Prognostic value of lymph node ratio and extramural vascular invasion on survival for patients undergoing curative colon cancer resection

Survival analysis in pT1-3 and paracolic lymph-node invasion colorectal cancer: the prognostic role of positive paracolic lymph-node ratio for adjuvant chemotherapy

PURPOSE

Several studies have observed that some stage III colorectal cancer (CRC) patients cannot benefit from standard adjuvant chemotherapy. However, there is no unified screening standard to date.

METHODS

Consecutive patients with pathologically confirmed colon adenocarcinoma treated in 3 centers between January 2016 and December 2018 were included. Patients were divided into four groups according to different stages and positive paracolic lymph-node ratio (P-LNR) [Cohort 1: pT1-3N0M0, Cohort 2: pT1-3N + (P-LNR ≤ 0.15)M0, Cohort 3: pT4N0M0, Cohort 4: stage III patients except for pT1-3N + (P-LNR ≤ 0.15)M0], and further overall survival was compared by Kaplan-Meier method. The univariate and multivariate analyses were employed for cox proportional hazards model.

RESULTS

We retrospectively reviewed 5581 consecutive CRC patients with, and 2861 eligible patients were enrolled for further analysis. The optimal cut-off value of P-LNR in our study was 0.15. There was no significant difference in OS (91.36 vs. 93.74%) and DFS (87.65 vs. 90.96%) between stage III patients with pT1-3N + (P-LNR ≤ 0.15)M0 and those with pT1-3N0M0. Further analysis demonstrated that CRC patients with pT1-3N + (P-LNR ≤ 0.15)M0 were less likely to benefit from 8 cycles of CAPOX or FOLFOX chemotherapy and suffered fewer adverse events from declining chemotherapy. Comparing with 0-4 cycles versus 8 cycles, the overall survival rates were 91.35 versus 90.19% (P = 0.79), and with a DFS of 87.50 versus 88.24% (P = 0.49), the duration of adjuvant chemotherapy was not an independent risk factor for patients with pT1-3N + (P-LNR ≤ 0.15)M0 (HR: 0.70, 95% CI 0.90-1.30, P = 0.42).

CONCLUSION

The concept of P-LNR we proposed might have a high clinical application value and accurately enable clinicians to screen out specific CRC patients who decline or prefer limited chemotherapy.

TRIAL REGISTRY

The clinical trial registration number: ChiCTR2300076883.

Prognostic Significance of Lymph Node Density in Pathological Node Positive Urothelial Carcinoma of the Bladder -Upfront Surgery and Post Neoadjuvant Chemotherapy Cohorts

AIM

To validate the role of lymph node density as a prognostic marker in patients undergoing primary surgery and postneoadjuvant therapy in pathological node-positive urothelial bladder carcinoma.

MATERIALS AND METHODS

Retrospective analysis of 503 patients who underwent radical cystectomy from 2006 to 2019 for muscle-invasive urothelial bladder carcinoma, of which 152 patients with pathological node-positive disease were analyzed. Demographic details, pathological findings, treatment details, disease-free, and overall survival were documented. X tile program analysis was used to divide patients with positive lymph nodes into 3 groups: LD1: <= 7, LD2 :>7 to <15, LD3: >15, and the optimal cut-off value obtained was 15%. To evaluate the impact of lymph node ratio, patients with positive lymph nodes into 3 categories for each cut-off point estimation method, the application generates the histogram, Kaplan-Meier plot and calculates hazard ratio, confidence intervals and P-values. Univariate and multivariate cox regression analysis was done with a P-value of <.05, considered significant.

RESULTS

One hundred fifty-two patients (30.2%) had pathological nodal metastasis, with 87 of them having perinodal extension. Ninety-six underwent primary surgery, and 56 were postneoadjuvant chemotherapy. The median follow-up was 55.42 months. 68 of the 152 node-positive patients died of the disease. Median number of lymph nodes removed was 17.11. Lymph node density divided into tertiles were LD1 <7%, LD2 7-<15%, LD3 >15% showed 5-year RFS 40.5%,29.3%, 22.6% and 5 year OS was 55.5%, 42.4%,32.1% respectively. Cox regression analysis showed that age less than 55 years ,higher tumor stage, lymphovascular invasion, and higher lymph node ratio were significant in univariate and multivariate analysis. The lymph node density cut-off value of 15% was substantial among node-positive patients (P = .027), and subgroup analysis in upfront surgery with the adjuvant treatment group and postneoadjuvant chemotherapy group was also significant (P =.021).

CONCLUSION

Pathological higher T stage, Age <55 years, Lymphovascular invasion, adjuvant chemotherapy , adjuvant radiation treatment and lymph node density had prognostic significance in both cohorts of patients who underwent upfront surgery and neoadjuvant chemotherapy. Lymph node density cut-off value of <15% was prognostically significant.

Evaluation of the prognostic performance of different cutoff values of lymph node ratio staging system for stage III colorectal cancer

This study attempted to compare the prognostic performance of lymph node ratio (LNR) staging system with different cutoff values relative to American Joint Committee on Cancer (AJCC) pN staging system in stage III colorectal cancer (CRC). Overall, 45,069 patients from the SEER dataset and 69 patients from the Second Affiliated Hospital of Nanjing Medical University (the External set) who underwent surgical resection of the primary tumor and were diagnosed with stage III CRC by postoperative pathology were included. Patients were divided into three subgroups based on the LNR cutoff used in previous studies, Kaplan-Meier curves were plotted, and log-rank test was used to compare the differences among groups in terms of cancer-specific survival (CSS). Cox regression model was applied for survival analysis. To evaluate the discriminatory power of different lymph node staging systems, Harrell's C statistic(C-index) and Akaike's Information Criterion (AIC) were applied. A set of optimal cutoff values (0.11; 0.36; 0.66) of LNR staging system with the most considerable discriminatory power to the prognosis in patients with stage III CRC (SEER set: C-index = 0.714; AIC = 58,942.46, External set: C-index = 0.809; AIC = 164.36) were obtained, and both were superior to the AJCC pN staging system (SEER set: C-index = 0.708; AIC = 59,071.20, External set: C-index = 0.788; AIC = 167.06). For evaluating the prognostic efficacy of patients with stage III colorectal cancer, the cutoff value (0.11; 0.36; 0.66) of LNR staging system had the best discrimination and prognostic ability, which was superior to LNR staging system under other cutoff values and AJCC pN staging system.

Prognostic Value of Metastatic Lymph Node Ratio and Identification of Factors Influencing the Lymph Node Yield in Patients Undergoing Curative Colon Cancer Resection

Due to the impact of nodal metastasis on colon cancer prognosis, adequate regional lymph node resection and accurate pathological evaluation are required. The ratio of metastatic to examined nodes may bring an additional prognostic value to the actual staging system. This study analyzes the identification of factors influencing a high lymph node yield and its impact on survival. The lymph node ratio was determined in patients with fewer than 12 or at least 12 evaluated nodes. The study included patients after radical colon cancer resection in UICC stages II and III. For the lymph node ratio (LNR) analysis, node-positive patients were divided into four categories: i.e., LNR 1 (<0.05), LNR 2 (≥0.05; <0.2), LNR 3 (≥0.2; <0.4), and LNR 4 (≥0.4), and classified into two groups: i.e., those with <12 and ≥12 evaluated nodes. The study was conducted on 7012 patients who met the set criteria and were included in the data analysis. The mean number of examined lymph nodes was 22.08 (SD 10.64, median 20). Among the study subjects, 94.5% had 12 or more nodes evaluated. These patients were more likely to be younger, women, with a lower ASA classification, pT3 and pN2 categories. Also, they had no risk factors and frequently had a right-sided tumor. In the multivariate analysis, a younger age, ASA classification of II and III, high pT and pN categories, absence of risk factors, and right-sided location remained independent predictors for a lymph node yield ≥12. The univariate survival analysis of the entire cohort demonstrated a better five-year overall survival (OS) in patients with at least 12 lymph nodes examined (68% vs. 63%, p = 0.027). The LNR groups showed a significant association with OS, reaching from 75.5% for LNR 1 to 33.1% for LNR 4 (p < 0.001) in the ≥12 cohort, and from 74.8% for LNR2 to 49.3% for LNR4 (p = 0.007) in the <12 cohort. This influence remained significant and independent in multivariate analyses. The hazard ratios ranged from 1.016 to 2.698 for patients with less than 12 nodes, and from 1.248 to 3.615 for those with at least 12 nodes. The LNR allowed for a more precise estimation of the OS compared with the pN classification system. The metastatic lymph node ratio is an independent predictor for survival and should be included in current staging and therapeutic decision-making processes.

Clinical and pathological characteristics of early-onset colorectal cancer in South Korea

Background

Early-onset colorectal cancer (EOCRC) may differ by race and ethnicity, and recently South Korea has witnessed a surge in cases. We aimed to evaluate the clinical and pathological features of patients with EOCRC, and to determine the predictors of overall survival.

Methods

In this retrospective study, EOCRC was defined as CRC diagnosed in patients aged < 50 years, and late-onset CRC was defined as CRC diagnosed in those over 75 years of age. The clinical and pathological characteristics of patients with EOCRC were compared with late-onset CRC. We also used multivariable Cox proportional hazard models to find predictors of overall survival in patients with EOCRC.

Results

The proportion of early-onset CRC was 9.1% of 518 patients with CRC, and the clinical and pathological characteristics were similar between early-onset (n = 47) and late-onset CRC (n = 134). However, EOCRC had a preponderance for distal tumor location (70.2% vs. 50.7%, P = 0.02) and T1-2 stage disease (23.4% vs. 11.2%, P = 0.04), compared with those of late-onset CRC. Using multivariable Cox proportional hazard models, only vascular invasion (hazard ratio = 8.75, 95% confidence interval 1.139‒67.197) was found to be a risk factor for overall survival (P = 0.04) for patients with CRC.

Conclusion

EOCRC had preponderance for distal tumor location and early T-stage disease, compared with late-onset CRC. Considering the increasing incidence of EOCRC, more studies on clinical and pathological characteristics of EOCRC may be warranted.

Construction and validation of a prognostic nomogram for predicting cancer-specific survival in patients with intermediate and advanced colon cancer after receiving surgery and chemotherapy

BACKGROUND

Existing predictive models often focus solely on overall survival (OS), neglecting the bias that other causes of death might introduce into survival rate predictions. To date, there is no strict predictive model established for cancer-specific survival (CSS) in patients with intermediate and advanced colon cancer after receiving surgery and chemotherapy.

METHODS

We extracted the data from the Surveillance, Epidemiology, and End Results (SEER) database on patients with stage-III and -IV colon cancer treated with surgery and chemotherapy between 2010 and 2015. The cancer-specific survival (CSS) was assessed using a competitive risk model, and the associated risk factors were identified via univariate and multivariate analyses. A nomogram predicting 1-, 3-, and 5-year CSS was constructed. The c-index, area under the curve (AUC), and calibration curve were adopted to assess the predictive performance of the model. Additionally, the model was externally validated.

RESULTS

A total of 18 risk factors were identified by univariate and multivariate analyses for constructing the nomogram. The AUC values of the nomogram for the 1-, 3-, and 5-year CSS prediction were 0.831, 0.842, and 0.848 in the training set; 0.842, 0.853, and 0.849 in the internal validation set; and 0.815, 0.823, and 0.839 in the external validation set. The C-index were 0.826 (se: 0.001), 0.836 (se: 0.002) and 0.763 (se: 0.013), respectively. Moreover, the calibration curve showed great calibration.

CONCLUSION

The model we have constructed is of great accuracy and reliability, and can help physicians develop treatment and follow-up strategies that are beneficial to the survival of the patients.

Prognostic value of the lymph node ratio in surgically treated stage III colorectal cancer patients with high numbers of harvested lymph nodes

BACKGROUND

The lymph node ratio (LNR), defined as the number of positive lymph nodes (LN) divided by the total number of harvested LN, has been demonstrated to be an independent factor in the prognosis of surgically treated colorectal cancer (CRC) patients. This study aims to establish the prognostic value of LNR in stage III CRC patients with high numbers of LN removed.

METHODS

Stage III CRC patients who underwent curative resections over an 8-year period were included to the study. Demographics, clinicopathological features, surgical as well as recurrence and survival outcomes were recorded and statistically analyzed. Calculations for LNR were carried out as a function of percentage rates and Cox proportional hazards regression analyses were performed to determine its effect on disease-free and overall survival.

RESULTS

Among a total of 493 surgically treated CRC cases, 104 patients were included to the study consisting of 68 (65.4%) men and 36 (34.6%) women with a median age of 64 (inter-quartile range: 55-74) years. The mean number of harvested LN was 31.6 ± 21.0 (range: 12-103). Multivariate Cox regression analyses proved LNR to be a significant factor in both disease-free and overall survival (p = 0.007 and p = 0.003, respectively). Forward elimination analyses showed that a 1% increase in LNR resulted with a 2% increase in both the risks of recurrence and mortality.

CONCLUSIONS

The LNR may be assessed as an adjunct to the current staging systems for the prediction of oncological outcomes and survival of surgically treated stage III CRC patients.

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.

Identification and Prognostic Effect of Extramural Venous Invasion in Locally Advanced Esophageal Squamous Cell Carcinoma

The role of extramural venous invasion (EMVI) in esophageal cancer is still unclear. This study aimed to identify EMVI and assess its impact on survival and recurrences in esophageal squamous cell carcinoma (ESCC). Retrospectively, we reviewed resection specimens of 147 locally advanced ESCC (pT3-T4aN0-3M0) patients who had a curative intended surgery alone at the Cancer Hospital of Shantou University from March 2009 to December 2013. After confirming pT≥3 in hematoxylin-eosin tumor slides, EMVI was evaluated by Verhoeff and Caldesmon staining. The impact of EMVI with other clinicopathological characteristics and survival were analyzed using the χ 2 test, Cox regression, and Kaplan-Meier method. EMVI was present in 30.6% (45/147) of the P ≥T3 ESCCs and associated with lymph-vascular invasion and poor differentiation grade ( P <0.05). Disease-free survival and overall survival in patients with EMVI-absent tumors were about 2.0 times longer than in those with EMVI-present tumors. In pN0 patients, EMVI-presence was associated with poor overall survival (HR 4.829, 95% CI 1.434-16.26, P =0.003) and Disease-free Survival (HR 4.026, 95% CI 0.685-23.32, P =0.018). In pN1-3 patients, EMVI had no additional effect on survival. Conclusions EMVI has an independent adverse prognostic effect on survival in ESCC patients after surgery alone. EMVI should be included in pathology reports as it might contribute to identify high-risk patients for potential additional treatment.

Grading criteria for venous invasion in thoracic esophageal squamous cell carcinoma

BACKGROUND

Venous invasion (VI) is an adverse prognostic indicator in esophageal squamous cell carcinoma. However, grading criteria for venous invasion in thoracic esophageal squamous cell carcinoma (ESCC) have not been established.

METHODS

We enrolled 598 thoracic ESCC patients from 2005 to 2017. We detected the presence of venous invasion using the hematoxylin and eosin (H&E)-staining method and evaluated the VI grade on the basis of the number and maximal size of the involved veins. The degree of VI was classified as either 0, V1, V2, or V3, according to the combination of V-number and V-size.

RESULTS

The 1-year, 3-year and 5-year disease-free survival rates were 79.7%, 64.7% and 61.2%, respectively. Multivariate analysis demonstrated that lymphatic invasion (HR: 1.457, 95% CI: 1.058-2.006, p = 0.021), T category (HR: 1.457, 95% CI: 1.058-2.006, p = 0.022), N category (HR: 1.535, 95% CI: 1.276-2.846, p < 0.001), stage (HR: 1.563, 95% CI: 1.235-1.976, p < 0.001) and the degree of venous invasion (HR: 1.526, 95% CI: 1.279-2.822, p < 0.001) were significant indicators of recurrence. The disease-free survival curves were distinguished especially well by the degree of venous invasion in stage III and IV patients.

CONCLUSIONS

The present study explored an objective grading criterion for VI and proved the prognostic value of the degree of venous invasion in ESCC. The classification of venous invasion into 4 groups is useful for the differentiation of prognosis in ESCC patients. The prognostic significance of the degree of VI in advanced ESCC patients for recurrence may have to be considered.

A modified mTNM staging system based on lymph node ratio for colon neuroendocrine tumors: A recursive partitioning analysis

BACKGROUND

In the current tumor-lymph node-metastasis (TNM) staging system for colon neuroendocrine tumors, lymph node status is divided into N1 and N0. An assessment of the lymph node ratio (LNR) and a proposal for a modified mTNM staging system were the objectives of this study.

METHODS

Selecting the optimal cut-off value of LNR was done using X-tile. A Cox regression model and the Kaplan-Meier method were performed to calculate patient cancer-specific survival in the Surveillance, Epidemiology and End Results cohort. Recursive partitioning analysis was used to improve TNM staging.

RESULTS

The study included 674 patients. The current TNM staging system showed inadequate discriminatory power between stage I and stage II patients (p = 0.088). The optimal cut-off value was determined as 0.6 for LNR. Based on multivariate Cox regression analysis, the modified mN classification could be classified into mN 0 (LNR = 0.00), mN 1 (LNR = 0.01-0.60), and mN 2 (LNR > 0.60), and was found to be an independent factor affecting prognosis (p < 0.001). Using the American Joint Committee on Cancer T and modified mN classifications, the modified mTNM system was constructed, and it exhibited better prognostic discriminatory power ability than the traditional TNM system (C-index: 0.587 vs. 0.665).

CONCLUSIONS

Our study determined that LNR is a prognostic factor in colon NET patients. In addition, to more accurately assess the prognosis of colon NET patients, we proposed a modified mTNM staging system.

The complementary role of lymphovascular invasion and perineural invasion in the TNM staging process of rectal cancer

The aim of this study is to clarify the association between lymphovascular invasion (LVI) and/or perineural invasion (PNI) and the clinical characteristics and prognostic importance of rectal cancer, to provide a basis for early adjuvant treatment of rectal cancer. We retrospectively analyzed patients diagnosed with rectal cancer. This study involved rectal cancer tissue samples were obtained by surgical methods. Data on histological form, tumor classification, tumor size, gross growth pattern, blood and lymphatic vessel invasion, and PNI of the slice by HE staining were obtained from pathological examination. Immunohistochemical analysis of tissue samples was performed to determine p53 and EGFR expressions. There were 330 rectal cancer patients included in the study. LVI and/or PNI can be used as a high-risk factor for the prognosis of rectal cancer, predict prognostic survival, and guide adjuvant therapy. The detection rates of LVI and PNI were 32.1% and 16.1%. Differentiation grade, Union for International Cancer Control staging, tumor-lymph node-metastasis staging are significantly related to LVI or PNI. Multivariate logistic regression analysis shows that poor differentiation and N ≥ 1 can be used as independent risk factors and predictive factors for LVI. At the same time, poor differentiation and T > 3 is an independent risk factor for PNI. Only poor differentiation is the risk factor for poor prognosis in Cox risk regression analysis. In addition, the simultaneous occurrence of LVI and PNI is an independent prognostic factor.

Beyond N staging in colorectal cancer: Current approaches and future perspectives

Traditionally, lymph node metastases (LNM) evaluation is essential to the staging of colon cancer patients according to the TNM (tumor–node–metastasis) system. However, in recent years evidence has accumulated regarding the role of emerging pathological features, which could significantly impact the prognosis of colorectal cancer patients. Lymph Node Ratio (LNR) and Log Odds of Positive Lymph Nodes (LODDS) have been shown to predict patients’ prognosis more accurately than traditional nodal staging and it has been suggested that their implementation in existing classification could help stratify further patients with overlapping TNM stage. Tumor deposits (TD) are currently factored within the N1c category of the TNM classification in the absence of lymph node metastases. However, studies have shown that presence of TDs can affect patients’ survival regardless of LNM. Moreover, evidence suggest that presence of TDs should not be evaluated as dichotomic but rather as a quantitative variable. Extranodal extension (ENE) has been shown to correlate with presence of other adverse prognostic features and to impact survival of colorectal cancer patients. In this review we will describe current staging systems and prognostic/predictive factors in colorectal cancer and elaborate on available evidence supporting the implementation of LNR/LODDS, TDs and ENE evaluation in existing classification to improve prognosis estimation and patient selection for adjuvant treatment.

Correlation and prognostic value of CT-detected extramural venous invasion and pathological lymph-vascular invasion in colon cancer

PURPOSE

To explore the association between CT-detected extramural vascular invasion (ctEMVI) and lymph-vascular invasion (LVI) in colon cancer, and analyze the prognostic value of ctEMVI in different conditions of LVI.

METHODS

This single-center, retrospective study included 448 colon cancer patients from January 2015 to December 2017. Preoperative CT features and clinical and pathological data were collected. Associations between ctEMVI and LVI were tested. Univariate and multivariate logistic regression was performed. Multivariate Cox regression was performed adjusted with propensity score(PS). Kaplan-Meier method was used to compare survival differences between the ctEMVI and LVI groups. A 1:1 patient pairing was conducted using PS matching to assess the prognostic effect of ctEMVI in LVI subgroups.

RESULTS

Among the 448 patients, there were 261 men and 187 women, with an average age of 63 ± 12 years. The coincidence rate of ctEMVI and LVI was 73.9%. The k coefficient for identifying ctEMVI was 0.84. ctEMVI and LVI were both independent risk factors for overall survival (ctEMVI: HR 2.8, 95% CI 1.5-5.5; LVI: HR 2.2, 95% CI 1.2-4.1) and metastasis-free survival (ctEMVI: HR 3.3, 95% CI 1.7-6.4; LVI: HR 2.4, 95% CI 1.3-4.5) adjusted with PS. In the LVI(+) subgroup, the prognosis of ctEMVI(+) was significantly worse than that of ctEMVI(-); in the LVI(-) subgroup, the prognosis of different ctEMVI states was similar.

CONCLUSION

ctEMVI is an independent prognostic risk factor and has different prognostic value in different LVI states. It is recommended to perform the evaluation in routine work, especially for patients with positive LVI.

Prognostic Factors of Recurrence and Survival in Operated Patients with Colorectal Cancer

BACKGROUND: The recurrence of colorectal cancers is considered to be one of the greatest post-surgical complications that is affected by various factors. This study was designed to investigate the prognostic factors that affect the recurrence and survival of patients with colon and rectal cancers. METHODS: A retrospective study was performed on 380 patients with colorectal cancers who underwent surgery were enrolled in the study (152 patients with colon cancer and 228 patients with rectal cancer). Preoperative serum albumin level, type of surgery, tumor size, differentiation grade, proximal, distal and radial, and marginal involvement, the total number of excised lymph nodes, the number of involved lymph nodes, and tumor stage were recorded. Also, the incidences of recurrence and metastasis were recorded during the study. RESULTS: 380 patients with a mean age of 57.11 years were enrolled in the study. 152 patients with an average age of 57.57 years were diagnosed as having colon cancer. Recurrence and metastasis occurred in two patients (1.3%) and five patients (3.3%), respectively. 18 patients (11.8%) died because of colon cancer. 228 patients with a mean age of 56.81 had rectal cancer. Recurrence was seen in 19 patients (8.3%) and metastasis in 33 patients (14.5%). 38 patients (16.7%) died because of rectal cancer. Tumor size and involved lymph nodes were independent prognostic factors for the recurrence and metastases of colon cancer. Only involved lymph nodes were associated with death due to colon cancer. Independent prognostic factors for rectal cancer metastasis include serum albumin level and age. The total number of excised lymph nodes was the only predictor of tumor recurrence and death in rectal cancer. The median survival times of colon and rectal cancers were 90 and 110 months, respectively. CONCLUSION: The size of the tumor and the number of involved lymph nodes were independent prognostic factors for recurrence and metastasis of colon cancer. Also, the number of involved lymph nodes was associated with colon cancer-related deaths. In the case of rectal cancer, serum albumin levels and age predicted metastases. Only the total number of excised lymph nodes had a reverse relationship with recurrence and rectal cancer-related death.

Intracorporeal versus Extracorporeal Anastomosis for Laparoscopic Right Hemicolectomy: Short-Term Outcomes

Laparoscopic right hemicolectomy represents an effective therapeutic approach for right colon cancer (RCC). The primary aim of this study was to evaluate bowel function recovery, length of hospital stay, operative time, and the number of general and anastomosis-related postoperative complications from intracorporeal anastomosis (ICA) vs. extracorporeal anastomosis (ECA); the secondary outcome was the number of lymph nodes retrieved. This observational study was conducted on 108 patients who underwent right hemicolectomy for RCC; after surgical resection, 64 patients underwent ICA and 44 underwent ECA. The operative time was slightly longer in the ICA group than in the ECA group, even though the difference was not significant (199.31 ± 48.90 min vs. 183.64 ± 35.80 min; p = 0.109). The length of hospital stay (7.53 ± 1.91 days vs. 8.77 ± 3.66 days; p = 0.036) and bowel function recovery (2.21 ± 1.01 days vs. 3.45 ± 1.82 days; p < 0.0001) were significantly lower in the ICA group. There were no significant differences in postoperative complications (12% in ICA group vs. 9% in ECA group), wound infection (6% in ICA group vs. 7% in ECA group), or anastomotic leakage (6% in ICA group vs. 9% in ECA group). We did not observe a significant difference between the two groups in the number of lymph nodes collected (19.46 ± 7.06 in ICA group vs. 22.68 ± 8.79 in ECA group; p = 0.086). ICA following laparoscopic right hemicolectomy, compared to ECA, could lead to a significant improvement in bowel function recovery and a reduction in the length of hospital stay in RCC patients.

Comparison of Vascular Invasion With Lymph Node Metastasis as a Prognostic Factor in Stage I-III Colon Cancer: An Observational Cohort Study

Purpose: This study aimed to evaluate the prognostic impact of vascular invasion (VI) in comparison with that of lymph node metastasis (LNM) in non-metastatic colon cancer.

Methods: Patients who underwent curative surgery for stage I-III colon cancer were divided into four groups depending on the status of VI and LNM (Group I: VI-/LNM-; Group II: VI+/LNM-; Group III: VI-/LNM+; Group IV: VI+/LNM+). Group III was subdivided according to the nodal (N) stage (Group IIIA: VI-/N1; Group IIIB: VI-/N2). Oncological outcomes were compared between Groups II and III.

Results: In total, 793 non-metastatic colon cancer patients were included. Group II [hazard ratio (HR) 2.34, 1.01–5.41] and Group III (HR 1.91, 1.26–2.89) were independently associated with poor disease-free survival (DFS). The 5-year DFS rates were comparable in Groups II (71.6%) and III (72.5%) (P = 0.637). When Group III was subdivided into Groups IIIA and IIIB, DFS deteriorated in the following order: Groups IIIA, II, and IIIB. The 5-year DFS rates were 79.7, 71.6, and 61.4% in Groups IIIA, II, and IIIB, respectively. Group II had a tendency toward early recurrence. The 1- and 2-year DFS rates were 76.3 and 71.6% in Group II and 88.3 and 79.8% in Group III, respectively (P = 0.067 and 0.247). All recurrences in Group II were distant metastases.

Conclusion: VI is a prognostic factor as significant as LNM and may be a stronger prognostic factor than N1 stage in non-metastatic colon cancer. Furthermore, a potential association was observed between VI and recurrence patterns, such as early recurrence and distant metastasis.

Prognostic value of lymph node ratio in children and adolescents with papillary thyroid cancer

OBJECTIVE

Neck lymph node (LN) metastasis is a common feature of paediatric papillary thyroid cancer, and LN ratio (LNR) is defined as the ratio of the number of positive LNs excised to the total number of removed. Unlike in adults, few data are available regarding the clinical implication of LNR in the paediatric population. Our purpose was to investigate the association of LNR with clinical outcomes in paediatric papillary thyroid cancer.

DESIGN & METHODS

The study retrospectively reviewed 136 consecutive children and adolescents with papillary thyroid cancer and LN involvement but no initial distant metastasis. Initial treatment, included in all patients a total thyroidectomy with central and/or lateral neck dissection followed by radioactive iodine ablation. Within the neck dissections, total number of LNs removed, total positive LNs and LN ratios were determined. The effect of clinicopathologic characteristics and intraoperative findings on persistent and recurrent diseases were analysed by univariate and multivariate analyses.

RESULTS

Median number of positive LNs was 9, and median LNR was 0.4. During a median follow-up of 49 months (range, 12.0-139 months), persistent disease occurred in 43 (31.6%) patients. The multivariable analysis showed that age and LNR were the independent factors predictive of persistent disease. Patients with a LNR >0.34 exhibited a threefold higher risk of persistent disease after initial therapy than the counterparts (P = .02).

CONCLUSION

Our findings suggest that LNR was an independent determinant predictive of persistent disease after initial therapy in children and adolescents with papillary thyroid cancer.

Addition of V-Stage to Conventional TNM Staging to Create the TNVM Staging System for Accurate Prediction of Prognosis in Colon Cancer: A Multi-Institutional Retrospective Cohort Study

We evaluated the prognostic impact of vascular invasion (VI) compared with nodal (N) stage and developed a new staging system including VI in colon cancer. Patients who underwent curative resection with stage II-III colon cancer were assigned to VI and non-VI groups; the latter was subclassified as N0, N1, and N2; a new TNVM staging was devised by adding the V-stage. Among the 2243 study participants, the VI group independently showed worse oncological outcomes than the N1 group (disease-free survival (DFS), hazard-ratio (HR) 1.704, 1.267–2.291; overall survival (OS), HR 2.301, 1.582–3.348). The 5-year DFS in the VI group was 63.4% [N1b (74.6%), p = 0.003; N2a (69.7%), p = 0.126; and N2b (56.8%), p = 0.276], and the 5-year OS was 76.6% [N1b (84.9%), p = 0.004; N2a (83.0%), p = 0.047; and N2b (76.1%), p = 0.906]. Thus, we considered VI as N2a in TNVM staging; 78 patients (3.5%) underwent upstaging. The 5-year OS rates of stage IIB and IIC increased from 88.6% and 65.9% in TNM staging to 90.5% and 85.7% in TNVM staging, respectively. In stage II–III colon cancer, VI had a similar prognostic impact as the N2 stage without VI. The incorporation of the V-stage into the conventional TNM staging facilitates better prediction of prognosis.

Metastatic lymph node ratio as a better prognostic tool than the TNM system in colorectal cancer

Background: The minimum number of lymph nodes that should be evaluated in colon cancer to adequately categorize lymph node status is still controversial. The lymph node ratio (LNR) may be a better prognostic indicator. Materials & methods: We studied 1065 patients treated from 1 January 2000 to 31 August 2012. Results: Significant differences in survival were detected according to regional lymph nodes (pN) (p < 0.001) and LNR (p < 0.001). LRN and pN are independent prognostic factors. Spearman correlation analysis showed a significant correlation between the total number of dissected lymph nodes and pN (rs = 0.167; p < 0.001), but the total number of dissected lymph nodes is not significantly correlated with LNR (rs = -0.019; p = 0.550). Interpretation: In this study, LNR seems to demonstrate a superior prognostic value compared with the pN categories, in part due to its greater independence regarding the extent of lymphadenectomy.

Prognostic nomogram to predict the overall survival of patients with early-onset colorectal cancer: a population-based analysis

PURPOSE

The present study aimed to identify independent clinicopathological and socio-economic prognostic factors associated with overall survival of early-onset colorectal cancer (EO-CRC) patients and then establish and validate a prognostic nomogram for patients with EO-CRC.

METHODS

Eligible patients with EO-CRC diagnosed from 2010 to 2017 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Patients were randomly divided into a training cohort and a testing cohort. Independent prognostic factors were obtained using univariate and multivariate Cox analyses and were used to establish a nomogram for predicting 3- and 5-year overall survival (OS). The discriminative ability and calibration of the nomogram were assessed using C-index values, AUC values, and calibration plots.

RESULTS

In total, 5585 patients with EO-CRC were involved in the study. Based on the univariate and multivariate analyses, 15 independent prognostic factors were assembled into the nomogram to predict 3- and 5-year OS. The nomogram showed favorable discriminatory ability as indicated by the C-index (0.840, 95% CI 0.827-0.850), and the 3- and 5-year AUC values (0.868 and 0.84869 respectively). Calibration plots indicated optimal agreement between the nomogram-predicted survival and the actual observed survival. The results remained reproducible in the testing cohort. The C-index of the nomogram was higher than that of the TNM staging system (0.840 vs 0.804, P < 0.001).

CONCLUSION

A novel prognostic nomogram for EO-CRC patients based on independent clinicopathological and socio-economic factors was developed, which was superior to the TNM staging system. The nomogram could facilitate postoperative individual prognosis prediction and clinical decision-making.

Radiomic signature-based nomogram to predict disease-free survival in stage II and III colon cancer

PURPOSE

To develop a radiomic nomogram to predict disease-free survival (DFS) in patients with colon cancer.

METHODS

We retrospectively identified 302 patients with stage III colon cancer and 269 patients with stage II colon cancer who had undergone multidetector computed tomography (MDCT) and radical resection between January 2009 and December 2015. Patients were divided into a training cohort (n = 322) and an external validation cohort (n = 249). Radiomic features were extracted from MDCT images, and a radiomic signature was built as to predict DFS. A radiomic nomogram integrating the radiomic signature and clinicopathologic characteristics was developed using multivariable logistic regression. The nomogram was evaluated with regard to calibration, discrimination, and clinical utility.

RESULTS

The radiomic signature was an independent prognostic factor for DFS in the training cohort (HR = 1.102; 95 % CI: 1.052-1.156; P < 0.001) and the external validation cohort (HR = 1.157; 95 % CI: 1.030-1.301; P = 0.014). The radiomic signature-based nomogram was more effective at predicting DFS than either the TNM staging system or a clinicopathologic nomogram. The C-indices of the radiomic nomogram and TNM staging system were 0.780 (95 % CI: 0.734-0.847) and 0.738 (0.687-0.784) respectively. The radiomic signature-based nomogram demonstrated good fitness (shown by calibration curves) and clinical usefulness (shown by decision curve analysis).

CONCLUSION

A radiomic signature derived from MDCT images can effectively predict DFS in patients with stage II and III colon cancer and could be used as a supplement for risk stratification.

Does resection improve overall survival for intrahepatic cholangiocarcinoma with nodal metastases?

Background

The potential benefit of surgical resection of intrahepatic cholangiocarcinoma in patients with locoregionally advanced disease has not been definitively determined.

Methods

The National Cancer Database was queried to identify patients with clinical evidence of node-positive intrahepatic cholangiocarcinoma. Resected patients were stratified by margin status and lymph node ratio (nodes positive to nodes harvested). Risk of death was determined using Cox regression models and Kaplan-Meier survival functions.

Results

A total of 1,425 patients with T(any)N1M0 intrahepatic cholangiocarcinoma were identified. Two hundred twelve (14.9%) underwent surgical resection. On multivariable Cox regression, R0 resection afforded a survival benefit regardless of lymph node ratio (lymph node ratio > 0.5: hazard ratio 0.466, 95% confidence interval 0.304–0.715; lymph node ratio ≤ 0.5: hazard ratio 0.444, 95% confidence interval 0.322–0.611), whereas a survival benefit was only seen in R1 patients with lymph node ratio ≤ 0.5 (hazard ratio 0.470, 95% confidence interval 0.316–0.701). On Kaplan-Meier, median survival was 11.6 months with chemotherapy, 15.7 months with R0 resection in lymph node ratio > 0.5, and 22.2 months with R0 resection in lymph node ratio ≤ 0.5 (P < .001).

Discussion

Margin negative resection is associated with a risk-adjusted survival benefit for patients with clinically N1 intrahepatic cholangiocarcinoma regardless of the degree of regional lymph node involvement.

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.

[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.

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.

Screen detection is a survival predictor independent of pathological grade in colorectal cancer. A prospective cohort study

INTRODUCTION

Patients with screened detected colorectal cancer (CRC) have a better survival than patients referred with symptoms. This may be because of cancers being identified in a younger population and at an earlier stage. In this study, we assess whether screened detected CRC has an improved outcome after controlling for key pathological and patient factors known to influence prognosis.

METHOD

This is a cohort study of all CRC patients diagnosed in NHS Grampian. Patients aged 51-75 years old between June 2007 and July 2017 were included. Data were obtained from a prospectively maintained regional pathology database and outcomes from ISD records. All-cause mortality rates at 1 and 5 years were examined. A Cox proportional hazards regression model was used to estimate the effect of screening status, age, gender, Duke stage, tumour location, extramural venous invasion (EMVI) status and lymph node ratio (LNR) on overall survival.

RESULTS

Of 1618 CRC cases, 449 (27.8%) were screened and 1169 (72.2%) were symptomatic. Screened CRC patients had improved survival compared to non-screened CRC at 1 year (88.9% vs 83.9% p < 0.001) and 5-years (42.5% vs 36.2%; p < 0.001). On multivariable analysis of patients who had no neoadjuvant therapy (n = 1272), screening had better survival (HR 0.57; 95% CI 0.44-0.74; p < 0.001). EMVI (HR 2.22; CI 1.76 to 2.79; p < 0.001) and tumour location were found to affect outcome.

CONCLUSION

Patients referred through screening had improved survival compared with symptomatic patients. Further research could be targeted to determine if screened CRC cases are pathologically different to symptomatic cancers or if the screening cohort is inherently more healthy.

Prognostic Performance of Different Lymph Node Staging Systems in Patients With Small Bowel Neuroendocrine Tumors

Background: The prognostic significance of the lymph node (LN) classification for small bowel neuroendocrine tumors (SBNETs) remains unknown. The aim of the present study was to evaluate and compare the prognostic assessment of different LN staging systems. Methods: Patients with SBNETs were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The X-tile program was used to determine the cutoff value of the resected lymph nodes (RLNs), negative lymph nodes (NLNs), lymph node ratio (LNR), and the log odds of positive lymph nodes (LODDS). Survival analyses were performed using Kaplan-Meier curves with log-rank test. Logistic regression analysis was used to evaluate the differences between different periods. Univariate and multivariate Cox proportional hazards models were used to assess the prognostic value of different LN staging systems on cause-specific survival (CSS). The relative discriminative abilities of the different LN staging systems were assessed using the Akaike information criterion (AIC) and the Harrell consistency index (HCI). Result: A total of 3,680 patients were diagnosed with SBNETs between 1988 and 2014 from the SEER database. A significant difference over time (1988-1999 vs. 2000-2014) was seen in age (P <0.001), tumor differentiation (P <0.001), T stage (P <0.001), and RLN (P <0.001) subgroups. Multivariate Cox survival analysis identified that LN status stratified by the number of RLNs, NLNs, LNR, and LODDS all predicted CSS in patients with SBNETs (all P <0.05), whereas the number of positive lymph nodes (PLNs) failed (P = 0.452). When assessed using categorical variables, LODDS staging systems showed the best prognostic performance (HCI: 0.766, AIC: 7,575.154) in the whole population. Further analysis based on different RLNs after eliminating the missing data showed that when the RLNs are <12, the LODDS (HCI: 0.769, AIC: 1,088.731) maintained the best prognostic performance as well when the RLNs are ≥12 (HCI: 0.835, AIC: 825.692). Among patients with LNR scores of 0 or 1, there was a residual heterogeneity of outcomes that were better stratified and characterized by the LODDS. Conclusion: LODDS was a better predicator of survival when LN status was stratified as a categorical variable and should be considered when assessing the prognosis of patients with SBNETs to allow a more reliable means to stratify patient survival.

Performance comparison between MRI and CT for local staging of sigmoid and descending colon cancer

PURPOSE

To compare the diagnostic performance of MRI and CT for local staging of sigmoid and descending colon cancer, with pathological results as the reference standard.

METHOD

This retrospective study included 116 patients with sigmoid or descending colon cancer who underwent both MRI and CT before surgery. MRI and CT images were separately reviewed by two independent and blinded radiologists to assess the following features: T-stage, presence of extramural extension (T3-4 disease), lymph node metastases (N+), and extramural vascular invasion (EMVI+). Diagnostic performance with sensitivity and specificity for detecting positive status (T3-4, N+ or EMVI+) were assessed using receiver-operating-characteristic (ROC) curve, and compared between MRI and CT.

RESULTS

MRI achieved correct T-stage in 81 of 116 patients (69.8 %) while CT in 66 (56.9 %). For detecting T3-4 disease, MRI showed better performance than CT with area under the curve (AUC) of 0.888 versus 0.712 (P =  0.002) and specificity of 81.82 % versus 54.6 % (P =  0.011). No significance was found in sensitivity between two modalities (89.2 % versus 83.1 %, P =  0.302). For detecting N+ disease, performance of MRI and CT were similar (AUC, 0.670 versus 0.650, P =  0.412). For detecting EMVI+, MRI showed better performance than CT (AUC, 0.780 versus 0.575, P =  0.012) with significantly higher sensitivity (68.6 % versus 40.0 %, P =  0.031) and similar specificity (both are 84.3 %).

CONCLUSIONS

MRI may offer more superior diagnostic performance than CT for detecting T3-4 disease and EMVI, thereby supporting its alternative application to CT in local staging of colon cancer.

The Impact of Extramural Venous Invasion in Colorectal Cancer: A Detailed Analysis Based on Tumor Location and Evaluation Methods

This study aimed to elucidate the prognostic implications of extramural venous invasion (EMVI) in colorectal cancer (CRC) through a meta-analysis. Eighteen eligible studies were included in this meta-analysis. Data on the prevalence of EMVI and the correlation between EMVI and survival were collected from these studies. In addition, a subgroup analysis was conducted based on tumor location and evaluation methods. The estimated prevalence of EMVI was 28.3% (95% confidence interval [CI] = 23.1% to 34.0%) in patients with CRC. The estimated prevalence of EMVI in patients with colon cancer and rectal cancer was 23.0% (95% CI = 17.6% to 29.6%) and 35.7% (95% CI = 22.3% to 51.6%), respectively. Based on the evaluation method, the estimated prevalence of EMVI were 28.3% (95% CI = 23.2% to 34.1%) and 27.3% (95% CI = 8.4% to 60.6%) in pathologic and radiologic examinations, respectively. The correlation of EMVI with worse overall and disease-free survival rates was significant (hazard ratio = 1.773, 95% CI = 1.483-2.120, and hazard ratio = 2.059, 95% CI = 1.683-2.520, respectively). However, in the subgroup analysis with radiologic examination, there was no significant difference in survival rates between patients with and without EMVI. Our study showed that EMVI was frequently detected in 28.3% of patients with CRC and was correlated to worse survival. The detection of EMVI can be useful for predicting the prognosis of patients with CRC.

Marked impact of tumor location on the appropriate cutoff values and the prognostic significance of the lymph node ratio in stage III colon cancer: a multi-institutional retrospective analysis

BACKGROUND

The prognostic significance of lymph node ratio (LNR) is not constant among studies. Exploration of appropriate location-specific cutoffs might be necessary because the number of lymph nodes harvested is generally higher in right than in left colon cancer. We aimed to determine appropriate cutoff values of LNR in right and left colon cancer and to clarify its clinical significance.

METHODS

The clinicopathologic data of 5463 patients with stage III colon cancer were collected. The best cutoff for LNR as a prognostic indicator for patients with right and left colon cancer was studied separately. We compared the prognostic impact between LNR and the number of lymph node metastasis using the Akaike information criterion (AIC), and evaluated the prognostic significance of LNR in each stage III subcategory.

RESULTS

The best performance was noted when LNR was categorized by cutoffs of 0.16 and 0.22 for right and left colon cancer, respectively. AIC scores were better with these categorizations than with subgrouping by number of positive nodes. LNR-low right colon cancer patients showed better cancer-specific survival than LNR-high in stage IIIA (95.7% vs. 89.3%), IIIB (86.7% vs. 77.2%), and IIIC (71.2% vs. 58.7%). The same results were obtained in left colon cancer patients with stage IIIB (88.3% vs. 80.7%) and IIIC (79.8% vs. 68.4%).

CONCLUSIONS

We demonstrated the difference in the appropriate cutoffs of LNR between right and left colon cancer. Categorization by location-specific cutoff of LNR may be useful for risk stratification of patients with stage III cancer.

Metastatic lymph node ratio as a prognostic indicator in patients with stage IV colon cancer undergoing resection

Background: It has been shown that the metastatic lymph node ratio (LNR, metastatic LNs divided by the total number of retrieved LNs) significantly affects the prognosis of patients with non-stage IV and some curative stage IV colon cancer undergoing curative resection. In this study, we aimed to evaluate the role of the LNR as a predictor of prognosis in patients with stage IV colon cancer undergoing curative or palliative resection. Patients and Methods: We conducted a retrospective study of 424 patients who were initially diagnosed with stage IV colon cancer at the Sun Yat-Sen University Cancer Center from 2003 to 2014. The patients were divided into the curative and palliative primary tumor resection groups with regional lymph nodes harvest. The median value was used as the cutoff for the LNR. Overall survival (OS) was assessed with the Kaplan-Meier method and log-rank test. Multivariate analysis was performed to identify the prognostic factors for OS. Results: The cutoff value for the LNR was 0.2. A total of 71 and 353 patients were classified as being in the curative and palliative resection groups, respectively. Patients in the palliative resection group showed higher pretreatment levels of carbohydrate antigen 19-9 (CA199; P = 0.014), a deeper infiltration of the primary tumor (P = 0.049), a lower regional lymph node harvest (i.e., total lymph node yield [TLN] ≤ 11; P = 0.001), and more extensive metastasis (P = 0.006). Among all patients, initial elevated CA199 levels, a TLN≤11, a negative lymph nodes (NLN) ≤7, and a LNR ≤0.2 were significantly associated with an unfavorable prognosis. OS was significantly longer in patients with a low LNR in both groups (P = 0.008 and P = 0.001, respectively). The LNR was an independent prognostic indicator in patients with stage IV colon cancer, with a hazard ratio (HR) of 1.47 (95% confidence interval [CI] 1.14-1.91; P = 0.003) in total population, and an HR of 1.43 (95% CI 1.09-1.86; P = 0.009) in patients with palliative resection. Conclusion: The LNR can be used as an independent prognostic factor in patients with stage IV colon cancer patients undergoing resection.

CT Colonography in Preoperative Staging of Colon Cancer: Evaluation of FOxTROT Inclusion Criteria for Neoadjuvant Therapy

OBJECTIVE

The purpose of the present study is to evaluate the diagnostic performance of and interreader agreement for CT colonography (CTC) in the local staging of colon cancer, with emphasis given to the FOxTROT (Fluoropyrimidine, Oxaliplatin, and Targeted-Receptor pre-Operative Therapy [Panitumumab]) trial inclusion criteria, which propose a new tailored treatment paradigm for colon cancer that uses neoadjuvant therapy for patients with a high-risk of locoregional disease as determined by imaging.

MATERIALS AND METHODS

This biinstitutional retrospective study involved 89 patients (with 93 tumors) who had colon cancer and underwent presurgical CTC. Two radiologists reviewed the CTC studies for local staging, including measurement of the tumor beyond the muscularis propria on a true orthogonal plane. Histopathologic findings for surgical colectomy specimens served as the reference standard for local pathologic staging. The sensitivity, specificity, positive predictive value, and negative predictive value for local determination of the T category, N category, and extramural vascular invasion (EMVI) were calculated separately for each reader. High-risk T category tumors were the same as those as used in the FOxTROT trial. Interreader agreement was assessed using the kappa statistic.

RESULTS

Thirty-five of 93 tumors (37.6%) were histologically classified as high-risk tumors (T3c, T3d, or T4 tumors). The interreader agreement was substantial (κ = 0.68) for classifying high-risk tumors with the use of CTC, moderate for differentiating N0 from N1 and N2 (κ = 0.44), and slight for detecting EMVI (κ = 0.15). The diagnostic statistics for CTC for the two readers were as follows: for detection of high-risk tumors, sensitivity was 65.7% and 82.9%, and specificity was 81.0% and 87.9%; for detection of N category-positive disease, sensitivity was 50.9% and 69.8%, and specificity was 50.0% and 72.5%; and for detection of EMVI, sensitivity was 18.2% and 66.7%, and specificity was 60.0% and 91.7%.

CONCLUSION

The present study shows that CTC might be a feasible imaging modality for preoperative local staging of higher-risk colon cancers for which neoadjuvant chemotherapy is more suitable on the basis of the FOxTROT trial criteria. However, further studies are required to allow a better generalization of our results.

A Prognostic Nomogram for Cervical Cancer after Surgery from SEER Database

Background: To develop and validate a nomogram based on the conventional measurements and log of odds between the number of positive lymph node and the number of negative lymph node (LODDS) in predicting prognosis for cervical cancer patients after surgery. Methods: A total of 8202 cervical cancer patients with pathologically confirmed between 2004 and 2014 were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. All the patients were divided into training (n=3603) and validation (n=4599) cohorts based on consecutive age of diagnosis. Demographic and clinical pathological factors were evaluated the association with overall survival (OS). Parameters significantly correlating with OS were used to create a nomogram. An independent external validation cohort was subsequently used to assess the predictive performance of the model. Results: In the training set, age at diagnosis, race, marital status, tumor grade, FIGO stage, histology, size and LODDS were correlated significantly with outcome and used to develop a nomogram. The calibration curve for probability of survival showed excellent agreement between prediction by nomogram and actual observation in the training cohort, with a bootstrap-corrected concordance index of 0.749(95% CI, 0.731-0.767). Importantly, our nomogram performed favorably compared to the currently utilized FIGO model, with concordance indices of 0.786 (95% CI, 0.764 to 0.808) vs 0.685 (95%CI, 0.660 to 0.710) for OS in the validation cohort, respectively. Conclusions: By incorporating LODDS, our nomogram may be superior to the currently utilized FIGO staging system in predicting OS in cervical cancer patients after surgery.

Lymph node ratio is inferior to pN-stage in predicting outcome in colon cancer patients with high numbers of analyzed lymph nodes

Background

The lymph node ratio (LNR), i.e. the number of positive lymph nodes (LN) divided by the total number of analyzed LN, has been described as a strong outcome predictor in node-positive colon cancer patients. However, most published analyses are constrained by relatively low numbers of analyzed LN. Therefore, the objective of the present study was to evaluate the prognostic impact of LNR in colon cancer patients with high numbers of analyzed LN.

Methods

One hundred sixty-six colon cancer patients underwent open colon resection. All node-positive patients were analyzed for this study. The number of analyzed LN, of positive LN, the disease-free (DFS) and overall survival (OS) time were prospectively recorded. Patients were dichotomously allocated to a high or a low LNR-group, respectively, with the median LNR (0.125) as a cut-off value. Median follow-up was 34.3 months.

Results

Fifty-eight patients (34.9%) were node-positive. The median number of analyzed LN was 23 (range 8–54). DFS and OS were significantly shorter in pN2 vs pN1 patients (p < 0.001, and p = 0.001, respectively), and in LNR high vs low patients (p = 0.032, and p = 0.034, respectively). pN2 (vs pN1) disease showed hazard ratios (HR) of 6.2 (p < 0.001), and 6.8 (p < 0.005; for DFS and OS, respectively), while LNR high (vs low) showed HR of 3.0 (p =0.041), and 4.5 (p = 0.054).

Conclusions

LNR is a reasonable outcome predictor in node-positive colon cancer patients. However, LNR is inferior to pN-stage in predicting survival in patients with high number of harvested lymph nodes.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0417-0) contains supplementary material, which is available to authorized users.

Modified AJCC staging of gastric neuroendocrine carcinoma based on T staging can improve the capacity of prognosis assessment

BACKGROUND OR PURPOSE

This study was designed to determine the value of AJCC staging 7th edition and improved AJCC staging in assessing the prognosis of gastric neuroendocrine carcinoma (GNEC).

METHODS

In total, GNEC 475 patients in the Surveillance, Epidemiology, and End Results (SEER) database and 129 GNEC patients in our department undergoing resection were included. The former served as the test group, and the latter served as the validation group. Those with stage IIIb disease were allocated into four subgroups, and improved AJCC staging was established. The AIC and C indices were used to evaluate the capacities of different TNM staging.

RESULTS

Significant overlap between stages IIIb and IIIa in both the test and validation groups was found. In the test group, T staging and age at disease diagnosis were independent prognostic factors for patients with stage IIIb. Stage IIIb was divided into T1N1, T2N1, T3N1 and T4N1, and the improved AJCC staging-mTNM staging was created. In mTNM staging, the IIIb survival curve did not cross those of stages IIIa and IIb, which had a smaller AIC (2490 vs. 2507) value and larger C index (0.7624 vs. 0.7450, P = 0.228). Similar results were obtained for the validation group.

CONCLUSION

T stage was an independent factor influencing the prognosis of stage IIIb GNEC patients, and the improved AJCC staging proposed here has good prognostic value.

Survival effect of different lymph node staging methods on ovarian cancer: An analysis of 10 878 patients

Background

To compare the survival impact of several lymph node staging methods and therapeutic role of lymphadenectomy in patients with epithelial ovarian cancer who had undergone lymphadenectomy.

Methods

Data were retrospectively collected from the Surveillance, Epidemiology, and End Results program between 1988 and 2013.

Results

An increasing number of resected lymph nodes (RLNs) was associated with a significant improvement in survival of FIGO stage II and III disease. However, for FIGO stage IV patients, better survival was not significantly associated with a more extensive lymphadenectomy. A higher lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS) were associated with poorer survival regardless of stage. Nevertheless, four‐category classification of LODDS was more suitable for stage IV patients when three‐category classification was compatible with stage I‐III disease. Multivariate analysis demonstrated that LODDS and LNR were significant independent prognostic factors, but not RLN classification.

Conclusion

Sixteen to thirty RLNs are recommended for stage I disease. For stages II and III patients, the more lymph node excision, the better the prognosis. However, lymphadenectomy was nonessential for stage IV patients. Considering staging methods, for stages II and III patients, three‐category classification of LODDS was recommended to evaluate the prognosis. For stage I and IV, three‐category classification of positive LNR was idoneous.

Prognostic role of the lymph node ratio in node positive colorectal cancer: a meta-analysis

The lymph node ratio (LNR) (i.e. the number of metastatic lymph nodes divided by the number of totally resected lymph nodes) has recently emerged as an important prognostic factor in colorectal cancer (CRC). However, the tumor node metastasis (TNM) staging system for colorectal cancer does not consider it as a prognostic parameter. Therefore, we conducted a meta-analysis to evaluate the prognostic role of the LNR in node positive CRC. A systematic search was performed in PubMed, Embase and the Cochrane Library for relevant studies up to November 2015. As a result, a total of 75,838 node positive patients in 33 studies were included in this meta-analysis. Higher LNR was significantly associated with shorter overall survival (OS) (HR = 1.91; 95% CI 1.71–2.14; P = 0.0000) and disease free survival (DFS) (HR = 2.75; 95% CI: 2.14–3.53; P = 0.0000). Subgroup analysis showed similar results. Based on these results, LNR was an independent predictor of survival in colorectal cancer patients and should be considered as a parameter in future oncologic staging systems.

Extramural Venous Invasion as Prognostic Factor of Recurrence in Stage 1 and 2 Colon Cancer

Aim

Extramural venous invasion (EMVI) is a prognostic indicator in patients with colorectal cancer. However, its additional value in patients with stage 1 and 2 colorectal cancer is uncertain. In the present study, the incidence of EMVI and the hazard ratio for recurrence in patients with stage 1 and 2 colon cancer were studied.

Methods

184 patients treated for stage 1 and 2 colon cancer were included with a follow-up of at least 5 years. Chart review was performed and EMVI was assessed by two separate pathologists. EMVI was scored with additional caldesmon staining on the resection specimen. Primary outcomes were recurrence-free survival (RFS) measured through the Cox regression analysis and prevalence of EMVI.

Results

There were 10 cases of EMVI and 3 cases of intramural venous invasion (IMVI) all occurring in patients with stage 2 disease corresponding to a prevalence of 9%. Thirty-one percent of the patients with venous invasion experienced recurrence versus 14% in patients without, corresponding with a hazard ratio of 2.39 (p = 0.11).

Conclusion

The present study demonstrates a trend towards an increased risk of recurrence in patients with stage 2 colon cancer with venous invasion. This warrants consideration of adjuvant chemotherapy despite the lack of lymph node metastases.

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

Aim

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

Materials and Methods

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

Results

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

Conclusions

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

Comparative evaluation of oncologic outcomes in colon cancer

PURPOSE

In this paper we report clinical variables on colon cancer series. Oncological outcomes were compared to low-income and high-income countries.

METHODS

We analysed a prospective database of 51 colon cancer patients submitted to primary tumor resection between 2010 and 2011, showing clinical variables and oncologic outcomes.

RESULTS

R0 resection obtained in 80.4%, 21.6% of patients was TNM stage IV, and only 13.7% showed TNM stage I. Disease-free survival was 32 months, overall survival was 46 months, and the tumoral recurrence rate was 9.8%. Univariate analysis showed association of serum CEA levels ≥ 5 ng/dl (p= 0.004), presence of metastasis at diagnosis (p= 0.012), compromised surgical margins (p < 0.001) and poorer tumor differentiation (p= 0.041) to death. Multivariate analysis identified compromised surgical margins as an independent risk factor for death due to colon cancer (P=0.003; odds ratio=0.36; 95% confidence interval=0.004-0.33). Nowadays, 62.7% of patients are alive.

CONCLUSION

Recurrence rate, disease-free survival and overall survival was similar to those observed in more developed countries. Serum CEA levels ≥ 5 ng/dl, the presence of metastasis at diagnosis, compromised surgical margins and poorer tumor differentiation were associated with death. A compromised surgical margin was the only independent risk factor for death.

Applying Additive Hazards Models for Analyzing Survival in Patients with Colorectal Cancer in Fars Province, Southern Iran

Introduction:

Colorectal cancer (CRC) is a commonly fatal cancer that ranks as third worldwide and third and the fifth in Iranian women and men, respectively. There are several methods for analyzing time to event data. Additive hazards regression models take priority over the popular Cox proportional hazards model if the absolute hazard (risk) change instead of hazard ratio is of primary concern, or a proportionality assumption is not made.

Methods:

This study used data gathered from medical records of 561 colorectal cancer patients who were admitted to Namazi Hospital, Shiraz, Iran, during 2005 to 2010 and followed until December 2015. The nonparametric Aalen’s additive hazards model, semiparametric Lin and Ying’s additive hazards model and Cox proportional hazards model were applied for data analysis. The proportionality assumption for the Cox model was evaluated with a test based on the Schoenfeld residuals and for test goodness of fit in additive models, Cox-Snell residual plots were used. Analyses were performed with SAS 9.2 and R3.2 software.

Results:

The median follow-up time was 49 months. The five-year survival rate and the mean survival time after cancer diagnosis were 59.6% and 68.1±1.4 months, respectively. Multivariate analyses using Lin and Ying’s additive model and the Cox proportional model indicated that the age of diagnosis, site of tumor, stage, and proportion of positive lymph nodes, lymphovascular invasion and type of treatment were factors affecting survival of the CRC patients.

Conclusion:

Additive models are suitable alternatives to the Cox proportionality model if there is interest in evaluation of absolute hazard change, or no proportionality assumption is made.

The association of p53 expression levels with clinicopathological features and prognosis of patients with colon cancer following surgery

The present study aimed to examine the association of p53 expression levels with clinicopathological features and prognosis of patients with colon cancer following surgery. The present study included 484 patients with colon cancer that underwent colon resection between December 2003 and December 2011. All follow-ups were censored in December 2013 with a median follow-up time of 43 months. Kaplan-Meier survival curves and Cox regression analysis were used to determine predictors for overall survival rate. p53 expression status (positive or negative) was significantly different between patient groups when categorized by age distribution, disease course, tumor location, maximum tumor diameter, depth of tumor invasion, Dukes' stage, distant metastasis and lymph node (LN) metastasis (P<0.05). Cox regression analysis revealed that age, surgery type, histological subtypes, tumor size, tumor location, LN metastasis, distant metastases, Dukes' stage and p53 expression status are independent factors influencing the survival rate of patients with colon cancer following surgery (P<0.05). Therefore, the present study revealed that the loss of p53 expression levels in tumors was associated with aggressive clinicopathological characteristics in patients with colon cancer.

Clinical value of MRI-detected extramural venous invasion in rectal cancer

Extramural venous invasion (EMVI) is associated with a poor prognosis and a poor overall survival rate in rectal cancer. It can independently predict local and distant tumor recurrences. Preoperative EMVI detection in rectal cancer is useful for determining the treatment strategy. EMVI status is beneficial for the post-treatment evaluation and analysis of rectal cancer. Magnetic resonance imaging (MRI) is a non-invasive diagnostic modality with no radiation effects. High-resolution MRI can detect EMVI with high accuracy. In addition, MRI results are equal to or even better than pathological results in the detection of medium to large EMVI in rectal cancer. MRI-detected EMVI (mrEMVI) can be used as a potential biomarker that facilitates treatment methods. This review highlights the importance of MRI before and after rectal cancer treatment. In addition, we analyze the prognostic correlation between mrEMVI and circulating tumor cells (CTC) in rectal cancer. This article may help shed light on the significance of mrEMVI.

Lymphovascular and perineural invasion in stage II rectal cancer: a report from the Swedish colorectal cancer registry

BACKGROUND

Adjuvant chemotherapy for stage II and III rectal cancer patients is a matter of discussion. The aim of the present study was to evaluate the prognostic value of lymphovascular (LVI) and perineural (PNI) invasion in stage II rectal cancer on a national level.

MATERIALS AND METHODS

Clinico-pathological factors associated with disease-free survival (DFS) and time to recurrence in stage II rectal cancer patients were analyzed from patient data registered in the Swedish Colorectal Cancer Registry between 2006 and 2012.

RESULTS

Of 2649 patients with TNM stage II disease, 1395 (53%) received preoperative radiotherapy and 456 (17%) preoperative chemoradiotherapy. LVI and PNI were detected in 387 (15%) and 269 (10%) patients, respectively. Adjuvant chemotherapy was planned in 14%, but more often if LVI or PNI was detected (25% and 31%, respectively, p < .001 for both). The three-year DFS and time to recurrence were 78% and 17%, respectively. Both LVI and PNI indicated worse outcome. In patients not receiving postoperative chemotherapy, the risks of recurrence after three years were 20% if LVI was seen and 22% if PNI was detected (p < .001 for both). In the absence of LVI and PNI, it was 13% and 12%, respectively. In a multivariate Cox regression analysis, patients with LVI (hazard ratio 1.44, 95% CI 1.09-1.90; p = .011) and PNI (hazard ratio 1.80, 95% CI 1.34-2.43, p < .001) had significantly increased risks of recurrence.

CONCLUSIONS

Stage II rectal cancer patients with LVI and PNI have an increased risk of recurrence which emphasizes the need to properly evaluate the role of adjuvant chemotherapy particularly in these subgroups.

Pattern of tumour growth of the primary colon cancer predicts long-term outcome after resection of liver metastases

OBJECTIVE

To identify significant predictive factors for overall survival (OS) and disease-free survival (DFS) after liver resection for colon cancer metastases, with special focus on features of the primary colon cancer, such as lymph node ratio (LNR), vascular invasion, and perineural invasion.

METHODS

Patients operated for colonic cancer liver metastases between 2006 and 2014 were included. Details on patient characteristics, the primary colon cancer operation and metastatic disease were collected. Multivariate analysis was performed to select predictive variables for OS and DFS.

RESULTS

Median OS and DFS were 67 and 20 months, respectively. 1-, 3- and 5-year OS were 97, 76, and 52%. 1-, 3- and 5-year DFS were 65, 42, and 37%. Multivariate analysis showed LNR to be an independent predictive factor for DFS but not for OS. Other identified predictive factors were vascular and perineural invasion of the primary colon cancer, size of the largest metastasis and severe complications after liver surgery for OS, and perineural invasion, number of liver metastases and preoperative CEA-level for DFS. Traditional N-stage was also considered to be an independent predictive factor for DFS in a separate multivariate analysis.

CONCLUSIONS

LNR and perineural invasion of the primary colon cancer can be used as a prognostic variable for DFS after a concomitant liver resection for colon cancer metastases. Vascular and perineural invasion of the primary colon cancer are predictive for OS.

The Characteristics and Prognostic Effect of E-Cadherin Expression in Colorectal Signet Ring Cell Carcinoma

Purpose

Signet ring cell carcinoma (SRCC) is rare. The aim of this study is to understand the clinicopathological features and identify the possible prognostic factors in colorectal SRCC.

Methods

Patients with SRCC who underwent primary lesion resection at Fudan University Shanghai Cancer Center from September 2008 to July 2014 were retrospectively analyzed. Patient’s gender, age, tumor location, depth of invasion, lymph node metastasis, synchronous distant metastasis, perineural invasion, lymphovascular invasion, and E-cadherin expression were studied with prognosis, and the correlation between E-cadherin expression and clinicopathological features were analyzed. All clinicopathological and molecular factors were put into multivariate analysis using Cox proportional hazards model for detecting independent prognostic factors.

Results

59 patients accounting for 0.89% of total colorectal cancer patients met the criteria and were enrolled in the study. The median survival time is 28.9 months, and the 3-year survival rate is 62.7%. SRCC were seen more common in young male patients. Advanced stage was more common in SRCC, 58 (98.3%) patients had T3/T4 lesions, 52 (88.1%) patients had lymph node metastasis, and 14 (23.7%) patients had distant metastasis. Distant metastases were seen more common in peritoneal cavity. Distant metastasis (HR = 4.194, 95% CI: 1.297–13.567), lymphovascular invasion (HR = 2.888, 95% CI: 1.115–7.483), and E-cadherin expression (HR = 0.272, 95% CI: 0.096–0.768) were independent predictors for survival.

Conclusions

SRCC is a rare subtype of colorectal cancer with poor prognosis. Distant metastasis, lymphovascular invasion, and E-cadherin expression can predict prognosis of colorectal SRCCs independently. More precise therapy and more close surveillance are needed for these patients.

The Evaluation of More Lymph Nodes in Colon Cancer Is Associated with Improved Survival in Patients of All Ages

Background

Improvement in survival of patients with colon cancer is reduced in elderly patients compared to younger patients. The aim of this study was to investigate whether the removal of ≥ 12 lymph nodes can explain differences in survival rates between elderly and younger patients diagnosed with colon cancer.

Methods

In a population-based cohort study, all patients (N = 41,074) diagnosed with colon cancer stage I to III from 2003 through 2010 from the Netherlands Cancer Registry were included. Age groups were defined as < 66, 66–75 and > 75 years of age. Main outcome measures were overall and relative survival, the latter as a proxy for disease specific survival.

Results

Over an eight years time period there was a 41.2% increase in patients with ≥ 12 lymph nodes removed, whereas the percentage of patients with the presence of lymph node metastases remained stable (35.7% to 37.5%). After adjustment for patient and tumour characteristics and adjuvant chemotherapy, it was found that for patients in which ≥ 12 lymph nodes were removed compared to patients with < 12 lymph nodes removed, there was a statistically significant higher overall survival (< 66: HR: 0.858 (95% CI, 0.789–0.933); 66–75: HR: 0.763 (95% CI, 0.714–0.814); > 75: HR: 0.734 (95% CI, 0.700–0.771)) and relative survival (< 66: RER: 0.783 (95% CI, 0.708–0.865); 66–75: RER: 0.672 (95% CI, 0.611–0.739); > 75: RER: 0.621 (95% CI, 0.567–0.681)) in all three age groups.

Conclusions

The removal of ≥ 12 lymph nodes is associated with an improvement in both overall and relative survival in all patients. This association was stronger in the elderly patient. The biology of this association needs further clarification.

Clinical Significance of International Union Against Cancer pN Staging and Lymph Node Ratio in Node-Positive Colorectal Cancer after Advanced Lymph Node Dissection

BACKGROUND

Lymph node retrieval in colorectal cancer can be improved by using advanced histopathological techniques like methylene blue-assisted lymph node dissection, which results in a doubling or even tripling of the lymph node count in comparison with conventional lymph node dissection techniques. However, it is not clear whether the established lymph node staging systems are suitable for predicting patients' prognoses under these circumstances.

OBJECTIVE

The aim of this study was to determine whether the current lymph node staging systems are suitable when advanced dissection methods are used.

DESIGN

This is a retrospective cohort study.

SETTING AND PATIENTS

We formed a study group (methylene blue-assisted lymph node dissection) of 293 patients and a control group (conventional lymph node dissection) of 232 patients, each with node-positive cases. Conventional pN staging according to the International Union Against Cancer, seventh edition, and lymph node ratio were applied.

MAIN OUTCOME MEASURES

Overall survival was compared by using the different staging systems in a uni- and multivariable fashion.

RESULTS

The lymph node ratio values were reduced in the advanced methylene blue-assisted lymph node dissection group in comparison with the conventional lymph node dissection group (0.1 vs 0.3, p < 0.001). Although pN staging proved to be reliable, the cutoff values for lymph node ratio staging had to be adapted. The new cutoffs (0.07, 0.15, and 0.34) were prognostic. However, multivariable analysis revealed pN staging and vascular invasion, but not lymph node ratio, as independently prognostic in the methylene blue-assisted lymph node dissection group.

LIMITATIONS

The study group and historical control group are not perfectly balanced because the case number in the stage III subgroup of the control group is small.

CONCLUSIONS

pN staging proved to be a robust prognostic marker in colorectal cancer under the circumstances of improved lymph node harvest. After adaptation of the cutoff values, lymph node ratio is also prognostic but not superior to pN staging.