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

Survival risk stratification based on prognosis nomogram to identify patients with esophageal squamous cell carcinoma who may benefit from postoperative adjuvant therapy

OBJECTIVE

The purpose of the study is to develop a prognosis nomogram for esophageal squamous cell carcinoma (ESCC) patients with radical resection and to identify patients who may benefit from postoperative adjuvant radiotherapy/chemoradiotherapy through survival risk stratification.

METHODS

We retrospectively enrolled patients who underwent esophagectomy in the First Affiliated Hospital of Nanjing Medical University from July 2015 to June 2017. Patients with stage I-III esophageal squamous cell carcinoma who received radical R0 resection with or without postoperative adjuvant radiotherapy/chemoradiotherapy were included. Further, patients were randomly allocated into two groups (training and validation cohorts) with a distribution ratio of 7:3. The prognosis nomogram was constructed based on independent factors determined by univariate and multivariate Cox analyses. The area under the receiver operating characteristic curve (AUC) and calibration curve were adopted to evaluate the discriminative ability and reliability of the nomogram. The accuracy and clinical practicability were respectively assessed by C-index values and decision curve analysis (DCA), and further contrasted the nomogram model and the eighth edition of the American Joint Committee on Cancer (AJCC) TNM staging system. In addition, survival risk stratification was further performed according to the nomogram, and the effect of postoperative adjuvant therapy on each risk group was appraised by the Kaplan-Meier survival analysis.

RESULTS

A total of 399 patients with esophageal squamous cell carcinoma were recruited in this study, including the training cohort (n = 280) and the validation cohort (n = 119). The nomogram-related AUC values ​​for 1, 3, and 5-year OS were 0.900, 0.795, and 0.802, respectively, and 0.800, 0.865, 0.829 in the validation cohort, respectively. The slope of the calibration curve for both cohorts was close to 1, indicating good consistency. The C-index value of the nomogram was 0.769, which was higher than that of the AJCC 8th TNM staging system by 0.061 (p < 0.001). Based on the prognosis nomogram, patients were stratified into three risk groups (low, medium, and high), and there were obvious differences in prognosis among the groups (p < 0.001). Furthermore, postoperative adjuvant therapy has been shown to enhance the 5-year survival rate by over 15% among patients classified as medium- and high-risk.

CONCLUSION

The constructed nomogram as developed resulted in accurate and effective prediction performance in survival outcomes for patients with stage I-III esophageal squamous cell carcinoma who underwent radical R0 resection, which is superior to the AJCC 8th TNM staging system. The survival risk stratification had potential clinical application to guide further personalized adjuvant therapy.

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.

Prognostic factors for patients with pathologic T1-T2N+ esophageal squamous cell carcinoma: A retrospective study with external validation

BACKGROUND

Lymph node metastasis is significantly associated with a worse prognosis in patients with localized early-stage esophageal squamous cell carcinoma. This study aimed to explore the prognostic factors and develop a nomogram for predicting survival in patients with pathologic T1-2N+ esophageal squamous cell carcinoma.

METHODS

Between 2014 and 2022, patients with pT1-2N+ esophageal squamous cell carcinoma who underwent esophagectomy with lymphadenectomy at 2 institutes were reviewed and assigned to training and external validation cohorts. Independent prognostic factors were identified via univariate and multivariate Cox regression analyses. The nomogram model was developed and evaluated by the area under the receiver operating characteristic curve and calibration curve.

RESULTS

In total, 268 patients with a median age of 65 years (range, 40-82) were included and assigned to training (n = 190) and external validation (n = 78) cohorts. The Cox proportional hazards model demonstrated that body mass index (P = .031), surgical approach (P < .001), T stage (P = .015), and Clavien-Dindo classification (P < .001) were independent prognostic factors in the training cohort. The nomogram showed good discrimination, with an area under the receiver operating characteristic curve for 1-year, 3-year, and 5-year of 0.810, 0.789, and 0.809 in the training cohort and 0.782, 0.679, and 0.698 in the validation cohort. The calibration curve showed that the predicted survival probability was in good agreement with the actual survival probability.

CONCLUSION

Lower body mass index, left surgical approach, T2 stage, and Clavien-Dindo classification grade III to V were related to worse prognosis in patients with pT1-T2N+ esophageal squamous cell carcinoma. The developed nomogram may predict individual survival accurately.

A depression-related lncRNA signature predicts the clinical outcome and immune characteristics of gastric cancer

Background

Depression and long non-coding RNA (lncRNA) have been reported to be associated with tumor progression and prognosis in gastric cancer (GC). This study aims to build a GC risk classification and prognosis model based on depression-related lncRNAs (DRLs).

Methods

To develop a risk model, we performed univariate Cox regression and least absolute shrinkage and selection operator (LASSO) regression analyses using RNA sequencing data of GC from The Cancer Genome Atlas (TCGA) and depression-related genes (DRGs) from previous studies. Kaplan-Meier analysis, receiver operating characteristic (ROC) curve analysis, nomogram construction, pathway enrichment analysis, assessment of immunological features, and drug sensitivity testing were conducted using a series of bioinformatics methods.

Results

Seven DRLs were identified to build a prognostic model, whose robustness was verified in an internal cohort. Subsequent prognostic analyses found that high risk scores were associated with worse overall survival (OS). Univariate and multivariate analyses revealed that the risk score could be used as an independent prognostic factor. Furthermore, the ROC curve indicated that the risk score had higher diagnostic efficiency than traditional clinicopathological features. The calibration curve confirmed the accuracy and reliability of the nomogram. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses showed that there were differences in digestive system and nervous system-related pathways between the high- and low-risk groups. Results of tumor mutational burden (TMB) and tumor immune dysfunction and exclusion (TIDE) analyses indicated that patients in the low-risk group had a better response rate to immunotherapy. Finally, the results of drug sensitivity analysis showed that risk score could influence sensitivity to EHT 1864 in GC.

Conclusion

We have successfully developed and verified a 7-DRL risk model which can assess the prognosis and immunological features and guide individualized therapy of GC patients.

Kinetics of plasma cell-free DNA as a prospective biomarker to predict the prognosis and radiotherapy effect of esophageal cancer

PURPOSE

The lack of reliable biomarkers for the prognosis and radiotherapy efficacy in esophageal cancer (EC) necessitates further research. The aim of our study was to investigate the predictive utility of plasma cell-free DNA (cfDNA) kinetics in patients with EC.

MATERIALS AND METHODS

We retrospectively analyzed the clinical data and cfDNA levels (pre-radiotherapy [pre-RT] and post-radiotherapy [post-RT]) and the cfDNA kinetics (cfDNA ratio: post-RT cfDNA/pre-RT cfDNA) of 88 patients. We employed Kaplan-Meier curves to examine the relationship between cfDNA and overall survival (OS) as well as progression-free survival (PFS). Univariate and multivariate Cox regression analyses were executed to ascertain the independent risk factors in EC.

RESULTS

The pre-RT cfDNA levels were positively correlated with clinical stage (P=0.001). The pre-RT cfDNA levels (cutoff value=16.915ng/mL), but not the post-RT cfDNA levels, were linked to a diminished OS (P<0.001) and PFS (P=0.0137). CfDNA kinetics (cutoff value=0.883) were positively associated with OS (P=0.0326) and PFS (P=0.0020). Notably, we identified independent risk factors for OS in EC treated with RT, including cfDNA ratio (high/low) (HR=0.447 [0.221-0.914] P=0.025), ECOG (0/1/2) (HR=0.501 [0.285-0.880] p=0.016), and histological type (esophagal squamous cell carcinoma [ESCC]/non-ESCC) (HR=3.973 [1.074-14.692] P=0.039).

CONCLUSION

Plasma cfDNA kinetics is associated with prognosis and radiotherapy effect in EC undergoing RT, suggesting potential clinical application of a cheap and simple blood-based test.

Increased resected lymph node stations improved survival of esophageal squamous cell carcinoma

BACKGROUND

Neoadjuvant chemoradiotherapy (nCRT) and surgery have been recommended as the standard treatments for locally advanced esophageal squamous cell carcinoma (ESCC). In addition, nodal metastases decreased in frequency and changed in distribution after neoadjuvant therapy. This study aimed to examine the optimal strategy for lymph node dissection (LND) in patients with ESCC who underwent nCRT.

METHODS

The hazard ratios (HRs) for overall survival (OS) and disease-free survival (DFS) were calculated using the Cox proportional hazard model. To determine the minimal number of LNDs (n-LNS) or least station of LNDs (e-LNS), the Chow test was used.

RESULTS

In total, 333 patients were included. The estimated cut-off values for e-LNS and n-LNS were 9 and 15, respectively. A higher number of e-LNS was significantly associated with improved OS (HR: 0.90; 95% CI 0.84-0.97, P = 0.0075) and DFS (HR: 0.012; 95% CI: 0.84-0.98, P = 0.0074). The e-LNS was a significant prognostic factor in multivariate analyses. The local recurrence rate of 23.1% in high e-LNS is much lower than the results of low e-LNS (13.3%). Comparable morbidity was found in both the e-LNS and n-LND subgroups.

CONCLUSION

This cohort study revealed an association between the extent of LND and overall survival, suggesting the therapeutic value of extended lymphadenectomy during esophagectomy. Therefore, more lymph node stations being sampled leads to higher survival rates among patients who receive nCRT, and standard lymphadenectomy of at least 9 stations is strongly recommended.

Role of immune related genes in predicting prognosis and immune response in patients with hepatocellular carcinoma

Immunotherapy has developed rapidly in recent years. This study aimed to establish a prognostic signature for immune-related genes (IRGs) and explore related potential immunotherapies. The RNA-seq transcriptome profiles and clinicopathological information of patients were obtained from The Cancer Genome Atlas. Differentially expressed IRGs in tumors and normal tissues were screened and a risk score signature was constructed to predict the prognosis in patients with hepatocellular carcinoma (HCC). Receiver operating characteristic curves, survival analyses, and correlation analyses were used to explore the clinical application of this model. We further analyzed the differences in clinical characteristics, immune infiltration, somatic mutations, and treatment sensitivity between the high- and low-risk populations characterized by the prognostic models. The immune cell infiltration score and immune-related pathway activity were calculated using the single sample gene set enrichment analysis (ssGSEA) set enrichment analysis. Gene ontology (GO), Kyoto encyclopedia of genes and genomes, and GSEA were used to explore the underlying mechanisms. We constructed a nine-IRG formula to predict the prognosis in HCC patients. The higher the risk score, the higher the malignancy of the tumor and the worse the prognosis. There were significant differences in immune related processes between the high- and low-risk groups. TP53 and CTNNB1 mutations were significantly different between different risk groups. The expression of model gene was closely related to the sensitivity of tumor cells to chemotherapeutic drugs. This risk score model, which is helpful for the individualized treatment of patients with different risk factors, could be a reliable prognostic tool for HCC patients.

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.

A novel metabolism-related gene signature in patients with hepatocellular carcinoma

Hepatocellular carcinoma (HCC) remains a global challenge as it is the sixth most common neoplasm worldwide and the third leading cause of cancer-related death. A key feature of HCC is abnormal metabolism, which promotes cancer cell proliferation, survival, invasion, and metastasis. However, the significance of metabolism-related genes (MRGs) in HCC remains to be elucidated. Here, we aim to establish a novel metabolism-related prognostic signature for the prediction of patient outcomes and to investigate the value of MRG expression in the prognostic prediction of HCC. In our research, a Metabolism-Related Risk Score (MRRS) model was constructed using 14 MRGs (DLAT, SEPHS1, ACADS, UCK2, GOT2, ADH4, LDHA, ME1, TXNRD1, B4GALT2, AK2, PTDSS2, CSAD, and AMD1). The Kaplan-Meier curve confirmed that the MRRS has a high accuracy in predicting the prognosis of HCC patients (p < 0.001). According to the MRRS model, the area under the curve (AUC) values for predicting the prognosis of patients with hepatocellular carcinoma at 1, 3, and 5 years reached 0.829, 0.760, and 0.739, respectively. Functional analyses revealed that signaling pathways associated with the cell cycle were largely enriched by differential genes between high and low-risk groups. In addition, dendritic cells (DCs) (p < 0.001), CD4+ T cells (p < 0.01), CD8+ T cells (p < 0.001), B cells (p < 0.001), neutrophils (p < 0.001), macrophages (p < 0.001) had a higher proportion of infiltrates in high-risk populations. Low GOT2 expression is associated with poor prognosis in patients with hepatocellular carcinoma. Knockdown of GOT2 significantly increased the migration capacity of the Huh7 and MHCC97H hepatocellular carcinoma lines. Our research reveals that GOT2 is negatively related to the survival of patients with hepatocellular carcinoma and GOT2 may contribute to tumor progression by inhibiting the ability of tumor cells to migrate.

A new lymph node ratio-based staging system for rectosigmoid cancer: a retrospective study with external validation

BACKGROUND

This study evaluated the clinical value of a new American Joint Committee on Cancer (AJCC) tumor node metastasis (TNM) staging prediction model based on lymph node ratio (LNR) in rectosigmoid cancer (RSC).

METHODS

The analysis included 1444 patients with nonmetastatic RSC diagnosed pathologically between 2010 and 2016 who were collected from the National Cancer Institute Surveillance, Epidemiology, and Results database. The AJCC N-stage was redefined according to the LNR cutoff point, and the ability of the new staging system to predict prognosis was compared with that of the AJCC TNM staging system. Data from 739 patients from our hospital were used for external validation.

RESULTS

According to the number of examined lymph nodes and LNR, the N stage was divided into five groups (LNR0-5). The 5-year OS of patients divided according to the new T lymph node ratio M (TLNRM) staging into stage I (T1LNR1, T1LNR2), IIA (T1LNR3, T2LNR1, T2LNR2, T2LNR3, T1LNR4, T3LNR1), IIB (T2LNR4), IIC (T3LNR2, T4a LNR1, T1LNR5), IIIA (T3LNR3, T2LNR5, T4b LNR1, T4a LNR2, T3LNR4), IIIB (T3LNR5, T4a LNR3, T4a LNR4, T4b LNR2), and IIIC (T4b LNR3, T4a LNR5, T4b LNR4, T4b LNR5) was significantly different ( P <0.05). Decision curve analysis showed that the net income of the new TLNRM staging system for different decision thresholds was higher than the prediction line of the traditional eighth TNM staging system. The smaller Akaike information criterion and Bayesian information suggested that the new staging system had a higher sensitivity for predicting prognosis than the traditional staging system. TLNRM II and III patients benefited from adjuvant chemotherapy, while adjuvant chemotherapy did not improve the prognosis of TNM II patients. These findings were confirmed by the external validation data.

CONCLUSION

The new TLNRM staging system was superior to the eighth edition AJCC staging system for staging and predicting the prognosis of patients with RSC and may become an effective tool in clinical practice.

High Systemic Immune-Inflammation Index, Predicting Early Allograft Dysfunction, Indicates High 90-Day Mortality for Acute-On-Chronic Liver Failure after Liver Transplantation

INTRODUCTION

The aim of the study was to investigate the relationship between systemic immune-inflammation index (SII) and early allograft dysfunction (EAD) and 90-day mortality after liver transplantation (LT) in acute-on-chronic liver failure (ACLF).

METHODS

Retrospective record analysis was done on 114 patients who had LT for ACLF. To identify the ideal SII, the receiver operating characteristic curve was used. The incidence of EAD and 90-day mortality following LT were calculated. The prognostic value of SII was assessed using the Kaplan-Meier technique and the Cox proportional hazards model.

RESULTS

The cut-off for SII was 201.5 (AUC = 0.728, p < 0.001). EAD occurred in 40 (35.1%) patients of the high SII group and 5 (4.4%) patients of the normal SII group, p < 0.001. 18 (15.8%) deaths occurred in the high SII group and 2 (1.8%) deaths occurred in the normal SII group, p = 0.008. The multivariate analysis demonstrated that SII ≥201.5, MELD ≥27 were independent prognostic factors for 90-day mortality after LT.

CONCLUSION

SII predicts the occurrence of EAD and is an independent risk factor for 90-day mortality after LT.

Can C-reactive protein/albumin ratio be a prognostic factor in acute stroke patients undergoing mechanical thrombectomy?

INTRODUCTION

C-reactive protein (CRP) and albumin are markers synthesized by the liver and may reflect inflammatory responses. CRP/Albumin ratio (CAR) serves better to reflect the inflammatory state and therefore the prognosis. Worse prognosis is reported in previous studies when CAR rate on admission is high in patients with stroke, aneurysmal subarachnoid hemorrhage, malignancy or patients followed in intensive care units. We aimed to investigate the relation of CAR with prognosis in mechanical thrombectomy performed acute stroke patients.

MATERIALS AND METHODS

Stroke patients admitted to five different stroke centers between January 2021 and August 2022 undergoing mechanical thrombectomy were included and retrospectively analyzed. The CAR ratio was calculated as the ratio of CRP to albumin level in the venous blood samples. Primary outcome was the relation between CAR and functional outcome at 90 days determined by modified Rankin Scale (mRS).

RESULTS

This study included 558 patients with a mean age of 66,5 ± 12.5 years (age range:18-89 years) best cutoff value of the CAR was 3.36, with 74.2 % sensitivity and 60.7 % specificity (Area under the curve: 0.774; 95 %CI: 0.693-0.794). There was no significant correlation between CAR rate and age, CAR rate and NIHSS on admission, and also between CAR rate and symptom recanalization (p > 0.05). CAR ratio in the mRS 3-6 group was statistically significantly higher (p < 0.001). In the multivariate analyses, CAR showed an association with 90-day mortality (odds ratio, 1.049; 95 % CI, 1.032-1.066) CONCLUSION: In acute ischemic stroke patients treated with mechanical thrombectomy, CAR may be one of the factors affecting poor clinical outcome and/or mortality in patients undergoing mechanical thrombectomy. Upcoming similar studies in this patient group may better clarify the prognostic role of CAR.

Lymph Node Ratio Improves Prediction of Overall Survival in Esophageal Cancer Patients Receiving Neoadjuvant Chemoradiotherapy: A National Cancer Database Analysis

OBJECTIVE

This study aimed to propose a revised ypN (r-ypN) classification based on lymph node ratio (LNR) and to examine its prognostic value in postneoadjuvant esophageal cancer.

BACKGROUND

A new postneoadjuvant pathologic (ypTNM) staging classification has been introduced for esophageal cancer. However, the ypN classification currently defined by the number of positive lymph nodes is influenced by the extent of lymphadenectomy.

METHODS

Data on 7195 esophageal cancer patients receiving neoadjuvant chemoradiation were extracted from the National Cancer Database (NCDB). Four r-ypN stages were defined by 3 LNR thresholds (0%, 10%, and 20% using X-tile software). A revised ypTNM (r-ypTNM) classification was developed by solely changing N categories. Kaplan-Meier method and Cox proportional hazards models were used for survival analyses. Akaike information criterion (AIC) and Harrell's concordance index ( C -index) were used to compare the predictive performance of the current and the revised classification. External validation was performed using an independent cohort from the NEOCRTEC5010 clinical trial.

RESULTS

Both ypN ( P <0.001) and r-ypN ( P <0.001) were independent prognostic factors of overall survival (OS) for esophageal cancer patients. Kaplan-Meier curves demonstrated a better discrimination with r-ypN than ypN categories. Within each ypN category (except ypN3), OS was significantly different comparing r-ypN strata; however, there were no differences between ypN strata within each r-ypN category (except r-ypN3). r-ypN (AIC: 60752 vs 60782; C -index: 0.591 vs 0.587) and r-ypTNM (AIC: 60623 vs 60628; C -index: 0.613 vs 0.610) showed better predictive performance than the current staging system, with a lower AIC (better calibration) and higher C -index (improved discrimination). This advantage was also confirmed by external validation using the NEOCRTEC5010 cohort.

CONCLUSIONS

LNR showed better performance than ypN in predicting OS of esophageal cancer patients after neoadjuvant chemoradiation and may be an improvement on the current staging system.

PLEK2 and IFI6, representing mesenchymal and immune-suppressive microenvironment, predicts resistance to neoadjuvant immunotherapy in esophageal squamous cell carcinoma

BACKGROUND

Immunotherapy has largely improved clinical outcome of patients with esophageal squamous cell carcinoma (ESCC). However, a proportion of patients still fail to benefit. Thus, biomarkers predicting therapeutic resistance and underlying mechanism needs to be investigated.

METHODS

Transcriptomic profiling was applied in FFPE tissues from 103 ESCC patients, including surgical samples from 66 treatment-naïve patients with long-term follow-up, and endoscopic biopsies from 37 local advanced ESCC cases receiving neoadjuvant immunotherapy plus chemotherapy. Unsupervised clustering indicated an aggressive phenotype with mesenchymal character in 66 treatment-naïve samples. Univariant logistic regression was applied to identify candidate biomarkers potentially predicted resistance to neoadjuvant immunotherapy within the range of mesenchymal phenotype enriched genes. These biomarkers were further validated by immunohistochemistry. Putative mechanisms mediating immunotherapy resistance, as indicated by microenvironment and immune cell infiltration, were evaluated by transcriptomic data, and validated by multiplex immunofluorescence.

RESULTS

PLEK2 and IFI6, highly expressed in mesenchymal phenotype, were identified as novel biomarkers relating to non-MPR in neoadjuvant immunotherapy cohort [PLEK2^high, OR (95% CI): 2.15 (1.07-4.33), P = 0.032; IFI6^high, OR (95% CI): 2.21 (1.16-4.23), P = 0.016). PLEK2^high and IFI6 ^high ESCC patients (versus low expressed patients) further exhibit higher chance of non-major pathological remissions (90%, P = 0.004) in neoadjuvant immunotherapy cohort and high mortality (78.9%, P = 0.05), poor prognosis in retrospective cohort. PLEK2^high/IFI6^high ESCC recapitulated mesenchymal phenotype, characterized by extracellular matrix composition and matrix remodeling. In addition, PLEK2^high or IFI6^high ESCC displayed an immune-unfavored microenvironment, represented by positive correlating with regulatory T cells, Helper 2 T cell as well as less infiltration of B cells, effector T cells and mast cells.

CONCLUSIONS

PLEK2 and IFI6 was discovered of first time to identify a distinct ESCC subpopulation cannot be benefited from neoadjuvant immunotherapy and present a poor survival, which putatively associated with mesenchymal and immune-suppressive microenvironment.

Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio as Predictive Factors for Mortality and Length of Hospital Stay after Cardiac Surgery

Background: Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are widely accepted indices positively correlated with disease severity, progression, and mortality. In this study, we tested whether NLR and PLR could predict mortality and length of hospital stay (LOS) after cardiac surgery. Methods: NLR and PLR were calculated on days 0, 3, 5, and 7 postoperatively. A ROC curve was generated to assess their prognostic value; multivariate logistic analysis identified independent risk factors for 90-day mortality. Results: Analysis was performed on 179 patients’ data, 11 of whom (6.15%) died within 90 days. The discriminatory performance for predicting 90-day mortality was better for NLR7 (AUC = 0.925, 95% CI:0.865–0.984) with the optimal cut-off point being 7.10. NLR5 and PLR3 also exhibited a significant strong discriminative performance. Similarly, a significant discriminative performance was prominent for PLR3, NLR5, and NLR7 with respect to LOS. Moreover, NLR7 (OR: 2.143, 95% CI: 1.076–4.267, p = 0.030) and ICU LOS (OR:1.361, 95% CI: 1.045–1.774, p = 0.022) were significant independent risk factors for 90-day mortality. Conclusions: NLR and PLR are efficient predictive factors for 90-day mortality and LOS in cardiac surgery patients. Owing to the simplicity of determining NLR and PLR, their postoperative monitoring may offer a reliable predictor of patients’ outcomes in terms of LOS and mortality.

Single-cell transcriptome analysis reveals functional changes in tumour-infiltrating B lymphocytes after chemotherapy in oesophageal squamous cell carcinoma

BACKGROUND

Tumour immune microenvironment is related with carcinogenesis and efficacy of immunotherapy. B cells play major roles in humoral immunity, but detailed functions of tumour-infiltrating B lymphocytes (TIL-Bs) are unknown. Therefore, our aim was to investigate the functional heterogeneity of TIL-Bs in oesophageal squamous cell carcinoma (ESCC) and lymph nodes (LNs) during chemotherapy.

METHODS

Single-cell transcriptome analysis was performed on 23 specimens. We also performed immunohistochemical analysis of immunoglobulin κ C (IGKC), an antibody-secreting cell (ASC) marker, in 166 ESCC samples and evaluated the implication of IGKC in 2-year recurrence free survival (RFS) and 3-year overall survival (OS).

RESULTS

A total of 81,246 cells were grouped into 24 clusters. We extracted B cell clusters based on canonical markers and identified 12 TIL-B subtypes in ESCC. We found that several functions, such as co-stimulation and CD40 signalling, were enhanced in TIL-Bs after chemotherapy. The proportion of naive B cells (NBCs) decreased and B cell activation genes were up-regulated in NBCs after chemotherapy. The proportion of ASCs in tumours increased with the loss of migratory abilities and antibody production in ASCs was promoted after chemotherapy. Differentially expressed genes up-regulated with chemotherapy in ASCs correlated with prolonged survival with oesophageal cancer (p = .028). In a metastatic LN, the ASC proportion increased and B cell differentiation was enhanced. In immunohistochemical analysis, RFS and OS of high IGKC expression cases were significantly better than those of low IGKC expression cases (RFS: p < .0001, OS: p < .0001). And in multivariable analysis, the expression of IGKC was an independent favourable prognostic factor for RFS (hazard ratio (HR): 0.23, 95% confidence interval (CI): 0.12-0.45, p < .0001) and OS (HR: 0.20, 95% CI: 0.086-0.47, p = .0002) in ESCC.

CONCLUSIONS

Our findings provide novel insights for the heterogeneity of TIL-Bs during chemotherapy and will be useful to understand the clinical importance of TIL-Bs.

Development and validation of the novel subclassification of pN3 for patients with esophageal cancer

Background

Patients with stage pN3 esophageal cancer (EC) have a large number of metastatic lymph nodes (mLNs) and have poor prognosis. This study was to elucidate whether subclassification of pN3 according to the number of mLNs could improve the discrimination ability of EC patients.

Methods

This study retrospectively analyzed patients with pN3 EC from the Surveillance, Epidemiology, and End Results (SEER) database as a training cohort and SEER validation cohort. Patients with pN3 esophageal cancer from the Affiliated Cancer Hospital of Harbin Medical University were used as the validation cohort. The optimal cutoff value of mLNs was identified using the X-tile software, and group pN3 into pN3-I and pN3-II based on mLNs. Kaplan-Meier method and log-rank test were used to analyze the disease-specific survival (DSS). The Cox proportional hazards regression analysis was used to identify the independent prognostic factors.

Results

For the training cohort, patients with 7 to 9 mLNs were categorized as pN3-I, while those with more than 9 mLNs were categorized as pN3-II. There were 183 (53.8%) pN3-I and 157 (46.2%) pN3-II. The 5-year DSS rates of pN3-I and pN3-II in the training cohort were 11.7% and 5.2% (P=0.033), and the pN3 subclassification was an independent risk factor associated with patient prognosis. More RLNs may not improve patient prognosis, but the use of mLNs/RLNs is effective in predicting patient prognosis. Furthermore, the pN3 subclassification was well validated in the validation cohort.

Conclusion

Subclassification of pN3 can better distinguish survival differences in EC patients.

A novel risk classification system based on the eighth edition of TNM frameworks for esophageal adenocarcinoma patients: A deep learning approach

Objective

To develop and validate a deep learning predictive model with better performance in survival estimation of esophageal adenocarcinoma (EAC).

Method

Cases diagnosed between January 2010 and December 2018 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. A deep learning survival neural network was developed and validated based on 17 variables, including demographic information, clinicopathological characteristics, and treatment details. Based on the total risk score derived from this algorithm, a novel risk classification system was constructed and compared with the 8th edition of the tumor, node, and metastasis (TNM) staging system.

Results

Of 7,764 EAC patients eligible for the study, 6,818 (87.8%) were men and the median (interquartile range, IQR) age was 65 (58-72) years. The deep learning model generated significantly superior predictions to the 8th edition staging system on the test data set (C-index: 0.773 [95% CI, 0.757-0.789] vs. 0.683 [95% CI, 0.667-0.699]; P < 0.001). Calibration curves revealed that the deep learning model was well calibrated for 1- and 3-year OS, most points almost directly distributing on the 45° line. Decision curve analyses (DCAs) showed that the novel risk classification system exhibited a more significant positive net benefit than the TNM staging system. A user-friendly and precise web-based calculator with a portably executable file was implemented to visualize the deep learning predictive model.

Conclusion

A deep learning predictive model was developed and validated, which possesses more excellent calibration and discrimination abilities in survival prediction of EAC. The novel risk classification system based on the deep learning algorithm may serve as a useful tool in clinical decision making given its easy-to-use and better clinical applicability.

Applying post-neoadjuvant pathologic stage as prognostic tool in esophageal squamous cell carcinoma

BACKGROUND

It is still uncertain whether the newly released eighth American Joint Committee on Cancer (AJCC) post-neoadjuvant pathologic (yp) tumor-node-metastasis (TNM) stage for esophageal carcinoma can perform well regarding patient stratification. The current study aimed to assess the prognostication ability of the eighth AJCC ypTNM staging system and attempted to explore how to facilitate the staging system for more effective evaluation of prognosis.

MATERIALS AND METHODS

A total of 486 patients treated with neoadjuvant radiotherapy/chemoradiotherapy (nRT/CRT) were enrolled. ypN stage was reclassified by recursive partitioning. Prognostic performance, monotonicity, homogeneity, and discriminatory of yp and modified yp (myp) staging systems were assessed by time-dependent receiver operating characteristic (ROC), linear trend log-rank test, likelihood ratio χ2 test, Harrell's c statistic, and Akaike information criterion (AIC).

RESULTS

The ypT stage, ypN stage, and pathologic response were significant prognostic factors of overall survival. Survival was not discriminated well using the eighth AJCC ypN stage and ypTNM stage. Recursive partitioning reclassified mypN0-N2 as metastasis in 0, 1-2, and ≥3 regional lymph nodes. Applying the ypT stage, mypN stage, and pathologic response to construct the myp staging system, the myp stage performed better in time-dependent ROC, linear trend log-rank test, likelihood ratio χ2 test, Harrell's c statistic, and AIC.

CONCLUSIONS

The eighth AJCC ypTNM staging system performed well in differentiating prognosis to some extent. By reclassifying the ypN stage and enrolling pathologic response as a staging element, the myp staging system holds significant potential for prognostic discrimination.

Application of apoptosis-related genes in a multiomics-related prognostic model study of gastric cancer

Gastric cancer (GC) is one of the most common tumors in the world, and apoptosis is closely associated with GC. A number of therapeutic methods have been implemented to increase the survival in GC patients, but the outcomes remain unsatisfactory. Apoptosis is a highly conserved form of cell death, but aberrant regulation of the process also leads to a variety of major human diseases. As variations of apoptotic genes may increase susceptibility to gastric cancer. Thus, it is critical to identify novel and potent tools to predict the overall survival (OS) and treatment efficacy of GC. The expression profiles and clinical characteristics of TCGA-STAD and GSE15459 cohorts were downloaded from TCGA and GEO. Apoptotic genes were extracted from the GeneCards database. Apoptosis risk scores were constructed by combining Cox regression and LASSO regression. The GSE15459 and TCGA internal validation sets were used for external validation. Moreover, we explored the relationship between the apoptosis risk score and clinical characteristics, drug sensitivity, tumor microenvironment (TME) and tumor mutational burden (TMB). Finally, we used GSVA to further explore the signaling pathways associated with apoptosis risk. By performing TCGA-STAD differential analysis, we obtained 839 differentially expressed genes, which were then analyzed by Cox regressions and LASSO regression to establish 23 genes associated with apoptosis risk scores. We used the test validation cohort from TCGA-STAD and the GSE15459 dataset for external validation. The AUC values of the ROC curve for 2-, 3-, and 5-years survival were 0.7, 0.71, and 0.71 in the internal validation cohort from TCGA-STAD and 0.77, 0.74, and 0.75 in the GSE15459 dataset, respectively. We constructed a nomogram by combining the apoptosis risk signature and some clinical characteristics from TCGA-STAD. Analysis of apoptosis risk scores and clinical characteristics demonstrated notable differences in apoptosis risk scores between survival status, sex, grade, stage, and T stage. Finally, the apoptosis risk score was correlated with TME characteristics, drug sensitivity, TMB, and TIDE scores.

A machine learning model predicting candidates for surgical treatment modality in patients with distant metastatic esophageal adenocarcinoma: A propensity score-matched analysis

Objective

To explore the role of surgical treatment modality on prognosis of metastatic esophageal adenocarcinoma (mEAC), as well as to construct a machine learning model to predict suitable candidates.

Method

All mEAC patients pathologically diagnosed between January 2010 and December 2018 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. A 1:4 propensity score-matched analysis and a multivariate Cox analysis were performed to verify the prognostic value of surgical treatment modality. To identify suitable candidates, a machine learning model, classification and regression tree (CART), was constructed, and its predictive performance was evaluated by the area under receiver operating characteristic curve (AUC).

Results

Of 4520 mEAC patients, 2901 (64.2%) were aged over 60 years and 4012 (88.8%) were males. There were 411 (9.1%) patients receiving surgical treatment modality. In the propensity score-matched analysis, surgical treatment modality was significantly associated with a decreased risk of death (HR: 0.47, 95% CI: 0.40-0.55); surgical patients had almost twice as much median survival time (MST) as those without resection (MST with 95% CI: 23 [17-27] months vs. 11 [11-12] months, P &lt;0.0001). The similar association was also observed in the multivariate Cox analysis (HR: 0.47, 95% CI: 0.41-0.53). Then, a CART was constructed to identify suitable candidates for surgical treatment modality, with a relatively good discrimination ability (AUC with 95% CI: 0.710 [0.648-0.771]).

Conclusion

Surgical treatment modality may be a promising strategy to prolong survival of mEAC patients. The CART in our study could serve as a useful tool to predict suitable candidates for surgical treatment modality. Further creditable studies are warranted to confirm our findings.

Comprehensive Analysis of the Aberrance and Functional Significance of Ferroptosis in Gastric Cancer

Objective: Ferroptosis is a type of iron-dependent necrosis related to cancer. Nevertheless, the features of ferroptosis in gastric cancer (GC) remain poorly understood. This study conducted a systematic analysis of ferroptosis regulators in GC.

Methods: We gathered five GC cohorts, namely, TCGA-STAD, GSE84437, GSE62254, GSE26901, and GSE15459. Unsupervised clustering analysis was adopted to cluster GC patients into different ferroptosis subtypes based on ferroptosis regulators. Immune cell infiltration and hallmark pathway activity were estimated via ssGSEA. The ferroptosis index was developed with the PCA computational method. Response to chemotherapy agents and small molecular compounds was inferred via GDSC, CTRP, and PRISM projects. Two anti-PD-1 therapy cohorts were gathered and the potential of FPI in predicting immune response was assessed.

Results: Expression profiles, genetic mutations, DNA methylation, prognostic implications, and drug sensitivity of ferroptosis regulators were characterized in GC. Three ferroptosis subtypes were clustered with distinct prognosis, hallmark pathway activity, and tumor-infiltrating immune cells. Ferroptosis levels were quantified based on the expression of prognostic ferroptosis-related signatures. The significant relationships between FPI and clinicopathological characteristics were observed. Furthermore, high FPI was in relation to poor prognosis, inflamed tumor microenvironment (TME) as well as high sensitivity to chemotherapy agents (docetaxel and cisplatin), and CTRP- and PRISM-derived compounds. Also, FPI acted as a promising predictor of immune response.

Conclusion: Collectively, our findings identified a novel ferroptosis-based subtype classification of GC, and revealed the potential of ferroptosis in forming TME diversity and complexity, and guiding individualized treatment.

Nomogram based on the systemic immune-inflammation index for predicting the prognosis of diffuse large B-cell lymphoma

AIM

To investigate systemic immune-inflammation index (SII) as prognostic factors and establish a nomogram based on SII for the prediction of survival in diffuse large B-cell lymphoma (DLBCL).

METHODS

One hundred and fifty-five DLBCL patients were randomized into primary (N = 100) and validation (N = 55) cohorts. Kaplan-Meier survival curves and Cox regression models were used to evaluate the impact of SII on survival. The nomogram based on SII was analyzed by using R software.

RESULTS

Univariate and multivariate analyses revealed that high SII (>1684.), C-reactive protein-to-albumin ratio (CAR > 0.21), and age-adjusted International Prognostic Index (aaIPI) score were independent predictors of overall survival (OS). High SII and aaIPI were independent predictors of progression-free survival. The nomogram had better accuracy and discrimination than the International Prognostic Index, National Comprehensive Cancer Network-International Prognostic Index, and aaIPI systems. The concordance index values of the nomogram for OS were 0.885 in the primary cohort and 0.821 in the validation cohort.

CONCLUSIONS

Our results suggested that SII, CAR, and aaIPI could be used to judge the prognosis of DLBCL patients. The nomogram was a reliable model for predicting the OS of DLBCL patients.

Inclusion of the Number of Metastatic Lymph Nodes in the Staging System for Medullary Thyroid Cancer: Validating a Modified American Joint Committee on Cancer Tumor-Node-Metastasis Staging System

Background: The current American Joint Committee on Cancer (AJCC) staging system (8th edition) for medullary thyroid cancer (MTC) was originally extrapolated from the staging system for differentiated thyroid cancer. However, the current staging system does not accurately predict the prognosis of patients with MTC. Patients and Methods: The present study was based on data from the Surveillance, Epidemiology, and End Results (SEER) database and validated by multicenter data from the Shanghai Tenth People's Hospital, Tongji University School of Medicine, Xuzhou City Central Hospital, and Suzhou Ninth People's Hospital. Hazard ratio with its 95% confidence interval [CI] was estimated by Cox proportional hazards regression analysis. The concordance index (C-index) was used to evaluate the discrimination accuracy of the current AJCC tumor-node-metastasis (TNM) staging system and the modified AJCC (mAJCC) TNM staging system. Results: A total of 1175 MTC patients were selected from the SEER database and 312 from the three hospitals in China. We redefined the N category according to the number of metastatic lymph nodes (LNs) as follows: N'0 category (0 metastatic LNs), N'1 category (1-9 metastatic LNs), and N'2 category (≥10 metastatic LNs). The four distinct tumor stages were reclassified in the mAJCC staging system as follows: stage I (T1-4N'0M0, T1N'1M0), stage II (T2-3N'1M0, T1N'2M0), stage III (T4N'1M0, T2-4N'2M0), and stage IV (TanyN'anyM1). The C-index of the current AJCC staging system and the mAJCC staging system was 0.72 [CI, 0.67-0.78] and 0.78 [CI, 0.73-0.84], respectively. Similar results were observed in the survival analysis of the multicenter data set. Conclusions: The mAJCC staging system could discriminate the prognosis of MTC patients more effectively than the current AJCC staging system, indicating that it is feasible and appropriate to modify the current AJCC staging system by introducing the number of metastatic LNs instead of the location of LNs. These findings might be adopted in the next edition of the AJCC staging system and be used to guide clinical practice.

Nomogram to predict overall survival based on the log odds of positive lymph nodes for patients with endometrial carcinosarcoma after surgery

PURPOSE

Aims to compare the prognostic performance of the number of positive lymph nodes (PLNN), lymph node ratio (LNR) and log odds of metastatic lymph nodes (LODDS) and establish a prognostic nomogram to predict overall survival (OS) rate for patients with endometrial carcinosarcoma (ECS).

METHODS

Patients were retrospectively obtained from Surveillance, Epidemiology and End Results (SEER) database from 2004 to 2015. The prognostic value of PLNN, LNR and LODDS were assessed. A prediction model for OS was established based on univariate and multivariate analysis of clinical and demographic characteristics of ECS patients. The clinical practical usefulness of the prediction model was valued by decision curve analysis (DCA) through quantifying its net benefits.

RESULTS

The OS prediction accuracy of LODDS for ECS is better than that of PLNN and LNR. Five factors, age, tumor size, 2009 FIGO, LODDS and peritoneal cytology, were independent prognostic factors of OS. The C-index of the nomogram was 0.743 in the training cohort. The AUCs were 0.740, 0.682 and 0.660 for predicting 1-, 3- and 5-year OS, respectively. The calibration plots and DCA showed good clinical applicability of the nomogram, which is better than 2009 FIGO staging system. These results were verified in the validation cohort. A risk classification system was built that could classify ECS patients into three risk groups. The Kaplan-Meier curves showed that OS in the different groups was accurately differentiated by the risk classification system and performed much better than FIGO 2009.

CONCLUSION

Our results indicated that LODDS was an independent prognostic indicator for ECS patients, with better predictive efficiency than PLNN and LNR. A novel prognostic nomogram for predicting the OS rate of ECS patients was established based on the population in the SEER database. Our nomogram based on LODDS has a more accurate and convenient value for predicting the OS of ECS patients than the FIGO staging system alone.

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.

A novel nomogram with preferable capability in predicting the overall survival of patients after radical esophageal cancer resection based on accessible clinical indicators: A comparison with AJCC staging

BACKGROUND

Esophageal cancer (EC) is a malignant tumor with high mortality. Nomogram is an important tool used in clinical prognostic assessment. We aimed to establish a novel nomogram to predict the overall survival (OS) of EC patients after radical esophagectomy.

METHODS

Data pertaining to the survival, demography, and clinicopathology of 311 EC patients who underwent radical esophagectomy were retrospectively investigated. The nomogram was established based on Cox hazard regression analysis. The calibration curves and Harrell's concordance index (C-index) were used to verify the predictive accuracy and ROC curves were used to assess the efficacy of the nomogram. Kaplan-Meier curves showed the prognostic value of the related risk classification system. Pearson correlation test was performed to determine the correlation between the risk classification system and TNM staging.

RESULTS

The median OS and 5-year survival rates in the primary and validation cohorts were 44 months and 29.8%, and 52 months and 27.1%, respectively. We used six independent prognostic factors-age, Sex, AGR, PRL, N stage, and PNI-in the nomogram. The C-index of nomogram was 0.75 and 0.70 in the primary and validation cohorts, respectively. Calibration curves indicated high consistency between actual and predicted OS. ROC curves showed that nomogram has a better efficacy compared with TNM staging in both cohorts. Patients were divided into three risk groups according to the total nomogram score, the median OS in each group was significantly different in both cohorts. Furthermore, the risk classification system was strongly correlated with the T and N staging system and exhibited a better OS prediction capability.

CONCLUSIONS

We established a novel and practical nomogram with a subordinate risk classification system to predict the OS of patients after radical esophagectomy. Compared with AJCC staging, this nomogram had preferable clinical capability in terms of individual prognosis assessment.

The Prognostic Value of Lymph Node Ratio in Locally Advanced Esophageal Cancer Patients Who Received Neoadjuvant Chemotherapy

BACKGROUND

The lymph node (LN) ratio (LNR) has been proposed as a sensitive prognosticator in patients with esophageal squamous cell carcinoma (ESCC), especially when the number of LNs harvested is insufficient. We investigated the association between the LNR and survival in patients with locally advanced ESCC who received neoadjuvant chemotherapy (NAC) and explored whether the LNR is a prognosticator in these patients when stratified by their response to NAC.

METHODS

We retrospectively reviewed 199 locally advanced ESCC patients who received curative resection after NAC between January 2011 and December 2019. The predictive accuracy of the adjusted X-tile cut-off values for LNR of 0 and 0.13 was compared with that in the Union for International Cancer Control pathological N (UICC pN) categories. The association between survival rate and clinicopathological features was examined.

RESULTS

Multivariate analysis identified that the LNR was an independent risk factor for recurrence-free survival [RFS; hazard ratio (HR) 6.917, p < 0.001] and overall survival (OS) (HR 4.998, p < 0.001). Moreover, even when stratified by response to NAC, the LNR was a significant independent risk factor for RFS and OS (p < 0.001). The receiver operating characteristic curves identified that the prognostic accuracy of the LNR tended to be better than that of the UICC pN factor in all cases and responders.

CONCLUSION

The LNR had a significant prognostic value in patients with locally advanced ESCC, including in those who received NAC.

Prognostic value of pre-treatment systemic immune-inflammation index in patients with endometrial cancer

BACKGROUND

The systemic immune-inflammation index (SII), which is calculated using absolute platelet, neutrophil, and lymphocyte counts, has recently attracted attentions as a prognostic indicator in patients with solid malignancies. In the current study, we retrospectively investigated the prognostic significance of pre-treatment SII among patients with endometrial cancer.

METHOD

Endometrial cancer patients treated at Nara medical university hospital between 2008 and 2018 were included in the current study. Receiver operating characteristic (ROC) curve was used to find the optimal SII cut-off values for 3-years progression free survival (PFS) and overall survival (OS). Then, the predictive abilities of SII and its superiority over neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) were investigated. Kaplan-Meier method was used to calculate the OS and PFS rates, and log-rank test was used to compare the survival rate between two groups. Univariate and multivariate Cox regression analysis were performed to identify risk factors for PFS and OS.

RESULT

A total of 442 patients were included in the current study. The cut-off value of SII for predicting PFS and OS were defined by ROC analysis as 931 and 910, respectively. Univariate analyses showed that elevated SII was associated with significantly shorter survival (p <0.001 for both PFS and OS). Cox regression analyses revealed that an advanced FIGO stage (p <0.001 for both PFS and OS) and an elevated SII (p = 0.014 for PFS, p = 0.011 for OS) are the independent prognostic factors for survival. When SII was compared with NLR and PLR, SII showed greater area under curve for predicting survival.

CONCLUSION

The SII is an independent prognostic factor in endometrial cancer patients, allowing more precise survival estimation than PLR or NLR.

Predicting Individual Survival after Curative Esophagectomy for Squamous Cell Carcinoma of Esophageal

BACKGROUND

Esophageal cancer is one of the leading causes of cancer-related death worldwide. Despite the significant progress in the overall treatment of esophageal cancer in recent years, the prognosis for patients who require surgery remains poor.

METHODS

The present study investigated the clinicopathological features of 503 patients who underwent radical esophagectomy at Huashan Hospital of Fudan University between January 2005 and January 2015. Nomograms that predicted the esophageal squamous cell carcinoma (ESCC) survival rates were established using the Cox proportional hazard regression model. Discrimination and calibration, which were calculated after bootstrapping, were used as a measure of accuracy.

RESULTS

Multivariate analyses were used to select five independent prognostic variables and build the nomogram. These variables were pathological T stage, pathological N factor, rate of positive LNs, history of chronic obstructive pulmonary disease (COPD) and postoperative sepsis. The nomogram was built to predict the rates for overall survival (OS) and disease-free survival (DFS). The concordance index for the nomogram prediction for OS and DFS was 0.720 and 0.707, respectively. Compared to the conventional TNM staging system, the nomogram had better predictive accuracy for survival (OS 0.720 vs. 0.672, P < 0.001; DFS 0.707 vs. 0.667; P < 0.001).

CONCLUSIONS

The present study incorporated pathological T stage, pathological N factor, rate of positive LNs, history of COPD, and postoperative sepsis into a nomogram to predict the OS and DFS of ESCC patients. This practical system may help clinicians in both decision-making and clinical study design. The assessment of lung function for patients with COPD preoperative, and the control of disease progression are needed. Furthermore, the postoperative infection of patients should be controlled. Further studies may help to extend the validation of this method and improve the model through parameter optimization.

Prognostic value of systemic immune-inflammatory index in survival outcome in gastric cancer: a meta-analysis

Background

In recent years, many studies have reported that the systemic immune-inflammatory index (SII) can be used to predict the prognosis of cancer patients; however, this finding remains controversial in gastric cancer (GC). Therefore, the purpose of this study was to systematically and comprehensively probe the prognostic role of SII in GC.

Methods

Relevant publications were extracted from PubMed, EMBASE, Cochrane Library databases, and WANFANG DATA (Chinese database). The included studies had patients with pathologically confirmed GC and long-term follow-up data. The patient's outcome was death, recurrence, or status at the end of follow-up. The studies included randomized controlled tests, case-control studies, or cohort studies using a multivariate proportional hazard model adjusted for survival outcomes. Cochran's Q test and Higgins' I-squared statistic were performed to assess heterogeneity. Publication bias was assessed by visual inspection of a Begg's funnel plot.

Results

A total of 6,925 patients in 11 studies were included. The pooled hazard ratio (HR) indicated that a higher SII value was significantly associated with worse overall survival (OS) [HR: 1.53, 95% confidence interval (CI): 1.27-1.83] and worse disease-free survival (DFS) (HR: 1.57, 95% CI: 1.24-1.97) in GC patients. In the subgroup analysis, the HR was 1.72 (95% CI: 1.51-1.95) and 1.27 (95% CI: 0.96-1.67) in the group of patients aged <59 and ≥59 years, respectively.

Conclusions

The pooled HR indicates that a higher SII in younger patients with GC predicts a poor prognosis. In elderly patients with GC, the prognostic role of SII needs further research.

Construction and Validation of a Ferroptosis-Related Prognostic Model for Gastric Cancer

BACKGROUND

Gastric cancer (GC), an extremely aggressive tumor with a very different prognosis, is the third leading cause of cancer-related mortality. We aimed to construct a ferroptosis-related prognostic model that can be distinguished prognostically.

METHODS

The gene expression and the clinical data of GC patients were downloaded from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus database (GEO). The ferroptosis-related genes were obtained from the FerrDb. Using the "limma" R package and univariate Cox analysis, ferroptosis-related genes with differential expression and prognostic value were identified in the TCGA cohort. Last absolute shrinkage and selection operator (LASSO) Cox regression was applied to shrink ferroptosis-related predictors and construct a prognostic model. Functional enrichment, ESTIMATE algorithm, and single-sample gene set enrichment analysis (ssGSEA) were applied for exploring the potential mechanism. GC patients from the GEO cohort were used for validation.

RESULTS

An 8-gene prognostic model was constructed and stratified GC patients from TCGA and meta-GEO cohort into high-risk groups or low-risk groups. GC patients in high-risk groups have significantly poorer OS compared with those in low-risk groups. The risk score was identified as an independent predictor for OS. Functional analysis revealed that the risk score was mainly associated with the biological function of extracellular matrix (ECM) organization and tumor immunity.

CONCLUSION

In conclusion, the ferroptosis-related model can be utilized for the clinical prognostic prediction in GC.

Modified nodal stage of esophageal cancer based on the evaluation of the hazard rate of the negative and positive lymph node

Background

The study aimed to propose a modified N stage of esophageal cancer (EC) on the basis of the number of positive lymph node (PLN) and the number of negative lymph node (NLN) simultaneously.

Method

Data from 13,491 patients with EC registered in the SEER database were reviewed. The parameters related to prognosis were investigated using a Cox proportional hazards regression model. A modified N stage was proposed based on the cut-off number of the re-adjusted ratio of the number of PLN (_numberPLN) to the number of NLN (_numberNLN), which were derived from the comparison of the hazard rate (HR) of _numberPLN and _numberNLN. The modified N stage was confirmed using the cross-validation method with the training and validation cohort, and it was also compared to the N stage from the American Joint Committee on Cancer (AJCC) staging system (7th edition) using Receiver Operating Characteristic (ROC) curve analysis.

Results

The _numberPLN on prognosis was 1.042, while _numberNLN was 0.968. The modified N stage was defined as follows: N1 stage: the ratio range was from 0 to 0.21; N2 stage: more than 0.21, but no more than 0.48; N3 stage: more than 0.48. The log-rank test indicated that significant survival differences were confirmed among the N1, N2 and N3 sub-groups of patients in the training population. The difference of all the patients using the modified N stage method were more significant than AJCC N stage. The result of ROC analysis indicated that the modified N stage could represent the N stage of EC more accurately.

Conclusion

The modified N stage based on the re-adjusted ratio of _numberPLN to _numberNLN can evaluate tumor stage more accurately than the traditional N stage.

Ratio between negative and positive lymph nodes is a novel prognostic indicator for patients with esophageal cancer: A Surveillance, Epidemiology and End Results database analysis

Background

The aim of this study was to explore whether the ratio between negative and positive lymph nodes (R_NP) could predict the overall survival (OS) of esophageal cancer (EC) patients with lymph node metastasis following esophagectomy.

Methods

We utilized the Surveillance, Epidemiology and End Results (SEER) database to include the records of 2374 patients with lymph node metastases post‐surgery. All patients were randomly assigned into the training cohort (n = 1424) and validation cohort (n = 950). Multivariate Cox regression analyses were performed to identify independent prognostic factors. A novel R_NP ‐based TR_NPM staging system was proposed. The prognostic value of N, R_NP, TNM and TR_NPM staging system was evaluated using the linear trend χ² test, likelihood ratio χ² test, and Akaike information criterion (AIC) to determine the potential superiorities. We constructed nomograms to predict survival in both cohorts, and the calibration curves confirmed the predictive ability.

Results

Univariate analyses showed that N and R_NP stage significantly influenced the OS of patients. Multivariate analyses revealed that R_NP was an independent prognostic predictor in both the training and validation cohorts. For the stratification analysis in the two cohorts, we found significant differences in the prognosis of patients in different R_NP groups on the basis of the different N stages and the number of dissected lymph nodes. In addition, the lower AIC value of R_NP stage and TR_NPM staging system represented superior predictive accuracy for OS than the N stage and TNM staging system, respectively. Furthermore, the calibration curves for the probability of three‐ and five‐year survival showed good consistency between nomogram predictive abilities and actual observation.

Conclusions

We demonstrated that compared to the classical pathological lymph nodal staging system, the R_NP stage showed superior predictive accuracy for OS and can serve as a more effective prognostic guidance for lymph node positive EC patients.

Prognostic Factors of Long-term Survival Following Radical Resection for Ampullary Carcinoma

BACKGROUND

The incidence of adenocarcinoma of the ampulla of Vater has been increasing over the past years. Nevertheless, it is still a rare disease and the prognostic factors predicting long-term survival are not sufficiently clarified. This study aims to evaluate the association between histopathological characteristics and long-term survival of patients with ampullary cancer after curative resection, as well as the efficiency of immunohistochemical expression of CK7, CK20, and CDX2 to distinguish the histopathological (intestinal or pancreaticobiliary) patterns.

METHODS

Demographic, histopathological data, pTNM stage, and immunohistochemical expression patterns were collected from 65 patients with adenocarcinoma of the ampulla of Vater. Five and 10-year overall and disease-free survival rates after curative resection were determined.

RESULTS

Of the 65 patients with ampullary carcinoma, 47 (72%) underwent radical resection. The 5- and 10-year overall survival rate was 46% and 37%, respectively. Our results demonstrate that the main prognostic factors were the presence and number of lymph node metastases, lymph node ratio (LNR), differentiation grade, and lymphovascular invasion. After multivariate analysis, only lymph node ratio ≥ 20% remained an independent prognostic factor of survival (HR: 2.63 95% CI: 1.05-6.61; p = 0.039).

CONCLUSION

Here, we demonstrated more evidence that the lymph node metastases are associated with poor prognosis in ampullary carcinoma. Particularly, the relation between the number of metastatic lymph nodes and the number of harvested lymph node (LNR) should be considered a major prognostic factor.

Prognostic value of fibrinogen-to-albumin ratio in patients with gastric cancer receiving first-line chemotherapy

The fibrinogen-to-albumin ratio (FAR), reflecting the systemic coagulation, nutritional and inflammation status of patients, has matured into a prognostic marker for several tumor types. However, only a few studies have assessed the utility of the FAR as a prognostic indicator in patients with advanced gastric cancer (GC) receiving first-line chemotherapy. In the present study, 273 patients with advanced GC who received first-line chemotherapy between January 2014 and January 2019 at the Cancer Hospital of China Medical University (Shenyang, China) were retrospectively analyzed. Using the cut-off values determined by receiver operating characteristic (ROC) analysis, the patients were divided into low-FAR (≤10.03) and high-FAR (>10.03), low-fibrinogen (<3.8 g/l) and high-fibrinogen (≥3.8 g/l), and low-albumin (<40.55 g/l) and high-albumin (≥40.55 g/l) groups. The associations of the pretreatment FAR and clinicopathological characteristics with progression-free survival (PFS) and overall survival (OS) were evaluated. In order to estimate the prognostic value of the FAR for patients with poor prognosis or normal fibrinogen and albumin levels, subgroup analyses were performed. The FAR had a higher area under the ROC curve (0.690; 95% CI: 0.628–0.752; P<0.001) compared with either fibrinogen or albumin alone, which are common indicators of coagulation, nutritional and inflammatory indices. A high FAR was significantly associated with a more advanced stage, peritoneal metastasis, increased CA72-4 levels and anemia (all P<0.05). On survival analysis, a low FAR was associated with a longer PFS and OS compared with a high FAR (202 vs. 130 days and 376 vs. 270 days, respectively; both P<0.001), while the hazard ratio (HR) and P-values of the FAR were lower compared with those of fibrinogen and albumin alone on multivariate analysis (PFS: HR=0.638, 95% CI: 0.436–0.932, P=0.020; OS: HR=0.568, 95% CI: 0.394–0.819, P=0.002). Subgroup analysis indicated that among patients with poor prognosis, including multiple metastases, TNM stage IV and abnormal CA72-4 levels, the FAR may be used as an accurate prognostic marker (all P<0.05), and may also reliably identify patients with poor prognosis among those with normal fibrinogen and albumin levels (all P<0.001). The FAR was indicated to be a valuable marker for predicting PFS and OS in patients with advanced GC receiving first-line chemotherapy and is superior to either fibrinogen or albumin alone.

A Novel Staging System to Forecast the Cancer-Specific Survival of Patients With Resected Gallbladder Cancer

Objective: Gallbladder cancer (GBC) is one of the most aggressive malignant tumors, and there is no effective and convenient method for predicting cancer-specific survival (CSS). We aim to develop a novel nomogram staging system based on the positive lymph node ratio (pLNR) for GBC patients.

Methods:A total of 1,356 patients enrolled in the study. We evaluated the prognostic value of the pLNR and built a prognostic nomogram staging system based on the pLNR in the training cohort. The concordance index and calibration plots were used to evaluate model discrimination. The predictive accuracy and clinical value of the nomograms were measured by decision curve analysis (DCA). The CSS nomogram was further validated in an internal validation cohort.

Results:The pLNR was an independent prognostic factor for CSS based on Cox regression analyses. A prognostic nomogram that combined T classification, pLNR, M classification, histologic grade, live metastasis, and tumor size was formulated with a c-index of 0.763 (95% CI, 0.728–0.798), while the c-indexes for the staging system of AJCC 8th, 7th, and 6th for CSS prediction were 0.718, 0.718, and 0.717, respectively. The calibration curves showed perfect agreement. The DCA showed that the nomogram provided substantial clinical value. The nomogram (the AUCs for 1, 3, and 5 years were 0.693, 0.716, and 0.726, respectively,) showed high prognostic accuracy.

Conclusion:We have developed a formulated nomogram staging system based on the pLNR that allows more accurate individualized predictions of CSS for resected GBC patients than the AJCC staging systems.

New prognostic western score predicting survival after curative resection of gastric cancer

The aim of our study was to develop a prognostic score for gastric cancer patients who underwent R0 resection with curative intent, to identify high-risk patients. Three thirty three patients curatively operated for gastric adenocarcinoma were enrolled in the study. To define our prognostic score pre-operative inflammation sieric markers such as neutrophil to lymphocytes ratio, platelet count, platelet to lymphocytes ratio, and other clinical pathological and surgical characteristics of our patients such as albumin preoperative level, CRP sieric level, hystological Lauren's subtype, tumor location, lymphonodal status were analyzed. Prognostic factors predicting OS were analyzed using Cox proportional hazards models and a prognostic score was built. 5Y-OS was 42% with a median survival of 41 months. The multivariate analysis identified four independent prognostic factors: preoperative albumin level (HR 2.5), preoperative N/L ratio (HR 2.4), Diffuse Lauren histological subtype (HR 1.5) and TNM stage III and IV (HR 1.2). According to the relative risk of each variable we construct a prognostic score and validated it internally. Four risk classes were built and patients were statistically different stratifying according to them. More important the stratification was maintained also when patients were subdivided according to the pathological stage. In summary, we were able to construct a prognostic score that could be easily used in all the clinical contests, being it cheap and prompt. Our results, however, need to be externally validated, by a major center to be introduced into the clinical practice.

[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.

A signature of 14 immune-related gene pairs predicts overall survival in gastric cancer

OBJECTIVE

Increasing evidence demonstrates that immune signature plays an important role in the prognosis of gastric cancer (GC). We aimed to develop and validate a robust immune-related gene pair (IRGP) signature for predicting the prognosis of GC patients.

METHODS

RNA-Seq data and corresponding clinical information of GC cohort were downloaded from the TCGA (The Cancer Genome Atlas Program) data portal. GSE84437 and GSE15459 microarray datasets were included as independent external cohorts. Least absolute shrinkage and selection operator (LASSO) regression analysis was used to build the best prognostic signature. All patients were classified into the high immune-risk and low immune-risk groups via the optimal cut-off of the signature scores determined by time-dependent receiver-operating characteristic (ROC) curve analysis. The prognostic role of the signature was measured by a log-rank test and a Cox proportional hazard regression model.

RESULTS

14 immune gene pairs consisting of 25 unique genes were identified to construct the immune prognostic signature. High immune-risk groups showed poor prognosis in the TCGA datasets and GSE84437 datasets as well as in the GSE15459 datasets (all P < 0.001). The 14-IRGP signature was an independent prognostic factor of GC after adjusting for other clinical factors (P < 0.05). Functional analysis revealed that DNA integrity checkpoint, DNA replication, T-cell receptor signaling pathway, and B-cell receptor signaling pathway were enriched in the low immune-risk groups. B cells naive and Monocytes were significantly higher in the high-risk group, and B-cell memory and T-cell CD4 memory activated were significantly higher in the low-risk group. The prognostic signature based on IRGP reflected infiltration by several types of immune cells.

CONCLUSION

The novel proposed clinical-immune signature is a promising biomarker for prediction overall survival in patients with GC and providing new insights into the treatment strategies.

Prognostic value of lymph node ratio in laryngeal and hypopharyngeal squamous cell carcinoma: a systematic review and meta-analysis

Background

Several recent studies have indicated that the lymph node ratio (LNR) is an independent prognostic factor for laryngeal and hypopharyngeal squamous cell carcinoma (LHSCC). The purpose of this paper is to assess the prognostic value of LNR and explore appropriate cutoff values by conducting a systematic review and meta-analysis.

Methods

Pubmed, Embase (via Ovid), and Cochrane library were systematically searched for studies on the prognostic value of LNR in LHSCC up to October 31, 2019. Then, Literature review, data extraction, and quality assessment of eligible studies were performed by two independent reviewers back-to-back. Lastly, Stata 14.0 software was hired to conduct a meta-analysis.

Results

A total of 445 articles were retrieved, and 13 studies published in English between 2013 and 2019 were included after the title/abstract and full-text screening. Among the 13 studies contributed to 4197 patients, seven studies were about hypopharyngeal squamous cell carcinoma (HPSCC), four studies about laryngeal squamous cell carcinoma (LSCC), and the remaining two studies about LHSCC. The meta-analysis results showed that shorter overall survival (OS) (HR 1.49; 95%CI: 1.18 to 1.88), disease-specific survival (DSS) (HR 1.66; 95%CI: 1.32 to 2.07) and disease-free survival (DFS) (HR 2.04; 95%CI: 1.54 to 2.71) were significantly correlated with a higher LNR in a random-effect model. The cutoff values of eligible studies were varied from 0.03 to 0.14, and the lowest significant LNR was 0.044.

Conclusion

LNR is a valuable prognostic factor in the survival of LHSCC and may be used to improve the tumor staging systems, which, however, requires the solid support of more high-quality studies.

Role of Perioperative Chemotherapy in Lymph Node-negative Esophageal Cancer After Resection: A Population-based Study With Propensity Score-matched Analysis

BACKGROUND

Multimodality treatment is increasingly accepted and becoming the standard care for local advanced esophageal cancer (EC) patients. However, for early stage lymph node-negative EC patients, surgery alone is still the primary treatment approach, and the role of perioperative chemotherapy remains unclear.

METHODS

Patients with lymph node-negative EC were identified from the Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2013. Survival was compared by the log-rank test. Cox proportional hazards analysis was used to identify covariates associated with overall survival (OS). Propensity score-matched analysis was also performed to control for confounding.

RESULTS

A total of 3071 patients (T1-4N0M0) were identified, 1363 (44.4%) of which received perioperative chemotherapy. The effect of chemotherapy on OS was remarkably dependent on the T stage. For stage T1 patients, chemotherapy was inversely associated with OS (hazard ratio [HR]=1.54; 95% confidence interval [CI], 1.27-1.86), and no impact of chemotherapy on OS was found for T2 patients (HR=0.92; 95% CI, 0.712-1.18), whereas a significant improvement in OS was observed with the addition of chemotherapy for patients with stages T3 (HR=0.52; 95% CI, 0.43-0.62) and T4 (HR=0.60; 95% CI, 0.36-0.98) disease. Multivariable analysis with demonstrated that chemotherapy usage, age, sex, tumor grade, and T stage (P<0.05) were significantly associated with OS in T3-T4 patients. The results were similar in subgroup analyses stratified by confounding covariates, and the propensity score-matched analysis.

CONCLUSIONS

This population-based study indicates perioperative chemotherapy is associated with improved survival in stage T3-4N0M0 patients with EC, which needs to be further validated by randomized trials.

Identification of key genes by integrating DNA methylation and next-generation transcriptome sequencing for esophageal squamous cell carcinoma

Aberrant DNA methylation leads to abnormal gene expression, making it a significant regulator in the progression of cancer and leading to the requirement for integration of gene expression with DNA methylation. Here, we identified 120 genes demonstrating an inverse correlation between DNA methylation and mRNA expression in esophageal squamous cell carcinoma (ESCC). Sixteen key genes, such as SIX4, CRABP2, and EHD3, were obtained by filtering 10 datasets and verified in paired ESCC samples by qRT-PCR. 5-Aza-dC as a DNA methyltransferase (DNMT) inhibitor could recover their expression and inhibit clonal growth of cancer cells in seven ESCC cell lines. Furthermore, 11 of the 16 genes were correlated with OS (overall survival) and DFS (disease-free survival) in 125 ESCC patients. ChIP-Seq data and WGBS data showed that DNA methylation and H3K27ac histone modification of these key genes displayed inverse trends, suggesting that there was collaboration between DNA methylation and histone modification in ESCC. Our findings illustrate that the integrated multi-omics data (transcriptome and epigenomics) can accurately obtain potential prognostic biomarkers, which may provide important insight for the effective treatment of cancers.

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.

Predicting the Value of Adjuvant Therapy in Esophageal Squamous Cell Carcinoma by Combining the Total Number of Examined Lymph Nodes with the Positive Lymph Node Ratio

BACKGROUND

The value of adjuvant therapy for esophageal squamous cell carcinoma (ESCC) has been controversial, at least partially due to the lack of efficient criteria for selecting suitable patients. This study aimed to explore the existence of parameters related to lymph node (LN) status that can predict the value of adjuvant therapy in ESCC.

METHODS

The study included 298 patients with ESCC who had undergone radical esophagectomy with lymphadenectomy. Adjuvant therapy was defined as reception of adjuvant chemotherapy, radiotherapy, or chemoradiotherapy. For the study, LN ratio (LNR), total number of resected LNs (TLNs), and pN stage were selected for Cox regression analyses, including their correlations and prognostic values for survival. Log-rank tests were used to compare the survival rates of the patients with and without adjuvant therapy stratified by pN stage, TLNs, LNR, or their combinations.

RESULTS

The independent prognostic factors for survival were TLNs, LNR, and pN stage. Whereas pN stage was significantly related to TLNs and LNR, TLNs were not correlated with LNR. The survival rates between the patients with and those without adjuvant therapy stratified by pN stage, TLNs, or LNR did not differ significantly. We used the median values of TLNs and LNR to group the patients into four groups. The patients in the group with fewer TLNs and higher LNR who had undergone adjuvant therapy showed a significantly better survival than those without adjuvant therapy (p = 0.030).

CONCLUSIONS

In contrast to TLNs, LNR, and pN stage as single factors, the combination of TLNs and LNR can predict the value of adjuvant therapy.

DCE-MRI-Derived Volume Transfer Constant (Ktrans) and DWI Apparent Diffusion Coefficient as Predictive Markers of Short- and Long-Term Efficacy of Chemoradiotherapy in Patients With Esophageal Cancer

This study aimed to evaluate both the short- and long-term efficacies of chemoradiotherapy in relation to the treatment of esophageal cancer . This was achieved through the use of dynamic contrast-enhanced magnetic resonance imaging–derived volume transfer constant and diffusion weighted imaging–derived apparent diffusion coefficient . Patients with esophageal cancer were assigned into the sensitive and resistant groups based on respective efficacies in chemoradiotherapy. Dynamic contrast-enhanced magnetic resonance imaging and diffusion weighted imaging were used to measure volume transfer constant and apparent diffusion coefficient, while computed tomography was used to calculate tumor size reduction rate. Pearson correlation analyses were conducted to analyze correlation between volume transfer constant, apparent diffusion coefficient, and the tumor size reduction rate. Receiver operating characteristic curve was constructed to analyze the short-term efficacy of volume transfer constant and apparent diffusion coefficient, while Kaplan-Meier curve was employed for survival rate analysis. Cox proportional hazard model was used for the risk factors for prognosis of patients with esophageal cancer. Our results indicated reduced levels of volume transfer constant, while increased levels were observed in ADC_min, ADC_mean, and ADC_max following chemoradiotherapy. A negative correlation was determined between ADC_min, ADC_mean, and ADC_max, as well as in the tumor size reduction rate prior to chemoradiotherapy, whereas a positive correlation was uncovered postchemoradiotherapy. Volume transfer constant was positively correlated with tumor size reduction rate both before and after chemoradiotherapy. The 5-year survival rate of patients with esophageal cancer having high ADC_min, ADC_mean, and ADC_max and volume transfer constant before chemoradiotherapy was greater than those with respectively lower values. According to the Cox proportional hazard model, ADC_mean, clinical stage, degree of differentiation, and tumor stage were all confirmed as being independent risk factors in regard to the prognosis of patients with EC. The findings of this study provide evidence suggesting that volume transfer constant and apparent diffusion coefficient as being tools allowing for the evaluation of both the short- and long-term efficacies of chemoradiotherapy esophageal cancer treatment.

Prognostic Value of Preoperative Systemic Immune-Inflammation Index in Patients with Cervical Cancer

The systemic immune-inflammation index (SII) based on peripheral lymphocyte, neutrophil and platelet counts has been considered a good index that reflects the local immune response and systemic inflammation. However, the use of the SII has not been reported in cervical cancer. In this study, Kaplan-Meier survival analysis showed that a high SII was associated with poor prognosis in cervical cancer patients in the primary and validation cohorts. A higher SII had a significant correlation with larger tumours but had no correlation with other clinicopathological parameters. Among all systemic immune indexes, the SII is the only independent prognostic factor for cervical cancer patients. Compared with the area under the curve for the neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and monocyte/lymphocyte ratio (MLR), the area for the SII was larger at 3 and 5 years. In addition, the SII still retains it prognostic values across all FIGO stages. The SII can independently predict the overall survival of patients with cervical cancer receiving radical resection and is thus superior to existing systemic inflammatory indexes. The prognostic nomogram based on the SII is a reliable model for predicting the postoperative survival of patients with cervical cancer.

Nomogram Based on Systemic Immune-Inflammation Index to Predict Overall Survival in Gastric Cancer Patients

Background

The systemic immune-inflammation index (SII), based on peripheral lymphocytes, neutrophils, and platelet count, has been used as a prognostic marker for several tumors. However, use of the SII has not been reported for gastric cancer.

Methods

We evaluated the prognostic value of the SII in primary and validation cohorts. We also established an effective prognostic nomogram for gastric cancer based on R language. The predictive accuracy and discriminative ability of the nomogram were determined using the concordance index (C index) and a calibration curve and were compared with TNM classifications.

Results

The Kaplan-Meier survival analysis results showed that the high SII was associated with poor prognosis of gastric cancer patients in the primary and validation cohorts. SII proved to be related to tumor location, histological grade, tumor size, TNM stage, and perineural infiltration in patients with gastric cancer and was an independent prognostic factor for patients with gastric cancer. SII has a better predictive ability than other existing prognostic indexes based on inflammation, such as NLR, PLR, and MLR. The nomogram established can accurately predict the 3- and 5-year survival rates of patients with gastric cancer after operation, and its accuracy is significantly higher than that of the 8th edition of the AJCC staging system.

Conclusion

SII can independently predict the overall survival of patients with gastric cancer after operation, which is superior to the existing systemic inflammatory indexes. The prognostic nomogram based on SII is a reliable model for predicting the postoperative survival of patients with gastric cancer.