The impact of N-ratio in minimizing stage migration phenomenon in gastric cancer patients with insufficient number or level of lymph node retrieved: results from a Chinese mono-institutional study in 2159 patients

Lymph node ratio and hematological parameters predict relapse-free survival in patients with high grade rectal neuroendocrine neoplasms after radical resection: a multicenter prognostic study

BACKGROUND

The prognostic nutritional index (PNI), alkaline phosphatase (ALP), and lymph node ratio (LNR) are reportedly related to prognosis. The aim of this study was to elucidate the clinical importance of the LNR and hematological parameters in patients with high grade rectal neuroendocrine neoplasms (HG-RNENs) who were undergoing radical resection.

METHODS

We reviewed the medical records of patients with HG-RNENs from 17 large-scale medical centers in China (January 1, 2010-April 30, 2022). A nomogram was constructed by using a proportional hazard model. Bootstrap method was used to draw calibration plots to validate the reproducibility of the model. Concordance index (C-Index), decision curve analysis (DCA), and time-dependent area under the receiver operating characteristic curve (TD-AUC) analysis were used to compare the prognostic predictive power of the new model with American Joint Committee on Cancer (AJCC) TNM staging and European Neuroendocrine Tumor Society (ENETS) TNM staging.

RESULTS

A total of 85 patients with HG-RNENs were enrolled in this study. In the 45 patients with HG-RNENs who underwent radical resection, PNI ≤ 49.13 (HR: 3.997, 95% CI: 1.379-11.581, P = 0.011), ALP > 100.0 U/L (HR: 3.051, 95% CI: 1.011-9.205, P = 0.048), and LNR > 0.40 (HR: 6.639, 95% CI: 2.224-19.817, P = 0.0007) were independent predictors of relapse-free survival. The calibration plots suggested that the nomogram constructed based on the three aforementioned factors had good reproducibility. The novel nomogram revealed a C-index superior to AJCC TNM staging (0.782 vs 0.712) and ENETS TNM staging (0.782 vs 0.657). Also, the new model performed better compared to AJCC TNM staging and ENETS TNM staging in DCA and TD-AUC analyses.

CONCLUSIONS

LNR, ALP, and PNI were independent prognostic factors in patients with HG-RNENs after radical resection, and the combined indicator had better predictive efficacy compared with AJCC TNM staging and ENETS TNM staging.

Prognostic Performance of Three Lymph-Node Staging Systems on Gastric Signet-Ring-Cell Carcinoma

BACKGROUND

The lymph-node staging system can predict the prognosis of gastric signet-ring-cell carcinoma (SRCC). However, there are significant differences in lymph-node status between early SRCC and advanced SRCC. Additionally, the optimal system for early and advanced SRCC remains unknown.

METHODS

This study retrospectively analyzed 693 SRCC patients who underwent radical resection in the Department of Gastrointestinal Surgery, Harbin Medical University Cancer Hospital. The predicted performance of three lymph-node staging systems, including pN staging, lymph-node metastasis rate (LNR), and log odds of positive lymph nodes (LODDS), was compared using the receiver characteristic operating curve (ROC) and c-index. The Kaplan-Meier method and the log-rank test analyzed the overall survival of patients. The Cox risk regression model identified independent risk factors associated with patient outcomes. The nomogram was made by R studio.

RESULTS

The 693 SRCC included 165 early SRCC and 528 advanced SRCC. ROC showed that LODDS had better predictive performance than pN and LNR in predicting prognosis regardless of early or advanced SRCC. LODDS can be used to predict the prognosis of early and advanced SRCC and was an independent risk factor associated with patient outcomes (p = 0.002, p < 0.001). Furthermore, the nomogram constructed by LODDS and clinicopathological features had good predictive performance.

CONCLUSIONS

LODDS showed clear prognostic superiority over both pN and LNR in early and advanced SRCC.

Number of positive lymph nodes combined with the logarithmic ratio of positive lymph nodes predicts long-term survival for patients with node-positive parotid gland carcinoma after surgery: a SEER population-based study

PURPOSE

To evaluate the prognostic value of the number of positive lymph nodes (NPLN), the ratio of positive lymph nodes (pLNR), and the logarithmic ratio of positive lymph nodes (LODDS) in patients with parotid gland carcinoma. On this basis, establishing and validating an optimal nomogram.

METHODS

A total of 895 patients with T1-4N1-3M0 parotid gland carcinoma were included in our study from the Surveillance, Epidemiology, and End Results (SEER) database. Patients' data were randomly assigned to the training cohort and the validation cohort by a ratio of 7:3. Univariate and multivariate COX regression analysis were used to explore the relationship between the study factors and the prognosis of parotid gland carcinoma, including overall survival (OS) and cause-specific survival (CSS). The Akaike Information Criterion (AIC) was used to evaluate model fit. Harrell's concordance index (C-index), integrated discrimination improvement (IDI), and net reclassification index (NRI) were used to evaluate the predictive ability of these models. The decision curve analysis was used to evaluate the clinical benefit of the nomograms compared with the TNM stage.

RESULTS

NPLN, pLNR, and LODDS are independent risk factors for the prognostic of PGC. According to the AIC, C index, IDI, and NRI, the models combined with NPLN and LODDS were the best. The decision curves suggested that our nomograms had good predictive abilities for the prognosis of parotid gland carcinoma.

CONCLUSION

The two nomograms which contained NPLN and LODDS had the potential to predict OS and CSS in patients with parotid gland carcinoma.

A novel prognostic model based on log odds of positive lymph nodes to predict outcomes of patients with anaplastic thyroid carcinoma after surgery

OBJECTIVE

The eighth version of the American Joint Committee on Cancer (8th AJCC) system for anaplastic thyroid carcinoma (ATC) added lymph node (LN) metastasis as the staging element. This study aimed to explore the association between LN status and ATC's prognosis, identify the optimal LN index and establish a novel prognostic model.

DESIGN AND PATIENTS

Data of 199 ATC patients after surgery were collected from the Surveillance, Epidemiology and End Results (SEER) database, then randomly divided into training and validation cohorts.

MEASUREMENTS

We compared the prognostic value of AJCC N status, number of positive LN (PLNN), ratio of LN (LNR) and log odds of positive LN (LODDS). We conducted univariate and multivariate Cox analyses to determine the independent prognostic factors for ATC, and constructed a novel prognostic model. The concordance index (C-index), area under the receiver-operating characteristic curve (AUC), calibration curves and decision curve analysis (DCA) were used to assess the nomogram's predictive performance.

RESULTS

LODDS showed the highest accuracy among four LN systems to predict overall survival (OS) for ATC. In the training cohort, the C-index of the LODDS-based nomogram was 0.738. The AUCs were 0.813, 0.850 and 0.869 for predicting 1-, 2- and 3-year OS, respectively. The calibration plots and DCA indicated the great clinical applicability of the model. The above results were verified in the validation cohort.

CONCLUSIONS

LODDS showed better predictive performance than other LN schemes in ATC. The LODDS-incorporated nomogram has the potential to more precisely predict the prognosis for ATC patients than the AJCC system.

Prognostic Effect of Lymph Node Metastases and Mesenteric Deposits in Neuroendocrine Tumors of the Small Bowel

Well-differentiated, low-grade neuroendocrine tumors (NETs) are the most frequent tumor types of the small bowel. Despite their generally indolent growth patterns and grade, these tumors tend to metastasize; indeed, at presentation, approximately 50% show nodal metastases and 30% of patients have distant metastases, even though they potentially show long survival. Little is available in the literature concerning the optimal nodal yield in small-bowel resections, and the clinical significance of nodal metastases and lymph node ratio (LNR) at this site is still debated. The aim of this review, through a systematic literature search, is to explore and analyze data regarding nodal status, adequacy of lymphadenectomy, and LNR on the prognosis of small bowel NETs using defined end points (progression-free survival, recurrence-free survival, and overall survival). Some surgical series have demonstrated that extended regional mesenteric lymphadenectomy, together with primary tumor resection, is associated with improved patient survival, and LNR is proving a prognostically important parameter. The new feature of mesenteric tumor deposits (MTDs; neoplastic deposits found in the mesenteric perivisceral adipose tissue that are not LN associated) seems to be a better prognostic predictor in small-bowel NETs compared to nodal metastases, and this feature is explored and critiqued in this review. In particular, increasing number of tumor deposits is correlated with increased risk of disease-specific death, and MTDs seem to correlate with peritoneal carcinomatosis.

Influence of different methods for classification of lymph node metastases on the survival of patients with oral squamous cell carcinoma

BACKGROUND

Despite the advances in the classification of oral squamous cell carcinoma (OSCC) based on its extension by the TNM system, there is still a need for methods to better classify the patients to predict prognosis and indicate adjuvant therapy.

OBJECTIVES

To analyze the influence of the number of positive lymph nodes (PN), lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) in survival of patients with OSCC.

METHODS

Clinicopathologic data from patients with OSCC who were treated with curative purposes by surgery and neck dissection (ND) with or without subsequent adjuvant therapies from 1991 to 2015 was retrospectively assessed. The impact of the PN, LNR, LODDS, and other variables on overall survival (OS) and disease-free survival (DFS) was analyzed in univariate and multivariate analyses.

RESULTS

One hundred nineteen patients were included in this study. In the univariate analysis the PN had a significant impact on OS (p = 0.001) and DFS (p = 0.020), and the LNR had a significant impact on the OS (p = 0.042). In the multivariate analysis with other relevant clinicopathologic variables, the PN was the only significantly independent factor influencing in the OS (p = 0.017) but not in DFS (p = 0.096).

CONCLUSIONS

The PN is an independent prognostic indicator for OS and DFS in patients with OSCC and has the potential to aggregate the current AJCC classification. The LNR has potential to be an important prognostic indicator, but the methods for this classification require lapidation. The LODDS did not demonstrate prognostic potential.

Mide kanserli hastaların demografik özelliklerinin sağ kalıma etkisi

Aim: This study aimed to investigate the relationship between some demographic and clinical factors and survival in patients with gastric cancer. Materials and Methods: We retrospectively evaluated the records of 252 gastric cancer patients followed up in the medical oncology department between 01.01.2016 and 10.01.2020. Gastric lymphoma, gastrointestinal stromal tumor, and neuroendocrine tumor were excluded. Factors evaluated in the study included age, sex, urban/non-urban residence, admitting complaints, smoking history, Eastern Cooperative Oncology Group (ECOG) score, stage at diagnosis, histological subtype, surgical history, tumor location, grade, diameter and macroscopic view of tumor, metastatic lymph node ratio, chemotherapy regimens, febrile neutropenia, post-chemotherapy radiological reports, chemoradiotherapy (CRT) history and survival after diagnosis. Results: Mean overall survival (OS) time was significantly shorter in patients with weight loss (p

Comparison of Four Lymph Node Staging Systems in Gastric Adenocarcinoma after Neoadjuvant Therapy – A Population-Based Study

Introduction

Neoadjuvant treatment leads in a reduction in positive lymph nodes and examined lymph nodes (ELN), which may affect assessment of lymph node staging and postoperative treatment. We aimed to compare the staging systems of lymph node ratio (LNR), the positive logarithm ratio of lymph nodes (LODDS), negative lymph nodes (NLN), and the 8th AJCC ypN stage for patients with gastric adenocarcinoma after neoadjuvant therapy.

Materials and Methods

Data was collected from the Surveillance, Epidemiology, and End Results database and 1,551 patients with gastric adenocarcinoma who underwent neoadjuvant therapy and radical surgery were enrolled. Harrell’s concordance index, the Receiver Operative Curve, the likelihood ratio test, and the Akaike information criterion were used to compare the predictive abilities of the different staging systems.

Results

Among the 1,551 patients, 689 (44.4%) had ELN < 16 and node-negative patients accounted for 395 (25.5%). When regarded as the categorical variable, LNR had better discrimination power, higher homogeneity, and better model fitness for CSS and OS compared to other stage systems, regardless of the status of ELN. When regarded as the continuos variable, LODDS outperformed others for CSS. Furthermore, the NLN staging system performed superior to others in node-negative patients.

Conclusions

LNR had a better predictive performance than ypN, LODDS and NLN staging systems regardless of the status of ELN when regarded as the categorical variable, whereas LOODS became the better predictive factor for CSS when regarded as the continuos variable. In node-negative patients, NLN might be a feasible option for evaluating prognosis. A combination of LNR and NLN should be considered as user-friendly method in the clinical prognostic assessment.

Relationship Between Neoadjuvant Chemotherapy and Log Odds of Positive Lymph Nodes and Their Prognostic Role in Advanced Ovarian Cancer Patients With Optimal Cytoreductive Surgery

Purpose

To analyze the relationship between neoadjuvant chemotherapy (NACT) and log odds of positive lymph nodes (LODDS), as well as their prognostic role in advanced ovarian cancer (AOC) patients with optimal cytoreductive surgery.

Patients and Methods

From the SEER database during 2010-2016, we identified 1,012 AOC patients with optimal cytoreductive surgery. Univariable and multivariable logistic regression was performed to identify the relationship between NACT and LODDS. Overall survival (OS) and cancer-specific survival (CSS) were assessed using the Kaplan-Meier method and log-rank test. Univariable and multivariable Cox regression was conducted to determine the independent prognostic factors for OS and CSS.

Results

Factors associated with significantly higher NACT odds included older (≥60 years old), married, tumor size ≥ 15 cm, FIGO IV, and LODDS ≤ 0.1. Multivariable Cox regression model confirmed older (≥60 years old), unmarried, separated, divorced, widowed, mucinous histology type, tumor size ≥ 15 cm, and LODDS > 0.1 were correlated with increased risks of OS and CSS. NACT was not an independent prognostic factor for OS and CSS. In the subgroup analyses, LODDS was an independent prognostic factor for OS and CSS in patients with < 75 years old, married, unmarried, FIGO III, and tumor size < 15 cm.

Conclusion

NACT did not show any survival benefit in AOC patients with optimal cytoreductive surgery, but it may be beneficial in reducing LODDS. Meanwhile, clinicians can use grade of LODDS to predict the prognosis of AOC patients with optimal cytoreductive surgery.

Standardizing the classification of gastric cancer patients with limited and adequate number of retrieved lymph nodes: an externally validated approach using real-world data

BACKGROUND

Currently, there is no formal consensus regarding a standard classification for gastric cancer (GC) patients with < 16 retrieved lymph nodes (rLNs). Here, this study aimed to validate a practical lymph node (LN) staging strategy to homogenize the nodal classification of GC cohorts comprising of both < 16 (Limited set) and ≥ 16 (Adequate set) rLNs.

METHODS

All patients in this study underwent R0 gastrectomy. The overall survival (OS) difference between the Limited and Adequate set from a large Chinese multicenter dataset was analyzed. Using the 8th American Joint Committee on Cancer (AJCC) pathological nodal classification (pN) for GC as base, a modified nodal classification (N') resembling similar analogy as the 8th AJCC pN classification was developed. The performance of the proposed and 8th AJCC GC subgroups was compared and validated using the Surveillance, Epidemiology, and End Results (SEER) dataset comprising of 10,208 multi-ethnic GC cases.

RESULTS

Significant difference in OS between the Limited and Adequate set (corresponding N0-N3a) using the 8th AJCC system was observed but the OS of N0_limited vs. N1_adequate, N1_limited vs. N2_adequate, N2_limited vs. N3a_adequate, and N3a_limited vs. N3b_adequate subgroups was almost similar in the Chinese dataset. Therefore, we formulated an N' classification whereby only the nodal subgroups of the Limited set, except for pT1N0M0 cases as they underwent less extensive surgeries (D1 or D1 + gastrectomy), were re-classified to one higher nodal subgroup, while those of the Adequate set remained unchanged (N'0 = N0_adequate + pT1N0M0_limited, N'1 = N1_adequate + N0_{limited (excluding pT1N0M0limited)}, N'2 = N2_adequate + N1_limited, N'3a = N3a_adequate + N2_limited, and N'3b = N3b_adequate + N3a_limited). This N' classification demonstrated less heterogeneity in OS between the Limited and Adequate subgroups. Further analyses demonstrated superior statistical performance of the pTN'M system over the 8th AJCC edition and was successfully validated using the SEER dataset.

CONCLUSION

The proposed nodal staging strategy was successfully validated in large multi-ethnic GC datasets and represents a practical approach for homogenizing the classification of GC cohorts comprising of patients with < 16 and ≥ 16 rLNs.

Long-term survival of patients with stage II and III gastric cancer who underwent gastrectomy with inadequate nodal assessment

BACKGROUND

Gastric cancer is an aggressive disease with frequent lymph node (LN) involvement. The NCCN recommends a D2 lymphadenectomy and the harvesting of at least 16 LNs. This threshold has been the subject of great debate, not only for the extent of surgery but also for more appropriate staging. The reclassification of stage IIB through IIIC based on N3b nodal staging in the eighth edition of the American Joint Committee on Cancer (AJCC) staging system highlights the efforts to more accurately discriminate survival expectancy based on nodal number. Furthermore, studies have suggested that pathologic assessment of 30 or more LNs improve prognostic accuracy and is required for proper staging of gastric cancer.

AIM

To evaluate the long-term survival of advanced gastric cancer patients who deviated from expected survival curves because of inadequate nodal evaluation.

METHODS

Eligible patients were identified from the Surveillance, Epidemiology, and End Results database. Those with stage II–III gastric cancer were considered for inclusion. Three groups were compared based on the number of analyzed LNs. They were inadequate LN assessment (ILA, < 16 LNs), adequate LN assessment (ALA, 16-29 LNs), and optimal LN assessment (OLA, ≥ 30 LNs). The main outcomes were overall survival (OS) and cancer-specific survival. Data were analyzed by the Kaplan-Meier product-limit method, log-rank test, hazard risk, and Cox proportional univariate and multivariate models. Propensity score matching (PSM) was used to compare the ALA and OLA groups.

RESULTS

The analysis included 11607 patients. Most had advanced T stages (T3 = 48%; T4 = 42%). The pathological AJCC stage distribution was IIA = 22%, IIB = 18%, IIIA = 26%, IIIB = 22%, and IIIC = 12%. The overall sample divided by the study objective included ILA (50%), ALA (35%), and OLA (15%). Median OS was 24 mo for the ILA group, 29 mo for the ALA group, and 34 mo for the OLA group (P < 0.001). Univariate analysis showed that the ALA and OLA groups had better OS than the ILA group [ALA hazard ratio (HR) = 0.84, 95% confidence interval (CI): 0.79–0.88, P < 0.001 and OLA HR = 0.73, 95%CI: 0.68–0.79, P < 0.001]. The OS outcome was confirmed by multivariate analysis (ALA HR = 0.68, 95%CI: 0.64–0.71, P < 0.001 and OLA: HR = 0.48, 95%CI: 0.44–0.52, P < 0.001). A 1:1 PSM analysis in 3428 patients found that the OLA group had better survival than the ALA group (OS: OLA median = 34 mo vs ALA median = 26 mo, P < 0.001, which was confirmed by univariate analysis (HR = 0.81, 95%CI: 0.75–0.89, P < 0.001) and multivariate analysis: (HR = 0.71, 95%CI: 0.65–0.78, P < 0.001).

CONCLUSION

Proper nodal staging is a critical issue in gastric cancer. Assessment of an inadequate number of LNs places patients at high risk of adverse long-term survival outcomes.

Early and late recurrences in lymph node-negative gastric cancer: a retrospective cohort study

BACKGROUND

Predictors of recurrence in patients with lymph node-negative gastric cancer (GC) who have undergone curative resection have been widely investigated, but not the effects of predictors on timing of recurrence.

OBJECTIVE

Determine the factors associated with early and late recurrence in patients with node-negative GC.

DESIGN

Retrospective cohort.

SETTING

Academic tertiary care center.

PATIENTS AND METHODS

The study included patients with node-negative GC after curative resection between 2008 and 2018 at two institutions. Early and late recurrences were determined using a minimum P value approach to evaluate the optimal cutoff for recurrence-free survival (RFS). A competing risk model and landmark analysis were used to analyze factors associated with early and late recurrences.

MAIN OUTCOME MEASURES

Recurrence-free survival and factors associated with survival.

SAMPLE SIZE

606.

RESULTS

After a median follow-up of 70 months, 50 (8.3%) patients experienced recurrent disease. The optimal length of RFS for distinguishing between early (n=26) and late recurrence (n=24) was 24 months (P=.0013). The median RFS in the early and late recurrence groups was 11 and 32 months, respectively. Diffuse tumors (hazard ratio 3.358, P=.014), advanced T stage (HR 8.804, P=.003), perineural invasion (HR 10.955, P<.001), and anemia (HR 2.351, P=.018) were independent predictors of early recurrence. Mixed tumor location (HR 5.586, P=.002), advanced T stage (HR 5.066, P<.001), lymphovascular invasion (HR 5.902, P<.001), and elevated CA19-9 levels (HR 5.227, P<.001) were independent predictors of late recurrence. Similar results were obtained in the landmark analysis.

CONCLUSIONS

Individualized therapeutic and follow-up strategies should be considered in future studies because of distinct patterns in predictors of early and late recurrence.

LIMITATIONS

Retrospective design, small sample size.

CONFLICT OF INTEREST

None.

Health-related quality of life after gastric cancer treatment in Brazil: Narrative review and reflections

In Brazil, gastric cancer is the third most common type of cancer among men and fifth among women, with an estimated 13360 new cases among men and 7870 among women each year during the 2020-2022 period. This study presents reflections and attempts to add knowledge to the theme of quality of life (QoL) in patients with gastric adenocarcinoma and describes some of its characteristics in three regions of Brazil, with an evaluation of the disease’s impacts in various dimensions of life, as reported by the patients themselves. We performed a narrative review of the literature and a data analysis of studies on QoL in Brazilian patients treated for gastric adenocarcinoma from three different cities in three geographic regions: Brasília (the midwest), Jaú (the southeast), and Macapá (the north).

The development and external validation of a nomogram predicting overall survival of gastric cancer patients with inadequate lymph nodes based on an international database

BACKGROUND

Inadequate sampling of lymph nodes could lead to stage migration and indicate a poor prognosis for gastric cancer after curative surgery. Some emerging novel predictors and the application of a nomogram could increase the accuracy of survival prediction.

METHODS

An international database regarding gastric cancer was employed as the primary cohort. The patients with inadequate (< 30) lymph nodes (LN) were analyzed by Cox proportional hazards regression. Based on the selected model, a nomogram was plotted and calibrated against an external validation database.

RESULTS

A total of 1109 patients were included in the primary cohort, and there were 6584 patients in the validation cohort. There were significant differences regarding the clinical characteristics between the two cohorts. The model containing age, T stages, N stages, metastatic lymph nodes (mLN), and the number of total LN retrieved (TLN) showed superiority over the conventional TNM stages. Harrell's concordance index of the nomogram and TNM stages was 0.744 and 0.717, respectively. The external validation demonstrated a good concordance with the nomogram-predicted survival.

CONCLUSIONS

The nomogram including age, T stages, N stages, mLN, and TLN had a better accuracy than the conventional TNM staging system in predicting overall survival for gastric cancer patients with inadequate (< 30) LN.

Positive lymph node ratio is an index in predicting prognosis for remnant gastric cancer with insufficient retrieved lymph node in R0 resection

The staging system of remnant gastric cancer (RGC) has not yet been established, with the current staging being based on the guidelines for primary gastric cancer. Often, surgeries for RGC fail to achieve the > 15 lymph nodes needed for TNM staging. Compared with the pN staging system, lymph node ratio (NR) may be more accurate for RGC staging and prognosis prediction. We retrospectively analyzed the data of 208 patients who underwent R0 gastrectomy with curative intent and who have ≤ 15 retrieved lymph nodes (RLNs) for RGC between 2000 and 2014. The patients were divided into four groups on the basis of the NR cutoffs: rN0: 0; rN1: > 0 and ≤ 1/6; rN2: > 1/6 and ≤ 1/2; and rN3: > 1/2. The 5-year overall survival (OS) rates for rN0, rN1, rN2, and rN3 were 84.3%, 64.7%, 31.5%, and 12.7%, respectively. Multivariable analyses revealed that tumor size (p = 0.005), lymphovascular invasion (p = 0.023), and NR (p < 0.001), but not pN stage (p = 0.682), were independent factors for OS. When the RLN count is ≤ 15, the NR is superior to pN as an important and independent prognostic index of RGC, thus predicting the prognosis of RGC patients more accurately.

Number of Positive Lymph Nodes Is Superior to LNR and LODDS for Predicting the Prognosis of Pancreatic Neuroendocrine Neoplasms

BACKGROUND

The American Joint Committee on Cancer (AJCC) staging for pancreatic neuroendocrine neoplasms (PanNENs) based on the number of positive lymph nodes (PLNs) is the most widely accepted nodal staging system. New nodal staging schemes that take both the number of PLNs and the number of examined lymph nodes into consideration have emerged as useful prognostic tools. The aim of the current study was to determine the most effective nodal staging system, among the 8th edition AJCC N staging (or PLN staging), lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS), for predicting the cause-specific survival of patients with PanNENs.

METHODS

The clinicopathological and prognostic data of 2,295 patients from the Surveillance, Epidemiology, and End Results (SEER) database, diagnosed with PanNENs between 1988 and 2015, were reviewed retrospectively.

RESULTS

A multivariate analysis identified PLN and LNR staging as independent prognostic factors, but not LODDS. The PLN staging exhibited higher C-index and area under the curve values than those of the LNR and LODDS, indicating better predictive discriminatory capacity. No significant difference in the survival of patients was observed within the same PLN staging subgroup according to the number (high or low) of examined lymph nodes. In contrast, intra-group heterogeneity was seen with use of LNR and LODDS staging, due to overestimation of the risk of insufficient examined lymph nodes, and LODDS failed to stratify patients without lymph nodes metastasis into different risk groups.

CONCLUSIONS

The PLN staging is more reliable than LNR and LODDS staging for predicting the cause-specific survival of PanNENs.

Impact of the 8th edition of the AJCC TNM classification on gastric cancer prognosis-study of a western cohort

Introduction

The 8th edition of the American Joint Committee on Cancer (AJCC) TNM classification for gastric cancer introduced changes, mainly in stage III, with the incorporation of the pN3 sub-classification in the final staging group. The goal was to compare the 7th and 8th editions to evaluate the discriminative capacity of the new edition.

Methods

This study was a retrospective review of patients with gastric cancer treated with surgery in 2013 and 2014.

Results

We analysed 310 patients, with a median age of 66 years and out of which 55.5% were male. The most commonly performed surgery was subtotal gastrectomy (n = 158; 51%), with a median of 30 lymph nodes removed. With a median follow-up of 39.5 months, the 1- and 3-year overall survival (OS) was 82% and 59%, respectively. In stage III (n = 115), there was stage migration in 40 cases (34.8%), with upstage in 11 cases and downstage in 29 cases. In this group, there was a statistically significant difference in OS between N3a and N3b patients (p = 0.002), as well as a statistically significant difference in OS between stages IIIA, IIIB and IIIC when the 8th edition was applied (p = 0.001), which was not verified with the 7th edition (p = 0.057). In multivariate analysis, both extracapsular extension and N classification from TNM were independent prognostic factors (p = 0.033 and p = 0.024, respectively).

Conclusion

The 8th edition of the AJCC TNM classification allows for a better prognostic refinement, namely in the new stage III groups after the stratification of lymph node disease in N3a and N3b. Factors that evaluate the biological behaviour of the disease remain excluded from this edition, such as extracapsular extension, which had a prognostic impact in our series.

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

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

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.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Superiority of log odds of positive lymph nodes (LODDS) for prognostic prediction after gastric cancer surgery: a multi-institutional analysis of 7620 patients in China

PURPOSE

To compare the 8th pN system with ratio-based and Log odds of positive lymph nodes (LODDS) staging systems for predicting the overall survival (OS) of gastric cancer (GC) patients after curative gastric resection.

METHODS

We analyzed, retrospectively, clinicopathologic and prognostic data from three Chinese medical centers, on 7620 patients who underwent curative surgery for GC. We established a hypothetical tumor-LODDS-metastasis (TLM) and tumor-ratio-metastasis (TRM) staging system. The relative discriminative abilities of the different staging systems were assessed using Akaike's Information Criterion (AIC), a linear trend chi-square test, and a likelihood ratio chi-square test.

RESULTS

The cut-off points of the LODDS were set as: ≤ - 1.5, - 1.5 to - 1.0, - 1.0 to - 0.5, - 0.5 to 0, and > 0. There were significant differences in the survival of patients in different LODDS classifications for each pN or LNR group. When stratified by the LODDS classification, the prognosis was more homologous according to the pN or lymph-node ratio (LNR) classifications. The modified TLM staging system had better discriminatory ability and better optimistic prognostic stratification than the 8th TNM or the TRM staging systems for predicting the prognosis of patients with GC.

CONCLUSIONS

The LODDS staging system was superior to other lymph-node classifications for predicting the prognosis of patients undergoing gastrectomy GC. LODDS may be incorporated into a GC staging system if these results are confirmed by other studies.

Clinical and pathological staging of gastric cancer: Current perspectives and implications

Accurate categorization of invasive depth and lymph node metastasis or optimization of TNM categories is fundamentally critical for prognostic assessment and decision making regarding subsequent therapies after surgery for gastric cancer. Improving the precision of the TNM staging is the ongoing goal. The evolution of the staging system indicates that there is no "ideal staging". Every update has criticized the lack of a standard approach for the stages to date. T staging depends on the accurate determination of the depth of infiltration based on pathological continuous sections. N staging is susceptible to the influence of lymph node detection, and insufficient lymph node detection can lead to N staging migration. M staging is required to improve the detection rate of peritoneal positive free cancer cells to determine the high risk factors of peritoneal metastasis. At present, the quality of standardized pathological diagnosis of gastric cancer requires improvement. Based on a review of the literature and experience from multiple gastric cancer centers, we present a new development in TNM staging and a way to improve clinical and pathological quality control of gastric cancer.

The Prognosis Value of Lymphatic Vessel Invasion in pN0 Gastric Cancer Patients with Insufficient Examined Lymph Nodes

OBJECTIVES

To investigate the prognosis value of lymphatic vessel invasion (LVI) in pN0 gastric cancer patients with insufficient examined lymph nodes (ELNs).

METHODS

Clinicopathologic and prognostic data of pN0 gastric cancer patients with insufficient ELNs who underwent radical surgery in our institution were retrospectively studied.

RESULTS

Firstly, we confirmed that less than 16 but not less than 30 ELNs were insufficient ELNs in the present study. Of the 350 pN0 patients with < 16 ELNs, 64 patients (18.29%) had LVI. The overall survival (OS) of patients with LVI was significantly poorer than those without LVI. Multivariate analysis suggested that LVI was one of the independent factors predicting prognosis of pN0 patients with < 16 ELNs. Further analyses suggested that there were similar prognoses between pN0 patients with < 16 ELNs who had LVI and pN1 patients, and between pN0 patients with < 16 ELNs who had no LVI and pN0 patients with ≥ 16 ELNs, respectively. Therefore, we proposed a novel pN classification, in which LVI-positive pN0 gastric cancer with < 16 ELNs was classified as pN1 disease. Two-step multivariate analysis demonstrated that the novel pN classification was more suitable for prognostic assessment than the original one.

CONCLUSIONS

LVI is a powerful and independent prognostic factor for pN0 gastric cancer patients with < 16 ELNs, and node-negative gastric cancer with < 16 ELNs which had LVI should be considered as node-positive disease. LVI is an effective indicator identifying patients stage migration happens to in pN0 patients with < 16 ELNs.

Proposal of a novel stage grouping of the Eighth Edition of American Joint Committee on Cancer TNM Staging System for Gastric Cancer: results from a retrospective study of 30 years clinical data from a single institute in China

Objectives: To improve the prognostic accuracy of 8th edition of American Joint Committee on Cancer TNM staging system for gastric cancer by reclassifying N3a category.Methods: 1446 patients who underwent R0 surgery for histologically proven gastric cancers with ≥16 lymph nodes retrieved were selected.Results: Significant prognostic difference was observed among patients in N3a category ('7-10' group vs '11-15' group; P = 0.029). We proposed a revised pN category in which patients with '7-10' metastatic lymph nodes were categorized as r-N3a, '11-15' as r-N3b, and '>15' as r-N3c. Prognosis for patients in T2r-N3aM0 was similar to that of patients in T4aN0M0/T3N1M0/T2N2M0/T1r-N3bM0 (P = 0.584), but significantly better than that of patients in T4bN0M0/T4aN1-2M0/T3N2M0/T2r-N3bM0 (P = 0.031). Similarly, prognoses for patients in T3r-N3aM0 and T4ar-N3aM0 were similar to that of patients in T4bN0M0/T4aN1-2M0/T3N2M0/T2r-N3bM0 (P = 0.136; P = 0.193), but significantly better than that of patients in T4bN1-2M0/T4ar-N3bM0/T3r-N3bM0/T1-2r-N3cM0 (P = 0.011; P = 0.017). A revised TNM system was also proposed, in which T2r-N3aM0 was incorporated into stage IIB, T3r-N3aM0 and T4ar-N3aM0 into stage IIIA. The revised TNM system had better homogeneity, discriminatory ability, and monotonicity of gradients than the 8th edition system.Conclusion: Patients with 7-10 metastatic lymph nodes in T2-T4a categories should be considered lower stage in the final TNM stage.

Modified lymph node ratio improves the prognostic predictive ability for breast cancer patients compared with other lymph node staging systems

Background

Metastatic regional lymph nodes (LN) is a strong predictor of worse long-term outcome. Therefore, different LN staging systems have been proposed in recent years. In this study, we proposed a modified lymph node ratio (mLNR) as a new lymph node staging system and then compared the prognostic performance of mLNR with American Joint Committee on Cancer N stage, lymph node ratio (LNR) and log odds of metastatic lymph nodes in breast cancer patients.

Methods

Breast cancer patients who underwent surgery between 2004 and 2012 were identified from the Surveillance, Epidemiology, and End Results database. Restricted cubic spline functions were calculated to characterize the association between variables and the risk of death. The Cox proportional hazards models were constructed to assess the predictive ability of different lymph node staging systems using the Akaike’s Information Criterion (AIC) and Harrell’s concordance index (C-index).

Results

A total of 264,096 breast cancer patients were enrolled and 187,785 (71.1%) patients had a limited number of LNs harvested. In the limited LN harvest cohort, the prognostic performance of LNR decreased and mLNR could greatly solve this problem. In addition, among the entire cohort, mLNR modeled as a continuous value had the best predictive ability (AIC: 922021.9 and C-index: 0.727) than other lymph node staging systems.

Conclusions

The predictive ability of LNR is restricted by a limited LN harvest. However, mLNR shows superiority to LNR and other lymph node staging systems especially in a limited LN harvest cohort, making mLNR the most powerful lymph node staging systems.

•

We selected 264,096 patients, which is enough to support our conclusion.

•

We used two indexes to fully verify the fit of different lymph staging systems.

•

The mLNR improved the prognostic predictive ability best.

Quality of life as a fundamental outcome after curative intent gastrectomy for adenocarcinoma: lessons learned from patients

Background

Gastric cancer has an important epidemiologic impact, and the main curative therapeutic modality for gastric cancer is surgical resection. However, even curative intent therapy can have negative effects on the quality of life (QoL) of these patients, which is undesirable; thus, it is difficult to balance the standardized treatment reported in the literature and treatment response to achieve full patient satisfaction. The purpose of our study was to evaluate the QoL and identify the association of scores on the Functional Assessment of Cancer Therapy-Gastric (FACT-Ga) and Short Form 36 Health Survey version 2 (SF36v2) questionnaires with sociodemographic, clinical and anatomopathological aspects of gastric adenocarcinoma patients undergoing curative surgery.

Methods

This was a cross-sectional study involving 104 patients from three regions of Brazil. Inferential analyses were used to compare (multiple regression and Mann-Whitney or Kruskal-Wallis tests) the relationships between these scores and variables (Spearman's coefficient).

Results

In the multiple regression analysis, we found correlations between Helicobacter pylori status and physical well-being (PWB) (P=0.026), between gender and emotional well-being (EWB) (P=0.008), between Lauren's histology and physical functioning (P=0.009), as well as the Short Form 36 Health Survey version 2 (SF-36v2) role-physical (P=0.027), between the tumor site and EWB (P=0.038), between the SF-36v2 mental health and N (the lower the staging, the better the score, P=0.006) and between the SF-36v2 mental health and lymph nodes removed (P=0.029). According to the Mann-Whitney or Kruskal-Wallis test, women had worse FACT-Ga total (P=0.049), PWB (P=0.005), EWB (P=0.007), gastric cancer subscale (GaCS, P=0.011), trial outcome index (TOI, P=0.030) and mental health scores than men (P=0.011). Patients with distal tumors had better scores (FACT-Ga, P=0.018; GaCS, P=0.014; TOI, P=0.020) than patients with proximal tumors. Patients with tumors located in the cardia had better physical functioning than those with proximal tumors (P=0.042). Patients who underwent partial gastrectomy had better FACT-Ga total scores (P=0.011), PWB (P=0.033), GaCS scores (P=0.006) and TOI scores (P=0.008) than those who underwent total gastrectomy. Patients who did not receive adjuvant therapy had worse bodily pain as reported on the SF-36v2 than those who received therapy (P=0.048). According to Spearman's coefficient, a higher lymph node stage corresponded to worse FACT-Ga total (s=-0.200, P=0.034), GaCS (s=-0.206, P=0.037), TOI (s=-0.216; P=0.028) and vitality (s=-0.215, P=0.029) scores. A longer time after treatment corresponded to a better SF-36v2 role-physical domain score (s=0.223; P=0.023).

Conclusions

The type of treatment instituted, postoperative time and sociodemographic and anatomopathological factors influence the QoL.

Retrieved lymph nodes from different anatomic groups in gastric cancer: a proposed optimal number, comparison with other nodal classification strategies and its impact on prognosis

Background

The optimal number of retrieved lymph nodes (LNs) in gastric cancer (GC) is still debatable and previous studies proposing new classification alternatives mostly focused on the number of retrieved LNs without proper consideration on the anatomic nodal groups’ location. Here, we assessed the impact of retrieved LNs from different nodal location groups on the survival of GC patients.

Methods

Stage I–III gastric cancer patients who had radical gastrectomy were investigated. LN grouping was determined according to the 13th edition of the JCGC. The optimal cut-off values of retrieved LNs in different LN groups (Group 1 and 2) were calculated, based on which a proposed nodal classification (rN) simultaneously accounting the optimal number and location of retrieved LNs was proposed. The performance of rN was then compared to that of LN ratio, log-odds of metastatic LNs (LODDs) and the 8th edition of the Union for International Cancer Control/American Joint Committee on Cancer (UICC/AJCC) N classification.

Results

The optimal cut-off values for Group 1 and 2 were 13 and 9, respectively. The 5-year overall survival (OS) was higher for patients in retrieved Group 1 LNs > 13 (vs. Group 1 LNs ≤ 13, 63.2% vs. 57.9%, P = 0.005) and retrieved Group 2 LNs > 9 (vs. Group 2 LNs ≤ 9, 72.5% vs. 60.7%, P = 0.009). Patients staged as pN0–3b were sub classified using this Group 1 and 2 nodal analogy. The OS of pN0–N2 patients in retrieved Group 1 LNs > 13 or Group 2 LNs > 9 were superior to those in retrieved Group 1 LNs ≤ 13 and Group 2 LNs ≤ 9 (All P < 0.05); except for pN3 patients. The rN classification was formulated and demonstrated better 5-year OS prognostication performance as compared to the LNR, LODDs, and the 8th UICC/AJCC N staging system.

Conclusions

The retrieval of > 13 and > 9 LNs for Group 1 and Group 2, respectively, could represent an alternative lymph node retrieval approach in radical gastrectomy for more precise survival prognostication and minimizing staging migration, especially if > 16 LNs is found to be difficult.

Should All Stage N3b Patients with Advanced Gastric Cancer Be Considered Equivalent? A 30-Year Single Center Study

PURPOSE

To investigate the survival of stage N3b patients with advanced gastric cancer (AGC) after radical surgery and to evaluate the TNM staging of subgroups of stage N3b patients.

METHODS

We reviewed the data of 222 stage N3b patients with AGC who underwent D2/D3 radical surgery. Depending on the number of metastatic lymph nodes (MLNs), we divided N3b patients into several groups and compared the survival differences among them. We found that survival of patients with 16-20 MLNs was better than that of patients with ≥ 21 MLNs. Therefore, we divided the N3b patients into two subgroups and defined patients with 16-21 MLNs as N3b1 and patients with ≥ 21 MLNs as N3b2. Then, we compared survival differences between the two groups and their subgroups. Patients who underwent palliative surgery served as the reference group. In addition, we selected stage IIIB, IIIC, and IV patients from the same database to properly re-classify the N3b subgroups in the TNM staging system.

RESULTS

Survival differed significantly between the new N3b1and N3b2 groups and between the new N3b1 group and the palliative group. However, the survival of the new N3b2 group was similar to that of the palliative group. Comparisons of survival according to T staging revealed similarities between the following groups: (1) stages T2-3N3b1 and IIIB, (2) stages T4N3b1 and IIIC, and (3) stages T2-4N3b2 and IV.

CONCLUSIONS

All stage N3b patients with AGC should not be considered equivalent. A significant difference in survival was observed between stage N3b1 and N3b2 patients after radical surgery, while the survival of stage N3b2 patients was similar to that of patients who undergo palliative surgery. We recommend re-classifying stage T2-3N3b1 as TNM stage IIIB, stage T4N3b1 as stage IIIC, and T2-4N3b2 as stage IV.

A novel prognosis prediction model after completion gastrectomy for remnant gastric cancer: Development and validation using international multicenter databases

BACKGROUND

Examined lymph node counts of remnant gastric cancer patients are often insufficient, and the prognostic ability of tumor-node-metastasis staging is therefore limited. This study aimed to create a simple and universally applicable prediction model for RGC patients after completion of gastrectomy.

METHODS

A 5-year overall survival prediction model for remnant gastric cancer patients was developed using a test dataset of 148 consecutive patients. Model coefficients were obtained based on the Cox analysis of clinicopathological factors. Prognostic performance was assessed with the concordance index (C-index) and decision curve analysis. For internal validation, the bootstrap method and calibration assessment were used. The model was validated using 2 external cohorts from China (First Affiliated Hospital of Fujian Medical University, n = 46) and the United States (Mayo Clinic, n = 20).

RESULTS

Depth of tumor invasion, number of metastatic lymph nodes, distant metastasis, and operative time were independent prognostic factors. Our model's C-index (0.761) showed better discriminatory power than that of the eighth tumor-node-metastasis staging system (0.714, P = .001). The model calibration was accurate at predicting 5-year survival. Decision curve analysis showed that the model had a greater benefit, and the results were also confirmed by bootstrap internal validation. In external validation, the C-index and decision curve analysis showed good prognostic performances in patient datasets from 2 participating institutions. Moreover, we verified the reliability of the model in an analysis of patients with different examined lymph node counts (>15 or ≤15).

CONCLUSION

Utilizing clinically practical information, we developed a universally applicable prediction model for accurately determining the 5-year overall survival of remnant gastric cancer patients after completion of gastrectomy. Our predictive model outperformed tumor-node-metastasis staging in diverse international datasets regardless of examined lymph node counts.

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

Objective

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

Patients and methods

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

Results

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

Conclusion

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

Integrated analysis of the prognostic role of the lymph node ratio in node-positive gastric cancer: A meta-analysis

BACKGROUND

The lymph node ratio (LNR) as a prognostic parameter for gastric cancer has yet to be fully validated in the current tumor node metastasis staging system. We assessed the prognostic role of LNR in lymph node-positive gastric cancer through a meta-analysis.

MATERIALS AND METHODS

PubMed and EMBASE were searched for relevant studies up until December 2016. The effect measure for meta-analysis of primary outcomes was the hazard ratio (HR) for overall survival. Pooled HRs and 95% confidence intervals were calculated using random effects models. The I² statistic was used to measure heterogeneity. Subgroup analysis and meta-regression were chosen to illustrate the potential heterogeneity of the risk factors of outcomes. Publication bias was assessed using Egger's test and Begg's funnel plots. Sensitivity analysis was applied to evaluate the origin of the heterogeneity.

RESULTS

We included 27 studies in this meta-analysis. Higher LNRs were significantly associated with a shorter overall survival (OS). High heterogeneity among the studies was identified (I² = 85.6), and the publication bias was moderate. Subgroup analysis showed similar results, and elevated LNR was associated with late-stage gastric cancer and indicative of a worse prognosis. Univariate meta-regression analysis of OS indicated that both treatment type and ethnicity may be causes of heterogeneity in patients with gastric cancer (p values were 0.005 and 0.008, respectively).

CONCLUSION

LNR was associated with a significantly poorer OS and LNR was an independent predictor of survival in patients with gastric cancer. LNR should be added as one of the parameters to be used in future tumor staging classification systems.

A novel nomogram individually predicting disease-specific survival after D2 gastrectomy for advanced gastric cancer

BACKGROUND

Few studies have shown nomograms that may predict disease-specific survival (DSS) probability after curative D2 gastrectomy for advanced gastric cancer (AGC), particularly among Chinese patients. This study sought to develop an elaborative nomogram that predicts long-term DSS for AGC in Chinese patients.

METHODS

A retrospective study was conducted on 6753 AGC patients undergoing D2 gastrectomy between January 1, 2000 and December 31, 2012 from three large medical hospitals in China. We assigned patients from Sun Yat-sen University Cancer Center to the training set, and patients from the First Affiliated Hospital of China Medical University and Tianjin Medical University Cancer Hospital to two separate external validation sets. A multivariate survival analysis was performed using Cox proportional hazards regression model in a training set, and a nomogram was constructed. Harrell's C-index was used to evaluate discrimination and calibration plots were used to validate similarities between survival probabilities predicted by the nomogram model and actual survival rates in two validation sets.

RESULTS

The multivariate Cox regression model identified age, tumor size, location, Lauren classification, lymphatic/venous invasion, depth of invasion, and metastatic lymph node ratio as covariates associated with survival. In the training set, the nomogram exhibited superior discrimination power compared with the 8th American Joint Committee on Cancer TNM classification (Harrell's C-index, 0.82 vs. 0.74; P < 0.001). In two validation sets, the nomogram's discrimination power was also excellent relative to TNM classification (C-index, 0.83 vs. 0.75 and 0.81 vs. 0.74, respectively; P < 0.001 for both). After calibration, the nomogram produced survival predictions that corresponded closely with actual survival rate.

CONCLUSIONS

The established nomogram was able to predict 3-, 5-, and 10-year DSS probabilities for AGC patients. Validation revealed that this nomogram exhibited excellent discrimination and calibration capacity, suggesting its clinical utility.

Is the 8th Edition of the AJCC TNM Staging System Sufficiently Reasonable for All Patients with Noncardia Gastric Cancer? A 12,549-Patient International Database Study

BACKGROUND

The aim of this work is to compare the prognostic ability between the 7th and 8th editions of the American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) classification for gastric cancer (GC).

METHODS

A total of 10,194 noncardia GC patients were identified from the Surveillance, Epidemiology, and End Results database from 1988 to 2008. Concordance index (C-index), bayesian information criterion (BIC), and time-dependent receiver operating characteristic (t-ROC) analyses were used. External validation was performed using a dataset (n = 2355) derived from Fujian Medical University Union Hospital.

RESULTS

Overall survival for all five AJCC N categories differed significantly when patients were subgrouped into ≤ 15 versus >15 examined lymph nodes (eLNs). The prognostic ability of the 8th edition (C-index 0.716) was not improved over the 7th edition (C-index 0.716). Subgroup analysis showed superior performance of the 8th over the 7th edition in patients with > 15 eLNs (C-index 0.742 vs. 0.735); however, the two editions showed similar performance for patients with ≤ 15 eLNs (C-index 0.713 vs. 0.713). The BIC and t-ROC analyses were consistent. To better predict the prognosis of patients with ≤ 15 eLNs, we established a novel prognostic model based on independent prognostic factors (C-index 0.735). BIC analysis showed that this new model was better than the 7th and 8th editions. Similar results were obtained from the validation set.

CONCLUSIONS

The 8th edition of the AJCC TNM classification shows better prognostic ability than the 7th edition in noncardia GC patients with > 15 eLNs, but no improvement was found in patients with ≤ 15 eLNs; therefore, a novel prognostic model is proposed.

Metastatic lymph node ratio and Lauren classification are independent prognostic markers for survival rates of patients with gastric cancer

The long-term prognosis for patients with gastric cancer (GC) following radical resection remains poor. It is important to identify prognostic markers to predict survival. In the present retrospective study, the association between the metastatic lymph node ratio (rN) and the Lauren classification on predicting overall survival (OS) was investigated. Furthermore, a subgroup analysis was performed on the Lauren classification, using rN score as an independent prognostic marker. In total, 261 pathologically confirmed patients with GC were retrospectively reviewed. Kaplan-Meier curves and Cox's proportional hazards modeling were applied to analyze the OS of patients, and were utilized in the subgroup analysis. Receiver operating characteristic (ROC) curves were used to compare the accuracy of prognosis between the rN score and lymph node staging (N stage). The χ² test was used to analyze the association between the rN score and Lauren classification. Univariate survival and multivariate analysis demonstrated that the rN score and Lauren classification were significant prognostic markers for patients with GC. The ROC analysis confirmed that the rN score was more effective than N staging for OS prediction. Subgroup analysis indicated that rN was more accurate at predicting OS time in patients with diffuse type GC. The rN score and the Lauren classification were independent prognostic factors for the OS of patients with GC following radical resection, and the rN score was more accurate than the N stage for predicting the prognosis. Overall, the rN may be suitable as an independent predictor for OS in patients with diffuse type GC.

Improvement of T stage precision by integration of surgical and pathological staging in radically resected stage pT3-pT4b gastric cancer

Background

Both surgical TNM (sTNM) and pathological TNM (pTNM) staging are important clinicopathologic indexes of gastric cancer (GC). However, surgeons and pathologists might assess tumor depth differently in the same patient. To investigate the prognostic significance of sTNM status in patients with radically resected stage pT3-pT4b GC, we examined the relationship between sTNM and pTNM.

Methods

Clinicopathologic and survival data of 1289 patients with stage pT3-pT4b GC were studied retrospectively, in the aftermath of radical surgery.

Results

The unconformity for assessing tumor invasion depth were frequently exhibited between sT and pT staging. Comparison of 5-year OS among them, no significant differences were observed (pT3/sT3 vs pT3/sT4a, p=0.962; pT4a/sT4b vs pT4b/sT4b, p=0.508). Also, pT3/sT4b, pT4a/sT3 and pT4a/sT4a were homogeneity in prognosis. We proposed a revised pT stage in which surgical macroscopic T4b (sT4b) was incorporated into the pT stage, namely, patients in the pT3 stage with sT4b cancers were reclassified as being in the r-pT4a stage; patients in the pT4a stage with sT4b cancers were reclassified as being in the r-pT4b stage. In two-step multivariate analysis, revised pT stage proved more suitable for determining prognosis, surpassing both UICC/AJCC pT stage and sT stage as an independent prognostic index.

Conclusions

Surgical T stage is a significant and independent prognostic index of overall survival (OS) in patients with radically resected advanced GC. Patients in the pT3/4a stage with sT4b cancers, are potentially underestimated, and should be considered higher stage in terms of prognostic.

Lymph nodes ratio based nomogram predicts survival of resectable gastric cancer regardless of the number of examined lymph nodes

To develop a nomogram to predict the prognosis of gastric cancer patients on the basis of metastatic lymph nodes ratio (mLNR), especially in the patients with total number of examined lymph nodes (TLN) less than 15. The nomogram was constructed based on a retrospective database that included 2,205 patients underwent curative resection in Cancer Center, Sun Yat-sen University (SYSUCC). Resectable gastric cancer (RGC) patients underwent curative resection before December 31, 2008 were assigned as the training set (n=1,470) and those between January 1, 2009 and December 31, 2012 were selected as the internal validation set (n=735). Additional external validations were also performed separately by an independent data set (n=602) from Jiangxi Provincial Cancer Hospital (JXCH) in Jiangxi, China and a data set (n=3,317) from the Surveillance, Epidemiology, and End Results (SEER) database. The Independent risk factors were identified by Multivariate Cox Regression. In the SYSUCC set, TNM (Tumor-node-metastasis) and TRM-based (Tumor-Positive Nodes Ratio-Metastasis) nomograms were constructed respectively. The TNM-based nomogram showed better discrimination than the AJCC-TNM staging system (C-index: 0.73 versus 0.69, p<0.01). When the mLNR was included in the nomogram, the C-index increased to 0.76. Furthermore, the C-index in the TRM-based nomogram was similar between TLN ≥16 (C-index: 0.77) and TLN ≤15 (C-index: 0.75). The discrimination was further ascertained by internal and external validations. We developed and validated a novel TRM-based nomogram that provided more accurate prediction of survival for gastric cancer patients who underwent curative resection, regardless of the number of examined lymph nodes.

The impact of the lymph node density on overall survival in patients with Wilms' tumor: a SEER analysis

Objective

The objective of this study was to determine the impact of the lymph node density (LND) on overall survival of patients with Wilms’ tumor (WT) using the Surveillance, Epidemiology, and End Results (SEER) database.

Methods

Data from the SEER database were extracted from patients with WT in whom the LND could be obtained. Patients were divided into a low LND group and high LND group. Survival curves based on the LND stratification were plotted using the Kaplan–Meier method and compared with the log-rank test. The impact of prognostic factors on overall survival was analyzed using Cox regression models.

Results

A total of 1,924 patients were identified from the database. Overall survival for the low LND group at 5, 10, and 20 years was significantly better than the high LND group (5-year survival: 94.1% vs 81.4%; 10-year survival: 92.6% vs 80.8%; 20-year survival: 90.6% vs 79.1%; P<0.001). In multivariate analysis, LND was a significant predictor of overall survival, regardless of whether it was a categorical variable or a continuous variable. Other significant predictors included age, race, SEER stage, and tumor laterality.

Conclusion

LND was a significant risk factor for overall survival of patients with WT. LND may provide a better prediction of the prognosis of WT patients and may be helpful for designing better treatments.

Prognostic value of fibrosis ratio in metastatic lymph nodes of node-positive advanced gastric cancer

Lymph node metastasis plays a crucial role in predicting prognosis in advanced gastric cancer (AGC). In the present study, we formulated a fibrosis ratio (FR), defined as the number of metastatic lymph nodes with fibrosis divided by the total number of lymph nodes, and sought to determine whether it can be used to predict the prognosis of patients with AGC and improve on existing node staging. We retrospectively analyzed 161 patients who underwent curative resection for node-positive AGC between 2001 and 2010, evaluating the association between FR, lymph node ratio (LNR), and micrometastasis, and the relationship between FR and clinicopathologic findings, overall survival (OS) and disease-free survival (DFS). A high FR was significantly related to T stage (P < .001), N stage (P < .001), tumor stage (P < .001), lymphatic invasion (P < .001), and venous invasion (P = .007). FR was significantly correlated with an increased number of metastatic lymph nodes (P = .001, R = 0.869) and LNR (P = .001, R = 0.943), but not with total harvested lymph nodes. Patients with micrometastases had a lower FR, compared with those without micrometastases (P < .001). A survival analysis showed poor OS for patients in the entire cohort (P < .001); N1 (P = .002), N2 (P = .004), N3a (P = .010), and N3b (P = .003) stages; and groups with high LNR (P = .013) and low LNR (P = .001). DFS was also poor for the entire cohort (P < .001) and the N2 (P = .013), N3b (P = .002), high-LNR (P = .036), and low-LNR (P = .001) groups, but not the N1 or N3a group. Univariate and multivariate analyses revealed that high FR was an independent prognostic factor for OS (hazard ratio [HR], 2.780; CI, 1.655-4.670; P < .001) and DFS (HR, 2.051; CI, 1.199-3.508; P = .009) in AGC. Collectively, our findings indicate that high FR is associated with adverse clinicopathologic parameters in AGC, clearly establishing nodal fibrosis as a pathological finding with value in predicting poor prognosis of patients with AGC. Thus, combining current N stage and LNR diagnostics with FR could improve prognostic prediction in AGC.

Adjuvant Chemotherapy Improves Survival in Stage III Gastric Cancer after D2 Surgery

Background: Stage III gastric cancer is characterized by locally advanced disease with varying anatomic extent as measured by the 7^th edition of the American Joint Committee on Cancer (AJCC) staging system. There are no prognostic factors specifically identified in patients with stage III gastric cancer following extended lymph node dissection (D2) surgery.

Materials and Methods: From 2007 to 2014, 534 patients with stage III gastric cancer underwent radical gastrectomy and D2 dissection at the Chang Gung Memorial Hospital. Patients' characteristics and the impact of adjuvant chemotherapy were analyzed using univariate and multivariate analyses to identify variables associated with overall survival (OS) and disease-free survival (DFS).

Results: There were 320 deaths (60.0%) and 284 recurrences (53.2%) by the end of the study. The median OS and DFS were 30.7 months (95% confidence interval [CI]: 27.5-33.9) and 26.4 months (95% CI: 21.2-31.6), respectively. The multivariate analysis identified 7 variables that were independent prognostic factors both for OS and DFS including ratio of metastatic lymph nodes to total resection lymph nodes, carcinoembryonic antigen level, Eastern Cooperative Oncology Group performance status, gastrectomy method, vascular invasion, surgical margin, and adjuvant chemotherapy. Patients with stage IIIA-IIIC disease who received adjuvant chemotherapy had better OS and DFS outcomes than those who did not.

Conclusions: Our study identified several independent prognostic factors that might help determine the appropriate counseling patients following surgical treatment. D2 surgery alone was inadequate to achieve long-term survival. As the only correctable independent prognostic factor, postoperative adjuvant chemotherapy should be recommended for eligible patients with stage III gastric cancer.

A prognostic model based on lymph node metastatic ratio for predicting survival outcome in gastric cancer patients with N3b subclassification

BACKGROUND

Determining the survival outcome for gastric cancer patients with metastases to more than 15 regional lymph nodes is difficult. This study aims to develop a lymph node metastatic ratio (LNR)-based prognostic model to predict the survival outcome after D2 surgery in such patient groups.

METHODS

Our study retrospectively enrolled 139 gastric cancer patients with metastases to more than 15 regional lymph nodes who underwent D2 surgery between 2007 and 2014. Clinicopathologic variables to predict overall survival (OS) using multivariate Cox regression were selected to create a prognostic model.

RESULTS

The prognostic model for predicting OS was developed based on five independent factors, namely, T-classification (T2 or T3 vs. T4), LNR (<0.80 vs. ≥0.80), carcinoembryonic antigen level (<5 vs. ≥5 ng/ml), Eastern Cooperative Oncology Group performance scale (scale 0-1 vs. ≥2), and adjuvant chemotherapy (yes vs. no). Using the prognostic score, patients were stratified into good, intermediate, and poor prognostic groups. The median OS in the good, intermediate, and poor prognostic risk groups was 32.0 months (95% confidence interval [CI]: 22.3-41.7), 12.4 months (95% CI: 8.5-16.3), and 5.4 months (95% CI: 2.1-8.7), respectively. The c-index of the prognostic model was 0.79 (95% CI: 0.71-0.87).

CONCLUSION

This study developed an accurate LNR-based prognostic model for predicting the survival outcome after D2 surgery in gastric cancer patients with metastasis to more than 15 regional lymph nodes. This model might assist clinicians in prognostic stratification of such patients and convince eligible patients to receive adjuvant chemotherapy.

Lymph Node Ratio-based Staging System Outperforms the Seventh AJCC System for Gastric Cancer: Validation Analysis With National Taiwan University Hospital Cancer Registry

BACKGROUND

On the basis of SEER data, in which most gastric cancer patients had limited lymph node dissection, node ratio-based staging system (TNrM) has been shown to have better accuracy than the AJCC TNM system. This study is to validate the result with patients from Taiwan, where D2 lymphadenectomy is routinely performed.

PATIENT AND METHOD

A total of 1405 consecutive gastric cancer patients treated at National Taiwan University Hospital between 1998 and 2010 were included. To evaluate the performance of the AJCC system, each TNM stage was stratified by TNrM stages. The homogeneity of patients' survival across TNrM strata was evaluated using the log-rank test. The performance of the TNrM system was evaluated with the same approach.

RESULTS

Five of the 7 evaluable AJCC stages (IA, IIA, IIIA, IIIB, and IIIC) contained TNrM subgroups with statistically heterogenous survival (P=0.003, 0.04, 0.002, 0.04, and <0.001, respectively). Thirty-six percent of patients (506/1405) were misclassified by the AJCC TNM system. However, of the assessable 6 TNrM stages, none of the AJCC subgroups showed significantly heterogenous survivals (P>0.05). About 19% of patients (264/1405) were misclassified by using the TNrM system.

CONCLUSIONS

Lymph node ratio significantly decreases the stage migration caused by inadequate examined lymph nodes. The advantage of TNrM was validated with a patient cohort from the Eastern medical center.

A Nomogram for Predicting Overall Survival of Gastric Cancer Patients with Insufficient Lymph Nodes Examined

Insufficient number of examined lymph nodes (eLNs) was considered to increase significantly the risk of stage migration in gastric cancer patients. The aim of our study is to establish a nomogram predicting the overall survival (OS) for patients with an insufficient number of eLNs. A total of 872 gastric cancer patients with extended lymphadenectomies were assigned randomly (2:1) to the development cohort and the validation cohort. The nomogram was established based on the Cox regression model using the development cohort. The concordance index (C-index) was used to evaluate the discriminative ability. We also compared our model with two other staging systems. Using multivariate analysis, age, sex, tumor location, depth of invasion, macroscopic type, lymphovascular invasion, the number of eLNs, and metastatic lymph nodes were selected and incorporated into the nomogram. The C-index of the nomogram was 0.742 and 0.743 in development and validation cohorts, respectively, which were significantly superior to the C-indices (range 0.705-0.712, all P < 0.001) of American Joint Committee on Cancer (AJCC) seventh edition and lymph node ratio staging systems in both cohorts. We established a nomogram which could predict accurately OS for gastric cancer patients with insufficient number of eLNs.

Less than 12 lymph nodes in the surgical specimen after neoadjuvant chemo-radiotherapy: an indicator of tumor regression in locally advanced rectal cancer?

BACKGROUND

The number of lymph node retrieved in the surgical specimen is important for tumor staging and has paramount impact on prognosis in colorectal cancer and imitates the adequacy of lymph node surgical clearance. The paucity of lymph node yields in patients undergoing resection after preoperative chemo radiotherapy (CRT) in rectal cancer has seen. Lower total number of lymph nodes in the total mesoractal excision (TME) specimen after CRT, could a marker of better tumor response.

METHODS

We retrospectively reviewed the prospectively managed data of patients underwent excision for rectal cancer, who treated by neoadjuvant radiotherapy with or without chemotherapy in locally advanced rectal cancer. From 2010 to 2014, 364 patients underwent rectal cancer surgery, of which ninety-one treated with neoadjuvant treatment. Standard surgical and pathological protocols were followed. Patients were categorized into two groups based on the number of total harvested lymph nodes with group 1, having 12 or more nodes harvested, and group 2 including patients who had <12 lymph nodes harvested. The total number of lymph nodes retrieved from the surgical specimen was correlated with grade of tumor regression with neoadjuvant treatment.

RESULTS

Out of 91 patients, 38 patients (42%) had less than 12 lymph nodes examined in specimen. The difference in median number of lymph nodes was observed significantly as 9 (range, 2-11) versus 16 (range, 12-32), in group 2 and 1, respectively (P<0.01). Patients with fewer lymph node group were comparable with respect to age, BMI, pre-operative staging, neoadjuvant treatment. Pathological complete response in tumor pCR was seen with significantly higher rate (40% vs. 26%, P<0.05) in group 2. As per Mandard criteria, there was significant difference in tumor regression grade (TRG) between both the groups (P<0.05). Among patients with metastatic lymph nodes, median LNR was lower in <12 lymph nodes group at 0.167 (range, 0.09-0.45) versus 0.187 (range, 0.05-0.54), difference was not statistically significant (P=0.81).

CONCLUSIONS

Retrieval of fewer than 12 lymph nodes in surgical specimen of rectal cancer who had received neo-adjuvant radiotherapy with or without chemotherapy should be considered as a good indicator of tumor response with better local disease control, and a good prognostic factor, rather than as a pointer of poor diligence of the surgical and pathological assessment.

Positive Lymph Node Ratio as an Indicator of Prognosis and Local Tumor Clearance in N3 Gastric Cancer

BACKGROUND

Nodal metastasis is an important clinical issue in gastric cancer patients. This study was designed to investigate the clinical usefulness of the positive lymph node ratio (PLNR), which reflects both metastatic and retrieved lymph node numbers, in patients with pN3 gastric cancer.

METHODS

We retrospectively analyzed the records of 138 consecutive pN3 patients who underwent curative gastrectomy with lymphadenectomy from 2000 to 2012.

RESULTS

A PLNR of 0.4 was proved to be the best cutoff value to stratify the prognosis of patients with pN3 gastric cancer (P < 0.001). Univariate and multivariate analyses revealed that older age, larger tumor size (≥10 cm), and PLNR ≥ 0.4 [P < 0.001, HR 3.1 (95 % CI 1.7-5.4)] were independent prognostic factors in pN3 gastric cancer. Regarding the recurrence, patients with PLNR <0.4 had a significantly lower rate of lymph node recurrence than those with PLNR ≥0.4 (P = 0.020). There was no significant difference in the lymph node recurrence rate between N3a and N3b patients in the PLNR <0.4 group [P = 0.546, 11.6 % (7/60) vs. 12.5 (1/8)], indicating a better local control regardless of pN3 subgroups.

CONCLUSIONS

PLNR is useful to stratify the prognosis and evaluate the extent of local tumor clearance in pN3 gastric cancer.

Evaluation of prognostic value and stage migration effect using positive lymph node ratio in gastric cancer

AIMS

To detect the best cut-off value of the positive lymph node ratio (PLNR) for stratifying the prognosis and analyzing its value with regard to stage migration effect using PLNR in gastric cancer.

METHODS

We retrospectively analyzed 1069 consecutive gastric cancer patients, who underwent curative gastrectomy with radical lymphadenectomy from 1997 through 2009.

RESULTS

1) The mean number of dissected lymph nodes was 42.6 in pStage I, 32.4 in pStage II and 37.1 in pStage III. The PLNR of 0.2 was proved to be the best cut-off value to stratify the prognosis of patients into two groups (P < 0.0001; PLNR <0.2 vs. PLNR ≥0.2), and patients were correctly classified into four groups: PLNR 0, PLNR 0-<0.2, PLNR 0.2-<0.4 and PLNR ≥0.4 by the Kaplan-Meier method. 2) Compared patients with the PLNR <0.2, those with the PLNR ≥0.2 had a significantly higher incidence of pT3 or greater, pN2 or greater, lymphatic invasion, vascular invasion and undifferentiated cancer. Multivariate analysis showed that the PLNR ≥0.2 was an independent prognostic factor [P < 0.0001, HR 2.77 (95% CI: 1.87-4.09)]. 2) The PLNR cut-off value of 0.2 could discriminate a stage migration effect in pN2-N3 and pStage II-III, which patients with PLNR ≥0.2 might be potentially diagnosed as a lower stage after gastrectomy.

CONCLUSION

The PLNR contributes to evaluating prognosis and stage migration effect even in a single institute and enable to identify those who need meticulous treatments and follow-up in patients with gastric cancer.

Prognostic value of three different lymph node staging systems in the survival of patients with gastric cancer following D2 lymphadenectomy

The log odds of positive lymph nodes (LODDS) was defined as the log of the ratio between the number of positive lymph nodes and the number of negative lymph nodes, which is a novel and promising nodal staging system for gastric cancer. Here, we aimed to compare the prognostic effect of pN, lymph node ratio (LNR) and LODDS. The association between overall survival and pN, LNR and LODDS was retrospectively analysed. The discriminatory ability and monotonicity of gradients (linear trend χ (2) score), homogeneity ability (likelihood ratio test) and prognostic stratification ability (Akaike information criterion [AIC] and receiver operating characteristic [ROC] curve) were compared among three lymph node staging systems. The pN, LNR and LODDS were all identified as independent prognostic factors for gastric cancer patients in the multivariate analysis. LODDS showed the best prognostic performance (linear trend χ (2) score 266.743, likelihood ratio χ (2) test score 427.771, AIC value 5670.226, area under the curve (AUC) 0.793), followed by LNR and pN. In patients with different levels of retrieved lymph nodes (≤10, 11-14, 15-25 and >25), LODDS was the most powerful for prognostic prediction and discrimination of the heterogeneity among the subgroups. Significant differences in survival were observed among patients in different LODDS subgroups after being classified according to the pN and LNR classifications. LODDS appears to be a more powerful system for predicting the overall survival of gastric cancer patients, as compared to LNR and pN, and may serve as an alternative nodal staging system for gastric cancer.

Staging for Remnant Gastric Cancer: The Metastatic Lymph Node Ratio vs. the UICC 7th Edition System

BACKGROUND

Unlike primary gastric cancer, a remnant gastric cancer (RGC) staging system has not been established. The retrieved lymph node counts (RLN) in RGC is generally lower than that in primary gastric cancer, so it is unclear whether positive lymph node count reflects the RGC patient's survival. Therefore, the lymph node ratio (LR) may be more useful for RGC staging than the 7th edition UICC classification.

METHODS

Patients (n = 191) who underwent gastrectomy with curative intent for RGC participated in this study. LR was classified as LR = 0, 0 < LR ≤ 0.1, 0.1 < LR ≤ 0.4, and 0.4 < LR. Modified TNM staging (mTNM-LR) was established by combining the pT (7th UICC) with LR. The predictive accuracy of LR and mTNM-LR was compared with that of the pN (7th UICC) and TNM (7th UICC), respectively.

RESULTS

The mean RLN was 14.4 and that of 128 patients (67 %) was ≤15. Fifty-one patients (27 %) had metastatic lymph nodes. Multivariable analyses revealed that pT (7th UICC) (p < 0.001) and pN (7th UICC) (p = 0.001), but not LR, were independent risk factors for overall survival. The overall c-index (95 % confidence interval) of each staging system was as follows: pN (7th UICC): 0.700 (0.627-0.771); LR: 0.701 (0.627-0.775), TNM (7th UICC): 0.808 (0.761-0.870); mTNM-LR: 0.807 (0.737-0.871). There were no significant differences in the predictive accuracy between pN (7th UICC) and LR, and TNM (7th UICC) and mTNM-LR.

CONCLUSIONS

LR was not superior to pN (7th UICC). Thus, the 7th edition UICC classification is a practical and reliable staging system for RGC.