Clinical significance of preoperative nutrition and inflammation assessment tools in gastrointestinal cancer patients undergoing surgery: a retrospective cohort study

Valentina Casalone^1*Sara Erika Bellomo²Enrico Berrino^2,3Simona Bo³Enrica Favaro³Alfredo Mellano⁴Elisabetta Fenocchio⁵Caterina Marchiò^2,3Anna Sapino^2,3

• ¹Clinical Nutrition and Dietetics Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (TO), Italy
• ²Pathology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (TO), Italy
• ³Department of Medical Sciences, School of Medicine, University of Turin, Turin, Piedmont, Italy
• ⁴Colorectal Surgical Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (TO), Italy
• ⁵Department of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (TO), Italy

Malnutrition and inflammation are associated with poorer surgical outcomes in patients with gastrointestinal cancer. However, it is debated which parameters should be used to assess nutritional and inflammatory status. The aim of the present study was to investigate the prognostic role of specific parameters in predicting postoperative outcomes in this subgroup of patients. This retrospective study included 391 adult patients. Malnutrition risk, was assessed by preoperative validated Malnutrition Universal Screening Tool (MUST) score ≥2, lymphocyte count <900 n/mm^3, albumin value <3.5 g/dL or a combination of the previous two parameters, the Prognostic Nutritional Index (PNI) <45; inflammation was evaluated using preoperative Neutrophil-to-Lymphocyte Ratio (NLR) >5, Platelet-to-Lymphocyte Ratio (PLR) >150 and Lymphocyte-to-Monocyte Ratio (LMR) <5. Statistical analysis was carried out using Univariate and Multivariate Analysis and General Linear Models. Patients with higher preoperative MUST score (p<0.0001), lower albumin level (p=0.0002) or lower PNI (p=0.002) had greater need for parenteral nutrition support and longer hospital stay was reported in patients with higher MUST score (p<0.0001), lower albumin (p<0.0001), lower PNI (p=0.0002), higher NLR (p=0.005) or lower LMR (p=0.027). Complications were more common in patients with higher MUST score (p=0.029), lower albumin (p=0.008) or lower PNI (p=0.006). A MUST score ≥1 or a PNI <45 was associated with a 2-fold risk of postoperative complications (p=0.008; p =0.001), whereas albumin levels <35 g/L were correlated with a 3-fold risk of postsurgical complications (p=0.008). OS was also worse in patients with higher MUST score (p=0.004), PNI (p=0.031) or NLR (p=0.0002), with a 3-fold risk of not surviving at 1 year in patients with a MUST score ≥2 (p=0.003) or NLR ≥5 (p=0.0003). Using general linear models for repeated measures, a preoperative MUST score >1 or albumin levels <35 mg/dl was associated with lower postoperative erythrocyte cells and haemoglobin levels. Multivariate analysis confirmed MUST score, PNI and NLR as independent prognostic factors for survival or postoperative complications. The presence of preoperative malnutrition and/or inflammation is associated with worse postoperative outcomes in patients with gastrointestinal cancer. Early nutritional assessment, including all the above parameters, may allow more tailored intervention to reduce the risk of adverse postoperative outcomes.