Prognostic value of different lymph node staging methods in esophageal squamous cell carcinoma after esophagectomy

Sex differences in survival following surgery for esophageal cancer: A systematic review and meta-analysis

The impact of sex on the prognosis of patients with esophageal cancer remains unclear. Evidence supports that sex- based disparities in esophageal cancer survival could be attributed to sex- specific risk exposures, such as age at diagnosis, race, socioeconomic status, smoking, drinking, and histological type. The aim of our study is to investigate the role of sex disparities in survival of patients who underwent surgery for esophageal cancer. A systematic review and meta-analysis of the existing literature in PubMed, EMBASE, and CENTRAL from December 1966 to February 2023, was held. Studies that reported sex-related differences in survival outcomes of patients who underwent esophagectomy for esophageal cancer were identified. A total of 314 studies were included in the quantitative analysis. Statistically significant results derived from 1-year and 2-year overall survival pooled analysis with Relative Risk (RR) 0.93 (95% Confidence Interval (CI): 0.90-0.97, I2 = 52.00) and 0.90 (95% CI: 0.85-0.95, I2 = 0.00), respectively (RR < 1 = favorable for men). In the postoperative complications analysis, statistically significant results concerned anastomotic leak and heart complications, RR: 1.08 (95% CI: 1.01-1.16) and 0.62 (95% CI: 0.52-0.75), respectively. Subgroup analysis was performed among studies with <200 and > 200 patients, histology types, study continent and publication year. Overall, sex tends to be an independent prognostic factor for esophageal carcinoma. However, unanimous results seem rather obscure when multivariable analysis and subgroup analysis occurred. More prospective studies and gender-specific protocols should be conducted to better understand the modifying role of sex in esophageal cancer prognosis.

Development and Validation of a Recurrence-Free Survival Prediction Model for Locally Advanced Esophageal Squamous Cell Carcinoma with Neoadjuvant Chemoradiotherapy

BACKGROUND

A recurrence-free survival (RFS) prediction model was developed and validated for patients with locally advanced esophageal squamous cell carcinoma treated with neoadjuvant chemoradiotherapy (NCRT) in combination with surgery.

PATIENTS AND METHODS

We included 282 patients with esophageal squamous cell carcinoma who received neoadjuvant chemoradiotherapy (NCRT) combined with surgery, constructed three models incorporating pathological factors, investigated the discrimination and calibration of each model, and compared the clinical utility of each model using the net reclassification index (NRI) and the integrated discrimination index (IDI).

RESULTS

Multivariable analysis showed that pathologic complete response (pCR) and lymph node tumor regression grading (LN-TRG) (p < 0.05) were independent prognostic factors for RFS. LASSO regression screened six correlates of LN-TRG, vascular invasion, nerve invasion, degree of differentiation, platelet grade, and a total diameter of residual cancer in lymph nodes to build model three, which was consistent in terms of efficacy in the training set and validation set. Kaplan-Meier (K-M) curves showed that all three models were able to distinguish well between high- and low-risk groups (p < 0.01). The NRI and IDI showed that the clinical utility of model 2 was slightly better than that of model 1 (p > 0.05), and model 3 was significantly better than that of model 2 (p < 0.05).

CONCLUSIONS

Clinical prediction models incorporating LN-TRG factors have high predictive efficacy, can help identify patients at high risk of recurrence after neoadjuvant therapy, and can be used as a supplement to the  AJCC/TNM staging system while offering a scientific rationale for early postoperative intervention.

Progress in gallbladder cancer with lymph node metastasis

Gallbladder cancer (GBC) is a malignant tumor that originates from the mucosal lining of the gallbladder. It is distinctly regional and is common in certain geographic regions of developing countries. GBC has a high degree of insidiousness as well as a high propensity for metastatic spread, resulting in the majority of patients being diagnosed at an advanced stage. Lymph node metastasis (LNM) is fairly common in GBC patients and is an independent risk factor for a poor prognosis. This article is focused on the lymph node pathways and metastatic directions of GBC. Furthermore, it summarizes the different lymph node groupings, disease stages and treatments. In the future, it is of great significance to develop individualized treatment and predict the outcomes of GBC patients with different lymph node conditions.

Thoracoscopic radical esophagectomy combined with left inferior pulmonary ligament lymphadenectomy for esophageal carcinoma via the right thoracic approach: A single-center retrospective study of 30 cases

To evaluate the necessity, safety, and feasibility of left inferior pulmonary ligament lymphadenectomy during video-assisted thoracic surgery (VATS) radical esophagectomy via the right thoracic approach.Thirty patients (20 men, 10 women) with thoracic esophageal squamous cell carcinoma (ESCC) were recruited for this study. The patients' age ranged from 50 to 80 years, with an average age of 66.17 ± 7.47 years. After the patients underwent VATS radical esophagectomy and left inferior pulmonary ligament lymph node dissection (LIPLND) via the right thoracic approach, the operative outcomes included operative time, length of hospital stay, postoperative complications, number of lymph nodes removed, and postoperative pathologic results were evaluated.There were no massive hemorrhages of the left inferior pulmonary vein during the operation. The operative time of LIPLND was 8.67 ± 2.04 minutes, and the length of postoperative hospital stay was 12.23 ± 2.36 days. The postoperative complications included 2 cases of left pneumothorax, 4 pulmonary infection cases, and no chylothorax. Moreover, 68 LIPLNs were dissected, 5 of which were positive, and the degree of metastasis was 7.4%. The postoperative pathologic results showed that 3 cases of LIPLNs were positive, with a metastasis rate of 10.0%. Among them, 2 cases were SCC of the lower thoracic esophagus, and 1 case was SCC of the middle thoracic esophagus, which involved the lower segment.Thoracoscopic esophagectomy combined with left inferior pulmonary ligament lymphadenectomy for esophageal carcinoma via the right thoracic approach will not increase the difficulty of operation, increase the incidence of postoperative complications or prolong the postoperative hospital stay, and can theoretically reduce tumor recurrence. Therefore, we believe that LIPLND is necessary, safe, and feasible and is worthy of clinical popularization and application.

Meta-analysis of prognostic factors of overall survival in patients undergoing oesophagectomy for oesophageal cancer

INTRODUCTION

Currently, the American Joint Commission on Cancer (AJCC) staging system is used for prognostication for oesophageal cancer. However, several prognostically important factors have been reported but not incorporated. This meta-analysis aimed to characterize the impact of preoperative, operative, and oncological factors on the prognosis of patients undergoing curative resection for oesophageal cancer.

METHODS

This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling to determine pooled univariable hazard ratios (HRs). The study was prospectively registered with the PROSPERO database (Registration: CRD42018157966).

RESULTS

One-hundred and seventy-one articles including 73,629 patients were assessed quantitatively. Of the 122 factors associated with survival, 39 were significant on pooled analysis. Of these. the strongly associated prognostic factors were 'pathological' T stage (HR: 2.07, CI95%: 1.77-2.43, P < 0.001), 'pathological' N stage (HR: 2.24, CI95%: 1.95-2.59, P < 0.001), perineural invasion (HR: 1.54, CI95%: 1.36-1.74, P < 0.001), circumferential resection margin (HR: 2.17, CI95%: 1.82-2.59, P < 0.001), poor tumor grade (HR: 1.53, CI95%: 1.34-1.74, P < 0.001), and high neutrophil:lymphocyte ratio (HR: 1.47, CI95%: 1.30-1.66, P < 0.001).

CONCLUSION

Several tumor biological variables not included in the AJCC 8th edition classification can impact on overall survival. Incorporation and validation of these factors into prognostic models and next edition of the AJCC system will enable personalized approach to prognostication and treatment.

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 Significance of Negative Lymph Nodes in Esophageal Cancer After Curative Resection: A Retrospective Cohort Study

Objective

The impact of negative lymph nodes (NLNs) count on prognosis in esophageal cancer (EC) was analyzed using two institutions surgical database.

Methods

We conducted a retrospective study of 768 EC patients treated by surgical resection between January 2010 and December 2012. The effects of the NLNs count on prognosis was analyzed. Cox regression model was conducted to determine the significant prognostic elements.

Results

The number of NLNs was studied as a categorical variable based on the quartiles (Q1: ≤15, Q2: 16–21, Q3: 22–30, Q4: ≥31). And a better overall survival (OS) was observed with increasing number of NLNs (HR= 0.762; 95% CI, 0.596–0.974 for Q2, HR= 0.666; 95% CI, 0.516–0.860 for Q3 and HR= 0.588; 95% CI, 0.450–0.768 for Q4) (all P<0.05). Multivariate regression analysis revealed that the NLNs count was an independent prognostic factor. Besides, for patients in T2 or T3 stage, a high number of NLNs was found to be significantly associated with a favorable OS (log rank P<0.001).

Conclusion

A higher number of NLNs is independently related to the better OS in EC patients after surgical resection.

How many lymph nodes should be dissected in esophagectomy with or without neoadjuvant therapy to get accurate staging?

It is essential to dissect an adequate number of lymph nodes (LNs) to ensure staging accuracy during esophagectomy with or without neoadjuvant therapy. We developed a statistical model to quantify the probability of precise nodal staging based on previous studies. Esophageal cancer patients who underwent esophagectomy were retrospectively reviewed in the Surveillance, Epidemiology, and End Results database. A β-binomial distribution was adopted to estimate the number of understaged patients based on the numbers of positive and examined LNs. Using 6,252 patients, we estimated a 90% confidence of accurate N0 staging could be achieved by examining 17 LNs without neoadjuvant therapy. To obtain similar accuracy in N1 and N2, 20 and 25 LNs should be examined. For patients with neoadjuvant therapy, 18, 19, and 28 LNs could achieve the same accuracy. Staging accuracy was a significant prognostic factor. We found when 90% confidence had been achieved, patient survival did not improve with more LNs examined and the ratio and log odds of positive LNs did not have significant prognostic values. The statistical model we developed for precise staging in patients with different N stages is of great value in guiding lymphadenectomy. It provided risk assessment for underestimated LN metastases and guided subsequent adjuvant treatment.

A new nomogram from the SEER database for predicting the prognosis of gallbladder cancer patients after surgery

Background

To study the prognostic significance in gallbladder cancer (GBC) patients of the four N stage methods of log odds of positive lymph nodes (LODDS), lymph node ratio (LNR), and N stage in the 7th and 8^th editions of the American Joint Committee on Cancer (AJCC), and to establish a prognostic model of GBC based on LODDS.

Methods

Data of 1,321 patients with GBC who underwent surgical resection of lymph nodes from 2010 to 2014 were collected from the Surveillance, Epidemiology, and End Results (SEER) database. We then randomly divided these data into a training set (n=925) and a validation set (n=396). C-index, Akaike information criterion (AIC), and area under the curve (AUC) were calculated to evaluate the accuracy of LODDS, LNR, and N stage in the 7^th and 8^th editions of the AJCC. Cox multivariate analysis was performed to determine whether LODDS was an independent prognostic factor, and a nomogram model was established. C-index was used to evaluate the accuracy of the nomogram. A receiver operating characteristic (ROC) curve was drawn and the area under the AUC was calculated to evaluate the accuracy of the nomogram in predicting patients' 1-, 3-, and 5-year overall survival (OS).

Results

Univariate analysis showed that the four methods were all correlated with OS. Through C-index, AIC and AUC, We found that LODDS had the best accuracy of the four methods. C-index and AUC analysis revealed that the nomogram based on LODDS had excellent prognostic ability. All the results were verified in the validation set.

Conclusions

LODDS is an independent prognostic factor for GBC patients, and it is the best N stage in the SEER database. This new nomogram-containing LODDS system is a great model to predict the prognosis of GBC patients.

Prognostic significance of preoperative lymph node assessment for patients with stage pN0 esophageal squamous cell carcinoma after esophagectomy

Background

Accurate preoperative lymph node (LN) staging is important for surgical treatments of esophageal squamous cell carcinoma (ESCC). The aim of the study was to investigate the role of preoperative lymph nodes assessment by computed tomography (CT) scans in prognostic estimates and lymph nodes dissection strategy.

Methods

A total of 233 stage pN0 ESCC patients who underwent radical esophagectomy from 2009 to 2016 were included, with the last follow-up time in 2018. Survival analysis was conducted to assess the relationship between preoperative clinical LN metastasis and the prognosis of patients with pN0 ESCC.

Results

Ninety-nine patients were classified as clinical positive LN metastasis by CT scans, but were confirmed as stage N0 by postoperative pathological examination, and survival analysis suggested that these patients had relatively poorer prognosis (P=0.027). Cox regression analysis indicated that the clinical LN metastasis on CT scans was an independent negative prognostic factor for patients with pN0 ESCC (P=0.031). The number of LNs dissected affected the prognosis of pN0 patients. Patients with positive LN metastasis on CT would have better prognosis when the number of dissected LNs was equal to or more than 15 LNs (P=0.036). Especially for patients with higher T stage, they were would obtain prognostic benefit with at least 17 LNs dissected (P=0.037). On the other hand, for those with negative LN metastasis on CT, at least 12 LNs dissected indicated better prognosis (P=0.019).

Conclusions

Preoperative LN assessment for ESCC patients is critically important, the optimal LN dissection number should refer to the preoperative CT performance.

Extracellular Hsp90α clinically correlates with tumor malignancy and promotes migration and invasion in esophageal squamous cell carcinoma

Purpose

Extracellular Hsp90α (eHsp90α) is known to be involved in tumor invasiveness and metastasis, and its prognostic value in many kinds of tumors has been identified. We aimed to evaluate the clinical and functional role of eHsp90α in esophageal squamous cell carcinoma (ESCC).

Patients and methods

A total of 193 patients with newly diagnosed ESCC were retrospectively evaluated. The relationship between serum Hsp90α levels before treatment and ESCC malignancy of the patients was analyzed. To test the role of eHsp90α in migration and invasion of ESCC cell lines, transwell assay was performed. Western blotting was used to explore the possible mechanism in which eHsp90α promotes ESCC migration and invasion.

Results

We found that the serum Hsp90α level before treatment is positively correlated with ESCC malignancy. Moreover, high serum Hsp90α level before treatment was significantly correlated with positive lymph node (LN) metastasis, which is the main prognostic factor for ESCC patients. Meanwhile, we demonstrated that eHsp90α promoted migration and invasion of ECA109 and ECA9706 in vitro. Further investigations revealed that eHsp90α stabilized MMP-2 and promoted epithelial-to-mesenchymal transition evidenced by downregulation of E-cadherin and upregulation of N-cadherin. On the other hand, Hsp90α neutralizing antibody functionally blocked the secreted Hsp90α and reversed those effects.

Conclusion

Our findings prove the critical role of eHsp90α in promoting ESCC migration and invasion, indicating it can be not only a promising predictor for ESCC LN status, but also an effective target in ESCC therapeutics, especially in preventing LN metastasis.

Recurrence and prognostic model for identifying patients at risk for esophageal cancer after surgery

Objective

The aim of this study was to construct a risk model to assess overall survival (OS) and disease-free survival (DFS) in patients with esophageal cancer (EC) after surgery.

Patients and methods

A total of 872 consecutive EC patients who had undergone surgery between February 2009 and October 2012 were retrospectively analyzed. The cutoff for risk value (RV) was inferred by receiver operating characteristic curves and the Youden index. A log-rank test was used to compare the survival curves, and a Cox regression analysis was performed to clarify the significant prognostic factors.

Results

The area under the curve was 0.688 for OS and 0.645 for DFS. The survival rates were 69.4% (259/373) and 39.1% (195/499), and the rates of recurrence were 19.2% (70/364) and 27.6% (132/479), respectively, for RV<0.218 and RV≥0.218 (c²=78.83, P<0.001; c²=9.07, P=0.003; respectively). A multivariate Cox regression analysis identified cases suffering from higher overall mortalities with RV≥0.218 compared to RV<0.218 (HR=1.45; 95% CI, 1.21–2.02; P=0.015); similar results were also found for DFS (HR=1.38; 95% CI, 1.03–1.86; P=0.033). Kaplan–Meier survival curves showed that cases with RV<0.218 had better OS and DFS than cases with RV≥0.218 (log rank = 75.80, P<0.001; log rank = 24.78, P<0.001).

Conclusion

This model could be applied to an integrated assessment of recurrence and prognostic risk after the surgical treatment of EC.

Strong expression of Id-1 in metastatic lymph nodes from esophageal squamous cell carcinoma is associated with better clinical outcome

Background

Over-expression of inhibitor of differentiation or DNA binding 1 (Id-1) is associated with poor prognosis in esophageal squamous cell carcinoma (ESCC). However, some biomarkers discordant expression in metastasis has been reported previously. We aimed to confirm possible differential expression and prognostic value of Id-1 in paired metastatic lymph node (PMLN).

Methods

Expression of Id-1 in primary tumors (PT) and paired regional metastatic lymph nodes of ESCC were evaluated with immunohistochemical (IHC) analysis. Statistical analysis of Kaplan-Meier method was performed to test the prognostic significance of Id-1 expression.

Results

The expression of Id-1 was down-regulated in metastatic lymph nodes compared with primary esophageal tumors (P<0.001). Patients with 1 to 2 lymph nodes involved had significantly higher Id-1 expression in metastatic lymph nodes (P=0.028). The similar association was observed between a ratio of involved to examined lymph nodes ≤0.2 and high level Id-1 expression in lymphatic metastases (P=0.011). Better overall survival with statistical significance was observed in patients with higher level Id-1 expression in metastatic lymph nodes (P=0.015). The results of Id-1 expression in metastatic lymph node and paired PT was to predict prognosis effective in out cohort (P=0.035).

Conclusions

The level of Id-1 protein expression was down-regulated from PT to metastatic lymph node. It was contrary to previous studies that strong expression of Id-1 in metastatic lymph nodes was associated with better clinical outcomes in patients with stage T3N1-3M0 ESCC.

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.

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.

Assessment of Lymph Node Ratio to Replace the pN Categories System of Classification of the TNM System in Esophageal Squamous Cell Carcinoma

INTRODUCTION

The seventh edition of the TNM staging system for esophageal cancer outlined by the American Joint Committee on Cancer (AJCC) defines the N classification on the basis of the number of metastatic lymph nodes. However, this classification is dependent on the actual number of examined lymph nodes. Here in this study, we have focused on revising this N classification system with the metastatic lymph nodes ratio (LNR) and also assessing whether this modification to the current AJCC staging system can better define the prognostic characteristics of esophageal squamous cell carcinoma (ESCC).

METHODS

We retrospectively reviewed 916 patients with ESCC who underwent curative resection. Prognostic performance of two staging systems was compared using the Akaike information criterion value and receiver operating characteristics curve. In addition, decision curve analysis evaluated the clinical practical usefulness of the prediction models by quantifying their net benefits.

RESULTS

The univariate and multivariate Cox regression analyses indicated that LNR was an independent risk factor for overall survival. The modified staging system based on LNR had better discriminatory ability, monotonicity, homogeneity, and stratification than the TNM staging system in determining the prognosis of patients with ESCC. However, the decision curves analysis suggested that the modified staging based on LNR has poor clinical practical value over the AJCC TNM staging system.

CONCLUSIONS

LNR can supplement the pN categorization system for more effective evaluation of prognosis. But the modified staging system based on LNR has a poor clinical practical value for patients with ESCC compared with the current TNM system and is not superior to AJCC pN staging for ESCC.

Value of Positive Lymph Node Ratio for Predicting Postoperative Distant Metastasis and Prognosis in Esophageal Squamous Cell Carcinoma

BACKGROUND

The aim of this study was to investigate the relationship between positive lymph node ratio (PLNR) and postoperative distant metastasis and prognosis in esophageal squamous cell carcinoma (ESCC).

PATIENTS AND METHODS

167 ESCC patients with regional lymph node metastasis, who underwent radical esophagectomy and lymphadenectomy at the Ningbo Yinzhou People's Hospital between October 2005 and December 2010, were enrolled in this study. The prognostic value of PLNR was calculated by univariate Kaplan-Meier survival analysis and multivariate Cox proportional hazard model analysis.

RESULTS

After a median follow-up time of 34 months, 88 (52.7%) of the 167 patients had distant metastasis and 76 (45.5%) had died. Patients with a PLNR of less than 0.15 had a 5-year distant metastasis-free survival (DMFS) rate of 33.3% while those with a PLNR greater than 0.15 had a 5-year DMFS rate of 25.5% (log-rank test, p = 0.002). Multivariate analysis indicated that a PLNR > 0.15 was an independent poor prognostic factor for DMFS (hazard ratio (HR) 1.92, 95% confidence interval (CI) 1.21-3.05) and overall survival (OS) (HR 2.08, 95% CI 1.26-3.43). This analysis was adjusted for patient age, sex, smoking behavior, and pT stage.

CONCLUSION

The PLNR is an independent prognostic factor for predicting postoperative distant metastasis and prognosis in ESCC, and patients with a PLNR ≤ 0.15 have better OS.