Prognostic Value of Preoperative Nutritional and Immunological Factors in Patients with Pancreatic Ductal Adenocarcinoma

Preoperative Prediction of Long-Term Survival After Surgery in Patients with Resectable Pancreatic Ductal Adenocarcinoma

BACKGROUND

Although some clinical trials have demonstrated the benefits of neoadjuvant therapy for resectable pancreatic ductal adenocarcinoma (PDAC), its optimal candidate has not been clarified. This study aimed to detect predictive prognostic factors for resectable PDAC patients who underwent upfront surgery and identify patient cohorts with long-term survival without neoadjuvant therapy.

PATIENTS AND METHODS

A total of 232 patients with resectable PDAC who underwent upfront surgery between January 2008 and December 2019 were evaluated.

RESULTS

The median overall survival (OS) time and 5-year OS rate of resectable PDAC with upfront surgery was 31.5 months and 33.3%, respectively. Multivariate analyses identified tumor diameter in computed tomography (CT) ≤ 19 mm [hazard ratio (HR) 0.40, p < 0.001], span-1 within the normal range (HR 0.54, p = 0.023), prognostic nutritional index (PNI) ≥ 44.31 (HR 0.51, p < 0.001), and lymphocyte-to-monocyte ratio (LMR) ≥ 3.79 (HR 0.51, p < 0.001) as prognostic factors that influence favorable prognoses after upfront surgery. According to the prognostic prediction model based on these four factors, patients with four favorable prognostic factors had a better prognosis with a 5-year OS rate of 82.4% compared to others (p < 0.001). These patients had a high R0 resection rate and a low frequency of tumor recurrence after upfront surgery.

CONCLUSIONS

We identified patients with long-term survival after upfront surgery by prognostic prediction model consisting of tumor diameter in CT, span-1, PNI, and LMR. Evaluation of anatomical, biological, nutritional, and inflammatory factors may be valuable to introduce an optimal treatment strategy for resectable PDAC.

Tumor location, clinicopathological features, and perioperative and prognostic outcomes in patients who underwent pancreatic resection following neoadjuvant chemoradiotherapy for resectable pancreatic cancer: A retrospective study

BACKGROUND

/Objective: Preoperative treatment of resectable pancreatic ductal adenocarcinoma (PDAC) is gaining popularity worldwide. However, the characteristics of tumors located in the pancreatic head (Ph), or those in the body or tail (Pbt), after surgery following neoadjuvant chemoradiotherapy (NACRT) remain unclear. This study aimed to evaluate and compare the clinicopathological features, perioperative outcomes, and prognosis of patients with resectable PDAC who underwent NACRT followed by curative pancreatic resection, focusing on distinguishing between Ph and Pbt PDACs.

METHODS

We included 107 patients with resectable PDAC who underwent curative resection following NACRT between 2009 and 2023. Clinicopathological features, perioperative and prognostic outcomes, recurrence patterns, and prognoses were compared between Ph and Pbt PDAC groups.

RESULTS

Tumors were found in the Ph and Pbt in 64 and 43 patients, respectively. Albumin levels and lymphocyte-to-monocyte ratios after NACRT were significantly lower in the Ph group than in the Pbt group. The Pbt group showed significantly higher rates of positive peritoneal lavage cytology and serosal, arterial, and portal vein invasion than the Ph group did. Overall and recurrence-free survival were similar between the two groups. The most common site of initial postoperative recurrence was the lung only in both groups; however, the rate of peritoneal dissemination only was significantly higher in the Pbt group than in the Ph group.

CONCLUSIONS

The prognoses based on tumor locations in the Ph and Pbt after surgery following NACRT are similar. Following the resection of resectable Pbt PDAC, the possibility of peritoneal dissemination recurrence should be considered.

The association between serum albumin and alkaline phosphatase in cancer patients

The role of serum albumin (ALB) has been extensively studied in patients with cancer; however, research on its effect on bone metastasis in these patients remains limited. This study aimed to investigate the relationship between serum ALB and alkaline phosphatase (ALP) levels in patients with tumors. Using data from the National Health and Nutrition Examination Survey 2011 to 2018, we assessed the correlation between serum ALB and ALP levels using a weighted multivariate linear regression model, whereas a weighted generalized additive model and smooth curve fitting were used to address potential nonlinearities. A total of 1876 patients with cancer were included in our study. In the subgroup analysis stratified by sex, race/ethnicity, and liver disease, the negative correlation of ALB with ALP remained for most groups, except in blacks (β = -1.755, 95%CI: [-3.848, 0.338], P = .103) and patients with gout (β = -0.676, 95%CI: [-2.061, 0.709], P = .340). In black people and patients with gout, the relationship between ALB and ALP showed an inverted U-shaped curve, with an inflection point at approximately 42 g/dL. Our study showed an inverse correlation between ALB and ALP levels in most patients with tumors, but not in black patients and those with gout. The measurement of ALB levels can serve as a screening tool for bone metastases while guiding therapeutic intervention strategies.

Predictive role of the prognostic nutritional index in patients with pancreatic ductal adenocarcinoma who underwent neoadjuvant chemoradiotherapy followed by curative pancreatic resection: A retrospective study using prospectively collected data

BACKGROUND

Despite a strong association between nutritional indices and disease prognosis, evidence regarding the evaluation of nutritional indices after preoperative treatment for pancreatic ductal adenocarcinoma (PDAC) is insufficient. We evaluated the clinical significance of the prognostic nutritional index (PNI) in patients with resectable (R-) and borderline resectable (BR-) PDAC who received neoadjuvant chemoradiotherapy (NACRT) followed by pancreatic resection.

METHODS

We assessed 153 patients with R- and BR-PDAC who underwent NACRT followed by curative resection between 2009 and 2022. We evaluated the association between preoperative PNI after NACRT and short- and long-term outcomes.

RESULTS

The median preoperative PNI value after NACRT was 42.1, and the optimal cutoff value from the time-dependent receiver operating characteristic curve was 38.6. The low PNI group (PNI < 38.6, n = 44) exhibited significantly worse inflammatory parameters, surgical outcomes, and prognoses than the high PNI group (PNI ≥ 38.6, n = 109). Multivariate analysis identified preoperative PNI ≤ 38.6 (hazard ratio [HR]: 2.32, 95% confidence interval [CI]: 1.00-5.38, p = .049), blood loss ≥1642 mL (HR: 3.05, 95% CI: 1.65-5.64, p < .001), node positive pathology (HR: 2.10, 95% CI: 1.32-3.34, p = .002), and lack of postoperative adjuvant chemotherapy (HR: 3.55, 95% CI: 2.05-6.15, p < .001) as significant predictors of overall survival.

CONCLUSIONS

For patients with R- and BR-PDAC receiving preoperative treatment, it is imperative to closely monitor their nutritional status when determining the optimal surgical procedure timing.

Short- and Long-Term Outcomes of Neoadjuvant Chemoradiotherapy Followed by Pancreatoduodenectomy in Elderly Patients with Resectable and Borderline Resectable Pancreatic Cancer: A Retrospective Study

Background: The efficacy of neoadjuvant chemoradiotherapy (NACRT) followed by pancreatoduodenectomy (PD) in elderly patients with pancreatic ductal adenocarcinoma (PDAC) remains unclear. Methods: This retrospective analysis of prospectively collected data examined the effect of NACRT followed by PD in elderly patients with PDAC. A total of 112 patients with resectable (R-) and borderline resectable (BR-) PDAC, who were planned for PD and received NACRT between 2009 and 2022, were assessed. Changes induced by NACRT, surgical outcomes, nutritional status, renal and endocrine functions, and prognosis were compared between elderly (≥75 years, n = 43) and non-elderly (<75 years, n = 69) patients over two years following PD. Results: Completion and adverse event rates during NACRT, nutritional status, renal function, endocrine function over two years postoperatively, and prognosis did not significantly differ between the two groups. Low prognostic index after NACRT and the absence of postoperative adjuvant chemotherapy may be adverse prognostic indicators for elderly patients undergoing NACRT for R- and BR-PDAC. Conclusions: Despite a higher incidence of postoperative complications, NACRT followed by PD can be safely performed in elderly patients, resulting in a prognosis similar to that in non-elderly patients.

Prognostic potential of nutritional risk screening and assessment tools in predicting survival of patients with pancreatic neoplasms: a systematic review

BACKGROUNDS & AIMS

The nutritional evaluation of pancreatic cancer (PC) patients lacks a gold standard or scientific consensus, we aimed to summarize and systematically evaluate the prognostic value of nutritional screening and assessment tools used for PC patients.

METHODS

Relevant studies were retrieved from major databases (PubMed, Embase, Web of Science, Cochrane Library) and searched from January 2010 to December 2023. We performed meta-analyses with STATA 14.0 when three or more studies used the same tool.

RESULTS

This analysis included 27 articles involving 6,060 PC patients. According to a meta-analysis of these studies, poor nutritional status evaluated using five nutritional screening tools Prognostic Nutritional Index (PNI), Geriatric Nutritional Risk Index (GNRI), Controlling Nutritional Status Score (CONUT), Nutrition Risk Screening (NRS2002) and Glasgow Prognostic Score (GPS) was associated with all-cause mortality in PC patients. But Modified Glasgow Prognostic Score (mGPS) did not. Of all tools analyzed, CONUT had the maximum HR for mortality (HR = 1.978, 95%CI 1.345-2.907, P = 0.001).

CONCLUSION

All-cause mortality in PC patients was predicted by poor nutritional status. CONUT may be the best nutritional assessment tool for PC patients. The clinical application value of Short Form Mini Nutritional Assessment (MNA-SF), Generated Subjective Global Assessment (SGA) and Patient-generated Subjective Global Assessment (PG-SGA) in PC patients need to be confirmed. In order to improve patients' nutritional status and promote their recovery, nutritional screening tools can be used.

REGISTRATION

This systematic review was registered at the International Prospective Register of Systematic Reviews (PROSPERO) (number CRD42022376715).

Effect of body fat mass loss on prognosis of radical resection for pancreatic ductal adenocarcinoma based on bioelectrical impedance analysis

BACKGROUND

Few reports have performed a prognostic analysis based on bioelectrical impedance analysis in patients with radical resection of pancreatic ductal adenocarcinoma (PDAC), and its usefulness in prognostic analysis remains unclear. This study aimed to evaluate body composition changes in patients undergoing radical resection for PDAC and analyze its impact on prognosis.

METHODS

The medical records of radical resection for patients with PDAC were retrospectively reviewed, and the parameters of body composition, including body weight, skeletal muscle mass, body fat mass (BFM), and extracellular water-total body water ratio, from preoperatively to 12 months postoperatively, for each surgical procedure were measured based on direct segmental multifrequency bioelectrical impedance analysis with an InBody 770 (InBody Inc., Tokyo, Japan) device. The clinicopathological and prognostic factors were analyzed.

RESULTS

Among 79 patients who underwent radical resection for PDAC, 36 (46%), 7 (8%), and 36 (46%) underwent pancreatoduodenectomy, total pancreatectomy, and distal pancreatectomy, respectively. The multivariate overall survival analysis demonstrated that BFM loss percentage at 1 month postoperatively ≧14% (p = 0.021), lymph node metastasis (p = 0.014), and non-adjuvant chemotherapy (p <  0.001) were independent poor prognostic factors. Multivariate analysis revealed that preoperative BFM < 12 kg and preoperative albumin < 3.5 g/dL were independently associated with BFM loss percentage at 1 month postoperatively ≧14% (p = 0.021 and p = 0.047, respectively).

CONCLUSIONS

Loss of BFM in the early postoperative period may have a poor prognosis in radical resection of PDAC.

Prognostic nutritional score based on pretreatment lymphocyte, platelet, and prealbumin predicts prognosis in patients with pancreatic cancer

BACKGROUND AND OBJECTIVES

Pretreatment immunological indicators and nutritional factors are associated with survival of many malignancies. This study aims to develop a prognostic nutritional score based on a combination of pretreatment lymphocyte, platelet, and prealbumin (Co-LPPa) in patients with pancreatic cancer (PC) and to investigate the prognostic significance of this score.

METHODS

Patients who underwent pancreatectomy with a curative intent for PC were retrospectively enrolled. A pretreatment prognostic score was established by immunological indicators and nutritional factors that were independently associated with survival.

RESULTS

Pretreatment lymphocyte (<1.6 × 109 /L), platelet (<160 × 109 /L) and prealbumin (<0.23 g/L) were independently associated with poorer overall survival (OS) and recurrence-free survival (RFS), and were used to create the Co-LPPa score. The Co-LPPa scores were inversely related to OS and RFS, and were able to stratify survival into four groups. The survival differences among the four groups were all significant. Besides, the Co-LPPa scores could stratify survival independently of pathological prognostic factors. The Co-LPPa score was superior to prognostic nutritional index and carbohydrate antigen 19-9 in predicting OS and RFS.

CONCLUSION

The Co-LPPa score could accurately predict the prognosis of PC patients who underwent curative resection. The score may be helpful for preoperative therapeutic strategies.

Prognostic Impact of Preoperative Osteosarcopenia for Patients with Pancreatic Ductal Adenocarcinoma After Curative Resection

BACKGROUNDS

The clinical significance of preoperative osteosarcopenia in pancreatic ductal adenocarcinoma (PDAC) has not been fully studied. The purpose of this study was to evaluate the role of preoperative osteosarcopenia in predicting the survival of patients with PDAC.

METHODS

We retrospectively analyzed 265 patients who underwent curative surgical resection for PDAC between 2012 and 2018 in two Japanese institutes. The skeletal muscle index at the L3 vertebrae and the bone mineral density at the Th11 vertebra were calculated for the evaluation of osteosarcopenia before surgery. The relationship between perioperative osteosarcopenia and clinicopathological factors and prognosis was analyzed.

RESULTS

The median overall survival (OS) and disease-free survival (DFS) of patients with osteosarcopenia were significantly shorter than those of patients without osteosarcopenia (OS: 23 and 48 months, respectively, P < 0.001; DFS: 13.4 and 21.2 months, respectively, P = 0.004). On multivariate analysis, osteosarcopenia was found to be an independent factor associated with OS (hazard ratio [HR] 1.98; 95% confidence interval [CI] 1.40-2.80; P < 0.001) and DFS (HR 1.53; 95% CI 1.11-2.10; P = 0.009).

CONCLUSIONS

Preoperative osteosarcopenia may be a useful prognostic factor in patients with PDAC who undergo surgical resection. Further studies are needed to assess whether perioperative, nutritional interventions and rehabilitation contribute to improving the prognosis of these patients.

Naples Prognostic Score is an Independent Prognostic Factor in Patients Undergoing Hepatectomy for Hepatocellular Carcinoma

Background

Nutritional and inflammatory status has been reported to be associated with the prognosis of hepatocellular carcinoma (HCC), but many studies did not include all biomarkers simultaneously. The present study aimed to determine the impact of Naples prognostic score (NPS) on the long-term survival in patients undergoing hepatectomy for HCC.

Methods

Patients with HCC after curative resection were eligible. Then, all patients were stratified into three groups according to the NPS. Clinical features and survival outcomes were compared among the three groups. Independent prognostic factors were determined by COX analysis. The time dependent receiver operating characteristic (ROC) curves were used to compare prognostic performance with other immunonutrition scoring systems.

Results

A total of 476 patients were enrolled eventually. Baseline characteristics showed that patients with higher NPS had a higher proportion of poor liver function and advanced tumor features. Accordingly, Kaplan-Meier survival curves showed that patients with higher NPS had a lower rate of overall survival (OS) and recurrence-free survival (RFS). Multivariable COX analysis demonstrated that NPS was an independent risk factor of OS (NPS group 2 vs 1: HR=1.958, 95% CI: 1.038-3.369, p = 0.038; NPS group 3 vs 1: HR=2.608, 95% CI: 1.358-5.008, p=0.004, respectively) and RFS (NPS group 2 vs 1: HR=2.014, 95% CI: 1.299-2-3.124, p=0.002; NPS group 3 vs 1: HR=2.002, 95% CI: 1.262-3.175, p=0.003, respectively). The time-dependent ROC curve showed that NPS was superior to other models in prognostic performance and discriminatory power for long-term survival (median AUC 0.675, 95% CI: 0.586-0.712, P < 0.05).

Conclusion

The NPS is a simple tool strongly associated with long-term survival in patients undergoing curative hepatectomy for HCC.

A Novel Scoring System in Predicting Prognosis After Adjuvant FOLFOX Chemotherapy in Gastric Cancer

Purpose: To evaluate the impact of neutrophil-to-lymphocyte ratio (NLR) and preoperative prognostic nutritional index (PNI) on prognosis of gastric cancer (GC) after adjuvant FOLFOX chemotherapy. Materials and Methods: Data on 749 GC patients who received operation after by adjuvant FOLFOX chemotherapy between January 2013 and December 2015 were enrolled in this study, retrospectively. Receiver-operating characteristic curve analysis was employed to assess optimal cutoff thresholds for PNI and NLR. The GC subjects having a low PNI (<52.8) and high NLR (>1.79) received a score of 2. Any variable that met these standards was scored as 1. If none of the two variables met these standards of the patient was assigned a score of 0. Correlation between PNI-NLR score and GC stage was also evaluated. Results: The mean overall survival (OS) and 5-year OS rate for subjects with PNI-NLR = 2 was lower than those of subjects with PNI-NLR = 1, or 0 (40.9% vs. 52.1%, 76.4% [46.0 vs. 61.0], 68.0 months, p ≤ 0.001). In multivariate analyses, the PNI-NLR score (p ≤ 0.001) and WHO grade (p ≤ 0.001) showed potential to independently influence OS. Conclusions: High PNI-NLR scores can independently affect worse prognosis of GC. Thus, it can be utilized to differentiate low risk from high risk subjects.

Focus on Therapeutic Options for Surgically Resectable Pancreatic Adenocarcinoma Based on Novel Biomarkers

Pancreatic ductal adenocarcinoma remains associated with a poor prognosis, even when diagnosed at an early stage. Consequently, it is imperative to carefully consider the available therapeutic options and tailor them based on clinically relevant biomarkers. In our comprehensive review, we specifically concentrated on the identification of novel predictive and prognostic markers that have the potential to be integrated into multiparametric scoring systems. These scoring systems aim to accurately predict the efficacy of neoadjuvant chemotherapy in surgically resectable pancreatic cancer cases. By identifying robust predictive markers, we can enhance our ability to select patients who are most likely to benefit from neoadjuvant chemotherapy. Furthermore, the identification of prognostic markers can provide valuable insights into the overall disease trajectory and inform treatment decisions. The development of multiparametric scoring systems that incorporate these markers holds great promise for optimizing the selection of patients for neoadjuvant chemotherapy, leading to improved outcomes in resectable pancreatic neoplasia. Continued research efforts are needed to validate and refine these markers and scoring systems, ultimately advancing the field of personalized medicine in pancreatic adenocarcinoma management.

Inflammation-Based Prognostic Scores in Pancreatic Cancer Patients-A Single-Center Analysis of 1294 Patients within the Last Decade

Inflammatory properties are known to promote tumor progression leading to an impaired median overall survival (mOS). Various small studies have focused on a wide range of inflammation-based prognostic indicators. By using sufficient data from 1294 out of 2323 patients diagnosed with pancreatic cancer between 2009 and 2021 at our cancer center, inflammatory markers such as the neutrophil to lymphocyte ratio (NRL), the platelet to lymphocyte ratio (PLR), the lymphocyte to monocyte ratio (LMR) and the CRP to albumin ratio (CAR) were evaluated. We identified a new combined score, termed the inflammatory benchmark index (IBI). We performed univariate and multivariate overall survival analyses and identified optimal prognostic cut-off values for each parameter. In univariate analyses, advanced age (p < 0.001), gender (p < 0.001), tumor stage (p < 0.001), CA19-9 (p = 0.001), NLR (p = 0.001), LMR (p = 0.004), PLR (p = 0.004), CAR (p = 0.001) and IBI (p = 0.001) were identified as prognostic markers. In multivariate analyses advanced age (p < 0.001), gender (p = 0.001), tumor stage (p < 0.001), CA19-9 (p < 0.001), NLR (p = 0.001), LMR (p = 0.038), CAR (p < 0.001) and IBI (p < 0.001) were independent prognostic markers. These findings emphasize the impact of inflammation in pancreatic cancer, provide easily accessible prognostic values for the clinician, and may be useful as stratification parameters for trials aimed at patient inflammation or immune response.

Clinical Implications of FDG-PET in Pancreatic Ductal Adenocarcinoma Patients Treated with Neoadjuvant Therapy

PURPOSE

To evaluate the clinical significance of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography in patients with pancreatic ductal adenocarcinoma who underwent neoadjuvant therapy.

METHODS

Among 285 consecutive patients who underwent pancreatic resection for pancreatic ductal adenocarcinoma between 2015 and 2021, 86 who underwent preoperative ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography after completion of neoadjuvant treatment were reviewed. Among preoperative factors, including post-treatment maximum standardized uptake value, predictors of early recurrence and poor prognosis were identified using multivariate analysis for decision making in surgery.

RESULTS

Nineteen (22%) patients with pancreatic ductal adenocarcinoma demonstrated high maximum standardized uptake (≥ 4.5). High post-treatment maximum standardized uptake (≥ 4.5) predicted early recurrence within 6 months after surgery and correlated with shorter recurrence-free survival. Elevated post-treatment CA19-9 level (> 37 U/ml) and maximum standardized uptake ≥ 4.5 were independent prognostic factors. Post-treatment, a high maximum standardized uptake value indicated a poorer prognosis than a low maximum standardized uptake value in both patients with elevated CA19-9 and normal CA19-9 levels. The median overall survival in patients with elevated post-treatment CA19-9 and high maximum standardized uptake was only 17 months; 67% experienced early recurrence. Dynamic changes in maximum standardized uptake during neoadjuvant therapy were correlated with pathological response to neoadjuvant therapy, but not with radiological response or change in CA19-9 level.

CONCLUSIONS

Post-treatment assessment using maximum standardized uptake value is useful for stratifying patients with pancreatic ductal adenocarcinoma who will benefit from surgery. Instead of subsequent curative resection, additional neoadjuvant therapy should be considered in patients with a persistently high maximum standardized uptake value.

Prognostic role of the prognostic nutritional index in patients with pancreatic cancer who underwent curative resection without preoperative neoadjuvant treatment: A systematic review and meta-analysis

Background

The prognostic nutrition index (PNI), which has been evaluated in various kinds of cancers, offered a simple yet effective approach to predict the prognosis. The aim of this meta-analysis is to reveal the correlation between preoperative PNI and the prognosis of patients with pancreatic ductal adenocarcinoma (PDAC) who underwent curative resection.

Methods

We searched the PubMed, Embase, Web of Science and Cochrane Library databases, and extracted the hazard ratio (HR) with 95% confidential interval (CI) from eligible studies. The pooled HR with 95% CI was applied to evaluate the association between PNI and overall survival (OS), recurrence-free survival (RFS).

Results

A total of fourteen studies with 3,385 patients were included for meta-analysis. The results (the pooled HR: 1.664, 95% CI: 1.424–1.994, I² = 42.6%, p value = 0.046) indicated that low preoperative PNI was closely related to poor OS. In addition, the results suggested that PNI was negatively correlated with RFS (the pooled HR: 1.369, 95%CI: 1.080–1.734). The robustness of these pooled results was verified by our subgroup analysis and sensitivity analysis. Moreover, different cutoff values among studies are responsible for the heterogeneity of pooled HR of OS through meta-regression analysis (p value = 0.042). Funnel plots, Begg's test (p value = 0.228) and Egger’s test (p value = 0.702) indicated no significant publication bias in OS.

Conclusion

Preoperative PNI might be a promising marker to predict the prognosis of PDAC patients who underwent curative resection.

The Glasgow Prognostic Score and stricture site can predict prognosis after endoscopic duodenal stent placement for malignant gastric outlet obstruction

Endoscopic duodenal stent (DS) placement for malignant gastric outlet obstruction (GOO) is rapidly increasing in clinical practice; however, the most suitable patient candidates for DS placement have not been determined. One hundred and thirty-five patients with GOO who underwent DS placement in three Japanese referral centers between January 2010 and October 2019 were retrospectively evaluated. Overall survival (OS) after DS placement, technical/clinical success rates, adverse events, and predictive factors affecting OS after DS placement were also analyzed. The median OS after DS placement of all patients was 81 (7–901) days. Technical and clinical success rates were 99.3% and 83.7%, respectively. The GOO Scoring System score significantly increased before and after DS placement (0.9 vs. 2.7, P < 0.001). The procedure-related complication rate was 6.0%. All 19 patients (14.1%) with stent occlusion underwent endoscopic re-intervention successfully. Multivariate analyses revealed chemotherapy after DS placement (P = 0.01), stricture site in D3 (distal part of the papilla) (P = 0.01), and a Glasgow Prognostic Score (GPS) of 0–1 before duodenal stent placement (P < 0.001) were factors significantly associated with prolonged OS. In conclusion, patients with a GPS of 0–1 and D3 stricture who are tolerant of chemotherapy are suitable candidates for DS placement.

Change in Neutrophil-to-Lymphocyte Ratio During Neoadjuvant Treatment Does Not Predict Pathological Response and Survival in Resectable Pancreatic Ductal Adenocarcinoma

BACKGROUND

Neutrophil-to-lymphocyte ratio (NLR) has been reported as prognostic in pancreatic ductal adenocarcinoma (PDAC). Data about NLR changes during neoadjuvant therapy (NAT) and its relationship with pathological tumor response and survival are lacking.

METHODS

Pancreatic ductal adenocarcinoma patients with NAT followed by resection between 2009 and 2015 were identified from a prospective database. Neutrophil-to-lymphocyte ratio was collected prior to NAT (baseline), on chemotherapy (prior to cycle 3), and prior to surgery. Baseline NLR, and changes in NLR between baseline and on chemotherapy (delta 1) and between baseline and surgery (delta 2) were compared with pathologic response (<90% and ≥90% defined as poor and good), overall (OS), and disease-free survival (DFS) using Wilcoxon rank-sum and Cox proportional hazard models.

RESULTS

Of 93 patients, 17% had good pathological response. Median (interquartile range) NLR at baseline, third cycle, and surgery were 2.7 (2.0-3.7), 2.5 (1.9-4.1), and 3.1 (2.1-5.3), respectively. Median change in NLR from baseline to third cycle was .06 (P = .72), and .6 from baseline to surgery (P < .01). Baseline NLR, delta 1, and delta 2 were not associated with pathological response, OS, or DFS.

DISCUSSION

Neutrophil-to-lymphocyte ratio increased after NAT, but a significant association between NLR and pathological response, OS, and DFS in resected PDAC patients was not observed.

Preoperative Osteopenia Is Associated with Significantly Shorter Survival in Patients with Perihilar Cholangiocarcinoma

Background: Osteopenia is defined as low bone mineral density (BMD) and has been shown to be associated with outcomes of patients with various cancers. The association between osteopenia and perihilar cholangiocarcinoma is unknown. The aim of this study was to evaluate osteopenia as a prognostic factor in patients with perihilar cholangiocarcinoma. Methods: A total of 58 patients who underwent surgery for perihilar cholangiocarcinoma were retrospectively analyzed. The BMD at the 11th thoracic vertebra was measured using computed tomography scan within one month of surgery. Patients with a BMD < 160 HU were considered to have osteopenia and b BMD ≥ 160 did not have osteopenia. The log-rank test was performed for survival using the Kaplan−Meier method. After adjusting for confounding factors, overall survival was assessed by Cox′s proportional-hazards model. Results: The osteopenia group had 27 (47%) more females than the non-osteopenia group (p = 0.036). Median survival in the osteopenia group was 37 months and in the non-osteopenia group was 61 months (p = 0.034). In multivariable analysis, osteopenia was a significant independent risk factor associated with overall survival in patients with perihilar cholangiocarcinoma (hazard ratio 3.54, 95% confidence interval 1.09−11.54, p = 0.036), along with primary tumor stage. Conclusions: Osteopenia is associated with significantly shorter survival in patients with perihilar cholangiocarcinoma.

Predictive factors of operability after neoadjuvant chemotherapy in resectable or borderline resectable pancreatic cancer: a single-center retrospective study

BACKGROUND/AIMS

Recently neoadjuvant chemotherapy (NAC) for pancreatic cancer has been shown to be superior to upfront surgery, but it remains a matter of debate for resectable cases. In clinical practice, some resectable cases may become unresectable after NAC. This study aimed to reveal the outcomes after NAC and to clarify the characteristics of unresected cases.

METHODS

The medical records of 142 patients who underwent NAC between 2016 and 2020 were retrospectively reviewed. Patient characteristics, effectiveness of NAC, and outcomes were compared between the surgical group and non-surgical group (NSG). Furthermore, the risk of recurrence limited to in the patients who received NAC with gemcitabine plus nab-paclitaxel, which were mostly administered in this cohort, following R0/R1 resection was assessed.

RESULTS

The overall and R0 resection rates after NAC were 89.1% and 79.7%, respectively. The neutrophil to lymphocyte ratio (NLR) > 2.78 (p = 0.0120) and anatomical borderline resectable pancreatic cancer (p = 0.0044) revealed a statistically significantly correlation with the NSG. On the other hand, NAC week < 8 (p = 0.0285), radiological response, stable disease or progression disease (p = 0.0212), and pathological stage > IIA (P = 0.0003) were significantly associated with recurrence. The tumor response rate was approximately 26.1%, and three patients with ≥ 30% reduction of primary tumor lost excision opportunities because of metastasis, interstitial pneumonia, and vascular invasion.

CONCLUSIONS

This study shows incomplete tumor shrinkage benefits, but pre-NAC NLR is a predictive factor for predicting operability after NAC. The NLR can be easily calculated by normal blood test, and can be considered as a suitable marker of operability.

Preoperative neutrophil-to-lymphocyte ratio predicts healing time for postoperative pancreatic fistula after distal pancreatectomy

PURPOSE

Postoperative pancreatic fistula is a serious complication of distal pancreatectomy. Although many studies have described the incidence and risk factors associated with postoperative pancreatic fistula (POPF), few have focused on the healing time. This study investigated the healing time and potential factors associated with the healing time of POPF after distal pancreatectomy (DP).

METHODS

Among 114 patients that underwent DP in our hospital from January 2010 to December 2020, we included 88 that developed POPF. The healing time for a postoperative pancreatic fistula was defined as the interval between the completion of DP and the removal of all drains related to the treatment for POPF. Based on the definition, three cases who required additional treatment after removal of all drains were excluded from this study. Clinical factors associated with the fistula healing times were investigated in the 85 patients.

RESULTS

The average POPF healing time was 11 ± 10 days (median: 6 days, range: 3-57). We found that the neutrophil-to-lymphocyte ratio, a marker of inflammatory and nutritional status, was the only factor independently associated with the POPF healing time; the mean healing time was significantly shorter in patients with neutrophil-to-lymphocyte ratio ≤2.1 (8 ± 6 days) than in those with neutrophil-to-lymphocyte ratio >2.1 (13 ± 12 days; P = .0139).

CONCLUSION

We demonstrated that the neutrophil-to-lymphocyte ratio could independently predict the POPF healing time after DP. These findings suggested that improving the neutrophil-to-lymphocyte ratio might shorten the healing times for POPF after DP.

Prognostic significance of preoperative Naples prognostic score on short- and long-term outcomes after pancreatoduodenectomy for ampullary carcinoma

BACKGROUND

The Naples prognostic score (NPS) is an effective and objective tool to assess the immune-nutritional status of patients with malignant tumors. The aim of this study was to investigate the clinical significance of preoperative NPS on short- and long-term outcomes after pancreatoduodenectomy (PD) for ampullary carcinoma.

METHODS

We retrospectively analyzed 404 consecutive patients with ampullary carcinoma who underwent PD between January 2012 and June 2018. Preoperative NPS was calculated from serum albumin and total cholesterol concentrations, and the neutrophil-lymphocyte ratio and lymphocyte-monocyte ratio (LMR). Patients were then divided into three groups according to their NPS. Clinicopathological variables, postoperative outcomes, and survival data were compared between the three groups. Univariate and multivariate Cox analysis of overall survival (OS) and recurrence-free survival (RFS) were also conducted, and time-dependent receiver operating characteristic (ROC) curves were created to evaluate the discriminatory ability of the prognostic scoring systems.

RESULTS

Patients with higher NPS had worse prognosis, and significant OS difference (group 0 vs. 1, P=0.02; group 1 vs. 2, P<0.001; group 0 vs. 2, P<0.001) and RFS difference (group 0 vs. 1, P=0.088; group 1 vs. 2, P<0.001; group 0 vs. 2, P<0.001). Multivariate analysis revealed that NPS was an independent significant predictor of OS (grade 2 vs. grade 1 or 0, hazard ratio: 3.067; P<0.001) and RFS (grade 2 vs. grade 1 or 0, hazard ratio: 2.732; P<0.001). The time-dependent receiver operating curve analysis showed that NPS had better prognostic performance for OS and RFS than other prognostic models. Additionally, significant differences in the incidence of postoperative morbidity were observed between the three groups, and the NPS was an independent risk factor of overall postoperative complications (grade 2 vs. grade 1 or 0, odds ratio: 1.692; P=0.02).

CONCLUSIONS

The NPS was an independent predictor of overall- and RFS in patients undergoing PD for ampullary carcinoma, and was independently associated with the incidence of postoperative complications.

Associations between Nutritional and Immune Status and Clinicopathologic Factors in Patients with Pancreatic Cancer: A Comprehensive Analysis

The aim of this study was to assess and analyze the nutritional status (NS) and immune status of pancreatic cancer (PC) patients. The retrospective analysis included 80 PC patients undergoing curative pancreatic resection in the Department of Digestive Tract Surgery of the Medical University (Katowice, Poland). Patients were divided by the tumor location (proximal vs. distal), age (≤65 years vs. >65 years), Nutritional Risk Score 2002 (NRS 2002) (<3 vs. ≥3), prognostic nutritional index (PNI) (<45 vs. ≥45), and the presence of postoperative complications (no-complication vs. complication) as well as the use of neoadjuvant chemotherapy (no neoadjuvant chemotherapy vs. neoadjuvant chemotherapy) into two subgroups, which were compared. Significantly higher weight loss was related to the proximal tumor location (p = 0.0104). Significantly lower serum total protein (p = 0.0447), albumin (p = 0.0468), hemoglobin (p = 0.0265) levels, and PNI (p = 0.03) were reported in older patients. The higher nutritional risk according to NRS 2002 was significantly associated with higher age (p = 0.0187), higher weight loss (p < 0.01), lower body mass index (BMI) (p = 0.0293), lower total lymphocyte count (p = 0.0292), longer duration of hospitalization (p = 0.020), neoadjuvant chemotherapy (p < 0.01), and preoperative biliary drainage (p = 0.0492). The lower PNI was significantly associated with higher weight loss (p = 0.0407), lower serum total protein and albumin concentration, lymphocyte count (p < 0.01) and higher neutrophil/lymphocyte (NLR), monocyte/lymphocyte (MLR), platelet/lymphocyte (PLR) ratios, and duration of hospitalization (p < 0.01). In the multiple logistic regression analysis, BMI ≥ 30 kg/m2 (OR: 8.62; 95% CI: 1.24-60.04; p = 0.029521) and NRS 2002 ≥ 3 (OR: 2.87; 95% CI: 0.88-9.33; p = 0.048818) predicted postoperative complications. In the multiple linear regression analysis, the higher NRS 2002 score was linked with the longer duration of hospitalization (b = 7.67948; p = 0.043816), and longer duration of postoperative hospitalization was associated with a higher complication rate (b = 0.273183; p = 0.003100). Nutritional impairment correlates with a systemic inflammatory response in PC patients. Obesity (BMI ≥ 30 kg/m2) and malnutrition (NRS 2002 ≥ 3) predict postoperative complications, which are associate with a longer hospital stay. Assessment of nutritional and immune status using basic diagnostic tools and PNI and immune ratio (NLR, MLR, PLR) calculation should be the standard management of PC patients before surgery to improve the postoperative outcome.

Prognostic significance of preoperative PNI and CA19-9 for pancreatic ductal adenocarcinoma: A multi-institutional retrospective study

BACKGROUND

The aim of this study was to investigate the clinical value of nutritional and immunological prognostic scores as predictors of outcomes and to identify the most promising scoring system for patients with pancreatic ductal adenocarcinoma (PDAC) in a multi-institutional study.

METHODS

Data were retrospectively collected for 589 patients who underwent surgical resection for PDAC. Prognostic analyses were performed for overall (OS) and recurrence-free survival (RFS) using tumor and patient-related factors, namely neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, Prognostic Nutritional Index (PNI), Glasgow Prognostic Score (GPS), modified GPS, C-reactive protein-to-albumin ratio, Controlling Nutritional Status score, and the Geriatric Nutritional Risk Index.

RESULTS

Compared with PDAC patients with high PNI values (≥46), low PNI (<46) patients showed significantly worse overall survival (OS) (multivariate hazard ratio (HR), 1.432; 95% CI, 1.069-1.918; p = 0.0161) and RFS (multivariate HR, 1.339; 95% CI, 1.032-1.736; p = 0.0277). High carbohydrate antigen 19-9 (CA19-9) values (≥450) were significantly correlated with shorter OS (multivariate HR, 1.520; 95% CI, 1.261-2.080; p = 0.0002) and RFS (multivariate HR, 1.533; 95% CI, 1.199-1.961; p = 0.0007). Stratification according to PNI and CA19-9 was also significantly associated with OS and RFS (log rank, P < 0.0001).

CONCLUSIONS

Our large cohort study showed that PNI and CA19-9 were associated with poor clinical outcomes in PDAC patients following surgical resection. Additionally, combining PNI with CA19-9 enabled further classification of patients according to their clinical outcomes.

Impact of osteopenia on surgical and oncological outcomes in patients with pancreatic cancer

INTRODUCTION

Osteopenia, which is defined as a decrease in bone mineral density, has been recently recognized as a metabolic and an oncological biomarker for surgery in patients with malignancy. We aimed to study the prognostic impact of osteopenia in patients with pancreatic cancer (PC) after resection.

METHODS

A total of 56 patients who underwent curative resection of PC were retrospectively investigated. The skeletal muscle index at the third lumbar spine and bone mineral density at the 11th thoracic vertebra were measured using computed tomography.

RESULTS

Sarcopenia and osteopenia were identified in 24 (43%) and 27 (48%) patients, respectively. The overall and disease-free survival rates were significantly lower in the sarcopenia group than in the non-sarcopenia group (p < 0.01 and p < 0.01, respectively) and in the osteopenia group than in the non-osteopenia group (p < 0.01 and p < 0.01, respectively). In multivariate analysis, sarcopenia (odds ratio [OR] 4.05; 95% confidence interval [CI] 1.23-13.38; p = 0.02) was a significant independent predictor of 1-year disease-free survival. Further, sarcopenia (OR 6.00; 95% CI 1.46-24.6; p = 0.01) and osteopenia (OR 4.66; 95% CI 1.15-18.82; p = 0.03) were significant independent predictors of 2-year overall survival.

CONCLUSION

Osteopenia is a significant negative factor for 2-year overall survival after curative resection of PC.

A presurgical prognostic stratification based on nutritional assessment and carbohydrate antigen 19-9 in pancreatic carcinoma: An approach with nonanatomic biomarkers

BACKGROUND

Nutritional status and tumor markers are important prognostic indicators for surgical decisions in pancreatic carcinoma. This study aimed to stratify the probability of surviving pancreatic carcinoma based on systematically chosen nonanatomic biomarkers.

METHODS

We included 187 consecutive patients that underwent surgical resections for pancreatic carcinoma. We performed multivariable analyses to evaluate prognostic indicators, including 4 blood-test indexes: the neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, prognostic nutritional index, and the modified Glasgow prognostic score; and 4 body-composition indexes: the normalized total psoas muscle area, the normalized total elector spine muscle area, the psoas muscle computed tomography value, and the elector spine muscle computed tomography value.

RESULTS

Poor survival was associated with 2 independent risk factors: neutrophil-to-lymphocyte ratio ≥3.0 (hazard ratio, 1.54) and prognostic nutritional index <36 (hazard ratio, 1.60), and with high carbohydrate antigen 19-9 levels (≥37 IU/mL). The 2 indexes were not significantly associated with clinicopathological factors, including carbohydrate antigen 19-9. Patients with no risk factors had significantly better survival than those with 1 (P = .007) or 2 risk factors (P = .001), and survival was similar in the latter 2 groups (P = .253). A presurgical nonanatomic scoring system (range, 0-2) was constructed: 0 points for no risk factors, 1 point for 1 or 2 nutritional risk factors, and 1 point for carbohydrate antigen 19-9 ≥37 IU/mL. Survival rate at 3 years decreased with increasing scores (76% for score 0, 42% for score 1, and 21% for score 2; all P < .05).

CONCLUSION

Neutrophil-to-lymphocyte ratio and prognostic nutritional index were independent prognostic risk factors in pancreatic carcinoma and integrating these indexes with carbohydrate antigen 19-9 levels could successfully stratify survival.

Development and Validation of a Nomogram Based on Nutritional Indicators and Tumor Markers for Prognosis Prediction of Pancreatic Ductal Adenocarcinoma

Purpose

This study aimed to develop and validate a nomogram with preoperative nutritional indicators and tumor markers for predicting prognosis of patients with pancreatic ductal adenocarcinoma (PDAC).

Methods

We performed a bicentric, retrospective study including 155 eligible patients with PDAC. Patients were divided into a training group (n = 95), an internal validation group (n = 34), an external validation group (n = 26), and an entire validation group (n = 60). Cox regression analysis was conducted in the training group to identify independent prognostic factors to construct a nomogram for overall survival (OS) prediction. The performance of the nomogram was assessed in validation groups and through comparison with controlling nutritional status (CONUT) and prognostic nutrition index (PNI).

Results

The least absolute shrinkage and selection operator (LASSO) regression, univariate and multivariate Cox regression analysis revealed that serum albumin and lymphocyte count were independent protective factors while CA19-9 and diabetes were independent risk factors. The concordance index (C-index) of the nomogram in the training, internal validation, external validation and entire validation groups were 0.777, 0.769, 0.759 and 0.774 respectively. The areas under curve (AUC) of the nomogram in each group were 0.861, 0.845, 0.773, and 0.814. C-index and AUC of the nomogram were better than those of CONUT and PNI in the training and validation groups. The net reclassification index (NRI), integrated discrimination improvement (IDI) and decision curve analysis showed improvement of accuracy of the nomogram in predicting OS and better net benefit in guiding clinical decisions in comparison with CONUT and PNI.

Conclusions

The nomogram incorporating four preoperative nutritional and tumor markers including serum albumin concentration, lymphocyte count, CA19-9 and diabetes mellitus could predict the prognosis more accurately than CONUT and PNI and may serve as a clinical decision support tool to determine what treatment options to choose.

Prognostic and clinical significance of modified glasgow prognostic score in pancreatic cancer: a meta-analysis of 4,629 patients

In this study, we evaluated the association of modified Glasgow Prognostic Score (mGPS) with prognosis in pancreatic cancer (PC) by performing a meta-analysis. Potentially eligible studies were shortlisted by searching PubMed, Embase, Web of Science, Scopus, and the Cochrane Library. A total of 4,629 patients with PC from 25 studies were finally included in this meta-analysis. Meta-analyses were performed using a random-effects model or fixed-effect model according to heterogeneity. We pooled the hazard ratios (HRs) with 95% confidence intervals (CIs) to estimate the association between mGPS and overall survival (OS). The results showed that elevated mGPS correlated with poor OS in patients with PC (HR=1.92, 95% CI=1.60–2.30, p<0.002). In addition, subgroup analysis indicated that increased mGPS remained a significant prognostic factor irrespective of the study design, region, disease status, treatment, survival analysis, cancer type, study center, or the Newcastle-Ottawa Scale (NOS) score (all p<0.05). There was a significant correlation between higher mGPS and male gender (Odds ratio [OR]=1.30, 95% CI=1.01–1.67, p=0.038). Elevated pretreatment mGPS is a marker of poor prognosis in patients with PC. As an easily available and cost-effective inflammatory parameter, mGPS can serve as a promising tool for prognostication in PC.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION/CONCLUSION

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

Impact of Osteopenia on Oncologic Outcomes After Curative Resection for Pancreatic Cancer

BACKGROUND/AIM

We evaluated the relationship between low bone mineral density (BMD), also called osteopenia, and prognosis in patients who underwent resection for pancreatic cancer (PC).

PATIENTS AND METHODS

We enrolled 91 consecutive patients who underwent curative resections for PC between May 2009 and January 2019. Their BMDs were measured at the Th11 vertebra using computed tomography. Patients were then divided by age-adjusted standard BMD values into the osteopenia group (n=34) and the non-osteopenia group (n=57). Their overall survival (OS) and recurrence-free survival (RFS) were compared (log-rank test).

RESULTS

The two groups did not differ in age, BMI, tumor marker, operation time, blood loss, postoperative complications or stage. The osteopenia group had significantly worse 3-year rates for OS (46% vs. 30%, p=0.04) and RFS (41% vs. 26%, p=0.01). In multivariate analysis, osteopenia was an independent prognostic factor for RFS (HR=2.16, p=0.01).

CONCLUSION

Osteopenia is an adverse prognostic factor for patients with resected PC.

The ultimate preoperative C-reactive protein-to-albumin ratio is a prognostic factor for survival after pancreatic cancer resection

Background

Emerging evidence indicates that an elevated C-reactive protein-to-albumin ratio (CAR) may be associated with a poor prognosis in pancreatic ductal adenocarcinoma (PDAC). Further evidence showing that this ratio has significant prognostic value could contribute to current prediction models and clinical decision-making.

Methods

Data were analysed of consecutive patients who underwent curative pancreatic resection between 2013 and 2018 and were histologically diagnosed with PDAC. We investigated the relation between the ultimate preoperative CAR and overall survival.

Results

A total of 163 patients were analysed. Median overall survival was 18 months (IQR 9–36). Multivariate analysis demonstrated that a higher CAR (HR 1.745, P = 0.004), a higher age (HR 1.062, P < 0.001), male sex (HR 1.977, P = 0.001), poor differentiation grade (HR 2.812, P < 0.001), and positive para-aortic lymph node(s) (HR 4.489, P < 0.001) were associated with a lower overall survival. Furthermore, a CAR ≥ 0.2 was associated with decreased overall survival (16 vs. 26 months, P = 0.003).

Conclusion

We demonstrated that an ultimate preoperative elevated CAR is an independent indicator of decreased overall survival after resection for PDAC. The preoperative CAR may be of additional value to the current prediction models.

Development of Wernicke's encephalopathy long after subtotal stomach-preserving pancreatoduodenectomy: a case report

BACKGROUND

Wernicke's encephalopathy (WE) is an acute neuropsychiatric disorder resulting from thiamine (vitamin B₁) deficiency, frequently associated with chronic alcoholism and total parenteral nutrition without thiamine. However, only a few reports have focused on the relationship between WE and subtotal stomach-preserving pancreatoduodenectomy (SSPPD).

CASE PRESENTATION

A 71-year-old woman underwent SSPPD for an adenocarcinoma of the ampulla of Vater. Although there had been no evidence of recurrence, the patient was treated with antibiotics for cholangitis at 12 and 31 months, respectively, post-surgery. Thereafter, the patient presented with vomiting and disorientation 33 months after surgery. Although she was admitted and underwent closer inspection by a neurologist and a psychiatrist, the exact cause of these syndromes remained unknown. The psychiatrist measured thiamine concentration to examine the cause of disorientation. After 6 days, her level of consciousness worsened. Magnetic resonance imaging of the head showed symmetrically multiple abnormal hyperintense signals on fluid-attenuated inversion-recovery and diffusion weighted image, compatible with WE. An administration of intravenous thiamine was immediately initiated. After 8 days of the measurement of the thiamine level, the patient's serum thiamine level was found to be 6 µg/mL (reference range, 24-66 µg/mL). Accordingly, the patient was diagnosed with WE. Shortly after starting the treatment, blood thiamine value reached above normal range with significant improvement of her confusional state. However, short-term memory and ataxia remained.

CONCLUSIONS

Development of WE after SSPPD is uncommon. However, to prevent an after-effect, the possibility of development of WE after SSPPD should be recognized.

Preoperative sarcopenia is associated with poor overall survival in pancreatic cancer patients following pancreaticoduodenectomy

OBJECTIVES

To analyze the effect of preoperative body composition on survival in patients with pancreatic cancer following pancreaticoduodenectomy (PD).

METHODS

Between October 2005 and August 2018, 116 patients (68 men, 48 women, mean age 66.2 ± 11.9 years) diagnosed with pancreatic adenocarcinoma following PD were retrospectively enrolled. The preoperative CT on vertebral level L3 was assessed for total abdominal muscle area (TAMA), visceral adipose tissue area (VAT), subcutaneous adipose tissue area (SAT), and mean skeletal muscle attenuation (SMD). The clinical data and pathological findings of tumors were collected. The impact of these factors on disease-free survival (DFS) and overall survival (OS) was evaluated by the Kaplan-Meier method and by univariable and multivariable Cox proportional hazards models.

RESULTS

The 3-year DFS and OS rates were 8% and 25%, respectively. Of 116 patients, 20 (17.2%), 3 (2.6%), and 46 (39.7%) patients were classified as having sarcopenia, sarcopenic obesity, and myosteatosis, respectively. The VAT-TAMA ratio (1.2 ± 0.7 vs 0.9 ± 0.5, p = 0.01) and the visceral to subcutaneous adipose tissue area ratio (1.3 ± 0.7 vs 0.9 ± 0.5, p = 0.04) were higher in sarcopenic patients than in the nonsarcopenic group. Preoperative sarcopenia and sarcopenic obesity were associated with shorter OS (p = 0.012 and p = 0.041, respectively), but not shorter DFS. Myosteatosis was neither associated with DFS nor OS. On multivariable analysis, sarcopenia was the only significant prognostic factor for OS (p = 0.039).

CONCLUSIONS

Preoperative sarcopenia assessed by CT is a poor prognostic factor for OS in pancreatic cancer patients after PD.

KEY POINTS

• Sarcopenia and sarcopenic obesity can be evaluated by abdominal CT on L3 level. • Patients with diabetes mellitus (DM) had lower sex-standardized subcutaneous adipose tissue area index and skeletal muscle density and higher visceral to subcutaneous adipose tissue area ratio than did those without DM. • Preoperative sarcopenia, sarcopenic obesity, and new-onset diabetes mellitus may predict poor overall survival in pancreatic cancer patients following pancreaticoduodenectomy.

The prognostic value of modified Glasgow Prognostic Score in pancreatic cancer: a meta-analysis

Background

Several studies were conducted to explore the prognostic value of modified Glasgow Prognostic Score (mGPS) in pancreatic cancer, which reported contradictory results. The purpose of this meta-analysis was to summarize and further investigate the correlation between mGPS and overall survival (OS) in pancreatic cancer.

Methods

A systematic literature search was performed in PubMed, EMBASE, ISI Web of Science, Cochrane library databases and OVID to identify eligible studies published from Jan 1, 2011 to June 20, 2020. Pooled hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) were used to detect the prognostic significance of mGPS in patients with pancreatic cancer.

Results

A total of 222 non-repetitive studies were identified, and 20 related studies that explored the association between survival outcomes and mGPS in pancreatic cancer patients were finally enrolled in this meta-analysis. The results showed a significant correlation between high level of mGPS and poor OS (HR = 1.50, 95% CI 1.20-1.89, P < 0.0001). Similar results were observed in the subgroup analyses based on the treatment regimen and research region.

Conclusions

Our study suggested the close association between poor prognosis and high level of mGPS, which will be helpful for future clinical applications in patients with pancreatic cancer.

Efficacy of the physiobiological parameter-based grading system for predicting the long-term prognosis after curative surgery for resectable pancreatic cancer

BACKGROUND

Several prognostic scoring systems based on cancer-related inflammation have been developed. We aimed to evaluate the efficacy of a novel physiobiological parameter-based grading system (PGS) for predicting the long-term prognosis after curative-intent surgery for pancreatic ductal adenocarcinoma.

METHODS

One-hundred fifty-nine consecutive patients with pancreatic ductal adenocarcinoma were enrolled. Univariate and multivariate analyses were performed to identify variables associated with overall survival and recurrence-free survival. Patients were stratified according to the PGS score with a cut-off value of 40.5 being estimated by receiver-operating characteristic curve analysis. Propensity score matching analysis (PSM) was performed to compare between patients with low and high scores in the physiobiological parameter-based grading system.

RESULTS

Univariate analysis showed that CEA elevation (p = 0.032), tumor size ≥20 mm (p < 0.001), lymph node metastasis (p < 0.001), high-PGS (p < 0.001), CA19-9 elevation (p < 0.001), Prognostic nutritious index (PNI) ≤40 (p = 0.002) and positive Glasgow prognostic score (GPS) (p = 0.001) were risk factors for poor overall survival. CEA elevation (p = 0.006), Tumor size ≥20 mm (p < 0.001), lymph node metastasis (p < 0.001), high-PGS (p < 0.001), CA19-9 elevation (p < 0.001), PNI ≤40 (p = 0.017) and positive GPS (p < 0.001) were identified as risk factors for poor recurrence-free survival. The multivariate analysis revealed that tumor size ≥20 mm (p = 0.007, p = 0.008, respectively) and high PGS score (p = 0.041, p = 0.018, respectively) were independently associated with poor overall survival and recurrence-free survival. Patients with high-PGS showed a significantly worse long-term prognosis even after PSM.

CONCLUSION

The PGS is a novel nomogram that could effectively predict long-term outcomes following curative surgery in patients with pancreatic ductal adenocarcinoma.

Neutrophil to lymphocyte ratio, not platelet to lymphocyte or lymphocyte to monocyte ratio, is predictive of patient survival after resection of early-stage pancreatic ductal adenocarcinoma

Background

NLR, PLR, and LMR have been associated with pancreatic ductal adenocarcinoma (PDAC) survival. Prognostic value and optimal cutpoints were evaluated to identify underlying significance in surgical PDAC patients.

Methods

NLR, PLR, and LMR preoperative values were available for 277 PDAC patients who underwent resection between 2007 and 2015. OS, RFS, and survival probability estimates were calculated by univariate, multivariable, and Kaplan-Meier analyses. Continuous and dichotomized ratio analysis determined best-fit cutpoints and assessed ratio components to determine primary drivers.

Results

Elevated NLR and PLR and decreased LMR represented 14%, 50%, and 50% of the cohort, respectively. OS (P = .002) and RFS (P = .003) were significantly decreased in resected PDAC patients with NLR ≥5 compared to those with NLR < 5. Optimal prognostic OS and RFS cutpoints for NLR, PLR, and LMR were 4.8, 192.6, and 1.7, respectively. Lymphocytes alone were the primary prognostic driver of NLR, demonstrating identical survival to NLR.

Conclusions

NLR is a significant predictor of OS and RFS, with lymphocytes alone as its primary driver; we identified optimal cutpoints that may direct future investigation of their prognostic value. This study contributes to the growing evidence of immune system influence on outcomes in early-stage pancreatic cancer.

The Prognostic Factors of Preoperative Prognostic Nutritional Index and Radiological Findings of Solid Pseudopapillary Tumors of Pancreas: A Single-Center Experience of 14 Years

Introduction

Solid pseudopapillary tumors of pancreas (SPTP) is an indolent rare tumor with malignant potential. The prediction of malignancy is an enigma. The aim of this study is to explore the relationship between operative measurements and malignancy prognosis of SPTP patients.

Methods

A cohort of consecutive 102 patients were enrolled in this study. Preoperative measurements and clinical outcomes were analyzed.

Results

Eighteen patients (17.6%) were confirmed as malignant. The malignant SPTP of the optimal cut-off value was 47.9 (p=0.012) for prognostic nutritional index (PNI). The value of PNI≤47.9 and incomplete capsule were significantly correlated with malignancy. Univariate analysis showed that the PNI≤47.9 (p=0.013) and incomplete capsule (p<0.001) were predictors of disease-specific survival (DSS). Multivariate analysis identified the PNI≤47.9 (p=0.036) and incomplete capsule (p=0.023) as the independent prognostic factors of DSS. The new score of 0,1,2 based on PNI and capsule presence stratified the patients into 3 groups. The patients with low PNI and incomplete capsule achieved the worst prognosis.

Conclusion

The combination test of operative PNI and capsule presence would be a reliable indicator of the aggressive natural history of SPTP.

Prognostic value of lymphocyte to monocyte ratio in pancreatic cancer: a systematic review and meta-analysis including 3338 patients

Background

Recently, reports have classified lymphocyte to monocyte ratio (LMR) as an effective indicator for predicting the prognosis of pancreatic cancer. Nevertheless, the prognostic value of LMR for pancreatic cancer remains controversial. Through meta-analysis, this work intends to evaluate the potential prognostic role of pretreatment LMR in patients diagnosed with pancreatic cancer.

Methods

We reviewed and extracted eligible articles from Web of Science, PubMed, Cochrane Library, and Embase. A meta-analysis was conducted using hazard ratio (HR) and 95% confidence intervals (CIs) to assess the comparison between pretreatment LMR and overall survival (OS) and disease-free survival/recurrence-free survival/time to progression (DFS/RFS/TTP).

Results

In total, 11 studies (16 cohorts) including 3338 patients diagnosed with pancreatic cancer (PC) were enrolled in our meta-analysis. Notably, we revealed that high pretreatment LMR predicted better overall survival (OS) (HR = 0.68, 95% CI 0.58–0.80, P < 0.001, I-squared = 69.3%, Ph < 0.001) and DFS/RFS/TTP (HR = 0.55, 95% CI 0.31–0.96, P = 0.037, I-squared = 89.9%, Ph < 0.001) in patients with pancreatic cancer. Further, through subgroup analyses, we showed that high pretreatment LMR was significantly associated with the favorable OS regardless of ethnicity, study design, treatment method, variable type, the cut-off value for LMR, and disease stages of I–IV and III–IV.

Conclusion

The findings from our study suggest that high pretreatment LMR is associated with better OS and DFS/RFS/TTP in patients diagnosed with pancreatic cancer. As such, it can potentially serve as a novel prognostic biomarker for patients with pancreatic cancer.

Preoperative Platelet to Lymphocyte Ratio as a Prognostic Factor for Resectable Pancreatic Cancer: A Systematic Review and Meta-Analysis

INTRODUCTION

Various inflammatory markers have been investigated for a prognostic role in patients with resectable pancreatic cancer. However, the value of preoperative platelet to lymphocyte ratio (PLR) remains controversial. We performed a systematic review and meta-analysis of PLR as a preoperative prognostic factor for resectable pancreatic cancer.

MATERIAL AND METHODS

Systematic literature search was conducted for studies assessing PLR influence as a preoperative prognostic factor in resectable pancreatic cancer patients. Random-effects model was applied for pooling hazard ratios and 95% confidence intervals related to overall survival (OS) and disease-free survival (DFS).

RESULTS

Fourteen articles with 2,743 patients were included in the study. According to the analysis, high PLR had no correlation with decreased OS. Due to high heterogeneity among studies, subgroup analysis was performed. Better OS was associated with low PLR in Asian patients, patients with mixed type of operation performed, and patients with preoperative PLR ≤150. Low PLR was associated with significantly better DFS.

CONCLUSIONS

PLR is a predictive factor of better DFS in patients with resectable pancreatic cancer. However, available evidence does not support PLR as a reliable prognostic factor for OS.

Prognostic Significance of the Modified Glasgow Prognostic Score in Patients With Pancreatic Cancer: A Meta-Analysis

BACKGROUND

The prognostic value of the modified Glasgow prognostic score (mGPS) in patients with pancreatic cancer is controversial, based on previous studies. Therefore, this meta-analysis aimed to explore the relationship between mGPS and prognosis in pancreatic cancer.

METHODS

The databases PubMed, Web of Science, Embase, and the Cochrane Library were searched to identify eligible studies. Hazard ratios (HRs) and 95% confidence intervals (CIs) were used to estimate the associations between mGPS score and survival outcomes.

RESULTS

A total of 26 studies with 5198 patients were included in this meta-analysis. In a pooled analysis, elevated mGPS predicted poorer overall survival (OS; HR = 1.98, 95% CI, 1.65-2.37, P < .001). In addition, elevated mGPS was also significantly associated with worse progression-free survival (PFS), disease-free survival (DFS), and cancer-specific survival (CSS; HR = 1.95, 95% CI, 1.36-2.80, P < .001). Subgroup analyses confirmed a significant association between mGPS and survival outcomes.

CONCLUSIONS

Our meta-analysis demonstrated that high mGPS was correlated to worse OS, PFS, DFS, and CSS in patients with pancreatic cancer. Therefore, mGPS could be employed as an effective prognostic factor for pancreatic cancer in clinical practice.

Predictive value of CONUT score combined with serum CA199 levels in postoperative survival of patients with pancreatic ductal adenocarcinoma: a retrospective study

Background

The preoperative controlling nutritional status (CONUT) score and serum carbohydrate antigen 199 (CA199) levels are individually correlated with the prognosis of pancreatic ductal adenocarcinoma (PDAC). The objective of this study aimed to investigate the efficacy of CONUT score and CA199 (CONUT-CA199) combination in predicting the prognosis of PDAC patients undergoing radical surgery.

Methods

We retrospectively analyzed the preoperative CONUT scores and serum CA199 levels of 294 patients with PDAC who underwent radical resection at the Affiliated Hospital of Southwest Medical University between March 2012 and July 2019. Patients were divided into four groups on the basis of their preoperative CONUT scores and serum CA199 levels: CONUT^low/CA199^low (1), CONUT^low/CA199^high (2), CONUT^high/CA199^low (3) and CONUT^high/CA199^high (4). The prognostic effects were compared among the groups.

Results

CONUT^high was more frequent in patients with positive peripancreatic infiltration and Clavien–Dindo classification of ≥IIIa (P < 0.001). Kaplan–Meier analysis revealed obvious difference in overall survival (OS) and recurrence-free survival (RFS) among patients with PDAC having CONUT-CA199 scores of 1, 2, 3 and 4 (P < 0.001). Peripancreatic infiltration, lymph node metastasis, pTNM stage, CONUT score, serum CA199 levels and CONUT-CA199 classification were found to be the independent prognostic factors for OS and RFS in multivariate analyses. In time-dependent receiver operating characteristic (ROC) analyses, the area of the CONUT-CA199 score under the ROC curve (AUC) was higher than that of the preoperative CONUT score or serum CA199 levels for the prediction of OS and RFS.

Conclusion

CONUT-CA199 classification may be more effective in predicting the postoperative prognosis of PDAC patients.

An integrated analysis of host- and tumor-derived markers for predicting high-grade dysplasia and associated invasive carcinoma of intraductal papillary mucinous neoplasms of the pancreas

PURPOSE

To clarify the usefulness of cancer-related inflammation, hypermetabolism, and subsequent host malnutrition biomarkers for predicting the histological grades of intraductal papillary mucinous neoplasms of the pancreas (IPMNs).

METHODS

The systemic immune-inflammation index (SII), prognostic nutritional index (PNI), and maximum standardized uptake value (SUVmax) on fluorodeoxyglucose-positron emission tomography were compared across 171 resected IPMN cases of different histological grades. The diagnostic performance of each marker and of their combinations for predicting IPMN with high-grade dysplasia (HGD)/associated invasive carcinoma (INV) was also tested.

RESULTS

Of the 171 IPMNs, the IPMN cases with HGD showed significantly higher values of SII (median 406 vs. 340; P = 0.041) and SUVmax (median 2.5 vs. 2.0; P = 0.001) than those with low-grade dysplasia (LGD). On a multivariate analysis, the SII and SUVmax were both independent markers for predicting HGD/INV. A combination analysis including the tumor- and host-derived markers in combination with imaging findings showed an improved diagnostic performance (area under the curve 0.824; sensitivity 75.9%; specificity 80.0%).

CONCLUSIONS

The combination of multiple markers of host-derived inflammation and tumor-derived focal hypermetabolism can serve as a predictor for the presence of HGD/INV.

Haemoglobin, albumin, lymphocyte and platelet predicts postoperative survival in pancreatic cancer

BACKGROUND

Systemic inflammation and nutrition status play an important role in cancer metastasis. The combined index of hemoglobin, albumin, lymphocyte, and platelet (HALP), consisting of haemoglobin, albumin, lymphocytes, and platelets, is considered as a novel marker to reflect both systemic inflammation and nutrition status. However, no studies have investigated the relationship between HALP and survival of patients with pancreatic cancer following radical resection.

AIM

To evaluate the prognostic value of preoperative HALP in pancreatic cancer patients.

METHODS

The preoperative serum levels of hemoglobin, albumin, lymphocyte counts, and platelet counts were routinely detected in 582 pancreatic adenocarcinoma patients who underwent radical resection. The relationship between postoperative survival and the preoperative level of HALP was investigated.

RESULTS

Low levels of HALP were significantly associated with lymph node metastasis (P = 0.002), poor tumor differentiation (P = 0.032), high TNM stage (P = 0.008), female patients (P = 0.005) and tumor location in the head of the pancreas (P < 0.001). Low levels of HALP were associated with early recurrence [7.3 mo vs 16.3 mo, P < 0.001 for recurrence-free survival (RFS)] and short survival [11.5 mo vs 23.6 mo, P < 0.001 for overall survival (OS)] in patients with resected pancreatic adenocarcinoma. A low level of HALP was an independent risk factor for early recurrence and short survival irrespective of sex and tumor location.

CONCLUSION

Low levels of HALP may be a significant risk factor for RFS and OS in patients with resected pancreatic cancer.

Chemotherapy-Induced Reduction of Neutrophil-to-Lymphocyte Ratio Is Associated With Better Survival in Pancreatic Adenocarcinoma: A Meta-Analysis

OBJECTIVES

Numerous studies have suggested that an increase in neutrophil-to-lymphocyte ratio (NLR) before treatment is associated with worse survival in pancreatic adenocarcinoma (PAC). The aim of this study was to investigate the prognostic value of treatment-induced NLR change among PAC patients so as to better identify the characteristics of those who can benefit more from treatment.

METHODS

This meta-analysis was undertaken using the PRISMA statement. Previously published studies between the correlation of NLR change and patients' survival were searched in Pubmed, Embase, and Web of Science databases. RevMan 5.3 was used to conduct statistical analysis.

RESULTS

A total of 1213 patients with PAC from 6 retrospective studies were included in this meta-analysis. Four studies investigated the HR of pre-treatment NLR, demonstrating its prognostic impact on overall survival (OS) (HR = 2.21, 95%CI: 1.45-3.36). One study reported that an elevated post-treatment NLR was associated with poorer OS (HR = 1.28, 95%CI = 1.08-1.52). Pooled analysis indicated that NLR reduction might predict favorable survival in both the overall population (HR = 1.52, 95% CI: 1.34-1.73) and the subgroup treated with chemotherapy (HR = 1.50, 95% CI: 1.32-1.70).

CONCLUSION

Treatment-induced NLR change can act as an early predictor for PAC. Patients with reduced NLR after chemotherapy are expected to have better survival.

Elevated NLR May Be a Feature of Pediatric Brain Cancer Patients

Pediatric brain tumors are the most common solid tumor type and the leading cause of cancer-related death in children. The immune system plays an important role in cancer pathogenesis and in the response to immunotherapy treatments. T lymphocytes are key elements for the response of the immune system to cancer cells and have been associated with prognosis of different cancers. Neutrophils on the other hand, which secrete pro-angiogenic and anti-apoptotic factors, enhance the ability of tumor cells to grow and develop into metastases. We conducted a retrospective study of 120 pediatric brain cancer patients and 171 elective pediatric patients hospitalized in Dana Children's Hospital and Sheba Medical Center. Data on age, sex, treatment, lymphocyte, neutrophil, and monocyte count were collected from routinely performed preoperative blood tests. Neutrophil-to-lymphocyte ratio (NLR), and the lymphocyte-to-monocyte ratio (LMR) were calculated and significance was determined by paired T test. p < 0.05 was considered as statistically significant. NLR was significantly higher in the pediatric brain cancer patients. The high NLR in pediatric brain cancer patients is the result of a combination of low lymphocytes and high neutrophils. Both of these factors can have a role in cancer development and propagation and also in response to therapy.