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. 2022 Oct 25:9:928659.
doi: 10.3389/fsurg.2022.928659. eCollection 2022.

A novel nomogram based on the prognostic nutritional index for predicting postoperative outcomes in patients with stage I-III gastric cancer undergoing robotic radical gastrectomy

Danli Shen  1   2 , Guowei Zhou  1 , Jian Zhao  2 , Gang Wang  1   2 , Zhiwei Jiang  1   2 , Jiang Liu  1 , Haifeng Wang  1 , Zhengming Deng  1 , Chaoqun Ma  1 , Jieshou Li  2
Affiliations

A novel nomogram based on the prognostic nutritional index for predicting postoperative outcomes in patients with stage I-III gastric cancer undergoing robotic radical gastrectomy

Danli Shen et al. Front Surg. .

Abstract

Background: The inflammation and nutrition status are crucial factors influencing the outcome of patients with gastric cancer. This study aims to investigate the prognostic value of the preoperative prognostic nutritional index (PNI) in patients with stage I-III gastric cancer undergoing robotic radical gastrectomy combined with Enhanced Recovery after Surgery (ERAS), and further to create a clinical prognosis prediction model.

Study: 525 patients with stage I-III gastric cancer who underwent ERAS combined with RRG from July 2010 to June 2018 were included in this work, and were divided randomly into training and validating groups in a 7-to-3 ratio. The association between PNI and overall survival (OS) was assessed by Kaplan-Meier analysis and the log-rank test. Independent risk factors impacting postoperative survival were analyzed with the Cox proportional hazards regression model. A nomogram for predicting OS was constructed based on multivariate analysis, and its predictive performance was evaluated using Harrell's concordance index (C-index), calibration plots, ROC curve, decision curve analysis (DCA), and time-dependent ROC curve analysis.

Results: Survival analyses revealed the presence of a significant correlation between low preoperative PNI and shortened postoperative survival (P = 0.001). According to multivariate analysis, postoperative complications (P < 0.001), pTNM stage (II: P = 0.007; III: P < 0.001), PNI (P = 0.048) and lymph node ratio (LNR) (P = 0.003) were independent prognostic factors in patients undergoing ERAS combined with RRG. The nomogram constructed based on PNI, pTNM stage, complications, and LNR was superior to the pTNM stage model in terms of predictive performance. The C-indexes of the nomogram model were respectively 0.765 and 0.754 in the training and testing set, while AUC values for 1-year, 3-year, and 5-year OS were 0.68, 0.71, and 0.74 in the training set and 0.60, 0.67, and 0.72 in the validation set.

Conclusion: Preoperative PNI is an independent prognostic factor for patients with stage I-III gastric cancer undergoing ERAS combined with robotic radical gastrectomy. Based on PNI, we constructed a nomogram for predicting postoperative outcomes of gastric cancer patients, which might be utilized clinically.

Keywords: enhanced recovery after surgery; gastric cancer; prediction model; prognostic nutritional index; robotic radical gastrectomy.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
The flow diagram of stage I–III gastric cancer patients underwent robotic radical gastrectomy enrolled in this study. GC, gastric cancer; RRG, robotic radical gastrectomy.
Figure 2
Figure 2
Nomogram for predicting 3- and 5-year overall survival (OS) of patients undergoing enhanced recovery after surgery (ERAS) combined with robotic radical gastrectomy. Nomogram for predicting the 3- and 5-year OS of patients undergoing ERAS combined with robotic radical gastrectomy (A). Calibration plot of the nomogram for (B) 3-year and (C) 5-year survival. PNI, prognostic nutrition index; LNR, Positive lymph node rate.
Figure 3
Figure 3
Receiver operating characteristic (ROC) curve for overall survival (OS) of patients undergoing enhanced recovery after surgery combined with robotic radical gastrectomy based on the nomogram. (A) ROC curve for 1-/3-/5- year OS based on the nomogram in the training set. (B) ROC curve for 1-/3-/5- year OS based on the nomogram in the validation set. AUC, area under the curve.
Figure 4
Figure 4
Prediction ability of the pTNM, no PNI-nomogram, and nomogram model for intensive overall survival (OS) of patients undergoing enhanced recovery after surgery (ERAS) combined with robotic radical gastrectomy in the training set. Decision curve analysis of 3- and 5-year OS of patients in the training set. The X-axis indicates the threshold probability for OS of patients undergoing enhanced recovery after surgery (ERAS) combined with robotic radical gastrectomy and the Y-axis indicates the net benefit. Compared to the pTNM, non PNI-nomogram, and nomogram model, the net benefit for the nomogram model was larger over the range of clinical threshold. [Model (A): the pTNM model; Model (B): the non PNI-nomogram model; Model (C): the nomogram model]. Abbreviations: AUC, area under the curve; PNI, prognostic nutrition index; pTNM, pathological tumor-node-metastasis.
Figure 5
Figure 5
Kaplan-Meier analysis for overall survival (OS) of patients undergoing enhanced recovery after surgery combined with robotic radical gastrectomy according to the preoperative PNI. Red and lake blue solid lines represent Kaplan-Meier analysis for OS according to preoperative PNI ≤ 45.39 (PNI = 0) and PNI >45.39 (PNI = 1). PNI, prognostic nutrition index.
Figure 6
Figure 6
Time-dependent receiver-operating characteristic (ROC) curves for the pTNM, non PNI-nomogram, and nomogram model for the prediction of overall survival. The horizontal axis represents the year after surgery, and the vertical axis represents the estimated area under the ROC curve for survival at the time of interest. Red, blue, and green solid lines represent the estimated AUCs of the pTNM, no PNI-nomogram, and nomogram model; and broken lines represent the 95% confidence intervals of each AUC. [Model (A): the pTNM model; Model (B): the non PNI-nomogram model; Model (C): the nomogram model]. AUC, area under the curve; PNI, prognostic nutrition index; pTNM, pathological tumor-node-metastasis.
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