Lymph-node ratio is an important clinical determinant for selecting the appropriate adjuvant chemotherapy regimen for curative D2-resected gastric cancer

Advanced diffusion-weighted MRI models for preoperative prediction of lymph node metastasis in resectable gastric cancer

OBJECTIVE

To investigate the potential of six advanced diffusion-weighted imaging (DWI) models for preoperative prediction of lymph node metastasis (LNM) in resectable gastric cancer (GC).

METHODS

Between Nov 2022 and Nov 2023, standard MRI scans were prospectively performed in consecutive patients with endoscopic pathology-confirmed gastric adenocarcinoma who were referred for direct radical gastrectomy. Six DWI models, including fractional order calculus (FROC), continuous-time random walk (CTRW), diffusion kurtosis imaging (DKI), intravoxel incoherent motion (IVIM), the mono-exponential model (MEM) and the stretched exponential model (SEM) were computed. Surgical pathologic diagnosis of LNM was the reference standard, and patients were classified into LNM-positive or LNM-negative groups accordingly. The morphological features and quantitative parameters of the DWI models in different LNM categories were analyzed and compared. Multivariable logistic regression was used to screen significant predictors. Receiver-operating characteristic curves and the area under the curve (AUC) were plotted to evaluate the performances, the Delong test was performed to compare the AUCs.

RESULTS

In the LNM-positive group, tumor thickness and kurtosis (DKI_K) were significantly higher, while anomalous diffusion coefficient (CTRW_D), diffusivity (DKI_D), diffusion coefficient (FROC_D), pseudodiffusion coefficient (IVIM_D*), perfusion fraction (IVIM_f), and ADC were lower compared to the LNM-negative group. Clinical tumor staging (cT) and CTRW_D were independent predictors. Their combination demonstrated a superior AUC of 0.930, significantly higher than that of individual parameters.

CONCLUSIONS

Tumor thickness, DKI_K, CTRW_D, DKI_D, FROC_D, IVIM_D*, IVIM_f and ADC were associated with LNM status. The combination of independent predictors of cT and CTRW_D further enhanced the performance.

A prognostic nomogram to predict the cancer-specific survival of patients with initially diagnosed metastatic gastric cancer: a validation study in a Chinese cohort

BACKGROUND

Few studies have been designed to predict the survival of Chinese patients initially diagnosed with metastatic gastric cancer (mGC). Therefore, the objective of this study was to construct and validate a new nomogram model to predict cancer-specific survival (CSS) in Chinese patients.

METHODS

We collected 328 patients with mGC from Northern Jiangsu People's Hospital as the training cohort and 60 patients from Xinyuan County People's Hospital as the external validation cohort. Multivariate Cox regression was used to identify risk factors, and a nomogram was created to predict CSS. The predictive performance of the nomogram was evaluated using the consistency index (C-index), the calibration curve, and the decision curve analysis (DCA) in the training cohort and the validation cohort.

RESULTS

Multivariate Cox regression identified differentiation grade (P < 0.001), T-stage (P < 0.05), N-stage (P < 0.001), surgery (P < 0.05), and chemotherapy (P < 0.001) as independent predictors of CSS. Nomogram of chemotherapy regimens and cycles was also designed by us for the prediction of mGC. Thus, these factors are integrated into the nomogram model: the C-index value was 0.72 (95% CI 0.70-0.85) for the nomogram model and 0.82 (95% CI 0.79-0.89) and 0.73 (95% CI 0.70-0.86) for the internal and external validation cohorts, respectively. Calibration curves and DCA also demonstrated adequate fit and ideal net benefit in prediction and clinical applications.

CONCLUSIONS

We established a practical nomogram to predict CSS in Chinese patients initially diagnosed with mGC. Nomograms can be used to individualize survival predictions and guide clinicians in making therapeutic decisions.

Positive Lymph Node Ratio as a new prognostic score in Geriatric patients with operated gastric cancer

Objective

The pivotal prognostic determinant for recurrence and survival in surgically treated gastric cancer (GC) patients remains the lymph node status. Despite the adoption of D2 lymph node dissection as the standard approach in recent years, its association with increased morbidity in elderly patients raises concerns. This study aims to explore the prognostic significance of the Positive Lymph Node Ratio (PLNR) score in the context of recurrence and survival among elderly patients with surgically treated GC.

Material and method

A retrospective review of files about surgically treated patients with GC was conducted. The prognostic impact of the PLNR score on overall survival (OS) was assessed through Receiver Operating Characteristic (ROC) analysis.

Results

The cut-off value for the PLNR, determined through ROC analysis, was identified as 0.138. This value serves as a crucial threshold, as it distinguishes patients with a higher risk of poor outcomes. Patients with a PLNR score of 0.138 or below exhibited a median OS of 111 months, whereas those with a PLNR score above 0.138 had a significantly lower median OS of 22 months (p = 0.004).

Conclusion

Our findings revealed that the PLNR emerged as an independent predictor of survival and recurrence in patients undergoing GC resection.However, it's important to note that while valuable, the PLNR system has limitations. It does not encompass the T stage, a key factor in cancer staging. Therefore, it cannot be a direct substitute for the comprehensive information TNM staging provides. It should be used as a supplementary tool in predicting prognosis, particularly in elderly patients unsuitable for standard lymph node dissection.

Construction and validation of a nomogram model for lymph node metastasis of stage II-III gastric cancer based on machine learning algorithms

Background

Gastric cancer, a pervasive malignancy globally, often presents with regional lymph node metastasis (LNM), profoundly impacting prognosis and treatment options. Existing clinical methods for determining the presence of LNM are not precise enough, necessitating the development of an accurate risk prediction model.

Objective

Our primary objective was to employ machine learning algorithms to identify risk factors for LNM and establish a precise prediction model for stage II-III gastric cancer.

Methods

A study was conducted at Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine between May 2010 and December 2022. This retrospective study analyzed 1147 surgeries for gastric cancer and explored the clinicopathological differences between LNM and non-LNM cohorts. Utilizing univariate logistic regression and two machine learning methodologies-Least absolute shrinkage and selection operator (LASSO) and random forest (RF)-we identified vascular invasion, maximum tumor diameter, percentage of monocytes, hematocrit (HCT), and lymphocyte-monocyte ratio (LMR) as salient factors and consolidated them into a nomogram model. The area under the receiver operating characteristic (ROC) curve (AUC), calibration curves, and decision curves were used to evaluate the test efficacy of the nomogram. Shapley Additive Explanation (SHAP) values were utilized to illustrate the predictive impact of each feature on the model's output.

Results

Significant differences in tumor characteristics were discerned between LNM and non-LNM cohorts through appropriate statistical methods. A nomogram, incorporating vascular invasion, maximum tumor diameter, percentage of monocytes, HCT, and LMR, was developed and exhibited satisfactory predictive capabilities with an AUC of 0.787 (95% CI: 0.749-0.824) in the training set and 0.753 (95% CI: 0.694-0.812) in the validation set. Calibration curves and decision curves affirmed the nomogram's predictive accuracy.

Conclusion

In conclusion, leveraging machine learning algorithms, we devised a nomogram for precise LNM risk prognostication in stage II-III gastric cancer, offering a valuable tool for tailored risk assessment in clinical decision-making.

A proposed grading scheme for predicting recurrence in medullary thyroid cancer based on the Ki67 index and metastatic lymph node ratio

PURPOSE

The Ki67 index and lymph node ratio (LNR) have been proposed as components of alternative pathological classification schemes, but the most appropriate classification for patients with medullary thyroid cancer (MTC) remains unknown. The aim of the present study was to examine the usefulness of a new grading system combining the Ki67 index and LNR as a predictor of prognostic and disease-free survival (DFS) in MTC.

METHODS

We conducted a retrospective study of patients with MTC who were registered at Sun Yat-sen University Cancer Center, Guangzhou, P. R. China from June 2003 to October 2021. The DFS rates were assessed using risk-adjusted Cox proportional hazard regression modeling to explore the relationship among pathological features, nutritional status and DFS. The Ki67 index (cutoff value: 5% and 10%) and LNR (cutoff value: 0.2 and 0.3) were combined to create a new grading system.

RESULTS

In total, 101 matched patients were assessed. The integrated grading system showed better separation of Kaplan Meier (KM) curves for DFS. As the grading stage progressed, there was a significant stepwise decrease in DFS, which was better than Ki67, LNR and N staging alone. According to the grading system, the high-risk group had a worse prognosis.

CONCLUSION

The proposed grading scheme demonstrated a better prognostic performance in MTC patients than the Ki67, LNR and N staging alone. However, larger scale studies are needed to further verify our findings.

Development and external validation of a novel nomogram for predicting cancer-specific survival in patients with ascending colon adenocarcinoma after surgery: a population-based study

BACKGROUND

This study aimed to develop and validate a novel nomogram to predict the cancer-specific survival (CSS) of patients with ascending colon adenocarcinoma after surgery.

METHODS

Patients with ascending colon adenocarcinoma were enrolled from the Surveillance, Epidemiology, and End Results (SEER) database from 1973 to 2015 and randomly divided into a training set (5930) and a validation set (2540). The cut-off values for age, tumour size and lymph node ratio (LNR) were calculated via X-tile software. In the training set, independent prognostic factors were identified using univariate and multivariate Cox analyses, and a nomogram incorporating these factors was subsequently built. Data from the validation set were used to assess the reliability and accuracy of the nomogram and then compared with the 8th edition of the American Joint Committee on Cancer (AJCC) tumour-node-metastasis (TNM) staging system. Furthermore, external validation was performed from a single institution in China.

RESULTS

A total of 8470 patients were enrolled from the SEER database, 5930 patients were allocated to the training set, 2540 were allocated to the internal validation set and a separate set of 473 patients was allocated to the external validation set. The optimal cut-off values of age, tumour size and lymph node ratio were 73 and 85, 33 and 75 and 4.9 and 32.8, respectively. Univariate and multivariate Cox multivariate regression revealed that age, AJCC 8th edition T, N and M stage, carcinoembryonic antigen (CEA), tumour differentiation, chemotherapy, perineural invasion and LNR were independent risk factors for patient CSS. The nomogram showed good predictive ability, as indicated by discriminative ability and calibration, with C statistics of 0.835 (95% CI, 0.823-0.847) and 0.848 (95% CI, 0.830-0.866) in the training and validation sets and 0.732 (95% CI, 0.664-0.799) in the external validation set. The nomogram showed favourable discrimination and calibration abilities and performed better than the AJCC TNM staging system.

CONCLUSIONS

A novel validated nomogram could effectively predict patients with ascending colon adenocarcinoma after surgery, and this predictive power may guide clinicians in accurate prognostic judgement.

Metastatic Lymph Node Ratio for Predicting Recurrence in Medullary Thyroid Cancer

Simple Summary

The anatomical staging system for thyroid cancer only contains categories for lymph node compartments. The metastatic lymph node ratio (LNR), which is the ratio of metastasized lymph nodes to the total number of evaluated lymph nodes, is suggested as a quantitative evaluation tool for lymph node metastasis in patients with medullary thyroid cancer in this study. The initial stratification implemented in this study was helpful in predicting structural recurrence, and LNR was identified as a predictor of disease-free survival.

Abstract

The lymph node ratio (LNR) has been investigated as a prognostic factor in many different types of cancers, including differentiated thyroid cancer; however, reports regarding medullary thyroid cancer (MTC) are limited. Therefore, this study aims to evaluate LNR as a risk factor for structural recurrence in patients with MTC. Medical records of patients treated for MTC in a single tertiary center between 1995 and 2017 were retrospectively reviewed. LNR is defined as the number of metastatic lymph nodes or lymph node metastases (LNM) divided by the number of retrieved lymph nodes or lymph node yield (LNY). In the survival analysis, recurrence-free survival was defined as the time from the date of total thyroidectomy to recurrence or last follow-up. To identify risk factors influencing structural recurrence, univariable and multivariable Cox proportional hazard models were used. A total of 132 patients were enrolled. The mean age of study participants was 49.7 years, and 86 patients (65%) were women. Structural recurrence was identified in 39 patients at the end of the study period, and the median follow-up period was 8.7 years. In univariable analyses, gross extra thyroidal extension, N stage, postoperative serum calcitonin and carcinoembryonic antigen (CEA) levels, and LNR were significant (p < 0.05) predictors of structural recurrence. In multivariable analysis, postoperative serum calcitonin, postoperative serum CEA, and LNR were identified as a predictor of disease-free survival (p < 0.05). LNR can potentially predict structural recurrence as a quantitative evaluation tool for lymph node metastasis in patients with MTC.

Development and Validation of Multivariate Models Integrating Preoperative Clinicopathological Parameters and Radiographic Findings Based on Late Arterial Phase CT Images for Predicting Lymph Node Metastasis in Gastric Cancer

RATIONALE AND OBJECTIVES

To develop and validate multivariate models integrating endoscopic biopsy, tumor markers, computed tomography (CT) morphological characteristics based on late arterial phase (LAP), and CT value-related and texture parameters to predict lymph node (LN) metastasis in gastric cancers (GCs).

MATERIALS AND METHODS

The preoperative differentiation degree based on biopsy, 6 tumor markers, 8 CT morphological characteristics based on LAP, 18 CT value-related parameters, and 35 CT texture parameters of 163 patients (111 men and 52 women) with GC were analyzed retrospectively. The differences in parameters between N (-) and N (+) GCs were analyzed by the Mann-Whitney U test. Diagnostic performance was obtained by receiver operating characteristic (ROC) curve analysis. Multivariate models based on regression analysis and machine learning algorithms were performed to improve diagnostic efficacy.

RESULTS

The differentiation degree, carbohydrate antigen (CA) 199 and CA242, 5 CT morphological characteristics, and 22 CT texture parameters showed significant differences between N (-) and N (+) GCs in the primary cohort (all p < 0.05). The multivariate model integrating clinicopathological parameters and radiographic findings based on regression analysis achieved areas under the ROC curve (AUCs) of 0.936 and 0.912 in the primary and validation cohorts, respectively. The model generated by the support vector machine algorithm achieved AUCs of 0.914 and 0.948, respectively.

CONCLUSION

We developed and validated multivariate models integrating endoscopic biopsy, tumor markers, CT morphological characteristics based on LAP, and CT texture parameters to predict LN metastasis in GCs and achieved satisfactory performance.

Comparison of a Tumor-Ratio-Metastasis Staging System and the 8th AJCC TNM Staging System for Gastric Cancer

Background

Despite the implementation of the 8th American Joint Committee on Cancer (AJCC) TNM staging system for gastric cancer (GC) in 2017, it still holds a significant level of stage migration which affects patients’ proper classification and accurate prognosis. Here, to reduce this effect, we evaluated the prognostic value of a lymph node ratio (LNR) and established a novel tumor–ratio–metastasis (TRM) staging system.

Method

The data of 15,206 GC patients from the Sun Yat-sen University Cancer Center (Training set; n=2,032) and the US Surveillance, Epidemiology, and End Results (SEER) database (Validation set; n=13,174) were analyzed. The training set was classified into 5 LNR categories, based on which the novel TRM staging system was constructed. The overall survival (OS) between the TRM and AJCC TNM systems was compared in the training set and validated in the validation set. The likelihood ratio x², liner trend x², C-index, and Akaike information criterion (AIC) values were used to measure the discriminatory ability between the two different staging systems. Decision curve analyses (DCAs) were conducted to test the clinical value of the two staging systems.

Result

The patients were classified into the following categories: LNR0: 0%, LNR1: 0%<LNR ≤ 10%, LNR2: 10%<LNR ≤ 25%, LNR 3a: 25%<LNR ≤ 60%, and LNR 3b: LNR>60%. Univariate analyses demonstrated that the log-rank x² of the LNR stage (Training/Validation set: x² = 463.1/2880.8) was larger than the AJCC pN stage (Training/Validation set: x² = 281.5/2240.8). For both the training set and validation set, stratified analyses using the Kaplan-Meier method identified significantly heterogeneous OS in every pN category but only one using the LNR. The TRM staging system had higher likelihood ratio x², liner trend x², C-index and smaller AIC values than the TNM system.

Conclusion

The TRM staging system demonstrated improved homogeneity and discriminatory ability in predicting the prognosis of GC patients compared with the AJCC TNM staging system.

A Novel Approach for Gastric Cancer Staging in Elderly Patients Based on the Lymph Node Ratio

Purpose

To date, no studies have been performed on staging based on the lymph node ratio (LNR) in elderly patients with gastric cancer who may require limited lymph node (LN) dissection due to morbidity and tissue fragility. We aimed to develop a new N staging system using the LNR in elderly patients with gastric cancer.

Materials and Methods

The present study included patients aged over 75 years who underwent curative gastrectomy between January 1989 and December 2018. Clinicopathological data including the number of retrieved and metastatic LNs were collected and the LNR values were obtained (LNR = the number of metastatic LNs/the number of retrieved LNs). Eleven LNR groups with intervals of 0.1 were divided into four stages based on the inflection points at which the hazard ratio (HR) increased. Survival analysis was performed to evaluate the prognostic value of the LNR.

Results

The four LNR stages included LNR0 (n=364), LNR1 (n=128), LNR2 (n=103), and LNR3 (n=10). In the multivariate analysis, both N staging and LNR staging exhibited significant prognostic values for predicting survival outcomes. However, the incremental change in the hazard ratio (HR) between consecutive stages was greater for the LNR staging than for the N staging (HRs: 1.607, 2.758, and 3.675 for N staging; 1.583, 3.514, and 10.261 for LNR staging).

Conclusions

LNR staging is more useful than N staging in predicting the prognosis in elderly patients with gastric cancer and may be used as a complement or alternative to N staging.

Which Lymph Node Staging System Better Predicts Prognosis in Patients With Gastric Carcinoma? A Comparative Study Between 3 Different Lymph Node Classifications for Resected Gastric Cancer in a Western Tertiary Center

INTRODUCTION

Gastric cancer (GC) is an aggressive disease with high mortality rates. Lymph node (LN) staging of GC is a major source of controversy. The aim of this study is to compare the prognostic value of 3 different LN classifications for patients with resected GC: the eighth TNM staging system, lymph node ratio (LNR, ratio between positive and total LN) and a new anatomic-based classification (Choi classification).

MATERIALS AND METHODS

A retrospective study of all cases of GC resected in a tertiary hospital in Spain (n=377). Clinical data were collected; histologic slides were reviewed; and univariate and multivariate analyses of disease-free survival (DFS) and overall survival (OS) were performed.

RESULTS

In all, 315 patients fulfilled inclusion criteria. Univariate analysis showed that all classifications were significantly associated with tumor death and progression (P<0.001). All staging systems were independent prognostic factors for DFS. Area under the curve ratios for Choi, N stage, and LNR classifications were 0.738, 0.730, and 0.735, respectively. TNM and LNR classifications were independent prognosticators for OS, while Choi classification was an independent factor only in patients with ≥16 LN resected. Area under the curve ratios for Choi, N stage, and LNR classifications were 0.707, 0.728, and 0.732, respectively. Kaplan-Meier curves depending on LNR classification showed the best patient stratification for both OS and DFS.

CONCLUSIONS

The 3-staging systems had similar prognostic performance, but LNR-based classification stratified patients better. Further studies are needed to evaluate the impact of the number of LN examined, cutoff values, and anatomic extent of LN disease in GC.

Development of a simplified tumor-lymph node ratio classification system for patients with resected gastric cancer: A western study

INTRODUCTION

Gastric cancer (GC) shows high recurrence and mortality rates. The AJCC TNM staging system is the best prognostic predictor, but lymph node assessment is a major source of controversy. Recent studies have found that lymph node ratio (LNR) may overcome TNM limitations. Our aim is to develop a simplified tumor-LNR (T-LNR) classification for predicting prognosis of resected GC.

METHODS

Retrospective study of all GC resected in a tertiary center in Spain (N = 377). Clinicopathological features were assessed, LNR was classified into N0:0%, N1:1-25%, N2:>25%, and a T-LNR classification was developed. Statistical analyses were performed.

RESULTS

317 patients were finally included. Most patients were male (54.6%) and mean age was 72 years. Tumors were intestinal (61%), diffuse (30.8%) or mixed (8.1%). During follow-up, 36.7% and 27.4% of patients progressed and died, respectively. T-LNR classification divided patients into five prognostic categories (S1-S5). Most cases were S1-S4 (26.2%, 19.9%, 22.6% and 23.6%, respectively). 7.6% of tumors were S5. T-LNR classification was significantly associated with tumor size, depth, macroscopical type, Laurén subtype, signet ring cells, histologic grade, lymphovascular invasion, perineural infiltration, infiltrative growth, patient progression and death. Kaplan-Meier curves for OS showed an excellent patient stratification with evenly spaced curves. As for DFS, T-LNR classification also showed good discriminatory ability with non-overlapping curves. T-LNR classification was independently related to both OS and DFS.

CONCLUSIONS

T-LNR classifications can successfully predict prognosis of GC patients. Larger studies in other geographic regions should be performed to refine this classification and to validate its prognostic relevance.

The prognostic value of the lymph node ratio for local advanced gastric cancer patients with intensity-modulated radiation therapy and concurrent chemotherapy after radical gastrectomy in China

BACKGROUND

Nearly 50% of new gastric cancer cases and gastric cancer-related deaths worldwide occur in China. No global consensus has been reached about the optimal management of locally advanced gastric cancer. Although the Guidelines for the Diagnosis and Treatment of Gastric Cancer from the National Health Commission of China, which has been updated three times since 2010, explicitly emphasize the necessity of adjuvant chemoradiation, few clinical institutions in China routinely adhere to the recommended radiotherapy guidelines. This study aimed to examine the efficacy, in terms of locoregional control and long-term survival, and the safety of adjuvant radiotherapy using intensity-modulated radiation therapy (IMRT) with concurrent and adjuvant fluoropyrimidine-based chemotherapy for gastric cancer.

METHODS

This was a retrospective evaluation of 156 patients with high-risk gastric cancer who underwent adjuvant chemoradiotherapy between September 2008 and May 2019. The prescribed planning target volume median dose was 45 Gy in 1.8 Gy daily fractions, and all patients received concurrent and adjuvant fluoropyrimidine-based chemotherapy. Locoregional control, distant metastasis, and overall survival rates were estimated. Clinicopathological characteristics and patterns of failure were retrospectively reviewed to identify factors associated with survival and recurrence.

RESULTS

The median follow-up duration was 56 months (range 3-130 months) for all patients. Of the patients, 11 (7.1%) were lost to follow-up, and 49 (31.4%) and 104 (66.7%) had stage II or III disease according to the eighth edition of the American Joint Committee on Cancer tumor-node-metastasis staging criteria. The frequencies of acute grade 3 or 4 gastrointestinal and hematological toxicity were 9.6% and 10.9%, respectively. In total, 152 patients (97.4%) completed the entire chemoradiation regimen. No toxicity-related deaths occurred. Nineteen patients (12.2%) had locoregional recurrence, 26 (16.7%) had distant metastases, and 12 (7.7%) had peritoneal metastasis. The overall survival (OS) rates were 83.5%, 65.0%, and 59.5%, while the disease-free survival rates were 75.1%, 61.0%, and 55.6% at 1, 3, and 5 years, respectively. In the multivariate analysis, age, pathological T stage and lymph node ratio (LNR) were found to be independent predictors of OS.

CONCLUSION

Postoperative concomitant IMRT and chemotherapy were well tolerated, with acceptable toxicities and encouraging locoregional tumor control and long-term survival. The LNR can be used as an important prognostic indicator for OS. Adjuvant chemoradiotherapy should be considered for all patients with a high risk of locoregional recurrence, especially in China.

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

BACKGROUND

We aimed to clarify the utility of lymph node ratio (LNR) for assessing the prognosis of patients with node-positive gastric cancer after curative gastrectomy.

METHODS

We retrospectively analyzed data of 973 patients with node-positive gastric cancer who had undergone curative gastrectomy at nine institutions from 2010 to 2014. Survival analysis was performed by comparing LNR low and high groups according to the optimal cutoff value of LNR, which was determined using receiver operating characteristic curve analysis.

RESULTS

LNR high was significantly associated with shorter disease-free survival and was an independent predictor of recurrence in all patients. Moreover, we obtained the similar results from analysis of each N stage. The prevalence of lymph node and peritoneal recurrence appeared to be higher in the LNR high group. Correlation analysis showed that LNR was negatively correlated with the number of retrieved nodes within every N stage; however, disease-free survival did not differ significantly between LNR low and high groups of each N stage with 16-30, 31-40, or >40 retrieved nodes.

CONCLUSIONS

LNR is a strong prognostic factor and predictor of recurrence in patients with node-positive gastric cancer who have undergone curative gastrectomy. The combination of LNR and N staging permits more accurate prognostic stratification of patients with gastric cancer and may contribute to developing novel prognostic models.

Observational Study of Peritoneal Washing Cytology-Positive Gastric Cancer without Gross Peritoneal Metastasis in Patients who Underwent Radical D2 Gastrectomy

Background The clinical features and therapeutic strategies for gastric cancer with positive peritoneal washing cytology but without visible gross peritoneal metastasis have not been defined. The aim of this study was to evaluate the effect and clinical prognostic value of postoperative chemotherapy in gastric cancer patients with positive peritoneal washing cytology without gross peritoneal metastasis who underwent radical D2 gastrectomy in terms of disease-free survival (DFS) and overall survival (OS). Materials and Methods Intraoperative peritoneal washing cytology was performed in 285 patients who underwent radical D2 gastrectomy between April 2004 and May 2016. Of them, 88 patients with positive cytology but without gross peritoneal metastasis were included in the study. In total, 64 patients received postoperative chemotherapy, whereas 24 patients underwent surgery only. Results Most gastric cancer patients with positive cytology without gross peritoneal metastasis demonstrated pT4 and/or pN3 disease. Postoperative chemotherapy improved DFS and OS compared to surgery only in gastric cancer patients with positive cytology without gross peritoneal metastasis (median DFS 11.63 vs. 6.98 months, p < 0.001; median OS 25.50 vs. 12.11 months, p < 0.001). In multivariate analyses of gastric cancer patients with positive cytology without gross peritoneal metastasis, no chemotherapy was the strongest clinical factor for poorer DFS (hazard ratio [HR] 3.76, p < 0.001) or OS (HR 4.37, p < 0.001). Conclusion Postoperative chemotherapy improves the survival outcome compared to surgery alone in gastric cancer patients with positive peritoneal washing cytology but without visible gross peritoneal metastasis who underwent radical D2 gastrectomy.

Should the Number of Metastatic Pelvic Lymph Nodes be Integrated into the 2018 Figo Staging Classification of Early Stage Cervical Cancer?

Introduction: Lymph node status has become part of the new staging system for cervical cancer (CC). It has been shown that patients staged as IIIC1 had heterogeneous prognoses and, in some cases, experienced better outcomes than patients with lower stages. We evaluated the impact of the number of metastatic pelvic lymph nodes (MPLNs) among patients with stage IIIC1 cervical cancer. Methods: Survival analyses were conducted in order to identify the best cut-off prognostic value relative to the number of MPLNs. Disease free survival (DFS) was considered the main outcome. Results: 541 patients were included in the study. Eighty-nine patients were of stage IIIC1. The best prognostic cut-off value of the number of MPLNs was 2. Patients with >2 MPLNs (n > 2 group) had worse DFS compared with those having <2 (N1-2 group) (5 yr DFS: 54.7% vs. 78.1%, p value = 0.006). Multivariate analyses demonstrated that the extent of MPLNs had little impact on DFS and that replacement of IIIC1 staging with N1-2 and n > 2 grouping provided a better, statistically significant model (p value = 0.006). Discussion: Using a cut-off value of 2, the number of MPLNs could better predict prognostic outcomes within stage IIIC1 cervical cancer and have potential implications for therapeutic decision-making in the treatment of patients with stage IIIC1 CC.

Association Between Lymph Node Ratio and Survival in Patients with Pathological Stage II/III Gastric Cancer

BACKGROUND

Lymph node ratio (LNR), defined as the ratio of metastatic nodes to the total number of examined lymph nodes, has been proposed as a sensitive prognostic factor in patients with gastric cancer (GC). We investigate its association with survival in pathological stage (pStage) II/III GC and explore whether this is a prognostic factor in each Union for International Cancer Control pStage (7th edition).

PATIENTS AND METHODS

We retrospectively examined 838 patients with pStage II/III GC who underwent curative gastrectomy between June 2000 and December 2018. Patients were classified into low-LNR (L-LNR), middle-LNR (M-LNR), and high-LNR (H-LNR) groups according to adjusted X-tile cutoff values of 0.1 and 0.25 for LNR, and their clinicopathological characteristics and survival rates were compared.

RESULTS

The 5-year recurrence-free survival (RFS) and overall survival (OS) rates postsurgery showed significant differences among the groups (P < 0.001). Multivariate analysis demonstrated that LNR was a significant predictor of poor RFS [M-LNR: hazard ratio (HR) 3.128, 95% confidence interval (CI) 2.254-4.342, P < 0.001; H-LNR: HR 5.148, 95% CI 3.546-7.474, P < 0.001] and OS (M-LNR: HR 2.749, 95% CI 2.038-3.708, P < 0.001; H-LNR: HR 4.654, 95% CI 3.288-6.588, P < 0.001). On subset analysis stratified by pStage, significant differences were observed between the groups in terms of the RFS curves of pStage II and III GC (P < 0.001 and < 0.001, respectively) and OS curves of pStage II and III GC (P = 0.001 and < 0.001, respectively).

CONCLUSIONS

High LNR is a predictor of worse prognosis in pStage II/III GC, including each substage.