The Cancer Cachexia Syndrome: A Review of Metabolic and Clinical Manifestations

Dose-dependent effect of megestrol acetate supplementation in cancer patients with anorexia-cachexia syndrome: A meta-analysis

There is inconsistent evidence relating to the effects of megestrol acetate (MA) supplementation on cancer patients suffering from anorexia-cachexia syndrome. This review aimed to examine the dose-response effect of MA supplementation in patients with cancer-associated anorexia/cachexia. Relevant keywords were searched in PubMed, Scopus and ISI Web of Science from inception to June 2023 for randomized controlled trials (RCTs) examining the effect of MA on pathologies in patients with cancer-associated cachexia. Our primary outcomes were changes in body weight and appetite. However, fatigue and quality of life were secondary outcomes. The mean difference (MD) and 95% confidence interval (95% CI) were estimated using the random-effects method. Thirteen trials comprising 1229 participants (mean age 60 years) were identified. The results of our highest versus lowest analysis revealed that MA supplementation was not associated with any increase in body weight (MD: 0.64 kg, 95% CI [-0.11, 1.38], P = 0.093, I2 = 69.1%; GRADE = very low certainty). Twelve trials, including 14 effect sizes derived from 1369 patients (intervention = 689, control = 680), provided data on the effect of MA on body weight. Subgroup analyses showed a significant increase in body weight following short-term intervention (≤8 weeks) and a combination of radiation/chemotherapy as concurrent treatment. A linear dose-response meta-analysis indicated that each 200 mg/day increment in MA consumption had a significant increase in weight gain (MD: 0.44; 95% CI [0.13, 0.74], P = 0.005; I2 = 97.1%); however, the magnitude of the effect was small. MA administration significantly affected the quality of life based on pooled effect sizes (MD: 1.15, 95% CI [0.76, 1.54], P < 0.001, I2 = 0%; n = 2 RCTs including 176 patients; GRADE = very low certainty). However, no significant effect of MA supplementation was observed on appetite (MD: 0.29, 95% CI [-0.05, 0.64], P = 0.096, I2 = 18.3%; n = 3 RCTs including 163 patients; GRADE = very low certainty) and fatigue (MD: 0.14, 95% CI [-0.09, 0.36], P = 0.236, I2 = 0%; n = 2 RCTs including 300 patients; GRADE = very low certainty). With very low certainty of the evidence, MA supplementation may not lead to a significantly increased weight gain and other outcomes.

Current and anticipated future state of cachexia care in patients with cancer

Aims: We assessed care in cancer patients with cachexia across leading health systems (LHSs).Patients & methods: Qualitative interviews and quantitative surveys were conducted with LHSs executives and frontline health care personnel, representing 46 total respondents and 42 unique LHSs and including oncology service line leaders, supportive care services, dietitians and surgical oncologists.Results: Cachexia was not considered a top priority, and formal diagnoses were rare. Participants highlighted the importance of addressing barriers to increase clinical trial enrollment and support frontline health care personnel and patients in early detection of cachexia.Conclusion: Cachexia prioritization needs to be elevated across LHSs executives to obtain capital and strategic imperatives to advance related care.

A Joint Model Based on Post-Treatment Longitudinal Prognostic Nutritional Index to Predict Survival in Nasopharyngeal Carcinoma

BACKGROUND

a low PNI in patients with NPC is linked to poor survival, but prior studies have focused on single-timepoint measurements. Our study aims to employ joint modeling to analyze longitudinal PNI data from each routine visit, exploring its relationship with overall survival.

METHODS

In this retrospective study using data from the Chang Gung Research Database (2007-2019), we enrolled patients with NPC undergoing curative treatment. We analyzed the correlation between patient characteristics, including the PNI, and overall survival. A joint model combining a longitudinal sub-model with a time-to-event sub-model was used to further evaluate the prognostic value of longitudinal PNI.

RESULTS

A total of 2332 patient were enrolled for the analysis. Separate survival analyses showed that longitudinal PNI was an independent indicator of a reduced mortality risk (adjusted HR 0.813; 95% CI, 0.805 to 0.821). Joint modeling confirmed longitudinal PNI as a consistent predictor of survival (HR 0.864; 95% CI, 0.850 to 0.879). An ROC analysis revealed that a PNI below 38.1 significantly increased the risk of 90-day mortality, with 90.0% sensitivity and 89.6% specificity.

CONCLUSIONS

Longitudinal PNI data independently predicted the overall survival in patients with NPC, significantly forecasting 90-day survival outcomes. We recommend routine PNI assessments during each clinic visit for these patients.

Machine-Based Learning Hierarchical Cluster Analysis: Sex-Based Differences in Prognosis Following Resection of Hepatocellular Carcinoma

BACKGROUND

Patients with hepatocellular carcinoma (HCC) may have a heterogeneous presentation, as well as different long-term outcomes following surgical resection. We sought to use machine learning to cluster patients into different prognostic groups based on preoperative characteristics.

METHODS

Patients who underwent curative-intent liver resection for HCC between 2000 and 2020 were identified from a large international multi-institutional database. A hierarchical cluster analysis was performed based on preoperative factors to characterize patterns of presentation and define disease-free survival (DFS).

RESULTS

Among 966 with HCC, 3 distinct clusters were identified: Cluster 1 (n = 160, 16.5%), Cluster 2 (n = 537, 55.6%) and Cluster 3 (n = 269, 27.8%). Cluster 1 (n = 160, 16.5%) consisted of female patients (n = 160, 100%), low inflammation-based scores, intermediate tumor burden score (TBS) (median: 4.71) and high alpha-fetoprotein (AFP) levels (median 41.3 ng/mL); Cluster 2 consisted of male individuals (n = 537, 100%), mainly with a history of HBV infection (n = 429, 79.9%), low inflammation-based scores, intermediate AFP levels (median 26.0 ng/mL) and lower TBS (median 4.49); Cluster 3 was comprised of older patients (median age 68 years) predominantly male (n = 248, 92.2%) who had low incidence of HBV/HCV infection (7.1% and 8.2%, respectively), intermediate AFP levels (median 16.8 ng/mL), high inflammation-based scores and high TBS (median 6.58). Median DFS worsened incrementally among the three different clusters with Cluster 3 having the lowest DFS (Cluster 1: median not reached; Cluster 2: 34 months, 95% CI 23.0-48.0, Cluster 3: 19 months, 95% CI 15.0-29.0, p < 0.05).

CONCLUSION

Cluster analysis classified HCC patients into three distinct prognostic groups. Cluster assignment predicted DFS following resection of HCC with the female cluster having the most favorable prognosis following HCC resection.

Changes in diet and supplement use in dogs with cancer

BACKGROUND

Many dog owners alter their dog's nutritional regimen after a diagnosis of cancer. There are limited data as to specific changes made and reasons behind these changes.

HYPOTHESIS/OBJECTIVES

To collect updated and detailed data on changes made by owners to their dog's diet and supplements after a cancer diagnosis.

ANIMALS

Responses were collected from a survey of dog owners who brought their dogs to the UC Davis Veterinary Medical Teaching Hospital's Oncology Service for the first time after a cancer diagnosis. Dogs with recurrence or presenting for a second type of cancer were excluded.

METHODS

Eligible owners were surveyed between December 2020 and March 2022. The survey contained 62 questions regarding diet, supplement use, and treats, and how these were altered after a cancer diagnosis. Responses were matched to medical record data.

RESULTS

One hundred twenty-eight surveys were retained for analysis, including 120 respondents that completed the survey. In response to a cancer diagnosis, 54.8% (95% CI; 45.7%-63.8%) of owners altered diets or supplements or both. The most common informational resource for dog diets was veterinarians (53.9%). Usage of home-prepared foods significantly increased after a cancer diagnosis (P = .03). There was no significant difference in commercial diet usage before or after a diagnosis (P = .25). Joint support products were the most common supplements given both before (37.4%) and after (35.0%) diagnosis.

CONCLUSIONS AND CLINICAL IMPORTANCE

Many dog owners alter their dog's nutritional intake after a cancer diagnosis. These owners should be provided information relating to commonly observed alterations, including home-prepared foods and supplements.

The Osaka prognostic score and Naples prognostic score: novel biomarkers for predicting short-term outcomes after spontaneous intracerebral hemorrhage

OBJECTIVES

Poor immune-nutritional status has been associated with an unfavorable outcome in critical illness. The Osaka prognostic score (OPS) and the Naples prognostic score (NPS), based on inflammatory and nutritional status, has been shown to predict prognosis following cancer and other diseases. The aim of this study was to investigate the relationship between the OPS and NPS and the short-term outcomes of patients with intracerebral hemorrhage (ICH).

METHODS

We retrospectively analyzed the clinical data of patients hospitalized with spontaneous ICH (n = 340) at The Second Affiliated Hospital of Chongqing Medical University between August 2016 and August 2021. Inclusion criteria included patients aged between 18 and 70, and if a blood sample was taken for laboratory testing within 24 h of admission (serum C-reactive protein, albumin, total cholesterol, and counts for neutrophils, lymphocytes, and monocytes were collected on admission). Exclusion criteria included a non-spontaneous cause of ICH and patient death during hospitalization. Patients were divided into four groups based on OPS or five groups according to NPS. Outcomes were evaluated by the modified Rankin Scale (mRS) at six months post-ICH hospitalization. An unfavorable outcome was defined as a mRS score ≥ 3.

RESULTS

A total of 289 patients met our inclusion criteria. The unfavorable outcome group had older age, a lower Glasgow Coma Scale score, a higher rate of complications and cerebral herniation, a longer hospital stay, and higher OPS and NPS when compared with the favorable outcome group. Univariate analysis showed that both OPS and NPS were strongly correlated with mRS (r = 0.196,P < 0.001; r = 0.244, P = 0.001, respectively). Multivariate analysis further showed that OPS and NPS were both independent predictors of unfavorable outcomes for patients with ICH with adjusted odds ratios of 1.802 (95% confidence interval [CI]:1.140-2.847, P = 0.012) and 1.702 (95% CI: 1.225-2.635, P = 0.02), respectively. The area under the curve (AUC) of NPS for predicting a poor outcome was 0.732 (95% CI: 0.665-0.799), which was similar to the AUC of OPS 0.724 (95% CI: 0.657-0.792).

CONCLUSIONS

In this cohort, a higher OPS and NPS on admission was associated with poor outcome at six months following ICH, supporting their potential role as markers for predicting the outcome of patients with ICH.

Pilot clinical trial of macimorelin to assess safety and efficacy in patients with cancer cachexia

BACKGROUND

Cancer cachexia is associated with reduced body weight, appetite and quality of life (QOL) with no approved treatments. Growth hormone secretagogues like macimorelin have potential to mitigate these effects.

METHODS

This pilot study assessed the safety and efficacy of macimorelin for 1 week. Efficacy was defined a priori as 1-week change in body weight (≥0.8 kg), plasma insulin-like growth factor (IGF)-1 (≥50 ng/mL) or QOL (≥15%). Secondary outcomes included food intake, appetite, functional performance, energy expenditure and safety laboratory parameters. Patients with cancer cachexia were randomized to 0.5 or 1.0 mg/kg macimorelin or placebo; outcomes were assessed non-parametrically.

RESULTS

Participants receiving at least one of either macimorelin dose were combined (N = 10; 100% male; median age = 65.50 ± 2.12) and compared with placebo (N = 5; 80% male; median age = 68.00 ± 6.19). Efficacy criteria achieved: body weight (macimorelin N = 2; placebo N = 0; P = 0.92); IGF-1 (macimorelin N = 0; placebo N = 0); QOL by Anderson Symptom Assessment Scale (macimorelin N = 4; placebo N = 1; P = 1.00) or Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F; macimorelin N = 3; placebo N = 0; P = 0.50). No related serious or non-serious adverse events were reported. In macimorelin recipients, change in FACIT-F was directly associated with change in body weight (r = 0.92, P = 0.001), IGF-1 (r = 0.80, P = 0.01), and caloric intake (r = 0.83, P = 0.005), and inversely associated with change in energy expenditure (r = -0.67, P = 0.05).

CONCLUSIONS

Daily oral macimorelin for 1 week was safe and numerically improved body weight and QOL in patients with cancer cachexia compared with placebo. Longer term administration should be evaluated for mitigation of cancer-induced reductions in body weight, appetite and QOL in larger studies.

Prognostic significance of the preoperative alkaline phosphatase‑to‑albumin ratio in patients with hepatocellular carcinoma after hepatic resection

This study aimed to investigate the prognostic value of the preoperative alkaline phosphatase-to-albumin ratio (APAR) in patients with hepatocellular carcinoma (HCC) who underwent radical hepatectomy. The clinicopathological data from 330 patients was retrospectively analyzed. Receiver operating characteristic curves of APAR for diagnostic tumor recurrence were plotted with a cut-off value of 1.74. A high preoperative APAR value was significantly associated with hepatitis B surface antigen level, tumor diameter, and tumor-node-metastasis stage. The disease-free survival (DFS) and overall survival (OS) of patients with a high preoperative APAR were shorter than those with a low APAR. The independent risk factors for DFS were an APAR ≥1.74, and macrovascular invasion or tumor thrombus. The independent risk factors for OS were an APAR ≥1.74, existing clinical symptoms, α-fetoprotein level ≥20 ng/ml, macrovascular invasion or tumor thrombus, and family history of cancer. In conclusion, a preoperative APAR (≥1.74) is an independent risk factor influencing the poor prognosis of patients with HCC after curative hepatectomy, and patients with such a result should be closely monitored.

Perspective for Discovery of Small Molecule IL-6 Inhibitors through Study of Structure–Activity Relationships and Molecular Docking

Interleukin-6 (IL-6) is a proinflammatory cytokine that plays a key role in the pathogenesis and physiology of inflammatory and autoimmune diseases, such as coronary heart disease, cancer, Alzheimer's disease, asthma, rheumatoid arthritis, and most recently COVID-19. IL-6 and its signaling pathway are promising targets in the treatment of inflammatory and autoimmune diseases. Although, anti-IL-6 monoclonal antibodies are currently being used in clinics, huge unmet medical needs remain because of the high cost, administration-related toxicity, lack of opportunity for oral dosing, and potential immunogenicity of monoclonal antibody therapy. Furthermore, nonresponse or loss of response to monoclonal antibody therapy has been reported, which increases the importance of optimizing drug therapy with small molecule drugs. This work aims to provide a perspective for the discovery of novel small molecule IL-6 inhibitors by the analysis of the structure-activity relationships and computational studies for protein-protein inhibitors targeting the IL-6/IL-6 receptor/gp130 complex.

Muscle mass, quality, and strength; physical function and activity; and metabolic status in cachectic patients with head and neck cancer

BACKGROUND & AIMS

Cancer cachexia is commonly associated with poor prognosis in patients with head and neck cancer (HNC). However, its pathophysiology and treatment are not well established. The current study aimed to assess the muscle mass/quality/strength, physical function and activity, resting energy expenditure (REE), and respiratory quotient (RQ) in cachectic patients with HNC.

METHODS

This prospective cross-sectional study analyzed 64 patients with HNC. Body composition was measured via direct segmental multifrequency bioelectrical impedance analysis, and muscle quality was assessed using echo intensity on ultrasonography images. Muscle strength was investigated utilizing handgrip strength and isometric knee extension force (IKEF). Physical function was evaluated using the 10-m walking speed test and the five times sit-to-stand (5-STS) test. Physical activity was examined using a wearable triaxial accelerometer. REE and RQ were measured via indirect calorimetry. These parameters were compared between the cachectic and noncachectic groups.

RESULTS

In total, 23 (36%) patients were diagnosed with cachexia. The cachectic group had a significantly lower muscle mass than the noncachectic group. Nevertheless, there was no significant difference in terms of fat between the two groups. The cachectic group had a higher quadriceps echo intensity and a lower handgrip strength and IKEF than the noncachectic group. Moreover, they had a significantly slower normal and maximum walking speed and 5-STS speed. The number of steps, total activity time, and time of activity (<3 Mets) did not significantly differ between the two groups. The cachectic group had a shorter time of activity (≥3 Mets) than the noncachectic group. Furthermore, the cachectic group had a significantly higher REE/body weight and REE/fat free mass and a significantly lower RQ than the noncachectic group.

CONCLUSIONS

The cachectic group had a lower muscle mass/quality/strength and physical function and activity and a higher REE than the noncachectic group. Thus, REE and physical activity should be evaluated to determine energy requirements. The RQ was lower in the cachectic group than that in the noncachectic group, indicating changes in energy substrate. Further studies must be conducted to examine effective nutritional and exercise interventions for patients with cancer cachexia.

Protective effects of hachimijiogan (HJG), a Japanese Kampo medicine, on cancer cachectic muscle wasting in mice

Myogenesis is required to generate skeletal muscle tissue and to maintain skeletal muscle mass. Decreased myogenesis under various pathogenic conditions results in muscular atrophy. Through a small screening of Japanese traditional (Kampo) medicines, hachimijiogan (HJG) was shown to promote the myogenic differentiation of C2C12 myoblasts through the upregulation of myogenin. In tumor-bearing cancer-cachectic mice, HJG was also found to have a protective effect against cancer-cachectic muscle wasting. This effect was significant when HJG was administered in combination with aerobic exercise by treadmill running. Moreover, HJG ameliorated the cellular atrophy of C2C12 myotubes induced by treatment with conditioned medium derived from a colon-26 cancer cell culture. In addition, HJG suppressed H2O2-dependent myotube atrophy, suggesting that HJG could reverse the atrophic phenotypes by eliminating reactive oxygen species.

Elevated C-reactive protein-to-albumin ratio with fever is a predictor of poor functional outcome in patients with mild traumatic brain injury

Introduction

The C-reactive protein -to-albumin ratio (CAR), a novel inflammation-based prognostic score, is useful in predicting clinical outcomes, including those in central nervous system diseases. However, no report has identified the relationship between CAR and long-term clinical outcomes in patients with mild traumatic brain injury (mTBI). We aimed to evaluate the relationship between CAR and long-term functional outcomes in patients with mTBI and analyze whether CAR is associated with the presence of fever.

Methods

This was a retrospective observational study includes 387 adult patients with mTBI who were treated at a level-1 trauma center between 2017 and 2021. The main exposure variable was an elevated CAR, and the main outcomes were degrees of disability and quality of life measured using the modified Rankin Scale (mRS). A multivariable logistic regression analysis was performed to estimate the effect size of CAR on study outcomes. An interaction analysis was performed between CAR and fever on study outcomes.

Results

Elevated CAR had no significant association with poor functional outcomes (aOR [95% CI]: 1.35 [0.39-4.69]) in patients with mTBI. In the interaction analysis, elevated CAR was not associated with increased poor functional outcomes in the absence of fever (1.08 [0.55-2.13]), but a significant increase in poor functional outcomes was observed when elevated CAR was accompanied by fever (1.32 [1.14-2.56)).

Conclusions

Elevated CAR with fever increased the risk of poor functional recovery at 6 months after hospital discharge in patients with mTBI. Our study findings suggest the need for strategies for the prevention of long-term poor functional recovery in the presence of high CAR and fever in patients with mTBI.

Prognostic value of preoperative C-reactive protein to albumin ratio in patients with thymic epithelial tumors: a retrospective study

Background

The C-reactive protein to albumin ratio (CAR) is associated with poor prognosis in various cancers. However, its value in thymic epithelial tumors remains to be elucidated, we aimed to evaluate the prognostic significance of preoperative CAR in patients with surgically resected thymic epithelial tumors (TETs).

Methods

We retrospectively collected data from 125 patients with TETs who underwent thymoma resection at our center. The best cutoff values ​​for the continuous variable, CAR, were obtained using X-tile software. Univariate and multivariate Cox regression analyses were used to evaluate CAR as an independent predictor of overall survival (OS) and recurrence-free survival (RFS). Kaplan–Meier analysis and log-rank tests were used to present risk stratification of patients based on CAR and the Glasgow-prognostic-score (GPS). The prognostic effect of CAR was assessed using a receiver operating characteristic curve.

Results

Patients were categorized into high (≥ 0.17) and low (< 0.17) CAR groups according to the optimal cutoff value of 0.17. Univariate and multivariate analyses showed that CAR was an independent predictor of prognosis. World health organization stage, CAR level, GPS score, and drinking history were important independent prognostic factors for OS (p < 0.05). T stage, CAR level, and drinking history were important independent prognostic factors for RFS (p < 0.05). The area under the curve value of CAR to predict prognosis was 0.734 for OS and 0.680 for RFS.

Conclusions

Elevated preoperative CAR was independently associated with poor OS and RFS after thymectomy. Therefore, CAR may be a valuable biomarker for the postoperative prognosis of TETs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-10234-x.

Host-related factors and cancer: Malnutrition and non-Hodgkin lymphoma

Assessment of host-related factors is a crucial aspect in the comprehensive management of cancer patients. A distinct nutritional disturbance linked to cancer has been recognized to be associated with negative outcomes. However, compared to solid tumors, only a limited number of studies have looked specifically at nutritional issues in the field of lymphoma. The aim of this review is to integrate the current knowledge on interactions between malnutrition and lymphoma and address most relevant and pertinent questions. We first provide a literature review on the mutual biological relationship between malnutrition and lymphoma. Next, we explore the overlap between malnutrition, sarcopenia, cachexia and frailty in lymphoma studies. In addition, we summarize the clinical assessment scales used to measure malnutrition in lymphoma subjects. Furthermore, we address the problem of nutritional interventions aimed at patients who are candidates for treatment for lymphoma. Malnutrition can arise as a consequence of lymphoma disease and can in turn promote lymphomagenesis, negatively affect the response to therapy and favor adverse event to treatment. There is increasing evidence that malnutrition, sarcopenia and cachexia in lymphoma are intimately inter-related and are a hallmark of frailty. A variety of different tools are recorded with the apparent ability to describe nutritional status and to impact prognosis in lymphoma patients. Finally, a network of prognostic host- and disease-related factors is proposed where malnutrition can interact with each other in complex ways.

Nutritional Interventions to Improve Cachexia Outcomes in Cancer—A Systematic Review

Background and Objectives: The prevalence of cachexia has increased across all of the cancer types and accounts for up to 20% of cancer-related deaths. This paper is a systematic review of nutritional interventions aiming to improve cachexia outcomes in cancer, focusing on weight gain. Materials and Methods: A search in Medline and Elsevier databases for articles up until the 23 January 2022, was conducted. Results: Out of 5732 screened records, 26 publications were included in the final analysis. Four randomized clinical trials showed a significant body weight (BW) increase in patients treated with eicosapentaenoic acid (EPA), β-hydroxy-beta-methyl butyrate (β-HMB), arginine, and glutamine or marine phospholipids (MPL). An upward BW trend was observed in patients treated with L-carnitine, an Ethanwell/Ethanzyme (EE) regimen enriched with ω-3 fatty acids, micronutrients, probiotics, fish oil, a leucine-rich supplement, or total parental nutrition (TPN) with a high dose of a branched-chain amino acid (BCAA). Conclusions: Although clinical trials relating to large numbers of nutritional supplements present promising data, many trials provided negative results. Further studies investigating the underlying mechanisms of action of these nutritional supplements in cancer cachexia are needed. Early screening for cancer cachexia risk and nutritional intervention in cancer patients before aggravating weight loss may stabilize their weight, preventing cachexia syndrome. According to the GRADE methodology, no positive recommendation for these nutritional supplements may be expressed.

Prognostic Nutritional Index in Hepatocellular Carcinoma Patients With Hepatitis B Following US-Guided Percutaneous Microwave Ablation: A Retrospective Study With 1,047 Patients

Objective

Several studies have revealed that the prognostic nutritional index (PNI) was associated with survival in several cancers. However, the prognostic value of PNI in hepatocellular carcinoma (HCC) patients following ultrasound-guided percutaneous microwave ablation (US-PMWA) remains unknown, especially in patients with hepatitis B virus (HBV) infection. Therefore, the present study aimed to evaluate the potential prognostic value of PNI in these patients.

Materials

The medical records of 1,047 HCC patients with HBV infection following US-PMWA were retrospectively reviewed. The association between preoperative PNI and overall survival (OS), as well as other clinical characteristics of HCC, were analyzed using the Kaplan–Meier plot, log-rank test, multi-parameter Cox proportional hazards model, restricted cubic spline (RCS), and time-dependent receiver operating characteristic (ROC) curve analyses.

Results

Patients with a preoperative PNI more than 45 were verified to have better OS than patients with a PNI less than 45. In the multi-parameter Cox proportional hazards models, the log-transformed PNI was verified as an independent prognostic factor for OS. The result of the RCS analysis revealed that there was a nearly linear relationship between PNI and OS. The area under the time-dependent ROC curve for PNI in predicting OS was 0.56, which is relatively stable.

Conclusion

Preoperative PNI represents a convenient, noninvasive, and independent prognostic indicator in HCC patients with HBV infection following US-PMWA.

Pretreatment serum albumin-to-alkaline phosphatase ratio is an independent prognosticator of survival in patients with metastatic gastric cancer

BACKGROUND

Previous studies have suggested that a low albumin-to-alkaline phosphatase ratio (AAPR) is associated with a lower survival rate in patients with various malignancies. However, the relationship between pretreatment AAPR and the prognosis of patients with gastric cancer (GC) remains unclear.

AIM

To investigate the prognostic value of AAPR in distant metastatic GC.

METHODS

A total of 191 patients with distant metastatic cancer from a single institute were enrolled in this study. Pretreatment clinical data, including serum albumin and alkaline phosphatase levels, were collected. A chi-square test or Fisher’s exact test was applied to evaluate the correlations between AAPR and various clinical parameters in GC patients. The Kaplan–Meier method and Cox proportional hazards regression model were used to evaluate the prognostic efficacy of AAPR in metastatic GC patients. A two-sided P value lower than 0.05 was considered statistically significant.

RESULTS

A receiver operating characteristic curve indicated that 0.48 was the optimal threshold value for AAPR. AAPR ≤ 0.48 was significantly associated with bone (P < 0.05) and liver metastasis (P < 0.05). Patients with high levels of AAPR had better survival in terms of overall survival (OS) and progression-free survival (PFS), regardless of the presence of liver/bone metastasis. Pretreatment AAPR was found to be a favorable predictor of OS and PFS based on a multivariate cox regression model. AAPR-M system, constructed based on AAPR and number of metastatic sites, showed superior predictive ability relative to the number of metastatic sites for predicting survival.

CONCLUSION

Pretreatment AAPR may serve as an independent prognostic factor for predicting PFS and OS in patients with metastatic GC. Furthermore, AAPR may assist clinicians with individualizing treatment.

Lactate Albumin Ratio Is Associated With Mortality in Patients With Moderate to Severe Traumatic Brain Injury

Background

Traumatic brain injury (TBI) is a serious public health issue all over the world. This study was designed to evaluate the prognostic value of lactate to albumin ratio (LAR) on patients with moderate to severe TBI.

Methods

Clinical data of 273 moderate to severe TBI patients hospitalized in West China Hospital between May 2015 and January 2018 were collected. Multivariate logistic regression analyses were used to explore risk factors and construct a prognostic model of in-hospital mortality in this cohort. A receiver operating characteristic (ROC) curve was drawn to evaluate the discriminative ability of this model.

Results

Non-survivors had higher LAR than survivors (1.09 vs. 0.53, p < 0.001). Results of multivariate logistic regression analysis showed that Glasgow Coma Scale (GCS; odds ratio [OR] = 0.743, p = 0.001), blood glucose (OR = 1.132, p = 0.005), LAR (OR = 1.698, p = 0.022), subdural hematoma (SDH; OR = 2.889, p = 0.006), intraparenchymal hemorrhage (IPH; OR = 2.395, p = 0.014), and diffuse axonal injury (DAI; OR = 2.183, p = 0.041) were independent risk factors of in-hospital mortality in included patients. These six factors were utilized to construct the prognostic model. The area under the ROC curve (AUC) values of single lactate, albumin, and LAR were 0.733 (95% Cl; 0.673–0.794), 0.740 (95% Cl; 0.683–0.797), and 0.780 (95% Cl; 0.725–0.835), respectively. The AUC value of the prognostic model was 0.857 (95%Cl; 0.812–0.901), which was higher than that of LAR (Z = 2.1250, p < 0.05).

Conclusions

Lactate to albumin ratio is a readily available prognostic marker of moderate to severe TBI patients. A prognostic model incorporating LAR is beneficial for clinicians to evaluate possible progression and make treatment decisions in TBI patients.

Prognostic Impact of Inflammation-Based Scores for Extrahepatic Cholangiocarcinoma

INTRODUCTION

Although the relationship between systemic inflammatory responses and prognosis has been known in various cancers, it remains unclear which scores are most valuable for determining the prognosis of extrahepatic cholangiocarcinoma. We aimed to verify the usefulness of various inflammation-based scores as prognostic factors in patients with resected extrahepatic cholangiocarcinoma.

METHODS

We analyzed consecutive patients undergoing surgical resection for extrahepatic cholangiocarcinoma at our institution between January 2000 and December 2019. The usefulness of the following inflammation-based scores as prognostic factor was investigated: glasgow prognostic score (GPS), modified GPS, neutrophil-to-lymphocyte ratio, platelet to lymphocyte ratio, lymphocyte-to-monocyte ratio, prognostic nutrition index, C-reactive protein to albumin ratio (CAR), controlling nutritional status (CONUT), and prognostic index.

RESULTS

A total of 169 patients were enrolled in this study. Of the nine scores, CAR and CONUT indicated prognostic value. Furthermore, multivariate analysis for overall survival revealed that high CAR (>0.23) was an independent prognostic factor (hazard ratio: 1.816, 95% confidence interval: 1.135-2.906, p = 0.0129), along with lymph node metastasis and curability. There was no difference in tumor staging and short-term outcomes between the low CAR (≤0.23) and high CAR groups.

CONCLUSIONS

CAR was the most valuable prognostic score in patients with resected extrahepatic cholangiocarcinoma.

Nomogram based on prognostic nutrition index and Chest CT imaging signs predicts lymph node metastasis in NSCLC patients

OBJECTIVE

To establish and validate a model capable of predicting lymph node metastasis (LNM) of non-small cell lung cancer (NSCLC) patients.

METHODS

Preoperative clinical and CT imaging data on patients with NSCLC undergoing surgery were retrospectively analyzed. A model was developed using a training cohort of 290 patients. The univariate analysis followed by dichotomous logistic regression was performed to estimate different risk factors of lymph node metastasis, and a nomogram was constructed. Using another testing cohort of 120 patients, the performance of the nomogram was validated using several evaluation methods and indices and evaluated including via the area under the curve (AUC), calibration curve, Hosmer-Lemeshow test and decision curve analysis (DCA).

RESULTS

CT-based imaging signs were important independent risk factors for lymph node metastasis in NSCLC patients. The possible risk factors also included four other independent risk factors through dichotomous logistic regression, i.e., age, SIRI, PNI and CEA, which were filtered and included in the nomogram. Nomogram yields AUC values of 0.828 [95% confidence interval (CI): 0.778-0.877] in the training cohort and 0.816 (95% CI: 0.737-0.895) in the validation cohort, respectively. The calibration curves showed high agreement in both the training and validation cohorts. At the threshold probability of 0-0.8, the nomogram increases the net outcomes compared to the treat-none and treat-all lines in the decision curve.

CONCLUSIONS

The nomogram based on the PNI and CT images signs holds promise as a novel and accurate tool for predicting the LNM in NSCLC patients and guiding intraoperative lymph node dissection.

Extracellular water to total body water ratio may mediate the association between phase angle and mortality in patients with cancer cachexia: A single-center, retrospective study

BACKGROUND & AIMS

Recently, prognostic factors for cancer cachexia patients have been reported. We hypothesized that phase angle (PhA), which is measured by bioelectrical impedance analysis (BIA), might be a promising marker for assessing the nutritional status and prognosis of cancer patients. This study aimed to evaluate the predictive utility of PhA, which is mediated by several BIA factors and other anthropometric parameters, such as calf circumference, for the prognosis of cancer cachexia patients.

METHODS

Consecutive patients (114, both outpatients and inpatients) with an unselected stage of cancer cachexia were recruited between July 2018 and December 2019 in Fujita Health University Hospital for this retrospective cohort study. Their mean age was 74.0 years (standard deviation, 8.5); among the total, 70 were men and 44 women. A time-dependent Cox proportional-hazards regression analysis (adjusted for age and sex) was performed to assess the following: 1) the association between potential mediators and mortality; 2) the association between five PhAs and statistically significant mediators from 1); and 3) the association between the five PhAs and mortality. Finally, Kaplan-Meier survival curves were constructed and compared between the two groups based on the patients' median baseline ratio of extracellular water (ECW) to total body water (TBW) using a log-rank test.

RESULTS

The ECW/TBW ratio (hazard ratio [HR] per 1-interquartile range [IQR] increase: 2.87; 95% confidence interval [CI]: 1.46, 5.46; p < 0.001) and skeletal muscle mass index (HR per 1-IQR increase: 0.67; 95% CI: 0.51, 0.89; p = 0.001) were associated with mortality. All five PhAs were associated with the ECW/TBW ratio (p < 0.001). Before adjustment for the ECW/TBW ratio, all five PhAs were associated with mortality (p < 0.001); only the association of the PhAs of the left arm and the trunk retained the statistical significance after adjusting for confounders (p < 0.05). The median survival times in the low (370 days; 95% CI: 168, not calculated) and high ECW/TBW groups (101 days; 95% CI: 61, 219) differed significantly (p < 0.001).

CONCLUSIONS

The association between PhA and mortality in cancer cachexia patients was largely mediated by the ECW/TBW ratio. We believe that adjusting PhA for the ECW/TBW ratio may improve the prognostication of cancer patients with cachexia, ultimately improving their palliative care.

Prognostic Value of Pretreatment Prognostic Nutritional Index in Patients With Renal Cell Carcinoma: A Meta-Analysis

Background

The pretreatment prognostic nutritional index (PNI) is correlated with poor prognosis in several malignancies. However, the prognostic role of PNI in patients with renal cell carcinoma (RCC) remains unclear. Therefore, we performed a meta-analysis to investigate the prognostic significance of PNI in patients with RCC.

Methods

We searched the PubMed, Web of Science, Embase, Scopus, and Cochrane Library databases up to February 2021. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were used to estimate correlation between PNI and survival endpoints in RCC.

Results

Ten studies with 4,908 patients were included in the meta-analysis. The pooled results indicated that a low PNI associated with poor overall survival (HR = 2.10, 95% CI = 1.67–2.64, p<0.001), shorter progression-free survival, disease-free survival, recurrence-free survival (HR = 1.99, 95% CI = 1.67–2.36, p<0.001), and poor cancer-specific survival (HR = 2.95, 95% CI = 1.61–5.39, p<0.001). Additionally, the prognostic ability of PNI was not affected by subgroup analysis factors.

Conclusion

The meta-analysis indicated that low PNI associated with shorter survival outcomes in patients with RCC. Therefore, PNI could be used as an effective prognostic indicator in RCC.

Relationship between CRP Albumin Ratio and the Mortality in Critically Ill Patients with AKI: A Retrospective Observational Study

Background

AKI is known to be associated with inflammation and nutritional status. The novel inflammatory prognostic score CAR (CRP/albumin ratio), which combines inflammation and nutritional status, was hypothesized to be associated with mortality in critically ill AKI patients in this study.

Methods

The included cases were patients admitted to the ICU of Shandong Provincial Hospital from January 2016 to November 2018 and diagnosed with AKI within 48 hours of ICU admission. From the electronic case database of Shandong Provincial Hospital, we extracted the baseline demographic information, vital signs, routine laboratory parameters, complications, and other data. The above records are measured within 48 hours of admission to ICU. The clinical endpoint was the total cause mortality rate in hospital and 2 years. We constructed two multivariate regression models to determine the statistically significant correlation between CAR and mortality and conducted subgroup analysis to determine the mortality among different subgroups.

Results

A total of 580 patients were included in this study. In multivariate regression analysis, higher CAR was associated with an increase in hospital and two-year all-cause mortality in critically ill patients with AKI after adjusting gender, age, respiratory frequency, temperature, and other confounding factors (tertile 3 versus tertile 1: OR, 95% CI: 2.97, 1.70-5.17; 3.03, 1.68-5.47, respectively; P < 0.001). Subgroup analysis showed that the CAR level in each subgroup increases with hospital mortality in critically ill patients with AKI.

Conclusion

The increase of CAR in critically ill patients with AKI was associated with an increased risk of all-cause death.

Untreated Squamous Cell Lung Carcinoma May Contribute to the Occurrence of Hemophagocytic Syndrome

A 44-year-old man presented at our hospital to be evaluated for persistent fever and dyspnea. A chest computed tomography (CT) scan showed diffuse ground glass shadows and a left hilar tumor shadow. Upon further examination, he was found to have leukopenia, thrombocytopenia, and elevated lactate dehydrogenase and ferritin levels. He was diagnosed with both squamous cell lung carcinoma by a transbronchial lung biopsy and hemophagocytic syndrome by a bone marrow biopsy. After receiving treatment with dexamethasone and etoposide, the blood test abnormalities and performance status improved. Chemotherapy for lung cancer was initiated. He had a partial response after first-line chemotherapy and thereafter underwent left upper sleeve lobectomy.

Relationship Between Prognostic Nutritional Index and Mortality in Overweight or Obese Patients with Cancer: A Multicenter Observational Study

Background

Overweight and obese patients with cancer present with chronic inflammation, dysfunctional antitumor immunity and malnutrition risk. Prognostic nutritional index (PNI) is a promising indicator for predicting inflammatory, immunological and nutritional states; however, its prognostic value in overweight and obese patients with cancer has not been explored. Therefore, the aim of the current study was to explore the prognostic value of PNI levels in overweight and obese patients with cancer.

Methods

The current large-scale retrospective cohort multicenter study included 3532 patients. Time-dependent receiver operating characteristic (ROC) curve analysis was used to determine the prediction accuracy of PNI levels for mortality of overweight and obese patients with cancer. Restricted cubic splines were used to model the association between PNI levels and mortality. Association between low PNI and overall survival rate was analyzed using the Kaplan–Meier method and Cox regression model.

Results

Area under the curve (AUC) of the PNI for all-cause mortality was higher compared with that of the neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) in overweight and obese patients with cancer. There was a significant inverse relationship between PNI levels and all-cause mortality (per SD increment-HR: 0.79; 95% CI: 0.74, 0.85; P<0.001). Subgroup analysis showed that the risk for mortality significantly decreased with increase in PNI levels in patients at risk of malnutrition (per SD increment-HR: 0.67; 95% CI: 0.57, 0.78; P<0.001) and elderly patients (per SD increment-HR: 0.74; 95% CI: 0.64, 0.84; P<0.001). In addition, PNI levels showed an inverse association with mortality in patients without malnutrition risk (per SD increment-HR: 0.81; 95% CI: 0.75, 0.88; P<0.001). Subgroup analysis based on tumor type showed that low PNI was an independent predictor of poor prognosis for patients with lung cancer, gastric cancer and hepatobiliary and pancreatic cancer.

Conclusion

Low PNI levels are associated with an increased risk for all-cause mortality. PNI level is a potential effective inflammation-based prognostic tool for overweight and obese patients with cancer.

Exploration of Novel Prognostic Markers in Grade 3 Neuroendocrine Neoplasia

Simple Summary

High grade neuroendocrine tumours and carcinomas (NETs/NECs) behave aggressively and have limited survival outcomes. The mainstay of therapy is systemic therapy, in which the associated side-effects are a key consideration in a palliative population. We have conducted a retrospective review of patients with high grade NETs and NECs to determine possible tests that will predict survival before patients start treatment. This will allow patients to avoid potentially toxic treatment that is unlikely to be of benefit.

Abstract

Background: High-grade neuroendocrine tumours and carcinomas (NET/NECs) behave aggressively, typically presenting at an advanced stage. Prognosis is poor, with median survival between 5 and 34 months. The mainstay of treatment is palliative systemic therapy. However, therapy carries a risk of toxicity, which can reduce quality of life. Therefore, accurate prognostic scores for risk stratification of patients with high-grade NET/NECs are needed to help guide patient management to decide whether active treatment is likely to improve overall survival (OS). We aimed to compare the prognostic ability of published prognostic scores to predict OS in a cohort of patients with high-grade NET/NECs of any primary site. Methods: Treatment, biochemical and clinicopathological data were collected retrospectively from 77 patients with high-grade NET/NECs across three hospitals between 2016 and 2020. Variables including performance status (PS), Ki-67, age at diagnosis, previous treatment and presence of liver metastases were recorded. Pre-treatment neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio, modified Glasgow prognostic score (mGPS), and gastrointestinal neuroendocrine carcinoma (GI-NEC) score were derived. Univariable and multivariable survival analyses were used to assess prognostic ability. Results: The median age of the cohort was 63 years (range: 31–85); 53% of subjects were female. Grade 3 NETs (G3-NETs) were identified in 32 patients and NECs in 45 patients. The median OS was 13.45 months (range: 0.87–65.37) with no difference observed between G3-NETs and NECs. Univariable analysis revealed that NLR (n = 72, p = 0.049), mGPS (n = 56, p = 0.003), GI-NEC score (n = 27, p = 0.0007) and Ki-67 (n = 66, p = 0.007) were significantly associated with OS. Multivariable analysis confirmed that elevated mGPS (p = 0.046), GI-NEC score (p = 0.036), and Ki-67 (p = 0.02) were independently prognostic for reduced OS across the entire cohort. mGPS was identified as an independent prognostic factor in G3-NETs. Independent predictors of OS in NECs were PS and Ki-67. Conclusions: mGPS, PS and Ki-67 are independent prognostic markers in high-grade NET/NEC patients. Our study supports the use of these prognostic scores for risk stratification of patients with high grade cancers and as useful tools to guide treatment decisions.

A Time-Course Comparison of Skeletal Muscle Metabolomic Alterations in Walker-256 Tumour-Bearing Rats at Different Stages of Life

Cancer cachexia is a severe wasting condition that needs further study to find ways to minimise the effects of damage and poor prognosis. Skeletal muscle is the most impacted tissue in cancer cachexia; thus, elucidation of its metabolic alterations could provide a direct clue for biomarker research and be applied to detect this syndrome earlier. In addition, concerning the significant changes in the host metabolism across life, this study aimed to compare the metabolic muscle changes in cachectic tumour-bearing hosts at different ages. We performed ¹H-NMR metabolomics in the gastrocnemius muscle in weanling and young adult Walker-256 tumour-bearing rats at different stages of tumour evolution (initial, intermediate, and advanced). Among the 49 metabolites identified, 24 were significantly affected throughout tumour evolution and 21 were significantly affected regarding animal age. The altered metabolites were mainly related to increased amino acid levels and changed energetic metabolism in the skeletal muscle, suggesting an expressive catabolic process and diverted energy production, especially in advanced tumour stages in both groups. Moreover, these changes were more severe in weanling hosts throughout tumour evolution, suggesting the distinct impact of cancer cachexia regarding the host's age, highlighting the need to adopting the right animal age when studying cancer cachexia.

Prognostic role of neutrophil-to-lymphocyte ratio (NLR) in urological tumors: an umbrella review of evidence from systematic reviews and meta-analyses

BACKGROUND

Neutrophil-to-lymphocyte ratio (NLR) has been studied as a biomarker for cancer prognosis, predicting survival in many tumors. The aim of this umbrella review was to combine the results from all systematic reviews and meta-analyses related to the prognostic role of the NLR in patients with urological tumors.

METHODS

A PubMed, Scopus, Embase and Cochrane search was undergone from inception through September 2020 for systematic reviews and meta-analyses investigating the prognostic value of NLR in urological tumors, subdivided into prostate cancer, renal cell carcinoma, urothelial bladder and upper tract carcinomas PROSPERO (CRD42020216310).

RESULTS

The results have shown, with a high level of evidence, that an elevated NLR predicts worse overall survival (OS), progression-free survival (PFS) and relapse-free survival (RFS) in prostate cancer, worse OS, PFS and RFS in renal cell carcinoma, worse OS, PFS, RFS and cancer-specific survival (CSS) in muscle invasive bladder cancer, worse PFS and RFS in non-muscle invasive bladder cancer, and worse OS, PFS, RFS and CSS in urothelial upper tract carcinoma.

CONCLUSION

NLR has a significant prognostic value in urological tumors and should be included in prognostic scores of these cancers.

Prognostic Significance of Prognostic Nutritional Index in Patients with Renal Cell Carcinoma: A Meta-Analysis

The prognostic nutrition index (PNI), based on the serum lymphocyte counts and albumin levels, has been introduced as a prognostic factor in various cancer. In the present study, we explore the prognostic significance of PNI in patients with renal cell carcinoma (RCC). A literature search of all publications was conducted using the Cochrane library, PubMed and Embase databases from inception to April 2020. A total of 12 studies consisting of 7,391 patients were enrolled in the present study. We found that low pretreatment PNI is significantly correlated to poor survival, including overall survival (OS) (P < 0.001), cancer-specific survival (CSS) (P = 0.002), progression-free survival/recurrence-free survival/disease-free survival (PFS/RFS/DFS) (P < 0.001). The age (P < 0.001), clear cell histology (P = 0.044), T3-T4 (P = 0.049), and Fuhrman grade 3-4 (P = 0.024) were significantly differed in the low and high pretreatment PNI group. In summary, low pretreatment PNI was associated with adverse clinicopathological features in patients with RCC. Besides, low pretreatment PNI was also an unfavorable factor of OS, CSS, and PFS/RFS/DFS in RCC patients, which could serve as an unfavorable factor. More studies with large participants are required to verify our results.Supplemental data for this article is available online at https://doi.org/10.1080/01635581.2021.1931702.

A Nomogram Model Involving Preoperative Fibrinogen and Prognostic Nutritional Index Score for Predicting Postoperative Outcome in Patients with Gastric Cancer

Background

Inflammation and nutrition play vital roles in the development of gastric cancer (GC). We combined the preoperative fibrinogen with prognostic nutritional index (PNI) to create a novel scoring system named as the fibrinogen and prognostic nutritional index (FPNI) score and establish a more effective model.

Patients and Methods

A total of 689 patients with gastric adenocarcinoma who underwent gastrectomy from January 2012 to December 2016 were reviewed. We measured correlations between FPNI score and clinicopathological variables and overall survival (OS). A nomogram predicting OS was constructed. Its predictive performance was verified using the concordance index, calibration curves, receiver operating characteristic curves, decision curve analysis and time-dependent receiver operating characteristic analysis.

Results

We observed that the FPNI score was an independent predictor of OS in patients with gastric cancer (P < 0.05). A high FPNI score was significantly related to older age at surgery, tumor size ≥4.6 cm, high ASA score, advanced TNM stage and poor outcome (both P < 0.05). And the FPNI score remained an independent indicator at various TNM stages (P < 0.05). Ultimately, the nomogram based on FPNI score, age, tumor size, histological grade and TNM stage showed a better predictive ability than TNM alone.

Conclusion

The preoperative FPNI score is a novel, simple, and effective predictor of OS in patients with GC. Furthermore, the nomogram involving FPNI score will help clinicians to optimize individualized treatment plans.

Aerobic Exercise Ameliorates Cancer Cachexia-Induced Muscle Wasting through Adiponectin Signaling

Cachexia is a multifactorial syndrome characterized by muscle loss that cannot be reversed by conventional nutritional support. To uncover the molecular basis underlying the onset of cancer cachectic muscle wasting and establish an effective intervention against muscle loss, we used a cancer cachectic mouse model and examined the effects of aerobic exercise. Aerobic exercise successfully suppressed muscle atrophy and activated adiponectin signaling. Next, a cellular model for cancer cachectic muscle atrophy using C2C12 myotubes was prepared by treating myotubes with a conditioned medium from a culture of colon-26 cancer cells. Treatment of the atrophic myotubes with recombinant adiponectin was protective against the thinning of cells through the increased production of p-mTOR and suppression of LC3-II. Altogether, these findings suggest that the activation of adiponectin signaling could be part of the molecular mechanisms by which aerobic exercise ameliorates cancer cachexia-induced muscle wasting.

Cancer Cachexia Affects Patients with Head and Neck Cancer in All Stages of Disease: A Prospective Cross-Sectional Study

The aim of the study was to determine the prevalence of cancer cachexia according to the clinical stage and determine differences in body composition, usual energy intake, and pro-inflammatory profile between cachectic and non-cachectic patients newly diagnosed with head and neck squamous cell carcinoma (HNSCC). A cross-sectional study was conducted in adult patients diagnosed with HNSCC admitted to the oncology unit before starting cancer treatment. Cancer cachexia was assessed according to Fearon criteria, and patients were divided into two groups: cachectic and non-cachectic patients. Body composition measured by bioelectrical impedance, energy intake, and biochemical and inflammatory markers were assessed. Comparative analyses were performed Student's-T test, using one-way ANOVA, chi-square and Mann Whitney-U test. Of the 79 consecutive patients included in the analysis, 72% (n = 57; 61 ± 15 years) were classified as cachectic and 28% (n = 22;59 ± 10 years) as non-cachectic. According to clinical stage, the prevalence of cachexia was stage I = 8.8%, stage II = 15.8%, stage III = 33.3% and stage IV = 42.1% (P = 0.564) and phase angle showed to be different between these groups (P < 0.05). Body composition showed that fat-free mass and total body water were significantly lower in patients with cachexia (p < 0.05). No differences were observed in phase angle, food intake or inflammatory markers between cachectic and non-cachectic patients. Cancer-cachexia is prevalent in all clinical stages in newly diagnosed patients with HNSCC. Early identification of cancer cachexia will allow initiate specialized nutrition support in a timely manner.

The prognostic nutritional index on postoperative day one is associated with one-year mortality after burn surgery in elderly patients

BACKGROUND

Burn injury in elderly patients can result in poor outcomes. Prognostic nutritional index (PNI) can predict the perioperative nutritional status and postoperative outcomes. We aim to evaluate the risk factors, including PNI, for one-year mortality after burn surgery in elderly patients.

METHODS

Burn patients aged ≥65 years were retrospectively included. PNI was calculated using the following equation: 10 × serum albumin level (g/dL) + 0.005 × total lymphocyte count (per mm³). Cox regression, receiver operating characteristic curve and Kaplan-Meier survival analyses were performed to evaluate the risk factors for postoperative one-year mortality.

RESULTS

Postoperative one-year mortality occurred in 71 (37.6%) of the 189 elderly burn patients. Risk factors for one-year mortality were PNI on postoperative day one (hazard ratio (HR) = 0.872; 95% CI = 0.812-0.936; p < 0.001), Sequential Organ Failure Assessment score (HR = 1.112; 95% CI = 1.005-1.230; p = 0.040), American Society of Anesthesiologists physical status (HR = 2.064; 95% CI = 1.211-3.517; p = 0.008), total body surface area burned (HR = 1.017; 95% CI = 1.003-1.032; p = 0.015) and preoperative serum creatinine level (HR = 1.386; 95% CI = 1.058-1.816; p = 0.018). The area under the curve of PNI for predicting one-year mortality after burn surgery was 0.774 (optimal cut-off value = 25.5). Patients with PNI ≤25.5 had a significantly lower one-year survival rate than those with PNI >25.5 (32.1% vs 75.9%, p < 0.001).

CONCLUSIONS

PNI on postoperative day one was associated with postoperative one-year mortality in elderly burn patients. The postoperative one-year survival rate was lower in patients with PNI ≤25.5 than in those with PNI >25.5. These findings indicate the importance of identifying elderly burn patients with low PNI, thereby reducing the mortality after burn surgery.

The Prognostic Prediction Value of Systemic Inflammation Score and the Development of a Nomogram for Patients With Surgically Treated Breast Cancer

Background: Systemic inflammation score (SIS) has been verified as a novel prognostic indicator in several cancer types. However, its prognostic value in breast cancer remains unknown. Furthermore, a nomogram based on SIS is yet to be constructed for breast cancer. We conducted this study to explore the association between SIS and prognosis of breast cancer, and to construct a good prognostic nomogram model. Methods: A total of 1,180 breast cancer patients who underwent curative surgery between December 2010 and January 2013 were recruited. They were randomly assigned to the training set (n = 944) or the validation set (n = 236). All patient blood samples were collected within 1 week prior to operation. According to previous reports, SIS was calculated for all patients, who were then classified into two groups: high-SIS and low-SIS. The Kaplan-Meier method was employed for survival analyses, and univariate and multivariate analyses (Cox proportional hazards regression model) were used for prognostic assessment. A nomogram was constructed based on the results of multivariate analysis. Calibration curves and concordance index (C-index) were compiled to determine predictive and discriminatory capacity. Results: In the training set, the median follow-up time was 6.07 years. Patients in the high-SIS group had an average OS time of 68.05 months, which is shorter than that of the low-SIS group (72.87 months; P = 0.033). Patients in the high-SIS group had average RFS and DMFS times of 56.04 and 54.46 months, respectively, which are shorter than those of the low-SIS group (60.85 and 59.47 months, respectively; P = 0.247 and P = 0.032). Univariate and multivariate analyses revealed SIS to be an independent prognostic factor for OS and DMFS time. The nomogram for the training set indicated OS and DMFS C-indexes of 0.794 (95% CI, 0.772-0.816) and 0.712 (95% CI, 0.684-0.740), respectively. In the validation set, the OS and DMFS C-indexes were 0.889 (95% CI, 0.845-0.933) and 0.696 (95%. CI, 0.611-0.781), respectively. Conclusions: SIS was confirmed as an independent prognostic predictor among patients with breast cancer who had undergone surgery with curative intent. Higher preoperative SIS may indicate higher risk of metastasis and shorter overall survival time. The prognostic nomogram based on SIS was dependable for breast cancer patients who underwent curative surgery.

Nomogram Based on Systemic Immune Inflammation Index and Prognostic Nutrition Index Predicts Recurrence of Hepatocellular Carcinoma After Surgery

Background

Surgery is a potential cure for hepatocellular carcinoma (HCC), but its postoperative recurrence rate is high, its prognosis is poor, and reliable predictive indicators are lacking. This study was conducted to develop a simple, practical, and effective predictive model.

Materials and Methods

Preoperative clinical and postoperative pathological data on patients with HCC undergoing partial hepatectomies at the Third Affiliated Hospital of Soochow University from January 2010 to December 2015 were retrospectively analyzed, and a nomogram was constructed. The model performance was evaluated using C-indexes, receiver operating characteristic curves, and calibration curves. The results were verified from validation cohort data collected at the same center from January 2016 to January 2017 and compared with the traditional staging systems.

Results

Three hundred three patients were enrolled in this study: 238 in the training cohort and 65 in the validation cohort. From the univariate and multivariate Cox regression analyses in the training cohort, six independent risk factors, i.e., age, alpha-fetoprotein (AFP), tumor size, satellite nodules, systemic immune inflammation index (SII), and prognostic nutritional index (PNI), were filtered and included in the nomogram. The C-index was 0.701 [95% confidence interval (CI): 0.654–0.748] in the training cohort and 0.705 (95% CI: 0.619–0.791) in the validation cohort. The areas under the curve for the 1- and 3-year recurrence-free survival were 0.706 and 0.716 in the training cohort and 0.686 and 0.743 in the validation cohort, respectively. The calibration curves showed good agreement. Compared with traditional American Joint Committee on Cancer 8th edition (AJCC8th) and Barcelona Clinic Liver Cancer (BCLC) staging systems, our nomogram showed better predictive ability.

Conclusion

Our nomogram is simple, practical, and reliable. According to our nomogram, predicting the risk of recurrence and stratifying HCC patient management will yield the greatest survival benefit for patients.

Prognostic Significance of Pretreatment Prognostic Nutritional Index (PNI) in Patients with Nasopharyngeal Carcinoma: A Meta-Analysis

OBJECTIVE

Previous studies have investigated the pretreatment prognostic nutritional index (PNI) as a prognostic factor in patients with nasopharyngeal carcinoma (NPC); however, the results remained inconsistent. We aimed to assess the prognostic value of PNI in patients with NPC through conducting meta-analysis. Methods: Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for low PNI of overall survival (OS), progression-free survival (PFS), distant metastasis-free survival (DMFS), loco-regional recurrence-free survival (LRFS), and cancer-specific survival (CSS). Results: Totally, eight studies involving 4299 patients were included in this meta-analysis. A low pretreatment PNI was associated with poor OS (HR = 1.86, 95% CI = 1.55-2.33, P < 0.001), DMFS (HR = 2.03, 95% CI = 1.69-2.44, P < 0.001), PFS (HR = 1.57, 95% CI = 1.31-1.90, P < 0.001), and CSS (HR = 2.29, 95% CI = 1.54-3.42, P < 0.001). The subgroup analysis showed that low PNI remained a significant factor for poor OS, DMFS, and PFS irrespective of treatment, country, and cutoff value of PNI. In addition, low PNI was correlated to female gender (OR = 1.35, 95% CI = 1.12-1.62, P = 0.002), older age (OR = 1.75, 95% CI = 1.17-2.62, P = 0.007), and T3-T4 stage (OR = 1.27, 95% CI = 1.06-1.53, P = 0.011). Conclusions: A low PNI was associated with poor survival outcomes in patients with NPC. Moreover, PNI could serve as an index to help guide clinical management for older patients.

Novel inflammation-based prognostic nomograms for individualized prediction in hepatocellular carcinoma after radical resection

Background

The prognosis for patients with hepatocellular carcinoma (HCC) after liver resection ranges widely and is unsatisfactory. This study aimed to develop two novel nomograms that combined tumor characteristics and inflammation-related indexes to predict overall survival (OS) and recurrence-free survival (RFS).

Methods

In total, 3,071 patients who underwent radical resection were recruited. Independent risk factors were identified by Cox regression analysis and used to conduct prognostic nomograms. The C-index, time-dependent areas under the receiver operating characteristic curve (time-dependent AUC), decision curve analysis (DCA), and calibration curves were used to assess the performance of the nomograms.

Results

Multivariate analysis revealed that alpha-fetoprotein (AFP), resection margin, neutrophil times γ-glutamyl transpeptidase-to-lymphocyte ratio (NrLR), platelet-to-lymphocyte ratio (PLR), γ-glutamyl transpeptidase-to-platelet ratio (GPR), tumor size, tumor number, microvascular invasion, and Edmondson-Steiner grade were the independent risk factors associated with OS. The independent risk factors associated with RFS were hepatitis, AFP, albumin-bilirubin (ALBI), NrLR, PLR, PNI, GPR, tumor size, tumor number, microvascular invasion, and Edmondson-Steiner grade. The C-index of the nomograms in the training and validation cohort were 0.71 [95% confidence interval (CI): 0.70–0.73] and 0.71 (95% CI: 0.69–0.74) for the OS, and 0.71 (95% CI: 0.70–0.73) and 0.74 (95% CI: 0.72–0.76) for RFS, respectively. The C-index, time-dependent AUC, and DCA of the nomograms showed significantly better predictive performances than those of commonly used staging systems. The models could stratify patients into three different risk groups. The web-based tools are convenient for clinical practice.

Conclusions

Two novel nomograms in which integrated inflammation-related indexes and accessible clinical parameters were developed to predict OS and RFS in HCC patients who underwent radical resection. Such models will help guide postoperative individualized follow-up and adjuvant therapy.

CRP Albumin ratio is positively associated with poor outcome in patients with traumatic brain injury

OBJECTIVES

The C-reactive protein/albumin ratio (CAR), a novel inflammation-based index, has been proved useful in predicting outcome of various diseases. We designed this study to explore the prognostic value of CAR in patients with traumatic brain injury (TBI).

PATIENTS AND METHODS

We retrospectively included 151 patients diagnosed with TBI and collected related clinical and laboratory data. Univariate and multivariate logistic regression were conducted to find independent risk factors of mortality. Then, we incorporated CAR into prognostic model and drew receiver operating characteristic (ROC) curve of models. Finally, we compared the predictive value of different models by evaluating the area under the receiver operating characteristic curves (AUC).

RESULTS

In this study, a total of 54 patients had poor survival outcome with mortality rate of 35.8 %. Results of multivariate analysis showed that GCS score in admission (OR 0.700, 95 %Cl 0.570-0.860, p=0.001), acute kidney injury (AKI) (OR 3.952, 95Cl 1.631-9.577, p=0.002) and CAR (OR 1.202, 95Cl 1.039-1.390, p=0.013) were independently associated with in-hospital mortality. The AUC value of predictive model composed of the above three factors was higher than GCS or CAR alone.

CONCLUSION

CAR is an independent risk factor of mortality in patients with TBI. Incorporating CAR into predictive model could increase the value in predicting outcome of TBI patients.

Controlling nutritional status (CONUT) score is a predictive marker for patients with traumatic brain injury

OBJECT

We designed this study to evaluate whether controlling nutritional status (CONUT) score was valuable in predicting outcome of patients with traumatic brain injury (TBI).

METHODS

Clinical and laboratory data of patients admitted with TBI in our hospital between January 2015 and January 2018 was retrospectively collected. We divided patients into two groups according to in-hospital and 90-day outcome respectively and compared baseline characteristics of two groups. Multivariate analyses were conducted to evaluate whether CONUT score was associated with outcome of included patients. Receiver operating characteristics (ROC) curves were drawn to compare the predictive value of CONUT score and constructed models.

RESULTS

A total of 365 patients were included in our study. Multivariate logistic regression analyses showed that CONUT score was independently associated with in-hospital mortality (OR = 1.244, 95% CI: 1.099-1.408, p = 0.001) and 90-day outcome (OR = 1.441, 95% CI: 1.193-1.741, p < 0.001). ROC curve showed that area under the ROC curve (AUC) of CONUT score for predicting in-hospital mortality and 90-day outcome were 0.790 (95% CI: 0.745-0.836, p < 0.001) and 0.839 (95% CI: 0.792-0.886, p < 0.001), respectively.

CONCLUSION

CONUT score is independently associated with in-hospital mortality and 90-day outcome of patients with TBI.

Development of the clinical calculator for mortality of patients with metastatic clear cell type renal cell carcinoma: An analysis of patients from Korean Renal Cancer Study Group database

Purpose

To develop the clinical calculator for mortality of patients with metastatic renal cell carcinoma (mRCC) using Korean Renal Cancer Study Group (KRoCS) database.

Materials and Methods

Data from 1,115 patients with mRCC treated in 4 hospitals joining KRoCS between 1993 and 2016 were pooled. Five-year survival rates were calculated using Kaplan–Meier curve. A clinical calculator for 5-year mortality was developed using multivariable logistic regression analysis and validated externally using dataset including 916 patients from 4 other hospitals.

Results

Overall survival rates and cancer specific survival rate at 5 years were 28.5% and 29.4%, respectively. Among baseline factors, increased neutrophil-lymphocyte ratio (≥4), synchronous metastasis, low albumin (<3.0 g/dL), and low hemoglobin (<lower limit of normal: male, 13 g/dL; female, 11.5 g/dL) were the significant factors in 5-year mortality. Good internal validity was demonstrated with area under the curve estimates being 0.774 at 5-year mortality calculation and the calibration plot. In the external validation, 758 (82.8%) died by 5 years among these patients, with the average model-predicted rate of 72.9%.

Conclusions

A clinical calculator has been developed to quantify the risk of death for individual patients after treatment of mRCC. This tool may be useful for patients or their guardians who want to know their prognosis and to identify patients requiring aggressive therapy and additional supportive measures during and after treatment.

Cancer cachexia: a multifactoral disease that needs a multimodal approach

PURPOSE OF REVIEW

Cancer cachexia is a complex condition that occurs in approximately 50% of cancer patients and in 80% of those with advanced cancer. It is characterized by lean body mass loss, adipose tissue loss, altered metabolism, increased inflammation, and a decrease in quality of life. Cancer cachexia is a frustrating condition to manage and treatment requires an innovative approach. The purpose of this article is to review the current treatments for cancer cachexia and how they could be used in a multimodal approach.

RECENT FINDINGS

Cancer cachexia has many causes, but is primarily a result of reduced energy-protein intake and altered metabolism augmented by a proinflammatory state. There is not a formal consensus on diagnosing cancer cachexia, but proactive screening and assessments for malnutrition are an effective first step toward identifying high-risk patients. Treatment of cancer cachexia includes optimizing nutrition care, using appropriate pharmacological agents, preserving lean body mass, and the cooperation of the healthcare team.

SUMMARY

Cancer cachexia is a complex multifactorial condition that can only be successfully managed and treated with a multimodal approach that involves a multidisciplinary team that includes an oncology registered dietitian nutritionist and exercise physiologist that target early detection and management of cancer cachexia.

[Pathogenetic mechanisms of development of myocardial pathology in patients with malignant tumors: the current state of the problem]

The myocardium, which has a high metabolic activity, responds to metabolic disorders and energy imbalance induced by a growing malignant tumor. In addition, the tumor itself can produce substances that directly affect metabolic processes and the life cycle of cells not involved in the neoplastic process, including cardiomyocytes. This review summarized and systematized current data on individual aspects of detrimental effects of oncogenes and tumor-related factors on the heart muscle and morpho-functional changes in the cardiovascular system of oncology patients. Also, the authors described in detail development of these pathogenetic mechanisms.

A novel prognostic score model based on combining systemic and hepatic inflammation markers in the prognosis of HBV-associated hepatocellular carcinoma patients

Objectives: The study aimed to evaluate the prognostic value of systemic inflammation markers [neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), Prognostic Nutritional Index (PNI)] and hepatic inflammation markers [aspartate aminotransferase-to-platelet ratio index (APRI), γ-glutamyl transferase (γ-GT)/alanine aminotransferase (ALT)] in patients with hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC) and further to develop a novel prognostic score model. Methods: A total of 401 cases with HBV-associated HCC who underwent hepatectomy as initial therapy were included in the analysis. Kaplan-Meier was performed to construct survival curves and receiver operating characteristic (ROC) analysis was used to detect the optimal cut-off value of markers. The prognostic score model was constructed using significant inflammation markers in the Cox model. Each factor was given a score of 1 and patients were stratified according to the scores. Results: In the Cox model, α-fetoprotein (AFP), ALT, tumour differentiation, maximum size of tumours, TNM stage, PNI and γ-GT/ALT were independently prognostic factors. We established a preoperative inflammation-based prognostic scoring model combining PNI and γ-GT/ALT. The novel preoperative inflammation-based prognostic score was superior (area under the curve [AUC], 0.659) to 7^th tumour-node-metastasis (TNM) stage (AUC, 0.600) despite no statistical significance (p = .1036). Conclusion: PNI and γ-GT/ALT are independent predictors for prognosis. The novel prognostic score model based on systemic and hepatic inflammation markers is suitable for the prognosis evaluation in patients with HBV-associated HCC.

Verification of inflammation-based prognostic marker as a prognostic indicator in hepatocellular carcinoma

AIM

Although inflammation-based markers in cancer have been used for prognostic prediction, the most useful marker for hepatocellular carcinoma (HCC) has not been established. We investigated the usefulness of various inflammation-based markers in HCC patients after hepatectomy.

METHODS

A total of 478 patients who underwent initial hepatectomy for HCC from 2009 to 2015 and were diagnosed with pathological HCC were included in this retrospective study. Inflammation-based markers consisted of the C-reactive protein to albumin ratio (CAR), Glasgow prognostic score (GPS), neutrophil to lymphocyte ratio, lymphocyte to monocyte ratio, platelet to lymphocyte ratio and prognostic index. Univariate and multivariate analyses for overall survival (OS) and disease-free survival (DFS) using the Cox proportional hazard model were carried out. Kaplan-Meier analysis and log-rank test were used for comparison of OS and DFS. To reduce influences of selection bias and confounders for stratifying CAR, clinicopathological characteristics of patients were balanced by propensity score matching.

RESULTS

Multivariate analysis identified only high CAR (>0.027) as an indicator of poor OS, and high CAR and high GPS (1-2) as indicators of poor DFS among inflammation-based markers. After propensity score matching, 124 patients each with low CAR and high CAR were matched. High CAR was correlated with both poor OS and DFS.

CONCLUSION

C-reactive protein to albumin ratio was the most valuable prognostic indicator after hepatectomy for HCC among inflammation-based markers.

Serial change in serum biomarkers during treatment of Non-HIV Pneumocystis pneumonia

BACKGROUND

For patients with non-human immunodeficiency virus (HIV) Pneumocystis pneumonia (PCP), data are limited on serial changes in serum biomarkers and the correlations with clinical outcomes.

OBJECTIVE

This study evaluated serial change in serum biomarkers and clinical outcomes of non-HIV PCP.

METHODS

We retrospectively reviewed data from 63 patients treated for non-HIV PCP at Toho University Omori Medical Center. The patients were classified as survivors and nonsurvivors on the basis of 60-day PCP mortality. The groups were compared for clinical course and levels of serum biomarkers (β-D glucan, Krebs von den Lungen-6 antigen [KL-6], and surfactant protein-D [SP-D]), which were measured at baseline, and 7 days and 14 days after starting treatment. In addition, serial changes in serum biomarkers were analyzed in survivors and nonsurvivors.

RESULTS

There were 14 PCP nonsurvivors and 49 survivors. Biomarker values were not different between groups at baseline. At 7 and 14 days after starting treatment, the proportions of patients with elevated β-D glucan and KL-6 did not significantly differ between groups; however, the proportion of patients with elevated SP-D was significantly lower among survivors than among nonsurvivors (57.1% vs. 100%, p = 0.009; 30% vs. 100%, p < 0.001; respectively). SP-D on day 14 was significantly lower than that at baseline among survivors (99.6 [61.0-190.3] vs. 156 [100.8-283.5]; p = 0.045) but significantly higher among nonsurvivors (974 [744.5-1565] vs. 317 [211-448]; p = 0.03).

CONCLUSION

Serum SP-D value continues to increase after failure of treatment for non-HIV PCP and may thus be associated with outcomes for non-HIV PCP patients.

Tumour stage and resection margin status are independent survival factors following partial pancreatoduodenectomy for duodenal adenocarcinoma

INTRODUCTION

There is limited published evidence on duodenal carcinoma due to its rarity. This study aimed to evaluate gastric outlet obstruction and obstructive jaundice along with pathological variables as survival factors in patients with duodenal adenocarcinoma following resection.

METHODS

Survival factor analysis was undertaken in patients undergoing duodenal cancer surgery from 1997 to 2015 in a single centre.

RESULTS

There were 57 patients of whom 18 had gastric outlet obstruction and 14 had obstructive jaundice. Fifty-three had a partial pancreatoduodenectomy and four had palliative bypass. Perioperative mortality and morbidity were 4% (2/53) and 47% (25/53) respectively in resected patients. With a median (95% confidence interval, CI) follow-up of 72 (57-86) months, median overall and recurrence-free survival was 38 months (95% CI 28-113) and 27 months (95% CI 18-83) respectively. The 1 and 3-year overall survival rates were 84% (95% CI 74-95) and 52% (95% CI 39-69) respectively. Median overall survival was 19 months in patients with gastric outlet obstruction vs 53 months in those without (p = 0.026) and 28 months in patients with obstructive jaundice vs 38 months in those without (p = 0.611). Univariate analysis revealed that tumour stage, resection margin status, pre-operative albumin status, gastric outlet obstruction and age were associated with poorer overall and recurrence-free survival but multivariate analysis confirmed only tumour stage and resection margin status to be significant.

CONCLUSION

Whereas gastric outlet obstruction in duodenal cancer appeared to be an important survival factor following partial pancreatoduodenectomy, multivariate analysis showed that only tumour stage and resection margin status were the key independent survival factors. Further multicentre studies are required to elucidate further characteristics of duodenal carcinoma and develop neoadjuvant/adjuvant management strategies.