Objective To evaluate the preoperative prognostic nutritional index (PNI) and postoperative outcomes, and estimate its prognostic value in predicting survival in ovarian cancer patients. Specifically, the primary objective was to assess the association between preoperative PNI and 30-day postoperative complications in ovarian cancer patients undergoing primary cytoreductive surgery (PCS), secondary cytoreductive surgery (SCS), or neoadjuvant chemotherapy followed by interval cytoreductive surgery (NACT-ICS). Secondary objectives included determining the prognostic value of PNI for overall survival (OS) and progression-free survival (PFS), identifying the optimal PNI cutoff for predicting adverse outcomes, and assessing the interaction between PNI and surgical complexity scores (Fagotti, Aletti) to guide treatment selection. Methods A retrospective review was conducted on 112 consecutive patients registered in the Affiliated Hospital of Jiangnan University, who underwent PCS, SCS, or NACT-ICS in the department of gynecology and obstetrics between January 2019 and January 2024. Patients were divided into three groups based on treatment history: (1) PCS (no prior NACT, n = 89); (2) NACT-ICS (3–4 cycles of paclitaxel plus carboplatin followed by interval cytoreductive surgery, n = 15); (3) SCS (secondary cytoreductive surgery for recurrence, no prior NACT, n = 8). PNI was calculated using the formula: serum albumin (g/L) + 5 × lymphocyte count (×10⁹/L) in peripheral blood. The optimal PNI cutoff for predicting OS was determined via receiver operating characteristic (ROC) curve analysis. Univariate and multivariate logistic regression analyses were performed to identify risk factors for postoperative complications, while univariate and multivariate Cox proportional hazards analyses were used to determine independent prognostic factors for OS and PFS. Frailty was assessed using the Fried Frailty Phenotype, and adjustments were made for confounders including frailty, sarcopenia (defined as skeletal muscle index < 52.4 cm²/m² for women), and perioperative blood transfusion (≥ 2 units of packed red blood cells). Results The optimal PNI cutoff was 45.3 (AUC = 0.745, 95% CI: 0.682–0.808) with sensitivity 67.3% and specificity 88.7%. Low PNI (< 45.3) was significantly associated with age, body mass index (BMI), ascites, CA125, chemosensitivity, albumin, lymphocyte, hemoglobin levels, neoadjuvant chemotherapy, and modified Glasgow prognostic score (mGPS). When stratified by surgical type, significant differences were observed in blood loss (PCS: p = 0.024; CSS: p = 0.011), postoperative serum CA125 (PCS: p = 0.005), residual tumor (PCS: p = 0.001), operative time (PCS: p < 0.001), hospitalization days (PCS: p = 0.015), ICU stay (PCS: p = 0.005), and maintenance therapy (PCS: p = 0.03) between low and high PNI groups. Multivariate logistic regression identified blood loss (HR = 1.718, 95% CI: 1.629–4.697, p = 0.015), operative time (HR = 1.277, 95% CI: 1.21–2.766, p = 0.019), low PNI (HR = 2.104, 95% CI: 2.01–3.743, p < 0.001), Fagotti score (HR = 1.206, 95% CI: 1.187–1.473, p = 0.041), and Aletti score (HR = 2.136, 95% CI: 1.338–3.191, p = 0.025) as independent predictors of postoperative complications. Patients with low PNI had significantly shorter PFS (24.7 vs. 37.6 months, p < 0.001) and OS (36.5 vs. 44.2 months, p < 0.013). In the NACT-ICS subgroup, low PNI was associated with higher suboptimal cytoreduction (66.7% vs. 20.0%, p = 0.03) and shorter OS (32.1 vs. 48.5 months, p = 0.02). Low PNI (HR = 5.533, 95% CI: 2.189–13.985, p = 0.006), advanced FIGO stage (HR = 1.224, 95% CI: 1.058–2.873, p < 0.001), residual tumor (HR = 3.106, 95% CI: 1.038–14.297, p = 0.042), histological subtypes (HR = 4.931, 95% CI: 1.800–13.503, p = 0.047), chemosensitivity (HR = 3.945, 95% CI: 1.614–9.641, p = 0.002), and maintenance therapy (HR = 1.203, 95% CI: 1.174–3.187, p = 0.035) were independent predictors of shortened OS after adjusting for frailty and sarcopenia. Low PNI was strongly associated with frailty (39.6% vs. 7.8%, p < 0.001), and patients with both low PNI and frailty had the worst prognosis (median OS: 28.5 months). Among patients receiving maintenance therapy, low PNI was associated with shorter PFS on PARP inhibitors (11.2 vs. 18.5 months, p = 0.003) and higher grade 3–4 hypertension with bevacizumab (26.3% vs. 8.7%, p = 0.04). Conclusions Preoperative low PNI is significantly associated with a higher incidence of postoperative complications and poor prognosis in ovarian cancer patients undergoing PCS, SCS, or NACT-ICS. Low PNI, advanced FIGO stage, residual tumor, histological subtypes, chemosensitivity, and maintenance therapy are independent predictors of shorter OS. The association between PNI and frailty, as well as its impact on maintenance therapy outcomes, highlights the potential of PNI to guide personalized treatment plans, including prehabilitation and supportive care.

Prognostic Nutritional Index and Postoperative Outcomes in Patients with Ovarian Cancer after Abdominal Surgery

期刊论文
发表日期：

2025年12月19日

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Shizhang Yang,
Jinjin Yu,
Xizhong Xu

摘要

Objective

To evaluate the preoperative prognostic nutritional index (PNI) and postoperative outcomes, and estimate its prognostic value in predicting survival in ovarian cancer patients. Specifically, the primary objective was to assess the association between preoperative PNI and 30-day postoperative complications in ovarian cancer patients undergoing primary cytoreductive surgery (PCS), secondary cytoreductive surgery (SCS), or neoadjuvant chemotherapy followed by interval cytoreductive surgery (NACT-ICS). Secondary objectives included determining the prognostic value of PNI for overall survival (OS) and progression-free survival (PFS), identifying the optimal PNI cutoff for predicting adverse outcomes, and assessing the interaction between PNI and surgical complexity scores (Fagotti, Aletti) to guide treatment selection.

Methods

A retrospective review was conducted on 112 consecutive patients registered in the Affiliated Hospital of Jiangnan University, who underwent PCS, SCS, or NACT-ICS in the department of gynecology and obstetrics between January 2019 and January 2024. Patients were divided into three groups based on treatment history: (1) PCS (no prior NACT, n = 89); (2) NACT-ICS (3–4 cycles of paclitaxel plus carboplatin followed by interval cytoreductive surgery, n = 15); (3) SCS (secondary cytoreductive surgery for recurrence, no prior NACT, n = 8). PNI was calculated using the formula: serum albumin (g/L) + 5 × lymphocyte count (×10⁹/L) in peripheral blood. The optimal PNI cutoff for predicting OS was determined via receiver operating characteristic (ROC) curve analysis. Univariate and multivariate logistic regression analyses were performed to identify risk factors for postoperative complications, while univariate and multivariate Cox proportional hazards analyses were used to determine independent prognostic factors for OS and PFS. Frailty was assessed using the Fried Frailty Phenotype, and adjustments were made for confounders including frailty, sarcopenia (defined as skeletal muscle index < 52.4 cm²/m² for women), and perioperative blood transfusion (≥ 2 units of packed red blood cells).

Results

The optimal PNI cutoff was 45.3 (AUC = 0.745, 95% CI: 0.682–0.808) with sensitivity 67.3% and specificity 88.7%. Low PNI (< 45.3) was significantly associated with age, body mass index (BMI), ascites, CA125, chemosensitivity, albumin, lymphocyte, hemoglobin levels, neoadjuvant chemotherapy, and modified Glasgow prognostic score (mGPS). When stratified by surgical type, significant differences were observed in blood loss (PCS: p = 0.024; CSS: p = 0.011), postoperative serum CA125 (PCS: p = 0.005), residual tumor (PCS: p = 0.001), operative time (PCS: p < 0.001), hospitalization days (PCS: p = 0.015), ICU stay (PCS: p = 0.005), and maintenance therapy (PCS: p = 0.03) between low and high PNI groups. Multivariate logistic regression identified blood loss (HR = 1.718, 95% CI: 1.629–4.697, p = 0.015), operative time (HR = 1.277, 95% CI: 1.21–2.766, p = 0.019), low PNI (HR = 2.104, 95% CI: 2.01–3.743, p < 0.001), Fagotti score (HR = 1.206, 95% CI: 1.187–1.473, p = 0.041), and Aletti score (HR = 2.136, 95% CI: 1.338–3.191, p = 0.025) as independent predictors of postoperative complications. Patients with low PNI had significantly shorter PFS (24.7 vs. 37.6 months, p < 0.001) and OS (36.5 vs. 44.2 months, p < 0.013). In the NACT-ICS subgroup, low PNI was associated with higher suboptimal cytoreduction (66.7% vs. 20.0%, p = 0.03) and shorter OS (32.1 vs. 48.5 months, p = 0.02). Low PNI (HR = 5.533, 95% CI: 2.189–13.985, p = 0.006), advanced FIGO stage (HR = 1.224, 95% CI: 1.058–2.873, p < 0.001), residual tumor (HR = 3.106, 95% CI: 1.038–14.297, p = 0.042), histological subtypes (HR = 4.931, 95% CI: 1.800–13.503, p = 0.047), chemosensitivity (HR = 3.945, 95% CI: 1.614–9.641, p = 0.002), and maintenance therapy (HR = 1.203, 95% CI: 1.174–3.187, p = 0.035) were independent predictors of shortened OS after adjusting for frailty and sarcopenia. Low PNI was strongly associated with frailty (39.6% vs. 7.8%, p < 0.001), and patients with both low PNI and frailty had the worst prognosis (median OS: 28.5 months). Among patients receiving maintenance therapy, low PNI was associated with shorter PFS on PARP inhibitors (11.2 vs. 18.5 months, p = 0.003) and higher grade 3–4 hypertension with bevacizumab (26.3% vs. 8.7%, p = 0.04).

Conclusions

Preoperative low PNI is significantly associated with a higher incidence of postoperative complications and poor prognosis in ovarian cancer patients undergoing PCS, SCS, or NACT-ICS. Low PNI, advanced FIGO stage, residual tumor, histological subtypes, chemosensitivity, and maintenance therapy are independent predictors of shorter OS. The association between PNI and frailty, as well as its impact on maintenance therapy outcomes, highlights the potential of PNI to guide personalized treatment plans, including prehabilitation and supportive care.