| BackgroundPulmonary carcinoma is one of the main malignant tumors which threatens the health of human in the world.With the development of modern imaging technology and the enhancement of health awareness of human,the high detection rate of lung cancer is observed in recent years.Lung cancer remains the leading malignancy in terms of morbidity(11.6%)and mortality(18.4%)in the world,which is more common in men than in women,according to authoritative statistics from"Global cancer statistics 2018",published in the journal of clinician cancer,the official journal of the American cancer society this year.And so it is in our country.The most significant risk factor associated with lung cancer is smoking.Surgical resection remains the most effective method for early cancer patients,and even can reverse it,especially for non small cell lung cancer(NSCLC).However,most lung cancer patients were in late stage(?B/? stage)when diagnosed,and lost the opportunity of radical resection.Then the chemical treatment,radiotherapy,target therapy or percutaneous thermal ablation are available to patients as a replacement.However,the patients with lung cancer might not benefit a lot from these alternative treatments and usually had a short survival period.Therefore,It is of great significance to analyze the prognostic factors of advanced lung cancer and make individual treatment plan to improve the prognosis and clinical outcome of patients.Patients with advanced lung cancer often got cough,hemoptysis,dyspnea,which may go on to develop respiratory failure because of poor lung function.Therefore,it is urgent to improve the severe symptoms.The conventional treatments work slowly and is of limited effect.On the other hand,with the rapid development of bronchoscope interventional technique,the treatment of malignant central airway obstruction is effective,and the quality of life of patients is improved.Studies have shown that repeated bronchoscopy intervention therapy,as an important adjuvant means of lung cancer multi-mode therapy,not only inhibits the growth of airway tumor,but also creates conditions for the follow-up treatment of lung cancer.Therefore,bronchoscope intervention plays a vital role in airway obstruction caused by advanced lung cancer.In recent years,some biomarkers,simple and measurable,have been used to predict the prognosis of malignant tumors.Prognostic nutritional index(PNI),which was reported to evaluate the immune-nutritional status of postoperative patients,has been a useful tool for the prognosis among multiple malignancies,such as gastric,liver,lung and esophageal cancer and pleural mesothelioma.There were some reports about PNI in NSCLC patients who underwent surgery.At present,the correlation between PNI and prognosis of lung cancer has been reported mostly in the studies of NSCLC patients with surgical indications.For advanced NSCLC,previous studies have shown that PNI has significant significance in the prognosis of chemotherapy in patients with advanced NSCLC.However,there are still few studies on the prognostic mechanism of PNI in advanced NSCLC patients.In addition,studies have shown that prognostic nutritional index(PNI)can also be used to assess the surgical risk and postoperative complications of tumor patients,and PNI has been found to be correlated with complications after treatment of a variety of cancers(liver cancer,pancreatic cancer,esophageal cancer,breast cancer,lung cancer,etc.)to a certain extent.In a meta-analysis of PNI and cancer,the authors observed significantly shorter overall survival and increased postoperative complications in patients with low PNI.Recent studies have shown that PNI is significantly associated with the risk of pneumothorax and pulmonary infection after NSCLC surgery,and patients with low PNI are at higher risk.However,studies on the complications of PNI and advanced NSCLC after bronchoscopic intervention are currently lacking.Based on the above status quo,this study was divided into two parts:The first part retrospectively analyzed the data of 315 patients with advanced(STAGE IIIB and?)NSCLC and calculated their PNI,analyzed the relationship between PNI and the clinical characteristics and survival time of the patients,so as to explore the prognostic value and prognostic mechanism of PNI for such patients.In the second part,the clinical data of 71 patients with advanced non-small cell lung cancer treated by bronchoscopy(ARGON plasma coagulation(APC),laser,freezing and airway stents)were analyzed to investigate the predictive value of PNI for common complications of advanced NSCLC after bronchoscopy.The first part:Prognostic impact of prognostic nutritional index in advanced non-small cell lung cancer patientsPurpose:We retrospectively analyzed the clinical material of 315 patients with advanced(stage ?B and ?)NSCLC who had received chemotherapy or EGFR-TKIs and calculate the PNI.The aim of this article is to demonstrate the impact of the prognostic nutritional index(PNI)on survival time among patients with advanced(stage ?B and ?)non-small cell lung cancer(NSCLC)Methods:We collected the clinical data of 315 patients with advanced(stage?B and ?)NSCLC who had received chemotherapy or epidermal growth factor receptor(EGFR)-tyrosine kinase inhibitors(TKIs)between January 2010 and June 2011.The clinical characteristics of patients in our study including age,sex,history of tobacco exposure,pathologic type,TNM stage,PNI and the treatments(systemic chemotherapy or EGFR-TKIs).The prognostic nutritional index was calculated as 10×serum albumin(g/dl)+0.005×total lymphocyte count(per mm 3)in peripheral blood.Survival curves were plotted using the Kaplan-Meier method.Multi variate analyses were used to evaluate prognostic significance of prognostic nutritional index in patients with advanced(stage ?B and ?)NSCLC.Results:1.A total of 315 patients with NSCLC were eligible for analysis.The age of patients ranged from 26 to 79 years(mean,58.53 years).Of these patients,213(67.6%)were males and 102(32.4%)were females.110(34.9%)patients smoked.According to TNM classification,there were 143 patients(45.4%)in Pathological stage ?B and 172 patients(54.6%)in stage ?.A total of 240(76.2%)patients received systemic chemotherapy and 75(23.8%)patients EGFR-TKIs.There were 162(51.4%)patients with adenocarcinoma,110(31.9%)with squamous cell carcinoma,and 43(13.7%)with other histological types.2.The PNI values of all the patients ranged from 5.15 to 73.25.The cutoff value of the PNI for clinically significant malnutrition was set at below 50 in this study.Then,315 patients were divided into low-PNI group(n=179,56.8%)and high-PNI group(n=136,43.2%).The median OS of patients with low PNI(PNI?50),and high PNI(PNI>50)was 14.4 and 17.95 months,respectively,and low PNI was highly associated with a short survival time(HR=1.331,95%CI:1.05-1.688,P=0.018).1-year OS rates of PNI>50 group is higher than that of PNI?50 group(74%,67%)(Fig.1).3.Table 2 shows the relationship between PNI and the clinicopathological features.Significant differences were observed with respect to disease stage and treatment.Patients with a higher PNI(?50)tended to be the ones treated with chemotherapy(p=0.049)than those with lower PNI.Moreover,PNI was significantly higher in patients diagnosed with stage ?B cancer compared with those with stage ? disease(p<0.0001).No significant correlation was observed between PNI and age,gender,smoking or pathology.3.Univariate analysis showed that the significant prognostic factors for overall survival(OS)in patients with advanced(stage ?B and ?)non-small cell lung cancer were disease stage(P=0.017),smoking(P=0.001),pathology(P=0.000)and prognostic nutritional index(PNI)(P=0.018).After multivariate analysis,we demonstrated that,smoking(P=0.000)disease stage(P=0.005)and prognostic nutritional index(PNI)(P=0.001)were significantly associated with overall survival(OS)in patients with advanced(stage ?B and ?)non-small cell lung cancer.However,pathology(P=0.423)had no influence on OS.Conclusions:PNI is an independent prognostic factor for advanced non-small cell lung cancer,in which patients with low PNI have a higher risk of death.The second part:The predictive value of PNI for common complications after tracheal endoscopic intervention in advanced non-small cell lung cancerPurpose:Bronchoscope has been widely used in advanced NSCLC patients with high efficiency and complications.This study focused on the correlation between prognostic nutritional index(PNI)and common complications in patients with advanced NSCLC after endotracheal interventional therapy(laser,cryoablation,and argon plasma coagulation(APC),and airway stent implantation).Methods:The data of 71 patients with malignant CAO caused by advanced non small cell lung caner was retrospectively analyzed.All of the patients underwent one or two methods of bronchoscopic inventions,including APC,laser,cryotherapy,stent,or combined techniques.We evaluated the success rate and the complications of the cancer patients.All the patients had the bronchoscopy examination more than once during hospitalization.Follow-up was performed for all patients every 1-3 months and lasted for six months.The follow-up included reviewing the patient's medical history,CT scans and bronchoscopy examination.age,sex,Karnofsky performance scores,Pathology,types of obstruction,degree of obstruction,techniques applied during bronchoscopic interventions,procedure-related complications were collected by the electronic medical record.The PNI values of all patients were calculated.See the calculation formula of PNI values in the first part.We analyzed the relationship between PNI and clinical characteristics,and also counted the common complications of bronchoscopic intervention.In this study,according to the ROC curve,the cutoff value of PNI was 44.5,and according to this value,the cutoff value was divided into the high PNI group and the low PNI group.We compared the occurrence of common complications of patients in the two groups after bronchoscopic intervention.We used statistical software SPSS22.0 to analyze the data.Measurement data were expressed as mean ± standard deviation,t-test,chi-square test or ANOVA were used for comparison between groups,and P values were calculated.P<0.05 was considered statistically significant.Results:1.Of all 71 patients,44(62%)were males and 27(38%)were females.The age of patients ranged from 31 to 88 years.there were29(40.8%)with adenocarcinoma,42(59.2%)with squamous cell carcinoma.According to the location of the cancer,the site of CAO was the trachea(57.7%),the left main bronchus(15.5%),the right main bronchus(19.7%)and right bronchus Intermedius(7.1%).There were 3 types of obstruction,including intraluminal(30,42.3%),extrinsic compression(16,22.5%)and mixed(25,35.2%).In this study,according to the ROC curve,the cutoff value of PNI was 44.5.According to this value,41 cases(57.7%)were in the high PNI group(PNI?44.5)and 30 cases(42.3%)in the low PNI group(PNI<44.5).The severity of airway stenos is was determined using the Myer-Cotton stenos is grading system.[7]:Grade ?,?50%luminal stenos is;Grade ?,51-70%luminal stenos is;Grade ?,71-99%luminal stenosis;and Grade IV,no lumen.By this classification,there were 23(32.4%)in Grade ?,43(60.6%))in Grade ? and 5(7%)in Grade ?.Of these patients,56(78.9%)patients received chemotherapy or radiotheraphy before or after bronchoscopic interventions.2.Times of endotracheal interventional therapy:According to Table2,all patients received a total of 256 times of endotracheal interventional therapy.The most frequent treatments were bronchoscopic cryotherapy(99 times),argon plasma coagulation(66 times),laser therapy(48 times),and airway stenting(43 times).If by lung cancer pathological type analysis,this research shows that:the lung glandular cancer patients were separately airway stents,laser,argon plasma coagulation,freezing technology for 14 times,30 times,25,38,lung squamous cancer patients respectively line of airway stents,laser,argon plasma coagulation,freezing technology for 29 times,18,41,61.3.According to Table3,As for the acute complications of bronchoscopic interventions,2 patients had a acute respiratory distress,4 excessive bleeding,1 pneumothorax.No one had the complication of perforation.1 patients died from excessive bleeding after bronchoscopic interventions within a few days,and 2 patients died from respiratory failure one month later.The chronic complications include mucostasis(n=2),restenosis caused by granulation tissue growth or tumor(n=1 9),stent migration(n=2)and stent fracture(n=2).4.The relationship between PNI and clinicopathological factors:According to Table4,Significant differences were observed with respect to age and sex.No significant correlation was observed between PNI and pathologic type,the KPS,the degree and types of obstruction,the location of obstruction,the common complication of endoscopic intervention.5.Relationship between PNI and common complications after bronchoscopic intervention:According to Table5,in this study,the common complications after interventional therapy were rest enosis and mucous adhesion caused by granulation or tumor tissue hyperplasia.According to the occurrence of complications between the two groups,we found that the incidence of lumen restenosis in the high PNI group was significantly lower than that in the low PNI group(P<0.05),which was statistically significant.There was no significant difference in the incidence of mucous adhesion between the two groups(P>0.5).6.The relationship between other clinicopathological factors and lumen restenosis:According to Table6,we found that among other factors,only the type of obstruction(P=0.024)was correlated with lumen restenosis,showing a statistically significant difference(P<0.05).There was no significant correlation between age,sex,pathological type,tumor site,KPS score,degree of obstruction and restenosis(P>0.05).Conclusions:Prognostic nutritional index(PNI)can be utilized to predict restenosis caused by granulation tissue or tumor in patients with advanced non-small cell lung cancer after endoscopic intervention.For the Patients with a lower prognostic nutritional index(PNI),we can take some measures,including nutritional support,immunotherapy and tracheoscopy,so as to reduce the incidence of complications after interventional therapy.Creativity:1.We first investigated the clinical value and prognostic mechanism of PNI in patients with advanced(?B/? stage)NSCLC treated with chemotherapy and EGFR-TKIs.2.We first analyzed the predictive effect of PNI on the complications of patients with advanced NSCLC after tracheoscopic intervention,so as to take early interventional measures,such as nutritional therapy,immunotherapy and thacheoscopy to improve the clinical prognosis of patients. |
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