Modelling prognostic factors in advanced pancreatic cancer. Br J Cancer. 2008;99:883-893. [PMID: 19238630 PMCID: PMC2538756 DOI: 10.1038/sj.bjc.6604568]

Impaired liver function: effect on paclitaxel toxicity, dose modifications and overall survival

BACKGROUND

The anticancer drug paclitaxel is primarily metabolized in the liver. Previous studies have indicated a correlation between impaired liver function and paclitaxel toxicity, which may indicate dose reduction. Since the evidence is limited, the aim of this study was to investigate the effect of impaired liver function on the hematological toxicity of paclitaxel, dose modifications and overall survival (OS).

METHODS

For this single-center retrospective observational study, patients treated with paclitaxel for breast, esophageal and ovarian cancer at the University Medical Centre Utrecht between 2011 and 2022 were identified from the Utrecht Patient Oriented Database (UPOD). Based on regression analysis, the risk of developing Grade 3/4 hematological toxicity was compared between patients with normal and impaired (based on the NCI criteria for bilirubin and ASAT (aspartate aminotransferase) concentrations) liver function. Additionally, differences in the occurrence of toxicity-related dose modifications and OS were evaluated between the two groups.

RESULTS

A total of 569 patients were included. Breast cancer patients who were receiving advanced treatment and had mildly impaired liver function (ASAT ≤ 2x ULN, bilirubin ≤ ULN) had an increased risk of developing grade 3/4 neutropenia (HR = 4.39, 95% CI 1.20-16.02; p = 0.03). In addition, patients with impaired liver function treated according to the advanced ovarian cancer regimen had an increased risk of developing grade 3/4 leukopenia (HR = 12.64, 95% CI 2.12-75.22, p = 0.01) and dose modification (treatment discontinuation) (HR = 3.91, 95% CI 1.74-8.79, p < 0.01). Impaired liver function was also associated with decreased OS in inoperable esophageal and advanced ovarian cancer patients (HR = 7.65, 95% CI 2.54-23.1, p < 0.01 and HR = 2.98, 95% CI 1.36-6.54, p < 0.01, respectively). The risk of developing grade 3/4 hematological toxicity during lower-dose paclitaxel treatment protocols was not significantly different in patients with impaired liver function.

CONCLUSIONS

This study revealed that patients with impaired liver function treated with paclitaxel for breast and ovarian cancer in an advanced setting are at greater risk of developing hematological toxicity than patients with normal liver function at the start of therapy. Furthermore, in patients with ovarian (advanced) or inoperable esophageal cancer, impaired liver function is associated with decreased OS. Within these groups of patients, it is important to weigh the risk of upfront paclitaxel dose modifications versus an adaptive strategy.

Machine learning models and nomogram based on clinical, laboratory profiles and skeletal muscle index to predict pancreatic fistula after pancreatoduodenectomy

Background

Postoperative pancreatic fistula (POPF) is a perilous complication that may arise subsequent to pancreaticoduodenectomy (PD). In recent times, there has been an escalating interest in employing machine learning (ML) techniques to aid in treatment decision-making. The purpose of this research is to assess the effectiveness of ML in comparison to conventional models, while also conducting an initial evaluation of the predictive capability of skeletal muscle index (SMI) concerning POPF.

Methods

This retrospective observational study was carried out at The First Affiliated Hospital of Wenzhou Medical University from January 2012 to January 2021, encompassing data from 269 patients who underwent PD. After identifying independent factors associated with the condition, a logistic regression model was employed to construct a nomogram, alongside the establishment of five ML models. To assess their effectiveness, the best-performing ML model and nomogram were evaluated on a separate test group comprising 77 additional patients. The evaluation involved comparing the area under the curve (AUC) and Brier score.

Results

Among the 269 patients studied, the incidence of POPF was found to be 56.9%, with 106 patients (69.3%) experiencing clinically-relevant POPF. We identified six independent factors associated with POPF, including body mass index (BMI), SMI, pancreatic duct dilatation, tumor size, triglyceride levels, and the ratio of aspartate aminotransferase to alanine aminotransferase (AST/ALT) on the first postoperative day. When evaluated on the test set, the Gaussian Naive Bayes (GNB) model, which was the best-performing ML model, achieved an AUC of 0.824 and a Brier score of 0.175. The corresponding performance indicators for the nomogram were 0.844 for AUC and 0.165 for the Brier score.

Conclusions

This study found that there is minimal difference between ML and the nomogram based on logistic regression in predicting POPF. Additionally, SMI shows promise as a potential and practical tool for assessing the risk of POPF.

Serum aspartate aminotransferase, a novel potential biomarker of prognosis in extranodal natural killer/T cell lymphoma, nasal type

BACKGROUND

Aspartate aminotransferase (AST), an indicator of liver cell damage, was related to the prognosis of certain malignant tumors.

OBJECTIVE

This study examined the predictive value of AST in patients with extranodal natural killer/T cell lymphoma (ENKTL).

METHODS

We reviewed 183 cases diagnosed with ENKTL and selected 26 U/L as the optimum cut-off value of AST. We used the univariate and multivariate Cox regression to compare the different AST groups' overall survival (OS) and progression-free survival (PFS).

RESULTS

Prior to propensity score matching (PSM), Kaplan-Meier analysis showed that patients in the low AST subgroup had better OS and PFS than the high AST subgroup. Multivariate analysis revealed that AST was an independent indicator for prognosis. After PSM, the low AST subgroup maintained a significantly better OS and PFS than the high AST subgroup.

CONCLUSION

AST might represent a significant prognostic marker for ENKTL patients.

Prognostic Effect of Preoperative Inflammatory Markers on Morbidity and Overall Survival in Pancreatic Adenocarsinoma

BACKGROUND/AIM

His study aimed to evaluate the availability of common diagnostic tests and biochemical markers in predicting poor prognosis in patients with pancreatic adenocarcinoma (PAC). The primary outcome measure was to identify predictive prognostic factors. The secondary outcome measure was to compare predictive measures in patients who survived or did not survive in the follow-up period.

MATERIALS AND METHODS

Medical data of 51 patients were obtained who underwent resection surgery for PAC between January 2016 and May 2022. There were two groups according to the mortality in the follow-up period group general mortality positive (GMP; n = 29) and group general mortality negative (GMN; n = 22). Stage IIb was the most common stage in subgroups.

RESULTS

Preoperative diagnostic tests revealed that aspartate aminotransferase (AST) level, De Ritis ratio (DRR), carcinoembryonic antigen (CEA), cancer antigen 19-9 (CA 19-9), immature granulocyte (IG) count, and IG ratio (IG%) are higher, and hemoglobin (Hgb) levels are lower in the GMP group (P < 0.05). In univariate analysis, seven variables, including AST ≥20.5 (P = 0.001), DRR ≥1.05 (P ≤ 0.001), CEA ≥3.32 (P = 0.02), IG count ≥0.06 (P < 0.01), Hgb ≤11.75 (P = 0.01), poor differentiation (P < 0.001) and existence of life-threatening complication (P < 0.01) were identified. In multivariate analysis, only DRR (≥1.05;100% specificity and 72% sensitivity) and poor differentiation (P = 0.019) were found to be independent prognostic factors for overall survival. The median overall survival of patients with the DRR ≥1.05 and poor tumor differentiation was lower, and the mortality rate was higher than the patients with DRR and without poor tumor differentiation (10.65 ± 3.11 months vs. 61.86 ± 5.36 months and 100% vs. 26.7%, P < 0.001).

CONCLUSION

Pretreatment high DRR, high IG counts and IG%, and poor differentiation of the tumor might be used as independent predictors of poor prognosis and mortality in patients with PAC.

Alternating Gemcitabine/Nab-Paclitaxel (GA) and 5-FU/Leucovorin/Irinotecan (FOLFIRI) as First-Line Treatment for De Novo Metastatic Pancreatic Cancer (MPC): Safety and Effect

BACKGROUND

Both gemcitabine- and 5-fluorouracil (5-FU)-based chemotherapy regimens have demonstrated efficacy in metastatic pancreatic cancer (MPC). Alternating these regimens may reduce toxicity, slow resistant cancer biology emergence, and provide a platform for the addition of other therapeutic agents. Alternating gemcitabine/nab-paclitaxel (GA) and 5-FU/leucovorin/irinotecan (FOLFIRI) in MPC has previously been reported at our own institution and elsewhere. An extension of our institutional observations is reported here.

METHODS

Patient eligibility required the following: biopsy-proven de novo MPC, no prior evidence of disease on CT, ECOG performance status (PS) ≤ 2, and bi-dimensionally measurable disease. Treatment (Tx) entailed gemcitabine 1000 mg/m2 and nab-paclitaxel 125 mg/m2 1, (8), 15 alternating every 8 weeks (2 cycles) with FOLFIRI using standard dosing. Patients were radiographically re-staged every 8 weeks. Tx spanned up to 12 cycles. Tx thereafter was decided following patient/physician discussion.

RESULTS

Median overall survival (mOS) was 13.2 months (95% CI 10.9-16.5 months). Median progression-free survival (mPFS) was 8.5 months (95% CI, 7.1-9.9). The 6-, 12-, 18-, and 24-month OS rates were 88%, 54%, 36%, and 20%, respectively. The disease control rate at 16 weeks was 83% (37% PR, 46% SD). Hematologic toxicity grade ≥ 3 included 9.3% anemia, 10.2% neutropenia, and 4.6% thrombocytopenia. Neutrophil growth factors were not used in this cohort. Non-hematologic toxicities grade ≥ 3 included neuropathy 0.9%, nausea/vomiting 0.9%, and diarrhea 0.9%. No patients experienced mucositis on this regimen.

CONCLUSIONS

Alternating GA/FOLFIRI in MPC has a favorable toxicity profile in comparison to current standard regimens. Median OS was at least competitive with standard regimens, and longer-term (18 and 24 months) OS seemed particularly encouraging. Treatment for ≥48 weeks and ECOG PS of zero at the time of treatment initiation were prognostically significant. Further investigation using this regimen including randomized comparisons, the incorporation of molecular data, and use of additional agents is merited.

A follow-up study of 100 patients with acute brucellosis for its prognosis and prevention

Objective

To prevent chronic brucellosis, this study analysed the changes in patient antibody titers, and the trajectories of biochemical indicators at different stages of brucellosis, identified relevant biomarkers, and explored risk factors affecting the prognosis of brucellosis patients.

Methods

A prospective cohort study was conducted to follow 100 patients with acute brucellosis. Laboratory serological test results [taken with a serum (tube) agglutination test (SAT)] and biochemical parameters (liver function, renal function, and hematological system) were measured repeatedly at four-time points: 0 weeks-baseline survey, 6 weeks after the first treatment, 12 weeks after the second treatment, and 3 months after the third treatment. The changes in the antibody titres and biochemical parameters at each time point were analysed for trend changes.

Results

One hundred patients with acute brucellosis were enrolled in this follow-up study, with 100% retention in follow-up. By the third follow-up, 21 patients had turned subacute and 11 had turned chronic. One-way repeated measures analysis of variance results showed statistically significant differences (p < 0.01) across the time points for the following five indicators: alanine aminotransferase, aspartate aminotransferase, total bilirubin, serum creatinine (SCr) and platelet count. The clinical symptoms of patients in the acute stage were mainly joint pain, fatigue, and fever, while those in the chronic stage complained primarily of joint pain and fatigue. The results of multivariate logistic analysis showed that joint pain [odds ratio (OR) = 3.652, 95% confidence interval (CI) =1.379-9.672], monoarticular pain (OR = 6.356, 95% CI = 4.660-8.669), elevated SCr (OR = 15.804, 95% CI = 1.644-151.966) and elevated haemoglobin (Hb) (OR = 1.219, 95% CI = 1.065-1.736) were risk factors for poor prognosis (not cured or chronic) in patients with brucellosis.

Conclusion

The trajectory of changes in patient SAT posirates and antibody titers can be used to distinguish patients with chronic brucellosis. The brucellosis is preventable and treatable, and the standard treatment can be effective in reducing the clinical symptoms of affected patients. If patients are not treated in a timely manner, joint pain, monoarticular pain, and elevated SCr are risk factors for patients who are not cured. Therefore, the treatment cycle for these patients should be extended.

Serum aspartate aminotransferase is an adverse prognostic indicator for patients with resectable pancreatic ductal adenocarcinoma

OBJECTIVE

In this study, the association between preoperative levels of serum liver enzymes and overall survival (OS) was evaluated in patients with resectable pancreatic cancer.

METHODS

Preoperative serum levels of alanine aminotransferase (ALT), aspartate aminotransferases (AST), γ-glutamyltransferase, alkaline phosphatase, and lactate dehydrogenase of 101 patients with pancreatic ductal adenocarcinoma (PDAC) were collected. Univariate and multivariate Cox hazard models were used to identify independent variables associated with OS in this cohort.

RESULTS

Patients with elevated AST levels had significantly worse OS than patients with lower AST levels. A nomogram was created using TNM staging and AST levels and was shown to be more accurate in prediction than the American Joint Committee on Cancer 8th edition standard method.

CONCLUSION

Preoperative AST levels could be a novel independent prognostic biomarker for patients with PDAC. The incorporation of AST levels into a nomogram with TNM staging can be an accurate predictive model for OS in patients with resectable PDAC.

Effect of hexavalent chromium on growth performance and metabolism in broiler chicken

Hexavalent chromium Cr (VI) is one of the most hazardous heavy metals in the environment and is toxic to living organisms causing tissue damage, disruption of the intestinal microbiota and cancer. However, there is little information on the relationship between the Cr (VI) and broiler chickens. The current study was performed to investigate the effect of Cr (VI) on growth performance, serum biochemical analysis, histopathological observations, and metabolomics analysis in broilers. Results show that Cr (VI) exposure significantly decreased the body weight (p < 0.01) and caused liver damages in broilers. With the extension of Cr (VI) action time, the liver appeared obvious pathological changes, including hepatic cord disorder, incomplete hepatocyte additionally, decreased serum biochemical indices of calcium (Ca), phosphorus (P), total protein (TP), phosphatase (ALP), and globin (GLB) significantly (p < 0.01). Moreover, metabolomics analysis indicated that 29 differential metabolites were identified, such as phytosphingosine, L-Serine, 12, 13-DHOME, Alpha-dimorphecolic acid, L-Methionine, L-Phenylalanine, 3-Dehydroshikimate, L-Tyrosine, and N-Acetyl-L-phenylalanine were significantly decreased under the action of Cr (VI) (p < 0.05). These 29 differential metabolites are mainly involved in 35 metabolic pathways, such as aminoacyl-tRNA biosynthesis, phenylalanine metabolism, sphingolipid, and linoleic metabolism. The study revealed that exposure to Cr (VI) resulted in a decrease in growth performance and metabolism, with the hazards and toxicity in broiler chicken. The findings provided new insight and a comprehensive understanding of the relationship between Cr (VI) and broiler chickens.

Integrated single-cell and bulk RNA sequencing revealed the molecular characteristics and prognostic roles of neutrophils in pancreatic cancer

Pancreatic cancer, one of the most prevalent tumors of the digestive system, has a dismal prognosis. Cancer of the pancreas is distinguished by an inflammatory tumor microenvironment rich in fibroblasts and different immune cells. Neutrophils are important immune cells that infiltrate the microenvironment of pancreatic cancer tumors. The purpose of this work was to examine the complex mechanism by which neutrophils influence the carcinogenesis and development of pancreatic cancer and to construct a survival prediction model based on neutrophil marker genes. We incorporated the GSE111672 dataset, comprising RNA expression data from 27,000 cells obtained from 3 patients with PC, and conducted single-cell data analysis. Thorough investigation of pancreatic cancer single-cell RNA sequencing data found 350 neutrophil marker genes. Using The Cancer Genome Atlas (TCGA), GSE28735, GSE62452, GSE57495, and GSE85916 datasets to gather pancreatic cancer tissue transcriptome data, and consistent clustering was used to identify two categories for analyzing the influence of neutrophils on pancreatic cancer. Using the Random Forest algorithm and Cox regression analysis, a survival prediction model for pancreatic cancer was developed, the model showed independent performance for survival prognosis, clinic pathological features, immune infiltration, and drug sensitivity. Multivariate Cox analysis findings revealed that the risk scores derived from predictive models is independent prognostic markers for pancreatic patients. In conclusion, based on neutrophil marker genes, this research created a molecular typing and prognostic grading system for pancreatic cancer, this system was very accurate in predicting the prognosis, tumor immune microenvironment status, and pharmacological treatment responsiveness of pancreatic cancer patients.

Nomogram Based on Liver Function Test Indicators for Survival Prediction in Nasopharyngeal Carcinoma Patients Receiving PD-1 Inhibitor Therapy

PURPOSE

The aim of this study was to investigate the prognostic significance of PD-1 inhibitor therapy in nasopharyngeal carcinoma (NPC) and to develop a nomogram to estimate individual risks.

METHODS

We retrospectively analyzed 162 NPC patients who were administered the PD-1 inhibitor combined with radiotherapy and chemotherapy at the Sun Yat-Sen University Cancer Center. In total, 108 NPC patients were included in the training cohort and 54 NPC patients were included in the validation cohort. Univariate and multivariate Cox survival analyses were performed to determine the prognostic factors for 1-year and 2-year progression-free survival (PFS). In addition, a nomogram model was constructed to predict the survival probability of PFS. A consistency index (C-index), a decision curve, a clinical impact curve, and a standard curve were used to measure predictive accuracy, the clinical net benefit, and the consistency of prognostic factors.

RESULTS

Univariate and multivariate analyses indicated that the metastasis stage, the levels of ALT, the AST/ALT ratio, and the LDH were independent risk factors associated with the prognosis of PD-1 inhibitor therapy. A nomogram based on these four indicators was constructed and the Kaplan-Meier survival analysis showed that patients with a higher total score have a shorter PFS. The C-index of this model was 0.732 in the training cohort and 0.847 in the validation cohort, which are higher than those for the TNM stages (training cohort: 0.617; validation cohort: 0.727; p <0.05). Decision Curve Analysis (DCA), Net Reclassification Improvement (NRI), and Integrated Discrimination Improvement (IDI) showed that our model has better prediction accuracy than TNM staging.

CONCLUSIONS

Predicting PFS in NPC patients based on liver function-related indicators before PD-1 treatment may help clinicians predict the efficacy of PD-1 treatment in these patients.

Prognostic value and model construction of preoperative inflammatory markers in patients with metastatic renal cell carcinoma

BACKGROUND

Inflammation is considered to be one of the driving factors of cancer, and chronic inflammation plays a crucial role in tumor growth and metastasis. The aim of this study was to examine the predictive value of preoperative inflammatory biomarkers for overall survival (OS) in patients with metastatic renal cell carcinoma (mRCC), including preoperative neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and aspartate aminotransferase-to-lymphocyte ratio (ALR), a novel inflammatory biomarker.

METHOD

This study included 198 patients with mRCC from a single center from 2006 to 2022. The optimal cut-off levels for the three biomarkers were derived using the receiver operating characteristic curve (ROC). Cox univariate and multivariate analyses were used to assess independent prognostic inflammatory biomarkers. Finally, independent prognostic inflammatory biomarkers were incorporated into the prognostic model to establish a nomogram to predict the postoperative survival of patients with mRCC.

RESULT

The area under the ROC curve for NLR, LMR, and ALR, respectively, is 0.71 (CI: 0.635-0.784), 0.68 (CI: 0.604-0.755), and 0.75 (CI: 0.680-0.819). The optimal LMR, NLR, and ALR cut-off levels as evaluated by the ROC curve were 3.836, 3.106, and 68.056, respectively. Patients with NLR and ALR higher than the cut-off level and LMR lower than the cut-off level had a significant relationship with OS. Multivariate analysis revealed that tumor necrosis, lower LMR, and higher ALR were independent risk factors for OS. In addition, a nomogram that includes independent prognostic inflammatory biomarkers can accurately predict the OS in patients with mRCC.

CONCLUSION

ALR and LMR are independent risk factors for the prognosis of individuals with mRCC. By monitoring ALR and LMR postoperatively, the prognosis of patients with mRCC can be better evaluated.

Development and validation of prognostic nomograms based on De Ritis ratio and clinicopathological features for patients with stage II/III colorectal cancer

BACKGROUND

Metabolic derangements and systemic inflammation are related to the progression of colorectal cancer (CRC) and the prognoses of these patients. The survival of stage II and III CRC patients existed considerable heterogeneity highlighting the urgent need for new prediction models. This study aimed to develop and validate prognostic nomograms based on preoperative serum liver enzyme as well as evaluate the clinical utility.

METHODS

A total of 4014 stage II/III primary CRC patients pathologically diagnosed from January 2007 to December 2013 were included in this study. These patients were randomly divided into a training set (n = 2409) and a testing set (n = 1605). Univariate and multivariate Cox analyses were used to select the independent factors for predicting overall survival (OS) and disease-free survival (DFS) of stage II/III CRC patients. Next, nomograms were constructed and validated to predict the OS and DFS of individual CRC patients. The clinical utility of nomograms, tumor-node-metastasis (TNM), and the American Joint Committee on Cancer (AJCC) system was evaluated using time-dependent ROC and decision curve analyses.

RESULTS

Among seven preoperative serum liver enzyme markers, aspartate aminotransferase-to-alanine aminotransferase ratio (De Ritis ratio) was identified as an independent factor for predicting both OS and DFS of stage II/III CRC patients. The nomograms incorporated De Ritis ratio and significant clinicopathological features achieved good accuracy in terms of OS and DFS prediction, with C-index of 0.715 and 0.692, respectively. The calibration curve showed good agreement between prediction by nomogram and actual observation. The results of time-dependent ROC and decision curve analyses suggested that the nomograms had improved discrimination and greater clinical benefits compared with TNM and AJCC staging.

CONCLUSIONS

De Ritis ratio was an independent predictor in predicting both the OS and DFS of patients with stage II/III CRC. Nomograms based on De Ritis ratio and clinicopathological features showed better clinical utility, which is expected to help clinicians develop appropriate individual treatment strategies for patients with stage II /III CRC.

A retrospect study based on real-world data to observe metabolic function in cancer patients using albumin-bound paclitaxel

There is substantial evidence that albumin-bound paclitaxel (nab-paclitaxel) is effective and safe for the treatment of breast, lung and pancreatic cancers. However, it can still cause adverse effects by affecting cardiac enzymes, hepatic enzyme metabolism and blood routine related indicators, which affects the use of chemotherapy for a full course of treatment. However, there are no relevant clinical studies to systematically observe the effects and dynamics of albumin-bound paclitaxel on cardiac enzymes, liver enzyme metabolism, and routine blood-related indices. The purpose of our study was to determine the levels of serum creatinine (Cre), aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), creatine kinase (CK), creatine kinase isoenzyme (CK-MB), white blood cells (WBC) and hemoglobin (HGB) in cancer patients treated with albumin-conjugated paclitaxel. This study retrospectively analyzed 113 patients with cancer. Patients who had received two cycles of nab-paclitaxel 260 mg/m² (administered intravenously on days 1, 8, and 15 of each 28-day cycle) were selected. Serum Cre, AST, ALT, LDH, CK, and CK-MB activities, WBC counts, and HGB levels were measured before and after treatment with two cycles. Fourteen cancer types were analyzed. The distribution of cancer types in patients was mainly concentrated in lung, ovarian, and breast cancer. Nab-paclitaxel treatment markedly decreased Cre, AST, LDH, and CK activities in the serum and WBC counts and HGB levels, respectively. Serum Cre and CK activities and HGB levels were remarkably downregulated at baseline compared to healthy controls. Patients receiving nab-paclitaxel treatment cause metabolic disorders in tumor patients by reducing the decrease of Cre, AST, LDH, CK, CK-MB, WBC and HGB indexes, thus inducing the occurrence of cardiovascular events, hepatotoxic events and fatigue and other symptoms. Therefore, for tumor patients, although receiving nab-paclitaxel improves the anti-tumor effect, it is still necessary to closely monitor the changes of related enzymatic and routine blood indicators, so as to detect and intervene at an early stage.

Prognostic value of alkaline phosphatase and gamma-glutamyl transferase in patients with metastatic pancreatic cancer

Background: Pancreatic cancer (PC) is one of the most lethal malignancies worldwide. This study evaluated the prognostic role of serum alanine phosphatase (ALP) and gamma-glutamyl-transferase (GGT) in metastatic PC patients. Materials & methods: 153 patients with metastatic PC receiving first-line treatment with nab-paclitaxel/gemcitabine were retrospectively enrolled in a multicenter study and stratified according to ALP (≤ or >260 U/l) and GGT (≤ or >45.5 U/l) levels. Results: Improved overall survival was recorded in patients with GGT levels ≤45.5 U/l (p < 0.05). In patients with liver metastasis, overall survival was significantly lower in patients with high ALP (p = 0.01) and GGT (p = 0.02). Conclusion: High levels of ALP and GGT were related to a poor prognosis in PC patients with liver metastasis receiving nab-paclitaxel/gemcitabine.

Optimizing First-Line Chemotherapy in Metastatic Pancreatic Cancer: Efficacy of FOLFIRINOX versus Nab-Paclitaxel Plus Gemcitabine

Pancreatic cancer (PC) is one of the most lethal tumors in Europe with an overall 5-year survival rate of 5%. Since 1992, gemcitabine (Gem) has been the treatment of choice for metastatic disease with significant improvement in median overall survival (OS) compared to fluorouracil. A good performance status (PS) at diagnosis appears to be a strong predictive factor for better survival. Overall, 50% of PC are metastatic or locally advanced at diagnosis, and more than 70% of the resected patients will experience a recurrence, with a median OS ranging from 4 to 10 months (mos). FOLFIRINOX (5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) and Nab-paclitaxel (Nab-p) plus Gem have recently increased survival of patients with metastatic PC, over Gem. Treatment with FOLFIRINOX is generally considered more effective with respect to the doublet, with toxicity concerns, FOLFIRINOX achieves an overall response rate (ORR) of 31.6%, while for Nab-p plus Gem ORR is 23%; however, FOLFIRINOX was associated with higher rates of grade 3 and higher adverse events. Although the international guidelines indicate that both regimens can be used as first-line therapy for patients with metastatic PC, FOLFIRINOX is the most widely used; Nab-p plus Gem is more frequently used in patients with lower PS. In this review, we critically analyze these two regimens to give a pragmatic guide to treatment options.

Preoperative lung immune prognostic index predicts survival in patients with pancreatic cancer undergoing radical resection

Background

Lung immune prognostic index (LIPI), a combination of derived neutrophil-to-lymphocyte ratio (dNLR) and lactate dehydrogenase (LDH), is currently attracting considerable interest as a potential prognostic indicator in many malignancies. Our study aimed to investigate the prognostic value of preoperative LIPI in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing radical resection.

Methods

We retrospectively reviewed PDAC patients treated with radical resection from February 2019 to April 2021 at Chinese People's Liberation Army (PLA) general hospital. Based on the cut-off value of dNLR and LDH identified by X-tile, patients were divided into LIPI good and LIPI intermediate/poor group. Kaplan-Meier curve and log-rank test were used to compare the recurrence-free survival (RFS) and overall survival (OS) of the two groups. Univariate and multivariate Cox regression was used to identify the independent prognostic value of LIPI. Subgroup analysis was performed to identify specific population benefited from radical resection.

Results

A total of 205 patients were included and the median RFS and OS was 10.8 and 24.3 months, respectively. Preoperative LIPI intermediate/poor was related to worse RFS and OS (p < 0.05). Preoperative LIPI intermediate/poor, vascular invasion and no adjuvant chemotherapy were indicators of poor OS. Patients with LIPI intermediate/poor had worse OS especially among females and those with adjuvant chemotherapy (p < 0.05). Adjuvant chemotherapy related to better RFS and OS in patients with LIPI good (p < 0.05).

Conclusions

Preoperative LIPI intermediate/poor can be an indicator of poor prognosis in patients with PDAC undergoing radical resection. LIPI good could be an effective marker of benefit from adjuvant chemotherapy. Larger studies are warranted for further validation.

Effect of a MUC5AC Antibody (NPC-1C) Administered With Second-Line Gemcitabine and Nab-Paclitaxel on the Survival of Patients With Advanced Pancreatic Ductal Adenocarcinoma: A Randomized Clinical Trial

IMPORTANCE

Treatment options are limited for patients with advanced pancreatic ductal adenocarcinoma (PDAC) beyond first-line 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX), with such individuals commonly being treated with gemcitabine and nab-paclitaxel.

OBJECTIVE

To determine whether NPC-1C, an antibody directed against MUC5AC, might increase the efficacy of second-line gemcitabine and nab-paclitaxel in patients with advanced PDAC.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter, randomized phase II clinical trial enrolled patients with advanced PDAC between April 2014 and March 2017 whose disease had progressed on first-line FOLFIRINOX. Eligible patients had tumors with at least 20 MUC5AC staining by centralized immunohistochemistry review. Statistical analysis was performed from April to May 2022.

INTERVENTIONS

Patients were randomly assigned to receive gemcitabine (1000 mg/m2) and nab-paclitaxel (125 mg/m2) administered intravenously on days 1, 8, and 15 of every 4-week cycle, with or without intravenous NPC-1C 1.5 mg/kg every 2 weeks.

MAIN OUTCOMES AND MEASURES

The primary end point was overall survival (OS). Secondary end points were progression-free survival (PFS), objective response rate (ORR), and safety. Pretreatment clinical variables were explored with Cox proportional hazards analysis.

RESULTS

A total of 78 patients (median [range] age, 62 [36-78] years; 32 [41%] women; 9 [12%] Black; 66 [85%] White) received second-line treatment with gemcitabine plus nab-paclitaxel (n = 40) or gemcitabine plus nab-paclitaxel and NPC-1C (n = 38). Median OS was 6.6 months (95% CI, 4.7-8.4 months) with gemcitabine plus nab-paclitaxel vs 5.0 months (95% CI, 3.3-6.5 months; P = .22) with gemcitabine plus nab-paclitaxel and NPC-1C. Median PFS was 2.7 months (95% CI, 1.9-4.1 months) with gemcitabine plus nab-paclitaxel vs 3.4 months (95% CI, 1.9-5.3 months; P = .80) with gemcitabine plus nab-paclitaxel and NPC-1C. The ORR was 3.1% (95% CI, 0.4%-19.7%) in the gemcitabine plus nab-paclitaxel and NPC-1C group and 2.9% (95% CI, 0.4%-18.7%) in the gemcitabine plus nab-paclitaxel group. No differences in toxicity were observed between groups, except that grade 3 or greater anemia occurred more frequently in patients treated with gemcitabine plus nab-paclitaxel and NPC-1C than gemcitabine plus nab-paclitaxel (39% [15 of 38] vs 10% [4 of 40]; P = .003). The frequency of chemotherapy dose reductions was similar in both groups (65% vs 74%; P = .47). Lower performance status, hypoalbuminemia, PDAC diagnosis less than or equal to 18 months before trial enrollment, lymphocyte-to-monocyte ratio less than 2.8, and CA19-9 greater than 2000 IU/mL were independently associated with poorer survival.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial of advanced PDAC, NPC-1C did not enhance the efficacy of gemcitabine/nab-paclitaxel. These data provide a benchmark for future trials investigating second-line treatment of PDAC.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01834235.

Assessing Performance and Clinical Usefulness in Prediction Models With Survival Outcomes: Practical Guidance for Cox Proportional Hazards Models

Risk prediction models need thorough validation to assess their performance. Validation of models for survival outcomes poses challenges due to the censoring of observations and the varying time horizon at which predictions can be made. This article describes measures to evaluate predictions and the potential improvement in decision making from survival models based on Cox proportional hazards regression.

As a motivating case study, the authors consider the prediction of the composite outcome of recurrence or death (the "event") in patients with breast cancer after surgery. They developed a simple Cox regression model with 3 predictors, as in the Nottingham Prognostic Index, in 2982 women (1275 events over 5 years of follow-up) and externally validated this model in 686 women (285 events over 5 years). Improvement in performance was assessed after the addition of progesterone receptor as a prognostic biomarker.

The model predictions can be evaluated across the full range of observed follow-up times or for the event occurring by the end of a fixed time horizon of interest. The authors first discuss recommended statistical measures that evaluate model performance in terms of discrimination, calibration, or overall performance. Further, they evaluate the potential clinical utility of the model to support clinical decision making according to a net benefit measure. They provide SAS and R code to illustrate internal and external validation.

The authors recommend the proposed set of performance measures for transparent reporting of the validity of predictions from survival models.

A Retrospective Analysis of the De Ritis Ratio in Muscle Invasive Bladder Cancer, with Focus on Tumor Response and Long-Term Survival in Patients Receiving Neoadjuvant Chemotherapy and in Chemo Naïve Cystectomy Patients-A Study of a Clinical Multicentre Database

Background: A high pre-treatment De Ritis ratio, the aspartate transaminase/alanine aminotransferase ratio, has been suggested to be of prognostic value for mortality in muscle-invasive bladder cancer (MIBC). Our purpose was to evaluate if a high ratio was associated with mortality and downstaging. Methods: A total of 347 Swedish patients with clinically staged T2-T4aN0M0, with administered neoadjuvant chemotherapy (NAC) or eligible for NAC and undergoing radical cystectomy (RC) 2009−2021, were retrospectively evaluated with a low ratio < 1.3 vs. high ratio > 1.3, by Log Rank test, Cox regression and Mann−Whitney U-test (MWU), SPSS 27. Results: Patients with a high ratio had a decrease of up to 3 years in disease-free survival (DFS), cancer-specific survival (CSS) and overall survival (OS) (p = 0.009, p = 0.004 and p = 0.009) and 5 years in CSS and OS (p = 0.019 and p = 0.046). A high ratio was associated with increased risk of mortality, highest in DFS (HR, 1.909; 95% CI, 1.265−2.880; p = 0.002). No significant relationship between downstaging and a high ratio existed (p = 0.564 MWU). Conclusion: A high pre-treatment De Ritis ratio is on a population level, associated with increased mortality post-RC in endpoints DFS, CSS and OS. Associations decrease over time and require further investigations to determine how strong the associations are as meaningful prognostic markers for long-term mortality in MIBC. The ratio is not suitable for downstaging-prediction.

Development of a Clinical-Biological Model to Assess Tumor Progression in Metastatic Pancreatic Cancer: Post Hoc Analysis of the PRODIGE4/ACCORD11 Trial

Background: The follow-up of pancreatic cancer (PC) is based on computed tomography (CT) assessment; however, there is no consensus on the use of clinical and biological criteria in tumor progression. We aimed to establish a clinical−biological model to highlight the progression of metastatic PC during first-line treatment. Methods: The patients treated with first-line chemotherapy in the phase 2/3 PRODIGE4/ACCORD11 clinical trial were evaluated retrospectively. Clinical and biological markers were evaluated at the time of CT scans and during treatment to determine tumor progression. Results: In total, 196 patients were analyzed, with 355 available tumor assessments. The clinical and biological factors associated with tumor progression in multivariate analysis included gemcitabine, global health status ≤ 33 (OR = 3.38, 95%CI [1.15; 9.91], p = 0.028), quality of life score between 34 and 66 (OR = 2.65, 95%CI [1.06; 6.59], p = 0.037), carcinoembryonic antigen (CEA) ≥ 3 times the standard value without any increase in the CEA level from inclusion (OR = 2.22, 95%CI [1.01; 4.89], p = 0.048) and with an increase in the CEA level from inclusion (OR = 6.56, 95%CI [2.73; 15.78], p < 0.001), and an increase in the carbohydrate antigen 19-9 level from inclusion (OR = 2.59, 95%CI [1.25; 5.36], p = 0.016). Conclusions: The self-assessment of patients’ general health status alongside tumor markers is an interesting approach to the diagnosis of the tumor progression of metastatic pancreatic cancer patients during first-line treatment.

Prognostic models to predict survival in patients with pancreatic cancer: a systematic review

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) has poor survival. Current treatments offer little likelihood of cure or long-term survival. This systematic review evaluates prognostic models predicting overall survival in patients diagnosed with PDAC.

METHODS

We conducted a comprehensive search of eight electronic databases from their date of inception through to December 2019. Studies that published models predicting survival in patients with PDAC were identified.

RESULTS

3297 studies were identified; 187 full-text articles were retrieved and 54 studies of 49 unique prognostic models were included. Of these, 28 (57.1%) were conducted in patients with advanced disease, 17 (34.7%) with resectable disease, and four (8.2%) in all patients. 34 (69.4%) models were validated, and 35 (71.4%) reported model discrimination, with only five models reporting values >0.70 in both derivation and validation cohorts. Many (n = 27) had a moderate to high risk of bias and most (n = 33) were developed using retrospective data. No variables were unanimously found to be predictive of survival when included in more than one study.

CONCLUSION

Most prognostic models were developed using retrospective data and performed poorly. Future research should validate instruments performing well locally in international cohorts and investigate other potential predictors of survival.

Stool Elastase as an Independent Prognostic Factor in Patients with Pancreatic Head Cancer

(1) Background: Patients with pancreatic exocrine insufficiency (PEI) have an increased risk of malnutrition, which in turn increases morbidity and mortality and is frequent in pancreatic head cancer. This study aimed to analyze the utility of PEI measured using the stool elastase (SE) level to predict the prognosis of patients with pancreatic head cancer. (2) Methods: Patients who underwent pancreaticoduodenectomy for pancreatic cancer at our institution between 2011 and 2015 were included. Only patients with data on preoperative SE levels were analyzed. Patients were classified into low and high SE groups based on preoperative SE levels (low < 100 µg/g < high). (3) Results: The median preoperative SE level was 67.2 µg/g, and 84 of 143 (58.7%) patients were included in the low SE group. The two groups had significantly different overall survival (OS) and disease-free survival (DFS), and the low SE group had a worse prognosis. In multivariate analysis, SE level < 100 µg/g and lymph node metastasis were independent poor prognostic factors for OS and DFS. (4) Discussion: PEI measured using SE levels is an independent prognostic factor in patients with pancreatic head cancer undergoing pancreaticoduodenectomy. Since poor nutritional status may be related to prognosis in patients with low levels of stool elastase preoperatively, aggressive treatment may be required.

Prognostic Role of Carbohydrate Antigen 19 to 9 in Predicting Survival of Patients With Pancreatic Cancer: A Meta-Analysis

This study evaluates the prognostic role of carbohydrate antigen 19 to 9 (CA19-9) in predicting survival of pancreatic cancer patients. Literature search was conducted in electronic databases (Google Scholar, Ovid, PubMed, and Science Direct) and study selection was based on precise eligibility criteria. Random-effects meta-analyses were performed to achieve overall estimates of median survival and hazard ratios (HRs) of survival with cutoff defined lower and higher CA19-9 levels before and after surgery or chemotherapy (CT)/radiotherapy (RT) and the changes in CA19-9 levels after any treatment. A total of 41 studies (6519 patients; 42% females; age 63.3 years [95% confidence interval [CI]: 62.2, 64.4]) were included. A pooled HR of 1.79 with a narrow 95% CI (1.58, 2.01) showed that higher CA19-9 levels or less decrease in CA19-9 levels after treatment predicted shorter survival. Median survival in patients with lower and higher preoperative CA19-9 levels was 23.2 months [95% CI: 17.2, 29.2] and 14.0 months [95% CI: 10.9, 17.2], respectively, whereas median survival with lower and higher postoperative CA19-9 levels was 25.0 months [95% CI: 21.9, 28.0] and 13.0 months [95% CI: 10.9, 15.0] respectively. Median survival with lower and higher pre-CT/RT CA19-9 levels was 11.9 months [95% CI: 10.2, 13.6] and 7.7 months [95% CI: 6.2, 9.2], respectively, whereas median survival with lower and higher post-CT/RT CA19-9 levels was 15.1 months [95% CI: 13.2, 17.0] and 10.7 months [95% CI: 7.3, 14.0] respectively. A decrease in CA19-9 levels after treatment was also associated with longer survival. Thus, both pretreatment and posttreatment CA19-9 levels or their changes after treatment have good prognostic value in determining the survival of pancreatic cancer patients.

Preoperative aspartate transaminase/alanine transaminase ratio as a prognostic biomarker in primary non-muscle-invasive bladder cancer: a propensity score-matched study

Purpose

To evaluate the prognostic value of the aspartate transaminase/alanine transaminase (AST/ALT) ratio in primary non-muscle-invasive bladder cancer (NMIBC) using propensity score matching (PSM) analysis.

Methods

We retrospectively collected the clinical and pathological data from 314 patients with primary NMIBC who underwent transurethral resection of bladder tumor. The full cohorts were divided into a low AST/ALT ratio group and a high AST/ALT ratio group according to the optimal cut-off value which was obtained based on the analysis of the receiver operating characteristic curve for the 3-year recurrence-free survival (RFS). After 1:1 PSM, the correlation between preoperative AST/ALT ratio and survival prognosis was evaluated by Kaplan–Meier analysis with log-rank tests. The independent prognostic factors for RFS and progression-free survival (PFS) were also analyzed.

Results

The optimum cutoff value of the preoperative AST/ALT ratio was 1.40. Before PSM, a high AST/ALT ratio was correlated with the larger proportion of age > 60 years (P = 0.007) and the worse pathological T stage (P < 0.001). After PSM, patients with a high AST/ALT ratio had poorer RFS and PFS than patients with a low AST/ALT ratio (all P < 0.001). In addition, multivariate Cox regression analysis indicated that preoperative AST/ALT ratio was considered as an independent prognostic factor of RFS (HR 2.865; 95%CI 1.873–4.381; P < 0.001) and PFS (HR 4.771; 95%CI 2.607–8.734; P < 0.001) in patients with primary NMIBC.

Conclusions

The high AST/ALT ratio group tended to have poorer RFS and PFS than the low AST/ALT ratio group. Our results also indicated that the elevated preoperative AST/ALT ratio could be seen as a useful prognostic biomarker for predicting early disease recurrence and progression in patients with primary NMIBC.

The association between serum liver enzymes and cancer mortality

Interpreting levels of liver enzymes is often challenging because they may be influenced by metabolic processes beyond the liver. Given their pathophysiologic roles in inflammation and oxidative stress, higher levels of these enzymes may be associated with increased risk of mortality. However, studies have found inconsistent results. Thus, we examined the association of liver enzymes levels with cancer mortality in the general US adult population. We used the US National Health and Nutrition Examination Survey from 1999 to 2016. Kaplan-Meier survival curve comparisons were examined across quartiles of liver enzymes. Cox proportional hazards models were built to examine the relationship between cancer mortality and liver enzymes quartiles without and with adjustment for potential confounding factors. During the 338,882 person-years follow-up, 1059 participants had cancer-related deaths. There was a nonlinear U-shaped relationship between serum alanine and aspartate aminotransferase (ALT and AST) levels and cancer mortality. There was no relationship between cancer mortality and gamma-glutamyltransferase (GGT); however, each 10 IU/L increase in GGT after median was associated with 1% higher mortality risk (HR = 1.01; 95% CI = 1.00, 1.02; P = 0.001). Only subjects with high levels of alkaline phosphatase (ALP) had higher cancer mortality (HR = 1.63; 95CI = 1.30, 2.05; P < 0.001 and HR = 1.52; 95%CI = 1.20, 1.94; P = 0.001, respectively). Only the lowest and highest serum ALT and AST levels are associated with increased cancer mortality. For ALP, the relationship is present at higher levels. The association with GGT was not robust to different analyses. The mechanisms underlying the observed relationships need further exploration.

Performance status as prognostic factor in phase III trials of first-line chemotherapy of unresectable or metastatic pancreatic cancer: A trial-level meta-analysis

For patients with unresectable or metastatic pancreatic adenocarcinoma (mPDAC), there are no standardized prognostic and predictive factors beyond performance status (PS). A poor PS, as defined by Eastern Cooperative Oncology Group (ECOG) score of 2 or more, has been related with a detrimental effect of chemotherapy. Therefore, even more trials enrolled patients with good PS. The current analysis aims to evaluate the results of PS as a prognostic factor in phase III trials of patients with mPDAC receiving first-line chemotherapy. A literature search on two databases, from 2000 to 2019, and a further selection of clinical trials were performed by predefined criteria. Twelve phase III studies have been included in the analysis: the trials, enrolling 5619 patients, confirmed the worse prognosis of patients with higher ECOG PS scores (hazard ratio [HR] = 1.45; 95% confidence interval [CI], 1.21-1.74; p-value < 0.001), and a similar trend was evident for patients with an ECOG PS 1 versus 0 (HR = 1.61; 95% CI, 1.43-1.80; p-value < 0.001) in six studies, enrolling 2799 patients. Heterogeneity of trials was high, with I²  = 91%. Some possible moderators have been suggested, such as the number of drugs in the chemotherapy regimen and the male gender. In conclusion, a low ECOG PS score appears to be related with a longer survival even in trials that excluded patients with an ECOG PS 2 score, but the meta-analyses reported high heterogeneity and publication bias.

Functional inhibition of lactate dehydrogenase suppresses pancreatic adenocarcinoma progression

BACKGROUND

Pancreatic adenocarcinoma (PAAD) a highly lethal malignancy. The current use of clinical parameters may not accurately predict the clinical outcome, which further renders the unsatisfactory therapeutic outcome.

METHODS

In this study, we retrospectively analyzed the clinical-pathological characteristics and prognosis of 253 PAAD patients. Univariate, multivariate, and Kaplan-Meier survival analyses were conducted to assess risk factors and clinical outcomes. For functional study, we performed bidirectional genetic manipulation of lactate dehydrogenase A (LDHA) in PAAD cell lines to measure PAAD progression by both in vitro and in vivo assays.

RESULTS

LDHA is particularly overexpressed in PAAD tissues and elevated serum LDHA-transcribed isoenzymes-5 (LDH-5) was associated with poorer patients' clinical outcomes. Genetic overexpression of LDHA promoted the proliferation and invasion in vitro, and tumor growth and metastasis in vivo in murine PAAD orthotopic models, while knockdown of LDHA exhibited opposite effects. LDHA-induced L-lactate production was responsible for the LDHA-facilitated PAAD progression. Mechanistically, LDHA overexpression reduced the phosphorylation of metabolic regulator AMPK and promoted the downstream mTOR phosphorylation in PAAD cells. Inhibition of mTOR repressed the LDHA-induced proliferation and invasion. A natural product berberine was selected as functional inhibitor of LDHA, which reduced activity and expression of the protein in PAAD cells. Berberine inhibited PAAD cells proliferation and invasion in vitro, and suppressed tumor progression in vivo. The restoration of LDHA attenuated the suppressive effect of berberine on PAAD.

CONCLUSIONS

Our findings suggest that LDHA may be a novel biomarker and potential therapeutic target of human PAAD.

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.

De Ritis Ratio as a Significant Prognostic Factor in Patients with Sepsis: A Retrospective Analysis

PURPOSE

This study was performed to investigate the relationship between the aspartate transaminase and/or alanine transaminase ratio (DRR) and long-term mortality of patients diagnosed with sepsis or septic shock.

MATERIALS AND METHODS

We conducted a retrospective study among adult septic patients who were admitted to the surgical intensive care unit (ICU) of the Chinese People's Liberation Army (PLA) General Hospital from January 2014 to December 2018. Baseline characteristics were compared between survivors and non survivors. We performed univariate and multivariate Cox regression analyses to evaluate the relation of DRR with 180-day mortality. The potential prognostic value of DRR in predicting mortality rate was assessed by receiver operating characteristic (ROC) curve analysis. In addition, we conducted subgroup analysis by the optimal DRR cutoff value.

RESULTS

We included a total of 183 patients in the current study, and 44 (24%) patients died within 180 days of hospitalization. Univariate and multivariate Cox analyses revealed that DRR was an independent predictor of 180-day mortality (hazard ratio [HR] 1.421, 95% confidence interval [CI] 1.073-1.883, P = 0.014). The predictive accuracy of DRR for 180-day mortality was presented as an ROC curve, which had an area under the curve (AUC) of 0.708 (95% CI 0.629-0.786, P < 0.001). After we stratified all enrolled patients into two groups by using the optimal cutoff value of 1.29, we observed a significantly higher mortality in patients with a relatively high DRR.

CONCLUSIONS

An elevated DRR was associated with higher 180-day mortality among septic patients, and DRR might be an optimal marker for predicting the long-term mortality of sepsis. More prospective and randomized trials are needed to confirm the prognostic value of DRR.

Real World First-Line Treatments and Outcomes of Nab-Paclitaxel Plus Gemcitabine, mFOLFIRINOX and GEMOX in Unresectable Pancreatic Cancer from a Chinese Single Institution

Background: There have not been any head-to-head prospective studies to compare the effects of different chemotherapy regimens as first-line treatments for unresectable pancreatic cancer (UPC). We aimed to compare the effectiveness of nab-paclitaxel plus gemcitabine, mFOLFIRINOX and gemcitabine plus oxaliplatin (GEMOX) as first-line treatments by using real-world data from Chinese patients. Methods: We retrospectively included patients with UPC treated with nab-paclitaxel plus gemcitabine, mFOLFIRINOX or GEMOX as a first-line treatment at Sun Yat-sen University Cancer Center. Overall survival (OS), progression-free survival (PFS), objective response rate (ORR) and disease control rate (DCR) were assessed. Results: A total of 117 patients were administered nab-paclitaxel plus gemcitabine (n = 62), mFOLFIRINOX (n = 30) or GEMOX (n = 25) as first-line chemotherapy. The median OS was 11.1, 10.1 and 10.2 months (p = 0.75) in the nab-paclitaxel plus gemcitabine, mFOLFIRINOX and GEMOX, respectively. The ORR was similar among the three groups (24%, 23% and 32%, p = 0.76) and the DCR was higher in the nab-paclitaxel-gemcitabine group (82%) than the other two groups (60% and 64%, p = 0.04). The most common adverse events of grade 3 or 4 were neutropenia (32%, 28% and 5%), peripheral neuropathy (13%, 16% and 0) and fatigue (9%, 16% and 5%). Febrile neutropenia occurred in 2%, 4% and 5% of the patients in the three groups. Conclusion: In the first line treatment of UPC, our results suggest that nab-paclitaxel plus gemcitabine was associated with a higher DCR than mFOLFIRINOX or GEMOX, while all groups demonstrated similar OS, PFS and ORR.

The AST/ALT (De Ritis) Ratio Predicts Survival in Patients with Oral and Oropharyngeal Cancer

Aminotransaminases, including aspartate aminotransaminase (AST) and alanine aminotransaminase (ALT), are strongly involved in cancer cell metabolism and have been associated with prognosis in different types of cancer. The purpose of the present study was to evaluate the prognostic significance of the pre-treatment AST/ALT ratio in a large European cohort of patients with oral and oropharyngeal squamous cell cancer (OOSCC). Data from 515 patients treated for OOSCC at a tertiary academic center from 2000–2017 were retrospectively analyzed. Levels of AST and ALT were measured prior to the start of treatment. Uni- and multivariate Cox regression analyses were applied to evaluate the prognostic value of the AST/ALT ratio for cancer-specific survival (CSS) and overall survival (OS), survival rates were calculated. Univariate analyses showed a significant association of the AST/ALT ratio with CSS (hazard ratio (HR) 1.71, 95% confidence interval (CI) 1.38–2.12; p < 0.001) and OS (HR 1.69, 95% CI 1.41–2.02; p < 0.001). In multivariate analysis, the AST/ALT ratio remained an independent prognostic factor for CSS and OS (HR 1.45, 95% CI 1.12–1.88, p = 0.005 and HR 1.42, 95% CI 1.14–1.77, p = 0.002). Applying receiver operating characteristics (ROC) curve analysis, the optimal cut-off level for the AST/ALT ratio was 1.44, respectively. In multivariate analysis, an AST/ALT ratio > 1.44 was an independent prognostic factor for poor CSS and OS (HR 1.64, 95% CI 1.10–2.43, p = 0.014 and HR 1.55, 95% CI 1.12–2.15; p = 0.008). We conclude that the AST/ALT ratio is a prognostic marker for survival in OOSCC patients and could contribute to a better risk stratification and improved oncological therapy decisions.

AST/ALT ratio as a significant predictor of the incidence risk of prostate cancer

BACKGROUND

To investigate the effect of serum aspartate transaminase/alanine transaminase (AST/ALT) on the risk of prostate cancer.

METHODS

A total of 404 patients undergoing prostate biopsy from April 2016 to July 2019 were enrolled. One hundred and ninety-four patients with prostatic cancer (PCa) were diagnosed by pathology. Two hundred and ten patients were diagnosed with benign prostatic hyperplasia (BPH). Multivariate logistic regression was used to analyze the effect of AST/ALT ratio and other factors on the incidence of PCa.

RESULT

AST/ALT ratio was significantly higher in PCa than in BPH patients (OR 2.313, 95%CI 1.337-4.003, P = .002). ROC curve indicated that the best cutoff was 1.155 in predicting the incidence risk of PCa. The age of PCa patients is higher than BPH patients (OR 1.054, 95%CI 1.027-1.082, P < .001). We also found that platelets were lower in PCa than in BPH patients. Multivariate analysis showed that AST/ALT ratio could be used as an independent predictor to assess the incident risk of PCa(OR 1.043, 95%CI 1.014-1.072, P = .003). However, AST/ALT ratio did not predict the incidence in high-risk or low-risk PCa.

CONCLUSION

AST/ALT ratio was an independent factor in predicting the incidence of PCa. When the level of AST/ALT ratio in serum raised, the incidence risk of PCa was significantly increased, which was helpful for the clinical diagnosis of PCa. We still needed a multicenter study to verify the role of AST/ALT ratio in the development of PCa.

The AST/ALT (De Ritis) ratio predicts clinical outcome in patients with pancreatic cancer treated with first-line nab-paclitaxel and gemcitabine: post hoc analysis of an Austrian multicenter, noninterventional study

Background:

The pretreatment De Ritis ratio [aspartate transaminase (AST)/alanine transaminase (ALT)] has been shown to be an adverse prognostic marker in various cancer entities. However, its relevance to advanced pancreatic ductal adenocarcinoma (PDAC) has not yet been studied. In the present study we investigated the AST/ALT ratio as a possible predictor of treatment response and disease outcome in patients with advanced PDAC treated with first-line gemcitabine/nab-paclitaxel.

Methods:

A post hoc analysis of a prospective, multicenter, noninterventional study was performed. A total of 202 patients with advanced PDAC treated with first-line gemcitabine/nab-paclitaxel for whom the AST/ALT ratio was measured were included in this analysis.

Results:

Median and 1-year progression-free survival estimates were 4.8 months and 5.1%, respectively in patients with an AST/ALT ratio above the 75th percentile of its distribution, and 6.0 months and 18.7%, respectively in patients with an AST/ALT ratio less than or equal to this cutoff, respectively (log-rank p = 0.004). In univariable Cox regression, a doubling of the AST/ALT ratio was associated with a 1.4-fold higher relative risk of progression or death [hazard ratio = 1.38, 95% confidence interval (CI): 1.06–1.80, p = 0.017]. The prognostic association was also found in multivariable analysis adjusting for Eastern Cooperative Oncology Group performance status and lung metastases (hazard ratio per AST/ALT ratio doubling = 1.32, 95% CI: 1.00–1.75, p = 0.047). In treatment response analysis, a doubling of the AST/ALT ratio was associated with a 0.5-fold lower odds of objective response (odds ratio = 0.54, 95% CI: 0.31–0.94, p = 0.020).

Conclusions:

The pretreatment serum AST/ALT ratio predicts poor disease outcome and response rate in patients with advanced PDAC treated with gemcitabine/nab-paclitaxel and might represent a novel and inexpensive marker for individual risk assessment in the treatment of pancreatic cancer.

What is the relevance of an ambulatory quick diagnosis unit or inpatient admission for the diagnosis of pancreatic cancer? A retrospective study of 1004 patients

Quick diagnosis units (QDU) have become an alternative hospital-based ambulatory medicine strategy to inpatient hospitalization for potentially serious illnesses in Spain. Whether diagnosis of pancreatic cancer is better accomplished by an ambulatory or inpatient approach is unknown. The main objective of this retrospective study was to examine and compare the diagnostic effectiveness of a QDU or inpatient setting in patients with pancreatic cancer.Patients with a diagnosis of pancreatic adenocarcinoma who had been referred to a university, tertiary hospital-based QDU or hospitalized between 2005 and 2018 were eligible. Presenting symptoms and signs, risk and prognostic factors, and time to diagnosis were compared. The costs incurred during the diagnostic assessment were analyzed with a microcosting method.A total of 1004 patients (508 QDU patients and 496 inpatients) were eligible. Admitted patients were more likely than QDU patients to have weight loss, asthenia, anorexia, abdominal pain, jaundice, and palpable hepatomegaly. Time to diagnosis of inpatients was similar to that of QDU patients (4.1 [0.8 vs 4.3 [0.6] days; P = .163). Inpatients were more likely than QDU patients to have a tumor on the head of the pancreas, a tumor size >2 cm, a more advanced nodal stage, and a poorer histological differentiation. No differences were observed in the proportion of metastatic and locally advanced disease and surgical resections. Microcosting revealed a cost of &OV0556;347.76 (48.69) per QDU patient and &OV0556;634.36 (80.56) per inpatient (P < .001).Diagnosis of pancreatic cancer is similarly achieved by an inpatient or QDU clinical approach, but the latter seems to be cost-effective. Because the high costs of hospitalization, an ambulatory diagnostic assessment may be preferable in these patients.

The Value of Alkaline Phosphatase-to-Albumin Ratio in Detecting Synchronous Metastases and Predicting Postoperative Relapses among Patients with Well-Differentiated Pancreatic Neuroendocrine Neoplasms

Backgrounds

Pancreatic neuroendocrine neoplasm (pNEN) is a highly heterogeneous entity, presenting widely varied biological behavior as well as long-term prognosis. Reliable biomarkers are urgently needed to make risk stratifications for pNEN patients, which could be beneficial to the development of individualized therapeutic strategy in the clinical practice. Here, we aimed to evaluate the predictive and prognostic roles of serum alkaline phosphatase-to-albumin ratio (APAR) in well-differentiated pNEN patients.

Methods

We retrospectively analyzed the pathologically confirmed grade 1/2 pNEN patients, who were originally treated in our hospital from February 2008 to April 2018. Univariate and multivariate analyses were performed to assess the value of APAR in detecting synchronous metastases and predicting relapses following curative resections.

Results

A total of 170 eligible cases were included into analysis. Logistic univariate analysis indicated APAR (P=0.002) was significantly associated with synchronous distant metastasis among well-differentiated pNEN patients, which was further demonstrated to be an independent risk factor by multivariate analysis (odds ratio 8.127, 95% confidence interval (CI) 2.105–31.372, P=0.002) was significantly associated with synchronous distant metastasis among well-differentiated pNEN patients, which was further demonstrated to be an independent risk factor by multivariate analysis (odds ratio 8.127, 95% confidence interval (CI) 2.105–31.372, P=0.002) was significantly associated with synchronous distant metastasis among well-differentiated pNEN patients, which was further demonstrated to be an independent risk factor by multivariate analysis (odds ratio 8.127, 95% confidence interval (CI) 2.105–31.372, P=0.002) was significantly associated with synchronous distant metastasis among well-differentiated pNEN patients, which was further demonstrated to be an independent risk factor by multivariate analysis (odds ratio 8.127, 95% confidence interval (CI) 2.105–31.372, P=0.002) was significantly associated with synchronous distant metastasis among well-differentiated pNEN patients, which was further demonstrated to be an independent risk factor by multivariate analysis (odds ratio 8.127, 95% confidence interval (CI) 2.105–31.372,

Conclusion

APAR may work as a convenient pretreatment marker to detect synchronous distant metastasis for well-differentiated pNEN patients and predict recurrences for curatively resected cases without nerve or vascular invasion. However, these findings should be further verified in prospectively well-designed studies.

The prognostic value of De Ritis (AST/ALT) ratio in patients after surgery for urothelial carcinoma: a systematic review and meta-analysis

Background

Recently, the De Ritis (AST/ALT) ratio has been considered as a prognostic biomarker for various malignancies. We conducted this systematic review and meta-analysis to explore the prognostic value of preoperative De Ritis ratio in patients after surgery for urothelial carcinoma.

Methods

We searched the online database Embase, PubMed and Cochrane Library up to October 2019. The hazard ratio (HR) and 95% confidence interval (CI) were extracted from the studies.

Results

A total of 8 studies incorporating 3949 patients were included in the quantitative synthesis. We observed that elevated preoperative De Ritis ratio is associated with inferior OS (HR = 1.97; 95% CI 1.70–2.28; P < 0.001), CSS (HR = 2.40; 95% CI 2.02–2.86; P < 0.001), RFS (HR = 1.31; 95% CI 1.11–1.54; P = 0.001), PFS (HR = 2.07; 95% CI 1.68–2.56; P < 0.001) and MFS (HR = 2.39; 95% CI 1.16–4.91; P = 0.018). Stratified by diseases, the elevated De Ritis ratio also served as an unfavorable factor.

Conclusion

The elevated preoperative De Ritis ratio is an unfavorable factor for patients with urothelial carcinoma. In patients with BC and UTUC, the elevated preoperative De Ritis ratio is also associated with poor prognosis. But De Ritis ratio must be validated in large, independent cohorts before it can be applied widely.

The De Ritis (Aspartate Transaminase/Alanine Transaminase) Ratio as a Prognosticator in Patients With End-stage Renal Disease-associated Renal Cell Carcinoma

BACKGROUND

The aspartate transaminase (AST)/alanine transaminase (ALT) ratio (ie, the De Ritis ratio) is associated with prognosis in some types of cancers including renal cell carcinoma (RCC). Meanwhile, an effective prognosticator for end-stage renal disease (ESRD)-associated RCC remains unknown. Thus, we investigated the prognostic impact of the AST/ALT ratio in patients with ESRD-associated RCC.

PATIENTS AND METHODS

We retrospectively evaluated 243 patients receiving radical nephrectomy for nonmetastatic ESRD-associated RCC. The patients were divided according to the cutoff value of preoperative AST/ALT ratio. Prognostic factors associated with cancer-specific survival (CSS) after radical nephrectomy were analyzed.

RESULTS

The maximum Youden index showed that the cutoff value of the AST/ALT ratio was 1.42. The high AST/ALT ratio group (≥ 1.42; n = 88) had a significantly shorter 10-year CSS than the low AST/ALT ratio group (64.3% vs. 87.2%; P = .0027). Multivariate analysis revealed that the AST/ALT ratio was an independent prognostic factor of CSS (hazard ratio [HR], 3.03; P = .0020), together with serum C-reactive protein level (HR, 4.84; P < .0001), pathologic stage (HR, 2.79; P = .0030), and tumor grade (HR, 7.08; P = .0087). Based on these independent factors, the patients were further classified into 3 groups: low (0-1 factor), intermediate (2 factors), and high risk (3-4 factors). The 10-year CSS in the high-risk group was significantly shorter than that of the other groups (68.9% vs. 70.9% vs. 94.4%; P < .0001).

CONCLUSION

The AST/ALT ratio can aid in the risk classification of patients with ESRD-associated RCC.

Pretreatment Aspartate Aminotransferase-to-Alanine Aminotransferase (De Ritis) Ratio Predicts the Prognosis of Nonmetastatic Nasopharyngeal Carcinoma

Background

The pretreatment aspartate aminotransferase-to-alanine aminotransferase (De Ritis) ratio is reportedly valuable in prognosis prediction of various malignancies. However, its value in the prognosis of nasopharyngeal carcinoma (NPC) has not yet been reported. This study aimed to evaluate the effect of the De Ritis ratio on the survival outcomes of patients with nonmetastatic NPC.

Methods

We retrospectively reviewed the medical data of 1023 patients with nonmetastatic NPC admitted between 2009 and 2013 at a single center. The Fine and Gray competing risk regression model was used to analyze the associations between the De Ritis ratio and the survival outcomes of cancer-specific survival (CSS) and progression-free survival (PFS) by using the subdistribution hazard ratio (SHR) and 95% confidence interval (CI) as size effects. The Cox proportional hazard model was used to evaluate the correlation between the De Ritis ratio and overall survival (OS) by using hazard ratio (HR) and 95% CI as size effects.

Results

Patients were divided into two groups in accordance with the pretreatment De Ritis ratio by using an optimal cutoff value of 1.65. Compared with the patients with low De Ritis ratio (< 1.65), those with elevated De Ritis ratio (≥ 1.65) had poorer prognosis with regard to CSS, PFS, and OS. Notably, multivariate analyses showed that high De Ritis ratio was independently associated with poor CSS (SHR = 1.64, 95% CI: 1.25–2.16), PFS (SHR = 1.69, 95% CI: 1.30–2.19), and OS (HR = 1.81, 95% CI: 1.39–2.40).

Conclusion

Pretreatment De Ritis ratio can be an independent prognostic predictor for patients with nonmetastatic NPC.

De Ritis ratio as a significant prognostic factor of international normalized ratio ≥4 in the initial 10 days of warfarin therapy

Aim: To assess the relationship between the De Ritis ratio on admission and warfarin sensitivity in the initial 10 days of anticoagulation therapy. Methods: We retrospectively reviewed data from 906 patients who underwent heart valve replacement surgery. Results: A De Ritis ratio of 1.19 was identified as the optimal cutoff according to the ROC curve. Patients with a high De Ritis ratio achieved an international normalized ratio (INR) ≥4 more easily and earlier than those with a low De Ritis ratio in the initial 10 days of warfarin therapy. Multivariate analysis showed that a high De Ritis ratio was an independent predictor of an INR ≥4 (HR: 2.567; p < 0.001). Conclusion: A De Ritis ratio ≥1.19 on admission was significantly associated with an INR ≥4 in the initial 10 days of warfarin therapy among patients underwent heart valve replacement surgery.

De Ritis Ratio (Aspartate Transaminase/Alanine Transaminase) as a Significant Prognostic Factor in Patients Undergoing Radical Cystectomy with Bladder Urothelial Carcinoma: A Propensity Score-Matched Study

INTRODUCTION

To investigate the correlation between preoperative De Ritis ratio (aspartate transaminase (AST)/alanine transaminase (ALT)) and postoperative outcome in patients with urothelial cell carcinoma (UC) treated with radical cystectomy.

MATERIALS AND METHODS

We analyzed the clinical and pathological data of 771 patients who underwent radical cystectomy for bladder UC. Patients were divided into two groups according to the optimal value of AST/ALT ratio. The effect of the AST/ALT ratio was analyzed using the Kaplan-Meier method and Cox regression hazard models for patients' cancer-specific survival (CSS), overall survival (OS), and recurrence-free survival (RFS). In addition, propensity score matching of 1 : 1 was performed between the two groups.

RESULTS

Median follow-up was 84.0 (36-275) months. Mean age was 64.8 ± 10.0 years. According to the receiver operating characteristic (ROC) analysis, the optimal threshold of the AST/ALT ratio was 1.1. In Kaplan-Meier analyses, the high AST/ALT group showed worse outcomes in CSS and OS (all P < 0.001). Also, RFS (P = 0.001) in the Cox regression models of clinical and pathological parameters was used to predict CSS, OS, and AST/ALT ratio (HR 2.15, 95% CI 1.23-3.73, P = 0.007) and pathological T stage (HR 4.80, 95% CI 1.19-19.28, P = 0.003). To predict OS and AST/ALT ratio (HR 2.05, 95% CI 1.65-2.56, P < 0.001), pathological T stage (HR 2.96, 95% CI 0.57-17.09, P = 0.037) and positive lymph node (HR 1.71, 95% CI 1.50-1.91, P = 0.021) were determined as independent prognostic factors.

CONCLUSION

Preoperative AST/ALT ratio could be an independent prognostic factor in patients with UC treated with radical cystectomy.

Comparisons of Outcomes of Real-World Patients With Advanced Pancreatic Cancer Treated With FOLFIRINOX Versus Gemcitabine and Nab-Paclitaxel: A Population-Based Cohort Study

OBJECTIVES

The aim of this study was to compare the efficacy and safety of FOLFIRINOX (5-FU/leucovorin, irinotecan, and oxaliplatin) and gemcitabine/nab-paclitaxel (GnP) in patients with advanced pancreatic cancer.

METHODS

Patients with newly diagnosed advanced pancreatic cancer in Saskatchewan, Canada, from 2011 to 2016, who received FOLFIRINOX or GnP were assessed. A Cox proportional multivariate analysis was performed to evaluate prognostic variables.

RESULTS

One hundred nineteen eligible patients with median age of 61 years and male/female ratio of 70:49 were identified. Seventy-seven percent had metastatic disease. Of 119 patients, 86 (72%) received FOLFIRINOX and 33 (28%) were treated with GnP. Median progression-free survival of the FOLFIRINOX group was 6.0 months [95% confidence interval (CI), 4.5-7.5] versus 4.0 months (95% CI, 2.9-5.1) with GnP (P = 0.39). The median overall survival of the FOLFIRINOX group was 9.0 months (95% CI, 7-11) compared with 9.0 months (95% CI, 4.2-13.8) with GnP (P = 0.88). On multivariate analysis, albumin [hazard ratio (HR), 0.63; 95% CI, 0.41-0.97], male sex (HR, 0.65; 95% CI, 0.43-0.97), and second-line therapy (HR, 0.50; 95% CI, 0.28-0.86) were correlated with survival.

CONCLUSIONS

Our results showed that real-world patients with advanced pancreatic cancer treated with FOLFIIRNOX or GnP had comparable survival with different safety profile.

The Preoperative Predictive Factors for Pathological T3a Upstaging of Clinical T1 Renal Cell Carcinoma

We aimed to determine the oncological outcomes of patients with clinical T1 renal cell carcinoma (RCC) upstaged to pathological T3a and to identify the preoperative predictive factors for upstaging. We retrospectively reviewed 272 patients with clinical T1 RCC who underwent surgical treatment. Thirty-three patients (12%) were upstaged to pathological T3a. These patients had a significantly larger tumor size on computed tomography (p < 0.0001), a higher aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio (p = 0.037), and an elevated c-reactive protein (CRP) level (p = 0.014) preoperatively compared with those with pathological T1 RCC. On multivariate analysis, tumor diameter was the only significant preoperative predictive factor for upstaging [hazard ratio (HR), 3.61; 95% confidence interval (CI), 1.32-9.84; p = 0.01]. The AST/ALT ratio tended to be a preoperative predictive factor for upstaging, although it was not significant (HR, 2.14; 95% CI, 0.97-4.73; p = 0.06). Pathological T3a upstaging occurred in 25% of those with a tumor diameter ≥30 mm and a preoperative AST/ALT ratio ≥1.1. There was a significant correlation between pathological T3a upstaging and the number of preoperative risk factors (p = 0.0002). The preoperative tumor diameter and serum AST/ALT ratio can be predictive factors for pathological T3a upstaging in patients with clinical T1 RCC.

Prognostic value of aspartate transaminase to alanine transaminase (De Ritis) ratio in solid tumors: a pooled analysis of 9,400 patients

BACKGROUND

Numerous studies have reported the association between pretreatment serum aspartate transaminase to alanine transaminase (AST/ALT) ratio and prognosis in multiple cancers. However, the results remain controversial and no consensus has been reached. Thus, we conducted this meta-analysis to quantitatively assess the prognostic value of pretreatment AST/ALT ratio in solid tumors.

METHODS

A systematic literature search was conducted by using PubMed, EMBASE, Web of Science, Cochrane Library, and Wanfang databases, as well as several trial registry platforms, including ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and Chinese Clinical Trial Registry, up to April 5, 2019. HR and 95% CI for overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) were calculated to estimate the effect size.

RESULTS

A total of 18 studies with 9,400 patients were included. Overall, a high level of pretreatment AST/ALT ratio was significantly associated with worse OS (pooled HR=1.70, 95% CI=1.38-2.09). The statistical significance was observed in all cancer types, including renal cell carcinoma (pooled HR=1.64, 95% CI=1.30-2.05), liver cancer (pooled HR=1.16, 95% CI=1.04-1.29), urinary tract urothelial carcinoma (pooled HR=1.96, 95% CI=1.53-2.51), bladder cancer (pooled HR =2.66, 95% CI=1.69-4.20), and other cancers (pooled HR=1.44, 95% CI=1.18-1.76). Moreover, an increased level of serum AST/ALT ratio predicted unfavorable CSS (pooled HR=2.07, 95% CI=1.74-2.46) and RFS (pooled HR=1.51, 95% CI=1.15-1.99).

CONCLUSION

Elevated level of serum AST/ALT ratio before treatment is significantly associated with poor clinical outcomes of OS, CSS, and RFS in patients with solid tumors. Pretreatment AST/ALT ratio can serve as a useful prognostic predictor for malignant patients.

Significance of the inflammation-based prognostic score in recurrent pancreatic cancer

BACKGROUND

Although the prognosis of recurrent pancreatic cancer (RPC) is improving with the appearance of new anticancer drugs, prognostic indicators for RPC are still poorly understood. The aim of this study was to evaluate significance of the inflammation-based prognostic score, including modified Glasgow Prognostic Score (mGPS), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and Prognostic Nutritional Index (PNI), in patients with RPC.

METHODS

This study reviewed 263 patients of pancreatic ductal adenocarcinoma at our institution between 2006 and 2015. A receiver operating characteristics curve analysis was performed to determine the cut-off values. The prognostic significance of the inflammation-based prognostic scores were evaluated by a multivariate analysis.

RESULTS

172 patients (65.4%) who had recurrence was included in this study. The optimal PNI for predicting 1-year survival after recurrence was 40 with higher area under receiver operating characteristics curve value (0.704) in comparison with other inflammation-based prognostic scores. A univariate and multivariate analysis revealed that liver metastasis (P < 0.001) and PNI < 40 (P < 0.001) were independently associated with the survival time after recurrence. When each of the two predictors was counted as one point and the points were calculated for all cases, a good stratified survival curve was obtained, showing the shorter survival in the higher points: median survival times of 2, 1, and 0 points were 4.3, 11.1, and 21.2 months, respectively (P < 0.001).

CONCLUSIONS

Inflammation-based prognostic scores, especially PNI is useful clinical biomarker for predicting the survival time after recurrence in patients with pancreatic adenocarcinoma.

Prognostic significance of serum aspartic transaminase in diffuse large B-cell lymphoma

Background

Liver function is routinely assessed in clinical practice as liver function tests provide sensitive indicators of hepatocellular injury. However, the prognostic value of enzymes that indicate hepatic injury has never been systematically investigated in lymphoma, including diffuse large B-cell lymphoma (DLBCL).

Methods

This study examined the prognostic value of baseline aspartic transaminase (AST) in DLBCL patients. The association between AST and clinical features was analyzed in 179 DLBCL patients treated from 2006 to 2016. All enrolled patients were treated with R-CHOP or R-CHOP-like chemotherapy. Log-rank test, univariable analysis, and subgroup analysis were performed to evaluate the impact of AST on survival.

Results

AST 33.3 U/L was considered to be the optimal threshold value for predicting prognosis. A higher AST level was associated with advanced stage (P = 0.001), poorer performance status (P = 0.014), elevated lactate dehydrogenase level (P <  0.0001), presence of B symptoms (P = 0.001), high-risk International Prognostic Index (IPI, IPI 3–5) (P = 0.002), non-germinal center B-cell subtypes (P = 0.038), hepatitis B virus surface antigen positivity (P = 0.045) and more extra nodal involvement (ENI, ENI ≥ 2) (P = 0.027). Patients with a higher AST level had a shorter overall survival (OS) (2-year OS rate, 53.6% vs. 83.6%, P <  0.001). Subgroup analysis indicated that higher AST levels have poorer prognostic values in patients without B symptoms and LDH positive groups.

Conclusion

A pretreatment AST level is associated with OS in DLBCL patients treated with R-CHOP or similar chemotherapy regimens. A high pretreatment AST level might be a reliable prognostic factor for predicting a dismal outcome in DLBCL patients. Serum AST levels may be investigated for use as an easily determinable, inexpensive biomarker for risk assessment in patients with DLBCL.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5758-2) contains supplementary material, which is available to authorized users.

Use of Machine-Learning Algorithms in Intensified Preoperative Therapy of Pancreatic Cancer to Predict Individual Risk of Relapse

Background: Although surgical resection is the only potentially curative treatment for pancreatic cancer (PC), long-term outcomes of this treatment remain poor. The aim of this study is to describe the feasibility of a neoadjuvant treatment with induction polychemotherapy (IPCT) followed by chemoradiation (CRT) in resectable PC, and to develop a machine-learning algorithm to predict risk of relapse. Methods: Forty patients with resectable PC treated in our institution with IPCT (based on mFOLFOXIRI, GEMOX or GEMOXEL) followed by CRT (50 Gy and concurrent Capecitabine) were retrospectively analyzed. Additionally, clinical, pathological and analytical data were collected in order to perform a 2-year relapse-risk predictive population model using machine-learning techniques. Results: A R0 resection was achieved in 90% of the patients. After a median follow-up of 33.5 months, median progression-free survival (PFS) was 18 months and median overall survival (OS) was 39 months. The 3 and 5-year actuarial PFS were 43.8% and 32.3%, respectively. The 3 and 5-year actuarial OS were 51.5% and 34.8%, respectively. Forty-percent of grade 3-4 IPCT toxicity, and 29.7% of grade 3 CRT toxicity were reported. Considering the use of granulocyte colony-stimulating factors, the number of resected lymph nodes, the presence of perineural invasion and the surgical margin status, a logistic regression algorithm predicted the individual 2-year relapse-risk with an accuracy of 0.71 (95% confidence interval [CI] 0.56–0.84, p = 0.005). The model-predicted outcome matched 64% of the observed outcomes in an external dataset. Conclusion: An intensified multimodal neoadjuvant approach (IPCT + CRT) in resectable PC is feasible, with an encouraging long-term outcome. Machine-learning algorithms might be a useful tool to predict individual risk of relapse. A small sample size and therapy heterogeneity remain as potential limitations.

Impact of increased aspartate aminotransferase to alanine aminotransferase (De Ritis) ratio in prognosis of testicular cancer

Purpose

Imaging studies can show metastasis in testicular cancer (TCa); however, a test for risk of metastasis in TCa has not been described. The ratio of aspartate aminotransferase to alanine aminotransferase, also called the De Ritis ratio (DRR), is used for many other malignancies. We aimed to evaluate the association between preoperatively assessed DRR and prognosis in patients with TCa.

Materials and Methods

One hundred twenty-eight patients with TCa were enrolled in a retrospective study between March 2007 and January 2017. Clinical, biochemical, and pathological data were recorded. Univariate and multivariate logistic regression analyses were used. The prognostic value of DRR and the threshold value were assessed by use of receiver operating characteristic curves. Significance was defined as p<0.05.

Results

Mean follow-up was 37±9.7 months. There were 45 and 73 TCa patients with and without lymph node metastasis, respectively. Lung metastases and other solid organ metastases occurred in 14 and 4 patients, respectively. The optimal DRR threshold was 1.30 for both retroperitoneal lymph node involvement and metastasis. DRR was determined as an independent prognostic factor for retroperitoneal lymph node involvement and organ metastasis in univariate and multivariate analyses (p<0.001, p=0.006 and p=0.002, p=0.047, respectively).

Conclusions

A preoperative DRR greater than 1.30 may be an independent risk factor for retroperitoneal lymph node involvement and organ metastases in patients with TCa.

Consensus statement on mandatory measurements in pancreatic cancer trials (COMM-PACT) for systemic treatment of unresectable disease

Variations in the reporting of potentially confounding variables in studies investigating systemic treatments for unresectable pancreatic cancer pose challenges in drawing accurate comparisons between findings. In this Review, we establish the first international consensus on mandatory baseline and prognostic characteristics in future trials for the treatment of unresectable pancreatic cancer. We did a systematic literature search to find phase 3 trials investigating first-line systemic treatment for locally advanced or metastatic pancreatic cancer to identify baseline characteristics and prognostic variables. We created a structured overview showing the reporting frequencies of baseline characteristics and the prognostic relevance of identified variables. We used a modified Delphi panel of two rounds involving an international panel of 23 leading medical oncologists in the field of pancreatic cancer to develop a consensus on the various variables identified. In total, 39 randomised controlled trials that had data on 15 863 patients were included, of which 32 baseline characteristics and 26 prognostic characteristics were identified. After two consensus rounds, 23 baseline characteristics and 12 prognostic characteristics were designated as mandatory for future pancreatic cancer trials. The COnsensus statement on Mandatory Measurements in unresectable PAncreatic Cancer Trials (COMM-PACT) identifies a mandatory set of baseline and prognostic characteristics to allow adequate comparison of outcomes between pancreatic cancer studies.

Association between De Ritis ratio (aspartate aminotransferase/alanine aminotransferase) and oncological outcomes in bladder cancer patients after radical cystectomy

Background

New biological prognostic predictors have been studied; however, some factors have limited clinical application due to tissue-specific expression and high cost. There is the need for a promising predictive factor that is simple to detect and that is closely linked to oncological outcomes in patients with urothelial bladder cancer (BC) who have undergone radical cystectomy (RC). Therefore, we investigated the clinical prognostic value of the preoperative De Ritis ratio (aspartate aminotransferase/alanine aminotransferase) on oncological outcomes in patients with urothelial BC after RC.

Methods

We retrospectively evaluated clinicopathological data of 118 patients with non-metastatic urothelial BC after RC between 2008 and 2013 at a single center. The association between the De Ritis ratio and clinicopathological findings was assessed. The potential prognostic value of the De Ritis ratio was analyzed using the Kaplan-Meier method, and multivariate Cox analyses were performed to identify the independent predictors of metastasis-free survival, cancer-specific survival, and overall survival.

Results

According to the receiver operating curve of the De Ritis ratio for metastasis, we stratified the patients into 2 groups using a threshold of 1.3. A high De Ritis ratio was more likely to be associated with old age and the female sex. Kaplan-Meier estimates revealed that patients with a high De Ritis ratio had inferior metastasis-free survival, cancer-specific survival, and overall survival outcomes (P = 0.012, 0.024, and 0.022, respectively). Multivariate analysis revealed that a high De Ritis ratio was an independent prognostic factor for metastasis (hazard ratio [HR], 2.389; 95% confidence interval [CI], 1.161–4.914; P = 0.018), cancer-related death (HR, 2.755; 95% CI, 1.214–6.249; P = 0.015), and overall death (HR, 2.761; 95% CI, 1.257–6.067; P = 0.011).

Conclusions

An elevated De Ritis ratio was significantly associated with worse prognosis in patients who underwent RC for urothelial BC. This ratio might further improve the predictive accuracy for prognosis in BC.

NAPOLI-1 phase 3 study of liposomal irinotecan in metastatic pancreatic cancer: Final overall survival analysis and characteristics of long-term survivors

BACKGROUND

Liposomal irinotecan (nal-IRI) plus 5-fluorouracil and leucovorin (5-FU/LV) is approved for patients with metastatic pancreatic ductal adenocarcinoma (mPDAC) previously treated with gemcitabine-based therapy. This approval was based on significantly improved median overall survival compared with 5-FU/LV alone (6.1 vs 4.2 months; hazard ratio [HR], 0.67) in the global phase 3 NAPOLI-1 trial. Here, we report the final survival analysis and baseline characteristics associated with long-term survivors (survival of ≥1 year) in the NAPOLI-1 trial.

PATIENTS AND METHODS

Patients with mPDAC were randomised to receive nal-IRI + 5-FU/LV (n = 117), nal-IRI (n = 151), or 5-FU/LV (n = 149) for the first 4 weeks of 6-week cycles. Baseline characteristics and efficacy in the overall population were compared with those in patients who survived ≥1 year. Through 16th November 2015, 382 overall survival events had occurred.

RESULTS

The overall survival advantage for nal-IRI+5-FU/LV vs 5-FU/LV was maintained from the original nanoliposomal irinotecan with fluorouracil and folinic acid in metastatic pancreatic cancer after previous gemcitabine-based therapy (NAPOLI-1) analysis (6.2 vs 4.2 months, respectively; HR, 0.75; 95% confidence interval: 0.57-0.99). Median progression-free survival, objective response rate and disease control rate also favoured nal-IRI+5-FU/LV therapy. Estimated one-year overall survival rates were 26% with nal-IRI+5-FU/LV and 16% with 5-FU/LV. Baseline characteristics associated with long-term survival in the nal-IRI+5-FU/LV arm were Karnofsky performance status ≥90, age ≤65 years, lower CA19-9 levels, neutrophil-to-lymphocyte ratio ≤5 and no liver metastases. No new safety concerns were detected.

CONCLUSIONS

The survival benefits of nal-IRI+5-FU/LV versus 5-FU/LV were maintained over an extended follow-up, and prognostic markers of survival ≥1 year were identified.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01494506.