Elevated NLR in gallbladder cancer and cholangiocarcinoma - making bad cancers even worse: results from the US Extrahepatic Biliary Malignancy Consortium

The prognostic role of albumin-bilirubin grade in the mortality of extrahepatic cholangiocarcinoma patients

OBJECTIVE

Cholangiocarcinoma (CCA) has a low survival rate of 5-17%, despite advancements in diagnosis and treatment. Liver function impacts disease prognosis, and the albumin-bilirubin (ALBI) score is a new assessment model for this purpose. While research suggests a correlation between ALBI score, liver failure and mortality in intrahepatic CCA (iCCA), predicting outcomes for extrahepatic CCA (eCCA) is challenging. Our objective was to assess the prognostic role of ALBI grade in predicting overall survival of eCCA patients.

METHODS

Patients with diagnosis of eCCA who had visited Firuzgar Hospital from 2015 to 2019 were consecutively included in the study. These individuals had previously undergone Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) or ERCP brush cytology followed by surgery. Exclusion criteria were patients with benign bile duct strictures, prior biliary tract surgery, concurrent liver disease impacting liver tests, inadequate data, or inconsistent monitoring. Clinical data of patients were collected to calculate ALBI score which was subsequently divided into three distinct grades (grade 1: ≤-2.60, grade 2: > -2.60 to ≤ - 1.39, grade 3: >-1.39). Kaplan-Meier analysis and Cox regression model were used to analyze overall survival, 1-, 3- and 5-year survival and parameters affecting patient survival.

RESULTS

In this study, 80 patients with diagnosis of eCCA with a median age of 67 (58.25-74) years (67.5% male) who visited Firuzgar Hospital from 2015 to 2019 were included. The average survival time of patients was 13.9 ± 16.4 months, and the 1-year, 3-year, and 5-year survival rates of patients were 36.6%, 27.1%, and 15.8%, respectively. The results showed that ALBI grade, Aspartate Aminotransferase (AST), white blood cell (WBC) and international normalized ratio (INR) have significant effects on the survival of patients (all P < 0.05). Based on the results of Cox regression, the risk of mortality due to CCA in patients with ALBI grade 3 (HR = 1.87, P = 0.0111), AST > 82.5 (HR = 1.90, P = 0.0091), WBC > 7.70 × 109/L (HR = 2.46, P = 0.0004), and INR > 1.08 (HR = 1.78, P = 0.0202) increases significantly.

CONCLUSION

We showed that ALBI grade, AST > 82.5 units/L, and INR > 1.08 can be used as predictive factors of survival in cholangiocarcinoma patients.

Analysis of the effectiveness and safety of lenvatinib/bevacizumab combined with PD-1/PD-L1 inhibitors and GEMOX in the first-line treatment of advanced biliary tract carcinoma

To assess the efficacy and safety of lenvatinib/bevacizumab combined with programmed death-1 (PD-1)/programmed death ligand 1 (PD-L1) inhibitors and gemcitabine/oxaliplatin (GEMOX) as first-line treatments in patients with advanced biliary tract cancer (BTC). Patients with advanced BTC who received lenvatinib/bevacizumab combined with PD-1/PD-L1 inhibitors plus gemcitabine/oxaliplatin (GEMOX) chemotherapy were retrospectively screened. The primary endpoints were overall survival (OS) and progression-free survival (PFS), whereas the secondary endpoints were objective response rate (ORR), disease control rate (DCR), and safety. Prognostic factors for survival were analyzed. A total of 172 individuals were enrolled and categorized into four groups: Group A received GEMOX plus PD-1 antibody (sintilimab or camrelizumab) and lenvatinib; group B received GEMOX and PD-1 antibody (sintilimab or camrelizumab) and bevacizumab; group C received GEMOX and PD-1 antibody (sintilimab or camrelizumab); and group D received GEMOX alone. The median OS was 13.63 months (95% confidence interval [CI]: 12.37-14.89), 12.41 months (95% CI: 10.67-12.32), 11.23 months (95% CI: 9.39-13.07), and 8.86 months (95% CI: 7.28-10.44) in groups A, B, C, and D, respectively (P = 0.312). In groups A, B, C, and D, the median PFS was 12.42 months, 11.05 months, 8.89 months, and 6.02 months. A statistically significant difference was observed (t = 2, 95% CI: 11.31-13.53, P < 0.01). The ORR was 45.00% (17/40) in group A, 34.78% (16/46) in group B, 16.67% (5/30) in group C, and 17.86% (10/56) in group D. The DCR was 87.50% (35/40), 78.26% (36/46), 76.67% (23/30), and 58.93% (33/56) in groups A, B, C, and D, respectively. In addition, regression analysis showed that patients' metastasis site, whether the neutrophil-lymphocyte ratio was < 2.3, and whether chemotherapy was administered through hepatic artery embolization and was independent prognostic factors influencing median OS and PFS. Almost all patients included in the study experienced treatment-related adverse events (TRAEs) of varying degrees of severity, with grade 1-2 adverse events predominating. Lenvatinib/bevacizumab combined with programmed death-1 (PD-1)/programmed death ligand 1 (PD-L1) inhibitors and gemcitabine/oxaliplatin (GEMOX) represent an effective and tolerable regimen for advanced BTC in a multicenter retrospective real-world study.

Dynamic monocyte changes as prognostic indicators in operable gastric cancer: a retrospective cohort analysis

Objective

This study aims to elucidate the relationship between postoperative monocyte count and gastric cancer prognosis. We introduce a standardized monocyte ratio (MMR) to predict postoperative survival rates in gastric cancer patients effectively.

Methods

A test cohort was created to develop and evaluate the pre- and postoperative MMR as a mortality predictor in gastric cancer patients. We used Kaplan-Meier survival analysis, complemented by univariate and multivariate analyses. The predictive utility of MMR was assessed via time-dependent ROC curves and decision-curve analysis.

Results

The sample distributions in both cohorts were similar. The MMR showed high predictive value and significant clinical benefits in 1, 3, and 5-year overall survival (OS) assessments. These findings enhance understanding of prognosis and aid in developing more precise treatment plans.

Conclusions

MMR is confirmed as an independent factor in predicting overall survival in gastric cancer patients, proving to be a reliable and cost-effective prognostic indicator.

Clinical significance of CA 19-9 elevation during postoperative surveillance for extrahepatic bile duct cancer: a nomogram-based approach for the prediction of short-term recurrence

BACKGROUND

This study aimed to assess the significance of elevated carbohydrate antigen (CA) 19-9 in postoperative surveillance of extrahepatic bile duct cancer and to identify short-term recurrence predictors.

METHODS

This retrospective study included patients with elevated CA 19-9 post-curative surgery. Patients were categorized into positive and negative CT groups based on the detection of recurrence at CA 19-9 elevation. Short-term recurrence was defined as recurrence within 6 months in the negative CT group. We identified the factors associated with short-term recurrence and devised a predictive nomogram.

RESULTS

Among the 190 patients, 91 (47.9 %) exhibited tumor recurrence with CA 19-9 elevation (CT-positive group), whereas 99 (52.1 %) showed no recurrence (CT-negative group). In the CT-negative group (n = 99), 22 (22.2 %) experienced short-term tumor recurrence within 6 months. Preoperative CA 19-9 (odds ratio [OR]: 1.5, p = 0.016), postoperative CA 19-9 (OR: 1.9, p = 0.047), adjuvant treatment (OR: 3.5, p = 0.032), and the absence of inflammation (OR: 3.5, p = 0.045) were predictors of short-term recurrence. The area under the curve of the nomogram was 0.80 (95 % CI: 0.69-0.90).

CONCLUSION

Despite elevated CA 19-9 levels, approximately 50 % of patients exhibited no recurrence during postoperative surveillance for extrahepatic bile duct cancer. Factors influencing short-term recurrence encompass pre- and postoperative CA 19-9, adjuvant treatment, and inflammatory status.

Prognostic evaluation in gallbladder carcinoma: Introducing a composite risk model integrating nutritional and immune markers

The importance of evaluating the nutritional status and immune condition prior to surgery has gained significant attention in predicting the prognosis of cancer patients in recent years. The objective of this study is to establish a risk model for predicting the prognosis of gallbladder carcinoma (GBC) patients. Data from GBC patients who underwent radical resection at West China Hospital of Sichuan University (China) from 2014 to 2021 were retrospectively collected. A novel risk model was created by incorporating the prognostic nutritional index and glucose-to-lymphocyte ratio, and each patient was assigned a risk score. The patients were then divided into low- and high-risk cohorts, and comparisons were made between the two groups in terms of clinicopathological features and prognosis. Propensity score matching was conducted to reduce potential bias. A total of 300 GBC patients receiving radical surgery were identified and included in this study. Patients in the high-risk group were older, had higher levels of serum carcinoembryonic antigen (CEA), cancer antigen 125 (CA125), and cancer antigen 19-9 (CA19-9), were more likely to experience postoperative complications, and had more aggressive tumor characteristics, such as poor differentiation, lymph node metastasis, and advanced tumor stage. They also had lower overall survival (OS) rates (5-year OS rate: 11.2% vs. 37.4%) and disease-free survival (DFS) rates (5-year DFS rate: 5.1% vs. 18.2%). After propensity score matching, the high-risk population still experienced poorer prognosis (5-year OS rate: 12.7% vs 20.5%; 5-year DFS rate: 3.2% vs 8.2%). The risk model combining prognostic nutritional index and glucose-to-lymphocyte ratio can serve as a standalone predictor for the prognosis and assist in optimizing the treatment approach for GBC patients.

Establishment and clinical application of a prognostic index for inflammatory status in triple-negative breast cancer patients undergoing neoadjuvant therapy using machine learning

OBJECTIVE

This study aims to establish a new prognostic index using machine learning models to predict the clinical outcomes of triple-negative breast cancer (TNBC) patients receiving neoadjuvant therapy.

METHODS

In this study, we collected data from the electronic medical records system of Harbin Medical University Cancer Hospital to establish a training set of 501 breast cancer patients who received neoadjuvant therapy from January 2017 to December 2021. Additionally, we collected data from Harbin Medical University Affiliated Cancer Hospital, Harbin Medical University Affiliated Second Hospital, and Harbin Medical University Affiliated Sixth Hospital to establish a validation set of 1533 patients during the same period. All patients underwent blood tests, and the following inflammatory and immune indices were calculated for each patient: neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), systemic immune-inflammatory index (SII), systemic inflammatory response index (SIRI), and advanced lung cancer inflammation index (ALI). The observed outcomes included Disease-free survival (DFS) and overall survival (OS). Survival analysis was performed using Kaplan‒Meier survival curves, Cox survival analysis, propensity score matching analysis (PSM), and a nomogram to comprehensively investigate the impact of inflammatory status on patient survival.

RESULTS

The training set comprised 501 patients with a mean age of 48.63 (9.41) years, while the validation set comprised 1533 patients with a mean age of 49.01 (9.51) years. The formula for ANLR established through Lasso regression analysis on the training set is: ANLR index = NLR - 0.04 × ALB (g/L). In both the training and validation sets, ANLR was significantly associated with patient DFS and OS (all P < 0.05). Additionally, ANLR was found to be an independent prognostic factor in this study. PSM analysis further confirmed its significant correlation with patient DFS and OS (76 cases vs. 76 cases, χ2 = 2.179, P = 0.001 and χ2 = 2.063, P = 0.002). The nomogram containing ANLR also demonstrated high prognostic value. The C-index for the nomogram in the training set was 0.742 (0.619-0.886) for DFS and 0.758 (0.607-0.821) for OS, while in the validation set, the C-index was 0.733 (0.655-0.791) for DFS and 0.714 (0.634-0.800) for OS.

CONCLUSION

ANLR was associated with the prognosis of TNBC patients receiving neoadjuvant therapy and could identify high-risk postoperative patients.

Outcomes of patients with gallbladder cancer presenting with acute cholecystitis

The main purpose of this study is to explore the outcomes of patients found to have gallbladder cancer during investigation and diagnosis of acute cholecystitis. The incidence of primary gallbladder cancer co-existing in acute cholecystitis is not well defined in the literature, with anecdotal reports suggesting that they experience worse outcomes than patients with gallbladder cancer found incidentally.

METHODS

A retrospective review of all patients with gallbladder cancer managed at the Canberra Health Service between 1998 and May 2022 were identified and reviewed.

RESULTS

A total of 65 patients were diagnosed with primary gallbladder cancer during the study period with a mean age of 70.4 years (SD 11.4, range 59-81.8 years) and a female preponderance (74% versus 26%) with a ratio of 2.8. Twenty (31%) patients presented with acute calculus cholecystitis and were found to have a primary gallbladder cancer. This group of patients were older and predominantly female, but the difference was not statistically significant. The overall 5-year survival in the cohort was 20% (stage 1 63%, stage 2 23%, stage 3 16%, and stage 4 0%). There was no statistically significant difference in survival between those who presented with acute cholecystitis vs other presentations.

CONCLUSIONS

A third of the patients with gallbladder cancer presented with acute cholecystitis. There was no statistically significant difference in survival in those with bile spillage during cholecystectomy as well those presenting with acute cholecystitis.

Prognostic value of combined preoperative inflammatory marker neutrophil-lymphocyte ratio and platelet distribution width in patients with gallbladder carcinoma

BACKGROUND

The neutrophil-lymphocyte ratio (NLR) and platelet distribution width (PDW) are associated with poor prognosis in various cancers. We aimed to analyze the prognostic value of the combination of preoperative NLR and PDW in patients with gallbladder carcinoma (GBC).

METHODS

A total of 287 GBC patients who underwent curative-intent surgery in our institution was included. The relationship between NLR and PDW and clinicopathological features were analyzed. The receiver operating characteristic (ROC) curves were used to determine the optimal cutoff value for NLR and PDW. Overall survival (OS) was estimated using the Kaplan-Meier method. Meanwhile, the univariate and multivariate Cox regression models were used to assess the risk factors for OS.

RESULTS

The optimal cutoff value of NLR and PDW was 3.00 and 14.76, respectively. In addition, survival analysis demonstrated that patients with NLR > 3.00 and PDW > 14.76 had a worse prognosis than patients with NLR ≤ 3.00 and PDW ≤ 14.76, respectively. The multivariate analysis showed that NLR and PDW were independent prognostic factors in the patients with GBC. When we combined NLR and PDW, the area under the ROC curve increased from 0.665 (NLR) and 0.632 (PDW) to 0.676. Moreover, the 1-, 3-, and 5-year OS of group A (patients with NLR ≤ 3.00 and PDW ≤ 14.76), group B (patients with either of NLR > 3.00 or PDW > 14.76) and group C (patients with NLR > 3.00 and PDW > 14.76) were 88.7%, 62.6%, 28.1%, 65.1%, 26.9%, 13.1%, and 34.8%, 8.3%, 0%, respectively.

CONCLUSION

The combination of NLR and PDW may serve as a significant prognostic biomarker for GBC patients superior to either NLR or PDW alone.

Haematologic biomarkers and survival in gallbladder cancer: a systematic review and meta-analysis

Background

Gallbladder cancer is a rare malignancy characterised by poor survival with lack of durable response to treatment. Thus, novel biomarkers are needed to prognosticate patients. This systematic review and meta-analysis sought to examine the role of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, platelet count (PC) and serum immune inflammation index in predicting the survival of patients with gallbladder cancer.

Materials and methods

A systematic search was done using PubMed, Cochrane, ClinicalTrials.gov and Google Scholar for articles published from inception until 8 February 2022. Hazard ratios (HR) with 95% confidence intervals (CI) were pooled and subgroup analyses were conducted according to treatment, region and cut-offs. The primary outcome of interest was overall survival (OS). Data were summarised using RevMan version 5.4.

Results

Twenty studies comprising 5,183 patients were included in the analysis. High neutrophil-lymphocyte ratio (HR 1.72, 95% CI 1.47-2.02), platelet-lymphocyte ratio (HR 1.51, 95% CI 1.33-1.72), monocyte-lymphocyte ratio (HR 1.96, 95% CI 1.46-1.64), PC (HR 1.20, 95% CI 1.02-1.40) and serum inflammation index (HR 1.73, 95% CI 1.36-2.18) were all associated with worse survival. The association was consistent across most subgroups on race and cut-offs with a trend towards poor survival for PC above 252.5.

Conclusion

High neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, monocyte-lymphocyte ratio, PC and SII are associated with worse OS in gallbladder cancer and are potential biomarkers for prognostication. Prospective studies are recommended to further evaluate their use.

The Prognosis Performance of a Neutrophil- and Lymphocyte-Associated Gene Mutation Score in a Head and Neck Cancer Cohort

The treatment of head and neck squamous cell carcinomas (HNSCCs) is multimodal, and chemoradiotherapy (CRT) is a critical component. However, the availability of predictive or prognostic markers in patients with HNSCC is limited. Inflammation is a well-documented factor in cancer, and several parameters have been studied, with the neutrophil-to-lymphocyte ratio (NLR) being the most promising. The NLR is the most extensively researched clinical biomarker in various solid tumors, including HNSCC. In our study, we collected clinical and next-generation sequencing (NGS) data with targeted sequencing information from 107 patients with HNSCC who underwent CRT. The difference in the NLR between the good response group and the poor response group was significant, with more patients having a high NLR in the poor response group. We also examined the genetic alterations linked to the NLR and found a total of 41 associated genes across eight common pathways searched from the KEGG database. The overall mutation rate was low, and there was no significant mutation difference between the low- and high-NLR groups. Using a multivariate binomial generalized linear model, we identified three candidate genes (MAP2K2, MAP2K4, and ABL1) that showed significant results and were used to create a gene mutation score (GMS). Using the NLR-GMS category, we noticed that the high-NLR-GMS group had significantly shorter relapse-free survival compared to the intermediate- or low-NLR-GMS groups.

Predicting the prognosis of operable gastric cancer patients by dynamic changes in platelets before and after surgery: a retrospective cohort study

PURPOSE

Since the relationship between postoperative platelet count and prognosis is still unclear, we designed a standardized index of platelet count to predict the prognosis of gastric cancer (GC).

METHODS

We designed a development validation cohort for the pre/post platelet ratio. We determined the ability of PPR to predict mortality in gastric cancer patients and validated them by a separate cohort. Survival was assessed by Kaplan-Meier analysis and associations explored by multivariate and multivariate analyses. The usefulness of the prediction was estimated by measuring the time-dependent ROC. Decision-curve analysis was used to validate the net clinical benefit.

RESULTS

The sample distribution was similar in the two cohorts, and the 1-, 3-, and 5-year OS evaluation of the postoperative/preoperative platelet ratio was the largest for AUC in the two cohorts. Meanwhile, PPR has a good predictive value and a net clinical benefit.

CONCLUSIONS

PPR has been identified and validated to be independently concerned about OS of patients with GC and was a reliable and economic indicator to evaluate the prognosis.

The value of the preoperative Naples prognostic score in predicting prognosis in gallbladder cancer surgery patients

PURPOSE

The Naples prognostic score (NPS) is a comprehensive prognostic model that includes inflammatory and nutrition-related indicators and is increasingly used as a prognostic score for various malignant tumors. Given its predictive effect on prognosis in patients with gallbladder cancer, it is currently unclear. This study aimed to investigate the role of preoperative NPS in predicting prognosis in gallbladder cancer surgery patients.

PATIENTS AND METHODS

A retrospective analysis was performed for 135 patients who underwent radical surgery for gallbladder cancer without preoperative treatment between March 2011 and January 2020. NPS was calculated by measuring the preoperative total cholesterol value, serum albumin value, neutrophil-lymphocyte ratio (NLR), and lymphocyte-monocyte ratio (LMR). They were then divided into 3 groups (groups 0, 1, and 2) based on NPS scores. Survival analysis was performed using the Kaplan-Meier method and log-rank test. Univariate and multivariate Cox proportional hazards models were used to identify independent prognostic factors. Plot time-dependent receiver operating characteristic (ROC) curves to compare the prognostic value of scoring systems. Finally, a nomogram model was developed with independent prognostic factors.

RESULTS

Multivariate analysis showed that NPS was an independent risk factor affecting OS (HR = 3.417, p < 0.05). The time-dependent ROC curve results showed that NPS had a better predictive value on survival prognosis than other indicators. The nomogram constructed according to independent factors such as NPS has a good predictive ability for OS.

CONCLUSION

As a simple and reliable tool, the NPS has important predictive value in the survival prognosis of gallbladder cancer patients. The nomogram model constructed by NPS will help determine prognosis and make individualized treatment decisions.

Efficacy and safety analysis of chemotherapy combined with immunotherapy compared with standard chemotherapy for advanced biliary tract malignant tumors

OBJECTIVE

The treatment of biliary tract (BTC) cancer remains relatively limited, especially in the setting of advanced BTC. Immune checkpoint inhibitors (ICIs) have shown some effects in a variety of solid tumors, but their efficacy and safety in patients with advanced BTC are still elusive, which require in-depth analysis.

METHODS

The clinical information of 129 patients diagnosed with advanced BTC between 2018 and 2021 were retrospectively reviewed. All patients were treated with chemotherapy, while a portion of them (64 patients) were treated with ICIs, the other 64 patients were not. Therefore, we divided the patients into two groups, SC (standard chemotherapy) and CI (chemotherapy in combined with immunotherapy), then we analyzed the benefit of adding ICIs according to efficacy, adverse events, progression-free survival (PFS), progressive disease (PD), and the influence of various factors and effectiveness.

RESULTS

The mean PFS was 9.67 months for CI group and 6.83 months for SC group. The PFS was prolonged by 2.84 months with ICI addition, and the difference was statistically significant (t = 3.114, 95% CI: 1.06-4.74, p < 0.001). The objective response rate (ORR) was 32.81% (21/64) for the CI group versus 10.77% (7/65) for the SC group, and the disease control rate (DCR) was 79.69% (51/64) versus 67.69% (44/65), respectively. Regression analysis showed that factors such as changes in CA19-9, the level of PD-L1 expression, tobacco and alcohol, and the neutrophil-lymphocyte (NLR) ratio all influenced PFS (p < 0.05 for all these factors). For the treatment-related adverse events (TRAEs), the highest grade 3-4 adverse effects were thrombocytopenia in 7.75% (10/129) and neutropenia in 3.1% (4/129), immune-related adverse events (irAEs) occurred in 32.8% (21/64), and all were grade 1-2.

CONCLUSIONS

Our results showed that ICIs combined with chemotherapy exhibited good antitumor activity with acceptable safety and could be recommended as first-line treatment for patients with advanced BTC.

Correlation between mismatch repair and survival of patients with gastric cancer after 5-FU-based adjuvant chemotherapy

BACKGROUND

Almost all adjuvant chemotherapy regimens for gastric cancer recommended by guidelines are fluorouracil (5-FU) based, and 5-FU-based adjuvant chemotherapy plays an important role in reducing the recurrence of gastric cancer after surgery. However, the effect of mismatch repair (MMR) status on survival after 5-FU-based adjuvant chemotherapy in patients with gastric cancer remains controversial.

MATERIALS AND METHODS

We prospectively included patients with gastric cancer who underwent radical gastrectomy between March 14, 2017 and September 30, 2021. The included patients received 5-FU-based adjuvant chemotherapy or surgery alone. The MMR status of patients was divided into MMR proficient (pMMR) and MMR defective (dMMR) according to four MMR proteins. Peripheral blood was collected for systemic inflammation analysis. The main purpose of this study was to analyze the effect of MMR status on survival after 5-FU-based adjuvant chemotherapy in patients with gastric cancer. We also analyzed the differences in systemic inflammation levels in different MMR status and their impact on survival.

RESULTS

A total of 479 patients were enrolled, with a median follow-up period of time was 36 months. In the surgery alone group, dMMR gastric cancer had better disease-free survival (DFS) (hazard ratio [HR] = 4.33, 95% confidence interval [CI] 1.25-15.02, p = 0.02) than pMMR, and in the adjuvant chemotherapy group, there was no significant difference in DFS (HR = 1.16, 95% CI 0.65-2.07, p = 0.61) between dMMR and pMMR gastric cancer. The same results were seen for overall survival (OS). In addition, the result show that in the dMMR group, there was no difference in DFS (HR = 1.62, 95% CI 0.46-5.77, p = 0.45) between patients receiving adjuvant chemotherapy and those receiving surgery alone. In the pMMR group, the DFS values (HR = 0.59, 95%CI 0.35-0.99, p = 0.04) of patients receiving adjuvant chemotherapy were better than those of patients receiving surgery alone, and the same results were observed for OS. In addition, among pMMR patients, patients with a low platelet lymphocyte ratio (PLR) who received 5-FU adjuvant chemotherapy and those with a low neutrophil lymphocyte ratio (NLR) and systemic immune-inflammation index (SII) who received surgery alone had better DFS and OS.

CONCLUSION

To our knowledge, this is the first prospective study to specifically explore the correlation between MMR and survival of patients with gastric cancer after 5-FU-based adjuvant chemotherapy. The results showed that gastric cancer patients with pMMR can benefit from 5-FU-based adjuvant chemotherapy, but those with dMMR cannot. Among pMMR patients, lower PLR and SII values with surgery alone and lower NLRs in those receiving 5-FU-based adjuvant chemotherapy were associated with higher DFS and OS.

Impact of acute cholecystitis comorbidity on prognosis after surgery for gallbladder cancer: a propensity score analysis

BACKGROUND

Cholecystitis can represent a comorbidity during gallbladder cancer surgery; nonetheless, the prognostic impact of acute cholecystitis comorbidity remains unclear. This study aimed to evaluate the impact of acute cholecystitis comorbidity on prognosis after gallbladder cancer surgery, with adjustment for background factors using propensity score analysis.

METHODS

A total of 218 patients who underwent gallbladder cancer surgery at our institute between 1986 and 2022 were retrospectively included in the analysis. Patients were divided into two groups according to the presence or absence of acute cholecystitis at the time of surgery. Background factors were adjusted by including intraoperative bile leakage as a covariate in propensity score calculation. Overall survival and recurrence-free survival were compared between the two groups using one-to-one propensity score matching and inverse probability weighting.

RESULTS

Of the 218 patients, 37 had coexisting acute cholecystitis. In one-to-one propensity score matching, the overall survival time in the acute cholecystitis group tended to be shorter than that in the non-acute cholecystitis group, although not significantly (hazard ratio, 2.41; 95% confidence interval, 0.96-6.06). Other analyses using inverse probability weighting showed significantly poor overall survival in the acute cholecystitis group. Regarding recurrence-free survival in propensity score matching, the acute cholecystitis group showed a significantly shorter duration than the non-acute cholecystitis group (hazard ratio, 6.69; 95% confidence interval, 1.46-30.6). The inverse probability weighting-adjusted analysis also indicated a significantly higher risk of recurrence in the acute cholecystitis group.

CONCLUSIONS

Acute cholecystitis comorbidity at the time of gallbladder cancer surgery may have a negative impact on gallbladder cancer prognosis.

Correlation between systemic immune inflammatory index and prognosis of patients with hepatic alveolar hydatid disease and establishment of a nomogram prediction model

BACKGROUND

To explore the evaluation value of systemic immune inflammation index (SII) in the prognosis of patients with alveolar hydatid disease, and establish a nomogram prediction model.

METHODS

Collect the clinical data of 351 patients undergoing hepatic alveolar hydatid surgery admitted to the Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hospital of Qinghai University from January 2015 to December 2020, calculate the SII value, and use the receiver operating characteristic curve (ROC curve) to determine According to the optimal clinical cut-off value of SII, patients were divided into two groups with high SII and low SII, and the relationship between SII and clinicopathological factors and prognosis of patients with alveolar echinococcosis was analyzed. Establish a nomogram prediction model based on independent risk factors for patient prognosis, and evaluate the prediction accuracy and discrimination ability of the nomogram through the consistency index (C-index) and calibration curve. The result is through the use of bootstrapping validation with 1,000 re-sampling Method for internal verification.

RESULTS

The ROC curve was used to determine the optimal cut-off value of SII before operation 761.192, and patients were divided into low SII group (n = 184) cases and high SII group (n = 167) cases. The 1, 3, and 5-year survival rates of patients with hepatic alveolar hydatid in the low SII group and the high SII group were 98.90%, 96.90%, 86.50% and 98.20%, 72.50%, 40.30%, respectively. The survival rate of worm disease patients was significantly better than that of the high SII group, and the overall survival rate difference between the two groups was statistically significant (P < 0.001). Multivariate Cox regression model analysis results showed that intraoperative blood loss (HR = 1.810, 95%CI: 1.227-2.668, P = 0.003), SII (HR = 5.011, 95%CI: 3.052-8.228, P < 0.001), Complications (HR = 1.720, 95%CI: 1.162-2.545, P = 0.007) are independent risk factors for the prognosis of patients with alveolar hydatid disease. Draw a nomogram and include statistically significant factors in the multivariate Cox regression model to predict the overall survival rate of patients with alveolar hydatid disease at 1, 3, and 5 years. The survival probability calibration curve is displayed. The nomogram is compared with The actual results have a high degree of agreement. The concordance index (C-index) of the nomogram model in the modeling sample is 0.777, and the C-index in the verification sample is 0.797, indicating that the nomogram model of this study has good accuracy and discrimination.

CONCLUSIONS

SII has a clear correlation to the prognosis of patients with alveolar echinococcosis. The nomogram prediction model constructed on this basis is beneficial to the clinically individualized analysis of the patient's prognosis.

Using machine learning to preoperatively stratify prognosis among patients with gallbladder cancer: a multi-institutional analysis

BACKGROUND

Gallbladder cancer (GBC) is an aggressive malignancy associated with a high risk of recurrence and mortality. We used a machine-based learning approach to stratify patients into distinct prognostic groups using preperative variables.

METHODS

Patients undergoing curative-intent resection of GBC were identified using a multi-institutional database. A classification and regression tree (CART) was used to stratify patients relative to overall survival (OS) based on preoperative clinical factors.

RESULTS

CART analysis identified tumor size, biliary drainage, carbohydrate antigen 19-9 (CA19-9) levels, and neutrophil-lymphocyte ratio (NLR) as the factors most strongly associated with OS. Machine learning cohorted patients into four prognostic groups: Group 1 (n = 109): NLR ≤1.5, CA19-9 ≤20, no drainage, tumor size <5.0 cm; Group 2 (n = 88): NLR >1.5, CA19-9 ≤20, no drainage, tumor size <5.0 cm; Group 3 (n = 46): CA19-9 >20, no drainage, tumor size <5.0 cm; Group 4 (n = 77): tumor size <5.0 cm with drainage OR tumor size ≥5.0 cm. Median OS decreased incrementally with CART group designation (59.5, 27.6, 20.6, and 12.1 months; p < 0.0001).

CONCLUSIONS

A machine-based model was able to stratify GBC patients into four distinct prognostic groups based only on preoperative characteristics. Characterizing patient prognosis with machine learning tools may help physicians provide more patient-centered care.

The prognostic value of neutrophil-to-lymphocyte ratio in cholangiocarcinoma: a systematic review and meta-analysis

The neutrophil-to-lymphocyte ratio (NLR) is used as biomarker in malignant diseases showing significant association with poor oncological outcomes. The main research question of the present study was whether NLR has also prognostic value in cholangiocarcinoma patients (CCA). A systematic review was carried out to identify studies related to NLR and clinical outcomes in CCA evaluating the literature from 01/2000 to 09/2021. A random-effects model, pooled hazard ratios (HR) and 95% confidence interval (CI) were used to investigate the statistical association between NLR and overall survival (OS) as well as disease-free survival (DFS). Subgroup analyses, evaluation of sensitivity and risk of bias were further carried out. 32 studies comprising 8572 patients were eligible for this systematic review and meta-analysis. The pooled outcomes revealed that high NLR prior to treatment is prognostic for poor OS (HR 1.28, 95% CI 1.18–1.38, p < 0.01) and DFS (HR 1.39, 95% CI 1.17–1.66, p < 0.01) with meaningful HR values. Subgroup analysis revealed that this association is not significantly affected by the treatment modality (surgical vs. non-surgical), NLR cut-off values, age and sample size of the included studies. Given the likelihood of NLR to be prognostic for reduced OS and DFS, pre-treatment NLR might serve as a useful biomarker for poor prognosis in patients with CCA and therefore facilitate clinical management.

Contrast-enhanced CT radiomics for prediction of recurrence-free survival in gallbladder carcinoma after surgical resection

OBJECTIVES

Gallbladder carcinoma (GBC) is the most common and aggressive biliary tract malignancy with high postoperative recurrence rates. This single-center study aimed to develop and validate a radiomics signature to estimate GBC recurrence-free survival (RFS).

METHODS

This study retrospectively included 204 consecutive patients with pathologically diagnosed GBC and were randomly divided into development (n = 142) and validation (n = 62) cohorts (7:3). The radiomics features of tumor were extracted from preoperative contrast-enhanced CT imaging for each patient. In the development cohort, the least absolute shrinkage and selection operator (LASSO) Cox regression was employed to develop a radiomics signature for RFS prediction. The patients were stratified into high-score or low-score groups according to their median value of radiomics score. A nomogram was established using multivariable Cox regression by incorporating significant pathological predictors and radiomics signatures.

RESULTS

The radiomics signature based on 12 features could discriminate high-risk patients with poor RFS. Multivariate Cox analysis revealed that pT3/4 stage (hazard ratio, [HR] = 2.691), pN2 stage (HR = 3.60), poor differentiation grade (HR = 2.651), and high radiomics score (HR = 1.482) were independent risk variables associated with worse RFS and were incorporated to construct a nomogram. The nomogram displayed good prediction performance in estimating RFS with AUC values of 0.895, 0.935, and 0.907 at 1, 3, and 5 years, respectively.

CONCLUSIONS

The radiomics signature and combined nomogram may assist in predicting RFS in GBC patients.

KEY POINTS

• A radiomics signature extracted from preoperative contrast-enhanced CT can be a useful tool to preoperatively predict RFS of GBC. • T3/T4 stage, N2, poor tumor differentiation, and high radiomics score were positively associated with postoperative recurrence.

A prognostic model in patients with advanced biliary tract cancer receiving first-line chemotherapy

BACKGROUND

Standard treatment of advanced biliary tract cancer (aBTC) is represented by first-line chemotherapy (CT1). However, some patients do not gain any benefit from CT1, contributing to the overall dismal prognosis of aBTC. The present study aimed to devise a prognostic model in aBTC patients receiving CT1.

METHODS

A large panel of clinical, laboratory, and pathology variables, available before the start of CT1, were retrospectively assessed in a multi-centric cohort to determine their prognostic value on univariate and multivariate regression analysis. The variables that showed a significant correlation with overall survival (OS) were computed in a three-tier prognostic score. External validation of the prognostication performance was carried out.

RESULTS

Clinical histories of 935 patients (median OS 10.3 months), with diagnosis dates ranging from 2001 to 2017, were retrieved from 14 institutions. According to multivariate analysis, Eastern Cooperative Oncology Group performance status, carbohydrate antigen 19.9, albumin levels, and neutrophil/lymphocyte ratio were strongly associated with OS (p <0.01). The prognostic score could generate a highly significant stratification (all between-group p values ≤0.001) into groups of favorable (comprising 51.5% of the sample), intermediate (39.2%), and poor prognosis (9.3%): median OS was 12.7 (CI_95% 11.0-14.4), 7.1 (CI_95% 5.8-8.4), and 3.2 months (CI_95% 1.7-4.7), respectively. This OS gradient was replicated in the validation set (129 patients), with median OS of 12.7 (CI_95% 11.0-14.3), 7.5 (CI_95% 6.1-8.9), and 1.4 months (CI_95% 0.1-2.7), respectively (all between-group p values ≤0.05).

CONCLUSION

A prognostic score, derived from a limited set of easily-retrievable variables, efficiently stratified a large population of unselected aBTC patients undergoing CT1. This tool could be useful to clinicians, to ascertain the potential benefit from CT1 at the start of treatment.

Prognostic Value of Peripheral Whole Blood Cell Counts Derived Indexes in Gallbladder Carcinoma: A Systematic Review and Meta-Analysis

Background

Gallbladder carcinoma (GBC) is a rare gastrointestinal malignancy with poor prognosis. Adequate pre-treatment prediction of survival is essential for risk stratification and patient selection for aggressive surgery or adjuvant therapeutic strategy. Whole blood cell count (WBCC) derived indexes are broadly used as prognosticative biomarkers in various cancer types, but their utility in GBC needs to be validated.

Methods

An extensive literature review was conducted in line with PRISMA guideline until June 31 2020, to identify original studies concerning WBCC-derived indexes as prognostic indicators in GBC. All relative parameters were extracted and pooled for statistical analyses.

Results

Fourteen studies incorporating 2,324 patients were included with a high quality and low risk of biases. All 14 studies evaluated the prognostic value of NLR showing a significant correlation with OS in GBC patients (HR = 1.94, P <0.001). Elevated NLR was revealed to correlate with TNM stage (stages III and IV, OR = 4.65, P <0.001), tumor differentiation (OR = 2.37, P <0.042), CA 19-9 (SMD = 0.47, P = 0.01), but no significance was found with age, sex and CEA. Positive indicative value of MLR and PLR were also confirmed with a HR of 2.06 (P <0.001) and 1.34 (P <0.001), respectively.

Conclusion

The WBCC-derived indexes including NLR, MLR/LMR and PLR were validated to be useful prognostic parameters for predicting survival outcomes in GBC patients. These series of indexes, especially NLR, could improve risk stratification and facilitate better patient selection for surgical resection or aggressive chemotherapy in the decision making of GBC patients.

The Relationship Between Preoperative Systemic Immune Inflammation Index and Prognostic Nutritional Index and the Prognosis of Patients With Alveolar Hydatid Disease

BACKGROUND

To explore the relationship between the preoperative immune inflammation index (SII) and the prognostic nutritional index (PNI) and the overall survival rate (OS) of patients with alveolar hydatid disease.

METHODS

The clinical data of patients with hepatic alveolar echinococcosis treated by surgery in the Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hospital of Qinghai University from January 2015 to January 2019 were analyzed retrospectively, and the SII, PNI, PLR and NLR were calculated. Spearman correlation analysis was utilized to analyze the correlation among SII, PNI, PLR and NLR. Receiver operating characteristic curve (ROC) was utilized to determine the best intercept values of SII, PNI, PLR and NLR, and Chi-square test was used to evaluate the relationship between SII, PNI and various clinicopathological features in patients with hepatic alveolar echinococcosis. The kaplan-Meier method was used to draw survival curves and analyze the relationship between them and the total survival time of patients. A cox regression model was used to analyze the relationship between SII, PNI and the prognosis of patients with hepatic alveolar echinococcosis. Finally, ROC curve was used to estimate the predictive efficacy of SII, PNI and COSII-PNI for the prognosis of patients with hepatic alveolar echinococcosis.

RESULTS

A total of 242 patients were included, including 96 males and 146 females, aged 11.0-67.0 (36.6 ± 11.7) years. The values of SII, PNI, PLR and NLR are calculated, and the best truncation values of SII, PNI, PLR and NLR are given in ROC curve. The kaplan-Meier survival curve was used to analyze the relationship between SII, PNI, PLR, NLR and the overall survival time of patients with hepatic alveolar echinococcosis. The results showed that the median follow-up time was 45 months (95%CI: 39.484-50.516), and the average survival time was 49 months (95%CI: 47.300-51.931), which was low p<0.001); The 5-year OS rate of low PNI was significantly lower than that of high PNI group (37.7% vs 71.6%; p<0.001); The 5-year OS rate in low PLR group was significantly higher than that in high PLR group (70.4% vs 24.3%; p<0.001); The 5-year OS rate in low NLR group was significantly higher than that in high NLR group (67.2% vs 28.8%; p<0.001). Cox unifoliate analysis showed that SII, PNI, PLR and NLR were important prognostic factors related to OS. Cox multivariate analysis showed that SII(HR=4.678, 95% CI: 2.581-8.480, P<0.001) and PNI(HR=0.530, 95%CI: 0.305-0.920, P<0.05) were identified as independent risk indicators of OS, while NL was identified as independent risk indicators of OS ROC curve analysis showed that AUC of SII, PNI, PLR, NLR and COSII-PNI were 0.670(95%CI: 0.601-0.738), 0.638(95%CI: 0.561-0.716) and 0.618(95% CI: 0.541-0.694), respectively COSII-PNI is superior to SII and PNI in evaluating prognosis (P < 0.05).

CONCLUSIONS

SII and PNI can be regarded as independent risk factors reflecting the prognosis of patients with hepatic alveolar echinococcosis. The lower SII and the higher PNI before operation, the better the prognosis of patients, and the combined application of SII and PNI before operation can improve the accuracy of prediction.

Prognostic Significance of Neutrophil-to-Lymphocyte Ratio in Differentiated Thyroid Carcinoma Having Distant Metastasis: A Comparison With Thyroglobulin-doubling Rate and Tumor Volume-doubling Rate

BACKGROUND/AIM

To date, thyroglobulin-doubling rate (Tg-DR) and tumor volume-doubling rate (TV-DR) of metastatic lesions have been identified as dynamic prognostic factors for differentiated thyroid carcinoma (DTC). In this study, we investigated the prognostic impact for another dynamic factor, the neutrophil-to-lymphocyte ratio (NLR), for DTC with distant metastasis.

PATIENTS AND METHODS

We enrolled 321 patients in total, and NLR at the first detection of distant metastasis (initial NLR) was collected for 312.

RESULTS

Patients with initial NLR >3 had a significantly poorer cause-specific survival than those with initial NLR ≤3. On multivariate analysis, initial NLR >3 was recognized as an independent prognostic factor together with Tg-DR >1/year, TV-DR >1/year, radioactive iodine-refractory distant metastasis, and distant metastasis to organs other than the lung.

CONCLUSION

Careful observation and active therapies, including multitarget kinase inhibitors, are recommended for patients with NLR >3 at the first detection of distant metastasis or during follow-up.

The predictive value of systemic immune inflammation index for postoperative survival of gallbladder carcinoma patients

BACKGROUND

Growing evidence indicates that systemic immune inflammation index (SII) can predict the prognosis of various solid tumors. The objective of this study aimed to investigate the efficacy of SII in predicting the prognosis of gallbladder carcinoma (GBC) patients after radical surgery.

METHODS

A consecutive series of 93 patients with GBC who underwent radical resection were enrolled in the retrospective study. The cutoff value for the SII was calculated using the time-dependent receiver operating characteristic (ROC) curve analysis by overall survival (OS) prediction. The associations between the SII and the clinicopathologic characteristics were analyzed using Pearson's χ² test and Fisher's exact test. Survival curves were calculated using the Kaplan-Meier method. Univariate analysis was performed to evaluate the prognostic relevance of preoperative parameters. The multivariate Cox regression proportional hazard model was used to assess variables significant on univariate analysis.

RESULTS

The Kaplan-Meier survival analysis and the multivariate analysis of patients with GBC who received radical resection showed SII independently predicted OS. The univariate analysis showed that the TNM stage, SII, CA19-9, ALP, prealbumin, NLR, MLR, lymph node metastasis, and histopathological type were all associated with overall survival. In time-dependent ROC analysis, the area of the SII-CA19-9 under the ROC curve (AUC) was higher than that of the preoperative SII or CA19-9 levels for the prediction of OS.

CONCLUSION

Our results demonstrate that high SII was a predictor of poor long-term outcomes among patients with GBC undergoing curative surgery. SII-CA19-9 classification may be more effective in predicting the postoperative prognosis of GBC patients.

Personalized Preoperative Nomograms Predicting Postoperative Risks after Resection of Perihilar Cholangiocarcinoma

INTRODUCTION

Curative treatment of perihilar tumors requires major hepatectomy responsible for high morbidity and mortality. Current nomograms are based on definitive pathological analysis, not usable for patient selection. Our aim was to propose preoperative predictors for severe morbidity (Dindo-Clavien ≥3) and mortality at sixth month after resection of perihilar tumors.

PATIENTS AND METHODS

We reviewed perioperative data of 186 patients operated with major hepatectomy for perihilar tumors between 2012 and 2018 in two high-volume centers. Univariate and multivariate analysis were performed to determine the preoperative predictors of morbidity and mortality. A stepwise regression in forward direction was developed to select variables for definitive models. Hosmer-Lemeshow test, Akaike information criteria and area under the ROC curves were calculated to validate both nomograms.

RESULTS

Resections were indicated for perihilar and intrahepatic cholangiocarcinoma in 125 and 61 cases, respectively. Severe complications occurred in 76 patients (40.8%). Nineteen patients (10.2%) deceased before the sixth postoperative month. The predictors of severe morbidity were: male gender, portal vein embolization, planned biliary resection, low psoas muscle area/height² and low hemoglobinemia. The predictors of early mortality were: age, high bilirubinemia, hypoalbuminemia, biliary drainage and long drainage-to-surgery interval. For both models, the p values of Hosmer-Lemeshow tests were of 0.9 and 0.99, respectively, the Akaike information criteria were of 35.5 and 37.7, respectively, and area under the curves was of 0.73 and 0.86, respectively.

CONCLUSION

We developed two accurate and practical nomograms based on exclusively preoperative data to predict early outcomes following the resection of perihilar tumors. If validated in larger series, these tools could be integrated in the decision-making process for patient selection.

The immunological characteristics of gallbladder carcinoma and advances in immunotherapy practices

Gallbladder carcinoma (GBC) is one of the most common malignant tumors in the biliary system, ranking sixth among gastrointestinal malignancies. In addition, the incidence of GBC has recently increased in China. GBC metastasizes early and invades adjacent organs such as the liver, making patients with GBC ineligible for radical surgery and giving them a poor prognosis. What is more, GBC is more inclined to develop chemo-resistance, which requires new strategies for clinical intervention. Cancer immunotherapy has made great advances over the past few years, with improved clinical efficacy against multiple malignancies, including GBC. This review summarizes the immunological characteristics of GBC as well as current advances in immunotherapies for GBC in order to provide new insights into future treatment and prevention of GBC.

Neutrophil to lymphocyte ratio as a prognostic marker in metastatic gallbladder cancer

BACKGROUND

Neutrophil-to-lymphocyte ratio (NLR) has been used as an inflammation based prognostic marker for various malignancies. This study evaluated the association between NLR and overall survival (OS) in patients with metastatic gallbladder cancer (GBC) METHODS: An optimal cut off point for NLR was identified by plotting spline-based hazard ratio curves to identify a threshold effect and patients were divided into two groups, ≥5 or <5. Kaplan-Meier curves were plotted for NLR≥5 and NLR<5 and OS between the two groups.

RESULTS

Of the 231 patients included, 138 (60%) had NLR <5 and 93 (40%) had NLR ≥5. There were no significant differences noted in gender, race, and administration of chemotherapy between the two groups. On univariable analysis, patients with NLR ≥5 had a significantly poor OS compared to those with NLR <5 (Median OS: 3.6 vs 8.7 months, p < 0.001). On multivariable analysis, adjusting for age, performance status, albumin, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, bilirubin, platelet count and no administration of chemotherapy, NLR of ≥5 was associated with a worse OS compared to NLR <5 (HR: 1.70, 95%CI:1.20-2.39, p < 0.05).

CONCLUSION

The current study demonstrates that NLR ≥5 is an independent predictor of poor prognosis in patients with metastatic GBC.

Clinical Significance of Glucose to Lymphocyte Ratio (GLR) as a Prognostic Marker for Patients With Pancreatic Cancer

Glucose metabolism and systemic inflammation have been associated with cancer aggressiveness and patient prognosis in various malignancies. This study aimed to evaluate the prognostic significance of pretreatment GLR(glucose to lymphocyte ratio) and systemic immune inflammation in patients with pancreatic cancer. We studied 360 patients with pathologically diagnosed pancreatic adenocarcinoma that was clinically unresectable. Baseline clinicopathological characteristics and laboratory investigations including fasting blood glucose, platelet count, lymphocyte count, neutrophil count, carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA199), and follow-up data were collected for further analysis. The patients were randomly divided into a training cohort (n = 238) and a validation cohort (n = 122). Univariate and multivariate Cox proportional hazard regression analyses were performed to identify the prognostic value of GLR, systemic immune-inflammation markers, and tumor biomarkers. A nomogram model was developed based on the identified prognostic factors, and we used the C-index to evaluate the accuracy of the Cox regression model prediction. Multivariate analysis revealed that GLR [hazard ratio (HR): 2.597; 95% confidence interval (CI): 1.728-3.904)] and CA199 (HR: 2.484; 95% CI: 1.295-4.765) are independent predictors of poor overall survival in the training cohort and were incorporated into the nomogram for OS as independent factors. Moreover, the C-index analyses demonstrated that the C-indexes in the training cohort and the validation cohort were 0.674 and 0.671, respectively. The nomogram model predicts overall survival relatively accurately. We found that the baseline GLR is an independent prognostic factor for patients with pancreatic cancer, and the proposed nomogram can be used as an effective tool for predicting the outcomes of prognosis of patients with pancreatic cancer.

Preoperative C-reactive protein-to-albumin ratio predicts long-term outcomes in extrahepatic cholangiocarcinoma patients

BACKGROUND

Systemic inflammation may have prognostic value in some malignancies and association with lymph node metastasis. This study aimed to evaluate the impact of systemic inflammatory biomarkers on long-term and oncological outcomes as well as to assess the association between biomarkers with lymph node metastasis in extrahepatic cholangiocarcinoma patients.

METHODS

We enrolled 271 consecutive patients who underwent surgical resection for extrahepatic cholangiocarcinoma. Poor prognostic factors were compared to identify the biomarkers that were most associated with overall survival (OS) and disease-free survival (DFS) using receiver operating characteristic curves and multivariable analysis. Furthermore, we evaluated the relationship between biomarkers and lymph node metastasis.

RESULTS

Four and two biomarkers were predictive for OS and DFS, respectively, among which, the C-reactive protein-to-albumin ratio (CAR) had the highest area under the curve values (OS: 0.631, DFS: 0.624). Multivariable analysis showed that a high CAR was an independent prognostic factor for both OS and DFS (P = .002 and P < .001, respectively). Although a high CAR was not significantly correlated with lymph node metastasis (P = .645), carbohydrate antigen 19-9 showed a significant correlation (P < .001).

CONCLUSIONS

Preoperative CAR is the most accurate prognostic factor for OS and DFS in extrahepatic cholangiocarcinoma patients and is independent of lymph node metastasis.

Preoperative Systemic Immune-Inflammation Index (SII) for Predicting the Survival of Patients with Stage I-III Gastric Cancer with a Signet-Ring Cell (SRC) Component

Background

Recently, a novel systemic immune-inflammation index (SII) based on peripheral lymphocytes, neutrophils, and platelets has been reported to be correlated with patient prognosis in several malignancies, including gastric cancer. However, the prognostic value of the SII for gastric cancer patients with a signet-ring cell (SRC) component has not yet been reported. In this study, we aimed to assess the prognostic value of the SII in gastric cancer patients with an SRC component after curative resection.

Methods

This study was a retrospective analysis of 512 GC patients with an SRC component who underwent curative resection. The prognostic value of the SII was analyzed by the Kaplan-Meier method and Cox proportional hazards regression model.

Results

In our study cohort, an optimal cut-off value for the SII of 527 was used to stratify patients with gastric cancer (GC) into low (<527) and high SII (≥527) groups. Our study indicated that a high SII (≥527) was significantly correlated with a large tumor size (p < 0.001), infiltration of serosa (p < 0.001), lymph node metastasis (p < 0.001), and advanced TNM stage (p < 0.001). Univariate and multivariate analyses further demonstrated that a low SII was correlated with better clinical outcome and was an independent prognostic predictor in GC patients with an SRC component. Furthermore, the SII retained prognostic value in the subgroup analysis, including subgroup of different TNM stages and pure or mixed signet-ring cell carcinomas (SRCCs).

Conclusion

The SII is a simple, promising, and practical prognostic biomarker for patients with surgically resected mixed SRCC and pure SRCC. The SII could complement current prognostic tools for better treatment planning and stratification of patients.

Preoperative gamma-glutamyltransferase to lymphocyte ratio predicts long-term outcomes in intrahepatic cholangiocarcinoma patients following hepatic resection

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is a heterogeneous hepatobiliary cancer with limited treatment options. A number of studies have illuminated the relationship between inflammation-based prognostic scores and outcomes in patients with ICC. However, the use of reliable and personalized prognostic algorithms in ICC after resection is pending.

AIM

To assess the prognostic value of the gamma-glutamyltransferase to lymphocyte ratio (GLR) in ICC patients following curative resection.

METHODS

ICC patients following curative resection (2009-2017) were divided into two cohorts: The derivation cohort and validation cohort. The derivation cohort was used to explore an optimal cut-off value, and the validation cohort was used to further evaluate the score. Overall survival (OS) and recurrence-free survival (RFS) were analyzed, and predictors of OS and RFS were determined.

RESULTS

A total of 527 ICC patients were included and randomly divided into the derivation cohort (264 patients) and the validation cohort (263 patients). The two patient cohorts had comparable baseline characteristics. The optimal cut-off value for the GLR was 33.7. Kaplan-Meier curves showed worse OS and RFS in the GLR > 33.7 group compared with GLR ≤ 33.7 group in both cohorts. After univariate and multivariate analysis, the results indicated that GLR was an independent prognostic factor of OS [derivation cohort: hazard ratio (HR) = 1.620, 95% confidence interval (CI): 1.066-2.462, P = 0.024; validation cohort: HR = 1.466, 95%CI: 1.033-2.142, P = 0.048] and RFS [derivation cohort: HR = 1.471, 95%CI: 1.029-2.103, P = 0.034; validation cohort: HR = 1.480, 95%CI: 1.057-2.070, P = 0.022].

CONCLUSION

The preoperative GLR is an independent prognostic factor for ICC patients following hepatectomy. A high preoperative GLR is associated with worse OS and RFS.

Neutrophil-lymphocyte ratio predicts disease severity and outcome after lower extremity procedures

OBJECTIVE

Neutrophil-lymphocyte ratio (NLR) has been associated with inferior outcomes after lower extremity interventions. NLR has been associated with systemic inflammation and atherosclerotic burden. We examined NLR, severity of peripheral artery disease (PAD), and outcomes after endovascular or open surgical procedures.

METHODS

Inpatients undergoing lower extremity procedures (2008-2016) were selected from Cerner Health Facts database (Cerner Corporation, North Kansas City, Mo) using International Classification of Diseases, Ninth Revision procedure codes. Disease severity was grouped into claudication, rest pain, and tissue loss. Outcomes were identified using International Classification of Diseases, Ninth Revision codes. NLR was calculated preoperatively and postoperatively. A χ² analysis and multivariable logistic regression were performed. A receiver operating characteristic curve analysis was used to determine the cutoff for preoperative (low, <3.65; high, ≥3.65) and postoperative (low, <5.96; high, ≥5.96) NLR values.

RESULTS

There were 3687 patients evaluated; 2183 (59%) underwent endovascular procedures and 1504 (41%) had open procedures. Compared with black patients, claudication was more frequent in white patients (81.7% vs 72.7%; P < .0001), and tissue loss was less common (12.9% vs 20.9%; P < .0001). NLR values were higher for patients with tissue loss than for patients with rest pain or claudication (4.89, 4.33, and 3.11, respectively; P < .0001). Open procedures were associated with higher postoperative NLR values than endovascular procedures (6.8 vs 5.2; P < .0001). Mean preoperative and postoperative NLR values were greater in patients with more severe PAD. Multivariable analysis demonstrated that preoperative high NLR was strongly associated with in-hospital death (odds ratio [OR], 5.4; 95% confidence interval [CI], 1.68-17.07), cardiac complications (OR, 2.9; 95% CI, 1.57-5.40), amputation (OR, 2.5; 95% CI, 1.65-3.87), renal failure (OR, 1.9; 95% CI, 1.18-2.93), respiratory complications (OR, 1.7; 95% CI, 1.09-2.76), and prolonged length of stay (OR, 1.9; 95% CI, 1.89-3.71).

CONCLUSIONS

Preoperative and postoperative NLR significantly increases with disease severity for PAD, providing further evidence of NLR as a biomarker of a patient's systemic inflammatory state. After adjustment for confounders, NLR still remained strongly associated with death and other adverse outcomes after intervention for PAD. Further study of the clinical association of NLR with other vascular disorders, such as symptomatic carotid stenosis and symptomatic and ruptured aortic aneurysmal disease, is planned to guide individualized treatment to prevent stroke or aneurysm rupture.

Associations between absolute neutrophil count and lymphocyte-predominant breast cancer

INTRODUCTION

Tumor-infiltrating lymphocytes (TILs) might be associated with host-cell mediated immunity, which could be partly reflected by peripheral blood cell counts. In addition, lymphocyte-predominant breast cancer (LPBC), which was defined as tumors having high TIL levels, showed a favorable prognosis among triple-negative breast cancer or HER2-positive breast cancer. We aimed to investigate whether peripheral blood cell counts are associated with LPBC.

METHODS

We evaluated the percentage of stromal TILs in breast cancer patients who underwent primary surgery, using the standardized methodology proposed by the international TIL Working Group. Lymphocyte-predominant breast cancer (LPBC) was defined as tumors having high TIL levels (≥50%). Peripheral blood cell counts including absolute neutrophil counts (ANC), absolute lymphocyte counts (ALC) and neutrophil-to-lymphocyte ratio (NLR) was obtained from pretreatment laboratory data.

RESULT

Of the 810 patients, 132 (16.3%) had LPBC, and 678 (83.7%) had non-LBPC. In a comparison of 3 markers of peripheral blood counts, LPBC had a significantly lower mean ANC than non-LPBC (3,304 vs. 3,564; P = 0.023), but the other means were not different. In multivariable analysis, each 1K increment in ANC corresponded to an odds ratio of 0.790 (95% CI, 0.642 to 0.971) for LPBC. In the ER-negative and high-Ki67 subgroups identified by interaction tests, significant inverse correlations between continuous ANC and TILs were noted.

CONCLUSION

Low peripheral ANC could be linked with LPBC, supporting the hypothesis that systemic immune cell counts might be associated with the tumor-immune microenvironment.

Glucose to Lymphocyte Ratio as a Prognostic Marker in Patients With Resected pT2 Gallbladder Cancer

BACKGROUND

We designed a clinical application of glucose to lymphocyte ratio (GLR) as it might be a sensitive parameter to determine the glucose metabolism and behavior of the cancer (i.e., its aggressiveness), and the immunologic status of a patient with cancer. Thus, we investigated the association of GLR with the overall survival (OS) and disease-free survival (DFS) of patients with T2 gallbladder (GB) cancer after curative-intent surgery.

METHODS

The medical records of patients with T2 GB cancer who underwent surgery were retrospectively reviewed. The clinicopathologic characteristics, preoperative complete blood counts, fasting blood glucose, albumin, cholesterol, and follow-up information were collected.

RESULTS

A total of 197 patients were included in the study. In multivariate analysis, high GLR (>69.3) was associated with poor OS (HR = 15.249, 95% CI: 4.090-56.849, P = 0.0001) along with R1 status (HR = 1.755, 95% CI: 0.033-0.910, P = 0.033), >3 metastatic lymph nodes (HR = 2.809, 95% CI: 1.403-5.625; P = 0.004), and lymphovascular invasion (HR = 8.041, 95% CI: 2.881-22.442; P = 0.0001). Moreover, high GLR (HR = 3.666, 95% CI: 1.145-11.737, P = 0.029), adjuvant chemotherapy (HR = 6.306, 95% CI: 1.921-20.699; P = 0.002), lymphovascular invasion (HR = 5.464, 95% CI: 1.783-16.746; P = 0.003), and high-grade tumor (HR = 2.143, 95% CI: 1.042-4.407; P = 0.038) were independently associated with DFS.

CONCLUSIONS

Preoperative GLR is an independent predictor of OS and DFS in T2 GB cancer. Further studies are required to validate these findings.

Clinical Significance of Prothrombin Time in Cholangiocarcinoma Patients with Surgeries

BACKGROUND

Prothrombin time (PT) can predict survival in several types of malignancies. This study aims to investigate the predictive values of PT levels in patients with cholangiocarcinoma (CCA).

METHODS

We retrospectively analyzed the PT from 86 CCA patients who underwent curative resection in our hospital from December 2008 to August 2017. The relationship between PT and survival times was analyzed through univariate and multivariate analyses (Cox proportional hazards model). Kaplan-Meier curves and log-rank test were used to assess the effects of PT on overall survival (OS) and tumor recurrence-free survival (RFS).

RESULTS

Increased PT level was an effective predictor for OS (P = 0.021; hazard ratio (HR), 1.799) and RFS (P = 0.016; HR, 1.871) in CCA patients, independent of age, tumor differentiation, and TNM stage. In the low PT level group (PT < 12.3 s), patients showed a higher mean OS (23.03 m vs. 14.38 m, P = 0.0250) and RFS (17.78 m vs. 8.30 m, P = 0.0511) than those with high PT levels (PT ≥ 12.3 s). A highly significant association was observed between high PT level and shortened OS (P = 0.0373) and worse RFS (P = 0.0151).

CONCLUSION

Preoperative increase in PT can serve as a simple but effective predictor of poor survival in CCA patients who undergo curative surgeries.

Systemic inflammatory response predicts oncological outcomes in patients undergoing elective surgery for mismatch repair-deficient colorectal cancer

INTRODUCTION

A variety of inflammatory scoring systems and their prognostic value have been reported in many solid organ cancers. This study aimed to examine the association between the systemic and local inflammatory responses, and oncological outcomes in patients undergoing elective surgery for mismatch repair-deficient (dMMR) phenotype colorectal cancer (CRC).

MATERIALS AND METHODS

Consecutive patients undergoing resection for dMMR CRC were identified from a prospectively maintained database and compared with a cohort of patients with proficient mismatch repair system tumours. Systemic inflammatory response was assessed by the modified Glasgow prognostic score (mGPS), neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio, lymphocyte-monocyte ratio, C-reactive protein/albumin ratio, prognostic index and prognostic nutritional index. Local inflammatory response was defined by the presence of tumour infiltrating lymphocytes, tumour infiltrating neutrophils, plasma cells or macrophages at the invasive front. The inflammatory infiltrate was assessed using the Klintrup-Mäkinen (KM) score.

RESULTS

On univariable analysis, preoperative NLR ≥ 5 (hazard ratio [HR] 2.5; 95% confidence interval [CI] 1.25-5.19; p = 0.007) and mGPS (HR 1.6; 95% CI 1.1-2.6; p = 0.03) predicted worse overall survival, but only NLR was associated with greater recurrence (HR 3.6; 95% CI 1.5-8.8; p = 0.004). Increased local inflammatory response, as measured by KM score (HR 0.31; 95% CI 0.1-0.7; p = 0.009) and the presence of macrophages in the peritumoral infiltrate (HR 0.17; 95% CI 0.07-0.3; p < 0.001), was associated with better outcomes. NLR was the only independent prognostic factor of overall and disease-free survival.

CONCLUSION

Systemic inflammatory response predicts oncological outcomes in CRC patients, but only NLR has prognostic value in the dMMR group.

Systematic review of management of incidental gallbladder cancer after cholecystectomy

BACKGROUND

Gallbladder cancer is rare, but cancers detected incidentally after cholecystectomy are increasing. The aim of this study was to review the available data for current best practice for optimal management of incidental gallbladder cancer.

METHODS

A systematic PubMed search of the English literature to May 2018 was conducted.

RESULTS

The search identified 12 systematic reviews and meta-analyses, in addition to several consensus reports, multi-institutional series and national audits. Some 0·25-0·89 per cent of all cholecystectomy specimens had incidental gallbladder cancer on pathological examination. Most patients were staged with pT2 (about half) or pT1 (about one-third) cancers. Patients with cancers confined to the mucosa (T1a or less) had 5-year survival rates of up to 100 per cent after cholecystectomy alone. For cancers invading the muscle layer of the gallbladder wall (T1b or above), reresection is recommended. The type, extent and timing of reresection remain controversial. Observation time may be used for new cross-sectional imaging with CT and MRI. Perforation at initial surgery had a higher risk of disease dissemination. Gallbladder cancers are PET-avid, and PET may detect residual disease and thus prevent unnecessary surgery. Routine laparoscopic staging before reresection is not warranted for all stages. Risk of peritoneal carcinomatosis increases with each T category. The incidence of port-site metastases is about 10 per cent. Routine resection of port sites has no effect on survival. Adjuvant chemotherapy is poorly documented and probably underused.

CONCLUSION

Management of incidental gallbladder cancer continues to evolve, with more refined suggestions for subgroups at risk and a selective approach to reresection.

Prognostic significance of neutrophil-lymphocyte ratio and carbohydrate antigen 19-9 in patients with gallbladder carcinoma

The neutrophil-lymphocyte ratio (NLR) is an immune response-related indicator and it is associated with poor prognosis of various cancers. The carbohydrate antigen19-9 (CA19-9) is a tumor-associated antigen and it has prognostic relevance in gallbladder carcinoma (GBC). We aimed to analyze whether preoperative NLR and serum CA19-9 were associated with outcomes of GBC patients after surgery with curative intent.Between January 2010 and May 2015, 90 resectable GBC patients who underwent curative surgery in our institution were included. All final diagnoses were confirmed by pathologic examination. The demographics, clinical, and histopathology data were analyzed. The Cox regression proportional hazard model and Kaplan-Meier method were used to assess prognostic factors.The cutoff values of 4.33 and 250.90 U/mL were defined as high NLR and high CA19-9, respectively. The univariate analyses showed that TNM stage, lymph node metastasis, the degree of tumor differentiation, margin status, combined hepatectomy, CA19-9, NLR, and PNI were all associated with overall survival (P < .05). According to the multivariable analysis, NLR (hazard ratio (HR) 3.840, 95% confidence interval (95% CI): 2.122-6.947, P < .001), CA19-9 (HR 2.230, 95% CI: 1.297-3.835, P = .004), TNM stage (HR 3.864, 95% CI: 1.819-8.207, P < .001), lymph node metastasis (HR 1.679, 95% CI: 1.005-2.805, P = .048), and margin status (HR 1.873, 95% CI: 1.063-3.300, P = .030) were independent prognostic factors. The median survival time in low NLR and CA19-9 group was better than high NLR and CA19-9 group (P < .05).The preoperative NLR and serum CA19-9 are associated with prognosis of patients with GBC. High NLR and high CA19-9 were predictors of poor long-term outcome among patients with GBC undergoing curative surgery.

Total lymphocyte count, neutrophil-lymphocyte ratio, and platelet-lymphocyte ratio as prognostic factors in advanced non-small cell lung cancer with chemoradiotherapy

Objective

The objective of this study was to investigate the prognostic significance and the efficacy evaluation of total lymphocyte count (TLC), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) in advanced non-small cell lung cancer (NSCLC) patients treated with chemoradiotherapy.

Patients and methods

A total of 389 advanced NSCLC patients who received chemoradiotherapy from 2011 to 2016 were enrolled in this retrospective study. TLC, NLR, and PLR were analyzed with overall survival (OS). Survival data were identified with the Kaplan-Meier method and optimal cutoff values with receiver operating characteristic curves.

Results

The median OS for all patients was 18.37 months. Pretreatment and median baseline TLC was 2.47×10³/μL (±0.78); NLR, 3.15 (±3.96); and PLR, 143.82 (±91.77); corresponding cutoffs were 2.4, 3.4, and 136.1. Higher TLC was associated with superior median OS (21.78 vs 15.66 months, P<0.001), and higher NLR and PLR with worse median OS (NLR: 14.13 vs 23.8 months, P<0.001; PLR: 15.49 vs 22.04 months, P<0.001).

Conclusion

The lymphopenia indicators (TLC, NLR, and PLR) were significant prognostic indicators of survival in advanced NSCLC patients treated with chemoradiotherapy.

The prognostic value of preoperative inflammatory indexes in gallbladder carcinoma with hepatic involvement

BACKGROUND

Neutrophil-Lymphocyte Ratio (NLR) and Platelet-Lymphocyte Ratio (PLR) have been considered as indicators for prognosis in various cancers. However, the prognostic values of NLR and PLR have never been tested in gallbladder carcinoma (GBC) with hepatic involvement.

OBJECTIVE

The aim of the current study was to assess the prognostic significance of NLR, PLR, and other candidate biomarkers in GBC with liver involvement.

METHODS

Receiver operating characteristic (ROC) curve analyses were utilized to pinpoint the cut-off values for NLR, PLR, and Monocyte-Lymphocyte Ratio (MLR). Univariate analyses were employed to estimate the impact of NLR, PLR, MLR, and other inflammatory indexes on median survival. Multivariate analyses were used to verify the independent prognostic predictors.

RESULTS

Eighty four patients were enrolled from 2009 to 2017. The cut-off values for NLR, PLR, and MLR were 3.20, 117.75, and 0.25, respectively. Univariate analyses revealed that TNM stage, NLR, PLR, MLR, lactate dehydrogenase, alkaline phosphatase, and carcinoembryonic antigen were significantly associated with decreased survival in GBC with hepatic involvement. Advanced TNM stage (P< 0.001) and elevated preoperative NLR (P= 0.002) were significantly associated with lower median survival periods, as revealed by multivariate analyses.

CONCLUSIONS

These findings suggest that preoperative NLR may be an independent prognostic factor in evaluating prognosis in GBC with liver involvement.

[Impact of the Pretreatment or Posttreatment NLR and PLR on the Response of First Line Chemotherapy and the Outcomes in Patients with Advanced Non-small Cell Lung Cancer]

背景与目的

中性粒细胞淋巴细胞比值(neutrophil-to-lymphocyte ratio, NLR)和血小板淋巴细胞比值(platelet-to-lymphocyte ratio, PLR)是机体系统性炎症的体现, 与多种肿瘤的预后有关。本研究旨在探讨NLR、PLR及其动态变化对非小细胞肺癌(non-small cell lung cancer, NSCLC)一线化疗疗效和预后的影响。

方法

回顾性分析68例2008年4月-2015年4月于北京大学第三医院接受一线化疗、符合入组标准的进展期NSCLC住院患者, 采集一线化疗前和2周期化疗后的NLR和PLR, 应用Kaplan-Meier方法进行生存分析, 单因素和Cox多因素分析NLR、PLR及其动态变化和各种临床特征与一线化疗疗效和总生存期(overall survival, OS)之间的关系。

结果

NLR在2周期化疗后显著下降, NLR2(2周期化疗后NLR)和NLR0(治疗前NLR)分别为(2.69±2.06)和(3.94±2.12)(P=0.000), PLR化疗前后无显著变化(P > 0.05);NLR2与一线化疗2周期和4周期的疗效显著相关(P < 0.05), 疾病进展患者中高NLR2的比例为100.0%, 显著高于部分缓解和疾病稳定组(P < 0.05);NLR0、NLR2和PLR0与OS显著相关(P < 0.05), 但与患者年龄、体力状况、病理类型、肿瘤分期、治疗状态、治疗方案均无关(P > 0.05);单因素分析显示OS与NLR0、NLR2、PLR0、二线治疗状态、二线方案选择、一线化疗2周期疗效、4周期疗效显著相关(P < 0.05), 与肿瘤分期、三线治疗状态及放疗状态无关(P > 0.05);多因素分析表明NLR0(P=0.004)、一线化疗4周期后疗效(P=0.022)、二线治疗状态(P=0.007)是OS的独立预测因素。

结论

治疗前NLR与NSCLC的预后显著相关, 化疗后NLR与一线治疗疗效显著相关。因此, NLR是预测进展期NSCLC一线化疗疗效和预后的理想指标, 也是治疗NSCLC潜在的干预靶点。

Pre-operative Sarcopenia Identifies Patients at Risk for Poor Survival After Resection of Biliary Tract Cancers

INTRODUCTION

Biliary tract cancers (BTC) are aggressive malignancies that require complex surgical procedures. Patients with BTC can present with skeletal muscle depletion, yet the effects of muscle wasting (sarcopenia) on outcomes have not been well studied. The objective of the current study was to define the impact of sarcopenia on survival among patients undergoing resection of BTC.

METHODS

Patients who underwent exploration for BTC who had a pre-operative CT scan available for review were identified. Body composition variables including total and psoas muscle area (cm²), muscle density (Hounsfield units), visceral fat area, subcutaneous fat area, and waist-to-hip ratio were analyzed at the level of L3. Outcomes were assessed according to the presence or absence of sarcopenia defined using sex- and BMI-specific threshold values for Psoas Muscle Index (PMI, cm²/m²).

RESULTS

Among 117 patients with BTC, 78 (67%) underwent curative-intent resection and 39 (33%) were explored but did not undergo resection due to metastatic/locally advanced disease. Tumor type included distal cholangiocarcinoma (n = 18, 15.4%), hilar cholangiocarcinoma (n = 27, 23.1%), gallbladder carcinoma (n = 52, 44.4%), and intrahepatic cholangiocarcinoma (n = 20, 17.1%). Median patient age was 65.6 years and 43.6% were male. Mean patient BMI was 26.1 kg/m² among men and 27.5 kg/m² among women. Overall, 41 (35.0%) patients had sarcopenia. Sarcopenia was associated with an increased risk of death among patients who underwent resection (HR 3.52, 95%CI 1.60-7.78, p = 0.002), which was comparable to patients with unresectable metastatic disease. Other factors such as low serum albumin (HR 3.17, 95% CI 1.30-7.74, p = 0.011) and low psoas density (HR 2.96, 95% CI 1.21-7.21, p = 0.017) were also associated with increased risk of death. Survival was stratified based on sarcopenia, psoas density, and serum albumin. The presence of each variable was associated with an incremental increased risk of death (0 variables ref.; 1 variable HR 3.8, 95% CI 1.0-14, p = 0.043; 2 variables HR 13.1, 95% CI 3.0-57.7, p = 0.001; 3 variables HR 14.6, 95% CI 2.5-87.1, p = 0.003). Patients who had no adverse prognostic factors had a 3-year OS of 67% versus no survival among patients with all 3 factors.

CONCLUSIONS

Sarcopenia was common among patients undergoing resection of BTC, occurring in 1 of every 3 patients. Sarcopenia was associated with poor survival after resection, particularly among patients who experienced a recurrence. Body composition metrics such as sarcopenia and low psoas muscle density in addition to low albumin level were able to stratify patients into different prognostic categories.

Dose escalation of radiotherapy in unresectable extrahepatic cholangiocarcinoma

Purpose

To evaluate the effect of escalated dose radiation therapy (EDR, defined as doses >50.4 Gy in 28 fractions [59.5 Gy BED]) on overall survival (OS), freedom from local progression (FFLP), and freedom from distant progression (FFDP) of patients with unresectable extrahepatic cholangiocarcinoma (EHCC).

Methods

A consecutive cohort of 80 patients who underwent radiotherapy for unresectable EHCC from 2001 to 2015 was identified. Demographic, tumor, treatment, toxicity, and laboratory variables were collected. The maximal RT doses ranged from 30 to 75 Gy (median 50.4 Gy, at 1.8‐4.5 Gy/fraction). Gross tumor volume (GTV) coverage by maximal dose in EDR group ranged from 38% to 100%. Kaplan–Meier method was used to estimate OS, FFLP, and FFDP. Univariate and multivariate Cox regression models were analyzed.

Results

After radiotherapy, median OS, FFLP, and FFDP were 18.7, 22.6, and 24.3 months, respectively. There was no significant difference in OS or FFLP between patients who received EDR to portions of the GTV and patients who did not. On multivariate analysis, bigger GTV, age, and ECOG performance status were independently associated with shorter OS. Local progression on chemotherapy prior to RT was independently associated with shorter FFLP. High baseline neutrophil/lymphocyte ratio (>5.3) was independently associated with shorter FFDP. Toxicity grades were similar in EDR and lower doses except lymphopenia which was higher in EDR (P = 0.053).

Conclusions

EDR to selective portions of the GTV may not benefit patients with unresectable EHCC despite having acceptable toxicity. New methods to improve local control and survival for unresectable EHCC are needed.

Relationship between blood parameters and Clonorchis sinensis infection: A retrospective single center study

Our study aims to retrospectively investigate neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and eosinophil-to-lymphocyte ratio (ELR) in patients infected with Clonorchis sinensis. This study analyzes a total of 151 patients with C. sinensis infections and 53 healthy control patients from our hospital. We found close relationships between the three candidate markers and the stages of C. sinensis infection-related biliary obstruction. The NLRs, PLRs and ELRs of patients with C. sinensis infections were significantly higher than those of healthy individuals; of those, ELRs showed the most superior diagnostic accuracy (sensitivity = 62.9%, specificity = 92.5%). Further, we constituted a logistic regression prediction model; applying two variables (age and NLR) with a sensitivity of 88.89% and a specificity of 83.78% in differentiating C. sinensis-related cholelithiasis from C. sinensis-untreated patients. Cancer antigen 19-9 (CA19-9) is a commonly used marker in the diagnosis of cholangiocarcinoma. Significant correlation was observed between NLR and CA19-9 in patients with C. sinensis-related cholangiocarcinoma (r = 0.590, P = 0.000). In the receiver operating characteristic analysis for separating C. sinensis-related cholelithiasis and cholangiocarcinoma, the cutoff value of PLR was 145.14 with a sensitivity of 65.62% and a specificity of 68.89%; the sensitivity of CA19-9 was 75.00% with a specificity of 77.78%. PLR showed acceptable efficiency to separate C. sinensis-related cholelithiasis from cholangiocarcinoma. In conclusion, all of the candidate markers (PLRs, NLRs and ELRs) may act as the valuable supplement in detecting C. sinensis infections and diseases.

Neutrophil-to-lymphocyte ratio in head and neck cancer prognosis: A systematic review and meta-analysis

BACKGROUND

Hematologic markers, such as the neutrophil-to-lymphocyte ratio (NLR), characterize the inflammatory response to cancer and are associated with poorer survival in various malignancies. We evaluate the effect of pretreatment NLR on overall survival (OS) in patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

Using multiple databases, a systematic search for articles evaluating the effect of NLR on OS in patients with HNSCC was performed. An inverse variation, random-effects model was used to analyze the data.

RESULTS

A total of 24 of 241 articles, including 6479 patients, were analyzed. The combined hazard ratio for OS in patients with an elevated NLR (range 2.04-5) was 1.78 (confidence interval [CI] 1.53-2.07; P < .0001). The hazard ratios for site-specific cancer: oral cavity 1.56 CI 1.23-1.98 (P < .001), nasopharynx 1.66 CI 1.35-2.04 (P < .001), larynx 1.55 CI 1.26-1.92 (P < .001), and hypopharynx 2.36 CI 1.54-3.61 (P < .001).

CONCLUSION

An elevated NLR is predictive of poorer OS in patients with HNSCC.

Surgical Site Infection Is Associated with Tumor Recurrence in Patients with Extrahepatic Biliary Malignancies

BACKGROUND

Surgical site infections (SSI) are one of the most common complications after hepato-pancreato-biliary surgery. Infectious complications may lead to an associated immune-modulatory effect that inhibits the body's response to cancer surveillance. We sought to define the impact of SSI on long-term prognosis of patients undergoing surgical resection of extrahepatic biliary malignancies (EHBM).

METHODS

Patients undergoing surgery for EHBM between 2000 and 2014 were identified using a large, multi-center, national cohort dataset. Recurrence free survival (RFS) was calculated and a multivariable Cox proportional hazards model was utilized to identify potential risk factors for RFS including SSI.

RESULTS

Seven hundred twenty-eight patients included in the analytic cohort; 236 (32.4%) patients had perihilar cholangiocarcinoma, 241 (33.1%) gallbladder cancer, and 251 (34.5%) distal cholangiocarcinoma. A major resection, liver resection, was performed in 205 (28.3%) patients, while 110 (15.2%) patients had a pancreaticoduodenectomy. The overall incidence of morbidity was 55.8%; among the 397 patients who experienced a complication, 161 patients specifically had an SSI. The SSI occurred as an infection of the surgical site (n = 70, 9.6%) or formation of an abscess in the operative bed (n = 91, 12.5%). SSI was associated with long-term survival as patients who experienced an SSI had a median RFS of 19.5 months compared with 30.5 months for those patients who did not have an SSI (HR 1.40, 95% CI 1.08-1.80; p = 0.01). Among 279 patients who had EHBM that had no associated lymph node metastases, well-to-moderate tumor differentiation, as well as an R0 resection margin, SSI remained associated with worse RFS (HR 1.84, 95% CI 1.03-3.29; p = 0.038), as well as overall survival (HR 1.87, 95% CI 1.18-2.97; p = 0.008).

CONCLUSION

SSI was a relatively common occurrence following surgery for EHBM as 1 in 10 patients experienced an SSI. In addition to standard tumor-specific factors, the occurrence of postoperative SSI was adversely associated with long-term survival.