Impact of extranodal tumor deposits on prognosis and N stage in gastric cancer

Correlation Analysis Between Tumor Deposit and Clinicopathologic Characteristics and Prognosis of Gastric Cancer: A Multicenter Retrospective Study

BACKGROUND

The mechanism underlying the formation of gastric tumor deposits (TDs) is unclear. We aimed to explore the risk factors for the formation and prognostic value of TDs.

METHODS

This retrospective analysis included 781 locally advanced gastric cancer (LAGC) patients from four medical institutions in China, from June 2014 to June 2018. The risk factors for TD formation and prognostic value were determined through univariate and multivariate analyses.

RESULTS

Univariate analysis revealed that TD positivity was closely related to tumor diameter, Borrmann classification, differentiation degree, pT stage, pN stage, pTNM stage, and nerve and vascular invasion (p < 0.05). Multivariate logistic regression revealed that tumor diameter ≥ 5 cm (odds ratio [OR] 1.836, 95% confidence interval [CI] 1.165-2.894, p = 0.009) and vascular invasion (OR 2.152, 95% CI 1.349-3.433, p = 0.001) were independent risk factors for TD positivity. Multivariate Cox analysis revealed that TD positivity (OR 1.533, 95% CI 1.101-2.134, p = 0.011), tumor diameter ≥ 5 cm (OR 1.831, 95% CI 1.319-2.541, p < 0.001), pT4a stage (OR 1.652, 95% CI 1.144-2.386, p = 0.007), and vascular invasion (OR 1.458, 95% CI 1.059-2.008, p = 0.021) were independent risk factors for GC prognosis. The 5-year overall and disease-free survival of the TD-positive group showed significant effects among patients in the pT4a and pN3b stages (p < 0.05).

CONCLUSIONS

TDs are closely related to tumor diameter and vascular invasion in LAGC patients, and TD positivity is an independent prognostic factor for LAGC patients, especially those at pT4a and pN3b stages.

Tumor deposits in axillary adipose tissue in patients with breast cancer: Do they matter?

Tumor deposits (TDs) are defined as discrete, irregular clusters of tumor cells lying in the soft tissue adjacent to but separate from the primary tumor, and are usually found in the lymphatic drainage area of the primary tumor. By definition, no residual lymph node structure should be identified in these tumor masses. At present, TDs are mainly reported in colorectal cancer, with a few reports in gastric cancer. There are very few reports on breast cancer (BC). For TDs, current dominant theories suggest that these are the result of lymph node metastasis of the tumor with complete destruction of the lymph nodes by the tumor tissue. Even some pathologists classify a TD as two lymph node metastases for calculation. Some pathologists also believe that TDs belong to the category of disseminated metastasis. Therefore, regardless of the origin, TDs are an indicator of poor prognosis. Moreover, for BC, sentinel lymph node biopsy is generally used at present. Whether radical axillary lymph node dissection should be adopted for BC with TDs in axillary lymph nodes is still inconclusive. The present commentary of this clinical issue has certain guiding significance. It is aimed to increase the awareness of the scientific community towards this under-recognized problem in BC pathology.

Prognostic effect of categorized tumor deposits in gastric cancer: A single-center retrospective study

BACKGROUND

Tumor deposits are defined as all types of isolated cancer lesions without lymphocyte aggregates considered part of the lymph node. Tumor deposits have been reported as a negative prognostic factor. However, the survival significance of categorized tumor deposits is uncertain, particularly in gastric cancer. This study aimed to investigate the prognostic difference among categorized tumor deposits.

METHODS

Patients who underwent gastrectomy for gastric cancer were enrolled. All tumor deposits were categorized into irregular nodule, irregular nodule star, smooth nodule, and vascular/neural invasion. There are some cases with more than 2 categorized tumor deposits. These cases were categorized as tumor deposit complex in the following analysis. We performed survival analysis between the patients with and without tumor deposits, and compared the survival among each categorized tumor deposit.

RESULTS

Of 868 patients, there were 96 (11.1%) and 772 (88.9%) patients with and without tumor deposits. Vascular/neural invasion, smooth nodule, irregular nodule, irregular nodule star, and the tumor deposits complex was observed in 6 (6.3%), 15 (15.6%), 43 (44.8%), 1 (1.0%), and 31 (32.3%) patients. Patients with tumor deposits displayed poorer survival than those without; the 3-year overall survival: tumor deposits negative = 87.0%, tumor deposits positive = 53.2% (P < .001). Survival analysis revealed tumor deposits can be a prognostic risk factor (hazard ratio: 1.9854, 95% confidence interval: 1.393-2.830, P < .01). Irregular nodule and the tumor deposits complex demonstrated the worst prognosis (irregular nodule 3-year overall survival: 51.2%, tumor deposits complex 3-year overall survival: 41.9%, P = .001), whereas smooth nodule demonstrated better prognosis (smooth nodule 3-year overall survival: 80%).

CONCLUSION

Tumor deposits exerted a negative survival effect in gastric cancer. Irregular nodule and the tumor deposits complex displayed a strong prognostic effect.

The clinical significance of SNAIL, TWIST, and E-Cadherin expression in gastric mesentery tumor deposits of advanced gastric cancer

Objective

To explore the relationships among the epithelial to mesenchymal transition (EMT)-related factors (SNAIL, TWIST, and E-Cadherin) and clinicopathological parameters and gastric mesangial tumor deposits (TDs) in advanced gastric cancer (AGC) patients and their value in gastric cancer prognosis judgment.

Materials and Methods

The data of 190 patients who underwent radical resection of ACG were analyzed retrospectively, including 75 cases of TDs (+) and 115 cases of TDs (-). The expression of EMT-related transforming factors Snail, Twist, and E-cadherin in the primary tumor, paracancerous normal tissues, and TDs was detected by immunohistochemistry.

Results

SNAIL and TWIST were overexpressed in primary tumors and TDs, whereas E-Cadherin was down-expressed in primary tumors. SNAIL was correlated significantly with tumor differentiation, lymph node metastases, and TDs (P < 0.05); TWIST was correlated strongly with tumor location, lymph node metastases, and TDs (P < 0.05); E-Cadherin was correlated closely with tumor differentiation and lymph node metastases (P < 0.05). Kaplan-Meier curves showed that SNAIL expression was correlated with DFS (P < 0.05), and TWIST expression was correlated with OS (P < 0.05). Tumor differentiation, lymph node metastasis, and TWIST expression were prognostic-independent risk factors of AGC patients (P < 0.05).

Conclusion

The occurrence and development of gastric cancer and the formation of TDs may be related to EMT, analyzing the expression of EMT-related transforming proteins may be helpful to judge the prognosis of gastric cancer.

Development and validation of a nomogram for preoperative prediction of tumor deposits in colorectal cancer

BACKGROUND

Based on the clinical data of colorectal cancer (CRC) patients who underwent surgery at our institution, a model for predicting the formation of tumor deposits (TDs) in this patient population was established.

AIM

To establish an effective model for predicting TD formation, thus enabling clinicians to identify CRC patients at high risk for TDs and implement personalized treatment strategies.

METHODS

CRC patients (n = 645) who met the inclusion criteria were randomly divided into training (n = 452) and validation (n = 193) cohorts using a 7:3 ratio in this retrospective analysis. Least absolute shrinkage and selection operator regression was employed to screen potential risk factors, and multivariable logistic regression analysis was used to identify independent risk factors. Subsequently, a predictive model for TD formation in CRC patients was constructed based on the independent risk factors. The discrimination ability of the model, its consistency with actual results, and its clinical applicability were evaluated using receiver-operating characteristic curves, area under the curve (AUC), calibration curves, and decision curve analysis (DCA).

RESULTS

Thirty-four (7.5%) patients with TDs were identified in the training cohort based on postoperative pathological specimens. Multivariate logistic regression analysis identified female sex, preoperative intestinal obstruction, left-sided CRC, and lymph node metastasis as independent risk factors for TD formation. The AUCs of the nomogram models constructed using these variables were 0.839 and 0.853 in the training and validation cohorts, respectively. The calibration curve demonstrated good consistency, and the training cohort DCA yielded a threshold probability of 7%-78%.

CONCLUSION

This study developed and validated a nomogram with good predictive performance for identifying TDs in CRC patients. Our predictive model can assist surgeons in making optimal treatment decisions.

Clinical significance of tumor deposits in gastric cancer after radical gastrectomy: a propensity score matching study

OBJECTIVE

The value of tumor deposits (TDs) in the prognosis and staging of gastric cancer (GC) is still under debate. This study aims to evaluate the prognostic value of TDs and the best ways to incorporate TDs in the TNM classification of GC.

METHODS

Patients (n = 3460) undergoing curative gastrectomy for GC in the West China Hospital from 2005 to 2017 were retrospectively reviewed and divided into two groups according to the TD status (positive vs. negative). Later, clinicopathological features and overall survival (OS) between the two groups were compared. Thereafter, the associations between the presence of TD and other clinicopathological factors were evaluated through logistic regression. In addition, univariate and multivariate Cox regression were conducted for determining prognostic factors. The possibility of selection bias was reduced through conducting the 1:1 propensity score matching (PSM) analysis. The modified classification systems proposed previously that incorporated TDs into the TNM staging system were assessed.

RESULTS

There were 10.5% of patients (362/3460) diagnosed with TDs. TDs were significantly related to unfavorable factors such as advanced T stage and N stage and independently associated with poor prognosis. The 5-year OS of patients with TDs was significantly lower than that of patients without TDs (31.0% vs. 60.9%, P < 0.001), whereas higher than that of patients with peritoneal metastasis (31.0% vs. 5.0%, P < 0.001). In patients receiving chemotherapy, the 5-year OS of patients with TDs was also significantly lower than that of patients without TDs (42.0% vs. 50.9%, P = 0.026). Moreover, the system incorporating TDs in the TNM classification as metastatic lymph nodes outperformed others.

CONCLUSIONS

TDs are related to the aggressive characteristics and are an independent prognostic factor for GC. Incorporating TDs in the TNM classification as the metastatic lymph nodes increases the accuracy in predicting prognosis.

Incorporation of perigastric tumor deposits into the TNM staging system for primary gastric cancer

BACKGROUND

The current prognostic significance of perigastric tumor deposits (TDs) in gastric cancer (GC) remains unclear.

AIM

To assess the prognostic value of perigastric TDs and put forward a new TNM staging framework involving TDs for primary GC.

METHODS

This study retrospectively analyzed the pathological data of 6672 patients with GC who underwent gastrectomy or surgery for GC with other diseases from January 1, 2012 to December 31, 2017 at the Chinese PLA General Hospital. According to the presence of perigastric TDs or not, the patients were divided into TD-positive and TD-negative groups by using the method of propensity score matching. The differences between TD-positive and TD-negative patients were analyzed using binary logistic regression modeling. The Kaplan-Meier method was used to plot survival curves. Multivariate Cox regression modeling and the log-rank test were used to analyze the data.

RESULTS

Perigastric TDs were found to be positive in 339 (5.09%) of the 6672 patients with GC, among whom 237 were men (69.91%) and 102 were women (30.09%) (2.32:1). The median age was 59 years (range, 27 to 78 years). Univariate and multivariate survival analyses indicated that TD-positive GC patients had a poorer prognosis than TD-negative patients (P < 0.05). The 1-, 3-, and 5-year overall survival rates of GC patients with TDs were 68.3%, 19.6%, and 11.2%, respectively, and these were significantly poorer than those without TDs of the same stages. There was significant variation in survival according to TD locations among the GC patients (P < 0.05). A new TNM staging framework for GC was formulated according to TD location. When TDs appear in the gastric body, the original stages T1, T2, and T3 are classified as T4a with the new framework, and the original stages T4a and T4b both are classified as T4b. When TDs appear in the lesser curvature, the previous stages N0, N1, N2, and N3 now both are classified as N3. When TDs appear in the greater curvature or the distant tissue, the patient should be categorized as having M1. With the new GC staging scheme including TDs, the survival curves of patients in the lower grade TNM stage with TDs were closer to those of patients in the higher grade TNM stage without TDs.

CONCLUSION

TDs are a poor prognostic factor for patients with primary GC. The location of TDs is associated with the prognosis of patients with primary GC. Accordingly, we developed a new TNM staging framework involving TDs that is more appropriate for patients with primary GC.

Tumor Deposit Is an Independent Factor Predicting Early Recurrence and Poor Prognosis in Gastric Cancer

BACKGROUND

Accurate prognostic estimation is crucial; however, the prognostic value of tumor deposits in gastric cancer remains controversial. This study aimed to investigate their prognostic significance.

METHODS

Clinicopathological and prognostic data of 1012 gastric cancer patients who underwent R0 or R1 surgery from 2010 to 2017 at the Osaka International Cancer Institute were retrospectively reviewed.

RESULTS

Overall, 6.3% patients had tumor deposits, which were associated with Borrmann type, surgical procedure, type of gastrectomy, extent of lymphadenectomy, tumor size, histology, pT, pN, pM, pStage, lymphatic invasion, vascular invasion, preoperative chemotherapy, and postoperative chemotherapy. Tumor deposit-positive patients had worse 5-year disease-free survival (32.60% vs. 92.45%) and overall survival (41.22% vs. 89.37%) than tumor deposit-negative patients. Subgroup analysis regarding pStage II-III also showed significant differences between patients with and without tumor deposits for 5-year disease-free survival (34.15% vs. 80.98%) and overall survival (43.17% vs. 75.78%). Multivariable analysis showed that older age, undifferentiated histology, deeper tumor invasion, lymph node metastasis, distant metastasis, and presence of tumor deposits were significantly correlated with early tumor recurrence and shorter survival time; these factors were identified as independent prognostic factors. The 5-year disease-free survival of tumor deposit-positive patients was significantly worse than that of patients in the pStage III group and comparable to that of patients in the pT4, pN3, and pM1 groups. The 5-year overall survival of tumor deposit-positive patients was comparable to that of the pT4, pN3, pM1, and pStage III groups.

CONCLUSIONS

Tumor deposits are strong and independent predictors of tumor recurrence and poor survival.

The short- and long-term effect of membrane anatomy-guided laparoscopic D2 lymphadenectomy plus regional complete mesogastrium excision for locally advanced gastric cancer

OBJECTIVE

Retrospectively analyzed the short- and long-term efficacy between laparoscopic D2 lymphadenectomy plus regional complete mesogastrium excision (D2 + rCME) and traditional laparoscopic D2 in the treatment of patients with locally advanced gastric cancer (LAGC), in order to obtain more evidence for D2 + rCME gastrectomy.

METHODS

A total of 599 LAGC patients who underwent laparoscopy-assisted radical gastrectomy from January 2014 to December 2019, including 367 cases in the D2 + rCME group and 232 cases in the D2 group. Intraoperative and postoperative clinicopathological parameters, postoperative complications and long-term survival in the two groups were statistically analyzed.

RESULTS

No significant differences in the positive rate of mesogastric tumor deposits, the number of positive lymph nodes and postoperative length of stay were found between the two groups (P > 0.05). In the D2 + rCME group, intraoperative blood loss was significantly reduced (84.20 ± 57.64 ml vs. 148.47 ± 76.97 ml, P < 0.001), the time to first postoperative flatus and first liquid diet intake were significantly shortened (3[2-3] days vs. 3[3-3] days, P < 0.001; 7[7-8] days vs. 8[7-8] days, P < 0.001), and the number of lymph nodes dissected was greater (43.57 ± 16.52 pieces vs. 36.72 ± 13.83 pieces, P < 0.001). The incidence of complications did not significantly differ between the D2 + rCME group (20.7%) and D2 group (19.4%) (P > 0.05). Although there was no statistically difference in 3-year OS and DFS between the two groups. However, the trend was better in D2 + rCME group. In subgroup analysis, patients with positive tumor deposits (TDs) in the D2 + rCME group had significantly better 3-year DFS compared With D2 group (P < 0.05).

CONCLUSION

Laparoscopic D2 + rCME is safe and feasible for the treatment of LAGC and is characterized by less bleeding, greater lymph node dissection and rapid recovery, without increasing postoperative complications. D2 + rCME group showed a better trend of long-term efficacy, especially significant beneficial for LAGC patients who with positive TDs.

Reappraisal of Tumor Deposit as a Prognostic Factor in Pancreatic Cancer

PURPOSE

Tumor deposits (TDs) are discrete tumor nodules within the lymphatic drainage area of the primary tumor without histological evidence of lymph node tissue or identifiable vascular or neural structure. This study aims to analyze the prognostic impact of TDs in patients with pancreatic ductal adenocarcinoma (PDAC) and explore their potential role in staging system.

METHODS

The prospectively maintained database from the Fudan University Shanghai Cancer Center was queried for patients undergoing resection for PDAC. Patients with TDs were matched by propensity score with those without TDs. The cumulative prevalence of recurrence was estimated using the cumulative incidence function. Overall survival was estimated using Kaplan-Meier curves.

RESULTS

A total of 123 patients (9.7%) had TDs, of whom 108 were matched at a 1:3 ratio with 324 patients without TDs. The cumulative incidence of recurrence was significantly higher for TD-positive patients than TD-negative patients (P = 0.04). The median overall survival was significantly shorter for patients with TDs than for those without TDs (15.9 versus 21.8 months, P < 0.001). The presence of TDs attenuated the effect of lymph node metastasis on survival, with no significance between node-negative and node-positive subpopulations (P = 0.165). Patients with TDs had comparable survival to N2 patients without TDs (15.9 versus 17.1 months, P = 0.383).

CONCLUSIONS

TD is an important prognostic factor for recurrence and survival in patients undergoing resection for PDAC. We suggest that patients presenting TDs be classified into the stage III category in the next edition of the staging system.

Prognostic value of tumor deposits in lymph node-negative gastric cancer: A propensity score matching study

BACKGROUND

The purpose of this study was to assess the prognostic value of TD in lymph node-negative GC.

METHODS

A retrospective study was conducted to collect the clinicopathological data from 1224 patients with lymph node-negative GC. According to their TD status, patients were categorized into TD-positive and TD-negative groups. Patients in both groups underwent a 1:1 propensity score matching analysis. Survival analysis was performed by the Kaplan-Meier method, and the differences between survival curves were measured by log-rank test. The cox proportional hazards model was used for univariate and multivariate analyses.

RESULTS

The TD-negative group had higher 5-year overall survival(OS) rate than TD-positive group(69.4%VS.36.4%,P < 0.05). Further subgroup analysis indicated that patients in the TD-negative group had higher 5-year OS rates than those in the TD-positive group in the T1-2, T3, and T4 subgroups(all with P < 0.05).The OS rates were decreased with the increase of the number of TD.The univariate Cox regression analysis demonstrated that tumor location in antrum, distal gastrectomy, perineural invasion, T4-stage,lymphovascular invasion and the number of TD were all associated with prognosis in patients undergoing curative gastric resection (P < 0.05).The multivariable analysis revealed that the number of TD, perineural invasion, lymphovascular invasion and T4 stage were independently associated with OS.

CONCLUSION

In lymph node-negative GC, TD is an independent risk factor for prognosis, regardless of T-stage, and patients with ≥3 TD have a worse prognosis.

Prognostic significance of tumor deposits in radically resected gastric cancer: a retrospective study of a cohort of 1915 Chinese individuals

Background

Tumor deposits (TDs) have been identified as an independent prognostic factor in gastric cancer (GC). However, the associated clinicopathological factors and how to simply and reasonably incorporate TD into the TNM staging system remain undetermined. The aim of the current study was therefore to assess the significance of TD among radically resected GC patients.

Methods

We retrospectively reviewed 1915 patients undergoing radical resection between 2007 and 2012. The patients were classified into two groups according to TD status (absent vs. present), and the clinicopathologic characteristics, DFS, and OS were compared. Associations of TD presence with other clinicopathologic factors were evaluated by logistic regression analysis. Univariate and multivariate Cox regression analyses were performed to determine the prognostic factors for DFS and OS in the primary cohort. Propensity score matching (PSM) was performed to reduce the possibility of selection bias according to the presence of TD. External validation of previously proposed modified staging systems incorporating TD was conducted.

Results

The detection rate of TD was 10.5% (201/1915). The presence of TD was significantly related to unfavorable clinicopathologic variables, including advanced T and N categories. According to the multivariate Cox regression analysis, the presence of TD was identified as an independent prognostic factor for DFS and OS in the primary cohort (both P < 0.001). In the after-PSM cohort, TD presence also significantly shortened DFS and OS. In the external validation, one system that incorporated TD into the pTNM stage had the best performance.

Conclusions

The presence of TD was significantly associated with poor survival in radically resected GC patients. The incorporation of TD into the TNM staging system can further improve the predictive capability. A multicenter cohort with a large sample size is needed to determine the appropriate method of incorporation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02773-1.

Family history of malignant tumor is a predictor of gastric cancer prognosis: Incorporation into a nomogram

The purpose of this study was to investigate the impact of a family history of malignant tumor on the prognosis of patients with gastric cancer and develop a nomogram that incorporates a family history of malignant tumor to predict overall survival (OS) in patients with gastric cancer to aid clinicians and patients in decision making. Four hundred eighty-eight patients with gastric cancer undergoing radical gastrectomy in our center were included and randomly split into a training set (n = 350) and a validation set (n = 138) at a ratio of 7:3. Cox univariate regression analysis was used to evaluate the influence of clinicopathological characteristics and family history of malignant tumors on their prognosis, and variables were screened by multivariate Cox regression analysis and consensus on clinical evidence. A nomogram was constructed for OS based on the filtered variables, and the C-index, receiver operating characteristic curve (ROC curve), and calibration curve were used to validate the nomogram and decision curve analysis curve (DCA curve) was used for clinical practicality assessment. Six variables related to OS, including the pathological differentiation degree, Lauren type, infiltration depth, lymph node metastasis, tumor deposit, and family history of malignant tumor, were screened to construct a nomogram. The nomogram developed in this study performed well in the training set and the validation set, with C-index of 0.776 and 0.757, and the area under the ROC curve(AUC) for predicting 1-, 3-, and 5-year survival rates are 0.838, 0.850, 0.820 and 0.754, 0.789, 0.808, respectively. The calibration curve shows that the estimated death risk of the nomogram in the 2 data sets is very close to the actual death risk. The net benefits of nomogram-guided prediction of patient survival at 1-, 3-, and 5 years were demonstrated by the DCA curves, which showed high clinical practicability. Family history of malignant tumors is an independent risk factor affecting the prognosis of patients with gastric cancer. The nomogram developed in this research can be used as an important tool to predict the prognosis of gastric cancer patients with family history data.

Tumor Characteristics Associated with Lymph Node Metastasis and Prognosis in Patients with ERBB2-Positive Gastric Cancer

Gastric cancers (GCs) that express human erb-b2 receptor tyrosine kinase 2 (ERBB2, also known as HER2) account for 7.3%–20.2% of GCs. The pathological and prognostic factors associated with lymph node metastasis of such tumors are still unclear. Therefore, we aimed to identify the risk factors for lymph node metastasis and prognostic factors of patients with ERBB2-positive GC. We conducted a retrospective analysis of pathological specimens after D2 radical surgery for locally advanced GC and D1+ surgery performed for early GC in our hospital from January 2015 to December 2018. Patients with ERBB2-positive GC were selected and the potential risk factors for lymph node metastasis and potential factors affecting prognosis were evaluated. Among 1,124 GC patients, 122 diagnosed with ERBB2-positive GC were included in the study. We found that risk factors for lymph node metastasis included tumor size (hazard ratio (HR)- 6.213, 95% confidence interval (CI)- 2.097–18.407, p = 0.001), neural invasion (HR- 2.876, 95% CI - 1.011–8.184, p = 0.048), and vascular invasion (HR- 16.881, 95% CI - 5.207–54.727, p < 0.001). T stage (HR- 4.615, 95% CI - 2.182–9.759, p < 0.001) and vascular invasion (HR- 3.036, 95% CI - 1.369–6.736, p = 0.006) were significant prognostic variables. These findings shed new light on the pathology and prognosis of patients with ERBB2-positive GC.

A model established using marital status and other factors from the Surveillance, Epidemiology, and End Results database for early stage gastric cancer

Currently, the postoperative prognosis of early stage gastric cancer (GC) is difficult to accurately predict. In particular, social factors are not frequently used in the prognostic assessment of early stage GC. Therefore, this study aimed to combine the clinical indicators and social factors to establish a predictive model for early stage GC based on a new scoring system. A total of 3647 patients with early stage GC from the Surveillance, Epidemiology, and End Results database were included in this study. A Kaplan-Meier survival analysis was used to compare differences in prognosis between different marital status, as an innovative prognostic indicator. Univariate and multivariate analyses were used to screen available prediction factors and then build a nomogram using the Cox proportional hazard regression model. The univariate analysis and multivariate analysis revealed that age at diagnosis, sex, histology, stage_T, surgery, tumor size, and marital status were independent prognostic factors of overall survival. Both the C-index and calibration curves confirmed that the nomogram had a great predictive effect on patient prognosis in training and testing sets. This nomogram based on clinical indicators and marital status can effectively help patients with early stage GC in the future.

Pathologic Lymph Node Staging of Gastric Cancer

OBJECTIVES

The TNM classification is the main tool for lymph node (LN) staging in gastric cancer (GC). However, alternative LN staging systems have been proposed, and the role of features other than the number of metastatic LNs is being investigated. Our aim is to discuss the main challenges of LN assessment in GC.

METHODS

Comprehensive review of the literature on alternative LN staging systems, examined LNs, sentinel LN (SLN) biopsy, LN micrometastases (LNMIs), extracapsular extension (ECE), and tumor deposits (TDs) in GC.

RESULTS

Many controversies exist regarding LN assessment in GC. The TNM classification shows excellent prognostic performance, but alternative prognostic methods such as the LN ratio or log odds of positive LNs have demonstrated to be better than the TNM system in terms of prognostic accuracy. The value of SLN biopsy and LNMIs in GC is still unclear, and several challenges concerning their clinical impact and pathologic analysis must be overcome before their introduction in clinical practice. Most authors have identified ECE and TDs as independent prognostic factors for survival in GC.

CONCLUSIONS

Further studies should be performed to evaluate the impact of these features on the TNM classification and patient outcomes, as well as to standardize alternative LN staging systems.

The prognostic value of tumor deposits and the impact on the TNM classification system in esophageal cancer patients

OBJECTIVE

To explore the prognostic significance of tumor deposits (TDs), isolated tumor foci lacking residual lymph nodes, in esophageal cancer (EC).

METHODS

A retrospective review of patients with EC undergoing esophagectomy between 2005 and 2017 was conducted. The prognostic value of TD was evaluated using a Cox regression model. Patients from different sources and periods were split into discovery and validation sets. A propensity score matching model was used in the validation set to reduce the confounding bias. The impact of TD on the TNM classification system was evaluated.

RESULTS

The discovery and validation sets included 179 and 2875 patients, respectively. Propensity-matched patients with and without TDs were constructed in the validation set with 132 patients in each group. Overall survival (p < .001 and p = .004, respectively) and disease-free survival (p < .001 and p = .019, respectively) were both decreased in TD positive patients in the discovery set and propensity-matched groups of validation set. Classifying patients with TDs into pN3 stage improved the discriminative power of the current TNM staging system.

CONCLUSIONS

TD is an independent prognostic factor for EC. The inclusion of TD in the TNM staging system may upstage appropriate patients to help guide therapy, and future studies are warranted.

Impact of examined lymph node count on staging and long-term survival of patients with node-negative stage III gastric cancer: a retrospective study using a Chinese multi-institutional registry with Surveillance, Epidemiology, and End Results (SEER) data validation

Background

Accumulating evidence has confirmed the potential prognostic value of examined lymph nodes (ELNs) in patients with gastric cancer (GC). However, there is currently no consensus on the threshold ELN number for predicting both stage migration and long-term survival, especially in patients with stage III GC. This study aimed to validate the need to increase the ELN count to improve its prognostic accuracy in node-negative patients with stage III GC after curative gastrectomy.

Methods

This retrospective, population-based study analyzed the clinical data of 84 patients with node-negative stage III GC from three high-volume institutions in China and 196 cases from the Surveillance, Epidemiology and End Results (SEER) program registry. The optimal number of ELNs was determined by receiver operating characteristic (ROC) curve analysis. Clinicopathological characteristics significantly related to survival were evaluated using the Kaplan-Meier method and Cox proportional hazards analysis. Stratified analyses were adopted to assess the prognostic predictive ability of the identified optimal number of ELNs in different populations. Survival differences among subgroups were analyzed to assess the impact of ELN count on stage migration according to overall survival (OS) among GC patients.

Results

The optimal number of ELNs was >31 according to ROC analysis of patients with node-negative stage III GC who underwent gastrectomy. Multivariate analysis identified ELNs as an independent predictor of postoperative OS in patients with node-negative stage III GC in both the Chinese cohort [hazard ratio (HR) 0.235; P<0.001] and the SEER cohort (HR 0.421; P<0.010). Stratified analysis demonstrated that >31 ELNs was a prerequisite for accurate prognostic evaluation of patients with node-negative stage III GC, regardless of sex, tumor size, and other factors. Stage migration between pT4bN0M0 and pT4bN1M0 was detected in patients with >31 ELNs. A nomogram was created to predict OS among patients with node-negative stage III GC. These results were validated using data from the SEER cohort.

Conclusions

The number of ELNs was significantly associated with prognosis in patients with stage III GC after gastrectomy with systemic lymphadenectomy in both the Chinese and SEER cohorts. The results suggest that >31 ELNs are required for an accurate prognostic evaluation in patients with GC, especially those with node-negative stage III GC.

Tumor deposit serves as a prognostic marker in gastric cancer: A propensity score-matched analysis comparing survival outcomes

BACKGROUND

Gastric cancer (GC) treatment is determined by accurate tumor staging. The value of tumor deposit (TD) in prognostic prediction staging system is not yet determined.

METHODS

We retrospectively analyzed clinical information on GC patients who underwent gastrectomy at the Department of General Surgery of the Chinese PLA General Hospital from July 2014 to June 2016. Propensity score matching (PSM) was performed to reduce the possibility of selection bias according to the presence of TD.

RESULTS

Of the 1034 GC patients, 240 (23.21%) presented with TD, which was associated with younger age and larger tumor size (all P < .05). TD-positive patients had a worse survival than TD-negative patients before (P < .001) and after (P = .017) matching. Multivariable analysis showed that mortality risk of patients with TD increased by 58%, 62%, 37%, and 40% in the crude (HR = 1.58, 95% CI 1.32-1.89, P < .001), adjusted I (HR = 1.62, 95% CI 1.35-1.94, P < .001), adjusted II (HR = 1.37, 95% CI 1.13-1.66, P = .001), and adjusted III (HR = 1.40, 95% CI 1.16-1.68, P < .001) models before matching. Similarly, in the PSM cohort patients with TD had worse prognosis in the crude (HR = 1.32, 95% CI 1.07-1.63, P = .011), adjusted I (HR = 1.35, 95% CI 1.09-1.67, P = .005), adjusted II (HR = 1.26, 95% CI 1.00-1.58, P = .049), and adjusted III (HR = 1.33, 95% CI 1.07-1.65, P = .010) models. TD had a similar value range between N1 and N2 stages among different models.

CONCLUSIONS

Among GC patients, TD is associated with survival and may have a role in the staging of patients.