Relationship Between Nutritional Status and Clinical Outcome in Patients With Gastrointestinal Stromal Tumor After Surgical Resection

Prognostic value of combined nutritional and inflammatory markers in NSCLC patients receiving ICIs

BACKGROUND

In the treatment of non-small cell lung cancer (NSCLC), immune checkpoint inhibitors (ICIs) have markedly improved patient survival, yet some patients do not benefit. The existing prognostic factors are limited, highlighting the development of reliable and convenient predictive indicators.

METHODS

A retrospective analysis was performed on 219 NSCLC patients treated with ICIs from June 2019 to January 2024. The nutritional risk screening (NRS 2002) and the neutrophil-to-lymphocyte ratio (NLR) were employed to evaluate the patients' nutritional status and inflammatory response, aiming to investigate the correlation between these markers and treatment outcomes.

RESULTS

The median follow-up duration for the overall population was 29 (IQR: 25.96-32.04) months. The analysis showed that the median progression-free survival (mPFS) and median overall survival (mOS) in the high nutritional risk group (NRS2002 ≥ 3, accounting for 23.74%) were significantly lower than those in the low nutritional risk group (NRS2002 < 3, accounting for 76.26%) (mPFS: 2.5 vs 16 months; mOS: 8 vs 16 months, both P < 0.001). Similarly, patients with high NLR values (> 4.92) had significantly shorter OS and PFS than those with low NLR (≤ 4.92) values (mOS: 7 vs 18 months; mPFS: 3 vs 17 months, both P < 0.001). Multivariate Cox analysis revealed that a high NRS 2002 score (HR = 2.76, 95% CI 1.68-4.54, P < 0.001) and high NLR (HR = 2.77, 95% CI 1.65-4.64, P < 0.001) were independent predictors of poor prognosis. Risk stratification was performed using a combined scoring system of NRS 2002 and NLR (0 points-low risk, 1 point-moderate risk, 2 points-high risk), and it was found that as the risk score increased, OS and PFS significantly decreased (mOS: 8 [2.61-13.39] vs 16 [13.04-18.96] vs NA [NA-NA] months; mPFS: 2.5 [0.99-4.02] vs 8.5 [5.47-11.53] vs 16 [11.41-20.59] months, respectively, both P < 0.001). The utility of the combined NLR and NRS2002 scoring model was assessed using a time-dependent receiver operating characteristic (ROC) curve, with results indicating that at 12 months, the AUC value of the combined scoring model was 0.81 (CI 0.72-0.90). At 24 and 36 months, the AUC values were 0.73 (CI 0.66-0.80) and 0.70 (CI 0.64-0.76), respectively. Moreover, the nomogram model exhibited high predictive accuracy in predicting survival prognosis, with AUC values of 0.84 (CI 0.77-0.91), 0.85 (CI 0.79-0.91), and 0.78 (CI 0.69-0.88) at 12, 24, and 36 months, respectively.

CONCLUSION

The combined NRS 2002 and NLR scoring can serve as an effective prognostic tool for NSCLC patients receiving ICIs treatment. This scoring system helps clinicians more accurately identify patients who will benefit from immunotherapy, thereby facilitating more personalized treatment plans. Further validation of this scoring system's applicability and reliability is warranted in future multicenter, large-sample prospective studies.

Malnutrition Diagnosed by Patient-Generated Subjective Global Assessment and the Risk of All-Cause Mortality in Adults With Gastrointestinal Cancer: A Systematic Review and Meta-Analysis

INTRODUCTION

Several reviews have highlighted that the Patient-Generated Subjective Global Assessment (PG-SGA) is the best diagnostic tool for assessing nutritional status in cancer patients. However, previous meta-analyses summarizing the prevalence of malnutrition and overall survival in patients with gastrointestinal (GI) cancer are quite limited. This study aims to determine the overall prevalence and association between malnutrition, as defined by the PG-SGA, and mortality in adults with GI cancer.

METHODS

A comprehensive systematic review of articles published from 2005 to 2023 was conducted using Google Scholar, PubMed, Web of Sciences and Scopus. The PRISMA guideline was followed to organize the entire content. A random-effects meta-analysis model using R Studio was performed to quantify the pooled proportion and hazard ratios (HRs). Publication bias was assessed using Egger's test and funnel plots. Heterogeneity was evaluated using I2 and Baujat plots. This study was registered in PROSPERO under the protocol number CRD42023465685.

RESULTS

In this study, 46 publications with 23,235 participants were included in the final meta-analysis. The overall prevalence of malnutrition among adults with GI cancer, as determined by the PG-SGA, was 61% (95% CI: 51%-70%, I2 = 99%). The pooled prevalence of moderate and severe malnutrition were 38% (95% CI: 31%-45%, I2 = 96%) and 21% (95% CI: 13%-31%, I2 = 98%), respectively. By cancer type, malnutrition was more common in patients with oesophageal cancer (78%, 95% CI: 45%-94%, I2 = 99%) and gastric cancer (75%, 95% CI: 68%-81%, I2 = 87%). Additionally, the overall risk (pooled HR) of malnutrition on mortality among GI cancer patients was 2.02 (95% CI: 1.63%-2.5%, I2 = 23%).

CONCLUSION

Malnutrition is common in adults with GI cancer and doubles the risk of all-cause mortality. These results emphasize the importance of ongoing efforts in prevention, early assessment, and intervention for malnutrition to minimize mortality rates.

NRS2002 score as a prognostic factor in solid tumors treated with immune checkpoint inhibitor therapy: a real-world evidence analysis

To observe the antitumour efficacy of programmed death 1 (PD-1) inhibitors in the real world and explore the relationship between NRS2002 score or other clinical characteristics and immunotherapy efficacy, we retrospectively analyzed 341 tumor patients who received immune checkpoint inhibitor (ICI) treatment at one center. A total of 341 solid tumor patients treated with ICIs from June 2018 to December 2021 were retrospectively included in this study. Patient characteristics, ICI responses, and survival status were documented, and the relationships between clinical factors and survival were analyzed. Among all patients, the median progression-free survival (PFS) was 5.8 months, and the median overall survival (OS) was 12.5 months. The Performance Status (PS), NRS2002 score, The Naples Prognostic Score (NPS), Lymphocyte and C-reactive protein ratio (LCR), line of therapy, and nutritional support were significantly related to PFS or OS according to univariate analysis. The median PFS and OS were significantly better in the group without nutritional risk (NRS2002 0-2) than those with nutritional risk (NRS2002 ≥ 3) (PFS: HR = 1.82, 95% CI 1.30-2.54, p value < .001; OS: HR = 2.49, 95% CI 1.73-3.59, p value < .001). Cox regression analysis revealed that the NRS2002 score was an independent prognostic factor for both PFS and OS. The objective response rate (ORR) in the group at nutritional risk was lower than that in the group without nutritional risk (8.33% and 19.71%, respectively, p value = .037). Patients at nutritional risk according to the NRS2002 score at initial treatment had a poorer prognosis than those without nutritional risk. The NRS2002 could be used as a preliminary index to predict the efficacy of immune checkpoint inhibitor therapy.

Subchronic oral toxic effects of 2,4-dinitroaniline in wistar rats: A comprehensive toxicity evaluation

2,4-dinitroaniline (2,4-D), a widely used dye intermediate, is one of the typical pollutants, and its potential health risks and toxicity are still largely unknown. To explore its subchronic oral toxicity, Wistar rats (equal numbers of males and females) were used as test animals, and a 90-day oral dosing experiment was conducted, divided into control group, low-dose group (0.055 mg/kg), medium-dose group (0.22 mg/kg), medium-high dose group (0.89 mg/kg), and high-dose group (3.56 mg/kg). The body weight data, clinical appearance, and drug reactions of each test rat within 90 days of dosing were recorded; morning urine samples were collected four times to test for eight urinary indicators; blood samples were collected to test for nineteen hematological indicators and sixteen biochemical indicators; tissue samples were collected for pathological analysis; moreover, the no-observed-adverse-effect level (NOAEL) was determined, and the benchmark dose method was used to support this determination and provide a statistical estimate of the dose corresponding. The results indicated that the chronic toxicity of 2,4-dinitroaniline showed certain gender differences, with the eyes, liver, and kidneys being the main potential target organs of toxicity. Moreover, the subchronic oral NOAEL for 2,4-dinitroaniline was determined to be 0.22 mg/kg body weight (0.22 mg/kg for males and 0.89 mg/kg for females), and a preliminary calculation of the safe exposure limit for human was 0.136 mg/kg. The research results greatly enriched the safety evaluation data of 2,4-dinitroaniline, contributing to a robust scientific foundation for the development of informed safety regulations and public health precautions.

Examining the impact of early enteral nutritional support on postoperative recovery in patients undergoing surgical treatment for gastrointestinal neoplasms

BACKGROUND

Patients with gastrointestinal tumors often suffer from poor nutritional status during treatment. Surgery is the main treatment for these patients, but the long postoperative recovery period is often accompanied by digestive and absorption dysfunction, leading to further deterioration of the nutritional status. Early enteral nutrition support is hypothesized to be helpful in improving this situation, but the exact effects have yet to be studied in depth.

AIM

To observe the effect of early enteral nutritional support on postoperative recovery in patients with surgically treated gastrointestinal tract tumors, with the expectation that by improving the nutritional status of patients, the recovery process would be accelerated and the incidence of complications would be reduced, thus improving the quality of life.

METHODS

A retrospective analysis of 121 patients with gastrointestinal tract tumors treated in our hospital from January 2020 to January 2023 was performed. Fifty-three of these patients received complete parenteral nutrition support as the control group for this study. The other 68 patients received early enteral nutritional support as the observation group of this study. The clinical indicators comparing the two groups included time to fever, time to recovery of postoperative bowel function, time to postoperative exhaustion, and length of hospital stay. The changes in immune function and nutritional indexes in the two groups were compared. Furthermore, we utilized the SF-36 scale to compare the changes in the quality of life between the two groups of patients. Finally, the occurrence of postoperative complications between the two patient groups was also compared.

RESULTS

The postoperative fever time, postoperative bowel function recovery time, postoperative exhaustion time, and hospitalization time were all higher in the control group than in the observation group (P < 0.05). The levels of CD3+, CD4+, immunoglobulin (Ig) A, IgM, and IgG in the observation group were significantly higher than those in the control group at 1 d and 7 d postoperatively, while CD8+ was lower than in the control group (P < 0.05). Total protein, albumin, prealbumin, and transferrin levels were significantly higher in the observation group than in the control group at 7 d postoperatively (P < 0.05). The SF-36 scores of patients in the observation group were significantly higher than those in the control group (P < 0.0001). The overall incidence of adverse reactions after the intervention was significantly lower in the control group than in the observation group (P = 0.021).

CONCLUSION

We found that patients with gastrointestinal tumors are nutritionally vulnerable, and early enteral nutrition support programs can improve the nutritional status of patients and speed up postoperative recovery. This program can not only improve the immune function of the patient and protect the intestinal function, but it can also help to improve the quality of life of the patient. However, this program will increase the incidence of complications in patients. Caution should be taken when adopting early enteral nutrition support measures for patients with gastric cancer. The patient's condition and physical condition should be comprehensively evaluated and closely monitored to prevent possible complications.

Controlling Nutritional Status (CONUT) score as a prognostic marker for gastrointestinal stromal tumours

BACKGROUND

The Controlling Nutritional Status (CONUT) score, regarded as the effective indicator of patient nutrition, has been demonstrated to be related to prognosis of numerous tumours. Nevertheless, the significance of CONUT for gastrointestinal stromal tumour (GIST) remains unclear. This study intended to clarify the association between CONUT and the prognosis of GISTs.

METHODS

Three hundred and fifty-five patients with GISTs undergoing surgical resection at our center were retrospectively assessed. Receiver operating characteristic curve analysis was used to help determine the cut-off value of CONUT score. Relapse-free survival (RFS) and overall survival (OS) were assessed by Kaplan-Meier curve analysis. Prognostic factors for RFS and OS were examined by Cox proportional hazards models.

RESULTS

A total of 355 patients were enrolled in this study. Areas under the curve (AUC) were 0.638 for CONUT score, and the cut-off value of CONUT was shown to be three. Kaplan-Meier curve analysis showed that high CONUT score was linked to poorer RFS and OS. Univariate and multivariate analyses ultimately revealed that CONUT was a risk factor for RFS and OS, independent of demographics and clinicopathological tumour characteristics.

CONCLUSIONS

CONUT score was an effective and novel predictor for prognosis of GIST patients treated with surgery, indicating its potential as a prognostic marker in the overall management.

The Use of Antibiotics During Immune Checkpoint Inhibitor Treatment Is Associated with Lower Survival in Advanced Esophagogastric Cancer

OBJECTIVE

Immune checkpoint inhibitors (ICI) are effective in only a minority of patients with esophagogastric cancer (EGC). Here, we aimed to explore the impact of antibiotic use on outcomes in ICI-treated EGC patients.

METHODS

Patients with advanced EGC treated with ICIs at our center were identified between 2017 and 2021. The impact of antibiotic use on overall survival (OS) and progression-free survival (PFS) was assessed by a log-rank test. Eligible articles were retrieved using PubMed, the Cochrane Library, EMBASE, and Google Scholar by December 17, 2022. Clinical outcomes were OS, PFS, and disease control rate (DCR).

RESULTS

In our cohort, 85 EGC patients were recruited. The results showed that antibiotic use significantly shortens OS (HR: 1.91, 95% CI: 1.11-3.28, P = 0.020) and PFS (HR: 2.13, 95% CI: 1.21-3.74, P = 0.009) and reduces DCR (OR: 0.27, 95% CI: 0.10-0.720, P = 0.013) in EGC patients treated with ICIs. The meta-analysis results revealed that antibiotic use was significantly associated with worse OS (HR = 2.454, 95% CI: 1.608-3.748, P < 0.001), PFS (HR = 2.539, 95% CI: 1.455-4.432, P = 0.001), and lower DCR (OR = 0.246, 95% CI: 0.105-0.577, P = 0.001). No publication bias existed, and sensitivity analysis confirmed stable results.

CONCLUSION

In patients with advanced EGC undergoing ICI, the use of antibiotics, such as cephalosporins, was associated with inferior survival rates.

Inflammation and nutritional status indicators as prognostic indicators for patients with locally advanced gastrointestinal stromal tumors treated with neoadjuvant imatinib

BACKGROUND

Previous studies have confirmed that preoperative nutritional-inflammatory indicators can predict prognosis in various malignancies. However, to the best of our knowledge, no study has investigated the assessment of systemic inflammatory immunity index (SII) combined with prognostic nutritional index (PNI) scores to predict prognosis after neoadjuvant treatment with imatinib in locally advanced gastrointestinal stromal tumours (LA-GIST). The aim of this study was to evaluate the predictive value of pretreatment SII-PNI scores in predicting recurrence after neoadjuvant therapy with imatinib in patients with LA-GIST.

METHODS

We retrospectively analyzed 57 patients with LA-GIST who received imatinib neoadjuvant from January 2013 to March 2019. Patients were divided into recurrence and non-recurrence groups according to their follow-up status, and SII and PNI cut-offs were calculated by receiver operating characteristic. The SII-PNI score ranged from 0 to 2 and were categorized into the following: score of 2, high SII (≥ 544.6) and low PNI (≤ 47.2); score of 1, either high SII (≥ 544.6) or low PNI (≤ 47.2); score of 0, no high SII (≥ 544.6) nor low PNI (≤ 47.2).

RESULTS

All patients received imatinib neoadjuvant therapy for a median treatment period of 8.5 months (ranging from 3.2 to 12.6 months), with 8 patients (14.04%) and 49 patients (85.96%) developing recurrence and non-recurrence, respectively. Patients with a high SII-PNI score had a significantly worse recurrence-free survival time than those with a low SII-PNI score (P = 0.022, 0.046), and had a poorer pathological response (P = 0.014). Multivariate analysis demonstrated that the SII-PNI score was an independent prognostic factor for prediction of recurrence-free survival (P = 0.002).

CONCLUSION

The pre-treatment SII-PNI score can be used to predict the efficacy after neoadjuvant treatment with imatinib in patients with LA-GIST, which may be a promising predictor of recurrence-free survival time for patients.

The prognostic significance of prognostic nutritional index in gastrointestinal stromal tumors: A systematic review and meta-analysis

BACKGROUND

Risk assessment before treatment is important for gastrointestinal stromal tumors (GISTs), which will determine the priority of surgery or preoperative treatment. The prognostic nutritional index (PNI) is an integrated parameter consisting of serum albumin and lymphocyte count. Immunonutritional status defined in this manner is well-known to be closely linked to the prognosis of several other cancers. Nevertheless, the prognostic value of PNI specifically in GISTs has not been well-established. This study aimed to verify the prognostic role of PNI in patients with GISTs.

METHODS

A comprehensive literature search was conducted on medical databases up to June, 2022, and the raw data (hazard ratios and 95% confidence intervals [CIs]) focusing on the prognostic value of PNI in patients with GISTs regarding recurrence-free survival were extracted and synthesized adopting the random-effects model. This review was registered in the PROSPERO database (CRD42022345440).

RESULTS

A total of 8 eligible studies including 2627 patients with GISTs was analyzed and the pooled results confirmed that an elevated PNI was associated with a better recurrence-free survival (hazard ratio: 0.52, 95% CI: 0.40-0.68), with a moderate heterogeneity (I-square, 38%). The findings from subgroup analysis were consistent with the overall pooled results, and a sensitivity analysis, not the subgroup analysis, identified the source of heterogeneity.

CONCLUSION

Elevated pretreatment PNI may be a useful indicator for assessing risk of recurrence in patients from China with GISTs. Studies in other countries and regions are needed to further verify the prognostic value of PNI in GISTs.

Prognostic Nomogram for Gastrointestinal Stromal Tumors after Surgery Based on the SEER Database

We aimed to determine prognostic factors and develop an effective and practical nomogram for predicting cancer-specific survival in gastrointestinal stromal tumor (GIST) patients. Postoperative data were obtained from the SEER database (2000-2018). Patients were divided into training and validation cohorts at random (7 : 3). Prognostic factors were screened, and a prognostic nomogram was established using log-rank testing and Cox regression. We used DCA, ROC curves, C-index, and calibration curves to evaluate our model's predictive performance. The clinical value of the nomogram and the modified National Institute of Health (M-NIH) classification were compared using the NRI and IDI. The Kaplan-Meier method was applied to examine survival by risk group, and log-rank tests were applied to compare variations in survival curves. Independent prognostic risk factors associated with cancer-specific survival on multivariate Cox proportional hazards regression analysis were age, race, and tumor location, size, grade, and stage. Clinically relevant variables need to be considered in addition to statistically significant variables when developing prognostic models to aid clinical decision-making. We included two additional variables (mitotic rate and chemotherapy) when constructing the prognostic model. The C-index was 0.766 (95% confidence interval (CI): 0.737-0.794) in the training cohort and 0.795 (95% CI: 0.754-0.836) in the internal validation group suggesting robustness. The areas under the ROC curve for three-year and five-year survival were >0.700, indicating satisfactory discrimination. The calibration curves showed good agreement between the predictions of the nomogram and the actual results. The NRI (0.346 for 3-year and 0.265 for 5-year cancer-specific survival for patients with GIST (GSS) prediction; validation cohort: 0.356 for 3-year and 0.246 for 5-year GSS prediction) and IDI values (0.047 for 3-year and 0.060 for 5-year GSS prediction; validation cohort: 0.071 for 3-year and 0.084 for 5-year GSS prediction) suggested that the established nomogram performed significantly better than the M-NIH classification. The DCA indicated that the nomogram was clinically useful and had a high discriminative ability in identifying patients who were at high risk of poor outcomes. According to nomogram findings, patients were divided into three groups (high, moderate, and low risk), with significantly different prognoses in both cohorts. Our nomogram satisfactorily predicted survival in postsurgical GIST patients, which may assist clinicians to evaluate the postoperative status and guide subsequent treatments.

Serum creatinine/cystatin C ratio is a systemic marker of sarcopenia in patients with gastrointestinal stromal tumours

Background

It is well known that sarcopenia is a common risk factor in patients with gastrointestinal tumours, which may negatively affect the clinical outcome and prognosis. Recent studies suggest that serum creatinine-cystatin C (Cr/CysC) ratio may be associated with sarcopenia, but this association lacks sufficient evidence in patients with gastrointestinal stromal tumours (GIST). Therefore, this study aimed to investigate whether the Cr/CysC ratio was associated with sarcopenia and recurrence-free survival (RFS) in patients with GIST.

Materials and methods

The study retrospectively analysed 413 patients with GIST who underwent surgical resection from January 2016 to January 2020. The serum Cr/CysC ratio was determined as a proxy for sarcopenia by comparing it with various biomarkers and Cox multifactorial analysis was used to determine the relationship between Cr/CysC ratio and prognosis.

Results

Serum Cr/CysC was positively correlated with skeletal muscle area (SMA) (r = 0.256, p &lt; 0.001), skeletal muscle index (SMI) (r = 0.300, p &lt; 0.001), and hand grip strength (HGS) (r = 0.251, p &lt; 0.001). The area under the receiver operator characteristic curve for sarcopenic subjects with serum Cr/CysC ratio was significantly greater than other biomarkers (Cr/CysC: 0.840, CysC: 0.732, Cr: 0.518). The optimal cut-off value for Cr/CysC was 0.65, and patients in the high Cr/CysC group had a higher 3-year recurrence-free survival (RFS) than those in the low Cr/CysC group (92.72 vs. 72.46%, p &lt; 0.001). Cox multifactorial analysis found that the Cr/CysC ratio was an independent risk factor for RFS in GIST patients (HR = 2.143, 95% CI: 1.431–5.459, p = 0.011).

Conclusion

Serum Cr/CysC ratio has satisfactory and comparable diagnostic accuracy, and prognostic value for sarcopenia in patients with GIST. Therefore, it can be a simple and practical clinical tool to screen sarcopenia in GIST patients. However, further studies are required to validate these findings.