1
|
Beirat AF, Amarin JZ, Suradi HH, Qwaider YZ, Muhanna A, Maraqa B, Al-Ani A, Al-Hussaini M. Lymph node ratio is a more robust predictor of overall survival than N stage in stage III colorectal adenocarcinoma. Diagn Pathol 2024; 19:44. [PMID: 38419109 PMCID: PMC10900724 DOI: 10.1186/s13000-024-01449-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 01/16/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Lymph node ratio (LNR) may offer superior prognostic stratification in colorectal adenocarcinoma compared with N stage. However, candidate cutoff ratios require validation. We aimed to study the prognostic significance of LNR and its optimal cutoff ratio. METHODS We reviewed the pathology records of all patients with stage III colorectal adenocarcinoma who were managed at the King Hussein Cancer Center between January 2014 and December 2019. We then studied the clinical characteristics of the patients, correlates of lymph node count, prognostic significance of positive lymph nodes, and value of sampling additional lymph nodes. RESULTS Among 226 included patients, 94.2% had ≥ 12 lymph nodes sampled, while 5.8% had < 12 sampled lymph nodes. The median number of lymph nodes sampled varied according to tumor site, neoadjuvant therapy, and the grossing pathologist's level of training. According to the TNM system, 142 cases were N1 (62.8%) and 84 were N2 (37.2%). Survival distributions differed according to LNR at 10% (p = 0.022), and 16% (p < 0.001), but not the N stage (p = 0.065). Adjusted Cox-regression analyses demonstrated that both N stage and LNR at 10% and 16% predicted overall survival (p = 0.044, p = 0.010, and p = 0.001, respectively). CONCLUSIONS LNR is a robust predictor of overall survival in patients with stage III colorectal adenocarcinoma. At a cutoff ratio of 0.10 and 0.16, LNR offers better prognostic stratification in comparison with N stage and is less susceptible to variation introduced by the number of lymph nodes sampled, which is influenced both by clinical variables and grossing technique.
Collapse
Affiliation(s)
- Amir F Beirat
- Office of Scientific Affairs and Research, King Hussein Cancer Center, Amman, 11941, Jordan
| | - Justin Z Amarin
- Office of Scientific Affairs and Research, King Hussein Cancer Center, Amman, 11941, Jordan
| | | | - Yasmeen Z Qwaider
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Adel Muhanna
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, 64110, USA
| | - Bayan Maraqa
- Department of Pathology and Laboratory Medicine, King Hussein Cancer Center, Amman, 11941, Jordan
| | - Abdallah Al-Ani
- Office of Scientific Affairs and Research, King Hussein Cancer Center, Amman, 11941, Jordan
| | - Maysa Al-Hussaini
- Department of Pathology and Laboratory Medicine, King Hussein Cancer Center, Amman, 11941, Jordan.
| |
Collapse
|
2
|
Mroczkowski P, Kim S, Otto R, Lippert H, Zajdel R, Zajdel K, Merecz-Sadowska A. Prognostic Value of Metastatic Lymph Node Ratio and Identification of Factors Influencing the Lymph Node Yield in Patients Undergoing Curative Colon Cancer Resection. Cancers (Basel) 2024; 16:218. [PMID: 38201643 PMCID: PMC10778473 DOI: 10.3390/cancers16010218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/10/2023] [Accepted: 12/31/2023] [Indexed: 01/12/2024] Open
Abstract
Due to the impact of nodal metastasis on colon cancer prognosis, adequate regional lymph node resection and accurate pathological evaluation are required. The ratio of metastatic to examined nodes may bring an additional prognostic value to the actual staging system. This study analyzes the identification of factors influencing a high lymph node yield and its impact on survival. The lymph node ratio was determined in patients with fewer than 12 or at least 12 evaluated nodes. The study included patients after radical colon cancer resection in UICC stages II and III. For the lymph node ratio (LNR) analysis, node-positive patients were divided into four categories: i.e., LNR 1 (<0.05), LNR 2 (≥0.05; <0.2), LNR 3 (≥0.2; <0.4), and LNR 4 (≥0.4), and classified into two groups: i.e., those with <12 and ≥12 evaluated nodes. The study was conducted on 7012 patients who met the set criteria and were included in the data analysis. The mean number of examined lymph nodes was 22.08 (SD 10.64, median 20). Among the study subjects, 94.5% had 12 or more nodes evaluated. These patients were more likely to be younger, women, with a lower ASA classification, pT3 and pN2 categories. Also, they had no risk factors and frequently had a right-sided tumor. In the multivariate analysis, a younger age, ASA classification of II and III, high pT and pN categories, absence of risk factors, and right-sided location remained independent predictors for a lymph node yield ≥12. The univariate survival analysis of the entire cohort demonstrated a better five-year overall survival (OS) in patients with at least 12 lymph nodes examined (68% vs. 63%, p = 0.027). The LNR groups showed a significant association with OS, reaching from 75.5% for LNR 1 to 33.1% for LNR 4 (p < 0.001) in the ≥12 cohort, and from 74.8% for LNR2 to 49.3% for LNR4 (p = 0.007) in the <12 cohort. This influence remained significant and independent in multivariate analyses. The hazard ratios ranged from 1.016 to 2.698 for patients with less than 12 nodes, and from 1.248 to 3.615 for those with at least 12 nodes. The LNR allowed for a more precise estimation of the OS compared with the pN classification system. The metastatic lymph node ratio is an independent predictor for survival and should be included in current staging and therapeutic decision-making processes.
Collapse
Affiliation(s)
- Paweł Mroczkowski
- Department for General and Colorectal Surgery, Medical University of Lodz, Pl. Hallera 1, 90-647 Lodz, Poland;
- Institute for Quality Assurance in Operative Medicine Ltd., Otto-von-Guericke-University, Leipziger Str. 44, 39120 Magdeburg, Germany; (S.K.); (R.O.); (H.L.)
- Department for Surgery, University Hospital Knappschaftskrankenhaus, Ruhr-University, In der Schornau 23-25, 44892 Bochum, Germany
| | - Samuel Kim
- Institute for Quality Assurance in Operative Medicine Ltd., Otto-von-Guericke-University, Leipziger Str. 44, 39120 Magdeburg, Germany; (S.K.); (R.O.); (H.L.)
- Sanitätsversorgungszentrum Torgelow, Bundeswehr Neumühler Str. 10b, 17358 Torgelow, Germany
| | - Ronny Otto
- Institute for Quality Assurance in Operative Medicine Ltd., Otto-von-Guericke-University, Leipziger Str. 44, 39120 Magdeburg, Germany; (S.K.); (R.O.); (H.L.)
| | - Hans Lippert
- Institute for Quality Assurance in Operative Medicine Ltd., Otto-von-Guericke-University, Leipziger Str. 44, 39120 Magdeburg, Germany; (S.K.); (R.O.); (H.L.)
- Department for General, Visceral and Vascular Surgery, Otto-von-Guericke-University, Leipziger Str. 44, 39120 Magdeburg, Germany
| | - Radosław Zajdel
- Department of Economic and Medical Informatics, University of Lodz, 90-214 Lodz, Poland;
- Department of Medical Informatics and Statistics, Medical University of Lodz, 90-645 Lodz, Poland;
| | - Karolina Zajdel
- Department of Medical Informatics and Statistics, Medical University of Lodz, 90-645 Lodz, Poland;
| | - Anna Merecz-Sadowska
- Department of Economic and Medical Informatics, University of Lodz, 90-214 Lodz, Poland;
- Department of Allergology and Respiratory Rehabilitation, Medical University of Lodz, 90-725 Lodz, Poland
| |
Collapse
|
3
|
Wang XW, Jiang YH, Ye W, Shao CF, Xie JJ, Li X. SIRT1 promotes the progression and chemoresistance of colorectal cancer through the p53/miR-101/KPNA3 axis. Cancer Biol Ther 2023; 24:2235770. [PMID: 37575080 PMCID: PMC10431729 DOI: 10.1080/15384047.2023.2235770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 08/15/2023] Open
Abstract
INTRODUCTION Sirtuin 1 (SIRT1) is a key modulator in several types of cancer, including colorectal cancer (CRC). Here, we probed into the molecular mechanism of SIRT1 regulating the development and chemoresistance of CRC. METHODS Differentially expressed genes related to the growth, metastasis and chemoresistance of CRC were identified by bioinformatics analysis. The expression of SIRT1 in clinical tissues from CRC patients and CRC cell lines was detected by RT-qPCR. Interactions among SIRT1, p53, miR-101 and KPNA3 were analyzed. The effect of SIRT1 on the cell viability, migration, invasion, epithelial-mesenchymal transformation and chemoresistance to 5-FU was evaluated using loss-function investigations in CRC cells. Finally, a xenograft model of CRC and a metastasis model were constructed for further exploration of the roles of SIRT1 in vivo. RESULTS SIRT1 was elevated in CRC tissues and cell lines. SIRT1 decreased p53 via deacetylation, and consequently downregulated the expression of miR-101 while increasing that of the miR-101 target gene KPNA3. By this mechanism, SIRT1 enhanced the proliferation, migration, invasion, epithelial-mesenchymal transformation, and resistance to 5-FU of CRC cells. In addition, in vivo data also showed that SIRT1 promoted the growth, metastasis and chemoresistance to 5-FU of CRC cells via regulation of the p53/miR-101/KPNA3 axis. CONCLUSIONS In conclusion, SIRT1 can function as an oncogene in CRC by accelerating the growth, metastasis and chemoresistance to 5-FU of CRC cells through the p53/miR-101/KPNA3 axis.
Collapse
Affiliation(s)
- Xiao-Wei Wang
- Department of Anorectal Surgery, The First People’s Hospital of Wenling, Wenling, China
| | - Ying-Hao Jiang
- Department of Anorectal Surgery, The First People’s Hospital of Wenling, Wenling, China
| | - Wei Ye
- Department of Anorectal Surgery, The First People’s Hospital of Wenling, Wenling, China
| | - Chun-Fa Shao
- Department of Anorectal Surgery, The First People’s Hospital of Wenling, Wenling, China
| | - Jian-Jin Xie
- Department of Anorectal Surgery, The First People’s Hospital of Wenling, Wenling, China
| | - Xia Li
- Department of Anorectal Surgery, The First People’s Hospital of Wenling, Wenling, China
| |
Collapse
|
4
|
Prognostic Implication of Metastatic Lymph Node Ratio in Colorectal Cancers: Comparison Depending on Tumor Location. J Clin Med 2019; 8:jcm8111812. [PMID: 31683773 PMCID: PMC6912301 DOI: 10.3390/jcm8111812] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/13/2019] [Accepted: 10/26/2019] [Indexed: 12/11/2022] Open
Abstract
Background: The proportion of the number of involved lymph nodes (LNs) to the number of examined LNs—defined as metastatic LN ratio (mLNR)—has been considered as a prognostic parameter. This study aims to elucidate the prognostic implication of the mLNR in colorectal cancer (CRC) according to the tumor location. Methods: We evaluated the correlation between prognoses and the involved and examined LNs as well as mLNR according to the tumor location in 266 surgically resected human CRCs. Besides, to evaluate the optimal cutoff for high and low mLNRs, we investigated the correlation between mLNR and survival according to the various cutoffs. Results: LN metastasis was found in 146 cases (54.9%), and colon and rectal cancers were found in 116 (79.5%) and 30 (20.5%) of the cases, respectively. The mean mLNRs were significantly higher in rectal cancer than in colon cancer (0.38 ± 0.28 vs. 0.21 ± 0.24, P = 0.003). Besides this, the number of involved LNs in rectal cancer was significantly high compared to colon cancer (11.83 ± 10.92 vs. 6.37 ± 7.78, P = 0.014). However, there was no significant difference in the examined LNs between the rectal and colon cancers (31.90 ± 12.28 vs. 36.60 ± 18.11, P = 0.181). In colon cancer, a high mLNR was significantly correlated with worse survival for all cutoffs (0.1, 0.2, 0.3, and 0.4). However, rectal cancer only showed a significant correlation between high mLNR and worse survival in the subgroup with a cutoff of 0.2. Conclusions: Our results showed that high mLNR was significantly correlated with worse survival. The number of involved LNs and mLNRs were significantly higher in rectal cancer than in colon cancer. The cutoff of 0.2 can be useful for the differentiation of prognostic groups, regardless of tumor location.
Collapse
|
5
|
Pyo JS, Kim JH, Lee SY, Baek TH, Kang DW. Metastatic Lymph Node Ratio (mLNR) is a Useful Parameter in the Prognosis of Colorectal Cancer; A Meta-Analysis for the Prognostic Role of mLNR. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:E673. [PMID: 31590275 PMCID: PMC6843621 DOI: 10.3390/medicina55100673] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 10/01/2019] [Indexed: 12/31/2022]
Abstract
Background and objectives: The presenting study aimed to elucidate the prognostic role of the metastatic lymph node ratio (mLNR) in patients with colorectal cancer (CRC), using a meta-analysis. Materials and Methods: Using data from 90,274 patients from 14 eligible studies, we performed a meta-analysis for the correlation between mLNR and survival rate. Besides, subgroup analyses were performed, based on tumor stage, tumor location, and mLNR. Results: A high mLNR showed significant correlation with worse overall survival and disease-free survival rates in CRC patients (hazard ratio (HR), 1.617, 95% confidence interval (CI) 1.393-1.877, and HR 2.345, 95% CI 1.879-2.926, respectively). In patients with stage III, who had regional LN metastasis, the HRs were 1.730 (95% CI 1.266-2.362) and 2.451 (95% CI 1.719-3.494) for overall and disease-free survival, respectively. According to tumor location, rectal cancer showed a worse survival rate when compared to colon cancer. In the analysis for overall survival, when mLNR was 0.2, HR was the highest across the different subgroups (HR 5.040, 95% CI 1.780-14.270). However, in the analysis for disease-free survival, the subgroup with an mLNR < 0.2 had a higher HR than the other subgroups (HR 2.878, 95% CI 1.401-5.912). Conclusions: The mLNR may be a useful prognostic factor for patients with CRC, regardless of the tumor stage or tumor location. Further studies are necessary for the detailed criteria of mLNR before its application in daily practice.
Collapse
Affiliation(s)
- Jung Soo Pyo
- Department of Pathology, Eulji University Hospital, Eulji University School of Medicine, Daejeon 35233, Korea.
- Study Group for Meta-Analysis, Eulji University Hospital, Eulji University School of Medicine, Daejeon 35233, Korea.
| | - Joo Heon Kim
- Department of Pathology, Eulji University Hospital, Eulji University School of Medicine, Daejeon 35233, Korea.
| | - Seung Yun Lee
- Department of Pathology, Eulji University Hospital, Eulji University School of Medicine, Daejeon 35233, Korea.
| | - Tae Hwa Baek
- Medical Examiner's Office, National Forensic Service, Wonju 26460, Korea.
| | - Dong Wook Kang
- Department of Pathology, Eulji University Hospital, Eulji University School of Medicine, Daejeon 35233, Korea.
| |
Collapse
|
6
|
Moccia F, Tolone S, Allaria A, Napolitano V, Rosa D, Ilaria F, Ottavia M, Cesaro E, Docimo L, Fei L. Lymph Node Ratio Versus TNM System As Prognostic Factor in Colorectal Cancer Staging. a Single Center Experience. Open Med (Wars) 2019; 14:523-531. [PMID: 31346549 PMCID: PMC6642801 DOI: 10.1515/med-2019-0058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 05/21/2019] [Indexed: 12/21/2022] Open
Abstract
Objective This study aims to establish the actual validity of the lymph node ratio (LNR) as a prognostic factor for colorectal cancer patients, and to verify differences of survival and disease-free interval. Methods Patients referred with colorectal cancer who underwent potentially curative surgery between January 1997 and December 2011 were included. Lymph node ratio, TNM staging and survival were extracted from surgical, histological and follow-up records. Results Two hundred eigthy six patients with different stages of colorectal cancer underwent surgery, with comparison of survival prediction based on lymph node ratio and TNM staging. The overall survival rate was 78.3%, the recurrence rate was 11.9% and the mortality rate was estimated as 21.7%. Univariate analysis in relation to survival was significant for the following variables: serum level of CEA, CA 19.9 value, degree of histological differentiation, and tumor growth. There weren’t any statistically significant differences for the LNR (LNR </ ≥0.16: p = 0.116). The TNM system was effective both in discriminating between survival stages (Stage II vs. Stage III: p = 0.05) and in differentiating sub-groups (p = 0.05). Conclusions LNR alone could not be considered a better prognostic factor than the TNM system. However, future studies are needed in a larger number of patients with a standardized surgical, pathological and medical protocol.
Collapse
Affiliation(s)
- Francesco Moccia
- Unit of Gastrointestinal Surgery, Department of Surgery, University of Campania “Luigi Vanvitelli”,Via Pansini 5, bld 17, ZIP 80100, Naples, Italy
| | - Salvatore Tolone
- Unit of Gastrointestinal Surgery, Department of Surgery, University of Campania “Luigi Vanvitelli”,Via Pansini 5, bld 17, ZIP 80100, Naples, Italy
| | - Alfredo Allaria
- Unit of Gastrointestinal Surgery, Department of Surgery, University of Campania “Luigi Vanvitelli”,Via Pansini 5, bld 17, ZIP 80100, Naples, Italy
| | - Vincenzo Napolitano
- Unit of Endoscopic Surgery, Department of Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - D’Amico Rosa
- Unit of Gastrointestinal Surgery, Department of Surgery, University of Campania “Luigi Vanvitelli”,Via Pansini 5, bld 17, ZIP 80100, Naples, Italy
| | - Ferrante Ilaria
- Unit of Gastrointestinal Surgery, Department of Surgery, University of Campania “Luigi Vanvitelli”,Via Pansini 5, bld 17, ZIP 80100, Naples, Italy
| | - Manto Ottavia
- Unit of Gastrointestinal Surgery, Department of Surgery, University of Campania “Luigi Vanvitelli”,Via Pansini 5, bld 17, ZIP 80100, Naples, Italy
| | - Edoardo Cesaro
- Unit of Gastrointestinal Surgery, Department of Surgery, University of Campania “Luigi Vanvitelli”,Via Pansini 5, bld 17, ZIP 80100, Naples, Italy
| | - Ludovico Docimo
- Unit of General, Mininvasive and Bariatric Surgery, Department of Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Landino Fei
- Unit of Gastrointestinal Surgery, Department of Surgery, University of Campania “Luigi Vanvitelli”,Via Pansini 5, bld 17, ZIP 80100, Naples, Italy
- Tel.+39 081 566 660, Fax +39 081 566 6691
| |
Collapse
|
7
|
Jakob MO, Guller U, Ochsner A, Oertli D, Zuber M, Viehl CT. Lymph node ratio is inferior to pN-stage in predicting outcome in colon cancer patients with high numbers of analyzed lymph nodes. BMC Surg 2018; 18:81. [PMID: 30285691 PMCID: PMC6171184 DOI: 10.1186/s12893-018-0417-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 09/23/2018] [Indexed: 02/07/2023] Open
Abstract
Background The lymph node ratio (LNR), i.e. the number of positive lymph nodes (LN) divided by the total number of analyzed LN, has been described as a strong outcome predictor in node-positive colon cancer patients. However, most published analyses are constrained by relatively low numbers of analyzed LN. Therefore, the objective of the present study was to evaluate the prognostic impact of LNR in colon cancer patients with high numbers of analyzed LN. Methods One hundred sixty-six colon cancer patients underwent open colon resection. All node-positive patients were analyzed for this study. The number of analyzed LN, of positive LN, the disease-free (DFS) and overall survival (OS) time were prospectively recorded. Patients were dichotomously allocated to a high or a low LNR-group, respectively, with the median LNR (0.125) as a cut-off value. Median follow-up was 34.3 months. Results Fifty-eight patients (34.9%) were node-positive. The median number of analyzed LN was 23 (range 8–54). DFS and OS were significantly shorter in pN2 vs pN1 patients (p < 0.001, and p = 0.001, respectively), and in LNR high vs low patients (p = 0.032, and p = 0.034, respectively). pN2 (vs pN1) disease showed hazard ratios (HR) of 6.2 (p < 0.001), and 6.8 (p < 0.005; for DFS and OS, respectively), while LNR high (vs low) showed HR of 3.0 (p =0.041), and 4.5 (p = 0.054). Conclusions LNR is a reasonable outcome predictor in node-positive colon cancer patients. However, LNR is inferior to pN-stage in predicting survival in patients with high number of harvested lymph nodes. Electronic supplementary material The online version of this article (10.1186/s12893-018-0417-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Manuel O Jakob
- Department of Surgery, Spitalzentrum Biel-Bienne AG, Vogelsang 84, CH-2501, Biel, Switzerland
| | - Ulrich Guller
- Department of Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Alex Ochsner
- Department of Surgery, Spital Limmattal, Schlieren, Switzerland
| | - Daniel Oertli
- Department of Surgery, University of Basel, Basel, Switzerland
| | - Markus Zuber
- Department of Surgery, Kantonsspital Olten, Olten, Switzerland
| | - Carsten T Viehl
- Department of Surgery, Spitalzentrum Biel-Bienne AG, Vogelsang 84, CH-2501, Biel, Switzerland.
| |
Collapse
|
8
|
Mohan HM, Walsh C, Kennelly R, Ng CH, O'Connell PR, Hyland JM, Hanly A, Martin S, Gibbons D, Sheahan K, Winter DC. The lymph node ratio does not provide additional prognostic information compared with the N1/N2 classification in Stage III colon cancer. Colorectal Dis 2017; 19:165-171. [PMID: 27317165 DOI: 10.1111/codi.13410] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 04/21/2016] [Indexed: 12/13/2022]
Abstract
AIM The ratio of positive nodes to total nodes, the lymph node ratio (LNR), is a proposed alternative to the current N1/N2 classification of nodal disease. The true clinical benefit of adopting the LNR, however, has not been definitively demonstrated. This study compared the LNR with the current N1/N2 classification of Stage III colon cancer. METHOD Patients with Stage III colon cancer were identified from a prospectively maintained database (1996-2012). The specificity and sensitivity of the N1/N2 classification in the prediction of overall survival were determined using R. A cut-off point for the LNR was determined by setting the specificity the same as for the N1/N2 classification. The sensitivity of the two methods was then compared, and bootstrapping 1000-fold was performed. This was then repeated for disease-specific survival. RESULTS The specificity and sensitivity of the N1/N2 classification in predicting 3-year overall survival in this cohort (n = 402) was 62.2% and 52.1%, respectively. The cut-off point for the LNR was determined to be 0.27 for these data. On comparing LNR with the N1/N2 classification showed that for a given specificity, the LNR did not provide a statistically significant improvement in sensitivity (52.8% vs 52.1%, P = 0.31). For disease-specific death at 3 years, the specificity and sensitivity were 60.8% and 54.6%, respectively. The LNR did not provide a statistically significant improvement (55.4% vs 54.6%, P = 0.44). CONCLUSION Both the N1/N2 system and the LNR predict survival in colon cancer, but both have low specificity and sensitivity. The LNR does not provide additional prognostic value to current staging for overall or disease-specific survival for a given cut-off point.
Collapse
Affiliation(s)
- H M Mohan
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - C Walsh
- Department of Statistics, Trinity College Dublin, Dublin, Ireland.,Department of Mathematics and Statistics, University of Limerick, Dublin, Ireland
| | - R Kennelly
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - C H Ng
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - P R O'Connell
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - J M Hyland
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - A Hanly
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - S Martin
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - D Gibbons
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - K Sheahan
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - D C Winter
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| |
Collapse
|
9
|
Systematic review and meta-analysis of the impact of tumour budding in colorectal cancer. Br J Cancer 2016; 115:831-40. [PMID: 27599041 PMCID: PMC5046217 DOI: 10.1038/bjc.2016.274] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 07/20/2016] [Accepted: 08/01/2016] [Indexed: 12/27/2022] Open
Abstract
Background: Tumour budding is a histological finding in epithelial cancers indicating an unfavourable phenotype. Previous studies have demonstrated that it is a negative prognostic indicator in colorectal cancer (CRC), and has been proposed as an additional factor to incorporate into staging protocols. Methods: A systematic review of papers until March 2016 published on Embase, Medline, PubMed, PubMed Central and Cochrane databases pertaining to tumour budding in CRC was performed. Study end points were the presence of lymph node metastases, recurrence (local and distal) and 5-year cancer-related death. Results: A total of 7821 patients from 34 papers were included, with a mean rate of tumour budding of 36.8±16.5%. Pooled analysis suggested that specimens exhibiting tumour budding were significantly associated with lymph node positivity (OR 4.94, 95% CI 3.96–6.17, P<0.00001), more likely to develop disease recurrence over the time period (OR 5.50, 95% CI 3.64–8.29, P<0.00001) and more likely to lead to cancer-related death at 5 years (OR 4.51, 95% CI 2.55–7.99, P<0.00001). Conclusions: Tumour budding in CRC is strongly predictive of lymph node metastases, recurrence and cancer-related death at 5 years, and its incorporation into the CRC staging algorithm will contribute to more effective risk stratification.
Collapse
|
10
|
Ong MLH, Schofield JB. Assessment of lymph node involvement in colorectal cancer. World J Gastrointest Surg 2016; 8:179-192. [PMID: 27022445 PMCID: PMC4807319 DOI: 10.4240/wjgs.v8.i3.179] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 10/24/2015] [Accepted: 01/04/2016] [Indexed: 02/06/2023] Open
Abstract
Lymph node metastasis informs prognosis and is a key factor in deciding further management, particularly adjuvant chemotherapy. It is core to all contemporary staging systems, including the widely used tumor node metastasis staging system. Patients with node-negative disease have 5-year survival rates of 70%-80%, implying a significant minority of patients with occult lymph node metastases will succumb to disease recurrence. Enhanced staging techniques may help to identify this subset of patients, who might benefit from further treatment. Obtaining adequate numbers of lymph nodes is essential for accurate staging. Lymph node yields are affected by numerous factors, many inherent to the patient and the tumour, but others related to surgical and histopathological practice. Good lymph node recovery relies on close collaboration between surgeon and pathologist. The optimal extent of surgical resection remains a subject of debate. Extended lymphadenectomy, extra-mesenteric lymph node dissection, high arterial ligation and complete mesocolic excision are amongst the surgical techniques with plausible oncological bases, but which are not supported by the highest levels of evidence. With further development and refinement, intra-operative lymphatic mapping and sentinel lymph node biopsy may provide a guide to the optimum extent of lymphadenectomy, but in its present form, it is beset by false negatives, skip lesions and failures to identify a sentinel node. Once resected, histopathological assessment of the surgical specimen can be improved by thorough dissection techniques, step-sectioning of tissue blocks and immunohistochemistry. More recently, molecular methods have been employed. In this review, we consider the numerous factors that affect lymph node yields, including the impact of the surgical and histopathological techniques. Potential future strategies, including the use of evolving technologies, are also discussed.
Collapse
|
11
|
Parnaby CN, Scott NW, Ramsay G, MacKay C, Samuel L, Murray GI, Loudon MA. Prognostic value of lymph node ratio and extramural vascular invasion on survival for patients undergoing curative colon cancer resection. Br J Cancer 2015; 113:212-9. [PMID: 26079302 PMCID: PMC4506392 DOI: 10.1038/bjc.2015.211] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 04/20/2015] [Accepted: 05/14/2015] [Indexed: 02/06/2023] Open
Abstract
Background: Increasing lymph node ratio (LNR) (ratio of metastatic lymph nodes to the total number of harvested lymph nodes) and extramural vascular invasion (EMVI) have been proposed as adverse prognostic indicators in colorectal cancer, although their use remains variable and controversial. The aim of the present study was to assess the prognostic value of LNR and EMVI in predicting survival for patients undergoing curative colon cancer resection. Methods: Between 2006 and 2012, 922 patients underwent curative colon cancer resection. Surgical technique and pathological assessment did not change during the study period. Clinical and pathological data were collected from a prospectively maintained database. The primary outcome measure was overall survival and disease-free survival. LNR was separated into five categories based on three previously calculated cutoff values: LNR 0 (no lymph nodes involved), LNR 1 (ratio 0.01<0.17), LNR 2 (ratio 0.18–0.41), LNR 3 (ratio 0.42–0.69), and LNR 4 (ratio >0.70). Results: Nine hundred and twenty-two patients underwent colon cancer resection. The median follow-up for survivors was 52.8 months (IQR 34.6–77.6). The median total number of lymph nodes harvested was 16 (IQR13-22). On multivariate analysis, both pN and LNR were strongly associated with overall and disease-free survival. Using the Akaike information criterion (AIC), LNR had greater prognostic value compared with pN. For overall survival, compared with patients in LNR category 0, hazard ratios (95% CI) for those in categories 1, 2, 3 and 4 were 1.37 (1.03,1.82), 2.37 (1.70,3.30), 2.40 (1.57,3.65) and 5.51 (3.16,9.58), respectively. For disease-free survival, patients had hazard ratios (95% CI) of 1.78 (1.25,2.52), 3.79 (2.56,5.61), 2.60 (1.50,4.48) and 4.76 (2.21,10.27), respectively. The presence of EMVI was a significant predictor of decreased overall and disease-free survival (P<0.001). Conclusions: This study demonstrated, in the presence of high surgical, oncology and pathological standards, EMVI and increasing LNR were independent predictors of decreased overall and disease-free survival for patients undergoing curative colon cancer resection. LNR was superior to pN stage in predicting overall and disease-free survival.
Collapse
Affiliation(s)
- C N Parnaby
- Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - N W Scott
- Medical Statistics Team, University of Aberdeen, Aberdeen, UK
| | - G Ramsay
- Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - C MacKay
- Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - L Samuel
- Department of Oncology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - G I Murray
- Department of Pathology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - M A Loudon
- Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| |
Collapse
|
12
|
Lymph node ratio improves TNM and Astler-Coller's assessment of colorectal cancer prognosis: an analysis of 761 node positive cases. J Gastrointest Surg 2014; 18:1824-36. [PMID: 25091835 DOI: 10.1007/s11605-014-2591-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 07/07/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prognosis assessment of node-positive colorectal cancer patients by Astler-Coller (AC) and TNM classifications is suboptimal. Recently, several versions of lymph node ratio (LNR; ratio metastatic/examined nodes) have been proposed but are still mostly unused. METHODS The prognostic value of several criteria, including LNR (two classes-LNR1 and LNR2-identified by a 15% cut-off) was studied in 761 consecutive patients, from 2000 through 2010. The relationships between total examined nodes, N, T and LNR were also analysed. LNR1 and LNR2 patients' survival was analysed within AC and TNM subgroups, and then coupled with them. RESULTS Age, tumour location and LNR are independent factors predicting survival. The relationships between LNR, N stage and T stage with examined nodes suggest confusing factors. LNR allows for identification of subgroups with different survival within AC and TNM classifications (p < 0.0001). Patients with LNR class discordant from AC stage (LNR1-C2 and LNR2-C1) have a similar 5-year survival (54 and 57%, respectively). LNR2 and TNM stage IIIC define a poor 5-year prognosis (33%). CONCLUSIONS LNR is a powerful prognosis predictor, easily integrated with TNM and AC classifications to improve prognosis assessment and facilitate clinical use. Possible confusing factors should be considered in future studies.
Collapse
|
13
|
Sugimoto K, Sakamoto K, Tomiki Y, Goto M, Kotake K, Sugihara K. Proposal of new classification for stage III colon cancer based on the lymph node ratio: analysis of 4,172 patients from multi-institutional database in Japan. Ann Surg Oncol 2014; 22:528-34. [PMID: 25160735 DOI: 10.1245/s10434-014-4015-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND We retrospectively examined the optimal lymph node ratio (LNR) cutoff value and attempted to construct a new classification using the LNR in stage III colon cancer. METHODS The clinical and pathological data of 4,172 patients with histologically proven lymph node metastasis who underwent curative surgery for primary colon cancer at multiple institutions between 1995 and 2004 were derived from the multi-institutional database of the Japanese Society for Cancer of the Colon and Rectum (JSCCR). We determined independent prognostic factors and constructed a new classification using these factors. Finally, we compared the discriminatory ability between the new classification and the TNM seventh edition (TNM 7th) classification. RESULTS The optimal LNR cutoff value was 0.18. Multivariate analysis revealed that year of surgery, age, gender, histological type, TNM 7th T category, lymphatic invasion, venous invasion, TNM 7th N category, and LNR were found to be significant independent prognostic factors. We attempted to construct a new classification based on the combination of TNM 7th T category and LNR. As a result, the cancer-specific survivals were well stratified (P < .0001). According to the Akaike's information criteria value, the new classification was judged to be superior to the TNM 7th classification with respect to both a better fit and lower complexity. CONCLUSIONS The optimal LNR cutoff value that was found using the Japanese multi-institutional database and the new classification using LNR are considered to be extremely significant. Therefore, these findings strongly support the application of LNR in the stage classification in stage III colon cancer.
Collapse
Affiliation(s)
- Kiichi Sugimoto
- Department of Coloproctological Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan,
| | | | | | | | | | | |
Collapse
|
14
|
Furukawa D, Chijiwa T, Matsuyama M, Mukai M, Matsuo EI, Nishimura O, Kawai K, Suemizu H, Hiraoka N, Nakagohri T, Yasuda S, Nakamura M. Zinc finger protein 185 is a liver metastasis-associated factor in colon cancer patients. Mol Clin Oncol 2014; 2:709-713. [PMID: 25054034 DOI: 10.3892/mco.2014.298] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 03/25/2014] [Indexed: 01/03/2023] Open
Abstract
LIM domain proteins are involved in several fundamental biological processes, including cell lineage specification, cytoskeleton organization and organ development. Zinc finger protein 185 (ZNF185) is one of the LIM domain proteins considered to be involved in the regulation of cellular differentiation and/or proliferation. However, the detailed functions and properties of ZNF185 in the multistep process of cancer biology have not yet been elucidated. In this study, we analyzed the association between ZNF185 and the clinicopathological characteristics of colon cancer, such as patient age and gender, histological type, lymphatic and venous involvement, T and N status, liver metastasis and stage. ZNF185 protein expression was immunohistochemically analyzed and ZNF185 was detected in the cancer cells of 78 of the 87 colon cancer patients. The correlation between ZNF185 and histological type was significant (P=0.010, G-test). ZNF185 expression was also significantly correlated with liver metastasis (P=0.030, G-test). A multivariate analysis using the Cox proportional hazards model was performed among cause-specific survival rate, ZNF185 expression and clinicopathological characteristics. Histological type, liver metastasis and ZNF185 expression were found to be independent prognostic indicators (P=0.028, P<0.0001 and P=0.036, respectively). Therefore, ZNF185 expression was found to be an independent indicator of liver metastasis and prognosis in patients with colon cancer.
Collapse
Affiliation(s)
- Daisuke Furukawa
- Department of Surgery, Tokai University School of Medicine, Isehara, Kanagawa 259-1193, Japan
| | - Tsuyoshi Chijiwa
- Laboratory Animal Research Department, Central Institute for Experimental Animals, Kawasaki, Kanagawa 210-0821, Japan
| | - Masahiro Matsuyama
- Department of Surgery, Tokai University School of Medicine, Isehara, Kanagawa 259-1193, Japan
| | - Masaya Mukai
- Department of Surgery, Tokai University Hachioji Hospital, Hachioji, Tokyo 192-0032, Japan
| | - Ei-Ichi Matsuo
- Global Application Development Center, Analytical and Measuring Instruments Division, Shimadzu Corporation, Kyoto 604-8511, Japan
| | - Osamu Nishimura
- The Integrated Center for Mass Spectrometry, Graduate School of Medicine, Kobe University, Kobe, Hyogo 650-0017, Japan
| | - Kenji Kawai
- Pathological Analysis Center, Central Institute for Experimental Animals, Kawasaki, Kanagawa 210-0821, Japan
| | - Hiroshi Suemizu
- Laboratory Animal Research Department, Central Institute for Experimental Animals, Kawasaki, Kanagawa 210-0821, Japan
| | - Nobuyoshi Hiraoka
- Division of Molecular Pathology, National Cancer Center Research Institute, Tokyo 104-0045, Japan
| | - Toshio Nakagohri
- Department of Surgery, Tokai University School of Medicine, Isehara, Kanagawa 259-1193, Japan
| | - Seiei Yasuda
- Department of Surgery, Tokai University School of Medicine, Isehara, Kanagawa 259-1193, Japan
| | - Masato Nakamura
- Department of Regenerative Medicine, Tokai University School of Medicine, Isehara, Kanagawa 259-1193, Japan
| |
Collapse
|
15
|
Zeestraten ECM, Reimers MS, Saadatmand S, Dekker JWT, Liefers GJ, van den Elsen PJ, van de Velde CJH, Kuppen PJK. Combined analysis of HLA class I, HLA-E and HLA-G predicts prognosis in colon cancer patients. Br J Cancer 2014; 110:459-68. [PMID: 24196788 PMCID: PMC3899753 DOI: 10.1038/bjc.2013.696] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/10/2013] [Accepted: 10/14/2013] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Evasion of immune surveillance and suppression of the immune system are important hallmarks of tumour development in colon cancer. The goal of this study was to establish a tumour profile based on biomarkers that reflect a tumour's immune susceptibility status and to determine their relation to patient outcome. METHODS The study population consisted of 285 stage I-IV colon cancer patients of which a tissue micro array (TMA) was available. Sections were immunohistochemically stained for the presence of Foxp3+ cells and tumour expression of HLA Class I (HLA-A, -B, -C) and non-classical HLA-E and HLA-G. All markers were combined for further analyses, resulting in three tumour immune phenotypes: strong immune system tumour recognition, intermediate immune system tumour recognition and poor immune system tumour recognition. RESULTS Loss of HLA class I expression was significantly related to a better OS (P-value 0.005) and DFS (P-value 0.008). Patients with tumours who showed neither HLA class I nor HLA-E or -G expression (phenotype a) had a significant better OS and DFS (P-value <0.001 and 0.001, respectively) compared with phenotype b (OS HR: 4.7, 95% CI: 1.2-19.0, P=0.001) or c (OS HR: 8.2, 95% CI: 2.0-34.2, P=0.0001). Further, the tumour immune phenotype was an independent predictor for OS and DFS (P-value 0.009 and 0.013, respectively). CONCLUSION Tumours showing absence of HLA class I, HLA-E and HLA-G expressions were related to a better OS and DFS. By combining the expression status of several immune-related biomarkers, three tumour immune phenotypes were created that related to patient outcome. These immune phenotypes represented significant, independent, clinical prognostic profiles in colon cancer.
Collapse
Affiliation(s)
- E C M Zeestraten
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - M S Reimers
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - S Saadatmand
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - J-W T Dekker
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - G J Liefers
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - P J van den Elsen
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Pathology, VU University Medical Center, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - C J H van de Velde
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - P J K Kuppen
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| |
Collapse
|
16
|
Resch A, Langner C. Lymph node staging in colorectal cancer: Old controversies and recent advances. World J Gastroenterol 2013; 19:8515-8526. [PMID: 24379568 PMCID: PMC3870496 DOI: 10.3748/wjg.v19.i46.8515] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 10/21/2013] [Accepted: 11/05/2013] [Indexed: 02/06/2023] Open
Abstract
Outcome prediction based on tumor stage reflected by the American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) tumor node metastasis (TNM) system is currently regarded as the strongest prognostic parameter for patients with colorectal cancer. For affected patients, the indication for adjuvant therapy is mainly guided by the presence of regional lymph node metastasis. In addition to the extent of surgical lymph node removal and the thoroughness of the pathologist in dissecting the resection specimen, several parameters that are related to the pathological work-up of the dissected nodes may affect the clinical significance of lymph node staging. These include changing definitions of lymph nodes, involved lymph nodes, and tumor deposits in different editions of the AJCC/UICC TNM system as well as the minimum number of nodes to be dissected. Methods to increase the lymph node yield in the fatty tissue include methylene blue injection and acetone compression. Outcome prediction based on the lymph node ratio, defined as the number of positive lymph nodes divided by the total number of retrieved nodes, may be superior to the absolute numbers of involved nodes. Extracapsular invasion has been identified as additional prognostic factor. Adding step sectioning and immunohistochemistry to the pathological work-up may result in higher accuracy of histological diagnosis. The clinical value of more recent technical advances, such as sentinel lymph node biopsy and molecular analysis of lymph nodes tissue still remains to be defined.
Collapse
|