Prognostic significance of metastatic lymph node ratio: the lymph node ratio could be a prognostic indicator for patients with gastric cancer

Revolutionizing T3-4N0-2M0 gastric cancer staging with an innovative pathologic N classification system

BACKGROUND

The current pathologic N (pN) classification exhibits limitations in the prognostic stratification of patients with pT3-4N0-2M0 gastric cancer (GC). Therefore, this study aimed to develop and validate a new lymph nodal staging method based on the number of examined lymph nodes (ELNs) and lymph node ratio (LNR).

METHODS

Data from 7883 patients with pT3-4N0-2M0 GC were collected from the Surveillance, Epidemiology, and End Results (SEER) database and Zhejiang Cancer Provincial Hospital. Optimal cutoff values for ELNs and LNR were determined using X-tile software. Kaplan-Meier methods, Log-rank tests, and Cox regression analyses were employed in this study. Patients were categorized into 3 new pN stages: new pN0 (pN0 with ELNs of >16), new pN1 (pN0 with ELNs of ≤16 or pN1-2 with LNR of ≤0.15), and new pN2 (pN1-2 with LNR of >0.15). The prognostic predictive power of both current and new pN staging was evaluated using the Akaike information criterion (AIC), Bayesian information criterion, concordance index (C-index), and receiver operating characteristic curve.

RESULTS

The new pN classification exhibited excellent performance in Kaplan-Meier survival analysis. After adjusting for confounding factors, the new pN staging emerged as an independent prognostic indicator in patients with GC. In the SEER cohort, the new pN staging demonstrated enhanced prognostic prediction accuracy over the American Joint Committee on Cancer pN staging (AIC: 75578.85 vs 75755.06; C-index: 0.642 vs 0.630; P < .001). Similar findings were validated in the Chinese cohort.

CONCLUSION

This study developed and validated an improved pN classification for patients with pT3-4N0-2M0 GC. Surgeons should consider ELNs and LNR when assessing postoperative prognosis in patients with GC.

Comparison of the predictive performance of three lymph node staging systems for late-onset gastric cancer patients after surgery

Introduction

Lymph node (LN) status is a vital prognostic factor for patients. However, there has been limited focus on predicting the prognosis of patients with late-onset gastric cancer (LOGC). This study aimed to investigate the predictive potential of the log odds of positive lymph nodes (LODDS), lymph node ratio (LNR), and pN stage in assessing the prognosis of patients diagnosed with LOGC.

Methods

The LOGC data were obtained from the Surveillance, Epidemiology, and End Results database. This study evaluated and compared the predictive performance of three LN staging systems. Univariate and multivariate Cox regression analyses were carried out to identify prognostic factors for overall survival (OS). Three machine learning methods, namely, LASSO, XGBoost, and RF analyses, were subsequently used to identify the optimal LN staging system. A nomogram was built to predict the prognosis of patients with LOGC. The efficacy of the model was demonstrated through receiver operating characteristic (ROC) curve analysis and decision curve analysis.

Results

A total of 4,743 patients with >16 removed lymph nodes were ultimately included in this investigation. Three LN staging systems demonstrated significant performance in predicting survival outcomes (P < 0.001). The LNR exhibited the most important prognostic ability, as evidenced by the use of three machine learning methods. Utilizing independent factors derived from multivariate Cox regression analysis, a nomogram for OS was constructed.

Discussion

The calibration, C-index, and AUC revealed their excellent predictive performance. The LNR demonstrated a more powerful performance than other LN staging methods in LOGC patients after surgery. Our novel nomogram exhibited superior clinical feasibility and may assist in patient clinical decision-making.

Prognostic significance of metastatic lymph node ratio in gastric cancer: a Western-center analysis

BACKGROUND

Tumor-node-metastasis (TNM) staging is the central gastric cancer (GC) staging system, but it has some disadvantages. However, the lymph node ratio (LNR) can be used regardless of the type of lymphadenectomy and is considered an important prognostic factor. This study aimed to evaluate the relationship between LNR and survival in patients who underwent curative GC surgery.

METHODS

All patients who underwent radical gastric surgery between January 2014 and June 2022 were retrospectively evaluated. Clinicopathological features of tumors, TNM stage, and survival rates were analyzed. LNR was defined as the ratio between metastatic lymph nodes and total lymph nodes removed. The LNR groups were classified as follows: LNR0 = 0, 0.01 < LNR1 ≤ 0.1, 0.1 < LNR2 ≤ 0.25 and LNR3 > 0.25. Tumor characteristics and overall survival (OS) of the patients were compared between LNR groups.

RESULTS

After exclusion, 333 patients were analyzed. The mean age was 62 ± 14 years. According to the LNR classification, no difference was found between groups regarding age and sex. However, TNM stage III disease was significantly more common in LNR3 patients. Most patients (43.2%, n = 144) were in the LNR3 group. In terms of tumor characteristics (lymphatic, vascular, and perineural invasion), the LNR3 group had significantly poorer prognostic factors. The Cox regression model defined LNR3, TNM stage II-III disease, and advanced age as independent risk factors for survival. Patients with LNR3 demonstrated the lowest 5-year OS rate (35.7%) (estimated mean survival was 30 ± 1.9 months) compared to LNR 0-1-2.

CONCLUSION

Our study showed that a high LNR was significantly associated with poor OS in patients who underwent curative gastrectomy. LNR can be used as an independent prognostic predictor in GC patients.

Reliability of the Lymph Node Ratio in the Prediction of Gastric Cancer Survival

Background. Lymph node metastasis is the major determinant factor in the prognosis of gastric cancer. There is still no definite consensus on the lymph node number that should be harvested during gastric cancer surgery. Lymph Node Ratio (LNR) is defined as the ratio of metastatic nodes to the total number of pathologically examined lymph nodes. LNR has been proposed to be a sensitive prognostic factor in patients with gastric cancer. In this study the reliability of the LNR is tested for being a prognostic factor in gastric cancer survival. Methods. Medical records of 244 patients, with neither distant metastases nor neoadjuvant treatment underwent curative gastrectomy, were analyzed retrospectively in terms of survival according to the lymph node ratio (LNR). Patients were divided in two groups by using LNR cut-off value. Results. LNR of 0.4 was proved to be the best cut-off value to predict the prognosis of patients with gastric cancer. Univariate and multivariate analysis revealed that age over 65 (p < 0.001), and LNR ≥ 0.4 (p = 0.02) were independent factors in gastric cancer survival. Patients with LNR ≥ 0.4 presented with worse outcomes regarding other prognostic parameters (tumor differentiation, tumor diameter, lymphovascular invasion or perineural invasion), despite similar numbers of lymph nodes being harvested in both groups during surgery. Conclusion. Lymph node ratio is a reliable parameter to predict the survival in gastric cancer.

Prognostic significance of metastatic lymph node ratio in patients with gastric cancer after curative gastrectomy: a single-center retrospective study

BACKGROUND

The objective of this study was to evaluate the prognostic value of Metastatic lymph node ratio (MLNR) after curative gastrectomy in patients with gastric cancer (GC) and the potential for new indicators to strengthen the current guidelines.

METHODS

We retrospectively researched 3864 GC patients with curative gastrectomy between February 2011 and February 2016. The following clinical data were collected from the included patients: gender, type of gastrectomy, tumor location, T stage, N stage, ELN, tumor size, age at surgery, perineural invasion, vascular invasion, TNM stage, survival time and survival status. Patients were divided into low-MLNR (L-MLNR), and high-MLNR (H-MLNR) groups based on adjusted the X-tile cutoff-value of 0.25 for MLNR, the survival rates and clinicopathological characteristics of each group were compared. For the assessment of significant associations between clinicopathological characteristics and patients' survival, univariate and multivariate analyses were performed using the Kaplan-Meier method and Cox proportional hazards analysis. The log-rank test was used to examine the statistical significance of differences among different survival curves. Clinicopathological features significantly associated with MLNR were assessed by the Chi-square test and multinomial logistic regression. The discriminative ability was measured by calculating the Bayesian Information Criterion (BIC) values for each category. Assessment of the effect of clinicopathological features on MLNR for predicting prognosis of GC patients used stratum analysis through Kaplan-Meier analysis and Cox proportional risk Analysis.

RESULTS

Survival analysis indicated that MLNR was negatively associated with overall survival (OS) (p < .001) and was an independent prognostic predictor in 3864 GC patients (p < .001). MLNR had significant prognostic significance in various subgroups with clinicopathological characteristics (gender, type of gastrectomy, tumor location, T stage, N stage, ELN, tumor size, age at surgery, perineural invasion, vascular invasion, and TNM stage) (p < .001).

CONCLUSIONS

The MLNR may become a new indicator to assess the prognosis of GC patients who underwent curative gastrectomy. The results may have potential clinical implications that should be considered when developing clinical practice guidelines or the design of the future investigation.

Machine Learning-Based Prediction of Lymph Node Metastasis Among Osteosarcoma Patients

Background

Regional lymph node metastasis is a contributor for poor prognosis in osteosarcoma. However, studies on risk factors for predicting regional lymph node metastasis in osteosarcoma are scarce. This study aimed to develop and validate a model based on machine learning (ML) algorithms.

Methods

A total of 1201 patients, with 1094 cases from the surveillance epidemiology and end results (SEER) (the training set) and 107 cases (the external validation set) admitted from four medical centers in China, was included in this study. Independent risk factors for the risk of lymph node metastasis were screened by the multifactorial logistic regression models. Six ML algorithms, including the logistic regression (LR), the gradient boosting machine (GBM), the extreme gradient boosting (XGBoost), the random forest (RF), the decision tree (DT), and the multilayer perceptron (MLP), were used to evaluate the risk of lymph node metastasis. The prediction model was developed based on the bestpredictive performance of ML algorithm and the performance of the model was evaluatedby the area under curve (AUC), prediction accuracy, sensitivity and specificity. A homemade online calculator was capable of estimating the probability of lymph node metastasis in individuals.

Results

Of all included patients, 9.41% (113/1201) patients developed regional lymph node metastasis. ML prediction models were developed based on nine variables: age, tumor (T) stage, metastasis (M) stage, laterality, surgery, radiation, chemotherapy, bone metastases, and lung metastases. In multivariate logistic regression analysis, T and M stage, surgery, and chemotherapy were significantly associated with lymph node metastasis. In the six ML algorithms, XGB had the highest AUC (0.882) and was utilized to develop as prediction model. A homemade online calculator was capable of estimating the probability of CLNM in individuals.

Conclusions

T and M stage, surgery and Chemotherapy are independent risk factors for predicting lymph node metastasis among osteosarcoma patients. XGB algorithm has the best predictive performance, and the online risk calculator can help clinicians to identify the risk probability of lymph node metastasis among osteosarcoma patients.

Surgeon-Pathologist Team Approach Dramatically Affects Lymph Nodes Detection and Improves Patients' Short-Term Outcome

Simple Summary

Appropriate lymph node harvesting for patients with gastric cancer is fundamental for a correct staging and is strongly related to survival. In this study, we present a new protocol for on-site macroscopic evaluation and sampling of lymph nodes for gastric cancer patients. With the joint collaboration of surgeons and pathologists, our method aims to provide the largest possible number of analyzed lymph nodes per patient, allowing for a better staging. We are convinced that this approach is routinely feasible, and our preliminary results seem to confirm better patient stratification compared to other lymph node dissection methods.

Abstract

The downstaging of gastric cancer has recently gained particular attention in the field of gastric cancer surgery. The phenomenon is mainly due to an inappropriate sampling of lymph nodes during standard lymphadenectomy. Hence, collection of the maximum number of lymph nodes is a critical factor affecting the outcome of patients. None of the techniques proposed so far have demonstrated a real efficiency in increasing the number of identified lymph nodes. To harvest the maximum number of lymph nodes, we designed a protocol for on-site macroscopic evaluation and sampling of lymph nodes according to the Japanese Gastric Cancer Association protocol. The procedure was carried out by a surgeon/pathologist team in the operating room. We enrolled one hundred patients, 50 of whom belonged to the study group and 50 to a control group. The study group included patients who underwent lymph node dissection following the proposed protocol; the control group encompassed patients undergoing standard procedures for sampling. We compared the number and maximum diameter of lymph nodes collected in both groups, as well as some postoperative variables, the 30-day mortality and the overall survival. In the study group, the mean number of lymph nodes harvested was higher than the control one (p = 0.001). Moreover, by applying the proposed technique, we sampled lymph nodes with a very small diameter, some of which were metastatic. Noticeably, no difference in terms of postoperative course was identified between the two groups, again supporting the feasibility of an extended lymphadenectomy. By comparing the prognosis of patients, a better overall survival (p = 0.03) was detected in the study group; however, to date, no long-term follow-up is available. Interestingly, patients with metastasis in node stations number 8, 9, 11 or with skip metastasis, experienced a worse outcome and died. Based on our preliminary results, the pathologist/surgeon team approach seems to be a reliable option, despite of a slight increase in sfaff workload and technical cost. It allows for the harvesting of a larger number of lymph nodes and improves the outcome of the patients thanks to more precise staging and therapy. Nevertheless, since a higher number of patients are necessary to confirm our findings and assess the impact of this technique on oncological outcome, our study could serve as a proof-of-concept for a larger, multicentric collaboration.

Prognostic value of different lymph node staging methods for node-positive cardia gastric cancer: a register-based retrospective cohort study

OBJECTIVE

To investigate the prognostic efficacy of lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS) in node-positive cardia gastric adenocarcinoma (CGA).

DESIGN

A registry-based retrospective cohort study.

SETTING

Patients diagnosed with node-positive CGA in the Surveillance, Epidemiology, and End Results database from 2010 to 2015.

PARTICIPANTS

A total of 1038 patients were enrolled and randomly assigned (7:3) to the training set (n=723) or validating set (n=315).

PRIMARY OUTCOME MEASURE

Cancer-specific survival (CSS).

RESULTS

The baseline characteristics of the training and validation sets were similar. Based on the optimal cut-off values, LNR was classified into low (<0.09), medium (0.09~0.33) and high (>0.33) groups; LODDS was also classified into low (<-2.09), medium (-2.09~-0.65) and high (>-0.65) groups. CSS was significantly different across LNR and LODDS subgroups. The Harrell concordance index of the N stage was lower than that of the LNR or LODDS. The Akaike information criterion of the N stage was higher than that of the LNR or LODDS. Independent predictors included race, T stage, M stage and LNR (or LODDS), and they were incorporated into nomograms for 1-year, 2-year and 5-year CSS prediction. Calibration plots showed satisfactory results for internal and external validity of the nomogram.

CONCLUSIONS

LNR and LODDS staging methods have better prognostic efficacy than the traditional N staging method in CGA with node metastasis. Moreover, the two values are promising substitutes for N staging in nomogram development when other independent prognostic factors are incorporated.

Towards standardization of lymph-node ratio classifications: Validation and comparison of different lymph node ratio classifications for predicting prognosis of patients with resected gastric cancer

INTRODUCTION

The TNM staging system is the main prognostic tool for GC, but the number of metastatic lymph nodes (LN) can be affected by surgical, pathological, tumor or host factors. Several authors have shown that lymph node ratio (LNR) may be superior to TNM staging in GC. However, cut-off values vary between studies and LNR assessment is not standardized.

MATERIAL AND METHODS

Retrospective study of all GC resected in a western tertiary center (N = 377). Clinical features were collected and pathological features were assessed by two independent pathologists. Eight LNR classifications were selected and applied to our patients. Statistical analyses were performed.

RESULTS

315 patients were included. Most tumors were T3 (49.2%) N+ (59.3%). During follow-up, 36.7% of patients progressed and 27.4% died due to tumor. All LNR classifications were significantly associated with clinicopathological features such as Laurén subtype, lymphovascular invasion, perineural infiltration, T stage, tumor progression or death. All LNR classifications were independent prognostic factors for OS and DFS, and ROC analyses calculated similar AUC values for all staging systems. Kaplan-Meier curves showed that Pedrazzani, Wang, Liu and Huang classifications stratified patients better into three (Pedrazzani) or four categories. These classifications tended to downstage TNM N2 and N3 tumors. In cases with less than 16 LNs resected, Pedrazzani and Wang classifications showed the best prognostic performance.

CONCLUSIONS

Pedrazzani, Wang, Liu and Huang classifications showed good prognostic performance in western GC patients. Larger studies in other cohorts are needed to identify the most consistent LNR classification for GC.

The Prognostic Value of Lymph Node Ratio after Neoadjuvant Chemotherapy in Patients with Locally Advanced Gastric Adenocarcinoma

Purpose

This study aimed to investigate the prognostic value of lymph node ratio (LNR) in patients with locally advanced gastric cancer who received neoadjuvant chemotherapy.

Materials and Methods

We retrospectively enrolled gastric cancer patients treated with neoadjuvant chemotherapy and curative surgery at the First Affiliated Hospital of Zhejiang University from 2004 to 2015 as the study cohort. Patients with the same inclusion criteria treated in 2016–2017 were enrolled as the validation cohort. Kaplan-Meier curves were assessed using the log-rank test to analyze the differences in overall survival (OS). Multivariate survival analysis was performed using the Cox proportional hazards model. The areas under the receiver operating characteristic curve of ypN and LNR categories for predicting the actual 3-year OS were compared.

Results

A total of 265 patients were included in the proposal cohort. The median number of retrieved lymph nodes (rLNs) was 32. The number of positive lymph nodes (pLNs) increased as rLN increased (P=0.037), but the LNR remained relatively constant (P=0.462). The LNR was categorized into 4 groups according to the prognosis: ypNr0, node-negative with rLN>25; ypNr1, node-negative with rLN≤25 or 0<LNR≤0.1; ypNr2, 0.1<LNR≤0.3; and ypNr3, LNR>0.3. In the validation cohort of 43 enrolled patients, there was a clear distinction in OS that significantly (P<0.001) varied depending on the LNR values and LNR was the only independent prognostic factor in multivariate analysis (P<0.001).

Conclusions

LNR was an independent prognostic factor for survival of patients with gastric cancer after preoperative chemotherapy and might be an alternative predictor for ypN stage.

Which Lymph Node Staging System Better Predicts Prognosis in Patients With Gastric Carcinoma? A Comparative Study Between 3 Different Lymph Node Classifications for Resected Gastric Cancer in a Western Tertiary Center

INTRODUCTION

Gastric cancer (GC) is an aggressive disease with high mortality rates. Lymph node (LN) staging of GC is a major source of controversy. The aim of this study is to compare the prognostic value of 3 different LN classifications for patients with resected GC: the eighth TNM staging system, lymph node ratio (LNR, ratio between positive and total LN) and a new anatomic-based classification (Choi classification).

MATERIALS AND METHODS

A retrospective study of all cases of GC resected in a tertiary hospital in Spain (n=377). Clinical data were collected; histologic slides were reviewed; and univariate and multivariate analyses of disease-free survival (DFS) and overall survival (OS) were performed.

RESULTS

In all, 315 patients fulfilled inclusion criteria. Univariate analysis showed that all classifications were significantly associated with tumor death and progression (P<0.001). All staging systems were independent prognostic factors for DFS. Area under the curve ratios for Choi, N stage, and LNR classifications were 0.738, 0.730, and 0.735, respectively. TNM and LNR classifications were independent prognosticators for OS, while Choi classification was an independent factor only in patients with ≥16 LN resected. Area under the curve ratios for Choi, N stage, and LNR classifications were 0.707, 0.728, and 0.732, respectively. Kaplan-Meier curves depending on LNR classification showed the best patient stratification for both OS and DFS.

CONCLUSIONS

The 3-staging systems had similar prognostic performance, but LNR-based classification stratified patients better. Further studies are needed to evaluate the impact of the number of LN examined, cutoff values, and anatomic extent of LN disease in GC.

Development of a simplified tumor-lymph node ratio classification system for patients with resected gastric cancer: A western study

INTRODUCTION

Gastric cancer (GC) shows high recurrence and mortality rates. The AJCC TNM staging system is the best prognostic predictor, but lymph node assessment is a major source of controversy. Recent studies have found that lymph node ratio (LNR) may overcome TNM limitations. Our aim is to develop a simplified tumor-LNR (T-LNR) classification for predicting prognosis of resected GC.

METHODS

Retrospective study of all GC resected in a tertiary center in Spain (N = 377). Clinicopathological features were assessed, LNR was classified into N0:0%, N1:1-25%, N2:>25%, and a T-LNR classification was developed. Statistical analyses were performed.

RESULTS

317 patients were finally included. Most patients were male (54.6%) and mean age was 72 years. Tumors were intestinal (61%), diffuse (30.8%) or mixed (8.1%). During follow-up, 36.7% and 27.4% of patients progressed and died, respectively. T-LNR classification divided patients into five prognostic categories (S1-S5). Most cases were S1-S4 (26.2%, 19.9%, 22.6% and 23.6%, respectively). 7.6% of tumors were S5. T-LNR classification was significantly associated with tumor size, depth, macroscopical type, Laurén subtype, signet ring cells, histologic grade, lymphovascular invasion, perineural infiltration, infiltrative growth, patient progression and death. Kaplan-Meier curves for OS showed an excellent patient stratification with evenly spaced curves. As for DFS, T-LNR classification also showed good discriminatory ability with non-overlapping curves. T-LNR classification was independently related to both OS and DFS.

CONCLUSIONS

T-LNR classifications can successfully predict prognosis of GC patients. Larger studies in other geographic regions should be performed to refine this classification and to validate its prognostic relevance.

Accurate Risk Stratification of Patients with Node-Positive Gastric Cancer by Lymph Node Ratio

BACKGROUND

We aimed to clarify the utility of lymph node ratio (LNR) for assessing the prognosis of patients with node-positive gastric cancer after curative gastrectomy.

METHODS

We retrospectively analyzed data of 973 patients with node-positive gastric cancer who had undergone curative gastrectomy at nine institutions from 2010 to 2014. Survival analysis was performed by comparing LNR low and high groups according to the optimal cutoff value of LNR, which was determined using receiver operating characteristic curve analysis.

RESULTS

LNR high was significantly associated with shorter disease-free survival and was an independent predictor of recurrence in all patients. Moreover, we obtained the similar results from analysis of each N stage. The prevalence of lymph node and peritoneal recurrence appeared to be higher in the LNR high group. Correlation analysis showed that LNR was negatively correlated with the number of retrieved nodes within every N stage; however, disease-free survival did not differ significantly between LNR low and high groups of each N stage with 16-30, 31-40, or >40 retrieved nodes.

CONCLUSIONS

LNR is a strong prognostic factor and predictor of recurrence in patients with node-positive gastric cancer who have undergone curative gastrectomy. The combination of LNR and N staging permits more accurate prognostic stratification of patients with gastric cancer and may contribute to developing novel prognostic models.

Preoperative prealbumin levels on admission as an independent predictive factor in patients with gastric cancer

BACKGROUND

To explore the role of preoperative prealbumin levels in predicting the prognosis of patients with gastric cancer.

METHODS

A total of 989 gastric cancer patients in the Affiliated Tumour Hospital of Harbin Medical University who underwent gastrectomy were included in this retrospective study. The preoperative prealbumin level, clinicopathological data, and follow-up data were recorded. According to the maximum chi-square survival correlation value, the survival of patients with low preoperative prealbumin (<140 mg/L) and high preoperative prealbumin (≥140 mg/L) were compared using the log-rank test and the Cox proportional hazard regression model.

RESULTS

Based on the best cut-off value of 140 mg/L, we divided the patients into the lower prealbumin group (<140 mg/L) and the higher prealbumin group (≥140 mg/L). Compared with the higher prealbumin group, the lower prealbumin group were older and had larger tumor volumes, lower hemoglobin (Hb) levels, and more upper gastric cancer tumors. The univariate analysis showed that prealbumin and other clinicopathological factors, including age, hemoglobin, tumor size, macroscopic type, cell differentiation, liver metastasis, operation type, N stage, and T stage, were significant prognostic factors. The multivariable analysis showed that age, prealbumin, macroscopic type, location, T stage, and N stage were independent prognostic factors.

CONCLUSIONS

The preoperative prealbumin level was an independent prognostic factor for patients with gastric cancer. The preoperative prealbumin level can be used to predict the prognosis of patients with gastric cancer and guide clinical practice.

"D2 plus" lymphadenectomy is associated with improved survival in distal gastric cancer with clinical serosa invasion: a propensity score analysis

The aim of this study was to elucidate the potential impact of “D2 plus” lymphadenectomy on the long-term survival of distal gastric cancer (GC) patients with clinical serosa invasion. A total of 394 distal GC patients with clinical serosa invasion who underwent at least standard D2 lymphadenectomy were enrolled. Patients were categorized into two groups according to the extent of lymphadenectomy: D2 group and “D2 plus” group. Propensity score matching was used to adjust for the differences in baseline characteristics. In the multivariate analysis for the whole study series, extent of lymphadenectomy was an independent prognostic factor for GC patients (P = 0.011). With the strata analysis, the significant prognostic differences between the two groups were only observed in patients at the IIIa-b or N1-3a stages. After matching, patients in “D2 plus” group still demonstrated a significantly higher 5-year overall survival rate than those in D2 group (55.3% versus 43.9%, P = 0.042). The common therapeutic value index of No. 12b, No. 12p, No. 14v and No. 13 LNs was 4.6, which was close to that of No. 5 LN station. In conclusion, “D2 plus” lymphadenectomy may be associated with improved overall survival in distal GC with clinical serosa invasion.

Study of Survival in Gastric Cancer with Emphasis on Lymph Node Status as an Independent Prognostic Factor

Background: Lymph node status in gastric cancer is known as an independent prognostic factor that guides the surgical and oncological treatment and independently influences long-term survival. Several studies suggest that the lymph node ratio has a greater importance in survival than the number of metastatic lymph nodes.

Aim: The aim of this study was to evaluate the clinical and morphological factors that can influence the survival of gastric cancer patients, with an emphasis on nodal status and the lymph node ratio.

Material and methods: We conducted a retrospective study in which 303 patients with gastric cancer admitted to the Department of Surgery of the Mureș County Hospital between 2008 and 2018 were screened for study enrolment. Data were obtained from the records of the department and from the histopathological reports. The examined variables included: age, gender, tumor localization, T stage, histological type, grade of differentiation, surgical procedure, lympho-vascular invasion, excised lymph nodes, metastatic lymph nodes, lymph node ratio. After screening, the study included a total number of 100 patients, for which follow-up data was available.

Results: The mean age of the study population was 66.43 ± 10 years, and 71% were males. The average survival period was 21.42 months. Statistical analysis showed that the localization of the tumor (p = 0.021), vascular invasion (p ---lt---0.001), T (p = 0.004) and N (p ---lt---0.001) stages, type of surgery (partial gastrectomy 59% vs. total gastrectomy 41%, p = 0.005), as well as the lymph node ratio (p ---lt---0.001) were prognostic factors for survival in patients with gastric cancer undergoing surgical therapy.

Conclusions: The survival of gastric cancer patients is significantly influenced by tumor localization, T stage, vascular invasion, type of surgery, N stage and the lymph node ratio based on univariate analysis. Also, the lymph node ratio proved to be an independent prognostic factor for survival.

Lymph Node Yield Following Packet Submission After Isolation By Surgeon During Gastrectomy

Purpose

To compare the lymph node yields of lymph node packet submission (PS), packet submission after isolation by surgeons (PSI), and en bloc lymph node submission (EBS) after gastrectomy.

Methods

We conducted a prospective study including 118 gastric cancer patients who underwent gastrectomy between June 2016 and August 2016. We also retrospectively reviewed 607 patients who underwent gastrectomy from May 2015 to May 2016. Following gastrectomy, lymph node specimens were either submitted en bloc (EBS group), divided into packets with accompanying adipose tissue according to the lymph node stations (PS group), or isolated individually based on the surgeon’s visualization and palpation before submission to the Pathology Department (PSI group).

Results

The average lymph node yield was significantly higher in the PSI compared with the PS group in the prospective study (46.5±19.4 vs 31.8±11.1), and significantly higher in the PS compared with the EBS group in the retrospective study (31.5±12.6 vs 23.9±8.9) (both P<0.001). There was no significant difference in positive lymph node yields in either of these comparisons (prospective study, P=0.581; retrospective study, P=0.489). The survival curve indicated no significant difference between the PS and PSI groups (log rank P=0.957); however, these three groups share different lymph node ratio (LNR).

Conclusion

PSI could yield more lymph nodes than PS or EBS with a lower LNR at pathological examination. However, the difference in lymph nodes harvested had no impact on survival, which may need further investigation.