Predicting survival in malignant pleural effusion: development and validation of the LENT prognostic score

Amelia O Clive, Brennan C Kahan, Clare E Hooper, Rahul Bhatnagar, Anna J Morley, Natalie Zahan-Evans, Oliver J Bintcliffe, Rogier C Boshuizen, Edward T H Fysh, Claire L Tobin, Andrew R L Medford, John E Harvey, Michel M van den Heuvel, Y C Gary Lee, Nick A Maskell, Amelia O Clive, Brennan C Kahan, Clare E Hooper, Rahul Bhatnagar, Anna J Morley, Natalie Zahan-Evans, Oliver J Bintcliffe, Rogier C Boshuizen, Edward T H Fysh, Claire L Tobin, Andrew R L Medford, John E Harvey, Michel M van den Heuvel, Y C Gary Lee, Nick A Maskell

Abstract

Background: Malignant pleural effusion (MPE) causes debilitating breathlessness and predicting survival is challenging. This study aimed to obtain contemporary data on survival by underlying tumour type in patients with MPE, identify prognostic indicators of overall survival and develop and validate a prognostic scoring system.

Methods: Three large international cohorts of patients with MPE were used to calculate survival by cell type (univariable Cox model). The prognostic value of 14 predefined variables was evaluated in the most complete data set (multivariable Cox model). A clinical prognostic scoring system was then developed and validated.

Results: Based on the results of the international data and the multivariable survival analysis, the LENT prognostic score (pleural fluid lactate dehydrogenase, Eastern Cooperative Oncology Group (ECOG) performance score (PS), neutrophil-to-lymphocyte ratio and tumour type) was developed and subsequently validated using an independent data set. Risk stratifying patients into low-risk, moderate-risk and high-risk groups gave median (IQR) survivals of 319 days (228-549; n=43), 130 days (47-467; n=129) and 44 days (22-77; n=31), respectively. Only 65% (20/31) of patients with a high-risk LENT score survived 1 month from diagnosis and just 3% (1/31) survived 6 months. Analysis of the area under the receiver operating curve revealed the LENT score to be superior at predicting survival compared with ECOG PS at 1 month (0.77 vs 0.66, p<0.01), 3 months (0.84 vs 0.75, p<0.01) and 6 months (0.85 vs 0.76, p<0.01).

Conclusions: The LENT scoring system is the first validated prognostic score in MPE, which predicts survival with significantly better accuracy than ECOG PS alone. This may aid clinical decision making in this diverse patient population.

Keywords: Lung Cancer; Mesothelioma; Pleural Disease.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Figures

Figure 1
Figure 1
Kaplan–Meier survival curves according to cell type for the UK, Australian and Dutch cohorts combined.
Figure 2
Figure 2
Survival curves according to the LENT score. (A) ‘UK Cohort 1’ and (B) ‘UK Cohort 2’. MS, median survival; IQR, interquartile range; HR, hazard ratio; 95% CI, 95% confidence interval; NA*, Unable to provide data as insufficient patients have died.
Figure 3
Figure 3
Proportion of patients surviving to 1, 3 and 6 months according to low-risk, moderate-risk and high-risk LENT scores. (A) ‘UK Cohort 1’ and (B) ‘UK Cohort 2’.
Figure 4
Figure 4
Receiver operating characteristic (ROC) curve analysis for the LENT score and Eastern Cooperative Oncology Group (ECOG) performance score (PS) for the outcome of mortality. (A)‘UK Cohort 1’ at 1 month. (B)‘UK Cohort 1’ at 3 months. (C) ‘UK Cohort 1’ at 6 months. (D)‘UK Cohort 2’ at 1 month. (E) ‘UK Cohort 2’ at 3 months. (F) ‘UK Cohort 2’ at 6 months.

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Source: PubMed

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