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      A novel, externally validated inflammation-based prognostic algorithm in hepatocellular carcinoma: the prognostic nutritional index (PNI)

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          There is increasing evidence that the presence of an ongoing systemic inflammatory response is a stage-independent predictor of poor outcome in patients with cancer. The aim of this study was to investigate whether an inflammation-based prognostic score, the prognostic nutritional index (PNI), is associated with overall survival (OS) in patients with hepatocellular carcinoma (HCC).


          All patients with a new diagnosis of HCC presenting to the Medical Oncology Department, Hammersmith Hospital between 1993 and 2011 ( n=112) were included. Demographic and clinical data were collected. Patients in whom the combined albumin (g l −1) × total lymphocyte count × 10 9 l −1 was ⩾45, at presentation, were allocated a PNI score of 0. Patients in whom this total score was <45 were allocated a score of 1. Univariate and multivariate analyses were performed to identify clinicopathological variables associated with OS. Independent predictors of survival identified on multivariate analysis were validated in an independent, stage-matched cohort of 68 patients.


          Univariate analyses showed that PNI ( P=0.003), intrahepatic spread ( P<0.001), the presence of extrahepatic disease ( P=0.006), portal vein thrombosis ( P=0.02), tumour multifocality ( P=0.003), alfa-fetoprotein >400 ng ml −1 ( P<0.001) and Barcelona Clinic Liver Cancer score ( P<0.01) were all predictors of OS in the training set. Multivariate analysis revealed the PNI ( P=0.05), presence of extrahepatic disease ( P<0.001) and degree of intrahepatic spread ( P<0.001) as independent predictors of worse OS in this population. The PNI retained independent prognostic value in the validation set ( P<0.001).


          The presence of a systemic inflammatory response, as measured by the PNI, is an independent and externally validated predictor of poor OS in patients with HCC.

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          Most cited references 41

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          Management of hepatocellular carcinoma.

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            Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver.

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              A comparison of inflammation-based prognostic scores in patients with cancer. A Glasgow Inflammation Outcome Study.

              Components of the systemic inflammatory response, combined to form inflammation-based prognostic scores (modified Glasgow Prognostic Score (mGPS), Neutrophil Lymphocyte Ratio (NLR), Platelet Lymphocyte Ratio (PLR), Prognostic Index (PI), Prognostic Nutritional Index (PNI)) have been associated with cancer specific survival. The aim of the present study was to compare the prognostic value of these scores. Patients (n=27,031) who had an incidental blood sample taken between 2000 and 2007 for C-reactive protein, albumin, white cell, neutrophil, lymphocyte and platelet counts, as well as a diagnosis of cancer (Scottish Cancer Registry) were identified. Of this group 8759 patients who had been sampled within two years following their cancer diagnosis were studied. On follow up, there were 5163 deaths of which 4417 (86%) were cancer deaths. The median time from blood sampling to diagnosis was 1.7 months. An elevated mGPS, NLR, PLR, PI and PNI were predictive of a reduced cancer specific survival independent of age, sex and deprivation and tumour site (all p<0.001). The area under the receiver operator curves was greatest for mGPS and PI. Specifically, in colorectal cancer, an elevated mGPS and PI were predictive of a reduced cancer specific survival independent of age, sex, deprivation and tumour stage (both p<0.001). The results of the present study show that systemic inflammation-based scores, in particular the mGPS and PI, have prognostic value in cancer independent of tumour site. Based on the present results and the existing validation literature, the mGPS should be included in the routine assessment of all patients with cancer. Copyright © 2011 Elsevier Ltd. All rights reserved.

                Author and article information

                Br J Cancer
                Br. J. Cancer
                British Journal of Cancer
                Nature Publishing Group
                10 April 2012
                20 March 2012
                : 106
                : 8
                : 1439-1445
                [1 ]Division of Experimental Medicine, Imperial College London, Hammersmith Hospital , Du Cane Road, London W12 0HS, UK
                [2 ]Division of Internal Medicine, Universitá degli Studi del Piemonte Orientale, Department of Clinical and Experimental Medicine , Novara, Italy
                [3 ]Statistical Advisory Service, Imperial College London, South Kensington Campus , London, UK
                Author notes
                Copyright © 2012 Cancer Research UK
                Molecular Diagnostics

                Oncology & Radiotherapy

                prognosis, hepatocellular carcinoma, inflammation, prognostic index, survival


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