The Characteristics, Prognosis, and Risk Factors of Lymph Node Metastasis in Early Gastric Cancer. Gastroenterol Res Pract. 2018;2018:6945743. [PMID: 29853864 PMCID: PMC5954923 DOI: 10.1155/2018/6945743]

Establishment and validation of a risk score model based on EUS: assessment of lymph node metastasis in early gastric cancer

BACKGROUND AND AIMS

Lymph node metastasis significantly affects the prognosis of early gastric cancer patients. EUS plays a crucial role in the preoperative assessment of early gastric cancer. This study evaluated the efficacy of EUS in identifying lymph node metastasis in early gastric cancer patients and developed a risk score model to aid in choosing the best treatment options.

METHODS

We retrospectively analyzed the effectiveness of EUS for detecting lymph node metastasis in early gastric cancer patients. A risk score model for predicting lymph node metastasis preoperatively was created using independent risk factors identified through binary logistic regression analysis and subsequently validated. Receiver operating characteristic curves were generated for both the development and validation cohorts.

RESULTS

The overall accuracy of EUS in identifying lymph node metastasis was 85.3%, although its sensitivity (29.2%) and positive predictive value (38.7%) were relatively low. Patients were categorized based on preoperative risk factors for lymph node metastasis, including tumor size of ≥20 mm, lymph nodes of ≥10 mm, body mass index of ≥24 kg/m2, and lymph node metastasis on CT scans. A 7-point risk score model was developed to assess the likelihood of lymph node metastasis. The areas under the receiver operating characteristic curve for the development and validation sets were 0.842 and 0.837, respectively, with sensitivities of 64% and 79%, respectively.

CONCLUSIONS

We developed a practical risk score model based on preoperative factors to help EUS predict lymph node metastasis in early gastric cancer patients, guiding the selection of optimal treatment approaches for these patients.

Inverse association between age and risk of lymph node metastasis in patients with early gastric cancer: a surveillance, epidemiology, and end results analysis

Background: Recent studies have shown that young patients with gastric cancer are at a more advanced stage and have poor survival, but the cause is still unclear. The prognosis of gastric cancer is closely related to LNM, but the relationship between age and LNM in early gastric cancer (EGC) is currently unclear. Therefore, we aimed to study the relationship between age and the risk of LNM in EGC. Materials and Methods: We screened out patients with EGC who underwent surgery from the SEER research database from 1975 to 2016, and retrospectively analyzed the proportion of LNM in different age groups. We grouped age into 18-39, 40-49, 50-59, 60-69, 70-79, and ≥ 80 years old, and used univariate analysis and multivariate logistic regression to analyze the correlation between age and LNM. Results: We included 9231 patients with EGC, with LNM rates of 20.3%, 23.3%, 21.0%, 19.8%, 18.1%, and 13.2% in the age groups of 18-39 years old (2.3%), 40-49 (6.1%), 50-59 years old (15.7%), 60-69 years old (24.8%), 70-79 years old (27.2%) and ≥80 years old (23.9%), respectively. We found that when older than 39 years old, the risk of LNM and postoperative survival time of EGC patients decrease (p<0.001). Multivariate analysis results showed that age, tumor size, the number of retrieved lymph nodes (rN), tumor grade, and tumor location were related to LNM. Conclusions: This study found that age in patients with EGC was inversely related to the risk of LNM, and positively correlated with postoperative survival. For older patients with EGC, endoscopic treatment is more appropriate. For young patients with EGC, LNM should be considered when choosing endoscopic treatment.

Assessment of risk factors of lymph node metastasis and prognosis of Siewert II/III adenocarcinoma of esophagogastric junction: A retrospective study

Adenocarcinoma of the esophagogastric junction (AEG) has a high incidence, and the extent of lymph node dissection (LND) and its impact on prognosis remain controversial. This study aimed to explore the risk factors for lymph node metastasis (LNM) and prognosis in Siewert II/III AEG patients. A retrospective review of 239 Siewert II/III AEG patients surgically treated at Beijing Friendship Hospital from July 2013 to December 2022 was conducted. Preoperative staging was conducted via endoscopy, ultrasound gastroscopy, CT, and biopsy. Depending on the stage, patients received radical gastrectomy with LND and chemotherapy. Clinicopathological data were collected, and survival was monitored semiannually until November 2023. Utilizing logistic regression for data analysis and Cox regression for survival studies, multivariate analysis identified infiltration depth (OR = 0.038, 95% CI: 0.011-0.139, P < .001), tumor deposit (OR = 0.101, 95% CI: 0.011-0.904, P = .040), and intravascular cancer embolus (OR = 0.234, 95% CI: 0.108-0.507, P < .001) as independent predictors of LNM. Lymph nodes No. 1, 2, 3, 4, 7, 10, and 11 were more prone to metastasis in the abdominal cavity. Notably, Siewert III AEG patients showed a higher metastatic rate in nodes No. 5 and No. 6 compared to Siewert II. Mediastinal LNM was predominantly found in nodes No. 110 and No. 111 for Siewert II AEG, with rates of 5.45% and 3.64%, respectively. A 3-year survival analysis underscored LNM as a significant prognostic factor (P = .001). Siewert II AEG patients should undergo removal of both celiac and mediastinal lymph nodes, specifically nodes No. 1, 2, 3, 4, 7, 10, 11, 110, and 111. Dissection of nodes No. 5 and No. 6 is not indicated for these patients. In contrast, Siewert III AEG patients do not require mediastinal LND, but pyloric lymphadenectomy for nodes No. 5 and No. 6 is essential. The presence of LNM is associated with poorer long-term prognosis. Perioperative chemotherapy may offer a survival advantage for AEG patients.

Prediction of lymph node metastasis in early gastric signet-ring cell carcinoma: A real-world retrospective cohort study

BACKGROUND

Signet-ring cell carcinoma (SRCC) was previously thought to have a worse prognosis than other differentiated gastric cancer (GC), however, recent studies have shown that the prognosis of SRCC is related to pathological type. We hypothesize that patients with SRCC and with different SRCC pathological components have different probability of lymph node metastasis (LNM).

AIM

To establish models to predict LNM in early GC (EGC), including early gastric SRCC.

METHODS

Clinical data from EGC patients who had undergone gastrectomy at the First Affiliated Hospital of Nanjing Medical University from January 2012 to March 2022 were reviewed. The patients were divided into three groups based on type: Pure SRCC, mixed SRCC, and non-signet ring cell carcinoma (NSRC). The risk factors were identified through statistical tests using SPSS 23.0, R, and Em-powerStats software.

RESULTS

A total of 1922 subjects with EGC were enrolled in this study, and included 249 SRCC patients and 1673 NSRC patients, while 278 of the patients (14.46%) presented with LNM. Multivariable analysis showed that gender, tumor size, depth of invasion, lymphovascular invasion, ulceration, and histological subtype were independent risk factors for LNM in EGC. Establishment and analysis using prediction models of EGC showed that the artificial neural network model was better than the logistic regression model in terms of sensitivity and accuracy (98.0% vs 58.1%, P = 0.034; 88.4% vs 86.8%, P < 0.001, respectively). Among the 249 SRCC patients, LNM was more common in mixed (35.06%) rather than in pure SRCC (8.42%, P < 0.001). The area under the ROC curve of the logistic regression model for LNM in SRCC was 0.760 (95%CI: 0.682-0.843), while the area under the operating characteristic curve of the internal validation set was 0.734 (95%CI: 0.643-0.826). The subgroups analysis of pure types showed that LNM was more common in patients with a tumor size > 2 cm (OR = 5.422, P = 0.038).

CONCLUSION

A validated prediction model was developed to recognize the risk of LNM in EGC and early gastric SRCC, which can aid in pre-surgical decision making of the best method of treatment for patients.

Predictive factors of lymphatic metastasis and evaluation of the Japanese treatment guidelines for endoscopic resection of early gastric cancer in a high-volume center in Perú

Purpose

This study aimed to identify the predictive factors of lymph node metastasis (LNM) in patients with early gastric cancer (EGC) and to evaluate the applicability of the Japanese treatment guidelines for endoscopic resection in the western population.

Methods

Five hundred-one patients with pathological diagnoses of EGC were included. Univariate and multivariate analyses were conducted to identify the predictive factors of LNM. EGC patients were distributed according to the indications for endoscopic resection of the Eastern guidelines. The incidence of LNM was evaluated in each group.

Results

From 501 patients with EGC, 96 (19.2%) presented LNM. In 279 patients with tumors with submucosal infiltration (T1b), 83 (30%) patients had LNM. Among 219 patients who presented tumors > 3 cm, 63 (29%) patients had LNM. Thirty-one percent of patients with ulcerated tumors presented LMN (33 out of 105). In 76 patients and 24 patients with lymphovascular and perineural invasion, the percentage of LMN was 84% and 87%, respectively. In the multivariate analysis, a tumor diameter >3 cm, submucosal invasion, lymphovascular, and perineural invasion were independent predictors of LMN in EGC. No patient with differentiated, non-ulcerated mucosal tumors presented LNM regardless of tumor size. Three of 17 patients (18%) with differentiated, ulcerated mucosal tumors and ≤ 3 cm presented LNM. No LNM was evidenced in patients with undifferentiated mucosal tumors and ≤ 2 cm.

Conclusions

The presence of LNM in Western EGC patients was independently related to larger tumors (>3 cm), submucosal invasion, lymphovascular and perineural invasion. The Japanese absolute indications for EMR are safe in the Western population. Likewise, Western patients with differentiated, non-ulcerated mucosal tumors, and larger than 2 cm are susceptible to endoscopic resection. Patients with undifferentiated mucosal tumors smaller than 2 cm presented encouraging results and ESD could be recommended only for selected cases.

High risk factors related to lymph node metastasis in early gastric cancer: A retrospective observational study

Lymph node metastasis (LNM) is a key factor affecting the prognosis of patients with early gastric cancer. This is a retrospective study, conducted between January 20, 2010 and January 30, 2019 and included 402 patients with early-stage gastric cancer who underwent radical gastrectomy at The Affiliated People Hospital of Ningbo University. Clinical and pathological data including patients' gender, age, tumor location, gross typing, depth of invasion, tumor maximum diameter, type of differentiation, vascular invasion, presence or absence of signet ring cells, and LNM data were collected and analyzed. Univariate analysis identified positive relationships between patient gender, tumor invasion depth, tumor size, presence or absence of vascular involvement, and differentiation type with LNM (P < .05). Multivariate analysis subsequently confirmed tumor size (odds ratio [OR]: 2.38, 95% confidence interval [CI]:1.15-4.92, P = .02), vascular involvement (OR: 4.35, 95% CI: 2.00-9.47, P < .001), and depth of invasion (OR: 6.63, 95% CI: 2.19-20.06, P = .001) as independent risk factors for LNM (P < .05). Tumor size, vascular involvement, and depth of invasion are independent risk factors for LNM in cases of early-stage gastric cancer.

Analysis of risk factors for lymph node metastasis and prognosis study in patients with early gastric cancer: A SEER data-based study

Background

Lymph node status is an important factor in determining the prognosis of patients with early gastric cancer (EGC) and preoperative diagnosis of lymph node metastasis (LNM) has some limitations. This study explored the risk factors and independent prognostic factors of LNM in EGC patients and constructed a clinical prediction model to predict LNM.

Methods

Clinicopathological data of EGC patients was collected from the public Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate logistic regression was used to identify risk factors for LNM in EGC patients. The performance of the LNM model was evaluated by C-index, calibration curve, receiver operating characteristic (ROC) curve, decision curve analysis (DCA) curve, and clinical impact curve (CIC) based on the results of multivariate regression to develop a nomogram. An independent data set was obtained from China for external validation. The Kaplan-Meier method and Cox regression model were used to identify potential prognostic factors for overall survival (OS) in EGC patients.

Results

A total of 3993 EGC patients were randomly allocated to a training cohort (n=2797) and a validation cohort (n=1196). An external cohort of 106 patients from the Second Hospital of Lanzhou University was used for external validation. Univariate and multivariate logistic regression showed that age, tumor size, differentiation, and examined lymph nodes count (ELNC) were independent risk factors for LNM. Nomogram for predicting LNM in EGC patients was developed and validated. The predictive model had a good discriminatory performance with a concordance index (C-index) of 0.702 (95% CI: 0.679-0.725). The calibration plots showed that the predicted LNM probabilities were the same as the actual observations in both the internal validation cohort and external validation cohort. The AUC values for the training cohort, internal validation cohort and external validation cohort were 0.702 (95% CI: 0.679-0.725), 0.709 (95% CI: 0.674-0.744) and 0.750(95% CI: 0.607-0.892), respectively, and the DCA curves and CIC showed good clinical applicability. The Cox regression model identified age, sex, race, primary site, size, pathological type, LNM, distant metastasis, and ELNC were prognostic factors for OS in EGC patients, while a year at diagnosis, grade, marital status, radiotherapy, and chemotherapy were not independent prognostic factors.

Conclusion

In this study, we identified risk factors and independent prognostic factors for the development of LNM in EGC patients, and developed a relatively accurate model to predict the development of LNM in EGC patients.

Endoscopic submucosal dissection for papillary early gastric carcinoma: Insights from a large-scale analysis of post-gastrectomy pathology specimens

Gastric papillary adenocarcinoma is considered a differentiated adenocarcinoma in the current endoscopic submucosal dissection indication guidelines. However, the safety of endoscopic submucosal dissection remains controversial. Currently, data regarding which papillary early gastric cancer should be considered for endoscopic submucosal dissection are unavailable. Thus, the aim of this study was to investigate lymph node metastasis and the safety of endoscopic submucosal dissection in patients with papillary early gastric cancer. This observational study recruited 4264 consecutive patients with early gastric cancer who underwent curative gastrectomy between October 2000 and December 2017 at the National Cancer Center, Korea. Of these, 45 had pathologically confirmed papillary early gastric cancer, 2106 had differentiated non-papillary early gastric cancer, and 2113 had undifferentiated early gastric cancer. Logistic regression analysis was performed to identify risk factors for lymph node metastasis. Mucosal tumors were less common in papillary early gastric cancer (37.9%) than in differentiated non-papillary early gastric cancer (48.8%) and undifferentiated early gastric cancer (60.4%) (both P < .001). Lymph node metastasis was more common in papillary early gastric cancer (20.0%) than in differentiated non-papillary early gastric cancer (9.2%) and undifferentiated early gastric cancer (11.7%; both P < .001). In multivariate analysis, non-mixed-type papillary early gastric cancer showed marginally increased odds of lymph node metastasis than differentiated early gastric cancer (odds ratio [OR]: 2.5, 95% confidence interval [CI]: 1.0-6.3). Rates of lymph node metastasis (1/10, 10%) and angiolymphatic invasion (2/10, 20%) for papillary early gastric cancer meeting expanded criteria were higher than those for other histology types meeting endoscopic submucosal dissection absolute or expanded criteria (P = .03 and P < .001, respectively). Endoscopic submucosal dissection should be considered carefully for papillary early gastric cancer, especially if it meets expanded endoscopic submucosal dissection indications since it is associated with high rates of submucosal invasion and lymph node metastasis.

Nomograms Involving HER2 for Predicting Lymph Node Metastasis in Early Gastric Cancer

Objective: We aimed to establish a nomogram for predicting lymph node metastasis in early gastric cancer (EGC) involving human epidermal growth factor receptor 2 (HER2).

Methods: We collected clinicopathological data of patients with EGC who underwent radical gastrectomy and D2 lymphadenectomy at Ruijin Hospital, Shanghai Jiao Tong University School of Medicine between January 2012 and August 2018. Univariate and multivariate logistic regression analysis were used to examine the relationship between lymph node metastasis and clinicopathological features. A nomogram was constructed based on a multivariate prediction model. Internal validation from the training set was performed using receiver operating characteristic (ROC) and calibration plots to evaluate discrimination and calibration, respectively. External validation from the validation set was utilized to examine the external validity of the prediction model using the ROC plot. A decision curve analysis was used to evaluate the benefit of the treatment.

Results: Among 1,212 patients with EGC, 210 (17.32%) presented with lymph node metastasis. Multivariable analysis showed that age, tumor size, submucosal invasion, histological subtype, and HER2 positivity were independent risk factors for lymph node metastasis in EGC. The area under the ROC curve of the model was 0.760 (95% CI: 0.719–0.800) in the training set (n = 794) and 0.771 (95% CI: 0.714–0.828) in the validation set (n = 418). A predictive nomogram was constructed based on a multivariable prediction model. The decision curve showed that using the prediction model to guide treatment had a higher net benefit than using endoscopic submucosal dissection (ESD) absolute criteria over a range of threshold probabilities.

Conclusion: A clinical prediction model and an effective nomogram with an integrated HER2 status were used to predict EGC lymph node metastasis with better accuracy and clinical performance.

Risk assessment of lymph node metastasis in early gastric cancer: Establishment and validation of a 7-point scoring model

BACKGROUND

Treatment options for early gastric cancer have evolved toward achieving accurate evaluation of lymph node metastasis. This study aimed to investigate risk factors of lymph node metastasis in patients with early gastric cancer and establish a risk score model to guide the selection of optimal treatment.

METHODS

The clinicopathological characteristics of 351 patients with early gastric cancer from January 2016 to December 2018 were reviewed retrospectively. On the basis of the independent risk factors determined by multivariate binary logistic regression analysis, we established a risk score model for predicting lymph node metastasis and then verified it. The receiver operating characteristic curves were plotted using the test and validation sets. The area under the receiver operating characteristic curve was used to assess the discriminant ability of the model.

RESULTS

Lymph node metastasis was observed in 10.5% (37/351) of early gastric cancer cases. Patients with early gastric cancer were grouped based on the independent risk factors for lymph node metastasis (tumor size, depth, histological type, and lymphovascular involvement) determined by multivariate analysis. A 7-point risk score model was established to predict the risk of lymph node metastasis. The area under the receiver operating characteristic curve in the development and validation sets were 0.839 (95% confidence interval, 0.769%-0.910%) and 0.820 (95% confidence interval, 0.711%-0.930%), respectively.

CONCLUSION

A feasible risk score model for lymph node metastasis was established to guide the optimal treatment of patients with early gastric cancer early gastric cancer.

A nomogram to predict risk of lymph node metastasis in early gastric cancer

Lymph node (LN) metastasis is known as one of the most important prognostic factors for early gastric cancer (EGC) patients. Patients without LNM normally have better prognosis. However, there is no evaluation criteria to accurately assess the possibility of LN metastasis. Therefore, this study aims to establish an effective nomogram for prognosis prediction. In this study, 285 EGC patients from January 2010 to December 2015 were enrolled. Pearson’s Chi-Square (χ²) test (including continuity correction when appropriate) and logistics regression analyses was used to identify the risk factors for LN metastasis. The independent risk factors identified were then incorporated in a nomogram model. The predictive accuracy and discriminative ability of the nomogram were evaluated by receiver operating characteristic curve (ROC) and calibration curve. LN metastasis occurred in 59 (20.7%) EGC patients. And most of these patients were submucosal cancers (48/59). Chi-square test indicated lymphovascular emboli, carbohydrate antigen 19-9 (CA19-9), ulcer, tumor size, tumor infiltration and histological grade were the risk factors, and multivariate logistics analyses confirmed all these six factors were independent risk factors of LN metastasis, which were selected to construct the nomogram. The nomogram proved well calibrated and had good discriminative ability (C-index value: 0.842). The proposed nomogram could result in more-accurate risk prediction for EGC patients.

Nomograms for Predicting the Lymph Node Metastasis in Early Gastric Cancer by Gender: A Retrospective Multicentric Study

Background

Lymph node metastasis (LNM) has a significant impact on the prognosis of patients with early gastric cancer (EGC). Our aim was to identify the independent risk factors for LNM and construct nomograms for male and female EGC patients, respectively.

Methods

Clinicopathological data of 1,742 EGC patients who underwent radical gastrectomy and lymphadenectomy in the First Affiliated Hospital, Second Affiliated Hospital, and Fourth Affiliated Hospital of Anhui Medical University between November 2011 and April 2021 were collected and analyzed retrospectively. Male and female patients from the First Affiliated Hospital of Anhui Medical University were assigned to training sets and then from the Second and Fourth Affiliated Hospitals of Anhui Medical University were enrolled in validation sets. Based on independent risk factors for LNM in male and female EGC patients from the training sets, the nomograms were established respectively, which was also verified by internal validation from the training sets and external validation from the validation sets.

Results

Tumor size (odd ratio (OR): 1.386, p = 0.030), depth of invasion (OR: 0.306, p = 0.001), Lauren type (OR: 2.816, p = 0.000), lymphovascular invasion (LVI) (OR: 0.160, p = 0.000), and menopause (OR: 0.296, p = 0.009) were independent risk factors for female EGC patients. For male EGC patients, tumor size (OR: 1.298, p = 0.007), depth of invasion (OR: 0.257, p = 0.000), tumor location (OR: 0.659, p = 0.002), WHO type (OR: 1.419, p = 0.001), Lauren type (OR: 3.099, p = 0.000), and LVI (OR: 0.131, p = 0.000) were independent risk factors. Moreover, nomograms were established to predict the risk of LNM for female and male EGC patients, respectively. The area under the ROC curve of nomograms for female and male training sets were 87.7% (95% confidence interval (CI): 0.8397–0.914) and 94.8% (95% CI: 0.9273–0.9695), respectively. For the validation set, they were 92.4% (95% CI: 0.7979–1) and 93.4% (95% CI: 0.8928–0.9755), respectively. Additionally, the calibration curves showed good agreements between the bias-corrected prediction and the ideal reference line for both training sets and validation sets in female and male EGC patients.

Conclusions

Nomograms based on risk factors for LNM in male and female EGC patients may provide new insights into the selection of appropriate treatment methods.

Is adjuvant chemotherapy necessary for early gastric cancer?

OBJECTIVE

To quantify the potential benefit of adjuvant chemotherapy (ACT) with respect to survival, and to identify factors for predicting prognoses in early gastric cancer patients.

METHODS

Patients with pT1 gastric cancer (GC) who underwent radical resection with D2 lymphadenectomy were retrospectively analyzed. Based on lymph node metastasis (LNM) status and treatment regimens, patients were classified into groups, and clinicopathological variables, overall survival (OS), and disease-specific survival (DSS) were compared.

RESULTS

Of 1,050 enrolled patients, 151 patients (14.4%) had a positive LNM status. Submucosal invasion, undifferentiated state, tumor size > 2 cm, ulceration, and lymphovascular invasion were independent risk factors for LNM using multivariate analyses. The 5-year OS of all patients was 96.4%. HER2 positive, perineural invasion, and LNM were independent factors for worse survival. Patients with pT1N3 GC had a worse 5-year OS and DSS than pT1N0, pT1N1, and pT1N2 patients (P < 0.001). The 5-year OS and DSS for pT1N1 patients showed no significant difference between ACT and surgery only patients. For pT1N2 patients, the 5-year OS and DSS showed no significant difference between S-1 and Xelox treatments. For pT1N3 patients, 7 (36.8%) received S-1, while 12 (63.2%) received Xelox treatment. Patients receiving Xelox treatment showed a better 5-year OS (75.0% vs. 14.3%) and DSS (81.8% vs. 20.0%) than patients receiving S-1 (P < 0.05).

CONCLUSIONS

Curative surgery only was adequate for patients with pT1N0 and pT1N1. Xelox showed no survival benefits for pT1N2 patients. Therefore, S-1 is the optimal choice for pT1N2 patients, when considering adverse effects. Xelox is recommended for pT1N3 patients.

Construction and Validation of a Risk-Scoring Model that Preoperatively Predicts Lymph Node Metastasis in Early Gastric Cancer Patients

OBJECTIVE

The aim of this study was to create a risk-scoring model to preoperatively predict the incidence of lymph node metastasis (LNM) in early gastric cancer (EGC) patients to guide treatment.

METHODS

To construct the risk-scoring model, we retrospectively analyzed a primary cohort of 548 EGC patients. Univariate analysis and logistic regression were performed. A risk-scoring model for predicting LNM in EGC patients was developed based on preoperative factors, and another cohort of 73 patients was then analyzed to validate the model.

RESULTS

In the primary cohort, LNM was pathologically confirmed in 72 (13.1%) patients. In the multivariate analysis, the presence of ulceration and tumor size on gastroscopy, undifferentiated histological type, and presence of enlarged lymph nodes on computed tomography or endoscopic ultrasonography were independent risk factors for LNM. A 17-point risk-scoring model was developed to predict LNM risk. The cut-off score of the model was 8, and the area under the receiver operating characteristic curve (AUC) of the model was 0.835 [95% confidence interval (CI) 0.784-0.886]. In the validation cohort, the AUC of the model was 0.829 (95% CI 0.699-0.959).

CONCLUSIONS

We developed and validated an effective 17-point risk-scoring model that could preoperatively predict LNM for EGC patients.

Establishment and verification of a nomogram for predicting the risk of lymph node metastasis in early gastric cancer

BACKGROUND

endoscopic submucosal dissection (ESD) has been widely recognized by patients and doctors due to its advantages in early gastric cancer (EGC). The accurate prediction of the risk of lymph node metastasis (LNM) in EGC is important to select suitable treatments with this procedure for patients. Unfortunately, the accuracy of endoscopic ultrasound and computed tomography in the diagnosis of EGC lymph node status is extremely limited. The purpose of the present study was to establish an LNM nomogram risk model of early gastric cancer patients based on clinical data, to guide treatment for clinicians.

METHODS

a retrospective examination of the records of EGC patients undergoing radical gastrectomy from August 2012 to August 2019 in the Gastrointestinal Center of Subei People's Hospital was performed. The clinicopathological data were classified into a training set and validation set according to the time. Univariate and multivariate analyses were performed to identify risk factors related to LNM. A risk model for predicting the occurrence of LNM in EGC was established and validated.

RESULTS

of the 503 EGC patients, 78 (15.5 %) had lymph node metastasis. Logistic stepwise regression analysis showed that the predictive factors included sex, tumor location, tumor diameter, differentiation, ulcer and lymphatic vascular invasion. The discrimination of the LNM prediction model was satisfactory with an AUC of 0.8033 (internal validation) and 0.7353 (external validation). The correction effect of the calibration was satisfactory and the DCA decision curve analysis showed a strong clinical practicability.

CONCLUSION

the nomogram risk prediction model of LNM has been established for EGC patients to assist in formulating personalized treatment plans.

Large population-based study using the SEER database: is endoscopic resection appropriate for early gastric cancer patients in the United States?

AIM

To investigate whether endoscopic treatment is applicable to American patients and explores the predictors of lymph node metastasis (LNM) in early gastric cancer (EGC).

METHODS

Patients with EGC confined to either mucosa (T1a, n = 1799) and submucosa (T1b, n = 1689) were identified from the Surveillance, Epidemiology, and End Result database. Multivariate logistic regression, Kaplan-Meier method, and univariate/multivariate Cox regression were used to assess the correlation between invasion depth and LNM or prognosis. A nomogram for predicting LNM was constructed and internally validated.

RESULTS

EGC limited to T1a exhibited a 2.4% incidence of LNM, which increased to 11.1% when the depth invaded T1b.LNM was present at 1.4%, 5.2%, and 5.0% for sizes ≤2, 2-5, and >5cm of low-grade T1a EGC, respectively, (p = .019) and at 4.8%, 12.4%, and 28.6% of T1b EGC, respectively (p  < .001).The multivariate logistic model revealed that older age, T1b invasion, larger tumor size, and high-grade lesions were associated with a higher risk of LNM. Moreover, the T1a EGC patients had better cancer-specific survival (OS) and overall survival(CSS) compared with the T1b EGC patients (5-year OS: 77.2% versus 67.4%, p < .001; 5-year CSS: 90.6% versus 81.4%, p < .001). The discrimination of the prediction model was 0.745.

CONCLUSIONS

Endoscopic treatment may only be suitable for patients in the US population who have low-grade T1a lesions of less than 2 cm in size. Patients with T1a lesions of greater than 2 cm in size, lesions with high-grade, and all T1b lesions may benefit from radical surgical resection with lymphadenectomy.

Association of TMPRSS4 expression with prognosis in gastric cancer based on data from Oncomine and Kaplan-Meier plotter databases

BACKGROUND

Gastric cancer (GC) is one of the leading causes of cancer related death worldwide and the most frequently diagnosed malignancy of the digestive system. However, the factors related to GC prognosis are not clear yet. In this study, we investigated a potential biomarker for GC prognosis through bioinformatics analysis.

AIM

To investigate the transmembrane protease serine 4 (TMPRSS4) mRNA expression in GC through data mining of the Oncomine and Kaplan-Meier Plotter databases.

METHODS

TMPRSS4 gene expression in GC was investigated and compared between cancer and normal gastric tissues in the Oncomie and Kaplan-Meier Plotter data platforms. The survival curves were drawn to compare the survival time of patients with high and low expression of TMPRSS4, and to explore the feasibility of TMPRSS4 as a prognostic molecular marker in patients with GC. Meanwhile, the clinical data of 50 patients with GC treated by surgery were retrospectively analyzed. The expression of TMPRSS4 protein in these 50 patients with GC was examined by immunohistochemistry. The correlation between TMPRSS4 expression and clinical characteristics was analyzed.

RESULTS

The Oncomine database contained 185 datasets on the TMPRSS4 expression in GC, breast cancer, and other common cancer tissues and corresponding normal tissues. There are 10 datasets on differentially expressed TMPRSS4, of which 9 showed highly expressed TMPRSS4 in cancer tissues, and 1 showed lowly expressed TMPRSS4 in cancer tissues. Hierarchical cluster analysis showed that genes co-expressed with TMPRSS4 in GC were LAMB3, LAD1, ANXA4, etc. The co-expression correlation coefficients of TMPRSS4 with LAMB3, LAD1, and ANXA4 were 0.57, 0.51, and 0.43, respectively. TMPRSS4 may have similar functions to LAMB3, LAD1, ANXA4, and other co-expressed genes. In the Oncomine database, three gene expression microarray datasets were used to study the differential expression of TMPRSS4 gene in GC tissues and normal tissues. The results showed that the expression level of TMPRSS4 in GC tissues was higher than that in normal gastric tissues (P < 0.05). Kaplan-Meier Plotter analysis showed that the total median survival time of the high and low TMPRSS4 expression groups was 22.0 mo and 32.6 mo, respectively, and the median survival time of the high expression group was significantly lower than that of the low expression group (HR = 1.31, 95%CI: 1.09-1.57, P < 0.05). The median disease-free survival time of the high expression group was also significantly lower than that of the low expression group (13.87 mo vs 22.40 mo, HR = 1.27, 95%CI: 1.03-1.58, P < 0.05). Immunohistochemistry showed that the positive expression of TMPRSS4 was correlated with vascular invasion. The percentage of TMPRSS4 positive patients with vascular invasion was significantly higher than that of TMPRSS4 negative patients (P < 0.05).

CONCLUSION

Compared with normal gastric tissues, the expression level of TMPRSS4 gene in GC tissues is significantly up-regulated. The high expression of TMPRSS4 gene is associated with vascular invasion and a poor prognosis in GC patients.

Feasibility of endoscopic treatment and predictors of lymph node metastasis in early gastric cancer

BACKGROUND

Endoscopic submucosal dissection (ESD) has been routinely performed in applicable early gastric cancer (EGC) patients as an alternative to conventional surgical operations that involve lymph node dissection. The indications for ESD have been recently expanded to include larger, ulcerated, and undifferentiated mucosal lesions, and differentiated lesions with slight submucosal invasion. The risk of lymph node metastasis (LNM) is the most important consideration when deciding on a treatment strategy for EGC. Despite the advantages over surgical procedures, lymph nodes cannot be removed by ESD. In addition, whether patients who meet the expanded indications for ESD can be managed safely remains controversial.

AIM

To determine whether the ESD indications are applicable to Chinese patients and to investigate the predictors of LNM in EGC.

METHODS

We retrospectively analyzed 12552 patients who underwent surgery for gastric cancer between June 2007 and December 2018 at the Affiliated Hospital of Qingdao University. A total of 1262 (10.1%) EGC patients were eligible for inclusion in this study. Data on the patients’ clinical, endoscopic, and histopathological characteristics were collected. The absolute and expanded indications for ESD were validated by regrouping the enrolled patients and determining the positive LNM results in each subgroup. Predictors of LNM in patients were evaluated by univariate and multivariate analyses.

RESULTS

LNM was observed in 182 (14.4%) patients. No LNM was detected in the patients who met the absolute indications (0/90). LNM occurred in 4/311 (1.3%) patients who met the expanded indications. According to univariate analysis, LNM was significantly associated with positive tumor marker status, medium (20-30 mm) and large (>30 mm) lesion sizes, excavated macroscopic-type tumors, ulcer presence, submucosal invasion (SM1 and SM2), poor differentiation, lymphovascular invasion (LVI), perineural invasion, and diffuse and mixed Lauren’s types. Multivariate analysis demonstrated SM1 invasion (odds ration [OR] = 2.285, P = 0.03), SM2 invasion (OR = 3.230, P < 0.001), LVI (OR = 15.702, P < 0.001), mucinous adenocarcinoma (OR = 2.823, P = 0.015), and large lesion size (OR = 1.900, P = 0.006) to be independent risk factors.

CONCLUSION

The absolute indications for ESD are reasonable, and the feasibility of expanding the indications for ESD requires further investigation. The predictors of LNM include invasion depth, LVI, mucinous adenocarcinoma, and lesion size.

Lysophosphatidic acid induces the migration and invasion of SGC-7901 gastric cancer cells through the LPA2 and Notch signaling pathways

Lysophosphatidic acid (LPA), a simple water‑soluble glycerophospholipid with growth factor‑like activity, regulates certain behaviors of multiple cancer types by binding to its receptor, LPA receptor 2 (LPA2). Notch1 is a key mediator in multiple human cancer cell types. The association between LPA2 and Notch1 in gastric cancer cells is not well known. The present study aimed to investigate the function of LPA2 and Notch1 in controlling the migration and invasion activities of SGC‑7901 gastric cancer cells following stimulation with LPA. It was revealed that LPA may stimulate the expression of Notch1 and Hes family bHLH transcription factor 1, and the phosphorylation of protein kinase B which belongs to the Notch pathway. Furthermore, by performing transwell migration and invasion assays, immunofluorescent staining, analyzing the expression of markers for the epithelial‑mesenchymal transition (EMT) and downregulating LPA2 and Notch1 expression, it was verified that LPA2 and Notch1 mediated the metastasis, invasion, EMT and rebuilding of the cytoskeleton of SGC‑7901 cells upon LPA treatment. An immunoprecipitation assay revealed that LPA2 interacted with Notch1 in SGC‑7901 cells. The present study may provide novel ideas and an experimental basis for identifying the factors that affect the functions of SGC‑7901 cells.

Histone deacetylase-1 as a prognostic factor and mediator of gastric cancer progression by enhancing glycolysis

Histone deacetylase 1 (HDAC1) has been shown to be closely associated with tumor development. We investigated its effects on survival and biological behavior in gastric cancer (GC). HDAC1 expression and glycolysis activity were analyzed in a cohort of 252 samples of primary GC tumors and in vitro study. High HDAC1 (HDAC1^High) staining was seen in 60.7% patients with GCs, which was significantly greater than was seen in normal epithelial cells (19.4%; P < .005). HDAC1^High expression was associated with larger tumor size (P = .001), advanced T stage (P = .001), lymph node metastases (N stage; P < .001), and lymphovascular invasion (P = .005). Univariate and multivariate survival analyses showed HDAC1 expression to be an independent prognostic factor for both disease-free survival and overall survival (P < .05). In vitro studies showed a notably decreased glycolysis rate in HDAC1 knockdown cells. In patients' samples, HDAC1^High expression was always accompanied with high Maximal standardized uptake value (SUVmax) value (P < .05). A hypoxia-inducible factor (HIF)-1α response element-luciferase reporter system showed HDAC1 to affect HIF1α activity in a dose-dependent manner. In conclusion, HDAC1 promotes glycolysis in GC and affects HIF-1α activity in tumor progression and metastasis. HDAC1^High expression was also an independent adverse prognostic factor for overall survival and disease-free survival.

Construction and external validation of a nomogram that predicts lymph node metastasis in early gastric cancer patients using preoperative parameters

Objective

To create a nomogram to predict the incidence of lymph node metastasis (LNM) in early gastric cancer (EGC) patients and to externally validate the nomogram.

Methods

To construct the nomogram, we retrospectively analyzed a primary cohort of 272 EGC patients. Univariate analysis and a binary logistic regression were performed. A nomogram predicting the incidence of LNM in EGC patients was created. The discrimination ability of the nomogram was measured using the concordance index (c-index), and the nomogram was also calibrated. Then, another prospective cohort of 81 patients was analyzed to validate the nomogram.

Results

In the primary cohort, LNM was pathologically confirmed in 37 (13.6%) patients. In multivariate analysis, the presence of an ulcer, the maximum lesion diameter observed via gastroscopy, the thickness of the lesion observed via endoscopic ultrasonography, and the presence of enlarged lymph nodes on computed tomography (CT) were independent risk factors for LNM. A nomogram was then created based on the regression model with the c-index of 0.905, and the calibration curve of the nomogram fell approximately on the ideal 45-degree line. The cut-off score of the nomogram was 110, and the sensitivity, specificity, positive predictive and negative predictive values of the nomogram in the primary cohort were 81.1%, 86.0%, 47.6% and 96.7%, respectively, and in the prospective validation cohort were 75.0%, 91.0%, 60.0% and 95.5%, respectively. The calibration curve of the external validation cohort was almost on the 45-degree line.

Conclusions

We developed an effective nomogram predicting the incidence of LNM for EGC patients.