Controlling Nutritional Status (CONUT) Score and Sarcopenia as Mutually Independent Prognostic Biomarkers in Advanced Urothelial Carcinoma

Latest evidence on clinical outcomes and prognostic factors of advanced urothelial carcinoma in the era of immune checkpoint inhibitors: a narrative review

The management of advanced (locally advanced or metastatic) urothelial carcinoma has been revolutionized since pembrolizumab was introduced in 2017. Several prognostic factors for advanced urothelial carcinoma treated with pembrolizumab have been reported, including conventional parameters such as performance status and visceral (especially liver) metastasis, laboratory markers such as the neutrophil-to-lymphocyte ratio, sarcopenia, histological/genomic markers such as programmed cell death ligand 1 immunohistochemistry and tumor mutational burden, variant histology, immune-related adverse events, concomitant medications in relation to the gut microbiome, primary tumor site (bladder cancer versus upper tract urothelial carcinoma) and history/combination of radiotherapy. The survival time of advanced urothelial carcinoma has been significantly prolonged (or 'doubled' from 1 to 2 years) after the advent of pembrolizumab, which will be further improved with novel agents such as avelumab and enfortumab vedotin. This review summarizes the latest evidence on clinical outcomes and prognostic factors of advanced urothelial carcinoma in the contemporary era of immune checkpoint inhibitors.

Prognostic and clinicopathological significance of the Controlling Nutritional Status (CONUT) score in patients with lymphoma: a meta-analysis

OBJECTIVES

The role of the Controlling Nutritional Status (CONUT) scores in predicting the prognosis of lymphoma cases has been extensively explored, with no consistent results. The present meta-analysis focused on accurately evaluating whether CONUT could be used to predict the prognosis of lymphoma cases and its clinicopathological value.

DESIGN

The present meta-analysis was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The prognostic significance of CONUT to overall survival (OS) and progression-free survival (PFS) in lymphoma was estimated by calculating pooled HRs with 95% CIs. The relationship between CONUT and clinicopathological characteristics was measured based on pooled ORs with 95% CIs.

DATA SOURCES

PubMed, Web of Science, Embase and Cochrane Library databases were comprehensively searched from inception through 24 March 2023.

STATISTICAL METHODS

Either a random-effects model or a fixed-effects model was selected depending on the level of heterogeneity among the included studies.

RESULTS

This meta-analysis enrolled seven articles, containing 2060 patients with lymphoma. According to the pooled analysis, a higher CONUT score significantly predicted poor OS (HR=1.94, 95% CI 1.46 to 2.57, p<0.001) as well as poorer PFS (HR=1.51, 95% CI 1.04 to 2.20, p=0.031). Furthermore, according to the combined analysis, a higher CONUT score was significantly associated with Ann Arbor stages III-IV (OR=3.75, 95% CI 2.96 to 4.75, p<0.001), an Eastern Cooperative Oncology Group performance status of 2-4 (OR=5.14, 95% CI 3.97 to 6.65, p<0.001), high-intermediate/high National Comprehensive Cancer Network International Prognostic Index (OR=8.05, 95% CI 5.11 to 12.66, p<0.001), B symptoms (OR=4.97, 95% CI 2.89 to 8.52, p<0.001), extranodal disease (OR=3.25, 95% CI 2.24 to 4.70, p<0.001), bone marrow involvement (OR=4.86, 95% CI 3.25 to 7.27, p<0.001) and elevated lactate dehydrogenase levels (OR=3.21, 95% CI 2.37 to 4.34, p<0.001).

CONCLUSIONS

According to our results, higher CONUT scores were significantly associated with poor OS and PFS in lymphoma.

Prognostic impact of pretreatment skeletal muscle index and CONUT score in diffuse large B-cell Lymphoma

BACKGROUND

Although the prognostic value of the Controlling Nutritional Status (CONUT) score in diffuse large B-cell lymphoma (DLBCL) has been reported in several previous studies, its clinical relevance for the presence of sarcopenia has not been assessed.

METHODS

In this study, 305 DLBCL patients were reviewed. They were categorized into normal/mild (n = 219) and moderate/severe (n = 86) CONUT groups. Sarcopenia was assessed using the L3-skeletal muscle index measured by baseline computed tomography imaging. Based on CONUT score and sarcopenia, patients were grouped: A (normal/mild CONUT and no sarcopenia), B (either moderate/severe CONUT or sarcopenia, but not both), and C (both moderate/severe CONUT and sarcopenia).

RESULTS

The moderate/severe CONUT group showed higher rates of ≥ grade 3 febrile neutropenia, thrombocytopenia, non-hematologic toxicities, and early treatment discontinuation not related to disease progression, compared to the normal/mild CONUT group. The moderate/severe CONUT group had a lower complete response rate (58.1% vs. 80.8%) and shorter median overall survival (18.5 vs. 162.6 months) than the normal/mild group. Group C had the poorest prognosis with a median survival of 8.6 months, while groups A and B showed better outcomes (not reached and 60.1 months, respectively). Combining CONUT score and sarcopenia improved the predictive accuracy of the Cox regression model (C-index: 0.763), compared to the performance of using either CONUT score (C-index: 0.754) or sarcopenia alone (C-index: 0.755).

CONCLUSIONS

In conclusion, the moderate/severe CONUT group exhibited treatment intolerance, lower response, and poor prognosis. Additionally, combining CONUT score and sarcopenia enhanced predictive accuracy for survival outcomes compared to individual variables.

Assessment of nutritional status and clinical outcomes: A comprehensive retrospective analysis of critically ill patients

Assessing nutritional status is vital for understanding and managing patients' clinical conditions. Controlling Nutritional Status (CONUT) score is one of the most frequently used scores that evaluate caloric status, protein reserve, and immunological response estimation. This study assesses the critically ill patients' nutritional status and its relationship with patient-related factors and mortality. Electronic medical records of 1687 Intensive Care Unit (ICU) patient files were reviewed from January 2019 to May 2023 retrospectively. Patient demographic information, clinical characteristics, and laboratory data were extracted and anonymized for analysis. The patients were divided according to the CONUT scores, and retrieved data were compared. The study population's demographic features and clinical outcomes were stratified by CONUT scores. The gender distribution was similar; however, there was a significant age difference between the Low-CONUT and High-CONUT groups (P < .001). High CONUT values are linked to an increased risk of death, intubation, age, APACHE-II scores, and the number of comorbidities. Malnutrition is prevalent in ICU patients with gastrointestinal illnesses and urogenital system disorders, including infections. Patients with a high CONUT score at admission had an increased risk of ICU death even after correcting for covariates. The CONUT score is a trustworthy and practical tool for assessing ICU patients' nutritional status, which is highly associated with ICU mortality. Patients admitted to the ICU with gastrointestinal, urogenital, or infectious disorders should have their nutritional condition assessed carefully. According to our study, the rate of intubated patients admitted to the intensive care unit is higher in malnourished patients. This suggests it should be reviewed in clinical settings, particularly in elderly, frail patients and those with numerous comorbidities.

Impact of a novel immune and nutritional score on prognosis in patients with upper urinary tract urothelial carcinoma following radical nephroureterectomy

BACKGROUND

This study aimed to evaluate the clinical significance of a novel immune and nutritional score combining prognostic values of the controlling nutritional status (CONUT) score and prognostic immune and nutritional index (PINI) on long-term outcomes in patients with upper tract urothelial carcinoma (UTUC) after radical nephroureterectomy (RNU).

METHODS

This study analyzed 437 consecutive patients with UTUC treated by RNU. Restricted cubic splines were used to visualize the relation of PINI with Survival in patients with UTUC. The PINI was stratified into low- (1) and high-PINI (0) categories. The CONUT score was divided into three groups: Normal (1), Light (2), and Moderate/severe (3). Subsequently, patients were grouped according to CONUT-PINI score (CPS) (CPS group 1; CPS group 2; CPS group 3; and CPS group 4). Survival curves were plotted using the Kaplan-Meier method and log-rank test. The Cox proportional hazards regression model was used to determine the risk factors associated with overall Survival (OS) and cancer-specific Survival (CSS). By comprising independent prognostic factors, a predictive nomogram was constructed.

RESULTS

PINI and CONUT score were identified as independent prognostic factors for OS and CSS. Kaplan-Meier survival analysis showed that the high CPS group was associated with worse OS and CSS than the low CPS group. Multivariate Cox regression and competing risk analyses showed that CPS, LVI, T stage, margin, and pN were independent factors associated with OS and CSS. Based on these five significant factors, we constructed a prognostic model for predicting clinical outcomes. The receiver operating characteristic curve indicated that the model had excellent predictive abilities for survival. The C-index of this model for OS and CSS were 0.773, and 0.789, respectively. The nomogram for OS and CSS showed good discrimination and calibration. Decision curve analysis (DCA) showed that this nomogram has a higher net benefit.

CONCLUSION

The CPS combined the prognostic capacity of PINI and CONUT score and was able to predict patient outcomes in our cohort of UTUC patients. We have developed a nomogram to facilitate the clinical use of the CPS and provide accurate estimates of survival for individuals.

Development of sarcopenia-based nomograms predicting postoperative complications of benign liver diseases undergoing hepatectomy: A multicenter cohort study

Background

Sarcopenia has a remarkable negative impact on patients with liver diseases. We aimed to evaluate the impact of preoperative sarcopenia on the short-term outcomes after hepatectomy in patients with benign liver diseases.

Methods

A total of 558 patients with benign liver diseases undergoing hepatectomy were prospectively reviewed. Both the muscle mass and strength were measured to define sarcopenia. Postoperative outcomes including complications, major complications and comprehensive complication index (CCI) were compared among four subgroups classified by muscle mass and strength. Predictors of complications, major complications and high CCI were identified by univariate and multivariate logistic regression analysis. Nomograms based on predictors were constructed and calibration cures were performed to verify the performance.

Results

120 patients were involved for analysis after exclusion. 33 patients were men (27.5%) and the median age was 54.0 years. The median grip strength was 26.5 kg and the median skeletal muscle index (SMI) was 44.4 cm²/m². Forty-six patients (38.3%) had complications, 19 patients (15.8%) had major complications and 27 patients (22.5%) had a CCI ≥ 26.2. Age (p = 0.005), SMI (p = 0.005), grip strength (p = 0.018), surgical approach (p = 0.036), and operation time (p = 0.049) were predictors of overall complications. Child-Pugh score (p = 0.037), grip strength (p = 0.004) and surgical approach (p = 0.006) were predictors of major complications. SMI (p = 0.047), grip strength (p < 0.001) and surgical approach (p = 0.014) were predictors of high CCI. Among the four subgroups, patients with reduced muscle mass and strength showed the worst short-term outcomes. The nomograms for complications and major complications were validated by calibration curves and showed satisfactory performance.

Conclusion

Sarcopenia has an adverse impact on the short-term outcomes after hepatectomy in patients with benign liver diseases and valuable sarcopenia-based nomograms were constructed to predict postoperative complications and major complications.