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Low serum albumin levels and liver metastasis are powerful prognostic markers for survival in patients with carcinomas of unknown primary site

We read with interest the results from the study of serum albumin and liver metastasis in patients with carcinomas of unknown primary site by Seve et al.[1] We can present some results from our unpublished study in patients with cancer of unknown primary site in which we explored a set of possible independent prognostic factors, which include novel factors (not presented here) and some known factors like lactate dehydrogenase (LDH) levels, liver metastasis, and performance status. Our prospective study included 83 patients who fulfilled the criteria for a diagnosis of cancer of unknown primary site. The study was done with statistic analyses using both univariate and multivariate Cox proportional-hazards regression models. Patients with and without liver metastasis survived for 113 days and 331 days, respectively, although our results barely reached the level of significance. We hypothesized that Eastern Cooperative Oncology Group (ECOG) performance status was the more powerful prognostic factor. This was confirmed by our results. Patients who had an ECOG performance status 0 or 1 had median survival of 400 days compared with patients who had a poor performance status (ECOG 2), who had a median survival of 118 days (hazard ratio, 0.39 ; 95% confidence interval, 0.21-0.72 ; P = .003). When they were incorporated separately into the model, serum liver metastasis, LDH levels, and albumin levels not reached the level of significance. We can conclude that, although the presence of liver metastasis at the time of diagnosis is a poor prognostic factor, performance status is a more powerful predictor and remains the cornerstone for deciding whether patients who have carcinomas of unknown primary site should receive symptomatic therapy only or should be entered onto indicated chemotherapy protocols. References 1 Seve P, Ray-Coquard I, Trillet-Lenoir V, et al. Low serum albumin levels and liver metastasis are powerful prognostic markers for survival in patients with carcinomas of unknown primary site. Cancer . 2006 ; 107: 2698-2705. Links Dragan Trivanovic, MD 1, Marija Petkovic, MD 2, Davor Stimac, PhD 3 1Department of Internal Medicine, General Hospital Pula, Pula, Croatia 2Department of Radiotherapy and Oncology University Hospital Rijeka Rijeka, Croatia 3Department of Internal Medicine University Hospital Rijeka Rijeka, Croatia Author reply: We thank Trivanovic et al for sharing their institutional experience of 83 patients with carcinoma of unknown primary, in which performance status (PS) was a more powerful prognostic factor than the presence of liver metastasis.. We and others investigators have previously demonstrated that PS was a powerful adverse clinical prognostic factor[1-3] in the setting of carcinoma of unknown primary site. In our univariate analysis of 370 patients, short survival was related more strongly to PS (P < .0001) than to the presence of liver metastasis (P = .001).[1] However, the presence of liver metastasis and low serum albumin levels were the most powerful adverse prognostic factors on multivariate analysis, which led us to develop and publish our new prognostic model. This new prognostic model outperforms the previous prognostic model based on PS and serum lactate dehydrogenase (LDH) levels.[3] This improvement in prognostic accuracy is because of the high rate of elevated LDH in patients who are classified as good-risk in our model. Larger prospective studies, including both clinical and biologic parameters, are warranted now to validate our prognostic model. Although we agree with Trivanovic et al that PS may used to guide chemotherapy treatment decisions, we previously reported that factors other than PS carry greater weight in the decision to use chemotherapy.[2] References 1 Seve P, Ray-Coquard I, Trillet-Lenoir V, et al. Low serum albumin levels and liver metastasis are powerful prognostic markers for survival in patients with carcinomas of unknown primary site. Cancer . 2006 ; 107: 2698-2705. Links 2 Seve P, Sawyer M, Hanson J, Broussolle C, Dumontet C, Mackey JR. The influence of comorbidities, age, and performance status on the prognosis and treatment of patients with metastatic carcinomas of unknown primary site: a population-based study. Cancer . 2006 ; 106: 2058-2066. Links 3 Culine S, Kramar A, Saghatchian M, et al. Development and validation of a prognostic model to predict the length of survival in patients with carcinomas of an unknown primary site. J Clin Oncol . 2002 ; 20: 4679-4683. Links Pascal Seve, MD 1, John Hanson, MD 2, John R. Mackey, MD 2 1Department of Internal Medicine, Hospices Civils de Lyon and University Claude Bernard, Lyon, France 2Department of Oncology, University of Alberta, Edmonton, Alberta, Canada

serum albumin; cancer patient; cancer survival; carcinoma; liver metastasis

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