Prognostic value of preoperative weight loss-adjusted body mass index on survival after esophagectomy for esophageal squamous cell carcinoma

The prognostic impact of pre-treatment cachexia in resectional surgery for oesophagogastric cancer: a meta-analysis and meta-regression

BACKGROUND

Cancer cachexia is not purely an end-stage phenomenon and can influence the outcomes of patients with potentially curable disease. This review examines the effect of pre-treatment cachexia on overall survival, in patients undergoing surgical resection of oesophagogastric cancer.

METHODS

A systematic literature search of MEDLINE, EMBASE and Cochrane Library databases was conducted, from January 2000 to May 2022, to identify studies reporting the influence of cachexia on patients undergoing an oesophagogastric resection for cancer with curative intent. Meta-analyses of the primary (overall survival) and secondary (disease-free survival and postoperative mortality) outcomes were performed using random-effects modelling. Meta-regression was used to examine disease stage as a potential confounder.

RESULTS

Ten non-randomized studies, comprising 7186 patients, were eligible for inclusion. The prevalence of pre-treatment cachexia was 35 per cent (95 per cent c.i.: 24-47 per cent). Pooled adjusted hazard ratios showed that cachexia was adversely associated with overall survival (HR 1.46, 95 per cent c.i.: 1.31-1.60, P < 0.001). Meta-analysis of proportions identified decreased overall survival at 1-, 3- and 5-years in cachectic cohorts. Pre-treatment cachexia was not a predictor of disease-free survival and further data are required to establish its influence on postoperative mortality. The proportion of patients with stage III/IV disease was a significant moderator of between-study heterogeneity. Cachexia may have a greater influence on overall survival in studies where more patients have a locally advanced malignancy.

CONCLUSION

Pre-treatment cachexia adversely influences overall survival following resection of an oesophagogastric malignancy.

Preoperative Prognostic Nutritional Index Predict Survival in Patients with Resectable Adenocarcinoma of the Gastroesophageal Junction: A Retrospective Study Based on Propensity Score Matching Analyses

Background

This study evaluated the value of PNI to predicting relapse-free survival (RFS) and overall survival (OS) in patients with resectable gastroesophageal junction adenocarcinoma (AGE).

Methods

Between 2016 and 2020, there were 236 resectable AGE patients underwent a retrospective review via propensity score matched (PSM) analysis. The PNI values were computed for each patient prior to surgery [PNI= 10×albumin (gr/dL) + 0.005×total lymphocyte count (mm3)]. By using disease progression and mortality as the end points, a receiver operating characteristic(ROC) curve was plotted to identify the PNI cut-off value. Kaplan-Meier curves and Cox proportional hazard models were used for survival analysis.

Results

The ROC curve indicated that the ideal cutoff value was 45.60. After propensity score matching, there were 143 patients in our retrospective study, which included 58 patients in the low-PNI group and 85 patients in the high-PNI group. When compared to the low PNI group, the high PNI group substantially increased RFS and OS (p<0.001, p=0.003, respectively) according to the Kaplan-Meier analysis and Log rank test. Advanced pathological N stage (p=0.011) and poor PNI (p=0.004) were also significant risk factors for a shorter OS, according to a univariate analysis. Multivariate analysis revealed that the N0 plus N1 group had an endpoint mortality risk that was 0.39 times lower than the N2 plus N3 group's (p=0.008). In comparison to the high PNI group, the hazard of endpoint mortality was 2.442 times greater in the low PNI group (p = 0.003).

Conclusion

PNI is a simplistic and practical predictive predictor of the RFS and OS time in patients with resectable AGE.

Weight loss during neoadjuvant therapy and short-term outcomes after esophagectomy: a retrospective cohort study

BACKGROUND

Neoadjuvant therapy (NAT) has become common worldwide for resectable advanced esophageal cancer and frequently involves weight loss. Although failure to rescue (death after major complications) is known as an emerging surgical quality measure, little is known about the impact of weight loss during NAT on failure to rescue. This retrospective study aimed to investigate the association of weight loss during NAT and short-term outcomes, including failure to rescue after esophagectomy.

MATERIALS AND METHODS

Patients who underwent esophagectomy after NAT between July 2010 and March 2019 were identified from a Japanese nationwide inpatient database. Based on quartiles of percent weight change during NAT, patients were grouped into four categories of gain, stable, small loss, and loss (>4.5%). The primary outcomes were failure to rescue and in-hospital mortality. The secondary outcomes were major complications, respiratory complications, anastomotic leakage, and total hospitalization costs. Multivariable regression analyses were used to compare outcomes between the groups, adjusting for potential confounders, including baseline BMI.

RESULTS

Among 15 159 eligible patients, in-hospital mortality and failure to rescue occurred in 302 (2.0%) and 302/5698 (5.3%) patients, respectively. Weight loss (>4.5%) compared to gain was associated with increased failure to rescue and in-hospital mortality [odds ratios 1.55 (95% CI: 1.10-2.20) and 1.53 (1.10-2.12), respectively]. Weight loss was also associated with increased total hospitalizations costs, but not with major complications, respiratory complications, and anastomotic leakage. In subgroup analyses, regardless of baseline BMI, weight loss (>4.8% in nonunderweight or >3.1% in underweight) was a risk factor for failure to rescue and in-hospital mortality.

CONCLUSION

Weight loss during NAT was associated with failure to rescue and in-hospital mortality after esophagectomy, independent of baseline BMI. This emphasizes the importance of weight loss measurement during NAT to assess the risk for a subsequent esophagectomy.

[Development and validation of a prognostic model based on SEER data for patients with esophageal carcinoma after esophagectomy]

OBJECTIVE

To develop a nomogram to predict the long-term survival of patients with esophageal cancer following esophagectomy.

METHODS

We collected the data of 7215 patients with esophageal carcinoma from the Surveillance, Epidemiology, and End Results (SEER) database during the period from 2004 and 2016. Of these patients, 5052 were allocated to the training cohort and the remaining 2163 patients to the internal validation cohort using bootstrap resampling, with another 435 patients treated in the Department of Cardiothoracic Surgery of Jinling Hospital between 2014 and 2016 serving as the external validation cohort.

RESULTS

In the overall cohort, the 1-, 3-, and 5-year cancer-specific mortality rates were 14.6%, 35.7% and 41.6%, respectively. Age (≥80 years vs < 50 years, P < 0.001), gender (male vs female, P < 0.001), tumor site (lower vs middle segment, P=0.013), histology (EAC vs ESCC, P=0.012), tumor grade (poorly vs well differentiated, P < 0.001), TNM stage (Ⅳ vs Ⅰ, P < 0.001), tumor size (> 50 mm vs 0-20 mm, P < 0.001), chemotherapy (yes vs no, P < 0.001), and LNR (> 0.25 vs 0, P < 0.001) were identified as independent risk factors affecting long-term survival of the patients. The nomograms established based on the model for predicting the survival probability of the patients at 1, 3 and 5 years after operation showed a C-index of 0.726 (95% CI: 0.714-0.738) for predicting the overall survival (OS) and of 0.735 (95% CI: 0.727-0.743) for cancer-specific survival (CSS) in the training cohort. In the internal validation cohort, the C-index of the nomograms was 0.752 (95% CI: 0.738-0.76) for OS and 0.804 (95% CI: 0.790-0.817) for CSS, as compared with 0.749 (95% CI: 0.736-0.767) and 0.788 (95%CI: 0.751-0.808), respectively, in the external validation cohort. The nomograms also showed a higher sensitivity than the TNM staging system for predicting long-term prognosis.

CONCLUSION

This prognostic model has a high prediction efficiency and can help to identify the high-risk patients with esophageal carcinoma after surgery and serve as a supplement for the current TNM staging system.

Body Mass Index-Adjusted Weight Loss Grading System and Cancer-Related Fatigue in Survivors 1 Year After Esophageal Cancer Surgery

BACKGROUND

The association between pre- and postoperative weight loss and cancer-related fatigue after esophageal cancer surgery is unclear. This nationwide, prospective, longitudinal cohort study aimed to assess the influence of weight loss on cancer-related fatigue among esophageal cancer survivors.

METHODS

Patients who underwent esophagectomy for cancer between 2013 and 2019 in Sweden were enrolled in this study. Exposure was measured by the body mass index-adjusted weight loss grading system (WLGS). Cancer-related fatigue was assessed using the fatigue scale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and the EORTC QLQ-Fatigue 12 (QLQ-FA12) questionnaire measuring overall fatigue and physical, emotional, and cognitive fatigue. Growth mixture models were used to identify unobserved trajectories of cancer-related fatigue. Multivariable linear and logistic regression models were fitted to assess the associations between WLGS and cancer-related fatigue, adjusting for potential confounders.

RESULTS

Three trajectories were identified-low, moderate, and severe persistent fatigue. Cancer-related fatigue remained stable in each trajectory between 1 and 3 years after esophagectomy. Among the 356 enrolled patients, 4.5-22.6% were categorized into the severe persistent fatigue trajectory in terms of QLQ-C30 (19.9%), FA12 overall (10.5%), physical (22.6%), emotional (15.9%), and cognitive fatigue (4.5%). No association between pre- or postoperative WLGS and cancer-related fatigue was found between 1 and 3 years after esophageal cancer surgery.

CONCLUSIONS

Weight loss did not seem to influence cancer-related fatigue after esophageal cancer surgery.

The Least Nodal Disease Burden Defines the Minimum Number of Nodes Retrieved for Esophageal Squamous Cell Carcinoma

Background

Clinically, a single positive lymph node (SPLN) should indicate the least nodal disease burden in node-positive patients with esophageal squamous cell carcinoma (ESCC) and may also be used to define the minimum number of examined lymph nodes (NELNs) in ESCC patients.

Methods

Data from three Chinese cohorts of 2448 ESCC patients who underwent esophagectomy between 2008 and 2012 were retrospectively analyzed. Based on lymph node status, patients were divided into two groups: N0 ESCC and SPLN ESCC. A Cox proportional hazards regression model was used to determine the minimum NELNs retrieved to maximize survival for ESCC patients with localized lymph node involvement. The results were then validated externally in the SEER database.

Results

A total of 1866 patients were pathologically diagnosed with N0 ESCC, and 582 patients were diagnosed with SPLN ESCC. The overall survival rate of patients with N0 ESCC was significantly better than that of patients with SPLN ESCC (HR 1.88, 95% CI 1.64-2.13, P<0.001), but no significant difference was found between SPLN ESCC patients with ≥ 20 lymph nodes harvested and N0 ESCC patients (HR 1.20, 95% CI 0.95-1.52, P=0.13). Analysis of patients selected from the SEER database showed the same trend, and no significant difference was observed between N0 ESCC patients and SPLN ESCC patients with ≥ 20 lymph nodes retrieved (HR: 1.02, 95% CI 0.72-1.43, P=0.92).

Conclusions

A minimum of 20 lymph nodes retrieved should be introduced as a quality indicator for ESCC patients with localized lymph node involvement.

Prognostic Value of Body Mass Index Stratified by Alcohol Drinking Status in Patients With Esophageal Squamous Cell Carcinoma

BACKGROUND

The goal of this study was to investigate the prognostic value of body mass index (BMI) in patients with esophageal squamous cell carcinoma (ESCC) when stratified by alcohol drinking status.

METHODS

A total of 620 patients with ESCC who underwent esophagectomy were analyzed. A receiver operating characteristic curve was constructed to set the appropriate cutoff point for BMI. Alcohol drinking was divided into ever and never. Kaplan-Meier and multivariate Cox regression analyses were conducted to investigate the association between clinicopathological factors and survival.

RESULTS

The cutoff point was 18.75 kg/m² for BMI. Two hundred and twenty-nine patients were ever drinkers, while the other 391 patients were never drinkers. The ever drinker group was found to have more males, longer tumor lengths, advanced pT category disease, advanced pN category disease, and lower tumor locations. However, no significant difference in BMI was found between ever drinkers and never drinkers. For ever drinkers, low BMI was significantly correlated with worse overall survival (hazard ratio = 1.690; P=0.035) and cancer-specific survival (hazard ratio = 1.763; P=0.024) than high BMI after adjusting for other factors. However, BMI was not a prognostic factor in univariate and multivariate analyses for never drinkers.

CONCLUSIONS

BMI is a prognostic factor only in ever drinkers with ESCC but not in never drinkers. Further studies are needed to elucidate the mechanism underlying the effect of the interaction between BMI and alcohol consumption on the prognosis of patients with ESCC.