Preoperative Glasgow Prognostic Score as additional independent prognostic parameter for patients with esophageal cancer after curative esophagectomy

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Abstract

Background

Inflammation accelerates tumor growth followed by reduced survival in patients with cancer. The aim of this study was to evaluate the prognostic relevance of preoperatively increased levels of C-reactive protein (CRP) and the corresponding Glasgow Prognostic Score (GPS) on patients with esophageal carcinoma undergoing curative esophagectomy.

Methods

The data of 174 operated esophageal cancer patients were evaluated retrospectively. Patient's demographic and clinico-pathological data, tumor specific data, preoperative plasma levels of CRP and albumin, the corresponding GPS, overall survival (OS) and progression free survival (PFS) were assessed.

Results

103 (59.2%) had adenocarcinoma and 71 (40.8%) had squamous cell carcinoma. 71 patients (43%) had elevated CRP concentrations. 118 patients (71%) had GPS 0, 41 (25%) GPS 1 and 8 (4%) GPS 2. Mean GPS was 0.3 (0–2). 5-year OS was higher in patients with normal CRP than in those with increased CRP (68% vs. 39%; p = 0.007). 5-year OS in patients with GPS 0 and GPS 1 and 2 were 65% and 31% (p = 0.001). 5-year OS for the whole cohort was 56% (1 year: 83%, 3 years: 64%). Recurrence rate was 16.1% closely associated with GPS (p = 0.002). Median follow-up was 23 months (0–118 months). In multivariate analysis GPS, lymph node involvement, T stage and tumor histology were the independent prognostic parameters (p = 0.004, <0.001, 0.035, 0.010).

Conclusions

Preoperatively increased GPS is significantly associated with reduced postoperative survival and tumor recurrence. The GPS as an independent prognosticator should be interpreted together with the TNM stage when the further postoperative treatment has to be scheduled.

Introduction

The incidence of esophageal carcinoma in Europe and the United States accounts for about 10 deaths per 100 000 annually. Squamous cell carcinoma (SCC) and adenocarcinoma (AC) represent more than 95% of esophageal tumors. The conventional treatment modality for the cure of esophageal cancer is still esophageal resection either with or without (neo-) adjuvant therapy. Nevertheless the overall 5-years survival rate after surgery is approximately 30% which still represents a distressing outcome although considerable efforts had been undertaken during the last decades to improve this poor prognosis.1

Serious prognostication of patient's individual survival time remains a considerable challenge. Over the years the TNM staging system of the International Union Against Cancer (UICC) had been established as widely accepted prognostic regimen.2 Biomarkers to predict survival especially in patients suffering from esophageal cancer, are used rarely.3

Based on the fact that inflammation is able to maintain tumor growth,4 the role of different inflammatory mediators had been investigated increasingly. In this context the C-reactive protein (CRP) plays an important key role within this complex relationship. High levels of CRP have been identified as risk factors for numerous occlusive vascular diseases. In addition CRP levels have to been shown considerably elevated in cancer patients proving the tight connection between inflammation and the tumorigenic process.5, 6

However, increased levels of CRP serve as reliable prognosticator of poor prognosis in cancer patients even after surgery.7, 8 For this reason concentration of CRP gained in increasing importance as additional predictive parameter for survival during postoperative follow-up in patients with cancer,9 especially after curative esophagectomy.10, 11, 12, 13, 14, 15

Originally, the Glasgow Prognostic Score (GPS) had been established to evaluate the influence of an elevated CRP concentration and low levels of albumin on the survival in patients suffering from advanced lung cancer.16

On this note the GPS serves as an independent significant prognosticator in patients with cancer,17 reflecting both the inflammatory component and the nutritional decline.6, 18 There is recent evidence which documents the prognostic impact of the GPS in both, patients with operable and inoperable cancer.6, 18 However, in case of resected esophageal cancer, only few data are available.19, 20, 21

Regarding these findings the goal of this retrospective analysis was to evaluate both the prognostic impact of preoperatively increased CRP levels and the corresponding GPS on the further survival in patients with resectable esophageal carcinoma undergoing curative esophagectomy.

Section snippets

Materials and methods

Between 2003 and 2011, 174 patients with esophageal carcinoma after curative esophagectomy were included in this retrospective analysis.

The inclusion criteria were histopathologically proven esophageal SCC or AC and radical curative esophagectomy and reconstruction with gastric pull-up and cervical esophagogastric anastomosis. Exclusion criteria were advanced tumor stage with distant tumor spread, disability of curative esophagectomy, medical history of previous cancer and ongoing inflammation

Results

The study cohort consisted of 148 men (85.1%) and 26 women (14.9%), mean aged 61.1 ± 10.4 years (range 22–81 years). The mean body weight was 75.9 ± 14.7 kg (range 39–127 kg). The mean BMI (Body Mass Index) was 25.4 kg/m2 (range 15.2–41.4 kg/m2). Underweight corresponding to malnutrition was evident in only 9 patients (5.2%) showing a BMI < 18.5 kg/m2. The vast majority (89/174; 51.1%) had excess weight: overweight (BMI: 25–30 kg/m2) could be detected in 66 patients (37.9%) and obesity

Discussion

This clinical analysis demonstrates that preoperatively increased GPS is connected with significantly reduced postoperative survival and increased tumor recurrence.

Serious prognostication remains an important component in the further postoperative follow-up. Currently the postoperative TNM classification represents the gold standard for both predicting outcomes and determination of possible adjuvant therapy even after curative esophageal surgery.21 The aim of this study was to evaluate simply

Conflict of interest statement

The authors declare no conflicts of interest.

Acknowledgements

There are no acknowledgments. There are no sources of funding.

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