Serum C-reactive protein concentration and the prognosis of ductal adenocarcinoma of the head of pancreas

C-Reactive Protein: Pathophysiology, Diagnosis, False Test Results and a Novel Diagnostic Algorithm for Clinicians

The current literature provides a body of evidence on C-Reactive Protein (CRP) and its potential role in inflammation. However, most pieces of evidence are sparse and controversial. This critical state-of-the-art monography provides all the crucial data on the potential biochemical properties of the protein, along with further evidence on its potential pathobiology, both for its pentameric and monomeric forms, including information for its ligands as well as the possible function of autoantibodies against the protein. Furthermore, the current evidence on its potential utility as a biomarker of various diseases is presented, of all cardiovascular, respiratory, hepatobiliary, gastrointestinal, pancreatic, renal, gynecological, andrological, dental, oral, otorhinolaryngological, ophthalmological, dermatological, musculoskeletal, neurological, mental, splenic, thyroid conditions, as well as infections, autoimmune-supposed conditions and neoplasms, including other possible factors that have been linked with elevated concentrations of that protein. Moreover, data on molecular diagnostics on CRP are discussed, and possible etiologies of false test results are highlighted. Additionally, this review evaluates all current pieces of evidence on CRP and systemic inflammation, and highlights future goals. Finally, a novel diagnostic algorithm to carefully assess the CRP level for a precise diagnosis of a medical condition is illustrated.

C-Reactive Protein Signaling Pathways in Tumor Progression

Many cancers arise from sites of chronic inflammation, which creates an inflammatory microenvironment surrounding the tumor. Inflammatory substances secreted by cells in the inflammatory environment can induce the proliferation and survival of cancer cells, thereby promoting cancer metastasis and angiogenesis. Therefore, it is important to identify the role of inflammatory factors in cancer progression. This review summarizes the signaling pathways and roles of C-reactive protein (CRP) in various cancer types, including breast, liver, renal, and pancreatic cancer, and the tumor microenvironment. Mounting evidence suggests the role of CRP in breast cancer, particularly in triple-negative breast cancer (TNBC), which is typically associated with a worse prognosis. Increased CRP in the inflammatory environment contributes to enhanced invasiveness and tumor formation in TNBC cells. CRP promotes endothelial cell formation and angiogenesis and contributes to the initiation and progression of atherosclerosis. In pancreatic and kidney cancers, CRP contributes to tumor progression. In liver cancer, CRP regulates inflammatory responses and lipid metabolism. CRP modulates the activity of various signaling molecules in macrophages and monocytes present in the tumor microenvironment, contributing to tumor development, the immune response, and inflammation. In the present review, we overviewed the role of CRP signaling pathways and the association between inflammation and cancer in various types of cancer. Identifying the interactions between CRP signaling pathways and other inflammatory mediators in cancer progression is crucial for understanding the complex relationship between inflammation and cancer.

Is the serum level of survivin, an antiapoptotic protein, a potential predictive and prognostic biomarker in metastatic pancreatic cancer?

In the present study, we aimed to assess the association between the serum survivin level and overall survival and treatment response rates in metastatic pancreatic cancer (MPC). Serum samples were prospectively collected from 41 patients with newly diagnosed MPC patients and 41 healthy individuals (control group) to assess the survivin levels. The median survivin level was 136.2 ng/mL in patients with MPC and 52 ng/mL in healthy individuals (P = .028). Patients were divided into low- and high-survivin groups according to the baseline median survivin level. Patients with a high serum survivin level compared with a low serum survivin level had shorter median progression-free survival (2.39 vs 7.06 months; P = .008, respectively) and overall survival (3.74 vs 9.52 months; P = .026, respectively). Patients with higher serum survivin levels had significantly worse response rates (P = .007). The baseline high level of serum survivin in patients with MPC may be associated with treatment resistance and poor prognosis. A confirmation will be needed for these results in future large multicenter prospective studies.

C-reactive protein/albumin ratio is the most significant inflammatory marker in unresectable pancreatic cancer treated with FOLFIRINOX or gemcitabine plus nab-paclitaxel

There are limited absolute biomarkers for determining the prognosis before first- and second-line palliative chemotherapy in unresectable pancreatic cancer (urPC) patients. To find the best prognostic inflammatory marker, we investigated relationships between overall survival (OS) and six inflammatory markers; C-reactive protein/albumin ratio (CAR), neutrophil-lymphocyte ratio (NLR), prognostic nutrition index (PNI), platelet-lymphocyte ratio (PLR), Glasgow prognostic score (GPS), and prognostic index (PI). We examined 255 patients who received gemcitabine + nab-paclitaxel or FOLFIRINOX as first-line chemotherapy and 159 patients who subsequently underwent second-line chemotherapy. First-line patients with lower CAR had better OS compared to those with a higher CAR (hazard ratio 0.57; 95% confidential index 0.42-77; P < 0.01). Similarly, lower NLR (P = 0.01), higher PNI (P = 0.04), lower PLR (P = 0.03), GPS score of 0 (P < 0.01) and PI score of 0 (P < 0.01) were all associated with better OS. CAR demonstrated the best superiority for determining survival prognosis through the use of area under the curve of time-dependent receiver-operating characteristic curves. Furthermore, a lower CAR before second-line therapy exhibited better OS versus higher CAR (P < 0.01). Therefore, CAR might be a useful biomarker for predicting urPC patient prognosis in both first- and second-line chemotherapy.

Effect of Preoperative Biliary Stenting on Outcomes of Pancreaticoduodenectomy

Biliary drainage before pancreaticoduodenectomy was introduced to decrease morbidity from obstructive jaundice. Recent retrospective and randomised data show that preoperative biliary drainage (PBD) increases perioperative infectious complications. Most patients presenting to our tertiary care centre have undergone drainage procedures prior to surgical consultation. We analysed the impact of PBD, specifically endoscopic stent placement, on the postoperative outcome of pancreaticoduodenectomy at our centre. A cohort of 87 patients undergoing pancreaticoduodenectomy from 2012 to 2016 was identified. Data was collected retrospectively and a comparative analysis of stented and nonstented patients was done. Comparison of the 23 stented patients was done with 23 nonstented patients after matching them for age, sex and bilirubin levels. Median total bilirubin level in stented patients was 10.2 mg/dl versus 7.7 mg/dl in nonstented patients. The infectious complication rate in the stented group was 39.1% versus 12.7% in the nonstented group (P value < 0.05). There was no difference in the anastomotic leak rate between the two groups. Time to curative surgery in the stented group was significantly more than in the nonstented group. Stented patients are at a higher risk for postoperative infectious complications. Patients with obstructive jaundice awaiting surgery should undergo selective biliary drainage after careful planning and discussion between the operating surgeon and the endoscopist.

Prediagnostic Inflammation and Pancreatic Cancer Survival

BACKGROUND

Chronic inflammation may promote initiation and progression of pancreatic cancer, but no studies have examined the association between inflammation in the period before diagnosis and pancreatic cancer survival.

METHODS

We prospectively examined the association of prediagnostic plasma levels of C-reactive protein, interleukin-6, and tumor necrosis factor-α receptor 2 with survival among 492 participants from 5 large US prospective cohort studies who developed pancreatic cancer. Using an empirical dietary inflammatory pattern (EDIP) score, we evaluated whether long-term proinflammatory diets were associated with survival among 1153 patients from 2 of the 5 cohorts. Cox proportional hazards regression was used to estimate hazard ratios for death with adjustment for potential confounders. All statistical tests were 2-sided.

RESULTS

Higher prediagnostic levels of C-reactive protein, interleukin-6, and tumor necrosis factor-α receptor 2 were individually associated with reduced survival (Ptrend = .03, .01, and .04, respectively). Compared with patients with a combined inflammatory biomarker score of 0 (all 3 marker levels below medians), those with a score of 3 (all 3 marker levels above medians) had a hazard ratio for death of 1.57 (95% confidence interval = 1.16 to 2.12; Ptrend = .003), corresponding to median overall survival times of 8 vs 5 months. Patients consuming the most proinflammatory diets (EDIP quartile 4) in the prediagnostic period had a hazard ratio for death of 1.34 (95% confidence interval = 1.13 to 1.59; Ptrend = .01), compared with those consuming the least proinflammatory diets (EDIP quartile 1).

CONCLUSION

Prediagnostic levels of inflammatory biomarkers and long-term proinflammatory diets were inversely associated with pancreatic cancer survival.

Combining CRP and CA19-9 in a novel prognostic score in pancreatic ductal adenocarcinoma

Inflammation promotes tumor progression, induces invasion and metastatic spread. This retrospective study explored CRP, CA19-9, and routine laboratory values as preoperative prognostic factors in pancreatic cancer patients. Between 2000 and 2016, there were 212 surgically treated pancreatic cancer patients at Helsinki University Hospital, Finland. Out of these, 76 borderline resectable patients were treated with neoadjuvant therapy (NAT); 136 upfront resected patients were matched for age and sex at a 1:2 ratio. We analyzed preoperative CRP, CA19-9, CEA, leukocytes, albumin, bilirubin and platelets. CRP and CA19-9 were combined into a prognostic score: both CRP and CA19-9 below the cut-off values (3 mg/l and 37 kU/l, respectively), either CRP or CA19-9 above the cut-off value, and finally, both CRP and CA19-9 above the cut-off values. Among all patients, median disease-specific survival times were 54, 27 and 16 months, respectively (p < 0.001). At 5 years, among patients with CRP and CA19-9 levels below the cut-off values, 49% were alive and 45% were disease-free. Among NAT patients the corresponding survival rates were 52% and 45% and among those undergoing upfront surgery 45% and 40%, respectively. This novel prognostic score combining CRP and CA19-9 serves as a useful preoperative tool estimating survival.

The ultimate preoperative C-reactive protein-to-albumin ratio is a prognostic factor for survival after pancreatic cancer resection

Background

Emerging evidence indicates that an elevated C-reactive protein-to-albumin ratio (CAR) may be associated with a poor prognosis in pancreatic ductal adenocarcinoma (PDAC). Further evidence showing that this ratio has significant prognostic value could contribute to current prediction models and clinical decision-making.

Methods

Data were analysed of consecutive patients who underwent curative pancreatic resection between 2013 and 2018 and were histologically diagnosed with PDAC. We investigated the relation between the ultimate preoperative CAR and overall survival.

Results

A total of 163 patients were analysed. Median overall survival was 18 months (IQR 9–36). Multivariate analysis demonstrated that a higher CAR (HR 1.745, P = 0.004), a higher age (HR 1.062, P < 0.001), male sex (HR 1.977, P = 0.001), poor differentiation grade (HR 2.812, P < 0.001), and positive para-aortic lymph node(s) (HR 4.489, P < 0.001) were associated with a lower overall survival. Furthermore, a CAR ≥ 0.2 was associated with decreased overall survival (16 vs. 26 months, P = 0.003).

Conclusion

We demonstrated that an ultimate preoperative elevated CAR is an independent indicator of decreased overall survival after resection for PDAC. The preoperative CAR may be of additional value to the current prediction models.

The effects of systemic inflammatory response on prognosis of pancreatic ductal adenocarcinoma

Backgrounds/Aims

The aim of this study was to investigate the prognostic significance of neutrophyil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), CRP and CA19-9 in patients were diagnosed with pancreatic ductal adenocarcinoma (PDAC) to better verify pre-operative risk stratification and management.

Methods

This retrospective study included data from 133 consecutive patients with PDAC, who were treated between 2013 and 2015. PDAC diagnosis was made by cytology or assumed by radiological assessment or surgical resection samples. All clinico-pathological data were retrieved from medical records at our institution. The laboratory data were obtained before any treatment modality. Dates of death were obtained from the central registry.

Results

There was a statistically significant relation between radiological staging and CA19-9 and survival (p=0.001, p=0.005) and there are significant differences in CA19-9 level between stage I and III, I and IV, II and III, and II and IV. Both CRP and CA19-9 levels were statistically significantly higher in patients with radiological lymph node metastasis than patients with N0 disease (p=0.037, p=0.026). NLR and CA19-9 levels were also higher in metastatic disease (p=0.032, p=0.007). According to Spearman's correlation analysis, we found in all patients that there was a negative correlation between the survival time and CRP and neutrophil count (p=0.019, p=0.011).

Conclusions

Preoperative CRP, CA19-9 and NLR are simple, repeatable, inexpensive and well available marker, can give information on lymph node and solid organ metastasis and survival, give clues to prognosis and be useful in clinical staging of patients with PDAC.

Prognostic Values of Systemic Inflammation Response (SIR) Parameters in Resectable Cervical Cancer

Background:

Cervical carcinoma is the leading cause of cancer mortality in women. C-reactive protein (CRP), albumin (ALB), globulin (GLB), lactate dehydrogenase (LDH), and albumin-to-globulin ratio (AGR) are indicators of systemic inflammation response correlated with tumor outcomes.

Methods:

This study recruited 110 patients with cervical cancer. The patients were divided into 2 groups according to pretreatment median values of CRP, ALB, GLB, LDH, and AGR. The post/preradiotherapy or post/pretreatment ratios were defined as rates of pretreatment CRP, ALB, GLB, LDH, and AGR values and the corresponding ones obtained after radiotherapy or whole treatment.

Results:

Higher pretreatment CRP or LDH levels were correlated with worse progression-free survival (PFS) and overall survival (OS). Increased post/preradiotherapy CRP ratio was correlated with worse PFS and OS, increased post/preradiotherapy LDH ratio was correlated with worse PFS. Increased post/pretreatment CRP ratio was correlated with worse PFS and OS, not-increased post/pretreatment AGR ratio was correlated with worse OS. Cox regression analysis model indicated that, moderately or poorly of differentiation, higher pretreatment CRP or LDH levels were independently associated with worse PFS, higher pretreatment CRP or LDH levels and increased post/pretreatment CRP ratio were independently associated with worse OS.

Conclusion:

CRP, LDH, or AGR are correlated with outcomes of resectable cervical cancer.

The Predictive Value of Inflammation-Related Peripheral Blood Measurements in Cancer Staging and Prognosis

In this review, we discuss the interaction between cancer and markers of inflammation (such as levels of inflammatory cells and proteins) in the circulation, and the potential benefits of routinely monitoring these markers in peripheral blood measurement assays. Next, we discuss the prognostic value and limitations of using inflammatory markers such as neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios and C-reactive protein measurements. Furthermore, the review discusses the benefits of combining multiple types of measurements and longitudinal tracking to improve staging and prognosis prediction of patients with cancer, and the ability of novel in silico frameworks to leverage this high-dimensional data.

Red blood cell distribution width as a predictor of survival in nasal-type, extranodal natural killer/T-cell lymphoma

We retrospectively enrolled 191 nasal-type, extranodal natural killer/T-cell lymphoma (ENKTL) patients newly diagnosed from 2008 to 2016 at the Sichuan Cancer Hospital, in order to evaluate the relationship between disease outcomes, demographic and clinical factors, and red blood cell distribution width (RDW). C-index, fisher's exact test, univariate analysis, and cox regression analysis were applied. The median age of patients was 44 years and 134 (70%) were men. The cutoff of RDW was 46.2 fL determined by Cutoff Finder. Patients with RDW≤46.2 fL had significantly better progression-free survival (PFS) (3-year PFS, 80.4% vs. 63.1%; P=0.01) and overall survival (OS) (3-year OS, 83.2% vs. 65.5%; P=0.004) than those with RDW>46.2 fL. Multivariate analysis demonstrated that elevated RDW is an independent adverse predictor of OS (P=0.021, HR=2.04). RDW is an independent predictor of survival outcomes in ENKTL, which we found to be superior to both the prognostic index of natural killer lymphoma (PINK) and the Korean Prognostic Index (KPI) in discriminating patients with different outcomes in low-risk and high-risk groups (all P < 0.05). The new models combining RDW with the International Prognostic Index (IPI), KPI, and PINK showed more powerful prognostic value than corresponding original models. RDW represents an easily available and inexpensive marker for risk stratification in patients with ENKTL treated with radiotherapy-based treatment. Further prospective studies are warranted to confirm the prognostic value of RDW in ENKTL.

Validation of Lymphocyte-to-Monocyte Ratio as a Prognostic Factor in Advanced Pancreatic Cancer: An East Asian Cohort Study of 2 Countries

OBJECTIVES

Although the prognostic value of lymphocyte-to-monocyte ratio (LMR) has been recently demonstrated in solid tumors, little is known of its impact on advanced pancreatic cancer (APC). This study evaluates and validates the cutoff value of LMR for predicting palliative chemotherapy outcome using a transnational cohort of APC patients.

METHODS

A total of 405 APC patients receiving first-line palliative chemotherapy were retrospectively reviewed. Of these, 153 patients were from Shanghai General Hospital (training set) and 252 patients were from Kyoto University Hospital (validation set). The optimal cutoff value of LMR was determined by a generating receiver operating characteristic curve for the training set. The association between LMR and survival was evaluated using log-rank tests, and a Cox regression model was used to validate the independent prognostic significance of LMR in APC patients.

RESULTS

The optimal cutoff value of LMR was 2.8. Overall survival was significantly longer in patients with LMR of 2.8 or greater than those with LMR of less than 2.8 (P < 0.001). Cox regression analysis showed that LMR was an independent prognostic factor. The impact of LMR was widely observed in all subgroups except the performance status 2 subgroup.

CONCLUSIONS

Lymphocyte-to-monocyte ratio may be considered as a promising prognostic marker for APC patients receiving palliative chemotherapy.

ERAS: Improving outcome in the cachectic HPB patient

The enhanced recovery after surgery (ERAS) program has reduced postoperative morbidity and duration of hospital stay but not mortality in patients undergoing hepatopancreatobiliary (HPB) surgery. Many HPB patients suffer from cancer cachexia, a syndrome of severe weight and muscle loss. This may affect outcomes of HPB surgery even within an ERAS program. A tailored ERAS approach may be essential in further improving outcome in this vulnerable patient category.

Pretreatment C-reactive protein to albumin ratio for predicting overall survival in advanced pancreatic cancer patients

Although previous studies demonstrated that elevated C-reactive protein to albumin ratio (CAR) predicted poor prognosis in various solid tumors, little was known about the prognostic value of CAR in patients with advanced pancreatic cancer (APC). The aim of the present study was to assess CAR as one independent prognostic factor in predicting overall survival (OS) in APC patients who had received palliative chemotherapy. Data of 142 APC patients who received palliative chemotherapy between 2009 and 2014 were retrospectively documented. We classified the patients into two groups based on the optimal cutoff value of CAR identified by generating receiver operating characteristics (ROC) curve. The clinicopathological parameters were compared between two CAR groups. Pearson correlation test showed that the level of C-reactive protein (CRP) was inversely correlated with albumin (r = −0.387; P < 0.001). Kaplan-Meier analysis demonstrated overall survival (OS) was significantly longer in CAR < 0.156 group than CAR ≥ 0.156 group (11.2 vs 5.9 months, P < 0.001). CAR was an independent prognostic factor for OS in the Cox regression model (HR, 1.623; 95% CI, 1.093–2.410; P = 0.016). Furthermore, the discrimination ability of CAR (AUC = 0.648, P = 0.025) was slightly higher than that of other inflammation-based factors. Therefore, pretreatment CAR could be an independent prognostic biomarker for APC patients.

Is plasma caveolin-1 level a prognostic biomarker in metastatic pancreatic cancer?

BACKGROUND/AIMS

To evaluate the prognostic significance of plasma caveolin (CAV)-1 and its association with survival and treatment response rates in metastatic pancreatic cancer (MPC).

PATIENTS AND METHODS

Plasma samples were prospectively collected from 41 patients with newly diagnosed MPC. Moreover, plasma samples were collected from 48 patients with chronic pancreatitis and 41 healthy individuals (control groups) for assessing Cav-1 levels. Plasma Cav-1 levels were evaluated at baseline and after three cycles of chemotherapy in the patients with MPC.

RESULTS

The median Cav-1 level was 13.8 ng/mL for the patients with MPC and 12.2 ng/mL for healthy individuals (P = 0.009). The Cav-1 cut-off level was calculated as 11.6 ng/mL by using the receiver operating characteristic curve. The median overall survival and progression-free survival rates were 5 and 2.4 months, respectively, for participants with a high basal plasma Cav-1 level; the corresponding values were 10.5 and 9.4 months for participants with a low plasma Cav-1 level (P = 0.011 and P= 0.003, respectively). Of the 41 patients with MPC, 23 completed at least three cycles of chemotherapy. The median Cav-1 level was 13 ng/mL for post-treatment MPC (r2: 0.917; P= 0.001). High basal plasma caveolin-1 level have continued to remain at high levels even after chemotherapy, showing a trend toward worse response rates (P = 0.086).

CONCLUSION

High basal plasma Cav-1 levels seem to be associated with poor survival and tend to yield worse therapeutic outcomes in patients with MPC. This study is the first to evaluate the prognostic significance of plasma Cav-1 levels as a prognostic factor in patients with MPC. However, larger prospective clinical trials are warranted.

Can Molecular Biomarkers Change the Paradigm of Pancreatic Cancer Prognosis?

Pancreatic ductal adenocarcinoma is one of the most lethal types of tumour, and its incidence is rising worldwide. Although survival can be improved when these tumours are detected at an early stage, this cancer is usually asymptomatic, and the disease only becomes apparent after metastasis. The only prognostic biomarker approved by the FDA to date is carbohydrate antigen 19-9 (CA19-9); however, the specificity of this biomarker has been called into question, and diagnosis is usually based on clinical parameters. Tumour size, degree of differentiation, lymph node status, presence of distant metastasis at diagnosis, protein levels of KI-67 or C-reactive protein, and mutational status of P53, KRAS, or BRCA2 are the most useful biomarkers in clinical practice. In addition to these, recent translational research has provided evidence of new biomarkers based on different molecules involved in endoplasmic reticulum stress, epithelial-to-mesenchymal transition, and noncoding RNA panels, especially microRNAs and long noncoding RNAs. These new prospects open new paths to tumour detection using minimally or noninvasive techniques such as liquid biopsies. To find sensitive and specific biomarkers to manage these patients constitutes a challenge for the research community and for public health policies.

Systematic review of peri-operative prognostic biomarkers in pancreatic ductal adenocarcinoma

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) continues to be associated with a poor prognosis. This systematic review aimed to summarize the literature regarding potential prognostic biomarkers to facilitate validation studies and clinical application.

METHODS

A systematic review was performed (2004-2014) according to PRISMA guidelines. Studies were ranked using REMARK criteria and the following outcomes were examined: overall/disease free survival, nodal involvement, tumour characteristics, metastasis, recurrence and resectability.

RESULTS

256 biomarkers were identified in 158 studies. 171 biomarkers were assessed with respect to overall survival: urokinase-type plasminogen activator receptor, atypical protein kinase C and HSP27 ranked the highest. 33 biomarkers were assessed for disease free survival: CD24 and S100A4 were the highest ranking. 17 biomarkers were identified for lymph node involvement: Smad4/Dpc4 and FOXC1 ranked highest. 13 biomarkers were examined for tumour grade: mesothelin and EGFR were the highest ranking biomarkers. 10 biomarkers were identified for metastasis: p16 and sCD40L were the highest ranking. 4 biomarkers were assessed resectability: sCD40L, s100a2, Ca 19-9, CEA.

CONCLUSION

This review has identified and ranked specific biomarkers that should be a primary focus of ongoing validation and clinical translational work in PDAC.

The C-reactive protein/albumin ratio predicts overall survival of patients with advanced pancreatic cancer

Recent studies have demonstrated the prognostic value of the C-reactive protein/albumin (CRP/Alb) ratio in cancer. However, the role of the CRP/Alb ratio in advanced pancreatic cancer (PC) has not been examined. A retrospective study of 233 patients with advanced PC was conducted. We investigated the relationship between the CRP/Alb ratio, clinicopathological variables, and overall survival (OS). The optimal cutoff point of the CRP/Alb ratio was 0.54. A higher CRP/Alb ratio was significantly associated with an elevated neutrophil-lymphocyte ratio (NLR) (P < 0.001) and higher modified Glasgow prognostic score (mGPS) (P < 0.001). Using univariate analyses, we found that the age (P = 0.009), disease stage (P < 0.001), NLR (P < 0.001), mGPS (P < 0.001), and CRP/Alb ratio (P < 0.001) were significant predictors of OS. Patients with a higher CRP/Alb ratio had a worse OS than patients with a lower CRP/Alb ratio (hazard ratio (HR) 3.619; 95 % CI 2.681-4.886; P < 0.001). However, the CRP/Alb ratio was identified as the only inflammation-based parameter with an independent prognostic ability in the multivariate analyses (P < 0.001). The pretreatment CRP/Alb ratio is a superior prognostic and therapeutic predictor of OS in advanced PC.

C-Reactive Protein Level Is an Indicator of the Aggressiveness of Advanced Pancreatic Cancer

OBJECTIVES

This study investigated the ability of serum levels of C-reactive protein (CRP) to stratify the aggressiveness of advanced pancreatic cancer (PCa), including poor outcomes, systemic weakness, and extent of the disease in patients receiving first-line chemotherapy.

METHODS

The prognostic CRP classification was constructed in the retrospective cohort, consisting of advanced PCa patients with first-line gemcitabine monotherapy (GEM). Stratification using the prognostic CRP classification was validated for relationships with the aggressiveness of advanced PCa in the prospective cohort, consisting of treatment-naive patients without obvious infections who received first-line GEM or GEM-based regimens.

RESULTS

C-reactive protein low (<0.5 mg/dL), intermediate (≥ 0.5 and <2.0 mg/dL), and high (≥ 2.0 mg/dL) related good, moderate, and poor survival, respectively, and were independent predictors of survival in multivariate analyses among the 280 patients in the retrospective cohort and the 141 patients in the prospective cohort. Low Karnofsky Performance Status, hypoalbuminemia, anemia, and large tumor burden were more common in the high CRP group than in the low CRP group. The intermediate CRP group showed a larger burden of tumor than the low CRP group.

CONCLUSIONS

C-reactive protein stratified the outcomes, systemic weakness, and tumor burden. C-reactive protein is an indicator of the aggressiveness of advanced PCa.

Pretreatment C-reactive protein level predicts outcome and patterns of failure after chemoradiotherapy for locally advanced pancreatic cancer

OBJECTIVES

In this study we evaluated the predictive value of pretreatment C-reactive protein (CRP) levels on patterns of failure and survival outcomes in patients with locally advanced pancreatic cancer (LAPC) who received chemoradiotherapy (CRT).

METHODS

Data from 65 patients who underwent CRT for LAPC from July 2001 to May 2013 were retrospectively collected. Factors, including age, gender, Eastern Cooperative Oncology Group performance status (PS), histological confirmation, tumor size, tumor location, biliary drainage, stage, induction chemotherapy, CRP levels, neutrophil-to-lymphocyte ratio, platelet-lymphocyte ratio, albumin and carbohydrate antigen 19-9, were evaluated with regard to overall survival (OS) and patterns of failure using a Cox proportional hazards model.

RESULTS

The 1-year OS and median follow-up for all of the patients were 63.9% and 15.2 months, respectively. The median survival time and 1-year OS were 18.0 months and 72.5%, respectively, in the patients with lower CRP levels (≤3.0 mg/L), whereas 11.0 months and 30.8%, respectively, in the patients with higher CRP levels (>3.0 mg/L). Thirty-seven patients had tumor recurrence after CRT. All of the patients with higher CRP levels developed distant metastases as a primary sign of treatment failure. In a multivariate analysis, higher CRP levels were significantly correlated with distant disease-free survival (p = 0.004, HR = 4.50) and OS (p = 0.004, HR = 3.001). By contrast, local progression-free survival was not significantly different between the CRP subgroups.

CONCLUSION

The CRP levels were a significant predictor of survival and distant disease control for the LAPC patients who received CRT.

High serum level of C-reactive protein is associated with worse outcome of patients with advanced-stage NSCLC treated with erlotinib

Erlotinib is a low molecular weight tyrosine kinase inhibitor (TKI) directed at epidermal growth factor receptor (EGFR), widely used in the treatment of locally advanced or metastatic-stage non-small cell lung cancer (NSCLC). Although introduction of EGFR-TKIs have significantly extended survival of advanced-stage NSCLC patients, their efficacy in the entire patient population is relatively low. Aside from activating EGFR mutations, no reliable biochemical or molecular predictors of response to erlotinib have been established. The aim of our retrospective study was to evaluate the association of baseline serum levels of C-reactive protein (CRP) with outcomes in patients with advanced-stage NSCLC treated with erlotinib. We retrospectively analyzed clinical data of 595 patients with advanced-stage NSCLC (IIIB or IV) treated with erlotinib. Serum CRP was measured using an immunoturbidimetric method. High baseline levels of CRP (≥10 mg/l) were measured in 387 (65 %) patients, and normal levels (<10 mg/l) were measured in 208 (35 %) patients. The median progression-free survival (PFS) and overall survival (OS) for patients with high CRP was 1.8 and 7.7 compared to 2.8 and 14.4 months for patients with low CRP (p < 0.001 and p < 0.001). The multivariable Cox proportional hazards model revealed that CRP was significantly associated with PFS and also with OS (hazard ratio (HR) = 1.57, p < 0.001, and HR = 1.63, p < 0.001, respectively). In conclusion, the results of the conducted retrospective study suggest that high baseline level of CRP was independently associated with worse outcome of patients with advanced-stage NSCLC treated with erlotinib. CRP is a commonly used biomarker which is simple and easy to detect, and thus, it is feasible for the use in the routine clinical practice.

Prognostic significance of pre-operative C-reactive protein and the neutrophil-lymphocyte ratio in resectable pancreatic cancer: a systematic review

BACKGROUND

Better pre-operative risk stratification may improve patient selection for pancreatic resection in pancreatic cancer. C-reactive protein (CRP) and the neutrophil-lymphocyte ratio (NLR) have demonstrated prognostic value in some cancers. The role of CRP and NLR in predicting outcome in pancreatic cancer after curative resection is not well established.

METHODS

An electronic search of MEDLINE, EMBASE and CINAHL was performed to identify studies assessing survival in patients after pancreatic cancer resection with high or low pre-operative CRP or NLR. Systematic review was undertaken using the PRISMA protocol.

RESULTS

In total, 327 studies were identified with 10 reporting on survival outcomes after a pancreatic resection in patients with high or low CRP, NLR or both. All but one paper showed a trend of lower inflammatory markers in patients with longer survival. Three studies from six showed low CRP to be independently associated with increased survival and two studies of eight showed the same for NLR. All studies were retrospective cohort studies of low to moderate quality.

DISCUSSION

Inflammatory markers might prove useful guides to the management of resectable pancreatic cancer but, given the poor quality of evidence, further longitudinal studies are required before incorporating pre-operative inflammatory markers into clinical decision making.

A prognostic index model to predict the clinical outcomes for advanced pancreatic cancer patients following palliative chemotherapy

Purpose

To establish a prognostic index model for advanced pancreatic cancer patients receiving palliative chemotherapy based on clinical variables.

Methods

The clinical data of 118 patients with advanced pancreatic cancer who received palliative chemotherapy between January 2006 and August 2013 in our center were retrospectively analyzed. Prognostic factors for overall survival were identified using Cox proportional hazards model. A prognostic index model was established by these pretreatment factors to predict prognosis. Kaplan–Meier estimation and log-rank test were performed to compare the overall survival difference between low-risk and high-risk group of patients.

Results

Median overall survival time for all patients was 8.8 months [95 % confidence interval (CI) 7.0–10.6 months]. Multivariate analysis identified ECOG score = 2 (hazard ratio 2.03; 95 % CI 1.07–3.85; P = 0.030), CA19-9 levels of ≥1000 U/mL (hazard ratio 2.07; 95 % CI 1.09–3.92; P = 0.026), and CRP levels of ≥5 mg/L (hazard ratio 2.05; 95 % CI 1.06–3.96; P = 0.033) as independent poor prognostic factors for overall survival. For the three factors, ECOG score = 2, CA19-9 levels of ≥1000 U/mL, and CRP levels of ≥5 mg/L were allocated 1 point each. There were 84 (71.2 %) patients allocated to low-risk group with total score 0–1 point, and 34 (28.8 %) patients were categorized as high-risk group with total scores 2–3 points. The median overall survival for low-risk group and high-risk group was 9.9 months (95 % CI 6.8–13.0) and 5.3 months (95 % CI 4.1–6.5), respectively (hazard ratio 0.27; 95 % CI 0.14–0.52; P < 0.001). The estimated 1-year survival rates for low-risk group and high-risk group were 40.5 and 5.9 %, respectively (P < 0.05).

Conclusions

A novel prognostic index model based on three clinical parameters was established to predict the prognosis of patients with advanced pancreatic cancer receiving palliative chemotherapy.

Phase I pilot study of Wilms tumor gene 1 peptide-pulsed dendritic cell vaccination combined with gemcitabine in pancreatic cancer

This study aimed to evaluate the feasibility of and immune response to Wilms tumor gene 1 (WT1) peptide-pulsed dendritic cell vaccination combined with gemcitabine (DCGEM) as a first-line therapy among patients with advanced pancreatic cancer. Ten HLA-A*2402 patients were treated with WT1 peptide-pulsed DC vaccination (1 × 10(7) cells) on days 8 and 22 and gemcitabine (1000 mg/m(2) ) on days 1, 8 and 15. Induction of a WT1-specific immune response was evaluated using the delayed-type hypersensitivity (DTH) skin test, interferon-γ enzyme-linked immunospot and HLA tetramer assays, along with assays for various immunological factors. DCGEM was well-tolerated, and the relative dose intensity of gemcitabine was 87%. Disease control associated with a low neutrophil/lymphocyte ratio was observed in all three patients with DTH positivity; it was also correlated with a low percentage of granulocytic myeloid derived suppressor cells in the pretreatment peripheral blood (P = 0.017). Patients with liver metastases and high levels of inflammatory markers such as C-reactive protein and interleukin-8 (IL-8) showed poor survival even though a WT1-specific immune response was induced in them. WT1 peptide-pulsed DCGEM is feasible and effective for inducing anti-tumor T-cell responses. Our results support future investigations for pancreatic cancer patients with non-liver metastases and favorable immunological conditions. This trial was registered with the University hospital Medical Information Network (UMIN) Clinical Trials Registry (http://www.umin.ac.jp/ctr/ number: UMIN-000004855).

Prognostic role of C-reactive protein in gastric cancer: a meta-analysis

BACKGROUND

A number of studies have investigated the association between increased pretreatment serum C-reactive protein (CRP) levels and the prognosis of gastric cancer. However, due to the inconsistent results, whether the serum CRP level can be a prognostic factor in primary gastric cancer remains controversial.

METHODS

We searched Medline, PubMed, Embase and the Cochrane Central Register of Controlled Trials for relevant high-quality reports. A meta-analysis was carried out using the included studies to assess the association between pretreatment serum CRP level and overall survival (OS) in patients with gastric cancer. Correlation analyses were conducted to evaluate the relationship between serum CRP and tumor characteristics such as tumor node metastasis (TNM) stage and recurrence.

RESULTS

Twelve reports involving 2,597 patients with gastric cancer were included. Primary meta-analysis indicated a significant association between elevated CRP level and poor OS (HR 1.77, 95% CI 1.56-2.00). Subgroup analyses showed no single factor could alter the primary results when we divided the included studies by "number of patients", "max follow-up period", "TNM stage", "treatment" and "cut-off value". Correlation analyses showed that serum CRP level was significantly related to TNM stage (OR 2.96, 95% CI 2.22-3.93) and tumor recurrence (OR 1.81, 95% CI 1.21-2.71).

CONCLUSIONS

We demonstrated that increased pretreatment serum CRP level (≥10mg/L) was significantly associated with poor prognosis in gastric cancer patients, either in early or advanced stages.

Prognostic role of serum C-reactive protein in esophageal cancer: a systematic review and meta-analysis

Background

Recent studies have shown that C-reactive protein (CRP) is a useful predictive factor in several cancers; however, its role in esophageal cancer (EC) is controversial.

Methods

A systematic literature search was performed using Medline, PubMed, and Web of Science to analyze the prognostic value of serum CRP in patients with EC. A meta-analysis was performed to assess the association between serum CRP and overall survival (OS) in patients with EC.

Results

A total of eight studies involving 1,471 patients were included in our study. Our pooled results demonstrated that a high level of serum CRP was associated with poor OS (hazard ratio [HR]: 1.40, 95% confidence interval [CI]: 1.25–1.57, I²=81.3%, P<0.0001). Subgroup analyses were performed in further investigations. When the patients were segregated according to treatment, pathological type, and cut-off level, high levels of serum CRP were found to be significantly correlated with OS.

Conclusion

Our meta-analysis revealed that high levels of serum CRP were significantly associated with poor OS in patients with EC.

Nomograms incorporating serum C-reactive protein effectively predict mortality before and after surgical treatment of renal cell carcinoma

OBJECTIVES

To incorporate C-reactive protein into nomograms estimating survival in patients with renal cell carcinoma.

METHODS

Patients undergoing surgery for renal cell carcinoma from 2005-2012 were studied retrospectively. Multivariable Cox proportional hazards regression and competing risks regression models including stage, grade, C-reactive protein levels and presence of metastatic disease were constructed. Outcomes analyzed include overall mortality overall mortality and renal cell carcinoma-specific mortality.

RESULTS

The cohort included 516 patients with a mean follow up of 1.7 years (SD 1.4 years). One- and 3-year renal cell carcinoma-specific mortality was 8.8% and 13.5%, respectively. Four nomograms were generated using overall mortality and renal cell carcinoma-specific mortality as end-points, two each for pre- and postoperative counseling. The factor with the largest effect on all nomograms was preoperative C-reactive protein. Based on the internal validation with bootstrapping, the concordance indices for renal cell carcinoma-specific mortality in the preoperative nomogram, postoperative nomogram, and the Mayo Clinic stage, size, grade and necrosis score were 0.889, 0.893, and 0.832, respectively (P = 0.005 and 0.002 comparing with stage, size, grade and necrosis scores for preoperative or postoperative nomograms). For overall mortality, the preoperative nomogram, postoperative nomogram, and stage, size, grade and necrosis score showed concordance indices of 0.866, 0.897, and 0.828, respectively (P = 0.123 and 0.008 compared with stage, size, grade and necrosis score for preoperative or postoperative nomograms).

CONCLUSIONS

We have generated nomograms incorporating serum C-reactive protein levels that effectively predict overall mortality and renal cell carcinoma specific mortality. Our findings warrant external validation.

C-reactive protein as a prognostic factor for human osteosarcoma: a meta-analysis and literature review

Background

Osteosarcoma is the most common primary bone cancer in growing adolescents and young adults. The prognostic role of C-reactive protein (CRP) in patients with osteosarcoma is not fully investigated. The purpose of this study is to perform a meta-analysis and literature review on the role of CRP in osteosarcoma and to assess the potential role of serum CRP as a prognostic factor for patients with osteosarcoma.

Methods

A detailed literature search was made in Medline for related research publications written in English. Methodological quality of the studies was also evaluated. The data were extracted and assessed by two reviewers independently. Analysis of pooled data were performed, risk ratio (RR) and corresponding confidence intervals (CIs) were calculated and summarized respectively.

Results

Final analysis of 397 patients from 2 eligible studies was performed. Combined RR of CRP expression suggested that the raised serum CRP level had an adverse prognostic effect on overall survival of patients with osteosarcoma (n = 397 in 2 studies; RR = 0.35; 95% CI: 0.18–0.68; p = 0.002). In the uni- and multivariate survival analysis, response rate and CRP levels were the only independent prognostic variables.

Conclusions

The results of this meta-analysis suggest that CRP expression confers a worse prognosis in patients with osteosarcoma. Large prospective studies are necessary to provide solid data to confirm the prognostic significance of CRP.

Prevalence of systemic inflammation and micronutrient imbalance in patients with complex abdominal hernias

OBJECTIVE

To determine the prevalence of low-grade inflammation, micronutrient imbalances and associated clinical profiles in patients being evaluated for complex abdominal hernia repair.

METHODS

Review of 127 consecutive adult patients for evaluation of complex ventral hernias from January 2012 to March 2013. Records were analyzed to determine the prevalence and correlations of clinical risk factors, attributes of hernias identified by computerized tomography, and laboratory indices of metabolism, inflammation and micronutrient imbalances.

RESULTS

Strong correlations (p < 0.001) were established for body mass index (BMI) with volume of hernia content and C-reactive protein (CRP) level. CRP levels correlated strongly with red cell distribution width and inversely with zinc (p < 0.01). Evidence of micronutrient imbalance (abnormal zinc or red cell distribution width [RDW]) was observed in 48%.

CONCLUSIONS

In this comorbidity-rich population with known variability in surgical outcomes, the prevalence of chronic inflammation and micronutrient deficiency are high enough to warrant systemic preoperative evaluation given their possible effect on wound healing and convalescence. Simple repletion is unlikely to improve outcomes without attention to the biological stresses that are associated with micronutrient imbalance.

Validation of C-reactive protein levels as a prognostic indicator for survival in a large cohort of pancreatic cancer patients

Background:

Recent evidence indicates that the host inflammatory response has an important role in the tumour progression. Elevated C-reactive protein (CRP) levels have been previously associated with poor prognosis in several cancer types including small-scale studies in pancreatic cancer (PC) patients. The purpose of the present study was to validate the prognostic impact of plasma CRP levels at date of diagnosis on cancer-specific survival (CSS) in a large cohort of PC patients.

Methods:

Data from 474 consecutive patients with adenocarcinoma of the pancreas, treated between 2004 and 2012 at a single centre, were evaluated retrospectively. CSS was analysed using the Kaplan–Meier method. To evaluate the prognostic significance of plasma CRP levels, univariate and multivariate Cox analyses were applied.

Results:

High plasma CRP levels at diagnosis were significantly associated with well-established prognostic factors, including high tumour stage and tumour grade and the administration of chemotherapy (P<0.05). In univariate analysis, we observed that a high plasma CRP level was a consistent factor for poor CSS in PC patients (hazard ratio (HR)=2.21; 95% confidence interval (CI)=1.68–2.92, P<0.001). In multivariate analysis, tumour stage, grade, administration of chemotherapy, a high neutrophil–lymphocyte ratio and the highest quartile of CRP levels (HR=1.60, 95% CI=1.16–2.21; P=0.005) were identified as independent prognostic factors in PC patients.

Conclusion:

In conclusion, we confirmed a significant association of elevated CRP levels with poor clinical outcome in PC patients. Our results indicate that the plasma CRP level might represent a useful marker for patient stratification in PC management.

Increased neutrophil-lymphocyte ratio is a poor prognostic factor in patients with primary operable and inoperable pancreatic cancer

Background:

The neutrophil-lymphocyte ratio (NLR) has been proposed as an indicator of systemic inflammatory response. Previous findings from small-scale studies revealed conflicting results about its independent prognostic significance with regard to different clinical end points in pancreatic cancer (PC) patients. Therefore, the aim of our study was the external validation of the prognostic significance of NLR in a large cohort of PC patients.

Methods:

Data from 371 consecutive PC patients, treated between 2004 and 2010 at a single centre, were evaluated retrospectively. The whole cohort was stratified into two groups according to the treatment modality. Group 1 comprised 261 patients with inoperable PC at diagnosis and group 2 comprised 110 patients with surgically resected PC. Cancer-specific survival (CSS) was assessed using the Kaplan–Meier method. To evaluate the independent prognostic significance of the NLR, the modified Glasgow prognostic score (mGPS) and the platelet-lymphocyte ratio univariate and multivariate Cox regression models were applied.

Results:

Multivariate analysis identified increased NLR as an independent prognostic factor for inoperable PC patients (hazard ratio (HR)=2.53, confidence interval (CI)=1.64–3.91, P<0.001) and surgically resected PC patients (HR=1.61, CI=1.02–2.53, P=0.039). In inoperable PC patients, the mGPS was associated with poor CSS only in univariate analysis (HR=1.44, CI=1.04–1.98).

Conclusion:

Risk prediction for cancer-related end points using NLR does add independent prognostic information to other well-established prognostic factors in patients with PC, regardless of the undergoing therapeutic modality. Thus, the NLR should be considered for future individual risk assessment in patients with PC.

Treatment outcome of advanced pancreatic cancer patients who are ineligible for a clinical trial

OBJECTIVE

The aim of this study was to evaluate the outcome of patients with advanced pancreatic cancer in clinical practice, and assess whether chemotherapy provided a clinical benefit for patients who did not meet the eligibility criteria of the clinical trial.

METHODS

We retrospectively analyzed the medical records of 75 patients who received first-line chemotherapy for pancreatic cancer between April 2006 and September 2011. Patients were treated with gemcitabine (GEM) alone, S-1 (tegafur, gimeracil, and oteracil potassium) alone, or GEM plus S-1. Patients were divided into the clinical trial eligible group (arm eligible) or the ineligible group (arm ineligible). We evaluated the efficacy and the safety of the chemotherapy.

RESULTS

A total of 23 patients out of 75 (31%) belonged to the ineligible group, for the following reasons: 20 patients had poor performance status, eight had massive ascites, one had synchronous malignancy, and one had icterus. The median progression-free survival (PFS) was 3.5 months, and the median overall survival (OS) was 6.7 months in all patients. In arm eligible, median PFS was 4.5 months, and median OS was 10.5 months. In arm ineligible, median PFS was 1.1 months, and median OS was 2.9 months.

CONCLUSION

The outcome of the patients who did not meet the eligibility criteria was very poor. It is important to select the patients that could benefit from either chemotherapy or optimal supportive care.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Serum apolipoprotein C-II is prognostic for survival after pancreatic resection for adenocarcinoma

BACKGROUND

Pancreaticoduodenectomy remains a major undertaking. A preoperative blood test, which could confidently predict the benefits of surgery would improve the selection of pancreatic cancer patients for surgery. This study aimed to identify protein biomarkers prognostic for long-term survival and to validate them with clinico-pathological information.

METHODS

Serum from 40 preoperative patients was used to train for predictive biomarkers using surface-enhanced laser desorption/ionisation time-of-flight mass spectrometry (SELDI), and the results were verified on 21 independent samples. Two predictive proteins were identified by tryptic peptide mass fingerprinting and sequencing, and validated on serum from another 57 patients by enzyme-linked immunosorbent assay (ELISA). The influence of these proteins on growth and invasion of two cancer cell lines was tested in-vitro.

RESULTS

The SELDI panel of m/z 3700, 8222 and 11 522 peaks predicted <12 months' survival (ROC AUC: 0.79, 0.64-0.90; P<0.039). When CA19-9 was added, the ROC AUC increased to 0.95 (0.84-0.99; P<0.0001). The six subjects in the verification group who died within 12 months were correctly classified. The m/z 8222 and 11 522 proteins were identified as Serum ApoC-II and SAA-1, respectively. In the validation samples, ELISA results confirmed that ApoC-II was predictive of survival (Kaplan-Meier P<0.009), but not SAA-I. ApoC-II, CA19-9 and major-vessel involvement independently predicted survival. ApoC-II and SAA-1 increased cell growth and invasion of both cancer cell lines.

CONCLUSION

Serum ApoC-II, CA19-9 and major-vessel invasion independently predict survival and improves selection of patients for pancreaticoduodenectomy.

Prognostic role of C-reactive protein in hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

C-reactive protein (CRP) which used to be a prototypical inflammatory cytokine has been identified involving in the progression of tumor-promoting inflammation. Several studies have indicated that CRP is a predictor for hepatocellular carcinoma (HCC), but the results are controversial.

METHODS

We conducted a systematic review of ten studies (1885 patients) to examine the association of high serum CRP expression with overall survival (OS) and recurrence-free survival (RFS) in HCC patients by meta-analysis. Moreover, the correlation between high serum CRP and tumor clinicopathological parameters was also assessed. Hazard ratio (HR) or odds ratio (OR) with its 95% confidence interval (CI) was used as the effect size estimate.

RESULTS

Our pooled results showed that high expression level of serum CRP (≥ 10 mg/L) was associated with poor OS (HR: 2.15, 95% CI: 1.76-2.63) and RFS (HR: 2.66, 95% CI: 1.54-4.58) in HCC. Serum CRP overexpression (≥ 10 mg/L) was also significantly associated with the presence of tumor vascular invasion (OR: 3.05, 95% CI: 1.79-5.23), multiple tumor (OR: 2.36, 95% CI: 1.36-4.10), larger tumor size (OR: 3.41, 95% CI: 1.04-11.18), and advanced TNM stage (OR: 3.23, 95% CI: 2.29-4.57). In addition, serum CRP overexpression (≥ 10 mg/L) tended to be correlated with poor differentiation (OR: 1.58, 95% CI: 0.74-3.39), though not significantly.

CONCLUSION

The present systematic review and meta-analysis demonstrate that high serum level of CRP (≥ 10 mg/L) denotes a poor prognosis of patients with HCC.

Pretreatment serum C-reactive protein levels predict benefit from multimodality treatment including radical surgery in malignant pleural mesothelioma: a retrospective multicenter analysis

OBJECTIVE

To evaluate the prognostic and predictive relevance of pretreatment serum C-reactive protein (CRP) in malignant pleural mesothelioma (MPM) patients.

BACKGROUND

MPM is a rare but aggressive disease with poor treatment outcome. Therapeutic decision is challenging, and predictive biomarkers for better treatment stratification are urgently needed.

METHODS

Clinical data, including survival and pretreatment CRP levels, were retrospectively collected from 115 patients with histologically proven MPM. Patients with any evidence for infectious disease were excluded. The association between CRP levels and survival was analyzed using Cox models adjusted for clinical and pathological factors.

RESULTS

Median pretreatment CRP of all patients was 1.19 mg/dL (range: 0.00-22.62 mg/dL). Patients with elevated CRP levels (≥1 mg/dL; n = 62, 53.9%) had a significantly shorter overall survival compared with those with normal CRP (hazard ratio [HR] 2.81, 95% confidence interval [CI] 1.82-4.33; P < 0.001). In multivariate survival analyses, elevated CRP was confirmed as an independent prognostic factor in MPM (HR 2.07, 95% CI 1.23-3.46; P = 0.01). Most interestingly, we observed a significant interaction between CRP and treatment modality (P < 0.001). Among patients with normal CRP levels, radical tumor resection within multimodality therapy was associated with distinctly prolonged overall survival when compared with treatment protocols without surgery (HR 7.26, 95% CI 3.40-15.49; P < 0.001). In contrast among patients with elevated CRP, no survival benefit was achieved by radical surgery within multimodality approaches (HR 0.911, 95% CI 0.53-1.58; P = 0.74).

CONCLUSIONS

Our results suggest that multimodality regimens including radical resection increase survival selectively in MPM patients with normal pretreatment serum CRP levels.

C-reactive protein concentration is associated with prognosis in patients suffering from peritoneal carcinomatosis of colorectal origin

PURPOSE

Only a limited number of patients with peritoneal carcinomatosis (PC) of colorectal origin benefit from palliative chemotherapy. Identification of prognostic factors may aid in patient selection. The plasma concentration of C-reactive protein (CRP) is increasingly recognized as prognostic factor in a variety of malignancies. However, its value in peritoneal PC of colorectal origin is currently unknown. The aim of the present study was to investigate the association of plasma CRP concentrations with survival in patients suffering from PC of colorectal origin who receive palliative chemotherapy.

METHODS

Fifty patients with colorectal PC were identified from the Eindhoven Cancer Registry. Relevant data were retrieved from their clinical records. The most discriminatory CRP concentration was identified and patients were stratified accordingly, resulting in a group with low and a group with high CRP concentrations. Further comparisons were made between these groups.

RESULTS

A CRP concentration <35 mg/L was associated with a better prognosis (median survival 22.4 months) than a CRP concentration ≥35 mg/L (7.9 months) (p = 0.0002). CRP concentrations were inversely related to albumin concentrations which could predict survival at a cut-off value of 35 g/L (median survival 7.2 vs. 12.9 months, p = 0.01). High CRP concentrations were related to a decreased resectability rate of the primary tumor.

CONCLUSION

Elevated CRP plasma concentrations are associated with decreased survival in patients with colorectal PC. This reflects the importance of inflammation in cancer survival. Further research is warranted to assess the clinical applicability of the current findings.

Preoperative neutrophil-to-lymphocyte ratio (NLR) is associated with reduced disease-free survival following curative resection of pancreatic adenocarcinoma

BACKGROUND

Serological proinflammatory markers such as C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) have been associated with reduced survival for many different types of cancer. This study determined the prognostic value of the preoperative value of these markers in patients with resectable pancreatic adenocarcinoma.

METHODS

Consecutive patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma were entered into our database from 2001 to the present day. CRP, NLR, and PLR at the time of presentation were recorded as well as overall and disease-free survival.

RESULTS

Seventy-four patients were identified. Overall median survival was 35.0 months and median disease-free survival was 27.0 months. Follow-up ranged from 1 to 125.8 months. Preoperative NLR was significantly greater in those patients who developed recurrence in the follow-up period (4.5 vs. 3.1). CRP and PLR were not found to differ significantly between the two groups. Kaplan-Meier survival analysis of patients with NLR > 5 demonstrated a disease-free survival of 12 months compared with 52 months for those patients with NLR < 5 (p < 0.001).

CONCLUSION

Preoperative NLR offers important prognostic information regarding disease-free survival following curative resection of pancreatic ductal adenocarcinoma.

A prognostic model to predict clinical outcomes with first-line gemcitabine-based chemotherapy in advanced pancreatic cancer

OBJECTIVE

Our aim was to devise a prognostic model for advanced pancreatic cancer based on clinical parameters.

METHODS

We retrospectively analyzed the medical records of 298 patients who received gemcitabine-based chemotherapy from January 1999 to November 2008.

RESULTS

The median survival of all patients was 7 months [95% confidence interval (CI) 6.2-7.8]. Multivariate analysis revealed poor prognostic factors for overall survival such as the presence of liver metastasis [p < 0.001, hazard ratio (HR) 2.628, 95% CI 1.620-4.264], the presence of ascites or peritoneal carcinomatosis (p = 0.005, HR 1.783, 95% CI 1.194-2.661), serum C-reactive protein levels >1.2 mg/dl (p = 0.021, HR 1.568, 95% CI 1.070-2.300), and serum albumin levels <3.5 g/dl (p = 0.021, HR 1.701, 95% CI 1.085-2.667). Of 298 patients, 168 patients (56.4%) were categorized as low-risk with 0 or 1 risk factor, 80 patients (26.8%) were categorized as intermediate-risk with 2 risk factors, and 50 patients (16.8%) were categorized as high-risk with 3 or 4 risk factors. The median survival duration for the low-, intermediate-, and high-risk groups was 10.0 months (95% CI 8.7-11.3), 6.7 months (95% CI 5.7-7.7), and 4.4 months (95% CI 3.2-5.6), respectively.

CONCLUSIONS

This prognostic model could help to select treatment for patients in clinical practice, and these risk-adapted treatment strategies should be further investigated in prospective studies in such patient populations.

Serum C-reactive protein and risk of pancreatic cancer in two nested, case-control studies

BACKGROUND

Many epidemiologic studies have examined the association between C-reactive protein (CRP) and risk of cancer with inconsistent results.

METHODS

We conducted two nested, case-control studies in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study (ATBC) and Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) to test whether prediagnostic circulating CRP concentrations were associated with pancreatic adenocarcinoma. Between 1985 and 2004, 311 cases occurred in ATBC and between 1994 and 2006, 182 cases occurred in PLCO. Controls (n = 510 in ATBC, n = 374 in PLCO) were alive at the time the case was diagnosed and were matched by age, date of blood draw, sex, and race. We used conditional logistic regression adjusted for smoking to calculate OR and 95% CI for pancreatic cancer.

RESULTS

CRP concentrations (ng/mL) tended to be inversely or not associated with pancreatic cancer risk in ATBC, PLCO, and combined analyses [per standardized quintile increase in CRP, continuous OR = 0.94 (95% CI, 0.89-0.99), OR = 0.99 (95% CI, 0.95-1.04), OR = 0.98 (95% CI, 0.95-1.01), respectively]. In combined analyses, we observed a significant interaction (P(interaction) = 0.02) such that inverse associations were suggestive in younger (OR = 0.95; 95% CI, 0.90-1.01), but not older, participants.

CONCLUSION

Our results do not support the hypothesis that higher CRP concentrations are associated with incident pancreatic cancer.

IMPACT

Our results highlight the importance of investigating more specific biomarkers for inflammation that may reflect the biological mechanisms underlying pancreatic cancer in prospective cohort studies.

Preoperative inflammation is a prognostic factor for gallbladder carcinoma

BACKGROUND

Inflammation frequently accompanies gallbladder carcinoma (GBC), but its impact on outcome is unclear. The present study investigated the impact of concomitant inflammation on survival of patients with GBC.

METHODS

All patients undergoing surgery for GBC between October 2003 and May 2009 were identified retrospectively from a prospectively collected database. Patients were classified according to whether preoperative inflammation was present (65 patients) or not (23).

RESULTS

A total of 88 patients were enrolled. There were no differences in sex, mean age, tumour node metastasis (TNM) stage and radicality of resection between the two groups. The overall 3-year survival rate was lower in patients with preoperative inflammation than in those without (33 versus 73 per cent; P = 0·001). In univariable analysis, preoperative inflammation, T, N and M category, TNM stage, radicality of surgery and tumour differentiation were significant prognostic factors. The presence of preoperative inflammation (hazard ratio (HR) 2·38, 95 per cent confidence interval 1·04 to 5·43), lymph node metastases (HR 5·23, 1·05 to 26·09) and R1 or R2 resection (HR 3·77, 1·47 to 9·72) were independent prognostic factors for poor survival.

CONCLUSION

The presence of preoperative inflammation is an independent prognostic factor for poor survival in patients with GBC.