Poor nutritional status negatively influences prognosis of malignant pleural mesothelioma patients undergoing multimodal therapy

Background:

Malignant pleural mesothelioma (MPM) is an extremely aggressive tumor arising from the pleura. Multimodal treatment (MMT) is recommended as the best therapy option in selected cases. Blood values including nutritional status have been recently reported as a useful prognosticator. We conducted a retrospective study to investigate the clinical importance of nutritional status in MPM patients intended to be treated in a multimodality therapy concept.

Material and method:

Of consecutive 477 MPM patients intended to be treated at the University Hospital of Zurich between September 1999 and April 2018, blood values were available for 86 patients, 74 underwent surgery with induction chemotherapy. Discriminative ability was investigated for neutrophil-lymphocyte ratio (NLR), CRP-albumin ratio (CAR), albumin, C-reactive protein (CRP), Glasgow prognostic score (GPS), modified Glasgow prognostic score (mGPS) and Cancer and Leukaemia Group B Score (CALGB). The first four of these are continuous parameters.

Median overall survival (OS) was estimated from Kaplan-Meier curves. Time-dependent ROC curves from censored survival data were fitted in order to assess discriminative ability of these markers at different time points using a method proposed by Heagerty et al. 2000. Detailed discriminative ability of the continuously measured markers at three years time are displayed as ROC curves. All analyses were conducted with R.

Fig. 1: Kaplan Meier plot of survival probability including 95% confidence interval. Time zero indicates start of first chemotherapy cycle.

Fig. 2: Detailed AUC curves of true positives (TP) versus false positives (FP) for the continuous markers at 36 months.

Result:

Median survival time was 17 months, 95% confidence interval (CI) from 11 to 26 months (Figure 1). The markers NLR, CAR, albumin, and CRP show better discriminative ability than the markers GPS, mGPS, and CALGB over the time interval from 12 to 60 months. The discriminative ability of CAR and CRP is relatively constant over time and it decreases after 4 years follow-up time. Figure 2 shows ROC curves at 3 years follow-up time.

Conclusion:

Nutritional and inflammatory parameters have potential to discriminate survival status of patients under MMT. These markers need validation in new and prospectively collected cohorts, and might be combined with other chemical, pathological and biological markers.