Postoperative prognostic nutritional index as a prognostic factor after non-small cell lung cancer surgery

A refined approach to chest tube removal: Impact of preoperative pleural fluid culture and nutritional status in non-fistulous empyema surgery

BACKGROUND

The acute pleural empyema guidelines recommend thoracoscopic-assisted surgery. However, there is no clear guideline for chest tube removal after surgery. This study aimed to evaluate the duration from surgery to chest tube removal, identify associated factors.

METHODS

A retrospective cohort study was conducted in 95 patients having non-fistulous empyema due to pulmonary infection caused by common bacteria who underwent surgery at our hospital from January 2011 to March 2023. Postoperative lavage was conducted until two consecutive pleural fluid cultures were negative. The chest tube was clamped and removed if there was no exacerbation of fever or inflammatory findings for 2 days.

RESULTS

Seventy-eight patients (82.1%) were men with a mean age of 72 years. The median duration from surgery to chest tube removal was 14 (interquartile range: 8-22) days. In the multivariable analysis, the independent factors associated with the duration from surgery to chest tube removal were lower prognostic nutritional index (hazard ratio [HR], 1.753; 95% confidence interval [CI], 1.101-2.792; P = 0.018) and positive preoperative pleural fluid culture (HR, 1.867; 95% CI, 1.069-3.261; P = 0.028). Ninety-two (96.8%) patients did not require additional treatment or rehospitalization.

CONCLUSIONS

Positive preoperative pleural fluid culture and nutritional status were significant independent factors associated with the duration from surgery to chest tube removal. Almost all patients did not require chest tube reinsertion in our approach. These findings using our approach may guide optimal management of chest tube removal in non-fistulous empyema.

Prognostic value of perioperative changes in the prognostic nutritional index in patients with surgically resected non-small cell lung cancer

PURPOSE

This single-institution retrospective cohort study was conducted to assess the prognostic significance of perioperative changes in the prognostic nutritional index (PNI) in patients who underwent surgery for non-small cell lung cancer (NSCLC).

METHODS

Clinicopathological data were collected from 441 patients who underwent lobectomy for NSCLC between 2010 and 2016.The PNI ratio (postoperative PNI/preoperative PNI) was used as an indicator of perioperative PNI changes. Prognostic differences were investigated based on PNI ratios.

RESULTS

The optimal cut-off value of the PNI ratio for overall survival (OS) was set at 0.88 using a receiver operating characteristic curve. The PNI ratio was inversely related to a high smoking index, interstitial lung disease, and postoperative pulmonary complications. The 5-year OS rates for the high vs. low PNI ratio groups were 88.2% vs. 68.5%, respectively (hazard ratio [HR]: 3.04, 95% confidence interval [CI]: 1.90-4.86). Multivariable analysis revealed that a low PNI ratio was significantly associated with poor prognosis (HR: 2.94, 95% CI: 1.77-4.87). The PNI ratio was a more sensitive indicator than postoperative PNI status alone for identifying patients at high risk of mortality, particularly those with non-lung cancer causes.

CONCLUSION

The perioperative PNI change is a significant prognostic factor for patients with NSCLC.

Combined systemic inflammatory immune index and prognostic nutrition index as chemosensitivity and prognostic markers for locally advanced gastric cancer receiving neoadjuvant chemotherapy: a retrospective study

BACKGROUND

The prognosis nutritional index (PNI) and the systemic inflammatory immunological index (SII) are characteristic indicators of the nutritional state and the systemic inflammatory response, respectively. However, there is an unknown combined effect of these indicators in the clinic. Therefore, the practicality of using the SII-PNI score to predict prognosis and tumor response of locally advanced gastric cancer (LAGC) following chemotherapy was the main focus of this investigation.

METHODS

We retrospectively analyzed 181 patients with LAGC who underwent curative resection after neoadjuvant chemotherapy in a prospective study (NCT01516944). We divided these patients into tumour regression grade(TRG) 3 and non-TRG3 groups based on tumor response (AJCC/CAP guidelines). The SII and PNI were assessed and confirmed the cut-off values before treatment. The SII-PNI values varied from 0 to 2, with 2 being the high SII (≥ 471.5) as well as low PNI (≤ 48.6), a high SII or low PNI is represented by a 1 and neither is represented by a 0, respectively.

RESULTS

51 and 130 samples had TRG3 and non-TRG3 tumor responses respectively. Patients with TRG3 had substantially higher SII-PNI scores than those without TRG3 (p < 0.0001). Patients with greater SII-PNI scores had a poorer prognosis (p < 0.0001). The SII-PNI score was found to be an independent predictor of both overall survival (HR = 4.982, 95%CI: 1.890-10.234, p = 0.001) and disease-free survival (HR = 4.763, 95%CI: 1.994-13.903, p = 0.001) in a multivariate analysis.

CONCLUSION

The clinical potential and accuracy of low-cost stratification based on SII-PNI score in forecasting tumor response and prognosis in LAGC is satisfactory.

Preoperative prognostic nutritional index is an independent indicator for perioperative prognosis in coronary artery bypass grafting patients

OBJECTIVES

The prognostic nutritional index is widely used for surgery prognosis, but the association between preoperative prognostic nutritional index and short-term prognosis for coronary artery bypass grafting surgery and the profiles of perioperative prognostic nutritional index remain unclear.

METHODS

This study retrospectively enrolled a total of 879 adult patients undergoing coronary artery bypass grafting surgery in the Shanghai Chest Hospital from 2006 to 2022. The prognostic nutritional index was calculated based on serum albumin and peripheral lymphocyte count. In-hospital mortality, demographic characteristics, blood biochemistry parameters, cardiovascular medical history, and physical examination results were collected from the hospital information system. The propensity score matching method and multivariate logistic regression were used to detect the association between preoperative prognostic nutritional index and in-hospital mortality.

RESULTS

Patients were divided into a high-prognostic nutritional index group (n = 500) and a low-prognostic nutritional index group (n = 379), using a cutoff value of 48.1 according to receiver operating characteristic curve analysis. The propensity score matching-adjusted mean prognostic nutritional index levels decreased from 48.35 before the operation to 34.04 an in ≤24 h after the operation and rebounded to 43.36 before discharge. High preoperative prognostic nutritional index was inversely associated with in-hospital mortality for coronary artery bypass grafting surgery (odds ratio = 0.86; 95% CI, 0.77-0.97) in propensity score matching-adjusted multivariate logistic regression.

CONCLUSIONS

Preoperative prognostic nutritional index is an independent indicator for in-hospital mortality of for coronary artery bypass grafting surgery, and the variation trend of prognostic nutritional index during perioperation tends to be U-shaped.

Role of prognostic nutritional index in postoperative radiotherapy for non-small cell lung cancer

BACKGROUND

The prognostic nutritional index (PNI) is known to be correlated with clinical outcomes in non-small cell lung cancer (NSCLC) patients. However, its role has not been studied in patients who have undergone postoperative radiotherapy (PORT). This study aimed to investigate the relationship between PNI and survival and recurrence in NSCLC patients with PORT.

METHODS

We reviewed 97 stage I-III NSCLC patients who received PORT between January 2006 and December 2016 at our institution. We obtained PNI values for both pre-RT (within 1 month before PORT) and post-RT (within 2 months after PORT) by using serum albumin and lymphocyte count. A cutoff value for PNI was determined by the receiver operating characteristic curve (ROC). The median follow-up period was 52.8 months.

RESULTS

The ROC curve of post-RT PNI exhibited a higher area under the curve (AUC 0.68, cut-off: 47.1) than that of pre-RT PNI (AUC 0.55, cutoff: 50.3), so the group was divided into high post-RT PNI (> 47.1) and low post-RT PNI ( ≤ 47.1). The five-year overall survival rate (OS) was 66.2% in the high post-RT group, compared with 41.8% in the low post-RT PNI group (p = 0.018). Those with both low pre-RT and low post-RT PNI had the worst five-year OS of 31.1%. Post-RT PNI (HR 0.92, p = 0.003) was an independent risk factor for mortality.

CONCLUSIONS

PNI after PORT was significantly associated with survival. This finding suggests that PNI can be used as a prognostic marker.

Prognostic nutritional index is a prognostic factor for patients with gastric cancer and esophagogastric junction cancer undergoing proximal gastrectomy with esophagogastrostomy by the double-flap technique: A secondary analysis of the rD-FLAP study

PURPOSE

Although proximal gastrectomy (PG) is commonly used in patients with upper gastric cancer (GC) and esophagogastric junction (EGJ) cancer, long-term prognostic factors in these patients are poorly understood. The double-flap technique (DFT) is an esophagogastrostomy with anti-reflux mechanism after PG; we previously conducted a multicenter retrospective study (rD-FLAP) to evaluate the short-term outcomes of DFT reconstruction. Here, we evaluated the long-term prognostic factors in patients with upper GC and EGJ cancer.

METHODS

The study was conducted as a secondary analysis of the rD-FLAP Study, which enrolled patients who underwent PG with DFT reconstruction, irrespective of disease type, between January 1996 and December 2015.

RESULTS

A total of 509 GC and EGJ cancer patients were enrolled. Univariate and multivariate analyses of overall survival demonstrated that a preoperative prognostic nutritional index (PNI) < 45 (p < 0.001, hazard ratio [HR]: 3.59, 95% confidential interval [CI]: 1.93-6.67) was an independent poor prognostic factor alongside pathological T factor ([pT] ≥2) (p = 0.010, HR: 2.29, 95% CI: 1.22-4.30) and pathological N factor ([pN] ≥1) (p = 0.001, HR: 3.27, 95% CI: 1.66-6.46). In patients with preoperative PNI ≥45, PNI change (<90%) at 1-year follow-up (p = 0.019, HR: 2.54, 95%CI: 1.16-5.54) was an independent poor prognostic factor, for which operation time (≥300 min) and blood loss (≥200 mL) were independent risk factors. No independent prognostic factors were identified in patients with preoperative PNI <45.

CONCLUSIONS

PNI is a prognostic factor in upper GC and EGJ cancer patients. Preoperative nutritional enhancement and postoperative nutritional maintenance are important for prognostic improvement in these patients.

The significance of immunonutrition nutritional support in patients undergoing postoperative adjuvant chemotherapy for lung cancer: case-control study

BACKGROUND

In this study, the effect of postoperative early nutritional supplementation on the course of the disease was investigated in patients who were operated for non-small cell lung cancer and received adjuvant chemotherapy.

METHODS

The study examined the data of patients who anatomical pulmonary resection for non-small cell lung cancer and who were treated with adjuvant chemotherapy at our clinic between January 2014 and January 2020. Patients who received early postoperative nutritional supplements and those who continued with a normal diet were compared in terms of complications, mortality, recurrence, and survival.

RESULTS

The study sample consisted of 68 (84%) male and 13 (16%) female patients, and the mean duration of postoperative follow-up was 31.6 ± 17.9 (4-75) months. Metastasis was identified in eight (17.4%) patients in Grup_{NS (Nutritional Supplements)} compared to 10 (28.6%) patients in Group_{C (Control)} (p = 0.231). Of the total, 11 (23.9%) patients died in Group_NS compared to 13 (37.1%) in Group_C (p = 0.196). Mean survival was 58.9 ± 3.8 (95% CI: 4.0-75.0) months in Group_NS compared to 43.5 ± 4.6 (95% CI: 6.0-66.0) months in Group_C (p = 0.045).

CONCLUSION

Early nutritional supplements should be considered as having a positive effect especially on survival in this specific patient group involving factors with high catabolic effects, such as neoplasia, operation, and chemotherapy together.

A low prognostic nutritional index is associated with chronic subdural hematoma recurrence

Chronic subdural hematoma (CSDH) is a common neurosurgical condition. Inflammation has been found to play an essential role in the formation of CSDHs, and the prognostic nutritional index (PNI), a nutritional and inflammatory baseline marker, plays a role in predicting the prognosis of many diseases. We aimed to identify the relationship between PNI and CSDH recurrence. This study retrospectively analyzed 261 CSDH patients who underwent burr hole evacuation in Beijing Tiantan Hospital from August 2013 to March 2018. The PNI was calculated as 5 ∗ lymphocyte count (10⁹/L) + serum albumin concentration (g/L), and these markers were obtained from the peripheral blood test on the day of discharge from the hospital. Recurrence was defined as operated hematoma enlargement accompanied by newly emerging neurological disorders. The comparison of baseline characteristics demonstrated that patients with bilateral hematoma and low levels of albumin, lymphocytes, and PNI were more likely to be recurrent. After adjusting for age, sex, and other important variables, decreased PNI levels were associated with an increased risk of CSDH (OR, 0.803, 95% CI: 0.715-0.902, p = 0.001). The addition of PNI to conventional risk factors significantly improved the risk prediction of CSDH (net reclassification index: 71.12%, p = 0.001; integrated discrimination index: 10.94%, p = 0.006). A low PNI level is associated with an increased risk of CSDH recurrence. As an easily obtainable nutritional and inflammatory marker, PNI may play a significant role in predicting the recurrence of CSDH patients.

Combination of Baseline and Variation of Prognostic Nutritional Index Enhances the Survival Predictive Value of Patients With Advanced Non-Small Cell Lung Cancer Treated With Programmed Cell Death Protein 1 Inhibitor

BACKGROUND

Low baseline prognostic nutritional index (PNI) scores are associated with poor survival for various malignancies; however, they vary based on the cohort and time resulting in inaccurate results. We determined the predictive value of the PNI score variations in addition to the baseline PNI scores for patients with advanced non-small cell lung cancer (NSCLC) who received programmed cell death protein 1 (PD-1) inhibitor.

METHODS

We retrospectively analysed 115 patients with advanced NSCLC who received PD-1 inhibitor. The median follow-up period was 28 months. Patients were clustered into four groups based on the combined PNI scores (combination of baseline and variation of PNI scores): ΔPNI-L-L, ΔPNI-L-H, ΔPNI-H-L, and ΔPNI-H-H subgroups. For instance, if PNI scores of patients with high baseline PNI score increased from baseline to 6 weeks after treatment, they were included in the ΔPNI-H-H subgroup. Cox regression models were used to identify the factors associated with survival.

RESULTS

The baseline PNI score was only related to the overall survival (OS) (P = .026), and not to the overall response rate (ORR) (P = .299) and progression-free survival (PFS) (P = .207). The ORR was associated with the combined PNI scores (P = .017). A multivariable Cox regression analysis confirmed that the combined PNI scores were independent factors for PFS (ΔPNI-L-H, 12 months, hazard ratio [HR] = 0.449, P = .009; ΔPNI-H-L, 14 months, HR = 0.500, P = .019; and ΔPNI-H-H, 17 months, HR = 0.390, P = .012; vs ΔPNI-L-L, 8 months) and OS (ΔPNI-L-H, 27 months, HR = 0.403, P = .019; ΔPNI-H-L, 28 months, HR = 0.369, P = .010; and ΔPNI-H-H, not reached, HR = 0.087, P = .002; vs ΔPNI-L-L, 15 months).

CONCLUSIONS

Patients with high baseline PNI and increased PNI score had the better survival outcome. On dynamic monitoring and comprehensive assessment, the combined PNI scores significantly enhanced the survival predictive ability of patients with NSCLC treated with PD-1 inhibitor.

Prognostic nutritional index before surgical treatment may serve as a prognostic biomarker for patients with upper tract urothelial carcinoma: A systematic review and meta-analysis

Objective

This meta-analysis aims to assess whether the prognostic nutritional index (PNI) score before treatment can be an independent biomarker of the prognosis of patients with upper tract urothelial carcinoma (UTUC).

Materials and methods

We systematically search PubMed, Embase, Scopus database, and Cochrane Library, and the search time is up to April 2021. Use STATA 16.0 software for data processing and statistical analysis.

Results

Six studies, including seven cohorts, were eventually included in our meta-analysis. The meta-analysis results showed that low PNI scores are associated with worse OS (HR: 1.92; 95% CI 1.60 to 2.30; P &lt; 0.01), DFS/RFS/PFS (HR: 1.57; 95% CI 1.33 to 1.85; P &lt; 0.01), and CSS/DSS (HR: 1.79; 95% CI 1.49 to 2.16; P &lt; 0.01), which supported the PNI score as an independent prognostic biomarker for survival outcomes. The subgroup analysis and Begg’s test showed that the results were stable.

Conclusion

Based on current evidence, this meta-analysis proves that the PNI score of UTUC patients before treatment is an independent prognostic biomarker. It performs well on OS, DFS/RFS/PFS, and CSS/DSS. This conclusion needs to be verified by a prospective cohort study with larger sample size and a more rigorous design.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022338503], identifier [CRD42022338503].

Evaluation of the prognostic nutritional index for the prognosis of Chinese patients with high/extremely high-risk prostate cancer after radical prostatectomy

BACKGROUND

The incidence of prostate cancer (PCa) is on the rise in China. The risk level of patients with PCa is associated with disease-free survival rate at 10 years after radical prostatectomy. Predicting prognosis in advance according to the degree of risk can provide a reference for patients, especially treatment options and postoperative adjuvant treatment measures for high-risk/extremely high-risk patients.

AIM

To explore the predictive value of the prognostic nutritional index (PNI) for biological recurrence in Chinese patients with high/extremely high-risk PCa after radical prostatectomy.

METHODS

The biochemical test results and clinical data of 193 patients who underwent radical prostatectomy for the first time from January 2015 to December 2020 were retrospectively collected. The PNI value of peripheral blood within 1 wk before surgery was calculated, and during the follow-up period, prostate-specific antigen ≥ 0.2 ng/mL was considered to have biological recurrence. The receiver operating characteristic (ROC) curve was used to calculate the optimal critical value and area under the curve (AUC) of the patients. According to the critical value, the progression-free survival of the high PNI group and low PNI group was compared. The independent influencing factors of the patients' prognosis were obtained by the Cox proportional hazards regression model.

RESULTS

The non-biological recurrence rates at 1, 3, and 5 years were 92.02%, 84.05%, and 74.85%, respectively. The optimal critical value for PNI to predict biological recurrence was 46.23, and the AUC was 0.789 (95% confidence interval: 0.651-0.860; P < 0.001). The sensitivity and specificity were 82.93% and 62.30%, respectively. In accordance with the optimal critical value of the ROC curve (46.23), 193 patients were further divided into a high PNI group (PNI ≤ 46.23, n = 108) and low PNI group (PNI > 46.23, n = 85). The incidence of postoperative complications in the high PNI group was lower than that in the low PNI group (21.18% vs 38.96%). Kaplan-Meier survival analysis showed that the overall survival rate at 5 years in the low PNI group was 87.96% (13/108), which was lower than that in the high PNI group (61.18%, 33/85; P < 0.05). Low PNI [hazard ratio (HR) = 1.74; P = 0.003] and positive incisal margin status (HR = 2.14; P = 0.001) were independent predictors of biological recurrence in patients with high/extremely high-risk PCa.

CONCLUSION

The PNI has predictive value for the prognosis of patients with high/extremely high-risk PCa, and is an independent prognostic factor. Patients with low PNI value have a shorter time of non-biological recurrence after prostatectomy. It is expected that the combined prediction of other clinicopathological data will further improve the accuracy and guide postoperative adjuvant therapy to improve the quality of prognosis.

Prognostic predictors of non-small cell lung cancer treated with curative resection: the role of preoperative CT texture features, clinical features, and laboratory parameters

AIM

To explore the value of preoperative contrast-enhanced computed tomography (CT) tumour texture characteristics, and clinical and laboratory parameters on the prognosis of curative resection for non-small-cell lung cancer (NSCLC).

MATERIALS AND METHODS

This retrospective study included 64 patients (34 men and 30 women) with NSCLC who underwent curative resection and were then followed up for 5 years or until death. Preoperative contrast-enhanced CT images, clinical features, and laboratory parameters were collected for these patients. CT texture features of the primary tumour before surgery were extracted from the contrast-enhanced CT images using ImageJ software. Based on the cut-off values determined by X-tile software, the preoperative CT texture features, clinical features, and laboratory parameters were divided into two groups. Kaplan-Meier survival curves and log-rank tests were used to compare the 5-year overall survival (OS) of patients. Multivariate Cox regression analysis was used to determine the independent factors influencing the prognosis.

RESULTS

The mean survival was 51.5 months. Tumour volume, entropy, platelet-to-lymphocyte ratio (PLR), prognostic nutritional index (PNI), and albumin-to-globulin ratio (AGR) were shown to be significantly associated with 5-year OS (p<0.05). Multivariate Cox regression analysis revealed that entropy was the independent factor of prognosis (hazard ratio 4.375, 95% confidence interval [CI]: 1.646-11.620, p=0.003).

CONCLUSION

Entropy is an important and potentially non-invasive imaging biomarker for predicting the prognosis of NSCLC undergoing curative resection.

Perioperative Inflammatory Response and Cancer Recurrence in Lung Cancer Surgery: A Narrative Review

While surgical resection is the gold standard treatment for solid tumors, cancer recurrence after surgery is common. Immunosurveillance of remnant tumor cells is an important protective mechanism. Therefore, maintenance of anti-tumor cell activity and proper levels of inflammatory mediators is crucial. An increasing body of evidence suggests that surgery itself and perioperative interventions could affect these pathophysiological responses. Various factors, such as the extent of tissue injury, perioperative medications such as anesthetics and analgesics, and perioperative management including transfusions and methods of mechanical ventilation, modulate the inflammatory response in lung cancer surgery. This narrative review summarizes the pathophysiological mechanisms involved in cancer recurrence after surgery and perioperative management related to cancer recurrence after lung cancer surgery.

Prognostic significance of the postoperative prognostic nutritional index in patients with glioblastoma: a retrospective study

BACKGROUND

The prognostic nutritional index (PNI) reflects immunonutritional status. We evaluated the effects of postoperative PNI and perioperative changes in the PNI on overall survival (OS) in glioblastoma (GBM) patients.

METHODS

Demographic, laboratory, and clinical data were retrospectively collected from 335 GBM patients. Preoperative and postoperative PNIs were calculated from serum albumin concentration and lymphocyte count, which were measured within 3 weeks before surgery and 1 month after surgery. Patients were classified into high (n = 206) or low (n = 129) postoperative PNI groups according to the postoperative PNI cutoff value and further classified into four groups according to the cutoff values of the preoperative and postoperative PNIs, as follows: Group HH (both high PNIs, n = 92), Group HL (high preoperative and low postoperative PNI, n = 70), Group LH (low preoperative and high postoperative PNI, n = 37), and Group LL (both low PNIs, n = 136).

RESULTS

The median OS was significantly longer in the high postoperative PNI (PNI ≥ 50.2) group than the low postoperative PNI (PNI < 50.2) group (24.0 vs. 15.0 months, p <  0.001). In multivariate analysis, high postoperative PNI was a significant predictor of OS. OS was significantly longer in Group HH than in Group LL and seemed longer in Group HH than in Group HL and in Group LH than in Group LL. OS was not different between Groups HH and LH or between Groups HL and LL.

CONCLUSIONS

High postoperative PNI was associated with improved OS and perioperative changes in PNI may provide additional important information for prognostic prediction in GBM patients.

Nutritional Support in Lung Cancer Patients: The State of the Art

Lung cancer (LC) represents the most commonly diagnosed neoplasm worldwide for both sexes and is the leading cause of cancer mortality. Malnutrition is a comorbidity frequently found in neoplastic patients, but it remains often underestimated and thus undertreated. In this review, we aimed to investigate the incidence of malnutrition among LC patients according to different screening and assessment tools, to evaluate the impact of weight loss and body composition on survival, and to analyze the efficacy of different nutritional interventions in this setting. Although malnutrition, weight loss, and body composition changes can affect survival and other clinical outcomes in LC patients, the role of nutritional interventions is not yet strongly proven, and further studies are recommended. Nevertheless, screening, assessing, and eventually treating malnutrition in LC patients are strongly recommended, according to the most recent nutritional intervention guidelines for oncology patients.