ORIGINAL ARTICLE

The prognostic nutritional index can be a prognostic indicatorin colorectal carcinoma

Tadahiro Nozoe • Mayuko Kohno • Tomohiro Iguchi •

Emiko Mori • Takashi Maeda • Akito Matsukuma •

Takahiro Ezaki

Received: 1 February 2011 / Accepted: 1 May 2011 / Published online: 3 December 2011

� Springer 2011

Abstract

Purpose Preoperative assessments regarding a patient’s

immunological and nutritional condition are required to

predict the outcomes of patients with malignant tumors.

The aim of the current study was to clarify the significance

of Onodera’s prognostic nutritional index (OPNI), which

can simply account for the immunological and nutritional

conditions, in patients with colorectal carcinoma.

Methods The correlations of the preoperative OPNI value

with clinicopathological features were examined in 219

patients with colorectal carcinoma who had been surgically

treated.

Results Not only the tumor stage (P = 0.028) and venous

invasion (P = 0.002), but also an OPNI of less than 40

(P = 0.002) were found to be independently correlated with

a worse prognosis of patients with colorectal carcinoma.

Conclusion The preoperative OPNI can be used as a

simple prognostic indicator in colorectal carcinoma.

Keywords Colorectal carcinoma � Onodera’s prognostic

nutritional index � Prognostic indicator

Introduction

It has been well known that the postoperative prognosis

of gastrointestinal malignant tumors could be reflected by

the preoperative nutritional condition of the patients [1].

Onodera’s prognostic nutritional index (OPNI) [2] can be

expressed as a parameter to determine the nutritional and

immunological condition of patients with malignant tumors

of the gastrointestinal tracts.

While the value can be calculated from only the values

of the serum albumin concentration and lymphocyte counts

in the peripheral blood, it can also be easily applied to

assess the nutritional status of the patients. Indeed, a lower

OPNI value has been reported to be an independent prog-

nostic indicator in patients with carcinoma of the esopha-

gus [3] and the stomach [4]. In this study, we investigated

the clinicopathologic significance of the preoperative OPNI

in patients with colorectal carcinoma, which has not been

previously clarified.

Patients and methods

Patients and blood samples

We evaluated 219 patients with colorectal carcinoma who

had been treated by surgical resection at our institution

from November 2002 to January 2010. The patients were

aged from 24 to 90 years and included 126 men and 93

women. None of the enrolled patients had received neo-

adjuvant therapy. All blood samples were collected just

before the operation.

Onodera’s prognostic nutritional index

The OPNI was calculated using the following formula:

109 serum albumin concentration (g/dl) ? 0.005 9 lym-

phocyte count (number/mm2) in peripheral blood. The

cutoff value of the OPNI was determined to be 40, based on

an original investigation by Onodera et al. [2].

T. Nozoe (&) � M. Kohno � T. Iguchi � E. Mori � T. Maeda �A. Matsukuma � T. Ezaki

Department of Surgery, Fukuoka Higashi Medical Center,

1-1-1 Chidori, Koga 811-3195, Japan

e-mail: paper7777@yahoo.co.jp; nozoet@fukuokae2.hosp.go.jp

123

Surg Today (2012) 42:532–535

DOI 10.1007/s00595-011-0061-0

Clinicopathological investigation

The clinicopathological factors were determined according

to the general rules for clinical and pathological studies on

cancer of the colon, rectum, and anus outlined by the

Japanese Research Society for Cancer of the Colon and

Rectum [5].

TNM tumor stage

The TNM tumor stages were determined by the TNM

classification of malignant tumors as described by the

International Union Against Cancer [6].

Follow-up of the patients

The patients were followed up until their death, and only

patients who died of colorectal carcinoma were categorized

as tumor-related deaths. The interval of the follow-up

period after the operation ranged from 60 days to 7 years

2 months.

Statistical analysis

Statistical analyses were performed using the StatView

software program (SAS Institute, Cary, NC, USA). The

Chi-squared test and Student’s t test were used to compare

the data. Survival curves were created by the Kaplan–Meier

method, and the Mantel–Cox test was used to analyze the

equality of the survival curves. The Cox proportional haz-

ards model was used for the multivariate analysis to

determine the independent prognostic factors. A P value of

less than 0.05 was considered to be statistically significant.

Results

The correlations of the OPNI with clinicopathological

features are shown in Table 1. Significant differences were

observed regarding the tumor depth (P = 0.0006), coex-

istence of intestinal obstruction derived from the tumor

(P \ 0.0001), histological type of the tumor (P = 0.028),

and the stage of the tumor (P = 0.001).

The 1-, 3-, and 5-year survival rates in patients with an

OPNI of less than 40 were 81.0, 48.9, and 32.6%, respec-

tively, and were significantly more unfavorable than those

in patients with an OPNI of 40 or higher (96.2, 87.5, and

85.3%, respectively, P \ 0.0001; Fig. 1). In addition to the

OPNI, other factors such as the tumor stage, lymphatic

invasion, venous invasion, and the incidence of intestinal

obstruction caused by the colorectal carcinomas were also

identified as factors to determine the prognosis according

to a univariate analysis. A multivariate analysis, in which

these factors were included, demonstrated that an OPNI of

less than 40 (P = 0.002) as well as the tumor stage

(P = 0.028) and venous invasion (P = 0.002) were the

factors that were independently associated with an unfa-

vorable prognosis in patients with colorectal carcinoma

(Table 2).

Table 1 Relationship between the Onodera prognostic nutritional

index (OPNI) value and the clinical background of patients

OPNI \ 40

(n = 23)

OPNI C 40

(n = 196)

P value

Sex

Male 14 (60.9) 112 (57.1) 0.731

Female 9 (39.1) 84 (42.9)

Age (years) 74.5 ± 8.8 69.8 ± 11.6 0.060

Tumor location

Cecum or ascending 5 (21.7) 37 (18.9) 0.995

Transverse 3 (13.1) 21 (10.7)

Descending 2 (8.7) 17 (8.7)

Sigmoid 7 (30.4) 60 (30.6)

Rectum 6 (26.1) 61 (31.1)

Depth of tumor invasion

Tis, T1 0 26 (13.3) 0.0006

T2 1 (4.3) 40 (20.4)

T3, 4 22 (95.7) 130 (66.3)

Intestinal obstruction

No 15 (65.2) 187 (95.4) \0.0001

Yes 8 (34.8) 9 (4.6)

Histologya

Well 6 (26.1) 63 (32.2) 0.028

Moderate 11 (47.8) 120 (61.2)

Undifferentiated 6 (26.1) 13 (6.6)

Lymph node metastasis

No 10 (43.5) 112 (57.1) 0.212

Yes 13 (56.5) 84 (42.9)

Lymphatic permeation

No 13 (56.5) 124 (63.3) 0.531

Yes 10 (43.5) 72 (36.7)

Venous invasion

No 18 (78.3) 150 (76.5) 0.842

Yes 5 (21.7) 46 (23.5)

Tumor stage

0, I 0 57 (29.1) 0.001

II 9 (39.1) 52 (26.5)

III 9 (39.1) 64 (32.7)

IV 5 (21.8) 23 (11.7)

Tis carcinoma in situa Well well-differentiated adenocarcinoma, Moderate moderately

differentiated adenocarcinoma, Undifferentiated poorly differentiated

adenocarcinoma and mucinous carcinoma

Surg Today (2012) 42:532–535 533

123

Discussion

Better criteria that can be used to determine the postoper-

ative prognosis of patients with malignant tumors, espe-

cially those that can be easily and simply measured and

calculated by using the usual clinical data, are needed.

Decreases in both the serum concentration of albumin [7]

and lymphocyte counts in the peripheral blood [8] have

been reported to be correlated with a worse prognosis of

patients with colorectal carcinoma. Therefore, the OPNI

[2], which is calculated based on the values of the serum

concentration of albumin and lymphocyte counts in the

peripheral blood, can be considered as a definitive criterion

to determine the prognosis of patients with colorectal

carcinoma.

In previous studies, when the average value of the PNI

was used to divide the patients with higher and lower PNI,

the prognosis of patients with esophageal carcinoma who

had a lower value of PNI was significantly worse than that

of patients who had a higher value of PNI [3], and similar

results regarding gastric carcinoma have been also reported

[4]. On the other hand, in the current study the border value

of the PNI was determined to be 40 based on the initial

investigation performed by Onodera et al. [2]. A detailed

analysis demonstrated that an OPNI of less than 40, as well

as the stage of the tumor and venous invasion, were inde-

pendent prognostic indicators.

Among tumor-related factors, the tumor depth and stage

were significantly correlated with a preoperative decrease

in the OPNI. While no significant relationship between the

OPNI and lymph node metastasis was observed, the close

correlation between the OPNI and stage of the tumors

could be reflected by the tumor depth. Although the OPNI

also seemed to be influenced by the tumor stage, both the

OPNI and tumor stage proved to be independently asso-

ciated with a worse prognosis for patients with colorectal

carcinoma. This demonstrates the clinical significance of

the OPNI value as a factor that can be used to predict the

aggressive potential of colorectal carcinoma.

The value of the OPNI in patients with obstructing

carcinoma was found to be significantly lower. This could

be influenced by the significant correlation between the

OPNI and the depth of invasion of the tumors. While

obstructing carcinoma of the colon and rectum derived

from the growth of the tumor could have aggressive

potential [9], the incidence of intestinal obstruction due to

the advanced colorectal carcinoma was not an independent

prognostic indicator in the current study.

In conclusion, the preoperative value of the OPNI,

which can be easily measured and clinically applied, can be

used as an independent prognostic indicator in patients

with colorectal carcinoma.

References

1. Delmore G. Assessment of nutritional status in cancer patients:

widely neglected? Support Care Cancer. 1997;5:376–80.

2. Onodera T, Goseki N, Kosaki G. Prognostic nutritional index in

gastrointestinal surgery of malnourished cancer patients. Nippon

Geka Gakkai Zasshi. 1984;85:1001–5 (in Japanese with an English

abstract).

3. Nozoe T, Kimura Y, Ishida M, Saeki H, Korenaga D, Sugimachi

K. Correlation of pre-operative nutritional condition with post-

operative complications in surgical treatment for oesophageal

carcinoma. Eur J Surg Oncol. 2002;28:396–400.

4. Nozoe T, Ninomiya M, Maeda T, Matsukuma A, Nakashima H,

Ezaki T. Prognostic nutritional index: a tool to predict the

biological aggressiveness of gastric carcinoma. Surg Today.

2010;40:440–3.

5. Japanese Society for Cancer of the Colon and Rectum. Japanese

classification: colorectal carcinoma, 2nd ed. Tokyo: Kanehara;

1997.

6. Sobin L, Gospodarowicz M, Wittekind C; International Union

Against Cancer. TNM classification of malignant tumours, 7th ed.

New York: Wiley-Blackwell; 2009. p. 73–7.

7. Boonpipattanapong T, Chewatanakornkul S. Preoperative carci-

noembryonic antigen and albumin in predicting survival in patients

Fig. 1 Survival curves of the patients. The survival of patients with a

preoperative Onodera prognostic nutritional index (OPNI)\40 (thickline) was significantly more unfavorable than that of patients with an

OPNI of 40 or higher (thin line; P \ 0.0001)

Table 2 Factors independently correlated with the prognosis

Variable Regression

coefficient

Odds ratio (95%

confidence interval)

P value

Stage of tumor

(I, II vs. III, IV)

1.39 4.22 (1.17–15.2) 0.028

Venous invasion 1.44 4.22 (1.72–10.4) 0.002

OPNI (\40 vs. C40) 1.386 4.00 (1.66–9.62) 0.002

534 Surg Today (2012) 42:532–535

123

with colon and rectal carcinomas. J Clin Gastroenterol. 2006;40:

592–5.

8. Walsh SR, Cook EJ, Goulder F, Justin TA, Keeling NJ.

Neutrophil–lymphocyte ratio as a prognostic factor in colorectal

cancer. J Surg Oncol. 2005;91:181–4.

9. Nozoe T, Yasuda M, Honda M, Inutsuka S, Korenaga D.

Obstructing carcinomas of the colon and rectum have a smaller

size compared with those of non-obstructing carcinomas. Oncol

Rep. 2001;8:1313–5.

Surg Today (2012) 42:532–535 535

123