. Mean age at diagnosis was 52 years. Follow-up data were available during a mean of 6.5 years. There were linear protective associations between CRF and mortality after any cancer diagnosis (hazard ratio [HR] for high vs. low CRF 0.70), malignant skin cancer (HR 0.80), non-Hodgkin lymphoma (HR 0.78), and cancer in the lungs (HR 0.80), head and neck (HR 0.68), pancreas (HR 0.83), stomach (HR 0.78), liver (HR 0.84), rectum (HR 0.79), and bladder (HR 0.71). Overweight and/or obesity were associated with increased mortality after any cancer (HR for obesity vs. normal weight 1.89), malignant skin cancer (HR 2.03), Hodgkin lymphoma (HR 2.86) and cancer in the head and neck (HR 1.38), thyroid (HR 3.04), rectum (HR 1.53), kidney (HR 1.90), bladder (HR 2.10), and prostate (HR 2.44).

CONCLUSION

We report dose-dependent associations between CRF and BMI in youth and mortality after site-specific cancer diagnoses in men. The associations with mortality could be due to both cancer inhibition and an improved tolerance to withstand cancer treatment. These results strengthen the incentive for public health efforts aimed at establishing a high CRF and normal weight in youth.

Treatment and mortality risk of older adults with non-small cell cancer in Taiwan: A population-based cohort study

BACKGROUND

Older patients tend to have decreased physical functions and more comorbidities than younger patients. At present, the best management for very elderly patients with lung cancer is not known. In this study, we aimed to investigate treatment and mortality risk of older adults with non-small cell cancer (NSCLC) in Taiwan.

METHODS

This study analyzed data from the Taiwan Cancer Registry database. Patients aged ≥80 years with newly diagnosed NSCLC between 2010 and 2017 were included. Treatment options were categorized as curative, palliative, and no treatment. Patients were followed up until death or December 31, 2020. Univariable and multivariable Cox proportional hazards models were used to estimate mortality risk, and Kaplan-Meier survival curves were drawn.

RESULTS

A total of 11 941 patients, aged ≥80 years, with newly diagnosed NSCLC between 2010 and 2017 were identified from the Taiwan Cancer Registry and followed up until 2020. The mean age was 84.4 ± 3.7 years old, and 7468 (62.54%) were men. The Kaplan-Meier survival curves showed significant differences across the three treatment options (log-rank p < 0.001). Results from multivariate Cox regression demonstrated that patients on palliative treatment (adjusted HR: 0.52, 95% CI: 0.48-0.56, p < 0.001) and curative treatment (adjusted HR: 0.45, 95% CI: 0.42-0.48, p < 0.001) had a significantly lower mortality risk than those with no treatment. The subgroup analyses stratified by cancer stages also showed consistent findings.

CONCLUSION

Elderly patients with NSCLC had significantly decreased mortality risk when receiving curative or palliative treatment compared with those without treatment. In the future, further studies are warranted to investigate complications and quality of life of elderly patients with NSCLC during palliative or curative treatment.

Survival and prognostic factors of early-stage non-small cell lung cancer in Central and Eastern Europe: A prospective cohort study

BACKGROUND

Although early diagnosis and surgical resection of the tumor have been shown to be the most important predictors of lung cancer survival, long-term survival for surgically-resected early-stage lung cancer remains poor.

AIMS

In this prospective study we aimed to investigate the survival and prognostic factors of surgically-resected early-stage non-small cell lung cancer (NSCLC) in Central and Eastern Europe.

METHODS

We recruited 2052 patients with stage I-IIIA NSCLC from 9 centers in Russia, Poland, Serbia, Czech Republic, and Romania, between 2007-2016 and followed them annually through 2020.

RESULTS

During follow-up, there were 1121 deaths (including 730 cancer-specific deaths). Median survival time was 4.9 years, and the 5-year overall survival was 49.5%. In the multivariable model, mortality was increased among older individuals (HR for each 10-year increase: 1.31 [95% CI: 1.21-1.42]), males (HR:1.24 [1.04-1.49]), participants with significant weight loss (HR:1.25 [1.03-1.52]), current smokers (HR:1.30 [1.04-1.62]), alcohol drinkers (HR:1.22 [1.03-1.44]), and those with higher stage tumors (HR stage IIIA vs. I: 5.54 [4.10 - 7.48]). However, education, chronic obstructive pulmonary diseases (COPD), and tumor histology were not associated with risk of death. All baseline indicators of smoking and alcohol drinking showed a dose-dependent association with the risk of cancer-specific mortality. This included pack-years of cigarettes smoked (p-trend = 0.04), quantity of smoking (p-trend = 0.008), years of smoking (p-trend = 0.010), gram-days of alcohol drank (p-trend = 0.002), frequency of drinking (p-trend = 0.006), and years of drinking (p-trend = 0.016).

CONCLUSION

This study shows that the 5-year survival rate of surgically-resected stage I-IIIA NSCLC is still around 50% in Central and Eastern Europe. In addition to non-modifiable prognostic factors, lifetime patterns of smoking and alcohol drinking affected the risk of death and disease progression in a dose-dependent manner in this population.

Obesity Measured via Body Mass Index May Be Associated with Increased Incidence but Not Worse Outcomes of Immune-Mediated Diarrhea and Colitis

Obesity defined by high body mass index (BMI) has traditionally been associated with gastrointestinal inflammatory processes but has recently been correlated with better survival in patients receiving immune checkpoint inhibitors (ICI). We sought to investigate the association between BMI and immune-mediated diarrhea and colitis (IMDC) outcomes and whether BMI reflects body fat content on abdominal imaging. This retrospective, single-center study included cancer patients with ICI exposure who developed IMDC and had BMI and abdominal computed tomography (CT) obtained within 30 days before initiating ICI from April 2011 to December 2019. BMI was categorized as <25, ≥25 but <30, and ≥30. Visceral fat area (VFA), subcutaneous fat area (SFA), total fat area (TFA: VFA+SFA), and visceral to subcutaneous fat (V/S) ratio were obtained from CT at the umbilical level. Our sample comprised 202 patients; 127 patients (62.9%) received CTLA-4 monotherapy or a combination, and 75 (37.1%) received PD-1/PD-L1 monotherapy. Higher BMIs ≥ 30 were associated with a higher incidence of IMDC than BMIs ≤ 25 (11.4% vs. 7.9%, respectively; p = 0.029). Higher grades of colitis (grade 3-4) correlated with lower BMI (p = 0.03). BMI level was not associated with other IMDC characteristics or did not influence overall survival (p = 0.83). BMI is strongly correlated with VFA, SFA, and TFA (p < 0.0001). Higher BMI at ICI initiation was linked to a higher incidence of IMDC but did not appear to affect outcomes. BMI strongly correlated with body fat parameters measured by abdominal imaging, suggesting its reliability as an obesity index.

Real-world surgical treatment patterns and clinical outcomes in patients with stages IA-IIIA non-small cell lung cancer: a retrospective multicentric observational study involving 11,958 patients

PURPOSE

Surgical resection is cornerstone treatment for early-stage non-small cell lung cancer (NSCLC) and offers a chance for cure. This study was conducted to determine current surgical treatment patterns and outcomes of Chinese patients with NSCLC.

METHODS

Data of patients with histologically confirmed NSCLC of stages IA-IIIA and who underwent surgery between July 2014 and July 2020 were retrospectively collected from 9 tertiary hospitals in China. Cox model was used for multivariate analyses.

RESULTS

This study included 11,958 patients, among whom 59.1%, 19.2%, and 21.7% were in stages I, II, and IIIA, respectively. Lobectomy was the most common operation method (78.4%), followed by wedge resection (8.2%), segmentectomy (5.4%), pneumonectomy (5.2%), and bronchial sleeve lobectomy (2.8%). Among patients who underwent wedge resection and segmentectomy, majority had stage I NSCLC (87.2% and 93.3%, respectively), and sublobectomy accounted for 20.7% of stage I operations. With a median follow-up time of 30.2 months, disease-free survival (DFS) and overall survival (OS) rates of entire population were 88.9% and 96.1% at 1 year, 75.2% and 85.1% at 3 years, and 65.3% and 77.0% at 5 years, respectively. The 5-year OS rates for stages IA, IB, IIA, IIB, and IIIA disease were 93.2%, 82.7%, 70.3%, 67.0%, and 52.1%, respectively.

CONCLUSION

This is the largest real-world cohort study of patients with NSCLC who underwent surgery in China, where we described characteristics of surgical treatment and survival outcomes. The results of our study provide insights into real-world surgical treatment status for surgeons and clinicians.

Specific organ metastases and prognosis in lung adenocarcinoma

OBJECTIVES

This study aims to characterize the specific organ metastatic rates in lung adenocarcinoma (LUAD) patients and identify the prognosis-associated factors.

METHODS

Using the Surveillance, Epidemiology and End Results database, 40 117 patients diagnosed with positive histology as the only primary LUAD were included. We stratified patients by diagnosed year, age, sex, race/ethnicity, marital status, insurance, location, TNM stage, organ-specific metastases, surgery, chemotherapy, and radiation therapy. We performed multivariable logistic and Cox regression to identify the factors associated with the presence of specific organ metastases and prognosis predictors.

RESULTS

For the 40 117 LUAD patients, 43.69%, 26.25%, 19.66%, 10.60%, and 17.89% had specific organ, bone, brain, liver, and lung metastases, respectively. The average survival in patients with organ metastases was 12.19 months, compared to 36.40 months in patients without metastases. In different kinds of metastatic organ cohorts, the longest average survival was 12.60 months in the lung metastases cohort, and the shortest was 8.43 months in liver metastases cohort. In total, 571 patients with metastases received surgery, which was significantly associated with decreased mortality (hazard ratio 1.82, 95% confidence interval 1.65-2.01, p < 0.01). Patients received surgery of lobectomy or extended (251 of 571, 43.96%) displayed the longest average survival (35.16 months); patients (294 of 571, 51.49%) received sub-lobar resection, had the average survival (19.90 months); patients received local tumor destruction (26 of 571, 4.55%) had the shortest average survival (13.73 months).

CONCLUSION

This study provides insights into the specific organ metastatic rates and prognosis in LUAD patients on a population level. These findings suggest that surgery resection should be taken into consideration in the treatment for these LUAD patients.

The Influence of Preoperative Nutritional and Systemic Inflammatory Status on Perioperative Outcomes following Da Vinci Robot-Assisted Thoracic Lung Cancer Surgery

Background: Nutrition is an important factor in the outcome of any disease process. We evaluated the relationship of nutritional status and inflammatory status of non-small cell lung cancer (NSCLC) patients undergoing robotic-assisted thoracic surgery (RATS) with postoperative complications. Methods: This prospective cohort study included 107 NSCLC patients undergoing surgical treatment, between 2019 and 2021. Nutritional status and inflammatory status were assessed before pulmonary resection using anthropometric assessment, blood tests, and body mass index (BMI). Results: The BMI was 27.5 ± 4.4. Based on BMI, 29% (n = 31) were classified as normal weight, 43% (n = 46) as overweight, and 28% (n = 30) as obese. The mean neutrophil/lymphocyte ratio (NLR) was 2.16 ± 0.85, the platelet/lymphocyte ratio (PLR) was 121.59 ± 44.21, and the lymphocyte/monocyte ratio (LMR) was 3.52 ± 1.17. There was no increase in the number of intraoperative complications or bleeding (p = 0.696), postoperative complications (p = 0.569), mean hospital stay (p = 0.258) or duration of chest drain (p = 0.369). Higher inflammatory status, with an NLR > 1.84, was associated with more overall postoperative complications (p = 0.028), only in univariate analysis, but this significance was not maintained on multivariate analysis. Conclusions: BMI was not a predictor of increased postoperative risk in this cohort; therefore, weight should not deter surgeons from using RATS for pulmonary resection.

Two-sided roles of adipose tissue: Rethinking the obesity paradox in various human diseases from a new perspective

Overweight and obesity, as a result of excess fat accumulation, have become a worldwide public health issue. Recent studies have shown that obesity is closely related to many human diseases, such as cancer, cardiovascular diseases, and type 2 diabetes mellitus, in which adipose tissue plays a dual role. In addition to thermal and mechanical insulation and a critical role in energy storage and heat production, adipose tissue is also a highly plastic endocrine and signaling organ that secretes multiple bioactive molecules for inter-organ crosstalk. The phenotypic and biological changes of adipose tissue under pathological conditions, especially in obesity, increase the challenge of deciphering the positive or negative effects of adipose tissue in disease. Despite numerous studies on obesity and adipose tissue, the ambiguous role of adipose tissue on specific organs or tissues in different diseases is not fully understood, and the definite mechanisms remain obscure. In this review, we first summarize the basic biological characteristics of adipose tissue in the physiological state and the abnormal remodeling of adipose tissue during obesity. We then discuss the complex and disparate effects of obesity on various human diseases, with a particular focus on the dual roles and underlying mechanisms of adipose tissue, a quintessential player in obesity, in this process. More importantly, rethinking the causes of the "obesity paradox" phenomenon in diseases from the perspective of adipose homeostasis and dysfunction provides a novel strategy for disease treatment by intervening in fat function.

Early recurrence factors in patients with stage III non-small cell lung cancer treated with concurrent chemoradiotherapy

BACKGROUND

The clinical characteristics and risk factors for cancer recurrence have not been well evaluated regarding early recurrence in patients with unresectable locally advanced non-small cell lung cancer (LA-NSCLC) who receive concurrent chemoradiotherapy (CRT). The aim of this study was to determine the clinical characteristics and risk factors of patients with stage III unresectable LA-NSCLC treated with CRT who developed early recurrence.

METHODS

We retrospectively reviewed the clinical records of 46 patients diagnosed with stage III unresectable LA-NSCLC treated with CRT at our center between July 2012 and July 2021. A tumor proportion score (TPS) < 50% was defined as "low expression" and a TPS > 50% was defined as "high expression."

RESULTS

A total of 17 (37.0%) patients had a confirmed recurrence within 1 year of treatment. More patients had a lower body mass index in the early recurrence group than in the later recurrence group (p = 0.038). A higher number of patients in the late recurrence group underwent surgery after CRT (p = 0.036). Patients with a higher TPS were more likely to experience late recurrence than early recurrence (p = 0.001), whereas more patients with stage N3 disease were in the early recurrence group (p = 0.011). Multivariate analysis identified lower TPS expression as an independent risk factor for early recurrence after CRT. Overall survival was prolonged in the late recurrence group (p < 0.001).

CONCLUSIONS

A lower TPS may be a predictor of early recurrence after CRT in patients with LA-NSCLC. These patients should be closely monitored for post-treatment recurrence.

Clinical and economic value of oral nutrition supplements in patients with cancer: a position paper from the Survivorship Care and Nutritional Support Working Group of Alliance Against Cancer

Malnutrition is a common clinical and public health problem that can frequently affect patients in hospital and community settings. In particular, cancer-related malnutrition results from a combination of metabolic dysregulation and anorexia, caused both by the tumor itself and by its treatment. Patients with head-neck cancer, or with gastroesophageal, pancreatic, lung, and colorectal cancer, are particularly at risk of developing malnutrition, with a prevalence varying between 30 and 50% depending on tumor location and anti-cancer treatment complications. Prevention and adequate management of malnutrition is now considered an essential key point of therapeutic pathways of patients with cancer, with the aim to enhance their quality of life, reduce complications, and improve clinical outcomes. Oral nutritional supplements (ONS) are part of the nutritional therapy and represent an effective tool to address cancer-related malnutrition, as supported by growing literature data. However, patients' access to ONS - which is regulated by different national and regional policies in terms of reimbursement - is quite heterogeneous. This narrative review aims to summarize the current knowledge about the role of ONS in terms of cost-effectiveness in the management of actively treated patients with cancer, following surgery and/or radiotherapy/chemotherapy treatment and to present the position on this issue of the Alliance Against Cancer, the Italian National Oncology Network, coming up from a focused virtual roundtable of the Survivorship Care and Nutritional Support Working Group.

Real-World Studies Link Nonsteroidal Anti-inflammatory Drug Use to Improved Overall Lung Cancer Survival

Inflammation is a cancer hallmark. Nonsteroidal anti-inflammatory drugs (NSAIDs) improve overall survival (OS) in certain cancers. Real-world studies explored here if NSAIDs improve non-small cell lung cancer (NSCLC) OS. Analyses independently interrogated clinical databases from The University of Texas MD Anderson Cancer Center (MDACC cohort, 1987 to 2015; 33,162 NSCLCs and 3,033 NSAID users) and Georgetown-MedStar health system (Georgetown cohort, 2000 to 2019; 4,497 NSCLCs and 1,993 NSAID users). Structured and unstructured clinical data were extracted from electronic health records (EHRs) using natural language processing (NLP). Associations were made between NSAID use and NSCLC prognostic features (tobacco use, gender, race, and body mass index, BMI). NSAIDs were statistically-significantly (P < 0.0001) associated with increased NSCLC survival (5-year OS 29.7% for NSAID users versus 13.1% for non-users) in the MDACC cohort. NSAID users gained 11.6 months over nonusers in 5-year restricted mean survival time. Stratified analysis by stage, histopathology and multicovariable assessment substantiated benefits. NSAID users were pooled independent of NSAID type and by NSAID type. Landmark analysis excluded immortal time bias. Survival improvements (P < 0.0001) were confirmed in the Georgetown cohort. Thus, real-world NSAID usage was independently associated with increased NSCLC survival in the MDACC and Georgetown cohorts. Findings were confirmed by landmark analyses and NSAID type. The OS benefits persisted despite tobacco use and did not depend on gender, race, or BMI (MDACC cohort, P < 0.0001). These real-world findings could guide future NSAID lung cancer randomized trials.

Obesity Does Not Increase Perioperative Outcomes in Older Patients Undergoing Thoracoscopic Anatomic Lung Cancer Surgery

Objectives

To investigate the relationship between obesity status and perioperative outcomes in elderly patients undergoing thoracoscopic anatomic lung cancer surgery.

Methods

From January 2016 to December 2018, we performed a monocentric retrospective cohort study among 4164 consecutive patients aged 65 years or older who underwent thoracoscopic anatomic lung cancer surgery at Shanghai Chest Hospital. Two groups were stratified by body mass index (BMI): nonobese (BMI<28kg/m²) and obese status (BMI≥28kg/m²). Using a 1:1 propensity score matching (PSM) analysis to compare perioperative outcomes between two groups.

Results

4035 older patients were eventually enrolled, with a mean age of 69.8 years (range: 65-87), and 305 patients were eligible for obese status, with a mean BMI of 29.8 ± 1.7kg/m². Compared with nonobese patients, obese patients were more likely to have higher rates of intraoperative hypoxemia (1.2% vs 3.9%, P=0.001) and new-onset arrhythmia (2.3% vs 4.3%, P=0.034). The difference in intraoperative transfusion and conversion rates and postoperative outcomes regarding pulmonary complications, new-onset arrhythmia, transfusion, length of hospital stay, 30-day readmission and hospitalization costs between two groups were not significant (P>0.05). After a 1:1 PSM analysis, the difference in both intraoperative and postoperative complications among two groups were not significant (P>0.05). In subgroup analysis, patients with BMI≥30kg/m² had a similar incidence of perioperative complications compared to patients with BMI between 28 and 30 kg/m² (P>0.05).

Conclusions

Our research data support evidence for “obesity paradox” and also contribute the growing body of evidence that obesity in older patients should not exclude candidates for thoracoscopic anatomic lung cancer surgery.

Development and Validation of a Prognostic Nomogram in Lung Cancer With Obstructive Sleep Apnea Syndrome

To analyze the prognostic factors and survival rate of lung cancer patients with obstructive sleep apnea (OSA) by nomogram. The nomogram was established by a development cohort (n = 90), and the validation cohort included 38 patients. Factors in the nomogram were identified by Cox hazard analysis. We tested the accuracy of the nomograms by discrimination and calibration, and plotted decision curves to assess the benefits of nomogram-assisted decisions. There were significant difference in sex, apnea hypopnea index (AHI), Tumor Node Metastasis (TNM), coronary heart disease, lowest arterial oxygen saturation [LSpO2 (%)], oxygen below 90% of the time [T90% (min)], the percentage of the total recorded time spend below 90% oxygen saturation (TS90%) and oxygen desaturation index (ODI4) between lung cancer subgroup and lung cancer with OSA subgroup (P < 0.05). Lung cancer patients with OSA age, AHI, TNM, cancer types, BMI and ODI4 were independent prognostic factor. Based on these six factors, a nomogram model was established. The c-index of internal verification was 0.802 (95% CI 0.767–0.885). The ROC curve analysis for the nomogram show 1-year survival (AUC = 0.827), 3-year survival (AUC = 0.867), 5-year survival (AUC = 0.801) in the development cohort were good accuracy. The calibration curve shows that this prediction model is in good agreement. Decision curve analysis (DCA) suggests that the net benefit of decision-making with this nomogram is higher, especially in the probability interval of <20% threshold. The nomogram can predict the prognosis of patients and guide individualized treatment.

Obesity-Specific Association of Statin Use and Reduced Risk of Recurrence of Early Stage NSCLC

Introduction

Statins, used for their lipid-lowering activity, have anti-inflammatory and anticancer properties as well. We evaluated this potential benefit of statin use in patients with NSCLC.

Methods

All 613 patients with pathologic stage 1 or 2 NSCLC who had lobectomy without neoadjuvant therapy at our institution during 2008 to 2015 were included. Association between presurgery statin use and overall survival and recurrence-free survival (RFS) was analyzed using Cox proportional hazards regression. Association of statin use with tumor transcriptome was evaluated in another 350 lung cancer cases.

Results

Univariable analyses did not reveal a statistically significant association of statin use with either overall survival or RFS, with hazard ratio equals to 1.19 and 0.70 (Wald p = 0.28 and 0.09), respectively. In subgroup analyses, significantly improved RFS was found in statin users, but only in overweight/obese patients (body mass index [BMI] > 25; n = 422), with univariable and multivariable hazard ratio of 0.49 and 0.46 (p = 0.005 and 0.002), respectively, but not in patients with BMI less than or equal to 25 (n = 191; univariable p = 0.21). Transcriptomes of tumor statin users had high expression of tumoricidal genes such as granzyme A and interferon-γ compared with those of nonusers among high- but not low-BMI patients with lung cancer.

Conclusions

Our study suggests that statins may improve the outcome of early stage NSCLC but only in overweight or obese patients. This benefit may stem from a favorable reprogramming of the antitumor immune response that statins perpetrate specifically in the obese.

Carboplatin versus cisplatin in combination with etoposide in the first-line treatment of small cell lung cancer: a pooled analysis

Background

Extensive-stage small cell lung cancer (ES-SCLC) is an aggressive disease with poor survival, and platinum-etoposide chemotherapy is indicated as the mainstay of treatment. In this study, we compared the efficacy and safety between the cisplatin plus etoposide (EP) and carboplatin plus etoposide (EC) regimens.

Methods

A total of 1305 patients with previously untreated ES-SCLC were included in this study. Data from five trials were collected from the public database Project Data Sphere. Survival analysis and adverse events (AEs) analysis were conducted.

Results

Of the 1305 patients, 800 received the EC regimen whereas 505 received the EP regimen as their front-line treatment. Overall, the median progression-free survival (PFS) and the median overall survival (OS) were 172 and 289 days, respectively. The EP and EC treatment groups did not have significantly different PFS or OS. After adjusting for age, sex, body mass index (BMI) and Eastern Cooperative Oncology Group (ECOG) performance status (PS), the EP regimen was independently associated with better PFS (hazard ratio [HR] = 0.76, 95% CI = 0.63–0.92, p = 0.0041) and OS (HR = 0.79, 95% CI = 0.64–0.97, p = 0.0220) among patients who were overweight and obese (BMI ≥ 25 kg/m²). In the safety analysis, patients who received the EC treatment experienced significantly more grade ≥ 3 AEs (n = 599, 74.9%) than those who received the EP treatment (n = 337, 66.7%; p = 0.002). Furthermore, the EC regimen was associated with a higher risk of grade 3–4 neutropaenia (p = 0.001), thrombocytopaenia (p < 0.001) and hyponatraemia (p = 0.036), whereas the EP regimen was associated with a higher risk of grade 3–4 vomiting (p = 0.021).

Conclusions

In summary, this study presented the efficacy and safety of the EC and EP regimens in patients with ES-SCLC in the first-line setting. Patients who are overweight and obese benefit more from the EP regimen than EC regimen. Approaches to define the optimal chemotherapy regimen in different BMI subgroups are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-09034-6.

Expected and paradoxical effects of obesity on cancer treatment response

Obesity, whose prevalence is pandemic and continuing to increase, is a major preventable and modifiable risk factor for diabetes and cardiovascular diseases, as well as for cancer. Furthermore, epidemiological studies have shown that obesity is a negative independent prognostic factor for several oncological outcomes, including overall and cancer-specific survival, for several site-specific cancers as well as for all cancers combined. Yet, a recently growing body of evidence suggests that sometimes overweight and obesity may associate with better outcomes, and that immunotherapy may show improved response among obese patients compared with patients with a normal weight. The so-called 'obesity paradox' has been reported in several advanced cancer as well as in other diseases, albeit the mechanisms behind this unexpected relationship are still not clear. Aim of this review is to explore the expected as well as the paradoxical relationship between obesity and cancer prognosis, with a particular emphasis on the effects of cancer therapies in obese people.

Difficult lung separation. An insight into the challenges faced during COVID-19 pandemic

Difficult lung isolation or separation in patients undergoing thoracic surgery using one-lung ventilation might be attributed to upper airway difficulty or abnormal anatomy of the lower airway. Additionally, adequate deflation of the surgical lung can impair surgical exposure. The coronavirus disease 2019 (COVID-19) has a harmful consequence for both patients and anesthesiologists. Management of patients with difficult lung isolation can be challenging during the COVID-19 pandemic. Careful planning and preparation, preoperative routine testing, protective personal equipment, standard safety measures, proper preoxygenation, and individualize the patients care are required for successful lung separation. A systematic approach for management of difficult lung separation is centered around securing the airway and providing adequate ventilation using either a blocker or double-lumen tube. Several measures are described to expedite lung collapse.

Association Between Body Mass Index and Survival Outcomes In Patients Treated With Immune Checkpoint Inhibitors: Meta-analyses of Individual Patient Data

Despite that immune checkpoint inhibitors (ICIs) had tremendous improved the survival of multiple solid tumors, only a limited proportion of patients are responsive to ICIs. Therefore, effective variables are urgently needed to predict the probability of response to ICIs. Systematic searches were conducted from inception up to May, 2020. Prospective or retrospective studies of ICIs that investigated the association between body mass index (BMI) and survival outcomes, including overall survival (OS) and/or progression-free survival (PFS), were selected. The association between each BMI category and survival outcomes was calculated using Cox proportional hazard regression models and quantified as hazard ratio (HR) with corresponding 95% confidence interval. Seven clinical studies involving data from 3768 individual patients were included. The median OS was 15.5 months (95% confidence interval: 14.7-16.2 mo) and the median PFS was 5.7 months (5.2-6.3 mo). The median OS was significantly longer in overweight/obese patients than in nonoverweight patients (20.7 vs. 11.3 mo; P<0.001). The difference in OS between overweight and obese patients was not statistically significant (HR: 1.14, P=0.098). Similar results were observed for PFS outcomes. Subgroup analysis demonstrated improved OS in overweight/obese patients with nonsmall-cell lung cancer (HR: 0.81, P=0.002), melanoma (HR: 0.66, P<0.001), renal cell carcinoma (HR: 0.53, P<0.001), and multiple cancer type (HR: 0.34, P<0.001), with parallel results noted regarding PFS outcomes. Results of the present study suggested that BMI may be a satisfactory prognostic factor for patients treated with ICIs.

The predictive value of body mass index on prognosis and adverse events of cancers treated with immunotherapy: a systematic review and meta-analysis

OBJECTIVE

High body mass index (BMI) greater than 25 kg/m² has a complex relationship with cancers. The aim of this systematic review and meta-analysis is to explore controversy over whether BMI is correlated with outcomes including survival and immunotherapy-related adverse events (irAEs) in cancer patients treated with immunotherapy.

METHODS

We searched PubMed, Embase, Web of Science, and The Cochrane Library for relevant studies published up to June 2020. Title/abstract screening, full-text review, data extraction, and quality assessment were performed independently. Subgroup analysis was based on sex, treatment lines, the status of programmed death-ligand 1 (PD-L1), and tumor types. Sensitivity analysis was performed by synthesizing studies that adjusted for certain covariates or studies with good quality. Statistical heterogeneity was evaluated by the I² value. Meta-analysis was performed with hazard ratio (HR) / odds ratio (OR) and 95% confidence intervals (CIs) as the effect measures.

RESULTS

Twenty studies were included for survival and irAEs analyses. Patients with high BMI who underwent immunotherapy had longer overall survival (OS) (pooled hazard ratio, pHR = 0.71 [95% CI: 0.59-0.85]) and progression-free survival (PFS) (pHR = 0.76 [95% CI: 0.65-0.88]) than those with low BMI; at the same time, high-BMI patients had increased irAEs (OR = 2.54 [95% CI: 1.12-5.79]).

CONCLUSION

In general, high BMI was correlated with improved OS and PFS in patients treated with immunotherapy along with a high risk of irAEs. However, discrepant findings from subgroup analyses urgently call for further analysis.

Impact of body mass index on survival and serious adverse events in advanced non-small cell lung cancer treated with bevacizumab: a meta-analysis of randomized clinical trials

PURPOSE

Lung cancer accounts for 28% of all cancer deaths, more deaths than any other cancer in the United States. The influence of body composition has been evaluated in several studies, specifically, the influence of obesity on lung cancer survival. Outcomes have been mixed, with some studies demonstrating a paradoxical beneficial effect in early lung cancer where survival is improved in obese patients. The study aim was to evaluate the impact of obesity on overall survival (OS), progression free survival (PFS), and occurrence of serious adverse events (SAE) in clinical trials evaluating bevacizumab for advanced non-small cell lung cancer (NSCLC).

METHODS

We performed a post hoc analysis combining available individual level data from bevacizumab randomized clinical trials available through the Clinical Study Data Request database. The primary outcome measured in our analysis was the influence of bevacizumab on OS stratified by body mass index (BMI). In addition to OS, both PFS and the occurrence of SAE requiring therapy interruption were evaluated. All endpoints were evaluated in patients who were obese (BMI ≥30.0 kg/m²) compared with non-obese (BMI <30.0 kg/m²). As a sensitivity analysis, endpoints were also evaluated in patients who were overweight (BMI ≥25.0 kg/m²) compared with non-overweight (BMI <25.0 kg/m²). In addition to analysis of each individual study, a meta-analysis was performed in order to calculate pooled hazard ratios (HR). Hazard ratios for both OS and PFS were calculated using multivariable Cox proportional hazards models. Odds ratios for SAE were calculated using multivariable logistic regression. The validity of the regression models was tested using a log-log plot and overall fit using the goodness of fit test.

RESULTS

After adjusting for covariates using a Cox proportional hazards model and combining the resulting adjusted hazard ratios using meta-analysis, there was no significant difference between obese and non-obese groups for OS or PFS. In addition, when treatment discontinuation due to an adverse event was assessed, none of the trials showed a significant difference between the obese and non-obese groups.

CONCLUSION

In this analysis of clinical trial data, obesity was not associated with worse survival versus non-obese individuals in advanced NSCLC. In addition, serious adverse events were similar between patients with and without obesity.

The different survival impacts of body mass index in elderly and non-elderly patients with gastric carcinoma

BACKGROUND

The age-dependent survival impact of body mass index (BMI) remains to be fully addressed in patients with gastric carcinoma (GC). We investigated the prognostic impacts of BMI in elderly (≥70 years) and non-elderly patients undergoing surgery for GC.

METHODS

In total, 1168 GC patients were retrospectively reviewed. Patients were stratified into 3 groups according to BMI; low (<20), medium (20-25) and high (>25). The effects of BMI on overall survival (OS) and cancer-specific survival (CSS) were assessed using univariate and multivariate Cox hazards models.

RESULTS

There were 242 (20.7%), 685 (58.7%) and 241 (20.6%) patients in the low-, medium- and high-BMI groups, respectively. The number of patients with high BMI but decreased muscle mass was extremely small (n = 13, 1.1%). Patients in the low-BMI group exhibited significantly poorer OS than those in the high- and medium-BMI group (P < 0.001). Notably, BMI classification significantly demarcated OS and CSS curves (both P < 0.001) in non-elderly patients, while did not in elderly patients (OS; P = 0.07, CSS; P = 0.54). Furthermore, the survival discriminability by BMI was greater in pStage II/III disease (P = 0.006) than in pStage I disease (P = 0.047). Multivariable analysis focusing on patients with pStage II/III disease showed low BMI to be independently associated with poor OS and CSS only in the non-elderly population.

CONCLUSIONS

BMI-based evaluation was useful for predicting survival and oncological outcomes in non-elderly but not in elderly GC patients, especially in those with advanced GC.

Prognostic value of the preoperative lymphocyte-to-monocyte ratio for survival after lung cancer surgery

Background

The aim of this study was to assess the effect of the lymphocyte-to-monocyte ratio (LMR), neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio on overall survival and disease-free survival in patients with lung cancer treated with radical surgery.

Methods

We performed a retrospective review of patients with lung cancer who prospectively underwent radical resection between 2004 and 2012. Blood samples were taken as part of the preoperative workup. The inflammatory markers studied were absolute values of lymphocytes, monocytes, neutrophils and platelets, with subsequent calculation of ratios. Median follow-up was 52 months.

Results

Two hundred and sixty-eight patients underwent surgery, of whom 218 (81.3%) were men. Mean age was 62.9 ± 8.7 years. A lymphocyte-to-monocyte ratio ≥ 2.5 was independently associated with longer disease-free survival (hazard ratio [HR] 0.476 (0.307–0.738), p = 0.001) and longer overall survival (HR, 0.546; 95% CI: 0.352–0.846; p = 0.007), in models adjusted for age, sex, stage, and type of resection. No other systemic inflammatory marker showed a significant association.

Conclusion

Preoperative LMR is an independent prognostic factor of overall survival and recurrence-free survival in patients with surgically-resected early stage lung cancer.

Association Between Body Mass Index and Overall Survival With Immune Checkpoint Inhibitor Therapy for Advanced Non-Small Cell Lung Cancer

Importance

High body mass index (BMI) is independently associated with overall survival benefit from immune checkpoint inhibitor therapy in patients with melanoma, yet whether BMI is associated with outcomes in patients with advanced non-small cell lung cancer treated with atezolizumab remains unknown.

Objective

To examine whether BMI is associated with survival outcomes and adverse events in patients with non-small cell lung cancer (NSCLC) treated with atezolizumab.

Design, Setting, and Participants

A pooled analysis of individual patient-level data from 4 international, multicenter clinical trials was performed. Two were single-arm phase 2 trials (BIRCH [data cutoff of May 28, 2015] and FIR [data cutoff of January 7, 2015]), and 2 were 2-arm randomized clinical trials (POPLAR [phase 2; data cutoff of May 8, 2015] and OAK [phase 3; data cutoff of July 7, 2016]). Patients with advanced NSCLC previously untreated or treated with at least 1 line of systemic therapy, with measurable disease and good organ function and without contraindications for chemotherapy or immune checkpoint inhibitor therapy, were included in these trials. Data analyses were performed from February 28, 2019, to September 30, 2019.

Interventions

The control group was treated with docetaxel once every 3 weeks until disease progression or unacceptable toxic effects occurred in POPLAR and OAK. The experimental group was treated with atezolizumab once every 3 weeks until disease progression or unacceptable toxic effects occurred in all available trials.

Main Outcomes and Measures

Association between BMI and overall survival (OS), progression-free survival (PFS), and treatment-related adverse events. Intention-to-treat analysis was conducted.

Results

Adequate data were available for 2110 patients from a total pool of 2261 across 4 trials. Of those 2110, 1434 patients (median age, 64 years [range, 57-70 years]; 890 men [62%]) received atezolizumab and 676 patients (median age, 63 years[range, 57-69 years]; 419 men [62%]) received docetaxel. There was a linear association between increasing BMI and OS in patients treated with atezolizumab. Obesity (BMI ≥30 [calculated as weight in kilograms divided by height in meters squared]) was associated with significantly improved OS in patients treated with atezolizumab, but not in those who received docetaxel after adjusting for confounding variables. The association between BMI and OS/PFS was the strongest in the high PD-L1 expression subgroup. Overall survival for patients with the highest category of PD-L1 expression (≥50% of tumor cells or ≥10% of tumor-infiltrating immune cells; n = 436) had hazard ratios of 0.36 (95% CI, 0.21-0.62) for the group with obesity and 0.69 (95% CI, 0.48-0.98) for the group with overweight. Patients with the highest category of PD-L1 expression had PFS hazard ratios of 0.68 (95% CI, 0.49-0.94) for the group with obesity and 0.72 (95% CI, 0.56-0.92) for the group with overweight. Treatment-related adverse events were not associated with BMI.

Conclusions and Relevance

High BMI appears to be independently associated with improved survival with atezolizumab in patients with NSCLC, raising the possibility that baseline BMI should be considered as a stratification factor in future immune checkpoint inhibitor therapy trials.

The Geriatric Nutritional Risk Index as a Prognostic Factor in Patients with Advanced Non-Small-Cell Lung Cancer

The Geriatric Nutritional Risk Index (GNRI) is widely applied as a prognostic factor in different cancers. We aimed to analyze the prognostic value of the GNRI in 257 patients diagnosed with advanced non-small-cell lung cancer (NSCLC). Patients with GNRI >98, 92-98, and <92 were grouped into normal, low risk and moderate/high risk groups, respectively. There were 45.1% patients at risk for malnutrition. Kaplan-Meier survival curves indicated that patients with lower GNRI scores had a poorer overall survival (OS). Two-year OS for normal, low risk and moderate/high risk groups were 57.4%, 42.3% and 15.8%, respectively. In multivariate survival analysis, GNRI (<92), body mass index (BMI, ≥24 kg/m2), combined therapy, hemoglobin and neutrophil-to-lymphocyte ratio (NLR) were independent prognostic factors of OS. Stratifying by age groups, GNRI (<92), hemoglobin and NLR were independent prognostic factors of OS in patients aged <65 years. GNRI (<92), smoking, BMI (≥24 kg/m2) and platelet-to-lymphocyte ratio were independent prognostic factors of OS in patients aged ≥65 years. In conclusion, GNRI was a significant prognostic factor in advanced NSCLC patients regardless of age. A decreased GNRI may be considered as a clinical trigger for nutritional support in advanced NSCLC patients, though additional studies are still required to confirm the best cut-point.

The Effect of Body Mass Index on Treatment Outcomes in Patients with Metastatic Non-Small Cell Lung Cancer Treated with Platinum-Based Therapy

To investigate the effect of body mass index(BMI) on treatment outcomes and side-effect profile in metastatic non-small cell lung cancer(NSCLC) patients receiving platinum-based chemotherapy(ChT) in the first-line setting. This was a retrospective analysis of 233 NSCLC patients who were treated and followed up from 2008 through 2018. NSCLC patients who had metastatic disease at the time of diagnosis and were treated with platinum-based ChT in the first-line setting were included. The patients were divided into 2 groups based on the BMI as follows; BMI < 25 kg/m² and BMI ≥ 25 kg/m². This retrospective analysis enrolled 233 patients, 35 (15.0%) of whom were female. The BMI in 132 patients (56.2%) was < 25 kg/m². The median age was 58 years (range, 21-90). Median progression-free survival(PFS) was 7 mo, in the patients with BMI ≥ 25 kg/m² compared to 5.0 mo, in those with BMI < 25 kg/m² (p = 0.032), with corresponding median overall survival(OS) durations of 12 vs. 9 mo, (p = 0.003). In multivariate analysis, ECOG PS 2, grade III histology, and brain or bone metastasis negatively affected OS, whereas BMI ≥ 25 kg/m² positively affected OS. A high BMI prior to therapy in patients with NSCLC treated with platinum-based ChT in the first-line setting was associated with more favorable PFS and OS.

Pretreatment body mass index and clinical outcomes in cancer patients following immune checkpoint inhibitors: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to evaluate the association between pretreatment body mass index (BMI) and clinical outcomes in cancer patients treated with immune checkpoint inhibitors (ICIs).

METHODS

Systematical searches of PubMed, Embase, and the Cochrane Library databases were carried out. Studies reporting on the association between BMI and outcomes of ICIs were included. The intended outcomes included overall survival (OS), progression-free survival (PFS), objective response rate (ORR) and immune-related adverse events (irAEs). Quantitative analyses and dose-response meta-analyses were performed under random effect models.

RESULTS

Twenty-two eligible studies involving 5686 cancer patients treated with ICIs were identified. Compared to those with lower BMI, patients with higher BMI obtained a significant benefit on OS (HR = 0.698, 95% CI 0.614-0.794, P < 0.001; I² = 45.9%) and PFS (HR = 0.760, 95% CI 0.672-0.861, P < 0.001; I² = 37.9%). Most stratified analyses for OS and PFS also showed similar pooled risk estimates. For an increment of every 5 kg/m² in BMI, the risk for death reduced by approximately 15.6% (HR = 0.844, 95% CI 0.752-0.945, P = 0.003). Moreover, patients with higher BMI had a remarkably better ORR (OR = 0.468, 95% CI 0.263-0.833, P = 0.010; I² = 73.6%) than that of those with lower BMI. However, no statistically significant differences were found in the incidence of any grade irAEs (P = 0.073) and ≥ 3 grade irAEs (P = 0.105) between higher and lower BMI.

CONCLUSION

Higher BMI is significantly associated with improved outcomes in patients treated with ICIs. Further large-scale prospective research is warranted to better illuminate the association between BMI and outcomes from ICIs.

Age-dependent survival impact of body mass index in patients with oesophageal squamous cell carcinoma

BACKGROUND

Patients with oesophageal squamous cell carcinoma (ESCC) generally have distinctive body compositions; being underweight is highly prevalent and sarcopenic obesity is rare. We investigated the survival impacts of body mass index (BMI) in elderly (≥65 years) and non-elderly patients undergoing surgery for ESCC.

METHODS

In total, 379 ESCC patients were retrospectively reviewed. Patients were divided into 3 groups according to BMI; low (<20), medium (20-25) and high (≥25). The skeletal muscle index (SMI) was calculated and its relationship with BMI was analysed. Univariate and multivariate Cox hazards models were applied to determine independent predictors of poor overall survival (OS) and cancer-specific survival (CSS).

RESULTS

The low-, medium- and high-BMI groups included 102 (26.9%), 231 (60.9%) and 46 (12.1%) patients, respectively. High BMI with low SMI was rare (n = 6, 1.6%). Patients with low BMI had significantly poorer OS and CSS than those with high and medium BMI (OS; P < 0.001, CSS; P = 0.003). Notably, OS and CSS curves were well-demarcated by BMI (both P < 0.001) in elderly patients, while not being stratified according to BMI in non-elderly patients (OS; P = 0.08, CSS; P = 0.54). Multivariable analysis revealed low BMI, as well as pStage III disease and non-curative resection, to be independent predictors of poor OS (HR 2.73, P < 0.001) and poor CSS (HR 2.88, P < 0.001) in the elderly group.

CONCLUSIONS

The survival and oncological impacts of low BMI were evident only in elderly patients with ESCC. Our findings highlight the age-dependent significance of BMI in patients with this tumour entity.

The Role of Malnutrition and Muscle Wasting in Advanced Lung Cancer

PURPOSE OF REVIEW

Malnutrition, cancer cachexia, and sarcopenia often co-occur in patients with advanced cancer and are associated with poorer response to chemotherapy and reduced survival. Here, we evaluate the current literature regarding the role of nutrition and these associated conditions in patients with advanced lung cancer.

RECENT FINDINGS

While rates of malnutrition are high, nutritional intervention studies have generally been limited by small sample sizes. Novel strategies such as home-based meal delivery may have promise. While no therapy is approved for cancer cachexia, ghrelin agonists and other targeted therapies have yielded promising data in clinical trials. Recent data also suggest that obesity may improve immunotherapy responsiveness. Malnutrition and associated muscle wasting are clearly negative prognostic markers in advanced lung cancer. Patients with malnutrition should be urgently referred for dietary counseling and guidelines for nutritional support should be followed. Optimal treatment of these syndromes will likely include nutrition and anti-cachexia interventions used in combination.

Pre-Disease and Pre-Surgery BMI, Weight Loss and Sarcopenia Impact Survival of Resected Lung Cancer Independently of Tumor Stage

Lower pre-surgery Body Mass Index (BMI) and low muscle mass impact negatively long-term survival of non-small cell lung cancer (NSCLC). We investigated their influence on survival after major lung resection for NSCLC.

METHODS

A retrospective analysis of a prospectively collected database was made on 304 consecutive patients.

RESULTS

Underweight, normal, overweight and obese patients represented 7.6%, 51.6%, 28.6%, and 12.6% of the pre-disease population. Weight loss and gain were recorded in 5% and 44.4% of patients, respectively. Low muscle mass was more frequently associated with BMI < 25 kg/m2 (p < 0.000001). Overall survival was positively affected by pre-disease (p = 0.036) and pre-surgery (p = 0.017) BMI > 25 kg/m2, and, even more, in case of BMI > 25 kg/m2 and increasing weight (p = 0.012). Long-term outcome was negatively influenced by low muscle mass (p = 0.042) and weight loss (p = 0.0052) as well as age (p = 0.017), ASA categories (p = 0.025), extent of resection (p = 0.0001), pleural invasion (p = 0.0012) and higher pathologic stage (p < 0.0001). Three stepwise multivariable models confirmed the independent favorable prognostic value of higher pre-disease (RR 0.66[0.49-0.89], p = 0.006) and pre-surgery BMI (RR 0.72[0.54-0.98], p = 0.034), and the absence of low muscle mass (RR 0.56[0.37-0.87], p = 0.0091).

CONCLUSIONS

Body reserves assessed by simple clinical markers impact survival of surgically treated NSCLC. Strategies improving body fat and muscular mass before surgery should be considered.

The Hemoglobin, Albumin, Lymphocyte, and Platelet (HALP) Score in Patients with Small Cell Lung Cancer Before First-Line Treatment with Etoposide and Progression-Free Survival

BACKGROUND The hemoglobin, albumin, lymphocyte, and platelet (HALP) score is a prognostic factor in patients who have some types of malignant tumors. The aim of this study was to investigate the prognostic significance of the HALP score in patients with small cell lung cancer (SCLC) before first-line treatment with etoposide. MATERIAL AND METHODS A retrospective study included 178 patients with SCLC who received first-line chemotherapy with etoposide between September 2015 and May 2019. The baseline clinical characteristics and blood parameters were recorded. Univariate and multivariate analysis and Kaplan-Meier plots were used to identify the factors associated with progression-free survival (PFS). RESULTS The optimal cut-off values of the HALP score was determined by X-tile software to be 25.8. Univariate and multivariate analysis showed that in 178 patients, the HALP score, body mass index (BMI), and serum albumin levels had no prognostic significance. In the patient age group <65 years, a BMI ≥24 kg/m² was an independent prognostic factor (HR, 1.943; 95% CI, 1.251-3.018) (P=0.003). In the patient age group ≥65 years, a HALP score >25.8 was an independent positive prognostic factor for outcome following first-line treatment with etoposide (HR, 0.483; 95% CI, 0.270-0.865) (P=0.014). CONCLUSIONS In patients <65 years with SCLC who underwent first-line treatment with etoposide, a BMI ≥24 kg/m² an independent prognostic factor, and in patients ≥65 years, a HALP score >25.8 was an independent predictor of improved outcome, associated with increased PFS.

Perioperative Management May Improve Long-term Survival in Patients After Lung Cancer Surgery: A Retrospective Cohort Study

BACKGROUND:

Surgical resection is the main treatment for patients with non–small-cell lung cancer (NSCLC), but patients’ long-term outcome is still challenging. The purpose of this study was to identify predictors of long-term survival in patients after lung cancer surgery.

METHODS:

Patients who underwent surgery for NSCLC from January 1, 2006, to December 31, 2009, were enrolled into this retrospective cohort study. The primary outcome was the survival length after surgery. Predictors of long-term survival were screened with the multivariable Cox proportional hazard model.

RESULTS:

Postoperative follow-up was completed in 588 patients with a median follow-up duration of 5.2 years (interquartile range, 2.0–6.8). Two hundred ninety-one patients (49.5%) survived at the end of follow-up with median survival duration of 64.3 months (interquartile range, 28.5–81.6). The overall survival rates were 90.8%, 70.0%, and 57.1% at the end of the first, third, and fifth year after surgery, respectively. Limited resection (hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.08–1.98; P = .013) and large tumor size (HR, 1.29; 95% CI, 1.17–1.42; P < .001) were associated with short survival; whereas high body mass index grade (HR, 0.82; 95% CI, 0.69–0.97; P = .021), highly differentiated tumor (HR, 0.59; 95% CI, 0.37–0.93; P = .024), dissection of mediastinal lymph node during surgery (HR, 0.45; 95% CI, 0.30–0.67; P < .001), and perioperative use of dexamethasone (HR, 0.70; 95% CI, 0.54–0.90; P = .006) were associated with long survival. No association was found between perioperative use of flurbiprofen axetil and long survival (HR, 0.80; 95% CI, 0.62–1.03; P = .086). However, combined administration of dexamethasone and flurbiprofen axetil was associated with longer survival (compared to no use of both: adjusted HR, 0.57; 95% CI, 0.38–0.84; P = .005).

CONCLUSIONS:

Certain factors in particular perioperative dexamethasone and flurbiprofen axetil therapy may improve patients’ long-term survival after surgery for NSCLC. Given the small sample size, these findings should be interpreted with caution, and randomized clinical trials are needed for further clarification.

Influence of the Body Mass Index and its Effect on Tumor Characteristics and Survival among a Population with Access to Surgical Management of Upper Tract Urothelial Carcinoma

Objective

To examine the association between the body mass index (BMI) and the risk of survival, and to evaluate whether tumor characteristics differ by BMI in patients with upper tract urothelial carcinoma (UTUC) managed by surgery.

Methods

A clinical series on 876 patients with localized UTUC following nephroureterectomy with a bladder cuff, with data from Osaka Medical College registry (discovery cohort) and the Nagoya group (validation cohort) was examined. In addition to analyzing the overall survival and cancer-specific survival (CSS), the survival impact adjusted by pathological variables was also assessed by the BMI group.

Results

The percentage of high risk features including positive lymphovascular invasion was doubled in the discovery cohort compared to the validation cohort. The group of BMI ≥ 25 kg/m² was associated with improved CSS in the discovery cohort (p = 0.004), and this tendency was verified in the validation cohort (p = 0.006). Nonproportional hazards existed for the group of BMI ≥ 25 kg/m² and the BMI 18.5-25 kg/m² relative to the group of BMI < 18.5 kg/m², with a change in the CSS hazard. In multivariable Cox models, the BMI group had a superior predictive value compared with other pre-clinical factors both in the discovery cohort (HR = 3.85, p = 0.01; 95%CI: 0.09-0.73) and the validation cohort (HR = 1.56, p = 0.01; 95%CI: 0.45-0.91). When adjusted by lymphovascular invasion, the concordance of the model proposed by the discovery cohort (0.52) challenged in the validation cohort was 0.59.

Conclusions

We found a clinically relevant signature for high risk patients with BMI grouping. Further research is necessary on whether tailoring recommendations for weight and nutrition management to tumor characteristics will improve outcomes.

Simplified synchronous disconnection of pulmonary arteries and veins for right upper lobectomy

BACKGROUND

Video-assisted thoracoscopic lobectomy with lymphadenectomy is considered one of the most effective treatments for early non-small cell lung cancer. We developed a novel approach for lobectomy in patients with right upper lung cancer through simplified synchronous disconnection of pulmonary arteries and veins. This study aimed to evaluate the feasibility, efficacy, safety, and cost-effectiveness of this minimally invasive technique in managing right upper lobectomy.

PATIENTS AND METHODS

From March 2016 to September 2017, 62 patients with right upper lung cancer underwent lobectomy via simplified synchronous disconnection of pulmonary arteriovenous by video-assisted thoracoscopic surgery. All patients were followed up for 6-12 months after the procedure through clinic visits or telephone/e-mail interviews.

RESULTS

Of the 62 patients (mean age, 57.2 ± 8.7 years), 28 were men (45.2%) and 34 (54.8%) were women. All procedures were successfully performed by thoracoscopy, with a mean operating time of 66.2 ± 9.0 min. The mean blood loss was 40.3 ± 19.5 mL. Only 1 (1.61%) patient required blood transfusion. The mean number of endoscopic linear stapling devices used was 2.6 ± 0.7. The mean number of lymph nodes harvested was 16.0 ± 1.6. Postoperative pneumonia was encountered in 4 (6.45%) patients. There was no postoperative mortality. The mean length of hospital stay was 5.3 ± 1.3 days. Six-month follow-up revealed an excellent clinical result and degree of satisfaction.

CONCLUSIONS

Simplified synchronous disconnection of pulmonary arteries and veins is a feasible, economical, safe, and effective therapeutic procedure for right upper lung carcinoma. This novel procedure shows promise as a viable surgical approach for right upper lobectomy.

Atrial fibrillation in patients with active malignancy and use of anticoagulants: Under-prescription but no adverse impact on all-cause mortality

Prescription of anticoagulants (ACs) in patients with cancer and atrial fibrillation (AF) is challenging and the impact on survival is not defined. In this study data prospectively collected in Oncology Units were retrospectively evaluated. Among 4664 patients admitted for malignancy, 394 patients (8.4%) had documented AF (mean age of 74 ± 9) and AC was prescribed to 155 patients (40%). Neither the type of cancer, the stage of the disease (metastatic or not) nor the ongoing treatments were significantly associated with prescription of AC, which was independently associated with BMI (OR 1.10; CI 95% 1.03-1.17; p = .003), valvular heart disease (OR 3.76; CI95% 1.59-8.87; p = .002), and previous venous thromboembolism (OR 6.67; 95%CI 2.67-16.70; p < .001). During a median follow-up of 212 days, survival from all-cause death was 37%, 28% and 18% at 6 months, 1 and 2 years, respectively. Only variables related to neoplastic disease or to patient clinical complexity were independently associated with mortality. A CHA₂DS₂VASc ≥ 4 was significantly associated with mortality (HR 1.33; 95%CI 1.06-1.67; p = .013). Treatment with ACs was not significantly related to mortality, neither in the whole cohort of patients, nor in patients with metastatic malignancies. In conclusion the prescription of ACs in patients with AF and active cancer was suboptimal, with one fourth of the patients not treated with ACs and one third using LMWH at prophylactic, non-therapeutic doses. Only few variables (BMI, valvular heart disease and previous venous thromboembolism) predicted prescription of ACs. Prescription of ACs was not associated with all-cause mortality, even in the subgroup with metastasis.

Impact of body mass index on long-term survival outcome in Asian populations with solid cancer who underwent curative-intent surgery: A six-year multicenter observational cohort study

Purpose: Being elevated body mass index (BMI) has been considered a poor prognostic factor in patients with cancer. However, studies about the impact of elevated BMI on the survival outcome after cancer surgery have conflicting results. This study aimed to evaluate the impact of BMI on long-term postoperative survival outcome in a large cohort of Asian population with solid cancers. Methods: A total of 33,551 patients who underwent curative-intent surgery for solid cancers between January 2007 and December 2012 at four hospitals in Taiwan were included. BMI was analyzed using univariate and multivariate regression analyses to determine its association with survival outcome. Results: With a median follow-up of 43.8 (range, 1-91) months, the rate of all-cause mortality was 21.7% (n=7264 patients), while that of cancer-related mortality was 13.4% (n=4499 patients). BMI was a significant prognostic factor in multivariate analysis for overall survival (OS) and cancer-specific survival (CSS). The adjusted hazard ratio (HR) per kg/m² was 0.922 (95% confidence interval [CI], 0.916-0.929; P<0.001) and 0.932 (95% CI, 0.924-0.940; P<0.001) for OS and CSS, respectively. Patients with BMI <17 kg/m² had the highest postoperative mortality risk, with a hazard ratio of 3.8-fold higher for OS and 5.0-fold higher for CSS than those with BMI >35 kg/m². Conclusions: This study showed that BMI was positively associated with survival outcome in patients with cancer who underwent radical surgery. BMI was an independent prognostic factor and can be used to risk stratify patients in Asians with solid cancers.

Association of body mass index and outcomes following lobectomy for non-small-cell lung cancer

Background

Obesity and overweight have become increasingly prevalent, but no consensus has been reached regarding the effect of body mass index (BMI) on surgical outcomes. In this study, we sought to examine the influence of BMI on perioperative outcomes in a large cohort of patients with non-small-cell lung cancer (NSCLC) who underwent lobectomy.

Methods

A retrospective study was conducted in 1198 patients who underwent lobectomy for primary NSCLC at Shandong Provincial Hospital between November 2006 and January 2017. BMI was calculated using measured height and weight on admission and categorized as obese (≥ 30 kg/m²), overweight (25 to 29.9 kg/m²), normal (18.5 to 24.9 kg/m²), or underweight (< 18.5 kg/m²). Patients’ baseline characteristics and outcomes were abstracted from medical records following institutional review board approval. Endpoints included operative mortality, perioperative complications, and length of stay (LOS). Complications were divided into four groups as respiratory, cardiovascular, other, and overall. Logistic regression models were constructed to assess the association between BMI and adverse outcomes.

Results

When compared with normal BMI, obesity and overweight did not increase the risk of complications in any category, operative mortality, or prolonged LOS. In fact, the incidence of operative mortality and respiratory complications tended to be lower in overweight patients than in normal weight patients (P = 0.047 and P = 0.041, respectively). Conversely, underweight patients experienced significantly more operative mortality, respiratory complications, and prolonged LOS (P = 0.004, P = 0.011, and P = 0.003, respectively).

Conclusions

Obesity and overweight did not confer adverse surgical outcomes. Underweight patients presented increased risk of respiratory complications, perioperative death, and prolonged LOS. Thus, overweight and obesity should not be a relative contraindication for lobectomy. Meanwhile, nurses and surgeons should focus on perioperative management of underweight patients.

Preoperative nutritional status assessment predicts postoperative outcomes in patients with surgically resected non-small cell lung cancer

BACKGROUND

As nutritional status plays an important role in outcomes after surgery, this study evaluated the association between preoperative nutritional status (NS) and postoperative outcomes after major resection for lung cancer.

METHODS

We identified 219 patients with a diagnosis of cancer who underwent pulmonary resection from 2010 to 2012. Preoperative NS was assessed by anthropometric and biological parameters, body mass index (BMI), and the Nutritional Risk Index (NRI). We stratified this population into 4 BMI groups: underweight, normal weight, overweight and obese and 4 NRI groups: well-nourished; mildly malnourished; moderately malnourished and severely malnourished. The outcomes measured were postoperative complications; 30-day postoperative mortality; hospital length of stay (LOS), overall survival (OS) and disease-free survival (DFS). We performed both unadjusted analysis and adjusted multivariable analysis, controlling for statistically significant variables.

RESULTS

Mean BMI and NRI were, respectively, 26.5 ± 4.3 and 112.4 ± 3.3. There were no significant differences between BMI categories and resection type, pathological stage, or overall postoperative complications. By contrast, significant differences (p < 0.05) in postoperative complications were observed among the NRI groups. LOS was longer in underweight and/or malnourished patients. In terms of OS, we found no significant differences according to NRI and BMI; however, patients with underweight had significantly shorter DFS compared with patients with overweight and obesity (log-rank p-value = 0.001).

CONCLUSION

NS as measured by the NRI is an independent predictor of the risk of postsurgical complications, regardless of clinicopathologic characteristics. NRI might therefore be an useful tool for identifying early-stage lung cancer patients at risk for postoperative complications.