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

Sarcopenia is a reliable prognostic factor in patients with advanced pancreatic cancer receiving FOLFIRINOX chemotherapy

BACKGROUND/OBJECTIVES

FOLFIRINOX is the reliable treatments for pancreatic cancer, but it has a relatively high toxicity and the selection of suitable patients for this regimen remains challenge. On the other hand, sarcopenia is one of the important prognostic factors of pancreatic cancer. The aim of this study was to investigate the effect of sarcopenia on overall survival (OS) and time to treatment failure (TTF) in patients with pancreatic cancer who received FOLFIRINOX.

METHODS

Clinical data of consecutive patients treated with FOLFIRINOX at our institution from 2011 to 2017 was retrospectively reviewed. Skeletal muscle index (SMI) and adipose tissue index (ATI) at the third lumbar spine level was calculated from computed tomography (CT) images. The association between clinical factors (SMI and ATI), and OS and TTF were determined using univariate and multivariate analyses.

RESULTS

We assessed 82 patients. The median OS of sarcopenia and the non-sarcopenia patients were 11.3 and 17.0 months, respectively (hazard ratio [HR], 2.49; 95% confidence interval [CI], 1.43-4.32; p = 0.001). Median TTF was 3.0 and 6.1 months in the sarcopenia and the non-sarcopenia patients, respectively (HR, 1.67; 95% CI, 1.03-2.71; p = 0.032). Multivariate analyses revealed that sarcopenia (HR, 1.37; 95% CI, 1.01-1.87; p = 0.045) was an independent prognostic factor of OS. High ATI (p = 0.022) and sarcopenic obesity (p = 0.008) were significantly associated with hematologic toxicity.

CONCLUSIONS

Sarcopenia is an independent indicator of poor prognosis in patients with pancreatic cancer who received FOLFIRINOX, while ATI and sarcopenic obesity predicted severe hematologic toxicity.

Prognostic value of pretreatment serum lactate dehydrogenase level in pancreatic cancer patients: A meta-analysis of 18 observational studies

BACKGROUND

Several studies were conducted to investigate the prognostic value of pretreatment serum lactate dehydrogenase (LDH) level in pancreatic cancer (PC), but the results were inconsistent. This study aims to comprehensively assess the prognostic value of pretreatment serum LDH level in PC patients by combining the data of the published literatures on this topic.

METHODS

Embase, PubMed, and Web of Science were completely retrieved until June, 2018. The observational studies focusing on the prognostic value of pretreatment serum LDH level in PC patients were eligible. STATA version 12.0 was used to undertake the statistical analysis.

RESULTS

Eighteen studies with a total of 3345 patients were included in this meta-analysis. The meta-analysis was conducted to generate pooled hazard ratios (HRs) and 95% confidence interval (CI) for overall survival (OS). Our analysis results suggested that high serum LDH level predicted worse OS (HR 1.57, 95% CI 1.30-1.90, P < .001) in PC patients. Moreover, for patients with advanced PC, the prognostic relevance of pretreatment serum LDH level not only existed in those receiving palliative chemotherapy (HR 1.72, 95% CI 1.35-2.18, P < .001), but also in those who were precluded from chemotherapy (HR 1.91, 95% CI 1.4219-2.58, P < .001).

CONCLUSION

The meta-analysis results demonstrated that pretreatment serum LDH level is closely associated with OS, and it may be a useful biomarker for assessing the prognosis of PC patients.

Chemotherapy in elderly patients with pancreatic cancer: Efficacy, feasibility and future perspectives

By 2030 70% of newly diagnosed pancreatic ductal adenocarcinoma (PDAC) will occur in older adults. Elderly patients, defined by the World Health Organization (WHO) as people older than 65 years, represent a heterogeneous group with different biological and functional characteristics that need personalized anticancer treatments. Since older patients are under-represented in randomized phase III trials, their management is mostly extrapolated from studies performed in younger patients, without robust evidence-based recommendations. However, data from retrospective studies and case-control series show that elderly may benefit from chemotherapy in both the adjuvant and advanced disease settings. Although with discordant results, gemcitabine-based treatment and dose-adapted fluorouracil combination regimens seem to be effective and well tolerated in this subset of patients. A proper balance of potential treatment benefits and side effects represent the crucial point for managing elderly patients with PDAC. Therefore an appropriate patient selection is essential to maximize the therapeutic benefit in the older population: randomized studies aiming to better standardizing fitness parameters and implementing the routine use of comprehensive geriatric assessments are strongly warranted. In this light, the detection of molecular prognostic markers able to detect patients who may benefit more from oncological treatments should be a primary endpoint of age-focused clinical trials. Altogether, the field of geriatric oncology will expand in the next years, and the clinical management of elderly patients affected by PDAC will become a major public health issue.

The effect of AST/ALT (De Ritis) ratio on survival and its relation to tumor histopathological variables in patients with localized renal cell carcinoma

Purpose

To assess the relationship between De Ritis (aspartate aminotransaminase [AST]/Alanine aminotransaminase [ALT]) ratio and pathological variables and whether it is an independent prognostic factor.

Materials and Methods

We analyzed 298 consecutive patients who underwent radical or partial nephrectomy for non-metastatic renal cell carcinoma (RCC) between 2006 and 2015. The association between De Ritis ratio and pathological variables including tumor size, presence of renal vein invasion, vena cava invasion, renal capsule infiltration, Gerota fascia invasion, renal sinus involvement, renal pelvic invasion, angiolymphatic invasion, adrenal gland involvement, lymph node involvement, tumor necrosis, and Fuhrman's grade was tested. Multivariable Cox analysis was performed to evaluate the impact of this ratio on overall survival and cancer-specific survival.

Results

An increased preoperative De Ritis ratio was significantly associated with renal vein invasion, renal capsule infiltration and renal pelvis involvement (p<0.05) in non-metastatic RCC. On multivariate analysis we found that tumor size, Fuhrman grade and lymph node involvement were independent prognostic factors for cancer-specific survival. AST/ALT ratio had no influence on the risk of overall and cancer-specific survival.

Conclusion

An increased preoperative AST/ALT ratio had a significant association with renal vein invasion, renal capsule infiltration and renal pelvis involvement in patients with non-metastatic RCC. However, it does not appear to be an independent prognostic marker in non-metastatic RCC.

Nab-paclitaxel plus gemcitabine versus FOLFIRINOX as the first-line chemotherapy for patients with metastatic pancreatic cancer: retrospective analysis

Purpose nab-paclitaxel plus gemcitabine (AG) and FOLFIRINOX have been established as standard first-line treatment in metastatic pancreatic cancer (mPC). We performed retrospective analysis comparing the efficacies of AG and FOLFIRINOX in daily practice setting. Materials and Methods We analyzed 308 patients who presented initially as mPC and received AG (n = 149) or FOLFIRINOX (n = 159) as first-line treatment between 2013 and 2016. Primary endpoints were progression-free survival (PFS) and overall survival (OS). Result There were no significant differences between the two groups in terms of baseline characteristics, except older age and higher Charlson Comorbidity Index (CCI) score in AG group. The response rates (34% vs 34%) and median PFS (6.8 vs 5.1 months) were comparable between two groups (p = 0.88 and p = 0.19, respectively), while median OS was significantly better with AG than FOLFIRINOX (11.4 vs 9.6 months; p = 0.002). Elevated baseline CA19-9 level and liver metastasis were independent adverse prognostic factors for PFS and OS. In subgroup analyses, PFS with AG was better in patients with age ≥ 65 years, peritoneal metastasis, and higher CCI than that with FOLFIRINOX. Conclusion Both AG and FOLFIRINOX showed comparable efficacy outcomes in daily practice setting. AG might be preferentially considered in patients with peritoneal metastasis, comorbid medical conditions or old age.

ANO9/TMEM16J promotes tumourigenesis via EGFR and is a novel therapeutic target for pancreatic cancer

Background:

Anoctamin (ANO)/transmembrane member 16 (TMEM16) proteins mediate diverse physiological and pathophysiological functions including cancer cell proliferation. The present study aimed to identify the role of ANOs in pancreatic cancer.

Methods:

In an initial screen of ANOs, ANO9/TMEM16J was overexpressed in pancreatic cancer cells, and its role in the pathogenesis of pancreatic cancer was evaluated using an integrated in vitro and in vivo approach. To determine clinical relevance of the experimental findings, the prognostic value of ANO9 was evaluated in patients with pancreatic cancer.

Results:

The ANO9 mRNA and protein levels were increased in pancreatic cancer-derived cells. Exogenous expression of ANO9 in PANC-1 cells significantly increased cell proliferation in cell cultures and in mice. In contrast, knockdown of ANO9 in AsPC-1, BxPC-3, and Capan-2 cells strongly inhibited cell proliferation. Mechanistic analysis suggested that physical association of ANO9 with epidermal growth factor receptor (EGFR) underlies ANO9-induced cell proliferation. Knockdown of ANO9 augmented the effects of the EGFR inhibitor and the cytotoxic agent on pancreatic cancer cell proliferation. In addition, high ANO9 expression is a poor prognostic factor in patients with pancreatic cancer.

Conclusions:

The ANO9/TMEM16J appears to be a clinically useful prognostic marker for pancreatic cancer and a potential therapeutic target.

Clinical predictive factors of long-term survival after curative resection of pancreatic cancer: a retrospective study

Pancreatic ductal adenocarcinoma (PDAC) continues to have the poorest prognosis of all gastrointestinal malignancies, even after the tumor has been completely resected. However, only a proportion of patients achieve 5-year survival after resection. The factors predictive of achieving 5-year survival remain unclear. The aim of this study was to investigate the pre- and postoperative clinicopathological characteristics of PDAC patients with a >5-year survival after curative resection. We retrospectively reviewed patients who underwent pancreatectomy for PDAC between January 1995 and December 2011. Logistic regression analysis was performed to determine the predictive factors for 5-year survival. One hundred and fifty-one patients were enrolled, including 38 patients with 5-year survival (actual 5-year survival rate, 25.2%). The independent preoperative factors predictive of achieving 5-year survival included serum albumin levels (odds ratio [OR]: 5.06, 95.0% confidence interval [CI]: 1.49-17.19; P = 0.009) and neoadjuvant chemoradiotherapy (OR: 3.02, 95.0% CI: 1.00-9.08; P = 0.049). Venous infiltration (OR: 2.99, 95.0% CI: 1.09-8.25; P = 0.034), liver recurrence (OR: 0.17, 95.0% CI: 0.04-0.69; P = 0.013), and perioperative portal vein infusion chemotherapy (OR: 3.06, 95.0% CI: 1.09-8.25; P = 0.028) were found to be independent postoperative predictive factors for achieving 5-year survival. Serum albumin levels could be a biomarker for predicting the prognosis of PDAC patients after curative resection. Liver recurrence and perioperative portal vein infusion chemotherapy were independent postoperative factors, suggesting that perioperative portal vein infusion chemotherapy could be promising for improving the survival rate of PDAC patients after curative resection.

Primary pancreatic lymphoma: what we need to know

Hodgkin's lymphoma is a group of malignant lymphoid which involve various organs including gastrointestinal tract. Stomach and small intestine are commonly involved more; however, pancreas can be primarily involved as well. The secondary involvement of pancreas caused by Hodgkin's lymphoma is more prevalent than the primarily involvement (1 .25-2.2% vs. <1%). Primary pancreatic lymphomas (PPLs) consist of 1-2% of all lymphoma outside nods. The symptoms and findings of PPL imaging can be akin to that of pancreas adenocarcinoma and differentiating them is difficult without examining the tissue sample. The prognosis and treatment of PPL are different from those of adenocarcinoma and due to the superior prognosis of PPL compared to pancreas adenocarcinoma, the proper diagnosis of the disease is important.

The De Ritis (aspartate transaminase/alanine transaminase) ratio as a predictor of oncological outcomes in patients after surgery for upper urinary tract urothelial carcinoma

PURPOSE

Recently, several studies have shown that the De Ritis ratio (aspartate transaminase/alanine transaminase) can be a useful prognostic biomarker for certain types of malignant tumors. However, the prognostic value of the De Ritis ratio in patients with upper tract urothelial carcinoma remains largely unknown. The aim of the present study was to evaluate the prognostic significance of the De Ritis ratio in patients who had undergone radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinoma.

METHODS

In total, 1049 patients who underwent RNU at eight institutions from 2004 to 2015 were reviewed retrospectively. The De Ritis ratio and conventional clinicopathological parameters were analyzed. Survival analysis was performed using the Kaplan-Meier method and log-rank test. Multivariate analysis was carried out using the Cox proportional hazards regression model. De Ritis ratio cutoff values were derived from receiver operating characteristic (ROC) curves.

RESULTS

ROC analysis showed the cutoff De Ritis ratio for overall death to be 1.6 (p = 0.002). The cancer-specific survival (CSS) and overall survival (OS) were significantly shorter for patients with a high De Ritis ratio (>1.6). Multivariate analysis revealed an independent relationship between an increased De Ritis ratio (>1.6) and shorter CSS (hazard ratio, HR 2.49, 95% confidence interval, CI 1.70-3.64; p = 0.001) and OS (HR 1.84, 95% CI 1.34-2.52; p = 0.001).

CONCLUSION

The De Ritis ratio can be a significant predictor of oncological outcomes in patients with upper urinary tract urothelial carcinoma after surgery.

De Ritis ratio (AST/ALT) as an independent predictor of poor outcome in patients with acute ischemic stroke

PURPOSE

The aspartate transaminase/alanine transaminase ratio (De Ritis ratio, AAR) was reported to be associated with patients' prognosis in certain diseases recently. The objective of the current study was to determine the association between the AAR at admission and poor outcome at 3 months in acute ischemic stroke (AIS) patients.

PATIENTS AND METHODS

This retrospective cohort study included patients who experienced their first-ever AIS between June 2015 and March 2016. The primary outcome measure was a poor outcome at 3 months (modified Rankin Scale score >2). Multivariate logistic regression models were used to assess the relationship between AAR quartiles and clinical outcomes among the AIS patients. Receiver operating characteristic curve analysis was applied to identify the optimal cutoff for AAR in predicting the prognosis of AIS.

RESULTS

In terms of the relationship between poor outcome and AAR, the adjusted odds ratio comparing the highest and lowest AAR quartiles was 2.15 (95% confidence interval =1.14-4.05). An AAR of 1.53 was identified as the optimal cutoff. In a prespecified subgroup analysis according to the time from symptom onset to treatment (>24 vs ≤24 hours), there was no significant difference in the effect of AAR >1.53 between the two groups.

CONCLUSION

An increased AAR at admission is significantly associated with a poor outcome at 3 months in AIS patients.

A Clinical Prediction Model to Assess Risk for Pancreatic Cancer Among Patients With New-Onset Diabetes

BACKGROUND & AIMS

Approximately 50% of all patients with pancreatic ductal adenocarcinoma (PDA) develop diabetes mellitus before their cancer diagnosis. Screening individuals with new-onset diabetes might allow earlier diagnosis of PDA. We sought to develop and validate a PDA risk prediction model to identify high-risk individuals among those with new-onset diabetes.

METHODS

We conducted a retrospective cohort study in a population representative database from the United Kingdom. Individuals with incident diabetes after the age of 35 years and 3 or more years of follow-up after diagnosis of diabetes were eligible for inclusion. Candidate predictors consisted of epidemiologic and clinical characteristics available at the time of diabetes diagnosis. Variables with P values <.25 in the univariable analyses were evaluated using backward stepwise approach. Model discrimination was assessed using receiver operating characteristic curve analysis. Calibration was evaluated using the Hosmer-Lemeshow test. Results were internally validated using a bootstrapping procedure.

RESULTS

We analyzed data from 109,385 patients with new-onset diabetes. Among them, 390 (0.4%) were diagnosed with PDA within 3 years. The final model (area under the curve, 0.82; 95% confidence interval, 0.75-0.89) included age, body mass index, change in body mass index, smoking, use of proton pump inhibitors, and anti-diabetic medications, as well as levels of hemoglobin A1C, cholesterol, hemoglobin, creatinine, and alkaline phosphatase. Bootstrapping validation showed negligible optimism. If the predicted risk threshold for definitive PDA screening was set at 1% over 3 years, only 6.19% of the new-onset diabetes population would undergo definitive screening, which would identify patients with PDA with 44.7% sensitivity, 94.0% specificity, and a positive predictive value of 2.6%.

CONCLUSIONS

We developed a risk model based on widely available clinical parameters to help identify patients with new-onset diabetes who might benefit from PDA screening.

Varying postresection lactate dehydrogenase with overall survival of early stage pancreatic cancer patients: A retrospective study

Several previously published studies revealed a hazardous role of pretreatment lactate dehydrogenase (LDH) in survival of advanced or metastatic pancreatic cancer (PC) patients. Nevertheless, in early stage PC patients who are eligible for curative resection, the prognostic role of postresection LDH has never been discussed. In this study, we aimed to explore the prognostic significance of varying postresection LDH among early stage PC patients. In total, 80 PC patients who received curative resection were retrospectively selected from a population-based electronic inpatients database which originated from Shanghai, China. A dynamic survival analysis method, counting process approach in combination with the multiple failure-time Cox model, was applied to evaluate the association between postresection LDH and OS. The multiple failure-time Cox model found that age, resection modality, and postresection LDH were significantly associated with OS: an elevated LDH (defined as > 250 U/L) was related to 2.93 (95% CI: 1.26-6.79) folds of death hazard. Further analysis disclosed an identifiable dose-response association between LDH and OS: compared with LDH≤155 U/L, the HRs for 155 U/L < LDH < 196 U/L, and LDH≥196 U/L were 2.07 (95% CI: 0.88-4.88) and 3.15 (95% CI: 1.30-7.59), respectively. Our study results suggest that postresection LDH is a prominent prognostic factor in this group of early stage PC patients. Maintaining normally ranged LDH after resection might bring about survival benefit in early stage PC patients.

Musashi2 promotes the development and progression of pancreatic cancer by down-regulating Numb protein

Musashi2-Numb interaction plays a vital role in the progression of myeloid leukemia. However, its potential role in solid cancers has rarely been reported. We investigated the coordinate function of Musashi2-Numb in the development of pancreatic cancer (PC) in vitro and vivo. Both Musashi2 protein and mRNA levels were higher in PC tissues than that in paired normal pancreas (P<0.05). Musashi2 overexpression and Numb positive expression were positively and negatively associated with tumor size and UICC stage, respectively (P<0.05). Multivariate analysis identified Musashi2 and Numb as adverse and favorable independent indicators for the survival of PC patients. Moreover, patients with high Musashi2 expression combining with negative Numb expression had a significantly worse overall survival (P=0.001). The negative relationship between Musashi2 and Numb was found at both PC tissue and cell levels. These two endogenous proteins can be co-immunoprecipitated from PC cell lines, and Musashi2 silence up-regulated Numb protein in vitro and vivo. Meanwhile, its silence decreased cell invasion and migration in vitro and inhibited the growth of subcutaneous tumors and the frequency of liver metastasis in vivo. However, Numb knockdown significantly reversed the decrease of cell invasion and migration induced by Musashi2 silence. Musashi2 promotes the development and progression of pancreatic cancer by down-regulating Numb protein. The interaction of Musashi2-Numb plays a significant role in the development and progression of PC.

Neutrophil/lymphocyte ratio helps select metastatic pancreatic cancer patients benefitting from oxaliplatin

BACKGROUND

High Neutrophil/Lymphocyte ratio (NLR), as a measure of enhanced inflammatory response, has been negatively associated with prognosis in patients with localized pancreatic ductal adenocarcinoma (PDA).

OBJECTIVE

In the present study, we aimed at investigating the prognostic value of NLR in two homogeneous groups of chemotherapy-naïve metastatic PDA patients. Patients were treated with either gemcitabine (GEM) or gemcitabine/oxaliplatin (GEMOXA). We also assessed whether NLR could identify patients benefiting from the use of oxaliplatin.

METHODS

Consecutive PDA patients treated at the Medical Oncology Unit of Tor Vergata University Hospital of Rome with either GEM or GEMOXA were included (n= 103). NLR was assessed before and during chemotherapy and correlated with outcome together with common clinical and biochemical variables.

RESULTS

Among 17 analyzed variables NLR, Karhofsky Perfomance Status (KPS), d-dimer and erythrocyte sedimentation rate were found to be significantly associated with median Overall Survival (mOS) at the univariate analysis. Only NLR and KPS were independent prognosticator at multivariate analysis, with NLR displaying the highest statistical significance. NLR was also predictive of oxaliplatin activity, as only patients with NLR > 2.5 (cutoff determined upon ROC analysis) derived benefit from GEMOXA over GEM.

CONCLUSIONS

NLR is both an independent prognostic and predictive factor in metastatic PDA, since only patients with high NLR seem to benefit from the addition of oxaliplatin. NLR may help select patients for whom a particularly poor prognosis might justify more intensive, yet less tolerable, combination regimens.

Prognostic relevance of lactate dehydrogenase in advanced pancreatic ductal adenocarcinoma patients

Background

The prognostic role of pretreatment serum lactate dehydronegase (LDH) has been well established in many malignant tumors, albeit it remains under-discussed in pancreatic cancer. In the present study, we aimed to assess the association between baseline LDH levels and overall survival (OS) in advanced pancreatic ductal adenocarcinoma (PDAC) patients who did and did not receive subsequent chemotherapy.

Methods

In total, 135 retrospectively determined patients with locally advanced or metastatic PDAC, who were diagnosed between 2012 and 2013, were analyzed. Baseline LDH levels were detected within 20 days after histopathological confirmation of the diagnosis. Multivariate Cox proportional hazards regression model was applied to estimate the adjusted hazards ratio (HR) for LDH levels and OS of PDAC. We used restricted cubic spline (RCS) to further investigate dose-effect relationship in the association.

Results

Having adjusted for possible confounders, we found that in advanced PDAC patients who went through subsequent chemotherapy, an elevated pretreatment LDH level (≥250 U/L) had an adjusted HR of 2.47 (95% CI = 1.28–4.77) for death, but patients, who did not receive chemotherapy, had no significant HR (adjusted HR = 1.57; 95% CI = 0.83–2.96). RCS fitting results revealed a steep increase in HR for PDAC patients received chemotherapy with a baseline LDH > 500 U/L.

Conclusions

Pretreatment LDH levels had noticeable prognostic value in PDAC patients who received subsequent chemotherapy. Tackling elevated LDH levels before the initiation of chemotherapy might be a promising measure for improving OS of patients after treatment for their advanced PDAC. Studies with a large sample size and a prospective design are warranted to substantiate our findings.

Transaminase Activity Predicts Survival in Patients with Head and Neck Cancer

Various serum biomarkers have been developed for predicting head and neck squamous cell carcinoma (HNSCC) prognosis. However, none of them have been proven to be clinically significant. A recent study reported that the ratio of aspartate aminotransaminase (AST) to alanine aminotransaminase (ALT) had a prognostic effect on non-metastatic cancers. This study aimed to examine the effect of the AST/ALT ratio on the survival of patients with HNSCC. Clinical data of 356 patients with locoregionally advanced HNSCC were collected. The effect of the AST/ALT ratio on overall survival was analyzed using a Cox proportional hazard model. Moreover, recursive partitioning analysis (RPA) was used to divide the patients into groups on the basis of the clinical stage and AST/ALT ratio. The prognostic ability of this grouping was validated using an independent data set (N = 167). The AST/ALT ratio ranged from 0.42 to 4.30 (median, 1.42) and was a prognostic factor for overall survival that was independent of age, primary sites, and tumor stage (hazard ratio: 1.36, confidence interval: 1.08−1.68, P = 0.010). RPA divided patients with stage IVA into the following two subgroups: high AST/ALT (≥2.3) and low AST/ALT (<2.3) subgroups. The 5-year survival rate for patients with stage III, stage IVA with a low AST/ALT ratio, stage IVA with a high AST/ALT ratio, and stage IVB were 64.8%, 49.2%, 28.6%, and 33.3%, respectively (p < 0.001). Compared with the low AST/ALT group, the adjusted hazard ratio for death was 2.17 for high AST/ALT group (confidence interval: 1.02–.22 P = 0.045). The AST/ALT ratio was demonstrated to be a prognostic factor of HNSCC. The ratio subdivided patients with stage IVA into low- and high-risk groups. Moreover, intensified treatment for the high-risk group may be considered.

Prognostic Factors for Risk Stratification of Patients with Recurrent or Metastatic Pancreatic Adenocarcinoma Who Were Treated with Gemcitabine-Based Chemotherapy

PURPOSE

The aim of this study was to verify prognostic factors including sarcopenia in patients with recurrent or metastatic pancreatic cancer receiving gemcitabine-based chemotherapy.

MATERIALS AND METHODS

Medical records and computed tomography scan of consecutive patients treated with palliative gemcitabine-based chemotherapy from 2008 to 2014 were reviewed. The lumbar skeletal muscle index at third lumbar spine level was computed, and together with clinicolaboratory factors, univariate and multivariable analyses for overall survival (OS) were performed.

RESULTS

A total of 88 patients were found. Median age was 65 years, and male patients were predominant (67.0%). Most patients had initially metastatic disease (72.7%), and gemcitabine monotherapy was administered in 29 patients (33.0%) while gemcitabine plus erlotinib was administered in 59 patients (67.0%). Seventy-six patients (86.3%) had sarcopenia. With a median follow-up period of 44.3 months (range, 0.6 to 44.3 months), median OS was 5.35 months (95% confidence interval [CI], 4.11 to 6.59). In univariate and multivariable analysis, high carcinoembryonic antigen level (hazard ratio [HR], 4.18; 95% CI, 1.95 to 8.97; p < 0.001), initially metastatic disease (HR, 3.37; 95% CI, 1.55 to 7.32; p=0.002), sarcopenia (HR, 2.97; 95% CI, 1.20 to 7.36; p=0.019), neutrophilia (HR, 2.94; 95% CI, 1.27 to 6.79; p=0.012), and high lactate dehydrogenase level (HR, 1.96; 95% CI, 1.07 to 3.58; p=0.029) were identified as independent prognostic factors for OS.

CONCLUSION

Five independent prognostic factors in patients with recurrent or metastatic pancreatic cancer who received gemcitabine-based chemotherapy were identified. These findings may be helpful in prediction of prognosis in clinical practice and can be used as a stratification factor for clinical trials.

Prognostic Scoring Index for Patients with Metastatic Pancreatic Adenocarcinoma

PURPOSE

This study focused on implementation of a prognostic scoring index based on clinico-laboratory parameters measured routinely on admission in metastatic pancreatic cancer patients.

MATERIALS AND METHODS

Records from 403 patients of metastatic disease were analyzed retrospectively. Continuous variables were dichotomized according to the normal range or the best cut-off values statistically determined by Contal and O'Quigley method, and then analyzed in association with prognosis-overall survival (OS), using Cox's proportional hazard model. Scores were calculated by summing the rounded chi-square scores for the factors that emerged in the multivariate analysis.

RESULTS

Performance status, hemoglobin, leucocyte count, neutrophil-lymphocyte ratio, and carcinoembryonic antigen were independent factors for OS. When patients were divided into three risk groups according to these factors, median survival was 11.7, 6.2, and 1.3 months for the low, intermediate, and high-risk groups, respectively (p < 0.001). Palliative chemotherapy has a significant survival benefit for low and intermediate-risk patients (median OS; 12.5 months vs. 5.9 months, p < 0.001 and 8.0 months vs. 2.0 months, p < 0.001, respectively).

CONCLUSION

We advocate the use of a multivariable approach with continuous variables for prognostic modeling. Our index is helpful in accurate patient risk stratification and may aid in treatment selection.

Influence of Preoperative Serum Aspartate Aminotransferase (AST) Level on the Prognosis of Patients with Non-Small Cell Lung Cancer

The purpose of this work is to analyze preoperative serum aspartate aminotransferase (AST) levels and their effect on the prognosis of patients with non-small cell lung cancer (NSCLC) after surgical operation. These analyses were performed retrospectively in patients with NSCLC followed by surgery; participants were recruited between January 2004 and January 2008. All clinical information and laboratory results were collected from medical records. We explored the association between preoperative serum AST and recurrence-free survival (RFS), and the overall survival (OS) of NSCLC patients. Kaplan-Meier analysis and Cox multivariate analysis, stratified by the AST median value, were used to evaluate the prognostic effect. A chi-squared test was performed to compare clinical characteristics in different subgroups. A p-value of ≤0.05 was considered to be statistically significant. A total of 231 patients were enrolled. The median RFS and OS were 22 and 59 months, respectively. The AST levels were divided into two groups, using a cut-off value of 19 U/L: High AST (>19 U/L), n = 113 vs. low AST (≤19 U/L), n = 118. Multivariate analysis indicated that preoperative serum AST > 19 U/L (hazard ratio (HR) = 0.685, 95% confidence interval (CI): 0.493-0.994, p = 0.046 for RFS, HR = 0.646, 95% CI: 0.438-0.954, p = 0.028 for OS) was an independent prognostic factor for both RFS and OS. High preoperative serum AST levels may serve as a valuable marker to predict the prognosis of NSCLC after operation.

Pancreatectomy with Mesenteric and Portal Vein Resection for Borderline Resectable Pancreatic Cancer: Multicenter Study of 406 Patients

PURPOSE

The role of pancreatectomy with en bloc venous resection and the prognostic impact of pathological venous invasion are still debated. The authors analyzed perioperative, survival results, and prognostic factors of pancreatectomy with en bloc portal (PV) or superior mesenteric vein (SMV) resection for borderline resectable pancreatic carcinoma, focusing on predictive factors of histological venous invasion and its prognostic role.

METHODS

A multicenter database of 406 patients submitted to pancreatectomy with en bloc SMV and/or PV resection for pancreatic adenocarcinoma was analyzed retrospectively. Univariate and multivariate analysis of factors related to histological venous invasion were performed using logistic regression model. Prognostic factors were analyzed with log-rank test and multivariate proportional hazard regression analysis.

RESULTS

Complications occurred in 51.9 % of patients and postoperative death in 7.1 %. Histological invasion of the resected vein was confirmed in 56.7 % of specimens. Five-year survival was 24.4 % with median survival of 24 months. Vein invasion at preoperative computed tomography (CT), N status, number of metastatic lymph nodes, preoperative serum albumin were related to pathological venous invasion at univariate analysis, and vein invasion at CT was independently related to venous invasion at multivariate analysis. Use of preoperative biliary drain was significantly associated with postoperative complications. Multivariate proportional hazard regression analysis demonstrated a significant correlation between overall survival and histological venous invasion and administration of adjuvant therapy.

CONCLUSIONS

This study identifies predictive factors of pathological venous invasion and prognostic factors for overall survival, including pathological venous invasion, which may help with patients' selection for different treatment protocols.

De Ritis (aspartate transaminase/alanine transaminase) ratio as a significant predictor of recurrence-free survival in patients with upper urinary tract urothelial carcinoma following nephroureterectomy

BACKGROUND

To evaluate the prognostic significance of preoperatively assessed aspartate aminotransaminase (AST), alanine aminotransaminase (ALT), and the AST/ALT (De Ritis) ratio in patients with upper urinary tract urothelial carcinoma (UUTUC).

METHODS

This study included a total of 109 consecutive patients with clinically localized UUTUC who underwent nephroureterectomy. Effects of preoperative levels of AST, ALT, and the De Ritis ratio in addition to conventional clinicopathological parameters on the extravesical recurrence-free survival (eRFS) in these 109 patients were retrospectively analyzed.

RESULTS

Despite the lack of a significant correlation of AST or ALT with any of the factors examined in this study, the elevation of the De Ritis ratio was significantly correlated with several unfavorable parameters, including elderly age, high pathological stage, high tumor grade, and lymphovascular invasion. During the observation period of this series (median = 40.8mo), extravesical disease recurrence developed in 39 (35.8%) of the 109 patients, with a 5-year eRFS rate of 56.8%. Of several factors examined, the tumor location, De Ritis ratio, pathological stage, lymph node metastasis, tumor grade, lymphovascular invasion, surgical margin status, and adjuvant chemotherapy were shown to be significantly correlated with eRFS by univariate analysis. Of these, the De Ritis ratio, pathological stage, lymph node metastasis, and tumor grade were identified as independent predictors of eRFS on multivariate analysis.

CONCLUSIONS

These findings suggest that preoperative assessment of the De Ritis ratio may provide useful information with respect to the clinical course of patients with clinically localized UUTUC who are scheduled to be treated with nephroureterectomy.

Predicting survival of pancreatic cancer patients treated with gemcitabine using longitudinal tumour size data

Purpose

Measures derived from longitudinal tumour size data have been increasingly utilised to predict survival of patients with solid tumours. The aim of this study was to examine the prognostic value of such measures for patients with metastatic pancreatic cancer undergoing gemcitabine therapy.

Methods

The control data from two Phase III studies were retrospectively used to develop (271 patients) and validate (398 patients) survival models. Firstly, 31 baseline variables were screened from the training set using penalised Cox regression. Secondly, tumour shrinkage metrics were interpolated for each patient by hierarchical modelling of the tumour size time-series. Subsequently, survival models were built by applying two approaches: the first aimed at incorporating model-derived tumour size metrics in a parametric model, and the second simply aimed at identifying empirical factors using Cox regression. Finally, the performance of the models in predicting patient survival was evaluated on the validation set.

Results

Depending on the modelling approach applied, albumin, body surface area, neutrophil, baseline tumour size and tumour shrinkage measures were identified as potential prognostic factors. The distributional assumption on survival times appeared to affect the identification of risk factors but not the ability to describe the training data. The two survival modelling approaches performed similarly in predicting the validation data.

Conclusions

A parametric model that incorporates model-derived tumour shrinkage metrics in addition to other baseline variables could predict reasonably well survival of patients with metastatic pancreatic cancer. However, the predictive performance was not significantly better than a simple Cox model that incorporates only baseline characteristics.

Electronic supplementary material

The online version of this article (doi:10.1007/s00280-016-2994-x) contains supplementary material, which is available to authorized users.

Prognostic and predictive markers in pancreatic adenocarcinoma

Pancreatic ductal adenocarcinoma is characterized by a poor prognosis and a low median survival, despite improvements observed for many other solid tumours. Intensive research efforts have been undertaken during the last decades to discover new prognostic and treatment predictive biomarkers for pancreatic ductal adenocarcinoma. The mainstay of medical treatment for the disease has been the well-tolerated nucleoside analogue, gemcitabine. The only targeted agent currently used in pancreatic ductal adenocarcinoma patients is the epithelial growth factor receptor inhibitor erlotinib in combination with gemcitabine. Recently, treatment regimens such as a combination of fluorouracil-leucovorin-irinotecan-oxaliplatin (FOLFIRINOX) and the combination of nab-paclitaxel with gemcitabine have been introduced for metastatic pancreatic ductal adenocarcinoma. Although these treatment regimens significantly improve survival of patients, there are no good predictive biomarkers available that can be used to identify who would benefit most from them. Therefore, the search for predictive biomarkers that would facilitate personalization of chemotherapy is highly relevant.

Patterns of care and outcomes of older versus younger patients with metastatic pancreatic cancer: A Fox Chase Cancer Center experience

BACKGROUND

Older patients with metastatic pancreatic cancer (mPC) are poorly represented in clinical trials. We compared patterns of care and outcomes of patients with mPC < and >65 yrs (Group 1 and Group 2, respectively) treated at Fox Chase Cancer Center (FCCC) to identify predictors of survival and better understand the treatment approaches.

METHODS

Charts of 579 patients with mPC treated at FCCC from 2000 to 2010 were reviewed. Group 1 and Group 2 were compared with respect to baseline, treatment characteristics, and overall survival (OS) after diagnosis of metastatic disease.

RESULTS

299 patients in Group 1 (median age 57) and 280 patients in Group 2 (median age 73) were evaluated. Patients in Group 2 were less likely to receive any chemotherapy for mPC compared to Group 1 (65% vs 75%, p=0.001) and if treated were less likely to receive more than one agent (37% vs 53%, p<0.001). Survival was comparable between the two groups (p=0.16) and Charlson Co-morbidity Index did not emerge as a prognostic factor. Longer OS was associated with higher number of agents used in both groups (p<0.001). Liver metastases conferred worse survival (p=0.02) while lung metastases conferred better survival in both groups (p=0.002).

CONCLUSIONS

Older mPC patients are less likely to receive chemotherapy and receive fewer agents yet have similar OS compared to younger patients. OS improves with increasing number of agents, supporting the use of combination chemotherapy in healthy older patients. Our findings encourage enrollment of older patients with mPC with good performance status onto clinical trials with stratification by site of metastases.

Prognostic significance of DNA cytometry for adjuvant therapy response in pancreatic cancer

BACKGROUND AND OBJECTIVES

The continuous progress in treatment options for pancreatic adenocarcinoma has lead to a re-evaluation of prognostic markers. In this study the prognostic relevance of DNA Index and classical histopathological parameters with regard to disease-free (DFS) and overall survival (OS) was analyzed within the CONKO-001 patient population.

METHODS

One hundred forty three fresh-frozen paraffin-embedded tissue samples of the resected tumor specimen of the CONKO-001 patient population were available for DNA index analysis to evaluate its impact on patient outcome.

RESULTS

Median DFS (7.3 vs. 14.3 months; P = 0.004) and median OS (16.6 vs. 29.2 months; P = 0.011) were significantly decreased in patients with a high DNA index (>1.4). Multivariate analysis revealed both DNA index (DFS: P = 0.002; OS: P = 0.019) and tumor grading (DFS: P = 0.004; OS: P = 0.004) as individual prognostic markers for DFS and OS. The following prognostic subgroups were identified: good (low DNA Index + G1/2 tumor grading), intermediate (low DNA Index + G3 tumor grading or high DNA Index + G1/2 tumor grading), poor (high DNA Index + G3 tumor grading).

CONCLUSION

The DNA index/tumor grading constellation may serve as a helpful guide for personalized treatment recommendations for adjuvant therapy of patients with pancreatic adenocarcinoma.

The Association Between Chemoradiation-related Lymphopenia and Clinical Outcomes in Patients With Locally Advanced Pancreatic Adenocarcinoma

OBJECTIVES

Lymphopenia is a common consequence of chemoradiation therapy yet is seldom addressed clinically. This study was conducted to determine if patients with locally advanced pancreatic cancer (LAPC) treated with definitive chemoradiation develop significant lymphopenia and if this affects clinical outcomes.

METHODS

A retrospective analysis of patients with LAPC treated with chemoradiation at a single institution from 1997 to 2011 was performed. Total lymphocyte counts (TLCs) were recorded at baseline and then monthly during and after chemoradiation. The correlation between treatment-induced lymphopenia, established prognostic factors, and overall survival was analyzed using univariate Cox regression analysis. Important factors identified by univariate analysis were selected as covariates to construct a multivariate proportional hazards model for survival.

RESULTS

A total of 101 patients met eligibility criteria. TLCs were normal in 86% before chemoradiation. The mean reduction in TLC per patient was 50.6% (SD, 40.6%) 2 months after starting chemoradiation (P<0.00001), and 46% had TLC<500 cells/mm. Patients with TLC<500 cells/mm 2 months after starting chemoradiation had inferior median survival (8.7 vs. 13.3 mo, P=0.03) and PFS (4.9 vs. 9.0 mo, P=0.15). Multivariate analysis revealed TLC<500 cells/mm to be an independent predictor of inferior survival (HR=2.879, P=0.001) along with baseline serum albumin (HR=3.584, P=0.0002), BUN (HR=1.060, P=0.02), platelet count (HR=1.004, P=0.005), and radiation planning target volume (HR=1.003, P=0.0006).

CONCLUSIONS

Severe treatment-related lymphopenia occurs frequently after chemoradiation for LAPC and is an independent predictor of inferior survival.

Treatment, Outcomes, and Clinical Trial Participation in Elderly Patients With Metastatic Pancreas Adenocarcinoma

BACKGROUND

Pancreas adenocarcinoma has a median age at diagnosis of 71 years. Limited studies have focused on the treatment of elderly patients with pancreas cancer.

PATIENTS AND METHODS

An analysis of systemic therapy use, clinical trial participation, and overall outcomes of 237 patients with metastatic pancreas adenocarcinoma ≥ 75 years of age evaluated at Memorial Sloan-Kettering Cancer Center between 2005 and 2013 was undertaken.

RESULTS

Median overall survival was 7 months for the entire study population. A total of 197 (83%) patients received systemic therapy, which was significantly associated with longer overall survival (P < .01). No significant difference was detected in survival between age groups 75 to 79, 80 to 84, and ≥ 85 years of age among those who received systemic therapy (P = .49). Seventy-seven (32%) patients participated in a clinical trial of whom 13 (5%) patients were enrolled in a therapeutic trial, including no patients aged ≥ 85 years. Multivariate analysis demonstrated that presence of liver metastases (P < .001), performance status (P < .001), and number of systemic agents (P < .001) were significantly associated with survival.

CONCLUSION

Receipt of systemic therapy was associated with longer survival in elderly patients ≥ 75 years of age with metastatic pancreas adenocarcinoma. Therapeutic clinical trial participation among these patients was low and future development of prognostic models for appropriate patient selection is warranted.

Dual-phase 18F-FDG PET/CT imaging in the characterization of pancreatic lesions: does it offer prognostic information?

OBJECTIVE

The primary aim of our prospective study was to evaluate the usefulness of dual-phase F-fluoro-deoxy-glucose PET/computed tomography (F-FDG PET/CT) in the characterization of pancreatic masses. The secondary aim was to assess whether delayed imaging revealed any prognostic information.

MATERIALS AND METHODS

Fifty patients with periampullary or pancreatic masses on conventional imaging were included in this study. Early and delayed PET/CT was performed, followed by pathological examination in all patients. PET/CT parameters including uptake pattern, SUVearly, SUVdelayed, lesion to background ratio (L/B), and retention index (RI) were assessed for their ability to differentiate benign from malignant lesions. Patients with malignant lesions were followed up for a median duration of 26 months. The association of 11 variables with survival was analyzed by univariate and multivariate methods.

RESULTS

Thirty-one patients had malignant lesions and 19 had benign lesions. The mean SUVearly, L/B, SUVdelayed, and RI between the malignant and benign lesions were statistically significant. The F-FDG uptake pattern of the lesions had higher sensitivity (93.5%) and specificity (100%) compared with RI (cutoff 25.7%) (84 and 37%, respectively) for diagnosing malignancy (P<0.05). In univariate analysis both RI (>18.7%) and tumor size (>2.6 cm) predicted significantly poor survival, whereas in multivariate analysis RI (P=0.04) was the only predictor of poor survival.

CONCLUSION

Dual-phase F-FDG PET/CT is not useful in characterizing pancreatic masses as it cannot differentiate benign from malignant lesions, and focal uptake on early PET imaging is the best indicator of malignancy. A possible benefit in performing a delayed scan is that a high RI (>18.7) can predict poor survival and hence may be useful in treatment planning.

The Preoperative AST/ALT (De Ritis) Ratio Represents a Poor Prognostic Factor in a Cohort of Patients with Nonmetastatic Renal Cell Carcinoma

PURPOSE

Aminotransaminases, which are strongly involved in cellular metabolism and cancer cell turnover, represent easily measureable, potential blood based biomarkers. We evaluated the prognostic value of the preoperatively assessed AST/ALT (De Ritis) ratio on clinically meaningful end points in a large European cohort of patients with nonmetastatic renal cell carcinoma.

MATERIALS AND METHODS

We retrospectively evaluated clinicopathological data on 698 patients with nonmetastatic renal cell carcinoma operated on between 2005 and 2013 at a single tertiary academic center. The potential prognostic value of the AST/ALT ratio was analyzed using the Kaplan-Meier method, and univariate and multivariate Cox proportional regression models. The impact of the ratio on the predictive accuracy of the Leibovich prognosis score was determined by the Harrell c-index.

RESULTS

An increased (1.26 or greater) preoperative AST/ALT ratio was statistically significantly associated with several well established prognostic factors, including pathological T stage, as well as with histological tumor necrosis (p <0.05). On multivariate analysis an increased preoperative AST/ALT ratio was an independent prognostic factor for metastasis-free survival (HR 1.61, 95% CI 1.25-2.07, p <0.001) and overall survival (HR 1.76, 95% CI 1.34-2.32, p <0.001). The Harrell c-index was 0.77 using the Leibovich prognosis score and 0.81 when AST/ALT was added.

CONCLUSIONS

In our study cohort with nonmetastatic renal cell carcinoma the preoperatively assessed AST/ALT ratio represented an independent prognostic factor. This ratio might further improve the predictive accuracy of well established prognosis scores.

Prognostic factors of survival in a randomized phase III trial (MPACT) of weekly nab-paclitaxel plus gemcitabine versus gemcitabine alone in patients with metastatic pancreatic cancer

BACKGROUND

nab-Paclitaxel in combination with gemcitabine has emerged as a new treatment option for patients with metastatic pancreatic cancer (MPC), based on superiority over gemcitabine demonstrated in the phase III MPACT trial. Previously, Karnofsky performance status (KPS) score and the presence of liver metastases were shown to be predictive of survival with nab-paclitaxel plus gemcitabine treatment. This analysis sought to further explore the relationship between clinical characteristics and survival in the MPACT trial and to identify potential predictors of overall survival and progression-free survival in patients with MPC.

MATERIALS AND METHODS

Cox regression models adjusted for stratification factors and a stepwise multivariate analysis of prespecified baseline prognostic factors were performed.

RESULTS

Treatment effect was significantly associated with survival, with a similar magnitude of reduction in risk of death compared with the previously reported primary analysis. Treatment effect consistently favored nab-paclitaxel plus gemcitabine across the majority of the prespecified factors. In addition to KPS score and presence of liver metastases, age and number of metastatic sites were independent prognostic factors of overall and progression-free survival. Baseline carbohydrate antigen 19-9 was not found to be an independent prognostic factor of survival in this analysis.

CONCLUSION

The results of this analysis confirm broad utility of nab-paclitaxel plus gemcitabine for the treatment of MPC. In addition, these findings suggest that KPS score, presence of liver metastases, age, and number of metastatic sites are important predictors of survival that may be useful when making treatment decisions and designing future clinical trials.

Quality-of-life (QoL) as a predictive biomarker in patients with advanced pancreatic cancer (APC) receiving chemotherapy: results from a prospective multicenter phase 2 trial

PURPOSE

Pancreatic cancer is rapidly fatal with median survival of only 6 months (mo). Quality-of-life (QoL) was analyzed prospectively in a phase 2 study of gemcitabine (G), capecitabine (C) and bevacizumab (B) in APC patients.

METHODS

A total of 50 patients with APC received B 15 mg/kg, C 1,300 mg/m(2) daily for 2 weeks and G 1,000 mg/m(2) weekly 2 times; cycles were repeated every 21 days.

ENDPOINTS

progression free survival (PFS), overall survival (OS) and assessment of QoL prior to each cycle using the European organization for research and treatment of cancer (EORTC) PAN-26 QoL questionnaire. An exact 95% confidence interval (CI) (Clopper-Pearson method) was used to assess rate of improved QoL (defined as >5% decrease in two consecutive scores compared with baseline).

RESULTS

Patient characteristics- Stage IIB/III/IV: 3/5/42; Sex: 28 M/22 F; Median age: 64 years. QoL in patients- improved: 56%, no improvement: 24%; unevaluable: 20%. Median PFS: 5.8 mo, OS: 9.8 mo. QoL improvement rate: 28/40=0.7 (95% CI: 0.53-0.83) in evaluable patients. Using QoL improvement rate, no significant difference was seen in patients with OS ≥6 mo compared to OS <6 mo. However QoL scores at 3 and 6 weeks from start of treatment correlated strongly with ≥6 mo survival (P value 0.0092 and 0.0081, respectively).

CONCLUSIONS

Baseline score and change in QoL scores of patients on G, C and B were not predictive of survival ≥6 mo. Post treatment scores at 3 and 6 weeks from start of therapy however, were predictive of survival ≥6 mo suggesting the potential predictive value of this tool for use in future studies.

Prognostic factors related with survival in patients with pancreatic adenocarcinoma

The prognosis in patients with pancreatic cancer is poor and this cancer is the fourth leading cause of cancer-related death worldwide. Although surgical resection is the only curative treatment of choice for pancreatic cancer, the majority of patients are diagnosed at an advanced stage, thus only 10%-15% of them are suitable for curative resection and the overall survival is less than 5%. Chemotherapy for metastatic disease is to palliate symptoms of patients and to improve survival. Therefore, prognostic factors are important and a correct definition of poor prognostic factors may help to guide more aggressive adjuvant or aggressive treatment protocols in patients with pancreatic cancer. This article reviews the prognostic factors affecting survival of patients with pancreatic cancer in the light of recent advances in the literature.

Comparative outcomes between initially unresectable and recurrent cases of advanced pancreatic cancer following palliative chemotherapy

OBJECTIVES

The objective of this study was to compare the clinical outcomes between initially unresectable and recurrent advanced pancreatic cancer (APC) patients after palliative chemotherapy.

METHODS

Data of a total of consecutive 269 patients with pathologically confirmed APC patients who received palliative chemotherapy between January 2006 and April 2012 were reviewed. Patients were classified into initially unresectable and recurrent group, and overall survival (OS) was compared between the 2 groups.

RESULTS

The median OS was significantly longer in the recurrent group compared with the initially unresectable group (383 vs 308 days; hazard ratio [HR], 0.59; 95% confidence interval, 0.44-0.80; P < 0.01). After adjustment for distant metastasis, performance status, and levels of carbohydrate antigen 19-9, carcinoembryonic antigen, C-reactive protein, and lactate dehydrogenase, the status of recurrent or unresectable disease remained as an independent prognostic factor with a clinically relevant HR value (HR, 0.66; 95% confidence interval, 0.48-0.90; P = 0.01). In addition, the 2-year OS rate of the recurrent group was significantly higher than that of the unresectable group (24.2% vs 9.6%, P = 0.01).

CONCLUSIONS

Our results suggested that the status of recurrent or initially unresectable disease was an independent prognostic factor in APC patients receiving palliative chemotherapy.

A proposed model for prediction of survival based on a follow-up study in unresectable pancreatic cancer

OBJECTIVES

To define an easy-to-use model for prediction of survival time in patients with unresectable pancreatic cancer in order to optimise patient' care.

DESIGN

An observational retrospective study on patients with unresectable pancreatic cancer. The initial radiographs at presentation of symptoms were reviewed and the maximum diameter of the primary tumour was determined. The occurrence of liver metastases and performance status that determines initiation of chemotherapy was also used in the regression analysis to identify prognostic subgroups.

SETTING

County hospital in south-east of Sweden.

POPULATION

Consecutive patients with unresectable pancreatic cancer who were diagnosed between January 2003 and May 2010 (n=132).

MAIN OUTCOME MEASURES

Statistical analyses were performed using Stata V.13. Survival time was assessed with Kaplan-Meier analysis, log-rank test for equality of survivor functions and Cox regression for calculation of individual hazard based on tumour diameter, presence of liver metastases and initiation of chemotherapy treatment according to patient performance status.

RESULTS

The individual hazard was log h=0.357 tumour size+1.181 liver metastases-0.989 performance status/chemotherapy. Three prognostic groups could be defined: a low-risk group with a median survival time of 6.7 (IQR 9.7) months, a medium-risk group with a median survival time of 4.5 (IQR 4.5) months and a high-risk group with a median survival time of 1.2 (IQR 1.7) months.

CONCLUSIONS

The maximum diameter of the primary tumour and the presence of liver metastases found at the X-ray examination of patients with pancreatic cancer, in conjunction with whether or not chemotherapy is initiated according to performance status, predict the survival time for patients who do not undergo surgical resection. The findings result in an easy-to-use model for predicting the survival time.

Prognostic factors in metastatic pancreatic cancer: Older patients are associated with reduced overall survival

Pancreatic cancer is a major health concern worldwide and, despite the attempts at management, the prognosis of patients with metastatic pancreatic cancer remains poor, with a median survival of a few months. The aim of this study was to identify and evaluate clinicopathological factors and elucidate the clinical significance of patient age for the outcome of metastatic pancreatic cancer. Data from a total of 154 metastatic patients with a histologically confirmed diagnosis of pancreatic cancer, who were treated and followed-up in our clinic, were recorded from medical charts. The patient sample included 102 (66%) males with a median age of 58 years (range, 25–88 years). The majority of the patients had a poor performance status (64%), weight loss of >10% body weight (74%), tumor size of >3 cm (75%) and elevated tumor markers, including carcinoembryonic antigen (CEA) (66%) and carbohydrate antigen 19-9 (CA19-9) (85%). The distributions of prognostic factors depending on patient age were largely identical. The median survival time of patients with metastatic disease was 179 days and the 1-year survival rate was 7%. The median survival time of elderly patients was significantly lower compared to younger patients (148 vs. 198 days, respectively; P=0.039). The 1-year survival rates in elderly and younger patients were 3 and 10%, respectively. In the univariate and multivariate analyses, elderly patients had poorer outcomes compared with younger patients (P=0.04 and 0.05, respectively). In all patients, the univariate analysis demonstrated that similar prognostic factors, including the performance status of the patients and tumor markers, such as serum CEA and CA19-9 levels, were associated with survival. In the multivariate analysis, younger patients with a poor performance status had a significantly shorter overall survival compared to those with a good performance status (P=0.008). However, no significant prognostic factor affecting the outcome was identified in the elderly patients. In conclusion, patient age is a major prognostic factor affecting the survival of patients with metastatic pancreatic cancer and elderly patients without poor prognostic factors may be eligible for the available treatment options.

Prognostic value of CA 19-9, CEA, CRP, LDH and bilirubin levels in locally advanced and metastatic pancreatic cancer: results from a multicenter, pooled analysis of patients receiving palliative chemotherapy

PURPOSE

CA 19-9 is the only established tumor marker in pancreatic cancer (PC); the prognostic role of other serum markers like CEA, CRP, LDH or bilirubin has not yet been defined.

METHODS

We pooled pre-treatment data on CA 19-9, CEA, CRP, LDH and bilirubin levels from two German multicenter randomized phase II trials together with prospective patient data from one high-volume German Cancer Center. Marker levels were assessed locally before the start of palliative first-line therapy for advanced PC and serially during treatment (for CA 19-9 only). Clinical and biomarker data (overall 12 variables) were correlated with the efficacy endpoints time-to-progression (TTP) and overall survival (OS) by using uni- and multivariate Cox models.

RESULTS

Data from 291 patients were included in this pooled analysis; 253 patients (87 %) received treatment within prospective clinical trials. Median TTP in the study cohort was 5.1 months and median OS 9.0 months. In univariate analysis, pre-treatment CA 19-9 (HR 1.55), LDH (HR 2.04) and CEA (HR 1.89) levels were significantly associated with TTP. Regarding OS, baseline CA 19-9 (HR 1.46), LDH (HR 2.07), CRP (HR 1.69) and bilirubin (HR 1.62) were significant prognostic factors. Within multivariate analyses, pre-treatment log [CA 19-9] (as continuous variable for TTP) and log [bilirubin] as well as log [CRP] (for OS) had an independent prognostic value. A CA 19-9 decline of ≥25 % during the first two chemotherapy cycles was predictive for TTP and OS, independent of the applied CA 19-9 assay.

CONCLUSION

Baseline CA 19-9 and CA 19-9 kinetics during first-line chemotherapy are prognostic in advanced PC. Besides that finding other serum markers like CRP, LDH and bilirubin can also provide prognostic information on TTP and OS.

Longitudinal health-related quality of life assessment implications for prognosis in stage IV pancreatic cancer

OBJECTIVES

We investigated whether changes in quality of life (QoL) during treatment could predict survival in stage IV pancreatic cancer.

METHODS

Quality of life was evaluated at baseline and after 3 months of treatment using European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) in 186 patients with stage IV pancreatic cancer. Cox regression evaluated the prognostic significance of baseline and changes in QoL scores after adjusting for age, sex, and treatment history.

RESULTS

One hundred twenty-one patients were males and 65 were females. One hundred twenty-seven patients' condition was newly diagnosed, whereas 59 were previously treated. The mean age at diagnosis was 55.1 years. Baseline QoL scale predictive of survival upon multivariate analysis was global health (hazard ratio, 0.88; 95% confidence interval, 0.81-0.95; P = 0.001). On multivariate analysis, QoL change variable that was significantly predictive of survival after 3 months of treatment was cognitive function (hazard ratio, 0.89; 95% confidence interval, 0.79-0.99; P = 0.04).

CONCLUSIONS

This study provides preliminary evidence to indicate that patients with stage IV pancreatic cancer who have a better global health at baseline as well as those whose cognitive function improves within 3 months of treatment have a significantly increased probability of survival.

Tumor size as measured at initial X-ray examination, not length of bile duct stricture, predicts survival in patients with unresectable pancreatic cancer

Background

The survival of unresectable pancreatic cancer patients is extremely poor. The aim of this study was to examine if tumor size could predict survival length in order to optimize patient care.

Methods

A retrospective observational study was performed on 185 consecutive patients with unresectable pancreatic cancer (ICD10: C250-2 and C258) who were diagnosed from 2003 to May 2010. The patients' initial radiographs at presentation of symptoms were reviewed by the same radiologist, and tumor extent was determined.

Results

The largest tumor diameter of the primary tumor was measured in 132 patients, 22 by an ultrasound and the other patients by a CT scan. In 53 patients, the tumor size could not be delimited and measured. Seventy-five patients (41%) had liver metastases at presentation of symptoms. Median survival for the entire patient group was only 119 days. The median diameter of the patient’s largest tumor was 4.35 cm, while the sample groups ranged from 1.2 to 14 cm. Patients were divided into two groups: those with a largest tumor diameter of ≤ 4.3 cm (66 patients) and those with a largest tumor diameter of > 4.3 cm (66 patients). Median survival for these groups was 149 and 94 days (p = 0.019), respectively. Cox regression showed a hazard ratio for tumor size of 1.48 (95% CI 1.02, 2.07) (p = 0.038), adjusted for the gemcitabine treatment which had been given to 49 patients and the presence of liver metastasis. In 88 patients, stricture length could be measured at ERCP. When comparing stricture lengths of ≤ 2 cm and > 2 cm, no difference in survival time was noted within a Kaplan-Meier analysis.

Conclusion

The size of the maximum tumor diameter of the primary tumor during the initial X-ray examination of patients with pancreatic cancer may predict survival time for those patients who had no surgical resection. Stricture length at ERCP gave no information on survival.

The association between treatment-related lymphopenia and survival in newly diagnosed patients with resected adenocarcinoma of the pancreas

Fifty-three patients with resected pancreatic adenocarcinoma were studied to determine if adjuvant chemo-radiation causes severe lymphopenia and if this is associated with adverse outcomes. Total lymphocyte counts (TLC) were normal in 91% before adjuvant chemo-radiation. Two months later, TLC fell by 63% (p < .0001) with 45% of patients having TLC < 500 cells/mm(3). Median survival in patients with low TLC was 14 versus 20 months (p = .048). Multivariate analysis revealed a significant association between treatment related lymphopenia and survival (HR 2.2, p = .014). Adjuvant chemo-radiation induced lymphopenia is frequent, severe, and an independent predictor for survival in patients with resected pancreatic adenocarcinoma.

External validation of 2 prognostic indices for patients with advanced pancreatic cancer treated with first-line therapy

OBJECTIVES

The objective of this study was to perform an external validation of 2 Asian prognostic indices for patients with advanced pancreatic cancer.

METHODS

A score was calculated in patients treated with frontline therapy derived from the factors Eastern Cooperative Oncology Group Performance Status, localization of primary tumor, and C-reactive protein level according to Sawaki and from the factors Eastern Cooperative Oncology Group Performance Status, pretreatment carcinoembryonic antigen, and presence/absence of distant metastasis following Ishii. For analysis, the Kaplan-Meier method and the log-rank test were used. An analysis of the Brier score was performed to determine how the prediction error was reduced by the introduction of prognostic factors.

RESULTS

For the Sawaki and Ishii score, 112 and 105 complete cases were available, respectively. Based on the 3 prognostic categories according to the Sawaki score, median overall survival was 12.3, 9.9, and 5.9 months, respectively (not statistically significant). By adapting the Ishii score to our population, 93% of the patients were allocated to the subgroup with "good" and only 7% to the subgroup with "intermediate" prognosis. Corresponding median OS was 10.5 and 3.8 months, respectively (P = 0.0035).

CONCLUSIONS

Both Asian indices may not be suitable for defining different prognostic subgroups for a white population with advanced pancreatic cancer.