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Clinical Value of Hemoglobin and Albumin Levels and Lymphocyte And Platelet Count (HALP) Combination in Predicting Postoperative Complications, Lymph Node Positivity and Prognosis in Gastric Cancer Patients Who Underwent Curative Surgical Resection.

INTRODUCTION

Gastric cancer is the fourth most common cancer and the second most common cause of cancer-related deaths (1). The incidence in our country is approximately 6.3-14.2 per hundred thousand. It ranks 2 (nd) in cancer related deaths in men and 4th in women in the world (2). Gastric cancer is still an important health problem in terms of incidence and prognosis. Knowledge of prognostic factors in gastric cancer is important for determining survival and optimal treatment strategies.

Tumor, nodes, and metastases (TNM) stage and distant metastasis of tumor have been accepted as the primary factor in determining prognosis (3). The disadvantage of TNM staging in determining prognosis is that it only reflects the characteristics of cancer. In particular, the outcomes of some patients at the same stage may be completely different. Therefore, other factors should be considered in predicting prognosis in patients with gastric cancer. Recently, various predictions have been defined and applied to predict the short-and long-term outcomes of gastric cancer patients. These predictions include cancer-related factors, host-related factors, surgical-related factors, and systemic inflammatory response markers (4-9).

Systemic inflammation and nutritional status play an important role in the prognosis of cancer patients (10). Hemoglobin and albumin levels are commonly used markers to assess nutritional status and performance of the patient. Anemia and low albumin were associated with poor prognosis in cancer (11, 12). In previous studies, increased preoperative platelet count was associated with increased recurrence, serosal invasion and advanced stage of gastric cancer (13). Lymphocytes play an important role in defense against cancer by inducing cytotoxic cell death, inhibiting cancer cell proliferation and migration (14). Based on this evidence, several inflammatory index combinations such as neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) HALP combination and systemic immune-inflammation index have been used to predict prognosis (15-19).

In recent studies, a new composite index named HALP, calculated as Hemoglobin (g/L) x Albumin (g/L) x Lymphocyte (/L) / Platelet (/L) was reported to be related to survival in gastric cancer (19), colorectal cancer (20), bladder cancer (21), and renal cancer (22) patients. Currently, there is no study on the relationship between HALP and postoperative complications in gastric cancer and its ability to predict lymph node positivity.

In this study, we aimed to determine the relationship between preoperative hemoglobin, albumin level and lymphocyte and platelet count (HALP) combination with prognosis, postoperative complications and lymph node positivity in patients with gastric cancer undergoing curative resection.

MATERIAL AND METHODS

Study Population and Data Collection

120 patients who underwent curative surgery for gastric cancer in Cukurova Medical Faculty General Surgery Clinic, between January 2015 and December 2018, were included in the study. Permission was obtained from Cukurova University Faculty of Medicine Ethics Committee dated 04.09.2019 and numbered 91/26. Patient files and hospital information system records were examined prospectively, and a database was created. Patients were analyzed retrospectively using this database. Patients with stage IV gastric cancer, patients under eighteen years of age, pregnant patients, patients with chronic inflammatory disease (Tuberculosis, Sarcoidosis, etc.), patients who underwent palliative surgery, patients with autoimmune disease, patients with hematologic disease, who were using steroids for any reason and whose records could not be accessed were excluded from the study. The remaining 82 patients were included in the study.

After the cut-off value was determined by ROC curves, the patients were divided into two groups according to the cut-off value as Group 1 (low HALP) and Group 2 (high HALP). Demographic characteristics, Body Mass Index (BMI), comorbidities, American Society of Anesthesiologists (ASA) score, neoadjuvant treatment status, type and nature of the operation, tumor localization and tumor pathologic stage were recorded. Pathological stage of the tumor, total and metastatic lymph node number, operation duration, mean blood loss, conversion rate in laparoscopic cases, mean time to start oral intake, postoperative complication status according to Clavien Dindo classification (23), rate of anastomosis leakage, postoperative hospital stay, 30-day mortality, unplanned re-admission rate and total survival rate in the postoperative 30-day period were recorded and this information was compared between the two groups. The clinical value of the HALP score in predicting postoperative complications and lymph node positivity was calculated.

Tumor-node-metastasis (TNM) 2016 system was used for tumor staging.

Anastomosis leakage was defined as a deterioration of anastomosis integrity determined by combination of clinical, radiological and operative tools.

Wound infection was defined as superficial or deep incisional surgical site infection in the surgical wound according to the definition of the Centers for Disease Control (CDC) (24).

Tumor invasion depth was evaluated preoperatively by endoscopic ultrasound in suspected cases. Contrast-enhanced thorax, upper and lower abdominal computed tomography were performed for staging and Positron Emition Tomography (PETCT) was performed for metastasis screening.

The total blood count was measured by an automated hematology analyzer (Roche Hitachi Cobas[R] 8000 Roche Diagnostics, Indianapolis, IN, USA). While calculating the HALP index, hemoglobin (g/L), albumin (g/L), lymphocytes (/L), platelets (/L) units conversion was performed in normal value units.

Statistical Analyses

Data were analyzed using IBM Statistical Package for the Social Sciences for Windows, version 24 (IBM Corp.; Armonk, NY, USA). When evaluating the data of the study, in addition to descriptive statistical methods (mean, standard deviation, median, frequency, ratio, minimum, maximum), Student's t test was used for the comparison of quantitative data and Mann Whitney U test was used for the evaluation of neutrophil/lymphocyte ratio which did not show normal distribution. Pearson's Chi-squared test and Fisher's Exact test were used to compare qualitative data, and logistic regression was used for multivariate evaluations. The patients were divided into two groups according to survival and cut off value was found by ROC analysis. The cut-off value for lymph node positivity was calculated by dividing the cases into lymph node positive and negative groups. Diagnostic accuracy was evaluated using receiver operating characteristic (ROC) curve analysis Appropriate cut-off values were identified, and sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio were calculated for parameters with an area under the curve (AUC) of above 0.600. To assess the association of HALP with gastric cancer overall survival, multivariate Cox's proportional hazard model was conducted to estimate Hazard ratios (HRs) and their 95% confidence intervals (CIs). Kaplan-Meier and Log Rank tests were used for survival analysis. A p value of <0.05 was considered statistically significant.

RESULTS

In order to create a cut-off value for HALP, ROC analysis and ROC curve were created. As a result of ROC analysis, the area under the ROC curve was calculated as 50.3%. The obtained cut-off value gives a correct answer at a rate of 50.3%. According to the cut-off value, if the HALP value was above 14.98, it was seen that Clavien Dindo 2 and more complications developed with 84.09% sensitivity and 33.33% specificity. The findings of this evaluation are shown in Table 1 and Figure 1.

In order to create a cut-off value for HALP, ROC analysis and ROC curve were created. As a result of ROC analysis, the area under the ROC curve was calculated as 50.3%. The obtained cut-off value gives a correct answer at a rate of 50.3%. According to the cut off value obtained, the lymph node positivity is assumed to be positive for a HALP value of 9.14 and below, with a sensitivity of 20.00% and specificity of 96.97%. It is shown in Table 2 and Figure 2.

Patients were divided into two groups according to the cut-off value of 14.98. Group 1 consisted of 20 patients and Group 2 consisted of 62 patients. The average age in Group 1 was higher than Group 2 (65 vs 57) (p=0.046). Female sex was higher in Group 2 than Group 1 (38.7% vs 15%) (p=0.042). Body mass index was higher in Group 2 than Group 1 (25.4 vs 22.91) (p=0.020). No statistically significant difference was found between the groups in terms of ASA scores and neoadjuvant treatment (p>0.05). Demographic characteristics and preoperative findings of the patients are shown in Table 3.

In both groups, conventional surgical operations were performed more frequently (95% vs 82.3%) than other surgical techniques (p=0.149). Duration of operation was similar in groups (2188 vs 232 min, p=0.385). Postoperative complication rates were similar among the groups according to the Clavien Dindo classification (p=0.298). Anastomotic leakage rates were similar in both groups (p=0.692). Postoperative mortality rates were similar in both groups (20% vs 8.1%; p=0.142). Postoperative hospital stay was similar among the groups (p=0.157). The most common reason for admission to the hospital within 30 days after discharge was wound infection (10% vs 9.7%, p=0.134). Intraoperative and postoperative outcomes are shown in Table 4.

Tumor localization was most commonly in the antrum in both groups (p=0.646). The total number of dissected lymph nodes was similar in the groups (30 vs 29) (p=0.876). The number of positive lymph nodes was significantly higher in Group 1 than Group 2 (14 vs 5; p=0.002). The rate of lymph node positivity was similar in the groups (p=0.089). The pathological stage was similar in the groups (p=0.110). The rate of well-differentiated tumors was lower in Group 1 (5% vs 29%; p=0.047). The pathological features of the tumors are shown in Table 5.

Total survival time was higher in Group 1 (41 vs 28; p=0.02). It is shown in Table 6 and Figure 3.

There were statistically significant differences in univariate and multivariate analyzes in terms of age and pathological grade groups (p <0.01). There was no statistically significant difference between the patients in terms of sex, pathological stage, HALP group, lymph node positivity and tumor localization (p>0.05). Univariate and multivariate analyzes of the variables of age, sex, pathological grade, pathological stage, HALP score level, lymph node positivity and tumor localization are shown in Table 7.

DISCUSSION

Proper prognostic evaluation is necessary for the optimal treatment of gastric cancer. TNM staging system plays an important role in the prognostic evaluation of gastric cancer in routine clinical practice. However, clinical outcomes may vary between patients with the same staging process, and this is evidence that the TNM staging system is not sufficient to predict prognosis (25-27). Due to the insufficiency of the TNM staging system in determining the prognosis, researchers have begun to work on new scoring systems.

It is widely accepted that inflammatory response and nutritional status are associated with the prognosis of cancer patients (4). Serum albumin is one of the most commonly used indicators to predict the nutritional status of the patient. Serum albumin level is one of the parameters used to evaluate cancer progression and prognosis. Low albumin levels in cancer patients are correlated with low survival rates (28). Anemia is a common finding in cancer patients and is considered a negative prognostic factor (11). Lymphopenia is also common in advanced cancer patients and is a warning for cancer progression. Metastasis formation is associated with platelet stimulation. Platelets are thought to protect cancer cells from immunological attacks (29-31). HALP is an integration of these four hematological and biochemical parameters and has been shown to have a prognostic value in patients with gastric cancer (19).

In this study, the HALP score was calculated based on preoperative hemoglobin, albumin, lymphocyte and platelet values and its importance in the prognostic evaluation of gastric cancer was evaluated.

In this study, the clinical significance of the HALP score in predicting cases with a score of 2 or more according to the Clavien Dindo scoring system evaluating postoperative complications was investigated. At a 14.98 cut off value, the sensitivity in detecting complications was as high as 84%, while the specificity was very low at 33%. When used to estimate lymph node positivity, the specificity of detecting lymph node positivity at a cutoff value of 9.14 was very high (96.7%), whereas its sensitivity was low (20%).

Chen XL et al. (19) found the HALP score to be closely related to many clinicopathological features such as tumor diameter, T and N stage, and vascular invasion. They found the HALP score as a risk factor for survival in multivariate analyzes, and the median survival time and overall survival rates for 1, 2, 3 years were higher in the high HALP group. In our study, it was associated with age, sex, and body mass index. We did not find any relationship between intraoperative and postoperative outcomes. Contrary to the findings of Chen XL et al. (19), it was not associated with pathological tumor stage. However, the rate of positive lymph nodes was high, especially in the group with low HALP scores (14 vs 5; p=0.002). The pathological grade had a higher proportion of well differentiated tumors in the group with high HALP (29% vs 5%; p=0.047).

We did not find the HALP score as a risk factor for survival in the multivariate analysis. The mean total survival time was higher in the low HALP group, contrary to expectations (41 months vs 28 months; p=0.020).

The most important limitation of our study was its retrospective evaluation and single-centeredness. However, we believe that it provides comprehensive data and contributes to valuable reference data in terms of HALP score's value in predicting lymph node positivity in gastric cancer. Multicenter prospective studies are needed to confirm our findings.

In our study contrary to what I expected to have a low Halp score, we did not find it related to poor prognosis. Preoperative high HALP score was found to be associated with poor prognosis. We did not find any correlation between HALP score and risk of postoperative complications. The HALP score is an easy-to-access and inexpensive biomarker. However, it cannot be used as a prognostic factor alone in gastric cancer. The. Prognostic tools are needed to create personalized cancer treatment programs.

Ethics Committee Approval: Ethics committee approval was received for this study from the ethics committee of Cukurova University Faculty of Medicine (04.09.2019/91/26).

Informed Consent: Due to the retrospective design of the study, informed consent was not taken.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept--O.Y., U.T., A.G.U., A.G.S.; Design - O.Y., U.T., A.G.U.; Supervision - O.Y.; Resources - O.Y., U.T., A.G.U., A.G.S.; Materials - O.Y., U.T., A.G.U., A.G.S.; Data Collection and/or Processing U.T., A.G.U.; Analysis and/or Interpretation - O.Y., U.T.; Literature Search - O.Y., U.T., A.G.U., A.G.S.; Writing Manuscript - O.Y., U.T.; Critical Review - O.Y., U.T.

Conflict of Interest: Authors have no conflicts of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.

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Orcun Yalav, Ugur Topal, Ayse Gizem Unal, Ahmet Gokhan Saritas

Department of General Surgery, Cukurova University School of Medicine, Adana, Turkey

Corresponding Author: Ugur Topal

E-mail: sutopal2005@hotmail.com

Received: 23.01.2020

Accepted: 18.03.2020

ORCID iDs of the authors: O.Y. 0000-0001-9239-4163; U. T. 0000-0003-1305-2056; A.G.U. 0000-0001-5775-8953; A.G.S. 0000-0002-2039-3994.

DOI:10.5152/cjms.2020.1747

Main Points:

* Nutritional and immune status is important to the prognosis of patients with gastric carcinoma.

* HALP score is closely related to clinicopathological features but it is not an independent prognostic factor for survival.

* We did not find any correlation between HALP score and risk of postoperative complications.

* HALP score is closely related to clinicopathological features.
TABLE 1. Proposed cut-off values for significant parameters in
postoperative complications, Clavien Dindo 2 and above

               HALP
AUC              0.503
Cut-off        >14.98
Specifity       33.33
95%-Cl (%)      19.1-50.2
Sensitive (%)   84.09
95%-Cl (%)      69.9-93.4
PPV             58.7
NPV             65.0
+LR              1.26
-LR              0.48
p                0.958

AUC: Area under the curve; PPV: Positive predictive value; NPV:
Negative predictive value; OR: Odds ratio; +LR: Positive likelihood
ratio; -LR: Negative likelihood ratio; HALP: Hemoglobin and Albumin
Levels and Lymphocyte and Platelet

TABLE 2. Proposed cut-off values for significant parameters in lymph
node positivity

               HALP

AUC             0.503
Cut-off        <9.14
Specificity    96.97
95%-Cl (%)     84.2-99.9
Sensitive (%)  20.0
95%-Cl (%)     10.0-33.7
PPV            90.9
NPV            44.4
+LR             6.60
-LR             0.83
p               0.962

AUC: Area under the curve; PPV: Positive predictive value; NPV:
Negative predictive value; OR: Odds ratio; +LR: Positive likelihood
ratio; -LR: Negative likelihood ratio; HALP: Hemoglobin and Albumin
Levels and Lymphocyte and Platelet

TABLE 3. Characteristics of patients

                                  Group 1 Low HALP

Age (min-max)                     65,30+17,82 (14-89)
Sex                       Female   3 (15.0)
                          Male    17 (85.0)
ASA score                 1       12 (60.0)
                          2        4 (20.0)
                          3        4 (20.0)
BMI (min-max)                     22,91+2,41 (19-28.6)
Neoadjuvant Chemotherapy  No      16 (80.0)
                          Yes      4 (20.0)

                          Group2 High HALP            p (*)

Age (min-max)             57.53+13.91 (28-85)         0.046
Sex                       24 (38.7)                   0.042
                          38 (61.3)
ASA score                 33 (53.2)                   0.449
                          21 (33.9)
                           8 (12.9)
BMI (min-max)             25.4[+ or -]4.47 (16-40.3)  0.020
Neoadjuvant Chemotherapy  43 (69.4)                   0.268
                          19 (30.6)

(*) p<0.05; BMI: Body Mass Index; ASA: American Society of
Anesthesiologists score; HALP: Hemoglobin and Albumin Levels and
Lymphocyte And Platelet

TABLE 4. Intraoperative and Postoperative outcomes

                                                     Group 1 Low HALP

Operation type                 Open                   19 (95.0)
                               Laparoscopic            1 (5.0)
Operation duration (min)                             218.25[+ or -]29.03
                                                     (180-310)
Complication (Clavien Dindo)   1                       1 (5.0)
                               2                      12 (60.0)
                               3A                      3 (15.0)
                               3B                      1 (5.0)
                               5                       3 (15.0)
Anastomosis leakage            None                   17 (85.0)
                               Stump leak              1 (5.0)
                               Esophagojejunostomy     2 (10.0)
Postoperative mortality        Yes                     4 (20.0)
                               No                     16 (80.0)
Postoperative duration
of hospitalization (day)       14.0+11.88 (5-45)      10.79+7.48
                                                      (2-46.0)
30-day readmission
to the hospital                None                   15 (75.0)
                               Ileus                   1 (5.0)
                               Oral intake disorder    1 (5.0)
                               Pneumonia               1 (5.0)
                               Wound site infection    2 (10.0)

                                                     Group2 High HALP

Operation type                 Open                   51 (82.3)
                               Laparoscopic           11 (17.7)
Operation duration (min)                             232.50[+ or -]70.76
                                                     (170-500)
Complication (Clavien Dindo)   1                      14 (22.6)
                               2                      34 (54.8)
                               3A                      9 (14.5)
                               3B                      2 (3.2)
                               5                       3 (4.8)
Anastomosis leakage            None                   55 (88.7)
                               Stump leak              4 (6.5)
                               Esophagojejunostomy     3 (4.8)
Postoperative mortality        Yes                     5 (8.1)
                               No                     57 (91.9)
Postoperative duration
of hospitalization (day)       14.0+11.88 (5-45)       0.157
30-day readmission
to the hospital                None                   55 (88.7)
                               Ileus                   1 (1.6)
                               Oral intake disorder    0 (0.0)
                               Pneumonia               0 (0.0)
                               Wound site infection    6 (9.7)

                                                     p*

Operation type                 Open                  0.149
                               Laparoscopic
Operation duration (min)                             0.385
Complication (Clavien Dindo)   1                     0.298
                               2
                               3A
                               3B
                               5
Anastomosis leakage            None                  0.692
                               Stump leak
                               Esophagojejunostomy
Postoperative mortality        Yes                   0.142
                               No
Postoperative duration
of hospitalization (day)       14.0+11.88 (5-45)
30-day readmission
to the hospital                None                  0.123
                               Ileus
                               Oral intake disorder
                               Pneumonia
                               Wound site infection

HALP: Hemoglobin and Albumin Levels and Lymphocyte And Platelet

TABLE 5. Characteristics of tumor

                                              Group 1 Low HALP

Tumor localization     Antrum                  6 (30.0)
                       Cardia                  1 (5.0)
                       Corpus                  7 (35.0)
                       Small curvature         3 (15.0)
                       Linitis Plastica        3 (15.0)
                       EGJ                     0 (0.0)
Total dissected
lymph node number
(mean) (min-max)                              30.35+15.85 (3-62)
Positive lymph
node number
(mean) (min-max)                              14.05+15.94 (0-47)
Lymph node positivity  Negative                5 (25.0)
                       Positive               15 (75.0)
pSTAGE                 1A                      0 (0.0)
                       1B                      1 (5.0)
                       2A                      1 (5.0)
                       2B                      4 (20.0)
                       3A                      1 (5.0)
                       3B                      3 (15.0)
                       3C                     10 (50.0)
Pathological grade     Non-differentiated      3 (15.0)
                       Poorly differentiated   9 (45.0)
                       Mildly differentiated   7 (35.0)
                       Well differentiated     1 (5.0)

                                              Group2 High HALP

Tumor localization     Antrum                 25 (40.3)
                       Cardia                  4 (6.5)
                       Corpus                 19 (30.6)
                       Small curvature         9 (14.5)
                       Linitis Plastica        3 (4.8)
                       EGJ                     2 (3.2)
Total dissected
lymph node number
(mean) (min-max)                              29.79+13.16 (7-63)
Positive lymph
node number
(mean) (min-max)                               5.54+7.77 (0-38)
Lymph node positivity  Negative               28 (45.2)
                       Positive               34 (54.8)
pSTAGE                 1A                     12 (19.4)
                       1B                      5 (8.1)
                       2A                      4 (6.5)
                       2B                     16 (25.8)
                       3A                      7 (11.3)
                       3B                      3 (4.8)
                       3C                     15 (24.2)
Pathological grade     Non-differentiated     11 (17.7)
                       Poorly differentiated  25 (40.3)
                       Mildly differentiated   8 (12.9)
                       Well differentiated    18 (29.0)

                                              p (*)

Tumor localization     Antrum                 0.646
                       Cardia
                       Corpus
                       Small curvature
                       Linitis Plastica
                       EGJ
Total dissected
lymph node number
(mean) (min-max)                              0.876
Positive lymph
node number
(mean) (min-max)                              0.002
Lymph node positivity  Negative               0.089
                       Positive
pSTAGE                 1A                     0.110
                       1B
                       2A
                       2B
                       3A
                       3B
                       3C
Pathological grade     Non-differentiated     0.047
                       Poorly differentiated
                       Mildly differentiated
                       Well differentiated

(*) p<0.05; EGJ: Esophagogastric junction; HALP: Hemoglobin and Albumin
Levels and Lymphocyte and Platelet

TABLE 6. Total survival time according to HALP groups

                       Mean (Mean+sd (Min-Max))

HALP Group  Low HALP   41.0+4.32
                       32.54-49.47
            High HALP  28.44+1.86
                       24.8-32.09

                       Median (Mean+sd (Min-Max))  p

HALP Group  Low HALP   44.02+5.27
                       33.68-54.37                 0.020
            High HALP  28.26+5.15
                       18.16-38.37

HALP: Hemoglobin and Albumin Levels and Lymphocyte and Platelet

TABLE 7. M Univariate and multivariable analysis of factors associated
with overall survival in gastric cancer

                                               Univariate
Measurements                                   p

Age group              <59                     0.006
                       >59
Sex                    Male                    0.051
                       Female
Pathological grade     Poorly differentiated   0.046
                       Non-differentiated
                       Well differentiated
                       Mildly differentiated
Pathological stage     1A                      0.108
                       1B
                       2A
                       2B
                       3A
                       3B
                       3C
HALP                   <14.98                  0.055
                       >14.98
Lymph node positivity  Negative                0.113
                       Positive
Tumor localization     Antrum                  0.664
                       Cardia
                       Corpus
                       Small curvature
                       Linitis Plastica
                       EGJ

                                               Multivariate
Measurements                                   HR (95% - CI)

Age group              <59                     1.00
                       >59                     0.258 (0.076-0.441)
Sex                    Male                    1.00
                       Female                  0.198 (0.110-0.396)
Pathological grade     Poorly differentiated   1.00
                       Non-differentiated
                       Well differentiated
                       Mildly differentiated   0.414 (0.126- 0.702)
Pathological stage     1A                      1.00
                       1B
                       2A
                       2B
                       3A                      0.233 (-0.147-0.613)
                       3B
                       3C
HALP                   <14.98                  1.00
                       >14.98                  0.247 (0.113-0.485)
Lymph node positivity  Negative                1.00
                       Positive                0.155 (-0.037-0.346)
Tumor localization     Antrum                  1.00
                       Cardia
                       Corpus
                       Small curvature         0.194 (-0.828-0.441)
                       Linitis Plastica
                       EGJ

Measurements                                  p

Age group              <59                    0.003
                       >59
Sex                    Male                   0.058
                       Female
Pathological grade     Poorly differentiated  0.039
                       Non-differentiated
                       Well differentiated
                       Mildly differentiated
Pathological stage     1A                     0.225
                       1B
                       2A
                       2B
                       3A
                       3B
                       3C
HALP                   <14.98                 0.061
                       >14.98
Lymph node positivity  Negative               0.148
                       Positive
Tumor localization     Antrum                 0.545
                       Cardia
                       Corpus
                       Small curvature
                       Linitis Plastica
                       EGJ

EGJ: Esophagogastric junction; HR: Hazard ratios; CI: confidence
intervals; HALP: Hemoglobin and Albumin Levels and Lymphocyte and
Platelet
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Title Annotation:Original Article
Author:Yalav, Orcun; Topal, Ugur; Unal, Ayse Gizem; Saritas, Ahmet Gokhan
Publication:Cyprus Journal of Medical Sciences
Geographic Code:9TAIW
Date:Jun 1, 2020
Words:4832
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