A novel prognostic marker in patients with non-small cell lung cancer: musculo-immuno-nutritional score calculated by controlling nutritional status and creatine kinase

Association between CONUT scores and survival outcomes in patients with non-small cell lung cancer: meta-analysis from 4973 Asian cases

Background

The controlling nutritional status (CONUT) score is associated with cancer prognosis. However, a consensus on its prognostic value in patients with non-small cell lung cancer(NSCLC) is lacking. The present study aims to investigate the relationship between the CONUT score and prognostic and clinicopathological features of NSCLC.

Methods

The PubMed, Embase, Web of Science and Cochrane Library were searched up to July 2024. Two researchers used the Newcastle Ottawa Scale (NOS) score to evaluate the quality of the included studies and extracted data. The primary and secondary outcomes were overall survival (OS) and disease-free survival (DFS), and the hazard ratio (HR) and 95% confidence interval (CI) were pooled for meta-analysis. The pooled odds ratio (OR) and 95% CI were used to estimate the correlation between the CONUT score and clinical characteristics. Subgroup analysis and sensitivity analysis were performed during the pooled analysis.Funnel plots as well as Begg's and Egger's tests were used to assess publication bias.

Results

Fifteen high-quality studies with 4973 patients were included. The results indicated that a high CONUT score was associated with poor OS (HR = 1.84, 95%CI: 1.55-2.18; P < 0.0001) and DFS (HR=2.40, 95%CI: 1.73-3.34; P < 0.0001).In addition, a high CONUT score was significantly related to male, advanced age, high CEA, and later TNM stage.

Conclusion

The results of our meta-analysis suggest that a high CONUT score predicts a poor prognosis of NSCLC patients. In clinical practice, the CONUT score could act as an valuable tool to predict clinical outcomes in patients with NSCLC.

Systematic Review Registration

https://inplasy.com, identifier INPLASY202408280100.

An exploratory study of serum creatine kinase as a prognostic marker for patients with resectable pancreatic cancer: looking into the relationship with body composition

BACKGROUND

Among cancer patients, pancreatic cancer patients have the highest rate of sarcopenia, which is a critical prognostic factor. Serum creatine kinase (CK) is closely related to skeletal muscle mass and has been reported to decline with the progression of cancer. This study investigated whether preoperative serum CK is associated with the survival of patients with pancreatic cancer.

METHODS

Data were obtained from patients with pathologically confirmed pancreatic cancer between June 2016 and March 2022. The prognostic significance of CK was analyzed based on sex-stratified groups. The Kaplan-Meier method was used to compare overall survival (OS) and disease-free survival (DFS). Multivariate Cox proportional hazards models were used to determine prognostic factors. Body composition was analyzed based on preoperative abdominal CT images to explore the sex-specific associations between skeletal muscle area (SMA) and serum CK levels.

RESULTS

A total of 166 patients were included in this study. Sarcopenia was presented in 70 patients (42.2%). A low serum CK level showed a significant correlation with the diagnosis of sarcopenia in male patients (P = 0.026). The levels of CK did not predict the outcome in female patients, while a low preoperative CK was notably linked to shorter OS in male patients (median OS: 15 months vs. 33 months, P = 0.011; median DFS: 5 months vs. 14 months, P = 0.007). Multivariate analyses further confirmed the effect of CK in predicting OS (CK>44 IU/L, HR:0.226, 95% CI:0.107-0.478, P < 0.001) and DFS (CK>44 IU/L, HR:0.272, 95% CI:0.139-0.529, P < 0.001) of male patients. Correlation analysis revealed a significant association between SMA and CK levels in male patients (r = 0.225, P = 0.025), and such a correlation was not observed in female patients (r = 0.088, P = 0.478).

CONCLUSION

The pretherapeutic CK may represent a simple marker for predicting poor survival in male patients with resectable pancreatic cancer, thereby aiding in the selection of therapeutic strategies.

Musculo-Immuno-Nutritional Score as a Prognostic Marker in Patients with Interstitial Pneumonia Awaiting Lung Transplantation

PURPOSE

This study evaluated the prognostic significance of the controlling nutritional status/creatine kinase score (CNKS), a composite index derived from the controlling nutritional status (CONUT) score and creatine kinase (CK) level, in patients with interstitial pneumonia awaiting lung transplantation (LT).

METHODS

We retrospectively analyzed 202 patients with interstitial pneumonia who were registered for LT between January 2014 and July 2023. CNKS was calculated using CK levels and the CONUT (derived from albumin level, lymphocyte count, and cholesterol level).

RESULTS

Among the 202 patients, 130 (64.4%) were alive, while 72 (35.6%) had died at the time of analysis. Among the surviving patients, 79 (39.1%) underwent cadaveric LT, and 51 (25.2%) remained on the waiting list. A high CNKS (n = 72 [35.6%]) was significantly associated with a lower body mass index (P <0.001), a shorter 6-minute walk distance (P <0.001), and lower forced vital capacity (P = 0.006) compared with a low CNKS (n = 130 [64.4%]). The results of the multivariate analysis showed that CNKS was a significant independent prognostic factor for survival during the waiting period (P = 0.031).

CONCLUSION

CNKS represents a promising prognostic marker, potentially useful in selecting lung transplant candidates and guiding nutritional and rehabilitative interventions during the pretransplant period.

Prognostic significance of creatine kinase in resected pancreatic cancer

BACKGROUND

Creatine kinase (CK) levels decrease with cancer progression and muscle wasting, but its association with pancreatic ductal adenocarcinoma (PDAC) remains unclear. The aim of this study was to investigate CK as a prognostic biomarker and surrogate marker for muscle mass in patients with PDAC.

METHODS

A retrospective analysis of 476 patients with PDAC was conducted. CK levels were categorized into low and high groups using receiver-operating characteristic (ROC) curve analysis.

RESULTS

Among the 476 patients, 200 (42.0%) and 276 (58.0%) were classified into the low and high CK groups, respectively. The low CK group had significantly poorer overall survival (p < .001) and recurrence-free survival (p < .001) compared to the high CK group. Multivariate analysis identified low CK as an independent poor prognostic factor (p < .001). The low CK group had significantly lower skeletal muscle index (p = .048) than the high CK group; however, the difference was slight and not significantly associated with sarcopenia. Additionally, combined risk assessment incorporating CK and resectability facilitated a more nuanced prognostic stratification.

CONCLUSIONS

CK served as a reliable prognostic marker independent from resectability but was less effective as a marker for sarcopenia in PDAC.

Low serum creatine kinase level is associated with poor prognosis in patients with hepatocellular carcinoma: A retrospective single‑center study

Previous studies have reported low serum creatine kinase (s-CK) levels as a poor prognostic factor in various cancers. However, there have been no reports on its significance in hepatocellular carcinoma. The present study aimed to evaluate the association of the preoperative s-CK levels with clinicopathologic features and their prognostic impact on survival in patients with hepatocellular carcinoma. This retrospective study included 163 patients with hepatocellular carcinoma (127 male and 36 female patients; median age, 69 years) who underwent radical liver resection between January 2004 and December 2021. A cutoff preoperative s-CK level of 91 U/l determined by receiver operating characteristic curve analysis was used to evaluate the significance of s-CK in predicting overall and recurrence-free survival. In addition, the prognostic impact of s-CK was evaluated using univariate and multivariate analysis. s-CK level was not associated with clinicopathologic factors. Overall survival and recurrence-free survival of the low s-CK group were significantly worse compared with the high s-CK group (P=0.043 and P=0.029, respectively). By multivariate analysis, low s-CK was an independent risk factor for poor overall survival and recurrence-free survival (P=0.019 and P=0.014, respectively). This trend was the same for male patients, but no significant difference was observed for female patients. Low preoperative s-CK level might be a poor prognostic biomarker in patients with hepatocellular carcinoma.

Preoperative Low Creatine Kinase as a Poor Prognostic Factor in Patients with Colorectal Cancer

PURPOSE

This study aimed to evaluate the clinicopathological and prognostic significance of preoperative serum creatine kinase (CK) levels in colorectal cancer.

METHODS

This study analyzed 1169 patients with colorectal cancer at stages 0 (n = 35), I (n = 301), II (n = 456), III (n = 339), and IV (n = 38). The CK cut-off value was 52 U/L to predict recurrence based on receiver operative characteristics curve. Clinicopathological factors were compared between the low (< 52 U/L) and high CK groups (≥ 52 U/L). The multivariate analysis evaluated relapse-free survival (RFS) and overall survival (OS) following CK status.

RESULTS

The female sex, elderly age (≥ 75), deep tumor (pT4), and carcinoembryonic antigen (+) were independently associated with low CK status. The recurrent rate was significantly higher in the low CK group than in the high CK group (19.1% vs. 11.7%, p < 0.001). Elderly age, pT4, pN (+), preoperative carbohydrate antigen (CA) 19-9 (+), and low CK status were independent risk factors for RFS. Elderly age, pT4, pN (+), preoperative CA19-9 (+), and low CK status were independent risk factors for OS.

CONCLUSION

Preoperative low CK status was associated with deep tumors and was a poor prognostic factor in patients with colorectal cancer.

Prognostic significance of preoperative creatine kinase in resected thymic epithelial tumors

Background

The preoperative serum creatine kinase (CK) concentration is a prognostic factor for malignant diseases. We investigated the significance of CK in surgically resected thymic epithelial tumors and the relationship between CK and clinicopathological factors.

Methods

We retrospectively evaluated the relationship between preoperative CK levels and prognosis in 120 patients with thymic epithelial tumors who underwent surgical resection at two centers. The cutoff for CK was determined by the standard value in our institution (<62 IU/L for men and <45 IU/L for women). The paravertebral muscle at the Th12 level was used to assess skeletal muscle area to investigate sarcopenia.

Results

Eighteen patients (15.0%) were categorized into the low CK group. The CK level was not associated with age, sex, performance status, myasthenia gravis, and pathological findings. Preoperative serum albumin and total cholesterol concentrations were significantly lower in the low CK group than in the normal CK group (both P<0.001). Moreover, the Th12 muscle index was lower in the low CK group (P=0.03), indicating that low CK was related to sarcopenia. Kaplan-Meier curve analysis illustrated that patients in the low CK group had significantly shorter disease-free survival (DFS) and overall survival (OS) than those in the normal CK group (P=0.03 and P=0.002, respectively). Multivariate analysis identified low CK as an independent prognostic factor for DFS (P=0.03) and OS (P=0.005).

Conclusions

Preoperative serum CK might reflect the host nutritional status in patients with resected thymic epithelial tumors; therefore, CK could be a biomarker of postoperative prognosis.

Preoperative low plasma creatine kinase levels predict worse survival outcomes in bladder cancer after radical cystectomy

BACKGROUND AND AIMS

To evaluate the prognostic significance of preoperative creatine kinase (CK) levels in bladder cancer (BCa) patients who underwent radical cystectomy (RC).

MATERIALS AND METHODS

570 BCa patients with RC were identified between 2010 and 2020. 108.5 U/L of CK levels were defined as the cutoff value. Logistic regression analysis and Cox regression models were performed to evaluate the association between CK levels and oncologic outcomes. Subgroup analyses were performed to address cofounding factors.

RESULTS

Preoperative low CK levels were associated with worse recurrence-free survival (RFS, log-rank P = 0.001) and overall survival (OS, log-rank P = 0.002). Multivariate analysis revealed that preoperative low CK levels were an independent predictor for worse RFS (hazard ratio [HR]: 1.683; P < 0.001) and OS (HR: 1.567; P = 0.002).

CONCLUSIONS

The preoperative low CK level independently predicts worse survival outcomes in BCa after RC. Incorporating it into prediction models might be valuable to assist risk stratification.

A high serum creatine kinase (CK)-MB-to-total-CK ratio in patients with pancreatic cancer: a novel application of a traditional marker in predicting malignancy of pancreatic masses?

BACKGROUND

The finding that some benign pancreatic masses mimic the imaging appearance of carcinomas poses a challenge for pancreatic surgeons. Preoperative markers that assist in the diagnosis are critical under this circumstance. Abnormal serum creatine kinase (CK) isozyme levels were reported in cancer patients, and this study aimed to explore the potential value of the CK-MB-to-total-CK ratio (CK ratio) in differentiating pancreatic cancer (PC) from benign masses when combined with carbohydrate antigen 19-9 (CA19-9).

METHODS

A total of 190 patients primarily diagnosed with pancreatic masses were retrospectively reviewed and assigned to the PC group and the benign pancreatic mass (BPM) group. Sixty-eight controls were enrolled for comparison. Levels of preoperative parameters, including total serum CK, CK-MB, absolute neutrophil count, absolute lymphocyte count, albumin, and CA19-9, were recorded as well as pathological information. A logistic regression model was established to assess the application value of the combination of CA19-9 and the CK ratio in diagnosis. Receiver operating characteristic (ROC) curves were constructed to evaluate the diagnostic value of the markers.

RESULTS

The CK ratio was significantly elevated in the PC group compared with the BPM group (P < 0.001). In the multivariate analysis, a CK ratio greater than 0.220 was a statistically significant variable for predicting malignancy of pancreatic masses (P=0.001). Patients with stage III/IV PC had a higher CK ratio than those with stage I/II PC (P<0.01). Combined detection of CA19-9 and the CK ratio produced an increased Youden index (0.739 vs. 0.815) with improved sensitivity (82.2% vs. 89.8%).

CONCLUSIONS

The CK ratio is elevated in patients with pancreatic adenocarcinoma and is an independent factor predicting pancreatic adenocarcinoma. The CK ratio augments the diagnostic capacity of CA19-9 in detecting malignancy.

Prognostic Value of Combination of Controlling Nutritional Status and Tumor Marker in Patients with Radical Non-Small-Cell Lung Cancer

Background

Controlling nutritional status (CONUT) and tumor markers are associated with prognosis in patients with non-small-cell lung cancer (NSCLC). This study is aimed at exploring the potential usefulness of T-CONUT, constructed by combining CONUT and tumor markers, for NSCLC patients undergoing radical surgery.

Methods

A total of 483 patients with NSCLC underwent radical surgical resection. The receiver characteristic operating curve (ROC) was used to select the tumor marker with the highest predictive performance, and CONUT was combined with this marker to construct the T-CONUT. The Kaplan–Meier method and log-rank test were used to analyze the overall survival (OS), and chi-square analysis was used to analyze the association between T-CONUT and clinicopathological characteristics. The independent risk factors were analyzed by Cox regression. A nomogram was constructed by R studio. Calibration plots, the c-index, and decision curves were evaluated for the performance of the nomogram.

Results

ROC analysis showed that the predictive performance of CYFRA21–1 was better than that of CEA, NSE, and SCC. CYFRA21–1 was selected for combining with CONUT to construct T-CONUT. Elevated T-CONUT indicates poor prognosis of patients. Histological type, pTNM, and T-CONUT are independent risk factors associated with patient prognosis. The areas under the curve of the nomogram for predicting 3- and 5-year OS were 0.760 and 0.761, respectively.

Conclusion

T-CONUT comprising CYFRA21–1 and CONUT can effectively predict the prognosis of NSCLC patients.

Prognostic significance of preoperative low serum creatine kinase levels in gastric cancer

PURPOSE

We evaluated the clinicopathological and prognostic significance of preoperative serum creatine kinase (CK) levels in gastric cancer.

PATIENTS AND METHODS

The subjects of this retrospective study were 942 patients who underwent surgery without preoperative chemotherapy for gastric cancer (643 men and 299 women), excluding Stage IV gastric cancer, between January, 2001 and December, 2020. We set the cutoff values for CK according to gender, as 64 U/L for men and 57 U/L for women, and evaluated the clinicopathological, prognostic, and gender significance of low CK levels by multivariate analysis.

RESULTS

Tumor depth was significantly associated with low serum CK levels (p < 0.001). The low CK group showed significantly worse overall survival than the high CK group (p = 0.01). The prognostic impact of low CK levels was evident only in men (p = 0.009). In women, low CK levels were not an independent risk factor for poor prognosis (p = 0.33). These prognostic impacts of low CK levels on overall survival and recurrence-free survival were similar.

CONCLUSION

Low preoperative CK levels in men with gastric cancer were predictive of poor survival. These prognostic impacts of low CK levels were not evident in women.

The C-reactive protein to albumin ratio is a prognostic factor for stage I non-small cell lung cancer in elderly patients: JACS1303

PURPOSE

To establish the prognostic significance of C-reactive protein (CRP) and albumin in octogenarians with non-small cell lung cancer (NSCLC) based on the study of the Japanese Association for Chest Surgery (JACS 1303).

METHODS

A total of 618 octogenarians with pathological stage I NSCLC, who underwent pulmonary resection, were included in the analysis. We conducted multivariable Cox regression analysis to evaluate the CRP to albumin ratio (CAR) as a potential prognostic factor. Other clinicopathological factors were also evaluated.

RESULTS

The median age was 82 years. Operations included lobectomy (n = 388; 62.8%) segmentectomy (n = 95; 15%), and wedge resection (n = 135; 22%). Pathological stage IA was diagnosed in 380 (61.5%) patients. The 3-year (OS) and cancer-specific survival (CS) rates were 86.7% and 94.6%, respectively. OS was significantly higher for patients with low CAR (< 0.106) than for those with high CAR (≥ 0.106) (hazard ratio = 3.13, 95% confidence interval: 1.99-4.93, p < 0.0001). Univariate analysis identified sex, poor performance status, smoking status, comorbidity, solid tumor, histology, high Glasgow prognostic scale, and high CAR as significant prognostic factors. Multivariate analysis identified only the CAR as a significant prognostic factor for both OS and CS.

CONCLUSIONS

Our analysis of the nationwide data demonstrated that the CAR is a useful prognostic factor for elderly patients with stage I NSCLC.

Preoperative low serum creatine kinase is associated with poor overall survival in the male patients with esophageal squamous cell carcinoma

BACKGROUND

Serum creatine kinase level has been reported to be a prognostic indicator in breast or lung cancers but no reports have been in esophageal cancer. We analyzed the prognostic significance of preoperative serum creatine kinase level in patients with esophageal carcinoma.

METHODS

We evaluated the preoperative serum creatine kinase levels of 148 patients (118 male and 30 female) with esophageal squamous cell carcinoma. According to their median serum creatine kinase levels, we divided the patients into high and low serum creatine kinase groups. Univariate and multivariate analyses were used to evaluate the impact of serum creatine kinase level on the prognosis of the patients.

RESULTS

The tumor depth (P < 0.01) and stage (P < 0.01) were significantly associated with serum creatine kinase levels. The prognosis was worse in the low serum creatine kinase group than in the high serum creatine kinase group (P = 0.02). In the subgroup analysis, although no survival difference was observed in the female patients between the groups (P = 0.171), the survival of low serum creatine kinase group was significantly worse than that of high creatine kinase group in the male patients (P = 0.001). Cox proportional hazard regression analysis revealed that nodal status (P = 0.019) and serum creatine kinase level (P = 0.047) were independent risk factors associated with overall survival in the male patients.

CONCLUSIONS

Preoperative low serum creatine kinase level was useful in predicting overall survival in the male patients with esophageal squamous cell carcinoma.

Prospective observational study of nutritional/immunologic indices as predictive biomarkers for the response to anti-PD-1 drugs in non-small cell lung cancer (ICI-PREDICT study)

Immune checkpoint inhibitors (ICIs) targeting programmed cell death-1 (PD-1) and programmed cell death-ligand 1 (PD-L1) have markedly improved the prognosis of many patients with advanced non-small cell lung cancer (NSCLC). However, the relationship between the patient’s nutritional/immunologic status and the outcomes of ICI treatment remains unclear. In previous retrospective studies, we reported that the controlling nutritional status (CONUT) score, skeletal muscle area, and neutrophil-to-lymphocyte ratio were independent predictors of the response of NSCLC patients to anti-PD-1 drugs. The aim of this prospective multi-center study is to investigate the clinical impact of pre-treatment nutritional/immunologic indices and early post-treatment changes in the indices on treatment outcomes in advanced NSCLC. The main inclusion criteria are: (1) stage IV NSCLC, or stage III NSCLC not applicable for definitive chemoradiotherapy; (2) treatment with ICIs (monotherapy or combined with chemotherapy) as first-line therapy; and (3) available data on PD-L1 expression on tumor cells. A total of 300 patients will be enrolled prospectively. Enrollment will begin in 2020 and the final analyses will be completed by 2025.

Body composition and inflammation impact in non-small-cell lung cancer patients treated by first-line immunotherapy

Background: Immunotherapy changed the landscape of non-small-cell lung cancer (NSCLC). Efforts were made to implement its action. This study aims to describe body composition, nutritional and inflammatory status in NSCLC patients treated by first-line immunotherapy, their correlation, variation and impact. Patients and methods: We retrospectively analyzed 44 consecutive patients who received pembrolizumab treatment. Results: During the therapy, inflammation and visceral fat increased, whereas muscle and subcutaneous fat decreased. Parameters related to inflammation had an interesting prognostic impact. High numbers of white blood cells remained significantly correlated with a high risk of death in multivariate model. Conclusion: For the best treatment choice, a combination of clinical and biological factors will be most likely be necessary. Prospective and larger studies with a multidimensional approach are needed.

Prognostic impact of the pre-treatment controlling nutritional status score in patients with non-small cell lung cancer: A meta-analysis

BACKGROUND

The influence of pre-treatment controlling nutritional status (CONUT) score on the prognosis of non-small cell lung cancer (NSCLC) patients is inconclusive. We performed this meta-analysis to evaluate the prognostic significance of CONUT score in NSCLC patients.

METHODS

A systematic literature review was conducted using PubMed, Embase, and the Cochrane Library databases. The hazard ratio (HR) and 95% confidence interval (CI) were extracted to assess the correlation between the CONUT score and the overall survival (OS), disease-free survival (DFS), recurrence-free survival (RFS), as well as the cancer-specific survival.

RESULTS

A total of 11 studies with 3029 patients were included in the analysis. Pooled results indicated that a high CONUT score was positively correlated with poor OS (HR: 1.63, 95%CI: 1.40-1.88, P < .001) and shortened DFS/RFS (HR: 1.65, 95%CI: 1.35-2.01, P < .001), but no significant relationship with the cancer-specific survival (HR: 1.28, 95%CI: 0.60-2.73, P = .517) was identified. The negative effect of high CONUT score on the OS and DFS/RFS was detected in every subgroup with varying treatment methods, cancer stage, CONUT cut-off values, sample size, and analysis methods of HR. Additionally, preoperative high CONUT score was an independent predictor of postoperative complications (odds ratio: 1.58, 95%CI: 1.21-2.06, P = .001) in NSCLC. Last but not least, high CONUT score was not significantly correlated with the patients' sex, smoking status, cancer stage, lymphatic invasion, vascular invasion, pleural invasion, and pathological cancer type.

CONCLUSION

These results demonstrate that high CONUT score is positively related to poor prognoses. The CONUT score may therefore be considered as an effective prognostic marker in NSCLC patients.

Impact of body composition, nutritional and inflammatory status on outcome of non-small cell lung cancer patients treated with immunotherapy

BACKGROUND AND AIMS

Body composition and balance of nutritional and inflammatory status are important for the immune system. Alterations of these aspects may impact on response, outcome and toxicities of immunotherapy. In this review we try to clarify some definitions and tools used for the assessment of the different aspects of nutritional disorders, body composition and inflammatory status with a focus on lung cancer.

METHODS

We primary investigate the definitions of malnutrition, cachexia, sarcopenia and overweight. Secondary, tools used to measure body composition, nutritional and inflammatory status, mainly in lung cancer are reviewed.

RESULTS

All these features, in the time of precision medicine may improve assessment and selection of patients, incorporating also early palliative care in standard therapy.

CONCLUSIONS

A multimodal approach based on nutrition assessment and physical exercise should be evaluated to improve aspects of the immune response against cancer and to propose the best treatment to every patient.