Preoperative nutritional status assessment predicts postoperative outcomes in patients with surgically resected non-small cell lung cancer

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Abstract

Background

As nutritional status plays an important role in outcomes after surgery, this study evaluated the association between preoperative nutritional status (NS) and postoperative outcomes after major resection for lung cancer.

Methods

We identified 219 patients with a diagnosis of cancer who underwent pulmonary resection from 2010 to 2012. Preoperative NS was assessed by anthropometric and biological parameters, body mass index (BMI), and the Nutritional Risk Index (NRI). We stratified this population into 4 BMI groups: underweight, normal weight, overweight and obese and 4 NRI groups: well-nourished; mildly malnourished; moderately malnourished and severely malnourished. The outcomes measured were postoperative complications; 30-day postoperative mortality; hospital length of stay (LOS), overall survival (OS) and disease-free survival (DFS). We performed both unadjusted analysis and adjusted multivariable analysis, controlling for statistically significant variables.

Results

Mean BMI and NRI were, respectively, 26.5 ± 4.3 and 112.4 ± 3.3. There were no significant differences between BMI categories and resection type, pathological stage, or overall postoperative complications. By contrast, significant differences (p < 0.05) in postoperative complications were observed among the NRI groups. LOS was longer in underweight and/or malnourished patients. In terms of OS, we found no significant differences according to NRI and BMI; however, patients with underweight had significantly shorter DFS compared with patients with overweight and obesity (log-rank p-value = 0.001).

Conclusion

NS as measured by the NRI is an independent predictor of the risk of postsurgical complications, regardless of clinicopathologic characteristics. NRI might therefore be an useful tool for identifying early-stage lung cancer patients at risk for postoperative complications.

Introduction

Preoperative nutritional status (NS) has been associated with the risk of postoperative complications [1], [2]. Although NS is not the only important preoperative criterion in patients with lung cancer, an increasing body of evidence indicates malnourished patients are at increased risk of postoperative complications after lung surgery [3], [4], [5], [6]. Thomas et al. [7], in a study recently carried out in France, found that malnutrition increased the risk of some complications immediately after lung cancer surgery, concluding that preoperative NS should be taken into account and mitigated as much as possible prior to surgery.

Although NS has traditionally been evaluated using the Body Mass Index (BMI), this parameter is not accurate to assess malnutrition. The modified Nutritional Risk Index (NRI), developed by Buzby et al. [8], [9], has shown to be a reliable nutritional screening tool for surgical inpatients and it can also be used to preoperatively stratify surgical patients according to their risk of complications. An important advantage of the modified NRI is that it avoids the limitations regarding the assessment of the patient's usual weight.

The close association between preoperative NS and postoperative outcomes in gastrointestinal surgery is well-established [10]. In this regard, patients with preoperative malnutrition are at high risk of developing postsurgical morbidity and mortality. By contrast, in the context of lung cancer surgery, no clear guidelines and/or recommendations have been published yet with regard to the optimal NS prior to surgery.

Given this context, the aim of this prospective study was to assess the impact of preoperative NS on postoperative outcomes in patients with surgically resected non-small cell lung cancer (NSCLC). We used both BMI and NRI to assess NS and to stratify patients according to their nutritional risk and their respective value as predictors of postoperative complications and survival was examined.

Section snippets

Study population

This prospective study included 219 patients diagnosed with NSCLC and considered eligible for radical lung surgery (lobectomy, pneumonectomy, or sublobar resection). In patients with functional contraindication for lobectomy (preoperative %DLCO < 50% or VO2 max between 10 and 15 ml/kg/min), a sublobar resection was performed. All patients signed the informed consent and this study was approved by the Institutional Review Board.

The surgery was performed between January 2010 and December 2012.

Results

The study population included 219 consecutive patients with early stage NSCLC whose tumors were surgically resected in a single center. Most patients were men (177, 80.8%) and the mean age was 62.4 ± 8.7 years. Table 1 shows the clinicopathological characteristics, surgical data, and nutritional parameters of the study population.

NS was significantly associated with past medical history. Higher BMI values were significantly correlated with hypertension, diabetes, hypercholesterolemia, and

Discussion

The main objective of this study was to determine whether preoperative nutritional status —assessed by BMI and NRI— is able to predict the likelihood of postoperative complications in patients with surgically resected early stage NSCLC. Our main finding was that the preoperative NRI score had independent predictive value of postsurgical complications regardless of the baseline sociodemographic characteristics or comorbidities.

Given the well-known association between preoperative NS and

Conflict of interest statement

The authors did not have any conflict of interest to disclose.

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