The impact of age and comorbidity in advanced or recurrent biliary tract cancer receiving palliative chemotherapy

Body mass index and survival among patients with advanced biliary tract cancer: a single-institutional study with nationwide data-based validation

BACKGROUND

Excess body weight may modulate the progression of various cancer types. The prognostic relevance of body mass index (BMI) has not been fully examined in patients with biliary tract cancer.

METHODS

Using a single-institutional cohort of 360 patients receiving gemcitabine-based chemotherapy for advanced biliary tract cancer, we examined the association of BMI with overall survival (OS). Using the Cox regression model with adjustment for potential confounders, we calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for OS according to BMI. The findings were validated using a Japanese nationwide inpatient database including 8324 patients treated at 201 hospitals.

RESULTS

In the clinical cohort, BMI was not associated with OS (Ptrend = 0.34). Compared to patients with BMI = 18.5-24.9 kg/m2, patients with BMI < 18.5 kg/m2 and ≥ 25.0 kg/m2 had adjusted HRs for OS of 1.06 (95% CI, 0.78-1.45) and 1.01 (95% CI, 0.74-1.39), respectively. There was no evidence on a non-linear relationship between BMI and OS (Pnonlinearity = 0.63). In the nationwide cohort, the null findings were validated (Ptrend = 0.18) with adjusted HRs of 1.07 (95% CI, 0.98-1.18) for BMI < 18.5 kg/m2 and 1.05 (95% CI, 0.96-1.14) for BMI ≥ 25.0 kg/m2 (vs. BMI = 18.5-24.9 kg/m2). In the clinical cohort, BMI was not associated with progression-free survival (Ptrend = 0.81).

CONCLUSIONS

BMI was not associated with survival outcomes of patients with advanced biliary tract cancer. Further research is warranted incorporating more detailed body composition metrics to explore the prognostic role of adiposity in biliary tract cancer.

Multivariate analysis of prognostic factors in patients with lip squamous cell carcinoma after surgery

BACKGROUND

Lip squamous cell carcinoma (LSCC) was one of the most common cancer types of head and neck tumors. This study aimed to find more predictors of the prognosis in postoperative LSCC patients.

METHODS

A total of 147 LSCC patients between June 2012 and June 2018 were collected from two tertiary care institutions. There were 21 clinicopathological factors included and analyzed in our study. The univariate and multivariate Cox regression analyses were performed to find the independent prognostic factors for predicting progression-free survival (PFS) and overall survival (OS) in postoperative LSCC patients. The role of adjuvant radiotherapy in various subgroups was displayed by Kaplan-Meier plots.

RESULTS

The 1-, 3-, and 5-year PFS of postoperative LSCC patients were 88.4%, 70.1%, and 57.8%, respectively. Similarly, the 1-, 3-, and 5-year OS of postoperative LSCC patients were 94.6%, 76.9%, and 69.4%, respectively. The results suggested that postoperative LSCC patients with age at diagnosis ≥ 70 years, grade with moderate or poor differentiate, the American Joint Committee on Cancer (AJCC) stage IV, higher systemic immune-inflammation index (SII), surgical margin < 5, and age-adjusted Charlson Comorbidity Index (ACCI) ≥ 5 tend to have a poorer PFS (all P < 0.05). Besides, postoperative LSCC patients with age at diagnosis ≥ 70 years, AJCC stage IV, higher GPS, higher SII, and ACCI ≥ 5 tend to have a worse OS (all P < 0.05). Additionally, postoperative patients with LSCC in the subgroup of ACCI < 5 and AJCC III-IV stage was more likely to benefit from adjuvant radiotherapy, but not for the other subgroups.

CONCLUSION

We identified a series of significant immune-inflammation-related and comorbidity-related clinicopathological factors associated with the prognosis of postoperative LSCC patients by local data from two tertiary care institutions in China, which can be helpful for patients and surgeons to pay more attention to nutrition, inflammation, and complications and finally obtained a better prognosis.

Development of a model based on the age-adjusted Charlson comorbidity index to predict survival for resected perihilar cholangiocarcinoma

BACKGROUND

Perihilar cholangiocarcinoma (pCCA) has a poor prognosis and urgently needs a better predictive method. The predictive value of the age-adjusted Charlson comorbidity index (ACCI) for the long-term prognosis of patients with multiple malignancies was recently reported. However, pCCA is one of the most surgically difficult gastrointestinal tumors with the poorest prognosis, and the value of the ACCI for the prognosis of pCCA patients after curative resection is unclear.

AIM

To evaluate the prognostic value of the ACCI and to design an online clinical model for pCCA patients.

METHODS

Consecutive pCCA patients after curative resection between 2010 and 2019 were enrolled from a multicenter database. The patients were randomly assigned 3:1 to training and validation cohorts. In the training and validation cohorts, all patients were divided into low-, moderate-, and high-ACCI groups. Kaplan-Meier curves were used to determine the impact of the ACCI on overall survival (OS) for pCCA patients, and multivariate Cox regression analysis was used to determine the independent risk factors affecting OS. An online clinical model based on the ACCI was developed and validated. The concordance index (C-index), calibration curve, and receiver operating characteristic (ROC) curve were used to evaluate the predictive performance and fit of this model.

RESULTS

A total of 325 patients were included. There were 244 patients in the training cohort and 81 patients in the validation cohort. In the training cohort, 116, 91 and 37 patients were classified into the low-, moderate- and high-ACCI groups. The Kaplan-Meier curves showed that patients in the moderate- and high-ACCI groups had worse survival rates than those in the low-ACCI group. Multivariable analysis revealed that moderate and high ACCI scores were independently associated with OS in pCCA patients after curative resection. In addition, an online clinical model was developed that had ideal C-indexes of 0.725 and 0.675 for predicting OS in the training and validation cohorts. The calibration curve and ROC curve indicated that the model had a good fit and prediction performance.

CONCLUSION

A high ACCI score may predict poor long-term survival in pCCA patients after curative resection. High-risk patients screened by the ACCI-based model should be given more clinical attention in terms of the management of comorbidities and postoperative follow-up.

The Age-adjusted Charlson Comorbidity Index predicts post-operative delirium in the elderly following thoracic and abdominal surgery: A prospective observational cohort study

Background

Post-operative delirium (POD) presents as a serious neuropsychiatric syndrome in the elderly undergoing thoracic and abdominal surgery, which is mostly associated with poor prognosis. The Age-adjusted Charlson Comorbidity Index (ACCI) has been widely recognized as an independently predictive factor for overall survival rate and mortality in various surgeries. However, no studies demonstrated the potential relationship between ACCI and POD. The current study was to explore the correlation between ACCI and POD, and determine the predictive effect of ACCI on POD in the elderly after thoracic and abdominal surgery.

Materials and methods

Total 184 patients (≥60 years) who underwent thoracic and abdominal surgery from 2021.10 to 2022.5 were enrolled in this prospective observational cohort study. ACCI was calculated by weighting comorbidities and age. POD was diagnosed using Confusion Assessment Method (CAM) twice a day in the first 3 days after surgery. The Visual Analog Scale (VAS) was applied to measure pre-operative and post-operative pain at rest and in motion. All demographic and perioperative data were compared in patients with POD and without POD. ACCI and other variables were analyzed by univariate and multivariate logistic regression analysis. The characteristic curve of receiver operating characteristic (ROC) was used to further evaluate the accuracy of ACCI to predict POD.

Results

Post-operative delirium was diagnosed in 36 of 184 patients included in our study. The prevalence of POD in the elderly after thoracic and abdominal surgery was 19.6%. The outcomes by multivariate regression analysis showed the independent risk factors for POD were ACCI (OR: 1.834; 95%CI: 1.434–2.344; P < 0.001), pre-operative Mini-Mental State Examination (MMSE) scores (OR: 0.873; 95%CI: 0.767–0.994; P = 0.040), serum albumin (OR: 0.909; 95%CI: 0.826–1.000; P = 0.049) and pain scores in the post-operative third day (OR: 2.013; 95%CI: 1.459–2.778; P < 0.001). ACCI can predict POD more accurately with the largest area under curve (AUC) of 0.794 and sensitivity of 0.861, respectively.

Conclusion

Age-adjusted Charlson Comorbidity Index, pre-operative MMSE scores, serum albumin and post-operative pain were independently associated with POD in geriatric patients following thoracic and abdominal surgery. Moreover, ACCI may become an accurate indicator to predict POD early.

Worldwide Incidence and Mortality of Biliary Tract Cancer

Background and Aims

Biliary tract cancer (BTC) consists of a group of hepatic and perihepatic tumors that are in close proximity but are anatomically different, including gallbladder cancer (GBC), cholangiocarcinoma (extrahepatic and intrahepatic [ICC]), and ampulla of Vater cancer (AVC). Most epidemiologic research has focused on 1 or more anatomic subtypes, or does not differentiate BTC from hepatocellular carcinoma or other primary liver cancers. Here, we provide a descriptive update on global incidence and mortality rates for BTC, overall and by anatomic subtypes.

Methods

Age-standardized rates (per 100,000 person-years) were derived from the International Agency for Research on Cancer, Cancer Incidence in Five Continents, Volume XI (2008-2012; 22 countries), and the World Health Organization Mortality Database (2006-2016; 38 countries).

Results

BTC incidence varied by country, with the highest in Chile (14.35) and the lowest in Vietnam (1.25). Mortality rates for BTC were highest for the Republic of Korea (11.64) and lowest for the Republic of Moldova (1.65). BTC mortality rates increased over time in 24 of 34 countries. Patients aged ≥75 years had 5-10 times higher mortality rates than the overall BTC rate in all countries. In most countries, incidence rates were highest for GBC, and mortality rates highest for ICC, while both were lowest for AVC. Females had and died from GBC more frequently than males. For ICC, extrahepatic cholangiocarcinoma, and AVC, males trended toward higher incidence and mortality rates.

Conclusion

The increasing incidence and mortality trends reported here indicate a need for improved prevention and treatment for all BTC subtypes.

Success rate of microsatellite instability examination and complete response with pembrolizumab in biliary tract cancer

BACKGROUND AND AIM

The success rate of microsatellite instability (MSI) examination in biliary tract cancer (BTC) and the treatment outcomes of pembrolizumab in patients with MSI-high (MSI-H) BTC have not been fully investigated. We examined the success rate of MSI examination and the rate of MSI-H status in patients with BTC as well as the treatment outcomes of patients with MSI-H status who underwent pembrolizumab treatment.

METHODS

We retrospectively reviewed 60 consecutive patients with unresectable or postoperative recurrent BTC who underwent MSI examination in a Japanese cancer referral center between January 2019 and September 2020.

RESULTS

The study included 24 intrahepatic cholangiocarcinomas, 12 hilar cholangiocarcinomas, 4 distal cholangiocarcinomas, 16 gallbladder carcinomas, and 4 ampullary carcinomas. The methods of cancer tissue sampling were percutaneous liver tumor biopsy in 26 cases, surgery in 15 cases, endoscopic ultrasound fine-needle aspiration in 12 cases, transpapillary bile duct biopsy in 5 cases, and others in 2 cases. The success rate of MSI examination was 98.3% (59 of 60). MSI examination failed in only one case using a surgical specimen due to time-dependent degradation of DNA. The frequency of MSI-H BTC was 3.3% (2 of 60 cases). One patient with MSI-H intrahepatic cholangiocarcinoma achieved a complete response with pembrolizumab treatment.

CONCLUSIONS

MSI examinations in BTC were successful in almost all cases, regardless of tissue sampling methods. We experienced a case in which pembrolizumab resulted in a complete response to MSI-H BTC. Since pembrolizumab for MSI-H BTC could prolong survival time, MSI examination should be performed proactively to increase treatment options.

The Clinical Impact of the Age-adjusted Charlson Comorbidity Index on Esophageal Cancer Patients Who Receive Curative Treatment

BACKGROUND/AIM

We investigated the impact of the age-adjusted Charlson comorbidity index (ACCI) on esophageal cancer survival and recurrence after curative treatment.

PATIENTS AND METHODS

This study included 122 patients who underwent curative surgery followed by adjuvant chemotherapy for esophageal cancer between 2005 and 2017. The risk factors for the overall survival (OS) and recurrence-free survival (RFS) were identified.

RESULTS

An ACCI of 5 was regarded as the optimal critical point of classification considering the survival rates. The OS rates at 3 and 5 years after surgery were 64.2% and 54.4% in the low-ACCI group, respectively, and 42.3% and 29.2% in high-ACCI group, respectively (p=0.035). The RFS rates at 3 and 5 years after surgery were 50.2% and 43.6% in the low-ACCI group, respectively, and 28.5% and 21.3% in high-ACCI group, respectively (p=0.021). A multivariate analysis demonstrated that ACCI was a significant independent risk factor for both the OS and RFS.

CONCLUSION

ACCI is a risk factor for survival in patients who undergo curative treatment for esophageal cancer. An effective plan for the perioperative care and surgical strategy should be developed according to ACCI.