title: A novel, externally validated inflammation-based prognostic algorithm in hepatocellular carcinoma: the prognostic nutritional index (PNI).
abstract: BACKGROUND
  There is increasing evidence that the presence of an ongoing systemic inflammatory response is a stage-independent predictor of poor outcome in patients with cancer. The aim of this study was to investigate whether an inflammation-based prognostic score, the prognostic nutritional index (PNI), is associated with overall survival (OS) in patients with hepatocellular carcinoma (HCC).
  
  
  METHODS
  All patients with a new diagnosis of HCC presenting to the Medical Oncology Department, Hammersmith Hospital between 1993 and 2011 (n=112) were included. Demographic and clinical data were collected. Patients in whom the combined albumin (g l(-1)) × total lymphocyte count × 10(9) l(-1) was ≥45, at presentation, were allocated a PNI score of 0. Patients in whom this total score was <45 were allocated a score of 1. Univariate and multivariate analyses were performed to identify clinicopathological variables associated with OS. Independent predictors of survival identified on multivariate analysis were validated in an independent, stage-matched cohort of 68 patients.
  
  
  RESULTS
  Univariate analyses showed that PNI (P=0.003), intrahepatic spread (P<0.001), the presence of extrahepatic disease (P=0.006), portal vein thrombosis (P=0.02), tumour multifocality (P=0.003), alfa-fetoprotein >400 ng ml(-1) (P<0.001) and Barcelona Clinic Liver Cancer score (P<0.01) were all predictors of OS in the training set. Multivariate analysis revealed the PNI (P=0.05), presence of extrahepatic disease (P<0.001) and degree of intrahepatic spread (P<0.001) as independent predictors of worse OS in this population. The PNI retained independent prognostic value in the validation set (P<0.001).
  
  
  CONCLUSIONS
  The presence of a systemic inflammatory response, as measured by the PNI, is an independent and externally validated predictor of poor OS in patients with HCC.
authors.affiliation: Division of Experimental Medicine, Imperial College London, Hammersmith Hospital, UK.
authors.forename: D J
authors.initials: DJ
authors.lastname: Pinato
authors.forename: B V
authors.initials: BV
authors.lastname: North
authors.forename: R
authors.initials: R
authors.lastname: Sharma
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D006528:Carcinoma, Hepatocellular / Q000150:complications* / Q000175:diagnosis* / Q000503:physiopathology; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007249:Inflammation / Q000150:complications* / Q000503:physiopathology*; D053208:Kaplan-Meier Estimate; D008113:Liver Neoplasms / Q000150:complications* / Q000175:diagnosis* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D015596:Nutrition Assessment; D011379:Prognosis; D012189:Retrospective Studies; D055815:Young Adult