Prognostic nutritional index serves as a predictive marker of survival and associates with systemic inflammatory response in metastatic intrahepatic cholangiocarcinoma

Correlation between Neurotransmitters (Dopamine, Epinephrine, Norepinephrine, Serotonin), Prognostic Nutritional Index, Glasgow Prognostic Score, Systemic Inflammatory Response Markers, and TNM Staging in a Cohort of Colorectal Neuroendocrine Tumor Patients

Neuroendocrine tumors are uncommon in the gastrointestinal system but can develop in the majority of the body's epithelial organs. Our goal was to examine the presence and clinical application of serum dopamine (DA), serotonin (ST), norepinephrine (NE), and epinephrine (EPI), in addition to determining the significance of the Prognostic Nutritional Index (PNI), Glasgow Prognostic Score (GPS), and systemic inflammatory response (SIR) markers as a prognostic factor for patients with colorectal neuroendocrine tumors (CR-NETs), in various tumor-node-metastasis (TNM) stages. We also wanted to identify the possible connection between them. This study included 25 consecutive patients who were diagnosed with CR-NETs and a control group consisting of 60 patients with newly diagnosed colorectal cancer (CRC). We used the Enzyme-Linked Immunosorbent Assay (ELISA) technique. This study revealed that CR-NET patients showed significantly higher serum levels of DA compared to CRC patients. We showed that serum DA was present in the early stages of CR-NETs, with increasing levels as we advanced through the TNM stages. Moreover, we found a close relationship between the levels of DA and the inflammation and nutritional status of the CR-NET patients in this study. CR-NET patients from the PNI < 47.00 subgroup had a higher level of DA than those from the PNI ≥ 47.00 subgroup. Pearson's correlation analysis revealed correlations between DA, PNI, and the neutrophil/lymphocyte ratio (NLR) and the platelet/lymphocyte ratio (PLR). Both hematological indices were negatively correlated with albumin (ALB). Our investigation's findings relating to the PNI, GPS, SIR, and DA indicate that these tools can be markers of nutritional and systemic inflammatory status, are simple to use, and are repeatable. Further research on this topic could provide valuable insights into which biomarkers to incorporate into clinical practice for the management of CR-NET patients.

PNI-Based Nomograms to Predict Tumor Progression and Survival for Patients with Unresectable Hepatocellular Carcinoma Undergoing Transcatheter Arterial Chemoembolization

BACKGROUND

The relationship between the prognostic nutritional index (PNI) and the prognosis of malignancy has been increasingly mentioned in recent research. This study aimed to construct nomograms based on the PNI to predict tumor progression and survival in patients with unresectable hepatocellular carcinoma (HCC) undergoing transcatheter arterial chemoembolization (TACE).

MATERIALS AND METHODS

The development set included 785 patients who underwent their first TACE between 2012 and 2016, and the validation set included 336 patients who underwent their first TACE between 2017 and 2018. The clinical outcomes included the time to progression (TTP) and overall survival (OS). Cox regression was applied to screen for independent risk factors of TTP and OS in the development set, and PNI-based nomograms were constructed for TTP and OS. The predictive performance of nomograms was conducted through the C-index, calibration curves, and decision analysis curves in the development set and validation set.

RESULTS

After multivariate analysis, the prognostic predictors of both TTP and OS included portal vessel invasion, extrahepatic metastasis, tumor number, alpha-fetoprotein (AFP) level, longest tumor diameter, and PNI. Furthermore, the Child-Pugh classification and platelets (PLTs) were independent risk factors for OS only. Nomograms for predicting TTP and OS were constructed using TTP and OS prognostic factors. In the development set and the validation set, the C-index of the TTP nomograms was 0.699 (95% confidence interval (CI): 0.680-0.718) and 0.670 (95%CI: 0.638-0.702), and the C-index of the OS nomograms was 0.730 (95%CI: 0.712-0.748) and 0.700 (95%CI: 0.665-0.723), respectively.

CONCLUSION

Nomograms based on the PNI can effectively predict tumor progression and survival in patients with unresectable HCC undergoing TACE.

Measuring direct non-medical burden among patients with advanced non-small cell lung cancer in China: is there a difference in health status?

Objective

This study was conducted to estimate the direct non-medical cost of advanced non-small cell lung cancer (NSCLC) patients and explore whether its associated factors vary by health status.

Methods

Data were obtained from 13 centers in five provinces for patients with advanced NSCLC in China. The direct non-medical cost of patients since the patients were diagnosed with NSCLC included the cost of transportation, accommodation, meal, hired caregiving, and nutrition. We measured patients' health status by EQ-5D-5L instrument and divided them into good (≥0.75) and poor (<0.75) groups based on the utility score. A generalized linear model (GLM) was used to assess independent associations between statistically significant factors and non-medical financial burden in health status subgroups.

Results

Data from 607 patients were analyzed. The direct non-medical cost associated with advanced NSCLC since diagnosis was $2,951 per case ($4,060 in the poor health group and $2,505 in the other), with nutrition costing the most. GLM results showed that residence(Urban area vs. Rural area: -1.038, [-2.056, -0.02]), caregivers' occupation type (Farmer vs. Employee: -1.303, [-2.514, -0.093]), hospitalization frequency (0.077, [0.033, 0.12]), average length of hospital stay (0.101, [0.032, 0.17]), and pathological type (Squamous carcinoma vs. Non-squamous carcinoma: -0.852, [-1.607, -0.097]) were independent factors influencing direct non-medical cost in the poor health group. Among participants with good health status, residence (Urban area vs. Rural area: -0.621, [-1.005, -0.236]), marital status (Others vs. Married: 0.762, [0.035, 1.488]), patients' employment status, current caregiving time per day (more than 9 hours per day vs. less than 3 hours per day: 0.471, [0.134, 0.807]), duration of disease (0.015, [0.007, 0.024]), and hospitalization frequency (0.091, [0.068, 0.113]) were statistically associated factors.

Conclusion

The direct non-medical economic burden of advanced NSCLC patients in China is considerable and differs by health status. Strengthening accessibility for more effective therapies and early nutritional intervention to improve prognosis, and further promoting accessible care forms within relevant healthcare insurance coverage may be potentially feasible approaches to alleviate the direct non-medical economic burden for patients and their families.

Safety and benefits of major hepatectomy with extrahepatic bile duct resection in older perihilar cholangiocarcinoma patients

PURPOSE

To evaluate the safety and benefits of major hepatectomy with extrahepatic bile duct resection in older perihilar cholangiocarcinoma patients and to identify possible predictors of surgical mortality.

METHODS

We retrospectively analyzed the data of 102 consecutive patients who underwent major hepatectomy with extrahepatic bile duct resection for perihilar cholangiocarcinoma in our institution between 2004 and 2021. The patients were included and divided into two groups: older patients ≥ 75 years and non-older patients < 75 years. Patient characteristics, preoperative nutritional and operative risk scores, intraoperative details, postoperative outcomes, and long-term prognosis were compared between the groups. Univariate and multivariate analyses were used to identify the predictors of 90-day mortality after major hepatectomy with extrahepatic bile duct resection.

RESULTS

Significant differences were identified for some preoperative surgical risk scores, but not for nutritional scores. Older patients had a higher morbidity rate of respiratory complications (p = 0.016), but there were no significant differences in overall (p = 0.735) or disease-specific survival (p = 0.858). A high Dasari's score was identified as an independent predictive factor of 90-day mortality.

CONCLUSIONS

Major hepatectomy with extrahepatic bile duct resection can be performed for optimally selected older and younger patients with perihilar cholangiocarcinoma, resulting in a good prognosis. However, indications for extended surgery should be recognized. Dasari's preoperative risk score may be a good predictor of 90-day mortality.

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 Novel Prognostic Tool in Western and Eastern Biliary Tract Cancer Patients Treated in First-line Setting: the ECSIPOT Index

BACKGROUND AND AIM

The need to estimate prognosis of advanced BTC (aBTC) patients treated with first-line chemotherapy is compelling. The aim of the study is to evaluate the ECSIPOT (psECogSIiPnigOT) index, influenced by PECS (PsECogSii) index, prognostic nutritional index (PNI), and GOT.

METHODS

This international study was conducted on a training cohort of 126 patients and in three validation cohorts, both European and Korean. ECSIPOT index formula: (PECS:0 = 1 point; PECS:1 = 1.4 points; PECS:2 = 3.2 points) + (PNI > 36.7 = 1 point; PNI < 36.7 = 2 points) + (GOT < 100 = 1 point; GOT > 100 = 2 points). Event-time distributions were estimated using the Kaplan-Meier method, and survival curves were compared using the log-rank test.

RESULTS

In the training cohort, mOS was 12.9, 6.3, and 2.8 months for patients with ECSIPOT-0, ECSIPOT-1, and ECSIPOT-2, respectively (ECSIPOT-0: HR 1; ECSIPOT-1: HR 2.11; ECSIPOT-2: HR 4.93; p < 0.0001). In the first validation cohort, mOS was 11.5, 7.3, and 3.3 months for ECSIPOT-0, ECSIPOT-1, and ECSIPOT-2, respectively (ECSIPOT-0: HR 1; ECSIPOT-1: HR 1.74; ECSIPOT-2: HR 3.41; p < 0.0001). In the second validation cohort, mOS was 25.2, 12.5, and 3.0 months for ECSIPOT-0, ECSIPOT-1, and ECSIPOT-2, respectively (ECSIPOT-0: HR = 1; ECSIPOT-1: HR 2.33; ECSIPOT-2: HR 8.46; p < 0.0001). In the third validation cohort, mOS was 11.8, 8.1, and 4.6 months for ECSIPOT-0, ECSIPOT-1, and ECSIPOT-2, respectively (ECSIPOT-0: HR = 1; ECSIPOT-1: HR 1.47; ECSIPOT-2: HR 3.17; p < 0.0001). Multivariate analysis in all cohorts confirmed the ECSIPOT index as an independent prognostic factor for OS.

CONCLUSION

The easy assessment and good risk-stratification performance make the ECSIPOT index a promising tool to comprehensively estimate the prognosis of aBTC patients.

Combination of albumin-globulin score and skeletal muscle index predicts long-term outcomes of intrahepatic cholangiocarcinoma patients after curative resection

BACKGROUND & AIMS

Sarcopenia is characterized by loss of skeletal muscle mass and associated with poor postoperative outcomes. This study aimed to investigate the prognostic value of preoperative albumin-globulin score (AGS), skeletal muscle index (SMI) as well as their combination in patients with intrahepatic cholangiocarcinoma (ICC) treated with surgical resection.

METHODS

A total of 613 newly diagnosed ICC patients from two centers were retrospectively analyzed (460 in discovery cohort and 153 in validation cohort). The plain computed tomography images were used to measure SMI. The effect of AGS, SMI and CAS grade on clinicopathological characteristics and long-term outcomes of patients with ICC were analyzed.

RESULTS

The SMI was significantly greater in males than in females. Patients with decreased AGS, increased SMI were associated with improved overall survival (OS) and recurrence-free survival (RFS). Stratefied by CAS grade, 68 (14.8%) patients in grade 1 were associated with increased body mass index (BMI) and best postoperative prognosis, whereas 194 (42.1%) patients in grade 3 were linked to worst OS and RFS. The CAS grade showed a promising accuracy in predicting OS and RFS of ICC patients (area under curves [AUCs] were 0.732 and 0.768). Multiple tumors, MVI and elevated CAS grades were identified as independent risk factors for OS and RFS of ICC patients. These results were confirmed by validation cohort.

CONCLUSION

The present study provided compelling evidence that a novel index based on combination of preoperative AGS and SMI was closely related to postoperative long-term outcomes for surgically treated ICC patients. Preoperative evaluation of CAS grade may be useful for risk classification and clinical therapeutic decision-making for ICC patients.

Prognostic Value of Inflammatory and Tumour Markers in Small-Duct Subtype Intrahepatic Cholangiocarcinoma after Curative-Intent Resection

Intrahepatic cholangiocarcinoma (ICC) is characterised by heterogeneity, and it can be subdivided into small-duct and large-duct types. Inflammatory and tumour markers could effectively predict prognosis in many cancers, but no similar studies have been conducted in the histological subtypes of ICC. A total of 102 and 72 patients with ICC undergoing curative-intent resection were retrospectively subclassified into large-duct and small-duct types by chemical staining, respectively. The prognostic value of inflammatory and tumour markers was studied for the first time in histological subtypes of ICC by using a Cox regression model. A novel predictor named prognostic inflammatory index (PII) was proposed and defined as neutrophil × monocyte/lymphocyte count (10⁹/L). Survival analysis showed that PII, neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), CA242, and ferritin were all predictors of DFS and OS in patients with ICC (P < 0.040). Subgroup analysis showed that PII, CA19-9, and ferritin were risk predictors of disease-free survival (DFS) and overall survival (OS) in small-duct type ICC (P < 0.015). In addition, in small-duct type ICC, NLR and LMR were correlated with OS (P < 0.025), whilst CEA and CA242 were correlated with DFS (P ≤ 0.010). In conclusion, PII is a convenient and efficient inflammatory predictor of DFS and OS in ICCs and their small-duct type. NLR and LMR, rather than platelet-to-lymphocyte ratio, were correlated with OS in small-duct type ICC. In addition, ferritin may be a supplement to CA19-9 in stratifying the survival outcome of patients with small-duct type ICC.

Preoperative risk grade predicts the long-term prognosis of intrahepatic cholangiocarcinoma: a retrospective cohort analysis

Background

Cumulating evidence indicates that the systemic inflammatory response (SIR) plays a crucial role in the prognosis of various cancers. We aimed to generate a preoperative risk grade (PRG) by integrating SIR markers to preoperatively predict the long-term prognosis of intrahepatic cholangiocarcinoma (ICC).

Methods

468 consecutive ICC patients who underwent hepatectomy between 2010 and 2017 were enrolled. The PRG and a nomogram were generated and their predictive accuracy was evaluated.

Results

The PRG consisted of two non-tumor-specific SIR markers platelet-to-lymphocyte ratio (PLR) and albumin (ALB), which were both the independent predictors of overall survival (OS). Multivariate analysis showed that the PRG was significantly associated with OS (PRG = 1: hazard ratio (HR) = 3.800, p < 0.001; PRG = 2: HR = 7.585, p < 0.001). The C-index of the PRG for predicting survival was 0.685 (95% CI 0.655 to 0.716), which was statistically higher than that of the following systems: American Joint Committee on Cancer (AJCC) 8th edition (C-index 0.645), Liver Cancer Study Group of Japan (LCSGJ) (C-index 0.644) and Okabayashi (C-index 0.633) (p < 0.05). Besides, the C-index of the nomogram only consisting of the tumor-specific factors (serum carcinoembryonic antigen, carbohydrate antigen 19-9, tumor number) could be improved to 0.737 (95% CI 0.062–0.768) from 0.625 (95% CI 0.585–0.665) when the PRG was incorporated (p < 0.001).

Conclusions

The PRG integrating two non-tumor-specific SIR markers PLR and ALB was a novel method to preoperative predicting the prognosis of ICC.

Prognostic nutritional index is related to myocardial performance index in newly diagnosed nondiabetic hypertensive patients

Background: Arterial hypertension (AH) leads to systolic and/or diastolic dysfunction of the left ventricle (LV) by causing structural changes in the myocardium. Myocardial performance index (MPI) provides the evaluation of LV systolic and diastolic functions together. Prognostic nutritional index (PNI) is an indicator of immunonutritional status. PNI was studied in patients with malignancy, malnutrition, and cardiovascular diseases so far. It was aimed to investigate the relationship between PNI and MPI in hypertensive patients.Methods: A total of 91 consecutive patients with newly diagnosed AH were included in the study. PNI was calculated according to the following formula: ((10 × serum albumin (g/dL))+(0.005 × total lymphocyte count)). MPI was obtained by dividing the sum of isovolumetric relaxation time (IVRT) and isovolumetric contraction time (IVCT) by the ejection time (ET) ((IVRT+IVCT)/ET). Patients were divided into two groups according to MPI is above or below the value of 0.5. The demographic characteristics and PNI values of patients were compared between two groups.Results: There were 65 patients in the higher and 26 patients were in the normal MPI group. Higher MPI group had male predominance (p = .002). Diastolic blood pressure (p = .021), interventricular septum thickness (p = .005), posterior wall thickness (PWT) (p = .001), serum albumin concentration (p = .045), and PNI (p = .013) were differed between groups. Multivariate logistic regression analysis revealed that PWT [OR = 1.835, 95% CI: 1.126-2.992, p = .015] and PNI [OR = 1.161, 95% CI: 1.004-1.343, p = .018] predicted higher MPI.Conclusion: Higher PNI was an independent predictor of LV dysfunction in newly diagnosed hypertensive patients. Immunonutritional status may be used as an indicator of the left ventricular function in patients with AH.

The prognostic impact of lymphocyte-to-C-reactive protein score in patients undergoing surgical resection for intrahepatic cholangiocarcinoma: A comparative study of major representative inflammatory / immunonutritional markers

BACKGROUND

In many malignancies including intrahepatic cholangiocarcinoma (iCCA), prognostic significance of host-related inflammatory / immunonutritional markers have attracted a lot of attention. However, it is unclear which is the strongest prognostic indicator for iCCA among these markers. The aim of this study was to firstly evaluate the prognostic utility of inflammatory / immunonutritional markers in resected iCCA patients using a multiple comparison in addition to a new marker, lymphocyte-to-C-reactive protein (CRP) score.

METHODS

A total of sixty iCCA patients, who underwent surgical resection between October 2004 and April 2019, were enrolled in this study. Their clinical and pathological data were retrospectively assessed using univariate and multivariate analysis to determine prognostic predictors for disease specific survival (DSS). Moreover, these patients, who were divided into high and low groups based on lymphocyte-to-CRP score, were compared these survival outcomes using Kaplan-Meier analysis with a log-rank test.

RESULTS

In multivariate analysis, the significant prognostic factors were preoperative lymphocyte-to-CRP score (p = 0.008), preoperative CRP-to-albumin ratio (CAR; p = 0.017), pathological T category (p = 0.003), and pathological vascular invasion (p < 0.001). Resected iCCA patients with a low lymphocyte-to-CRP score (score 0) had significant better prognosis than patients with a high score (score 1 or 2) (p = 0.016). Notably, the mortality of the high lymphocyte-to-CRP score group did not show statistically difference from the poor mortality of unresected iCCA patients (p = 0.204).

CONCLUSIONS

Preoperative lymphocyte-to-CRP score was the strongest prognostic indicator in iCCA patients with surgical resection. In these patients, early intervention with nutritional support should be considered prior to operation.

Nutrition and metabolism status alteration in advanced hepatocellular carcinoma patients treated with anti-PD-1 immunotherapy

PURPOSE

The aim of this study was to evaluate the nutrition and metabolism status alteration during immunotherapy in advanced hepatocellular carcinoma (HCC) patients.

METHODS

Patients with advanced HCC who participated in the clinical trials of single-agent anti-PD-1 immunotherapy or sorafenib were retrospectively included. We analyzed self-comparison of the nutritional and metabolic indices of patients in the anti-PD-1 and sorafenib treatment group. We conducted mutual-comparison of the mentioned indices between the disease progression group and disease control group among anti-PD-1 treatment patients. We further analyzed those indices with statistical differences by partial correlation and survival analysis.

RESULTS

Both self-comparison before and after treatment in the anti-PD-1 group and mutual-comparison of disease progression and the control group showed significant differences in multiple indices, but we did not observe significant differences in the sorafenib group. Strikingly, albumin (ALB)/prognostic nutritional index (PNI, calculated by serum albumin and lymphocyte count) decreased distinctly in the immunotherapy disease progression group patients. However, changes in ALB/PNI were not significant in disease progression patients from the sorafenib group or in the disease control patients with immunotherapy. Partial correlation analysis suggested that ALB and PNI were positively correlated with the efficacy of immunotherapy. Furthermore, survival analysis showed that the median progression-free survival and median overall survival of patients in the ALB/PNI decreased group were significantly shorter than those of patients from the ALB/PNI increased group.

CONCLUSION

Anti-PD-1 immunotherapy might alter the nutritional and metabolic status in advanced HCC patients. We also should pay attention to the nutritional and metabolic status of patients when drug resistance is detected.

C-reactive protein : albumin ratio in patients with resectable intrahepatic cholangiocarcinoma

BACKGROUND

The C-reactive protein : albumin ratio (CAR) has been reported as a novel prognostic marker in several cancers. The aim of this study was to investigate the prognostic value of CAR in patients with intrahepatic cholangiocarcinoma (ICC).

METHODS

This was a single-centre retrospective study of patients who underwent surgery for ICC in a university hospital in Japan between 1998 and 2018. CAR, Glasgow Prognostic Score (GPS) and modified GPS (mGPS) were calculated. Their correlation with recurrence-free survival (RFS) and overall survival (OS) was analysed with Cox proportional hazards models.

RESULTS

Seventy-two patients were included in the study. Patients were divided into two groups according to the optimal CAR cut-off value of 0·02. CAR above 0·02 was associated with higher carbohydrate antigen 19-9 levels (20·5 versus 66·1 units/ml for CAR of 0·02 or less; P = 0·002), larger tumour size (3·2 versus 4·4 cm respectively; P = 0·031) and a higher rate of microvascular invasion (9 of 28 versus 25 of 44; P = 0·041). RFS and OS were shorter in patients with CAR above 0·02: hazard ratio (HR) 4·31 (95 per cent c.i. 2·02 to 10·63) and HR 4·80 (1·85 to 16·40) respectively. In multivariable analysis CAR above 0·02 was an independent prognostic factor of RFS (HR 3·29 (1·33 to 8·12); P < 0·001), but not OS.

CONCLUSIONS

CAR was associated with prognosis in patients who had hepatic resection for ICC.

Pretreatment Prognostic Nutritional Index (PNI) as a Prognostic Factor in Patients with Biliary Tract Cancer: A Meta-Analysis

OBJECTIVE

Many reports have shown that the prognostic nutritional index (PNI) is associated with the clinical outcomes of patients with biliary tract cancer (BTC), with the results being inconsistent. We therefore comprehensively evaluated the prognostic significance of the PNI in BTC by performing a meta-analysis.

METHODS

We identified relevant studies by searching PubMed, Embase, Web of Science and, the Cochrane Library. The combined hazard ratio (HR) and odds ratio (OR) with 95% confidence interval (CI) were used to evaluate the association between PNI and overall survival (OS) and the clinical characteristics of BTC.

RESULTS

We included seven studies with 1608 patients in this meta-analysis. The pretreatment low PNI correlated significantly with worse OS (HR = 1.65, 95%CI = 1.42-1.93, p < 0.001). In addition, the prognostic effect of PNI are reliable in different subgroups of ethnicity, sample size, histology, treatment, PNI cutoff, and cutoff determination. The low PNI was also related to poor differentiation (OR = 1.95, 95%CI = 1.34-2.85, p = 0.001) as well as higher T stage (OR = 2.51, 95%CI = 1.69-3.74, p < 0.001) in BTC.

CONCLUSION

The low PNI is significantly associated with inferior prognosis of patients with BTC and aggressive clinical factors. The PNI could be applied as an independent prognostic marker for patients with BTC.

Advanced Biliary Tract Cancer Treated with Gemcitabine plus Cisplatin (GEMCIS) and Novel Inflammatory Markers

OBJECTIVE

It is known that chronic inflammation plays an important role in the etiopathogenesis of biliary tract carcinoma (BTC). In this study, we wanted to examine the effect of neutrophil-to-lymphocyte ratio (NLR), derived neutrophil-to-lymphocyte ratio (dNLR), and prognostic nutritional index (PNI) on survival in advanced BTC treated with gemcitabine plus cisplatin (GEMCIS) regimen.

METHODS

Forty-two patients with advanced BTC treated with GEMCIS regimen were included in the study. Measurements for NLR, dNLR and PNI were calculated with available formulas. NLR, dNLR, and PNI values were dichotomized based on receiver operating characteristic curve analysis (cut-off values 3.94, 2.66, and 46, respectively). Univariate and multivariate analyses were performed to identify prognostic factors for 6-month progression free survival (PFS) and overall survival (OS) using a Cox proportional hazards model.

RESULTS

The mean PFS was 5.3 (median 5) months, and the mean OS was 10.7 (median 11) months. The pre-treatment increased NLR (≥ 3.94) value was prognostic for lower 6-month PFS and 12-month OS rates. dNLR was not found to be important for survival times. Low PNI (< 36) value was prognostic for lower 6-month PFS and 12-month OS rates. In the multivariate analysis, increased NLR value was determined as an independent prognostic factor for 6-month PFS.

CONCLUSION

In patients with advanced BTC using GEMCIS as the first-line chemotherapy regimen, NLR and PNI can be used as prognostic inflammatory markers for 6-month PFS and 12-month OS.

Assessment of Liver Function for Evaluation of Long-Term Outcomes of Intrahepatic Cholangiocarcinoma: A Multi-Institutional Analysis of 620 Patients

Background: Liver function is a routine laboratory test prior to curative liver resection. It remains unclear whether the albumin–bilirubin (ALBI) grade and albumin-to-alkaline phosphatase ratio (AAPR) can predict long-term outcomes of surgically treated patients with intrahepatic cholangiocarcinoma (ICC).

Methods: This study investigated the correlation between ALBI grade and AAPR with overall survival (OS) after liver resection and then compared their accuracy to the Child–Pugh score. Harrell's concordance index (C-index) and Akaike information criterion (AIC) were used to compare accuracy of models.

Results: A total of 620 ICC patients were included, 477 in derivation cohort and 143 for validation. 0.348 was identified as the cutoff value for AAPR after calculating the Youden index. In the derivation cohort, elevated ALBI grade was associated with worse prognosis [hazard ratio (HR): 1.751, 95% confidence interval (CI): 1.329 to 2.306], and a decreased AAPR value was correlated with shorter OS (HR: 1.969, 95% CI: 1.552 to 2.497). Multivariate analysis suggested that the ALBI grade, AAPR, CA19-9, tumor number, and microvascular invasion were independent prognostic predictors for OS. ALBI grade and AAPR showed more accuracy in evaluating OS for surgically treated ICC patients than the Child–Pugh score (C-index: 0.559, 0.600 vs. 0.528; AIC: 3023.84, 3007.73 vs. 3034.66). Our findings were validated in an independent cohort from another clinical center.

Conclusions: Importantly, the ALBI grade and AAPR showed greater discriminatory power than the Child–Pugh score in assessing long-term outcomes following hepatectomy for ICC. The AAPR was more accurate than the ALBI grade. It was beneficial to consider the ALBI grade and AAPR as useful surrogate markers to identify patients at risk of poor postoperative outcomes.

Preoperative gamma-glutamyltransferase to lymphocyte ratio predicts long-term outcomes in intrahepatic cholangiocarcinoma patients following hepatic resection

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is a heterogeneous hepatobiliary cancer with limited treatment options. A number of studies have illuminated the relationship between inflammation-based prognostic scores and outcomes in patients with ICC. However, the use of reliable and personalized prognostic algorithms in ICC after resection is pending.

AIM

To assess the prognostic value of the gamma-glutamyltransferase to lymphocyte ratio (GLR) in ICC patients following curative resection.

METHODS

ICC patients following curative resection (2009-2017) were divided into two cohorts: The derivation cohort and validation cohort. The derivation cohort was used to explore an optimal cut-off value, and the validation cohort was used to further evaluate the score. Overall survival (OS) and recurrence-free survival (RFS) were analyzed, and predictors of OS and RFS were determined.

RESULTS

A total of 527 ICC patients were included and randomly divided into the derivation cohort (264 patients) and the validation cohort (263 patients). The two patient cohorts had comparable baseline characteristics. The optimal cut-off value for the GLR was 33.7. Kaplan-Meier curves showed worse OS and RFS in the GLR > 33.7 group compared with GLR ≤ 33.7 group in both cohorts. After univariate and multivariate analysis, the results indicated that GLR was an independent prognostic factor of OS [derivation cohort: hazard ratio (HR) = 1.620, 95% confidence interval (CI): 1.066-2.462, P = 0.024; validation cohort: HR = 1.466, 95%CI: 1.033-2.142, P = 0.048] and RFS [derivation cohort: HR = 1.471, 95%CI: 1.029-2.103, P = 0.034; validation cohort: HR = 1.480, 95%CI: 1.057-2.070, P = 0.022].

CONCLUSION

The preoperative GLR is an independent prognostic factor for ICC patients following hepatectomy. A high preoperative GLR is associated with worse OS and RFS.

The prognostic nutritional index predicts survival and response to first-line chemotherapy in advanced biliary cancer

BACKGROUND

An accurate risk-stratification is key to optimize the benefit-to-risk ratio of palliative treatment in advanced biliary cancer. We aimed at assessing the impact of the prognostic nutritional index (PNI) on survival and treatment response in advanced biliary cancer (ABC) receiving first-line chemotherapy.

METHODS

Medical records of ABC treated with standard chemotherapy at the Modena Cancer Centre were retrospectively reviewed for variables deemed of potential interest, including the PNI. Univariate and multivariate analyses were performed to investigate the association between the covariates and overall survival (OS).

RESULTS

114 ABC fulfilled the inclusion criteria and made up the training cohort. A PNI cut-off value of 36.7 was established using the receiver operating characteristic (ROC) analysis. At both the univariate and the multivariate analysis, low PNI value (<36.7) was associated with shorter OS (P = .0011), together with increased NLR (P = .0046) and ECOG >1 (P < .0001). The median OS was 5.4 vs 12.1 months in the low- vs high PNI-group. Moreover, a PNI value >36.7 resulted in a higher disease control in patients treated with gemcitabine/platinum combination (61.4% vs 34.3%). These results were validated in an independent cohort of 253 ABC.

CONCLUSIONS

We demonstrated and externally validated a prognostic role for the PNI in ABC treated with first-line chemotherapy. Although the PNI turned out to be predictive in the subset of patients receiving platinum/gemcitabine combination, future prospective confirmation is needed.

Correlation between Prognostic Nutritional Index, Glasgow Prognostic Score, Systemic Inflammatory Response, and TNM Staging in Colorectal Cancer Patients

Background: Various biomarkers have been shown to assess and diagnose colorectal cancer in some researchers. Three indicators including PNI, SIR, GPS were used to predict the outcome for a variety of cancers in existing studies. However, few studies have analyzed the relationship between these biomarkers and different TNM staging. The aim of this study was to investigate the relationship between biomarkers and TNM staging and metastasis of CRC.Patients and methods: Three hundred fifty-five eligible patients were included who were diagnosed with CRC from October 2012 to October 2018 in People's Hospital of Yuxi City. Firstly, we separately calculated PNI, SIR markers and GPS in these patients. Next, the relationship between PNI and GPS with clinical factors were evaluated. Finally, the relationship between TNM staging and tumor metastasis was analyzed.Results: Our results demonstrate that there were statistical differences between PNI and TNM staging, distance metastasis, NLR, PLR, LMR, GPS, CEA, CA199, ALB, L, N, M, PLT, Hb, CRP. GPS with age, TNM staging, distance metastasis, NLR, CA199, ALB, N, CRP have statistical differences. PNI is associated with SIR in patients with CRC, and in which PNI is negatively proportional to NLR and PLR, but positively proportional to LMR.Conclusion: We attempt to combine PNI, SIR, GPS with TNM staging, and the results showed that the three indicators were closely related to TNM staging. Therefore, they can assist in the diagnosis of CRC and are closely related to TNM staging. Detection of three indicators is of important clinical value in the evaluation of TNM staging and metastasis prediction.

Clinical Significance of Prothrombin Time in Cholangiocarcinoma Patients with Surgeries

BACKGROUND

Prothrombin time (PT) can predict survival in several types of malignancies. This study aims to investigate the predictive values of PT levels in patients with cholangiocarcinoma (CCA).

METHODS

We retrospectively analyzed the PT from 86 CCA patients who underwent curative resection in our hospital from December 2008 to August 2017. The relationship between PT and survival times was analyzed through univariate and multivariate analyses (Cox proportional hazards model). Kaplan-Meier curves and log-rank test were used to assess the effects of PT on overall survival (OS) and tumor recurrence-free survival (RFS).

RESULTS

Increased PT level was an effective predictor for OS (P = 0.021; hazard ratio (HR), 1.799) and RFS (P = 0.016; HR, 1.871) in CCA patients, independent of age, tumor differentiation, and TNM stage. In the low PT level group (PT < 12.3 s), patients showed a higher mean OS (23.03 m vs. 14.38 m, P = 0.0250) and RFS (17.78 m vs. 8.30 m, P = 0.0511) than those with high PT levels (PT ≥ 12.3 s). A highly significant association was observed between high PT level and shortened OS (P = 0.0373) and worse RFS (P = 0.0151).

CONCLUSION

Preoperative increase in PT can serve as a simple but effective predictor of poor survival in CCA patients who undergo curative surgeries.

The postoperative peak number of leukocytes after hepatectomy is a significant prognostic factor for cholangiocarcinoma

Cholangiocarcinoma (CCA) is a lethal disease. A new predictive factor to identify patients suitable for adjuvant chemotherapy is needed. The relationship between the long-term prognosis and the perioperative immune responses in patients with CCA remains unclear. We therefore investigated the clinical impact of perioperative immune responses on the long-term prognosis in patients receiving hepatectomy for CCA. We investigated 81 patients who underwent hepatectomy between February 2000 and October 2012: 57 intra-hepatic CCA (iCCA) patients and 24 extra-hepatic CCA (eCCA) patients. We checked the postoperative level of C-reactive protein and the numbers of leukocytes. A multivariate analysis of the clinicopathological factors identified 2 significant risk factors for the overall survival: The postoperative maximum number of leukocytes (PNL) among patient factors (P=0.0406) and the TNM-stage among tumor factors (P=0.0059). On evaluating the distribution of each kind of leukocyte with a multivariate analysis, both the postoperative maximum number of neutrophils (PNN) and the postoperative maximum number of eosinophils (PNE) were detected as significant factors among leukocytes (PNN/PNE, P=0.0367/0.0083). In conclusion, the PNL after hepatectomy was significantly associated with the long-term prognosis in patients with CCA. Changes in the numbers of leukocytes after hepatectomy may be a marker on treatment for CCA.

Association of Preoperative Platelet-to-Lymphocyte Ratio with Poor Outcome in Patients with Distal Cholangiocarcinoma

BACKGROUND

Several preoperative systemic inflammatory parameters, such as the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and Glasgow Prognostic Score, have been reported to be associated with the prognosis of solid tumors. However, there are conflicting survival data regarding these parameters in cholangiocarcinoma.

OBJECTIVES

In this study, we performed a retrospective cohort analysis of patients with distal cholangiocarcinoma (DCC) who underwent surgical resection to evaluate the prognostic value of a cluster of preoperative hematological inflammatory parameters for survival.

METHOD

Fifty-three patients with DCC who underwent pancreaticoduodenectomy with curative intent were enrolled. The optimal cutoff values of hematological inflammatory parameters, including the absolute lym-phocyte count, NLR, PLR, and LMR, were determined by time-dependent receiver operating characteristic analysis. -Results: The univariate analysis for overall survival (OS) of conventional factors and hematological inflammatory parameters identified that portal vein invasion and PLR had p values of ≤0.1. The univariate analysis for disease-free survival (DFS) identified that lymph node metastasis, PLR, lymphocyte count, and number of positive lymph nodes (≥3) had p values of ≤0.1. These factors were incorporated into the full model and variables were selected using the backward stepwise method. The multivariate analysis identified portal vein invasion and high PLR as independent prognostic factors for OS (p = 0.033 and 0.039, respectively) and high PLR and number of positive lymph nodes (≥3) as independent prognostic factors for DFS (p = 0.016 and 0.004, respectively).

CONCLUSIONS

Preoperative PLR assessment may be useful for detecting high-risk DCC patients undergoing surgical resection for aggressive adjuvant therapy.

Systemic inflammation score predicts survival in patients with intrahepatic cholangiocarcinoma undergoing curative resection

Inflammation has a critical role in the development and progression of cancers. We developed a novel systemic inflammation score (SIS) based on lymphocyte, monocyte, and CA19-9 and explored its prognostic value in intrahepatic cholangiocarcinoma (ICC). From January 2005 to December 2011, 322 consecutive ICC patients who underwent curative resection in our center were included in this study, and validated in a retrospective study of 126 patients enrolled from 2012 to 2014. Clinicopathological variables including preoperative serum CA19-9 and LMR were analyzed. The cutoff values of CA19-9 and LMR were determined based on receiver operating characteristics curve analysis in the primary cohort. Kaplan-Meier curves and multivariate Cox-regression analyses were calculated for time to recurrence (TTR) and overall survival (OS). In univariate analysis of all patients, all three inflammatory and tumor marker including NLR ≥ 2.49 (P<0.001), LMR ≤ 4.45 (P=0.002), and CA19-9≥89 (P<0.001) were associated with poor prognoses. When omitting SIS in multivariate analysis, preoperative LMR (P =0.006) and serum CA19-9 (P<0.001) were independent predictors of OS. In addition, elevated CA19-9 (P=0.001), multiple tumors (P<0.001), and lymph node metastasis (P<0.001) were significant predictors of worse recurrence free survival. Moreover, high SIS was significantly associated with aggressive tumor behaviours including large tumor size (P<0.001), multiple tumors (P=0.033), lymphonodus node metastasis (P=0.001), and high TNM stage (P<0.0001). Finally, univariate and multivariate analyses revealed the SIS was an independent predictor for TTR (HR=2.077, 95% CI, 1.365-3.162, P=0.001) and OS (HR=3.133 95% CI, 2.058-4.769, P<0.001). These results were further confirmed in the validation cohort. In conclusions, our findings demonstrate that the SIS as a potentially powerful prognostic biomarker in ICC that predicts poor clinical outcomes and is a promising tool for ICC treatment strategy decisions.

Prognostic value of inflammation-based indexes for intrahepatic cholangiocarcinoma following curative resection

It is widely acknowledged that inflammatory indices may serve as effective prognosis indicators for various malignancies. In the present study, the prognostic value of systemic inflammatory biomarkers for patients undergoing curative resection for intrahepatic cholangiocellular carcinoma (ICC) was investigated. Clinical data of ICC patients who underwent curative resection between September 2008 and July 2017 were collected. Inflammatory indictors were analyzed using the Area Under the Receiver Operating Characteristic Curve. Indictors that were significantly associated with the overall survival (OS) were used to establish a systemic inflammation-based score system and tested via nomogram using R software. The neutrophil To lymphocyte ratio (NLR) and lymphocyte to macrophages ratio (LMR) were significantly associated with the OS and disease-free survival of the patients. High NLR and low LMR were associated with worse clinicopathological and survival outcomes. The univariate and multivariate analyses indicated that tumor T stage, incisal margin, NLR and LMR were associated with the OS of the patients. The systemic inflammation-based scoring system based on LMR and NLR demonstrated a stronger discriminatory capacity and may serve as a useful prognostic parameter for patients undergoing curative resection for ICC. Low LMR and high NLR were observed to be associated with poor prognosis and worse clinical outcomes for patients with ICC undergoing curative surgery. A combined inflammation-based scoring system based on LMR and NLR may effectively predict the outcomes and serve as a novel prognostic predictor for these patients.

Prognostic significance of preoperative prognostic nutritional index in hepatocellular carcinoma: a meta-analysis

BACKGROUND

To date, epidemiological evidence of the association between preoperative prognostic nutritional index (PNI) and the prognosis of hepatocellular carcinoma (HCC) remains controversial.

METHODS

A literature search was performed in the databases of PubMed, Embase, and Web of Science. Hazard ratio (HR), odds ratio (OR), and 95% confidence interval (CI) were extracted to estimate the association of preoperative PNI with overall survival (OS), disease-free survival (DFS), and postoperative recurrence of HCC, respectively. A random-effects model was used to calculate the pooled effect size.

RESULTS

Thirteen studies with a total of 3,738 patients with HCC met inclusion criteria for this meta-analysis. It indicated that a lower level of preoperative PNI was a significant predictor of worse OS (HR = 1.82, 95%CI: 1.44-2.31) and DFS (HR = 1.49, 95% CI: 1.06-2.07). In addition, risk of postoperative recurrence was significantly higher in patients with a lower preoperative PNI (OR = 1.92, 95% CI: 1.33-2.76). Subgroup analysis based on therapeutic intent demonstrated a significant positive association between preoperative low PNI and worse OS for those patients undergoing surgical resection and for those undergoing TACE or non-surgical treatment.

CONCLUSION

The current meta-analysis demonstrates that preoperative PNI is a prognostic marker in HCC.

Prognostic value of preoperative prognostic nutritional index and its associations with systemic inflammatory response markers in patients with stage III colon cancer

Background

The prognostic nutritional index (PNI) has been widely applied for predicting survival outcomes of patients with various malignant tumors. Although a low PNI predicts poor prognosis in patients with colorectal cancer after tumor resection, the prognostic value remains unknown in patients with stage III colon cancer undergoing curative tumor resection followed by adjuvant chemotherapy. This study aimed to investigate the prognostic value of PNI in patients with stage III colon cancer.

Methods

Medical records of 274 consecutive patients with stage III colon cancer undergoing curative tumor resection followed by adjuvant chemotherapy with oxaliplatin and capecitabine between December 2007 and December 2013 were reviewed. The optimal PNI cutoff value was determined using receiver operating characteristic (ROC) curve analysis. The associations of PNI with systemic inflammatory response markers, including lymphocyte-to-monocyte ratio (LMR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP) level, and clinicopathologic characteristics were assessed using the Chi square or Fisher’s exact test. Correlation analysis was performed using Spearman’s correlation coefficient. Disease-free survival (DFS) and overall survival (OS) stratified by PNI were analyzed using Kaplan–Meier method and log-rank test, and prognostic factors were identified by Cox regression analyses.

Results

The preoperative PNI was positively correlated with LMR (r = 0.483, P < 0.001) and negatively correlated with NLR (r = − 0.441, P < 0.001), PLR (r = − 0.607, P < 0.001), and CRP level (r = − 0.333, P < 0.001). A low PNI (≤ 49.22) was significantly associated with short OS and DFS in patients with stage IIIC colon cancer but not in patients with stage IIIA/IIIB colon cancer. In addition, patients with a low PNI achieved a longer OS and DFS after being treated with 6–8 cycles of adjuvant chemotherapy than did those with < 6 cycles. Multivariate analyses revealed that PNI was independently associated with DFS (hazard ratios 2.001; 95% confidence interval 1.157–3.462; P = 0.013).

Conclusion

The present study identified preoperative PNI as a valuable predictor for survival outcomes in patients with stage III colon cancer receiving curative tumor resection followed by adjuvant chemotherapy.

Prognostic Implication of Inflammation-based Prognostic Scores in Patients with Intrahepatic Cholangiocarcinoma Treated with First-line Gemcitabine plus Cisplatin

Background We aimed to comprehensively evaluate the prognostic value of inflammation-based prognostic scores, including the modified Glasgow Prognostic Score (mGPS), neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR), exclusively in patients with advanced intrahepatic cholangiocarcinoma (iCCA). Methods Between May 2010 and April 2015, 305 patients with histologically documented unresectable or metastatic iCCA were treated with first-line gemcitabine plus cisplatin (GemCis). Among these, 257 patients had complete data for inflammation-based prognostic scores and were included. Results Median age was 59 (range: 27-78) years, and 158 patients (61.5%) were males. High mGPS was independently associated with poor progression-free survival (PFS; mGPS ≥1 vs. 0: median, 3.9 vs. 5.5 months; P = 0.001) and overall survival (OS; mGPS ≥1 vs. 0; median, 6.9 vs. 14.1 months; P = 0.002) in the multivariate analysis. Regarding high NLR (> median) and PLR (> median), although a potential association existed with poor PFS or OS in the univariate analysis, these did not remain as significant in the multivariate analyses. Conclusion The current study suggests that mGPS might be the relevant prognostic index that could stratify the survival outcomes of patients with unresectable or metastatic iCCA who received first-line GemCis.

Validation of a novel prognostic scoring system using inflammatory response biomarkers in patients undergoing curative thoracoscopic esophagectomy for esophageal squamous cell carcinoma

Background

Systemic inflammatory markers, including the lymphocyte-to-monocyte ratio, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio have been shown to predict postoperative recurrence and survival in various types of cancer. However, their role in esophageal cancer has yet to be determined. This study aimed to evaluate the prognostic significance of an inflammatory response biomarker (IRB) score, independent of conventional clinicopathological criteria, in patients with esophageal cancer undergoing curative resection.

Patients and methods

We retrospectively reviewed a database containing the medical records of 147 consecutive patients who underwent curative esophagectomy for esophageal squamous cell carcinoma. The IRB score was determined as follows: a low lymphocyte-to-monocyte ratio (<4), a low neutrophil-to-lymphocyte ratio (<1.6), and a high platelet-to-lymphocyte ratio (>147), which were each scored as 1, with all remaining values scored as 0. The scores were added together to produce the IRB score (range: 0–3).

Results

An IRB score of 2–3 (hazard ratio: 6.023, 95% confidence interval: 1.675–13.078; P<0.01) was identified as an independent poor prognostic factor of cancer-specific survival (CSS) in a multivariate logic regression analysis. The 5-year CSS rates in patients with the IRB scores of 0−1, 2, and 3 were 37.8%, 67.8%, and 72.5%, respectively. As determined by Kaplan–Meier analysis and the log-rank test, these differences were significant (P<0.001).

Conclusion

The IRB score can predict the systemic inflammatory response as accurately as conventional tumor markers and is useful for determining CSS in patients with esophageal cancer undergoing curative thoracoscopic esophagectomy.