Tumor Related Anemia During Perioperative Period As Prognostic Predictors In Esophageal Squamous Cell Carcinoma Patients With Esophagectomy

Backgrounds:Esophageal cancer is the third most common cancer in China,with approximately 477,900 new cases in 2015,and is also the fourth leading cause of death in the world,with approximately 375,000 deaths in 2015.In high-risk region,such as China,the esophageal squamous cell carcinoma(ESCC)accounts for over 90%of all cases with a significantly increasing incidence rate.Surgical treatment is the main treatment for esophageal squamous cell carcinoma.Anemia is known to be a common condition in cancer patients,and about 30%of cancer patients suffer from anemia.Some studies indicated that anemia was associated with poor prognosis in many carcinomas.Anemia was found to be an independent prognostic factor for poor survival in solid malignant tumors and hematologic malignancies in a meta-analysis.The study aimed to analyze the anemia status and assess the prognostic value of tumor related Perioperative anemia in esophageal squamous cell carcinoma patients who underwent esophagectomy.Objective:The retrospective study is to verify the correlations of Perioperative Period anemia with clinicopathological characteristics and evaluate their prognostic values on disease-free survival(DFS)and OS in ESCC patients.Methods:Preoperative and postoperative hemoglobin(during Perioperative Period)were collected from 209 patients who were diagnosed with esophageal squamous cell carcinoma in 2012,and received esophagectomy in Qilu Hospital of Shandong University from January 2012 to December 2012.Preoperative and postoperative patients both were categorized into two groups:anemic and non-anemic,based on HB level based on the World Health Organization(WHO)classification(male and female patients with<130 and<120 g/L HB,respectively).Patients were followed up by telephone and face-to-face communication in the outpatient clinics every 3 months in the first 2 years after operation,then every 6 months until they were dead or lost.The last follow-up was on January 3 2018.The endpoints were 5-year DFS and 5-year OS.Differences in patient characteristics were assessed using the t test for continuous variables and the χ2 test for categorical variables.For DFS and OS analyses,the Kaplan-Meier curves and log-rank analysis were used in this study.Moreover,the Cox proportional hazards model was applied to determine the hazard ratio(HR)of variables on OS and DFS in univariate and multivariate analysis.The results were given as HR with their 95%CI.The two-sided p value was used in our analyses,and P<0.05 was considered significant.Statistical analysis was performed using the Statistical Package for Social Science(SPSS for Windows,version 20,USA).Results:We found that the incidence and the severity degree of anemia were higher after operation(P<0.05).The Preoperative anemia was associated with TNM stage.Postoperative anemia was associated with TNM stage、PNI and smoking status.Kaplan-Meier survival analysis indicated that preoperative anemia was associated with poorer disease-free survival(DFS)and overall survival(OS).The median survival time of preoperative non-anemia group(54 month)was significantly higher than that of preoperative anemia group(32 month),the difference was statistically significant.Nevertheless,the postoperative anemia(both 3-5days and 8-i2days)did not indicate shorter disease-free survival and overall survival.The multivariate analysis showed that preoperative anemia was an independent prognostic factor in ESCC for DFS and OS.Preoperative anemia was subgroup analysis according to TNM staging.Preoperative anemia had an effect on the 5-year overall survival of patients with stage Ⅱ&Ⅲ esophageal squamous cell carcinoma,and had no effect on the 5-year overall survival of patients with stage I esophageal squamous cell carcinoma.Preoperative anemia was subgroup analysis based on postoperative adjuvant therapy.Preoperative anemia had an effect on the 5-year overall survival and 5-year disease-free survival of patients who did not receive adjuvant therapy and those who underwent adjuvant therapy.Patients with preoperative anemia were subgroup analyzed based on PNI levels.When the prognostic nutritional index was high,i.e.PNI ≥45,preoperative anemia in patients of esophageal squamous cell carcinoma had statistically significant significance for 5-year disease-free survival and 5-year overall survival;whereas patients whose PNI<45 had no statistical significance with preoperative anemia for 5-year disease-free survival and 5-year overall survival.Conclusion:The study indicated that the incidence and the degree of anemia in patients with esophageal squamous cell carcinoma are further increased after operation.Preoperative anemia can serve as a promising prognostic indicator in ESCC.Applied to clinical practice,more frequent follow-up of preoperative anemia is beneficial for personalized treatment in ESCC patients.