Accurate Risk Stratification of Patients with Node-Positive Gastric Cancer by Lymph Node Ratio

Lymph node ratio-based model for predicting survival and assessing the benefit of adjuvant chemotherapy in postoperative duodenal adenocarcinoma

BACKGROUND

This study aimed to evaluate the prognostic significance of lymph node ratio in postoperative duodenal adenocarcinoma and develop a nomogram-based model for prognosis assessment and treatment optimization.

METHODS

Clinical information of patients with duodenal adenocarcinoma were retrieved from the Surveillance, Epidemiology, and End Results database, and prognostic factors were identified by univariate and multivariable analyses. Prognostic factors influencing patient outcomes were identified using univariate and multivariable Cox analyses. Subsequently, a novel nomogram and risk stratification system were developed based on these identified factors.

RESULTS

A total of 943 eligible patients were included, with 656 in the training cohort and 287 in the validation cohort. Lymph node ratio ≥0.12 were associated with poorer overall survival (hazard ratio 1.562, 95% confidence interval 1.195-2.041, and P = .001 for lymph node ratio = 0.12-0.30; hazard ratio 2.431, 95% confidence interval 1.847-3.199, and P < .001 for lymph node ratio >0.30). Prognostic factors including age at diagnosis, race, T stage, lymph node ratio, and tumor size were integrated into the nomogram. Patients in the low-risk group demonstrated significantly better overall survival compared with those in the high-risk group. Additionally, adjuvant chemotherapy significantly improved overall survival in the high-risk subgroup, whereas low-risk patients might be exempt from adjuvant chemotherapy.

CONCLUSIONS

This study represented the pioneering endeavor in introducing a lymph node ratio-based nomogram model for prognosis stratification and adjuvant chemotherapy decision-making protocol for patients with duodenal adenocarcinoma, thereby guiding personalized treatment strategies and minimizing overtreatment.

Prognostic significance of metastatic lymph node ratio in gastric cancer: a Western-center analysis

BACKGROUND

Tumor-node-metastasis (TNM) staging is the central gastric cancer (GC) staging system, but it has some disadvantages. However, the lymph node ratio (LNR) can be used regardless of the type of lymphadenectomy and is considered an important prognostic factor. This study aimed to evaluate the relationship between LNR and survival in patients who underwent curative GC surgery.

METHODS

All patients who underwent radical gastric surgery between January 2014 and June 2022 were retrospectively evaluated. Clinicopathological features of tumors, TNM stage, and survival rates were analyzed. LNR was defined as the ratio between metastatic lymph nodes and total lymph nodes removed. The LNR groups were classified as follows: LNR0 = 0, 0.01 < LNR1 ≤ 0.1, 0.1 < LNR2 ≤ 0.25 and LNR3 > 0.25. Tumor characteristics and overall survival (OS) of the patients were compared between LNR groups.

RESULTS

After exclusion, 333 patients were analyzed. The mean age was 62 ± 14 years. According to the LNR classification, no difference was found between groups regarding age and sex. However, TNM stage III disease was significantly more common in LNR3 patients. Most patients (43.2%, n = 144) were in the LNR3 group. In terms of tumor characteristics (lymphatic, vascular, and perineural invasion), the LNR3 group had significantly poorer prognostic factors. The Cox regression model defined LNR3, TNM stage II-III disease, and advanced age as independent risk factors for survival. Patients with LNR3 demonstrated the lowest 5-year OS rate (35.7%) (estimated mean survival was 30 ± 1.9 months) compared to LNR 0-1-2.

CONCLUSION

Our study showed that a high LNR was significantly associated with poor OS in patients who underwent curative gastrectomy. LNR can be used as an independent prognostic predictor in GC patients.

Reliability of the Lymph Node Ratio in the Prediction of Gastric Cancer Survival

Background. Lymph node metastasis is the major determinant factor in the prognosis of gastric cancer. There is still no definite consensus on the lymph node number that should be harvested during gastric cancer surgery. Lymph Node Ratio (LNR) is defined as the ratio of metastatic nodes to the total number of pathologically examined lymph nodes. LNR has been proposed to be a sensitive prognostic factor in patients with gastric cancer. In this study the reliability of the LNR is tested for being a prognostic factor in gastric cancer survival. Methods. Medical records of 244 patients, with neither distant metastases nor neoadjuvant treatment underwent curative gastrectomy, were analyzed retrospectively in terms of survival according to the lymph node ratio (LNR). Patients were divided in two groups by using LNR cut-off value. Results. LNR of 0.4 was proved to be the best cut-off value to predict the prognosis of patients with gastric cancer. Univariate and multivariate analysis revealed that age over 65 (p < 0.001), and LNR ≥ 0.4 (p = 0.02) were independent factors in gastric cancer survival. Patients with LNR ≥ 0.4 presented with worse outcomes regarding other prognostic parameters (tumor differentiation, tumor diameter, lymphovascular invasion or perineural invasion), despite similar numbers of lymph nodes being harvested in both groups during surgery. Conclusion. Lymph node ratio is a reliable parameter to predict the survival in gastric cancer.

A novel nomogram based on the prognostic nutritional index for predicting postoperative outcomes in patients with stage I-III gastric cancer undergoing robotic radical gastrectomy

BACKGROUND

The inflammation and nutrition status are crucial factors influencing the outcome of patients with gastric cancer. This study aims to investigate the prognostic value of the preoperative prognostic nutritional index (PNI) in patients with stage I-III gastric cancer undergoing robotic radical gastrectomy combined with Enhanced Recovery after Surgery (ERAS), and further to create a clinical prognosis prediction model.

STUDY

525 patients with stage I-III gastric cancer who underwent ERAS combined with RRG from July 2010 to June 2018 were included in this work, and were divided randomly into training and validating groups in a 7-to-3 ratio. The association between PNI and overall survival (OS) was assessed by Kaplan-Meier analysis and the log-rank test. Independent risk factors impacting postoperative survival were analyzed with the Cox proportional hazards regression model. A nomogram for predicting OS was constructed based on multivariate analysis, and its predictive performance was evaluated using Harrell's concordance index (C-index), calibration plots, ROC curve, decision curve analysis (DCA), and time-dependent ROC curve analysis.

RESULTS

Survival analyses revealed the presence of a significant correlation between low preoperative PNI and shortened postoperative survival (P = 0.001). According to multivariate analysis, postoperative complications (P < 0.001), pTNM stage (II: P = 0.007; III: P < 0.001), PNI (P = 0.048) and lymph node ratio (LNR) (P = 0.003) were independent prognostic factors in patients undergoing ERAS combined with RRG. The nomogram constructed based on PNI, pTNM stage, complications, and LNR was superior to the pTNM stage model in terms of predictive performance. The C-indexes of the nomogram model were respectively 0.765 and 0.754 in the training and testing set, while AUC values for 1-year, 3-year, and 5-year OS were 0.68, 0.71, and 0.74 in the training set and 0.60, 0.67, and 0.72 in the validation set.

CONCLUSION

Preoperative PNI is an independent prognostic factor for patients with stage I-III gastric cancer undergoing ERAS combined with robotic radical gastrectomy. Based on PNI, we constructed a nomogram for predicting postoperative outcomes of gastric cancer patients, which might be utilized clinically.

Development and validation of lymph node ratio-based nomograms for primary duodenal adenocarcinoma after surgery

Background

The prediction models for primary duodenal adenocarcinoma (PDA) are deficient. This study aimed to determine the predictive value of the lymph node ratio (LNR) in PDA patients and to establish and validate nomograms for predicting overall survival (OS) and cancer-specific survival (CSS) for PDAs after surgical resection.

Methods

We extracted the demographics and clinicopathological information of PDA patients between 2004 and 2018 from the Surveillance, Epidemiology and End Results database. After screening cases, we randomly divided the enrolled patients into training and validation groups. X-tile software was used to obtain the best cut-off value for the LNR. Univariate and multivariate Cox analyses were used in the training group to screen out significant variables to develop nomograms. The predictive accuracy of the nomograms was evaluated by the concordance index (C-index), calibration curves, area under the receiver operating characteristic curve (AUC) and decision curve analysis (DCA). Finally, four risk groups were created based on quartiles of the model scores.

Results

A total of 978 patients were included in this study. The best cut-off value for the LNR was 0.47. LNR was a negative predictive factor for both OS and CSS. Age, sex, grade, chemotherapy and LNR were used to construct the OS nomogram, while age, grade, chemotherapy, the number of lymph nodes removed and LNR were incorporated into the CSS nomogram. The C-index, calibration curves and AUC of the training and validation sets revealed their good predictability. DCA showed that the predictive value of the nomograms was superior to that of the American Joint Committee on Cancer (AJCC) TNM staging system (8th edition). In addition, risk stratification demonstrated that patients with higher risk correlated with poor survival.

Conclusions

The LNR was an adverse prognostic determinant for PDAs. The nomograms provided an accurate and applicable tool to evaluate the prognosis of PDA patients after surgery.

Benchmarks for nodal yield and ratio for node-positive gastric cancer

BACKGROUND

We aimed to elucidate prognostic markers of node-positive gastric cancers with a focus on examined lymph nodes and lymph node ratio.

METHODS

Patients treated with curative-intent gastrectomy at The University of Texas MD Anderson Cancer Center from 1995-2019 were evaluated. Patients with non-metastatic, node-positive gastric cancers were considered for analysis.

RESULTS

Of 775 patients, 281 met the inclusion criteria. The mean age was 58 years, 61% were male, 51% were White, 65% received preoperative therapy, and 71% of tumors were located in the gastric body. The median overall survival was 3.6 years, and 1-, 5-, and 10-year overall survival rates were 91%, 41%, and 29%, respectively. pN3 category was associated with worse overall survival (hazard ratio 1.79, P = .001) and recurrence-free survival (hazard ratio 1.92, P = .004). Nodal burden was associated with aggressive biologic traits in primary tumors, including higher rates of lymphovascular and perineural invasion and lower preoperative therapy response rates. By receiver-operative characteristic analysis, threshold values of ≥30 examined lymph nodes and <30% lymph node ratio were most discriminant for overall survival. On adjusted analysis, positive margins, additional organ resection, <30 examined lymph nodes, and ≥30% lymph node ratio were associated with worse recurrence-free survival and overall survival. Among patients with high node burden (pN3), <30 examined lymph nodes remained significant on adjusted survival analysis.

CONCLUSION

Greater than or equal to 30 examined lymph nodes and <30% lymph node ratio were significantly associated with longer recurrence-free survival and overall survival, independent of lymphadenectomy type. These prognostic benchmarks should be considered in the surgical management of gastric cancer in the United States.

Laparoscopic gastrectomy plus D2 lymphadenectomy is as effective as open surgery in terms of long-term survival: a single-institution study on gastric cancer

BACKGROUND

Laparoscopic surgery has been widely accepted to treat early-stage gastric cancer. However, it is still controversial to perform laparoscopic gastrectomy plus D2 lymphadenectomy for locally advanced gastric cancer. We performed the present study to compare the long-term outcomes of patients after laparoscopic or open gastrectomy plus D2 lymphadenectomy.

METHODS

The clinicopathological data of 182 gastric cancer patients receiving gastrectomy plus D2 lymphadenectomy between January 2011 and December 2015 at Shenzhen Traditional Chinese Medicine Hospital were retrospectively retrieved. The overall survival (OS) and disease-free survival (DFS) of these 182 patients were compared. Then, the prognostic significance of positive lymph node ratio (LNR) was assessed.

RESULTS

As a whole, OS (P = 0.789) and DFS (P = 0.672) of patients receiving laparoscopic gastrectomy plus D2 lymphadenectomy were not significantly different from those of patients receiving open surgery. For stage I patients, laparoscopic gastrectomy plus D2 lymphadenectomy was not significantly different from open surgery in terms of OS (P = 0.573) and DFS (P = 0.157). Similarly, for stage II patients, laparoscopic gastrectomy plus D2 lymphadenectomy was not significantly different from open surgery in terms of OS (P = 0.567) and DFS (P = 0.830). For stage III patients, laparoscopic gastrectomy plus D2 lymphadenectomy was not significantly different from open surgery in terms of OS (P = 0.773) and DFS (P = 0.404). Laparoscopic or open gastrectomy plus D2 lymphadenectomy was not proven by Cox regression analysis to be an independent prognostic factor for OS and DFS. High LNR was significantly associated with worse OS (P < 0.001) and DFS (P < 0.001). Surgical type did not significantly affect prognosis of patients with low LNR or survival of patients with high LNR.

CONCLUSIONS

For patients with gastric cancer, laparoscopic gastrectomy plus D2 lymphadenectomy was not inferior to open surgery in terms of long-term outcomes. LNR is a useful prognostic marker for GC patients.