Malnutrition, Inflammation: Which Parameter Is Interesting to Detect in Planned Oncologic Surgery?

Abstract

We are grateful to Dr. Muscaritoli and colleagues [1] for their comment and their recommendation concerning the need to assess inflammation parameters before surgery, especially C-reactive protein (CRP), and we totally agree with their advice. This point was recently confirmed in the study published this year by Moyes et al. [2], in which the Glasgow prognostic score (GPS) [3] using albumin (Alb) and C-reactive protein (CRP) values to determine the level of risk, was significantly associated with an increased risk of developing a postoperative infection during elective surgery in 385 colorectal cancer resections (odds ratio [OR] = 1.75; 95% confidence interval [CI] = 1.17–2.63; p = 0.007). The goals of our study were to detect easily collected data on nutritional parameters that would allow us to define a group for which a nutritional treatment could reduce the number of complications after surgery. In the course of our study [4] CRP data were collected before surgery in 76% of the cases. Three CRP threshold values were studied: [15, [50, and 100 mg/l. In the univariate analysis, only a CRP value of [50 mg/l was found to be associated with total major complications (TMC) (p = 0.02), with major infectious complications (p = 0.03) and with major non-infectious complications (p = 0.05). No statistically significant relationship was found for a CRP value [15 mg/l or for CRP [ 100 mg/l. In the multivariate analysis, CRP was no longer associated with the occurrence of postoperative complications. We also analyzed the frequency of complications according to the Prognostic Inflammatory Nutritional Index: [PINI = CRP (mg/l) 9 orosomucoid (mg/l)]/[albumin g/ l 9 transthyretin (mg/l)], determined before surgery. Overall, PINI values were obtained for 72% of the patients. A relationship with the frequency of TMC was found only in the univariate analysis (p = 0.04), not in the multivariate analysis. As reported by some authors [5], as well as by Dr. Muscaritoli, albumin is dependent not only on the patient’s nutritional status but also on the inflammatory status. McMillan et al. [3] obtained better survival at 3 years in colorectal cancer patients using the GPS: 86% for a GPS 0 (Alb [ 35 g/l and CRP \ 10 mg l), 71% for a GPS 1 (Alb \ 35 g/l or CRP \ 10 mg/l), and 46% for a GPS 2 (Alb \ 35 g/l and CRP [ 10 mg/l) (p \ 0.0001). After analyzing our results according to the same threshold values, a similar role was found for the inflammatory factor. Major complications were more frequent (p = 0.03) for the highest GPS values; respectively, 23, 31, and 47% for a GPS of 0, 1, and 2. In the study by McMillan et al. [3], only 16/109 patients had an isolated low albumin level without elevation of CRP. The survival of these patients at 3 months (94%) was similar to that of the patients with a GPS 0 (84%). In our study, 14 patients had an Alb \ 35 without elevated CRP with 43% of TMC, and 35 patients had elevated CRP without a low albumin level with 29% of TMC. These groups were too small to allow statistical comparisons, but when we performed a chi square test adjusted for CRP, it showed that Alb was correlated with TMC (p = 0.02), whereas this was not the case for CRP when adjusted for Alb. The results of the multivariate analysis, as well as the chi square test, show that a low albumin level is a risk factor for TMC, independent of the inflammation status S. Antoun (&) A. Rey Institut Gustave-Roussy, Villejuif, France e-mail: sami.antoun@igr.fr