Dailei Qin,* Kewei Huang,* Zehui Yao,* Pu Xi, Lingmin Jiang, Ran Wei, Shengping Li

State Key Laboratory of Oncology in South China, Guangdong Provincial ClinicalResearch Center for Cancer, Department of Hepatobiliary and Pancreatic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People’s Republic of China

*These authors contributed equally to this work

Correspondence: Ran Wei; Email weiran@sysucc.org.cn Shengping Li, Email lishengp@mail.sysu.edu.cn

Background: Pancreatic cancer (PCA) is a highly malignant tumor with a 5-year survival rate of < 10%. It is characterized as a cold tumor with an immunosuppressive microenvironment. Liver dysfunction due to biliary obstruction can affect the inflammation index, an indicator of immune status. Adjusting inflammation indices for liver function may enhance their clinical utility for predicting overall survival (OS) in PCA patients.
Methods: Resected PCA cases were selected using specific criteria. Liver function indicators identified by Spearman’s analysis were integrated into a covariance analysis to refine inflammation indices, including modified neutrophil-to-lymphocyte ratio (mNLR), modified platelet-to-lymphocyte ratio (mPLR), modified lymphocyte-to-monocyte ratio (mLMR), modified systemic immune-inflammation index (mSII), and modified C-reactive protein (mCRP). These modified indices and clinicopathological factors were analyzed to identify independent OS predictors. A nomogram was developed and compared with a primary inflammation-based model using calibration curves, decision curve analysis (DCA), and the concordance index (C-index).
Results: Liver function indicators including direct bilirubin (DBIL), indirect bilirubin (IBIL), alanine aminotransferase (ALT), and aspartate aminotransferase (AST), lactate dehydrogenase (LDH), gamma-glutamyl transferase (GGT), alkaline phosphatase (ALP), and albumin (ALB) were integrated to refine inflammation indices. In PCA patients, higher mNLR, mSII, CA19-9, T stage, and N stage were associated with worse OS, while higher mLMR or PNI levels correlated with better OS. Vascular invasion predicted poor OS, whereas chemotherapy improved OS. The nomogram model’s clinical utility surpassed that of the primary inflammation-based model.
Conclusion: The nomogram incorporating modified inflammation indices demonstrated superior clinical utility. Adjusting inflammation indices for liver function is recommended for prognostic prediction, especially in PCA patients with biliary obstruction. For patients with advanced T and N staging or poorly differentiated tumors, intraoperative margin nanoknife ablation and timely postoperative adjuvant chemotherapy are recommended to enhance prognosis.

Keywords: pancreatic cancer, modified inflammation indexes, nomogram, overall survival