Controlling Nutritional Status (CONUT) Score is Associated with Overall Survival in Patients with Unresectable Hepatocellular Carcinoma Treated with Lenvatinib: A Multicenter Cohort Study

Associations of Preoperative Nutritional Status and Sarcopenia With Mortality in Patients With Abdominal Aortic Aneurysm After Open and Endovascular Abdominal Aortic Aneurysm Repair: A Retrospective Study

OBJECTIVE

The effect of preoperative malnutrition and sarcopenia on outcomes in patients with abdominal aortic aneurysm (AAA) after open surgical repair (OSR) and endovascular abdominal aortic aneurysm repair is undefined. The authors conducted the study to address this issue in this population.

DESIGN

A retrospective observational study.

SETTING

A large tertiary hospital.

PARTICIPANTS

Patients with AAA who underwent OSR and endovascular aneurysm repair (EVAR).

INTERVENTIONS

Evaluation of nutritional status (Nutritional Risk Screening 2002 [NRS 2002] and the Controlling Nutritional Status [CONUT] scores), muscle size (skeletal muscle index), and postoperative parameters.

MEASUREMENTS AND MAIN RESULTS

A total of 199 patients were reviewed from January 2020 to December 2022. Patients weew categorized into group A (CONUT <4) and group B (CONUT ≥4) based on whether their CONUT scores were less than 4. The mortality (p = 0.004) and the incidence of Clavien-Dindo class III complications (p = 0.007) in group B were higher than those in group A. CONUT score was an independent risk factor for midterm mortality (hazard ratio 1.329; 95% CI, 1.104-1.697; p = 0.002) and Clavien-Dindo class III complications (odds ratio 1.225; 95% CI, 1.012-1.482; p = 0.037) according to univariate and multivariate analyses, whereas NRS 2002 score and sarcopenia were not. Kaplan-Meier curves showed a lower midterm survival rate in group B (log-rank p < 0.001).

CONCLUSION

In patients with AAA undergoing OSR or EVAR, a CONUT score ≥4 was associated with increased Clavien-Dindo class III complications and mortality. Preoperative nutritional status should be evaluated and optimized in this high-risk population.

Controlling Nutritional Status (CONUT) Score is Associated with Overall Survival in Patients with Hepatocellular Carcinoma Treated with Conventional Transcatheter Arterial Chemoembolization: A Propensity Score Matched Analysis

PURPOSE

This study aims to evaluate the prognostic value of controlling nutritional status (CONUT) score in determining the prognosis of patients with hepatocellular carcinoma (HCC) treated with conventional transcatheter arterial chemoembolization (cTACE).

METHODS

This study retrospectively analyzed 936 patients who underwent cTACE for HCC between January 2012 and December 2018, and divided them into two groups based on their CONUT score. To balance the bias in baseline characteristics, propensity score matched (PSM) analysis was conducted. The Kaplan-Meier method was used to establish a cumulative survival curve, and the log-rank test was employed to determine differences in overall survival (OS) and progression-free survival (PFS) among the CONUT score groups. Furthermore, the Cox proportional hazard model was employed to assess the correlation between CONUT score and OS and PFS, whereby hazard ratios (HRs) and 95% confidence intervals (95% CIs) were computed.

RESULTS

Before PSM, the median OS for the low (≤ 3) and high (≥ 4) CONUT group (558 vs. 378 patients) was 21.7 and 15.6 months, respectively, and the median PFS was 5.7 and 5 months. Following PSM, both the low and high CONUT score groups comprised 142 patients. The low CONUT score group exhibited a significantly longer OS compared to the high CONUT score group, as determined by the log-rank test (median OS 22.2 vs. 17.0 months, P = 0.014). No significant association was observed between CONUT group and PFS (median PFS 6.4 vs. 4.7 months, log-rank test, P = 0.121). Cox proportional hazard regression analysis revealed that a CONUT score of ≥ 4 was an independent risk factor for OS in patients with HCC who underwent cTACE (HR = 1.361; 95% CI: 1.047-1.771; P = 0.022). These findings were consistent across most subgroup analyses.

CONCLUSION

A high CONUT score has been found to be a prognostic factor for poorer OS in patients with HCC who underwent cTACE.

LEVEL OF EVIDENCE

Level 3, Non-randomized controlled cohort.

Controlling the nutritional status score: a new tool for predicting postoperative mortality in patients with infrarenal abdominal aortic aneurysm treated with endovascular aneurysm repair

Background

AAA is a fatal condition that commonly occurs during vascular surgery. Nutritional status exerts a significant influence on the prognosis of various pathological conditions Scores from the CONUT screening tool have been shown to predict outcomes of certain malignancies and chronic diseases. However, the ramifications of nutritional status on AAA patients undergoing EVAR have not been elucidated in prior studies. In this study, we aimed to elucidate the correlation between CONUT scores and postoperative prognostic outcomes in patients with AAA undergoing EVAR.

Methods

This was a retrospective review of 177 AAA patients treated with EVAR from June 2018 to November 2019 in a single center. Patient characteristics, CONUT scores, and postoperative status were collected. These patients were stratified into groups A and B according to CONUT scores. Subsequently, a comparative analysis of the baseline characteristics between the two cohorts was conducted. Cox proportional hazards and logistic regression analyses were employed to identify the autonomous predictors of mid-term mortality and complications, respectively.

Results

Compared with group A, patients in group B had higher midterm mortality (p < 0.001). Univariate analysis showed that CONUT scores; respiratory diseases; stent types; preoperative Hb, CRP, PT, and Fb levels were risk factors for death. Multivariate analysis confirmed that CONUT score [HR, 1.276; 95% CI, 1.029-1.584; p = 0.027] was an independent risk factor for mortality. Logistic regression analysis showed that prior arterial disease, smoking, and D-dimer levels were risk factors, although multivariate analysis showed smoking (OR, 3.492; 95% CI, 1.426-8.553; p = 0.006) was an independent risk factor. Kaplan-Meier curves showed that patients in group B had shorter mid-term survival than those in group A (log-rank p < 0.001).

Conclusion

Malnutrition was strongly associated with mid-term mortality in patients with infrarenal AAA treated with EVAR.

The Performance of a Survival Nomogram and Albumin-Bilirubin Grade as Prognostic Tools in Advanced Hepatocellular Carcinoma Treated with FOLFOX4

BACKGROUND

The ability of the survival nomogram developed in the EACH study and albumin-bilirubin (ALBI) grade to predict the survival of advanced hepatocellular carcinoma (HCC) patients receiving oxaliplatin plus 5-fluorouracil/leucovorin (FOLFOX4) remains unvalidated. Here, we comprehensively evaluated these prognostic tools.

METHODS

The survival nomogram and ALBI grade of each patient were assessed, and the area under the receiver operating curve (AUROC) and Harrell's C-index for the risk classification model were calculated.

RESULTS

Overall, 76 HCC patients who received FOLFOX4 between August 2017 and June 2023 were included. The survival nomogram classified patients into low-, intermediate-, and high-risk groups, with a median overall survival (OS) of 9.82, 10.64, and 3.70 months, respectively (p = 0.23). The AUROC was 0.621 and Harrell's C-index was 0.589. However, the ALBI grade categorized all patients into grade 1, 2, and 3, with a median OS of 9.82, 6.83, and 1.58 months, respectively (p = 0.00024). The AUROC was 0.663 and Harrell's C-index was 0.663.

CONCLUSION

The ALBI grade can be a potential prognostic tool. However, the survival nomogram does not provide clear discrimination. Therefore, FOLFOX4 should be an option for patients with ALBI grade 1 who cannot receive immunotherapy or targeted therapy. Additional prospective studies with a larger cohort are warranted to validate the survival nomogram and ALBI grade as prognostic tools.

Development of a Multivariate Prognostic Model for Lenvatinib Treatment in Hepatocellular Carcinoma

BACKGROUND

Lenvatinib is a first-line agent for advanced hepatocellular carcinoma (HCC), but individual responses to treatment are highly heterogeneous. The aim of this study was to investigate the clinical parameters that influence the efficacy of Lenvatinib and to develop a prognostic model.

METHODS

We retrospectively enrolled 333 Lenvatinib-treated patients with HCC with a median age of 57 years. Two hundred nd sixty-three of these patients had BCLC (2022) stage C. The median overall survival (mOS) time within the cohort was 12.1 months, and the median progression-free survival (mPFS) time was 4.7 months. Univariate Cox regression, best subset regression, and Lasso regression were used to screen primary variables for possible contribution to OS, multivariate Cox analysis was used to fit selected models, and the final model was selected using the maximum area under the curve (AUC) and minimum AIC. Receiver operating curves (ROC), calibration curves, and decision curve analysis were plotted to assess model performance, and 5-fold cross-validation was performed for internal validation. X-tile software was used to select the best cutoff points and to divide the study cohort into 3 different risk groups.

RESULTS

Seven variables were included in the final model: BCLC stage, prior transarterial chemoembolization and immunotherapy history, tumor number, prognostic nutritional index, log (alpha-fetoprotein), and log (platelet-to-lymphocyte ratio). We named this final model the "multivariate prognostic model for Lenvatinib" (MPML), and a nomogram was constructed to predict the probability of survival at 6, 9, and 12 months. The MPML had good discrimination, calibration, and applicability. Cross-validation showed mean AUC values of 0.7779, 0.7738, and 0.7871 at 6, 9, and 12 months, respectively. According to nomogram points, mOS time was 21.57, 8.70, and 5.37 months in the low, medium, and high-risk groups, respectively (P < .001), and these differences were also observed in the PFS survival curve (P < .001).

CONCLUSIONS

The MPML stratified patients according to baseline clinical characteristics had a strong performance in predicting Lenvatinib efficacy and has the potential for use as an auxiliary clinical tool for individualized decision-making.

The controlling nutritional status score predicts postoperative mortality in patients with ruptured abdominal aortic aneurysm: a retrospective study

Background

Ruptured abdominal aortic aneurysms (rAAAs) are challenging for vascular surgeons because they have a high mortality rate. In many diseases, nutritional status is closely associated with prognosis. The Controlling Nutritional Status (CONUT) screening tool score is a prognostic factor in some malignant and chronic diseases; however, the impact of nutritional status on rAAA has not yet been reported. In this study, we explored the relationship between the CONUT score and the postoperative prognosis of patients with rAAA.

Methods

This was a retrospective review of 39 patients with rAAA who underwent surgical treatment from March 2018 to September 2021 at one center. Patient characteristics, nutritional status (CONUT score), and postoperative status were recorded. The patients were divided into groups A and B based on the CONUT score. The baseline characteristics of the two groups were compared, and Cox proportional hazards and logistic regression analyses were used to determine independent predictors of mid-term mortality and complications, respectively.

Results

The overall mid-term mortality rate was 28.21% (11/39). Compared with group A, group B had higher intraoperative (P = 0.047) and mid-term mortality (P = 0.033) rates. The univariate analysis showed that age [hazard ratio (HR), 1.098; 95% confidence interval (CI), 1.019-1.182; P = 0.014], CONUT score (HR, 1.316; 95% CI, 1.027-1.686; P = 0.03), and surgical procedure (HR, 0.127; 95% CI, 0.016-0.992; P = 0.049) were associated with mid-term mortality, whereas the multivariate analysis showed that the CONUT score (HR, 1.313; 95% CI, 1.009-1.710; P = 0.043) was an independent predictor of mid-term mortality. The multivariate logistic regression analysis did not reveal any associations with complications. The Kaplan-Meier curves showed that group B had a lower mid-term survival rate (log-rank P = 0.024).

Conclusion

Malnutrition is closely associated with the prognosis of patients with rAAA, and the CONUT score can be used to predict mid-term mortality.

Five years of lenvatinib in hepatocellular carcinoma: are there any predictive and/or prognostic factors?

INTRODUCTION

Lenvatinib was the first drug approved in 2017 for first-line treatment of hepatocarcinoma (HCC) after 10 years of Sorafenib as exclusive standard of care. The therapeutic armamentarium has recently expanded following the approval of atezolizumab plus bevacizumab.

AREAS COVERED

Numerous studies have been conducted during the past 5 years on Lenvatinib use in real-world settings in an effort to determine prognostic and predictive factors of Lenvatinib efficacy. In order to choose the most effective therapeutic approach, it may be helpful to summarize these results in this review.

EXPERT OPINION

A subgroup that appears to benefit most from Lenvatinib therapy are patients with non-viral cirrhosis. This aspect is of great importance today considering the increase in NASH prevalence. Also, a significant proportion of BCLC B patients appear to respond well to Lenvatinib therapy. The biological heterogeneity highlighted in HCC patients, along with the growing number of therapeutic options, makes the identification of stratification tools able to define which patients are more likely to respond to a treatment rather than another one of crucial interest. Further investigation deepening the biological pathways underlying HCC carcinogenesis are of particular interest in order to pave the way for precision medicine even for HCC patients.

Controlling Nutritional Status (CONUT) as a Novel Postoperative Prognostic Marker in Breast Cancer Patients: A Retrospective Study

PURPOSE

This investigation seeks to elucidate the potential prognostic significance as well as the clinical utility of the controlling nutritional status (CONUT) score in breast cancer patients.

METHODS

Breast cancer patients managed in our center between January 2010 and December 2016 were recruited for our study. They comprised 187 patients who did not undergo neoadjuvant chemotherapy and 194 who did. A receiver operating characteristic curve (ROC) was utilized in identifying the ideal cut-off CONUT value. This cut-off score was then used to reclassify patients into those with high CONUT scores (≥1) and low CONUT scores (<1). The outcomes were analyzed by statistical methods.

RESULTS

Univariate and multivariate Cox regression survival analyses revealed that a CONUT score cut-off of 1 was able to significantly predict duration of disease-free survival (DFS) (p < 0.001; hazard ratio [HR]: 3.184; 95% CI: 1.786-5.677; and p < 0.001; HR: 2.465; 95% CI: 1.642-3.700) and overall survival (OS) (p < 0.001; HR: 2.326; 95% CI: 1.578-3.429; and p < 0.001; HR: 2.775; 95% CI: 1.791-4.300). The mean DFS and OS in those with lower CONUT scores were 41.59 (95% CI: 37.66-45.51 months) and 77.34 months (95% CI: 71.79-82.90 months), respectively. On the other hand, the average DFS and OS for all individuals in the raised CONUT score group were 39.18 (95% CI: 34.41-43.95 months) and 71.30 months (95% CI: 65.47-77.12 months), respectively. Moreover, Kaplan-Meier survival analysis revealed that those in the raised CONUT score cohort had remarkably worse DFS and OS survival rates compared to individuals in the low CONUT score cohort (Log-rank test, DFS: χ 2 = 12.900, p = 0.0003, and OS: χ 2 = 16.270, p < 0.0001).

CONCLUSION

The survival times of breast cancer patients may be reliably predicted using the CONUT score. This score is an easy, convenient, readily accessible, and clinically significant means of prognosticating patients with breast cancer.

Nomograms including the controlling nutritional status score in patients with hepatocellular carcinoma undergoing transarterial chemoembolisation for prediction survival: a retrospective analysis

This retrospective study investigated the predictive value of the Controlling Nutritional Status (CONUT) score in patients with intermediate-stage hepatocellular carcinoma (HCC) who received transarterial chemoembolization (TACE). Nomograms were developed to predict progression-free and overall survival (PFS, OS). The medical data of 228 patients with HCC and treated with TACE were collected. The patients were apportioned to 2 groups according to CONUT score: low or high (<4, ≥4). Univariate and multivariate analyses were performed using Cox regression for OS and PFS. OS and PFS were estimated by the Kaplan-Meier curve and compared with the log-rank test. Nomograms were constructed to predict patient OS and PFS. The nomograms were evaluated for accuracy, discrimination, and efficiency. The cut-off value of CONUT score was 4. The higher the CONUT score, the worse the survival; Kaplan-Meier curves showed significant differences in OS and PFS between the low and high CONUT score groups (P = 0·033, 0·047). The nomograms including CONUT, based on the prognostic factors determined by the univariate and multivariate analyses, to predict survival in HCC after TACE were generated. The CONUT score is an important prognostic factor for both OS and PFS for patients with intermediate HCC who underwent TACE. The cut-off value of the CONUT score was 4. A high CONUT score suggests poor survival outcomes. Nomograms generated based on the CONUT score were good models to predict patient OS and PFS.

Associations Among Multimorbid Conditions in Hospitalized Middle-aged and Older Adults in China: Statistical Analysis of Medical Records

BACKGROUND

Multimorbidity has become a new challenge for medical systems and public health policy. Understanding the patterns of and associations among multimorbid conditions should be given priority. It may assist with the early detection of multimorbidity and thus improve quality of life in older adults.

OBJECTIVE

This study aims to comprehensively analyze and compare associations among multimorbid conditions by age and sex in a large number of middle-aged and older Chinese adults.

METHODS

Data from the home pages of inpatient medical records in the Shenzhen National Health Information Platform were evaluated. From January 1, 2017, to December 31, 2018, inpatients aged 50 years and older who had been diagnosed with at least one of 40 conditions were included in this study. Their demographic characteristics (age and sex) and inpatient diagnoses were extracted. Association rule mining, Chi-square tests, and decision tree analyses were combined to identify associations between multiple chronic conditions.

RESULTS

In total, 306,264 hospitalized cases with available information on related chronic conditions were included in this study. The prevalence of multimorbidity in the overall population was 76.46%. The combined results of the 3 analyses showed that, in patients aged 50 years to 64 years, lipoprotein metabolism disorder tended to be comorbid with multiple chronic conditions. Gout and lipoprotein metabolism disorder had the strongest association. Among patients aged 65 years or older, there were strong associations between cerebrovascular disease, heart disease, lipoprotein metabolism disorder, and peripheral vascular disease. The strongest associations were observed between senile cataract and glaucoma in men and women. In particular, the association between osteoporosis and malignant tumor was only observed in middle-aged and older men, while the association between anemia and chronic kidney disease was only observed in older women.

CONCLUSIONS

Multimorbidity was prevalent among middle-aged and older Chinese individuals. The results of this comprehensive analysis of 4 age-sex subgroups suggested that associations between particular conditions within the sex and age groups occurred more frequently than expected by random chance. This provides evidence for further research on disease clusters and for health care providers to develop different strategies based on age and sex to improve the early identification and treatment of multimorbidity.

The ALBI score: From liver function in patients with HCC to a general measure of liver function

The (albumin-bilirubin) ‘ALBI’ score is an index of ‘liver function’ that was recently developed to assess prognosis in patients with hepatocellular carcinoma, irrespective of the degree of underlying liver fibrosis. Other measures of liver function, such as model for end-stage liver disease (MELD) and Child-Pugh score, which were introduced for specific clinical scenarios, have seen their use extended to other areas of hepatology. In the case of ALBI, its application has been increasingly extended to chronic liver disease in general and in some instances to non-liver diseases where it has proven remarkably accurate in terms of prognosis. With respect to chronic liver disease, numerous publications have shown that ALBI is highly prognostic in patients with all types and stages of chronic liver disease. Outside of liver disease, ALBI has been reported as being of prognostic value in conditions ranging from chronic heart failure to brain tumours. Whilst in several of these reports, explanations for the relationship of liver function to a clinical condition have been proposed, it has to be acknowledged that the specificity of ALBI for liver function has not been clearly demonstrated. Nonetheless, and similar to the MELD and Child-Pugh scores, the lack of any mechanistic basis for ALBI’s clinical utility does not preclude it from being clinically useful in certain situations. Why albumin and bilirubin levels, or a combination thereof, are prognostic in so many different diseases should be studied in the future.

Safety and Efficacy of Sintilimab and Anlotinib as First Line Treatment for Advanced Hepatocellular Carcinoma (KEEP-G04): A Single-Arm Phase 2 Study

Purpose

Immune checkpoint inhibitors plus antiangiogenic tyrosine kinase inhibitors may offer a first-line treatment for advanced hepatocellular carcinoma (HCC). In this phase 2 trial [registered with clinicaltrials.gov (NCT04052152)], we investigated the safety and efficacy of first-line anti-PD-1 antibody sintilimab plus antiangiogenic TKI anlotinib for advanced HCC.

Methods and Materials

Pathologically-proven advanced HCC patients received sintilimab (200 mg) on day 1 and anlotinib (12 mg) once daily on days 1 to 14 every 3 weeks, with a safety run-in for the first six participants to assess dose-limiting toxicities (DLTs). The primary endpoints were safety and objective response rate (ORR) per RECIST v1.1.

Results

Twenty advanced HCC patients were enrolled. No DLTs occurred in the safety run-in. All patients had treatment-related adverse events (TRAEs). Grade 3 TRAEs occurred in 8 (40.0%) patients, the most common being decreased platelet count (10.0%) and increased γ-glutamyl transferase (10.0%). No grade 4/5 TRAEs occurred. Five (25%) patients developed immune-related AEs. The ORR was 35.0% (95%CI 15.4%-59.2%) per RECIST v1.1 and 55.0% (95%CI 31.5%-76.9%) per modified RECIST. At data cutoff (March 31, 2021), the median progression-free survival was 12.2 months (95%CI, 3.8 to not reached). The median PFS was significantly longer in patients with lower LDH levels (not reached [NR], 95% CI, 8.7 to NR vs. higher LDH levels 5.2 months, 95% CI 3.4 to NR; P=0.020) and a CONUT score ≤2 (NR, 95% CI 5.1 to NR vs. CONUT score >2 6.2 months, 95% CI 1.8 to NR; P=0.020). Furthermore, patients showing tumor response had a significantly higher median proportion of CD16⁺CD56⁺ NK cells than patients who had stable or progressive disease (21.6% vs. 14.6%; P=0.026).

Conclusion

Sintilimab plus anlotinib showed promising clinical activities with manageable toxicity as first-line treatment of advanced HCC.

The Controlling Nutritional Status (CONUT) Score and Prognosis in Malignant Tumors: A Systematic Review and Meta-Analysis

Increasing evidences indicate that the controlling nutritional status (CONUT) score is associated with cancer prognosis. This study was conducted to investigate the prognostic significance of pretreatment CONUT score on patients with various malignant tumors. The correlation between CONUT score and clinical outcomes of tumor patients were studied by electronic literature retrieval. Pooled hazard ratios (HR), odds ratios (OR) and 95% confidence intervals (95% CI) were calculated to clarify the conclusion. Subgroup analysis were conducted in line with cancer type, cancer stage, treatment, sample size and cut-off value. A total of 62 studies involving 25224 patients were included in this study. Pooled analysis showed that higher CONUT scores were associated with shorter overall survival (HR 1.62, 95% CI 1.45-1.79, p < 0.001), cancer-specific survival (HR 1.80, 95% CI 1.48-2.13, p < 0.001), progress/recurrence-free survival (HR 1.54, 95% CI 1.23-1.85, p < 0.001) and disease-free survival (HR 1.56, 95% CI 1.39-1.74, p < 0.001). In addition, high CONUT score was correlated to higher incidence of postoperative complications (OR 1.64, 95% CI 1.38-1.95, p < 0.001) and mortality (OR 4.22, 95% CI 2.22-8.02, p < 0.001). Consequently, the pretreatment CONUT score is a valuable indicator to predict the clinical outcomes of patients with various malignant tumors.

Impact of Controlling nutritional status (CONUT) in patients with unresectable advanced pancreatic cancer receiving multi-agent chemotherapy: A single center, retrospective cohort study

Controlling nutritional status (CONUT) calculated using the serum albumin concentration, total lymphocyte count, and total cholesterol, was developed as a screening tool for the early detection of undernutrition. In addition, CONUT has been reported to be a prognostic predictor of various malignancies.

AIM

To investigate the impact of CONUT in patients with advanced pancreatic cancer (APC).

METHODS

Between June 2014 and October 2020, 110 consecutive patients with APC who received multi-agent chemotherapy were retrospectively reviewed. Patients were classified into four categories (normal, 1; light, 2; moderate, 3; severe, 4) based on CONUT. Progression-free survival (PFS) and overall survival (OS) were evaluated.

RESULTS

Thirty-nine (35.4%), 63 (57.2%), and 8 (7.2%) patients had CONUT 1, 2, and 3, respectively, but no patients for CONUT 4. The baseline characteristics did not differ significantly between CONUT classifications. In the multivariate analyses, the presence of metastasis (hazard ratio [HR], 2.06; 95% confidence interval [CI], 1.22-3.52), CONUT 2 (HR, 2.15; 95% CI, 1.32-3.54), and CONUT 3 (HR, 9.18; 95% CI, 2.67-23.50) were independent risk factors for PFS. The presence of metastasis (HR, 1.76; 95% CI, 1.04-3.07), CONUT 2 (HR, 1.92; 95% CI, 1.16-3.24), and CONUT 3 (HR, 10.71; 95% CI, 3.87-27.63) were also independent risk factors for OS. A median OS in CONUT 1, 2, and 3 were 20, 14.5, and 3.5 months (CONUT 1 vs. CONUT 2, p = 0.02; CONUT 1 vs. CONUT 3, p < 0.01; CONUT 2 vs. CONUT 3, p < 0.01), respectively.

CONCLUSION

CONUT could be a predictor of prognosis for survival in patients with APC.

CONUT Score: A New Tool for Predicting Prognosis in Patients with Advanced Thyroid Cancer Treated with TKI

Simple Summary

Many studies have shown that an impaired nutritional status correlated with a worse prognosis in cancer patients. The aim of our retrospective study was to evaluate the potential role of baseline Controlling Nutritional Status (CONUT score) in predicting prognosis of advanced thyroid cancer treated with tyrosine kinase inhibitors (TKI). We were able to confirm that baseline CONUT score significantly correlated with progression free survival (PFS) and overall survival (OS) and was the only independent prognostic factor for both outcomes. In particular, a CONUT score ≥3 was associated with a worse PFS and OS. The CONUT score represents a relatively new screening tool that is useful in predicting prognosis in thyroid cancer patients before the beginning of anti-tumoral treatment.

Abstract

(1) Background: The Controlling Nutritional Status (CONUT) score is an immuno-nutritional screening tool based on serum albumin, total cholesterol, and lymphocyte count. The aim of the study was to assess the CONUT score as a potential prognostic factor of response to therapy in patients with advanced thyroid cancer treated with tyrosine kinase inhibitors (TKIs). (2) Methods: We retrospectively evaluated 42 metastatic thyroid cancer patients (54.8% female). The median age at the time of TKI treatment was 69 years. Histological diagnosis was differentiated thyroid cancer in 66.7%, poorly differentiated thyroid cancer in 21.4%, and medullary thyroid cancer in 11.9% of patients. CONUT score was assessed before starting TKI therapy. (3) Results: Progression-free survival (PFS) and overall survival (OS) were significantly influenced by baseline CONUT score. The best CONUT cut-off able to predict the response to treatment was 3. Both PFS and OS were better in patients with CONUT score <3 than in those with CONUT score ≥3 (p < 0.0001). CONUT score was the only independent prognostic factor associated with PFS (p = 0.021) and OS (p = 0.007). (4) Conclusions: CONUT score represents a relatively new screening tool, easily applicable in clinical practice and potentially useful in predicting prognosis in thyroid cancer patients treated with TKIs.

The Relationship between the SARC-F Score and the Controlling Nutritional Status Score in Gastrointestinal Diseases

We sought to examine the relationship between the SARC-F score and the Controlling Nutritional Status (CONUT) score in patients with gastrointestinal diseases (GDs, n = 735, median age = 71 years, and 188 advanced cancer cases). The SARC-F score ≥ 4 (highly suspicious of sarcopenia) was found in 93 cases (12.7%). Mild malnutritional condition was seen in 310 cases (42.2%), moderate in 127 (17.3%) and severe in 27 (3.7%). The median SARC-F scores in categories of normal, mild, moderate and severe malnutritional condition were 0, 0, 1 and 1 (overall p < 0.0001). The percentage of SARC-F score ≥ 4 in categories of normal, mild, moderate and severe malnutritional condition were 4.4%, 12.9%, 26.8% and 25.9% (overall p < 0.0001). The SARC-F score was an independent factor for both the CONUT score ≥ 2 (mild, moderate or severe malnutrition) and ≥5 (moderate or severe malnutrition). In the receiver operating characteristic (ROC) curve analysis for the CONUT score ≥ 2, C reactive protein (CRP) had the highest area under the ROC (AUC = 0.70), followed by the SARC-F score (AUC = 0.60). In the ROC analysis for the CONUT score ≥ 5, CRP had the highest AUC (AUC = 0.79), followed by the SARC-F score (AUC = 0.63). In conclusion, the SARC-F score in patients with GDs can reflect malnutritional status.

ALBI grade: Evidence for an improved model for liver functional estimation in patients with hepatocellular carcinoma

Hepatocellular carcinoma (HCC) usually arises in the context of a chronically damaged liver. Liver functional estimation is of paramount importance in clinical decision making. The Child-Pugh score (CPS) can be used to categorise patients into 3 classes (A to C) based on the severity of liver functional impairment according to 5 parameters (albumin, bilirubin, prothrombin time, presence of ascites and hepatic encephalopathy). The albumin-bilirubin (ALBI) grade has emerged as an alternative, reproducible and objective measure of liver functional reserve in patients with HCC, defining worsening liver impairment across 3 grades (I to III). The ALBI score can identify different subgroups of patients with different prognoses across the diverse Barcelona Clinic Liver Cancer stages and CP classes, making it an appealing clinical predictor. In patients treated with potentially curative approaches (resection, transplantation, radiofrequency ablation, microwave ablation), ALBI grade has been shown to correlate with survival, tumour relapse, and post-hepatectomy liver failure. ALBI grade also predicts survival, toxicity and post-procedural liver failure in patients treated with transarterial chemoembolisation, radioembolisation, external beam radiotherapy as well as multi-kinase inhibitors (sorafenib, lenvatinib, cabozantinib, regorafenib) and immune checkpoint inhibitor therapy. In this review, we summarise the body of evidence surrounding the role of ALBI grade as a biomarker capable of optimising patient selection and therapeutic sequencing in HCC.

The Combined Usage of the Global Leadership Initiative on Malnutrition Criteria and Controlling Nutrition Status Score in Acute Care Hospitals

INTRODUCTION

The Global Leadership Initiative on Malnutrition (GLIM) lacks reliable blood tests for evaluating the nutrition status. We retrospectively compared the GLIM criteria, Controlling Nutrition Status (CONUT) score, and Subjective Global Assessment (SGA) to establish effective malnutrition screening and provide appropriate nutritional interventions according to severity.

METHODS

We classified 177 patients into 3 malnutrition categories (normal/mild, moderate, and severe) according to the GLIM criteria, CONUT score, and SGA. We investigated the malnutrition prevalence, concordance of malnutrition severity, predictability of clinical outcome, concordance by etiology, and clinical outcome by inflammation.

RESULTS

The highest prevalence of malnutrition was found using the GLIM criteria (87.6%). Concordance of malnutrition severity was low between the GLIM criteria and CONUT score. Concordance by etiology was low in all groups but was the highest in the "acute disease" group. The area under the curve of clinical outcome and that of the "with inflammation group" were significantly higher when using the CONUT score versus using the other tools (0.679 and 0.683, respectively).

CONCLUSION

The GLIM criteria have high sensitivity, while the CONUT score can effectively predict the clinical outcome of malnutrition. Their combined use can efficiently screen for malnutrition and patient severity in acute care hospitals.

Prognostic Value of Peripheral Whole Blood Cell Counts Derived Indexes in Gallbladder Carcinoma: A Systematic Review and Meta-Analysis

Background

Gallbladder carcinoma (GBC) is a rare gastrointestinal malignancy with poor prognosis. Adequate pre-treatment prediction of survival is essential for risk stratification and patient selection for aggressive surgery or adjuvant therapeutic strategy. Whole blood cell count (WBCC) derived indexes are broadly used as prognosticative biomarkers in various cancer types, but their utility in GBC needs to be validated.

Methods

An extensive literature review was conducted in line with PRISMA guideline until June 31 2020, to identify original studies concerning WBCC-derived indexes as prognostic indicators in GBC. All relative parameters were extracted and pooled for statistical analyses.

Results

Fourteen studies incorporating 2,324 patients were included with a high quality and low risk of biases. All 14 studies evaluated the prognostic value of NLR showing a significant correlation with OS in GBC patients (HR = 1.94, P <0.001). Elevated NLR was revealed to correlate with TNM stage (stages III and IV, OR = 4.65, P <0.001), tumor differentiation (OR = 2.37, P <0.042), CA 19-9 (SMD = 0.47, P = 0.01), but no significance was found with age, sex and CEA. Positive indicative value of MLR and PLR were also confirmed with a HR of 2.06 (P <0.001) and 1.34 (P <0.001), respectively.

Conclusion

The WBCC-derived indexes including NLR, MLR/LMR and PLR were validated to be useful prognostic parameters for predicting survival outcomes in GBC patients. These series of indexes, especially NLR, could improve risk stratification and facilitate better patient selection for surgical resection or aggressive chemotherapy in the decision making of GBC patients.

Pretreatment Positron Emission Tomography with 18F-Fluorodeoxyglucose May Be a Useful New Predictor of Overall Prognosis Following Lenvatinib Treatment

BACKGROUND AND AIM

The aim of this study was to identify the utility of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) as a predictor of overall prognosis in patients with hepatocellular carcinoma treated with lenvatinib.

METHODS

Forty-eight consecutive patients who received lenvatinib treatment were reviewed. The oncological aggressiveness of tumors estimated using 18F-FDG-PET/CT was investigated by the analysis of progression-free survival (PFS), post-progression survival (PPS), and overall survival (OS). Multivariate analysis was used to identify potential confounders for OS during lenvatinib therapy.

RESULTS

Using the Modified Response Evaluation Criteria in Solid Tumors, a tumor-to-normal liver ratio (TLR) ≥2, indicating higher oncological aggressiveness in HCCs, was associated with a better objective response to lenvatinib than a TLR <2 (78 vs. 62%), resulting in a similar PFS (p = 0.751). Because of a significantly worse PPS, OS with a TLR ≥2 was poor compared to a TLR < 2 (p = 0.012). Multivariate analysis confirmed that a TLR ≥ 2 was associated with poor OS (hazard ratio, 2.709; 95% CI, 1.140-6.436; p = 0.024). Analysis of 24 patients who received a repeat 18F-FDG-PET/CT showed that daily changes expressed as ΔTLR × 103/day over the treatment course tended to be different among the types of subsequent treatment. A R0 resection and lenvatinib-TACE sequential therapy provided good disease control (median, -4.593 and -0.024, respectively) compared with other treatments (median, 5.278) (p = 0.075).

CONCLUSION

Lenvatinib has acceptable disease control regardless of estimated tumor differentiation. A high TLR (≥2) is a poor prognostic factor of OS following lenvatinib treatment, while ΔTLR × 103/day provides useful information of disease control status.

Immunonutritive Scoring in Patients With Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization: Prognostic Nutritional Index or Controlling Nutritional Status Score?

OBJECTIVES

The Prognostic Nutritional Index (PNI) and Controlling Nutritional Status (CONUT) score are immunonutritive scoring systems with proven predictive ability in various cancer entities, including hepatocellular carcinoma (HCC). We performed the first evaluation of the CONUT score for patients undergoing transarterial chemoembolization (TACE) and compared CONUT and PNI in the ability to predict median overall survival (OS).

METHODS

Between 2010 and 2020, we retrospectively identified 237 treatment-naïve patients with HCC who underwent initial TACE at our institution. Both scores include the albumin level and total lymphocyte count. The CONUT additionally includes the cholesterol level. Both scores were compared in univariate and multivariate regression analyses taking into account established risk factors. In a second step, a subgroup analysis was performed on BCLC stage B patients, for whom TACE is the recommended first-line treatment.

RESULTS

A high CONUT score and low PNI were associated with impaired median OS (8.7 vs. 22.3 months, p<0.001 and 6.8 vs. 20.1 months, p<0.001, respectively). In multivariate analysis, only the PNI remained an independent prognostic predictor (p=0.003), whereas the CONUT score lost its predictive ability (p=0.201). In the subgroup of recommended TACE candidates, both CONUT and PNI were able to stratify patients according to their median OS (6.6 vs. 17.9 months, p<0.001 and 10.3 vs. 22.0 months, p<0.001, respectively). Again, in the multivariate analysis, only the PNI remained an independent prognostic factor (p=0.012).

CONCLUSION

Both scores were able to stratify patients according to their median OS, but only the PNI remained an independent prognostic factor. Therefore, PNI should be preferred when evaluating the nutritional status of patients undergoing TACE.

BEZ235 Increases the Sensitivity of Hepatocellular Carcinoma to Sorafenib by Inhibiting PI3K/AKT/mTOR and Inducing Autophagy

Acquired resistance of hepatocellular carcinoma (HCC) to sorafenib (SFB) is the main reason for the failure of SFB treatment of the cancer. Abnormal activation of the PI3K/AKT/mTOR pathway is important in the acquired resistance of SFB. Therefore, we investigated whether BEZ235 (BEZ) could reverse acquired sorafenib resistance by targeting the PI3K/mTOR pathway. A sorafenib-resistant HCC cell line Huh7^R was established. MTT assay, clone formation assay, flow cytometry, and immunofluorescence were used to analyze the effects of BEZ235 alone or combined with sorafenib on cell proliferation, cell cycle, apoptosis, and autophagy of Huh7 and Huh7^R cells. The antitumor effect was evaluated in animal models of Huh7^R xenografts in vivo. Western blot was used to detect protein levels of the PI3K/AKT/mTOR pathway and related effector molecules. In vitro results showed that the Huh7^R had a stronger proliferation ability and antiapoptosis effect than did Huh7, and sorafenib had no inhibitory effect on Huh7^R. SFB + BEZ inhibited the activation of the PI3K/AKT/mTOR pathway caused by sorafenib. Moreover, SFB + BEZ inhibited the proliferation and cloning ability, blocked the cell cycle in the G0/G1 phase, and promoted apoptosis in the two cell lines. The autophagy level in Huh7^R cells was higher than in Huh7 cells, and BEZ or SFB + BEZ further promoted autophagy in the two cell lines. In vivo, SFB + BEZ inhibited tumor growth by inducing apoptosis and autophagy. We concluded that BEZ235 enhanced the sensitivity of sorafenib through suppressing the PI3K/AKT/mTOR pathway and inducing autophagy. These observations may provide the experimental basis for sorafenib combined with BEZ235 in trial treatment of HCC.

Prevalence and profiles of ramucirumab-associated severe ascites in patients with hepatocellular carcinoma

Severe ascites is an adverse event of ramucirumab (RAM), a second-line treatment for hepatocellular carcinoma (HCC). Ascites can be associated with various factors, including nutritional status and muscle quality. The aim of the present study was to investigate the prevalence and profiles of RAM-associated severe ascites in patients with HCC. This retrospective study enrolled 14 consecutive patients with HCC treated with RAM (median age, 72 years; Barcelona Clinic Liver Cancer stage B/C, 6/8). Nutritional status and muscle quality were evaluated using the controlling nutritional status (CONUT) score and intramuscular adipose tissue (IMAT) content, respectively. Factors associated with severe ascites were evaluated using decision-tree analysis. The median progression-free survival (PFS) time was 2.1 months, and the overall objective response and disease control rates were 14 and 50%, respectively. Severe ascites developed in 57.1% of the patients, and the median onset was 37.5 days (range, 14-61 days) after initiation of RAM treatment. In the decision-tree analysis, the CONUT score and IMAT content were the first and second splitting variables for the development of severe ascites. In patients with a CONUT score ≥5 and IMAT <-0.54, the prevalence of severe ascites was 80 and 100%, respectively. A high incidence of severe ascites was observed in patients treated with RAM. A CONUT score ≥5 and an IMAT <-0.54 were associated with severe ascites. Thus, caution must be taken for severe ascites in patients with HCC treated with RAM, in particular patients with malnutrition and fat infiltration in muscle.

Controlling Nutritional Status (CONUT) score as a predictive marker for short-term complications following gastrectomy of gastric cancer: a retrospective study

Background

It is well established that the controlling nutritional status (CONUT) score was correlated with long-term outcomes in gastric cancer (GC), but the significance of CONUT for postoperative short-term outcomes remains unclear. The study aimed to characterize the relationship between CONUT and short-term complications following gastrectomy of GC.

Methods

We collected data on 1479 consecutive GC patients at Nanjing Drum Tower Hospital between January 2016 and December 2018. Univariate and multivariate analyses of predictive factors for postoperative complications were performed. The cutoff value of the CONUT score was determined by Youden index.

Results

Among all of the patients, 431 (29.3%) patients encountered postoperative complications. Multivariate analyses identified CONUT was an independent predictor for postoperative short-term complications (OR 1.156; 95% CI 1.077–1.240; P < 0.001). Subgroup analysis elucidated that CONUT was related to postoperative complications both in early gastric cancer and advanced gastric cancer. We further explored that patients with high CONUT score had prolonged hospital stay (12.3 ± 6.0 vs 11.1 ± 4.6, P < 0.001) and more total hospital charges (7.6 ± 2.4 vs 7.1 ± 1.6, P < 0.001).

Conclusions

The present study demonstrated that the preoperative CONUT was an independent predictor for short-term complications following gastrectomy of GC.

Lenvatinib for Hepatocellular Carcinoma: A Literature Review

Lenvatinib, which is an oral multikinase inhibitor, showed non-inferiority to the sorafenib in terms of overall survival (OS) and a higher objective response rate (ORR) and better progression-free survival (PFS) in patients with hepatocellular carcinoma (HCC). A good liver function and Barcelona Clinic Liver Cancer (BCLC) intermediate stage were the key factors in achieving therapeutic efficacy. The management of adverse events plays an important role in continuing lenvatinib treatment. While sequential therapies contributed to prolonging overall survival, effective molecular targeted agents for the administration after lenvatinib have not been established. Repeated transcatheter arterial chemoembolization (TACE) was associated with a decline in the liver function and poor therapeutic response in BCLC intermediate patients. Recently, the Asia-Pacific Primary Liver Cancer Expert (APPLE) Consensus Statement proposed the criteria for TACE unsuitability. Upfront systemic therapy may be better for the BCLC intermediate stage HCC patients with a high tumor burden, while selective TACE will be recommended for obtaining a curative response in patients with a low tumor burden. This article reviews the therapeutic response, management of adverse events, post-progression treatment after Lenvatinib, and treatment strategy for BCLC intermediate stage HCC.

Effect of Handgrip Strength on Clinical Outcomes of Patients with Hepatocellular Carcinoma Treated with Lenvatinib

Previous studies have reported prognostic factors for hepatocellular carcinoma (HCC) patients receiving lenvatinib; however, no studies have evaluated the effects of both handgrip strength and skeletal muscle mass on the clinical outcomes. Therefore, this retrospective study investigated the individual effect of handgrip strength, skeletal muscle mass, and sarcopenia on clinical outcomes of 53 HCC patients treated with lenvatinib. Before receiving lenvatinib, handgrip strength and skeletal muscle index (SMI) were measured. Low handgrip strength and muscle depletion were defined as <26 and <18 kg and SMI <42 and SMI <38 cm2/m2 in men and women, respectively. Sarcopenia was defined as having low handgrip strength and muscle depletion. Multivariate analysis identified modified albumin–bilirubin grade 1–2a (p = 0.010), Barcelona Clinic Liver Cancer stage A–B (p = 0.011), and absence of low handgrip strength (p = 0.015) as favorable prognostic factors for survival. Furthermore, sarcopenia was an independent significant prognostic factor for survival. Time to treatment failure was associated with handgrip strength and sarcopenia. Our findings suggest that handgrip strength may be a useful marker of clinical outcomes in HCC patients treated with lenvatinib.

Clinical Significance of Adverse Events for Patients with Unresectable Hepatocellular Carcinoma Treated with Lenvatinib: A Multicenter Retrospective Study

We sought to investigate the clinical profile(s) associated with the discontinuation of lenvatinib (LEN) due to severe adverse events (DLSAE) in patients with unresectable hepatocellular carcinoma (HCC). This retrospective study enrolled 177 patients with HCC treated with LEN. Independent factors associated with DLSAE were advanced age, albumin-bilirubin (ALBI) grade 2, fatigue grade ≥ 3, and appetite loss ≥ 2. The overall survival (OS) in the group that did not require DLSAE was significantly longer compared to the group that did require DLSAE (median survival time (MST): not reached vs. 12.8 months, p < 0.001). Moreover, advanced age was the most important variable for DLSAE in a decision tree analysis. Hypertension and hand-foot-skin-reaction (HFSR) were also significantly associated with longer survival, and the occurrence of hypertension was the earliest predictor for improved prognosis, while appetite loss and development of grade ≥ 3 fatigue were predictive of a poor prognosis. We concluded that the appearance of hypertension has potential as an early surrogate marker to predict improved prognosis. Moreover, careful management to avoid discontinuation of treatment leads to longer survival in patients receiving LEN.