Prognosis of Patients With Colorectal Cancer Is Associated With Lymph Node Ratio: A Single-Center Analysis of 3026 Patients Over a 25-Year Time Period

Mismatch Repair Status and Lymph Node Ratio in Survival Prediction of Stage II/III Rectal Cancer Patients: A Comprehensive Analysis of a Multi-Center Retrospective Study

BACKGROUND

The microsatellite status (dMMR vs. pMMR) in colorectal cancer can serve as a guiding factor for patient prognosis and treatment, where dMMR status indicates a better prognosis and often obviates the need for adjuvant chemotherapy (ACT). Conversely, a higher lymph node ratio (LNR) is associated with a poorer prognosis. This study aims to elucidate the prognostic significance of LNR and MMR status in relation to ACT in stages II and III colorectal cancer.

METHODS

A total of 1946 patients who underwent radical resection for colorectal cancer and were pathologically staged as II and III from three medical centers between 2012 and 2019 were selected. Among them, 1104 patients were included after MMR status was tested and postoperative chemotherapy was administered, along with other clinical information. MMR (mismatch repair) status was determined via pathological immunohistochemistry (IHC), and LNR was calculated. Patients were divided into three groups based on the LNR value and subjected to Kaplan-Meier and Cox regression analysis to assess the impact of MMR, LNR, and ACT on overall survival (OS) and disease-free survival (DFS).

RESULTS

A total of 6.47% of stage II and III colorectal cancers were detected as dMMR. Significant differences in OS and DFS between dMMR and pMMR patients were observed when the LNR ranged from 0.03 to 0.31, with pMMR patients showing a better prognosis. Stratified analysis with ACT revealed that postoperative chemotherapy did not affect the prognosis within the dMMR patient group. However, compared to the pMMR group, dMMR patients experienced significantly adverse effects on prognosis after receiving postoperative chemotherapy (p < 0.05). This result was more pronounced in the stratified analysis based on LNR (0.03-0.31) (p < 0.01).

CONCLUSIONS

Integrating LNR based on the microsatellite status of colorectal tumors provides comprehensive prognostic predictions, enhancing postoperative prognostic considerations for tumor patients. Additionally, our study suggests that patients with stage II and III colorectal cancer with dMMR status do not require any adjuvant chemotherapy postoperatively.

Prognostic and predictive value of tumor infiltration proportion within lymph nodes in N1 colorectal cancer

Introduction

Lymph node metastasis is a crucial determinant of prognosis in colorectal cancer (CRC), significantly impacting survival outcomes and treatment decision-making. This study aims to evaluate the prognostic value of tumor infiltration proportion within lymph nodes (TIPLN) in N1 CRC patients and to develop a TIPLN-based nomogram to predict prognosis.

Methods

A total of 416 N1 CRC patients who underwent radical resection were enrolled and divided into training and validation cohorts. Whole-slide images of lymph nodes were annotated to assess the TIPLN. Univariable and multivariable Cox regression analyses were conducted to identify independent prognostic factors and to develop a nomogram for predicting patient outcomes. The precision and discrimination of the nomogram were evaluated using the area under the receiver operating characteristic curve (AUC), concordance index (C-index), and calibration curve. Decision curve analysis (DCA) was performed to compare the net benefit of the nomogram at different threshold probabilities. Additionally, net reclassification index (NRI) and integrated discrimination improvement (IDI) were used to evaluate the nomogram's clinical utility.

Results

High TIPLN levels were significantly associated with poorer overall survival (OS). Five variables, including TIPLN, were selected to construct the nomogram. The C-index in OS prediction was 0.739 and 0.753 for the training and validation cohorts, respectively. Additionally, strong precision and discrimination were demonstrated through AUC and calibration curves. The NRI (training cohort: 0.191 for 3-year and 0.436 for 5-year OS prediction; validation cohort: 0.180 for 3-year and 0.439 for 5-year OS prediction) and IDI (training cohort: 0.079 for 3-year and 0.094 for 5-year OS prediction; validation cohort: 0.078 for 3-year and 0.098 for 5-year OS prediction) suggest that the TIPLN-based nomogram significantly outperformed the clinicopathological nomogram. Furthermore, DCA demonstrated the high clinical applicability of the TIPLN-based nomogram for predicting OS.

Conclusions

TIPLN could serve as a prognostic predictor for N1 CRC patients. The TIPLN-based nomogram enhances survival prediction accuracy and facilitates more informed, individualized clinical decision-making.

Prognostic Significance of Lymph Node Ratio in Intrahepatic and Extrahepatic Cholangiocarcinomas

Background/Objectives. Lymph Node Ratio (LNR) is increasingly recognized as an important prognostic factor in various cancer types, with the potential to enhance patient stratification for intrahepatic (ICC) and extrahepatic (ECC) cholangiocarcinoma. The study aimed to assess the impact of LNR on survival in surgically resected patients with ICC and ECC. Methods. This was a retrospective analysis of National Cancer Database (2004-2020) included ICC and ECC (excluding distal bile duct) patients who underwent primary site resection with adequate lymphadenectomy (≥4 LNs excised). Exclusions comprised age < 18 years, distant metastasis, or incomplete key data. LNR was calculated as the ratio of positive LNs to total examined LNs. Survival probabilities were estimated using Kaplan-Meier analysis and Cox regression. Results. The inclusion criteria were met by 954 patients with ICC and 1607 patients with ECC. In patients with ICC, the median OS time was 62.7 months in LNR0 group, 40.8 months in LNR < 30%, and 25.2 months in LNR ≥ 30% (p < 0.001). In ICC, 3-year OS was 69.3%, 54.6%, and 34% for LNR 0, LNR < 30%, and LNR ≥ 30%, respectively (p < 0.05). When adjusted for age, sex, Charlson-Deyo score, histology, surgical margins, chemo- and radiotherapy using Cox regression, LNR < 30% and LNR ≥ 30% were associated with worse OS in patients with ICC (HR 2.1 (95% CI 1.6-2.7) and HR 2.94 (95% CI 2.3-3.8)) and ECC (HR 2.1 (95% CI 1.8-2.5) and HR 3 (95% CI 2.4-3.7)). Conclusions. It is well-known that LN-negative patients have significantly better survival than LN-positive patients with ICC and ECC. This study strongly demonstrates that survival prognosis can be further stratified based on LNR for ICC and ECC patients and that it is not simply a binary factor.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRY

The clinical trial registration number: ChiCTR2300076883.

Outcomes of medial to lateral vs. lateral to medial approaches in laparoscopic colorectal cancer resections

Introduction

Bowel cancer is a significant global health concern, ranking as the third most prevalent cancer worldwide. Laparoscopic resections have become a standard treatment modality for resectable colorectal cancer. This study aimed to compare the clinical and oncological outcomes of medial to lateral (ML) vs lateral to medial (LM) approaches in laparoscopic colorectal cancer resections.

Methods

A retrospective cohort study was conducted at a UK district general hospital from 2015 to 2019, including 402 patients meeting specific criteria. Demographic, clinical, operative, postoperative, and oncological data were collected. Participants were categorised into LM and ML groups. The primary outcome was 30-day complications, and secondary outcomes included operative duration, length of stay, lymph node harvest, and 3-year survival.

Results

A total of 402 patients (55.7% males) were included: 102 (51.6% females) in the lateral mobilisation (LM) group and 280 (58.9% males) in the medial mobilisation (ML) group. Right hemicolectomy (n=157, 39.1%) and anterior resection (n=150, 37.3%) were the most performed procedures. The LM group had a shorter operative time for right hemicolectomy (median 165 vs. 225 min, P<0.001) and anterior resection (median 230 vs. 300 min, P<0.001). There was no significant difference between the two groups in terms of wound infection (P=0.443), anastomotic leak (P=0.981), postoperative ileus (P=0.596), length of stay (P=0.446), lymph node yield (P=0.848) or 3-year overall survival rate (Log-rank 0.759).

Discussion

The study contributes to the limited evidence on ML vs LM approaches. A shorter operative time in the LM group was noted in this study, contrary to some literature. Postoperative outcomes were comparable, with a non-significant increase in postoperative ileus in the LM group. The study emphasises the safety and feasibility of both approaches.

Lymph node ratio prognosticates overall survival in patients with stage IV colorectal cancer

BACKGROUND

Lymph node ratio (LNR) is suggested to address the shortcomings of using only lymph node yield (LNY) or status in colorectal cancer (CRC) prognosis. This study explores how LNR affects survival in patients with metastatic colorectal cancer (mCRC), seeking to provide clearer insights into its application.

METHODS

This observational cohort study investigated stage IV patients with CRC (1995-2021) who underwent an upfront resection of their primary tumour at Concord Hospital, Sydney. Clinicopathological data were extracted from a prospective database, and LNR was calculated both continuously and dichotomously (LNR of 0 and LNR > 0). The primary endpoint was overall survival (OS). The associations between LNR and various clinicopathological variables were tested using regression analyses. Kaplan-Meier and Cox regression analyses estimated OS in univariate and multivariate survival models.

RESULTS

A total of 464 patients who underwent a primary CRC resection with clear margins (mean age 68.1 years [SD 13.4]; 58.0% M; colon cancer [n = 339,73.1%]) had AJCC stage IV disease. The median LNR was 0.18 (IQR 0.05-0.42) for colon cancer (CC) resections and 0.21 (IQR 0.09-0.47) for rectal cancer (RC) resections. A total of 84 patients had an LNR = 0 (CC = 66 patients; RC = 18 patients). The 5-year OS for the CC cohort was 10.5% (95% CI 8.7-12.3) and 11.5% (95% CI 8.4-14.6) for RC. Increasing LNR demonstrated a decline in OS in both CC (P < 0.001) and RC (P < 0.001). In patients with non-lymphatic dissemination only (LNR = 0 or N0 status), there was better survival compared with those with lymphatic spread (CC aHR1.50 [1.08-2.07;P = 0.02], RC aHR 2.21 [1.16-4.24;P = 0.02]).

CONCLUSIONS

LNR is worthy of consideration in patients with mCRC. An LNR of 0 indicates patients have a better prognosis, underscoring the need for adequate lymphadenectomy to facilitate precise mCRC staging.

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

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

Prognostic significance of negative lymph node count in microsatellite instability-high colorectal cancer

BACKGROUND

Microsatellite instability-high (MSI-H) tumors, with elevated tumor mutational burden and expression of neoantigens, represent a distinct immune-activated subpopulation in colorectal cancer (CRC), characterized by strong lymph node reaction, locally advanced tumor and higher total lymph nodes harvested (TLN), but less metastatic lymph nodes and fewer incidence of III-IV stage. Host immune response to tumor and lymph nodes may be an important prognostic factor. However, N stage and LNR (Lymph-Node Ratio) have limitations in predicting the prognosis of MSI-H patients. Negative lymph node count (NLC) provided a more precise representation of immune activation status and extent of tumor metastasis. The study aims to detect prognostic significance of NLC in MSI-H CRC patients, and compare it with N stage, TLN and LNR.

METHODS

Retrospective data of 190 consecutive MSI-H CRC patients who received curative resection were collected. Survival analyses were performed using the Kaplan-Meier method. Clinicopathological variables including NLC, N stage, TLN and LNR were studied in univariate and multivariate COX regression analyses. ROC (receiver operating characteristic curve) and concordance index were employed to compare the differences in predictive efficacy between NLC, N stage, TLN and LNR.

RESULTS

Patients with increased NLC experienced a significantly improved 5-years DFS and OS in Kaplan-Meier analysis, univariate analysis, and multivariate analysis, independent of potential confounders examined. Increased NLC corresponded to elevated 5-years DFS rate and 5-years OS rate. AUC (area under curve) and concordance index of NLC in DFS and OS predicting were both significantly higher than N stage, TLN and LNR.

CONCLUSIONS

Negative lymph node is an important independent prognostic factor for MSI-H patients. Reduced NLC is associated with tumor recurrence and poor survival, which is a stronger prognostic factor than N stage, TLN and LNR.

Construction of a nomogram based on clinicopathologic features to predict the likelihood of No. 253 lymph node metastasis in rectal cancer patients

PURPOSE

To explore the high-risk factors for rectal cancer No.253 lymph node metastasis (LNM) and to construct a risk nomogram for the individualized prediction of No.253 LNM.

METHODS

This was a retrospective analysis of 425 patients with rectal cancer who underwent laparoscopic-assisted radical surgery. Independent risk factors for rectal cancer No.253 LNM was identified using multivariate logistic regression analysis, and a risk prediction nomogram was constructed based on the independent risk factors. In addition, the performance of the model was evaluated by discrimination, calibration, and clinical benefit.

RESULTS

Multivariate logistic regression analysis showed that No.253 lymphadenectasis on CT (OR 10.697, P < 0.001), preoperative T4-stage (OR 4.431, P = 0.001), undifferentiation (OR 3.753, P = 0.004), and preoperative Ca199 level > 27 U/ml (OR 2.628, P = 0.037) were independent risk factors for No.253 LNM. A nomogram was constructed based on the above four factors. The calibration curve of the nomogram was closer to the ideal diagonal, indicating that the nomogram had a better fitting ability. The area under the ROC curve (AUC) was 0.865, which indicated that the nomogram had high discriminative ability. In addition, decision curve analysis (DCA) showed that the model could show better clinical benefit when the threshold probability was between 1% and 50%.

CONCLUSION

Preoperative No.253 lymphadenectasis on CT, preoperative T4-stage, undifferentiation, and elevated preoperative Ca199 level were found to be independent risk factors for the No.253 LNM. A predictive model based on these risk factors can help surgeons make rational clinical decisions.

Clinicopathologic Analysis and Prognostic Factors for Survival in Patients with Operable Ampullary Carcinoma: A Multi-Institutional Retrospective Experience

Background and Objectives: In ampullary cancer, 5-year survival rates are 30-50%, even with optimal resection and perioperative systemic therapies. We sought to determine the important clinicopathological features and adjuvant treatments in terms of the prognosis of patients with operable-stage ampullary carcinomas. Materials and Methods: We included 197 patients who underwent pancreaticoduodenectomy to treat ampullary carcinomas between December 2003 and May 2019. Demographics, clinical features, treatments, and outcomes/survival were analyzed. Results: The median disease-free survival (mDFS) and median overall survival (mOS) were 40.9 vs. 63.4 months, respectively. The mDFS was significantly lower in patients with lymphovascular invasion (p < 0.001) and lymph node involvement (p = 0.027). Potential predictors of decreased OS on univariate analysis included age ≥ 50 years (p = 0.045), poor performance status (p = 0.048), weight loss (p = 0.045), T3-T4 tumors (p = 0.018), surgical margin positivity (p = 0.01), lymph node involvement (p = 0.001), lymphovascular invasion (p < 0.001), perineural invasion (p = 0.007), and poor histological grade (p = 0.042). For the multivariate analysis, only nodal status (hazard ratio [HR]1.98; 95% confidence interval [CI], 1.08-3.65; p = 0.027) and surgical margin status (HR 2.61; 95% CI, 1.09-6.24; p = 0.03) were associated with OS. Conclusions: Nodal status and a positive surgical margin were independent predictors of a poor mOS for patients with ampullary carcinomas. Additional studies are required to explore the role of adjuvant therapy in patients with ampullary carcinomas.

INFLUENCE OF NEOADJUVANT THERAPY ON THE RATIO OF LYMPH NODES

BACKGROUND

To evaluate the relationship between the ratio of affected lymph nodes (LNR) and clinical and anatomopathological variables in patients with rectal adenocarcinoma submitted or not to neoadjuvant chemoradiotherapy.

METHODS

The LNR was determined by dividing the number of compromised LNR by the total number of LNR dissected in the surgical specimen. Patients were divided into two groups: with QRT and without QRT. In each group, the relationship between LNR and the following variables was evaluated: degree of cell differentiation, depth of invasion in the rectal wall, angiolymphatic /perineural invasion, degree of tumor regression and occurrence of metastases. The LNR was evaluated in patients with more than 1, LNR (LNR >12) or less (LNR<12) in the surgical specimen with overall survival (OS) and disease-free survival (DFS). The results were expressed as the mean with the respective standard deviation. Qualitative variables were analyzed using Fisher's exact test, while quantitative variables were analyzed using the Kruskal -Wallis and Mann-Whitney tests. The significance level was 5%.

RESULTS

We evaluated 282 patients with QRT and 114 without QRT, between 1995-2011. In the QRT Group, LNR showed a significant association with mucinous tumors (P=0.007) and degree of tumor regression (P=0.003). In both groups, LNR was associated with poorly differentiated tumors (P=0.001, P=0.02), presence of angiolymphatic invasion (P<0.0001 and P=0.01), perineural (P=0.0007, P=0.02), degree of rectal wall invasion (T3>T2; P<0.0001, P=0.02); Compromised LNR (P<0.0001, P<0.01), metastases (P<0.0001, P<0.01). In patients with QRT, LNR<12 was associated with DFS (5.889; 95%CI1.935-19.687; P=0.018) and LNR>12 with DFS and OS (17.984; 95%CI5.931-54.351; P<0.001 and 10.286; 95%CI 2.654-39.854; P=0.007, respectively).

CONCLUSION

LNR was associated with histological aspects of poor prognosis, regardless of the use of QRT. In the occurrence of less than 12 evaluated LNR, the LNR was associated only with the DFS.

BACKGROUND

• Assessment of the lymph nodes during pathological analysis of the surgical specimen is crucial to determine treatment and prognosis.

BACKGROUND

• Neoadjuvance therapy reduces the number of lymph nodes, being lower than recommended, therefore the lymph node ratio can be an alternative analysis for a better prognosis.

Acetone compression improves lymph node yield and metastasis detection in colorectal cancer

Lymph node status is one of the most important prognostic factors in colorectal cancer, and accurate pathological nodal staging and detection of lymph node metastases is crucial for determination of post-operative management. Current guidelines, including the TNM staging system and European Society for Medical Oncology (ESMO) guidelines, recommend examination of at least 12 lymph nodes. However, identification of an adequate number of lymph nodes can be challenging, especially in the setting of neoadjuvant treatment, which may reduce nodal size. In this study, we investigated 384 colorectal cancer resections that were processed at our department of pathology between January 2012 and December 2022, in which the number of detected lymph nodes was less than 12 subsequent to conventional preparation of mesocolic fat tissue. By means of acetone compression, lymph node harvest increased significantly (p < 0.0001), and the intended number of ≥ 12 lymph nodes was achieved in 98% of resection specimens. The number of nodal positive cases increased significantly from n = 95 (24.7%) before versus n = 131 (34.1%) after acetone compression due to additionally identified lymph node metastases (p < 0.001). In 36 patients (9.4%) initially considered as nodal negative, acetone compression led to a staging adjustment to a nodal positive category and thereby drove a recommendation to offer post-operative therapy. In conclusion, acetone compression is a reliable and useful method implementable in routine surgical pathology for the retrieval of lymph nodes in colorectal cancer specimen, allowing for an adequate lymph node sampling and an increase in nodal staging reliability.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Differential Immune Infiltration Profiles in Colitis-Associated Colorectal Cancer versus Sporadic Colorectal Cancer

BACKGROUND

Chronic inflammation is a significant factor in colorectal cancer (CRC) development, especially in colitis-associated CRC (CAC). T-cell exhaustion is known to influence inflammatory bowel disease (IBD) progression and antitumor immunity in IBD patients. This study aimed to identify unique immune infiltration characteristics in CAC patients.

METHODS

We studied 20 CAC and 20 sporadic CRC (sCRC) patients, who were matched by tumor stage, grade, and location. Immunohistochemical staining targeted various T-cell markers (CD3, CD4, CD8, and FOXP3), T-cell exhaustion markers (TOX and TIGIT), a B-cell marker (CD20), and a neutrophil marker (CD66b) in tumor and tumor-free mucosa from both groups. The quantification of the tumor immune stroma algorithm assessed immune-infiltrating cells.

RESULTS

CAC patients had significantly lower TOX+ cell infiltration than sCRC in tumors (p = 0.02) and paracancerous tissues (p < 0.01). Right-sided CAC showed increased infiltration of TOX+ cells (p = 0.01), FOXP3+ regulatory T-cells (p < 0.01), and CD20+ B-cells (p < 0.01) compared to left-sided CAC. In sCRC, higher tumor stages (III and IV) had significantly lower TIGIT+ infiltrate than stages I and II. In CAC, high CD3+ (p < 0.01) and CD20+ (p < 0.01) infiltrates correlated with improved overall survival. In sCRC, better survival was associated with decreased TIGIT+ cells (p < 0.038) and reduced CD8+ infiltrates (p = 0.02).

CONCLUSION

In CAC, high CD3+ and CD20+ infiltrates relate to improved survival, while this association is absent in sCRC. The study revealed marked differences in TIGIT and TOX expression, emphasizing distinctions between CAC and sCRC. T-cell exhaustion appears to have a different role in CAC development.

Evaluating prognostic value and stage migration effects using a positive lymph node ratio in adenocarcinoma of the esophagogastric junction

BACKGROUND

Adenocarcinoma of the esophagogastric junction (AEG) is increasing worldwide. Lymph node metastasis is an important clinical issue in AEG patients. This study investigated the usefulness of a positive lymph node ratio (PLNR) to stratify prognosis and evaluate stage migration.

METHODS

We retrospectively analysed 117 consecutive AEG patients (Siewert type I or II) who received a lymphadenectomy between 2000 and 2016.

RESULTS

A PLNR cut-off value of 0.1 most effectively stratified patient prognosis into two groups (P < 0.001). Also, prognosis could be clearly stratified into four groups: PLNR = 0, 0 < PLNR < 0.1, 0.1 ≤ PLNR < 0.2, and 0.2 ≤ PLNR (P < 0.001, 5-year survival rates (88.6%, 61.1%, 34.3%, 10.7%)). A PLNR ≥ 0.1 significantly correlated with tumour diameter ≥ 4 cm (P < 0.001), tumour depth (P < 0.001), greater pathological N-status (P < 0.001), greater pathological Stage (P < 0.001), and oesophageal invasion length ≥ 2 cm (P = 0.002). A PLNR ≥ 0.1 was a poor independent prognostic factor (hazard ratio 6.47, P < 0.001). The PLNR could stratify prognosis if at least 11 lymph nodes were retrieved. A 0.2 PLNR cut-off value discriminated a stage migration effect in pN3 and pStage IV (P = 0.041, P = 0.015) patients; PLNR ≥ 0.2 might potentially diagnose a worse prognosis and need meticulous follow-up post-surgery.

CONCLUSION

Using PLNR, we can evaluate the prognosis and detect higher malignant cases who need meticulous treatments and follow-up in the same pStage.

Impact of DNA mismatch repair proteins deficiency on number and ratio of lymph nodal metastases in colorectal adenocarcinoma

BACKGROUND

Approximately 15 % of colorectal adenocarcinomas (CRCs) are characterized by an altered expression of DNA mismatch repair (MMR) proteins (i.e. MMR deficiency [MMRd]). Lymph node ratio (LNR) represents one of the most important prognostic markers in non-advanced CRCs. No significant data are available regarding LNR distribution depending on MMR status.

PURPOSE OF THE STUDY

The aim of the present work was to compare pathological and clinical characteristics of MMRd tumors versus MMR proficient (MMRp) cases. Particular attention was paid to how these molecular sub-groups relate to the LNR.

MATERIALS AND METHODS

A mono-Institutional series of 1037 consecutive surgically treated stage I-IV CRCs were retrospectively selected and data were obtained from pathological reports. Cases were characterized for MMR/MSI status by means of immunohistochemistry or for microsatellite instability (MSI) analysis.

RESULTS

MMRd/MSI tumors (n = 194; 18.7 %) showed significant differences in comparison to MMRp lesions for sex (female prevalence 50.5 % vs 40.7 %; p = 0.013), age (74.2 vs 69.2; p < 0.001), location (right side; p < 0.001), diameter (larger than MMRp; p < 0.001), growth pattern (expansive pattern of growth; p < 0.001), peri- (p = 0.0002) and intra-neoplastic (p = 0.0018) inflammatory infiltrate, presence of perineural invasion (p < 0.001), stage (lower stage at presentation; p < 0.001), grade (higher prevalence of high-grade tumors; p < 0.001), and LNR (lower; p < 0.001).

CONCLUSIONS

MMRd/MSI tumors are a distinct molecular CRC subtype characterized by a significantly lower LNR in comparison to MMRp lesions. These data further support the prognostic impact of MMRd/MSI status in early-stage CRCs.

Time to treatment initiation and its impact on real-world survival in metastatic colorectal cancer and pancreatic cancer

BACKGROUND

Given the dearth of data regarding the time to treatment initiation (TTI) in the palliative setting, and its impact on survival outcomes, we sought to determine TTI in a real-world cohort of metastatic colorectal cancer (mCRC) and metastatic pancreatic cancer (mPC) patients and evaluate the impact of TTI on real-world survival outcomes.

METHODS

We collected survival and treatment data for mCRC and mPC from the Flatiron Health electronic health records (EHR) derived database. We divided TTI into 3 categories: < 2 weeks, 2-< 4 weeks, and 4-8 weeks, from diagnosis to first-line therapy. Outcome measures were median TTI, real-world overall survival (RW-OS) based on TTI categories by Kaplan-Meier method, and impact of TTI on survival using cox proportional hazard models.

RESULTS

Among 7108 and 3231 patients with mCRC and mPC treated within 8 weeks of diagnosis, the median TTI were 28 days and 20 days. Median RW-OS for mCRC was 24 months; 26.9 months versus 22.6 and 18.05 months in the 4-8-week, 2-< 4 week (control) and < 2-week groups, respectively (p < 0.0001). For mPC, median RW-OS was 8 months, without significant difference in RW-OS among the groups (p = 0.05). The 4-8-week group was associated with lower hazard of death (HR 0.782, 95% CI 0.73-0.84, p < 0.0001) and the < 2-week group was associated with a higher hazard of death (HR 1.26, 95% CI 1.15-1.38, p < 0.0001) in mCRC. The 4-8-week group was associated with lower hazard of death for mPC (HR 0.88, 95% CI 0.8-0.97, p = 0.0094).

CONCLUSION

In a real-world cohort of patients treated within 8 weeks of diagnosis, and with the limitations of a retrospective study, later TTI did not have a negative impact on survival outcomes in mCRC and mPC.

Real-world survival of colon cancer after radical surgery: A single-institutional retrospective analysis

The survival rate for colon cancer after radical surgery has been the focus of extensive debate. To assess the postoperative survival and prognostic factors for overall survival (OS), we collected clinicopathological information for 2,655 patients. The survival time and potential risk factors for OS were analyzed by using Kaplan–Meier curves, Cox proportional hazards models, best subset regression (BSR), and least absolute shrinkage and selection operator (LASSO). The 5-year survival rates of stage I–IV colon cancer were 96.6%, 88.7%, 69.9%, and 34.3%, respectively. Adjuvant chemotherapy improved the survival rate (90.4% vs. 82.4%, with versus without adjuvant chemotherapy, respectively) in stage II patients with high-risk factors. Elevated preoperative carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) were significantly associated with worse OS compared with patients without these elevations. Less than 12 versus more than 12 harvested lymph nodes (LNs) affected prognosis (84.6% vs. 89.7%, respectively). Regarding the lymph node ratio (LNR), the 5-year OS rate was 89.2%, 71.5%, 55.8%, and 34.5% in patients with LNR values of 0, 0.3, 0.3–0.7, and &gt;0.7, respectively. We constructed a nomogram comprising the independent factors associated with survival to better predict prognosis. On the basis of these findings, we propose that stage II colon cancer patients without high-risk factors and with both elevated preoperative CEA and CA199 should receive adjuvant therapy. Furthermore, the LNR could complement TNM staging in patients with &lt;12 harvested LNs. Our nomogram might be useful as a new prognosis prediction system for colon cancer patients.

Construction of a new clinical staging system for colorectal cancer based on the lymph node ratio: A validation study

Aim

This study aims to construct a new staging system for colorectal cancer (CRC) based on the lymph node ratio (LNR) as a supplement to the American Joint Committee on Cancer (AJCC) tumor node metastasis (TNM) staging system for predicting the prognosis of CRC patients with <12 lymph nodes.

Methods

The data of 26,695 CRC patients with <12 lymph nodes were extracted from the Surveillance, Epidemiology, and End Results (SEER) database as a training set. A total of 635 CRC patients were also enrolled from Northern Jiangsu People's Hospital affiliated with Yangzhou University as an independent validation set. Classification and regression tree analysis was used to obtain the LNR cutoff value. Survival curves were estimated using the Kaplan–Meier method, and the log-rank test was used for comparisons of differences among the survival curves. The monotonic decreasing trend of the overall survival curve in the staging system was expressed by the linear correlation degree R.

Results

The 5-year survival rates of patients in the training set based on the AJCC staging system from stage I to stage IV were 75.6% (95%CI: 74.4–76.8), 59.8% (95%CI: 58.6–61.0), 42.1% (95%CI: 34.5–49.7), 33.2% (95%CI: 24.6–41.8), 72.0% (95%CI: 69.1–74.9), 48.8% (95%CI: 47.4–50.2), 26.5% (95%CI: 23.0–30.0), and 11.3% (95%CI: 10.3–12.3). The 5-year survival rates of patients in the training set from stage I to stage IIIC were 80.4%, 72.9%, 59.8%, 48.4%, 32.5%, and 15.0%, according to the TNM + LNR (TNRM) staging system. According to the AJCC staging system, the 5-year survival rates of patients in the validation set from stage I to stage IIIC were 91.3%, 90.8%, 72.6%, 61.3%, 72.4%, 58.1%, and 32.8%. Based on the TNRM staging system, the 5-year survival rates of patients in the validation set from stage I to stage IIIC were 99.2%, 90.5%, 81.4%, 78.6%, 60.2%, and 35.8%.

Conclusion

The TNRM staging system successfully eliminated “survival paradox” in the AJCC staging system, which might be superior to the AJCC staging system.

Retrospective Cohort Analysis of the Effect of Age on Lymph Node Harvest, Positivity, and Ratio in Colorectal Cancer

Introduction: Colon cancer among young patients has increased in incidence and mortality over the past decade. Our objective was to determine if age-related differences exist for total positive nodes (TPN), total lymph node harvest (TLH), and lymph node ratio (LNR). Material and Methods: A retrospective review of stage III surgically resected colorectal cancer patient data in the National Cancer Database (2004−2016) was performed, reviewing TPN, TLH, and LNR (TPN/TLH). Results: Unadjusted analyses suggested significantly higher levels of TLH and TPN (p < 0.0001) in younger patients, while LNR did not differ by age group. On adjusted analysis, TLH remained higher in younger patients (<35 years 1.56 (CI 95 1.54, 1.59)). The age-related effect was less pronounced for LNR (<35 years 1.16 (CI 95 1.13, 1.2)). Conclusion: Younger patients have increased TLH, even after adjusting for known confounders, while age does not have a strong independent impact on LNR.

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

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

Prognostic value of lymph node ratio in resectable rectal cancer after preoperative short-course radiotherapy-results from randomized clinical trial

PURPOSE

The value of the lymph node ratio (LNR) in patients with rectal cancer has not yet been unequivocally established. This study aims to assess the effect of the lymph node ratio on the prognosis of rectal cancer in patients operated after short-course preoperative 25 Gy radiotherapy, at 10-year follow-up.

METHODS

This is a substudy based on data from a prospective randomized clinical trial. A total of 141 patients with resectable rectal cancer were included. Lymph node yield was compared in patients with short and long time intervals between radiotherapy and surgery. Survival curves were compared between patients with different ypN and LNR categories. Univariate and multivariate analyses were performed to identify independent prognostic factors for overall survival and disease-free survival.

RESULTS

Survival and recurrence data were available for a median follow-up of 11.6 years. The lymph node yield did not differ significantly between the patients in the short- and long-interval groups. A greater difference in 10-year survival was observed in patients with LNR ≤ 0.41 and > 0.41 when compared to the ypN categories. Separate prognostic factor analyses were performed for the entire population and for subgroups that had < 12 and 12 lymph nodes resected. LNR was identified as an independent prognostic factor for overall survival, in multivariate analyses, for all patients and those with less than 12 retrieved lymph nodes.

CONCLUSION

The lymph node yield is comparable in patients with different time intervals between radiation therapy and surgery. LNR better discriminates patients in terms of overall survival than ypN categories.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT01444495, date of registration: September 30, 2011.

N, LNR or LODDS: Which Is the Most Appropriate Lymph Node Classification Scheme for Patients with Radically Resected Pancreatic Cancer?

Simple Summary

To date, no data are available regarding the most appropriate alternative LN classification system with respect to prognostic power and discriminative ability in cases with resectable pancreatic ductal adenocarcinoma (PDAC). We compared different lymph node classification systems with regard to accurate evaluation of overall survival in 319 patients with resected PDAC. One LNR and one LODDS classification scheme were found to out-perform the N category in distinct patient subgroups. Only the LODDS classification exhibited statistically significant, gradually increasing HRs of their subcategories and, at the same time, significantly better discriminative potential in the subgroups of patients with PDAC of the head or corpus and in patients with tumor-free resection margins or M0 status, respectively.

Abstract

Background: Even though numerous novel lymph node (LN) classification schemes exist, an extensive comparison of their performance in patients with resected pancreatic ductal adenocarcinoma (PDAC) has not yet been performed. Method: We investigated the prognostic performance and discriminative ability of 25 different LN ratio (LNR) and 27 log odds of metastatic LN (LODDS) classifications by means of Cox regression and C-statistic in 319 patients with resected PDAC. Regression models were adjusted for age, sex, T category, grading, localization, presence of metastatic disease, positivity of resection margins, and neoadjuvant therapy. Results: Both LNR or LODDS as continuous variables were associated with advanced tumor stage, distant metastasis, positive resection margins, and PDAC of the head or corpus. Two distinct LN classifications, one LODDS and one LNR, were found to be superior to the N category in the complete patient collective. However, only the LODDS classification exhibited statistically significant, gradually increasing HRs of their subcategories and at the same time significantly higher discriminative potential in the subgroups of patients with PDAC of the head or corpus and in patients with tumor free resection margins or M0 status, respectively. On this basis, we built a clinically helpful nomogram to estimate the prognosis of patients after radically resected PDAC. Conclusion: One LNR and one LODDS classification scheme were found to out-perform the N category in terms of both prognostic performance and discriminative ability, in distinct patient subgroups, with reference to OS in patients with resected PDAC.

ICG-Guided Lymphadenectomy during Surgery for Colon and Rectal Cancer-Interim Analysis of the GREENLIGHT Trial

Lymphadenectomy is crucial for an optimal oncologic resection of colon and rectal cancers. However, without a direct visualization, an aberrant route of lymph node (LN) diffusion might remain unresected. Indocyanine-green (ICG) lymphatic mapping permits a real-time LNs visualization. We designed the GREENLIGHT trial to explore in 100 patients undergoing robotic colorectal resection the clinical significance of a D3 ICG-guided lymphadenectomy. The primary endpoint was the number of patients in whom ICG changed the extent of lymphadenectomy. We report herein the interim analysis on the first 70 patients. After endoscopic ICG injection 24 h (n = 49) or 72 h (n = 21) ahead, 19, 20, and 31 patients underwent right colectomy, left colectomy, and anterior rectal resection. The extent of lymphadenectomy changed in 35 (50%) patients, mostly (29 (41.4%)) for the identification of LNs (median two) outside the standard draining basin. Identification of such LNs was less frequent in rectal tumors that had undergone chemoradiotherapy (26.3%) (p > 0.05). A non-significant correlation between time-to-ICG injection and identification of aberrant LNs was observed (48.9% at 24 h vs. 23.8% at 72 h). The presence of LN metastases did not affect a proper fluorescent mapping. These data indicate that ICG lymphatic mapping provides relevant information in 50% of patients, thus increasing the accuracy of potentially curative resections.

Establishment of a Competing Risk Nomogram in Patients with Pulmonary Sarcomatoid Carcinoma

Background and aim: Pulmonary sarcomatoid carcinoma (PSC) is a rare subtype of nonsmall cell lung cancer with a poor prognosis. This study aimed to analyze the clinicopathological characteristics and survival outcomes among patients with PSC, lung squamous cell cancer (SCC), and lung adenocarcinoma (LAC), and to construct a competing risk nomogram for patients with PSC. Method: Data of 3 groups of patients diagnosed with PSC, SCC, or LAC from the surveillance, epidemiology, and end results (SEER) database between 1988 and 2015 were retrospectively reviewed. A 1:1 propensity score matching (PSM) analysis was used to balance the baseline data of patients. Independent risk factors associated with survival outcomes were screened by the least absolute shrinkage and selection operator and further determined by univariate and multivariate Cox proportional risk regression analyses. The overall survival (OS) of patients was evaluated by Kaplan–Meier analysis and compared with a log-rank test. The cumulative incidence function was used to estimate the 5-year probabilities of the cancer-specific mortality of PSC. A nomogram was constructed to illustrate the competing risk model to predict the 3- and 5-year OS, and corresponding concordance indexes (C-indexes) and calibration curves were used to assess and validate the competing risk nomogram. Results: A total of 2285 patients with PSC were included in this study. Compared with SCC and LAC patients, the Kaplan–Meier analysis showed that patients with PSC had a worse prognosis, with a median survival of 5 months (95% confidence interval [CI]: 5-6 months) and a 5-year OS rate of 15.3% (95% CI: 13.9%-16.9%). Similar outcomes were demonstrated after 1:1 PSM. Moreover, the competing risk model showed that age, T stage, M stage, tumor size, lymph node ratio (LNR), surgery, and chemotherapy were associated with PSC-specific mortality. The 5-year C-index of the nomogram was 0.718. Calibration curves illustrated that the nomogram was well-validated and had great accuracy. Conclusions: Patients with PSC had a worse survival outcome compared with SCC or LAC patients. Age, T stage, M stage, tumor size, LNR, surgery, and chemotherapy were associated with PSC-specific mortality. The competing risk nomogram displayed excellent discrimination in predicting PSC-specific mortality.

Prognostic Factors for Survival of Colorectal Adenocarcinoma Patients in Uganda

Background

In Uganda, similar to other countries in East Africa, the incidence of colorectal cancer (CRC) has been steadily increasing. This increase in incidence is accompanied by a poor prognosis. There is limited knowledge on factors responsible for the poor outcome of patients with CRC in Uganda. Cancer survival analysis is one way of determining some of these prognostic factors. The aim of this study was to determine prognostic factors associated with CRC survival in Ugandan patients.

Methods

This was a retroprospective cohort study involving patients with linked data in the Kampala cancer registry and medical records from hospitals in Uganda. Participants with a diagnosis of colorectal adenocarcinoma between 1st January 2008 and 31st December 2018 were included. Variables included patients’ demographic data, grade, stage and location of CRC, data on whether a patient was operated on, type of operation, treatment modalities and date of diagnosis. Our outcome variable was time to death after diagnosis. We computed and compared survival using the Log rank test and used Cox proportional hazards regression to determine factors associated with survival.

Results

A total of 247 patients were included in the study with a mean (SD) age of 53.3 (15.7) years and a female: male ratio of 1.14:1. The proportions of patients surviving at 1, 2 and 3 years were 65.2% (95% CI: 58.8–70.9), 42.0% (95% CI:35.6–48.3) and 33.3% (95% CI:27.3–39.4) respectively. In multivariate analysis, factors associated with increased mortality included clinical stage II (aHR = 2.44, 95% CI: 1.10–5.41, p=0.028), stage III (aHR=2.65, 95% CI: 1.31–5.39, p=0.007) and stage IV (aHR=5.47, 95% CI: 2.40–12.48, p<0.001). Curative surgery alone (aHR=0.63, 95% CI: 0.39–1.01, p=0.057) and curative surgery with chemotherapy (aHR=0.53, 95% CI: 0.32–0.88, p=0.015) were associated with a better survival.

Conclusion

The survival rate among CRC patients in Uganda is low. Advanced stage CRC accelerates mortality, while surgery alone or in combination with chemotherapy improves survival. Implementation of national screening programmes for early diagnosis of CRC and increasing surgery and oncology infrastructure is recommended to improve the CRC survival rate in the Ugandan population.

Prognostic Performance of Alternative Lymph Node Classification Systems for Patients with Medullary Thyroid Cancer: A Single Center Cohort Study

BACKGROUND

Lymph node ratio (LNR) and the log odds of positive lymph nodes (LODDS) have been proposed as alternative lymph node (LN) classification schemes. Various cut-off values have been defined for each system, with the question of the most appropriate for patients with medullary thyroid cancer (MTC) still remaining open. We aimed to retrospectively compare the predictive impact of different LN classification systems and to define the most appropriate set of cut-off values regarding accurate evaluation of overall survival (OS) in patients with MTC.

METHODS

182 patients with MTC who were operated on between 1985 and 2018 were extracted from our medical database. Cox proportional hazards regression models and C-statistics were performed to assess the discriminative power of 28 LNR and 28 LODDS classifications and compare them with the N category according to the 8th edition of the AJCC/UICC TNM classification in terms of discriminative power. Regression models were adjusted for age, sex, T category, focality, and genetic predisposition.

RESULTS

High LNR and LODDS are associated with advanced T categories, distant metastasis, sporadic disease, and male gender. In addition, among 56 alternative LN classifications, only one LNR and one LODDS classification were independently associated with OS, regardless of the presence of metastatic disease. The C-statistic demonstrated comparable results for all classification systems showing no clear superiority over the N category.

CONCLUSION

Two distinct alternative LN classification systems demonstrated a better prognostic performance in MTC patients than the N category. However, larger scale studies are needed to further verify our findings.

Value of the log odds of positive lymph nodes for prognostic assessment of colon mucinous adenocarcinoma: Analysis and external validation

Purpose

To evaluate the impact of the log odds of positive lymph nodes (LODDS) on cancer‐specific survival (CSS) in colon mucinous adenocarcinoma (MAC) patients, compared with pN stage and the lymph nodes ratio (LNR).

Methods

A total of 10,182 colon MAC patients from the Surveillance, Epidemiology, and End Results database were divided into the training group. The external validation group included 153 patients from Fujian Medical University Union Hospital. The Cox regression method was used to identify prognostic risk factors. Nomograms were evaluated by Harrell's concordance index (C‐index) and calibration curves. Recursive partitioning analysis (RPA) was used to develop a novel staging system.

Results

Time‐dependent receiver operating characteristic curves (ROC) to predict CSS showed the areas under the ROC curve of LODDS were always higher than pN stage and LNR. LNR and LODDS classifications can well distinguish the prognosis of patients with the same pN stage. Cox analyses indicated that age, tumor size, pT stage, pN stage, LNR, and LODDS were independent predictors of CSS (p < 0.05). Based on three lymph nodes classifications, we constructed three prognostic nomograms models for CSS. The C‐index of the pN, LNR, and LODDS classification nomograms were 0.746 (95% confidence interval [95% CI]: 0.736–0.756), 0.750 (95% CI: 0.740–0.760), and 0.758 (95% CI: 0.748–0.768), respectively. In external validation, we observed the C‐index of LODDS classification nomograms was 0.787 (95% CI: 0.648–0.926). RPA stage, including four stages, was constructed successfully based on pT stage and LNR or LODDS, respectively. The 3‐, 5‐, and 8‐year areas under the ROC curve of LNR‐RPA stage and LODDS‐RPA stage were superior to tumor‐node‐metastasis stage.

Conclusion

LODDS to be a better prognostic factor of CSS for colon MAC patients than pN stage and LNR. A nomogram and RPA stage base on LODDS can provide accurate information for personalized cancer treatment.

Prognosis for Poorly Differentiated, High-Grade Rectal Neuroendocrine Carcinomas

INTRODUCTION

Rectal neuroendocrine carcinomas (rNECs) are poorly characterized and, given their aggressive nature, optimal management is not well-established. We therefore sought to describe clinicopathologic traits, treatment details, and survival patterns for patients with rNECs.

METHODS

Patients captured in the National Cancer Database (NCDB; 2004-2016) with rNECs managed with observation, chemotherapy, or proctectomy ± chemotherapy were considered for analysis.

RESULTS

The inclusion criteria were met by 777 patients. Mean age was 62.4 years, 45% were male, 80% were Caucasian, 40% presented with lymph nodes metastases, and 49% presented with distant metastases. Chemotherapy and surgical resection were administered in 72 and 19% of cases, respectively. Median overall survival (OS) was 0.83 years (1 year, 41%; 3 years, 13%; 5 years, 10%). During the study interval, 659 (85%) patients died, with a median follow-up of 0.79 years. On multivariable analysis, age ≥60 years, male sex, and distant metastases were associated with worse survival; surgical resection and administration of chemotherapy were associated with a reduced risk of death. Among non-metastatic patients treated with surgical resection, administration of chemotherapy was protective, while a positive lymph node ratio (LNR) ≥42% (median value) was associated with an increased risk of death. There was no difference in the number of examined lymph nodes between LNR cohorts.

CONCLUSIONS

Patients with rNECs experience dismal survival outcomes, including those with non-metastatic disease treated with curative-intent surgical resection. Neoadjuvant therapy can serve as a useful biologic test, and surgical resection should be judiciously employed.

Liver transplantation for non-resectable colorectal liver metastases: the International Hepato-Pancreato-Biliary Association consensus guidelines

Colorectal cancer is a prevalent disease worldwide, with more than 50% of patients developing metastases to the liver. Despite advances in improving resectability, most patients present with non-resectable colorectal liver metastases requiring palliative systemic therapy and locoregional disease control strategies. There is a growing interest in the use of liver transplantation to treat non-resectable colorectal liver metastases in well selected patients, leading to a surge in the number of studies and prospective trials worldwide, thereby fuelling the emerging field of transplant oncology. The interdisciplinary nature of this field requires domain-specific evidence and expertise to be drawn from multiple clinical specialities and the basic sciences. Importantly, the wider societal implication of liver transplantation for non-resectable colorectal liver metastases, such as the effect on the allocation of resources and national transplant waitlists, should be considered. To address the urgent need for a consensus approach, the International Hepato-Pancreato-Biliary Association commissioned the Liver Transplantation for Colorectal liver Metastases 2021 working group, consisting of international leaders in the areas of hepatobiliary surgery, colorectal oncology, liver transplantation, hepatology, and bioethics. The aim of this study was to standardise nomenclature and define management principles in five key domains: patient selection, evaluation of biological behaviour, graft selection, recipient considerations, and outcomes. An extensive literature review was done within the five domains identified. Between November, 2020, and January, 2021, a three-step modified Delphi consensus process was undertaken by the workgroup, who were further subgrouped into the Scientific Committee, Expert Panel, and Transplant Centre Representatives. A final consensus of 44 statements, standardised nomenclature, and a practical management algorithm is presented. Specific criteria for clinico-patho-radiological assessments with molecular profiling is crucial in this setting. After this, the careful evaluation of biological behaviour with bridging therapy to transplantation with an appropriate assessment of the response is required. The sequencing of treatment in synchronous metastatic disease requires special consideration and is highlighted here. Some ethical dilemmas within organ allocation for malignant indications are discussed and the role for extended criteria grafts, living donor transplantation, and machine perfusion technologies for non-resectable colorectal liver metastases are reviewed. Appropriate immunosuppressive regimens and strategies for the follow-up and treatment of recurrent disease are proposed. This consensus guideline provides a framework by which liver transplantation for non-resectable colorectal liver metastases might be safely instituted and is a meaningful step towards future evidenced-based practice for better patient selection and organ allocation to improve the survival for patients with this disease.

Prognostic Impact of Indicators of Systemic Inflammation and the Nutritional Status of Patients with Resected Carcinoma of the Ampulla of Vater: A Single-Center Retrospective Study

BACKGROUND

Several indicators of systemic inflammation and nutritional status were recently shown to serve as novel prognostic factors for certain cancers. Here, we aimed to investigate the prognostic impact of preoperative indicators of systemic inflammation and nutritional status associated with the survival of patients with resected ampulla of Vater carcinoma (AC).

METHODS

We retrospectively analyzed the records of 91 patients who underwent pancreatoduodenectomy (PD) for AC from January 2002 through December 2018. Indices for systemic inflammation and nutritional status (Systemic immune-inflammation index [SII], Prognostic nutritional index [PNI], modified Glasgow prognostic score [mGPS], and Controlling nutritional status score [CONUT]) were determined using preoperative blood tests. Clinicopathological factors and these indices were analyzed to identify predictors of overall survival (OS).

RESULTS

The median preoperative SII and PNI values were 456.7 and 47.5, respectively, and their optimal cut-off values were 670.0 and 50.0, respectively. Univariate analysis revealed that high SII, low PNI, mGPS ≥ 1, and malnutrition, assessed using the CONUT, were significant predictors of shorter OS. Multivariate analysis revealed that high SII (HR = 2.71, p = 0.023) and malnutrition assessed using the CONUT (hazard ratio = 3.98, p = 0.006) were independent predictors of shorter OS.

CONCLUSION

SII and the CONUT predicted the survival of patients with AC after radical resection. These indicators are easily calculated using preoperative blood tests and may contribute to the development of improved strategies to treat AC.

The Key Role of Exosomes on the Pre-metastatic Niche Formation in Tumors

Exosomes or other extracellular vesicles released from cells play an important role in cell-to-cell communication by transferring bio-information (DNA, coding/non-coding RNA, and proteins), which indicates parental cell status to recipient cells in the extracellular environment. Increasingly, evidence shows that tumor-derived exosomes mediate tumor pre-metastatic niche (PMN) remodeling to establish a supportive and receptive niche to promote tumor cell colonization and metastasis. Uptake of genetic information by target cells in the extracellular environment triggers epigenetic changes that contribute to PMN formation. Here, we provide a comprehensive overview of the current understanding of exosomes-mediated reprogramming of cells in PMN formation.

Screening and validation of a novel T stage-lymph node ratio classification for operable colon cancer

BACKGROUND

Lymph node ratio (LNR) has advantages in predicting prognosis compared with American Joint Committee on Cancer (AJCC) pathological N stage. However, the prognostic value of a novel T stage-lymph node ratio (TLNR) classification for colon cancer combining LNR and pathological primary tumor stage (T stage) is currently unknown.

METHODS

We included 62,294 patients with stage I-III colon cancer from the Surveillance, Epidemiology, and End Results Program as a training cohort. External validation was performed in 3,327 additional patients. A novel LNR stage was established and combined with T stage in a novel TLNR classification. Patients with similar survival were grouped according to T and LNR stages, with T1LNR1 as a reference.

RESULTS

We developed a novel TLNR classification as follows: stages I (T1LNR1-2, T1LNR4), IIA (T1LNR3, T2LNR1-2, T3LNR1), IIB (T1LNR5, T2LNR3-4, T3LNR2, T4aLNR1), IIC (T2LNR5, T3LNR3-4, T4aLNR2, T4bLNR1), IIIA (T3LNR5, T4aLNR3-4, T4bLNR2), IIIB (T4aLNR5, T4bLNR3-4), and IIIC (T4bLNR5). In the training cohort, the novel TLNR classification had better prognostic discrimination (area under receiver operating characteristic curve, 0.621 vs. 0.608, two-sided P<0.001), superior model-fitting ability for predicting overall survival (Akaike information criteria, 561,129 vs. 562,052), and better net benefits compared with the AJCC 8th tumor/node/metastasis classification. Similar results were found in the validation cohort for predicting both overall and disease-free survival.

CONCLUSIONS

This novel TLNR classification may provide better prognostic discrimination, model-fitting ability, and net benefits than the AJCC 8th TNM classification, for potentially better stratification of patients with operable stage I-III colon cancer; however, further studies are required to validate the novel TLNR classification.

Prognostic implications of ENE and LODDS in relation to lymph node-positive colorectal cancer location

•

This is the first study on LODDS and ENE together. The current study showed that LODDS and ENE are liable prognostic parameters of CRC or CC.

•

ENE is an independent influencing factor on the prognosis of both CRC and CC, and the prognostic impact of ENE was observed in both CRC and CC.

•

The frequency of ENE increases from the proximal (right) to the distal (left) colon as well as the rectum.

Background

Extranodal extension (ENE) and log odds of positive lymph nodes (LODDS) are associated with the aggressiveness of both colon and rectal cancers. The current study evaluated the clinicopathological significance and the prognostic impact of ENE and LODDS in the colon and rectal patients independently.

Methods

The clinical and histological records of 389 colorectal cancer (CRC) patients who underwent curative surgery were reviewed.

Results

For the ENE system, 244 patients were in the ENE1 group and 145 in the ENE2 system. Compared with the ENE1 system, the patients included in the ENE2 system were prone to nerve invasion (P < 0.001) and vessel invasion (P < 0.001) with higher TNM (P = 0.009), higher T category (P = 0.003), higher N category (P < 0.001), advanced differentiation (P = 0.013), more number of positive lymph nodes (NPLN) (P < 0.001), more lymph node ratio (LNR) (P < 0.001), and a higher value of LODDS (P < 0.001). ENE was more frequent in patients with left and rectal than right cancer. For the LODDS system, 280 patients were in the LODDS1 group, and 109 in the LODDS2 group. Compared to the LODDS1 group, the patients included in the LODDS2 group were more prone to nerve invasion (P = 0.0351) and vessel invasion (P < 0.001) with a higher rate of N2 stage, less NDLN (P < 0.001), more NPLN (P < 0.001), more LNR (P < 0.001), and a higher value of ENE (P < 0.001). Based on the results in the univariable analysis, the N, NPLN, LNR, LODDS, and ENE were separately incorporated into five different Cox regression models combined with the same confounders. The multivariable Cox regression analysis demonstrated that all the five staging systems were independent prognostic factors for overall survival.

Conclusion

The current study confirmed that the LODDS stage is an independent influence on the prognosis of both CRC and CC patients. ENE is an independent influencing factor on the prognosis of both CRC and CC patients, and the prognostic impact of extracapsular lymph node was observed in both CRC and CC. The frequency of ENE increases from the proximal (right) to the distal (left) colon as well as the rectum. Therefore, combining ENE and LODDS into the current TNM system to compensate for the inadequacy of pN staging needs further investigation.

Prognostic Discrimination of Alternative Lymph Node Classification Systems for Patients with Radically Resected Non-Metastatic Colorectal Cancer: A Cohort Study from a Single Tertiary Referral Center

BACKGROUND

Lymph node ratio (LNR) and the Log odds of positive lymph nodes (LODDS) have been proposed as a new prognostic indicator in surgical oncology. Various studies have shown a superior discriminating power of LODDS over LNR and lymph node category (N) in diverse cancer entities, when examined as a continuous variable. However, for each of the classification systems various cut-off values have been defined, with the question of the most appropriate for patients with CRC still remaining open. The present study aimed to compare the predictive impact of different lymph node classification systems and to define the best cut-off values regarding accurate evaluation of overall survival in patients with resectable, non-metastatic colorectal cancer (CRC).

METHODS

CRC patients who underwent surgical resection from 1996 to 2018 were extracted from our medical data base. Cox proportional hazards regression models and C-statistics were performed to assess the discriminative power of 25 LNR and 26 LODDS classifications. Regression models were adjusted for age, sex, extent of the tumor, differentiation, tumor size and localization.

RESULTS

Our study group consisted of 654 consecutive patients with non-metastatic CRC. C-statistic revealed 2 LNR and 5 LODDS classifications that demonstrated superior prognostic performance in patients with UICC III CRC, compared to the N category. No clear advantage of one classification over another could be demonstrated in any other patient subgroup.

CONCLUSIONS

Distinct LNR and LODDS classifications demonstrate a prognostic superiority over the N category only in patients with Stage III radically resected CRC.

Brain derived neurotrophic factor declines after complete curative resection in gastrointestinal cancer

Background

Brain derived neurotrophic factor (BDNF) is a neurotrophin involved in neural and metabolic diseases, but it is also one of the crucial factors in cancer development and metastases. In the current study, we investigated serum BDNF concentrations in patients that underwent surgical treatment for colorectal cancer or pancreatic cancer.

Methods

Serum BDNF concentrations were measured with standard enzyme-linked immunosorbent assays, before and on the third day after the operation, in 50 consecutive patients with colorectal cancer and 25 patients with pancreatic cancer (tumours in the head of pancreas). We compared pre- and postoperative BDNF levels, according to the subsequent TNM stage, histologic stage, lymph node involvement, neuro- or angio-invasion, and resection range.

Results

In the pancreatic cancer group, BDNF concentrations fell significantly postoperatively (p = 0.011). In patients that underwent resections, BDNF concentrations fell (p = 0.0098), but not in patients that did not undergo resections (i.e., laparotomy alone). There were significant pre- and postoperative differences in BDNF levels among patients with (p = 0.021) and without (p = 0.034) distant metastases. Significant reductions in BDNF were observed postoperatively in patients with small tumours (i.e., below the median size; p = 0.023), in patients with negative angio- or lymphatic invasion (p = 0.028, p = 0.011, respectively), and in patients with lymph node ratios above 0.17 (p = 0.043). In the colon cancer group, the serum BDNF concentrations significantly fell postoperatively in the entire group (p = 0.0076) and in subgroups of patients with or without resections (p = 0.034, p = 0.0179, respectively). Significant before-after differences were found in subgroups with angioinvasions (p = 0.050) and in those without neuroinvasions (p = 0.049). Considering the TNM stages, the postoperative BDNF concentration fell in groups with (p = 0.0218) and without (p = 0.034) distant metastases and in patients with tumours below the median size (p = 0.018).

Conclusion

Our results suggested that BDNF might play an important role in gastrointestinal cancer development. BDNF levels were correlated with tumour volume, and with neuro-, angio- and lymphatic invasions. In pancreatic cancer, BDNF concentrations varied according to the surgical procedure and they fell significantly after tumour resections. Thus, BDNF may serve as a potential marker of complete resections in underdiagnosed patients. However, this hypothesis requires further investigation. In contrast, no differences according to the procedure was made in patients with colon cancer.

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

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

Prognostic Impact of Lymph Node Ratio in Patients Undergoing Preoperative Chemoradiotherapy Followed by Curative Resection for Locally Advanced Rectal Cancer

BACKGROUND/AIM

To analyze the prognostic significance of nodal status in patients undergoing preoperative chemoradiotherapy (CRT) followed by curative resection for locally advanced rectal cancer.

PATIENTS AND METHODS

Between 2000 and 2015, 80 consecutive patients with rectal cancer underwent preoperative CRT followed by curative resection. The lymph node ratio (LNR) was defined as the number of positive lymph nodes (LNs) divided by the examined LNs, and log odds of positive lymph nodes (LODDS) was the log of the ratio between positive and negative LNs. The prognostic value of these indicators was evaluated in terms of overall (OS) and disease-free (DFS) survival.

RESULTS

The median follow-up period for patients overall was 59 months (range=11-190 months). The median number of examined LNs and number of positive LNs were 10 (range=1-29) and 2 (range=1-27), respectively, and the median LNR and LODDS values were 0.0 (range=0.0-0.96) and -1.0 (range=-1.7-1.3), respectively. The 5-year OS and DFS were 83% and 64%, respectively. In multivariate analysis, LNR was an independent prognostic factor in terms OS (p=0.041) but not for DFS (p=0.075). LODDS was not significantly associated with OS or DFS. In patients with clinical stage III rectal cancer, LNR was significantly associated with OS and DFS when the number of evaluated LNs was greater than 12 (p=0.038 for OS, p=0.006 for DFS).

CONCLUSION

Our study suggests that LNR is a more effective prognostic factor than LODDS in terms of predicting survival. LNR was a significant predictor for survival for patients with clinical stage III rectal cancer with >12 harvested LNs.

Re-interpreting mesenteric vascular anatomy on 3D virtual and/or physical models: positioning the middle colic artery bifurcation and its relevance to surgeons operating colon cancer

Background

The impact of the position of the middle colic artery (MCA) bifurcation and the trajectory of the accessory MCA (aMCA) on adequate lymphadenectomy when operating colon cancer have as of yet not been described and/or analysed in the literature. The aim of this study was to determine the MCA bifurcation position to anatomical landmarks and to assess the trajectory of aMCA.

Methods

The colonic vascular anatomy was manually reconstructed in 3D from high-resolution CT datasets using Osirix MD and 3-matic Medical and analysed. CT datasets were exported as STL files and supplemented with 3D printed models when required.

Results

Thirty-two datasets were analysed. The MCA bifurcation was left to the superior mesenteric vein (SMV) in 4 (12.1%), in front of SMV in 17 (53.1%) and right to SMV in 11 (34.4%) models. Median distances from the MCA origin to bifurcation were 3.21 (1.18–15.60) cm. A longer MCA bifurcated over or right to SMV, while a shorter bifurcated left to SMV (r = 0.457, p = 0.009). The main MCA direction was towards right in 19 (59.4%) models. When initial directions included left, the bifurcation occurred left to or anterior to SMV in all models. When the initial directions included right, the bifurcation occurred anterior or right to SMV in all models. The aMCA was found in 10 (31.3%) models, following the inferior mesenteric vein (IMV) in 5 near the lower pancreatic border. The IMV confluence was into SMV in 18 (56.3%), splenic vein in 11 (34.4%) and jejunal vein in 3 (9.4%) models.

Conclusion

Awareness of the wide range of MCA bifurcation positions reported is crucial for the quality of lymphadenectomy performed. The aMCA occurs in 31.3% models and its trajectory is in proximity to the lower pancreatic border in one half of models, indicating that it needs to be considered when operating splenic flexure cancer.

Supplementary information

The online version of this article (10.1007/s00464-020-08242-8) contains supplementary material, which is available to authorized users.

Fluorescence-guided D3 lymphadenectomy in robotic right colectomy with complete mesocolic excision

BACKGROUND

In robotic right hemicolectomy for cancer, appropriate lymphadenectomy is essential. Visualization of draining lymph nodes and blood flow with near-infrared (NIR) fluorescence DaVinci^® imaging system is a recent development. We present the technique of robotic right colectomy with complete mesocolic excision (CME) and D3 lymphadenectomy using Indocyanine Green (ICG) endoscopic submucosal injection to intraoperatively identify tumour lymphatic basin.

METHODS

The day before surgery, in patients scheduled for robotic right colectomy an endoscopic submucosal injection of 3 mg of ICG solution around the tumor is realized. Robotic right hemicolectomy is performed with suprapubic trocars layout and "bottom to up dissection", realizing a CME with central vessel ligation and D3 lymphadenectomy. Site of primary tumor and lymphatic basin are visible with the FireflyTM camera modality.

RESULTS

From July 2016 to July 2020, 85 patients received a robotic right colectomy with CME and D3 lymphadenectomy. In 50 patients, ICG submucosal injection was performed: visualisation of the site of primary tumour and of LN in the D3 area was possible in all cases; in 17/50 patients (34%), LN out from anatomical lymphatic basin were identified. No side effects were observed.

CONCLUSIONS

In this series, submucosal ICG injection showed to be feasible and safe. The accuracy in identification of D3 lymphatic basin was high, thus permitting an image-guided radical lymphadenectomy. Fluorescent technology represents an interesting innovation to ameliorate surgery of colon cancer.

The Role of Hyperthermic Intraperitoneal Chemotherapy for Non-colorectal Peritoneal Surface Malignancies

BACKGROUND

Peritoneal carcinomatosis, from a variety of gastrointestinal and gynecological malignancies, has been historically challenging to treat and there remains a wide range of biologic aggressiveness in these patients. Malignancies commonly associated with PC include those of colorectal, appendiceal, gastric, ovarian, sarcoma, small intestinal, and primary peritoneal origin among others. Advances in our understanding of this unique disease process have led to significant interest in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) as an emerging treatment option. The goal of CRS-HIPEC is to remove all visible macroscopic disease while preserving organ function, and then treat microscopic disease through perfusion of the peritoneal cavity with heated chemotherapy.

PURPOSE

Although recent reviews have focused on the management of peritoneal carcinomatosis secondary to colorectal cancer given the publication of several recent randomized controlled trials, the purpose of the current review is to summarize the evidence on CRS-HIPEC for non-colorectal peritoneal surface malignancies, including appendiceal neoplasms, malignant peritoneal mesothelioma, gastric cancer, and ovarian cancer.

RESULTS

While retrospective studies have clarified the importance of prognostic factors such as the peritoneal carcinomatosis index, completeness of cytoreduction, histopathological characteristics, and lymph node positivity, the lack of convincing level 1 evidence for the use of CRS-HIPEC has led to it remaining a highly controversial topic.

CONCLUSION

The decision to utilize CRS-HIPEC should involve a multidisciplinary team approach and evaluation of prognostic factors to balance the short-term morbidity of the operation with maximum long-term benefits. Large, multi-institutional groups and ongoing trials hold promise for clarifying the role of CRS-HIPEC in peritoneal surface malignancies.

Application of Carbon Nanoparticles in Tracing Lymph Nodes and Locating Tumors in Colorectal Cancer: A Concise Review

Background

Accurate lymph node (LN) staging has considerably prognostic and therapeutic value in patients with colorectal cancer (CRC). The purpose of this study is to evaluate the feasibility of applying carbon nanoparticles (CNPs) to track LN metastases in CRC.

Methods

Two researchers independently screened publications in PubMed, EMBASE, Cochrane and Ovid MEDLINE databases. The keywords were (carbon nanoparticles OR activated carbon nanoparticles) AND (colon cancer OR rectal cancer OR colorectal cancer). Titles and abstracts of the articles were meticulously read to rule out potential publications. Next, full texts of the ultimately obtained eligible publications were retrieved and analyzed in detail.

Results

The search produced 268 publications, and 140 abstracts were identified after a bibliographic review. Finally, 20 studies relevant to our subject were obtained; however, only 14 papers met our inclusion criteria and were included for final review. All studies included have compared the control group with carbon nanoparticles group (control group, defined as nontattooed group; and carbon nanoparticles group, defined as administering carbon nanoparticles during surgery) for their efficacy in intraoperative detecting and positioning. After analysis, appreciably less amount of bleeding (3/5 trials), shorter operation time (2/4 trials), and shorter time to detect lesions and dissect LNs (2/2 trials) were revealed in CNPs group compared to control group. Thirteen studies have recorded the numbers of the harvested LNs in both groups; meanwhile, CNPs group shows superiority to control group in LN retrieval as well (11/13 trials), which also could effectively aid in locating and harvesting more LNs with diameter below 5 mm.

Conclusion

The tracing technique for CNPs is a safe and useful strategy both in localizing tumor and tracing LNs in CRC surgery. But there is still a need for more randomized controlled trials to further establish its contribution to patient survival.

Selecting the number of categories of the lymph node ratio in cancer research: A bootstrap-based hypothesis test

The high impact of the lymph node ratio as a prognostic factor is widely established in colorectal cancer, and is being used as a categorized predictor variable in several studies. However, the cut-off points as well as the number of categories considered differ considerably in the literature. Motivated by the need to obtain the best categorization of the lymph node ratio as a predictor of mortality in colorectal cancer patients, we propose a method to select the best number of categories for a continuous variable in a logistic regression framework. Thus, to this end, we propose a bootstrap-based hypothesis test, together with a new estimation algorithm for the optimal location of the cut-off points called BackAddFor, which is an updated version of the previously proposed AddFor algorithm. The performance of the hypothesis test was evaluated by means of a simulation study, under different scenarios, yielding type I errors close to the nominal errors and good power values whenever a meaningful difference in terms of prediction ability existed. Finally, the methodology proposed was applied to the CCR-CARESS study where the lymph node ratio was included as a predictor of five-year mortality, resulting in the selection of three categories.

Prognostic Factors Affecting Short- and Long-Term Recurrence-Free Survival of Patients with Rectal Cancer using Cure Models: A Cohort Study

Background:

Understanding the prognostic factors affecting the recurrence-free survival (RFS) of patients with rectal cancer (RC) is the mainstay of care. The present study aimed to identify factors affecting both short- and long-term RFS of patients with RC using semiparametric mixture cure models.

Methods:

The data were obtained from the database of the Colorectal Research Center of Shiraz University of Medical Sciences, Shiraz, Iran, which was collected during 2007-2017. To determine the factors affecting recurrence, cure models were applied to short-term and long-term RFS of patients with RC separately. The cure rate was calculated using the smcure package in R 3.5.1 (2018-07-02) software. P<0.05 was considered statistically significant.

Results:

Out of the 376 eligible patients with RC, 75.8% of men and 74.5% of women were long-term survivors. The mean age of the patients was 57.0±13.8 years. Lymph node ratio (LNR)≤0.2 increased the probability of short-term RFS. The prominent factors affecting long-term RFS were body mass index (BMI)<25 kg/m² (OR=1.98, P=0.047), tumor-node-metastasis (TNM) stage (OR=6.48, P<0.001), abdominal pain (OR=2.15, P=0.007), and computed tomography (CT) scan detected pelvic lymph nodes (OR=3.40, P=0.01). Over a 9-year follow-up period, the empirical and estimated values of cure rates were 75.3% and 83.9%, respectively.

Conclusion:

The results showed that factors affecting short-term RFS might be different from long-term RFS. A lower BMI was related to a poorer prognosis in patients with RC. Early diagnosis leads to a lower TNM stage and could increase the probability of long-term RFS.

Stratification of Stage III colon cancer may identify a patient group not requiring adjuvant chemotherapy

Purpose

Adjuvant chemotherapy for colon cancer with lymph node involvement (Stage III) has been the standard of care since the 1990s. Meanwhile, considerable evolvement of surgery combined with dedicated histopathological examinations may have led to stage migration. Furthermore, prognostic factors other than lymph node involvement have proven to affect overall survival. Thus, adjuvant chemotherapy in Stage III colon cancer should be reconsidered. The objective was to compare recurrence rates and survival in stage III colon cancer patients treated with or without adjuvant chemotherapy. Further, to assess the impact of extensive mesenterectomy, lymph node stage and vascular invasion on outcome.

Methods

Consecutive patients operated for Stage III colon carcinoma between 31 December 2005 and 31 December 2015 were identified in the pathological code register by matching colon (T67) and either adenocarcinoma (M81403) or mucinous adenocarcinoma (M84803), with lymph node (T08) and metastasis of adenocarcinoma (M81406 or M84806). Medical records of all identified patients were reviewed.

Results

Of 216 identified patients, 69 received no postoperative adjuvant chemotherapy (group NC), 69 insufficient adjuvant chemotherapy (FLV or < minimum recommended 6 cycles FLOX, group IC), and 78 sufficient adjuvant chemotherapy (≥ 6 cycles FLOX, group SC). When adjusted for age and comorbidity, 5-year overall survival did not differ statistically significant between groups (76% vs. 83% vs. 85%, respectively). Vascular invasion and a high lymph node ratio significantly reduced overall survival.

Conclusion

The findings imply that subgroups of Stage III colon cancer patients have good prognosis also without adjuvant chemotherapy. For definite conclusions about necessity of adjuvant chemotherapy, prospective trials are needed.

Significance of lymph node ratio on survival of women with borderline ovarian tumors

PURPOSE

To assess the qualitative and quantitative measures of the effect of pelvic lymph node involvement on survival of women with borderline ovarian tumors (BOTs).

METHODS

This is a retrospective study examining the Surveillance, Epidemiology, and End Results Program between 1988 and 2003. Women with stage T1-3 BOTs who had results of pelvic lymph node status at surgery were included. The effect of lymph node involvement on cause-specific survival (CSS) was evaluated using multivariable analysis with the following approaches: (1) any involvement, (2) involvement of multiple nodes (≥ 2 nodes), and (3) lymph node ratio (LNR), defined as the ratio of the number of tumor-containing lymph nodes to the total number of harvested lymph nodes.

RESULTS

A total of 1524 women were examined for analysis. Median count of sampled nodes was 8 (interquartile range 3-15), and there were 81 (5.3%, 95% confidence interval [CI] 4.2-6.4) women who had lymph node involvement. Median follow-up was 15.8 (interquartile range 13.8-18.9) years, and 83 (5.4%) women died of BOTs. After controlling for age, histology, stage, and tumor size, only LNR remained an independent prognostic factor for decreased CSS (adjusted hazard ratio [HR] per percentage unit 1.015, 95% CI 1.003-1.026, P = 0.014), whereas any involvement (adjusted HR 1.700, 95% CI 0.843-3.430, P = 0.138) and involvement of multiple nodes (adjusted HR 1.644, 95% CI 0.707-3.823, P = 0.249) did not. On cutoff analysis, LNR ≥ 13% had the largest magnitude of significance on multivariable analysis of CSS (adjusted HR 2.399, 95% CI 1.163-4.947, P = 0.018).

CONCLUSION

Our study suggests that high pelvic LNR may be a prognostic factor associated with decreased CSS in women with BOTs.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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