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Significance of Markers of Systemic Inflammation for Predicting Survival

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Significance of Markers of Systemic Inflammation for Predicting Survival ANTICANCER RESEARCH 35: 5037-5046 (2015) Significance of Markers of Systemic Inflammation for Predicting Survival and Chemotherapeutic Outcomes and Monitoring Tumor Progression in Patients with Unresectable Metastatic Colorectal Cancer MASATSUNE SHIBUTANI, KIYOSHI MAEDA, HISASHI NAGAHARA, HIROSHI OHTANI, KATSUNOBU SAKURAI, SADAAKI YAMAZOE, KENJIRO KIMURA, TAKAHIRO TOYOKAWA, RYOSUKE AMANO, NAOSHI KUBO, HIROAKI TANAKA, KAZUYA MUGURUMA, MASAICHI OHIRA and KOSEI HIRAKAWA Department of Surgical Oncology, Osaka City University Graduate School of Medicine, Abeno–ku, Osaka, Japan Abstract. Background: Markers of systemic inflammation, treatment NLR/CRP/GPS, and that with high post-treatment such as the neutrophil to lymphocyte ratio (NLR), C-reactive CRP/GPS; the progression-free survival rate was significantly protein (CRP) level and Glasgow prognostic score (GPS), worse in the high post-treatment CRP group. As for have been reported to be useful prognostic indicators for chemotherapeutic response, patients with a low post-treatment various types of cancers. However, most of the existing reports CRP level had a significantly higher disease control rate than investigated the preoperative status, and the significance of those with a high post-treatment CRP level. Moreover, the markers of systemic inflammation remains unclear in patients patients with a high pre-treatment CRP level and with unresectable metastatic colorectal cancer. The aim of the normalization after treatment exhibited better overall and present retrospective study was to evaluate the significance of progression-free survival rates and had a significantly higher markers of systemic inflammation for predicting the prognosis disease control rate than those with high pre- and post- and chemotherapeutic outcomes and monitoring the treatment CRP levels. Conclusion: Pre-treatment markers of progression of the tumor in patients with unresectable systemic inflammation are useful for predicting prognosis in metastatic colorectal cancer receiving palliative patients with unresectable metastatic colorectal cancer who chemotherapy. Patients and Methods: A total of 110 patients receive palliative chemotherapy. Moreover, the CRP level can with unresectable metastatic colorectal cancer who underwent be used as a marker for predicting chemotherapeutic outcome palliative chemotherapy for metastatic tumors were enrolled and monitoring the progression of the tumor. in the study. We evaluated the relationships between the survival/chemotherapeutic response and pre-/post-treatment Colorectal cancer (CRC) is the third leading cause of cancer- markers of systemic inflammation. The pre-treatment markers related death worldwide (1). In particular, patients with of systemic inflammation were measured within one week unresectable metastatic disease have the worst prognosis before the initiation of chemotherapy and the post-treatment among those with CRC. markers of systemic inflammation were measured eight weeks Despite major advances in chemotherapy for unresectable after initiation of chemotherapy. Results: The overall survival CRC within the last 10 years (2, 3), it remains difficult to rates were significantly worse in the group with high pre- achieve a complete response with chemotherapy alone. Moreover, some patients are expected to have worse survival due to ineffectiveness of chemotherapy. The guidelines of the European Society for Medical Oncology recommend that Correspondence to: Masatsune Shibutani, Osaka City University physicians individualize treatment of patients with metastatic Graduate School of Medicine, Department of Surgical Oncology, CRC according to tumor- and disease-related characteristics, 1–4–3 Asahi-machi, Abeno–Ku, Osaka City, Osaka Prefecture, 545- such as the clinical presentation and pattern of tumor biology 8585, Japan. Tel: +81 666453838, Fax: +81 666466450, e-mail: (4). Therefore, it is necessary to identify patients with a high [email protected] possibility of poor survival, and various biomarkers for Key Words: Colorectal cancer, unresectable, prognosis, neutrophil predicting survival and the chemotherapeutic outcome have to lymphocyte ratio, C-reactive protein, Glasgow prognostic score. been examined. 0250-7005/2015 $2.00+.40 5037 ANTICANCER RESEARCH 35: 5037-5046 (2015) Recently, markers of systemic inflammation have been The cut-off value for the serum CRP concentration used in this reported to correlate with survival in various types of cancers, study was determined according to the definition of the GPS. Based including CRC (5-16). However, most previous reports on a cut-off value of 1.0 mg/dl, 30 patients were classified into the high pre-treatment CRP group and 72 patients were classified into investigated the prognostic significance of preoperative markers the low pre-treatment CRP group. of systemic inflammation in patients treated with surgery (5, 6, According to the definition of the GPS, 64 patients were classified 9, 11, 12), and there exist only few reports focusing on patients as having a GPS of 0, 26 patients as having a GPS of 1 and nine with unresectable metastatic cancer (7, 8, 10, 13-16). patients as having a GPS of 2. The patients with a GPS of 0 exhibited Moreover, only a few reports have investigated the significance a better prognosis than did the patients with a GPS of 1 (p=0.0274), of post-treatment markers of systemic inflammation and their while there were no significant differences between the patients with usefulness as predictors of the chemotherapeutic response, and a GPS of 1 and the patients with a GPS of 2 as to the overall survival rate (p=0.6990). Therefore, the patients with a GPS of 1 or 2 were of factors for monitoring tumor progression (7, 8, 16). classified into the high pre-treatment GPS group and those with a The aim of this retrospective study was to evaluate the GPS of 0 were classified into the low pre-treatment GPS group. significance of markers of systemic inflammation for predicting We then examined the correlations between the markers of survival and chemotherapeutic outcomes and monitoring the systemic inflammation and survival and chemotherapeutic response. progression of the tumor in patients with unresectable metastatic colorectal cancer receiving palliative chemotherapy. Evaluation. Response evaluations were performed every 8 weeks. A variation of approximately 1 week was regarded as allowable error. Patients and Methods All patients were followed up with a physical examination, computed tomography, ultrasonography and blood tests, including Patients’ characteristics. We retrospectively reviewed a database of measurements of the levels of tumor markers, such as 18 110 patients who underwent palliative combination chemotherapy carcinoembryonic antigen (CEA). Some patients underwent F- 18 for unresectable colorectal cancer at the Department of Surgical fluorodeoxyglucose positron-emission tomography ( F-FDG-PET) Oncology of Osaka City University between 2006 and 2011. or colonoscopy as needed. The patients’ characteristics are listed in Table I. The patient We adopted the Response Evaluation Criteria in Solid Tumors population consisted of 63 males and 47 females, with a median age (RECIST) (18) to classify the treatment response, as follows: complete of 64 years (range=27 to 86). Sixty-four patients had primary response (CR), partial response (PR), stable disease (SD) and tumors located in the colon and 46 patients had primary tumors progressive disease (PD). The objective response was defined as CR or located in the rectum. A total of 46 patients had metachronous PR, while disease control was defined as CR, PR or SD. Progression- unresectable cancer and 64 patients had synchronous unresectable free survival was defined as the time from the date of initiation of the cancer. Sixty-two patients had only one organ affected by metastasis first-line chemotherapy to disease progression. Overall survival was and 48 patients had more than one organ affected by metastasis. All defined as the time from the date of initiation of the first-line patients underwent combination chemotherapy with oxaliplatin or chemotherapy to death from any cause or the last contact. irinotecan plus 5-fluorouracil/leucovorin or a pro-drug of 5- fluorouracil as first-line chemotherapy. Statistical analysis. The significance of correlations between the pre-treatment markers of systemic inflammation and the 2 Measurement and definition of markers of systemic inflammation. clinicopathological characteristics was analyzed using the χ test. The pre-treatment blood samples were obtained within one week The duration of survival was calculated according to the before the initiation of chemotherapy and the post-treatment blood Kaplan–Meier method. Differences in the survival curves were samples were obtained 8 weeks after the initiation of chemotherapy. assessed with the log-rank test. A multivariate analysis was The differential white blood cell count was analyzed using an XE- performed according to the Cox proportional hazard model. All 5000 hematology analyzer (Sysmex, Kobe, Japan), and the serum C- statistical analyses were conducted using the SPSS software reactive protein (CRP) and albumin concentrations were measured package for Windows (SPSS Japan, Tokyo, Japan). Statistical using a chemiluminescent immunoassay (Wako, Osaka, Japan) based significance was set at a p-value of <0.05. on the manufacturer’s protocol. The neutrophil to lymphocyte ratio (NLR) was calculated from the blood samples by dividing the Ethics statement. This research
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