Prognostic Factors and Scoring Model for Survival in Metastatic Biliary Tract Cancer

A Single-Arm Phase II Study of Nab-Paclitaxel Plus Gemcitabine and Cisplatin for Locally Advanced or Metastatic Biliary Tract Cancer

PURPOSE

Patients with advanced biliary tract cancer (BTC) have a poor survival. We aim to evaluate the efficacy and safety of nab-paclitaxel plus gemcitabine and cisplatin regimen in Chinese advanced BTC patients.

MATERIALS AND METHODS

Eligible patients with locally advanced or metastatic BTC administrated intravenous 100 mg/m2 nab-paclitaxel, 800 mg/m2 gemcitabine, and 25 mg/m2 cisplatin every 3 weeks. The primary endpoint was progression-free survival (PFS). The secondary endpoints included overall survival (OS) and adverse events, while exploratory endpoint was the association of biomarkers with efficacy.

RESULTS

After the median follow-up of 25.0 months, the median PFS and OS of 34 enrolled patients were 7.1 months (95% confidence interval [CI], 5.4 to 13.7) and 16.4 months (95% CI, 10.9 to 23.6), respectively. The most common treatment-related adverse events at ≥ 3 grade were neutropenia (26.5%) and leukopenia (26.5%). Survival analyses demonstrated that carcinoembryonic antigen (CEA) levels could monitor patients' survival outcomes. A significant increase in the number of infiltrating CD4+ cells (p=0.008) and a decrease in programmed death-1-positive (PD-1+) cells (p=0.032) were observed in the response patients.

CONCLUSION

In advanced BTC patients, nab-paclitaxel plus gemcitabine and cisplatin regimen showed therapeutic potential. Potential prognostic factors of CEA levels, number of CD4+ cells and PD-1+ cells may help us maximize the efficacy benefit.

Development of a nomogram to predict survival in advanced biliary tract cancer

The prognosis of advanced biliary tract cancer (BTC) patients remains poor due to limited efficacy of chemotherapy and difficulties in management. Thus, prediction of survival is crucial for the clinical management of advanced BTC. The aim was to develop and validate a nomogram to predict 6-month and 12-month survival in advanced BTC patients treated with chemotherapy. A multivariable Cox regression model was used to construct a nomogram in a training set (JCOG1113, a phase III trial comparing gemcitabine plus S-1 [GS] and gemcitabine plus cisplatin, n = 351). External validity of the nomogram was assessed using a test set (JCOG0805, a randomized, phase II trial comparing GS and S-1 alone, n = 100). Predictive performance was assessed in terms of discrimination and calibration. The constructed nomogram included lymph node metastasis, liver metastasis, carbohydrate antigen 19-9, carcinoembryonic antigen, albumin, and C-reactive protein. Uno's concordance index was 0.661 (95% confidence interval [CI] 0.629-0.696) in the training set and 0.640 (95% CI 0.566-0.715) in the test set. The calibration plots for 6-month and 12-month survival showed good agreement in the two analysis sets. The present nomogram can facilitate prediction of the prognosis of advanced BTC patients treated with chemotherapy and help clinicians' prognosis-based decision-making.

Cell-Free Tumor DNA Dominant Clone Allele Frequency Is Associated With Poor Outcomes in Advanced Biliary Cancers Treated With Platinum-Based Chemotherapy

PURPOSE

This investigation sought to evaluate the prognostic value of pretreatment of circulating tumor DNA (ctDNA) in metastatic biliary tract cancers (BTCs) treated with platinum-based first-line chemotherapy treatment.

MATERIALS AND METHODS

We performed a retrospective analysis of 67 patients who underwent ctDNA testing before platinum-based chemotherapy for first-line treatment for metastatic BTC. For analysis, we considered the detected gene with highest variant allele frequency as the dominant clone allele frequency (DCAF). Results of ctDNA analysis were correlated with patients' demographics, progression-free survival (PFS), and overall survival (OS).

RESULTS

The median age of patients was 67 (27-90) years. Fifty-four (80.6%) of 67 patients evaluated had intrahepatic cholangiocarcinoma; seven had extrahepatic cholangiocarcinoma, and six gallbladder cancers. Forty-six (68.6%) of the patients were treated with cisplatin plus gemcitabine, and 16.4% of patients received gemcitabine and other platinum (carboplatin or oxaliplatin) combinations, whereas 15% of patients were treated on a clinical trial with gemcitabine and cisplatin plus additional agents (CX4945, PEGPH20, or nab-paclitaxel). TP53, KRAS, FGFR2, ARID1A, STK11, and IDH1 were the genes with highest frequency as DCAF. The median DCAF was 3% (0%-97%). DCAF > 3% was associated with worse OS (median OS: 10.8 v 18.8 months, P = .032). Stratifying DCAF in quartiles, DCAF > 10% was significantly related to worse PFS (median PFS: 3 months, P = .014) and worse OS (median OS: 7.0 months, P = .001). Each 1% increase in ctDNA was associated with a hazard ratio of 13.1 in OS when adjusting for subtypes, metastatic sites, size of largest tumor, age, sex, and CA19-9.

CONCLUSION

DCAF at diagnosis of advanced BTC can stratify patients who have worse outcomes when treated with upfront platinum-based chemotherapy. Each increase in %ctDNA decreases survival probabilities.

Pre-treatment Nutritional Risk Assessment by NRS-2002 Predicts Prognosis in Patients With Advanced Biliary Tract Cancer: A Single Center Retrospective Study

We investigated the predictors of survival in patients with advanced BTC according to their baseline nutritional status estimated by the Nutritional Risk Screening (NRS)-2002. From September 2006 to July 2017, we reviewed the data of 601 inpatients with BTC. Data on demographic and clinical parameters was collected from electronic medical records, and overall survival (OS) and progression-free survival were analyzed using the Kaplan-Meier method and the stepwise Cox regression analysis. Patients with an NRS-2002 score of ≤ 2, 3, and ≥ 4 were respectively classified as “no risk,” “moderate risk,” “high risk.” Following initial NRS-2002 score, 333 patients (55%) were classified as “no-risk,” 109 patients (18%) as “moderate-risk,” and 159 patients (27%) as “high-risk.” Survival analysis demonstrated significant differences in the median OS: “no-risk”: 12.6 months (95% confidence interval [CI], 11.5–13.7); “moderate-risk”: 6.1 months (95% CI, 4.3–8.0); and “high-risk”: 3.9 months (95% CI, 3.2–4.6) (p < 0.001). NRS-2002 score was an independent factor for OS (hazard ratio [HR], 1.616 for “moderate-risk”, 95% CI, 1.288–2.027, p < 0.001; HR, 2.121 for “high-risk”, 95% CI, 1.722–2.612, p < 0.001), along with liver metastasis, peritoneal seeding, white blood cell count, platelet count, neutrophil-to-lymphocyte ratio, cholesterol, carcinoembryonic antigen, and carbohydrate antigen 19-9. In conclusion, baseline NRS-2002 is an appropriate method for discriminating those who are already malnourished and who have poor prognosis in advanced BTC patient. Significance of these results merit further validation to be integrated in the routine practice to improve quality of care in BTC patients.

A prognostic model in patients with advanced biliary tract cancer receiving first-line chemotherapy

BACKGROUND

Standard treatment of advanced biliary tract cancer (aBTC) is represented by first-line chemotherapy (CT1). However, some patients do not gain any benefit from CT1, contributing to the overall dismal prognosis of aBTC. The present study aimed to devise a prognostic model in aBTC patients receiving CT1.

METHODS

A large panel of clinical, laboratory, and pathology variables, available before the start of CT1, were retrospectively assessed in a multi-centric cohort to determine their prognostic value on univariate and multivariate regression analysis. The variables that showed a significant correlation with overall survival (OS) were computed in a three-tier prognostic score. External validation of the prognostication performance was carried out.

RESULTS

Clinical histories of 935 patients (median OS 10.3 months), with diagnosis dates ranging from 2001 to 2017, were retrieved from 14 institutions. According to multivariate analysis, Eastern Cooperative Oncology Group performance status, carbohydrate antigen 19.9, albumin levels, and neutrophil/lymphocyte ratio were strongly associated with OS (p <0.01). The prognostic score could generate a highly significant stratification (all between-group p values ≤0.001) into groups of favorable (comprising 51.5% of the sample), intermediate (39.2%), and poor prognosis (9.3%): median OS was 12.7 (CI_95% 11.0-14.4), 7.1 (CI_95% 5.8-8.4), and 3.2 months (CI_95% 1.7-4.7), respectively. This OS gradient was replicated in the validation set (129 patients), with median OS of 12.7 (CI_95% 11.0-14.3), 7.5 (CI_95% 6.1-8.9), and 1.4 months (CI_95% 0.1-2.7), respectively (all between-group p values ≤0.05).

CONCLUSION

A prognostic score, derived from a limited set of easily-retrievable variables, efficiently stratified a large population of unselected aBTC patients undergoing CT1. This tool could be useful to clinicians, to ascertain the potential benefit from CT1 at the start of treatment.

Clinical insights and prognostic factors from an advanced biliary tract cancer case series: a real-world analysis

Advanced biliary tract cancer (aBTC) comprises a heterogeneous group of rare malignancies with dismal prognosis. Given the scarcity of prospective evidence, the aim of this study was to derive clinically useful insights and prognostic factors from a large, real-world series of aBTC. Clinicopathologic variables and treatment outcomes were retrospectively collected involving 940 patients diagnosed with aBTC between 2001 and 2017, and treated with first-line chemotherapy (CT1) at 14 Italian medical oncology institutions. Median overall survival (OS) was 10.3 months (CI_95% 9.5-11.1). CT1 with gemcitabine-Platinum salts doublets achieved OS of 11.7 months vs 7.5 with gemcitabine alone (HR 0.67, p < 0.001). However, a clear temporal trend towards improved OS could not be demonstrated. Radical surgery of recurrent disease achieved a relapse-free survival of 5.9 months. A substantial minority (44.5%) of patients were able to receive a second-line chemotherapy, which achieved a response rate of 7.6%, and disease control in 30% of patients with no significant differences between combination regimens and monotherapies. In a large retrospective series of real-world aBTC, outcomes of standard CT1 closely resembled those of the registrational trials. A limited set of easily retrievable independent prognostic factors was defined. Further research is needed on second-line regimens.

Clinical epidemiology of gallbladder cancer in North-Central India and association of immunological markers, NLR, MLR and PLR in the diagnostic/prognostic prediction of GBC

INTRODUCTION

The incidence of Gallbladder Cancer (GBC) is found to be increasing in the rural populations of north-central India. Role of multiple demographic factors, including poor socio-economic conditions, illiteracy and miserable primary healthcare services appear to be significant factors for this increase. Here, we aim to assess the present status of GBC in north-central India and evaluate the role of immunological markers in its management.

METHODS

A total of 1845 cases of different Gallbladder diseases, including GBC, from rural and urban areas both, registered at CHRI, Gwalior during 2009-2014 and 2018 were included in this study. The demographic and clinical information of the patients were analysed using various statistical tests.

RESULTS

Of all the cases (1845) included in this study, 1125 (60.97%) were diagnosed with GBC, of which, 707 (62.84%) were from rural background and 418 (37.15%) from urban settings. Mean age for GBC cases for both male and female was about 53.49 years. Females were more affected, being 70.37%, while male patients were only 29.63%. The pathological investigations showed elevated levels of total bilirubin and liver function enzymes both. The NLR, PLR and MLR were found to be significantly associated with different clinical parameters as well as OS.

CONCLUSION

We infer that the growing trend of GBC, particularly in rural areas, in north-central India is primarily associated with the lack of awareness, inadequate medical support and poor socio-economic conditions. Evaluation of haematological markers may help in the predictive diagnosis/ prognosis and or management of GBC cases in the studied population.

Construction of a Five-Super-Enhancer-Associated-Genes Prognostic Model for Osteosarcoma Patients

Osteosarcoma is a malignant tumor most commonly arising in children and adolescents and associated with poor prognosis. In recent years, some prognostic models have been constructed to assist clinicians in the treatment of osteosarcoma. However, the prognosis and treatment of patients with osteosarcoma remain unsatisfactory. Notably, super-enhancer (SE)-associated genes strongly promote the progression of osteosarcoma. In the present study, we constructed a novel effective prognostic model using SE-associated genes from osteosarcoma. Five SE-associated genes were initially screened through the least absolute shrinkage and selection operator (Lasso) penalized Cox regression, as well as univariate and multivariate Cox regression analyses. Meanwhile, a risk score model was constructed using the expression of these five genes. The excellent performance of the five-SE-associated-gene-based prognostic model was determined via time-dependent receiver operating characteristic (ROC) curves and Kaplan-Meier curves. Inferior outcome of overall survival (OS) was predicted in the high-risk group. A nomogram based on the polygenic risk score model was further established to validate the performance of the prognostic model. It showed that our prognostic model performed outstandingly in predicting 1-, 3-, and 5-year OS of patients with osteosarcoma. Meanwhile, these five genes also belonged to the hub genes associated with survival and necrosis of osteosarcoma according to the result of weighted gene co-expression network analysis based on the dataset of GSE39058. Therefore, we believe that the five-SE-associated-gene-based prognostic model established in this study can accurately predict the prognosis of patients with osteosarcoma and effectively assist clinicians in treating osteosarcoma in the future.

Prognostic Significance of Sarcopenia in Advanced Biliary Tract Cancer Patients

Background: Sarcopenia, systemic inflammation, and low muscularity significantly impact the survival of cancer patients. However, few studies have investigated how sarcopenia and systemic inflammation affect the prognosis of biliary tract cancer with distant metastasis. In this study, we investigated the association between sarcopenia with systemic inflammation and prognosis of metastatic biliary tract cancer. Materials and Methods: Data collected from 353 metastatic biliary tract cancer patients from 2007 to 2016 were analyzed. To evaluate the skeletal muscle mass, computed tomography images at the upper level of the third lumbar vertebra (L3) were used. Sarcopenia was defined using the Japan Society of Hepatology guideline; L3 muscle index <42 cm²/m² for male and <38 cm²/m² for female patients. Systemic inflammation was evaluated using the neutrophil lymphocyte ratio (NLR). Patients with NLR > 3 were categorized into the inflammatory category. The overall survival (OS) and progression free survival (PFS) were analyzed. Subgroup analysis was performed on those who received gemcitabine/cisplatin (GP) chemotherapy and depending on the presence of sarcopenia and inflammation. Results: Patients with sarcopenia showed lesser 1-year OS than those without (25.5 vs. 38.2%, p = 0.019). The patients with high NLR (NLR > 3) were associated with a shorter OS than were those with a low NLR (NLR ≤ 3) (21.0 vs. 52.8%, p < 0.001). Based on these results, we categorized the patients into three groups; sarcopenia accompanied by high NLR, no sarcopenia and low NLR, and either sarcopenia or high NLR. The OS of patients was well-stratified according to this grouping (1-year OS; 18.3 vs. 30.3 vs. 55.8%, p < 0.001). Concordant with OS results, the PFS was well-stratified based on the presence of either sarcopenia or high NLR (Sarcopenia; 9.5 vs. 19.4%, p < 0.001, NLR; 10.0 vs. 23.4%, p < 0.001). The PFS was significantly associated with high NLR and sarcopenia (1-year PFS; 7.8 vs. 13.0 vs. 27.9%, p < 0.001). Conclusion: Sarcopenia with inflammation was associated with inferior OS and PFS. In addition, sarcopenia accompanied by inflammation was associated with poor prognosis. Conservative treatments such as nutritional support, exercise, and pharmacologic intervention could help metastatic biliary tract cancer patients to overcome sarcopenia and the inflammatory status.

The neonatal Fc receptor in cancer FcRn in cancer

Since the neonatal IgG Fc receptor (FcRn) was discovered, it was found to be involved in immunoglobulin recycling and biodistribution, immune complexes routing, antigen presentation, humoral immune response, and cancer immunosurveillance. The latest data show that FcRn plays a part in cancer pathophysiology. In various types of cancers, such as lung and colorectal cancer, FcRn has been described as an early marker for prognosis. Dysregulation of FcRn expression by cancer cells allows them to increase their metabolism, and this process could be exploited for passive targeting of cytotoxic drugs. However, the roles of this receptor depend on whether the studied cell population is the tumor tissue or the infiltrating cells, bringing forward the need for further studies.

Therapeutic outcomes and prognostic factors in unresectable gallbladder cancer treated with gemcitabine plus cisplatin

BACKGROUND

Gallbladder cancer (GBC) is likely to be diagnosed at progressive stages and shows a very poor prognosis. Combination therapy with gemcitabine and cisplatin (GEMCIS) has been widely used as first-line palliative chemotherapy for advanced GBC. This study was designed to investigate the efficacy of GEMCIS and identify prognostic factors in patients with unresectable GBC.

METHODS

Patients with GBC who were treated with GEMCIS from January 2008 to June 2017 in a single tertiary hospital were included. All cases of GBC were diagnosed by pathologic findings and extent of the tumour was assessed by imaging tests. Combination chemotherapy consisted of cisplatin 25 mg/m² and gemcitabine 1000 mg/m² intravenously on days 1 and 8 every 3 weeks. To determine factors affecting prognosis, Kaplan-Meier survival analysis, log-rank test and the Cox proportional hazard regression linear model were used. All variables with P < 0.1 in univariable analysis were included in the multivariable model.

RESULTS

A total of 173 patients received a median of 5.3 ± 4.4 cycles of chemotherapy over 3.8 ± 3.9 months. Most of the patients (94.8%) were stage IVB at the time of diagnosis and the most common site of metastasis was the liver (42.8%). Disease control rate was 59.5%: 2 (1.2%) patients with complete response, 26 (15.0%) patients with partial response and 75 (43.4%) patients with stable disease. Overall survival (OS) and progression-free survival were 8.1 (95% confidence interval [CI], 7.1-10.2) and 5.6 (95% CI 4.5-6.8) months, respectively. Multivariable regression model indicated that metastasis to liver (hazard ratio [HR] = 1.63, 95% CI 1.11-2.40; P = 0.013), neutrophil-to-lymphocyte ratio (NLR) ≥3 (HR 1.65, 95% CI 1.09-2.49; P = 0.017), CEA ≥ 5 ng/mL (HR 1.50, 95% CI 1.02-2.19; P = 0.038), and CA19-9 ≥ 500 U/mL (HR 1.59, 95% CI 1.01-2.50; P = 0.043) were significantly associated with OS.

CONCLUSIONS

GEMCIS demonstrated a high disease control rate in patients with unresectable GBC. Factors independently related to OS were metastasis to liver, NLR ≥ 3, CEA ≥ 5 ng/mL and CA19-9 ≥ 500 U/mL.

Predictive factors of the treatment outcome in patients with advanced biliary tract cancer receiving gemcitabine plus cisplatin as first-line chemotherapy

BACKGROUND

Few studies have clearly identified the prognostic factors in patients with advanced biliary tract cancer (BTC) receiving gemcitabine plus cisplatin (GC) which is acknowledged as standard chemotherapy regimen.

OBJECTIVES

The aim of this study was to identify predictive factors of the overall survival (OS) in advanced BTC patients receiving GC therapy.

METHODS

Data of 307 patients with advanced BTC who received GC therapy as the first-line chemotherapy at our institution from January 2007 to June 2017 were reviewed retrospectively. The patients were randomly assigned to the investigation or the validation dataset at the ratio of 2:1. Multivariate analysis was conducted to identify the prognostic factors, a prognostic index is proposed from the investigation dataset, and the usefulness of this index was confirmed in the validation dataset.

RESULTS

Multivariate analysis identified poor performance status, elevated serum lactate dehydrogenase, and elevated neutrophil-to-lymphocyte ratio as independent unfavorable predictors. The patients could be classified into three groups according to these factors, and it was found that the outcomes differed significantly among the three groups (P = 0.0002, good- vs. intermediate-prognosis groups; P = 0.005, intermediate- vs. poor-prognosis groups). When this index was applied to the validation dataset, the OS was confirmed to differ significantly among the three groups (P = 0.04, good- vs. intermediate-prognosis groups, P < 0.0001, intermediate- vs. poor-prognosis groups).

CONCLUSIONS

We identified three predictors of the OS in patients with advanced BTC receiving GC therapy in this study, based on which we could classify the patients into three risk groups.

Significance of serum ferritin as a prognostic factor in advanced hepatobiliary cancer patients treated with Korean medicine: a retrospective cohort study

Background

Advanced hepatobiliary cancers are highly lethal cancers that require precise prediction in clinical practice. Serum ferritin level increases in malignancy and high serum ferritin level is associated with poor survival in various cancers. This study aimed to identify whether serum ferritin could independently predict the overall survival (OS) of patients with advanced hepatobiliary cancers.

Methods

The retrospective cohort study was performed by reviewing medical records of patients with advanced hepatobiliary cancers from June 2006 to September 2016. The demographic and clinicopathological characteristics as well as the biochemical markers were evaluated at the initiation of Korean medicine (KM) treatment. The OS was calculated using Kaplan-Meier estimates. The Cox proportional hazard model was used to identify the independent prognostic significance of serum ferritin for survival.

Results

The median OS of all subjects was 5.1 months (range, 0.5–114.9 months). The median OS of group with low ferritin levels and that with high ferritin levels was 7.5 months (range, 0.7–114.9 months) and 2.8 months (range, 0.5–22.8 months), respectively (P < 0.001). The results of the univariate analysis showed that the Eastern Cooperative Oncology Group Performance Status (ECOG-PS) (P = 0.002), tumor type (P = 0.001), prior treatment (P = 0.023), serum ferritin (P < 0.001), hemoglobin (P = 0.002), total bilirubin (P = 0.002), gamma-glutamyl transpeptidase (P = 0.007), albumin (P = 0.013), white blood cell (P = 0.002), and C-reactive protein (CRP) (P < 0.001) were significant factors for the patients’ survival outcome. On multivariate analysis controlling confounding factors, ferritin (P = 0.041), CRP (P = 0.010), ECOG-PS (P = 0.010), and tumor type (P = 0.018) were identified as independent prognostic factors for survival.

Conclusions

These results indicate that serum ferritin is a valid clinical biochemical marker to predict survival of patients with advanced hepatobiliary cancers.