PREDICTIVE SCORE FOR MALIGNANT PLEURAL EFFUSION

The PROMISE score accurately predicts three-month mortality in patients with malignant pleural effusion, according to a new report.

Treatments for malignant pleural effusion have expanded during the past decade, but the factors that drive malignant progression, resistance to therapy and mortality are poorly understood.

Dr. Ioannis Psallidas from Oxford University Hospitals NHS Foundation Trust, in Oxford, UK, and colleagues used data from five different clinical groups to develop and validate PROMISE, the first score dedicated to the prospective assessment of survival in patients with malignant pleural effusion.

The final PROMISE score assigned points for seven clinical elements (chemotherapy, radiotherapy, blood test results, cancer type and performance status) and added points for tissue inhibitor of metalloproteinases 1 (TIMP1) concentration as the biological element.

The overall PROMISE score (clinical plus biological) showed good discrimination between patients in the external validation dataset who died within three months and those who survived (C statistic, 0.90), the team reported in The Lancet Oncology, online June 13.

PROMISE scores were used to classify patients into four categories of risk for three-month mortality: A, less than 25% (0-20 points); B, 25% to less than 50% (21-27 points clinical, 21-28 points biological, i.e., including TIMP1); C, 50% to less than 75% (28-35 points clinical, 29-35 points biological); and D, 75% or more (>35 points clinical, >37 points biological).

In terms of survival discrimination, PROMISE outperformed the LENT score, which predicts patient survival on the basis of tumor type, pleural fluid lactate dehydrogenase (LDH), performance status and blood neutrophil-to-lymphocyte ratio.

"Although future confirmatory studies are required, the PROMISE score (either clinical or biological) could potentially be used in everyday clinical practice as a method to improve patient management and reduce associated health-care costs, and as an enrichment strategy for future clinical trials," the researchers conclude.

"Individuals with a PROMISE score category A (with <25 a="" absolute="" aggressive="" and="" be="" category="" correlates="" could="" d="" death="" for="" good="" management="" more="" n="" of="" oncological="" or="" particularly="" patients="" pleural="" potential="" prognosis="" promise="" risk="" score="" selected="" surgical="" these="" they="" with="" write.="">=75% absolute risk of death), it is reasonable to offer minimally invasive procedures aimed at symptom control (e.g., therapeutic aspiration or indwelling pleural catheter insertion), best supportive care, and a strategy to spend as few days as possible in hospital."

"Although clear recommendations cannot be given for patients with scores in categories B and C, the PROMISE study score provides a personalized absolute risk of death that can be openly discussed during clinical consultation and can be used as a basis for rational patient choices of further treatments offered," they note.

"The effect of adding TIMP1 to the standard prognostic factors is very modest," write Dr. Paul Baas and Dr. Sajak Burgers from the Netherlands Cancer Institute, in Amsterdam, in a related editorial. "Inclusion of TIMP1 only contributed 2 of the maximum of 43 points (C-reactive protein contributed ten points), which underlines its limited value. The proposed new prognostic score might not be practice changing."

"Effective antitumor treatment remains one of the best therapies for malignant pleural effusions," they note. "A multitude of therapies have evolved over the past decade. Targeted treatment and immunotherapy are the best examples. The optimal approach of patients with symptomatic pleural effusions will be a balance between an optimal systemic antitumor treatment and local pleural fluid control."

Dr. Psallidas did not respond to a request for comments.

SOURCE: https://bit.ly/2lKBp3A and https://bit.ly/2tEiFXM

Lancet Oncol 2018.