Prognostic impact of the combination of the neutrophil-to-lymphocyte ratio and serum carbohydrate antigen 19-9 in patients with pancreas head cancer

Dynamics of Serum CA19-9 in Patients Undergoing Pancreatic Cancer Resection

BACKGROUND

Carbohydrate antigen (CA) 19-9 is an established perioperative prognostic biomarker for pancreatic ductal adenocarcinoma (PDAC). However, it is unclear how CA19-9 monitoring should be used during postoperative surveillance to detect recurrence and to guide the initiation of recurrence-focused therapy.

OBJECTIVE

This study aimed to elucidate the value of CA19-9 as a diagnostic biomarker for disease recurrence in patients who underwent PDAC resection.

METHODS

Serum CA19-9 levels at diagnosis, after surgery, and during postoperative follow-up were analyzed in patients who underwent PDAC resection. All patients with at least two postoperative follow-up CA19-9 measurements before recurrence were included. Patients deemed to be nonsecretors of CA19-9 were excluded. The relative increase in postoperative CA19-9 was calculated for each patient by dividing the maximum postoperative CA19-9 value by the first postoperative value. Receiver operating characteristic analysis was performed to identify the optimal threshold for the relative increase in CA19-9 levels to identify recurrence in the training set using Youden's index. The performance of this cutoff was validated in a test set by calculating the area under the curve (AUC) and was compared to the performance of the optimal cutoff for postoperative CA19-9 measurements as a continuous value. In addition, sensitivity, specificity, and predictive values were assessed.

RESULTS

In total, 271 patients were included, of whom 208 (77%) developed recurrence. Receiver operating characteristic analysis demonstrated that a relative increase in postoperative serum CA19-9 of 2.6× was predictive of recurrence, with 58% sensitivity, 83% specificity, 95% positive predictive value, and 28% negative predictive value. The AUC for a 2.6× relative increase in the CA19-9 level was 0.719 in the training set and 0.663 in the test set. The AUC of postoperative CA19-9 as a continuous value (optimal threshold, 52) was 0.671 in the training set. In the training set, the detection of a 2.6-fold increase in CA19-9 preceded the detection of recurrence by a mean difference of 7 months ( P <0.001) and in the test set by 10 months ( P <0.001).

CONCLUSIONS

A relative increase in the postoperative serum CA19-9 level of 2.6-fold is a stronger predictive marker for recurrence than a continuous CA19-9 cutoff. A relative CA19-9 increase can precede the detection of recurrence on imaging for up to 7 to 10 months. Therefore, CA19-9 dynamics can be used as a biomarker to guide the initiation of recurrence-focused treatment.

Does Preoperative Serum Neutrophil to Lymphocyte Ratio (NLR), Platelet to Lymphocyte Ratio (PLR), and Lymphocyte to Monocyte Ratio (LMR) Predict Prognosis Following Radical Surgery for Pancreatic Adenocarcinomas? Results of a Retrospective Study

BACKGROUND

Pretherapy serum neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and lymphocyte to monocyte ratio (LMR) have been shown to predict prognosis in patients with pancreatic ductal adenocarcinoma (PDAC). However, the published literature is conflicting; hence, we aimed to evaluate their role in predicting survival outcomes in operated patients of PDAC.

METHODS

A retrospective analysis was performed in all operated cases of PDAC who underwent curative resection between 2011 and 2018. The pretherapy NLR, PLR, and LMR were calculated and analyzed with respect to pathological and survival outcomes RESULTS: One hundred thirty-four operated patients were included. The median overall survival for NLR of less than 2, 2.7, and 5 was 30.8, 27.2, and 27.5 months and for NLR of more than 2, 2.7, and 5 was 22.9, 21.6, and 21.5 months, respectively, and was statistically insignificant (p-value-0.32, 0.91, 0.34, respectively). Similarly, the PLR was not significant for a cutoff of 150 (p-value-0.27), and LMR was not significant for a cutoff of 2.8 (p-value-0.13) and 4.8 (p-value-0.11). On univariate analysis age, CA 19-9 levels, perineural invasion, margin positivity, lymph node positivity, and TNM stage were found to have a significant correlation with overall survival. However, on multivariate analysis, only TNM stage was found to be significant.

CONCLUSION

The NLR, PLR, and LMR do not correlate with overall survival in operated patients with PDAC in this study. A combination of inflammatory markers or their dynamic testing might probably achieve prognostic significance.

Development of a Biomarker-Based Scoring System Predicting Early Recurrence of Resectable Pancreatic Duct Adenocarcinoma

Background

Resectable pancreatic ductal adenocarcinoma (R-PDAC) often recurs early after radical resection, which is associated with poor prognosis. Predicting early recurrence preoperatively is useful for determining the optimal treatment.

Patients and methods

One hundred and seventy-eight patients diagnosed with R-PDAC on computed tomography (CT) imaging and undergoing radical resection at Hirosaki University Hospital from 2005 to 2019 were retrospectively analyzed. Patients with recurrence within 6 months after resection formed the early recurrence (ER) group, while other patients constituted the non-early recurrence (non-ER) group. Early recurrence prediction score (ERP score) was developed using preoperative parameters.

Results

ER was observed in 45 patients (25.3%). The ER group had significantly higher preoperative CA19-9 (p = 0.03), serum SPan-1 (p = 0.006), and CT tumor diameter (p = 0.01) compared with the non-ER group. The receiver operating characteristic (ROC) curve analysis identified cutoff values for CA19-9 (133 U/mL), SPan-1 (78.2 U/mL), and preoperative tumor diameter (23 mm). When the parameter exceeded the cutoff level, 1 point was given, and the total score of the three factors was defined as the ERP score. The group with an ERP score of 3 had postoperative recurrence-free survival (RFS) of 5.5 months (95% CI 3.02–7.98). Multivariate analysis for ER-related perioperative and surgical factors identified ERP score of 3 [odds ratio (OR) 4.63 (95% CI 1.82–11.78), p = 0.0013] and R1 resection [OR 3.20 (95% CI 1.01–10.17), p = 0.049] as independent predictors of ER.

Conclusions

For R-PDAC, ER could be predicted by the scoring system using preoperative serum CA19-9 and SPan-1 levels and CT tumor diameter, which may have great significance in identifying patients with poor prognoses and avoiding unnecessary surgery.

Identification of Preoperative Risk Factors for Poor Survival in Patients with Resectable Pancreatic Cancer Treated with Upfront Surgery

INTRODUCTION

The aim of this study was to identify preoperative risk factors for poor survival in patients with resectable pancreatic ductal adenocarcinoma (PDAC) treated with upfront surgery.

METHODS

Medical records of 268 patients with resectable PDAC defined by resectability status who underwent upfront surgery were reviewed retrospectively. Multivariate analyses were performed to identify preoperative risk factors for recurrence-free survival (RFS) and overall survival (OS). Moreover, a binary logistic regression model was built to determine preoperative independent risk factors of 2- and 3-year recurrence and survival.

RESULTS

Multivariate analyses identified CA19-9 (≥100 U/mL, p < 0.001) as an independent risk factor for poor RFS, and worse performance status (1 or 2, p = 0.03), platelet:lymphocyte ratio (<150, p = 0.04), and preoperative CA19-9 (≥100 U/mL, p < 0.001) as independent risk factors for poor OS. Moreover, preoperative CA19-9 (≥100 U/mL) was the only independent risk factor identified for 2- and 3-year recurrence and survival.

DISCUSSION/CONCLUSION

Preoperative CA19-9 (≥100 U/mL) was the most reliable preoperative predictive factor for poor survival in resectable PDAC treated with upfront surgery. These findings warrant further clinical trials investigating efficacy of neoadjuvant therapy targeting the subset of patients with resectable PDAC who have elevated preoperative CA19-9, namely, those with high risk of poor prognosis.

C-Reactive Protein and Neutrophil/Lymphocytes Ratio: Prognostic Indicator for Doubling overall survival Prediction in Pancreatic Cancer Patients

Background: Despite modern chemotherapy regimens, survival of patients with locally advanced/metastatic pancreatic cancer remains dismal. Long-term survivors are rare and there are no prognostic scores to identify patients benefitting most from chemotherapy. Methods: This retrospective study includes 240 patients with pancreatic cancer who were treated in a primary palliative setting between the years 2007 to 2016 in a single academic institution. Survival rates were analyzed using the Kaplan–Meier method. Prognostic models including laboratory and clinical parameters were calculated using Cox proportional models in univariate and multivariate analyses. Results: Median age at diagnosis was 67 years (range 29–90 years), 52% were female and a majority had an ECOG performance status of 0 or 1. Locally advanced pancreatic cancer was diagnosed in 23.3% (n = 56) and primary metastatic disease in 76.7% (n = 184) of all patients. Median overall survival of the whole study cohort was 8.3 months. Investigating potential risk factors like patient characteristics, tumor marker or inflammatory markers, multivariate survival analysis found CRP (c-reactive protein) and NLR (neutrophil to lymphocyte ratio) elevation before the start of palliative chemotherapy to be independent negative prognostic factors for OS (overall survival) (p < 0.001 and p < 0.01). Grouping patients with no risk factor versus patients with one or two of the above mentioned two risk factors, we found a median OS of 16.8 months and 9.4 months (p < 0.001) respectively. By combining these two factors, we were also able to identify pancreatic cancer patients that were more likely to receive any post first line therapy. These two risk factors are predictive for improved survival independent of disease stage (III or IV) and applied chemotherapy agents in first line. Conclusion: By combining these two factors, CRP and NLR, to create a score for OS, we propose a simple, new prognostic tool for OS prediction in pancreatic cancer.