Prognostic nutritional index is an independent prognostic factor for gastric cancer patients with peritoneal dissemination

Nomogram for predicting overall survival after curative gastrectomy using inflammatory, nutritional and pathological factors

PURPOSE

To establish a nomogram for predicting the overall survival (OS) in patients with gastric cancer (GC) based on inflammatory, nutritional and pathological factors.

METHODS

GC patients underwent curative gastrectomy from January 2012 to June 2017 in our hospital were included, and were classified into training set and validation set with a ratio of 7:3. Then variables associated with OS were analyzed using univariate and multivariate Cox regression analysis. Nomograms predicting OS were built using variables from multivariable Cox models. Finally, Kaplan-Meier curve and Log-rank test were also conducted to analyze the 1-yr, 3-yr and 5-yr OS to validate the efficiency of risk stratification of the nomogram.

RESULTS

A total of 366 GC patients were included. After univariate and multivariate Cox regression analysis, age (HR = 1.52, 95% CI = 1.01-2.30, P = 0.044), CA50 (HR = 1.90, 95% CI = 1.12-3.21, P = 0.017), PNI (HR = 1.65, 95% CI = 1.13-2.39, P = 0.009), SII (HR = 1.46, 95% CI = 1.03-2.08, P = 0.036), T stage (HR = 2.26, 95% CI = 1.01-5.05, P = 0.048; HR = 7.24, 95% CI = 3.64-14.40, P < 0.001) were independent influencing factors on the survival time of GC patients. Five factors including CEA, prognostic nutritional index (PNI), systemic immune-inflammation index (SII), ln (tumor size), T stage, and N stage were identified and entered the nomogram, which showed good discrimination and calibration in both sets. On internal validation, 1-yr, 3-yr and 5-yr nomogram demonstrated a good discrimination with an area under the ROC curve (AUC) of 0.77, 0.84 and 0.86, respectively. The AUC for 1-yr, 3-yr and 5-yr nomogram in validation set was 0.77, 0.79 and 0.81, respectively. The OS in low risk group of training cohort and validation cohort was significantly higher than that of intermediate risk group and high risk group, respectively.

CONCLUSIONS

We established a nomogram based on PNI, SII and pathological factors for predicting OS in GC patients. In addition, its efficiency was validated by validation set and stratified analysis.

Nutritional index in relation to prognosis of endometrial cancer

Objective: Evaluate the prognostic value of the prognostic nutritional index (PNI) in patients with endometrial cancer (EC). Method: Laboratory and clinicopathological data from 370 patients who were diagnosed with EC between January 2010 and December 2021 were reviewed. The PNI was analyzed for correlations with recurrence and survival. The receiver operating characteristic curves were generated for the PNI. Optimal cut-off values were determined as the points at which the Youden index (sensitivity + specificity - 1) was maximal. Based on the results of the ROC curve analysis, the patients were grouped into high and low PNI groups. Differences in the clinicopathological characteristics between patients with high and low PNI were compared between the two groups. The effects of the prognostic factors were analyzed using univariate and multivariate Cox proportional hazards model. Results: The optimal cutoff value of the PNI was 52.74 for DFS (area under the curve: 0.817; 95% CI: 0.738-0.858, p <0.001). Significantly more patients in the low PNI group experienced recurrence (30.6% vs. 5.2%, p <0.001) and cancer-related death (17.8% vs. 2.8%, p <0.001). In multivariate analysis, PNI were independent prognostic factors for both DFS and overall survival OS. Conclusion: Low PNI was significantly associated with worse clinical outcomes in patients with EC. Our findings demonstrate that the PNI may be clinically reliable and useful as a prognostic marker for patients with EC. Further large-scale prospective studies are needed to confirm our findings.

Regional Immunotherapy for Peritoneal Carcinomatosis in Gastroesophageal Cancer: Emerging Strategies to Re-Condition a Maladaptive Tumor Environment

Peritoneal carcinomatosis originating from gastric/gastroesophageal junction cancer (GC-PC) occurs in a defined subset of gastric cancer patients with unique clinical, pathologic, molecular and immunologic characteristics that create significant obstacles to effective treatment with modern therapy. Although systemic chemo- and immuno- therapy have yielded disappointing results in GC-PC, recent advances in the characterization of GC-PC and peritoneal immune biology present new opportunities for targeted therapeutics. In this review article, we discuss the distinct properties of GC-PC and the peritoneal immune environment as they pertain to current and investigative treatment strategies. We discuss pre-clinical studies and clinical trials relevant to the modulation of the peritoneal environment as a therapeutic intervention in GC-PC. Finally, we present a road map for future combinatorial strategies based on the conception of the peritoneal cavity as a bioreactor. Within this isolated compartment, prevailing immunosuppressive conditions can be altered through regional interventions toward an adaptive phenotype that would support the effectiveness of regionally delivered cellular therapy products. It is hoped that novel combination strategies would promote efficacy not only in the sequestered peritoneal environment, but also via migration into the circulation of tumor-reactive lymphocytes to produce durable systemic disease control, thereby improving oncologic outcome and quality of life in patients with GC-PC.

Clinical significance of prognostic nutritional index (PNI)-monocyte-to-lymphocyte ratio (MLR)-platelet (PLT) score on postoperative outcomes in non-metastatic clear cell renal cell carcinoma

BACKGROUND

Prognositic nutritional index (PNI), monocyte-to-lymphocyte ratio (MLR) and platelet (PLT) are associated with tumor survival in many human malignancies. Whereas, no study combined PNI-MLR-PLT score and indicated its predictive significance on the prognosis of patients with non-metastatic clear cell renal cell carcinoma (ccRCC).

METHODS

In this study, we retrospectively collected the clinicopathological characteristics and prognostic data from 164 cases of non-metastatic ccRCC and aimed to determine the clinical significance of PNI-MLR-PLT score on patients' outcomes after surgery. The optimal cut-off values of PNI (PNI > 47.40 vs PNI < 47.40), MLR (MLR > 0.31 vs MLR < 0.31) and PLT (PLT > 245 vs PLT < 245) were identified with relative operating characteristic (ROC) curve analysis. The PNI-MLR-PLT score system was established by the value of three indexes, each indication was assigned a score of 0 or 1. Overall survival (OS) and metastasis-free survival (MFS) were analyzed using Kaplan-Meier estimate and Cox regression models.

RESULTS

The mean follow-up period was 85.67 months. Eight (5.0%) patients died, 4 (2.0%) relapsed, and 7 (4.0%) developed metastasis after surgery. The 3-year OS and MFS rates were 98.2% and 97.6%, and the 5-year OS and MFS rates were both 90.2%. Our results suggested that PNI-MLR-PLT score negatively correlated with pathological T stage and tumor grade. Survival outcomes revealed that lower PNI-MLR-PLT score is associated with inferior OS (P < 0.001) and MFS (P < 0.001) after surgery. Subgroup analysis regarding pathological T stage, tumor grade and surgical modalities obtained consistent results. univariable and multivariable Cox analysis showed that high PNI-MLR-PLT score was the independent protective factor of tumor survival in non-metastatic ccRCC patients.

CONCLUSIONS

Our data suggested that PNI-MLR-PLT score could serve as a promising independent prognostic factor in patients with non-metastatic ccRCC.

Nutritional index for immune-checkpoint inhibitor in patients with metastatic gastro-esophageal junction/gastric cancer

BACKGROUND

Nutritional status is strongly associated to prognosis in metastatic gastrooesophageal junction (mGOJ)/gastric cancer (GC) patients. The aim of the present study was to develop an immune-checkpoint inhibitor (ICI)-specific nutritional index (NI).

METHODS

Ten serum and anthropometric nutritional markers derived from blood tests or CT scans were analyzed at baseline in patients treated with second-line ICI and correlated with overall survival (OS). An ICI-specific NI (the NUTRIICI) was developed with its specificity assessed in an independent group of patients treated with standard second-line chemotherapy.

RESULTS

From June 2014 to December 2018, 57 mGOJ/GC patients (14 females, 43 males) with a median(m) age of 61 years (range 29-85) received ICI as second-line therapy (Pembrolizumab n=26, Nivolumab n=16, Avelumab n=15). Among the 10 analyzed variables, Onodera's prognostic NI (PNI) ≤33 and waist-to-hip (WHR) <1 were independent predictors of OS and used to build the NUTRIICI. Patients with both favorable factors (i.e., PNI >33 and WHR ≥1, comparator group) had a mOS of 18.0 vs. 6.7 months of patients with one unfavorable factor (either PNI ≤33 or WHR <1, Hazard Ratio, HR 3.06), vs. 1.3 months of patients with both unfavorable factors (HR 17.56), overall P<0.0001. In the independent group of patients treated with standard chemotherapy NUTRIICI was not associated with prognosis (P=0.57).

CONCLUSIONS

NUTRIICI is the first ICI-specific NI for mOGJ/GC patients receiving second-line ICI. A validation in larger cohorts is strongly encouraged.

Prognostic Significance of PNI in Patients With Pancreatic Head Cancer Undergoing Laparoscopic Pancreaticoduodenectomy

Background

Recently, several prognosis indicators based on inflammatory and nutritional factors, such as the neutrophil-to-lymphocyte ratio (NLR), plated-to-lymphocyte (PLR), lymphocyte-to-monocyte (LMR) and prognosis nutritional index (PNI), have been proposed as prognosis factors for several cancers. However, few studies have looked into PNI. The goal of this research was to see if preoperative PNI had any predictive value in patients with pancreatic head cancer who were having a laparoscopic pancreaticoduodenectomy.

Methods

From February 11, 2018 to May 31, 2019, two hundred and fifty-one pancreatic head carcinoma patients were retrospectively enrolled. The receiver operator characteristic (ROC) curve was used to determine the cut-off value. Patients were divided into two groups: PNI > 45.1 (high PNI group) and PNI < 45.1 (low PNI group), and clinic-pathological data was compared between the two groups. The link between PNI and NLR, PLR, and LMR, and their effect on overall survival. In addition, the factors of postoperative survival were analyzed univariate and multivariate.

Results

PNI, NLR, PLR and LMR cut-off values were 45.1, 3.7,287.2 and 3.6, respectively. Between the two groups of patients, the low PNI group exhibited considerably higher PLR and lower LMR. PNI had a negative correlation with PLR and NLR (r = −0.329, p < 0.001 and r = 0.170, p = 0.014), but a positive correlation with LMR (r = 0.476, p < 0.001). The high PNI group had a considerably greater survival rate than the low PNI group (median survival days, 217 vs. 468, log-rank = 45.92, p < 0.001). PNI < 45.1(HR: 0.357, 95 percent CI, 0.263–0.485, p < 0.001) and LMR <3.6(HR: 0.705, 95 percent CI, 0.528–0.942, p < 0.018) were revealed to be possible predictive variable in univariate analysis. Only PNI <45.1 was found to be an independent predictive factor in multivariate analysis (HR: 0.359, 95%CI,: 0.256–0.502, p < 0.001).

Conclusions

Our findings shoe that PNI is linked to a variety of systemic inflammatory response and can be used to predict survival in individuals with pancreatic head cancer.

Body composition and immunonutritional status in patients treated with pressurized intraperitoneal aerosol chemotherapy (PIPAC) for gastrointestinal peritoneal metastases: a prospective single-center analysis

Objectives

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a novel drug administration method with promising efficacy for the treatment of peritoneal metastases (PM). This study aimed to evaluate the prognostic value of an immunonutritional assessment on the feasibility, safety, and survival in this setting.

Methods

Data of PM patients undergoing PIPAC between September 2018 and May 2020 were prospectively recorded. A CT scan-derived body composition assessment was performed for each patient.

Results

Fifty-one patients were enrolled, of which 30 (58%) underwent multiple PIPAC cycles, with a pathological response rate of 55%. Prognostic nutritional index (PNI) and neutrophil-to-lymphocytes predicted completion of more than one PIPAC cycle, with a cut off of 36.5 and 4.8 respectively. Muscle attenuation and body fat tissues were associated with pathological response. At multivariate Cox regression analysis, only the presence of a low PNI (HR 2.41, 95% CI 1.08–5.46) was significantly associated with a worse OS.

Conclusions

A pretreatment immunonutritional assessment may provide valuable information for PIPAC patients’ selection and survival, while body composition parameters are able to predict pathological response. Further larger studies are needed to validate the role of these biomarkers in tailoring the treatment and monitoring PM patients undergoing PIPAC.

The Association between the Preoperative Prognostic Nutritional Index and the Controlling Nutritional Status Score on Tumor Stage, Chemotherapeutic Response and Overall Survival in Ovarian Cancer

This study aimed to investigate the association between preoperative prognostic nutritional index (PNI) and controlling nutritional status (CONUT) scores on the stage of ovarian cancer (OC), chemotherapeutic response, and overall survival (OS) in patients with OC.

The data of the patients who operated due to OC between January 2015 and January 2020 in a tertiary referral hospital were recorded. The patients' basic characteristics, preoperative total cholesterol, albumin, lymphocyte count, tumor markers, disease stage, grade, chemotherapeutic response, OS, and progression-free survival were recorded. The PNI and the CONUT score were calculated.

The mean PNI level was considerably higher in the early-stage group than the advanced-stage group (50.02 ± 6.8 vs. 46.3 ± 7.4, p = 0.005). The AUC was 63% for the cutoff point 45.98 of PNI, whereas the AUC was 42% for the cutoff point 1.5 of CONUT score in predicting early-stage disease. The PFS and OS were significantly higher in the high PNI group than the low PNI group (p = 0.01, p = 0.002, respectively).

The patients with early-stage OC had significantly higher PNI levels and lower CONUT scores in our study population.

Modified Glasgow Prognostic Score, Prognostic Nutritional Index and ECOG Performance Score Predicts Survival Better than Sarcopenia, Cachexia and Some Inflammatory Indices in Metastatic Gastric Cancer

Background: Gastric carcinoma (GC) patients usually present with locally advanced or metastatic disease; therefore treatment aim is mainly palliation. In this study our purpose is to analyze the prognostic values of the sarcopenia index (SI), cachexia index (CIn) and other inflammatory indexes (advanced lung cancer inflammation index [ALI], modified Glasgow Prognostic Score [mGPS], prognostic index [PI], prognostic nutritional index [PNI] and neutrophil-to-lymphocyte ratio [NLR]) in metastatic GC patients.Methods: Data from the files of metastatic GC patients, who applied to Medical Oncology outpatient clinic in Marmara University Pendik Education and Research Hospital between January 2011 and June 2016, were retrospectively reviewed. Five hundred seventy patients with gastric cancer were detected. Exclusion criteria were the inability to reach the patient surveys for prognostic index calculations, the presence of additional comorbidities to affect the laboratory parameters, and the absence of metastatic disease. Finally, 87 of these patients were included in this study. For SI calculation L3 level muscle area was measured from patients' computed tomography (CT) by a radiologist. SI reference value was obtained from western-EGWSOP (The European Working Group on Sarcopenia in Older People) and eastern (Harada Y, et al.) sources separately, as Turkey doesn't have a reference value for SI. NLR cutoff value was accepted as the median value of patients' NLR measurements. Statistical analysis was conducted using SPSS. Kaplan-Meier and Cox regression models were used to assess independent prognostic factors. The area under the curve was used to compare the prognostic value of indexes.Results: The median length of follow-up of 87 patients was nine months (1-64 mo,/s), and 78 patients died during follow-up. Fifty-nine patients were male (63%), and the median age was 62 (range, 23-88). According to univariate analysis high mGPS and PI score, PNI level <45, NLR level ≥ 3.41, ALI level <18, CI level under 35, SI (Harada Y, et al) ≤44.5 for males and ≤36.5 for females, ECOG score ≥ 2, weight loss more than 10% during last 6 mo, BMI under 24 were poor prognostic factors. Age, gender, having multiple organ metastasis, history of gastric surgery, positivity C-erb-B2, SI (EGWSOP) ≤52.4 for males, and ≤38.4 for females did not have any impact on survival. According to multivariate analysis, high mGPS (score 2) (HR 2,494, 95% CI 1.25-4 .94, p = 0.02), PNI (score 1) (HR 4.2, 95% CI 1.73-10.1, p < 0.001) and ECOG score (≥2) (HR 1.541, 95% CI 1,089-4,214, p = 0.004) have been found to be independent prognostic factors which are determining the survival. mGPS was found to be more valuable than other indexes for predicting mortality by measuring the AUC with ROC analysis.Conclusions: In our study, mGPS, PNI and ECOG score were independent indicators for shorter survival in metastatic gastric cancer patients. mGPS and PNI, which can be done by using only serum CRP, albumin level and complete blood count, might be inexpensive, practical and beneficial to use in routine clinical practice to determine survival.

Achieving sequential therapy in advanced gastric cancer: the importance of appropriate patient management for the elderly and/or those with ascites

Treatment options for patients with advanced gastric cancer (AGC) are limited. One approach to improving survival in patients with AGC is to optimize the available agents via sequential therapy. However, clinical trial reports of first-line chemotherapy indicate that elderly patients and patients with massive ascites are less likely to receive subsequent lines of therapy. In addition, clinical trials of second- and third-line chemotherapy generally exclude these two patient populations because they are likely to have poor performance status and additional issues that are difficult to manage. Good patient management is likely to be key to the successful use of sequential therapy in these two patient populations by minimizing adverse effects to allow patients to derive benefit from the additional treatment. This narrative review summarizes the available information on AGC treatment and patient management in elderly patients and patients with massive ascites. The available data suggest that elderly patients benefit from chemotherapy; however, monitoring toxicity is essential to avoid chemotherapy-related toxicities. Important aspects of patient management for elderly patients include symptom monitoring, nutritional support, and fall prevention. The available data for patients with massive ascites show limited success for a range of treatment approaches, including systemic chemotherapy. The management of ascites is also challenging, with no clear guidance on the preferred strategies. To address these gaps in knowledge, future clinical trials should incorporate more inclusive eligibility criteria to enroll populations of patients with AGC that are more reflective of the real-world population with respect to age, complications, and overall health status.

Prognostic significance of the controlling nutritional status (CONUT) score in epithelial ovarian cancer

Purpose

The controlling nutritional status (CONUT) score is a nutritional indicator that serves as a prognostic factor for many malignancies. This study aimed to investigate the prognostic significance of pre-treatment CONUT scores in patients with epithelial ovarian cancer.

Methods

We evaluated newly diagnosed patients with epithelial ovarian cancer who were treated at the Nantong Tumor Hospital, between January 2013 and April 2016. Pre-treatment CONUT scores were calculated using serum albumin levels, total lymphocyte counts, and cholesterol levels. The optimal CONUT score cut-off was determined via receiver operating characteristic curve and Youden’s index. The difference in survival rates between the high-CONUT score group and the low-CONUT score group was analyzed using Kaplan-Meier curves and the log-rank test. Univariate and multivariate Cox proportional hazard regression models were used to identify prognostic factors influencing survival in these patients.

Results

In total, 206 patients were included. The optimal cut-off value for the CONUT score was 3. The high-CONUT score group (score ≥3) had higher International Federation of Gynecology and Obstetrics (FIGO) stages, medium-large amounts of ascitic fluid, higher CA125 levels, and more chemoresistance than those with a low-CONUT score (score <3). The low-CONUT score group had longer median overall survival (64.8 vs 32.3 months, respectively; p<0.001) and longer median progression-free survival (32.3 vs 18.8 months, respectively; p=0.002) than those in the high-CONUT score group. Multivariate analysis showed that the CONUT score was an independent prognostic factor for overall survival.

Conclusions

The CONUT score predicts the prognosis of epithelial ovarian cancer and is thus helpful for individualizing treatment and improving survival in these patients.

Prognostic significance of malignant ascites in gastric cancer patients with peritoneal metastasis: A systemic review and meta-analysis

BACKGROUND

Recent evidence indicates that malignant ascites may be associated with the high malignancy and poor prognosis of gastric cancer (GC) with peritoneal metastasis (PM), but no robust consensus has been reached until now.

AIM

To evaluate the prognostic significance of malignant ascites in GC patients with PM.

METHODS

Two independent authors conducted database searches. The searches were performed in the EMBASE, PubMed, and Cochrane Library databases, and the terms used to search included stomach neoplasms, GC, ascites, peritoneal effusion, survival, and survival analysis. Outcomes included overall survival and hazard ratios with 95% confidence intervals (CIs). Three pairs of comparisons for measuring survival were made: (1) Patients with ascites vs those without ascites; (2) Patients with massive ascites vs those with mild to moderate ascites; and (3) Patients with massive ascites vs those with no to moderate ascites.

RESULTS

Fourteen articles including fifteen studies were considered in the final analysis. Among them, nine studies assessed the difference in prognosis between patients with and without malignant ascites. A pooled HR of 1.63 (95%CI: 1.47-1.82, P < 0.00001) indicated that GC patients with malignant ascites had a relatively poor prognosis compared to patients without ascites. We also found that the prognosis of GC patients with malignant ascites was related to the volume of ascites in the six other studies.

CONCLUSION

GC patients with malignant ascites tend to have a worse prognosis, and the volume of ascites has an impact on GC outcomes.

Prognostic Value of the Nutritional Risk Screening 2002 Scale in Metastatic Gastric Cancer: A Large-Scale Cohort Study

Background: The prognostic value of the nutritional risk screening 2002 (NRS 2002) scale in metastatic gastric cancer remains unclear. We aimed to explore the role of NRS 2002 in metastatic gastric cancer.

Methods: In this study, 1664 metastatic gastric cancer patients at our institution between 2000 and 2015 were retrospectively analyzed. The characteristics and clinical outcomes of the included patients were analyzed.

Results: Receiver operating characteristic (ROC) curves showed that the regrouping NRS 2002 scale (≤ 3 vs. > 3) provided a similar risk stratification predicting 2-year overall survival (OS) (area under the curves [AUCs]: 0.563 vs. 0.564, P > 0.05) but a better stratification predicting the risk of complications of palliative surgery (AUCs: 0.563 vs. 0.522, P = 0.050) than the original NRS 2002 scale (< 3 vs. ≥ 3). Patients with NRS 2002 > 3 tended to have higher postoperative morbidity (13.3% vs. 8.5%, P = 0.027) and mortality (5.3% vs. 2.0%, P = 0.013) and shorter progression-free survival (PFS) (median PFS: 6.70 vs. 7.70 months, P = 0.002) and overall survival (OS) (median OS: 9.03 vs. 12.63 months, P < 0.001) than those with NRS 2002 ≤ 3. Multivariable analysis demonstrated that the regrouping NRS 2002 scale was the independent prognostic factor for PFS (hazard ratio [HR]: 1.16, P = 0.028) and OS (HR: 1.29, P < 0.001).

Conclusions: The present study indicated that the NRS 2002 scale (regrouping scale) was an independent prognostic factor to predict the morbidity, mortality and survival outcomes for metastatic gastric cancer.

Geriatric nutritional risk index is not an independent predictor in patients with diffuse large B-cell lymphoma

BACKGROUND

The prognostic value of geriatric nutritional risk index (GNRI) for diffuse large B-cell lymphoma (DLBCL) treated in the rituximab era was not clear.

OBJECTIVE

To investigate the prognostic impact of GNRI in patients with DLBCL in our hospital.

METHODS

DLBCL patients were recruited and classified into two groups with and without malnutrition based on GNRI. Clinical features, concentration of T-helper cell type (Th1/Th2/Th17) cytokine profiles and overall survival were compared between these two groups.

RESULTS

One hundred and five (39%) out of 267 patients were classified into malnutrition group. Patients with malnutrition had lower levels of albumin and hemoglobin, but older age, higher lactate dehydroxygenase (LDH) level, higher frequencies of advanced stage, poor performance status, B symptoms and extranodal involvement, higher scores of NCCN-IPI and higher level of INF-γ. Moreover, patients with malnutrition had poor overall survival in univariate analyses. But these significances did not stand after stratified analyses by NCCN-IPI, or in the context of NCCN-IPI in the multivariate analyses.

CONCLUSIONS

GNRI is not an independent predictor for DLBCL patients.