Prognostic significance of lymph node ratio in esophageal cancer

The Prognostic Significance of Lymph Node Ratio for Esophageal Cancer: A Meta-Analysis

INTRODUCTION

This meta-analysis aimed to investigate the prognostic significance of positive lymph node ratio (LNR) in patients with esophageal cancer.

MATERIALS AND METHODS

The meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We conducted a systematic search of relevant literature published until April 2022 in PubMed, EMBASE, and the Cochrane Library. The primary and secondary outcomes were overall survival (OS) and disease-free survival (DFS), with corresponding hazard ratios (HR) and 95% confidence intervals (CI). The included studies were subgrouped based on age, study area, adjuvant therapy, sensitivity analysis, and assessment of publication bias. We analyzed and discussed the results.

RESULTS

We included 21 studies with 29 cohorts and 11,849 patients. The Newcastle-Ottawa Scale scores of the included studies were no less than six, indicating high research quality. The combined results of HR and 95% CI showed that patients with esophageal cancer with a lower LNR had better OS (HR, 2.58; 95% CI, 2.15-3.11; P < 0.001) and DFS (HR, 3.07; 95% CI, 1.85-5.10; P < 0.001). The subgroup analysis suggested that geographic region, age, and adjuvant therapy affected OS. When any cohort was excluded, no significant changes were observed in the pooled HR of the OS group, indicating reliable and robust results. Egger's and Begg's tests showed no potential publication bias in the studies that used OS as an outcome measurement index, indicating reliable results. Sensitivity analyses and assessments of publication bias (<10) were not performed because of an insufficient number of DFS studies.

CONCLUSION

Patients with a lower positive LNR had a higher survival rate, suggesting that positive LNR may be a promising predictor of EC prognosis in esophageal cancer. After radical resection of esophageal cancer, the ratio of the number of dissected lymph nodes to the number of positive lymph nodes in patients with esophageal cancer should be considered to accurately evaluate the prognosis.

Association of survival with adjuvant radiotherapy for pN0 esophageal cancer

INTRODUCTION

This study was conducted to elucidate the link between adjuvant radiotherapy and survival in pathologic node-negative (pN0) esophageal cancer patients with upfront esophagectomy.

METHODS

From 2000 to 2016, patients with pN0 esophageal cancer who underwent upfront esophagectomy were selected from the Surveillance, Epidemiology, and End Results (SEER) database. The association of high-risk covariates with survival after adjuvant radiotherapy was evaluated using propensity score matching and multivariate analysis.

RESULTS

We identified 3197 patients, 321 (10.0%) underwent postoperative radiotherapy and 2876 (90.0%) underwent esophagectomy alone. In the unmatched cohort, postoperative radiotherapy was associated with a statistically significant but modest absolute decrease in survival outcomes (P < 0.001). In the matched cohort, the survival differences disappeared. Additionally, adjuvant radiotherapy was linked to a 5-year overall survival (OS) benefit for patients with the pT3-4N0 disease (34.8% vs. 27.7%; P = 0.008). Adjuvant radiotherapy for pT3-4N0 disease with tumor length ≥3 cm, adenocarcinoma, and evaluated lymph node count <12 was shown to independently function as a risk factor for improved OS, as per a multivariate analysis (P < 0.01).

CONCLUSIONS

This population-based trial showed that high-risk patients with pT3-4N0 esophageal cancer had better OS following upfront esophagectomy followed by radiotherapy therapy. This discovery may have major significance in the use of adjuvant radiotherapy following upfront esophagectomy in patients with pN0 esophageal cancer.

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.

Differentially Expressed mRNAs and Potential Mechanisms of Radiation-Induced TUT4−/− Esophageal Cell Injury

Radiation-induced esophageal injury remains a limitation for the process of radiotherapy for lung and esophageal cancer patients. Esophageal epithelial cells are extremely sensitive to irradiation, nevertheless, factors involved in the radiosensitivity of esophageal epithelial cells are still unknown. Terminal uridyl transferase 4 (TUT4) could modify the sequence of miRNAs, which affect their regulation on miRNA targets and function. In this study, we used transcriptome sequencing technology to identify mRNAs that were differentially expressed before and after radiotherapy in esophageal epithelial cells. We further explored the mRNA expression profiles between wild-type and TUT4 knockout esophageal epithelial cells. Volcano and heatmap plots unsupervised hierarchical clustering analysis were performed to classify the samples. Enrichment analysis on Gene Ontology functional annotations and Kyoto Encyclopedia of Genes and Genomes pathways was performed. We annotated differential genes from metabolism, genetic information processing, environmental information processing, cellular processes, and organismal systems human diseases. The aberrantly expressed genes are significantly enriched in irradiation-related biological processes, such as DNA replication, ferroptosis, and cell cycle. Moreover, we explored the distribution of transcription factor family and its target genes in differential genes. These mRNAs might serve as therapeutic targets in TUT4-related radiation-induced esophageal injury.

Clinical impact of remnant lymphatic invasion on the recurrence of esophageal squamous cell carcinoma after esophagectomy with neoadjuvant chemotherapy

For stage II and III esophageal squamous cell carcinoma (ESCC), neoadjuvant chemotherapy (NAC) followed by esophagectomy is recommended in the Japanese guidelines for the diagnosis and treatment of esophageal cancer. However, recurrence of ESCC is common regardless of the NAC regimen and surgical method, and NAC demonstrates limited efficacy against recurrence. Therefore, the present study was conducted to identify risk factors of recurrence of ESCC with surgery after NAC. The outcomes of 51 patients who underwent esophagectomy for ESCC after NAC from 2010 to 2017 at Kyushu University Hospital were retrospectively analyzed. A total of 52 patients with ESCC without NAC followed by esophagectomy from 2001 to 2017 were selected for comparison. Among patients who underwent NAC followed by surgery, only lymphatic invasion (LY; hazard ratio, 2.761; 95% CI, 1.86-6.43, P=0.018) was an independent factor significantly associated with 3-year recurrence-free survival in the multivariate analysis. In patients with pathologic lymph node metastasis (pN) and no LY after NAC, there was significantly less recurrence compared with patients with pN and LY (P=0.0085), whereas in patients without LY after NAC, the presence of pN was not significantly associated with recurrence (P=0.2401). There were significantly fewer LY (+) patients in the NAC (+) group (P=0.0158) compared with those in the NAC (-) group. The presence of LY was an independent risk factor for recurrence of ESCC after esophagectomy following NAC. Overall, adjuvant treatment after surgery may be required in cases with remnant LY after NAC.

A modified survival model for patients with esophageal squamous cell carcinoma based on lymph nodes: A study based on SEER database and external validation

Background

The counts of examined lymph nodes (ELNs) in predicting the prognosis of patients with esophageal squamous cell carcinoma (ESCC) is a controversial issue. We conducted a retrospective study to develop an ELNs-based model to individualize ESCC prognosis.

Methods

Patients with ESCC from the SEER database and our center were strictly screened. The optimal threshold value was determine by the X-tile software. A prognostic model for ESCC patients was developed and validated with R. The model’s efficacy was evaluated by C-index, ROC curve, and decision curve analysis (DCA).

Results

3,629 cases and 286 cases were screened from the SEER database and our center, respectively. The optimal cut-off value of ELNs was 10. Based on this, we constructed a model with a favorable C-index (training group: 0.708; external group 1: 0.687; external group 2: 0.652). The model performance evaluated with ROC curve is still reliable among the groups. 1-year AUC for nomogram in three groups (i.e., 0.753, 0.761, and 0.686) were superior to that of the TNM stage (P < 0.05). Similarly, the 3-year AUC and the 5-year AUC results for the model were also higher than that of the 8th TNM stage. By contrast, DCA showed the benefit of this model was better in the same follow-up period.

Conclusion

More than 10 ELNs are helpful to evaluate the survival of ESCC patients. Based on this, an improved model for predicting the prognosis of ESCC patients was proposed.

The Relationship Between Lymph Node Ratio and Survival Benefit With Adjuvant Chemotherapy in Node-positive Esophageal Adenocarcinoma

BACKGROUND

We hypothesized that the ratio of positive lymph nodes to total assessed lymph nodes (LNR) is an indicator of cancer burden in esophageal adenocarcinoma and may identify patients who may most benefit from AC.

OBJECTIVE

The aim of this study was to discern whether there is a threshold LNR above which AC is associated with a survival benefit in this population.

METHODS

The 2004-2015 National Cancer Database was queried for patients who underwent upfront, complete resection of pT1-4N1-3M0 esophageal adenocarcinoma. The primary outcome, overall survival, was examined using multivariable Cox proportional hazards models employing an interaction term between LNR and AC.

RESULTS

A total of 1733 patients were included: 811 (47%) did not receive AC whereas 922 (53%) did. The median LNR was 20% (interquartile range 9-40). In a multivariable Cox model, the interaction term between LNR and receipt of AC was significant (P = 0.01). A plot of the interaction demonstrated that AC was associated with improved survival beyond a LNR of about 10%-12%. In a sensitivity analysis, the receipt of AC was not associated with improved survival in patients with LNR <12% (hazard ratio 1.02; 95% confidence interval 0.72-1.44) but was associated with improved survival in those with LNR ≥12% (hazard ratio 0.65; 95% confidence interval 0.50-0.79).

CONCLUSIONS

In this study of patients with upfront, complete resection of node-positive esophageal adenocarcinoma, AC was associated with improved survival for LNR ≥12%. LNR may be used as an adjunct in multidisciplinary decision-making about adjuvant therapies in this patient population.

The prognostic performance of the log odds of positive lymph nodes in patients with esophageal squamous cell carcinoma: A population study of the US SEER database and a Chinese single-institution cohort

Background

The purpose of this study was to assess the prognostic performance of the log odds of positive lymph nodes (LODDS) value compared with the pathological N stage and lymph node ratio (LNR) in patients with esophageal squamous cell carcinoma (ESCC).

Method

In total 1144 patients diagnosed with ESCC from the Surveillance, Epidemiology, and End Results (SEER) database and 930 patients from our validation cohort were eligible. Kaplan–Meier plotter and multivariate Cox proportional hazards models were conducted to investigate the prognostic value of the N stage, LNR stage, and LODDS stage. The homogeneity, discriminatory ability, and monotonicity of these variables were evaluated using the linear trend χ² test, likelihood ratio χ² test, Akaike information criterion (AIC), and consistency index (C‐index) to determine the potential superiorities.

Results

The prognostic LODDS cutoff values were determined to be −1.49 and −0.55 (p < 0.001). Univariate analyses showed significant association among the N, LNR, and LODDS stages and overall survival of the patients (all p < 0.001). Multivariate analyses confirmed that the LODDS stage remained an independent prognostic indicator in both the SEER database and our validation cohort. Subgroup analyses identified the ability of LODDS stage to distinguish heterogeneous patients within various groups in both independent databases. Furthermore, the model with the highest C‐index and smallest AIC value was the one incorporating the LODDS stage among the three investigated nodal classifications of both cohorts.

Conclusion

The novel LODDS stage demonstrated better prognostic performance than the traditional N or LNR stages in ESCC patients. It can serve as an auxiliary factor to improve prognostic performance and can be applied to evaluate the lymph node status to increase the precision of staging and evaluation of survival.

Comparison of three lymph node staging systems in evaluating the prognosis of patients with pT3 esophageal squamous cell carcinoma

To explore the prognostic value of three lymph node staging systems, including number of positive lymph nodes (pN), lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS), in patients with pT3 stage esophageal squamous cell carcinoma (ESCC). Data from 1667 patients with pT3 stage ESCC who underwent surgical resection were reviewed. The log-rank test was used to assess the differences in overall survival (OS) between groups. Multivariate analysis was performed to identify independent prognostic factors. The receiver operating characteristic curve was used to assess the prognostic accuracy of the three staging methods. The median survival time for the entire group was 48.0 months, and the 1-, 3- and 5-year OS rates were 83.9%, 55.1% and 66.6%, respectively. All three lymph node staging systems were significantly correlated with OS in univariate and multivariate analyses. However, LNR and LODDS staging systems could more accurately predict survival than the pN staging system in patients with < 15 lymph nodes dissected, while LODDS have the best prognostic homogeneity. All three staging systems could be used for prognostic assessment in pT3 stage ESCC. But LODDS staging system might be superior to the others due to its prognostic homogeneity.

The Value of Lymphadenectomy Post-Neoadjuvant Therapy in Carcinoma Esophagus: a Review

Lymph nodal metastasis is one of the most important prognostic factors determining survival in patients with carcinoma esophagus. Radical esophagectomy, with the resection of surrounding lymph nodes, is considered the prime treatment of carcinoma esophagus. An extensive lymphadenectomy improves the accuracy of staging and betters locoregional control, but its effect on survival is still not apparent and carries the disadvantage of increased morbidity. The extent of lymphadenectomy during esophagectomy also remains debatable, with many studies revealing contradictory results, especially in the era of neoadjuvant therapy. The pattern of distribution and the number of nodal metastasis are modified by neoadjuvant therapy. The paper reviews the existing evidence to determine whether increased lymph node yield improves oncological outcomes in patients undergoing esophagectomy with particular attention to those patients receiving neoadjuvant therapy.

Surgical Outcomes After Neoadjuvant Chemoradiation Followed by Curative Surgery in Patients With Esophageal Cancer: An Intergroup Phase lll Trial of the Swiss Group for Clinical Cancer Research (SAKK 75/08)

OBJECTIVE

To assess the impact of surgical technique in regard to morbidity and mortality after neoadjuvant treatment for esophageal cancer.

BACKGROUND

The SAKK trial 75/08 was a multicenter phase III trial (NCT01107639) comparing induction chemotherapy followed by chemoradiation and surgery in patients with locally advanced esophageal cancer.

METHODS

Patients in the control arm received induction chemotherapy with cisplatin and docetaxel, followed by concomitant chemoradiation therapy with cisplatin, docetaxel, and 45Gy. In the experimental arm, the same regimen was used with addition of cetuximab. After completion of neoadjuvant treatment, patients underwent esophagectomy. The experimental arm received adjuvant cetuximab. Surgical outcomes and complications were prospectively recorded and analyzed.

RESULTS

Total of 259 patients underwent esophagectomy. Overall complication rate was 56% and reoperation rate was 15% with no difference in complication rates for transthoracic versus transhiatal resections (56% vs 54%, P = 0.77), nor for video assisted thoracic surgeries (VATS) versus open transthoracic resections (67% vs 55%, P = 0.32). There was a trend to higher overall complication rates in squamous cell carcinoma versus adenocarcinoma (65% vs 51%, P = 0.035), and a significant difference in ARDS in squamous cell carcinoma with 14% versus 2% in adenocarcinoma (P = 0.0002). For patients with involved lymph nodes, a lymph node ratio of ≥0.1 was an independent predictor of PFS (HR 2.5, P = 0.01) and OS (HR 2.2, P = 0.03).

CONCLUSIONS

This trial showed no difference in surgical complication rates between transthoracic and transhiatal resections. For patients with involved lymph nodes, lymph node ratio was an independent predictor of progression free survival and overall survival.

Critical number of lymph node involvement in esophageal and gastric cancer and its impact on long-term survival-A single-center 8-year study

BACKGROUND

Nodal disease in esophageal and gastric cancer is associated with poor survival.

OBJECTIVES

To determine the critical level of lymph node involvement where survival becomes significantly compromised.

METHODS

Survival analyses using multivariable Cox regression and receiver operator characteristics (ROC) were undertaken to determine what number of positive lymph nodes were most sensitive and specific in predicting survival.

RESULTS

A total of 317 patients underwent esophagectomy (n = 190, 59.9%) and gastrectomy (n = 127, 40.1%) for adenocarcinoma. At multivariable analyses, four nodes positivity (irrespective of T-category) was associated with nearly a fivefold increased risk of mortality when compared to node-negative patients (hazard ratio [HR], 4.9; interquartile range 2.0-11.5; P < .001). A positive ratio of up to 50.0% was not associated with worse survival than having four nodes positive (HR, 4.6; 95% confidence interval, 2.6-8.1; P < .001). ROC analysis demonstrated four lymph nodes positive to have a sensitivity of 80.5%, a specificity of 60.1%, and an accuracy of 77.8 (P < .001).

CONCLUSION

The absolute number of nodes positive for cancer is more important than the proportion of positive nodes in predicting survival in esophageal/gastric cancer. Four positive lymph nodes are associated with a fivefold increase in mortality. Beyond this, increasing numbers of positive lymph nodes make no appreciable difference to survival.

[Positive lymph node ratio ≥0.16 is an independent risk factor affecting the prognosis of patients with esophageal cancer]

OBJECTIVE

To investigate the value of positive lymph node ratio (LNR) in predicting the prognosis of patients with esophageal cancer.

METHODS

We retrieved the data of a total of 862 patients with esophageal cancer with complete clinical pathology data archived in SEER database in 2010 to 2015. The best cutoff point of LNR was selected using X-tile software. Univariate and multivariate COX proportional hazard models were used to assess the value of LNR in predicting the prognosis of patients after propensity score matching (PSM).

RESULTS

The best cut-off point of LNR determined using X-tile 3.6.1 software was 0.16. The patients with LNR < 0.16 and those with LNR≥0.16 showed significant differences in the number of positive lymph nodes, pathological type, T stage and M stage. After 1:1 propensity score matching, the two groups showed no significant difference in the clinical data or pathological parameters. Matched univariate and multivariate COX regression analyses showed that LNR, primary tumor site and M staging were all independent risk factors affecting the prognosis of patients, and among them LNR had the most significant predictive value (LNR < 0.16 vs LNR≥0.16: HR=1.827, 95% CI: 1.140-2.929; P=0.000). The median survival time of patients with LNR < 0.16 was 31 months (95%CI: 22.556-39.444 months), as compared with 16 months (95%CI: 12.989-19.011) in patient with LNR≥0.16 (Log Rank χ2=27.392, P < 0.0001). LNR had a better accuracy than N stage for assessing the patients' prognosis with an area under the ROC curve of 0.617 (95%CI: 0.567-0.666), as compared with 0.515 (95%CI: 0.463-0.565) of N stage (z=3.008, P=0.0026).

CONCLUSIONS

LNR≥0.16 is an independent risk factor affecting the prognosis of patients with esophageal cancer and has better prognostic value than N stage.

Lymph node ratio, an independent prognostic factor for patients with stage II-III rectal carcinoma

BACKGROUND

Identification of the proper surgical method and the most reliable prognostic parameters of rectal carcinomas is a challenging issue. The aim of this paper was to determine the possible prognostic role of the number of harvested lymph nodes versus lymph node ratio (LNR) in patients with rectal carcinomas, and the proper value of LNR that can be used as prognostic parameter.

MATERIALS AND METHODS

A retrospective study was performed in 186 consecutive patients with rectal carcinomas that underwent surgical resection. The LNR was calculated for cases from stage II-III, and was correlated with classic prognostic parameters and overall survival (OS).

RESULTS

A statistically significant difference was found between LNR of 0.15 and OS (p = 0.03), respectively LNR > 0.15 and TNM stage (p < 0.0001), but also tumor infiltration level (p < 0.05). The number of harvested lymph nodes was not correlated with the tumor stage (r = 0.148, p = 0.06) and this parameter did not influence the OS, when the number of 12 or 14 lymph nodes was used as the ideal value (p = 0.6 and p = 0.66, respectively).

CONCLUSION

In patients with rectal carcinomas that underwent preoperative chemoradiotherapy, a LNR of 0.15 is a parameter with independent prognostic value, comparing with the number of harvested lymph nodes. The specific LNR should be calculated in larger cohorts.

An RNA-seq-Based Expression Profiling of Radiation-Induced Esophageal Injury in a Rat Model

Radiation-induced acute injury is the main reason for the suspension of radiotherapy and unsuccessful treatment of cancer. It is of great importance to understand the molecular mechanism of radiation-induced esophageal injury. We used RNA-seq data from normal esophageal tissue and irradiated esophageal tissues and applied computational approaches to identify and characterize differentially expressed genes and detected 40 059 messenger RNAs (mRNAs) previously annotated and 717 novel long noncoding RNAs (lncRNAs). There were 14 upregulated and 32 downregulated lncRNAs among the differentially expressed lncRNA group. Their target genes were involved in the mRNA surveillance pathway, pathological immune responses, and cellular homeostasis. Additionally, we found 853 differentially expressed mRNAs, and there were 384 upregulated and 469 downregulated mRNAs. Notably, we found that the differentially expressed mRNAs were enriched for steroid biosynthesis, the tumor necrosis factor signaling pathway, focal adhesion, pathways in cancer, extracellular matrix-receptor interaction, and so on. The response of normal esophageal tissues to ionizing radiation is multifarious. The radiation-induced cell damage response by multiple pathways followed by pathological immune responses activated. Studies on the dynamic network of molecules involved in radiation-induced esophageal injury are under way to clarify the regulatory mechanisms and identify the candidate targets.

Pattern of recurrence and prognostic factors in patients with pT1-3 N0 esophageal squamous cell carcinoma after surgery: analysis of a single center experience

Background

The aims of this study were to determine the recurrence rate and the prognostic factors for recurrence-free survival (RFS) in esophageal squamous cell carcinoma (ESCC) patients without lymph node metastasis (LNM).

Methods

Between January 2011 and June 2017, 101 patients with ESCC were treated and pathologically confirmed to be lymph node negative. The clinicopathological parameters were evaluated to identify the prognostic factors for RFS using Cox proportional hazards models.

Results

Nineteen out of 101 patients (18.8%) developed recurrence, and the median RFS was 41 months. The most common pattern of relapse was local recurrence (n = 11; 57.9%), followed by distant recurrence (n = 7; 36.8%); one patient developed local and distant recurrence simultaneously. The results of multivariate analysis showed that the independent prognostic factors for decreased RFS in node-negative patients were a tumor located in the upper chest (odds ratio [OR], 0.767; 95% confidence intervals (CI), 1.523–14.916, P = 0.007), the presence of lymphovascular invasion (OR, 3.534; 95% CI, 1.077–11.596, P = 0.037), and a preoperative serum carcinoembryonic antigen level ≥ 5 μg/ml (OR = 5.466; 95% CI, 1.590–18.787, P = 0.007).

Conclusions

The aforementioned parameters were the prognostic factors in node-negative ESCC patients, and they associated with a higher probability of recurrence after surgery. These patients should be followed closely, and adjuvant therapy should be considered.

Metastatic to negative lymph node ratio demonstrates significant prognostic value in patients with esophageal squamous cell carcinoma after esophagectomy

Aims

The prognostic value of metastatic lymph node ratio (LNR) has been reported in some studies; however, there is no report on the prognostic significance of metastatic to negative lymph node ratio (MNLNR) in cancer patients. The aim of this study was to compare the prognostic value of pN, LNR and MNLNR on the survival of patients with esophageal squamous cell carcinoma (ESCC) after esophagectomy.

Methods

The data of 290 patients with ESCC after curative esophagectomy was retrospectively analyzed. The optimal cut-point for LNR and MNLNR were set as 0, 01-0.2, and >0.2. Univariate and multivariate analyses were performed to identify prognostic factors for overall survival (OS).

Results

Patients classified as LNR 0, 0.01-0.20, and 0.21-1.0, the observed 5-year OS rates were 46.6%, 26.0%, and 11.6%, respectively (P = 0.000). Patients classified as MNLNR 0, 0.01-0.20, and >0.2, the observed 5-year OS rates were 46.6%, 31.2%, and 7.4%, respectively, respectively (P = 0.000). The pN stage, LNR or MNLNR category was confirmed as a significant independent prognostic factor, respectively (P = 0.032, P = 0.011 and P = 0.003, respectively); However, only the MNLNR category (P = 0.003) remained as a significant prognostic factor when the pN stage, LNR and MNLNR category simultaneously included in the multivariate analysis models.

Conclusions

The MNLNR was recognized as an independent prognostic factor in ESCC patients after curative esophagectomy. In addition, MNLNR showed better prognostic value than pN stage and LNR category.

Pathologic lymph node ratio is a predictor of esophageal carcinoma patient survival: a literature-based pooled analysis

The positive lymph node ratio (LNR) has been suggested as a predictor of survival in patients with esophageal carcinoma (EC). However, existed evidences did not completely agree with each other. We sought to examine whether LNR was associated with overall survival (OS). Electronic database was searched for eligible literatures. The primary outcome was the relationship between LNR and OS, which was presented as hazard ratio (HR) with 95% confidence intervals (CIs). All statistical analyses were performed using STATA 11.0 software. A total of 18 relevant studies which involved 7,664 cases were included. Patients with an LNR of 0.3 or greater had an increased risk of death compared to those with an LNR of less than 0.3(HR = 2.33; 95% CI 2.03-2.68; P<0.01). Similarly, patients with an LNR greater than 0.5 was also associated with a decreased OS(HR = 1.95; 95% CI 1.52-2.50; P<0.01). No publication bias was found. This meta-analysis confirmed that LNR was a significant predictor of survival in patients with EC and should be considered in prognostication.

Lymph node ratio, but not the total number of examined lymph nodes or lymph node metastasis, is a predictor of overall survival for pancreatic neuroendocrine neoplasms after surgical resection

Aim

To evaluate the prognostic significance of lymph node metastasis, extent of examined lymph nodes (ELNs) and lymph node ratio (LNR) for resected pancreatic neuroendocrine neoplasms (pNENs).

Materials and Methods

Surgically resected pNENs were assimilated from the Surveillance, Epidemiology, and End Results database. Kaplan-Meier and Cox proportional hazard models were used to examine the prognostic effect of clinicopathological characteristics on overall survival; Harrell's concordance index was performed to assess the prognostic accuracy of all independent prognostic factors; and the Spearman's rank correlation was used to assess the correlation between LNR and other clinicopathological characteristics.

Results

Totally, 1,273 pathologically confirmed pNENs were included in our study. The extent of ELNs failed to show any survival benefit in entire cohort (ELNs ≤ 12 vs. ELNs > 12, P = 0.072) or pNENs without lymph node metastasis (ELNs ≤ 28 vs. ELNs > 28, P = 0.108). Lymph node metastasis and LNR > 0.40 were significantly (both P < 0.001) adverse prognostic factors of overall survival. However, only LNR > 0.40 was the independent predictor of survival after adjusted for other clinicopathological characteristics. Besides LNR, the age, gender, primary tumor site, grade and stage also were the independent predictors of overall survival; and this survival model had an acceptable predictive power (Harrell's concordance index, 0.731).

Conclusions

The current study suggested that the LNR, not the total number of ELNs and the lymph node metastasis, is an independent prognostic indicator of overall survival for pNENs after surgical resection.

Log odds of positive lymph nodes is a novel prognostic indicator for advanced ESCC after surgical resection

BACKGROUND

To investigate the prognostic value of the log odds of positive lymph nodes (LODDS) in patients with advanced esophageal squamous cell carcinoma (ESCC) after surgical resection.

METHODS

Clinical data of 260 patients with advanced ESCC undergoing surgical resection were retrospectively reviewed. Univariate and multivariate analysis were done using the chi-square test and Cox regression model. Receiver-operating-characteristic (ROC) curve was used to compare the association of pathologic nodal (pN) and LODDS with 3- or 5-year overall survival (OS). The cut-point analyses were performed to determine whether there was a cutoff LODDS related to the greatest OS difference.

RESULTS

The mean follow-up duration was 30 months (range, 3 to 106 months). The 1-, 3-, 5-year OS rates were 70.0%, 41.9% and 30.3%, respectively. Univariate analyses indicated that the 5-year OS rates were 51.2%, 30.5%, 24.6%, and 14.2% in LODDS1, LODDS2, LODDS3, and LODDS4, respectively, and the median survival times were 68.7, 34.6, 24.0, and 14.6 months, respectively (P=0.000) for all patients, and subgroup analysis showed the effect did not change in 155 patients without lymph node (LN) metastasis (P=0.024). Multivariate analysis showed that LODDS [hazard ratio (HR) =1.309, P=0.003] to be independent and significant prognostic factors for all patients, so as in node-negative patients LODDS (HR =1.610, P=0.038). The AUC of LODDS stage (AUC =0.630) was larger than that of pN stage (AUC =0.621) in prediction of 3-year OS, however LODDS were smaller in prediction of 5-year OS (AUC =0.620, 0.631, respectively), and the differences were not statistically significant (P>0.05 all). Lastly, the step analysis identified the best cut-off point for LODDS as -1.2 that is significantly associated with the prognosis of the node-negative patients (P=0.024), and the ROC analysis also indicated that a cut-off value of -1.2 for LODDS provided the highest sensitivity and specificity interestingly.

CONCLUSIONS

LODDS may be suitable for evaluation of OS in advanced ESCC patients without LN metastasis.

Prognosis of patients with esophageal squamous cell carcinoma after esophagectomy using the log odds of positive lymph nodes

To compare the log odds of positive lymph nodes (LODDS) with the number of positive lymph nodes (pN), lymph node ratio (LNR), removed lymph node (RLN) count, and negative lymph node (NLN) count in determining the prognosis of patients with esophageal squamous cell carcinoma (ESCC) after esophagectomy. The records of patients with ESCC who received esophagectomy were retrospectively reviewed. The log-rank test was used to compare curves for overall survival (OS), and Cox regression analysis was performed to identify prognostic factors. The prognostic performance of the different lymph node staging systems were compared using the linear trend chi-square test, likelihood ratio chi-square test, and Akaike information criterion. A total of 589 patients were enrolled. Univariate Cox analysis showed that pN stage, LNR, RLN count, NLN count, and the LODDS were significantly associated with OS (p < 0.05 for all). Multivariate Cox analysis adjusted for significant factors indicated that LODDS was independent risk factor on overall survival (OS), and a higher LODDS was associated with worse OS (hazard ratio = 3.297, 95% confidence interval: 2.684–4.050, p < 0.001). The modified Tumor-LODDS-Metastasis staging system had better discriminatory ability, monotonicity, and homogeneity, and better optimistic prognostic stratification than the Tumor-Node-Metastasis staging system in determining the prognosis of patients with ESCC. The LODDS staging system was superior to other lymph node classifications in determining the prognosis of patients with ESCC after esophagectomy. LODDS may be incorporated into esophageal staging system if these results are eventually confirmed by other studies.

Prognostic significance of lymph node metastasis in esophageal squamous cell carcinoma

Prediction of lymph node metastasis in esophageal squamous cell carcinoma (ESCC) is very important to have prognostic significance. The objective of this study which involved a relatively large number of ESCC patients was to investigate the correlated factors for lymph node metastasis and prognosis in ESCC. We analyzed a retrospective review of 446 patients with ESCC treated by esophagectomy between January 2010 and July 2016. The relationship between lymph node metastasis and clinicopathological parameters were analyzed. The association between overall survival and clinicopathological factors were evaluated using univariate and multivariable Cox regression models. In the present study, 36.8% esophageal squamous cell carcinoma patients were histologically shown to have lymph node metastasis. Lymph node metastasis was closely correlated with tumor differentiation (p=0.016), perineural invasion (p=0.022), advanced stage tumor (p<0.001) and venous invasion (p<0.001). Kaplan-Meier survival analysis revealed that patients with tumor size, higher T stage, perineuronal invasion, lymph node metastasis, N stage and LNR higher than 0.2 had unfavorable prognosis (p<0.05). The univariate analysis revealed for overall survival that tumor size, pathological stage, perineuronal invasion, lymph metastasis, N stage, involved LNR were relevant prognostic indicators. Furthermore, tumor size, lymph metastasis, N stage and LNR could as independent prognostic factors.

The Prognostic Impact of Lymph Node Involvement in Large Scale Operable Node-Positive Esophageal Squamous Cell Carcinoma Patients: A 10-Year Experience

Background

Lymph node (LN)-related factors including the number of LN regions involved, the LN ratio (LNR), and the number of metastatic LNs are strong prognostic indicators for esophageal squamous cell carcinoma (ESCC) patients. Accurately staging LN involvement may improve the stratification of patients and guide the management of patients.

Methods

A total of 688 potentially resectable patients who had regional LN metastases were enrolled in this retrospective study.

Results

ESCC involving a single region was associated with better outcomes than that involving multiple regions (P < 0.001 for both PFS and OS). An increased number of metastatic LNs was significantly associated with reduced PFS and OS based on univariate analysis (P < 0.001). PFS and OS were significantly higher in patients with a lower cancer-involved LNR, with 5-year OS rates of 9.7% and 31.4% for patients with a lower and higher cancer-involved LNR, respectively. Based on multivariate analysis, patients with N1 LN involvement experienced longer survival than patients with N2 LN involvement (HR: 1.37; 95% CI: 1.12-1.68) or N3 LN involvement (HR: 1.96; 95% CI: 1.52-2.53). Higher LNR resulted in longer OS than lower LNR based on multivariate analysis (HR: 1.45; 95% CI: 1.15-1.84; P = 0.002).

Conclusions

Our study has shown that not only the number of metastatic LNs but also the number of involved LN regions predicts outcomes after definitive surgery among Chinese patients with N-positive ESCC. LNR might serve as a powerful indicator that should be included in TNM staging for EC patients.