title: Predicting survival in malignant pleural effusion: development and validation of the LENT prognostic score.
abstract: BACKGROUND
  Malignant pleural effusion (MPE) causes debilitating breathlessness and predicting survival is challenging. This study aimed to obtain contemporary data on survival by underlying tumour type in patients with MPE, identify prognostic indicators of overall survival and develop and validate a prognostic scoring system.
  
  
  METHODS
  Three large international cohorts of patients with MPE were used to calculate survival by cell type (univariable Cox model). The prognostic value of 14 predefined variables was evaluated in the most complete data set (multivariable Cox model). A clinical prognostic scoring system was then developed and validated.
  
  
  RESULTS
  Based on the results of the international data and the multivariable survival analysis, the LENT prognostic score (pleural fluid lactate dehydrogenase, Eastern Cooperative Oncology Group (ECOG) performance score (PS), neutrophil-to-lymphocyte ratio and tumour type) was developed and subsequently validated using an independent data set. Risk stratifying patients into low-risk, moderate-risk and high-risk groups gave median (IQR) survivals of 319 days (228-549; n=43), 130 days (47-467; n=129) and 44 days (22-77; n=31), respectively. Only 65% (20/31) of patients with a high-risk LENT score survived 1 month from diagnosis and just 3% (1/31) survived 6 months. Analysis of the area under the receiver operating curve revealed the LENT score to be superior at predicting survival compared with ECOG PS at 1 month (0.77 vs 0.66, p<0.01), 3 months (0.84 vs 0.75, p<0.01) and 6 months (0.85 vs 0.76, p<0.01).
  
  
  CONCLUSIONS
  The LENT scoring system is the first validated prognostic score in MPE, which predicts survival with significantly better accuracy than ECOG PS alone. This may aid clinical decision making in this diverse patient population.
authors.affiliation: Academic Respiratory Unit, University of Bristol, Bristol, UK North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
authors.forename: Amelia O
authors.initials: AO
authors.lastname: Clive
authors.affiliation: Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK.
authors.forename: Brennan C
authors.initials: BC
authors.lastname: Kahan
authors.affiliation: Academic Respiratory Unit, University of Bristol, Bristol, UK North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
authors.forename: Clare E
authors.initials: CE
authors.lastname: Hooper
authors.affiliation: Academic Respiratory Unit, University of Bristol, Bristol, UK North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
authors.forename: Rahul
authors.initials: R
authors.lastname: Bhatnagar
authors.affiliation: North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
authors.forename: Anna J
authors.initials: AJ
authors.lastname: Morley
authors.affiliation: North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
authors.forename: Natalie
authors.initials: N
authors.lastname: Zahan-Evans
authors.affiliation: North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
authors.forename: Oliver J
authors.initials: OJ
authors.lastname: Bintcliffe
authors.affiliation: Thoracic Oncology, The Netherlands Cancer Institute, Antonie van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
authors.forename: Rogier C
authors.initials: RC
authors.lastname: Boshuizen
authors.affiliation: Respiratory Department, Sir Charles Gairdner Hospital, Perth, Australia Centre for Asthma, Allergy & Respiratory Research, School of Medicine & Pharmacology, University of Western Australia, Perth, Australia.
authors.forename: Edward T H
authors.initials: ET
authors.lastname: Fysh
authors.affiliation: Respiratory Department, Sir Charles Gairdner Hospital, Perth, Australia.
authors.forename: Claire L
authors.initials: CL
authors.lastname: Tobin
authors.affiliation: North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
authors.forename: Andrew R L
authors.initials: AR
authors.lastname: Medford
authors.affiliation: North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
authors.forename: John E
authors.initials: JE
authors.lastname: Harvey
authors.affiliation: Thoracic Oncology, The Netherlands Cancer Institute, Antonie van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
authors.forename: Michel M
authors.initials: MM
authors.lastname: van den Heuvel
authors.affiliation: Respiratory Department, Sir Charles Gairdner Hospital, Perth, Australia Centre for Asthma, Allergy & Respiratory Research, School of Medicine & Pharmacology, University of Western Australia, Perth, Australia.
authors.forename: Y C Gary
authors.initials: YC
authors.lastname: Lee
authors.affiliation: Academic Respiratory Unit, University of Bristol, Bristol, UK North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
authors.forename: Nick A
authors.initials: NA
authors.lastname: Maskell
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001315:Australia / Q000453:epidemiology; D014408:Biomarkers, Tumor / Q000378:metabolism; D015331:Cohort Studies; D016208:Databases, Factual; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D007770:L-Lactate Dehydrogenase / Q000378:metabolism; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D016066:Pleural Effusion, Malignant / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality; D011379:Prognosis; D015203:Reproducibility of Results; D018570:Risk Assessment / Q000379:methods; D012720:Severity of Illness Index; D006113:United Kingdom / Q000453:epidemiology
chemical_list: D014408:Biomarkers, Tumor; D007770:L-Lactate Dehydrogenase
keywords: Lung Cancer; Mesothelioma; Pleural Disease
references.citation: Ann Thorac Surg. 2000 Feb;69(2):369-75
references.pmid: 10735665
references.citation: JAMA. 2012 Jun 13;307(22):2383-9
references.pmid: 22610520
references.citation: Am J Respir Crit Care Med. 2000 Nov;162(5):1987-2001
references.pmid: 11069845
references.citation: Int J Cancer. 2014 May 15;134(10):2403-13
references.pmid: 24122750
references.citation: Chest. 1998 Mar;113(3):723-31
references.pmid: 9515850
references.citation: Eur J Cardiothorac Surg. 2006 May;29(5):829-38
references.pmid: 16626967
references.citation: Stat Med. 1996 Feb 28;15(4):361-87
references.pmid: 8668867
references.citation: Chest. 2005 Mar;127(3):909-15
references.pmid: 15764775
references.citation: J Thorac Oncol. 2012 Mar;7(3):587-94
references.pmid: 22307011
references.citation: J Clin Oncol. 1998 Jan;16(1):145-52
references.pmid: 9440736
references.citation: Eur J Intern Med. 2008 Jul;19(5):334-9
references.pmid: 18549935
references.citation: J Thorac Oncol. 2010 Oct;5(10):1544-50
references.pmid: 20802350
references.citation: Int J Epidemiol. 1999 Oct;28(5):964-74
references.pmid: 10597998
references.citation: Chest. 2000 Jan;117(1):73-8
references.pmid: 10631202
references.citation: BMJ. 2012 Sep 14;345:e5840
references.pmid: 22983531
references.citation: Thorax. 2010 Aug;65 Suppl 2:ii32-40
references.pmid: 20696691
references.citation: Cancer Immunol Immunother. 2011 Dec;60(12):1721-8
references.pmid: 21769693
references.citation: Clin Cancer Res. 2010 Dec 1;16(23):5805-13
references.pmid: 20956618
references.citation: Respiration. 1998;65(2):108-13
references.pmid: 9580921
references.citation: Stat Med. 2011 Feb 20;30(4):377-99
references.pmid: 21225900
references.citation: Chest. 2000 Jan;117(1):79-86
references.pmid: 10631203
references.citation: Respiration. 2014;87(4):311-6
references.pmid: 24457947
references.citation: Eur J Cancer. 2011 Nov;47(17):2633-41
references.pmid: 21724383
references.citation: Eur J Intern Med. 2010 Feb;21(1):30-4
references.pmid: 20122610