Malnutrition is a common finding in cancer patients, which can affect disease progression and survival. This review aims to critically summarize the prognostic role of nutritional status, from Body Mass Index (BMI) and weight loss to nutrition screening tools and biochemical indices, in cancer patients. According to the currently available data, Prognostic Nutritional Index (PNI) was a significant prognostic factor of patients' survival, both in univariate and multivariate analyses. Pre-operative albumin was also correlated with worse outcomes, being an independent prognostic factor of survival in several studies. BMI was also well-studied, with contradictory results. Although, lower BMI was found to be an independent prognostic factor of shorter survival in some studies, in others it did not have an impact on survival. In this aspect, this review highlights the significant prognostic role of nutritional status in the disease progression and survival of cancer patients. Further, good-quality prospective studies are needed in order to draw precise conclusions on the prognostic role of specific nutritional assessment tools, and biochemical indices associated with the nutritional status in more cancer types, such as liver, breast and prostate cancer, and hematological malignancies.

Clinical Value of Nutritional Status in Cancer: What is its Impact and how it Affects Disease Progression and Prognosis?

Background 
We previously reported the role of IL-6 in a murine model of cancer cachexia and currently documented a patient in whom tocilizumab, anti-IL-6 receptor antibody, dramatically improved cachexia induced by IL-6 over-expressing lung cancer. Despite this potential to alleviate cancer cachexia, tocilizumab has not been approved for this clinical use. Therefore, preceding our planned clinical trial of tocilizumab, we designed the two studies described here to evaluate the levels of IL-6 in patients with lung cancer and the effect of tocilizumab in a murine model of human cancer cachexia.
Methods 
First, we measured serum IL-6 levels in patients with lung cancer and analyzed its association with cachexia and survival. Next, we examined the effect of a rodent analog of tocilizumab (MR16-1) in the experimental cachexia model.
Results 
Serum IL-6 levels were higher in patients with cachexia than those without cachexia. In patients with chemotherapy-resistant lung cancer, a high IL-6 serum level correlated strongly with survival, and the cut-off level for affecting their prognosis was 21 pg/mL. Meanwhile, transplantation of IL-6-expressing Lewis Lung Carcinoma cells caused cachexia in mice, which then received either MR16-1 or 0.9% saline. Tumor growth was similar in both groups; however, the MR16-1 group lost less weight, maintained better food and water intake and had milder cachectic features in blood. MR16-1 also prolonged the survival of LLC-IL6 transplanted mice (36.6 vs. 28.5 days, p = 0.016).
Conclusion 
Our clinical and experimental studies revealed that serum IL-6 is a surrogate marker for evaluating cachexia and the prognosis of patients with chemotherapy resistant metastatic lung cancer and that tocilizumab has the potential of improving prognosis and ameliorating the cachexia that so devastates their quality of life. This outcome greatly encourages our clinical trials to evaluate the safety and efficacy of tocilizumab treatment for patients with increased serum IL-6.

/pdf/tocilizumab-a-proposed-therapy-for-the-cachexia-of-3i0slv0yjb.pdf

Tocilizumab, a Proposed Therapy for the Cachexia of Interleukin6-Expressing Lung Cancer

Preoperative assessment of patients’ immunologic and nutritional conditions is required to predict the outcome of patients with malignant tumors. The aim of the current study was to clarify the significance of the prognostic nutritional index (PNI), which simply accounts for immunological and nutritional conditions, in patients with renal cell carcinoma (RCC). We included 1437 patients who underwent nephrectomy for RCC between 1994 and 2008. PNI was calculated using the following formula: 10 × serum albumin concentration (g/dL) + 0.005 × lymphocyte counts (number/mm2) in peripheral blood. We examined the correlation of the preoperative PNI value with clinicopathological features. A Cox regression model and the Harrell concordance index with variables only or combined PNI data were used to evaluate the prognostic significance in the T1-4NallMall and T1-4N0M0 groups. The mean preoperative PNI value was 52.7 ± 6.3 (range 27.7–85.3). The mean PNI values were significantly lower in patients with more advanced tumor T stage, regional lymph node metastasis, distant metastases, higher Fuhrman grade, and sarcomatoid differentiation than in patients without such factors (p  51, p < 0.001). Multivariate analysis showed that low PNI was significantly associated with cancer-specific survival (p = 0.026 and p = 0.009) and overall survival (p = 0.013 and p = 0.011) in the T1-4NallMall and T1-4N0M0 groups, respectively, after correcting for other clinicopathological factors. PNI is an independent prognostic factor for predicting survival after nephrectomy in patients with RCC.

Preoperative Prognostic Nutritional Index is a Significant Predictor of Survival in Renal Cell Carcinoma Patients Undergoing Nephrectomy.

Objective

To evaluate the impact of the preoperative American Society of Anesthesiologists (ASA) score and serum albumin level on complications, recurrences and survival rates of patients who underwent radical cystectomy (RC) for urothelial bladder cancer (UBC).




Patients and Methods

In all, 1964 patients underwent RC for UBC at our institution between 1971 and 2008.
Preoperative serum albumin and ASA score were available in 1471 and 1140 patients, respectively.
A complication was defined as any surgery related/unrelated event leading to lengthening hospital stay or re-admission.
Endpoints were 90-day complication (90dC) rate, recurrence-free survival (RFS) and overall survival (OS).




Results

The median (range) follow-up was 12.4 (0.2–27.3) years. In all, 197 patients (13.4%) had a low albumin level (<3.5 g/dL) and 740 (64.8%) had a high ASA score (3 or 4).
Low serum albumin and a high ASA score were associated with higher 90dC rate (42% vs 34%, P = 0.03 and 40% vs 28%, P < 0.001, respectively).
On multiple logistic regression analysis, a high ASA score remained independently associated with increased 90dC rate (hazard ratio [HR] 1.52, P = 0.005) and decreased OS (HR 1.45, 95% confidence interval [CI] 1.13–1.86). A low serum albumin level was also independently associated with RFS (HR 1.68, 95% CI 1.16–2.43) and OS (HR 1.93, 95% CI 1.43–2.63).




Conclusion

A low serum albumin level was independently associated with cancer recurrence and decreased OS after RC.
A high ASA score was also independently associated with decreased OS.
These parameters potentially could be used as prognosticators after RC.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/bju.12240

The association of preoperative serum albumin level and American Society of Anesthesiologists (ASA) score on early complications and survival of patients undergoing radical cystectomy for urothelial bladder cancer

Objective

To determine the association between preoperative serum albumin and mortality and postoperative complications after radical cystectomy and urinary diversion.




Patients and Methods

We conducted a retrospective review of 1097 radical cystectomies performed for the treatment of bladder cancer between 1992 and 2005.


All data were entered prospectively into a hospital-based complications database.


We used multivariable logistic regression to assess the association between preoperative serum albumin and complications and mortality within 90 days of surgery, while controlling for preoperative patient and disease characteristics.




Results

Low preoperative serum albumin was identified in 14% of the cohort.


Preoperative serum albumin was a predictor of postoperative complications (adjusted odds ratio [OR] per unit increase in albumin: 0.61, 95% confidence interval [CI] 0.42–0.90) and 90-day mortality (OR 0.33, 95% CI 0.14–0.75) when controlling for sex, race, age-adjusted Charlson score, body mass index, prior history of abdominal surgery, clinical stage, and neoadjuvant chemotherapy.


As serum albumin decreased, the risk of complications and mortality increased.




Conclusions

In addition to age-adjusted Charlson score, low preoperative serum albumin is a significant predictor of complications and mortality after radical cystectomy.


Serum albumin testing can be used to identify individuals at high-risk for morbidity and mortality.





Keywords: hypoalbuminemia, postoperative complications, urinary bladder neoplasms


INTRODUCTION
Radical cystectomy (RC) for muscle-invasive bladder cancer is a major extirpative procedure that is associated with significant postoperative complications and mortality. Our group has reported complication rates of 64% and 30-day postoperative mortality rates of 1.5%.[1]

Modifiable factors, such as nutrition status, are associated with postoperative outcomes in other major surgical procedures such as colorectal and cardiac surgery.[2, 3] Low preoperative serum albumin, in particular, as a surrogate marker for nutrition status, is a strong predictor of postoperative morbidity and mortality for procedures in multiple surgical disciplines; however, only a few small studies have focused on urologic surgery.[4–7] These prior studies have confirmed the association between preoperative serum albumin and mortality after RC, but an association between serum albumin and postoperative complications has not been investigated. The objective of this study was to define the relationship between preoperative serum albumin and 90-day complication and mortality rates in a large cohort of patients undergoing RC at a major tertiary cancer center.

/pdf/preoperative-serum-albumin-is-associated-with-mortality-and-zg02pts8kv.pdf

Jack Lambert

Papers

Using preoperative albumin levels as a surrogate marker for outcomes after radical cystectomy for bladder cancer.

Common Laboratory Values Are Unreliable in Identifying the Presence of Metastatic Renal Cell Carcinoma in the Liver and Bones