Establishment of a Nomogram-Based Model for Predicting the Prognostic Value of Inflammatory Biomarkers and Preoperative D-Dimer Level in Spinal Ewing's Sarcoma Family Tumors: A Retrospective Study of 83 Patients

Treatment outcomes in patients with Ewing sarcoma of the spine in a resource-challenged setting: 17-year experience from a single center in India

Ewing sarcoma (ES) of the spine is a rare childhood cancer with sparse literature on treatment outcomes. We aimed to describe survival outcomes and prognostic factors in patients with spinal ES treated at a single institute in a resource-challenged setting. We conducted a retrospective analysis of patients with spinal ES registered at a tertiary care oncology center between 2003-2019. Clinical patient data was retrieved from hospital records. Cox regression analysis was used to identify the association of baseline clinical parameters with event free survival (EFS) and overall survival (OS). A cohort of 85 patients was analyzed including 38 (45%) patients with metastatic disease. The median age was 15 years with 73% being male. Local therapy was administered in 62 (72.9%) patients with surgery alone in 8 (9.4%), radiotherapy alone in 36 (42.4%) and both in 18 (21.2%) patients. A higher proportion of males received local therapy than females (80.3% versus 59.1%; p = 0.049). The median EFS and OS were 20.1 and 28.6 months, respectively. On univariable analysis, age ≤ 15 years, female sex, serum albumin ≤3.5 g/dL and hemoglobin ≤11 g/dL were associated with inferior EFS while younger age, female sex, hypoalbuminemia and metastatic disease were associated with inferior OS. On multivariable analysis, only hypoalbuminemia was predictive for inferior EFS (HR:2.41; p = 0.005) while hypoalbuminemia (HR:2.06;p = 0.033) and female sex (HR:1.83; p = 0.046) were associated with inferior OS. We concluded that hypoalbuminemia confers poor prognosis in ES spine. Survival outcomes are poorer in females treated in our setting, possibly due to prevailing sex-based biases.

The prognostic utility of neutrophil-lymphocyte ratio in spinal surgery: A systematic review and meta-analysis

PURPOSE

Neutrophil-lymphocyte ratio (NLR) is reportedly an effective prognostic tool across various medical and surgical fields, but its value in spinal surgery is unestablished. We aim to investigate the relationship between elevated baseline/postoperative NLR and patient outcomes in spinal surgery.

MATERIALS AND METHODS

We performed a systematic search in PubMed, EMBASE, and SCOPUS databases for studies investigating the prognostic value of NLR in spine patients.Odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (CIs) were analysed on the RevMan 5.4 software. Where meta-analysis was not possible, we vote-counted the direction of the effect of elevated NLR. The GRADE framework for prognostic factor research was utilised to assess the certainty of the evidence for each outcome measure.

RESULTS

Five outcome measures (overall survival, mortality, disease-free survival, functional recovery and complications) were assessed across 16 studies involving 5471 patients. Elevated baseline NLR was associated with reduced overall survival (HR: 1.63, 95 % CI: 1.05 - 2.54) (GRADE: low) and worsened functional recovery (OR: 0.93, 95 % CI: 0.87 - 0.98) (GRADE: low). There was no association between baseline NLR and disease-free survival (HR: 2.42, 95 % CI: 0.49 - 11.83) (GRADE: very low) or mortality (OR: 1.39, 95 % CI: 0.41 - 4.75) (GRADE: very low). Elevated NLR levels measured on days 3-4 and days 6-7 postoperatively, but not NLR measured at baseline or on days 1-2 postoperatively, were associated with greater risks of complications (GRADE: low).

CONCLUSIONS

NLR is an objective tool with the potential to identify the patients that would benefit from surgery and facilitate shared decision-making.

The Prognostic Value of the Serum Level of C-Reactive Protein for Survival of Children with Ewing's Sarcoma

The purpose of the present study was to evaluate the prognostic role of C-reactive protein (CRP) in children with Ewing's sarcoma. We conducted a retrospective study on 151 children undergoing multimodal treatment for Ewing's sarcoma in the appendicular skeleton from December 1997 to June 2020. Univariate Kaplan-Meier analyses of laboratory biomarkers and clinical parameters showed that CRP and metastatic disease at presentation were poor prognostic factors associated with overall survival and disease recurrence at 5 years (p < 0.05). A multivariate Cox regression model showed that pathological CRP (≥1.0 mg/dL) [HR of 3.67; 95% CI, 1.46 to 10.42] and metastatic disease [HR of 4.27; 95% CI, 1.58 to 11.47] were associated with a higher risk of death at 5 years (p < 0.05). In addition, pathological CRP (≥1.0 mg/dL) [HR of 2.66; 95% CI, 1.23 to 6.01] and metastatic disease [HR of 2.56; 95% CI, 1.13 to 5.55] were associated with a higher risk of disease recurrence at 5 years (p < 0.05). Our findings demonstrated that CRP was associated with the prognosis of children with Ewing's sarcoma. We recommend pre-treatment measurement of the CRP in order to recognize children with Ewing's sarcoma who are at greater risk of death or local recurrence.

C-Reactive Protein Pretreatment-Level Evaluation for Ewing's Sarcoma Prognosis Assessment-A 15-Year Retrospective Single-Centre Study

Background: A pathological/inflamed cellular microenvironment state is an additional risk factor for any cancer type. The importance of a chronic inflammation state in most diffuse types of tumour has already been analysed, except for in Ewing’s sarcoma. It is a highly malignant blue round cell tumour, with 90% of cases occurring in patients aged between 5 and 25 years. Worldwide, 2.9 out of 1,000,000 children per year are affected by this malignancy. The aim of this retrospective study was to analyse the role of C-reactive protein (CRP) as a prognostic factor for Ewing’s sarcomas. Methods: This retrospective study at Klinikum rechts der Isar included 82 patients with a confirmed Ewing’s sarcoma diagnosis treated between 2004 and 2019. Preoperative CRP determination was assessed in mg/dL with a normal value established as below 0.5 mg/dL. Disease-free survival time was calculated as the time between the initial diagnosis and an event such as local recurrence or metastasis. Follow-up status was described as death of disease (DOD), no evidence of disease (NED) or alive with disease (AWD). The exclusion criteria of this study included insufficient laboratory values and a lack of information regarding the follow-up status or non-oncological resection. Results: Serum CRP levels were significantly different in patients with a poorer prognosis (DOD) and in patients who presented distant metastasis (p = 0.0016 and p = 0.009, respectively), whereas CRP levels were not significantly different in patients with local recurrence (p = 0.02). The optimal breakpoint that predicted prognosis was 0.5 mg/dL, with a sensitivity of 0.76 and a specificity of 0.74 (AUC 0.81). Univariate CRP analysis level >0.5 mg/dL revealed a hazard ratio of 9.5 (95% CI 3.5−25.5). Conclusions: In Ewing’s sarcoma cases, we consider a CRP pretreatment value >0.5 mg/dL as a sensitive prognostic risk factor indication for distant metastasis and poor prognosis. Further research with more data is required to determine more sensitive cutoff levels.

Do coagulation or fibrinolysis reflect the disease condition in patients with soft tissue sarcoma?

BACKGROUND

Coagulation and fibrinolysis are distinct processes that are highly correlated. Cells control coagulation and fibrinolysis by expression of tissue factor and urokinase-type plasminogen activator receptor on their surface. Tumor cells express these proteins, adjust their microenvironment and induce tumor exacerbation. We hypothesized that the expression of plasma markers for coagulation and fibrinolysis in patients with soft tissue sarcomas (STSs) was dependent on the level of tumor malignancy. To elucidate which markers are predictive of recurrence, metastasis and prognosis, coagulation or fibrinolysis, we analyzed the correlation between plasma levels of thrombin-antithrombin III complex (TAT), soluble fibrin (SF), plasmin-α2 plasmin inhibitor complex (PIC), D-dimer (DD) and clinical parameters in patients with STSs.

METHODS

TAT, SF, PIC or DD were measured in pre-treatment blood samples from 64 patients with primary STSs and analyzed with clinicopathological parameters, and 5-year recurrence free survival (RFS), 5-year metastasis free survival (MFS) and 5-year overall survival (OS) were evaluated.

RESULTS

The metastasis group had significantly higher DD (p = 0.0394), PIC (p = 0.00532) and SF (p = 0.00249) concentrations than the group without metastasis. The group that died of disease showed significantly higher DD (p = 0.00105), PIC (p = 0.000542), SF (p = 0.000126) and TAT (p = 0.0373) than surviving patients. By dividing the patients into low and high groups, the group with high DD, PIC, SF and TAT showed significantly lower 5-year MFS and 5-year OS than the corresponding low group. Furthermore, in multivariate COX proportional hazard analysis of continuous variables for 5-year MFS, only PIC was found to be a significant factor (HR: 2.14).

CONCLUSION

Fibrinolysis was better than coagulation at reflecting the disease condition of patients with STS. Notably, PIC levels ≥ 1.1 can not only predict the risk of metastasis and poor prognosis, but also increasing PIC levels correspond to further increases in risks of metastasis and poor prognosis.

Nomogram based on pre-treatment inflammatory biomarkers predicting survival in patients with head and neck soft tissue sarcoma

BACKGROUND

Systemic inflammatory biomarkers reflect level of inflammatory response, which have been suggested as prognostic factors in cancer patients.

OBJECTIVE

To estimate the prognostic value of inflammatory biomarkers in 149 patients with head and neck soft tissue sarcoma (HNSTS).

METHODS

Pre-treatment neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), systemic immune-inflammation index (SII), neutrophil-platelet score (NPS) and Aarhus Composite Biomarker Score (ACBS) were analyzed for association with overall survival (OS) and progression-free survival (PFS). Nomograms were consisted of independent predictors for OS and PFS, and evaluated by calibration curve and concordance index (C-index).

RESULTS

In multivariate analysis, LMR (HR = 0.42, 95% CI: 0.19-0.94, P= 0.035), ACBS (HR = 2.05, 95% CI: 1.02-4.12, P= 0.045) and AJCC stage were independent prognostic markers of OS. Moreover, high NLR (HR = 1.78, 95% CI: 1.07-2.94, P= 0.024) and advanced AJCC stage were independently related with worse PFS. Calibration curves reflected good discriminative ability of prognosis. The nomograms showed better accuracy of predicting OS (C-index: 0.748 vs. 0.690, P= 0.009) and PFS (C-index: 0.644 vs. 0.612, P= 0.028) than stage.

CONCLUSIONS

Pre-treatment LMR, ACBS and AJCC stage were effective predictor of OS. The NLR and AJCC stage could independently predict PFS. The nomogram might act as a promising prognostic model for OS and PFS in HNSTS.

The prognostic value of the C-reactive protein to albumin ratio in cancer: An updated meta-analysis

BACKGROUND

Previous studies have demonstrated that the C-reactive protein to albumin ratio (CAR) is correlated with the clinical outcomes of solid tumors. However, the available data have not been systematically evaluated. The objective of the present meta-analysis was to explore the prognostic value of the CAR in solid tumors.

METHODS

Eligible studies were identified from the PubMed, EMBASE and Web of Science electronic databases. The clinical characteristics, disease -free survival (DFS) /progression-free survival (PFS) and overall survival (OS) were extracted from the eligible studies. The pooled hazard ratios (HRs) and 95% confidence intervals were calculated with STATA 12.0 software. We also performed subgroup, meta-regression and sensitivity analyses.

RESULTS

In total, twenty-seven eligible studies including 10556 patients were enrolled in the present meta-analysis. The pooled HRs with 95% confidence intervals showed that the CAR was significantly associated with poor OS (HR = 1.95, 95% CI: 1.71-2.22) and DFS/PFS (HR = 1.82, 95% CI: 1.61-2.07) in patients with solid tumors. Although publication bias was found in the studies with regard to OS, a further trim and fill analysis revealed that the adjusted HR was 1.82 (95% CI: 1.69-1.96), which was close to the original HR. Subgroup analysis confirmed the CAR as a strong prognostic marker in patients with solid tumors, regardless of the tumor type, detection time, cut-off value, sample size and area.

CONCLUSION

Our meta-analysis indicated that a high CAR might be an unfavorable prognostic marker for OS and DFS/PFS in patients with solid tumors.

The Prognostic Role of Glasgow Prognostic Score and C-reactive Protein to Albumin Ratio for Sarcoma: A System Review and Meta-Analysis

Backgrounds

Both pretreatment serum CRP (C-reactive protein) level and ALB (albumin) level have been found to be predictive of survival for multiple malignancies including sarcoma. Since both of the GPS (Glasgow prognostic score) and CAR (C-reactive protein to albumin ratio) are based on the combination of CRP and ALB, we conducted a meta-analysis to evaluate the prognostic role of these two parameters for sarcoma patients.

Methods

A detailed literature search was conducted in MEDLINE, Embase, and Cochrane Library for relevant research publications written in English. Patients' clinical characteristics, outcomes of overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were extracted. Pooled hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were combined to evaluate the prognostic role of GPS or CAR.

Results

Twelve articles containing 2695 patients were identified as eligible studies. The results showed that an elevated GPS was significantly correlated with poor OS (HR = 2.42; 95% CI: 1.98-2.94; p < 0.001; fixed-effects model), DSS (HR = 2.28; 95% CI: 1.75-2.97; p < 0.001; fixed-effects model), and DFS (HR = 2.05; 95% CI: 1.62-2.60; p < 0.001; fixed-effects model). A higher CAR also was shown to be significantly correlated with poor OS (HR = 2.23; 95% CI: 1.70-2.92; p < 0.001; fixed-effects model) and DFS (HR = 1.81; 95% CI: 1.7-2.58; p = 0.001; fixed-effects model).

Conclusion

An elevated GPS is predictive of poor survival in patients with sarcomas and is promising to be used as a factor for risk stratification. A higher CAR value is also predictive of poor survival; however, the optimal CAR cut-off value is still to be determined.

Prognostic Significance of Preoperative Inflammatory Biomarkers and Traditional Clinical Parameters in Patients with Spinal Metastasis from Clear Cell Renal Cell Carcinoma: A Retrospective Study of 95 Patients in a Single Center

Purpose

The purpose of this retrospective study was to identify preoperative inflammatory biomarkers and clinical parameters and evaluate their prognostic significance in patients with spinal metastasis from clear cell renal cell carcinoma (CCRCC).

Patients and methods

Correlations of overall survival (OS) with traditional clinical parameters and inflammatory indicators including the neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR), lymphocyte–monocyte ratio (LMR), albumin–globulin ratio (AGR), and C-reactive protein to albumin ratio (CRP/Alb ratio) were analyzed in 95 patients with spinal metastasis from CCRCA using the Kaplan–Meier method to identify potential prognostic factors. Factors with P values ≤ 0.1 were subjected to multivariate analysis by Cox regression analysis. P values ≤ 0.05 were considered statistically significant.

Results

The 95 patients included in this study were followed up by a mean of 48.8 months (median 51 months; range 6–132 months), during which 21 patients died, with a death rate of 22.1%. The statistical results indicated that patients with total piecemeal spondylectomy (TPS), targeted therapy, NLR < 3.8 and PLR < 206.9 had a significantly longer OS rate.

Conclusion

TPS and targeted therapy could significantly prolong the OS of patients with spinal metastasis from CCRCC. In addition, NLR and PLR are robust and convenient prognostic indicators that have a discriminatory ability superior to other inflammatory biomarkers.

Construction and Validation of Nomograms for Predicting the Prognosis of Juvenile Osteosarcoma: A Real-World Analysis in the SEER Database

BACKGROUND

Osteosarcoma is one of the most common malignant bone tumors, with a high incidence in adolescence. The objective of this study was to construct prognostic nomograms for predicting the prognosis of juvenile osteosarcoma.

METHODS

Patients with osteosarcoma diagnosed between 2004 and 2015 were identified in the Surveillance, Epidemiology, and End Results (SEER) database. The essential clinical predictors were identified with univariate and multivariate Cox analysis. Nomograms were constructed to predict the 3- and 5-year cancer- specific survival (CSS) and overall survival (OS). Concordance index (C-index) and calibration plots were performed to validate the predictive performance of nomograms.

RESULTS

We enrolled 736 adolescents with osteosarcoma from the SEER database, with 516 samples grouped into a training cohort and 220 samples grouped into a validation cohort. In multivariate analysis of the training cohort, predictors including tumor size, surgery treatment and AJCC stage were found to be associated with OS and CSS, while age was only associated with CSS. Construction of nomograms based on these predictors was performed to evaluate the prognosis of adolescents with osteosarcoma. The C-index and calibration curves also showed the satisfactory performance of these nomograms for prognosis prediction.

CONCLUSION

The developed nomograms are useful tools for precisely predicting the prognosis of adolescents with osteosarcoma, which could enable patients to be more accurately managed in clinical practice.

Clinical significance of traditional clinical parameters and inflammatory biomarkers for the prognosis of patients with spinal chondrosarcoma: a retrospective study of 150 patients in a single center

BACKGROUND

To investigate the clinical significance of five inflammatory biomarkers and conventional clinical parameters in prognostic prediction of spinal chondrosarcoma.

METHODS

Univariate and multivariate analyses were performed to investigate independent prognostic factors for recurrence and death of patients with spinal chondrosarcoma. Disease-free survival (DFS) and overall survival (OS) were estimated by Kaplan-Meier curve, and differences were analyzed by log-rank test. The optimal cutoff values for NLR, PLR, LMR, and CAR were determined by X-tile program.

RESULTS

The optimal cutoff value for NLR, PLR, LMR, AGR, and CAR was 2.7, 200, 3.0, 1.5, and 0.2, respectively. Of the 150 patients included, recurrence was detected in 105 patients, and death occurred in 78 patients. Multivariate analysis indicated that Tomita I-III, total resection, and CAR < 0.2 were significantly associated with longer DFS. Meanwhile, preoperative Frankel score D-E, total resection, and CAR < 0.2 were favorable prognostic factors for OS. Subtype analysis showed that only total resection was an independent prognostic factor for DFS of recurrent spinal chondrosarcoma.

CONCLUSION

Total resection could significantly reduce the recurrence rate of spinal chondrosarcoma and improve OS of chondrosarcoma patients. Tomita classification I-III was a favorable factor for DFS, and preoperative Frankel score A-C was an adverse prognostic factor for OS. CAR was the most robust prognostic indicator with a discriminatory ability as compared with other inflammatory indicators. These slides can be retrieved under Electronic Supplementary Material.