Albumin synthesis rates are not decreased in hypoalbuminemic cachectic cancer patients with an ongoing acute-phase protein response

Predictive values of sarcopenia and systemic inflammation-based markers in advanced hepatocellular carcinoma after hepatectomy

BACKGROUND

Sarcopenia accompanied by systemic inflammation is associated with poor prognosis in patients with advanced hepatocellular carcinoma (HCC). However, the effect of sarcopenia combined with systemic inflammation on the prognosis of patients with advanced HCC who underwent hepatectomy is unclear. This study aimed to evaluate the effect of sarcopenia and inflammation on the prognosis of patients with advanced HCC.

METHODS

This retrospective study included 151 patients recruited between July 2010 and December 2022. We defined advanced HCC as that presenting with vascular invasion or tumor size ≥2 cm or multiple tumors. Sarcopenia was assessed using the psoas muscle index. Preoperative inflammatory markers were used by calculating the prognostic nutritional index, albumin-globulin ratio (AGR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio. Cox regression analysis was performed to determine the prognostic factors for overall survival.

RESULTS

Of 151 patients, sarcopenia occurred in 84 (55.6 %). Sarcopenia was significantly associated with male sex, older age, body mass index (<25 kg/m2), and a higher NLR. In the multivariate analysis, AGR <1.25 (hazard ratio [HR], 2.504; 95% confidence interval [CI]: 1.325-4.820; p < 0.05); alpha-fetoprotein levels ≥25 ng/mL (HR, 1.891; 95% CI: 1.016-3.480; p = 0.04); and sarcopenia (HR, 1.908; 95% CI: 1.009-3.776; p < 0.05) were independent predictors of overall survival. The sarcopenia and low AGR groups had significantly worse overall survival than either the non-sarcopenia and high AGR or sarcopenia and low AGR groups.

CONCLUSION

Sarcopenia and AGR are independent prognostic factors in patients with advanced HCC. Thus, sarcopenia may achieve a better prognostic value when combined with AGR.

Combination of sarcopenia and systemic inflammation-based markers for predicting the prognosis of patients undergoing pancreaticoduodenectomy for pancreatic cancer

BACKGROUND

This study aimed to evaluate the effects of sarcopenia and inflammation on the prognosis of patients with pancreatic cancer after pancreaticoduodenectomy.

METHODS

Eighty patients who had undergone pancreaticoduodenectomy for pancreatic cancer between July 2010 and December 2023 were included in this study. The psoas muscle index was used to assess sarcopenia. The C-reactive protein-to-albumin ratio, prognostic nutritional index, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio were used to calculate the preoperative inflammatory marker levels. The prognostic factors for overall survival were determined using Cox regression analysis.

RESULTS

Twenty-four patients were diagnosed with sarcopenia. Sarcopenia showed a significant association with advanced tumor stage. Univariate analysis revealed a significant reduction in overall survival in patients with a prognostic nutritional index of <45, C-reactive protein-to-albumin ratio of ≥0.047, cancer antigen 19-9 levels of ≥130 U/mL, sarcopenia, lymph node metastasis, and vascular invasion. Multivariate analysis revealed that a C-reactive protein-to-albumin ratio of ≥0.047 (hazards ratio, 3.383; 95% confidence interval: 1.384-8.689; p< 0.001), cancer antigen 19-9 levels of ≥130 U/mL (hazards ratio, 2.720; 95% confidence interval: 1.291-6.060; p = 0.008), sarcopenia (hazards ratio, 3.256; 95% confidence interval: 1.535-7.072; p = 0.002) and vascular invasion (hazards ratio, 2.092; 95% confidence interval: 1.057-4.170; p = 0.034) were independent predictors of overall survival. Overall survival in the sarcopenia and high C-reactive protein-to-albumin ratio groups was significantly poorer than that in the non-sarcopenia and low C-reactive protein-to-albumin ratio and sarcopenia or high C-reactive protein-to-albumin ratio groups.

CONCLUSION

Sarcopenia and a high C-reactive protein-to-albumin ratio are independent prognostic factors in patients with pancreatic cancer after pancreaticoduodenectomy. Thus, sarcopenia may have a better prognostic value when combined with the C-reactive protein-to-albumin ratio.

Retrospective study of a novel hematological parameter for predicting the survival of patients with nasopharyngeal carcinoma

Purpose

This study aims to explore the prognostic values of routine pre-treatment hematological parameters in patients with nasopharyngeal carcinoma (NPC).

Methods

The hematological parameters and clinical data of patients with NPC were collected from January 2012 to December 2013 at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. The survival statistics were obtained by regularly following-up the patients. The cut-off values for the hematological parameters were calculated using X-tile software. SPSS version 24.0 was used for the statistical analysis. The relationship between the hematological parameters and the prognosis of patients with NPC was analyzed using the Kaplan-Meier method and Cox multivariate regression. The discriminating abilities of the factors, which predict the prognosis, were evaluated by utilizing the receiver operating characteristic (ROC) area under the curve (AUC).

Results

This study included 179 patients with NPC. Multivariate analysis shows that pretreatment platelet-to-lymphocyte ratio (PLR; hazard ratio; HR = 0.44, 95% CI [0.21-0.91], p = 0.029), serum albumin (ALB; HR = 2.49, 95% CI [1.17-5.30], p = 0.018), and globulin (GLO; HR = 0.44, 95% CI [0.21-0.90], p = 0.024) are independent predictors for 5-year overall survival (OS) in patients with NPC. In addition, pre-treatment PLR (HR = 0.47, 95% CI [0.25-0.90], p = 0.022) and pre-treatment GLO (HR = 0.37, 95% CI [0.19-0.72], p = 0.001) are associated with 5-year progression-free survival (PFS) in patients with NPC. Based on the results of the multivariate analysis, we proposed a new biomarker GLO-PLR, which is observably correlated with the T stage, N stage and clinical stage in patients with NPC. The OS resolving ability of the GLO-PLR evaluated by AUC is 0.714, which is better than those of GLO and PLR. The PFS resolving ability of the GLO-PLR evaluated by AUC was 0.696, which is also better than those of GLO and PLR.

Conclusion

Pre-treatment PLR, ALB, and GLO are independent predictors of 5-year OS in patients with NPC, where PLR and GLO are also independent predictors of 5-year FPS. Compared with other hematological parameters, the proposed GLO-PLR is an inexpensive, effective, objective, and easy-to-measure marker for predicting the prognosis of NPC.

Influence of intravenous 10% amino acids infusion on serum albumin concentration in hypoalbuminemic dogs

Objective

To evaluate the effect of parenteral amino acid application in hospitalized hypoalbuminemic dogs.

Materials and methods

Medical records of client-owned hypoalbuminemic dogs (albumin ≤ 25 g/L) were analyzed. Dogs receiving amino acids for only 1-2 days, receiving transfusions or surgery, or <6 months of age were excluded. Dogs were grouped as those receiving intravenous amino acids (AA, 80 dogs) over 3 days and longer, and those without additional amino acid treatment (CON, 78 dogs). Duration of hospitalization, albumin, and total protein concentrations were compared between groups by Mann-Whitney U test. Course of albumin and total protein concentration was evaluated by Friedman test and Dunn's multiple comparison test. Significance was set to p ≤ 0.05.

Results

Dogs in group AA received 10% amino acid solution intravenously over median 4 days (3-11 days). No significant differences regarding survival and adverse effects were observed between groups. Dogs of group AA had significantly longer duration of hospitalization (median 8 days; 3-33 days) compared to group CON dogs (median 6 days, 3-24 days; p < 0.001). Initial albumin concentration was lower in group AA compared to CON (p < 0.001). This difference was no longer present on day 2 (p = 0.134).

Conclusions and clinical relevance

Intravenous application of 10% amino acid solution in hypoalbuminemic dogs can improve albumin concentration after 2 days, but does not influence outcome.

Pretreatment Nutritional Status in Combination with Inflammation Affects Chemotherapy Interruption in Women with Ovarian, Fallopian Tube, and Peritoneal Cancer

BACKGROUND

Discontinuing chemotherapy worsens cancer prognosis. This study aimed to investigate the relationship between nutritional status at the start of chemotherapy and chemotherapy discontinuation in patients with ovarian, fallopian tube, and primary peritoneal cancer.

METHODS

This was a retrospective cohort study. One hundred and forty-six patients to whom weekly paclitaxel and carboplatin were administered as postoperative chemotherapy were included. Six courses in 21-day cycles were defined as complete treatment. As nutritional indicators, body mass index, weight change rate, serum albumin, total lymphocyte count, prognostic nutritional index, and C-reactive protein-to-albumin ratio (CAR) were compared between complete and incomplete treatment groups. Patients were divided into two groups according to CAR. The number of chemotherapy cycles was compared between these two groups. A Cox proportional hazard model was used for covariate adjustment.

RESULTS

Several indicators differed between complete and incomplete treatment groups, and among the indicators, CAR had the highest discriminatory ability. The number of chemotherapy cycles was shorter in the high CAR group than in the low CAR group. A high CAR was associated with chemotherapy interruption even after adjusting for covariates.

CONCLUSION

Based on CAR, nutritional status before chemotherapy is suggested to be associated with the risk of chemotherapy discontinuation.

Evaluation of the Prognostic Capacity of a Novel Survival Marker in Patients with Sinonasal Squamous Cell Carcinoma

Sinonasal squamous cell carcinoma (SNSCC) is a malignant tumor associated with poor survival, and easily obtainable prognostic markers are of high interest. Therefore, we aimed to assess the prognostic value of a novel survival index (SI) combining prognostic values of clinical (T and N classifications and invasion across Ohngren’s line), inflammatory (neutrophil-to-lymphocyte ratio), and nutritional (albumin and body-mass index) markers. All patients with primarily treated SNSCC between 2002 and 2020 (n = 51) were included. Each of the six SI components was stratified into a low- (0) and high-risk (1) categories. Subsequently, the cohort was stratified into low- (SI of 0–2) and high-risk SI groups (SI of 3–6). Overall survival (OS) and disease-free survival (DFS) were compared between patients with low- and high-risk SI. The log-rank test was used to test for statistical significance. Overall, the mortality rate was 41.2% (n = 21), and the recurrence rate was 43.1% (n = 22). We observed significantly better OS in patients with low-risk SI (n = 24/51, 47.1%, mean OS: 7.9 years, 95% confidence interval (CI): 6.3–9.6 years) than in high-risk SI (n = 27/51, 52.9%, mean OS: 3.4 years, 95% CI: 2.2–4.5 years; p = 0.013). Moreover, we also showed that patients with low-risk SI had a longer DFS than patients with high-risk SI (mean DFS: 6.4, 95% CI: 4.8–8.0 vs. mean DFS: 2.4 years, 95% CI 1.3–3.5, p = 0.012). The SI combines the prognostic capacity of well-established clinical, radiologic, inflammatory, and nutritional prognosticators and showed prognostic potential in our cohort of SNSCC patients.

Prognostic role of pre-treatment serum ALB in Patients with oropharyngeal cancer: A retrospective cohort study

BACKGROUND

The morbidity of oropharyngeal cancer (OPC) is continuing to rise in numerous developed countries. An accurate prognostic assessment is needed to evaluate the malignant degree or risk classification to optimize treatment. Albumin (ALB) as an independent prognostic indicator of cancer survival has been established in previous studies. This study investigated the prognostic value of pre-treatment serum ALB in OPC patients.

METHODS

The clinicopathological data of 246 patients diagnosed with OPC from 2010 to 2019 were analyzed retrospectively. Analyze the relationship between ALB and clinicopathological characteristics of patients. The optimal cut-off values for ALB were determined via Cutoff Finder (Method for cutoff determination: Survival: significance (log-rank test)). To determine the independent prognostic factors, the Cox proportional hazards model was used to perform univariate and multivariate analyses of the serum ALB levels related to overall survival (OS) and disease-free survival (DFS).

RESULTS

The optimal cut-off point for ALB was 39.15 g/L determined via Cutoff Finder. Serum ALB levels were significantly associated with age (P=0.047), Presence of comorbidity (P=0.009), Charlson score index (P=0.007), Hemoglobin (P<0.001), Neutrophil to Lymphocyte Ratio (P=0.002), Albumin-To-Alkaline Phosphatase Ratio (P<0.001), Alkaline phosphatase (P=0.005), T stage (P=0.016), and HPV status (P=0.002). In the univariate and multivariate analyses, ALB was found to be an independent prognostic indicator for DFS (HR =0.39, 95% CI:0.23-0.66, P=0.000) and OS (HR =0.46, 95% CI: 0.25-0.83, P=0.01) in OPC patients.

CONCLUSIONS

Pre-treatment serum ALB could serve as a valuable prognostic biomarker for the prognostic stratification of OPC patients.

Demystifying Malnutrition to Improve Nutrition Screening and Assessment in Oncology

OBJECTIVE

Patients with cancer and malnutrition are more likely to experience poor treatment tolerance, prolonged length of hospital stay, and decreased quality of life. Early and sustained nutrition risk screening is the first step to tackling this patient and health care burden. Yet, malnutrition remains largely overlooked and undertreated. Malnutrition mismanagement could be indicative of a systemic misunderstanding. With this narrative review, we aimed to (1) define malnutrition, (2) address common malnutrition misconceptions, and (3) summarize nutrition recommendations for patients with cancer.

DATA SOURCES

PubMed and international clinical practice guidelines were used.

CONCLUSION

Malnutrition represents an unbalanced nutritional state that alters body composition and diminishes function. Malnutrition is not always physically obvious, and albumin is not a reliable marker of nutritional status; therefore, systematically screening all patients with a validated nutrition risk screening tool at time of cancer diagnosis, and periodically throughout treatment, is necessary to provide optimal, equitable care. Nutrition risk screening takes less than 1 minute to complete and can be completed by any health care professional. Patients that screen positive for nutrition risk should be referred to a registered nutritionist or dietitian for comprehensive nutritional assessment, diagnosis, and treatment.

IMPLICATIONS FOR NURSING PRACTICE

All health care professionals can and should be responsible for preventing and treating malnutrition. Registered nurses can actively participate in improving patient outcomes by screening patients for nutrition risk, weighing patients at every visit, referring patients to dietitians for nutrition treatment, and providing supportive medical management of nutrition impact symptoms such as nausea.

Treatment-Interval Changes in Serum Levels of Albumin and Histidine Correlated with Treatment Interruption in Patients with Locally Advanced Head and Neck Squamous Cell Carcinoma Completing Chemoradiotherapy under Recommended Calorie and Protein Provision

We investigated risk factors for treatment interruption (TI) in patients with locally advanced head and neck squamous-cell carcinoma (LAHNSCC) following concurrent chemoradiotherapy (CCRT), under the provision of recommended calorie and protein intake; we also evaluated the associations between clinicopathological variables, calorie and protein supply, nutrition–inflammation biomarkers (NIBs), total body composition change (TBC), and a four-serum-amino-acid metabolite panel (histidine, leucine, ornithine, and phenylalanine) among these patients. Patients with LAHNSCC who completed the entire planned CCRT course and received at least 25 kcal/kg/day and 1 g of protein/kg/day during CCRT were prospectively recruited. Clinicopathological variables, anthropometric data, blood NIBs, CCRT-related factors, TBC data, and metabolite panels before and after treatment were collected; 44 patients with LAHNSCC were enrolled. Nine patients (20.4%) experienced TIs. Patients with TIs experienced greater reductions in hemoglobin, serum levels of albumin, uric acid, histidine, and appendicular skeletal mass, and suffered from more grade 3/4 toxicities than those with no TI. Neither increased daily calorie supply (≥30 kcal/kg/day) nor feeding tube placement was correlated with TI. Multivariate analysis showed that treatment-interval changes in serum albumin and histidine levels, but not treatment toxicity, were independently associated with TI. Thus, changes in serum levels of albumin and histidine over the treatment course could cause TI in patients with LAHNSCC following CCRT.

Serum Albumin: Early Prognostic Marker of Benefit for Immune Checkpoint Inhibitor Monotherapy But Not Chemoimmunotherapy

BACKGROUND

Cancer cachexia exhibits decreased albumin and associates with short overall survival (OS) in patients with non-small cell lung cancer (NSCLC), but whether on-treatment albumin changes associate with OS in NSCLC patients treated with immune checkpoint inhibitors (ICIs) and combination chemoimmunotherapy has not been thoroughly evaluated.

PATIENTS AND METHODS

We conducted a single-center retrospective study of patients with advanced NSCLC who received first-line ICI with or without chemotherapy between 2013 and 2020. The association of pretreatment albumin and early albumin changes with OS was evaluated using Kaplan-Meier method and Cox regression models.

RESULTS

A total of 210 patients were included: 109 in ICI cohort and 101 in ICI + Chemo cohort. Within a median of 21 days from treatment initiation, patients with ≥ 10% of albumin decrease had significantly shorter OS compared to patients without albumin decrease in ICI cohort. Pretreatment albumin and albumin decrease within the first or second cycle of treatment were significantly and independently associated with OS in ICI cohort, but not in ICI + Chemo cohort. The lack of association between albumin and OS with the addition of chemotherapy was more pronounced among patients with ≥ 1% PD-L1 expression in subgroup analysis.

CONCLUSION

Pretreatment serum albumin and early albumin decrease in ICI monotherapy was significantly associated with OS in advanced NSCLC. Early albumin change, as a routine lab value tested in clinic, may be combined with established biomarkers to improve outcome predictions of ICI monotherapy. The underlying mechanism of the observed association between decreased albumin and ICI resistance warrants further investigation.

Background for the introduction of enhanced recovery after surgery and patient outcomes

Background: To facilitate early postoperative recovery of surgical patients, various efforts have been made to develop effective treatment methods since 1990; moreover, these efforts have not been limited to surgical techniques and include multiple aspects of the entire treatment process. Enhanced recovery after surgery (ERAS) is a surgical quality improvement project that has advanced substantially since it was first introduced in 1995 and has now been firmly established in the field of perioperative care.Current Concepts: ERAS consists of many components that cover each stage before, during, and after surgery, and its clinical application changes according to the results of evidence-based research for each item. To date, more than 20 ERAS guidelines have been created for each disease, and more guidelines are expected in the future. Many studies have reported that ERAS is associated with meaningful improvements in clinical outcomes and reductions of medical costs in many surgical fields.Discussion and Conclusion: ERAS remains a work in progress, and continuous research and improvement is needed in relation to the components, areas of application, audit of compliance and results, education, and a multidisciplinary approach.

Preoperative Albumin-to-Globulin Ratio Predicts Prognosis in Hepatocellular Carcinoma: A Cohort Study Including Non-Hepatitis Virus-Infected Patients

INTRODUCTION

We evaluated the prognostic significance of the preoperative albumin-to-globulin ratio (AGR) in patients with hepatocellular carcinoma (HCC) with various liver etiologies.

METHODS

We retrospectively analyzed 157 patients with HCC between July 2010 and February 2021. The relationship between clinicopathological variables was investigated using univariate and multivariate analyses. Statistical significance was set at p < 0.05.

RESULTS

The mean overall survival (OS) was 24.5 months. The 1-, 3-, and 5-year OS rates were 90.4%, 81.2%, and 68.7%, respectively. Patients were classified into 2 groups: AGR <1.16 (low-AGR group; n = 43) and AGR ≥1.16 (high-AGR group; n = 114). In univariate analysis, OS was significantly reduced in patients with a low AGR (AGR <1.16), an alpha-fetoprotein level ≥25 ng/mL, a tumor size ≥3.5 cm, microvascular invasion, and poor tumor differentiation. In multivariate analysis, a low AGR (hazard ratio [95% confidence interval]) (2.394 [1.092-5.213]; p = 0.030) and microvascular invasion (2.268 [1.019-5.169]; p = 0.045) were independent predictors of OS.

DISCUSSION/CONCLUSION

A low AGR was significantly associated with poor OS in patients with HCC, regardless of liver etiology. This may assist in treatment stratification and better management of patients with HCC.

FcRn expression in cancer: Mechanistic basis and therapeutic opportunities

There is an urgent need to identify new cellular targets to expand the repertoire, potency and safety of cancer therapeutics. Neonatal Fc Receptor (FcRn)-driven cellular recycling plays a predominant role in the prolonged serum half-life of human serum albumin (HSA) and immunoglobulin G (IgG) exploited in long-acting cancer drug designs. FcRn-mediated HSA and IgG uptake in epithelial cells and dendritic cell antigen presentation offers new therapeutic opportunities beyond half-life extension. Altered FcRn expression in solid tumours accounting for HSA catabolism or recycling supports a role for FcRn in tumour metabolism and growth. This review addresses the mechanistic basis for different FcRn expression profiles observed in cancer and exploitation for targeted drug delivery. Furthermore, the review highlights FcRn-mediated immunosurveillance and immune therapy. FcRn offers a potential attractive cancer target but in-depth understanding of role and expression profiles during cancer pathogenesis is required for tailoring targeted drug designs.

Prognostic significance of preoperative systemic inflammatory biomarkers in patients with hepatocellular carcinoma after microwave ablation and establishment of a nomogram

The study aimed to evaluate the prognostic significance of preoperative systemic inflammatory biomarkers including albumin to globulin ratio (AGR), neutrophil to lymphocyte ratio (NLR), lymphocyte to monocyte ratio (LMR), and platelet to lymphocyte ratio (PLR) and establish a nomogram in hepatocellular carcinoma (HCC) patients after microwave ablation (MWA). 192 HCC patients receiving MWA as initial therapy from the first ward of hepatobiliary surgery were classified as training cohort. Whereas, 84 patients from the second of hepatobiliary surgery were classified as validation cohort. Kaplan–Meier (KM) method and univariate analyses showed that AGR, NLR, LMR, and PLR were significantly associated with OS in the training cohort. Multivariate analysis including clinicopathologic features screened out independent predictors including ascites, tumor size, cancer embolus, AGR, and PLR. Based on those variables, a nomogram for predicting OS was established. The C-index was 0.794 in the training cohort and 0.772 in the validation cohort. Calibration plots identified the nomogram performed well with an ideal model. Compared with Barcelona Clinic Liver Cancer (BCLC) staging system and simple tumor size, the nomogram showed better predictive ability. Besides, the nomogram discovered the highest diagnostic accuracy in predicting postoperative clinical outcome than the combination of the present models with tumor size. In conclusion, the constructed nomogram could accurately predict individualized survival probability and might support clinician in individual treatment optimization and clinical decision-making.

High level of pre-treatment C-reactive protein to albumin ratio predicts inferior prognosis in diffuse large B-cell lymphoma

The C-reactive protein-to-albumin ratio (CAR) has not been assessed in diffuse large B cell lymphoma (DLBCL, the most common non-Hodgkin lymphoma). This retrospective study evaluated the prognostic value of CAR in 186 DLBCL patients. A CAR value of 0.158 was selected as the most discriminative cut-off for identifying patients with high CAR values (73/141 patients, 51.8%). During a median follow-up of 32.5 months, the high CAR group had significantly poorer complete response to induction therapy (64.4% vs. 92.6%; p < 0.001), 3-year overall survival (OS) (68.3% vs. 96.2%; p < 0.0001), and 3-year progression-free survival (PFS) (53.5% vs. 88.0%; p < 0.0001). After adjusting for the International Prognostic Index components, a high CAR value independently predicted poor OS (HR: 6.02, 95% CI 1.19-30.38; p = 0.030) and PFS (HR: 3.62, 95% CI 1.40-9.36; p = 0.008). In an independent validation cohort (n = 50), patients with CAR > 0.158 also showed worse 3-year OS (47.9% vs. 87.2%, p = 0.0035) and 3-year PFS (36.1% vs. 82.1%, p = 0.0011). A high CAR remained significantly associated with poor outcomes for > 60-year-old patients (OS: p = 0.0038, PFS: p = 0.0015) and younger patients (OS: p = 0.0041, PFS: p = 0.0044). Among older patients, a high CAR value also predicted non-relapse mortality (p = 0.035). Therefore, the CAR might complement the International Prognostic Index in DLBCL cases.

Nutritional assessment and the role of preexisting inflammation with a bearing on COVID-19

 Although there is consensus in the European, American, Latin-American, and Asiatic nutrition and metabolic scientific societies regarding the definition of malnutrition, this definition has not been operationalized. This means that in different countries, the risk of malnutrition on outcome cannot be adequately determined or predicted. In patients with inflammatory activity, the preexistent nutritional status is an important predictor of outcome. Malnutrition is characterized by three crucial elements: undernutrition, inflammation, and diminished function. Malnutrition in our countries as well as in countries with famine almost always is caused by varying degrees of deficient nutritional intake in combination with disease or other damaging inflammatory causes of varying severity. The female genome appears to be better equipped to survive intercurrent trauma or illness than the male one, which impacts on longevity and the ability to overcome certain infections like COVID-19 at higher ages.

Outpatient Microsurgical Breast Reconstruction

Background:

The extensive nature of perforator-based breast reconstructions, combined with the need for postoperative flap monitoring, often leads to long hospitalizations. We present an early report demonstrating the feasibility and advantages of a modified operative technique and recovery protocol, allowing us to perform outpatient breast reconstructions with the DIEP flap. This follow-up comprises the experience gained, which is expanded to other perforator-based flaps and not limited to DIEP breast reconstructions.

Methods:

We have implemented a general protocol in patients undergoing breast reconstruction with autologous flaps, promoting early mobilization and discharge by improving postoperative pain and decreasing opioid requirements. This protocol includes intraoperative local anesthesia, a microfascial incision for DIEP harvest with rib preservation, along with prophylactic anticoagulation.

Results:

Ninety-two consecutive patients underwent autologous tissue-based breast reconstruction with DIEP, IGAP, and PAP flaps. No intraoperative complications were reported. All patients were discharged within 23 hours, without evidence of flap compromise. One patient required operative takeback for evacuation of a hematoma on postoperative day 4. No partial or total flap losses were documented. The aim of any procedure should be to get to the patient back to the preoperative status as quickly as possible, as prolonged hospitalizations are associated with higher incidences of infection, deep venous thrombosis, overall dissatisfaction, and higher overall costs of care.

Conclusions:

By using a modified operative technique, multimodal pain control, and postoperative anticoagulant therapy, outpatient perforator-flap–based breast reconstructions can be performed with high success and low complication rates.

Human serum albumin presents isoform variants with altered neonatal Fc receptor interactions

Human serum albumin (HSA) is the most abundant protein in plasma and presents the particularity, with IgG, to have an extraordinary long serum half-life conferred by its interaction with the neonatal Fc receptor (FcRn). If the impact of IgG post-translational modifications (PTMs) on FcRn binding is well documented, it is far less reported for HSA despite numerous PTMs occurring on the protein in plasma. HSA is susceptible to numerous degradation reactions in plasma, because of aging, oxidative stress or liver and pancreas related pathologies. In the present study, we combined FcRn affinity chromatography and mass spectrometry to investigate the impact of HSA PTMs upon FcRn binding. This methodology presents the advantage to distinguish the effect of a single modification from a plasma HSA preparation made of a mixture of different isoforms. Cys₃₄ oxidation, Lys₅₂₅ glycation, and Leu₅₈₅ C-terminal truncation, which are modifications related to several pathological conditions, were demonstrated to act negatively on HSA-FcRn interaction. The HSA-FcRn binding alteration generated by these modifications is consistent with their vicinity with the interaction interface of the two proteins. Results were discussed regarding altered half-life of HSA observed in several disease states and pave the way toward new understandings of the hypoalbuminemia pathogenesis. SIGNIFICANCE STATEMENT: In this study, we investigated the impact of several post-translational modifications of HSA toward its ability to bind to the neonatal Fc receptor using in vitro affinity chromatography, mass spectrometry, and surface plasmon resonance. Cys34 oxidation, Lys525 glycation, and Leu585 C-terminal truncation were demonstrated to decrease HSA-FcRn binding. These modifications occurring in circulating HSA were discussed in relation to several pathologies as well as for the use of HSA as a therapeutic protein.

Low serum albumin is an independent risk factor in elderly patients with aggressive B‐cell lymphoma: Results from prospective trials of the German High‐Grade Non‐Hodgkin's Lymphoma Study Group

Serum albumin a well‐known risk factor predicting outcome in many solid tumors. We explore the role of low serum albumin (≤3.5 g/dL) as an independent risk factor in elderly patients with aggressive B‐cell lymphoma. Outcome of 429 patients treated with R‐CHOP‐14 in the RICOVER‐60 trial and available serum albumin were analyzed in this retrospective study. Of the 429 patients in the RICOVER‐60 trial, 137 (32%) had low and 292 (68%) had normal serum albumin levels (>3.5 g/dL). In the low albumin group, patients had significantly higher International Prognostic Index (IPI), bulky disease, extralymphatic involvement, and B‐symptoms. Event‐free survival (EFS) (P < .001), progression‐free survival (PFS) (P < .001), and overall survival (OS) (P < .001) were significantly inferior for patients with low compared to those with normal serum albumin. Multivariate analysis adjusted for IPI shows following Hazard ratios (HR) for low serum albumin: EFS (HR = 1.5; 95% confidance interval [CI] [1.1; 2.1], P = .009), PFS (HR = 1.7; 95% CI [1.2; 2.4], P = .001) and OS (HR = 1.6; 95% CI [1.1; 2.3], P = .006). Results were confirmed in 185 patients from the DENSE‐R‐CHOP‐14 and SMARTE‐R‐CHOP‐14 trials. In conclusion, low serum albumin is an independent risk factor in elderly patients with aggressive B‐cell lymphoma treated with R‐CHOP.

Cross-Talk Between the Tumor Microenvironment, Extracellular Matrix, and Cell Metabolism in Cancer

The extracellular matrix (ECM) is a complex network of secreted proteins which provides support for tissues and organs. Additionally, the ECM controls a plethora of cell functions, including cell polarity, migration, proliferation, and oncogenic transformation. One of the hallmarks of cancer is altered cell metabolism, which is currently being exploited to develop anti-cancer therapies. Several pieces of evidence indicate that the tumor microenvironment and the ECM impinge on tumor cell metabolism. Therefore, it is essential to understand the contribution of the complex 3D microenvironment in controlling metabolic plasticity and responsiveness to therapies targeting cell metabolism. In this mini-review, we will describe how the tumor microenvironment and cancer-associated fibroblasts dictate cancer cell metabolism, resulting in increased tumor progression. Moreover, we will define the cross-talk between nutrient signaling and the trafficking of the ECM receptors of the integrin family. Finally, we will present recent data highlighting the contribution of nutrient scavenging from the microenvironment to support cancer cells growth under nutrient starvation conditions.

Plasma Lipid Profile and Systemic Inflammation in Patients With Cancer Cachexia

Cancer cachexia affects about 80% of advanced cancer patients, it is linked to poor prognosis and to date, there is no efficient treatment or cure. The syndrome leads to progressive involuntary loss of muscle and fat mass induced by systemic inflammatory processes. The role of the white adipose tissue (WAT) in the onset and manifestation of cancer cachexia gained importance during the last decade. WAT wasting is not only characterized by increased lipolysis and release of free fatty acids (FFA), but in addition, owing to its high capacity to produce a variety of inflammatory factors. The aim of this study was to characterize plasma lipid profile of cachectic patients and to correlate the FA composition with circulating inflammatory markers; finally, we sought to establish whether the fatty acids released by adipocytes trigger and/or contribute to local and systemic inflammation in cachexia. The study selected 65 patients further divided into 3 groups: control (N); weight stable cancer (WSC); and cachectic cancer (CC). The plasma FA profile was significantly different among the groups and was positively correlated with pro-inflammatory cytokines expression in the CC patients. Therefore, we propose that saturated to unsaturated FFA ratio may serve as a means of detecting cachexia.

Prognostic role of pre-treatment serum albumin in patients with nasopharyngeal carcinoma: A meta-analysis and systematic review

BACKGROUND

Pre-treatment serum albumin (ALB) is a novel index that was identified in recent years and is considered to be closely related to the prognosis of nasopharyngeal carcinoma (NPC). However, the association between ALB and NPC remains controversial.

OBJECTIVE OF REVIEW

To assess the prognostic significance of pre-treatment serum ALB in patients with NPC.

TYPE OF REVIEW

A systematic review and meta-analysis.

SEARCH STRATEGY

We searched PubMed, the Cochrane Library and the Web of Science for studies published up to August 2018. The keywords used were related to albumin, nasopharyngeal carcinoma and prognosis.

EVALUATION METHOD

We extracted the following data from all included studies: author, publication year, country, cancer centre, time points of randomisation, sample size, mean or median age, gender, TNM stage of NPC, cut-off value of pre-treatment serum albumin, number of high-grade cases and duration of follow-up. Then, we generated the pooled hazard ratios (HR) for overall survival (OS) and distant metastasis-free survival (DMFS) to perform this meta-analysis.

RESULTS

Ten studies comprising 7339 cases were included. Lower pre-treatment serum ALB levels were significantly associated with worse OS (HR = 1.32, 95% CI 1.17-1.48) and DMFS (HR = 1.40, 95% CI 1.08-1.80). In general, our findings were further verified in the subgroup analyses based on three features, including cancer stage, cut-off value and analysis type.

CONCLUSION

A decreased level of pre-treatment serum albumin implies a poor prognosis and can be detected to define the risk stratification of NPC patients.

Impact of pretherapeutic neutrophil-to-lymphocyte ratio, serum albumin, body-mass index, and advanced lung cancer inflammation index on clinical outcome in sinonasal squamous cell carcinoma

BACKGROUND

Squamous cell carcinoma of the nasal cavity and paranasal sinuses is a rare and aggressive cancer entity with poor survival rates. Data on this group of head and neck tumors are scarce. Inflammation and cachexia-based markers and their impact on clinical outcome have been studied in several cancer groups. The aim of this study was to evaluate their prognostic potential in sinonasal squamous cell carcinoma.

PATIENTS AND METHODS

This retrospective analysis included all patients treated for sinonasal squamous cell carcinoma at a tertiary referral center between 2002 and 2015. Patients were divided into groups with low and high pretherapeutic values based on the values of serum albumin (ALB, median 41.6 g/l), neutrophil-to-lymphocyte ratio (NLR, median 3.5), body-mass index (BMI, median 24.7), or advanced lung cancer inflammation index (ALI, median 29.5). Main outcome measures were overall survival (OS) and disease-free survival (DFS). Statistical analysis included calculation of survival differences using log-rank tests, hazard ratios (HR), and respective 95% confidence intervals (CI).

RESULTS

41 patients were included. Low ALB values did not influence OS (median OS not reached in both groups; p = 0.59, HR = 0.75, CI = 0.3-2.1) or DFS (median DFS 0.9 years vs 2.2 years; p = 0.6, HR = 0.8, CI = 0.4-1.8). High NLR was significantly associated with worse OS rates (median OS not reached vs 1.7 years, p = 0.02, HR = 3.4, CI = 1.0-108) but with no influence on DFS (median DFS 3.1 years vs 0.8 years; p = 0.15, HR = 1.8, CI = 0.8-4.2). Similar results were observed for patients with low ALI (median OS 1.7 years vs not reached; p = 0.03, HR = 0.3, CI = 0.1-0.9 and median DFS 0.8 years vs 2.2 years; p = 0.58, HR = 0.8, CI = 0.3-1.8). BMI was the strongest prognosticator in our study. Low pretherapeutic BMI was linked to significantly worse OS (median OS 1.4 years vs not reached; p = 0.003, HR = 0.2, CI = 0.0-0.6) and DFS (median DFS 0.8 years vs not reached; p = 0.02, HR = 0.4, CI = 0.2-0.8). In multivariate analysis BMI was revealed as an independent marker for OS (p = 0.015). No marker reached the level of significance in regard to DFS in multivariate analysis.

CONCLUSION

Pretherapeutic BMI had a superior prognostic value in patients with sinonasal squamous cell carcinoma in comparison with other tested variables. BMI may be a simple tool for estimating clinical outcome in SNSCC. However, larger studies are necessary to validate our results.

Prognostic significance of albumin levels prior to treatment in patients with head and neck squamous cell carcinoma

INTRODUCTION AND OBJECTIVES

Pre-treatment albumin levels have been shown to have prognostic capacity in oncological patients. The aim of this study is to analyse the relationship between albumin levels and prognosis in patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

We performed a retrospective study in a cohort of 741 patients with HNSCC and a plasmatic albumin testing within the 4weeks prior to the start of treatment. The relationship between disease-specific survival and plasma albumin levels was analysed by a recursive partitioning analysis.

RESULTS

Albumin levels showed a directly proportional and statistically significant association with disease-specific survival. According to the results of the recursive partitioning analysis, the cut-off points with a higher prognostic capacity were 37.5g/L and 46.1g/L. Taking patients with albumin levels >46.1g/L as the benchmark, patients with albumin levels between 37.5-46.1g/L had a 1.44 times higher risk of disease-specific death (95%CI: .95-2.19, P=.081), and patients with levels <37.5g/L had a 3.19 times higher risk (95%CI: 2.01-5.04, P=.0001). The differences in survival based on albumin levels were only seen in patients with advanced stage tumours (stagesIII-IV).

CONCLUSION

Pre-treatment plasmatic albumin is an independent prognostic factor for patients with advanced stage HNSCC (III-IV), 37.5g/L being the cut-off point with the highest prognostic capacity.

Prognostic Nutritional Index and Neutrophil-to-Lymphocyte Ratio Are Respectively Associated with Prognosis of Gastric Cancer with Liver Metatasis Undergoing and without Hepatectomy

Background. To clarify the efficacy of hepatectomy for gastric cancer liver metastasis (GCLM) and to investigate the association between prognostic nutrition index (PNI) or neutrophil-to-lymphocyte ratio (NLR) and prognosis of GCLM undergoing or without hepatectomy. Methods. We retrospectively studied 374 patients with GCLM. The ROC curve was used to determine the optimal cut-off of PNI and NLR. Patients were divided into groups based on whether hepatectomy was performed, and survival analysis was conducted before and after grouping. The overall survival (OS) time and 1, 3, 5-year survival rates were also compared. Results. Multivariate analysis of all GCLM patients revealed that hepatectomy (p = 0.001) was an independent prognosis factor. And there were statistical differences in OS and 1, 3, 5-year survival rates (p = 0.001 of all) between hepatectomy group and nonhepatectomy group. Multivariate analysis of GCLM undergoing hepatectomy showed that PNI was an independent prognosis factor (p = 0.001). And there were statistical differences in OS and 1, 3, 5‐year survival rates (p = 0.001p = 0.005, p = 0.001 and p = 0.020, respectively) between high PNI group and low PNI group. Multivariate analysis of GCLM without hepatectomy showed that NLR was an independent prognosis factor (p = 0.001). And there were statistical differences in OS and 1, 3, 5-year survival rates (p = 0.001p = 0.008p = 0.031 and p = 0.026, respectively) between low NLR group and high NLR group. Conclusions. GCLM has a better prognosis with hepatectomy. High preoperative PNI is a benign prognostic predictor for patients undergoing hepatectomy. And high preoperative NLR is an adverse prognostic factor for patients without hepatectomy.

Evaluation of covariate effects on pharmacokinetics of monoclonal antibodies in oncology

AIMS

The development of monoclonal antibodies (mAbs) requires an understanding of the interindividual variability (IIV) in pharmacokinetics (PK) at the population level facilitated by population PK (PopPK) modelling. However, there is no clear rationale for selecting which covariates to screen during PopPK model development. Here, we compare the effect of covariates on PK parameters for mAbs in oncology and identify the most commonly used covariates affecting PK parameters.

METHODS

All 25 mAbs approved for therapeutic use in oncology until December 2017 by the Food and Drug Administration and the European Medicines Agency were selected for study. Literature searches revealed 23 available PopPK models for these mAbs. To understand the magnitude and types of covariate effect on PK parameters, all covariates included in the final PopPK model for each mAb were summarized.

RESULTS

The most commonly identified covariates were baseline body weight (BW; 17 mAbs), baseline serum albumin (8 mAbs), and sex (7 mAbs) on clearance; and BW (16 mAbs) and sex (12 mAbs) on central volume of distribution. A reduced PopPK model was developed for nivolumab and ipilimumab using these covariates, and the percentage of explained IIV from the reduced model (20.3% and 16.8%, respectively) was compared with that from the full model (24.5% and 27.9%, respectively).

CONCLUSIONS

This analysis provides a uniform platform for selecting covariates and suggests that the effect of BW, albumin and sex should be included during the development of PopPK models for mAbs in oncology. The reduced model was able to explain IIV to a similar extent as the full model.

Effects of Serum Albumin Levels on Antithrombin Supplementation Outcomes Among Patients With Sepsis-Associated Coagulopathy: A Retrospective Study

Background

Severe sepsis is commonly associated with mortality among critically ill patients and is known to cause coagulopathy. While antithrombin is an anticoagulant used in this setting, serum albumin levels are known to influence serum antithrombin levels. Therefore, this study aimed to evaluate the outcomes of antithrombin supplementation in patients with sepsis-associated coagulopathy, as well as the relationship between serum albumin levels and the effects of antithrombin supplementation.

Methods

This retrospective study evaluated patients who were >18 years of age and had been admitted to either of two intensive care units for sepsis-associated coagulopathy. The groups that did and did not receive antithrombin supplementation were compared for outcomes up to 1 year after admission. Subgroup analyses were performed for patients with serum albumin levels of <2.5 g/dL or ⩾2.5 g/dL.

Results

Fifty-one patients received antithrombin supplementation and 163 patients did not. The Cox proportional hazards model revealed that antithrombin supplementation was independently associated with 28-day survival (hazard ratio [HR]: 0.374, P = 0.025) but not with 1 year survival (HR: 0.915, P = 0.752). In addition, among patients with serum albumin levels of <2.5 g/dL, antithrombin supplementation was associated with a significantly lower 28-day mortality rate (9.4% vs 36.8%, P = .009).

Conclusion

Antithrombin supplementation may improve short-term survival, but not long-term survival, among patients with sepsis-associated coagulopathy.

High preoperative plasma fibrinogen and serum albumin score is associated with poor survival in operable esophageal squamous cell carcinoma

This study was performed to investigate the prognostic significance of a cumulative score based on the preoperative plasma fibrinogen and serum albumin (FA score) in operable esophageal squamous cell carcinoma (ESCC). Clinicopathologic characteristics, preoperative fibrinogen, and albumin concentrations were retrospectively reviewed in patients who underwent transthoracic esophagectomy. The optimal cutoff value was defined as 4.0 g/L for fibrinogen according to previous studies and as 41.0 g/L for albumin for the lower quartile. Subjects with elevated fibrinogen and decreased albumin levels were allocated a score of 2, those with only one of these two abnormalities were assigned a score of 1, and those with neither of the abnormalities were allocated a score of 0. The preoperative FA score was significantly associated with tumor length, depth of invasion, lymph node involvement, tumor-node-metastasis (TNM) stage, and the modified Glasgow Prognostic Score (mGPS). No significant differences in age, gender, tumor location, degree of differentiation, smoking or alcohol consumption were found between groups. Univariate survival analysis revealed that high preoperative FA score (1/2) was significantly associated with unfavorable disease-free survival (DFS) [hazard ratio (HR), 1.675; 95% confidence interval (CI), 1.278-2.195; P < 0.001] and overall survival (OS) (HR, 1.685; 95% CI, 1.268-2.239; P < 0.001). Furthermore, it remained an independent prognostic indicator for both DFS (HR, 1.394; 95% CI, 1.035-1.879; P = 0.029) and OS (HR, 1.369; 95% CI, 1.010-1.878; P = 0.048) in multivariable Cox regression analysis. A high preoperative FA score could significantly predict impaired long-term survival for ESCC patients who underwent transthoracic esophagectomy.

Hypoalbuminemia: Pathogenesis and Clinical Significance

Hypoalbuminemia is associated with inflammation. Despite being addressed repeatedly in the literature, there is still confusion regarding its pathogenesis and clinical significance. Inflammation increases capillary permeability and escape of serum albumin, leading to expansion of interstitial space and increasing the distribution volume of albumin. The half‐life of albumin has been shown to shorten, decreasing total albumin mass. These 2 factors lead to hypoalbuminemia despite increased fractional synthesis rates in plasma. Hypoalbuminemia, therefore, results from and reflects the inflammatory state, which interferes with adequate responses to events like surgery or chemotherapy, and is associated with poor quality of life and reduced longevity. Increasing or decreasing serum albumin levels are adequate indicators, respectively, of improvement or deterioration of the clinical state. In the interstitium, albumin acts as the main extracellular scavenger, antioxidative agent, and as supplier of amino acids for cell and matrix synthesis. Albumin infusion has not been shown to diminish fluid requirements, infection rates, and mortality in the intensive care unit, which may imply that there is no body deficit or that the quality of albumin “from the shelf” is unsuitable to play scavenging and antioxidative roles. Management of hypoalbuminaemia should be based on correcting the causes of ongoing inflammation rather than infusion of albumin. After the age of 30 years, muscle mass and function slowly decrease, but this loss is accelerated by comorbidity and associated with decreasing serum albumin levels. Nutrition support cannot fully prevent, but slows down, this chain of events, especially when combined with physical exercise.

Prognostic Significance of Albumin-Globulin Score in Patients with Operable Non-Small-Cell Lung Cancer

OBJECTIVE

This study was designed to evaluate the prognostic value of the preoperative albumin-globulin score (AGS) in the patients with non-small cell lung cancer (NSCLC) after pulmonary lobectomy.

METHODS AND RESULTS

The optimal cutoff level was 40.00 and 27.05 g/L for Alb and Glb, respectively. Based on this and the previous study, patients with both an hypoalbuminemia (< 40.00 g/L) and an elevated Glb level (≥ 27.05 g/L) were assigned a score of 2, and patients with one or neither were assigned a score of 1 or 0, respectively. We investigated the correlations between the AGS and the clinicopathological characteristics of patients and found that AGS was significantly associated with TNM stage (P = 0.016). Multivariate Cox analyses indicated that the AGS was an independent prognostic indicator for NSCLC for disease-free survival (DFS) (P = 0.001) and overall survival (OS) (P = 0.004). Kaplan-Meier analysis and log-rank test demonstrated that there were significant differences in DFS (P < 0.001) and OS (P < 0.001) among the three AGS groups. Furthermore, our study showed that DFS and OS are significantly different in three groups of patients with different AGS, in both Squamous carcinoma (P < 0.001 for DFS; P < 0.001 for OS) or adenocarcinoma (P = 0.034 for DFS; P = 0.035 for OS). In addition, we enrolled 53 patients as an independent set of cases for the further validation of AGS. Multivariate analyses verified AGS was an independent prognostic factor for NSCLC patients (P = 0.020 for DFS; P = 0.018 for OS).

CONCLUSIONS

Preoperative AGS is an independent prognostic factor for patients with operable NSCLC.

The preoperative sensitive-modified Glasgow prognostic score is superior to the modified Glasgow prognostic score in predicting long-term survival for esophageal squamous cell carcinoma

The present study was designed to investigate the prognostic significance of the preoperative sensitive-modified Glasgow prognostic score (S-mGPS) and its superiority in esophageal squamous cell carcinoma (ESCC). Clinicopathologic characteristics, preoperative albumin and C-reactive protein (CRP) levels were retrospectively collected in 442 patients who underwent transthoracic esophagectomy. The S-mGPS was calculated before surgery based on optimal cutoff values of 45.6 g/L for albumin and 10.0 mg/L for CRP. 360, 74 and 8 cases were assigned an mGPS of 0, 1 and 2, respectively. In contrast, the S-mGPS was 0 in 114, 1 in 258 and 2 in 70 patients. Of the 360 patients with an mGPS of 0, 246 migrated to the S-mGPS-1 group. Both mGPS and S-mGPS were significantly correlated with tumor length, depth of invasion, pathological tumor-node-metastasis (pTNM) stage and adjuvant treatment. In addition, they were significantly associated with disease free survival (DFS) and overall survival (OS) in univariate analysis. Furthermore, multivariate Cox regression analysis identified S-mGPS as an independent prognostic indicator for both DFS [hazard ratio (HR), 1.577; 95% confidence interval (CI), 1.149-2.163; P = 0.005] and OS (HR, 1.762; 95% CI, 1.250-2.484; P = 0.001), but not mGPS (HR, 0.957; 95% CI, 0.692-1.323; P = 0.790 for DFS and HR, 1.089; 95% CI, 0.781-1.517; P = 0.615 for OS, respectively). Moreover, subgroup analysis revealed that the prognostic impact of the S-mGPS was especially striking in pTNM stage II patients. The preoperative S-mGPS is superior to the mGPS as a prognostic predictor in patients with resectable ESCC.

Cumulative score based on preoperative plasma fibrinogen and serum C-reactive protein could predict long-term survival for esophageal squamous cell carcinoma

The present study was to establish a prognostic indicator based on preoperative fibrinogen and C-reactive protein (CRP) (FC score) in esophageal squamous cell carcinoma (ESCC). Clinicopathologic characteristics, preoperative plasma fibrinogen and serum CRP levels were reviewed in patients who underwent transthoracic esophagectomy. The optimal cut-off value for fibrinogen and CRP was defined as 4.0 g/dL and 10.0 mg/L according to previous reports. Patients with elevated fibrinogen and CRP levels were assigned a score of 2, those with only one of these two abnormalities were allocated a score of 1, and those with neither of the two abnormalities were assigned a score of 0. Preoperative FC score was significantly correlated with degree of differentiation, depth of invasion, tumor-node-metastasis (TNM) stage and modified Glasgow Prognostic Score (mGPS). No significant differences in age, gender, tumor length, tumor location, lymph node status or smoking were identified between groups. Univariate survival analysis demonstrated that high preoperative FC score (1/2) was significantly associated with impaired disease free survival (DFS) [hazard ratio (HR), 1.650; 95% confidence interval (CI), 1.181-2.303; P = 0.003] and overall survival (OS) (HR, 1.879; 95% CI, 1.333-2.648; P<0.001), and it remained an independent predictor for both DFS (HR, 1.468; 95% CI, 1.043-2.067; P=0.028) and OS (HR, 2.070; 95% CI, 1.266-3.385; P=0.004) in multivariate Cox regression analysis. Preoperative FC score might represent a new potential marker of worst prognosis that warrants further evaluation in prospective and large cohort studies among ESCC patients who underwent transthoracic esophagectomy.

Low preoperative albumin-globulin score predicts favorable survival in esophageal squamous cell carcinoma

This study retrospectively investigated the prognostic significance of the preoperative albumin-globulin score (AGS) and albumin/globulin ratio (AGR) in esophageal squamous cell carcinoma (ESCC). A cohort of 458 newly diagnosed ESCC patients who underwent radical esophagectomy in Sun Yat-sen University Cancer Center (Guangzhou, China) between January 2006 and December 2010 were selected into this study. The optimal cut-off value was identified to be 45.6 g/L, 26.9 g/L and 1.30 for albumin (ALB), globulin (GLB) and AGR in terms of survival, respectively. Patients with low ALB levels (< 45.6 g/L) and high GLB levels (≥ 26.9 g/L) were assigned an AGS of 2, those with only one of the two abnormalities were assigned an AGS of 1, and those with neither of the two abnormalities were assigned an AGS of 0. Univariate survival analysis showed that low AGS (0) was significantly associated with favorable disease free survival (DFS) [hazard ratio (HR), 0.635; 95% confidence interval (CI), 0.441-0.914; P = 0.015] and overall survival (OS) (HR, 0.578; 95% CI, 0.387-0.862; P = 0.007), and it remained an independent predictor for OS (HR, 0.630; 95% CI, 0.418-0.952; P = 0.028), but not for DFS (HR, 0.697; 95% CI, 0.479-1.061; P = 0.060) in multivariate models. High AGR (≥ 1.30) was also correlated with favorable DFS (HR, 0.626; 95% CI, 0.430-0.910; P = 0.014) and OS (HR, 0.622; 95% CI, 0.422-0.916; P = 0.016) in univariate analysis, but it failed to be an independent prognostic indicator for DFS (HR, 0.730; 95% CI, 0.494-1.078; P = 0.114) or OS (HR, 0.759; 95% CI, 0.507-1.137; P = 0.181) by multivariate analysis. Low preoperative AGS could serve as a valuable and convenient biochemical marker to predict favorable long-term survival in ESCC patients.

Pretreatment albumin level predicts survival in head and neck squamous cell carcinoma

OBJECTIVES/HYPOTHESIS

Poor nutritional status in patients with head and neck squamous cell carcinoma (HNSCC) is associated with tumor progression and survival. This study examined the prognostic value of nutritional and hematological markers in patients with HNSCC who received definitive treatments.

STUDY DESIGN

A prospective observational cohort study.

METHODS

This study included 338 consecutive patients who underwent surgery and/or radiotherapy/chemoradiotherapy for treatment-naïve HNSCC. Body weight and nutritional and hematological parameters were regularly measured before and after treatment. Univariate and multivariate analyses using Cox proportional hazards models were performed to identify factors associated with disease-free survival (DFS), cancer-specific survival (CSS), and overall survival (OS).

RESULTS

Body weight, serum total protein and albumin levels, and hematological variables significantly decreased after treatment. Univariate analyses illustrated that age, tumor site, T and N classifications, overall stage, pretreatment serum albumin (<3.5 g/dL) and hemoglobin (<12 g/dL) levels, and neutrophil-lymphocyte ratio were significantly associated with DFS, CSS, and OS (all P < .05). Multivariate analyses identified age, tumor site, N classification, and pretreatment albumin levels as independent predictors of DFS, CSS, and OS (all P < .05). Patients with low serum albumin levels prior to treatment experienced approximately sixfold increases in the risks of tumor progression and cancer-specific and overall mortality compared to the findings in their counterparts.

CONCLUSIONS

Our results suggest that pretreatment serum albumin levels predict DFS, CSS, and OS in patients who received definitive treatment for HNSCC. These findings might help to predict treatment outcome and guide nutritional intervention in patients with HNSCC.

LEVEL OF EVIDENCE

2b. Laryngoscope, 127:E437-E442, 2017.

Significant prognostic difference between Grade Group 4 and 5 in the 2014 International Society of Urological Pathology Grading System for High Grade Prostate Cancer with Bone Metastasis

Background

To investigate prognostic difference between Gleason Score (GS) 8 and 9–10, as the 2014 International Society of Urological Pathology Gleason Grading Systems proposed, in patients with prostate cancer (PCa) with bone metastasis.

Materials and methods

We retrospectively reviewed data on 106 patients with GS 8–10 between 2006 and 2016. All patients received androgen deprivation therapy immediately. We validated biochemical recurrence, PCa-specific survival, and overall survival, and analyzed the predictive value for overall survival.

Results

Patients with GS 9–10 had significantly lower PCa-specific survival (50.5% vs. 83.4%, P = 0.01) and overall survival (38.8% vs. 66.3%, P = 0.04) at 5 years than those with GS 8, while biochemical recurrence rate was not significantly different (P = 0.26). Furthermore, these significant differences between GS 8 and 9–10 were also observed among high-risk groups proposed in Japan Cancer of the Prostate Risk Assessment Stratification (prostate cancer-specific survival: P = 0.03, overall survival: P = 0.04, respectively). Pathological GS 9–10 was an independent prognostic factor for overall survival (hazard ratio = 1.97, P = 0.04) in multivariable cox proportional hazard regression analysis. Among patients with GS 9–10, albumin level was an only prognostic factor for overall survival (hazard ratio = 0.33, P < 0.01).

Conclusion

Pathological GS 9–10 predicts significantly worse outcomes than GS 8 in Japanese PCa patients with bone metastasis. Our data indicated clinical significance of discriminating the 2014 International Society of Urological Pathology Gleason Grading Group 4 and 5 among high-risk PCa patients with bone metastasis.

Direct evidence for cancer-cell-autonomous extracellular protein catabolism in pancreatic tumors

Mammalian tissues rely on a variety of nutrients to support their physiological functions. It is known that altered metabolism is involved in the pathogenesis of cancer, but which nutrients support the inappropriate growth of intact malignant tumors is incompletely understood. Amino acids are essential nutrients for many cancer cells that can be obtained through the scavenging and catabolism of extracellular protein via macropinocytosis. In particular, macropinocytosis can be a nutrient source for pancreatic cancer cells, but it is not fully understood how the tumor environment influences metabolic phenotypes and whether macropinocytosis supports the maintenance of amino acid levels within pancreatic tumors. Here we utilize miniaturized plasma exchange to deliver labeled albumin to tissues in live mice, and we demonstrate that breakdown of albumin contributes to the supply of free amino acids in pancreatic tumors. We also deliver albumin directly into tumors using an implantable microdevice, which was adapted and modified from ref. 9. Following implantation, we directly observe protein catabolism and macropinocytosis in situ by pancreatic cancer cells, but not by adjacent, non-cancerous pancreatic tissue. In addition, we find that intratumoral inhibition of macropinocytosis decreases amino acid levels. Taken together, these data suggest that pancreatic cancer cells consume extracellular protein, including albumin, and that this consumption serves as an important source of amino acids for pancreatic cancer cells in vivo.

TNF-α and cancer cachexia: Molecular insights and clinical implications

Cancer cachexia characterized by a chronic wasting syndrome, involves skeletal muscle loss and adipose tissue loss and resistance to conventional nutritional support. Cachexia is responsible for the reduction in quality and length of life of cancer patients. It also decreases the muscle strength of the patients. The pro-inflammatory and pro-cachectic factors produced by the tumor cells have important role in genesis of cachexia. A number of pro-inflammatory cytokines, like interleukin-1 (IL-1), IL-6, tumor necrosis factor- alpha (TNF-α) may have important role in the pathological mechanisms of cachexia in cancer. Particularly, TNF-α has a direct catabolic effect on skeletal muscle and causes wasting of muscle by the induction of the ubiquitin-proteasome system (UPS). In cancer cachexia condition, there is alteration in carbohydrate, protein and fat metabolism. TNF-α is responsible for the increase in gluconeogenesis, loss of adipose tissue and proteolysis, while causing decrease in protein, lipid and glycogen synthesis. It has been associated with the formation of IL-1 and increases the uncoupling protein-2 (UCP2) and UCP3 expression in skeletal muscle in cachectic state. The main aim of the present review is to evaluate and discuss the role of TNF-α in different metabolic alterations and muscle wasting in cancer cachexia.

Prognostic significance of pretreatment albumin/globulin ratio in patients with hepatocellular carcinoma

BACKGROUND

Pretreatment nutritional and immunological statuses play an indispensable role in predicting the outcome of patients with various types of malignancies. The purpose of this study is to evaluate the predictive value of albumin/globulin ratio (AGR) in overall survival (OS) and recurrence in patients with hepatocellular carcinoma (HCC) following radical hepatic carcinectomy.

PATIENTS AND METHODS

This retrospective study included a total of 172 patients with HCC with complete medical and follow-up information between 2002 and 2012. AGR was calculated according to the following formula: AGR = albumin/globulin. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff value. The associations of AGR with clinicopathological characteristics and prognosis were assessed. Further multivariate analysis using Cox regression model and subgroup analysis was performed to evaluate the predictive value.

RESULTS

Receiver operating characteristic curve determined 37.65, 31.99, and 1.48 as the optimal cutoff values of albumin, globulin, and AGR in terms of 5-year OS or death, respectively. On the basis of the cutoff value of AGR, all the patients were divided, respectively, into low-AGR (n=105) and high-AGR (n=67) groups. AGR was found to be significantly correlated with age, cancer embolus, international normalized ratio, and postoperative outcome (P<0.05). Hepatitis B virus infection (hazard ratio [HR]: 2.125; 95% confidence interval [CI]: 1.285-3.153), tumor node metastasis stage (HR: 1.656; 95% CI: 1.234-2.223), serum albumin (HR: 0.546; 95% CI: 0.347-0.857), and AGR (HR: 0.402; 95% CI: 0.233-0.691) were independent predictors of OS via univariate and multivariate survival analyses. However, alpha-fetoprotein (HR: 1.708; 95% CI: 1.027-2.838), tumor node metastasis stage (HR: 1.464; 95% CI: 1.078-1.989), and AGR (HR: 0.493; 95% CI: 0.293-0.828) functioned as independent risk variables for predicting recurrence. Moreover, AGR showed superior prognostic value for OS and recurrence in the subgroups with normal level of albumin or survival time beyond 6 months.

CONCLUSION

Pretreatment AGR might serve as an effective biomarker to evaluate the prognosis of patients with a diagnosis of HCC. Based on the results, AGR, characterized with easy accessibility, objectivity, and noninvasiveness, should be included in the routine assessment of HCC.

Human serum albumin homeostasis: a new look at the roles of synthesis, catabolism, renal and gastrointestinal excretion, and the clinical value of serum albumin measurements

Serum albumin concentration (CP) is a remarkably strong prognostic indicator of morbidity and mortality in both sick and seemingly healthy subjects. Surprisingly, the specifics of the pathophysiology underlying the relationship between CP and ill-health are poorly understood. This review provides a summary that is not previously available in the literature, concerning how synthesis, catabolism, and renal and gastrointestinal clearance of albumin interact to bring about albumin homeostasis, with a focus on the clinical factors that influence this homeostasis. In normal humans, the albumin turnover time of about 25 days reflects a liver albumin synthesis rate of about 10.5 g/day balanced by renal (≈6%), gastrointestinal (≈10%), and catabolic (≈84%) clearances. The acute development of hypoalbuminemia with sepsis or trauma results from increased albumin capillary permeability leading to redistribution of albumin from the vascular to interstitial space. The best understood mechanism of chronic hypoalbuminemia is the decreased albumin synthesis observed in liver disease. Decreased albumin production also accounts for hypoalbuminemia observed with a low-protein and normal caloric diet. However, a calorie- and protein-deficient diet does not reduce albumin synthesis and is not associated with hypoalbuminemia, and CP is not a useful marker of malnutrition. In most disease states other than liver disease, albumin synthesis is normal or increased, and hypoalbuminemia reflects an enhanced rate of albumin turnover resulting either from an increased rate of catabolism (a poorly understood phenomenon) or enhanced loss of albumin into the urine (nephrosis) or intestine (protein-losing enteropathy). The latter may occur with subtle intestinal pathology and hence may be more prevalent than commonly appreciated. Clinically, reduced CP appears to be a result rather than a cause of ill-health, and therapy designed to increase CP has limited benefit. The ubiquitous occurrence of hypoalbuminemia in disease states limits the diagnostic utility of the CP measurement.

Pretreatment Serum Albumin Level is an Independent Prognostic Factor in Patients with Stage IIIB Non-Small Cell Lung Cancer: A Study of the Turkish Descriptive Oncological Researches Group

BACKGROUND

Several prognostic factors have been studied in NSCLC, although it is unknown which is most useful. In this study, we aimed to investigate whether pre-treatment serum albumin level has prognostic value in patients with Stage IIIB NSCLC.

MATERIALS AND METHODS

This cross-sectional study included a total of 204 patients with Stage IIIB NSCLC who met the inclusion criteria. Pre-treatment serum albumin levels and demographic, clinical, and histological characteristics, as well as laboratory variables were recorded. A cut-off value was defined for serum albumin level and the patients were stratified into four groups on thios basis.

RESULTS

The majority of the patients was males and smokers, with a history of weight loss, and squamous histological type of lung cancer. The mean serum albumin level was 3.2±1.7 g/dL (range, 2.11-4.36 g/dL). A cut-off value 3.11 g/dL was set and among the patients with a lower level, 68% had adenocarcinoma and 82% were smokers. The patients with low serum albumin levels had a lower response rate to e first-line chemotherapy with a shorter progression-free survival and overall survival. Multivariate analysis showed that low serum albumin level was an independent poor prognostic factor for NSCLC.

CONCLUSIONS

This study results suggest that low serum albumin level is an independent poor prognostic factor in patients with Stage IIIB NSCLC, associated with reduction in the response rate to first-line therapy and survival rates.

The pretreatment albumin to globulin ratio predicts survival in patients with natural killer/T-cell lymphoma

Background. The pretreatment albumin to globulin ratio (AGR) has been reported to be a predictor of survival in several types of cancer. The aim of this study was to evaluate the prognostic impact of AGR in patients with natural killer/T-cell lymphoma (NKTCL). Methods. We retrospectively reviewed the available serum biochemistry results for 331 NKTCL patients before treatment. AGR was calculated as albumin/(total protein-albumin), and a cut-off value of 1.3 was used to define AGR as low or high. Survival analysis was used to assess the prognostic value of AGR. Results. A low AGR (<1.3) was associated with significantly more adverse clinical features, including old age, poor performance status, advanced stage, elevated lactate dehydrogenase, B symptoms, and high International Prognostic Index (IPI) and natural killer/T-cell lymphoma prognostic index (NKPI) scores. Patients with a low AGR had a significantly lower 5-year overall survival (44.5 vs. 65.2%, P < 0.001) and progression-free survival (33.1 vs. 57.4%, P < 0.001). In the multivariate analysis, a low AGR remained an independent predictor of poorer survival. Additionally, AGR distinguished patients with different outcomes in the IPI low-risk group and in the NKPI high-risk group. Discussion. Pretreatment AGR may serve as a simple and effective predictor of prognosis in patients with NKTCL.

Understanding cachexia as a cancer metabolism syndrome

Metabolic reprogramming occurs in tumors to foster cancer cell proliferation, survival and metastasis, but as well at a systemic level affecting the whole organism, eventually leading to cancer cachexia. Indeed, as cancer cells rely on external sources of nitrogen and carbon skeleton to grow, systemic metabolic deregulation promoting tissue wasting and metabolites mobilization ultimately supports tumor growth. Cachectic patients experience a wide range of symptoms affecting several organ functions such as muscle, liver, brain, immune system and heart, collectively decreasing patients' quality of life and worsening their prognosis. Moreover, cachexia is estimated to be the direct cause of at least 20% of cancer deaths. The main aspect of cachexia syndrome is the unstoppable skeletal muscle and fat storage wasting, even with an adequate caloric intake, resulting in nutrient mobilization – both directly as lipid and amino acids and indirectly as glucose derived from the exploitation of liver gluconeogenesis – that reaches the tumor through the bloodstream. From a metabolic standpoint, cachectic host develops a wide range of dysfunctions, from increased insulin and IGF-1 resistance to induction of mitochondrial uncoupling proteins and fat tissue browning resulting in an increased energy expenditure and heat generation, even at rest. For a long time, cachexia has been merely considered an epiphenomenon of end-stage tumors. However, in specific tumor types, such as pancreatic cancers, it is now clear that patients present markers of tissue wasting at a stage in which tumor is not yet clinically detectable, and that host amino acid supply is required for tumor growth. Indeed, tumor cells actively promote tissue wasting by secreting specific factors such as parathyroid hormone-related protein and micro RNAs. Understanding the molecular and metabolic mediators of cachexia will not only advance therapeutic approaches against cancer, but also improve patients' quality of life.

Promoting Perioperative Metabolic and Nutritional Care

Surgery represents a major stressor that disrupts homeostasis and can lead to loss of body cell mass. Integrated, multidisciplinary medical strategies, including enhanced recovery programs and perioperative nutrition support, can mitigate the surgically induced metabolic response, promoting optimal patient recovery following major surgery. Clinical therapies should identify those who are poorly nourished before surgery and aim to attenuate catabolism while preserving the processes that promote recovery and immunoprotection after surgery. This review will address the impact of surgery on intermediary metabolism and describe the clinical consequences that ensue. It will also focus on the role of perioperative nutrition, including preoperative nutrition risk, carbohydrate loading, and early initiation of oral feeding (centered on macronutrients) in modulating surgical stress, as well as highlight the contribution of the anesthesiologist to nutritional care. Emerging therapeutic concepts such as preoperative glycemic control and prehabilitation will be discussed.

Relationship of obesity with serum concentrations of leptin, CRP and IL-6 in breast cancer survivors

INTRODUCTION

Several mechanisms have been proposed to explain the adverse effect of obesity on quality of life among women with breast cancer, including alteration in some inflammatory markers. The aim of this study was to determine the status of serum levels of leptin, IL-6 and CRP in obese, overweight and normal weight breast cancer survivors in order to determine the relationship between inflammatory markers' levels and obesity.

MATERIALS AND METHODS

This cross-sectional study was done on 75 women with breast cancer, 30 obese, 15 overweight and 30 normal weight patients. Serum leptin, IL-6, CRP, total protein, albumin and lipid profile as well as anthropometric parameters were measured in three groups.

RESULTS

Serum leptin levels of obese patients were significantly higher than those of overweight and normal weight patients (P<0.05). Higher serum CRP and lower albumin levels were observed in obese patients in comparison with normal weight patients (P<0.05). HDL-C level was significantly different between overweight and normal weight patients (P<0.05). Significant differences in serum IL-6 levels were not observed between the study groups (P>0.05). Moreover, multiple regression analysis showed that leptin was significantly associated with BMI (P<0.001), while albumin was negatively correlated with BMI (P<0.05). CRP levels were significantly correlated with BMI and waist-to-hip ratio (WHR) (P<0.05).

CONCLUSIONS

In conclusion, high leptin levels and alteration in acute phase proteins in obese patients may exaggerate the inflammation status. As inflammation has the potential to increase the susceptibility of the patients to metastasis development, it is necessary to decline its rate.

Nonmuscle Tissues Contribution to Cancer Cachexia

Cachexia is a syndrome associated with cancer, characterized by body weight loss, muscle and adipose tissue wasting, and inflammation, being often associated with anorexia. In spite of the fact that muscle tissue represents more than 40% of body weight and seems to be the main tissue involved in the wasting that occurs during cachexia, recent developments suggest that tissues/organs such as adipose (both brown and white), brain, liver, gut, and heart are directly involved in the cachectic process and may be responsible for muscle wasting. This suggests that cachexia is indeed a multiorgan syndrome. Bearing all this in mind, the aim of the present review is to examine the impact of nonmuscle tissues in cancer cachexia.