Pretreatment anemia is associated with poorer survival in patients with stage I and II gastric cancer

Association between the Khorana risk score and all-cause mortality in Japanese patients with gastric and colorectal cancer: A retrospective cohort study

BACKGROUND

The Khorana risk score (KRS) has poor predictive value for cancer-associated thrombosis in a single tumor type but is associated with early all-cause mortality from cancer. Evidence for the association between KRS and all-cause mortality in Japanese patients with gastric and colorectal cancer is limited.

AIM

To investigate whether KRS was independently related to all-cause mortality in Japanese patients with gastric and colorectal cancer after adjusting for other covariates and to shed light on its temporal validity.

METHODS

Data from Dryad database were used in this study. Patients in the Gastroenterology Department of Sapporo General Hospital, Sapporo, Japan, were enrolled. The starting and ending dates of the enrollment were January 1, 2008 and January 5, 2015, respectively. The cutoff date for follow-up was May 31, 2016. The independent and dependent (target) variables were the baseline measured using the KRS and final all-cause mortality, respectively. The KRS was categorized into three groups: Low-risk group (= 0 score), intermediate-risk group (1-2 score), and high-risk group (≥ 3 score).

RESULTS

Men and patients with Eastern Cooperative Oncology Group Performance Status (ECOG PS) ≥ 2 displayed a higher 2-year risk of death than women and those with ECOG PS 0-1 in the intermediate/high risk group for KRS. The higher the score, the higher the risk of early death; however, the relevance of this independent prediction decreased with longer survival. The overall survival of each patient was recorded via real-world follow-up and retrospective observations, and this study yielded the overall relationship between KRS and all-cause mortality.

CONCLUSION

The prechemotherapy baseline of KRS was independently associated with all-cause mortality within 2 years; however, this independent predictive relationship weakened as survival time increased.

Nomogram based on clinical characteristics for predicting overall survival in gastric cancer patients with preoperative anemia

BACKGROUND

Preoperative anemia is associated with increased postoperative morbidity and mortality and increased perioperative transfusion risk. For surgical patients, this affects physical and cognitive ability and quality of life, but it is an important and modifiable risk factor.

AIM

To determine the effect of preoperative anemia on the prognosis of gastric cancer (GC) patients and generate a prognostic nomogram to predict the postoperative overall survival (OS) of GC patients with preoperative anemia.

METHODS

Clinicopathological and follow-up data of GC patients treated at Zhejiang Provincial People's Hospital (China) from 2010 to 2015 were collected. Independent prognostic factors were screened by univariate and multivariate Cox regression analyses. Then, these factors were used to construct a nomogram to predict 1-, 3-, and 5-year postoperative OS in preoperative anemic GC patients. The nomogram was assessed by calibration curves, receiver operating characteristic (ROC) curves, and decision curve analysis (DCA).

RESULTS

Nine hundred and sixty GC patients were divided into two groups (preoperatively anemic and nonanemic), and postoperative survival analysis was performed on both groups, yielding a shorter postoperative survival for preoperatively anemic patients than for nonanemic patients. A total of 347 GC patients with preoperative anemia were included. Age, preoperative alpha-fetoprotein level, monocyte count, lymphocyte count, clinicopathological stage, liver metastasis, and GC type were identified as independent prognostic factors for OS. The area under the ROC curve (AUC) of the nomogram for predicting 1-, 3-, and 5-year OS was 0.831, 0.845, and 0.840, respectively, for the training cohort, and the corresponding AUC values in the validation cohort were 0.827, 0.829, and 0.812, respectively. Calibration curves and DCA indicated good performance of the nomogram.

CONCLUSION

In all, we have successfully produced and verified a useful nomogram for predicting OS in GC patients with preoperative anemia. This nomogram based on a variety of clinicopathological indices can provide an effective prognostic assessment and help clinicians choose an appropriate treatment strategy for GC patients with preoperative anemia.

The Impact of Perioperative Events on Cancer Recurrence and Metastasis in Patients after Radical Gastrectomy: A Review

Radical gastrectomy is a mainstay therapy for patients with locally resectable gastric cancer (GC). GC patients who are candidates for radical gastrectomy will experience at least part of the following perioperative events: surgery, anesthesia, pain, intraoperative blood loss, allogeneic blood transfusion, postoperative complications, and their related anxiety, depression and stress response. Considerable clinical studies have shown that these perioperative events can promote recurrence and decrease the long-term survival of GC patients. The mechanisms include activation of neural signaling and the inflammatory response, suppression of antimetastatic immunity, increased release of cancer cells into circulation, and delayed adjuvant therapy, which are involved in every step of the invasion-metastasis cascade. Having appreciated these perioperative events and their influence on the risk of GC recurrence, we can now use this knowledge to find strategies that might substantially prevent the deleterious recurrence-promoting effects of perioperative events, potentially increasing cancer-free survival in GC patients.

Prognostic significance of the preoperative hemoglobin to albumin ratio for the short-term survival of gastric cancer patients

BACKGROUND

Hemoglobin and albumin are associated with the prognosis of gastric cancer (GC) patients. However, the prognostic value of the hemoglobin to albumin ratio (HAR) for the short-term survival of GC patients with D2 radical resection has not been studied.

AIM

To investigate the significance of the HAR in evaluating the short-term survival of GC patients after D2 radical resection and to construct a nomogram to predict the prognosis in GC patients after surgery, thus providing a reference for the development of postoperative individualized treatment and follow-up plans.

METHODS

Cox regression and Kaplan-Meier analysis was used for prognostic analysis. Logistic regression was used to analyze the relationships between HAR and the clinicopathological characteristics of the GC patients. A prognostic nomogram model for the short-term survival of GC patients was constructed by R software.

RESULTS

HAR was an independent risk factor for the short-term survival of GC patients. GC patients with a low HAR had a poor prognosis (P < 0.001). Low HAR was markedly related to high stage [odds ratio (OR) = 0.45 for II vs I; OR = 0.48 for III vs I], T classification (OR = 0.52 for T4 vs T1) and large tumor size (OR = 0.51 for ≥ 4 cm vs < 4 cm) (all P < 0.05). The nomogram model was based on HAR, age, CA19-9, CA125 and stage, and the C-index was 0.820.

CONCLUSION

Preoperative low HAR was associated with short-term survival in GC patients. The prognostic nomogram model can accurately predict the short-term survival of GC patients with D2 radical resection.

Clinical and Endoscopic Characteristics Associated With Post-Endoscopy Upper Gastrointestinal Cancers: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Ten percent of patients with an upper gastrointestinal cancer will have received an esophagogastroduodenoscopy (EGD) within 3 years before diagnosis, termed post-endoscopy upper gastrointestinal cancers (PEUGIC). We aimed to determine the characteristics of PEUGIC, and compare these with detected cancers.

METHODS

We searched MEDLINE and Embase from inception for studies comparing the characteristics of PEUGIC and detected upper gastrointestinal cancers, and reported findings at the initial "cancer-negative" endoscopy. We synthesized results using random effects meta-analysis. This review is registered on PROSPERO, CRD42019125780.

RESULTS

A total of 2696 citations were screened and 25 studies were included, comprising 81,184 UGI cancers, of which 7926 were considered PEUGIC. For PEUGIC assessed within 6 to 36 months of a "cancer-negative" EGD, the mean interval was approximately 17 months. Patients with PEUGIC were less likely to present with dysphagia (odds ratio [OR] 0.37) and weight loss (OR 0.58) and were more likely to present with gastroesophageal reflux (OR 2.64) than detected cancers. PEUGICs were more common in women in Western populations (OR 1.30). PEUGICs were typically smaller at diagnosis and associated with less advanced disease staging compared with detected cancers (OR 2.87 for stage 1 vs 2-4). Most EGDs (>75%) were abnormal preceding diagnosis of PEUGIC.

CONCLUSIONS

There is a substantial delay in the diagnosis of PEUGIC. They are less likely to present with alarm symptoms than detected cancers. PEUGICs are overall less advanced at diagnosis. Most patients with PEUGIC have abnormalities reported at the preceding "cancer-negative" EGD. The epidemiology of PEUGIC may inform preventive strategy.

Dilemma in selection of treatment for preoperative anemia in patients with gastric cancer

One of the common comorbidities of patients with gastric cancer waiting for gastrectomy is anemia, which negatively affects the postoperative outcomes and prognosis. Therefore, preoperative anemia often needs to be corrected. The most commonly used strategy to treat preoperative anemia in gastric cancer is transfusion. Currently, a large amount of evidence shows that transfusion can increase the incidence of postoperative complications and affect the long-term survival of patients. Therefore, there is a dilemma in choosing the treatment for preoperative anemia in patients with gastric cancer. Surgeons need to fully understand the duality of therapy strategies for preoperative anemia in gastric cancer patients. In this study, we review the studies on preoperative anemia and its treatment in patients with gastric cancer, aiming to help clinicians manage patients undergoing gastrectomy for cancer better.

Efficacy and safety of a novel anti-HER2 therapeutic antibody RC48 in patients with HER2-overexpressing, locally advanced or metastatic gastric or gastroesophageal junction cancer: a single-arm phase II study

Background

Current treatment options for human epidermal growth factor receptor 2 (HER2)‐overexpressing gastric cancer at third‐line have shown limited clinical benefit. Further, there is no specific treatment for HER2 immunohistochemistry (IHC) 2+ and fluorescence in‐situ hybridization‐negative patients. Here, we report the efficacy and safety of a novel anti‐HER2 antibody RC48 for patients with HER2‐overexpressing, advanced gastric or gastroesophageal junction cancer.

Methods

Patients with HER2‐overexpressing (IHC 2+ or 3+), locally advanced or metastatic gastric or gastroesophageal junction cancer who were under at least second‐line therapy were eligible and received RC48 2.5 mg/kg alone every 2 weeks. The primary endpoint was the objective response rate (ORR) assessed by an independent review committee. Secondary endpoints included progression‐free survival (PFS), overall survival (OS), duration of response, time to progression, disease control rate, and safety.

Results

Of 179 patients screened, 125 were eligible and received RC48 treatment. The ORR was 24.8% (95% confidence interval [CI]: 17.5%‐33.3%). The median PFS and OS were 4.1 months (95% CI: 3.7‐4.9 months) and 7.9 months (95% CI: 6.7‐9.9 months), respectively. The most frequently reported adverse events were decreased white blood cell count (53.6%), asthenia (53.6%), hair loss (53.6%), decreased neutrophil count (52.0%), anemia (49.6%), and increased aspartate aminotransferase level (43.2%). Serious adverse events (SAEs) occurred in 45 (36.0%) patients, and RC48‐related SAEs were mainly decreased neutrophil count (3.2%). Seven patients had adverse events that led to death were not RC48‐related.

Conclusions

RC48 showed promising activity with manageable safety, suggesting potential application in patients with HER2‐overexpressing, advanced gastric or gastroesophageal junction cancer who have previously received at least two lines of chemotherapy.

Clinical practice guideline: evidence, recommendations and algorithm for the preoperative optimization of anemia, hyperglycemia and smoking

Preoperative optimization has not been explored comprehensively in the surgical literature, as this responsibility has often been divided among surgery, anesthesia and medicine. We developed an evidence-based clinical practice guideline to summarize existing evidence and present diagnostic and treatment algorithms for use by surgeons caring for patients scheduled to undergo major elective surgery. We focus on 3 common comorbid conditions seen across surgical specialties - anemia, hyperglycemia and smoking - as these conditions increase complication rates in patients undergoing major surgery and can be optimized successfully as soon as 6-8 weeks before surgery. With the ability to address these conditions earlier in the patient journey, surgeons can positively affect patient outcomes. The aim of this guideline is to bring optimization in the preoperative period under the existing umbrella of evidence-based surgical care.

The prognostic impact of pretreatment anemia in patients with gastric cancer and nonhypoalbuminemia undergoing curative resection: a retrospective study

Background

The influence of pretreatment anemia on the prognosis of patients with advanced gastric cancer (GC) remains controversial. We retrospectively examined the impact of pretreatment anemia on the overall survival (OS) of patients with GC with nonhypoalbuminemia undergoing curative resection.

Methods

The clinicopathological data of 2,916 patients with advanced GC who received a radical gastrectomy from 1994 to 2015 were analyzed. The patients were divided into two subgroups by hemoglobin level, <120 and ≥120 g/L. OS was analyzed using the Kaplan-Meier method, and a multivariate Cox proportional hazards model was used to identify the independent prognostic factor.

Results

A total of 1,099 patients were included in our study. The median follow-up duration was 43 (IQR, 24–66) months. The prevalence of anemia was 40.9%. Among these 1,099 patients, 505 (46.0%) had nonhypoalbuminemia. Kaplan-Meier survival analysis showed that patients with GC who were anemic had a poorer OS than patients who were not (5-year OS rate: 58.4% vs. 66.8%, P<0.0001). Multivariate analysis revealed that pretreatment anemia was an independent prognostic factor [hazard ratio (HR) =1.455, 95% CI, 1.013–2.09; P=0.043].

Conclusions

Our findings indicate that pretreatment anemia may serve as an independent prognostic factor for patients with advanced GC with nonhypoalbuminemia after radical gastrectomy, especially those with larger tumor size and pT3 disease.

Preoperative Platelet-to-Lymphocyte Ratio (PLR) for Predicting the Survival of Stage I-III Gastric Cancer Patients with a MGC Component

Background

The preoperative platelet-to-lymphocyte ratio (PLR) evaluates the prognosis of gastric cancer patients. However, whether preoperative PLR may be used to evaluate the prognosis of mucinous gastric carcinoma (MGC) patients is poorly investigated. The present study evaluated the effect of preoperative PLR on overall survival in gastric cancer patients with a mucinous component.

Methods

A total of 336 MGC were enrolled in this study, and the characteristics of the tumor, including pathological features and clinical data, were retrospectively analyzed.

Results

A high PLR was associated with larger tumor size, advanced tumor invasion, lymph node metastasis, advanced TNM stage, tumor location, total gastrectomy, low hemoglobin level, low albumin level, high fibrinogen level, high platelet level, and high neutrophil-to-lymphocyte ratio (NLR, all P's < 0.05). Multivariate analysis identified age (HR = 1.876; 95% CI 1.361-2.585, P < 0.001), TNM stage (HR = 2.350; 95% CI 1.216-4.542, P = 0.011), globulin (HR = 1.520; 95% CI 1.067-2.165, P = 0.020), total gastrectomy (HR = 0.537; 95% CI 0.373-0.772, P = 0.001), and PLR (HR = 1.582; 95% CI 1.066-2.348, P = 0.023) as independent prognostic factors for OS.

Conclusion

Preoperative PLR is related to pathological features and may independently evaluate the survival of MGC. Therefore, preoperative PLR may help physicians develop treatment plans and evaluate survival in these patients.

Perioperative Transfusions for Gastroesophageal Cancers: Risk Factors and Short- and Long-Term Outcomes

BACKGROUND

Perioperative blood transfusions have been associated with increased morbidity and poorer oncologic outcomes for numerous surgical procedures. However, this issue is understudied among patients with gastroesophageal malignancies. The objective was to clarify the risk factors and impact of perioperative transfusions on quality of life and surgical and oncologic outcomes among patients undergoing gastric and esophageal cancer surgery.

METHODS

Patients undergoing curative-intent resections for gastroesophageal cancers between 2010 and 2018 were included. Perioperative blood transfusion was defined as any transfusion within 24 h pre-operatively, during surgery, or the primary post-operative hospitalization period. Patient and tumor characteristics, surgical and oncological outcomes, and quality of life were compared.

RESULTS

A total of 435 patients were included. Perioperative transfusions occurred in 184 (42%). Anemia, blood loss, female sex, open surgical approach, and operative time emerged as independent risk factors for transfusions. Factors found to be independently associated with overall survival were neoadjuvant therapy, tumor size and stage, major complications, and mortality. Transfusions did not independently impact overall survival, disease-free survival, or quality of life.

CONCLUSIONS

Perioperative transfusions did not impact oncologic outcomes or quality of life among patients undergoing curative-intent surgery for gastroesophageal cancers.

Establishment of Decision Rules and Risk Assessment Model for Preoperative Prediction of Lymph Node Metastasis in Gastric Cancer

Background: Preoperative accurate prediction of lymph node status is especially important for the formulation of treatment plans for patients with gastric cancer (GC). The purpose of this study was to establish decision rules and a risk assessment model for lymph node metastasis (LNM) in GC using preoperative indicators. Methods: The clinical data of 554 patients who underwent gastrectomy with D2 lymphadenectomy were collected. A 1:1 propensity score matching (PSM) system was used, and the clinical data of the matched 466 patients were further analyzed. The important risk factors for LNM were extracted by the random forest algorithm, and decision rules and nomogram models for LNM were constructed with a classification tree and the "rms" package of R software, respectively. Results: Tumor size (OR: 2.058; P = 0.000), computed tomography (CT) findings (OR: 1.969; P = 0.001), grade (OR: 0.479; P = 0.000), hemoglobin (Hb) (OR: 1.211; P = 0.005), CEA (OR: 1.111; P = 0.017), and CA19-9 (OR: 1.040; P = 0.033) were independent risk factors for LNM in GC. Tumor size did rank first in the ranking of important factors for LNM in GC and was the first-level segmentation of the two initial branches of the classification tree. The accuracy, sensitivity, specificity, and positive predictive value of the decision rules in diagnosing preoperative LNM in GC were 75.6, 85.7, 73.9, 73.5, and 79.3%, respectively. The accuracy, sensitivity, and specificity of the risk assessment model in predicting preoperative LNM in GC were 79.3, 80.3, and 79.4%, respectively. Conclusion: Tumor size was the most important factor for evaluating LNM in GC. This decision rules and nomogram model constructed to take into account tumor size, CT findings, grade, hemoglobin, CEA, and CA19-9 effectively predicted the incidence of LNM in preoperative GC.

Mean corpuscular hemoglobin concentration correlates with prognosis of resected hepatocellular carcinoma

Aim: To evaluate the prognostic role of mean corpuscular hemoglobin concentration (MCHC) in hepatocellular carcinoma (HCC) after hepatectomy. Patients & methods: A total of 289 HCC patients were classified into two groups based on the cut-off value of MCHC. Significant prognostic factors were screened by univariate and multivariate analysis. Results: Low MCHC value was significantly associated with tumor diameter (p = 0.004) and vascular invasion (p = 0.038). Besides, Cox regression analysis showed that low MCHC was significantly associated with poor prognostic outcomes with HCC after hepatectomy (overall survival: hazard ratio: 0.372; 95% CI: 0.206-0.672; p = 0.001; recurrence-free survival: hazard ratio: 0.450; 95% confidence interval: 0.317-0.638; p < 0.001). Conclusion: Preoperative MCHC can predict prognosis for patients with HCC, and the lower MCHC value was associated with poor prognosis after hepatectomy.

Blood-based Markers in the Prognostic Prediction of Esophagogastric Junction Cancer

Esophagogastric junction cancer poses a great threat to human beings both in western countries and East Asia, especially in China and Japan, and its incidence has increased during recent decades. The 5-year survival rate of esophagogastric junction cancer is quite poor compared with that of other gastric cancer sites. Until now, the traditional TNM staging system has been widely used in clinical practice for prognosis. However, the TNM system is based on pathology after surgical resection or radiology using CT and MRI, not on blood markers. Evidently, some research has been reported concentrated on the prognostic value of blood-based markers with the character of non-invasive and non-radioactive in EJA. Hematologic, biochemical and coagulation parameters could be obtained from clinical data and utilized to analyze their prognostic values. Tumor-associated antigens, microRNAs and circulating tumor cells have also been reported in EJC prognosis. In this article, we review research focused on blood-based markers to evaluate their prognostic value in esophagogastric junction cancer, especially its main subtype adenocarcinoma.

Preoperative Hematocrit (HCT) is a Novel and Simple Predictive Marker for Gastric Cancer Patients Who Underwent Radical Gastrectomy

BACKGROUND

Previous studies have suggested that preoperative anemia negatively influences survival in patients with gastric cancer (GC). We sought to investigate which anemic markers can better predict the prognosis of patients with resectable GC.

METHODS

The study involved 2277 GC patients who underwent curative resection between December 2008 and December 2014. Cox regression models were used to identify the best anemic markers associated with prognosis. Time-dependent receiver operating characteristics analysis (t-ROC) and the estimated area under the curve (AUC) were used to compare the prognostic values.

RESULTS

Of all patients, 1709 (75.1%) were male, and the median age was 61 years. Univariate analyses showed that preoperative hematocrit (HCT), hemoglobin, and mean corpuscular volume were associated with OS (all P < 0.05). However, in a separate analysis of individual stages, only HCT was shown to be significantly prognostic across all tumor stages (all P < 0.05). In the multivariate analysis, preoperative HCT remained an independent prognostic factor for GC. Low HCT was significantly associated with older age, female sex, lower body mass index, higher American Society of Anesthesiologists score, higher preoperative transfusion rate, 90-day mortality, adjuvant chemotherapy, larger tumor size, lymph node metastasis, later stage, and vascular involvement. The t-ROC curve and AUC for HCT were similar to those for the controlling nutritional status and prognostic nutritional index throughout the observation period.

CONCLUSIONS

The preoperative HCT is a novel, simple, and powerful prognostic indicator of poor outcome in patients with GC and can be used as a part of the preoperative risk stratification process.

Preoperative Anemia or Low Hemoglobin Predicts Poor Prognosis in Gastric Cancer Patients: A Meta-Analysis

Background

The prognostic value of preoperative anemia in gastric cancer remains unclear. Therefore, the purpose of the present study is to evaluate the prognostic value of preoperative anemia in gastric cancer.

Methods

We searched Embase and PubMed databases for relevant studies from inception to March 2018. The prognostic value of preoperative anemia in gastric cancer was determined by calculating the hazard ratio (HR) and the corresponding 95% confidence interval (CI) as effect measures. A random effect model was used in cases in which there was significant heterogeneity; otherwise, a fixed effect model was used. Statistical analyses were performed using Stata software.

Results

Seventeen studies involving 13,154 gastric cancer patients were included. The estimated rate of preoperative anemia was 36% (95%CI = 27-44%). The overall survival of preoperative anemia was poor (HR = 1.33, 95%CI = 1.21-1.45). Moreover, disease-free survival was significantly lower in patients with preoperative anemia compared with those without this condition (HR = 1.62, 95%CI = 1.13-2.32). These findings were corroborated by the results of subgroup analyses.

Conclusions

The results indicate that preoperative anemia predicts poor prognosis in gastric cancer, including overall survival and disease-free survival. Therefore, preoperative anemia may be a convenient and cost-effective blood-derived prognostic marker for gastric cancer.

Autologous cytokine-induced killer cell immunotherapy may improve overall survival in advanced malignant melanoma patients

AIMS

Our study was conducted to explore the efficacy of autologous cytokine-induced killer (CIK) cells in patients with advanced malignant melanoma. Materials & Methods: Here we reviewed 113 stage IV malignant melanoma patients among which 68 patients received CIK cell immunotherapy alone, while 45 patients accepted CIK cell therapy combined with chemotherapy. Results: We found that the median survival time in CIK cell group was longer than the combined therapy group (21 vs 15 months, p = 0.07). In addition, serum hemoglobin level as well as monocyte proportion and lymphocyte count were associated with patients' survival time.

CONCLUSIONS

These indicated that CIK cell immunotherapy might extend survival time in advanced malignant melanoma patients. Furthermore, serum hemoglobin level, monocyte proportion and lymphocyte count could be prognostic indicators for melanoma.

Impact of preoperative anemia on outcomes in patients undergoing curative resection for gastric cancer: a single-institution retrospective analysis of 2163 Chinese patients

We sought to evaluate whether preoperative anemia was an important determinant of survival in gastric cancer (GC). A single institution cohort of 2163 GC patients who underwent curative resection were retrospectively analyzed. Anemia was defined as a preoperative hemoglobin level <120 g/L in males and <110 g/L in females. Overall survival (OS) was analyzed using the Kaplan-Meier method, and a multivariate Cox proportional hazards model was performed to identify the independent prognostic factor. Anemic patients had a poorer OS compared with nonanemic patients after resection for tumor-nodes-metastasis (TNM) stage III tumors (5-year OS rate: 32.2% vs. 45.7%, P < 0.001) but not stage I (P  =  0.480) or stage II (P  =  0.917) tumors. Multivariate analysis revealed that preoperative anemia was an independent prognostic factor in TNM stage III (hazard ratio [HR], 1.771; 95% CI, 1.040-3.015; P = 0.035). In a stage-stratified analysis, preoperative anemia was still independently associated with OS in TNM stages IIIa through IIIc (P < 0.001, P = 0.075, and P = 0.012, respectively), though the association was only marginal in stage IIIb. Of note, preoperative mild anemia had a similar prognostic value in TNM stage III GC. Furthermore, preoperative anemia was significantly associated with more perioperative transfusions, postoperative complications and several nutritional-based indices, including the prognostic nutritional index (PNI), preoperative weight loss and performance status (all P < 0.05). Preoperative anemia, even mild anemia, was an important predictor of postoperative survival for TNM stage III GC.

Peri-Operative Blood Transfusion Does Not Influence Overall and Disease-Free Survival After Radical Gastrectomy for Stage II/III Gastric Cancer: a Propensity Score Matching Analysis

OBJECTIVE

Whether peri-operative blood transfusions (BTF) negatively impact long-term survival after gastrectomy for gastric cancer (GC) remains controversial. The aim of this retrospective study was to investigate independent predictive factors of BTF and the potential impact of BTF on overall survival (OS) and disease-free survival (DFS) in patients who underwent radical gastrectomy for stage II/III GC.

METHODS

Of 1020 patients who underwent gastrectomy for stage II/III GC from November 2010 to December 2015, 231 (22.6%) patients received BTF. The independent predictive factors of BTF were identified using univariate and multivariate analyses. Cox regression and propensity score matching (PSM) analyses of OS and DFS in patients who received BTF or not were compared.

RESULTS

Multivariate analysis revealed that age, pre-operative hemoglobin levels, tumor size, operation time, combined multi-organ resection, and intra-operative blood loss were independent predictive factors for BTF. PSM analysis created 205 pairs of patients. BTF was significantly associated with decreased OS (P = 0.025) and DFS (P = 0.034) in the entire cohort before PSM. After PSM, there was no longer a significant association between BTF and OS (P = 0.850) or DFS (P = 0.880). BTF was not identified as an independent risk factor for OS or DFS by multivariate Cox regression analysis.

CONCLUSIONS

The present study revealed that BTF did not influence OS and DFS after radical gastrectomy for stage II/III GC. Worse oncological outcomes were caused by clinical circumstances requiring blood transfusions, including longer operation time and advanced tumor stage, not due to BTF itself.

Clinical Value of Nutritional Status in Cancer: What is its Impact and how it Affects Disease Progression and Prognosis?

Malnutrition is a common finding in cancer patients, which can affect disease progression and survival. This review aims to critically summarize the prognostic role of nutritional status, from Body Mass Index (BMI) and weight loss to nutrition screening tools and biochemical indices, in cancer patients. According to the currently available data, Prognostic Nutritional Index (PNI) was a significant prognostic factor of patients' survival, both in univariate and multivariate analyses. Pre-operative albumin was also correlated with worse outcomes, being an independent prognostic factor of survival in several studies. BMI was also well-studied, with contradictory results. Although, lower BMI was found to be an independent prognostic factor of shorter survival in some studies, in others it did not have an impact on survival. In this aspect, this review highlights the significant prognostic role of nutritional status in the disease progression and survival of cancer patients. Further, good-quality prospective studies are needed in order to draw precise conclusions on the prognostic role of specific nutritional assessment tools, and biochemical indices associated with the nutritional status in more cancer types, such as liver, breast and prostate cancer, and hematological malignancies.

Preoperative Anemia as a Simple Prognostic Factor in Patients with Urinary Bladder Cancer

BACKGROUND To evaluate the incidence of preoperative anemia and its prognostic role in patients with urinary bladder cancer (BC). MATERIAL AND METHODS A total of 317 patients diagnosed with BC were enrolled in this retrospective cohort study. Univariate and multivariate analysis was used to identify independent prognostic factors and Kaplan-Meier survival analysis was applied to examine the influence of anemia on survival. RESULTS 109 patients (34.4%) were anemic with a median preoperative hemoglobin of 114 g/L (interquartile range 104 to 122.5). After a median of 6 years follow-up (range: 2 to 8 years), the median recurrence-free survival (RFS), progression-free survival (PFS), and overall survival (OS) in anemic patients were significantly lower than non-anemic patients (p≤0.001). Multivariate Cox analysis indicated that anemia remained an independent predictor of RFS and OS (p=0.010, 0.007). CONCLUSIONS Anemic patients with BC are likely to have a shorter RFS and OS than non-anemic patients, and anemia is an independent predictor of RFS and OS.

A prospective appraisal of preoperative body mass index in D2-resected patients with non-metastatic gastric carcinoma and Siewert type II/III adenocarcinoma of esophagogastric junction: results from a large-scale cohort

Objective

To prospectively investigate associations of presurgical body mass index (BMI) with clinicopathological factors and its prognostic significance in radically D2-resected patients with non-metastasized gastric cancer (GC) and Siewert type II/III adenocarcinoma of esophagogastric junction (AEG).

Methods

A large prospective cohort consisting of radically-resected GC and AEG patients was analyzed. Follow-up was successful in 671 out of 700 patients, who were categorized into underweight (BMI<18.5), normal-weight (BMI=18.5-22.9), overweight (BMI=23-24.9), and obese (BMI≥25) groups according to Asian standards. BMI-associated factors were explored using multivariable logistic regression with adjustment. Cancer-specific survival analyses were conducted applying both univariable and multivariable Cox regression methods.

Results

Pre-operation, higher hemoglobin levels and smaller anemia proportions were observed in larger BMI groups. Higher BMI tended to be associated with higher neutrophil-lymphocyte ratios (NLRs). Patients with higher BMI had smaller tumors and more often stage I tumors, but longer surgical time and postsurgical stay. In multivariable analyses, higher hemoglobin levels, upper tumor location, poorer differentiation, and higher NLR were significantly associated with higher BMI. Overall, survival analyses revealed no significant role of BMI. However, in further stratifications after adjustment, compared to patients with normal BMI, obese patients had better survival in women, but worse in those with AEG; underweight was associated with reduced mortality risk in tumors differentiated well to moderately; overweight patients had increased death hazard when having thrombocytopenia.

Conclusion

Overall, preoperative BMI had limited prognostic significance in operated GC patients. However, under specific conditions (e.g., female, AEG, good differentiation, and thrombocytopenia), BMI might indicate postoperative survival.

Clinical implication of FDG uptake of bone marrow on PET/CT in gastric cancer patients with surgical resection

AIM

To determine the relationship between F-18 fluorodeoxyglucose (FDG) uptake of bone marrow (BM) on positron emission tomography/computed tomography (PET/CT) and clinical factors and to assess the prognostic value of FDG uptake of BM in gastric carcinoma.

METHODS

We retrospectively enrolled 309 gastric cancer patients who underwent staging FDG PET/CT and curative surgical resection. FDG uptake of primary tumor was visually classified as positive or negative FDG uptake. Mean FDG uptake of BM (BM SUV) and BM-to-liver uptake ratio (BLR) were measured. The relationships of BM SUV or BLR with clinical factors were evaluated. The prognostic values of BM SUV, BLR, and other clinical factors for predicting recurrence-free survival (RFS) and overall survival (OS) were assessed.

RESULTS

Of 309 patients, 38 patients (12.3%) experienced cancer recurrence and 18 patients (5.8%) died. Patients with advanced gastric cancer, positive FDG uptake, and recurrence had higher values of BM SUV and BLR than those with early gastric cancer, negative FDG uptake, and no recurrence (P < 0.05). BM SUV and BLR were significantly correlated with hemoglobin level, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio (P < 0.05). On multivariate analysis, multiple tumors, T stage, lymph node metastasis, tumor involvement of resection margin, and BLR were significantly associated with RFS (P < 0.05). T stage, lymph node metastasis, hemoglobin level, and BLR were significantly associated with OS (P < 0.05).

CONCLUSION

BLR on PET/CT was an independent prognostic factor for RFS and OS in gastric cancer patients with curative surgical resection.

The hematologic markers as prognostic factors in patients with resectable gastric cancer

BACKGROUND

Recently, many studies have investigated the value of the hematologic markers in the prognosis of gastric cancer (GC). However, most studies only focused on the pre-operative markers. The aim of this study was to investigate the prognostic value of the hematologic markers of resectable GC patients at three different periods of the treatment (preoperative, postoperative and before the first chemotherapy).

METHODS

Clinical data from 451 GC patients were retrospectively collected. Hematologic markers including leukocyte, neutrophil, lymphocyte, red blood cell (RBC), platelet, mean platelet volume (MPV), neutrophil proportion (NP), lymphocyte proportion (LP), neutrophil lymphocyte ratio (NLR), and platelet lymphocyte ratio (PLR) were adopted as potential prognostic biomarkers. The Kaplan-Meier method and Cox regression model were applied to reveal the prognostic significance of the hematologic markers.

RESULTS

Preoperative PLR was independently associated with overall survival (OS) via multivariate analysis (hazard ratio, 1.399; 95% confidence interval, 1.015-1.928; p = 0.04). Elevated PLR predicted a larger tumor size (P< 0.001), deeper tumor invasion (P= 0.035) and elevated level of CEA (P= 0.012).

CONCLUSIONS

Although only high preoperative PLR could serve as an independent unfavorable prognostic factor, other markers such as preoperative and postoperative NLR could also provide additionally prognostic information.

Understanding Perioperative Transfusion Practices in Gastrointestinal Surgery-a Practice Survey of General Surgeons

BACKGROUND

Despite guidelines recommending restrictive red blood cell transfusion (RBCT) strategies, perioperative transfusion practices still vary significantly. To understand the underlying mechanisms that lead to gaps in practice, we sought to assess the attitudes of surgeons regarding the perioperative management of anemia and use of RBCT in patients having gastrointestinal surgery.

METHODS

We conducted a self-administered Web-based survey of general surgery staff and residents, in a network of eight academic institutions at the University of Toronto. We developed a questionnaire using a systematic approach of items generation and reduction. We tested face and content validity and test-retest reliability. We administered the survey via emails, with planned reminders.

RESULTS

Total response rate was 48.1 % (62/125). Half (51.0 %) of respondents stated that they were unlikely to conduct a preoperative anemia work-up. About 54.0 % reported ordering preoperative oral iron supplementation for anemia. Most respondents indicated using a 70 g/L hemoglobin trigger (92.0 %) for transfusion. Factors increasing thresholds above 70 g/L included cardiac comorbidity (58.0 %), acute cardiac disease (94.0 %), symptomatic anemia (68.0 %), and suspected bleeding (58.0 %). With those factors, the transfusion threshold often increased above 90 g/L. Respondents perceived RBCTs to increase the postoperative morbidity (62 %), but not to impact the mortality (48 %) and cancer recurrence (52 %). Institutional protocols (68.0 %), blood conservation clinics (44.0 %), and clinical practice guidelines (84.0 %) were believed to encourage restrictive use of RBCTs.

CONCLUSION

Self-reported perioperative transfusion practices for GI surgery are heterogeneous. Few respondents investigated preoperative anemia. Stated use of RBCT indications varied from recommendations in published guidelines for patients with symptomatic anemia. Establishing team consensus and implementing local blood management guidelines appear necessary to improve uptake of evidence-based recommendations.

A clinical prognostic scoring system for resectable gastric cancer to predict survival and benefit from paclitaxel- or oxaliplatin-based adjuvant chemotherapy

Background

Gastrectomy with D2 lymphadenectomy is a standard procedure of curative resection for gastric cancer (GC). The aim of this study was to develop a simple and reliable prognostic scoring system for GC treated with D2 gastrectomy combined with adjuvant chemotherapy.

Methods

A prognostic scoring system was established based on clinical and laboratory data from 579 patients with localized GC without distant metastasis treated with D2 gastrectomy and adjuvant chemotherapy.

Results

From the multivariate model for overall survival (OS), five factors were selected for the scoring system: ≥50% metastatic lymph node rate, positive lymphovascular invasion, pathologic TNM Stage II or III, ≥5 ng/mL preoperative carcinoembryonic antigen level, and <110 g/L preoperative hemoglobin. Two models were derived using different methods. Model A identified low- and high-risk patients for OS (P<0.001), while Model B differentiated low-, intermediate-, and high-risk patients for OS (P<0.001). Stage III patients in the low-risk group had higher survival probabilities than Stage II patients. Both Model A (area under the curve [AUC]: 0.74, 95% confidence interval [CI]: 0.69–0.78) and Model B (AUC: 0.79, 95% CI: 0.72–0.83) were better predictors compared with the pathologic TNM classification (AUC: 0.62, 95% CI: 0.59–0.71, P<0.001). Adjuvant paclitaxel- or oxaliplatin-based or triple chemotherapy showed significantly better outcomes in patients classified as high risk, but not in those with low and intermediate risk.

Conclusion

A clinical three-tier prognostic risk scoring system was established to predict OS of GC treated with D2 gastrectomy and adjuvant chemotherapy. The potential advantage of this scoring system is that it can identify high-risk patients in Stage II or III who may benefit from paclitaxel- or oxaliplatin-based regimens. Prospective studies are needed to confirm these results before they are applied clinically.

Allogeneic blood transfusion and the prognosis of gastric cancer patients: systematic review and meta-analysis

BACKGROUND

Perioperative allogeneic blood transfusion (ABT) may be a deleterious predictor on the prognosis of gastric cancer (GC) for subjects who had undergone curative surgeries. In this article we proposed to figure out the effect of ABT with a systematic review and meta-analysis.

METHODS

Relevant articles were identified by searching Pubmed and Embase to March 2014. A random-effects model or fixed-effects model was used to calculate pooled odds ratios (ORs). Sensitivity analysis, meta-regression, stratified analysis, dose-response meta-analysis were conducted, and publication bias tested.

RESULTS

Eighteen studies (9120 GC patients) were included, of which 36.3% received transfusions. ABT was associated with increased all-cause mortality (OR, 2.17; 95% confidence interval [CI], 1.72-2.74; p<0.001; I2=75%). Sensitivity analysis showed significant changes in ORs while meta-regression had little influence on ORs. Galbraith plot revealed the OR reduced to 2.10 (95% CI, 1.86-2.37; p<0.001) with tau2 reduced to 0.00 and I2 reduced to 0%. RESULTS of stratified analysis were robust and consistent. Dose-response meta-analysis revealed that all-cause mortality was significantly lower in patients transfused with ≤800 mL of blood than those transfused with >800 mL (OR, 0.58; 95% CI, 0.37-0.92; p=0.02; I2=54%). ABT was also associated with increased cancer-related mortality (OR, 2.57, p=0.011) and recurrence (OR, 1.52, p=0.017).

CONCLUSIONS

In GC patients undergoing curative surgeries, ABTs are associated with a worse prognosis, including all-cause mortality, cancer-related mortality and recurrence. Patient blood management should be investigated further to minimize use of ABT.

Lower mean corpuscular hemoglobin concentration is associated with unfavorable prognosis of resected lung cancer

ABSTRACT 

Background: The association of preoperative red blood cell indexes in non-anemic patients undergoing lung resections for non-small-cell lung cancer with recurrence-free survival (RFS) and overall survival (OS) has never been investigated. Methods: We retrospectively examined the impact of preoperative red blood cell indexes on RFS and OS and the relationships between the indexes and clinicopathological factors in lung cancer. Results: A total of 649 patients were evaluated. The mean corpuscular hemoglobin concentration was showed as an independent prognostic factor in all patients for OS (hazard ratio [HR]: 0.697; 95% CI: 0.502–0.969; p = 0.032) and RFS (HR: 0.688; 95% CI: 0.519–0.914; p = 0.010). The mean corpuscular volume was an independent prognostic factor in all patients for OS (HR: 0.589; 95% CI: 0.380–0.912; p = 0.018), but not for RFS (HR: 0.684; 95% CI: 0.461–1.015; p = 0.059). Conclusion: In conclusion, the results of this study suggest that mean corpuscular hemoglobin concentration is an independent prognostic factor for OS and RFS in non-small-cell lung cancer.

A risk score system to preoperatively predict TNM stages in gastric cancer

BACKGROUND

To improve the estimation of tumor status and facilitate the stage-dependent treatment planning, we developed a reliable and easy-to-use risk score for prediction of tumor-node-metastasis stages in gastric cancer.

METHODS

Clinicopathological data were collected prospectively from 108 curatively resected patients with gastric cancer. The risk score was established on the basis of independent predictive factors for tumor stages, and its performance was evaluated by receiver operating characteristic (ROC) analysis.

RESULTS

The following 4 independent factors were included in our score: serum albumin levels, tumor size, T and N categories determined by helical computed tomography. Using ROC analysis, we chose a score at 7 as the optimal cut point for differentiating the more advanced disease (stage III/IV) from the less advanced one (stage I/II). With the defined cut point, our score allowed predicting stage III/IV with sensitivity of 79.6%, specificity of 85.2%, and accuracy of 82.4%. The discriminative ability of this score was good (the area under the ROC curve, 0.861-0.965).

CONCLUSIONS

The risk score may be helpful to preoperative gastric cancer staging. It probably assists surgeons in deciding the extent of surgery and in choosing the appropriate perioperative adjuvant therapies.

Adjuvant FOLFOX-4 in patients with radically resected gastric cancer: Tolerability and prognostic factors

The aim of the present study was to evaluate the toxicity and efficacy of the FOLFOX-4 regimen as adjuvant chemotherapy in patients with gastric cancer after radical surgery. Fifty-four patients (1 stage Ib, 6 stage II, 22 stage IIIa, 14 stage IIIb and 11 stage IV) received 8-12 cycles of FOLFOX-4 (oxaliplatin 85 mg/m(2), Day 1; leucovorin 100 mg/m(2) i.v., Days 1 and 2; 5-fluorouracil 400 mg/m(2) i.v. bolus, Days 1 and 2 and 600 mg/m(2) in 22 h i.v. continuous infusion, Days 1 and 2; every 14 days). Toxicity was recorded at each cycle according to the National Cancer Institute Common Toxicity Criteria. Disease-free (DFS) and overall survival (OS) were calculated according to the Kaplan-Meier method. Thirty-eight patients (70.4%) completed the prescribed number of cycles of chemotherapy. The toxicity was mild. Grade 3-4 neutropenia occurred in 57% of patients, thrombocytopenia and anemia in 2% of cases. Peripheral neuropathy was experienced by 46% of the patients (grade 4 in 2% of cases). Five patients experienced grade 3 gastrointestinal toxicity. After a median follow-up of 33.1 months, 17 patients relapsed and 17 succumbed to the disease. The mean observed DFS and OS were 49.7 months (range 40.7-58.8) and 57.9 months (range 49.6-66.2), respectively. At univariate analysis, females and patients who had received <8 cycles of chemotherapy had a significantly worse probability of DFS and OS. The Cox model showed gender to be independent of the factors affecting DFS. Adjuvant FOLFOX-4 is feasible and well-tolerated in patients radically resected for gastric cancer. Receiving <4 months of adjuvant FOLFOX-4 could be detrimental to prognosis.

Factors influencing perioperative blood transfusions in patients with gastrointestinal cancer

BACKGROUND

Patients undergoing major cancer resections often receive blood transfusions (TFs). Preoperative erythropoietin (EPO) offers the rationale to reduce TFs and related morbidity.

METHODS

Perioperative TF information was collected prospectively in a single surgeon practice over 5 years.

RESULTS

Three hundred forty-four patients underwent a major procedure, including pancreatic (n = 130, 38%), hepatobiliary (n = 87, 25%), gastroesophageal (n = 69, 20%), and other operations (n = 58, 17%). Median estimated blood loss (EBL) was 375 mL. PRBC TFs were given in 83 cases (24%), at a median of 2 units [1-16]. TF frequency and EBL did not differ between diagnoses. Multivariate TF associations existed for Hgb (P < 0.0001, OR 0.335), EBL (P < 0.0001, OR 1.007), serum Cl (P = 0.004, OR 1.25), serum Na (P = 0.02, OR 0.810), and age (P = 0.04, OR 1.033). TFs (versus no TFs) were linked to major complications (43 versus 20%, P = 0.0002), mortality (12% versus 3%, P = 0.001), and increased LOS (9 versus 7 days, P < 0.0001). A potential benefit for preoperative EPO to avoid TFs could be derived for only 31 patients (9%).

CONCLUSIONS

In this low TF rate of 24% for major visceral resections, few preoperative parameters are able to identify subgroups at risk for TFs aside from blood counts. Our data would not support generalized preoperative EPO administration.

Anemia may influence the outcome of patients undergoing neo-adjuvant treatment of rectal cancer

BACKGROUND

We hypothesized that anemia could represent one of the major factors influencing the outcome of patients undergoing neo-adjuvant treatment of rectal cancer.

PATIENTS AND METHODS

This analysis included all the consecutive patients who underwent neo-adjuvant treatment (chemotherapy and/or radiotherapy) before surgery for rectal cancer in three oncology/radiotherapy departments from June 1996 to December 2003.

RESULTS

Three hundred and seventeen patients were eligible for our analysis. Median age at diagnosis was 64 years (range 26-88 years); male/female ratio was 184/133. Two hundred and eighty-five patients (89.9%) were diagnosed with adenocarcinoma, while 32/317 (10.1%) with mucinous adenocarcinoma. Neo-adjuvant treatments carried out were as follows: radiotherapy alone in 75/317 patients (23.7%), radiotherapy plus chemotherapy in 242/317 patients (76.3%). At univariate and multivariate analysis, only the hemoglobin (Hb) level (group 1: < or=12 g/dl versus group 2: >12 g/dl) resulted in a significant factor for disease-free survival. The role of the Hb level seemed to be confirmed further by the clinical downstaging obtained in approximately 55% of patients in group 2, in comparison with 35% of the patients achieving a significant downstaging in group 1.

CONCLUSION

Our results indicated that anemia could represent an important parameter able to influence the outcome in patients receiving neo-adjuvant treatment of rectal cancer.

An elevated C-reactive protein concentration, prior to surgery, predicts poor cancer-specific survival in patients undergoing resection for gastro-oesophageal cancer

There is increasing evidence that the presence of an ongoing systemic inflammatory response is associated with poor outcome in patients undergoing resection for a variety of tumours. The aim of the present study was to examine the relationship between clinico-pathological status, preoperative C-reactive protein concentration and cancer-specific survival in patients undergoing resection for gastro-oesophageal cancer. One hundred and twenty patients attending the upper gastrointestinal surgical unit in the Royal Infirmary, Glasgow, who were selected for potentially curative surgery, were included in the study. Laboratory measurements of haemoglobin, white cell, lymphocyte and platelet counts, albumin and C-reactive protein were carried out at the time of diagnosis. All patients underwent en-bloc resection with lymphadenectomy and survived at least 30 days following surgery. On multivariate analysis, only the positive to total lymph node ratio (hazard ratio (HR) 2.02, 95% confidence interval (CI) 1.44–2.84, P<0.001) and preoperative C-reactive protein concentration (HR 3.53, 95% CI 1.88–6.64, P<0.001) were independent predictors of cancer-specific survival. The patient group with no evidence of a preoperative systemic inflammatory response (C-reactive protein ⩽10 mg l⁻¹) had a median survival of 79 months compared with 19 months in the elevated systemic inflammatory response group (P<0.001). The results of the present study indicate that in patients selected to undergo potentially curative resection for gastro-oesophageal cancer, the presence of an elevated preoperative C-reactive protein concentration is an independent predictor of poor cancer-specific survival.

Perioperative Anemia

Perioperative anemia is common and is associated with increased need for blood transfusion in the perioperative period. Perioperative anemia has also been linked to increased morbidity and mortality in surgical patients. Anemia may impede a patient's ability to recover fully and participate in postoperative rehabilitation. Pre-operative treatment of anemia is associated with a reduction in the need for blood transfusion in the perioperative period. Additional advances in surgical technology that reduce blood loss intraoperatively are associated with a reduction in postoperative anemia and should be used whenever possible. All strategies to prevent anemia in the perioperative period should be considered in an effort to minimize exposure of surgical patients to blood transfusion.