Increasing negative lymph node count is independently associated with improved long-term survival in stage IIIB and IIIC colon cancer

Lymph node density as a prognostic marker of relapse in patients who underwent primary retroperitoneal lymph node dissection

INTRODUCTION

Primary retroperitoneal lymph node dissection (pRPLND) is a treatment option for clinical stage (CS) II testicular germ cell tumors (TGCTs) and CS I with retroperitoneal relapse. Increasing raw lymph node yield during pRPLND has been associated a decreased relapse risk. However, this metric has limitations due to variations in surgical templates and specimen processing methods. We aimed to evaluate the lymph node density (LND), which is the ratio of positive lymph nodes to the total number of nodes removed, as a prognostic marker for relapse after pRPLND.

METHODS

We reviewed all patients who underwent pRPLND at the Princess Margaret Cancer Centre between 1990 and 2022. The primary endpoint was relapse-free survival (RFS). RFS was calculated using the Kaplan-Meier product-limit method. The log-rank test was used to assess the impact of LND, and recursive binary partitioning was used to determine the threshold LND that provides optimum separation in RFS.

RESULTS

In this study, 178 patients were treated with pRPLND. A total of 137 (77%) patients had pathological evidence of nodal metastasis, 96 were treated with open RPLND, and 41 with robotic RPLND. The median number of lymph nodes harvested was 32 (IQR 23-43) and median total positive nodes was 2 (IQR 1-36). This translated into a median LND of 3.1% (IQR 1.7-57.1). There was no significant difference in the LND between robotic and open approaches (P = 0.6664). After a median follow-up of 38.6 months, 11 patients (8.02%) had relapsed. LND was not significantly associated with relapse (HR 1.018, 95% CI, 0.977-1.061). The optimal threshold to dichotomize LND that provides optimum separation in RFS was ≥ 26.75%, however, it did not reach statistical significance (P = 0.0651).

CONCLUSION

In conclusion, the LND was not associated with RFS after pRPLND in patients with TGCTs. The unique characteristics of TGCTs and the presence of other established risk factors limit the utility of the LND alone in predicting relapse.

Prognostic significance of negative lymph node count in microsatellite instability-high colorectal cancer

BACKGROUND

Microsatellite instability-high (MSI-H) tumors, with elevated tumor mutational burden and expression of neoantigens, represent a distinct immune-activated subpopulation in colorectal cancer (CRC), characterized by strong lymph node reaction, locally advanced tumor and higher total lymph nodes harvested (TLN), but less metastatic lymph nodes and fewer incidence of III-IV stage. Host immune response to tumor and lymph nodes may be an important prognostic factor. However, N stage and LNR (Lymph-Node Ratio) have limitations in predicting the prognosis of MSI-H patients. Negative lymph node count (NLC) provided a more precise representation of immune activation status and extent of tumor metastasis. The study aims to detect prognostic significance of NLC in MSI-H CRC patients, and compare it with N stage, TLN and LNR.

METHODS

Retrospective data of 190 consecutive MSI-H CRC patients who received curative resection were collected. Survival analyses were performed using the Kaplan-Meier method. Clinicopathological variables including NLC, N stage, TLN and LNR were studied in univariate and multivariate COX regression analyses. ROC (receiver operating characteristic curve) and concordance index were employed to compare the differences in predictive efficacy between NLC, N stage, TLN and LNR.

RESULTS

Patients with increased NLC experienced a significantly improved 5-years DFS and OS in Kaplan-Meier analysis, univariate analysis, and multivariate analysis, independent of potential confounders examined. Increased NLC corresponded to elevated 5-years DFS rate and 5-years OS rate. AUC (area under curve) and concordance index of NLC in DFS and OS predicting were both significantly higher than N stage, TLN and LNR.

CONCLUSIONS

Negative lymph node is an important independent prognostic factor for MSI-H patients. Reduced NLC is associated with tumor recurrence and poor survival, which is a stronger prognostic factor than N stage, TLN and LNR.

Cancer spreading patterns based on epithelial-mesenchymal plasticity

Introduction: Metastasis is a major cause of cancer-related deaths, underscoring the necessity to discern the rules and patterns of cancer cell spreading. Epithelial-mesenchymal plasticity contributes to cancer aggressiveness and metastasis. Despite establishing key determinants of cancer aggressiveness and metastatic ability, a comprehensive understanding of the underlying mechanism is unknown. We aimed to propose a classification system for cancer cells based on epithelial-mesenchymal plasticity, focusing on hysteresis of the epithelial-mesenchymal transition and the hybrid epithelial/mesenchymal phenotype. Methods: We extensively reviewed the concept of epithelial-mesenchymal plasticity, specifically considering the hysteresis of the epithelial-mesenchymal transition and the hybrid epithelial/mesenchymal phenotype. Results: In this review and hypothesis article, based on epithelial-mesenchymal plasticity, especially the hysteresis of epithelial-mesenchymal transition and the hybrid epithelial/mesenchymal phenotype, we proposed a classification of cancer cells, indicating that cancer cells with epithelial-mesenchymal plasticity potential could be classified into four types: irreversible hysteresis, weak hysteresis, strong hysteresis, and hybrid epithelial/mesenchymal phenotype. These four types of cancer cells had varied biology, spreading features, and prognoses. Discussion: Our results highlight that the proposed classification system offers insights into the diverse behaviors of cancer cells, providing implications for cancer aggressiveness and metastasis.

Colon cancer: the 2023 Korean clinical practice guidelines for diagnosis and treatment

Colorectal cancer is the third most common cancer in Korea and the third leading cause of death from cancer. Treatment outcomes for colon cancer are steadily improving due to national health screening programs with advances in diagnostic methods, surgical techniques, and therapeutic agents.. The Korea Colon Cancer Multidisciplinary (KCCM) Committee intends to provide professionals who treat colon cancer with the most up-to-date, evidence-based practice guidelines to improve outcomes and help them make decisions that reflect their patients' values and preferences. These guidelines have been established by consensus reached by the KCCM Guideline Committee based on a systematic literature review and evidence synthesis and by considering the national health insurance system in real clinical practice settings. Each recommendation is presented with a recommendation strength and level of evidence based on the consensus of the committee.

Acetone compression improves lymph node yield and metastasis detection in colorectal cancer

Lymph node status is one of the most important prognostic factors in colorectal cancer, and accurate pathological nodal staging and detection of lymph node metastases is crucial for determination of post-operative management. Current guidelines, including the TNM staging system and European Society for Medical Oncology (ESMO) guidelines, recommend examination of at least 12 lymph nodes. However, identification of an adequate number of lymph nodes can be challenging, especially in the setting of neoadjuvant treatment, which may reduce nodal size. In this study, we investigated 384 colorectal cancer resections that were processed at our department of pathology between January 2012 and December 2022, in which the number of detected lymph nodes was less than 12 subsequent to conventional preparation of mesocolic fat tissue. By means of acetone compression, lymph node harvest increased significantly (p < 0.0001), and the intended number of ≥ 12 lymph nodes was achieved in 98% of resection specimens. The number of nodal positive cases increased significantly from n = 95 (24.7%) before versus n = 131 (34.1%) after acetone compression due to additionally identified lymph node metastases (p < 0.001). In 36 patients (9.4%) initially considered as nodal negative, acetone compression led to a staging adjustment to a nodal positive category and thereby drove a recommendation to offer post-operative therapy. In conclusion, acetone compression is a reliable and useful method implementable in routine surgical pathology for the retrieval of lymph nodes in colorectal cancer specimen, allowing for an adequate lymph node sampling and an increase in nodal staging reliability.

Colorectal resections for malignancy: A pilot study comparing conventional vs freehand robot-assisted laparoscopic colectomy

BACKGROUND

Laparoscopic colectomy is widely accepted as a safe operation for colorectal cancer, but we have experienced resistance to the introduction of the FreeHand® robotic camera holder to augment laparoscopic colorectal surgery.

AIM

To compare the initial results between conventional and FreeHand® robot-assisted laparoscopic colectomy in Trinidad and Tobago.

METHODS

This was a prospective study of outcomes from all laparoscopic colectomies performed for colorectal carcinoma from November 29, 2021 to May 30, 2022. The following data were recorded: Operating time, conversions, estimated blood loss, hospitalization, morbidity, surgical resection margins and number of nodes harvested. All data were entered into an excel database and the data were analyzed using SPSS ver 20.0.

RESULTS

There were 23 patients undergoing colectomies for malignant disease: 8 (35%) FreeHand®-assisted and 15 (65%) conventional laparoscopic colectomies. There were no conversions. Operating time was significantly lower in patients undergoing robot-assisted laparoscopic colectomy (95.13 ± 9.22 vs 105.67 ± 11.48 min; P = 0.045). Otherwise, there was no difference in estimated blood loss, nodal harvest, hospitalization, morbidity or mortality.

CONCLUSION

The FreeHand® robot for colectomies is safe, provides some advantages over conventional laparoscopy and does not compromise oncologic standards in the resource-poor Caribbean setting.

Combination of the Ratio Between Negative and Harvested Lymph Nodes and Metastatic Lymph Node Count as a Prognostic Indicator in Stage III Colon Cancer: A Retrospective Cohort Study

BACKGROUND

This study aimed to investigate the relationship between the ratio of negative lymph nodes (NLN) number to the number of metastatic lymph nodes (MLN) and the harvested lymph nodes (HLN) number ratio survival rate and compare its prognostic value.

METHODS

This retrospective cohort study included 207 stage III colon cancer patients between 2010 and 2018 at a single center. NLN/MLN and NLN/HLN cut-off values were determined with the receiver operating characteristic (ROC) curve according to 5-year survival. The patients were divided into high-risk and low-risk groups according to the cut-off value. These 2 groups were evaluated according to the clinicopathological data of the patients.

RESULT

The time-dependent ROC curve showed the optimal cut-off values of NLN as 3.86 and .79, respectively. These values show 83 patients in the high-risk group and 124 in the low-risk group. There was no difference between the groups in tumor localization and T stage. According to Kaplan-Meier survival analysis, mean survival was 35.88 months in the high-risk group and 50.18 months in the low-risk group. The risk of death in the high-risk group was 305% compared to the low-risk group (Hazard Ratio: 3.05, 95% 1.91 - 4.88) (P < .001).

CONCLUSION

NLNs are among the critical prognostic factors in colon cancer. Although NLNs have a positive correlation with the survival rate of the patients, there is no statistical difference in tumor T stage and localization.

Advantage of log odds of positive lymph nodes in prognostic evaluation of patients with early-onset colon cancer

BACKGROUND

Colon cancer (CC) is one of the most common cancers of the digestive tract, the third most common cancer worldwide, and the second most common cause of cancer-related deaths. Previous studies have demonstrated a higher risk of lymph node metastasis (LNM) in young patients with CC. It might be reasonable to treat patients with early-onset locally advanced CC with extended lymph node dissection. However, few studies have focused on early-onset CC (ECC) patients with LNM. At present, the methods of predicting and evaluating the prognosis of ECC patients with LNM are controversial.

AIM

To compare the prognostic values of four lymph node staging indices and establish the best nomogram for patients with ECC.

METHODS

From the data of patients with CC obtained from the Surveillance, Epidemiology, and End Results (SEER) database, data of young patients with ECC (≤ 50 years old) was screened. Patients with unknown data were excluded from the study, while the remaining patients were included. The patients were randomly divided into a training group (train) and a testing group (test) in the ratio of 7:3, while building the model. The model was constructed by the training group and verified by the testing group. Using multiple Cox regression models to compare the prediction efficiency of LNM indicators, nomograms were built based on the best model selected for overall survival (OS) and cause-specific survival (CSS). In the two groups, the performance of the nomogram was evaluated by constructing a calibration plot, time-dependent area under the curve (AUC), and decision curve analysis. Finally, the patients were grouped based on the risk score predicted by the prognosis model, and the survival curve was constructed after comparing the survival status of the high and low-risk groups.

RESULTS

Records of 26922 ECC patients were screened from the SEER database. N classification, positive lymph nodes (PLN), lymph node ratio (LNR) and log odds of PLN (LODDS) were considered to be independent predictors of OS and CSS. In addition, independent risk factors for OS included gender, race, marital status, primary site, histology, grade, T, and M classification, while the independent prognostic factors for CSS included race, marital status, primary site, grade, T, and M classification. The prediction model including LODDS is composed of minimal Akaike information criterion, maximal concordance indexes, and AUCs. Factors including gender, race, marital status, primary site, histology, grade, T, M classification, and LODDS were integrated into the OS nomogram, while race, marital status, primary site, grade, T, M classification, and LODDS were included into the CSS nomogram. The nomogram representing both cohorts had been successfully verified in terms of prediction accuracy and clinical practicability.

CONCLUSION

LODDS is superior to N-stage, PLN, and LNR of ECC. The nomogram containing LODDS might be helpful in tumor evaluation and clinical decision-making, since it provides an appropriate prediction of ECC.

Negative Lymph Node Is an Independent Prognostic Factor for Stage III Gastric Cancer Patients After Curative Gastrectomy: A Surveillance, Epidemiology, and End Results-Based Study

BACKGROUND

Negative lymph node (NLN)' s prognostic impact on stage III gastric cancer (GC) patients after curative gastrectomy has not been rigorously studied. We aimed to explore the relationship between NLNs count and outcomes of stage III GC patients.

METHODS

We retrospectively investigated stage III gastric cancer cases between 2008 and 2018 from Surveillance, Epidemiology, and End Results (SEER) database. Variables were compared by chi2 test. Kaplan-Meier methods and COX proportional hazard models were used to ascertain independent prognostic factors. Survival differences among the subgroups were analyzed to assess the effects of NLN count on overall survival (OS) in stage III GC patients.

RESULTS

2373 patients with curative gastrectomy for stage III GC were identified. Univariate analysis demonstrated that NLNs count >14 was associated better 5-year OS (43.7% VS 23.1%, P< .001) comparing with the NLNs count ≤ 14. Subgroup analysis showed that the NLNs count could predict survival in both node-negative and node-positive patients. Multivariate analysis revealed NLNs count is an independent prognostic factor.

CONCLUSIONS

The NLNs count is an independent prognostic factor for survival in stage III gastric cancer patients after curative gastrectomy and should be recommended for clinical applications.

Lymph node retrieval colon cancer: Are we making the grade?

BACKGROUND

Adequate lymph node (LN) excision is imperative for pathologic staging and determination of adjuvant treatment.

METHODS

he 2004-2017 National Cancer Database (NCDB) was queried for curative colon cancer resections. Tumors were categorized by location: left, right, and transverse colon cancers. Adequate (12-20 LNs) vs. inadequate (<12 LNs) lymphadenectomy was examined and sub-analysis of <12 LNs, 12-20 LNs or >20 LNs. Primary outcome was predictors of inadequate lymph node retrieval.

RESULTS

Of 101,551 patients, 11.2% (11,439) had inadequate lymphadenectomy. The inadequate lymphadenectomy rate steadily decreased. On multivariable analysis, inadequate LN retrieval was associated with transverse (OR 1.49, CI [1.30-1.71]) and left colon cancers (OR 2.66, CI [2.42-2.93], whereas income >$63,333 had decreased likelihood of inadequate LN retrieval (OR 0.68, CI[0.56-0.82].

CONCLUSION

We are making the grade as NCDB data demonstrates a steady decrease in inadequate lymphadenectomy (2004-2017). There remain socioeconomic risk factors for inadequate lymphadenectomy that need to be addressed.

Immune microenvironment and lymph node yield in colorectal cancer

BACKGROUND

Lymph node (LN) harvesting is associated with outcomes in colonic cancer. We sought to interrogate whether a distinctive immune milieu of the primary tumour is associated with LN yield.

METHODS

A total of 926 treatment-naive patients with colorectal adenocarcinoma with more than 12 LNs (LN-high) were compared with patients with 12 or fewer LNs (LN-low). We performed immunohistochemistry and quantification on tissue microarrays for HLA class I/II proteins, beta-2-microglobulin (B2MG), CD8, CD163, LAG3, PD-L1, FoxP3, and BRAF V600E.

RESULTS

The LN-high group was comprised of younger patients, longer resections, larger tumours, right-sided location, and tumours with deficient mismatch repair (dMMR). The tumour microenvironment showed higher CD8+ cells infiltration and B2MG expression on tumour cells in the LN-high group compared to the LN-low group. The estimated mean disease-specific survival was higher in the LN-high group than LN-low group. On multivariate analysis for prognosis, LN yield, CD8+ cells, extramural venous invasion, perineural invasion, and AJCC stage were independent prognostic factors.

CONCLUSION

Our findings corroborate that higher LN yield is associated with a survival benefit. LN yield is associated with an immune high microenvironment, suggesting that tumour immune milieu influences the LN yield.

Role of lymphatic invasion in predicting biochemical recurrence after radical prostatectomy

Objective

Lymphatic invasion in prostate cancer is associated with poor prognosis. However, there is no consensus regarding the clinical and prognostic value of lymphatic invasion. This study aimed to investigate the prognostic value of lymphatic invasion in biochemical recurrence (BCR) and compare the recurrence rates between patients with lymphatic invasion and lymph node metastasis.

Methods

We retrospectively analyzed 2,207 patients who underwent radical prostatectomy (RP) without pelvic lymph node dissection (PLND) and 742 patients who underwent RP with PLND for clinically localized or locally advanced prostate cancer, between 1993 and 2020, at Seoul National University Hospital. Kaplan-Meier analysis was performed to estimate BCR-free survival (BCRFS) using the log-rank test. The Cox proportional hazards model was used to identify the significant factors for BCR. Propensity score matching was performed with a 1:2 ratio to match age, initial PSA level, pathological T stage, and Gleason score to exclude confounding effects.

Results

Of the 2,207 patients who underwent RP without PLND, lymphatic invasion (L1Nx) was observed in 79 (3.5%) individuals. Among the 742 patients who underwent RP with PLND, lymph node metastases were found in 105 patients (14.2%). In patients with lymph node metastasis, lymphatic invasion was observed in 50 patients (47.6%), whereas lymphatic invasion was observed in 53 patients (8.3%) among those without lymph node metastasis. In patients who underwent RP without PLND, Kaplan-Meier analysis showed significantly poorer BCR-free survival in the L1Nx group than in the L0Nx group (p < 0.001). In patients who underwent RP with PLND, the L1N0, L0N1, and L1N1 groups showed significantly worse prognoses than the L0N0 group (p < 0.001). However, there was no significant difference in BCRFS between the L1N0 and lymph node metastasis groups, including the L0N1 and L1N1 groups. After propensity score matching at a 1:2 ratio, the L1Nx group showed significantly poorer outcomes in terms of BCRFS than the L0Nx group (p = 0.05). In addition, the L1N0 group showed a significantly worse prognosis than the L0N0 group after propensity score matching.

Conclusion

Lymphatic invasion in radical prostatectomy specimens is an independent prognostic factor, which can complement lymph node status for predicting biochemical recurrence. Considering lymphatic invasion as an adverse pathological finding, similar to lymph node metastasis, adjuvant therapy could be considered in patients with lymphatic invasion.

Prognostic Relevance of Negative Lymph Node Count in Resected Stage I-IIIa Small-cell Lung Cancer

OBJECTIVES

The prognostic significance of the negative lymph node (NLN) count has been confirmed in various cancers but not in small-cell lung cancer (SCLC). We aimed to evaluate the correlation between the NLN count and the prognosis of patients with stages I-IIIa SCLC who underwent lobectomy.

METHODS

Data on the clinical characteristics of SCLC patients who underwent lobectomy between 2000 and 2019 were collected from the SEER database and organized based on the X-tile plots to identify the optimal cutoff point for the NLN count. Kaplan-Meier curves and a Cox proportional hazard model were used to evaluate the prognostic factors for overall survival (OS) and lung cancer-specific survival.

RESULTS

Based on the X-tile plot-determined cutoff points of 3 and 7, the participants were grouped into the low (<3), middle (3-7), and high (>7) NLN subgroups for the analysis of OS. Univariable analysis showed that a higher NLN count correlated with more favorable OS and lung cancer-specific survival (both P <0.001). Multivariate analysis demonstrated that, after adjustment for related factors, the NLN count was positively associated with the prognosis and might thus be an independent risk factor for prognosis. Subgroup analyses revealed that, among different LN statuses and varied positive LN counts, the NLN count could predict the prognosis independently.

CONCLUSIONS

Higher NLNs correlated with better survival for patients who underwent lobectomy of stages I-IIIa SCLC. A predictive marker that combines the NLN count with the N stage and positive LN count could provide more prognostic information in SCLC.

Construction and validation of a nomogram model for predicting the overall survival of colorectal cancer patients

BACKGROUND

Colorectal cancer (CRC) is a frequent cancer worldwide with varied survival outcomes.

OBJECTIVE

We aimed to develop a nomogram model to predict the overall survival (OS) of CRC patients after surgery.

DESIGN

This is a retrospective study.

SETTING

This study was conducted from 2015 to 2016 in a single tertiary center for CRC.

PATIENTS

CRC patients who underwent surgery between 2015 and 2016 were enrolled and randomly assigned into the training (n = 480) and validation (n = 206) groups. The risk score of each subject was calculated based on the nomogram. All participants were categorized into two subgroups according to the median value of the score.

MAIN OUTCOME MEASURES

The clinical characteristics of all patients were collected, significant prognostic variables were determined by univariate analysis. Least absolute shrinkage and selection operator (LASSO) regression was applied for variable selection. The tuning parameter (λ) for LASSO regression was determined by cross-validation. Independent prognostic variables determined by multivariable analysis were used to establish the nomogram. The predictive capacity of the model was assessed by risk group stratification.

RESULTS

Infiltration depth, macroscopic classification, BRAF, carbohydrate antigen 19 - 9 (CA-199) levels, N stage, M stage, TNM stage, carcinoembryonic antigen levels, number of positive lymph nodes, vascular tumor thrombus, and lymph node metastasis were independent prognostic factors. The nomogram established based on these factors exhibited good discriminatory capacity. The concordance indices for the training and validation groups were 0.796 and 0.786, respectively. The calibration curve suggested favorable agreement between predictions and observations. Moreover, the OS of different risk subgroups was significantly different.

LIMITATIONS

The limitations of this work included small sample size and single-center design. Also, some prognostic factors could not be included due to the retrospective design.

CONCLUSIONS

A prognostic nomogram for predicting the OS of CRC patients after surgery was developed, which might be helpful for evaluating the prognosis of CRC patients.

Prognostic Significance of Negative Lymph Node Long Axis in Esophageal Cancer: Results From the Randomized Controlled UK MRC OE02 Trial

OBJECTIVE

To analyze the relationship between negative lymph node (LNneg) size as a possible surrogate marker of the host antitumor immune response and overall survival (OS) in esophageal cancer (EC) patients.

BACKGROUND

Lymph node (LN) status is a well-established prognostic factor in EC patients. An increased number of LNnegs is related to better survival in EC. Follicular hyperplasia in LNneg is associated with better survival in cancer-bearing mice and might explain increased LN size.

METHODS

The long axis of 304 LNnegs was measured in hematoxylin-eosin stained sections from resection specimens of 367 OE02 trial patients (188 treated with surgery alone (S), 179 with neoadjuvant chemotherapy plus surgery (C+S)) as a surrogate of LN size. The relationship between LNneg size, LNneg microarchitecture, clinicopathological variables, and OS was analyzed.

RESULTS

Large LNneg size was related to lower pN category ( P = 0.01) and lower frequency of lymphatic invasion ( P = 0.02) in S patients only. Irrespective of treatment, (y)pN0 patients with large LNneg had the best OS. (y)pN1 patients had the poorest OS irrespective of LNneg size ( P < 0.001). Large LNneg contained less lymphocytes ( P = 0.02) and had a higher germinal centers/lymphocyte ratio ( P = 0.05).

CONCLUSIONS

This is the first study to investigate LNneg size in EC patients randomized to neoadjuvant chemotherapy followed by surgery or surgery alone. Our pilot study suggests that LNneg size is a surrogate marker of the host antitumor immune response and a potentially clinically useful new prognostic biomarker for (y)pN0 EC patients. Future studies need to confirm our results and explore underlying biological mechanisms.

The optimal minimum lymph node count for carcinoembryonic antigen elevated colon cancer: a population-based study in the SEER set and External set

PURPOSE

The aim of this paper was to clarify the optimal minimum number of lymph node for CEA-elevated (≥ 5 ng/ml) colon cancer patients.

METHODS

Thirteen thousand two hundred thirty-nine patients from the SEER database and 238 patients from the Second Affiliated Hospital of Harbin Medical University (External set) were identified. For cancer-specific survival (CSS), Kaplan-Meier curves were drawn and data were analyzed using log-rank test. Using X-tile software, the optimal cut-off lymph node count was calculated by the maximal Chi-square value method. Cox regression model was applied to perform survival analysis.

RESULTS

In CEA-elevated colon cancer, 18 nodes were defined as the optimal minimum node. The number of lymph node examined (< 12, 12-17 and ≥ 18) was an independent prognosticator in both SEER set (HR_{12-17 nodes} = 1.329, P <  0.001; HR_{< 12 nodes} = 1.985, P <  0.001) and External set (HR_{12-17 nodes} = 1.774, P <  0.032; HR_{< 12 nodes} = 2.741, P <  0.006). Moreover, the revised 18-node standard could identify more positive lymph nodes compared with the 12-node standard in this population.

CONCLUSIONS

With the purpose of favorable long-term survival and accurate nodal stage for CEA-elevated colon cancer patients, the 18-node standard could be regarded as an alternative to the 12-node standard advocated by the ASCO and NCCN guidelines.

Prediction model of colorectal cancer (CRC) lymph node metastasis based on intestinal bacteria

BACKGROUND

Lymph node metastasis is the main metastatic mode of CRC. Lymph node metastasis affects patient prognosis.

OBJECTIVE

To screen differential intestinal bacteria for CRC lymph node metastasis and construct a prediction model.

METHODS

First, fecal samples of 119 CRC patients with lymph node metastasis and 110 CRC patients without lymph node metastasis were included for the detection of intestinal bacterial 16S rRNA. Then, bioinformatics analysis of the sequencing data was performed. Community structure and composition analysis, difference analysis, and intragroup and intergroup correlation analysis were conducted between the two groups. Finally, six machine learning models were used to construct a prediction model for CRC lymph node metastasis.

RESULTS

The community richness and the community diversity at the genus level of the two groups were basically consistent. A total of 12 differential bacteria (Agathobacter, Catenibacterium, norank_f__Oscillospiraceae, Lachnospiraceae_FCS020_group, Lachnospiraceae_UCG-004, etc.) were screened at the genus level. Differential bacteria, such as Agathobacter, Catenibacterium, norank_f__Oscillospiraceae, and Lachnospiraceae_FCS020_group, were more associated with no lymph node metastasis in CRC. In the discovery set, the RF model had the highest prediction accuracy (AUC = 1.00, 98.89% correct, specificity = 55.21%, sensitivity = 55.95%). In the test set, SVM model had the highest prediction accuracy (AUC = 0.73, 72.92% correct, specificity = 69.23%, sensitivity = 88.89%). Lachnospiraceae_FCS020_group was the most important variable in the RF model. Lachnospiraceae_UCG - 004 was the most important variable in the SVM model.

CONCLUSION

CRC lymph node metastasis is closely related to intestinal bacteria. The prediction model based on intestinal bacteria can provide a new evaluation method for CRC lymph node metastasis.

Indocyanine green for radical lymph node dissection in patients with sigmoid and rectal cancer: randomized clinical trial

BACKGROUND

D3 lymph node dissection is recommended for patients with advanced sigmoid and rectal cancer in Japan. This trial aimed to investigate the feasibility of indocyanine green (ICG) as a tracer to increase the nodal harvest during D3 lymph node dissection in patients with sigmoid and rectal cancer.

METHODS

This prospective randomized clinical trial was performed between May 2021 and April 2022. The inclusion criteria were patients with stage I-III sigmoid or rectal cancer eligible for laparoscopic resection. Patients were 1: 1 randomized to either the ICG group (endoscopic ICG injection at the tumour site and intraoperative imaging to guide dissection) or the control group (routine laparoscopic white-light imaging). All patients were treated with D3 dissection, and the primary outcome was the number of harvested lymph nodes at the D3 level.

RESULTS

Out of 210 patients screened, a total of 66 patients were enrolled and randomized. Patients in the two groups presented similar ages and clinical stages (ICG group versus control group, median age of 58.0 versus 58.5 years; stage III 36.4 per cent versus 36.4 per cent, whereas the rate of rectal cancer was 27.3 per cent versus 48.5 per cent respectively). ICG imaging was helpful for completely dissecting D3 lymph nodes and could identify a median of more than 2 (range 1-6) D3 lymph nodes neglected by routine laparoscopic white-light imaging during surgery. The median number of D3 lymph nodes harvested in the ICG group was significantly higher than that in the control group (7.0 versus 5.0, P = 0.003); however, there was no significant difference in the median numbers of positive D1, D2, and D3 lymph nodes between the two groups.

CONCLUSION

ICG is safe and feasible to guide D3 lymph node dissection and can increase the number of harvested D3 lymph nodes in patients with sigmoid and rectal cancer. Registration number: NCT04848311 (http://www.clinicaltrials.gov).

Prognostic value of elastic lamina staining in patients with stage III colon cancer

OBJECTIVE

The objectives of this study were to analyze the difference between the preoperative radiological and postoperative pathological stages of colorectal cancer (CRC) and explore the feasibility of elastic lamina invasion (ELI) as a prognostic marker for patients with stage III colon cancer.

METHODS

A total of 105 consecutive patients underwent radical surgery (R0 resection) for stage III colon cancer at the Cancer Hospital of China Medical University between January 2015 and December 2017. Clinicopathological features, including radiological stage and elastic lamina staining, were analyzed for prognostic significance in stage III colon cancer.

RESULTS

A total of 105 patients with stage III colon cancer who met the criteria and had complete data available were included. The median follow-up period of survivors was 41 months. During the follow-up period, 33 (31.4%) patients experienced recurrence after radical resection, and the 3-year disease-free survival (DFS) rate was 64.8%. The consistency between preoperative radiological and postoperative pathological staging was poor (κ = 0.232, P < 0.001). The accuracy of ≤ T2 stage diagnoses was 97.1% (102/105), that of T3 stage was 60.9% (64/105), that of T4a stage was 68.6% (72/105) and that of T4b stage was 91.4% (96/105). The DFS rate of T3 ELI (+) patients was significantly lower than that of both T3 ELI (-) patients (P = 0.000) and pT4a patients (P = 0.013). The DFS rate of T3 ELI (-) patients was significantly higher than that of pT4b patients (P=0.018). T3 ELI (+) (HR (Hazard ratio), 8.444 [95% CI, 1.736-41.067]; P = 0.008), T4b (HR, 57.727[95% CI, 5.547-600.754]; P = 0.001), N2 stage (HR, 10.629 [95% CI, 3.858-29.286]; P < 0.001), stage III (HR, 0.136 [95% CI, 0.31-0.589]; P = 0.008) and perineural invasion (PNI) (HR, 8.393 [95% CI, 2.094-33.637]; P = 0.003) were independent risk factors for postoperative recurrence of stage III colon cancer.

CONCLUSIONS

The consistency between preoperative radiological and postoperative pathological staging was poor, especially for tumors located in the ascending colon and descending colon. Elastic lamina staining is expected to become a stratified indicator of recurrence risk for patients with stage III colon cancer and a guide for individualized adjuvant chemotherapy, thus improving patient prognosis.

Impact of examined lymph node number on lymph node status and prognosis in FIGO stage IB-IIA cervical squamous cell carcinoma: A population-based study

Objective

We aimed to investigate the association of examined lymph node (ELN) number with lymph node status and long-term survival in FIGO stage IB-IIA cervical squamous cell carcinoma(CSCC) and to determine the minimum number of ELN associated with survival improvement.

Method

Data from the Surveillance, Epidemiology, and End Results Program (SEER) database of FIGO stage IB-IIA CSCC patients undergoing hysterectomy and pelvic lymphadenectomy in 2004-2016 were analyzed to explore the relationship between ELN number and lymph node status and overall survival (OS) by using the multivariable approach. The estimated probability of falsely identifying a patient as node-negative and the hazard ratios (HRs) for each ELN was fitted with a LOWESS smoother, and the structural breakpoints were determined. X-tile software was used to determine the optimal cutoff value for ELNs.

Results

A total of 2627 patients were analyzed. The optimal cutoff value of the ELN number was identified as 7 based on the results of X-tile software. The structural breakpoints according to the associations between the number of ELNs and the estimated risk of false-negative lymph node dissection and HRs for overall survival were 9 and 8, respectively. The multivariate analysis indicated that ELN number was an independent prognostic factor for OS, both as a continuous or categorical variable. To further explore the effect of more ELNs on survival, another cutoff value of 17 was chosen to compare the survival curves of patients. The multivariate-adjusted COX model showed that patients with ELN<8 had a significantly higher risk of death than those with ELN8-17 (HR=1.447, 95% CI =1.075-1.947, p=0.015), but there was no significant difference in overall survival between patients with ELN>17 and patients with ELN8-17 (HR=0.822, 95%CI =0.665-1.016, p=0.070).

Conclusion

A sufficient number of ELNs was associated with better long-term survival in FIGO stage IB-IIA CSCC. At least 8 ELNs need to be examined for prognostic stratification. Excessive lymph node dissection (ELN>17) may not confer additional survival benefits.

Is increasing nodal count associated with improved recurrence-free and overall survival following standard right hemicolectomy for colon cancer?

BACKGROUND AND OBJECTIVES

Increasing lymph node harvest for right-sided colon cancer is associated with improved overall survival (OS), but most relevant studies failed to report the extent of resection. We examined the association between increasing lymph node count with standard right hemicolectomy according to nodal status and prognostic outcomes in right-sided tumors.

METHODS

Retrospective analysis of prospectively collected clinical data from patients with proximal colonic adenocarcinomas (n = 1390) following right hemicolectomy. Associations between lymph node counts (0-12 vs. 13-15, 16-20, and >20) and recurrence-free survival (RFS) and OS were examined using multivariate Cox modeling adjusted for confounders.

RESULTS

We found no association between increasing nodal count and RFS, regardless of nodal status. In the absence of nodal metastases, increasing nodal count (16-20 and >20 vs. 0-12 nodes) was associated with 57% (95% confidence interval [CI]: 0.21-0.89) and 52% (95% CI: 0.24-0.95) improved OS, respectively. In the presence of nodal metastases, increasing nodal count was not associated with OS. Adjuvant chemotherapy did not modify this effect.

CONCLUSION

Increasing nodal count (>15 nodes) with right hemicolectomy was not associated with improved RFS. Improved OS was only found for node-negative tumors, casting some doubt on the benefits of resecting more lymph nodes in the presence of nodal metastases.

The efficiency of neoadjuvant chemotherapy in colon cancer with mismatch repair deficiency

Colon cancers with mismatch repair deficiency (dMMR) have specific clinicopathologic characteristics compared with mismatch repair proficiency (pMMR); however, the effect of MMR status on the efficiency of neoadjuvant chemotherapy (NCT) remains unclear. In our study, 439 dMMR and 26 pMMR colon cancer patients with or without NCT from 2010 to 2017 were retrospectively collected. Clinicopathological features, treatment response, and survival were compared between different groups. In the dMMR group, patients with NCT were likely to have higher CEA (abnormal CEA: 51.6% vs. 17.4%, p < 0.001), more multiorgan resection (38.7% vs. 16.8%, p = 0.006), and larger postoperative tumor diameter (7.26 vs. 6.21, p = 0.033) than those without NCT, but nearly half of cT4b patients who had NCT (42.9%, 9/21) avoid multiorgan resection. pT4 stage (HR, 14.97; 95% CI, 1.88-118.92; p = 0.010), number of positive lymph nodes (HR, 1.17; 95% CI, 1.09-1.26; p < 0.001), and tumor deposit (HR, 6.73; 95% CI, 2.08-21.74; p = 0.001) were independent prognosis factors of disease-free survival (DFS). For the advanced tumor subset, there is no significant difference between patients with or without NCT for OS (p = 0.13) and DFS (p = 0.11), although the survival rate of NCT was higher than non-NCT patients. Moreover, tumor regression grade was similar between dMMR and pMMR patients who had NCT. This study showed that NCT was more likely to be employed in dMMR patients with advanced tumors and may reduce the rate of multiorgan resection for cT4b dMMR patients. More large-scaled researches are needed to further explore if MMR status could predict the efficacy of neoadjuvant chemotherapy in patients with colon cancer.

Analysis of the risk factor of insufficient examined lymph nodes in stage II colon cancer from the perspective of stage migration: A retrospective study combined with external validation

BACKGROUND

An insufficient examined lymph node (ELN) count is a high risk factor for recurrence in patients with stage II colon cancer (CC). This study aimed to explore this risk factor in relation to stage migration.

METHODS

We screened 18,544 patients with stage II (pT3/4N0M0) and IIIB (pT3/4N1M0) CC diagnosed after radical resection from 2010 to 2015, using the National Cancer Institute Surveillance, Epidemiology, and End Results database. Propensity score matching was used to balance confounding factors for short-term and long-term survival, and survival analysis was carried out using the Kaplan-Meier method and log-rank test. The optimal cutoff for the number of ELNs in patients with stage II CC was determined using X-tile software. Independent prognostic factors were screened using Cox proportional hazards regression analysis. Finally, the results were externally validated in 318 patients with stage Ⅱ and ⅢB CC in our hospital from 2013 to 2015.

RESULTS

The best cutoff value for the number of ELNs in patients with stage II CC was 14. Multivariate analysis identified age, grade, histology, tumor size, T stage, N stage, ELN count, and chemotherapy as independent prognostic factors, and the Akaike and Bayesian information criteria values for the prognostic value of ELN count were relatively small. Patients with stage II CC with <15 ELNs had similar prognoses to patients with stage ⅢB CC (P = 0.939). Subgroup analysis and external validation yielded similar results.

CONCLUSION

Patients with stage II CC should be considered as stage ⅢB if the ELN count is insufficient.

Exploration of a modified stage for pN0 colon cancer patients

Exploring a modified stage (mStage) for pN0 colon cancer patients. 39,637 pN0 colon cancer patients were collected from the SEER database (2010–2015) (development cohort) and 455 pN0 colon cancer patients from the Second Affiliated Hospital of Harbin Medical University (2011–2015) (validation cohort). The optimal lymph nodes examined (LNE) stratification for cancer-specific survival (CSS) was obtained by X-tile software in the development cohort. LNE is combined with conventional T stage to form the mStage. The novel N stage was built based on the LNE (N0a: LNE ≥ 26, N0b: LNE = 11–25 and N0c: LNE ≤ 10). The mStage include mStageA (T1N0a, T1N0b, T1N0c and T2N0a), mStageB (T2N0b, T2N0c and T3N0a), mStageC (T3N0b), mStageD (T3N0c, T4aN0a and T4bN0a), mStageE (T4aN0b and T4bN0b) and mStageF (T4aN0c and T4bN0c). Cox regression model showed that mStage was an independent prognostic factor. AUC showed that the predictive accuracy of mStage was better than the conventional T stage for 5-year CSS in the development (0.700 vs. 0.678, P < 0.001) and validation cohort (0.649 vs. 0.603, P = 0.018). The C-index also showed that mStage had a superior model-fitting. Besides, calibration curves for 3-year and 5-year CSS revealed good consistencies between observed and predicted survival rates. For pN0 colon cancer patients, mStage might be superior to conventional T stage in predicting the prognosis.

Log odds of positive lymph nodes as a novel prognostic predictor for colorectal cancer: a systematic review and meta-analysis

BACKGROUND

Colorectal cancer (CRC) is the third most prevalent cancer in the world, which remains one of the leading causes of cancer-related deaths. Accurate prognosis prediction of CRC is pivotal to reduce the mortality and disease burden. Lymph node (LN) metastasis is one of the most commonly used criteria to predict prognosis in CRC patients. However, inaccurate surgical dissection and pathological evaluation may lead to inaccurate nodal staging, affecting the effectiveness of pathological N (pN) classification in survival prediction among patients with CRC. In this meta-analysis, we aimed to estimate the prognostic value of the log odds of positive lymph nodes (LODDS) in patients with CRC.

METHODS

PubMed, Medline, Embase, Web of Science and the Cochrane Library were systematically searched for relevant studies from inception to July 3, 2021. Statistical analyses were performed on Stata statistical software Version 16.0 software. To statistically assess the prognostic effects of LODDS, we extracted the hazard ratio (HR) and 95% confidence interval (CI) of overall survival (OS) and disease-free survival (DFS) from the included studies.

RESULTS

Ten eligible articles published in English involving 3523 cases were analyzed in this study. The results showed that LODDS1 and LODDS2 in CRC patients was correlated with poor OS compared with LODDS0 (LODDS1 vs. LODDS0: HR = 1.77, 95% CI (1.38, 2.28); LODDS2 vs. LODDS0: HR = 3.49, 95% CI (2.88, 4.23)). Meanwhile, LODDS1 and LODDS2 in CRC patients was correlated with poor DFS compared with LODDS0 (LODDS1 vs. LODDS0: HR = 1.82, 95% CI (1.23, 2.68); LODDS2 vs. LODDS0: HR =3.30, 95% CI (1.74, 6.27)).

CONCLUSIONS

The results demonstrated that the LODDS stage was associated with prognosis of CRC patients and could accurately predict the prognosis of patients with CRC.

ICG-Guided Lymphadenectomy during Surgery for Colon and Rectal Cancer-Interim Analysis of the GREENLIGHT Trial

Lymphadenectomy is crucial for an optimal oncologic resection of colon and rectal cancers. However, without a direct visualization, an aberrant route of lymph node (LN) diffusion might remain unresected. Indocyanine-green (ICG) lymphatic mapping permits a real-time LNs visualization. We designed the GREENLIGHT trial to explore in 100 patients undergoing robotic colorectal resection the clinical significance of a D3 ICG-guided lymphadenectomy. The primary endpoint was the number of patients in whom ICG changed the extent of lymphadenectomy. We report herein the interim analysis on the first 70 patients. After endoscopic ICG injection 24 h (n = 49) or 72 h (n = 21) ahead, 19, 20, and 31 patients underwent right colectomy, left colectomy, and anterior rectal resection. The extent of lymphadenectomy changed in 35 (50%) patients, mostly (29 (41.4%)) for the identification of LNs (median two) outside the standard draining basin. Identification of such LNs was less frequent in rectal tumors that had undergone chemoradiotherapy (26.3%) (p > 0.05). A non-significant correlation between time-to-ICG injection and identification of aberrant LNs was observed (48.9% at 24 h vs. 23.8% at 72 h). The presence of LN metastases did not affect a proper fluorescent mapping. These data indicate that ICG lymphatic mapping provides relevant information in 50% of patients, thus increasing the accuracy of potentially curative resections.

Postoperative Quality Assessment Score Can Select Patients with High Risk for Locoregional Recurrence in Colon Cancer

BACKGROUND

Monitoring surgical quality has been shown to reduce locoregional recurrence (LRR). We previously showed that the arterial stump length (ASL) after complete mesocolic excision (CME) is a reproducible quality instrument and correlates with the lymph-node (LN) yield. We hypothesized that generating an LRR prediction score by integrating the ASL would predict the risk of LRR after suboptimal surgery.

METHODS

502 patients with curative resections for stage I-III colon cancer were divided in two groups (CME vs. non-CME) and compared in terms of surgical data, ASL-derived parameters, pathological parameters, LRR and LRR-free survival. A prediction score was generated to stratify patients at high risk for LRR.

RESULTS

The ASL showed significantly higher values (50.77 mm ± 28.5 mm) with LRR vs. (45.59 mm ± 28.1 mm) without LRR (p < 0.001). Kaplan-Meier survival analysis showed a significant increase in LRR-free survival at 5.58 years when CME was performed (Group A: 81%), in contrast to non-CME surgery (Group B: 67.2%).

CONCLUSIONS

The prediction score placed 76.6% of patients with LRR in the high-risk category, with a strong predictive value. Patients with long vascular stumps and positive nodes could benefit from second surgery to complete the mesocolic excision.

Number of negative lymph nodes with a positive impact on survival of stage III colon cancer; a retrospective observation study for right side and left side colon

Background

The purpose was to examine the effect of negative lymph nodes (NLN) number on survival in stage III colon cancer. To reduce the interference of acute inflammation, we included patients with stage III colon cancer who had undergone elective surgery and excluded those who had tumor perforation, obstruction, ischemia, or massive tumor bleeding.

Methods

This retrospective cohort study included 2244 patients with stage III colon cancer between 1995 and 2016 at a single center. The effect of NLN on 5-year relapse-free survival (RFS), 5-year overall survival (OS), and comparison of multivariate factors was assessed according to tumor locations.

Results

The two optimal cutoff values of NLN for proximal and distal colon, namely 27 and 12, were determined by plotting the time-dependent receiver operating characteristic curve. Overall, 499 of 891 and 1020 of 1353 patients with right-side and left-side colon cancer, respectively, had high NLN. In right-side colon cancer, patients with high NLN (≥ 27) had superior OS (74.9% vs. 62.7%, P <  0.001) and RFS (75.0% vs. 61.9%, P <  0.001) than did those with low NLN. Moreover, in left-side colon cancer, patients with high NLN (≥12) experienced significantly superior OS (80.8% vs. 68.6%, P <  0.001) and RFS (77.3% vs. 66.2%, P <  0.001) than did those with low NLN. Among the different subgroups of stage III colon cancer, the high NLN group showed significantly superior RFS and OS in stage IIIB (RFS: 77.0% vs. 68.0%, P = 0.001; OS: 78.6% vs. 67.9%, P <  0.001) and IIIC (RFS: 58.2% vs. 44.1%, P = 0.001; OS: 65.7% vs. 51.1%, P <  0.001) colon cancer. However, in stage IIIA colon cancer, high NLN only showed survival benefit in OS (91.5% vs. 89.8%, P = 0.041). Multivariate analyses confirmed that high NLN, high carcinoembryonic antigen (≥ 5 ng/mL) level, and stage IIIC status are three independent prognostic factors in both the proximal and distal colon.

Conclusions

NLN is a crucial prognostic factor for stage III colon cancer in various tumor locations or in the subgroups of stage III disease. In advanced stage III colon cancer, the importance of NLN and its role in anti-cancer immune response could be highlighted.

Establishment and Validation of a Nomogram Based on Negative Lymph Nodes to Predict Survival in Postoperative Patients with non-Small Cell Lung Cancer

Background: The importance of the negative lymph node (NLN) count has recently attracted attention. This study aimed to determine the prognostic value of NLN count in patients with non-small cell lung cancer (NSCLC) after radical surgery by constructing NLN-based prognostic models. Methods: This study included 33 756 patients pooled from the case listing session of the US Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2015 and 545 patients collected from The First Affiliated Hospital of Shandong First Medical University between 2012 and 2016. X-tile software was used to calculate the optimal cutoff value for the NLN count. The associated clinical factors were determined using univariate and multivariate Cox analyses. Nomograms were developed using the SEER database and validated using hospital data. Results: The training cohort was divided into high and low NLN count subgroups based on the cancer-specific survival (CSS) and overall survival (OS), respectively. Multivariate analysis showed that NLN count was an independent prognostic factor, and the high NLN count subgroup had better CSS and OS than those of the low NLN count subgroup (HR = 0.632, 95% CI 0.551-0.724, P < .001 for CSS and HR = 0.641, 95% CI 0.571-0.720, P < .001 for OS). Nomograms were established, exhibiting good discrimination ability with a C-index of 0.789 (95% CI 0.778 −0.798) for CSS and 0.704 (95% CI, 0.694 −0.714) for OS. The calibration plots of the validation cohorts showed optimal agreement with the training cohort, with a C-index of 0.681 (95% CI 0.646 −0.716) for CSS and 0.645 (95% CI 0.614 −0.676) for OS. Conclusions: NLN count is a strong prognostic factor for OS and CSS in NSCLC patients and the prognostic model provides a useful risk stratification for NSCLC patients when applied to clinical practice.

A Postsurgical Prognostic Nomogram for Locally Advanced Rectosigmoid Cancer to Assist in Patient Selection for Adjuvant Chemotherapy

Background

The perioperative treatment model for locally advanced rectosigmoid junction cancer (LARSC) has not been finalized; whether this model should refer to the treatment model for rectal cancer remains controversial.

Methods

We screened 10,188 patients with stage II/III rectosigmoid junction adenocarcinoma who underwent surgery between 2004 and 2016 from the National Cancer Institute Surveillance, Epidemiology, and End Results database. Among them, 4,960 did not receive adjuvant chemotherapy, while 5,228 did receive adjuvant chemotherapy. Propensity score matching was used to balance the two groups for confounding factors, and the Kaplan-Meier method and log-rank test were used for survival analysis. Cox proportional hazards regression analysis was used to identify independent prognostic factors and build a predictive nomogram of survival for LARSC. X-tile software was used to divide the patients into three groups (low, medium, and high) according to their risk scores. 726 patients in our hospital were included for external validation.

Results

LARSC patients did not show a benefit from neoadjuvant radiotherapy (P>0.05). After further excluding patients who received neoadjuvant radiotherapy, multivariate analysis found that age, grade, tumor size, T stage, and log odds of positive lymph nodes were independent prognostic factors for patients without adjuvant chemotherapy and were included in the nomogram. The C-index of the model was 0.690 (95% confidence interval: 0.668–0.712). We divided the patients into low, moderate, and high risk subgroups based on prediction scores of the nomogram. We found that adjuvant chemotherapy did not improve the prognosis of low risk patients, while moderate and high risk patients benefited from adjuvant therapy. External validation data found that moderate, and high risk patients also benefited from AT.

Conclusion

Direct surgery plus adjuvant chemotherapy may be the best perioperative treatment for LARSC. Moreover, adjuvant chemotherapy is only recommended for moderate and high risk patients as it did not benefit low risk patients.

Comparison of Four Lymph Node Stage Methods for Predicting the Prognosis of Distal Cholangiocarcinoma Patients After Surgery

Background

The metastatic status of regional lymph nodes is an effective risk factor for the prognosis of distal cholangiocarcinoma (dCCA). But existing lymph node staging is not accurate enough and is susceptible to interference. This study aims to explore the predictive ability of the log odds of positive lymph nodes (LODDS) staging system of dCCA compared with existing lymph node staging systems.

Methods

A total of 928 dCCA patients were selected from the Surveillance, Epidemiology, and End Results (SEER) database as the training cohort, and 207 dCCA patients from West China Hospital who underwent surgery were reviewed as the validation cohort. The least absolute shrinkage and selection operator (LASSO) and multivariate Cox regression were conducted to identify the most meaningful factors relevant to prognosis. The performance of four lymph node stage systems was compared by a model-based approach.

Result

Age at diagnosis, pathological grade, American Joint Committee on Cancer (AJCC) tumor 7th T stage, tumor size, radiotherapy, chemotherapy, and lymph node stage system were independent prognostic factors. The model with the LODDS system had a better model fit with the highest C-index (0.679) and 1-/3-/5- area under the receiver operating characteristic curve (AUC) (0.739/0.671/0.658) as well as the lowest Akaike information criterion (AIC) (5,020.52). External validation results from 207 dCCA patients showed a C-index of 0.647 and 1-/3-/5-AUC of 0.740/0.683/0.589. Compared with the lymph node ratio (LNR), AJCC 8th N system, and 7th N system, the 5-year net reclassification improvement (NRI) of the LODDS system was 0.030 (95% CI: -0.079 to 0.147), 0.042 (95% CI: -0.062 to 0.139), and 0.040 (95% CI: -0.057 to 0.146), respectively. The integrated discrimination improvement (IDI) of LODDS improved compared with the LNR model (0.016; 95% CI: -0.001 to 0.036), AJCC 8th N system (0.020; 95% CI: 0.003-0.037), and AJCC 7th N system (0.019; 95% CI: 0.002-0.036). Decision curve analysis (DCA) also shows a greater net benefit of LODDS. In lymph node-negative patients, LODDS reveals a positive linear relationship with the hazard ratio (HR). The stage capacity of LODDS in a subgroup analysis stratified by examined lymph node number (ELNN) was consistent.

Conclusions

The LODDS lymph node stage system has superior predictive performance as compared with the LNR, AJCC 7th, and 8th lymph node stage systems. Meanwhile, LODDS has a more detailed staging ability and good stability.

Combination of the ratio between metastatic and harvested lymph nodes and negative lymph node count as a prognostic indicator in advanced gastric cancer: a retrospective cohort study

Background

The aim of our study was to examine the impact of the combination of the ratio between metastatic and harvested lymph nodes (RML) and negative lymph node (NLN) count on overall survival (OS) in patients with advanced gastric cancer (GC).

Methods

The clinicopathological data of 2,952 advanced GC patients who received curative resection between 1994 and 2015 were collected. They were divided into four groups according to the RML: 0, 0-0.1, 0.1-0.4, and >0.4. We distinguished survival differences through Kaplan-Meier analysis among the subgroups to investigate the impacts of the RML on OS in advanced GC patients. OS was examined according to clinicopathological variables. Spearman's correlation coefficient was used to assess the relationships between the RML and metastatic lymph node (MLN) count and NLN count.

Results

A total of 1,182 patients were enrolled into the study. The median follow-up time was 39 months (interquartile range 20 to 68 months). The 5-year OS rate of all 1,182 GC patients was 54.4%. Kaplan-Meier survival analysis showed that the median OS declined significantly with increasing RML (5-year survival rate 81.2% vs. 69.1% vs. 42.8% vs. 13.1%, P<0.001). As the NLN count increased, the survival rate of GC patients increased (5-year survival rate 12.8% vs. 25.2% vs. 60.2%, P<0.05). The RML, not NLN count, was identified as an independent factor for OS (P<0.001) through multivariate analysis. Spearman correlation analysis suggested that the RML was positively correlated with the number of MLNs (ρ=0.973, P<0.001) and inversely associated with the NLN count (ρ=-0.513, P<0.001).

Conclusions

The RML is an independent prognostic predictor of OS in advanced GC patients, and the NLN count may serve as a supplementary strategy for the present tumor-node-metastasis (TNM) classification to further improve the prognostic prediction efficiency. The combination of the RML and NLN count should be an important predictor for current clinical applications.

Stage II colon cancer staging using the number of retrieved lymph nodes may be superior to current TNM staging for prognosis stratification: the Japanese study group for postoperative follow-up of colorectal cancer

PURPOSE

The purpose of the study was to compare staging of stage II colon cancer using the number of retrieved lymph nodes (RN) to current TNM staging for stratification of prognosis.

METHODS

The subjects were 6307 patients with stage II colon cancer who underwent curative resection at 24 Japanese institutions. The cutoff for the number of RN was established using Akaike information criterion (AIC) values for relapse-free survival (RFS) and overall survival (OS). Comparison of survival using TNM and T + RN (TRN) staging was performed using a Cox proportional hazards regression model.

RESULTS

AIC was lowest for 14 retrieved lymph nodes for RFS and OS. This number was used as the cutoff. In multivariate analysis, age (≥ 69), male gender, V1, CEA (> 5), pT (T4a, T4b), and RN-L were independent factors associated with RFS and OS. Six combinations of pT and RN categories were used to establish three subgroups: TRN stages IIA, IIB, and IIC. The 5-year RFS was 83.9%, 72.3%, and 71.8% in TNM stages IIA, IIB, and IIC; and 86.0%, 76.9%, and 60.3% in TRN stages IIA, IIB, and IIC. The 5-year OS was 90.0%, 81.3%, and 82.6% for the TNM stages; and 91.6%, 85.0%, and 71.9% for the TRN stages. The AIC for RFS was lower for TRN (22,318.2) than for TNM (22,390.6), and that for OS was also lower for TRN (16,285.3) than for TNM (16,355.1).

CONCLUSION

Stage II colon cancer staging using the number of retrieved lymph nodes may be superior to current TNM staging for prognosis stratification.

Validation of a prognostic model including the number of harvested lymph-nodes in the setting of non-small cell lung cancer patients undergoing curative resection: a multicentre analysis

BACKGROUND

The prognostic role of the extension of lymphadenectomy in Non-small-cell lung cancer is still a debated and intriguing issue. The aim of this study is to validate a prognostic score including the number of resected lymph-nodes previously reported using a large multicentre dataset.

METHODS

From 01/2002 to 12/2012, data on 4858 NSCLC patients undergoing curative-intent surgery in six Institutions were retrospectively reviewed. To test the discriminative ability of the model, composed of a panel of high-risk,pathologic stage, nodal status, age, number of Resected Nodes and intermediate risk factors (gender, grading, histology), was determined. The Kaplan-Meier method was used to estimate Overall(OS), Cancer-Specific(CSS) and Disease-free Survival(DFS) curves, and the log rank test was adopted to evaluate the differences between groups.

RESULTS

Pathological stages were: I in 46,5%, II in 24,1%, III in 27,8% and IV in 1,6% of cases. Overall, 5-years OS, CSS and DFS were 54,6%, 76,7% and 44,8%, respectively. Stratifying the sample of 3948 patients with complete data into Low-risk (LR, #107), Intermediate-risk (IR, #1268) and High-Risk (HR, #2573) groups, the optimal prognostic discrimination power of this score was confirmed (C-statistics: 0.71, 95%CI 69-73). Specifically in LR, IR and HR, 5-years OS was 83,5%, 66,4% and 46,2% (p<0.0001), 5y-CSS was 95,8%, 89% and 69% (p<0.0001), and 5y-DFS was 74,7%, 59.1% and 35,5% (p<0.0001), respectively CONCLUSIONS: Our study confirms the optimal prognostic discrimination power of the previous prognostic model including the number of harvested nodes.

Optimal examined lymph node count in node-negative colon cancer should be determined

Background: We aimed to investigate the association between optimal examined lymph node (ELNs) and overall survival to determine the optimal cutoff point. Methods: Cox models and locally weighted scatterplot smoothing were used to fit hazard ratios and explore an optimal cutoff point based on the Chow test. Results: Overall survival increased significantly with the corresponding increase in the number of ELNs after adjusting for covariates. In Chow's test, the optimal cutoff point for node-negative colon cancer was 15, which was validated in both cohorts after controlling for confounders (Surveillance, Epidemiology, and End Results database: hazard ratio: 0.701, p < 0.001; single-center: HR: 0.563, p = 0.031). Conclusions: We conservatively suggest that the optimal number of ELNs for prognostic stratification is 15 in node-negative colon cancer.

Advances in radiological staging of colorectal cancer

The role of imaging in clinically staging colorectal cancer has grown substantially in the 21^st century with more widespread availability of multi-row detector computed tomography (CT), high-resolution magnetic resonance imaging (MRI) with diffusion weighted imaging (DWI), and integrated positron-emission tomography (PET)/CT. In contrast to staging many other cancers, increasing colorectal cancer stage does not highly correlate with survival. As has been the case previously, clinical practice incorporates advances in staging and it is used to guide therapy before adoption into international staging guidelines. Emerging imaging techniques show promise to become part of future staging standards.

Horizontal spread of pericolic lymph node metastasis as a prognostic factor for recurrence in Stage III colorectal cancer

AIM

Main lymph node (LN) metastasis dissected with a high vascular tie at the root of the feeding artery is a poor prognostic factor in colorectal cancer (CRC). However, the effects of horizontal spread on recurrence after curative resection remain unclear. The purpose of this study is to evaluate the relationship between the horizontal spread of LN metastasis and recurrence in CRC.

METHOD

In this retrospective study, 189 CRC patients (98 men, 91 women) who underwent curative resection at our hospital from 2003 to 2018 and had only pericolic LN metastasis were divided into two groups: patients with LN metastasis beside the tumour only (T group, n = 121) and those with LN metastasis with horizontal spread (S group, n = 68) (mean follow-up period 50.9 ± 34.1 months). The primary outcome was recurrence-free survival (RFS). We investigated the correlation between clinicopathological background factors and recurrence using Cox regression analysis.

RESULTS

Fewer than three LN metastases (N1) were found in 157 patients (107 T group, 50 S group), and four or more metastases (N2a) were found in 32 patients (14 T group, 18 S group). Univariate analyses revealed significantly shorter RFS in the S group [hazard ratio (HR) 1.95, 95% CI 1.07-3.55; p = 0.03). Multivariate analyses revealed that horizontal spread is an independent risk factor for recurrence (HR 1.95, 95% CI 1.05-3.68; p = 0.03).

CONCLUSION

Although further investigation is needed, horizontal spread of LN metastasis is a prognostic factor for recurrence in Stage III CRC.

[Metastasis of the right colon mucinous adenocarcinoma to aortocaval and retropancreatic space: case report and literature review]

Metastases of the right colon cancer to extra-regional lymph nodes are rarely observed. Available literature data cannot be a reliable guide to choose the optimal treatment strategy. Indeed, excision of extra-regional lymph nodes is a rare experience and its results are poorly represented. According to our clinical experience, surgical intervention following comprehensive examination may be radical in patients with right colon cancer if distant metastases are absent. Resection of extra-regional lymph nodes can be safely performed in these cases. We report a patient with the right colon cancer and lesion of extra-regional lymph nodes behind the pancreatic head, paracaval and paraaortic space, hepatoduodenal ligament. Standard laparoscopic right-sided hemicolectomy with D-3 lymph node dissection was accompanied by resection of a conglomerate of nodal metastases behind the pancreatic head and superficial resection of the pancreas. Extra-regional lymph node excision is a reasonable option for colon mucinous adenocarcinoma stage I-III. However, comprehensive preoperative examination is required. Technical difficulty of extra-regional lymph node excision it is not the reason for limitation of surgical intervention. However, safe and total resection requires an adequate surgical approach.

Impact of the extent of negative lymph nodes in gastric adenocarcinoma undergoing primary surgical resection: An institutional report

BACKGROUND

Sub-total/total gastrectomy with lymph node dissection (LND) remains an effective therapeutic strategy for resectable gastric adenocarcinomas (GACs). Despite the prognostic significance of positive lymph nodes (PLNs) defined in N-status, few have appraised the impacts of negative lymph nodes (NLNs) and the percentage of NLN (=number of NLNs/number of total lymph nodes [TLNs], %), as well as the extent of TLNs to be dissected in GACs.

METHODS

We retrospectively analyzed 62 GAC patients (mean age of 67.1 years; 41 men) undergoing primary sub-total/total gastrectomy from a single institute. Candidate variables, including the number of NLNs (≤9 and >9) and the percentage of NLN (≤37.5, 37.5-80.6 and >80.6, %), were evaluated to determine their prognostic impacts and hazard ratios (HRs).

RESULTS

Under the multivariate Cox proportional-hazards regression model, tumor length exceeding 4 cm (p = 0.017; HR = 2.828), perineural invasion (p = 0.037; HR = 3.182), and lower percentage of NLN (p = 0.016 and p = 0.060; HRs = 1.000, 0.327, and 0.333 for subgroups ≤37.5, 37.5-80.6, and >80.6, respectively) were three independent predictors with elevated HRs for poor prognosis. GAC patients with the percentage of NLN > 80.6 were highly related to those with NLNs > 9 (p < 0.001), and GAC patients with NLNs > 9 were highly related to those with TLNs > 15 (p < 0.001). For all 62 GAC or 42 N(+) GAC patients, those who underwent LND with TLNs>15 tended to have more PLNs (p = 0.018, p = 0.003) and more NLNs (p < 0.001, p = 0.029) than did those with TLNs ≤ 15. Among the 42 GAC patients with TLNs > 15, a lower percentage of NLN (p = 0.026 and p = 0.015; HRs = 1.000, 0.272, and 0.180 for subgroups ≤37.5, 37.5-80.6, and >80.6, respectively) remained an independent predictor of poor prognosis.

CONCLUSION

The percentage of NLN could predict the prognosis of GAC patients properly. However, an accurate percentage of NLN needs a minimal requirement of TLNs > 15 to detect an adequate number of PLNs and sufficient number of NLNs.

Does transverse colon cancer spread to the extramesocolic lymph node stations?

BACKGROUND

Transverse colon cancers show behavioral differences in terms of the involvement of extramesocolic lymph nodes since they are closely related to all three embryological planes. These tumors have also been observed in the gastroepiploic-omental (GEOM) region, outside their usual regional areas. We will evaluate this new metastatic route in our own cases.

METHODS

Thirty-four patients (16 female, 18 male) that presented to our clinic with hepatic flexure, transverse colon, and splenic flexure cancer between October 2011 and May 2017 were included in the study. Type of surgery, histopathology, and factors causing metastasis, morbidity, and mortality were evaluated.

RESULTS

Cancer was located in the transverse colon in 20 patients (58.8%), hepatic flexure in 10 (29.4%), and splenic flexure in four (11.7%). Lymph node positivity in the GEOM region was present in four patients: in the infrapyloric region and pancreatic head, close to the hepatic flexure in three patients; and the midline of GEOM, close to the inferior body of the pancreas in one patient. Perineural invasion (p < .05) and N stage (p < .05) were associated with GEOM region metastasis. Tumor localization and age significantly increased pleural effusion.

CONCLUSIONS

In transverse colon and both flexural tumors, we recommend planning the surgery according to the localization of the tumor and including the GEOM, infrapyloric and infrapancreatic areas. It is possible to discuss whether to perform extended excision for all or only selected patients. The best approach seems to be to evaluate the co-factors to manage these patients.

Impact of D3 lymph node dissection on upstaging and short-term survival in clinical stage I right-sided colon cancer

BACKGROUND

D3 lymph node dissection is becoming the standard procedure for the treatment of advanced right colon cancer and has shown increasing evidence of its oncologic benefit. However, a clear indication for its application is lacking and data on this topic is unsatisfactory. Thus, the necessity for D3 lymph node dissection in clinical stage I right colon cancer remains controversial.

METHODS

We retrospectively analyzed data from clinical stage I right colon cancer patients who underwent radical surgery at three hospitals of Korea university medical center between January 2015 and June 2018. We compared surgical complications and short-term oncologic outcomes between D2 and D3 lymph node dissections in these patients.

RESULTS

Among 512 patients, 122 (23.8%) were clinical stage I. Of these, 88 and 34 patients received D2 and D3 lymph node dissection, respectively. There were no statistically significant differences in clinicopathologic variables and surgical outcomes between the two groups. Upstaging occurred in 16 patients (47.1%) in the D3 group and 23 patients (26.1%) in the D2 group. There were four recurrences in the D2 group but no recurrence in the D3 group. Log-rank tests showed no statistically significant difference in disease-free survival rates between the two groups (p = 0.210).

CONCLUSION

There was no significant difference in disease-free survival rates between D2 and D3 lymph node dissection in clinical stage I right colon cancer patients. However, recurrence occurred in the D2 group. Efforts to improve the accuracy of clinical staging are required and more studies with better quality are needed.

D3-lymphadenectomy enhances oncological clearance in patients with right colon cancer. Results of a meta-analysis

BACKGROUND

D3-Lymphadenectomy, together with complete mesocolic excision (CME), were introduced to provide oncological results after right colon cancer. The aim of this systematic review with meta-analysis was to assess the short and long-term outcomes of right-sided hemicolectomy with CME + D3 as compared with classic right hemicolectomy. Secondary aims included the prevalence of D3-metastasis and skip metastasis when performing CME + D3.

MATERIAL AND METHODS

A systematic review with meta-analysis was conducted, according to PRISMA methodology.

RESULTS

29 studies were enrolled (2592 patients). No differences were accounted in morbidity variables associated with the measured techniques. CME + D3 was significantly associated with a greater distance between the tumour and the closest vascular tie, a longer colonic resection, a wider resection of mesentery and an increased number of harvested lymph nodes. Regarding to long-terms outcomes, we found a significant decrease in local recurrence in patients undergoing CME + D3 (HR:0.17) and a significant improvement in 3-year and 5-year overall survival rates (HR:0.53 vs. HR:0.57, respectively), as well as an improving survival in patients with stage II and III disease. Overall prevalence of patients with lymphatic metastases in D3-territory was of 8.6% and 2.2% of skip metastases.

CONCLUSIONS

CME + D3 is a feasible surgical procedure that allows to obtain specimens with higher quality oncological resection, without greater associated morbidity, thus improving survival in patients with stage II and III right colon cancer.

Prognostic Impact of Lymph Node Ratio in Patients Undergoing Preoperative Chemoradiotherapy Followed by Curative Resection for Locally Advanced Rectal Cancer

BACKGROUND/AIM

To analyze the prognostic significance of nodal status in patients undergoing preoperative chemoradiotherapy (CRT) followed by curative resection for locally advanced rectal cancer.

PATIENTS AND METHODS

Between 2000 and 2015, 80 consecutive patients with rectal cancer underwent preoperative CRT followed by curative resection. The lymph node ratio (LNR) was defined as the number of positive lymph nodes (LNs) divided by the examined LNs, and log odds of positive lymph nodes (LODDS) was the log of the ratio between positive and negative LNs. The prognostic value of these indicators was evaluated in terms of overall (OS) and disease-free (DFS) survival.

RESULTS

The median follow-up period for patients overall was 59 months (range=11-190 months). The median number of examined LNs and number of positive LNs were 10 (range=1-29) and 2 (range=1-27), respectively, and the median LNR and LODDS values were 0.0 (range=0.0-0.96) and -1.0 (range=-1.7-1.3), respectively. The 5-year OS and DFS were 83% and 64%, respectively. In multivariate analysis, LNR was an independent prognostic factor in terms OS (p=0.041) but not for DFS (p=0.075). LODDS was not significantly associated with OS or DFS. In patients with clinical stage III rectal cancer, LNR was significantly associated with OS and DFS when the number of evaluated LNs was greater than 12 (p=0.038 for OS, p=0.006 for DFS).

CONCLUSION

Our study suggests that LNR is a more effective prognostic factor than LODDS in terms of predicting survival. LNR was a significant predictor for survival for patients with clinical stage III rectal cancer with >12 harvested LNs.

Fluorescence-guided D3 lymphadenectomy in robotic right colectomy with complete mesocolic excision

BACKGROUND

In robotic right hemicolectomy for cancer, appropriate lymphadenectomy is essential. Visualization of draining lymph nodes and blood flow with near-infrared (NIR) fluorescence DaVinci^® imaging system is a recent development. We present the technique of robotic right colectomy with complete mesocolic excision (CME) and D3 lymphadenectomy using Indocyanine Green (ICG) endoscopic submucosal injection to intraoperatively identify tumour lymphatic basin.

METHODS

The day before surgery, in patients scheduled for robotic right colectomy an endoscopic submucosal injection of 3 mg of ICG solution around the tumor is realized. Robotic right hemicolectomy is performed with suprapubic trocars layout and "bottom to up dissection", realizing a CME with central vessel ligation and D3 lymphadenectomy. Site of primary tumor and lymphatic basin are visible with the FireflyTM camera modality.

RESULTS

From July 2016 to July 2020, 85 patients received a robotic right colectomy with CME and D3 lymphadenectomy. In 50 patients, ICG submucosal injection was performed: visualisation of the site of primary tumour and of LN in the D3 area was possible in all cases; in 17/50 patients (34%), LN out from anatomical lymphatic basin were identified. No side effects were observed.

CONCLUSIONS

In this series, submucosal ICG injection showed to be feasible and safe. The accuracy in identification of D3 lymphatic basin was high, thus permitting an image-guided radical lymphadenectomy. Fluorescent technology represents an interesting innovation to ameliorate surgery of colon cancer.

Construction and Validation of a Nomogram Based on the Log Odds of Positive Lymph Nodes to Predict the Prognosis of Medullary Thyroid Carcinoma After Surgery

BACKGROUND

This study aimed to explore the prognostic impact that the log odds of positive lymph nodes (LODDS) has on medullary thyroid cancer (MTC) and to develop a nomogram incorporating LODDS to predict the cancer-specific survival (CSS) of MTC.

METHODS

Data from 1110 MTC patients after total thyroidectomy were collected from the Surveillance, Epidemiology, and End Results (SEER) database and divided into training and validation cohorts. The prognostic efficiency of N status from the American Joint Committee on Cancer (AJCC) staging system, the number of positive lymph nodes (PLNN), and LODDS were compared using the Harrell concordance index (C-index), the Akaike information criterion (AIC), and area under the receiver operating characteristic (ROC) curve (AUC). A multivariate Cox analysis was performed to determine the independent prognostic factors, and a nomogram based on LODDS was constructed. The nomogram's performance was assessed with the C-index, AUC, calibration curves, and decision curve analysis (DCA).

RESULTS

Among the three lymph node (LN) staging systems, LODDS showed the highest accuracy in predicting CSS for MTC. In the training cohort, the C-index of the LODDS-based nomogram was 0.895. The AUCs were 0.949, 0.917, 0.925, and 0.901 for predicting 1-, 3-, 5- and 10-year CSS, respectively. The calibration plots and DCA showed the superior clinical applicability of the nomogram. These results were verified in the validation cohort.

CONCLUSIONS

As an independent prognostic factor for MTC, LODDS demonstrated superior prognostic efficiency over N status and PLNN. This LODDS-based nomogram yielded better performance than the AJCC tumor-node-metastasis (TNM) staging system in predicting CSS after surgery for MTC.

Optimal Range of Lymphadenectomy in Pathological Stage T1 and T2 Esophageal Squamous Cell Carcinoma

BACKGROUND

Lymph node metastasis is a primary contributor to tumor progression in esophageal squamous cell carcinoma (ESCC), and the optimal extent of lymphadenectomy during esophagectomy remains controversial. This study aimed to investigate the appropriate number of lymph nodes to be dissected in pT1-2Nany stage ESCC to achieve the best prognosis and avoid missing positive lymph nodes (PLNs).

METHODS

A total of 497 patients with pT1 to pT2 esophageal cancer from two institutions were retrospectively analyzed and their surgical and pathological records were critically reviewed. Stepwise analyses were conducted by calculating a serial of hazard ratios and odd ratios to determine the optimal range of lymphadenectomy for overall survival (OS).

RESULTS

The best survival outcome can be obtained when the number of lymph node examined (NLNE) is 10-18 in pT1N0 ESCC, while the NLNE should exceed 24 in pT2N0 diseases. In patients with pT1-2Nany and pT2Nany ESCC, resection of 15-25 and 24-37 lymph nodes, respectively, could provide significant added value for identifying positive nodal metastasis. When the NLNE exceeds this appropriate range, resection of extra lymph node is not helpful to improve the probability of finding PLNs.

CONCLUSIONS

For ESCC patients undergoing radical esophagectomy, the optimal extent of lymphadenectomy is 15-25 for pT1Nany disease and 24-37 for pT2Nany disease.

Retrospective survival analysis of stage II-III rectal cancer: tumour regression grade, grading and lymphovascular invasion are the only predictors

BACKGROUND

Tumour regression grade is gaining interest as a prognostic factor of patients undergoing neoadjuvant chemoradiotherapy and surgery for locally advanced rectal cancer.

METHODS

A series of 68 consecutive patients with locally advanced rectal cancer treated by neoadjuvant chemoradiotherapy and surgery between 2010 and 2016 was retrospectively studied. The impact on disease-free survival (DFS) and overall survival (OS) of several criteria was analysed. Univariate analysis was performed through Kaplan-Meier statistics. Multivariate analysis was performed through Cox regression model. Using criteria found to be related to long-term outcomes, a predictive model of patient's OS was calculated.

RESULTS

Poor tumour regression grade - TRG3 (P = 0.010), poor grading - G3 (P = 0.001) and lymphovascular invasion (LVI; P = 0.030) were associated with short OS at univariate analysis. OS was associated with TRG3 and G3 at multivariate analysis (P = 0.016 and P = 0.027, respectively). DFS was associated with LVI (P = 0.001), G3 tumours (P = 0.046) and TRG3 (P = 0.045) at univariate analysis. At multivariate analysis, only LVI was associated with DFS (P = 0.041). A score, pondering the impact of three parameters (2 points for TRG3, 2 for G3 and 1 for LVI), was created and resulted to predict patient OS (P = 0.008), ranging from 94.5 months (score = 0-1) to 32 months (score = 3-5).

CONCLUSION

TRG3 and G3 were associated with poor OS, and LVI was the most significant predictor of DFS. An easy-to-use score may allow for a more accurate prediction of OS.

Negative lymph node count is an independent prognostic factor for female patients with node positive breast cancer

Background

Negative lymph node (NLN) count has been reported to associate with the prognosis of various cancers. This study aims to reveal the prognostic value of NLN count in breast cancer.

Methods

Clinical characteristics of patients were collected from the Surveillance, Epidemiology, and End Results (SEER) database. The X-tile program was used to determine the optimal cutoffs for NLN count. Univariate and multivariate analysis were used to assess the risk factors for breast cancer-specific survival (BCSS).

Results

The X-tile program identified that cutoff value of 2 and 10 could divide the patients into high, middle and low risk subgroups. According to multivariate analysis, patients with NLN count ≤1, over 60 years old, being black, higher tumor grade, higher T or N stage, negative hormone receptor, no radiotherapy or no chemotherapy would more likely suffer poor survival outcome. Subgroup analysis showed that NLN count could still predict survival independently.

Conclusions

NLN count is a potentially effective predictor of breast cancer and is a good supplement for N stage and TNM stage. Combining NLN count with other prognostic factors will be a better predictor for the survival of breast cancer patients.

Prognostic significance of lymph node yield in patients with synchronous colorectal carcinomas

BACKGROUND

The National Comprehensive Cancer Network (NCCN) guidelines recommend examination of a minimum of 12 lymph nodes (LNs) for accurate staging of a single case of colorectal cancer. However, the guidelines do not support the examination of LNs in synchronous colorectal carcinoma (SCC). This study aimed to investigate the association between lymph node yield and the prognosis of SCC patients.

METHODS

Synchronous colorectal carcinoma patients were selected from the Surveillance, Epidemiology, and End Results (SEER) database over a 10-year interval (2004 to 2013). Systematic dichotomization for optimal cut-off point identification was performed using X-tile. The baseline for the two LNs groups generated was balanced using the propensity score matching (PSM) method.

RESULTS

A total of 4616 patients met the inclusion criteria. The cut-off number for lymph node retrieved from a single patient was 15 and 12 for the first- and second-time diagnosis of SCC, respectively. Age, T category, N category, tumor grade, tumor site, tumor size, and radiation sequence were not balanced in the two groups. After adjusting the baseline in the two groups, the same results were observed. Age, T category, N category, tumor site had a partial effect on lymph node yield. There might be some biological characteristics of the tumor that influence lymph node yield.

CONCLUSIONS

Retrieval of fewer than 15 LNs at the first time of SCC diagnosis indicates worse SCC prognosis. Because factors such as manner of surgical examination influence SCC prognosis, specimens should be preserved for at least 6 months to enable reevaluation should there be a need. Irb: IRB approval is not required because the SEER data are freely accessible.

Impact of examined lymph node count on staging and long-term survival of patients with node-negative stage III gastric cancer: a retrospective study using a Chinese multi-institutional registry with Surveillance, Epidemiology, and End Results (SEER) data validation

Background

Accumulating evidence has confirmed the potential prognostic value of examined lymph nodes (ELNs) in patients with gastric cancer (GC). However, there is currently no consensus on the threshold ELN number for predicting both stage migration and long-term survival, especially in patients with stage III GC. This study aimed to validate the need to increase the ELN count to improve its prognostic accuracy in node-negative patients with stage III GC after curative gastrectomy.

Methods

This retrospective, population-based study analyzed the clinical data of 84 patients with node-negative stage III GC from three high-volume institutions in China and 196 cases from the Surveillance, Epidemiology and End Results (SEER) program registry. The optimal number of ELNs was determined by receiver operating characteristic (ROC) curve analysis. Clinicopathological characteristics significantly related to survival were evaluated using the Kaplan-Meier method and Cox proportional hazards analysis. Stratified analyses were adopted to assess the prognostic predictive ability of the identified optimal number of ELNs in different populations. Survival differences among subgroups were analyzed to assess the impact of ELN count on stage migration according to overall survival (OS) among GC patients.

Results

The optimal number of ELNs was >31 according to ROC analysis of patients with node-negative stage III GC who underwent gastrectomy. Multivariate analysis identified ELNs as an independent predictor of postoperative OS in patients with node-negative stage III GC in both the Chinese cohort [hazard ratio (HR) 0.235; P<0.001] and the SEER cohort (HR 0.421; P<0.010). Stratified analysis demonstrated that >31 ELNs was a prerequisite for accurate prognostic evaluation of patients with node-negative stage III GC, regardless of sex, tumor size, and other factors. Stage migration between pT4bN0M0 and pT4bN1M0 was detected in patients with >31 ELNs. A nomogram was created to predict OS among patients with node-negative stage III GC. These results were validated using data from the SEER cohort.

Conclusions

The number of ELNs was significantly associated with prognosis in patients with stage III GC after gastrectomy with systemic lymphadenectomy in both the Chinese and SEER cohorts. The results suggest that >31 ELNs are required for an accurate prognostic evaluation in patients with GC, especially those with node-negative stage III GC.