Can lymph node ratio replace pn categories in the tumor-node-metastasis classification system for esophageal cancer? J Thorac Oncol. 2014; 9:1214-1221. [PMID: 25157776 DOI: 10.1097/jto.0000000000000216]

Accurate location describe and management of lymph node recurrence after esophagectomy for thoracic esophageal squamous cell carcinoma: a retrospective cohort study

BACKGROUND

Describe the accurate locations of lymph node recurrence (LNR) of Chinese patients with postoperative thoracic esophageal squamous cell carcinoma (ESCC) is essential for determining the need for further surveillance protocols and treatments. The authors aimed to evaluate the patterns of postoperative ESCC and its current risk stratification with LNR.

METHODS

This population-based cohort study included a retrospective review of the medical records and image material of patients with ESCC who underwent LNR after radical surgery between January 2013 and September 2022, with a median follow-up time of 5.71 years. Clinical features were extracted from these records, and survival analysis was performed. The primary endpoint was the accurate location and range of LNR according to the nomenclature of the Japanese Society for Esophageal Diseases. The second endpoints was to explore the related factors of recurrence range and overall survival.

RESULTS

A total of 3268 lymph node regions were recurrence from 1129 patients, with a mean of 2.89 regions per patient. No.104, 106, and 107 was the most common recurrence of thoracic ESCC with an LNR rate higher than 15%. In upper thoracic ESCC, No.105 was a common recurrence site and abdominal LNR was rare. In lower thoracic ESCC, retroperitoneal lymph node was a unique regions (15.4%). Anastomotic recurrence is an important recurrence pattern in patients with postoperative esophageal cancer, with an incidence of 24.5%. Rates of LNR in range of lymph node dissection was low (13.9%). The median time of LRT was 20.0 (1.5-184.0) months. High range of recurrence was associated with significantly poorer OS in patients. Multiple linear regression analysis identified demonstrated N stage, tumor differentiation, adjuvant radiotherapy, and total lymph nodes removed were association with recurrence range for patients.

CONCLUSIONS

Supraclavicular and upper mediastinums lymph nodes were common recurrence site for ESCC patients, and careful initial staging and surveillance are needed. Thorough lymph node dissection may reduce the range of regional recurrence.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

An optimized postsurgery follow-up strategy for patients with esophageal cancer: a cohort study

BACKGROUND

After radical surgery, patients with esophageal cancer should undergo long-term surveillance of disease relapse. However, the optimal follow-up strategy remains to be explored.

METHOD

A total of 4688 patients were recruited. Recursive partition analysis was applied to develop recurrence risk stratification for patients. The follow-up strategies of each stratification were developed based on monthly recurrence probability and validated by bootstrap validation and an external dataset. A Markov decision-analytic model was constructed to evaluate the cost-effectiveness of the follow-up strategies.

RESULTS

Patients were stratified into four groups according to four pathological features. The authors applied a random survival forest to calculate the monthly recurrence probability of each group. Based on the temporal distribution of recurrences, the authors further established surveillance strategies for four groups. The strategies were validated as optimal protocols by bootstrap resampling and another dataset. Markov cost-effective analysis indicated that our recommended strategies outperformed the mainstream protocols from guidelines. Using less than 12 visits across the first 5 years on average, our follow-up strategies were more efficient than the NCCN recommended strategies (14 visits average). Our results also supported the computerized tomography from the neck to the upper abdomen as a routine examination and PETCT of distant metastasis for some groups with high risks.

CONCLUSION

Our study provided data-driven evidence of personalized and economic follow-up strategies for esophageal cancer patients and shed light on follow-up optimization for other cancer types.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

GNB1 promotes hepatocellular carcinoma progression by targeting BAG2 to activate P38/MAPK signaling

G-proteins are intracellular partners of G-protein-coupled receptors. As a member of the G-protein family, GNB1 has been shown to play a pro-cancer role in lung cancer and breast cancer. However, the biological function and detailed mechanisms of GNB1 in hepatocellular carcinoma progression are unclear. In this study, we investigated the effects of GNB1 and its possible mechanism of action in hepatocellular carcinoma (HCC). The clinical significance of GNB1 was evaluated in a large cohort of HCC patients, showing that GNB1 was overexpressed in HCC compared to adjacent normal liver tissues, and increased GNB1 expression was associated with poor prognosis. We also demonstrated that GNB1 enhances cell proliferation, colony formation, and cell migration and invasion in vitro and promotes the epithelial-to-mesenchymal transition process in HCC cells. Tumor xenograft model assay confirmed the oncogenic role of GNB1 in tumorigenicity in nude mice. Activation of P38 signaling was found in the GNB1 overexpressed HCC cells. Further intervention of P38 confirmed it as an important signaling pathway for the oncogenic role of GNB1 in HCC. Moreover, co-immunoprecipitation followed by liquid chromatograph-mass spectrometry identified that GNB1 exerted oncogenic functions via the interaction of BAG2 and activated P38 signaling pathway. Together, our results reveal that GNB1 plays a pivotal oncogenic role in HCC by promoting the P38 pathway via cooperating with BAG2. GNB1 may serve as a prognostic biomarker for patients with HCC.

Characterization of the Immune Infiltration Landscape and Identification of Prognostic Biomarkers for Esophageal Cancer

Immunotherapy is an effective treatment for esophageal cancer (ESCA) patients. However, there are no dependable markers for predicting prognosis and immunotherapy responses in ESCA. Our study aims to explore immune gene prognostic models and markers in ESCA as well as predictors for immunotherapy. The expression profiles of ESCA were obtained from The Cancer Genome Atlas (TCGA), the Gene Expression Omnibus (GEO), and International Cancer Genome Consortium (ICGC) databases. Cox regression analysis was performed to construct an immune gene prognostic model. ESCA was grouped into three immune cell infiltration (ICI) clusters by CIBERSORT algorithm. The immunotherapy response of patients in different ICI score clusters was also compared. The copy number variations, somatic mutations, and single nucleotide polymorphisms were analyzed. Enrichment analyses were also performed. An immune gene prognostic model was successfully constructed. The ICI score may be used as a predictor independent of tumor mutation burden. Enrichment analyses showed that the differentially expressed genes were mostly enriched in microvillus and the KRAS and IL6/JAK/STAT3 pathways. The top eight genes with the highest mutation frequencies in ESCA were identified and all related to the prognosis of ESCA patients. Our study established an effective immune gene prognostic model and identified markers for predicting the prognosis and immunotherapy response of ESCA patients.

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

Background

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

Methods

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

Results

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

Conclusion

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

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The Least Nodal Disease Burden Defines the Minimum Number of Nodes Retrieved for Esophageal Squamous Cell Carcinoma

Background

Clinically, a single positive lymph node (SPLN) should indicate the least nodal disease burden in node-positive patients with esophageal squamous cell carcinoma (ESCC) and may also be used to define the minimum number of examined lymph nodes (NELNs) in ESCC patients.

Methods

Data from three Chinese cohorts of 2448 ESCC patients who underwent esophagectomy between 2008 and 2012 were retrospectively analyzed. Based on lymph node status, patients were divided into two groups: N0 ESCC and SPLN ESCC. A Cox proportional hazards regression model was used to determine the minimum NELNs retrieved to maximize survival for ESCC patients with localized lymph node involvement. The results were then validated externally in the SEER database.

Results

A total of 1866 patients were pathologically diagnosed with N0 ESCC, and 582 patients were diagnosed with SPLN ESCC. The overall survival rate of patients with N0 ESCC was significantly better than that of patients with SPLN ESCC (HR 1.88, 95% CI 1.64-2.13, P<0.001), but no significant difference was found between SPLN ESCC patients with ≥ 20 lymph nodes harvested and N0 ESCC patients (HR 1.20, 95% CI 0.95-1.52, P=0.13). Analysis of patients selected from the SEER database showed the same trend, and no significant difference was observed between N0 ESCC patients and SPLN ESCC patients with ≥ 20 lymph nodes retrieved (HR: 1.02, 95% CI 0.72-1.43, P=0.92).

Conclusions

A minimum of 20 lymph nodes retrieved should be introduced as a quality indicator for ESCC patients with localized lymph node involvement.

The Relationship Between Lymph Node Ratio and Survival Benefit With Adjuvant Chemotherapy in Node-positive Esophageal Adenocarcinoma

BACKGROUND

We hypothesized that the ratio of positive lymph nodes to total assessed lymph nodes (LNR) is an indicator of cancer burden in esophageal adenocarcinoma and may identify patients who may most benefit from AC.

OBJECTIVE

The aim of this study was to discern whether there is a threshold LNR above which AC is associated with a survival benefit in this population.

METHODS

The 2004-2015 National Cancer Database was queried for patients who underwent upfront, complete resection of pT1-4N1-3M0 esophageal adenocarcinoma. The primary outcome, overall survival, was examined using multivariable Cox proportional hazards models employing an interaction term between LNR and AC.

RESULTS

A total of 1733 patients were included: 811 (47%) did not receive AC whereas 922 (53%) did. The median LNR was 20% (interquartile range 9-40). In a multivariable Cox model, the interaction term between LNR and receipt of AC was significant (P = 0.01). A plot of the interaction demonstrated that AC was associated with improved survival beyond a LNR of about 10%-12%. In a sensitivity analysis, the receipt of AC was not associated with improved survival in patients with LNR <12% (hazard ratio 1.02; 95% confidence interval 0.72-1.44) but was associated with improved survival in those with LNR ≥12% (hazard ratio 0.65; 95% confidence interval 0.50-0.79).

CONCLUSIONS

In this study of patients with upfront, complete resection of node-positive esophageal adenocarcinoma, AC was associated with improved survival for LNR ≥12%. LNR may be used as an adjunct in multidisciplinary decision-making about adjuvant therapies in this patient population.

Lymph Node Ratio Is an Independent Prognostic Factor for Patients with Siewert Type II Adenocarcinoma of Esophagogastric Junction: Results from a 10-Year Follow-up Study

PURPOSE

Emerging evidences suggest that lymph node ratio (LNR), the number of metastatic lymph node (LN) to the total number of dissected lymph nodes (NDLN), may predict survival in multiple types of solid tumor. However, the prognostic role of LNR in adenocarcinoma of the esophagogastric junction (AEG) remains uninvestigated. The present study is intended to determine the prognostic value of LNR in the patients with Siewert type II AEG.

METHODS

A total of 342 patients with Siewert type II AEG who underwent R0 resection were enrolled in this study. The optimal cutoff of LNR was stratified into tertiles using X-tile software. The log-rank test was used to evaluate the survival differences, and multivariate Cox regression analyses were performed to determine the independent prognostic variables.

RESULTS

The optimal cutoff of LNR were classified as LNR = 0, LNR between 0.01 and 0.40, and LNR > 0.41. Patients with high LNR had a shorter 5- and 10-year disease-specific survival (DSS) rate (8.5%, 1.4%) compared with those with moderate LNR (20.4%, 4.9%) and low LNR (58.0%, 27.5%) (P < 0.001). Multivariate Cox regression analysis indicated that LNR was an independent factor for DSS after adjusting for confounding variables (P < 0.05). Furthermore, after stratification by NDLN between NDLN < 15 group and NDLN ≥ 15 group, the LNR remained a significant predictor for DSS (P < 0.05).

CONCLUSIONS

LNR is an independent predictor for DSS in patients with Siewert type II AEG regardless of NDLN. Patients with higher LNR have significantly shorter DSS.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prognostic value of the extent of lymphadenectomy for esophageal cancer-specific survival among T1 patients

Background

Clinically, there are no clear guidelines on the extent of lymphadenectomy in patients with T1 esophageal cancer. Studying the minimum number of lymph nodes for resection may increase cancer-specific survival.

Methods

Patients who underwent esophagectomy and lymphadenectomy at T1 stage were selected from the Surveillance, Epidemiology and End Results Program (United States, 1998–2014). Maximally selected rank and Cox proportional hazard models were used to examine three variables: the number of lymph nodes examined, the number of negative lymph nodes and the lymph node ratio.

Results

Approximately 18% had lymph node metastases, where the median values were 10, 10 and 0 for the number of lymph nodes examined, the number of negative lymph nodes and the lymph node ratio, respectively. All three examined variables were statistically associated with cancer-specific survival probability. Dividing patients into two groups shows a clear difference in cancer-specific survival compared to four or five groups for all three variables: there was a 29% decrease in the risk of death with the number of lymph nodes examined ≥14 vs < 14 (hazard ratio 0.71, 95% confidence interval: 0.57–0.89), a 35% decrease in the risk of death with the number of negative lymph nodes ≥13 vs < 13 (hazard ratio 0.65, 95% confidence interval: 0.52–0.81), and an increase of 1.21 times in the risk of death (hazard ratio 2.21, 95% confidence interval: 1.76–2.77) for the lymph node ratio > 0.05 vs ≤ 0.05.

Conclusions

The extent of lymph node dissection is associated with cancer-specific survival, and the minimum number of lymph nodes that need to be removed is 14. The number of negative lymph nodes and the lymph node ratio also have prognostic value after lymphadenectomy among T1 stage patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Prognostic Value of Log Odds of Positive Lymph Nodes in Early-Stage Esophageal Cancer Patients: A Study Based on the SEER Database and a Chinese Cohort

Objective

Early detection and timely treatment are important for improving the prognosis of esophageal cancer (EC). Identification of the prognostic risk factors could help us to discern the high-risk population. This study was aimed at exploring the prognostic significance of log odds of positive lymph nodes (LODDS) in early-stage EC patients.

Methods

Patients who underwent esophagectomy and diagnosed as pathologic T1-2 N0 EC were reviewed between January 2005 and December 2015 from the Surveillance, Epidemiology, and End Results (SEER) database (the development cohort, n = 1004). The X-tile software was used to determine the optimal cutoff values of LODDS. A separate Chinese cohort including 245 patients (the validation cohort) was used to externally validate the results of the SEER database.

Result

Patients were divided into two groups based on the cutoff points of LODDS: <-1.40 (LODDS1) and ≥-1.40 (LODDS2). In the development cohort, the 5-year overall survival (OS) rate was 75.3% for patients in the LODDS1 group, compared with 67.5% for those in the LODDS2 group (P=0.002). In multivariate Cox analysis, LODDS was associated with OS significantly (hazard ratio (HR), 1.48; 95% confidence intervals (CI), 1.19-1.85). In the validation cohort, the 5-year OS rate was 76.6% for patients in the LODDS1 group, compared with 64.4% for those in the LODDS2 group (P=0.006). The HR value in multivariate Cox analysis for OS was 2.00 (95% CI, 1.26-3.18).

Conclusion

LODDS was an important independent factor for survival in early-stage EC patients.

Log odds of positive lymph nodes is a better prognostic factor for oesophageal signet ring cell carcinoma than N stage

BACKGROUND

Signet ring cell carcinoma is a rare type of oesophageal cancer, and we hypothesized that log odds of positive lymph nodes (LODDS) is a better prognostic factor for oesophageal signet ring cell carcinoma.

AIM

To explore a novel prognostic factor for oesophageal signet ring cell carcinoma by comparing two lymph node-related prognostic factors, log odds of positive LODDS and N stage.

METHODS

A total of 259 cases of oesophageal signet ring cell carcinoma after oesopha-gectomy were obtained from the Surveillance, Epidemiology, and End Results database between 2006 and 2016. The prognostic value of LODDS and N stage for oesophageal signet ring cell carcinoma was evaluated by univariate and multivariate analyses. The Akaike information criterion and Harrell’s C-index were used to assess the value of two prediction models based on lymph nodes. External validation was performed to further confirm the conclusion.

RESULTS

The 5-year cancer-specific survival (CSS) and 5-year overall survival (OS) rates of all the cases were 41.3% and 27.0%, respectively. The Kaplan-Meier method showed that LODDS had a higher score of log rank chi-squared (OS: 46.162, CSS: 41.178) than N stage (OS: 36.215, CSS: 31.583). Univariate analyses showed that insurance, race, T stage, M stage, TNM stage, radiation therapy, N stage, and LODDS were potential prognostic factors for OS (P < 0.1). The multivariate Cox regression model showed that LODDS was an significant independent prognostic factor for oesophageal signet ring carcinoma patients after surgical resection (P < 0.05), while N stage was not considered to be a significant prognostic factor (P = 0.122). Model 2 (LODDS) had a higher degree of discrimination and fit than Model 1 (N stage) (LODDS vs N stage, Harell’s C-index 0.673 vs 0.656, P < 0.001; Akaike information criterion 1688.824 vs 1697.519, P < 0.001). The results of external validation were consistent with those in the study cohort.

CONCLUSION

LODDS is a superior prognostic factor to N stage for patients with oesophageal signet ring cell carcinoma after oesophagectomy.

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

Background

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

Method

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

Results

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

Conclusion

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

Delayed postoperative radiotherapy might improve the long-term prognosis of locally advanced esophageal squamous cell carcinoma

•

Postoperative radiotherapy timing for esophageal cancer remains to be determined.

•

Delayed postoperative radiotherapy (>48 days) provides better survival benefit.

•

Postoperative radiotherapy following 2–4 chemotherapy cycles achieved best survival.

Objective

There is no consensus on the optimal timing of postoperative radiotherapy (PORT) for locally advanced esophageal squamous cell carcinoma (ESCC). We aimed to determine whether the timing of PORT affects the long-term prognosis of ESCC, and plotted nomograms to predict survival.

Methods

We retrospectively analyzed 351 ESCC patients who underwent radical surgery and PORT. Receiver operating characteristic curves were used to estimate the optimal cutoff point of the time interval between surgery and PORT. Cox proportional hazards regression was used to identify prognostic predictors. Overall survival (OS) and progression-free survival (PFS) were predicted using nomograms.

Results

The median follow-up was 53 months (range: 3–179 months). Compared to early PORT, PORT at >48 days after surgery was associated with better OS (adjusted hazard ratio [HR]: 1.406, p = 0.037) and PFS (adjusted HR: 1.475, p = 0.018). In the chemotherapy subgroup, incorporation of chemotherapy timing into the analysis suggested that 2–4 chemotherapy cycles followed by PORT was the optimal treatment schedule as compared to 0–1 chemotherapy cycle followed by PORT and concurrent chemoradiotherapy (5-year PFS: 65.9% vs. 51.0% vs. 50.1%; p = 0.049). The nomograms for OS and PFS were superior to the TNM classification (concordance indices: 0.721 vs. 0.626 and 0.716 vs. 0.610, respectively).

Conclusions

Delayed PORT (>48 days) provides better survival benefit than early PORT among ESCC patients. PORT following 2–4 chemotherapy cycles might lead to the best survival rate. The nomogram plotted in this study effectively predicted survival and may help guide treatment.

Prognostic impact of lymph node ratio in patients with pT1-2N1M0 non-small cell lung cancer

Background

This study evaluated the lymph node ratio (LNR) defined as the ratio of the number of metastatic lymph nodes to the number of dissected lymph nodes as a prognostic factor for survival in patients with pT1–2N1M0 non-small cell lung cancer (NSCLC).

Methods

We retrospectively reviewed 413 patients with pathologic T1–2N1M0 NSCLC after complete surgical resection and mediastinal LN dissection between January 2004 and December 2012. The cut-off value for LNR was determined using χ² tests, which were calculated using Cox proportional hazards regression model. Based on this model, the optimal cut-off value for LNR was 0.1.

Results

The study included 337 males and 76 females with a mean age of 62 years (range, 34–83 years). Patients with a high LNR (≥0.1) were more likely to be female and have more adenocarcinomas compared with patients with a low LNR (<0.1). The overall survival (OS) and disease-free survival (DFS) rates were significantly worse in the high LNR group than the low LNR group (OS, 55.4% vs. 69.8%, respectively P=0.003; DFS, 33.2% vs. 61.7%, P<0.001). In the multivariate analysis, a high LNR was associated with significantly worse OS [adjusted hazard ratio (aHR), 2.69; 95% confidence interval (CI), 1.74–4.17] and DFS (aHR, 2.41; 95% CI, 1.57–3.68).

Conclusions

LNR is an independent prognostic factor for survival in patients with pT1–2N1M0 NSCLC. These findings may provide useful prognostic information to allow the selection of patients for more aggressive postoperative therapy or follow-up strategies.

Impact of Examined Lymph Node Count for Esophageal Squamous Cell Carcinoma in Patients who Underwent Right Transthoracic Esophagectomy

BACKGROUND

The impact of the number of examined lymph nodes (ELNs) on stage correction and prognostication in patients with esophageal squamous cell carcinoma (ESCC) who underwent right transthoracic esophagectomy is still unclear.

METHODS

Patients with ESCC who underwent right transthoracic esophagectomy at Sun Yat-sen University Cancer Center between January 1997 and December 2013 were retrospectively enrolled. The Cox proportional hazards regression model was used to determine the effect of ELN count on overall survival. The impact of ELN count on stage correction was evaluated using the hypergeometric distribution and Bayes theorem and β-binomial distribution estimation, respectively. The threshold of ELNs was determined using the LOWESS smoother and piecewise linear regression.

RESULTS

Among the 875 included patients, greater ELNs were associated with a higher rate of nodal metastasis. Significant association between staging bias and the number of ELNs is only observed through the Bayes method. The ELN count did not impact 90-day mortality but significantly impacted long-term survival (adjusted hazard ratio [aHR] 0.986), especially in those patients with node-negative disease (aHR 0.972). In patients with node-negative disease, cut-point analysis showed a threshold ELN count of 21.

CONCLUSIONS

A greater number of ELNs is associated with more accurate node staging and better long-term survival in resected ESCC patients. We recommended harvesting at least 21 LNs to acquire accurate staging and long-term survival information for patients with declared node-negative disease using the right thoracic approach.

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.

Surgical Outcomes After Neoadjuvant Chemoradiation Followed by Curative Surgery in Patients With Esophageal Cancer: An Intergroup Phase lll Trial of the Swiss Group for Clinical Cancer Research (SAKK 75/08)

OBJECTIVE

To assess the impact of surgical technique in regard to morbidity and mortality after neoadjuvant treatment for esophageal cancer.

BACKGROUND

The SAKK trial 75/08 was a multicenter phase III trial (NCT01107639) comparing induction chemotherapy followed by chemoradiation and surgery in patients with locally advanced esophageal cancer.

METHODS

Patients in the control arm received induction chemotherapy with cisplatin and docetaxel, followed by concomitant chemoradiation therapy with cisplatin, docetaxel, and 45Gy. In the experimental arm, the same regimen was used with addition of cetuximab. After completion of neoadjuvant treatment, patients underwent esophagectomy. The experimental arm received adjuvant cetuximab. Surgical outcomes and complications were prospectively recorded and analyzed.

RESULTS

Total of 259 patients underwent esophagectomy. Overall complication rate was 56% and reoperation rate was 15% with no difference in complication rates for transthoracic versus transhiatal resections (56% vs 54%, P = 0.77), nor for video assisted thoracic surgeries (VATS) versus open transthoracic resections (67% vs 55%, P = 0.32). There was a trend to higher overall complication rates in squamous cell carcinoma versus adenocarcinoma (65% vs 51%, P = 0.035), and a significant difference in ARDS in squamous cell carcinoma with 14% versus 2% in adenocarcinoma (P = 0.0002). For patients with involved lymph nodes, a lymph node ratio of ≥0.1 was an independent predictor of PFS (HR 2.5, P = 0.01) and OS (HR 2.2, P = 0.03).

CONCLUSIONS

This trial showed no difference in surgical complication rates between transthoracic and transhiatal resections. For patients with involved lymph nodes, lymph node ratio was an independent predictor of progression free survival and overall survival.

Evaluating the eighth edition TNM staging system for esophageal cancer among patients receiving neoadjuvant therapy: A SEER study

BACKGROUND

The evaluation of the eighth edition of ypTNM staging system for patients with esophageal cancer was limited in the setting of neoadjuvant therapy.

METHODS

A total of 2324 patients with esophageal cancer receiving radio(chemo)therapy prior to surgery from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2013 were eligible for the analysis. Kaplan-Meier method and Cox proportional hazards models were used to estimate overall survivals.

RESULTS

Among patients with preoperative therapy, both the seventh edition TNM grouping and the eighth edition ypTNM grouping could significantly stratify the overall survival (both log-rank P < .001). There was not significant difference in the C-index of the seventh edition TNM grouping (0.575; 95%CI, 0.558-0.593) and the eighth edition ypTNM grouping (0.569; 95%CI, 0.551-0.587) (P = .098). In multivariable Cox analysis, ypN category was the strongest predictor of overall survival (P < .001), followed by tumor grade (HR, 1.33; 95%CI, 1.12-1.56; P = .001). The combination of ypT, ypN, and ypG categories yielded significantly higher C-index (0.591; 95%CI, 0.573-0.609) than that of the seventh edition TNM staging (P = .024).

CONCLUSION

Tumor grade remained an independent predictor of overall survival in the setting of neoadjuvant therapy, and could improve the performance of ypTNM staging system.

LTBP1 promotes esophageal squamous cell carcinoma progression through epithelial-mesenchymal transition and cancer-associated fibroblasts transformation

BACKGROUND

Esophageal squamous cell carcinoma (ESCC) is one of the most prevalent cancers worldwide. Due to its high morbidity and mortality rates, it is urgent to find a molecular target that contributes to esophageal carcinogenesis and progression. In this research, we aimed to investigate the functions of Latent transforming growth factor β binding protein 1(LTBP1) in ESCC progression and elucidate the underlying mechanisms.

METHODS

The tandem mass tag-based quantitative proteomic approach was applied to screen the differentially expressed proteins (DEPs) between 3 cases of ESCC tumor samples and paired normal tissues. Then the DEPs were validated in human ESCC tissues using western blot assays and GEPIA database respectively. The expression level of LTBP1 was detected in 152 cases of ESCC tissues and paired normal tissues. Loss-of-function assays were performed to detect the function of LTBP1 in vivo and in vitro. Immunofluorescence and Western blot assays were used to detect the expression of apoptosis, epithelial-mesenchymal transition (EMT) and cancer-associated fibroblasts (CAFs) markers.

RESULTS

A total of 39 proteins were screened to be up-regulated (ratio > 2.0) in all three ESCC tissues. The results of immunohistochemistry assays indicated that the expression level of LTBP1 was higher in ESCC tissues than that in paired normal tissues (p < 0.001). Overexpression of LTBP1 was positively associated with lymphatic metastasis in ESCC (p = 0.002). Down-regulation of LTBP1 inhibited the invasion and migration as well as metastatic abilities in vitro and in vivo. It was also observed the down-regulation of LTBP1 not only decreased the mesenchymal phenotypes but also inhibited TGFβ-induced EMT in ESCC cells. We further found that down-regulation of LTBP1 enhanced ESCC cells' sensitivity to 5-FU treatment. Inhibition of LTBP1 expression could also attenuate induction of CAFs transformation and restrain fibroblast express fibronectin (FN1) in ESCC cells.

CONCLUSION

Overexpression of LTBP1 was associated with lymph node metastasis in ESCC. Our results indicated that LTBP1 not only increased the malignant behaviors of ESCC cells but also induced EMT and CAFs transformation. Our studies suggested an oncogenic role of LTBP1 in ESCC progression and it may serve as a potential therapeutic target for ESCC patients.

Log odds of positive lymph nodes predicts survival in patients treated with neoadjuvant therapy followed by esophagectomy

BACKGROUND AND OBJECTIVES

We aimed to evaluate the efficacy of the log odds of positive lymph nodes (LODDS) in survival prediction of patients with esophageal carcinoma receiving neoadjuvant therapy, compared with N descriptor and positive lymph node ratio (LNR).

METHODS

Patients with esophageal carcinoma receiving neoadjuvant therapy from 2004 to 2015 were reviewed in Surveillance, Epidemiology, and End Results database. The receiver operating characteristics curve and area under the curve (AUC) were used to compare discriminatory power among N descriptor, LNR, and LODDS. The goodness of fit was measured using the -2 log-likelihood ratio (-2LLR).

RESULTS

About 2239 patients with a 22 months median follow-up and a 37.8% 5-year overall survival rate were included. LODDS had the best discriminatory power and goodness of fit (LODDS vs N descriptor, AUC 0.666 vs 0.626, -2LLR 15 680.402 vs 15 746.162; LODDS vs LNR, AUC 0.666 vs 0.635, -2LLR 15 680.402 vs 15 712.379; all P < .001). LODDS was the best for fewer than 15 lymph nodes retrieved (LODDS vs N descriptor, AUC 0.652 vs 0.618, P < .001; LODDS vs LNR, AUC 0.652 vs 0.625, P = .005). The prognosis of patients without metastatic nodes could be discriminated by LODDS.

CONCLUSIONS

LODDS could better predict survival of patients with esophageal carcinoma receiving neoadjuvant therapy.

Low psoas muscle index associates with long-term mortality in cirrhosis: construction of a nomogram

Background

To develop a nomogram incorporating indicator of muscle waste to prognosticate long-term mortality in liver cirrhosis (LC), and identify the prognostic impact of psoas muscle index (PMI).

Methods

A total of 251 LC patients who underwent computed tomography were included in this study. Multiple Cox regression was performed, and sex-specific nomogram models incorporating PMI were developed. The utility of the proposed models were evaluated by Harrell’s concordance index (C-index), calibration curve and decision curve analysis. X-tile was used to determine optimal cutpoint for stratifying subjects with distinct outcomes. Subgroup analysis was implemented in terms of age and MELD score. The correlation between PMI and gait speed was also evaluated.

Results

On multiple analysis, independent predictors for 3-year all-cause mortality were age, BMI, PMI and MELD for males, and age, PMI and MELD for females. Both nomogram models gave rise to moderately strong discrimination, with a C-index of 0.792 (95% CI: 0.723–0.861) in males and 0.715 (95% CI: 0.637–0.793) in females, respectively. The calibration curve implied predicted survival corresponding optimally with the actual outcomes. The proposed models were feasible in clinical settings based on decision curve analysis. On subgroup analysis, PMI might confer valid predictive value on LC patients with MELD <15. Moreover, a definitely positive correlation between PMI and gait speed was revealed.

Conclusions

Our proposed nomogram embedding PMI rendered an individualized predictive tool for long-term mortality in LC. The diminishing value of PMI is likely indicative of muscle dysfunction.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

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

Prognostic nomogram based on log odds of positive lymph nodes for gastric carcinoma patients after surgical resection

Aim: To build a prognostic nomogram based on log odds of positive lymph nodes for patients with gastric carcinoma (GC) after resection, and to compare the predictive performance with the American Joint Committee on Cancer (AJCC) staging system and lymph node ratio (LNR). Methods: Multivariate analyses were performed to identify the independent variables for cancer-specific survival (CSS). A nomogram was constructed based on independent clinicopathological factors. Results: The C-indices for predicting CSS were 0.674 in development cohort and 0.647 in validation cohort, which were higher than that of the AJCC staging system and LNR. Conclusion: The nomogram was more accurate than the AJCC staging system and LNR for predicting CSS in patients undergoing resection for GC.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Lymph node ratio, an independent prognostic factor for patients with stage II-III rectal carcinoma

BACKGROUND

Identification of the proper surgical method and the most reliable prognostic parameters of rectal carcinomas is a challenging issue. The aim of this paper was to determine the possible prognostic role of the number of harvested lymph nodes versus lymph node ratio (LNR) in patients with rectal carcinomas, and the proper value of LNR that can be used as prognostic parameter.

MATERIALS AND METHODS

A retrospective study was performed in 186 consecutive patients with rectal carcinomas that underwent surgical resection. The LNR was calculated for cases from stage II-III, and was correlated with classic prognostic parameters and overall survival (OS).

RESULTS

A statistically significant difference was found between LNR of 0.15 and OS (p = 0.03), respectively LNR > 0.15 and TNM stage (p < 0.0001), but also tumor infiltration level (p < 0.05). The number of harvested lymph nodes was not correlated with the tumor stage (r = 0.148, p = 0.06) and this parameter did not influence the OS, when the number of 12 or 14 lymph nodes was used as the ideal value (p = 0.6 and p = 0.66, respectively).

CONCLUSION

In patients with rectal carcinomas that underwent preoperative chemoradiotherapy, a LNR of 0.15 is a parameter with independent prognostic value, comparing with the number of harvested lymph nodes. The specific LNR should be calculated in larger cohorts.

A Model Shows Utility in Predicting Postoperative Recurrence and Distant Metastasis in Curatively Resected Esophageal Squamous Cell Cancer

After curative treatment of esophageal squamous cell cancer (ESCC), patients are at high risk for recurrence. The objective of this study was to develop an index with a high sensitivity and specificity to predict ESCC patients’ recurrence and prognosis. A retrospective analysis was conducted on consecutive patients with EC who underwent esophagectomy. In total, 1417 patients were included in the current investigation. In total, 770 patients were included in the current study’s exploratory group. Alcohol consumption, TNM classification, number of lymph node station metastases, and number of lymph node metastases were significantly correlated with recurrence. Multivariate logistical regression analysis resulted in the development of an equation for predicting recurrence and prognosis (REEC). When using the REEC value to predict recurrence, the cutoff value was 1.095, the area under the curve (AUC) values of the REEC were 0.68 (p < 0.001) in the Exploratory Group and 0.65 (p < 0.001) in the Validation Group, and the sensitivity and specificity were 76.68% and 51.18%, respectively. When using the REEC value to predict prognosis, the cutoff value was 1.215, the AUC values of the REEC were 0.65 (p < 0.001) in the Exploratory Group and 0.64 (p < 0.001) in the Validation Group, and the sensitivity and specificity were 73.12% and 50.67%, respectively. In the Exploratory Group, when the REEC value was >1.095, patients had a longer median overall survival (OS) and median disease-free survival (DFS) than those whose REEC value was < 1.095 (70.01±2.01 months versus 50.92±2.85 months and 75.66±1.35 months versus 53.68±2.81 months, respectively, p < 0.001). The differences were confirmed to still exist in the Validation Group (48.12±1.47 vs 32.68±2.53 months and 55.61±1.32 vs 35.68±2.73 months respectively, p < 0.001).This study reported an index that can predict esophageal cancer recurrence and prognosis, and its use can benefit patients.

Comparison of different prognostic models for predicting cancer-specific survival in bladder transitional cell carcinoma

OBJECTIVE

To construct the newly valuable nomogram which can compare the predictive performance with American Joint Committee on Cancer (AJCC) staging system in bladder transitional cell carcinoma (BTCC).

METHODS

BTCC patients were screened (2004-2015) from the SEER database. The nomogram incorporating lymph node ratio was constructed to evaluate individualized cancer-specific survival.

RESULTS

The C-index of the nomogram for predicting cancer-specific survival was 0.743 (95% CI: 0.720-0.766), which was higher than C-index of the AJCC staging system.

CONCLUSION

Lymph node ratio can be a reliable prognostic indicator for BTCC. The proposed nomogram showed more satisfactory predictive accuracy and wider applicability than current AJCC staging system in individualized prediction of BTCC patients.

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.

Surgical evaluation of lymph nodes in esophageal adenocarcinoma: Standardized approach or personalized medicine?

The extent of lymphadenectomy for esophageal adenocarcinoma remains controversial. Outstanding issues include the appropriate technical approach such as transthoracic versus transhiatal, or open versus minimally invasive, both of which have implications on overall lymph node harvest numbers and morbidity. Recent data on the relationship of total number of lymph nodes harvested and oncologic survival have been conflicting, due in part to a likely differential impact of lymphadenectomy on survival based on tumor stage and response to neoadjuvant therapy. While standardizing the extent of lymphadenectomy may be desirable, a more useful approach might be to tailor lymphadenectomy considering the multidimensional impact of surgical technique and multimodal treatment strategy.

Lymph node ratio-based staging system as an alternative to the current TNM staging system to assess outcome in adenocarcinoma of the esophagogastric junction after surgical resection

This study aimed to assess the prognostic value of the hypothetical tumor-N-ratio (rN)-metastasis (TrNM) staging system in adenocarcinoma of the esophagogastric junction (AEG). The clinical data of 387 AEG patients who received surgical resection were retrospectively reviewed. The optimal cut-off point of rN was calculated by the best cut-off approach using log-rank test. Kaplan-Meier plots and Cox regressions model were applied for univariate and multivariate survival analyses. A TrNM staging system based on rN was proposed. The discriminating ability of each staging was evaluated by using an adjusted hazard ratio (HR) and a −2log likelihood. The prediction accuracy of the model was assessed by using the area under the curve (AUC) and the Harrell's C-index. The number of examined lymph nodes (LNs) was correlated with metastatic LNs (r = 0.322, P < 0.001) but not with rN (r = 0.098, P > 0.05). The optimal cut-points of rN were calculated as 0, 0~0.3, 0.3~0.6, and 0.6~1.0. Univariate analysis revealed that pN and rN classifications significantly influenced patients’ RFS and OS (P < 0.001). Multivariate analysis adjusted for significant factors revealed that rN was recognized as an independent risk factor. A larger HR, a smaller −2log likelihood and a larger prediction accuracy were obtained for rN and the modified TrNM staging system. Taken together, our study demonstrates that the proposed N-ratio-based TrNM staging system is more reliable than the TNM staging system in evaluating prognosis of AEG patients after curative resection.

A new classification of lymph node metastases according to the lymph node stations for predicting prognosis in surgical patients with esophageal squamous cell carcinoma

Lymph node metastasis (LNM) is one of the major prognostic factors for esophageal squamous cell carcinoma (ESCC). However there is no consensus regarding the prognostic significance of the location of LNM. Therefore, a novel classification was proposed to identify the lymph node (LN) stations which may be useful in predicting prognosis. A total of 260 ESCC patients were enrolled in this prospective study. The prognostic values of LNM in different lymph node (LN) stations were evaluated by random survival forests (RSF). Their prognostic significance was examined by Cox regression and receiver operating characteristic curve (ROC). The three most frequently involved LN stations were station 16 (24.49%), station 1 (22.22%) and station 2 (21.05%). Stations 1, 2, 8M, 8L and 16 were grouped as dominant LN stations (DLNS) which showed higher values in predicting overall survival (OS) and disease-free survival (DFS) than the remaining LN stations, which we define as non-dominant LN stations (N-DLNS). LNM features of DLNS (number of positive LN stations, number of positive LNs and LN ratio), but not those from N-DLNS, served as independent prognostic factors (P<0.05) whenever used alone or when combined with factors from N-DLNS. Furthermore, the area under ROC indicated that DLNS is a more accurate prediction than N-DLNS (P<0.05). This study demonstrated the value of LNM in DLNS in predicting prognosis in surgical ESCC patients, which outperformed those from N-DLNS. Therefore, the method of dominant and non-dominant classification may serve as an additional parameter to improve individualized therapeutic strategies.

The correlation between XIAP gene polymorphisms and esophageal squamous cell carcinoma susceptibility and prognosis in a Chinese population

OBJECTIVE

This study aims to explore the correlation between X-linked inhibitor of apoptosis protein (XIAP) gene polymorphisms (rs8371 and rs9856) with the susceptibility and prognosis of esophageal squamous cell carcinoma (ESCC), providing a potential treatment for ESCC.

METHOD

A total of 170 ESCC patients (case group) and 191 healthy people (control group) were enrolled in our study. Genotyping was conducted on the basis of the ligase detection reaction (LDR). The expressions of XIAP polymorphisms were detected. The patients were followed up every three months until death or the last follow-up day. The overall survival (OS) and progression free survival (PFS) were recorded by Kaplan-Meier survival curve, and the relationship between XIAP gene polymorphism and risk and prognosis of ESCC was assessed by Cox multivariate analysis.

RESULT

TT+CT genotype and T allele frequencies of XIAP rs8371 and rs9856 in the case group were significantly lower compared to those of the control group (all P<0.05), suggesting that TT+CT genotype of XIAP rs8371 and rs9856 was associated with ESCC susceptibility. XIAP rs8371 and rs9856 polymorphisms were associated with tumor node metastasis (TNM) staging, depth of invasion and lymph node metastasis. The OS and PFS of TT+CT genotype carriers of rs8371 were longer than those of CC genotype carriers. Smoking, alcohol, TNM staging, depth of invasion, and lymph node metastasis were significantly associated with the OS and PFS in ESCC patients. Higher TNM staging, depth of invasion, and presence of lymph node metastasis were independent risk factors, while XIAP rs8371 was an independent protective factor for the prognosis of ESCC patients.

CONCLUSION

The present study demonstrates that XIAP rs8371 and rs9856 are associated with susceptibility to ESCC, and rs8371 polymorphisms might serve as an indicator for improved clinical efficacy and prognosis of ESCC patients.

Metastatic to negative lymph node ratio demonstrates significant prognostic value in patients with esophageal squamous cell carcinoma after esophagectomy

Aims

The prognostic value of metastatic lymph node ratio (LNR) has been reported in some studies; however, there is no report on the prognostic significance of metastatic to negative lymph node ratio (MNLNR) in cancer patients. The aim of this study was to compare the prognostic value of pN, LNR and MNLNR on the survival of patients with esophageal squamous cell carcinoma (ESCC) after esophagectomy.

Methods

The data of 290 patients with ESCC after curative esophagectomy was retrospectively analyzed. The optimal cut-point for LNR and MNLNR were set as 0, 01-0.2, and >0.2. Univariate and multivariate analyses were performed to identify prognostic factors for overall survival (OS).

Results

Patients classified as LNR 0, 0.01-0.20, and 0.21-1.0, the observed 5-year OS rates were 46.6%, 26.0%, and 11.6%, respectively (P = 0.000). Patients classified as MNLNR 0, 0.01-0.20, and >0.2, the observed 5-year OS rates were 46.6%, 31.2%, and 7.4%, respectively, respectively (P = 0.000). The pN stage, LNR or MNLNR category was confirmed as a significant independent prognostic factor, respectively (P = 0.032, P = 0.011 and P = 0.003, respectively); However, only the MNLNR category (P = 0.003) remained as a significant prognostic factor when the pN stage, LNR and MNLNR category simultaneously included in the multivariate analysis models.

Conclusions

The MNLNR was recognized as an independent prognostic factor in ESCC patients after curative esophagectomy. In addition, MNLNR showed better prognostic value than pN stage and LNR category.

Comparative Quantitative Lymph Node Assessment in Localized Esophageal Cancer Patients After R0 Resection With and Without Neoadjuvant Chemoradiation Therapy

INTRODUCTION

The effects of neoadjuvant chemoradiation therapy on lymph node retrieval during esophagectomy for patients with esophageal cancer are unclear. The aim of this study was to quantify lymph node retrieval after R0 esophagectomy and to assess its impact on overall survival in induction therapy patients.

METHODS

One hundred seventy-four consecutive patients underwent esophagectomy with or without induction therapy from 2008 to 2015 for esophageal cancer. Total lymph nodes, positive lymph nodes, and lymph node ratios were compared between two groups of patients: those treated with either upfront surgery or those treated with neoadjuvant chemoradiation therapy followed by surgery. Comparisons were made using Student's t test. Overall survival was obtained and compared using Kaplan Meier survival curves.

RESULTS

Total lymph node counts were less in the induction therapy group (p = 0.027), while positive lymph node counts and lymph node ratios did not differ between groups (p = 0.262 and p = 0.310, respectively). In the neoadjuvant chemoradiation followed by surgery group, overall survival was significantly shorter for patients who had any positive lymph nodes in the pathologic specimen (p = 0.0065).

CONCLUSIONS

Total lymph node counts were significantly lower in the induction therapy group, while positive lymph node counts and lymph node ratios did not differ from the upfront surgery group. Although overall survival was not different between groups, it was decreased within the induction therapy cohort among those who had any positive lymph nodes retrieved at surgery. This study confirms that unstratified gross lymph node counts do not substantially relate to prognosis in the heterogeneous population of locally advanced esophageal cancer patients who may or may not have had neoadjuvant chemoradiation.

Prognostic performance of three lymph node staging schemes for patients with Siewert type II adenocarcinoma of esophagogastric junction

The prognostic performance of different lymph node staging schemes for adenocarcinoma of esophagogastric junction (AEG) remains controversial. The objective of the present study was to compare the prognostic efficacy of the number of lymph node metastases (LNMs), the positive lymph node ratio (LNR) and the log odds of positive lymph nodes (LODDS). Patients diagnosed with Siewert type II AEG were included from the Surveillance, Epidemiology, and End Results database. Harrell's C-index statistic, Schemper's proportion of explained variation (PEV), the Akaike information criterion (AIC) and restricted cubic spine analyses were adopted to assess the predictive accuracy of LNM, LNR and LODDS. A total of 1302 patients with post-surgery Siewert type II AEG were included. LNM, LNR and LODDS all showed significant prognostic value in the multivariate Cox regression analyses. LODDS performed higher predictive accuracy than LNM and LNR, with relatively higher C-index, higher Schemper's PEV value and lower AIC value. For patients with no nodes involved, LODDS still performed significantly discriminatory utility. LODDS showed more accurate prognostic performance than LNM and LNR for post-surgery Siewert type II AEG, and it could help to detect survival heterogeneity for patients with no positive lymph nodes involved.

Pathologic lymph node ratio is a predictor of esophageal carcinoma patient survival: a literature-based pooled analysis

The positive lymph node ratio (LNR) has been suggested as a predictor of survival in patients with esophageal carcinoma (EC). However, existed evidences did not completely agree with each other. We sought to examine whether LNR was associated with overall survival (OS). Electronic database was searched for eligible literatures. The primary outcome was the relationship between LNR and OS, which was presented as hazard ratio (HR) with 95% confidence intervals (CIs). All statistical analyses were performed using STATA 11.0 software. A total of 18 relevant studies which involved 7,664 cases were included. Patients with an LNR of 0.3 or greater had an increased risk of death compared to those with an LNR of less than 0.3(HR = 2.33; 95% CI 2.03-2.68; P<0.01). Similarly, patients with an LNR greater than 0.5 was also associated with a decreased OS(HR = 1.95; 95% CI 1.52-2.50; P<0.01). No publication bias was found. This meta-analysis confirmed that LNR was a significant predictor of survival in patients with EC and should be considered in prognostication.