Comparison of Inflammation-Based Prognostic Scores in a Cohort of Patients with Resectable Esophageal Cancer

Development of an alarm symptom-based risk prediction score for localized oesophagogastric adenocarcinoma (VIOLA score)

BACKGROUND

Gastroesophageal adenocarcinoma is a major contributor to global disease burden with poor prognosis even in resectable, regionally limited stages. Feasible prognostic tools are crucial to improve patient management, yet scarce.

PATIENTS AND METHODS

Disease-related symptoms, patient, tumour, treatment as well as laboratory parameters at initial diagnosis and overall survival (OS) of patients with stage II and III gastroesophageal adenocarcinoma, who were treated between 1990 and 2020 at the Medical University of Vienna, were evaluated in a cross-validation model to develop a feasible risk prediction score.

RESULTS

In total, 628 patients were included in this single-centre analysis. The final score ranked from 0 to 10 and included the factors sex (female +1), age, years (30-59 +1, >60 +2), underweight classified by body mass index (+2), location of the tumour (stomach +1), stage (III +2), stenosis in endoscopy (+1) and weight loss (+1). The score was grouped into low- (0-3), medium- (4-6) and high-risk (7+) subgroups. The median OS were 70.3 [95% confidence interval (CI) 51.2-111.8], 23.4 (95% CI 21.2-26.7) and 12.6 (7.0-16.1) months, respectively. The 1-year survival probabilities were 0.88 (95% CI 0.83-0.93), 0.75 (95% CI 0.70-0.79) and 0.54 (95% CI 0.39-0.74), whereas the 5-year survival probabilities were 0.57 (95% CI 0.49-0.66), 0.24 (95% CI 0.20-0.28) and 0.09 (95% CI 0.03-0.28), respectively.

CONCLUSIONS

The VIennese risk prediction score for Oesophagogastric Localized Adenocarcinoma (VIOLA) risk prediction score poses a feasible tool for the estimation of OS in patients with regionally limited gastroesophageal adenocarcinoma and, thus, may improve patient management in clinical routine. Prospective analyses should be carried out to confirm our findings.

Clinical Significance of Nutrition and Inflammation in Esophageal Cancer Patients with Surgery: A Meta-Analysis

Many studies have reported that the geriatric nutritional risk index (GNRI) and C-reactive protein to albumin ratio (CAR) may be associated with prognosis of esophageal cancer (EC); however, the results are inconsistent. Therefore, we performed a meta-analysis to evaluate the effect of preoperative GNRI and CAR on the prognosis of EC. PubMed, Embase, Cochrane Library, and Web of Science databases were searched. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were used to analyze the relationship between GNRI/CAR and prognosis. Publication bias was estimated using Begg's funnel plot asymmetry test and Egger's test. A total of 21 studies comprising 5,018 patients were included in the meta-analysis. A decreased GNRI was significantly associated with poorer overall survival (OS) (HR = 1.808, 95% CI: 1.489-2.196, P < 0.001) and cancer-specific survival (CSS) (HR = 1.769, 95% CI: 1.193-2.624, P = 0.005), and an increased CAR was significantly associated with lower OS (HR = 2.179, 95% CI: 1.587-2.992, P < 0.001), CSS (HR = 1.733, 95% CI: 1.333-2.253, P < 0.001), and recurrence-free survival (HR = 2.178, 95% CI: 1.328-3.573, P = 0.002). Thus, preoperative GNRI and CAR may be noninvasive and powerful tools for predicting survival outcomes in patients with EC.

C-Reactive Protein and C-Reactive Protein-Based Scores to Predict Survival in Esophageal and Junctional Adenocarcinoma: Systematic Review and Meta-Analysis

BACKGROUND

Esophageal adenocarcinoma (EAC) has a poor prognosis; predictive markers of prognosis would facilitate advances in personalized therapy. C-reactive protein (CRP) and CRP-based scores are increasingly recommended across oncology; however, their role and value in EAC is unclear. This systematic review and meta-analysis examined CRP cut-point and scores and how they may best be applied in predicting survival in EAC.

METHODS

A systematic literature search was conducted in EMBASE, Medline, Web of Science, Cochrane, Scopus and CINAHL databases, from inception to 1st October 2020. Studies reporting data from adults with EAC including adenocarcinoma of the gastro-esophageal junction (AEG), pre-treatment CRP or CRP-based score and Hazard Ratio (HR) for survival were included. QUIPS tool assessed risk of bias. Meta-analysis was undertaken.

RESULTS

A total of 819 records were screened. Eight papers were included, with data for 1475 people. CRP cut-points ranged from 2.8 to 10 mg/L. The Glasgow Prognostic Score (GPS) and modified GPS were the most commonly reported scores. On meta-analysis, elevated preoperative GPS/mGPS was significantly associated with worse overall survival (hazards ratio [HR] 1.81, 95% confidence interval [CI] 1.25-2.62, p = 0.002); results were similar in subgroup analyses of multimodal treatment, M0 disease, and R0 resection.

CONCLUSIONS

This is the first review to evaluate comprehensively the evidence for CRP and CRP-based scores in EAC. Meta-analysis demonstrated that elevated preoperative GPS or mGPS was significantly associated with reduced overall survival in EAC, including AEG. There is insufficient evidence to support use of CRP alone. Future studies should examine GPS/mGPS in EAC prospectively, alone and combined with other prognostic markers.

High Systemic Immune-Inflammation Index is an Adverse Prognostic Factor for Patients With Gastroesophageal Adenocarcinoma

OBJECTIVE

The aim of this study was to determine the clinical role of the systemic immune-inflammation index in patients with resectable adenocarcinoma of the gastroesophageal junction treated with or without neoadjuvant therapy.

BACKGROUND

Adenocarcinoma of the gastroesophageal junction is an aggressive disease, with less than 20% of overall patients surviving more than 5 years after diagnosis, while currently available clinical staging for esophageal cancer is lacking necessary accuracy. The systemic immune-inflammation index (SII) based on peripheral neutrophil, lymphocyte, and platelet counts has shown a prognostic impact in various malignancies.

METHODS

Data of consecutive patients undergoing esophagectomy (n = 320, 1992 to 2016) were abstracted. The cut point for high and low SII before neoadjuvant treatment and before surgery was calculated for illustration of the Kaplan-Meier curves. SII was used for the correlation with patients' clinicopathological characteristics as a continuous variable. Survival was analyzed with Cox proportional hazards models using clinical or pathological staging, adjusting for other known survival predictors.

RESULTS

In both neoadjuvantly treated and primarily resected patients, high SII was significantly associated with diminished overall [hazard ratio (HR) 1.3, 95% confidence interval (95% CI) 1.2-1.4; HR 1.2, 95% CI 1.2-1.3, respectively] and disease-free survival (HR 1.3, 95% CI 1.2-1.3; HR 1.2, 95% CI 1.2-1.3, respectively). In multivariable survival analysis, SII remained an independent prognostic factor for overall survival (HR 1.3, 95% CI 1.2-1.4; HR 1.2, 95% CI 1.2-1.3, respectively) and disease-free survival (HR 1.3, 95% CI 1.2-1.3; HR 1.2, 95% CI 1.2-1.3, respectively) in primarily resected and neoadjuvantly treated patients.

CONCLUSION

Elevated SII is an independent adverse prognostic factor in patients with resectable gastroesophageal adenocarcinomas with and without neoadjuvant treatment.

Usefulness of Neutrophil to Lymphocyte Ratio at Recurrence for Predicting Long-Term Outcomes in Patients with Recurrent Esophageal Squamous Cell Carcinoma

BACKGROUND

Although radical esophagectomy with multifield lymph node dissection is a promising treatment to achieve long-term survival for resectable esophageal cancer, survival after postoperative recurrence remains poor. To select the optimal treatment for patients with recurrent esophageal cancer, simple, objective indicators for predicting of long-term outcomes are needed.

PATIENTS AND METHODS

We conducted a single-institution, retrospective cohort study between 2004 and 2019, wherein 586 patients underwent transthoracic esophagectomy for primary esophageal squamous cell carcinoma. Of these, 133 patients with postoperative recurrence were included in this analysis. Several predictors of survival after recurrence were investigated.

RESULTS

Among all patients, the 1- and 3-year survival rates after recurrence were 48.0% and 23.1%, respectively. On multivariate analysis, the neutrophil to lymphocyte ratio (NLR) at recurrence was identified as a significant predictor of death after recurrence (hazard ratio 1.061; 95% confidence interval 1.002-1.125; p = 0.043). Time-dependent receiver operating characteristics curves showed that the area under the curve value of the NLR at recurrence was superior to the modified Glasgow Prognostic Score at recurrence in all terms. To simulate the clinical decision process, we set the cut-off NLR at recurrence for survival using survival classification and regression tree (CART) and defined the optimal cut-off value as 3.374.

CONCLUSIONS

NLR at recurrence was a significant indicator of survival after recurrence in patients with recurrent esophageal cancer. CART analysis was used to determine the optimal cut-off value for the prediction of survival, allowing the NLR to be used clinically to facilitate decision making.

Comparative Analysis of Immunoinflammatory and Nutritional Measures in Surgically Resected Esophageal Cancer: A Single-center Retrospective Study

BACKGROUND/AIM

Several immunoinflammatory and nutritional measures have been reported to be good prognostic indicators for esophageal cancer (EC). However, the association between those markers and the postoperative survival of EC patients remains unclear due to varying study designs and treatment strategies. The aim of this study was to compare the significance of preoperative immunoinflammatory and nutritional measures in patients with EC.

PATIENTS AND METHODS

One hundred and five patients with EC who underwent McKeown esophagectomy with gastric tube reconstruction without neoadjuvant therapy between 2006 and 2014 were included in this study. The prognostic values of preoperative modified Glasgow prognostic score (mGPS), controlling nutritional status (CONUT) score, prognostic nutritional index (PNI), C-reactive protein (CRP)-to-albumin ratio (CAR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) were investigated using univariate and multivariate survival analyses.

RESULTS

Multivariate analysis revealed that CAR and pathological stage are independent prognostic factors for overall survival (OS). CAR was significantly associated with more advanced pathological stage as both a subject and a continuous variable.

CONCLUSION

Preoperative CAR was an independent prognostic factor for the OS of EC patients who underwent McKeown esophagectomy. The tumor-stage related increase in CAR demonstrated that a high CAR is associated with tumor progression in EC patients.

Systemic Immune-Inflammation Index (SII) Predicts Poor Survival in Pancreatic Cancer Patients Undergoing Resection

BACKGROUND

The systemic immune-inflammation index based on peripheral neutrophil, lymphocyte, and platelet counts has shown a prognostic impact in several malignancies. The aim of this study was to determine the prognostic role of systemic immune-inflammation index in patients with pancreatic ductal adenocarcinoma undergoing resection.

METHODS

Consecutive patients who underwent surgical resection at the department of surgery at the Medical University of Vienna between 1995 and 2014 were included into this study. The systemic immune-inflammation index was calculated by the formula platelet*neutrophil/lymphocyte. Optimal cutoffs were determined using Youden's index. Uni- and multivariate analyses were calculated by the Cox proportional hazard regression model for overall survival.

RESULTS

Three hundred twenty-one patients were included in this study. Clinical data was achieved from a prospective patient database. In univariate survival analysis, elevated systemic immune-inflammation index was found to be significantly associated with shortened patients' overall survival (p = 0.007). In multivariate survival analysis, systemic immune-inflammation index remained an independent prognostic factor for overall survival (p = 0.004). No statistical significance could be found for platelet to lymphocyte ratio and neutrophil to lymphocyte ratio in multivariate analysis. Furthermore, area under the curve analysis showed a higher prognostic significance for systemic immune-inflammation index, compared to platelet to lymphocyte ratio and neutrophil to lymphocyte ratio.

CONCLUSION

A high systemic immune-inflammation index is an independent, preoperative available prognostic factor in patients with resectable pancreatic ductal adenocarcinoma and is superior to platelet to lymphocyte ratio and neutrophil to lymphocyte ratio for predicting overall survival in pancreatic ductal adenocarcinoma patients.

Prognostic value of the C-reactive protein to albumin ratio in esophageal cancer: A systematic review and meta-analysis

In recent years, some studies suggested that the pretreatment C-reactive protein to albumin ratio (CAR) may be predictive for prognosis of esophageal cancer (EC), but their results were inconsistent. Therefore, the current meta-analysis was preformed to better determine the prognostic value of pretreatment CAR in EC. The PubMed, EMBASE, Web of Science, Cochrane Library, and PubMed Central databases were searched up to January 10, 2019 to identify studies evaluating the correlation between CAR and prognosis of EC. The primary outcome was the overall survival (OS) and secondary outcomes were disease-free survival (DFS) and cancer-specific survival (CSS). Pooled hazard ratios (HRs) and corresponding 95% confidence intervals (95% CIs) were used to estimate the predictive role of CAR for prognosis in EC. Based on the results of this research, a total of 11 studies with 2930 patients diagnosed as EC were included. Pooled results suggested that elevated pretreatment CAR was significantly associated with poor OS (HR = 1.80, 95% CI: 1.31-2.47, P < .001) with high heterogeneity (I² = 86.5%, P < .001) and poor CSS (HR = 1.72, 95% CI: 1.33-2.22, P < .001) without heterogeneity (I² = 0.0%, P < .323); however, no significant association was observed between pretreatment CAR and DFS (HR = 1.41, 95% CI: 0.60-3.34, P = .429) with high heterogeneity (I² = 76.7%, P < .038). Subgroup analyses further manifested that EC patients with higher CAR had worse OS. An elevated pretreatment CAR may indicate poor survival in patients with EC. Thus, pretreatment CAR may serve as a promising biomarker in EC and could be used to predict prognosis and help decision-making in clinical work.

The prognostic value of pretreatment Glasgow Prognostic Score in patients with esophageal cancer: a meta-analysis

Objectives

To examine the predictive role of Glasgow Prognostic Score (GPS) on long-term survival in esophageal cancer.

Method

Comprehensive searches of electronic databases were performed to identify potential studies that evaluated the prognostic value of pretreatment GPS in esophageal cancer patients. We combined the hazard ratios (HRs) with 95% confidence intervals (CIs) to assess the association of GPS with overall survival (OS), disease-free survival (DFS) and cancer-specific survival (CSS).

Results

A total of 21 studies including 6115 patients were analyzed. Compared with patients with GPS 0, patients with elevated GPS had poorer OS (HR =2.12, 95% CI: 1.83–2.45, P<0.001) and CSS (HR =2.16, 95% CI: 1.56–2.98, P<0.001); but no significant relationship was observed between the elevated GPS and DFS (HR=2.14, 95% CI:1.00–4.61, P=0.051). Subgroup analysis outcomes were similar to overall analyses.

Conclusion

Pretreatment GPS could serve as a valuable factor in predicting the prognosis of patients with esophageal cancer. More well-designed prospective studies are warranted to confirm our findings.

Clinical significance of systemic immune-inflammation index (SII) and C-reactive protein-to-albumin ratio (CAR) in patients with esophageal cancer: a meta-analysis

Background: Numerous studies have reported that systemic immune-inflammation index (SII) and C-reactive protein-to-albumin ratio (CAR) correlate with tumor progression and prognosis in various types of human cancer. The aim of this study is to systematically investigate the clinical significance of SII and CAR in esophageal cancer (EC).

Methods: We searched a number of databases for articles reporting the effect of pretreatment SII and CAR on the survival of EC patients. Review Manager 5.3 and STATA/SE 14.1 were applied in this meta-analysis. The multivariable-adjusted hazard ratio (HR) was used for calculating the relationship between SII and CAR and overall survival (OS), and the odds ratio (OR) was applied for the clinical pathology.

Results: Five original studies for SII and seven original datasets for CAR were included for analysis. Increased SII showed a significant association with shorter OS in EC patients after surgery (HR: 1.34, 95% CI: 1.15–1.53, P<0.001) and high CAR indicated worse long-term OS in EC (HR: 1.60, 95% CI: 1.29–1.90, P<0.001). Different subgroup analyses were also confirmed the prognostic roles in EC patients. Furthermore, the adverse impacts of elevated SII and CAR on tumor progression were revealed in the infiltration depth, lymph node metastasis, and clinical stage.

Conclusions: Both pretreatment SII and CAR might be promising predictors of cancer survival and tumor progression in EC. Further studies are warranted to verify the clinical usefulness in patients with EC.

Comparison of the Prognostic Value of Systemic Inflammation Response Markers in Small Cell Lung Cancer Patients

Increasing evidences support that systemic inflammation-based prognostic scores, modified Glasgow Prognostic Score (mGPS), C-reactive Protein/Albumin (CRP/ALB), Albumin/Globulin (AGR), Prognostic Nutritional Index (PNI) and Advanced Lung cancer Inflammation index (ALI), are key determinants of patients' outcome in solid tumors. However, in small cell lung cancer (SCLC), there have been no direct comparisons of them. Thus, the aim of this study was to compare the prognostic value of these markers in SCLC, and select a most appropriative one. The patients with confirmed SCLC were screened between 2006 and 2011, and inflammation-based prognostic factors (mGPS, CRP/ALB, AGR, PNI, ALI) were examined. Kaplan-Meier and Cox regression analysis were performed to assess these inflammation-based prognostic scores associated with overall survival (OS). Subsequently, we compared the prognostic value of these inflammation-based prognostic scores using the area under the curve (AUC). In 451 patients, on univariate analysis, mGPS (P<0.001), CRP/ALB (P<0.001), AGR (P<0.001), PNI (P<0.001) and ALI (P<0.001) were the strongest predictors of OS. Further multivariate analysis confirmed mGPS (P<0.001), CRP/ALB (P=0.007), AGR (P=0.034) and PNI (P=0.026) as independent markers associated with OS. Further subgroup analysis revealed CRP/ALB was able to predict outcome in both limited (P=0.005) and extensive disease (P=0.013). The CRP/ALB had higher AUC values compared with other inflammation-based prognostic socres (0.566). The CRP/ALB was characterized as best, in comparison to other systemic inflammation-based prognostic scores, for its predictive power of SCLC patients' survival, and had the potential to be hierarchical factor in future clinical trials.

PLCE1 Promotes the Invasion and Migration of Esophageal Cancer Cells by Up-Regulating the PKCα/NF-κB Pathway

PURPOSE

To investigate the effect and mechanism of phospholipase C epsilon gene 1 (PLCE1) expression on esophageal cancer cell lines.

MATERIALS AND METHODS

The esophageal carcinoma cell lines Eca109 and EC9706 and normal esophageal epithelial cell line HEEC were cultured. The expression of PLCE1, protein kinase C alpha (PKCα), and nuclear factor kappa B (NF-κB) p50/p65 homodimer in cells were comparatively analyzed. The esophageal cancer cells were divided into si-PLCE1, control siRNA (scramble), and mock groups that were transfected with specific siRNA for PLCE1, control siRNA, and blank controls, respectively. Expression of PLCE1, PKCα, p50, and p65 was detected by Western blotting. Transwell assay was used to detect migration and invasion of Eca109 and EC9706 cells.

RESULTS

Compared with HEEC, the expression of PLCE1, PKCα, p50, and p65 was increased in Eca109 and EC9706 cells. The expression of PLCE1 was positively correlated with the expression of PKCα and p50 (PKCα: r=0.6328, p=0.032; p50: r=0.6754, p=0.041). PKCα expression had a positive correlation with the expression of p50 and p65 (p50: r=0.9127, p=0.000; p65: r=0.9256, p=0.000). Down-regulation of PLCE1 significantly decreased the expression of PKCα and NF-κB-related proteins (p65: p=0.002, p=0.004; p50: p=0.005, p=0.009) and inhibited the migration and invasion of Eca109 and EC9706 cells.

CONCLUSION

PLCE1 activated NF-κB signaling by up-regulating PKCα, which could promote invasion and migration of esophageal cancer cells.

The value of preoperative Glasgow Prognostic Score and the C-Reactive Protein to Albumin Ratio as prognostic factors for long-term survival in pathological T1N0 esophageal squamous cell carcinoma

Plenty of studies have confirmed the prognostic values of inflammation-based prognostic scores in many malignant tumors. In present study, we aim to explore whether these indexes has same prognostic values in patients with stage T1N0 esophageal squamous cell carcinoma (ESCC). The clinicopathological data of 160 consecutive patients with pathological stage T1N0 ESCC from January 2005 to December 2012 were collected retrospectively. As prognostic factors, the inflammation-based prognostic scores, including C-reactive protein (CRP), Glasgow prognostic score (GPS), prognostic index (PI), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR) and CRP to albumin ratio (CAR), were evaluated. The best cut-off values were determined by the receiver operating characteristic (ROC) curves. The median follow-up time was 71.8 months. During the follow-up period, 34 (21.3%) patients occurred postoperative recurrence and 30 (18.8%) tumor-related deaths were recorded. The best cut-off values of CRP, NLR, PLR and CAR were 1.090, 1.976, 103.200 and 0.023, respectively. After multivariate analysis, the GPS and CAR were identified as independently prognostic factors for overall survival (OS) (p=0.017 and 0.040, respectively). Of all 160 individuals, there were 86 (53.8%) and 85 (53.1%) patients classified into high GPS group (1-2) and elevated CAR group (>0.023), respectively. In addition, the GPS were positively associated with PI (p<0.000) and the levels of serum CRP (p<0.000), NLR (p=0.004), PLR (p=0.029) and CAR (p<0.000) and the above correlations were also observed between the CAR and other inflammation-based prognostic scores (all p<0.050, except for p=0.054 for PLR levels). The preoperative GPS and CAR were simple, inexpensive, readily available predictor for long-term survival in stage T1N0 ESCC patients who underwent esophagectomy.

Validation and optimization of the Systemic Inflammation-Based modified Glasgow Prognostic Score in predicting postoperative outcome of inflammatory bowel disease: preliminary data

Systemic Inflammation-Based modified Glasgow Prognostic Score (mGPS) was developed as an objective tool to grade state of inflammation. However, the association between mGPS and postoperative complications for inflammatory bowel disease (IBD) patients was still unknown. In our study, 270 IBD patients [Crohn’s disease (CD), n = 186; Ulcerative colitis (UC), n = 84] from January 2013 and January 2016 who underwent elective bowel resection were retrospectively analyzed, and, the levels of preoperative C-reactive protein (CRP) and albumin were included as parameters of mGPS. The incidence of overall postoperative complications was 44.81% (121/270), including 46.77% (87/186) of CD and 40.48% (34/84) of UC. According to multivariate analysis, mGPS (CD: OR = 3.47, p = 0.003; UC: OR = 3.28, p = 0.019) was independently associated with an increased risk of postoperative complications. Patients with a higher mGPS also suffered longer postoperative stay and increased SSIs (both p < 0.05). Combining mGPS with neutrophil ratio improved its prognostic value with a better area under the curve (AUC), using receiver operating characteristic (ROC) method. Then we confirmed that mGPS was associated with postoperative complications in IBD patients undergoing elective bowel resection and the addition of neutrophil ratio enhanced its prognostic value.

The modified glasgow prognostic score is an independent prognostic indicator in neoadjuvantly treated adenocarcinoma of the esophagogastric junction

The modified Glasgow Prognostic Score (mGPS) combines the indicators of decreased plasma albumin and elevated CRP. In a number of malignancies, elevated mGPS is associated with poor survival. Aim of this study was to investigate the prognostic role of mGPS in patients with neoadjuvantly treated adenocarcinomas of the esophagogastric junction 256 patients from a prospective database undergoing surgical resection after neoadjuvant treatment between 2003 and 2014 were evaluated. mGPS was scored as 0, 1, or 2 based on CRP (>1.0 mg/dl) and albumin (<35 g/L) from blood samples taken prior (preNT-mGPS) and after (postNT-mGPS) neoadjuvant therapy. Scores were correlated with clinicopathological patients’ characteristics. From 155 Patients, sufficient data was available. Median follow-up was 63.8 months (33.3–89.5 months). In univariate analysis, Cox proportional hazard model shows significant shorter patients OS (p = 0.04) and DFS (p = 0.02) for increased postNT-mGPS, preNT-hypoalbuminemia (OS: p = 0.003; DFS: p = 0.002) and post-NT-CRP (OS: p = 0.03; DFS: p = 0.04). Elevated postNT-mGPS and preNT-hypoalbuminemia remained significant prognostic factors in multivariate analysis for OS (p = 0.02; p = 0.005,) and DFS (p = 0.02, p = 0.004) with tumor differentiation and tumor staging as significant covariates. PostNT-mGPS and preNT-hypoalbuminemia are independent prognostic indicators in patients with neoadjuvantly treated adenocarcinomas of the esophagogastric junction and significantly associated with diminished OS and DFS.