Hyperfibrinogenemia after preoperative chemoradiotherapy predicts poor response and poor prognosis in rectal cancer

Landscape of Biomarkers and Pathologic Response in Rectal Cancer: Where We Stand?

Colorectal cancer (CRC) is a neoplasm with a high prevalence worldwide, with a multimodal treatment that includes a combination of chemotherapy, radiotherapy, and surgery in locally advanced stages with acceptable pathological complete response (pCR) rates, this has improved with the introduction of total neoadjuvant therapy (TNT) reaching pCR rates up to 37% in compare with classic neoadjuvant treatment (NAT) where pCR rates of around 20-25% are achieved. However, the patient population that benefits most from this therapy has not been determined, and there is a lack of biomarkers that can predict the course of the disease. Multiple biomarkers have been studied, ranging from hematological and molecular markers by imaging technique and combinations of them, with contradictory results that prevent their use in routine clinical practice. In this review, we evaluate the most robust prognostic biomarkers to be used in clinical practice, highlighting their advantages and disadvantages and emphasizing biomarker combinations and their predictive value.

Diagnostic and Prognostic Value of Fibrinogen, Fibrinogen Degradation Products, and Lymphocyte/Monocyte Ratio in Patients With Laryngeal Squamous Cell Carcinoma

OBJECTIVES

Laryngeal squamous cell carcinoma (LSCC) is a common squamous cell carcinoma of the head and neck with no reliable diagnostic biomarkers. However, recent studies have shown that inflammation plays an essential role in tumor development, and several inflammation-based biomarkers have been shown to have prognostic value. This study aimed to investigate the auxiliary value of fibrinogen (FIB), fibrinogen degradation products (FDP), and lymphocyte/monocyte ratio (LMR) in LSCC diagnosis and prognosis.

METHODS

Clinical data from 218 patients recently diagnosed with LSCC and 207 diagnosed with benign laryngeal lesions (BLLs) were retrospectively reviewed. Potential diagnostic biomarkers were evaluated using univariate and multivariate analyses; receiver operating characteristic (ROC) curve analysis was used to identify cut-off values and diagnostic efficiency. Least absolute shrinkage and selection operator (LASSO) Logistic regression analysis was used to screen for independent risk factors to construct a diagnostic nomogram. The chi-squared test and Kaplan-Meier method were performed to investigate the correlation of clinicopathological characteristics and 3-year overall survival (OS) with FIB, FDP, and LMR in patients with LSCC.

RESULTS

FIB, FDP, and LMR levels were significantly different between the LSCC and BLL groups (P < .001), and all were independent risk factors for LSCC. The area under the ROC curve of the diagnostic nomogram was .894. Additionally, FIB, FDP, and LMR were correlated with some invasive clinicopathological features, and LMR ≥4.29 was associated with reduced OS (P = .038).

CONCLUSION

FIB, FDP, and LMR demonstrated potential as biomarkers for the diagnosis and prognosis of LSCC; however, further studies are needed to confirm their efficacy.

Evaluation of C-reactive protein and fibrinogen in comparison to CEA and CA72-4 as diagnostic biomarkers for colorectal cancer

Carcinoembryonic antigen (CEA) and carbohydrate antigen 72-4 (CA72-4) are commonly used markers for colorectal cancer (CRC) in clinical applications. However, low positivity rate and sensitivity limits their clinical effectiveness. In this study, we explored the potential of C-reactive protein (CRP) and fibrinogen to improve the diagnostic efficiency of traditional biomarkers of CRC. The concentrations of CRP and fibrinogen in plasma were significantly higher in CRC patients compared with benign or healthy controls. The area under the ROC curves (AUCs) showed that the diagnostic efficacy of CRP and fibrinogen was 0.745 (95% CI: 0.712-0.779) and 0.699 (95% CI: 0.663-0.734), respectively. AUC increased to 0.750 (95% CI: 0.716-0.784) when CRP and fibrinogen were combined. It also further improved to 0.889 (95% CI: 0.866-0.913) when CRP and fibrinogen were integrated with CEA and CA72-4. Moreover, this combination increased the maximum area under AUC to 0.857 (95% CI: 0.830-0.883), which effective differentiated CRC from benign disease. Overall, this study found that CRP and fibrinogen were highly expressed in the plasma of CRC patients, suggesting their potential to improve the diagnostic efficiency of traditional biomarkers of CRC.

Can Pre-Treatment Inflammatory Parameters Predict the Probability of Sphincter-Preserving Surgery in Patients with Locally Advanced Low-Lying Rectal Cancer?

There is evidence suggesting that pre-treatment clinical parameters can predict the probability of sphincter-preserving surgery in rectal cancer; however, to date, data on the predictive role of inflammatory parameters on the sphincter-preservation rate are not available. The aim of the present cohort study was to investigate the association between inflammation-based parameters and the sphincter-preserving surgery rate in patients with low-lying locally advanced rectal cancer (LARC). A total of 848 patients with LARC undergoing radiotherapy from 2004 to 2019 were retrospectively reviewed in order to identify patients with rectal cancer localized ≤6 cm from the anal verge, treated with neo-adjuvant radiochemotherapy (nRCT) and subsequent surgery. Univariable and multivariable analyses were used to investigate the role of pre-treatment inflammatory parameters, including the C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) for the prediction of sphincter preservation. A total of 363 patients met the inclusion criteria; among them, 210 patients (57.9%) underwent sphincter-preserving surgery, and in 153 patients (42.1%), an abdominoperineal rectum resection was performed. Univariable analysis showed a significant association of the pre-treatment CRP value (OR = 2.548, 95% CI: 1.584–4.097, p < 0.001) with sphincter preservation, whereas the pre-treatment NLR (OR = 1.098, 95% CI: 0.976–1.235, p = 0.120) and PLR (OR = 1.002, 95% CI: 1.000–1.005, p = 0.062) were not significantly associated with the type of surgery. In multivariable analysis, the pre-treatment CRP value (OR = 2.544; 95% CI: 1.314–4.926; p = 0.006) was identified as an independent predictive factor for sphincter-preserving surgery. The findings of the present study suggest that the pre-treatment CRP value represents an independent parameter predicting the probability of sphincter-preserving surgery in patients with low-lying LARC.

The clinical significance of preoperative plasma fibrinogen levels and platelet counts in resectable colon cancer

BACKGROUND AND AIM

Several aspects of the correlation between colon cancer and hemostatic markers are still unknown to many researchers in the field. In this study, we evaluated the association, if any, of preoperative platelet (PLT) counts and plasma fibrinogen levels with postoperative lymph node involvement and venous invasion in colon cancer patients.

METHODS

This study retrospectively included eighty patients with colon cancer (mean age 58.09 years; 37% female 63% male).

RESULTS

Patients with negative lymph nodes and venous invasion showed a significantly lower PLT count and higher fibrinogen level than their counterparts, i.e., patients with positive lymph nodes (p<0.001, all of them) and venous invasion (p<0.001, all of them). The results also showed a positive association of PLT counts and fibrinogen levels with lymphatic invasion (r=0.670, p<0.001 and r=0.639, p<0.001, respectively) and a positive association of PLT counts and fibrinogen levels with venous invasion (r=0.3988, p<0.001 and r=0.5268, p<0.001, respectively). According to the results of the ROC curve analysis, when the PLT count cutoff was 290/mm³, the sensitivity and specificity were 82% and 86.67%, respectively (AUC = 0.8840, p<0.0001, 95% CI 0.8084-0.9596). When the fibrinogen level cutoff was 310.0 mg/dL, the sensitivity and specificity were 72% and 96.67%, respectively (AUC 0.8790, p <0.0001, 95% CI 0.8067-0.9513).

CONCLUSION

The preoperative PLT count and plasma fibrinogen level may be considered key markers to monitor postoperative lymph node involvement and venous invasion in colon cancer patients.

Combination of Preoperative Plasma Fibrinogen and Neutrophil-to-Lymphocyte Ratio (the F-NLR Score) as a Prognostic Marker of Locally Advanced Rectal Cancer Following Preoperative Chemoradiotherapy

BACKGROUND

Coagulation and inflammation play important roles in tumor progression. This study aimed to explore the prognostic impact of combined analysis of fibrinogen and neutrophil-to-lymphocyte (NLR) ratio (F-NLR score) in locally advanced rectal cancer (LARC) receiving preoperative chemoradiotherapy (pCRT) and radical surgery.

METHOD

Totally 317 patients were included. X-tile analysis was used to determine the optimal cutoff values of preoperative fibrinogen and NLR. F-NLR scores were defined as 2 (both high fibrinogen and NLR), 1 (one of these abnormalities), or 0 (neither abnormality). Time-dependent ROC analysis was used to evaluate the predictive accuracy of fibrinogen, NLR, and F-NLR score. Cox regression analysis was performed to evaluate the prognostic impact of the F-NLR score. A predictive nomogram for disease-free survival (DFS) was developed and validated internally.

RESULTS

One hundred and seventeen (36.9%), 156 (49.2%), and 44 (13.9%) patients had F-NLR score of 0, 1, and 2, respectively. Higher F-NLR score was associated with poorly differentiated tumors, deeper tumor invasion, lymph node metastasis, and more advanced pTNM stage (all P < 0.05). The 5-year OS rates in the F-NLR 0, 1, and 2 groups were 93.6%, 87.3%, and 68.4%, respectively (P < 0.001), while the 5-year DFS rates were 91.8%, 76.8%, and 56.1%, respectively (P < 0.001). Cox regression analysis demonstrated that F-NLR score (F-NLR 1, HR = 2.021, P = 0.046; F-NLR 2, HR = 3.356, P = 0.002), pTNM stage III (HR = 3.109, P = 0.009), and circumferential resection margin (CRM) involvement (HR = 3.120, P = 0.021) were independently associated with DFS. A nomogram for DFS was developed (C-index 0.708).

CONCLUSION

F-NLR score is a promising predictor for disease recurrence in LARC patients after pCRT.

Clinical parameters predictive for sphincter-preserving surgery and prognostic outcome in patients with locally advanced low rectal cancer

Background

Although controversial, there are data suggesting that clinical parameters can predict the probability of sphincter preserving procedures in rectal cancer. The purpose of this study was to investigate the association between clinical parameters and the sphincter-preserving surgery rate in patients who had undergone neoadjuvant combination therapy for advanced low rectal cancer.

Methods

In this single center study, the charts of 540 patients with locally advanced rectal cancer who had been treated with induction chemotherapy-and/or neoadjuvant concomitant radiochemotherapy (nRCT) over an 11-year period were reviewed in order to identify patients with rectal cancer ≤6 cm from the anal verge, who had received the prescribed nRCT only. Univariate and multivariate analyses were used to identify pretreatment patient- and tumor associated parameters correlating with sphincter preservation. Survival rates were calculated using Kaplan-Meier analyses.

Results

Two hundred eighty of the 540 patients met the selection criteria. Of the 280 patients included in the study, 158 (56.4%) underwent sphincter-preserving surgery. One hundred sixty-four of 280 patients (58.6%) had a downsizing of the primary tumor (ypT < cT) and 39 (23.8%) of these showed a complete histopathological response (ypT0 ypN0). In univariate analysis, age prior to treatment, Karnofsky performance status, clinical T-size, relative lymphocyte value, CRP value, and interval between nRCT and surgery, were significantly associated with sphincter-preserving surgery. In multivariate analysis, age (hazard ratio (HR) = 1.05, CI95%: 1.02–1.09, p = 0.003), relative lymphocyte value (HR = 0.94, CI95%: 0.89–0.99, p = 0.029), and interval between nRCT and surgery (HR = 2.39, CI95%: 1.17–4.88, p = 0.016) remained as independent predictive parameters.

Conclusions

These clinical parameters can be considered in the prognostication of sphincter-preserving surgery in case of low rectal adenocarcinoma. More future research is required in this area.

Fibrinogen and Albumin Score Changes during Preoperative Treatment Can Predict Prognosis in Patients with Locally Advanced Rectal Cancer

Background

Fibrinogen (Fib) and albumin (Alb) levels are indicators of systemic inflammatory responses. Elevated Fib and decreased Alb levels are considered negative prognostic factors in different types of cancer. Here, we explored the prognostic value of changes in pre- and post- neoadjuvant chemoradiotherapy (NCRT) plasma fibrinogen and serum albumin (FA) scores in patients with locally advanced rectal cancer (LARC).

Methods

A total of 106 patients with LARC who underwent NCRT followed by surgical resection at Jinhua Municipal Central Hospital between 2011 and 2015 were analyzed. In addition, plasma Fib and serum Alb levels before and after NCRT were collected. FA scores were calculated based on the Fib and Alb levels dichotomized by clinical reference values. Patients were classified into two groups based on the changes in FA scores during NCRT: in group A, FA scores decreased or remained unchanged (n = 84), and in group B, FA scores increased (n = 22). Changes in FA scores were compared with patient outcomes.

Results

Increased FA scores were associated with worse disease-free survival (DFS) and overall survival (OS) in patients with LARC. The occurrence of systemic failure was higher in group B than in group A (40.9% vs. 19%, P = 0.032). In multivariate analysis, changes in FA scores, pretreatment carcinoembryonic antigen (CEA) levels, and pathologic differentiation were independent prognostic parameters for DFS and changes in FA scores and pretreatment CEA levels were independent prognostic parameters for OS.

Conclusions

Increased FA score after NCRT was an independent negative prognostic factor for DFS and OS in patients with NCRT-treated LARC.

Prognostic value of pretreatment plasma fibrinogen in patients with colorectal cancer: A systematic review and meta-analysis

BACKGROUND

Growing evidence showed that high pretreatment plasma fibrinogen could be used as a potential prognostic marker in colorectal cancer (CRC). However, the conclusions were controversial. Therefore, this meta-analysis was conducted to evaluate the prognostic value of pretreatment plasma fibrinogen in patients with CRC.

METHODS

Relevant studies were searched in the databases including PubMed, EMBASE, Web of Science, Cochrane library, and China National Knowledge Infrastructure up until December 10th, 2018. Pooled hazard ratios (HRs) with their 95% confidence intervals (CIs) were used to estimate the effects.

RESULTS

A total of 17 articles with 6863 patients were included in this meta-analysis. The results revealed that elevated pretreatment plasma fibrinogen was significantly associated with both poor overall survival (univariate analysis: HR = 1.69, 95% CI 1.47-1.95, P = .000; multivariate analysis: HR = 1.50, 95% CI 1.28-1.77, P = .000) and poor disease-free survival (univariate analysis: HR = 1.90, 95% CI 1.49-2.41, P = .000; multivariate analysis: HR = 2.08, 95% CI 1.52-2.86, P = .000) in patients with CRC.

CONCLUSIONS

High pretreatment plasma fibrinogen level is significantly associated with worse survival outcomes in CRC patients. Plasma fibrinogen may be used as an effective prognostic marker and potential therapeutic target. Further studies are required to support these results.

A Retrospective Study of The Prognostic Significance of Preoperative Plasma Fibrinogen, Mean Platelet Volume, and the Neutrophil-to-Lymphocyte Ratio in Patients with Laryngeal Squamous Cell Carcinoma

BACKGROUND This study aimed to evaluate the prognostic significance of plasma fibrinogen, serum albumin, the mean platelet volume (MPV), and the neutrophil-to-lymphocyte ratio (NLR) in patients with laryngeal squamous cell carcinoma (LSCC) who underwent surgical resection. MATERIAL AND METHODS A retrospective study included 110 patients with LSCC who underwent surgical resection between January 2008 to June 2015. Clinicopathologic and demographic data were recorded. Preoperative levels of plasma fibrinogen, serum albumin, MPV, and NLR were measured, and all patients underwent postoperative follow-up. The Kaplan-Meier method was used to determine the impact of these factors on overall survival (OS) and disease-free survival (DFS). RESULTS Preoperative hyperfibrinogenemia was significantly correlated with clinical stage, T stage, and tumor location in patients with LSCC (P<0.05). Serum albumin, MPV, and NLR were significantly correlated with the clinical stage and the T stage (P<0.05). The OS and DFS were significantly reduced in patients with hyperfibrinogenemia compared with patients with plasma fibrinogen <4 g/dL (P<0.05). Serum albumin of 35 g/L was not significantly correlated with OS (P>0.05). Patients with an MPV <9.5 fL had a significantly longer OS compared with patients with an MPV ≥9.5 fL (P=0.026). The DFS of patients with an NLR <2.22 was significantly longer than for those with an NLR ≥2.22. CONCLUSIONS Preoperative hyperfibrinogenemia, increased MPV and NLR were associated with reduced prognosis in patients with LSCC.

Prognostic significance of pretreatment plasma fibrinogen level in patients with digestive system tumors: a meta-analysis

High pretreatment levels of plasma fibrinogen have been widely reported to be a potential predictor of prognosis in digestive system tumors; however, the conclusions are not consistent. Therefore, we performed a meta-analysis to comprehensively assess the prognostic roles of high pretreatment plasma fibrinogen levels in digestive system tumors. We searched for eligible studies in the PubMed, Embase, and Web of Science electronic databases for publications from the database inception to 1 September 2017. The endpoints of interest included overall survival, disease-free survival, and recurrence-free survival. We investigated the relationship between fibrinogenemia and overall survival in colorectal cancer (10 studies), gastric cancer (6), pancreatic cancer (6), hepatocellular carcinoma (7), and esophageal squamous cell carcinoma (10); the pooled results indicated that fibrinogenemia was significantly related to a worse overall survival (hazard ratio (HR) 1.73; 95% confidence interval (CI) 1.52, 1.97; P <0.001; HR 1.71; 95% CI 1.28, 2.28; P <0.001; HR 1.57; 95% CI 1.13, 2.17; P = 0.007; HR 1.89; 95% CI 1.57, 2.27; P <0.001, and HR 1.67; 95% CI 1.35, 2.07; P <0.001). Taken together, an increased pretreatment plasma fibrinogen level was related to worse survival in digestive system tumors, indicating that it could be a useful prognostic marker in these types of tumors.

Preoperative plasma fibrinogen, but not D-dimer might represent a prognostic factor in non-metastatic colorectal cancer: A prospective cohort study

BACKGROUNDS

Cancer progression has been associated with host hemostasis system. Whether preoperative plasma hemostasis factors can predict survival in colorectal cancer is quite intriguing.

METHODS

We conducted a prospective cohort study to validate the prognostic significance of three hemostasis parameters - fibrinogen, fibrin degradation products (FDPs) and D-dimer - in non-metastatic colorectal cancer patients treated with curative resection.

RESULTS

All three parameters were positively correlated with C reactive protein (CRP) levels and Glasgow Prognostic scores (GPS). In univariate cox hazards regression model, as continuous variables, both fibrinogen (HR: 1.07, 95%CI: 1.01-1.13) and FDPs (HR: 1.17, 95%CI: 1.05-1.31) were prognostic, while D-dimer levels were not. Patients with hyperfibrinogenemia had a 2.12-fold increased mortality risk compared with patients without hyperfibrinogenemia. Patients with positive FDPs had a 3.68-fold increased mortality risk compared with patients with negative FDPs. In multivariate models, hyperfibrinogenemia was prognostic (HR: 3.39, 95%CI: 1.34-8.67) in patients with normal GPS scores.

CONCLUSIONS

Preoperative fibrinogen levels appeared as an independent mortality risk factor in non-metastatic colorectal cancer patients with normal GPS scores. Fibrinogen could be a reliable marker to identify high risk patients for those without systematic inflammation responses.

LMR predicts outcome in patients after preoperative chemoradiotherapy for stage II-III rectal cancer

BACKGROUND

Recently, lymphocyte-to-monocyte ratio (LMR) has attracted attention as a new marker of the chronic systemic inflammatory response and has been associated with patient prognosis in those who underwent chemoradiotherapy (CRT) for several solid cancers. This study aimed to evaluate the association between LMR and the prognosis of patients with rectal cancer.

METHODS

A total of 183 stage II-III rectal cancer patients who underwent preoperative CRT followed by surgical R0 resection were retrospectively reviewed. The LMR was calculated from pre- and post-CRT blood samples. To determine the optimal cutoff value for pre- and post-CRT LMR for predicting relapse-free survival (RFS) and overall survival (OS), a receiver operator characteristic curve was used. Cox's proportional hazard models were applied to identify risk factors for recurrence and overall mortality.

RESULTS

Low LMR was observed in 54 patients (pre-CRT <4.0) and 29 patients (post-CRT <1.5). Although pre-CRT LMR correlated with tumor size and ypT stage, post-CRT LMR showed no correlation to any pathologic features. Median follow-up term was 66.3 months; the 5-year RFS and OS of all patients were 72.5% and 88.7%, respectively. We found that a low pre-CRT LMR was an independent risk factor for OS (hazard ratio, 2.83; 95% confidence interval 1.03-8.13; P = 0.043).

CONCLUSIONS

In rectal cancer patients who have undergone preoperative CRT, a low pre-CRT LMR is a poor prognostic factor for OS.

Preoperative peripheral plasma fibrinogen level is an independent prognostic marker in penile cancer

BACKGROUND AND AIM

High levels of peripheral plasma fibrinogen have recently been revealed that related to poor clinical prognosis in various types of malignant tumors. The purpose of this research was to identify the prognostic significance of the preoperative peripheral serum fibrinogen level in patients with penile cell carcinoma.

METHODS

This retrospective research included 72 penile cancer patients with date about their serum fibrinogen value before surgery who undergone either partial or radical penectomy at The 2nd Hospital of Tianjin Medical University between January 2002 to January 2012. They had a mean follow-up of 30.8 months. To determine the factors that were significant in predicting a patient's prognosis, univariate and multivariate analyses were performed according to the Cox proportional hazards regression model.

RESULTS

The 5-year cancer specific survival (CSS) rate was 62.4% of patients with preoperative fibrinogen levels below 340 mg/dl and 41.9% for those with higher levels (p = 0.001). Multivariate analysis revealed that the pathological T stage (p < 0.001), tumor grade (p = 0.036), postoperative chemotherapy (p = 0.041), nodal metastasis(p < 0.001), pathological type (p < 0.001) and fibrinogen (p = 0.023) were independent prognostic factors for survival. Patients with low fibrinogen level (<340mg/dl) had significantly longer CSS and the different survival rate were defined using the log-rank test.

CONCLUSIONS

The high preoperative peripheral serum fibrinogen level was related to poor survival in penile cancer patients. Fibrinogen may serve as a powerful predictor of CSS in penile cancer patients.

Serum peptidome profiling for the diagnosis of colorectal cancer: discovery and validation in two independent cohorts

Colorectal cancer (CRC) is one of the most common malignant neoplasms worldwide. Except for the existing fecal occult blood test, colonoscopy and sigmoidoscopy, no widely accepted in vitro diagnostic methods have been available. To identify potential peptide biomarkers for CRC, serum samples from a discovery cohort (100 CRC patients and 100 healthy controls) and an independent validation cohort (91 CRC patients and 91 healthy controls) were collected. Peptides were fractionated by weak cation exchange magnetic beads (MB-WCX) and analysed by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). Five peptides (peaks at m/z 1895.3, 2020.9, 2080.7, 2656.8 and 3238.5) were identified as candidate biomarkers for CRC. A diagnostic panel based on the five peptides can discriminate CRC patients from healthy controls, with an accuracy of 91.8%, sensitivity of 95.6%, and specificity of 87.9% in the validation cohort. Peptide peaks at m/z 1895.3, 2020.9 and 3238.5 were identified as the partial sequences of complement component 4 (C4), complement component 3 (C3) and fibrinogen α chain (FGA), respectively. This study potentiated peptidomic analysis as a promising in vitro diagnostic tool for diagnosis of CRC. The identified peptides suggest the involvement of the C3, C4 and FGA in CRC pathogenesis.

Elevated fibrinogen plasma level is not an independent predictor of poor prognosis in a large cohort of Western patients undergoing surgery for colorectal cancer

AIM

To evaluate the clinical significance of the preoperative fibrinogen plasma level as a prognostic marker after surgery for colorectal cancer.

METHODS

This retrospective study analysed 652 patients undergoing surgery for stage I-IV colorectal cancer between January 2005 and December 2012, at the Division of General Surgery A, University of Verona Hospital Trust, in whom preoperative fibrinogen plasma values were assessed at baseline. Fibrinogen is involved in tumourigenesis as well as tumour progression in several malignancies. Correlations between preoperative plasma fibrinogen values and clinicopathological characteristics were investigated. Univariate and multivariate survival analyses were performed to identify factors associated with overall and tumour-related survival.

RESULTS

Among the 652 patients, the fibrinogen value was higher than the threshold of 400 mg/dL in 345 patients (53%). The preoperative mean ± SD of fibrinogen was 426.2 ± 23.2 mg/dL (median: 409 mg/dL; range: 143-1045 mg/dL). Preoperative fibrinogen values correlated with age (P = 0.003), completeness of tumour resection, potentially curative vs palliative (P < 0.001), presence of systemic metastasis (P < 0.001), depth of tumour invasion pT (P < 0.001), nodes involvement pN (P = 0.001) and CEA serum level (P < 0.001). The mean fibrinogen value (± SD) was 395.6 ± 120.4 mg/dL in G1 tumours, 424.1 ± 121.4 mg/dL in G2 tumours and 453.4 ± 131.6 mg/dL in G3 tumours (P = 0.045). The overall survival and tumour-related survival were significantly higher in patients with fibrinogen values ≤ 400 mg/dL (P < 0.001). However, hyperfibrinogenemia did not retain statistical significance regarding either overall (P = 0.313) or tumour-related survival (P = 0.355) after controlling for other risk factors in a multivariate analysis.

CONCLUSION

Preoperative fibrinogen levels correlate with cancer severity but do not help in predicting patient prognosis after colorectal cancer surgery.

Elevated platelet count as predictor of recurrence in rectal cancer patients undergoing preoperative chemoradiotherapy followed by surgery

The impact of systemic inflammatory response (SIR) on prognostic and predictive outcome in rectal cancer after neoadjuvant chemoradiotherapy (CRT) has not been fully investigated. This retrospective study enrolled 89 patients with locally advanced rectal cancer who underwent neoadjuvant CRT and for whom platelet (PLT) counts and SIR status [neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR)] were available. Both clinical values of PLT and SIR status in rectal cancer patients were investigated. Elevated PLT, NLR, PLR, and pathologic TNM stage III [ypN(+)] were associated with significantly poor overall survival (OS). Elevated PLT, NLR, and ypN(+) were shown to independently predict OS. Elevated PLT and ypN(+) significantly predicted poor disease-free survival (DFS). Elevated PLT was identified as the only independent predictor of DFS. PLT counts are a promising pre-CRT biomarker for predicting recurrence and poor prognosis in rectal cancer.

Prognostic role of pretreatment plasma fibrinogen in patients with solid tumors: A systematic review and meta-analysis

BACKGROUND

Plasma fibrinogen may be involved in several stages of cancer progression. Clinical studies have demonstrated that pretreatment plasma fibrinogen is associated with poor survival in various cancers. The aim of this meta-analysis was to examine the prognostic effect of circulating fibrinogen in solid tumors.

MATERIALS AND METHODS

We searched Medline, EMBASE, Cochrane Database of Systematic Reviews, and meeting proceedings to identify studies assessing the effect of pretreatment plasma fibrinogen on survival of cancer patients. Pooled multivariable-adjusted hazard ratios (HRs) for overall survival (OS), disease-free survival (DFS), and cancer-specific survival (CSS) were estimated using random-effects models.

RESULTS

Data from 52 observational studies and 15,371 patients were summarized. An elevated baseline plasma fibrinogen was significantly associated with worse OS (pooled HR = 1.69; 95% CI = 1.48–1.92). The highest negative effect of elevated plasma fibrinogen on OS was demonstrated in renal cell carcinoma (pooled HR = 2.22), followed by head and neck cancer (pooled HR = 2.02), and colorectal cancer (pooled HR = 1.89). The adverse prognostic impact of high plasma fibrinogen remained in both non-metastatic and metastatic disease and patients of different ethnicity. Patients with high baseline fibrinogen had a significantly shorter DFS (pooled HR = 1.52) and CSS (pooled HR = 2.50).

CONCLUSIONS

An elevated pretreatment plasma fibrinogen significantly correlates with decreased survival in patients with solid tumors. Future clinical trials are warranted to determine whether plasma fibrinogen could be incorporated in cancer staging systems and whether fibrinogen-lowering therapies have a favorable effect on disease recurrence and mortality.

[Analysis of the factors associated with abnormal coagulation and prognosis in patients with non-small cell lung cancer]

背景与目的

凝血及纤溶系统激活在肺癌患者中较为常见，与肺癌侵袭、转移的高风险和预后差相关。非小细胞肺癌（non-small cell lung cancer, NSCLC）占肺癌的80%-85%，本研究旨在回顾性分析凝血功能指标对NSCLC的预后价值，为目前NSCLC患者高凝状态的预防及治疗提供参考。

方法

回顾性分析2009年1月-2012年12月首次就诊于河北医科大学第四医院的604例经病理学证实的NSCLC患者的临床资料。资料内容包括患者治疗前凝血功能相关指标[血浆凝血酶原时间（prothrombin time, PT）、凝血酶原活动度（prothrombin time activity, PTA）、国际标准化比率（international normalized ratio, INR）、活化部分凝血活酶时间（activated partial thromboplastin time, APTT）、纤维蛋白原（fibrinogen, Fib）、D二聚体（D-dimer, D-D）、血小板计数（platelet count, PLT）]、性别、年龄、病理分型、TNM分期、淋巴结状态等。本研究选择了50例同期就诊于河北医科大学第四医院的非癌症患者作为对照组。采用SPSS 13.0统计软件进行分析。

结果

NSCLC组与对照组之间所有的凝血功能指标（包括PT、PTA、INR、APTT、Fib、D-D、血小板计数）的血浆水平显示均有统计学差异[除了Fib（P=0.001, 5）、Plt（P=0.004, 5），其余指标（P＜0.001）]。纤维蛋白原水平与NSCLC的组织学亚型之间相关，鳞癌比腺癌的Fib水平明显升高（P＜0.001）。Ⅲ期、Ⅳ期期比Ⅰ期-Ⅱ期患者的Fib、PLT水平升高（P＜0.001, P=0.014），APTT缩短（P＜0.001）。与N0患者相比，N1-N3患者的APTT，明显缩短（P＜0.001），Fib、D-D水平升高（P＜0.001, P=0.048）。对生存率的比较研究显示，PT、INR延长（P=0.032, P=0.001），Fib升高（P＜0.001），PTA下降（P=0.005），在统计学上对总生存有明显的不利影响。多因素生存分析显示，在凝血功能指标中INR是唯一的独立预后因素（P=0.017）。

结论

NSCLC患者往往存在凝血纤溶系统的激活，导致凝血纤溶指标的亚临床改变。肺腺癌患者以及分期为晚期、淋巴结存在转移的NSCLC患者更易出现高血凝状态。PT、INR的延长与NSCLC患者生存率的下降密切相关，INR是NSCLC的独立预后因素，PT、INR可能成为NSCLC的预后指标。

The role of fibrinogen as a predictor in preoperative chemoradiation for rectal cancer

BACKGROUND

To perform chemoradiotherapy (CRT) effectively, it is clinically beneficial to identify predictors of tumor response after CRT. This study examined the association between plasma fibrinogen level before preoperative CRT and tumor response in advanced rectal cancer.

METHODS

This was a retrospective study of 947 patients who received preoperative CRT followed by curative surgery for primary rectal cancer. We analyzed clinical factors that could be associated with pathologic tumor response in terms of downstaging (ypStage 0-I), primary tumor regression (ypT0-1), and complete response (ypT0N0).

RESULTS

Downstaging was observed in 366 patients (38.6%), primary tumor regression in 187 patients (19.7%) and complete response in 138 patients (14.6%). Multivariate analysis found that pre-CRT carcinoembryonic antigen (CEA) level, fibrinogen level, hemoglobin level, clinical T and N classification, distance from anal verge, and histologic grade were significant predictive factors for downstaging; CEA level, fibrinogen level, and N classification predicted primary tumor regression; CEA level, and fibrinogen level were predictive for complete response.

CONCLUSIONS

This study demonstrated that fibrinogen level was a significant predictor of pathologic tumor response after preoperative CRT.

Clinical significance of plasma fibrinogen level as a predictive marker for postoperative recurrence of esophageal squamous cell carcinoma in patients receiving neoadjuvant treatment

Among multidisciplinary therapies developed for advanced esophageal cancer, neoadjuvant chemotherapy and chemoradiotherapy have been established as standard treatments. To deliver cautious follow up and intense treatment for high-risk patients, a simple and instructive biomarker for the postoperative recurrence needs to be identified. Fibrinogen, a common component of hemostasis, has been suggested to not only play an important role in cancer metastasis, but also correlate with tumor recurrence. We aim to clarify the validity of plasma fibrinogen as a marker for predicting the postoperative recurrence of esophageal squamous cell carcinoma patients who received neoadjuvant treatment. We reviewed 72 consecutive patients with esophageal squamous cell carcinoma who received neoadjuvant chemotherapy or chemoradiotherapy, followed by esophagectomy at the Keio University Hospital from 2001 to 2010. Of them, we retrospectively examined 68 patients who underwent plasma fibrinogen examination before and after neoadjuvant treatment and underwent transthoracic radical esophagectomy. We investigated patient characteristics, clinicopathological factors, neoadjuvant treatment effects, postoperative course, and plasma fibrinogen levels. We investigated pretreatment and preoperative (postneoadjuvant treatment) plasma fibrinogen levels, as well as changes in fibrinogen levels before and after neoadjuvant treatment. Patients with preoperative hyperfibrinogenemia (>350 mg/dL) and patients with increased plasma fibrinogen levels during neoadjuvant treatment showed significantly shorter postoperative disease-free survival (DFS) (P = 0.002 and P = 0.037, respectively). Moreover, we classified these patients into three classes on the basis of their preoperative fibrinogen levels and changes in fibrinogen levels during neoadjuvant treatment. Patients who had both high preoperative plasma fibrinogen and increased fibrinogen levels showed significantly shorter DFS than others. In contrast, patients who had normal preoperative plasma fibrinogen and decreased fibrinogen levels showed significantly longer DFS. Based on this fibrinogen classification, we could differentiate between significantly favorable and poor prognosis patients group. Overall, this classification (hazard ratio = 1.812, P = 0.013) and the response to neoadjuvant treatment (hazard ratio = 0.350, P = 0.007) were found to be significant determining factors for postoperative DFS. With the validity of preoperative plasma fibrinogen levels and changes in fibrinogen levels during neoadjuvant treatment, the plasma fibrinogen level was found to be a possible biomarker for postoperative recurrence in advanced esophageal cancer patients who received neoadjuvant treatment. Moreover, plasma fibrinogen classification could be a simple and valuable predictive marker for postoperative follow up.

Colorectal cancer and hypercoagulability

Since the first report of the spontaneous appearance of venous thrombophlebitis as a sign of visceral cancer by Trousseau in 1865, many other studies have documented the existence of cancer-associated coagulation disorders. In this review, we describe the hypercoagulable state associated with colorectal cancer, from three perspectives: first, the incidence, risk factors and prevention of clinically symptomatic thromboembolic conditions associated with cancer, such as venous thromboembolism and arterial thrombosis; second, the association between hypercoagulable conditions, such as thrombocytosis, hyperfibrinogenemia, or D-dimer elevation, and the clinical progression and poor prognosis of cancer patients; third, the experimental approach to elucidate the role of various coagulation-related factors in the process of cancer progression, focusing specifically on the role of platelets and tissue factors.

Preoperative plasma hyperfibrinogenemia is predictive of poor prognosis in patients with nonmetastatic colon cancer

BACKGROUND

The outcomes of colorectal cancer are determined by host factors, including systemic inflammation. The purpose of this study was to evaluate the prognostic significance of fibrinogen and inflammation-based scores, as markers of the inflammatory response, in colon cancer.

METHODS

We retrospectively reviewed the medical records of patients with nonmetastatic colon cancer who underwent curative resection between January 2005 and December 2007. Fibrinogen, albumin, C-reactive protein, neutrophil, lymphocyte, and platelet counts were measured at the time of diagnosis. Correlations between preoperative plasma fibrinogen levels and clinicopathologic characteristics were analyzed. Univariate and multivariate survival analyses were performed to identify factors associated with disease-free and overall survival.

RESULTS

A total of 624 patients who underwent curative resection for colon cancer were eligible for this study. Mean preoperative plasma fibrinogen levels were 325.24±88.19 mg/dl. Higher preoperative plasma fibrinogen levels were associated with sex (male), old age, poorly/mucinous differentiated tumor, advanced tumor stage, elevated carcinoembryonic antigen (CEA) levels, higher modified Glasgow Prognostic Score, and higher neutrophil:lymphocyte and platelet:lymphocyte ratios. In multivariate analysis, elevated plasma fibrinogen level [disease-free survival: hazard ratio (HR) 1.999, 95% confidence interval (95% CI) 1.081-3.695, P=.027; overall survival: HR 3.138, 95% CI 1.077-9.139, P=.036], advanced tumor stage, and higher CEA levels were independently associated with worse disease-free survival and overall survival. None of the inflammation-based scores were significantly associated with survival.

CONCLUSIONS

Fibrinogen as one of inflammatory markers may be considered a possible prognostic marker in colon cancer.

Thrombocytosis before pre-operative chemoradiotherapy predicts poor response and shorter local recurrence-free survival in rectal cancer

PURPOSE

Although thrombocytosis has been reported in patients with various cancers including the colorectal one, the impact of elevated platelet counts on the response to chemoradiotherapy (CRT) for rectal cancer has not been fully investigated. We investigated the clinical significance of pre- and post-CRT platelet counts in patients with rectal cancer.

METHODS

The medical records of 101 patients with rectal cancer, who had received CRT followed by surgical resection, were retrospectively reviewed. The correlations between the clinicopathological variables and the pre- or post-CRT platelet counts were analyzed. The correlations between tumor regression rate induced by CRT, as evaluated by barium enema and pathological examination, and the pre- or post-CRT platelet counts were also evaluated. Finally, the impact of pre-CRT thrombocytosis on the prognosis of these patients was assessed.

RESULTS

The pre-CRT platelet count correlated with venous invasion and tumor size, and it strongly correlated with the response rate evaluated by barium enema and the grade of pathological tumor regression. Furthermore, patients with pre-CRT thrombocytosis had significantly shorter local recurrence-free survival.

CONCLUSION

Platelet count before CRT should be a promising biomarker for predicting the efficacy of CRT and the risk of local recurrence in rectal cancer patients after CRT.

Tumor response and survival in patients with advanced non-small-cell lung cancer: the predictive value of chemotherapy-induced changes in fibrinogen

BACKGROUND

Hyperfibrinogenemia is a common problem associated with various carcinomas, and is accompanied by hypercoagulablity. In advanced non-small-cell lung cancer (NSCLC) it remains unclear whether or not chemotherapy-induced changes in fibrinogen level relate to chemotherapeutic response and prognosis. The purposes of this study were to: 1) analyze the association between chemotherapy-induced changes in plasma fibrinogen level and the chemotherapeutic response after the first two courses of standard first-line platinum-based chemotherapy; and 2) evaluate the prognostic significance of the basal plasma fibrinogen level in patients with advanced NSCLC.

METHODS

In this retrospective study, the data from 160 patients with advanced NSCLC were collected. The association between the changes in fibrinogen and the response to chemotherapy, or between the pre-and post-chemotherapy fibrinogen levels and patient clinical characteristics, were analyzed using SPSS software. In addition, the prognostic value of pre-chemotherapy fibrinogen levels was assessed.

RESULTS

The median pre-chemotherapy plasma fibrinogen level was 4.4 g/L. Pre-chemotherapy plasma fibrinogen levels correlated significantly with gender (p = 0.041). Post-chemotherapy plasma fibrinogen levels correlated with gender (p = 0.023), age (p = 0.018), ECOG (p = 0.002) and tumor response (p = 0.049). Plasma fibrinogen levels markedly decreased after chemotherapy in 98 (61.25 %) patients with pre-chemotherapy hyperfibrinogenemia (p = 0.008); and in this population there was a significant link between the decrease in fibrinogen level, and initial partial response (PR; p = 0.017) and stable disease (SD; p = 0.031). Univariate and multivariate analysis revealed that higher levels of fibrinogen (≥4.4 g/L) and ECOG 1 were positively associated with shorter overall survival (OS). CEA and CA125 also decreased significantly (p =0.015, p =0.000) in DCR group after chemotherapy.

CONCLUSIONS

This study showed that the reduction in plasma fibrinogen levels induced by chemotherapy might be as a promising biomarker as CEA and CA125 for evaluating the efficacy of chemotherapy in advanced NSCLC. In addition, basal plasma fibrinogen levels could be used as an independent prognostic parameter for the OS of patients with advanced NSCLC.