Aging-related prognosis analysis of definitive radiotherapy for very elderly esophageal cancer

Prognostic Significance of Dynamic Lymphocyte Changes in Esophageal Cancer Patients Receiving Fluorouracil-Cisplatin Combined with Radiotherapy: A Systematic Review and Meta-Analysis

IntroductionChemoradiotherapy (CRT) is important to the esophageal cancer (EC) management. However, the predictive value of lymphocyte-related parameters, such as lymphocyte count (L), neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR), is not yet fully understood. Moreover, chemotherapy agents like fluorouracil and cisplatin may have an impact on lymphocyte dynamics. This meta-analysis aims to evaluate the prognostic value of these parameters in EC patients undergoing concurrent CRT (eg, radiotherapy combined with fluorouracil and cisplatin), particularly in the context of specific chemotherapy regimens.MethodsElectronic databases were comprehensively searched up to September 2023 for research that assesses the prognostic role of lymphocyte-related indicators in EC patients undergoing CRT. Combined Hazard Ratios (HR) were estimated with a random-effects model, supplemented by meta-regression and subgroup analyses for enhanced insights.ResultsOf the 41 studies selected for qualitative evaluation, 22 were eligible for meta-analysis. These results revealed that increased pre-NLR (HR = 1.87, 95% CI = 1.55-2.26), lower pre-LMR (HR = 1.94, 95% CI = 1.36-2.77), lower dur-L (HR = 1.56, 95% CI = 1.28-1.90), and higher post-NLR (HR = 1.95, 95% CI = 1.08-3.51) predicted poorer overall survival (OS). Lower pre-LMR (HR = 1.73, 95% CI = 1.14-2.65) and lower dur-L (HR = 1.39, 95% CI = 1.14-1.69) were significant predictors of worse progression-free survival (PFS). The predominant chemotherapy regimen analyzed was fluorouracil combined with cisplatin, which significantly influenced lymphocyte counts and ratios during treatment.ConclusionsOur meta-analysis indicates that pre-treatment NLR, pre-treatment LMR, during-treatment L, and post-treatment NLR are valuable prognostic biomarkers for EC undergoing CRT, particularly in those treated with fluorouracil and cisplatin. Further investigations are warranted to explore their prognostic implications and therapeutic potential.

Prognosis of radiotherapy for esophageal cancer in elderly patients exceeding seventy-five years old

BACKGROUND

Esophageal cancer (EC) often occurs in the elderly, with approximately 33% of patients aged ≥ 75 years at the time of diagnosis.

AIM

To evaluate the prognostic factors for radiotherapy (RT) in elderly patients with unresectable EC.

METHODS

We retrospectively analyzed the clinical characteristics, toxic reactions, and survival information of EC patients aged ≥ 75 years who underwent intensity-modulated RT at Lu'an Hospital of Anhui Medical University between January 2016 and September 2023. Kaplan-Meier analysis was used to draw the overall survival (OS) curves, and Cox regression analysis was employed to evaluate the influence of various clinical factors on the prognosis.

RESULTS

A total of 139 patients were enrolled. The median follow-up time was 52.0 months. The median OS was 20.0 months. The 1-year, 2-year, 3-year, and 5-year OS rates were 69.8%, 38.7%, 28.2%, and 17.5%, respectively. Univariate analysis showed that age, radiation dose, and chemotherapy had no significant impact on prognosis. Multivariate analysis indicated that clinical stage [III-IVa vs I-II, hazard ratio (HR) = 2.421, 95% confidence interval (CI): 1.242-4.718, P = 0.009; IVb vs I-II, HR = 4.222, 95%CI: 1.888-9.438, P < 0.001), Charlson comorbidity index (CCI) (0 vs ≥ 1, HR = 1.539, 95%CI: 1.015-2.332, P = 0.042), and nutritional risk screening 2002 (NRS2002) (< 3 vs ≥ 3, HR = 2.491, 95%CI: 1.601-3.875, P < 0.001) were independent prognostic factors for OS.

CONCLUSION

Our results suggest that CCI and NRS2002 were independent prognostic factors of OS for unresectable elderly EC patients undergoing RT. For elderly patients with EC, full attention should be given to biological age-related indicators, such as comorbidities and nutrition, when formulating treatment protocols. These factors should be considered in future clinical practice.

Nutritional Status as a Prognostic Factor for Survival in Palliative Care: A Retrospective Observational Analysis of Home Parenteral Nutrition in Cancer Patients with Inoperable Malignant Bowel Obstruction

Palliative care patients with malignant bowel obstruction are particularly at risk of developing malnutrition, which in turn directly shortens survival time and worsens quality of life (QoL). According to the available data, the survival time in this patient group is often less than three months. To avoid further complications related to malnutrition and poor outcomes in oncological therapy, nutritional therapy such as home parenteral nutrition (HPN) is offered. The aim of this study was to investigate whether nutritional status is a prognostic factor for survival in palliative care patients with malignant inoperable bowel obstruction qualified for home parenteral nutrition and which nutritional assessment tool has the most accurate prognostic value. This retrospective observational analysis included 200 patients with malignant bowel obstruction referred for home parenteral nutrition between January 2018 and August 2023. The analysis included laboratory test results, body mass index (BMI), Subjective Global Assessment (SGA), Nutritional Risk Index (NRI), Geriatric Nutritional Risk Index (GNRI), Prognostic Nutritional Index (PNI) and malnutrition as defined by the Global Leadership Initiative on Malnutrition (GLIM). The average survival time of the patients was 75 days. Patients with higher NRI and PNI scores were more likely to survive (NRI: p < 0.001; PNI: p < 0.001). The GLIM criteria, SGA scores and BMI values did not prove to be good prognostic factors for survival (GLIM p = 0.922, SGA p = 0.083, BMI p = 0.092). The results suggest that the use of NRI and PNI may be helpful in prognosing survival in these patients and that prevention of the development of malnutrition through earlier nutritional assessment and intervention should be considered in this patient group.

Survival analysis of 80 elderly patients with esophageal squamous cell carcinoma receiving definitive concurrent chemoradiotherapy with S-1

PURPOSE

This single-center retrospective study aimed to observe survival and prognosis of elderly patients with esophageal cancer receiving radical radiotherapy combined with S1 chemotherapy, and to preliminarily explore whether hematologic indicators or inflammatory indicators before radiotherapy are prognostic factors.

MATERIAL AND METHODS

We retrospectively collected data of 80 elderly patients with esophageal cancer who had received radical concurrent chemoradiotherapy from January 2015 to July 2018. The patients were older than 70 years. Radiation therapy was delivered with intensity-modulated irradiation therapy (IMRT) or volumetric modulated arc therapy (VMAT), while the chemotherapy regimen was S1 alone. Toxicities were evaluated in accordance with the criteria of the Radiation Therapy Oncology Group. Baseline hematologic basic nutritional indicators, such as hemoglobin (HGB), albumin (ALB), and prealbumin (PAB), along with inflammatory indicators, such as the ratio of neutrophils to lymphocytes (NLR), the ratio of platelets to lymphocytes (PLR), were collected to preliminarily analyze their relationship with progression and survival.

RESULTS

The median follow-up time was 39 months (range 30-65 months). The median overall survival and progression-free survival times were 24 and 17 months, respectively. The 1-, 2-, and 3-year overall survival rates were 76.5%, 48.1%, and 31.3%, respectively. The 1-, 2-, and 3-year progression-free survival rates were 57.5%, 37.8%, and 29.4%, respectively. T stage, clinical staging, and lesion region were independent prognostic factors for OS. No significant associations with prognosis were observed either for baseline hematologic or for inflammatory indicators (all P>0.05). The rates of esophagitis (grade 2 and above) and hematologic toxicity were 60% and 45%, respectively.

CONCLUSION

Oral S-1 combined with definitive concurrent radiotherapy for elderly patients with esophageal cancer has a significant survival benefit. The toxicities are well tolerated. It seems that prognosis does not correlate with baseline hematologic nutritional indicators and inflammatory indicators.

Benefit of chemotherapy based on platinum with definitive radiotherapy in older patients with locally advanced esophageal squamous cell carcinoma

Objective

There is still no definitely therapeutic evidence of a beneficial effect of chemotherapy with radiotherapy for older patients with esophageal squamous cell carcinoma (ESCC). We aim to determine the influence of chemoradiotherapy (CRT) and radiotherapy (RT) alone in patients aged 65 years or older with locally advanced ESCC.

Methods

We retrospectively analyzed 581 ESCC patients who underwent CRT and RT alone. Univariate and multivariate Cox regression analysis was used to analyze the impact of clinical factors on long‐term overall survival (OS) and progression-free survival (PFS). Finally, we compared the toxicity rates of these patients.

Results

The median OS and PFS of the overall population were 23.2 months (2.0–162.6 months) and 18.6 months (1.1–159.6 months). Multivariate Cox regression analysis showed that chemotherapy (p < 0.05), tumor thickness (p < 0.01), and N stage (p < 0.05) were independent prognostic factors associated with both OS and PFS. In the chemotherapy subgroup, patients who received 2–8 cycles of chemotherapy had better OS than those who received 1 cycle (p = 0.015). The results also revealed that the CRT group has better OS and PFS than RT alone group for patients aged 65–74 years (both p < 0.01). However, for patients aged 75 years or older, there was no statistically significant difference between CRT and RT alone (both p > 0.05). Besides, higher staged ESCC has the inferior OS and PFS than lower staged ESCC for patients received RT alone and aged 65–74 years (both p < 0.05). Finally, there were significantly more severe hematologic toxicities in the CRT group than in those treated with RT alone in this study (p < 0.001).

Conclusions

The present study suggested that CRT for locally advanced ESCC in patients aged 65 years or older had a significant benefit over RT alone in terms of OS and PFS. However, for patients aged 75 years or older, there was no statistically significant difference between CRT and RT alone. CRT should be performed with special attention in patients aged 75 years or older.

C-reactive protein/albumin ratio predicts survival after curative surgery in elderly patients with colorectal cancer

Inflammation-based markers, including the C-reactive protein/albumin ratio (CAR), lymphocyte/monocyte ratio (LMR), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), Onodera's prognostic nutritional index (PNI), and Glasgow Prognostic Score (GPS), have been demonstrated to serve as prognostic indicators in various malignancies. This study aimed to evaluate their potential predictive value for colorectal cancer (CRC) in the elderly. We retrospectively evaluated 163 patients with CRC, aged 80 years and older, who had undergone curative surgery. The receiver operating characteristic curve analyses and the corresponding areas under the curve (AUCs) were used to determine and compare the discriminatory ability of the inflammation-based markers. Besides, the associations of inflammatory markers and clinical characteristics with overall survival (OS), relapse-free survival (RFS), and cancer-specific survival (CSS) were analyzed. The CAR had a significantly larger AUC than the GPS, PLR, NLR, and LMR (p = 0.006, 0.012, 0.018, and 0.002, respectively), except for the PNI (p = 0.052). The optimal cut-off value was 0.106 for the CAR and 44.894 for the PNI. Moreover, a CAR ≥ 0.106 turned out to be significantly associated with worse 5-year OS, RFS, and CSS compared with a CAR < 0.106. The multivariate analysis indicated that the CAR ≥ 0.106 was an independent prognostic factor for poor OS (HR = 3.596, p = 0.0006), RFS (HR = 2.945, p = 0.003), and CSS (HR = 4.411, p = 0.02). CAR is a useful and promising prognostic marker in elderly patients undergoing curative surgery for CRC.

Relationship between markers of malnutrition and clinical outcomes in older adults with cancer: systematic review, narrative synthesis and meta-analysis

Malnutrition predicts poorer clinical outcomes for people with cancer. Older adults with cancer are a complex, growing population at high risk of weight-losing conditions. A number of malnutrition screening tools exist, however the best screening tool for this group is unknown. The aim was to systematically review the published evidence regarding markers and measures of nutritional status in older adults with cancer (age ≥ 70). A systematic search was performed in Ovid Medline, EMBASE, Web of Science, CINAHL, British Nursing Database and Cochrane CENTRAL; search terms related to malnutrition, cancer, older adults. Titles, abstracts and papers were screened and quality-appraised. Data evaluating ability of markers of nutritional status to predict patient outcomes were subjected to meta-analysis or narrative synthesis. Forty-two studies, describing 15 markers were included. Meta-analysis found decreased food intake was associated with mortality (OR 2.15 [2.03-4.20] p = < 0.00001) in univariate analysis. Prognostic Nutritional Index (PNI) was associated with overall survival (HR 1.89 [1.03-3.48] p = 0.04). PNI markers (albumin, total lymphocyte count) could be seen as markers of inflammation rather than nutrition. There a suggested relationship between very low body mass index (BMI) (<18 kg/m2) and clinical outcomes. No tool was identified as appropriate to screen for malnutrition, as distinct from inflammatory causes of weight-loss. Risk of cancer-cachexia and sarcopenia in older adults with cancer limits the tools analysed. Measures of food intake predicted mortality and should be included in clinical enquiry. A screening tool that distinguishes between malnutrition, cachexia and sarcopenia in older adults with cancer is needed.

Peripheral blood cell count ratios are predictive biomarkers of clinical response and prognosis for non-surgical esophageal squamous cell carcinoma patients treated with radiotherapy

Background

Peripheral blood cell count ratios, including the neutrophil‐to‐lymphocyte ratio (NLR), platelet‐to‐lymphocyte ratio (PLR), and lymphocyte‐to‐monocyte ratio (LMR), have been reported to be prognostic factors in many malignancies as markers of inflammation and immune status. The aim of this study was to determine whether NLR, PLR, or LMR can be clinical response and prognostic biomarkers of non‐surgical esophageal squamous cell carcinoma (ESCC) patients treated with radiotherapy.

Methods

193 non‐surgical ESCC patients who underwent radiotherapy were retrospectively analyzed. The peripheral blood cell count ratios were obtained before, during (weekly) and at the end of the treatment. Then, we compared the subsequent results with the corresponding pretreatment values and computed the rates of change, which were defined as cNLR, cPLR, and cLMR. Univariate and multivariate Cox regression analyses were used for overall survival (OS). Ordinal logistic regression was used to analyze the clinical response.

Results

In multivariate analysis, cNLR at week 4(P = .026) and week 5(P = .025) during radiotherapy were significantly associated with OS, along with BMI, tumor stage, tumor length, tumor location, and grade of adverse events. Besides, BMI, tumor stage, tumor length, adverse event grade, cNLR at week 4(P = .044) and week 5(P = .013), and cPLR at week 4(P = .034) and week 5(P = .015) were significantly associated with the clinical response in the multivariate logistic regression analysis.

Conclusions

The cNLR at weeks 4 and 5 was negatively correlated with the OS and clinical response of non‐surgical ESCC patients treated with radiotherapy. The elevated cPLR at weeks 4 and 5 was only related to poor clinical response.

Outcomes and Tolerability of Definitive and Preoperative Chemoradiation in Elderly Patients With Esophageal Cancer: A Retrospective Institutional Review

Purpose

Our purpose was to report outcomes of elderly patients who underwent definitive treatment involving radiation therapy for esophageal cancer at our institution.

Methods and Materials

We performed a retrospective review of patients aged ≥75 years with esophageal cancer treated with definitive radiation therapy (≥45 Gy) at our institution from 1997 to 2019. Acute and late Radiation Therapy Oncology Group grade 3+ toxicities were recorded. Survival was estimated using the Kaplan-Meier method.

Results

Of the 89 patients included, median age was 80 and 78% were male. Median adjusted Charlson Comorbidity Index and Karnofsky Performance Status were 5 (3-12) and 80 (50-100), respectively. The majority of cancers were adenocarcinoma (58%), distal (67%), and stage III (62%). Fifty-eight percent underwent definitive chemoradiotherapy, and one-third underwent preoperative intent chemoradiotherapy. Median prescribed dose was 50 Gy (45-66 Gy), and intensity modulated radiation therapy was used in 76%. Eighty-five percent completed the radiation therapy course. Among these, 20% had radiation therapy breaks. For those receiving concurrent chemotherapy, 37% had a dose reduction and 39.5% had a break/cycle reduction. Acute grade 3+ toxicity was 22%, with 2% grade 5 toxicity. Twenty-one of the 29 patients (72%) treated with preoperative intent underwent surgery. There were no deaths 90 days postoperatively. For patients who underwent surgery, 1- and 2-year overall survival were 95% and 84%. For those who did not undergo surgery, 1- and 2-year overall survival were 70% and 52%.

Conclusions

There is a role for aggressive radiation therapy in well-selected elderly patients with esophageal cancer. However, optimization of supportive care, chemotherapy regimens, radiation therapy dose/fractionation, and surgical indications are needed to reduce toxicity.

Impact of adaptive intensity-modulated radiotherapy on the neutrophil-to-lymphocyte ratio in patients with nasopharyngeal carcinoma

Purpose

Nutritional status and haematological parameters are related to the prognosis of patients treated with radiotherapy, but the correlation between adaptive radiotherapy (ART) and haematological indicators has never been reported. This study explores the influence of ART on the change in haematological indicators and provides a theoretical basis for the use of ART in patients with nasopharyngeal carcinoma (NPC).

Patients and methods

We retrospectively analysed 122 patients with NPC from January 2014 to December 2015. Patients in two treatment groups were matched using the propensity score matching method at a ratio of 1:1. The data were analysed with the Kaplan–Meier method, log-rank tests, regression analyses and paired t tests.

Results

Significant differences were detected for changes in the neutrophil-to-lymphocyte ratio (ΔNLR), circulating lymphocyte count (ΔCLC), circulating platelet count (ΔCPC), and circulating neutrophil granulocyte count (ΔCNC) during radiotherapy (P = 0.002, P < 0.001, and P = 0.036, respectively) between the ART and non-ART groups. Differences in acute radiation injury to the parotid glands (PGs) (P < 0.001), skin (P < 0.001), and oral structures (P < 0.001), Δweight (kg) (P = 0.025), and Δweight (%) (P = 0.030) were also significant between the two groups. According to univariate and multivariate analyses, ART (R = 0.531, P = 0.004), skin-related side effects (R = 0.328, P = 0.020), and clinical stage (R = -0.689, P < 0.001) are influencing factors for the ΔNLR in patients. ART is also the influencing factor for the ΔCLC (R = 2.108, P < 0.001) and the only factor affecting the ΔCPC (R = 0.121, P = 0.035). Based on subgroup analyses, for stage T1–2N0–3 disease, ΔCLC was higher in patients in the ART group than in patients in the non-ART group (P < 0.001, P = 0.003, and P = 0.003).

Conclusion

ART ameliorates changes in haematological indexes (ΔNLR, ΔCLC, and ΔCPC) and reduces side effects to the skin and PGs and weight loss during radiotherapy in patients with NPC, and patients with stage T1–2 disease experience a greater benefit.

Electronic supplementary material

The online version of this article (10.1186/s13014-019-1350-9) contains supplementary material, which is available to authorized users.

Prognostic value of neutrophil-to-lymphocyte ratio in older patients with head and neck cancer

INTRODUCTION

Neutrophil-to-lymphocyte ratio (NLR), may predict treatment response and outcomes in some human malignancies. However, NLR has rarely been examined in older patients with head and neck squamous cell carcinoma (HNSCC). This study evaluated factors, including pre-treatment evaluation tests, predictive of mortality in older patients with HNSCC.

METHODS

This study prospectively enrolled 233 consecutive HNSCC patients aged 65 years or older. Pre-treatment evaluations included patient demographics, comorbidity, body weight loss, voice handicap index, dysphagia, Beck's depression inventory, comprehensive geriatric assessment, and circulating biomarkers. Cumulative incidence and cause-specific hazard functions were used to analyse the risk factors for overall mortality (OM), cancer mortality (CM), and non-cancer mortality (NCM).

RESULTS

Multivariate analyses showed that age, performance scale, NLR, and nodal stage were independent predictors of OM and CM (all P < .05). Age, body weight loss, frailty, and NLR were independent predictors of NCM (all P < .05). Older age ≥ 75 years and NLR showed strong association with all OM, CM, and NCM (all P < .05). NLR >2.5 was related to a higher risk of OM (hazard ratio [HR] = 1.77, 95% confidence interval [CI]: 1.05-2.97, P = .031), CM (HR = 1.89, 95% CI: 1.09-3.29, P = .023), and NCM (HR = 6.29, 95% CI: 2.16-18.37, P = .001).

CONCLUSION

Cancer and non-cancer mortalities among older patients with HNSCC may be predicted by several clinical and haematological data. NLR might be used as a circulating prognostic marker for mortality in older patients with HNSCC.

A meta-analysis of the impact of neutrophil-to-lymphocyte ratio on treatment outcomes after radiotherapy for solid tumors

BACKGROUND

To evaluate the impact of neutrophil-to-lymphocyte ratios (NLR) as a prognostic factor in predicting treatment outcomes after radiotherapy (RT) for solid tumors.

METHODS

PubMed and Embase databases were used to search for articles published by February 2019 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Hazard ratios (HR) with 95% confidence intervals (CI) were used to evaluate the association between NLR levels and treatment outcomes after RT. The primary endpoint was overall survival (OS) rates. Secondary endpoints included progression-free survival, disease-free survival, and disease-specific survival rates.

RESULTS

Thirty-eight datasets with a total of 7065 patients were included in the meta-analysis. Patients with high pretreatment NLR demonstrated significantly worse OS with a pooled HR of 1.90 (95% CI 1.66-2.17, P < .001). In patients receiving RT alone, the pooled HR for OS was 1.71 (95% CI 1.44-2.04, P < .001) with no between-study heterogeneity (I = 0%, P = .46).

CONCLUSION

Elevated pretreatment NLR is associated with poorer survival in cancer patients undergoing RT. Elevated pretreatment NLR prior to RT initiation may be a useful biomarker to predict treatment outcomes and select a subgroup of patients in need of a more aggressive treatment approach.

Definitive Radiotherapy for Older Patients Aged ≥75 Years With Localized Esophageal Cancer

BACKGROUND/AIM

To evaluate the predictive factors in older patients with localized esophageal cancer treated with definitive radiotherapy.

PATIENTS AND METHODS

We retrospectively analyzed patients aged ≥75 years who were treated with three-dimensional conformal radiotherapy between 2008 and 2017. The patients were classified into the oldest-old group (≥80 years) and the old group (75-79 years).

RESULTS

Fifty patients were identified, 28 in the oldest-old group and 22 in the old group. Forty-six patients (92%) completed the planned radiotherapy. The median follow-up time was 21 months. Two-year overall survival (OS), disease-free survival, and locoregional control rates were 53%, 42%, and 51%, respectively. Univariate analyses for OS showed that neither the radiotherapy field nor total radiotherapy dose was a significant factor. Clinical T stage, clinical N stage, and age were independent predictors of OS.

CONCLUSION

Age ≥80 years is an independent prognostic factor for OS. Elective nodal irradiation and total radiotherapy dose above 50.4 Gy did not improve survival. Our findings may help in the treatment decisions for localized esophageal cancer in older patients.