Prediction Efficacy for Clinical Outcome of Prognostic Nutritional Index in Patients with Resectable Biliary Tract Cancer Depends on Sex and Obstructive Jaundice Status

Prognostic roles nutritional index in patients with resectable and advanced biliary tract cancers

BACKGROUND

Biliary tract cancer (BTC) is a rare, aggressive malignancy with increasing incidence and poor prognosis. Identifying preoperative prognostic factors is crucial for effective risk-benefit assessments and patient stratification. The prognostic nutritional index (PNI), which reflects immune-inflammatory and nutritional status, has shown prognostic value in various cancers, but its significance in BTC remains unclear.

AIM

To assess the prognostic value of the preoperative PNI in BTC patients, with a focus on overall survival (OS) and disease-free survival (DFS).

METHODS

Comprehensive searches were conducted in the PubMed, EMBASE, and Web of Science databases from inception to April 2024. The primary outcomes of interest focused on the associations between the preoperative PNI and the prognosis of BTC patients, specifically OS and disease-free survival (DFS). Statistical analyses were conducted via STATA 17.0 software.

RESULTS

Seventeen studies encompassing 4645 patients met the inclusion criteria. Meta-analysis revealed that a low PNI was significantly associated with poorer OS [hazard ratio (HR) 1.91, 95%CI: 1.59-2.29; P < 0.001] and DFS (HR 1.93, 95%CI: 1.39-2.67; P < 0.001). Subgroup analyses revealed consistent results across BTC subtypes (cholangiocarcinoma and gallbladder cancer) and stages (resectable and advanced). Sensitivity analyses confirmed the robustness of these findings, and no significant publication bias was detected.

CONCLUSION

This study demonstrated that a low preoperative PNI predicts poor OS and DFS in BTC patients, highlighting its potential as a valuable prognostic tool. Further prospective studies are needed to validate these findings and enhance BTC patient management.

Prognostic Significance of Sarcopenia and Systemic Inflammatory Markers in Biliary Tract Cancer: A Retrospective Cohort Study

PURPOSE

To evaluate the prognostic significance of sarcopenia and systemic inflammatory markers in patients with surgically resected biliary tract cancer (BTC).

METHODS

Between July 2010 and December 2022, 146 patients were recruited. Sarcopenia was assessed using the psoas muscle index. Preoperative inflammatory markers were used to calculate the prognostic nutritional index (PNI), neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio. Cox regression analysis was performed to determine prognostic factors for overall survival (OS) and recurrence-free survival (RFS). P < 0.05 was considered statistically significant.

RESULTS

Sixty-four patients had sarcopenia. Sarcopenia was associated with body mass index (< 22 kg/m2), lymph node metastasis, and low PNI (< 42). R1/R2 resection (P = 0.02), sarcopenia (P < 0.001), lymph node metastasis (P = 0.007), intrahepatic cholangiocarcinoma (P < 0.001), and low PNI (P = 0.01) were independent predictors of OS, while male sex (P = 0.04), R1/R2 resection (P < 0.001), lymph node metastasis (P = 0.005), intrahepatic cholangiocarcinoma (P < 0.001), tumor differentiation (other than well; P = 0.003), and low PNI (P = 0.03) were independent predictors of RFS. Patients were stratified into no sarcopenia and high PNI (≥ 42; A), sarcopenia or low PNI (B), and sarcopenia and low PNI (C) groups. Group C had worse OS than the other two groups (P < 0.001 and P = 0.02, respectively).

CONCLUSION

Sarcopenia is associated with the PNI. Sarcopenia and the PNI are independent prognostic factors among patients with resected BTC. Sarcopenia may have better prognostic value when combined with the PNI.

Survival analysis of patients with extrahepatic cholangiocarcinoma: a nomogram for clinical and MRI features

BACKGROUND

This study aimed to establish a predictive model to estimate the postoperative prognosis of patients with extrahepatic cholangiocarcinoma (ECC) based on preoperative clinical and MRI features.

METHODS

A total of 104 patients with ECC confirmed by surgery and pathology were enrolled from January 2013 to July 2021, whose preoperative clinical, laboratory, and MRI data were retrospectively collected and examined, and the effects of clinical and imaging characteristics on overall survival (OS) were analyzed by constructing Cox proportional hazard regression models. A nomogram was constructed to predict OS, and calibration curves and time-dependent receiver operating characteristic (ROC) curves were employed to assess OS accuracy.

RESULTS

Multivariate regression analyses revealed that gender, DBIL, ALT, GGT, tumor size, lesion's position, the signal intensity ratio of liver to paraspinal muscle (SIRLiver/Muscle), and the signal intensity ratio of spleen to paraspinal muscle (SIRSpleen/Muscle) on T2WI sequences were significantly associated with OS, and these variables were included in a nomogram. The concordance index of nomogram for predicting OS was 0.766, and the AUC values of the nomogram predicting 1-year and 2-year OS rates were 0.838 and 0.863, respectively. The calibration curve demonstrated good agreement between predicted and observed OS. 5-fold and 10-fold cross-validation show good stability of nomogram predictions.

CONCLUSIONS

Our nomogram based on clinical, laboratory, and MRI features well predicted OS of ECC patients, and could be considered as a convenient and personalized prediction tool for clinicians to make decisions.

A Bayesian Network Prediction Model for Microvascular Invasion in Patients with Intrahepatic Cholangiocarcinoma: A Multi-institutional Study

BACKGROUND

Microvascular invasion (MVI) has been reported to be an independent prognostic factor of recurrence and poor overall survival in patients with intrahepatic cholangiocarcinoma (ICC). This study aimed to explore the preoperative independent risk factors of MVI and establish a Bayesian network (BN) prediction model to provide a reference for surgical diagnosis and treatment.

METHODS

A total of 531 patients with ICC who underwent radical resection between 2010 and 2018 were used to establish and validate a BN model for MVI. The BN model was established based on the preoperative independent variables. The ROC curves and confusion matrix were used to assess the performance of the model.

RESULTS

MVI was an independent risk factor for relapse-free survival (RFS) (P < 0.05). MVI has a correlation with postoperative recurrence, early recurrence (< 6 months), median RFS and median overall survival (all P < 0.05). The preoperative independent risk variables of MVI included obstructive jaundice, prognostic nutritional index, CA19-9, tumor size, and major vascular invasion, which were used to establish the BN model. The AUC of the BN model was 78.92% and 83.01%, and the accuracy was 70.85% and 77.06% in the training set and testing set, respectively.

CONCLUSION

The BN model established based on five independent risk variables for MVI is an effective and practical model for predicting MVI in patients with ICC.

Preoperative Fibrinogen Albumin Ratio is an Effective Biomarker for Prognostic Evaluation of Gallbladder Carcinoma After Radical Resection: A 10-Year Retrospective Study at a Single Center

Background

To explore and screen preoperative serum immune response level-related biomarkers with better prognostic ability and developed a prognostic model for decision-making in clinical practice for gallbladder carcinoma (GBC) patients.

Methods

A total of 427 patients who underwent radical resection for GBC in the Department of Hepatobiliary Surgery of the First Affiliated Hospital of Xi'an Jiaotong University from January 2011 to December 2020 were retrospectively analyzed. Time-dependent receiver operating characteristic (time-ROC) was performed to determine the prognostic predictive power of preoperative biomarkers. A nomogram survival model was established and validated.

Results

Time-ROC indicated that the preoperative fibrinogen-to-albumin ratio (FAR) had a better predictive ability for overall survival among preoperative serum immune response level-related biomarkers. Multivariate analysis indicated that FAR was an independent risk factor (P<0.05). The proportion of clinicopathological characteristics of poor prognosis (such as advanced T stage, and N1-2 stage) was significantly higher in high FAR group (P<0.05). Subgroup analyses indicate the prognostic discrimination ability of FAR depended on CA19-9, CA125, liver involvement, major vascular invasion, perineural invasion, T stage, N stage, and TNM stage (all P <0.05). A nomogram model was established based on the prognostic independent risk factors with the C-index of 0.803 (95% CI:0.771~0.835) and 0.774 (95% CI:0.696~0.852) in the training and testing sets, respectively. The decision curve analysis indicated the nomogram model had a better predictive ability than the FAR and TNM staging system in the training and testing sets.

Conclusion

Preoperative serum FAR has a better predictive ability for overall survival among preoperative serum immune response level-related biomarkers, and it can be used for survival assessment of GBC and guide clinical decision-making.

Preoperative prognostic nutritional index predicts short-term complications after radical resection of distal cholangiocarcinoma

Background

The occurrence of postoperative complications of distal cholangiocarcinoma (dCCA) is an indicator of poor patient prognosis. This study aimed to determine the immune-nutritional indexes (INIs) that can predict short-term postoperative complications.

Methods

A retrospective analysis of 148 patients with dCCA who were operated radical pancreaticoduodenectomy at the First Hospital of Lanzhou University from December 2015 to March 2022 was conducted to assess the predictive value of preoperative INIs and preoperative laboratory tests for short-term postoperative complications, and a decision tree model was developed using classification and regression tree (CART) analysis to identify subgroups at risk for overall complications.

Results

In this study, 83 patients (56.08%) experienced overall complications. Clavien-Dindo grade III-V complications occurred in 20 patients (13.51%), and 2 patients died. The areas under curves (AUCs) of the preoperative prognostic nutritional index (PNI), controlling nutritional status (CONUT) score, and neutrophil-to-lymphocyte ratio (NLR) were compared; the PNI provided the maximum discrimination for complications (AUC = 0.685, 95% CI = 0.600-0.770), with an optimal cutoff value of 46.9, and the PNI ≤ 46.9 group had higher incidences of overall complications (70.67% vs. 40.00%, P < 0.001) and infectious complications (28.77% vs. 13.33%, P = 0.035). Multivariate logistic regression analysis identified PNI (OR = 0.87, 95% CI: 0.80-0.94) and total bilirubin (OR = 1.01, 95% CI: 1.00-1.01) were independent risk factors for overall complications (P < 0.05). According to CART analysis, PNI was the most important parameter, followed by the total bilirubin (TBIL) level. Patients with a PNI lower than the critical value and TBIL higher than the critical value had the highest overall complication rate (90.24%); the risk prediction model had an AUC of 0.714 (95% CI, 0.640-0.789) and could be used to stratify the risk of overall complications and predict grade I-II complications (P < 0.05).

Conclusion

The preoperative PNI is a good predictor for short-term complications after the radical resection of dCCA. The decision tree model makes PNI and TBIL easier to use in clinical practice.

Prognostic value of combined inflammatory and nutritional biomarkers in HCC within the Milan criteria after hepatectomy

Aims

This study aimed to evaluate the predictive value of the combined prognostic nutritional index (PNI) and GGT/ALT for the postoperative prognosis of patients with hepatocellular carcinoma (HCC) within Milan criteria undergoing radical hepatectomy.

Methods

This single-center retrospective study included 283 patients with HCC within the Milan criteria who underwent hepatectomy. The receiver operating characteristic (ROC) curve was used to calculate the optimal PNI and GGT/ALT cut-off values. Pre-treatment PNI, GGT/ALT, and PNI-GGT/ALT grades were calculated. Overall survival (OS) and recurrence-free survival (RFS) were estimated using the Kaplan–Meier method, and multivariate analysis was used to identify prognostic factors.

Results

Multivariate Cox regression analysis identified that the PNI, GGT/ALT, tumor number were significant prognostic markers for OS, and that the GGT/ALT, tumor number were significant prognostic markers for OS. The survival curves showed that low PNI, high GGT/ALT ratio, and high PNI-GGT/ALT grade were associated with poorer OS and DFS. With an area under the curve (AUC) of 0.690, PNI-GGT/ALT outperformed each individual score.

Conclusion

PNI-GGT/ALT, a new prognostic scoring model, qualifies as a novel prognostic predictor for patients with HCC within the Milan criteria after curative resection.

Prediction Efficacy of Prognostic Nutritional Index and Albumin-Bilirubin Grade in Patients With Intrahepatic Cholangiocarcinoma After Radical Resection: A Multi-Institutional Analysis of 535 Patients

Background

The preoperative nutritional status and the immunological status have been reported to be independent prognostic factors of patients with intrahepatic cholangiocarcinoma (ICC). This study aimed to investigate whether prognostic nutritional index (PNI) + albumin–bilirubin (ALBI) could be a better predictor than PNI and ALBI alone in patients with ICC after radical resection.

Methods

The prognostic prediction evaluation of the PNI, ALBI, and the PNI+ALBI grade was performed in 373 patients with ICC who underwent radical resection between 2010 and 2018 at six Chinese tertiary hospitals, and external validation was conducted in 162 patients at four other Chinese tertiary hospitals. Overall survival (OS) and relapse-free survival (RFS) were estimated using the Kaplan–Meier method. Multivariate analysis was conducted to identify independent prognostic factors. A time-dependent receiver operating characteristic (ROC) curve and a nomogram prediction model were further constructed to assess the predictive ability of PNI, ALBI, and the PNI+ALBI grade. The C-index and a calibration plot were used to assess the performance of the nomogram models.

Results

Univariate analysis showed that PNI, ALBI, and the PNI+ALBI grade were prognostic factors for the OS and RFS of patients with ICC after radical resection in the training and testing sets (p < 0.001). Multivariate analysis showed that the PNI+ALBI grade was an independent risk factor for OS and RFS in the training and testing sets (p < 0.001). Analysis of the relationship between the PNI+ALBI grade and clinicopathological characteristics showed that the PNI+ALBI grade correlated with obstructive jaundice, alpha-fetoprotein (AFP), cancer antigen 19-9 (CA19-9), cancer antigen 125 (CA125), PNI, ALBI, Child–Pugh grade, type of resection, tumor size, major vascular invasion, microvascular invasion, T stage, and N stage (p < 0.05). The time-dependent ROC curves showed that the PNI+ALBI grade had better prognostic predictive ability than the PNI, ALBI, and the Child–Pugh grade in the training and testing sets.

Conclusion

Preoperative PNI+ALBI grade is an effective and practical predictor for the OS and RFS of patients with ICC after radical resection.

A combined prediction model for biliary tract cancer using the prognostic nutritional index and pathological findings: a single-center retrospective study

Background

The prognostic nutritional index, a marker of nutritional status and systemic inflammation, is a known biomarker for various cancers. However, few studies have evaluated the predictive value of the prognostic nutritional index in patients with biliary tract cancer. Therefore, we investigated the prognostic significance of the prognostic nutritional index, and developed a risk-stratification system to identify prognostic factors in patients with biliary tract cancer.

Methods

Between July 2010 and March 2021, 117 patients with biliary tract cancer were recruited to this single-center, retrospective study. The relationship between clinicopathological variables, including the prognostic nutritional index, and overall survival was analyzed using univariate and multivariate analyses. A P < 0.05 was considered statistically significant.

Results

The median age was 75 (range 38–92) years. Thirty patients had intrahepatic cholangiocarcinoma; 29, gallbladder carcinoma; 27, distal cholangiocarcinoma; 17, ampullary carcinoma; and 13, perihilar cholangiocarcinoma. Curative (R0) resection was achieved in 99 patients. In univariate analysis, the prognostic nutritional index (< 42), lymph node metastasis, carbohydrate antigen 19-9 level (> 20 U/mL), preoperative cholangitis, tumor differentiation, operation time (≥ 360 min), and R1–2 resection were significant risk factors for overall survival. The prognostic nutritional index (P = 0.027), lymph node metastasis (P = 0.040), and tumor differentiation (P = 0.006) were independent prognostic factors in multivariate analysis. A combined score of the prognostic nutritional index and pathological findings outperformed each marker alone, in terms of discriminatory power.

Conclusions

The prognostic nutritional index, lymph node metastasis, and tumor differentiation were independent prognostic factors after surgical resection in patients with biliary tract cancer. A combined prediction model using the prognostic nutritional index and pathological findings accurately predicted prognosis, and can be used as a novel prognostic factor in patients with biliary tract cancer.

Development and Validation of Nomograms for Predicting Cancer-Specific Survival in Elderly Patients with Intrahepatic Cholangiocarcinoma After Liver Resection: A Competing Risk Analysis

Background

There are few studies on the prognosis of elderly intrahepatic cholangiocarcinoma (iCCA) patients after liver resection. The aims of this study were to assess the cumulative incidences of cancer-specific mortality in elderly iCCA patients and to construct a corresponding competing risk nomogram for elderly iCCA patients.

Methods

We performed a retrospective analysis of elderly patients with iCCA who underwent liver resection between January 2006 and December 2019. Eligible elderly iCCA patients were randomly divided into training and validation sets at a ratio of 7:3. Based on the results of multivariate analysis using the Fine-Gray competing risk model, we developed a competing risk nomogram using data from the training set to predict the cumulative probabilities of iCCA-specific mortality. The performance of the nomogram was measured by the concordance index (C-index) and calibration curves. To evaluate the clinical usefulness of the nomogram, the clinical benefit was measured by using decision curve analysis (DCA). Furthermore, the patients were categorized into two groups according to the dichotomy values of the nomogram-based scores, and their survival differences were assessed using Kaplan–Meier and cumulative incidence function (CIF) curves.

Results

The 1-year, 3-year and 5-year cumulative iCCA-specific mortalities were 19.7%, 48.3% and 56.1%, respectively, for elderly iCCA patients. The multivariate Fine-Gray analysis indicated that microvascular invasion, macroscopic vascular invasion and lymph node metastasis were related to a significantly higher likelihood of iCCA specific mortality. The established nomogram was well calibrated and had a good discriminative ability, with a concordance index (C-index) of 0.742 (95% CI, 0.708–0.748). Furthermore, the DCA indicated that the nomogram had positive net benefits compared with the conventional staging systems. In the training set and validation sets, the high-risk group had the higher probabilities of iCCA cancer-specific mortality than the low-risk group; meanwhile, the patients in the high-risk the group had significantly poorer overall survival (OS) than those in the low-risk group.

Conclusion

Elderly iCCA patients had comparable long-term outcomes with non-elderly iCCA patients. In addition, we constructed a prognostic nomogram for predicting survival in elderly iCCA patients based on the competing risk analysis. The competing risk nomogram displayed excellent discrimination and calibration.