Comparison of the prognostic value of tumour- and patient-related factors in patients undergoing potentially curative surgery for colon cancer

Taiwan Society of Colon and Rectum Surgeons (TSCRS) Consensus for Anti-Inflammatory Nutritional Intervention in Colorectal Cancer

Malnutrition and systemic inflammatory response (SIR) frequently occur in patients with colorectal cancer (CRC) and are associated with poor prognosis. Anti-inflammatory nutritional intervention is not only a way to restore the malnourished status but also modulate SIR. Nine experts, including colorectal surgeons, physicians and dieticians from 5 hospitals geographically distributed in Taiwan, attended the consensus meeting in Taiwan Society of Colon and Rectum Surgeons for a 3-round discussion and achieved the consensus based on a systematic literature review of clinical studies and published guidelines. The consensus recommends that assessment of nutritional risk and SIR should be performed before and after CRC treatment and appropriate nutritional and/or anti-inflammatory intervention should be adapted and provided accordingly.

Clinical Impact of Combined Modified Glasgow Prognostic Score and C-Reactive Protein/Albumin Ratio in Patients with Colorectal Cancer

The prognostic impact of the combination of the modified Glasgow prognostic score (mGPS) and C-reactive protein/albumin ratio (CAR) in colorectal cancer (CRC) is unclear. We aimed to investigate the clinical usefulness of this combination as a predictor of survival in CRC patients. We retrospectively evaluated 769 CRC patients who had undergone surgery between January 2006 and March 2014. The CAR and mGPS within 1 month postoperation were examined. The integrated area under the curve (iAUC) was compared among mGPS, CAR, and the combined classification (CC). The optimal CAR cut-off for discriminating overall survival was 0.14. Based on this cut-off, the mGPS 0 group was divided into the mGPS 0 with low CAR and the mGPS 0 with high CAR groups, whereas all mGPS 1 and 2 patients were classified into the high CAR group. CC was an independent prognostic factor, and its iAUC value (0.587, 95% CI 0.553–0.624) was superior to those of the mGPS (0.544, 95% CI 0.516–0.576) (bootstrap iAUC mean difference = 0.043; 95% CI = 0.015–0.072) and CAR (0.578, 95% CI 0.545–0.613) (bootstrap iAUC mean difference = 0.009; 95% CI = 0.002–0.017), respectively. In conclusion, the combination of mGPS and CAR has a synergistic effect and has a higher prognostic accuracy than mGPS or CAR alone in patients with CRC.

Neutrophil-to-lymphocyte ratio is a prognostic factor for colon cancer: a propensity score analysis

Background

A large number of patients suffer recurrence after curative resection, and mortality from colon cancer remains high. The role of systemic inflammatory response, as reflected by neutrophil-to-lymphocyte ratio (NLR), in cancer recurrence and death has been increasingly recognized. This study aimed to analyze long-term oncologic outcomes of Stage II-III colon cancer to examine the prognostic value of NLR using a propensity score analysis.

Methods

A total of 375 patients with colon cancer underwent radical surgery between 2000 and 2014 at Tokyo Medical University Hospital. Long-term oncologic outcomes of these patients were evaluated according to NLR values. A cut-off NLR of 3.0 was used based on receiver operating characteristic curve analysis. Primary outcomes were overall survival (OS) and relapse-free survival (RFS). An analysis of outcomes according to tumor sidedness was also performed.

Results

Patients with lower NLR values (“lower NLR group”) were more likely to have lymph node metastasis compared to those with higher NLR values (“higher NLR group”) before case matching. After case matching, clinical outcomes were similar between the two groups. There were no significant differences in 5-year OS and 5-year RFS rates between the two groups before case matching based on propensity scores. After case matching, 5-year OS rates were 94.5% in the lower NLR group (n = 135) and 87.0% in the higher NLR group (n = 135), showing a significant difference (p = 0.042). Five-year RFS rates were 87.8% in the lower NLR group and 77.9% in the higher NLR group, also showing a significant difference (p = 0.032). Among patients with left-sided colon cancer in the matched cohort, 5-year OS and 5-year RFS rates were 95.2 and 87.3% in the lower NLR group (n = 88), respectively, and 86.4 and 79.2% in the higher NLR group (n = 71), respectively, showing significant differences (p = 0.014 and p = 0.047, respectively).

Conclusions

The NLR is an important prognostic factor for advanced colon cancer, especially for left-sided colon cancer.

The prevalence of cancer associated systemic inflammation: Implications of prognostic studies using the Glasgow Prognostic Score

The prognostic importance of SIR in patients with cancer is widely recognised. More recently it has become clear that the systemic inflammatory response is an important etiologic factor in the development of cancer cachexia. Two recent meta-analysis carried out in 2017 and 2018 were interrogated and the number of patients with specific cancer types were identified. The percentage of patients with operable cancer (n>28,000) who were systemically inflamed varied from 21% to 38%. The percentage of patients with inoperable cancer (n>12,000) who were systemically inflamed varied from 29% to 79%. Overall, the percentage of patients (n>40,000) who were systemically inflamed varied from 28% to 63% according to tumour type. The most commonly studied cancer was colorectal cancer (n∼10,000 patients) and 40% were systemically inflamed.

Epithelial NOTCH Signaling Rewires the Tumor Microenvironment of Colorectal Cancer to Drive Poor-Prognosis Subtypes and Metastasis

The metastatic process of colorectal cancer (CRC) is not fully understood and effective therapies are lacking. We show that activation of NOTCH1 signaling in the murine intestinal epithelium leads to highly penetrant metastasis (100% metastasis; with >80% liver metastases) in KrasG12D-driven serrated cancer. Transcriptional profiling reveals that epithelial NOTCH1 signaling creates a tumor microenvironment (TME) reminiscent of poorly prognostic human CRC subtypes (CMS4 and CRIS-B), and drives metastasis through transforming growth factor (TGF) β-dependent neutrophil recruitment. Importantly, inhibition of this recruitment with clinically relevant therapeutic agents blocks metastasis. We propose that NOTCH1 signaling is key to CRC progression and should be exploited clinically.

Association of preoperative anemia and perioperative allogenic red blood cell transfusion with oncologic outcomes in patients with nonmetastatic colorectal cancer

Background

We investigated whether preoperative anemia and perioperative blood transfusion (pbt) are associated with overall survival and recurrence-free survival in patients with nonmetastatic colorectal cancer.

Methods

From 1 January 2009 to 31 December 2014, 1003 patients with primary colorectal cancer were enrolled in the study. Perioperative clinical and oncologic outcomes were analyzed based on the presence of preoperative anemia and pbt.

Results

Preoperative anemia was found in 468 patients (46.7%). In the anemia and no-anemia groups, pbt was performed in 44% and 15% of patients respectively. Independent predictors for pbt were preoperative anemia, higher American Society of Anesthesiologists score, laparotomy, lengthy operative time, advanced TNM stage, T4 stage, and 30-day morbidity. The use of pbt, but not preoperative anemia, was found to be an independent adverse prognostic factor for overall survival. In terms of recurrence-free survival, the presence of preoperative anemia was similarly not a significant prognostic factor, but the use of pbt was an independent factor for an unfavourable prognosis.

Conclusions

The use of pbt, but not preoperative anemia, was independently associated with worse overall and recurrence-free survival in nonmetastatic colorectal cancer. For better oncologic outcomes, our findings indicate a need to reduce the use of blood transfusion during the perioperative period.

Neutrophils: Homing in on the myeloid mechanisms of metastasis

The metastasis cascade is complex and comprises several stages including local invasion into surrounding tissue, intravasation and survival of tumour cells in the circulation, and extravasation and colonisation of a distant site. It is increasingly clear that these processes are driven not only by signals within the tumour cells, but are also profoundly influenced by stromal cells and signals in the tumour microenvironment. Amongst the many cell types within the tumour microenvironment, immune cells such as lymphocytes, macrophages and neutrophils play a prominent role in tumour development and progression. Neutrophils, however, have only recently emerged as important players, particularly in metastasis. Here we review the current evidence suggesting a multi-faceted role for neutrophils in the metastatic cascade.

The impact of preoperative anaemia and anaemic subtype on patient outcome in colorectal cancer

AIM

Preoperative anaemia is associated with adverse outcomes in colorectal cancer (CRC). To clarify the reason for this we aimed to comprehensively assess the association of preoperative anaemia with tumour characteristics, host systemic inflammation and nutrition status, and perioperative blood transfusion.

METHOD

We used an integrated database of 592 CRC patients. The association of preoperative anaemic subtype, calculated from haemoglobin and erythrocyte mean corpuscular volume levels, with patient outcome, preoperative serum data relating to systemic inflammation and nutrition and perioperative blood transfusion was analysed.

RESULTS

Preoperative anaemia was significantly associated with poorer overall survival and relapse-free survival (RFS); in particular microcytic anaemia had a trend to poorer RFS than other forms of anaemia (P = 0.0648). In addition, preoperative anaemia was significantly correlated with right-sided tumours, greater depth of tumour invasion, use of neoadjuvant chemotherapy, poorer prognostic nutritional index and higher modified Glasgow Prognostic Score (mGPS). Microcytic anaemia in particular had a strong association with a greater depth of tumour invasion (P = 0.0072) and higher mGPS (P = 0.0058) than other causes of anaemia. Perioperative blood transfusion for CRC patients with anaemia was associated with adverse outcomes.

CONCLUSIONS

Preoperative anaemia, especially microcytic anaemia, was associated with poor patient outcomes, possibly due to poor systemic inflammatory and nutritional status, and it was not improved by perioperative blood transfusion. Our data suggest that preoperative anaemia and the anaemic subtype may serve as an easily available predictor of outcome in CRC.

Tumor-derived granzyme B-expressing neutrophils acquire antitumor potential after lipid A treatment

Neutrophils are known to possess both pro- and anti-tumor properties, a feature that could be related to the diversity and plasticity of these cells. Here we explored the hypothesis that under an appropriate environment and stimuli, neutrophils could induce an effective response against tumor cells. In a rat and mouse models, we show that a substantial amount of colon tumor associated-neutrophils (TAN) expressed the cytolytic enzyme granzyme B, which is absent in spleen or blood circulating neutrophils. This TAN population was also found into tumors of patients with colon cancer. Tumor neutrophil infiltration was correlated with an increase of chemokines known to attract neutrophils in both rat models and patients. These cells were involved in a Lipid A analog-mediated colon tumor regression. Mechanistically, treating the rats with the Lipid A analog triggered granzyme B release from neutrophils in tumor cell vicinity, which was correlated to tumor regression. Alteration of granzyme B function in tumor cells decreased the cytotoxic effect of Lipid A in rat and mouse models. Granzyme B expression in neutrophils could be induced by the lipid A analog but also by some of the cytokines that were detected in the tumor microenvironment. These results identify a subpopulation of neutrophils expressing granzyme B that can act as a key player of lipid A-mediated colon cancer regression in rat and mouse models and the molecular mechanisms involved may provide novel approaches for human therapeutic intervention.

Prognostic significance of pretreatment elevated platelet count in patients with colorectal cancer: a meta-analysis

Background

The prognostic effect of pretreatment elevated platelet count remains controversial in colorectal cancer patients. We conducted this meta-analysis to evaluate the prognostic impact of it in these patients.

Methods

PubMed, EMBASE and Cochrane Library were searched and studies on the prognostic significance of pretreatment elevated platelet count in colorectal patients were identified. We performed the meta-analysis, using overall survival and disease-free survival as outcomes and presenting data with hazard ratio and its 95% confidence interval. Heterogeneity among studies and publication bias were also evaluated.

Results

Thirty studies were included in the meta-analysis. Compared with normal platelet count, pretreatment elevated platelet count was associated with poorer overall survival (Hazard ratio = 1.837, 95% confidence interval, 1.497 to 2.255, p = 0.000) and poorer disease-free survival (Hazard ratio = 1.635, 95% confidence interval, 1.237 to 2.160, p = 0.001) in patients with colorectal cancer. In subgroup analyses, pretreatment elevated platelet count was also associated with poorer overall survival and disease-free survival in most subgroups.

Conclusion

Pretreatment elevated platelet count was an independent prognostic factor of overall survival and disease-free survival in colorectal cancer patients. Large-scale prospective studies and a validation study are warranted.

Preoperative anemia in colorectal cancer: relationships with tumor characteristics, systemic inflammation, and survival

Anemia is common in colorectal cancer (CRC) but its relationships with tumor characteristics, systemic inflammation, and survival have not been well characterized. In this study, blood hemoglobin levels and erythrocyte mean corpuscular volume (MCV) levels were measured in two independent cohorts of 148 CRC patients and 208 CRC patients, and their correlation with patient and tumor characteristics, systemic inflammatory markers (modified Glasgow Prognostic Score: mGPS; serum levels of thirteen cytokines, C-reactive protein, albumin), and survival were analyzed. We found that anemia, most frequently normocytic, followed by microcytic, was present in 43% of the patients. Microcytic anemia was most commonly associated with proximal colon tumor location. Average MCV and blood hemoglobin levels were lower in tumors with high T-class. Low blood hemoglobin associated with systemic inflammation, including high mGPS and high serum levels of C-reactive protein and IL-8. Particularly, normocytic anemia associated with higher mGPS. Normocytic anemia associated with a tendency towards worse overall survival (multivariate hazard ratio 1.61, 95% confidence interval 1.07–2.42, p = 0.023; borderline statistical significance considering multiple hypothesis testing). In conclusion, anemia in CRC patients is most frequently normocytic. Proximal tumor location is associated with predominantly microcytic anemia and systemic inflammation is associated with normocytic anemia.

Prognostic Significance of Serum Inflammatory Markers in Gastric Cancer

BACKGROUND

The aim of this study was to assess the relative prognostic value of biomarkers to measure the systemic inflammatory response (SIR) and improve prognostic modeling in a cohort of patients undergoing potentially curative surgery for gastric adenocarcinoma. The hypothesis was that a single SIR biomarker would be associated with the most prognostic value.

METHODS

Consecutive 331 patients undergoing surgery for gastric cancer between 2004 and 2016 within a regional UK cancer network were identified. Serum measurements of hemoglobin, C-reactive protein, albumin, modified Glasgow Prognostic Score, and differential white cell counts were obtained before surgery, and correlated with histopathological factors (pTNM stage, differentiation, and vascular invasion) and survival. Primary outcome measures were disease-free (DFS) and overall survival (OS).

RESULTS

Consecutive 331 patients were identified and 291 underwent potentially curative gastrectomy for adenocarcinoma. On univariable DFS analysis, female gender (p = 0.027), proximal location (p = 0.018), pT stage (p < 0.001), pN stage (p < 0.001), pTNM stage (p < 0.001), vascular invasion (p < 0.001), poor differentiation (p = 0.001), lymph node ratio (p < 0.001), R1 status (p < 0.001), platelet count (p = 0.038), and mGPS (p = 0.001) were significantly associated with poor survival. The mGPS was associated with advanced pT stage (p = 0.001), pTNM stage (p = 0.013), and poor differentiation (p = 0.030). On multivariable DFS analysis, mGPS [hazard ratio (HR) 2.51, 95% confidence interval (CI) 1.35-4.65, p = 0.011] was the only inflammatory marker to retain independent significance. Multivariable OS analysis revealed similar findings; mGPS (HR 2.75, (95% CI 1.65-4.59), p < 0.001).

CONCLUSION

mGPS is an important and only SIR-related prognostic biomarker independently associated with both DFS and OS in gastric cancer.

The role of the systemic inflammatory response in predicting outcomes in patients with operable cancer: Systematic review and meta-analysis

Cancer remains a leading causes of death worldwide and an elevated systemic inflammatory response (SIR) is associated with reduced survival in patients with operable cancer. This review aims to examine the evidence for the role of systemic inflammation based prognostic scores in patients with operable cancers. A wide-ranging literature review using targeted medical subject headings for human studies in English was carried out in the MEDLINE, EMBASE, and CDSR databases until the end of 2016. The SIR has independent prognostic value, across tumour types and geographical locations. In particular neutrophil lymphocyte ratio (NLR) (n = 158), platelet lymphocyte ratio (PLR) (n = 68), lymphocyte monocyte ratio (LMR) (n = 21) and Glasgow Prognostic Score/ modified Glasgow Prognostic Score (GPS/mGPS) (n = 60) were consistently validated. On meta-analysis there was a significant relationship between elevated NLR and overall survival (OS) (p < 0.00001)/ cancer specific survival (CSS) (p < 0.00001), between elevated LMR and OS (p < 0.00001)/CSS (p < 0.00001), and elevated PLR and OS (p < 0.00001)/CSS (p = 0.005). There was also a significant relationship between elevated GPS/mGPS and OS (p < 0.00001)/CSS (p < 0.00001). These results consolidate the prognostic value of the NLR, PLR, LMR and GPS/mGPS in patients with resectable cancers. This is particularly true for the NLR/GPS/mGPS which should form part of the routine preoperative and postoperative workup.

Combined neutrophil-platelet score and hemoglobin level predict survival in esophageal squamous cell carcinoma patients treated with chemoradiotherapy

Systemic inflammation and hematological markers have prognostic value in patients with esophageal squamous cell carcinoma (ESCC). The objective of this study was to evaluate the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), combined neutrophil-platelet (CNP) score, and hemoglobin (Hb) to inform treatment decisions and predict outcomes in patients with locally advanced ESCC treated with chemoradiotherapy (CRT). A total of 168 patients with locally advanced ESCC were retrospectively evaluated. Patients were stratified by marker value using a receiver operating characteristic curve analysis to determine the cutoff point. Logistic regression was used to identify markers associated with sensitivity to treatment. Overall survival (OS) was calculated by the Kaplan-Meier method. Multivariate Cox logistic regression modeling was used to assess the influences of OS. Smoking history, tumour site, clinical stage, NLR, PLR, CNP, and Hb (p ≤ 0.05) were associated with the sensitivity to therapy. In multivariate analysis, a high CNP score was independently associated with poor treatment sensitivity (OR = 2.066, p = 0.021). Univariate analysis revealed that PLR, CNP, and Hb levels were associated with OS, and Cox multivariate analysis found that CNP (HR = 1.47, p = 0.027) and Hb level (HR = 0.44, p = 0.007) were independent predictors of OS. In conclusion, CNP and Hb are inexpensive and universally available prognostic markers in patients with locally advanced ESCC patients. CNP score is a systemic inflammatory marker that predicted sensitivity to CRT.

A Nomogram to Predict Adequate Lymph Node Recovery before Resection of Colorectal Cancer

Increased lymph node count (LNC) has been associated with prolonged survival in colorectal cancer (CRC), but the underlying mechanisms are still poorly understood. The study aims to identify new predictors and develop a preoperative nomogram for predicting the probability of adequate LNC (≥ 12). 501 eligible patients were retrospectively selected to identify clinical-pathological factors associated with LNC ≥ 12 through univariate and multivariate logistic regression analyses. The nomogram was built according to multivariate analyses of preoperative factors. Model performance was assessed with concordance index (c-index) and area under the receiver operating characteristic curve (AUC), followed by internal validation and calibration using 1000-resample bootstrapping. Clinical validity of the nomogram and LNC impact on stage migration were also evaluated. Multivariate analyses showed patient age, CA19-9, circulating lymphocytes, neutrophils, platelets, tumor diameter, histology and deposit significantly correlated with LNC (P < 0.05). The effects were marginal for CEA, anemia and CRC location (0.05 < P < 0.1). The multivariate analyses of preoperative factors suggested decreased age, CEA, CA19-9, neutrophils, proximal location, and increased platelets and diameter were significantly associated with increased probability of LNC ≥ 12 (P < 0.05). The nomogram achieved c-indexes of 0.75 and 0.73 before and after correction for overfitting. The AUC was 0.75 (95% CI, 0.70–0.79) and the clinically valid threshold probabilities were between 10% and 60% for the nomogram to predict LNC < 12. Additionally, increased probability of adequate LNC before surgery was associated with increased LNC and negative lymph nodes rather than increased positive lymph nodes, lymph node ratio, pN stages or AJCC stages. Collectively, the results indicate the LNC is multifactorial and irrelevant to stage migration. The significant correlations with preoperative circulating markers may provide new explanations for LNC-related survival advantage which is reflected by the implication of regional and systemic antitumor immune responses.

Glasgow Prognostic Score (GPS) can be a useful indicator to determine prognosis of patients with colorectal carcinoma

The Glasgow Prognostic Score (GPS), an inflammation-based score, has been used to predict the biologic behavior of malignant tumors. The aim of the current study was to elucidate a further significance of GPS in colorectal carcinoma. Correlation of GPS and modified GPS (mGPS), which are composed of combined score provided for serum elevation of C-reactive protein and hypoalbuminemia examined before surgical treatment, with clinicopathologic features was investigated in 272 patients with colorectal carcinoma. Survival of GPS 1 patients was significantly worse than that of GPS 0 patients (P= 0.009), and survival of GPS 2 patients was significantly worse than that of GPS 1 patients (P < 0.0001). Similarly, survival of mGPS 1 patients was significantly worse than that of mGPS 0 patients (P = 0.009), and survival of mGPS 2 patients was significantly worse than that of mGPS 1 patients (P = 0.0006). Multivariate analysis demonstrated that GPS (P < 0.0001) as well as tumor stage (P= 0.004) and venous invasion (P = 0.011) were factors independently associated with worse prognosis. Both GPS and mGPS could classify outcome of patients with a clear stratification, and could be applied as prognostic indicators in colorectal carcinoma.

Prognostic factors in relation to racial disparity in advanced colorectal cancer survival

INTRODUCTION

Colorectal cancer mortality rates are significantly greater in AA than in EA individuals, and the disparity is worsening. We investigated the relationship between race and metastatic CRC (mCRC) survival in younger and older patients.

PATIENTS AND METHODS

Using data from the Hollings Cancer Center (Charleston, SC), we studied the role of clinical, pathologic, and treatment-related factors on the disparity in survival. We carried out a retrospective cohort study of 82 mCRC patients (26 AA, 56 EA). The data source was medical record data from June 1, 2004 through May 31, 2008 with follow-up through June 30, 2010. Using Kaplan-Meier methods, we generated median survival time according to race and age (< 61, ≥ 61 years). Cox proportional hazards regression models were used to model the risk of death according to race.

RESULTS

The median age was 56.7 years for AA and 61.6 years for EA patients. Compared with EA, median survival in AA patients was 59% worse in younger patients (12.7 vs. 31.0 months) and 29% worse in older patients (11.7 vs. 16.4 months). The risk of death among younger AA compared with EA patients was 2.45 (95% confidence interval [CI], 1.15-5.23) and among older patients was 1.16 (95% CI, 0.49-2.73).

CONCLUSION

Our results highlight the importance of considering younger age, clinical prognostic markers, and tumor phenotypes as potential sources of the disparity in advanced stage CRC.

Prognostic criteria in colorectal carcinoma constructed by the combination of tumor-related and host-related factors

BACKGROUND

The significance of prognostic criteria based on a combination of tumor-related and host-related factors for patients with colorectal carcinoma has not been appreciated fully.

METHODS

Correlation of tumor-related and host-related score (TRHRS), which are constructed by the combination of serum elevation of C-reactive protein and pathologic lymph node metastasis (scores ranging 0 to 2), with clinicopathologic features including prognosis was studied in 271 patients with colorectal carcinoma who had been treated with curative resection.

RESULTS

Significant difference regarding survival was observed both between TRHRS 0 and 1 (P = .028) and between TRHRS 1 and 2 (P < .0001). Multivariate analysis showed that histologic types (P = .040) and TRHRS (P < .0001) were independent prognostic indicators.

CONCLUSION

Criteria for the prediction of prognosis in colorectal carcinoma treated with curative resection based on both tumor-related and host-related factors could provide a strict stratification.

Clinical utility of inflammation-based prognostic systems in patients with colorectal cancer

SUMMARY This systematic review focuses on the clinical utility of three inflammation-based prognostic systems for patients with colorectal cancer (CRC): the Glasgow Prognostic Score (GPS) and its modified version – the modified GPS, neutrophil:lymphocyte ratio (NLR) and reactive thrombocytosis. The GPS/modified GPS had prognostic value in patients undergoing surgery, patients receiving chemo-/radiation therapy, patients with inoperable CRC, patients receiving nutritional evaluation and patients with perioperative complications. The NLR and reactive thrombocytosis also had prognostic value in patients undergoing surgery, patients receiving chemo-/radiation therapy and patients with inoperable CRC. The recommended cut-off value for the NLR is considered to be 5. Because thrombocytosis has been investigated in only seven studies, involving 1971 patients, and the recommended cut-off value is considered to be 300–400 × 109/l, further studies will be required to decide the ideal cut-off value for reactive thrombocytosis in patients with CRC.

Preoperative neutrophil to lymphocyte ratio >5 is a prognostic factor for recurrent colorectal cancer

AIM

Previous studies have demonstrated that raised preoperative neutrophil to lymphocyte ratio (NLR) is associated with poor prognosis in colorectal cancer (CRC). The aim of this study was to assess whether preoperative NLR could predict patients at risk of recurrence of CRC.

METHOD

All consecutive patients who underwent surgical resection for CRC over a 2-year period at our institution were analysed. Demographic data including CRC recurrence were prospectively collected from our institutional cancer database. CRC recurrence was diagnosed on radiological and endoscopic histopathological data. Preoperative NLR was calculated on baseline blood results, with a value >5 being a poor prognostic factor. Parametric survival analysis was used to identify risk factors for CRC recurrence. Hazard ratios (HRs) were calculated for gender, CRC stage using Jass score, preoperative NLR and CRC site. P < 0.05 was considered statistically significant.

RESULTS

In all, 297 patients (157 men) underwent CRC resection at a median age of 70 years (range 23-93); 164 patients had colon cancer, 111 rectal cancer and 22 recto-sigmoid cancer. The distribution by stage of CRC was 30.2% for stage 1, 23.8% for stage 2, 19.5% for stage 3 and 26.5% for stage 4. Over a median follow-up period of 3.35 (0.1-8) years, 59 (19.8%) patients had recurrent CRC. Multivariate analysis revealed CRC stage (HR 8.69, 95% CI 3.85-19.6, P < 0.0001) and NLR >5 (HR 1.81, 95% CI 1.07-3.07, P = 0.028) to be significant and independent risk factors predictive of recurrent CRC.

CONCLUSION

These data suggest that preoperative NLR >5 is predictive of CRC recurrence.

The relationship between tumour site, clinicopathological characteristics and cancer-specific survival in patients undergoing surgery for colorectal cancer

AIM

It is recognised that colorectal cancer may arise from different genomic instability pathways. There is evidence to suggest that colon and rectal cancers exhibit different clinicopathological features. We examined the relationship between tumour site, clinicopathological characteristics and cancer-specific survival in patients undergoing potentially curative resection for colorectal cancer.

METHOD

Four hundred and eleven patients who underwent surgery. Clinicopathological data including components of the Peterson index, Klintrup scores, haemoglobin and the modified Glasgow Prognostic Score (mGPS) were studied.

RESULTS

There were 134 (33%) right sided, 125 (30%) left sided and 152 (37%) rectal tumours. Emergency presentation (P < 0.001), anaemia (P < 0.001), higher mGPS (P < 0.001), advanced T stage (P < 0.001), poor differentiation (P < 0.001) and older age (P < 0.05) were more commonly observed in right sided cancer. The mean follow-up was 94 months (minimum 36 months) and 114 patients died of cancer. There was no difference between tumour site and survival (P = 0.427). On multivariate analysis older age (P = 0.015), lymph node ratio (P < 0.001), mGPS (P = 0.028), Peterson Index (P < 0.001) and Klintrup score (P = 0.008) were independently related to cancer-specific survival. Klintrup score was only associated with poor cancer-specific survival in rectal cancer (P = 0.009).

CONCLUSION

The study suggests that colorectal cancer is a group of heterogeneous tumours with different clinicopathological features. Despite this, there was no difference between tumour site and survival. The prognostic role of clinicopathological factors in tumours arising from different genomic instability pathways requires further study.

Prognostic factors assessed for 15,096 patients with colon cancer in stages I and II

BACKGROUND

We focused on the risk factors for poor outcome after curative resection of a colon cancer in UICC stages I and II based on the data of the Germany-wide quality assurance study "colon/rectum cancer (primary tumor)." In some countries, all stage II colon cancer patients are encouraged to participate in a clinical trial. We feel that this approach is too broad.

METHODS

Using the data of 15,096 patients operated on from January 1, 2000 to December 31, 2004, the following factors were analyzed with the Cox regression model: age, comorbidities, ASA score, gender, localization of the tumor (left colon vs. right colon), perioperative complications (yes/no), pT stage, grading (G1/G2 vs. G3/G4), L-status (lymph vessels invasion yes/no), and V-status (venous invasion yes/no).

RESULTS

The probability of a local relapse in stages I and II was 1.5 and 4.6%, respectively, or distant metastases 4.7 and 10.2%, respectively. Only pT stage [hazard ratio (HR) for pT1 = 1, pT2 = 1.821, pT3 = 2.735, and pT4 = 5.881], L-status (HR for L1 = 1.393), age (HR per year = 1.021), as well as ASA score IV (HR = 4.536) had significant influence on tumor-free survival.

CONCLUSIONS

Despite favorable prognosis and R0 resection, a small percentage of patients will still relapse. The most important risk factor comprising the tumor-free survival is the pT stage followed by L-status and age. These results should be taken into consideration when determining the course for adjuvant chemotherapy, especially if the course includes the recommendation of clinical trial participation for stage II colon cancer patients after an R0 resection.

The relationships between body composition and the systemic inflammatory response in patients with primary operable colorectal cancer

Background

Weight loss is recognised as a marker of poor prognosis in patients with cancer but the aetiology of cancer cachexia remains unclear. The aim of the present study was to examine the relationships between CT measured parameters of body composition and the systemic inflammatory response in patients with primary operable colorectal cancer.

Patient and Methods

174 patients with primary operable colorectal cancer who underwent resection with curative intent (2003–2010). Image analysis of CT scans was used to measure total fat index (cm²/m²), subcutaneous fat index (cm²/m²), visceral fat index (cm²/m²) and skeletal muscle index (cm²/m²). Systemic inflammatory response was measured by serum white cell count (WCC), neutrophil:lymphocyte ratio (NLR) and the Glasgow Prognostic Score (mGPS).

Results

There were no relationships between any parameter of body composition and serum WCC or NLR. There was a significant relationship between low skeletal muscle index and an elevated systemic inflammatory response, as measured by the mGPS (p = 0.001). This was confirmed by linear relationships between skeletal muscle index and both C-reactive protein (r = −0.21, p = 0.005) and albumin (r = 0.31, p<0.001). There was no association between skeletal muscle index and tumour stage.

Conclusions

The present study highlights a direct relationship between low levels of skeletal muscle and the presence of a systemic inflammatory response in patients with primary operable colorectal cancer.

Prognostication in advanced cancer: a study examining an inflammation-based score

CONTEXT

Prognostication in advanced cancer is challenging. Biomarkers of systemic inflammation (C-reactive protein and albumin) combined in the modified Glasgow Prognostic Score (mGPS) have been used to assist prognostication in various cancer types.

OBJECTIVES

The aim of this study was to examine whether an inflammation-based prognostic score (mGPS) is useful in prognostication in advanced cancer patients.

METHODS

Cancer patients who had biomarkers (C-reactive protein and albumin) recorded were allocated an mGPS ranging from 0-2. Groups were compared using Jonckheere-Terpstra and Chi-squared tests. Survival analyses were carried out using Kaplan-Meier and multivariate Cox regression models.

RESULTS

A total of 296 patients were included, and a representative subgroup of 102 had biomarkers recorded. The mGPS was predictive of death (P=0.014) adjusted for sex, cancer site, age, hemoglobin, and white cell count. Patients with an mGPS of 2 had 2.7 times the risk of death of those with an mGPS of 0 (P=0.011). Patients with an mGPS less than 2 had an 86.1% and 74.3% chance of being alive at two and four weeks, respectively.

CONCLUSION

A role for the mGPS in prognostication near the end of life is suggested. Biomarkers (e.g., mGPS) may assist clinical decisions as to whether intensive treatments are appropriate and may facilitate end-of-life care planning.

Preoperative thrombocytosis is associated with survival after surgery for colorectal cancer

OBJECTIVE

To evaluate the influence of preoperative thrombocytosis on survival after surgery in patients with colorectal cancer (CRC).

METHODS

Four hundred fifty-three patients who had undergone CRC surgery were retrospectively identified from institutional database. On the basis of receiver operating characteristic (ROC) curve analysis, they were classified into two groups: group A, with a preoperative platelet count of ≤300 (×10(9) /L), and Group B, with a preoperative platelet count of >300 (×10(9) /L). Uni- and multivariate analyses were performed to evaluate the relationship to overall survival. Kaplan-Meier analysis and log rank test were used to compare the survival curves between groups A and B.

RESULTS

There was a significant difference in overall survival between the two groups (P = 0.007). Multivariate analysis of selected preoperative clinicolaboratory characteristics showed that overall survival was associated with the platelet count (Group A/B) (odds ratio, 1.642; 95% CI, 1.025-2.629; P = 0.039) as well as the number of tumors (1/≥2), and the serum levels of C-reactive protein (CRP) and carcinoembryonic antigen (CEA).

CONCLUSION

Preoperative thrombocytosis is associated with survival after surgery in CRC patients, and is able to divide such patients into two independent groups before surgery.

Adjuvant chemotherapy for resected colon cancer: comparison of the prognostic value of tumour and patient related factors

PURPOSE

Despite proven benefits of adjuvant chemotherapy in colon cancer, outcomes remain heterogeneous. Several non-validated prognostic factors have been proposed. This study examines the prognostic value of tumour and patient factors currently included in the Numeracy and Adjuvant! models together with measures of the local and systemic inflammatory responses in patients receiving adjuvant chemotherapy for colon cancer.

METHODS

Three hundred and forty-eight patients underwent resection between 1997 and 2007. Of these, 76 received adjuvant chemotherapy. Chemotherapy was 5-FU based (single or combination). Variables from the Numeracy and Adjuvant! calculators were examined. The Petersen Index was used to assess other tumour characteristics considered high risk for recurrence (venous invasion, serosal involvement, surgical margin involvement and perforation through the tumour). Local inflammatory infiltrate was scored by the Jass and Klintrup criteria; the systemic inflammatory response by the Glasgow Prognostic Score (mGPS).

RESULTS

Median follow-up was 78 months. Chemotherapy prescription was higher in younger patients with less comorbidity or tumours with higher nodal involvement, increasing T stage and high-risk characteristics (all P < 0.05). On univariate analysis, high-risk tumour characteristics such as T stage and high-risk Petersen Index in addition to the mGPS related to survival. Only the GPS retained prognostic significance on multivariate analysis (P < 0.005).

CONCLUSION

The results of the present study showed that the components of Numeracy and Adjuvant! models and the tumour inflammatory infiltrate had inferior prognostic value compared with that of the systemic inflammatory response, as evidenced by the mGPS, in patients receiving adjuvant chemotherapy for colon cancer.

A clinical risk score to predict 3-, 5- and 10-year survival in patients undergoing surgery for Dukes B colorectal cancer

Background:

The prognosis of patients with Dukes stage B colorectal cancer is unpredictable and there is continuing interest in simply and reliably identifying patients at high risk of developing recurrence and dying of their disease. The aim of this study was to devise a clinical risk score to predict 3-, 5- and 10-year survival in patients undergoing surgery for Dukes stage B colorectal cancer.

Methods:

A total of 1350 patients who underwent surgery for Dukes stage B colorectal cancer between 1991 and 1994 in 11 hospitals in Scotland were included in the analysis.

Results:

On follow-up, 926 patients died of whom 479 died of their cancer. At 10 years, cancer-specific survival was 61% and overall survival was 38%. On multivariate analysis, age ⩾75 (hazard ratio (HR) 1.45, 95% confidence interval (CI) 1.15–1.82, P=0.001), emergency presentation (HR 1.59, 95% CI 1.27–1.99, P<0.001) and anastomotic leak (HR 2.17, 95% CI 1.24–3.78, P<0.01) were independently associated with cancer-specific survival in colon cancer. On multivariate analysis, only age ⩾75 (HR 1.58, 95% CI 1.14–2.18, P<0.01) was associated with cancer-specific survival in rectal cancer. Age, presentation and anastomotic leak hazards could be simply added to form a clinical risk score from 0 to 2 in colon cancer. In patients with Dukes B stage colon cancer, the cancer-specific survival at 5 years for patients with a cumulative score 0 was 81%, 1 was 67% and 2 was 63%. The cancer-specific survival rate at 10 years for patients with a clinical risk score of 0 was 72%, 1 was 58% and 2 was 53%.

Conclusion:

The results of this study, in a mature cohort, introduce a new simple clinical risk score for patients undergoing surgery for Dukes B colon cancer. This provides a solid foundation for the examination of the impact of additional factors and treatment on prediction of 3-, 5- and 10-year cancer-specific survival.