Is the 8th Edition of the AJCC TNM Staging System Sufficiently Reasonable for All Patients with Noncardia Gastric Cancer? A 12,549-Patient International Database Study

Screening high-risk individuals for primary gastric carcinoma: evaluating overall survival probability score in the presence and absence of lymphatic metastasis post-gastrectomy

OBJECTIVE

The aim of this study was to develop and validate prognostic models for predicting overall survival in individuals with gastric carcinoma, specifically focusing on both negative and positive lymphatic metastasis.

METHODS

A total of 1650 patients who underwent radical gastric surgery at Shanxi Cancer Hospital between May 2002 and December 2020 were included in the analysis. Multiple Cox Proportional Hazards analysis was performed to identify key variables associated with overall survival in both negative and positive lymphatic metastasis cases. Internal validation was conducted using bootstrapping to assess the prediction accuracy of the models. Calibration curves were used to demonstrate the accuracy and consistency of the predictions. The discriminative abilities of the prognostic models were evaluated and compared with the 8th edition of AJCC-TNM staging using Harrell's Concordance index, decision curve analysis, and time-dependent receiver operating characteristic curves.

RESULTS

The nomogram for node-negative lymphatic metastasis included variables such as age, pT stage, and maximum tumor diameter. The C-index for this model in internal validation was 0.719, indicating better performance compared to the AJCC 8th edition TNM staging. The nomogram for node-positive lymphatic metastasis included variables such as gender, age, maximum tumor diameter, neural invasion, Lauren classification, and expression of Her-2, CK7, and CD56. The C-index for this model was 0.674, also outperforming the AJCC 8th edition TNM staging. Calibration curves, time-dependent receiver operating characteristic curves, and decision curve analysis for both nomograms demonstrated excellent prediction ability. Furthermore, significant differences in prognosis between low- and high-risk groups supported the models' strong risk stratification performance.

CONCLUSION

This study provides valuable risk stratification models for lymphatic metastasis in gastric carcinoma, encompassing both node-positive and negative cases. These models can help identify low-risk individuals who may not require further intervention, while high-risk individuals can benefit from targeted therapies aimed at addressing lymphatic metastasis.

Advances in Diagnostic, Staging, and Restaging Evaluation of Esophageal and Gastric Cancer

The initial endoscopic and staging evaluation of esophagogastric cancers must be accurate and comprehensive in order to select the optimal therapeutic plan for the patient. Esophageal and gastric cancers (and treatment paradigms) are delineated by their proximity to the cardia (within 2 cm). The most frequent and important symptom that informs the initial staging evaluation is dysphagia, which is associated with at least cT3 or locally advanced disease. Endoscopic ultrasound is often needed if earlier stage disease is suspected, preferably in combination with endoscopic mucosal or submucosal resection or fine-needle aspiration of suspicious lymph nodes to enhance staging accuracy.

Prognostic value of tumor regression grade (TRG) after oncological gastrectomy for gastric cancer

PURPOSE

Perioperative chemotherapy combined with surgical resection represent the gold standard in the treatment of locally advanced gastric cancer. The Mandard tumor regression score (TRG) is widely used to evaluate pathological response to neoadjuvant treatment. The aim of this study was to assess the prognostic value of TRG in terms of overall survival (OS) and disease-free (DFS).

METHODS

Retrospective analysis of all consecutive patients who underwent oncological gastrectomy after neoadjuvant chemotherapy from January 2007 to December 2019 for gastric adenocarcinoma was performed. Based on their TRG status they were categorized into two groups: good responders (TRG 1-2) and poor responders (TRG 3-5). Subsequent multivariable analyses were conducted.

RESULTS

Seventy-four patients were included, whereby 15 (20.3%) were TRG 1-2. Neoadjuvant regimens for TRG 1-2 vs. TRG 3-5 were similar: MAGIC (53% vs. 39%), FLOT (40% vs. 36%), FOLFOX (7% vs. 15%, p = 0.462). Histologic types according to Lauren classification for TRG 1-2 vs. TRG 3-5 were: 13% vs. 29% intestinal, 53% vs. 44% diffuse and 34% vs. 27% indeterminate (p = 0.326). TRG 1-2 group exhibited significantly less advanced ypT (46% vs. 10%, p = 0.001) and ypN stages (66% vs. 37%, p = 0.008), alongside a diminished recurrence rate (20% vs. 42%, p = 0.111). The 3-year DFS was significantly better in this group (81% vs. 47%, p = 0.041) whereas the disparity in three-year OS (92% vs. 55%, p = 0.054) did not attain statistical significance.

CONCLUSIONS

TRG 1-2 was associated with less advanced ypT and ypN stage and better DFS compared to TRG 3-5 patients, without a significant impact on OS.

Predictive value of positive lymph node ratio in patients with locally advanced gastric remnant cancer

BACKGROUND

Traditional lymph node stage (N stage) has limitations in advanced gastric remnant cancer (GRC) patients; therefore, establishing a new predictive stage is necessary.

AIM

To explore the predictive value of positive lymph node ratio (LNR) according to clinicopathological characteristics and prognosis of locally advanced GRC.

METHODS

Seventy-four patients who underwent radical gastrectomy and lymphadenectomy for locally advanced GRC were retrospectively reviewed. The relationship between LNR and clinicopathological characteristics was analyzed. The survival analysis was performed using Kaplan-Meier survival curves and Cox regression model.

RESULTS

Number of metastatic LNs, tumor diameter, depth of tumor invasion, Borrmann type, serum tumor biomarkers, and tumor-node-metastasis (TNM) stage were correlated with LNR stage and N stage. Univariate analysis revealed that the factors affecting survival included tumor diameter, anemia, serum tumor biomarkers, vascular or neural invasion, combined resection, LNR stage, N stage, and TNM stage (all P < 0.05). The median survival time for those with LNR0, LNR1, LNR2 and LNR3 stage were 61, 31, 23 and 17 mo, respectively, and the differences were significant (P = 0.000). Anemia, tumor biomarkers and LNR stage were independent prognostic factors for survival in multivariable analysis (all P < 0.05).

CONCLUSION

The new LNR stage is uniquely based on number of metastatic LNs, with significant prognostic value for locally advanced GRC, and could better differentiate overall survival, compared with N stage.

Short-and long-term outcomes of one-stage versus two-stage gastrectomy for perforated gastric cancer: a multicenter retrospective propensity score-matched study

OBJECTIVE

There is no scientific consensus about the treatment of perforated gastric cancer (PGC). Therefore, the aim of this study was to investigate which is the better treatment option for PGC between the single-stage and two-stage strategies.

METHODS

All 81 PGC patients from 13 medical institutions were retrospectively enrolled in this study. The PGC patients who underwent R0 gastrectomy were divided into one-stage surgery and two-stage surgery groups. The clinicopathological characteristics of the two groups were compared, and 415 regular gastric cancer patients without perforation were randomly selected as a control. The propensity score matching (PSM) method was used to find matched regular GC patients with similar clinicopathological parameters. The OS (overall survival) and the number harvested lymph nodes from PGC patients and regular GC patients were compared.

RESULTS

Compared with PGC patients who underwent one-stage surgery, those who underwent two-stage surgery harvested significantly more lymph nodes [31(27, 38) vs 17 (12, 24), P < 0.001], required less blood transfusion [0 (0, 100) vs 200 (0, 800), P = 0.034], had a shorter ICU stay [0 (0, 1.5) vs 3 (0, 3), P = 0.009], and had a significantly better OS (Median OS: 45 months vs 11 months, P = 0.007). Compared with propensity score-matched regular GC patients without perforation, PGC patients who underwent one-stage gastrectomy had a poorer quality of lymphadenectomy [17 (12, 24) vs 29 (21, 37), P < 0.001] and suffered a worse OS (Median OS: 18 months vs 30 months, P = 0.024). Conversely, two-stage gastrectomy can achieve a comparable quality of lymphadenectomy (P = 0.506) and a similar OS (P = 0.096) compared to propensity score-matched regular GC patients.

CONCLUSIONS

For PGC patients in poor condition, two-stage treatment is a better option when D2 radical gastrectomy cannot be achieved in emergency surgery, based on our findings that two-stage gastrectomy could provide PGC patients with a better quality of lymphadenectomy and a better OS.

Prognostic nomograms for gastric carcinoma after D2 + total gastrectomy to assist decision-making for postoperative treatment: based on Lasso regression

OBJECTIVE

This study aimed to establish novel nomograms that could be used to predict the prognosis of gastric carcinoma patients who underwent D2 + total gastrectomy on overall survival (OS) and progression-free survival (PFS).

METHODS

Lasso regression was employed to construct the nomograms. The internal validation process included bootstrapping, which was used to test the accuracy of the predictions. The calibration curve was then used to demonstrate the accuracy and consistency of the predictions. In addition, the Harrell's Concordance index (C-index) and time-dependent receiver operating characteristic (t-ROC) curves were used to evaluate the discriminative abilities of the new nomograms and to compare its performance with the 8th edition of AJCC-TNM staging. Furthermore, decision curve analysis (DCA) was performed to assess the clinical application of our model. Finally, the prognostic risk stratification of gastric cancer was conducted with X-tile software, and the nomograms were converted into a risk-stratifying prognosis model.

RESULTS

LASSO regression analysis identified pT stage, the number of positive lymph nodes, vascular invasion, neural invasion, the maximum diameter of tumor, the Clavien-Dindo classification for complication, and Ki67 as independent risk factors for OS and pT stage, the number of positive lymph nodes, neural invasion, and the maximum diameter of tumor for PFS. The C-index of OS nomogram was 0.719 (95% CI: 0.690-0.748), which was superior to the 8th edition of AJCC-TNM staging (0.704, 95%CI: 0.623-0.783). The C-index of PFS nomogram was 0.694 (95% CI: 0.654-0.713), which was also better than that of the 8th edition of AJCC-TNM staging (0.685, 95% CI: 0.635-0.751). The calibration curves, t-ROC curves, and DCA of the two nomogram models showed that the prediction ability of the two nomogram models was outstanding. The statistical difference in the prognosis between the low- and high-risk groups further suggested that our model had an excellent risk stratification performance.

CONCLUSION

We reported the first risk stratification and nomogram for gastric carcinoma patients with total gastrectomy in Chinese population. Our model could potentially be used to guide treatment selections for the low- and high-risk patients to avoid delayed treatment or unnecessary overtreatment.

High expression of the circadian clock gene NPAS2 is associated with progression and poor prognosis of gastric cancer: A single-center study

BACKGROUND

The prognostic assessment of patients after surgical resection of gastric cancer (GC) patients is critical. However, the role of the circadian clock gene NPAS2 expression in GC remains unknown.

AIM

To explore the relationship between NPAS2 and the survival prognosis of GC patients and clarify its role in evaluating GC prognosis.

METHODS

The tumor tissues and clinical data of 101 patients with GC were collected retrospectively. Immunohistochemical staining (IHC) was used to detect the expression of NPAS2 protein in GC and adjacent tissues. Univariate and multivariate Cox regression analysis was used to determine the independent prognostic factors of GC, and a nomogram prediction model was established. The receiver operating characteristic (ROC) curve, the ROC area under the curve, the calibration curve, and C-index were used to evaluate the predictive effectiveness of the model. Kaplan Meier analysis was used to compare the risk stratification of subgroups according to the median score in the nomogram model of each patient.

RESULTS

Microarray IHC analysis showed that the positive rate of NPAS2 protein expression in GC tissues was 65.35%, which was significantly higher than 30.69% in adjacent tissues. The high expression of NPAS2 was correlated with tumor-node-metastasis (TNM) stage (P < 0.05), pN stage (P < 0.05), metastasis (P < 0.05), venous invasion (P < 0.05), lymphatic invasion (P < 0.05), and lymph node positive (P < 0.05) of GC. Kaplan Meier survival analysis showed that the 3-year overall survival (OS) of patients with high NPAS2 expression was significantly shortened (P < 0.0001). Univariate and multivariate COX regression analysis showed that TNM stage (P = 0.009), metastasis (P = 0.009), and NPAS2 expression (P = 0.020) were independent prognostic factors of OS in GC patients for 3 years. The nomogram prediction model based on independent prognostic factors has a C-Index of 0.740 (95%CI: 0.713-0.767). Furthermore, subgroup analysis showed that the 3-year OS time of the high-risk group was significantly lower than that of the low-risk group (P < 0.0001).

CONCLUSION

NPAS2 is highly expressed in GC tissues and is closely related to worse OS in patients. Therefore, the evaluation of NPAS2 expression may be a potential marker for GC prognosis evaluation. Notably, the nomogram model based on NPAS2 can improve the accuracy of GC prognosis prediction and assist clinicians in postoperative patient management and decision-making.

A Comprehensive Review of Prognostic Factors in Patients with Gastric Adenocarcinoma

Gastric adenocarcinoma remains associated with a poor long-term survival, despite recent therapeutical advances. In most parts of the world where systematic screening programs do not exist, diagnosis is often made at advanced stages, affecting long-term prognosis. In recent years, there is increasing evidence that a large bundle of factors, ranging from the tumor microenvironment to patient ethnicity and variations in therapeutic strategy, play an important role in patient outcome. A more thorough understanding of these multi-faceted parameters is needed in order to provide a better assessment of long-term prognosis in these patients, which probably also require the refinement of current staging systems. This study aims to review existing knowledge on the clinical, biomolecular and treatment-related parameters that have some prognostic value in patients with gastric adenocarcinoma.

Nomogram-Based Prognostic Evaluation of Gastric Cancer Patients with Low Counts of Examined Lymph Nodes Outperforms the Predictive Ability of the 7th and 8th Editions of the American Joint Committee on Cancer Staging System

BACKGROUND

The American Joint Committee on Cancer (AJCC) staging system has limited accuracy in predicting survival of gastric cancer patients with inadequate counts of evaluated lymph nodes (LNs). We therefore aimed to develop a prognostic nomogram suitable for clinical applications in such cases.

METHODS

A total of 1511 noncardia gastric cancer patients treated between 1990 and 2010 in the academic surgical center were reviewed to compare the 7^th and 8^th editions of the AJCC staging system. A nomogram was developed for the prediction of 5-year survival in patients with less than 16 LNs evaluated (n = 546). External validation was performed using datasets derived from the Polish Gastric Cancer Study Group (n = 668) and the SEER database (n = 11,225).

RESULTS

The 8th edition of AJCC staging showed better overall discriminatory power compared to the previous version, but no improvement was found for patients with < 16 evaluated LNs. The developed nomogram had better concordance index (0.695) than the former (0.682) or latest (0.680) staging editions, including patients subject to neoadjuvant treatment, and calibration curves showed excellent agreement between the nomogram-predicted and actual survival. High discriminatory power was also demonstrated for both validation cohorts. Subsequently, the nomogram showed the best accuracy for the prediction of 5-year survival through the time-dependent ROC curve analysis in the training and validation cohorts.

CONCLUSIONS

A clinically relevant nomogram was built for the prediction of 5-year survival in patients with inadequate numbers of LNs evaluated in surgical specimens. The predictive accuracy of the nomogram was validated in two Western populations.

Clinical value of regional lymph node sorting in gastric cancer

BACKGROUND

Increasing evidence have shown that regional lymph node metastasis is a critical prognostic factor in gastric cancer (GC). In addition, lymph node dissection is a key factor in determining the appropriate treatment for GC. However, the association between the number of positive lymph nodes and area of lymph node metastasis in GC remains unclear.

AIM

To investigate the clinical value of regional lymph node sorting after radical gastrectomy for GC.

METHODS

This study included 661 patients with GC who underwent radical gastrectomy at Tianjin Medical University General Hospital between January 2012 and June 2020. The patients were divided into regional sorting and non-sorting groups. Clinicopathological data were collected and retrospectively reviewed to determine the differences in the total number of lymph nodes and number of positive lymph nodes between the groups. Independent sample t-tests were used for intergroup comparisons. Continuous variables that did not conform to a normal distribution were expressed as median (interquartile range), and the Mann-Whitney U test was used for inter-group comparisons.

RESULTS

There were no significant differences between the groups in terms of the surgical method, tumor site, immersion depth, and degree of differentiation. The total number of lymph nodes was significantly higher in the regional sorting group (n = 324) than in the non-sorting group (n = 337) (32.5 vs 21.2, P < 0.001). There was no significant difference in the number of positive lymph nodes between the two groups. A total of 212 patients with GC had lymph node metastasis in the lymph node regional sorting group, including 89 (41.98%) cases in the first dissection station and 123 (58.02 %) cases in the second dissection station. Binary and multivariate logistic regression results showed that the number of positive lymph nodes (P < 0.001) was an independent risk factor for lymph node metastases at the second dissection station.

CONCLUSION

Regional sorting of lymph nodes after radical gastrectomy may increase the number of detected lymph nodes, thereby improving the reliability and accuracy of lymph node staging in clinical practice.

Prognostic nomograms for gastric carcinoma after surgery to assist decision-making for postoperative treatment with chemotherapy cycles <9 or chemotherapy cycles ≥9

Objective

We sought to develop novel nomograms to accurately predict overall survival (OS) of chemotherapy cycles &lt;9 and chemotherapy cycles ≥9 and construct risk stratification to differentiate low-risk and high-risk of two cohorts.

Methods

Patients who underwent curative-intent resection for gastric cancer between January 2002 and May 2020 at a single China institution were identified. Variables associated with OS were recorded and analyzed according to multivariable Cox models. Nomograms predicting 3- and 5-year OS were built according to variables resulting from multivariable Cox models. Discrimination ability was calculated using the Harrell's Concordance Index. The constructed nomogram was subjected to 1,000 resamples bootstrap for internal validation. Calibration curves for the new nomograms were used to test the consistency between the predicted and actual 3- and 5-year OS. Decision curve analysis (DCA) was performed to assess the clinical net benefit. The Concordance index (C-index) and time-dependent receiver operating characteristic (t-ROC) curves were used to evaluate and compare the discriminative abilities of the new nomograms. Finally, prognostic risk stratification of gastric cancer was conducted with X-tile software and nomograms converted into a risk-stratified prognosis model.

Results

For the nomogram predict OS of chemotherapy cycles &lt;9, C-index was 0.711 (95% CI, 0.663–0.760) in internal validation and 0.722 (95% CI, 0.662–0.783) in external validation, which was better than AJCC 8th edition TNM staging (internal validation: 0.627, 95% CI, 0.585–0.670) and (external validation: 0.595,95% CI, 0.543–0.648). The C-index of the nomogram for chemotherapy cycles ≥9 in internal validation was 0.755 (95% CI, 0.728–0.782) and 0.785 (95% CI, 0.747–0.823) in external validation, which was superior to the AJCC 8th edition TNM staging (internal validation: 0.712 95% CI, 0.688–0.737) and (external validation 0.734, 95% CI, 0.699–0.770).The calibration curves, t-ROC curves and DCA of the two nomogram models show that the recognition performance of the two nomogram models was outstanding. The statistical differences in the prognosis among the two risk stratification groups further showed that our model had an excellent risk stratification performance.

Conclusion

This is first reported risk stratification for chemotherapy cycles of gastric carcinoma. Our proposed nomograms can effectively evaluate postoperative prognosis of patients with different chemotherapy cycles of gastric carcinoma. Chemotherapy cycles ≥9 is therefore recommended for high-risk patients with chemotherapy cycles &lt;9, but not for low-risk patients. Meanwhile, combination with multiple therapies are essential to high-risk patients with chemotherapy cycles ≥9 and unnecessary for low-risk patients.

A New Nomogram for Predicting the Postoperative Overall Survival in Patients with Middle-Aged and Elderly Rectal Cancer: A Single Center Retrospective Study in Chinese Population

Purpose

Patients with middle-aged and elderly rectal cancer (MERC) usually have poor prognosis after surgery. This study aimed to develop a nomogram to achieve individualized prediction of overall survival (OS) in patients with MERC and to guide follow-up and subsequent diagnosis and treatment plans.

Patients and Methods

A total of 349 patients were randomly assigned to the training and validation cohorts in a 7:3 ratio. Multivariate Cox regression analysis was performed using the results of univariate Cox regression analysis to confirm independent prognostic factors of OS. Thereafter, the nomogram was built using the “rms” package. Subsequently, discriminative ability and calibration of the nomogram were evaluated using receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA). Integrated discrimination improvement (IDI), net reclassification improvement (NRI), and the area under the ROC curves (AUC) were compared between the nomogram and the tumor-node-metastasis (TNM) staging system (8th edition). Finally, we established a predictive model to assess the survival benefit of patients with MERC by calculating nomogram scores for each patient.

Results

Six variables were identified as independent prognostic factors and included in the nomogram: smoking history, family history, hematochezia, tumor size, N stage, and M stage. Based on these factors, we successfully constructed a nomogram and evaluated its discriminative and predictive abilities using ROC curves, calibration curves, and DCA. ROC curves, IDI, and NRI showed that the nomogram had outstanding clinical utility compared with the TNM staging system (8th edition) for OS prediction. The predictive model successfully distinguished between high-, medium-, and low-risk MERC patients.

Conclusion

Our nomogram provided a more satisfactory survival prediction ability than the TNM staging system (8th edition) for MERC patients. In addition, the nomogram was able to accurately categorize patients into different risk groups after surgery.

Revisiting the 8th AJCC system for gastric cancer: A review on validations, nomograms, lymph nodes impact, and proposed modifications

Gastric cancer is the fifth most frequently diagnosed cancer worldwide, behind breast, lung, colorectal, and prostate cancers. In gastric cancer, multimodality treatment shows prospective benefits and also improves survival. Surgery, however, is the mainstay of curative treatment. The staging of gastric cancer patients is critical for harmonization of care. Accurate stages assure that informed clinical decisions are timely made. The American Joint Committee on Cancer (AJCC) staging system is the most widely applied system in to determine the disease's prognosis and survival prediction. The recently adopted 8th AJCC TNM staging system has been revised to enhance its survival predictive power. Subsequent studies have established the validity of the current edition, demonstrating improved stage stratification, discriminatory power, and survival prediction. However, other studies have cast doubt on the superiority of the new edition. Innovations aimed at further improving its prognosis have resulted in developing of novel models. Advances in our understanding of the tumor microenvironment and molecular categorization of cancer have resulted in proposals for their inclusion in TNM staging as potential complementary factors that enhance survival prediction and prognostic assessment ability. The purpose of this study is to conduct a review of the published literature regarding the validity of the 8th AJCC TNM staging system, proposed modifications, and nomograms.

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The 8th AJCC is valid in prognostic stratification of gastric cancer, however, revisions are still required.

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The yPT staging requires some modifications and inclusion of stages that currently don't exist in the 8th AJCC.

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High lymph nodes count and anatomical localization improve the prediction ability of the current AJCC.

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Nomograms comprising of individual prognostic factors are crucial to the current AJCC.

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Molecular markers positively influence survival prediction of gastric cancer.

The New American Joint Committee on Cancer T staging system for stomach: increased complexity without clear improvement in predictive accuracy for endoscopic ultrasound

Background

The efficacy of endoscopic ultrasound (EUS) for determining the T category of gastric cancer is variable. The aim of this study was to evaluate the superiority of EUS by using the 6th edition American Joint Committee on Cancer (AJCC) staging system for stomach cancer compared to the new 7th/8th edition.

Methods

A retrospective analysis of clinical and EUS imaging features of 348 gastric carcinoma patients who underwent radical resection were retrospectively analyzed. Differences between the 6th and 7th/8th edition T staging systems for preoperative EUS evaluation were compared.

Results

The accuracy of EUS T staging was 72.4% for the 7th/8th edition and 78.4% for the 6th edition. T3 stage accuracy was significantly worse when the T3 group status was changed. The tumor location, echoendoscope type, and histological type were associated with inaccuracy. We further analyzed the EUS image features for each tumor T stage and found that an indistinctly visible muscularis propria (MP) or with obvious thickening was considered an indicator of lesions involved in the MP with a sensitivity of 81.3%; an MP completely disappeared and accompanied with a serosal layer intact may be a marker that the lesion invaded to the subserosa. We also found that irregularities in the outer edge of the gastric wall were markers of gastric serosal layer penetration with a positive predictive value of 92.2%.

Conclusions

The increased complexity of the 7th/8th edition T staging system is accompanied by worsening of the predictive accuracy for EUS as compared to the 6th edition. Furthermore, the tumor location, echoendoscope type, histological type, and EUS image features for each tumor T stage should warrant attention.

Prognostic significance of combined Lymphocyte-monocyte Ratio and Tumor-associated Macrophages in Gastric Cancer Patients after Radical Resection

Background: Immune function is recognized as an important prognostic indicator in gastric cancer (GC). The relationship between the lymphocyte-monocyte ratio (LMR) and tumor-associated macrophage (TAM) has received far less attention.

Methods: A total of 401 patients from a prospective trial (NCT02327481) were enrolled in this study. The relationships between the LMR, TAM, and clinicopathologic variables were analyzed using a Kaplan-Meier log-rank survival analysis, and multivariate Cox regression models were used to identify associations with recurrence-free survival (RFS) and overall survival (OS). The discriminatory power of the prognostic models for both RFS and OS were compared. The decision curve analysis was performed to compare the clinical utility of the prognostic models.

Results: High LMR was observed in 81.5% of the 401 GC patients, and high TAM infiltration was observed in 45.9% of the patients. In a multivariate Cox analysis of all patients, LMR and TAM were both independent prognostic factors for RFS and OS. Patients with high TAM expression had similar mean LMR levels than patients with low TAM expression. Moreover, LMR appeared to lose its prognostic significance in patients with high TAM expression levels. Finally, the model that included the TAM had better predictive capability and clinical utility for both RFS and OS.

Conclusions: Although LMR and TAM are both independent predictors of RFS and OS in resectable GC patients, LMR seem to attenuate its prognostic significance in patients with high TAM expression. This information may be helpful in the clinical management of patients with GC. Further external studies are warranted to confirm this hypothesis.

Score for the Overall Survival Probability of Patients With Pancreatic Adenocarcinoma of the Body and Tail After Surgery: A Novel Nomogram-Based Risk Assessment

Pancreatic adenocarcinoma of the body and tail often has a dismal prognosis and lacks a specific prognostic stage. The aim of this study was to construct a nomogram for predicting survival of patients with pancreatic adenocarcinoma of the body and tail after surgery. Data of patients were selected from the Surveillance, Epidemiology, and End Results (SEER) database and from medical records of Sun Yat-sen University Cancer Center (SYSUCC). In a multivariate analysis for overall survival (OS), the following six variables were identified as independent predictors and incorporated into the nomogram: age, tumor differentiation, tumor size, lymph node ratio (LNR), and chemotherapy. A nomogram was built based on independent risk predictors. The concordance index (C-index) for nomogram, Tumor-Node-Metastasis (TNM) 7th and 8th stage system were 0.775 [95% confidence interval (CI), 0.731–0.819], 0.617 (95%CI, 0.575–0.659), and 0.632 (95%CI, 0.588–0.676), respectively. The calibrated nomogram predicted survival rates which closely corresponded to the actual survival rates. Furthermore, the values of the area under receiver operating characteristic (ROC) curves (AUC) of the nomograms were higher than those of the TNM 7th or 8th stage system in predicting 1-, 2-, and 3-year survival of patients in training and external validation cohorts. The well-calibrated nomogram could be used to predict prognosis for patients with pancreatic adenocarcinoma of the body and tail after surgery.

Application value of nomogram and prognostic factors of gastric cancer patients who underwent D2 radical lymphadenectomy

BACKGROUND

The aim of this study was to explore the prognostic factors and establish a nomogram to predict the long-term survival of gastric cancer patients.

METHODS

The clinicopathological data of 421 gastric cancer patients, who were treated with radical D2 lymphadenectomy by the same surgical team between January 2009 and March 2017, were collected. The analysis of long-term survival was performed using Cox regression analysis. Based on the multivariate analysis results, a prognostic nomogram was formulated to predict the 5-year survival rate probability.

RESULTS

In the present study, the total overall 3-year and 5-year survival rates were 58.7 and 45.8%, respectively. The results of the univariate Cox regression analysis revealed that tumor staging, tumor location, Borrmann type, the number of lymph nodes dissected, the number of lymph node metastases, positive lymph nodes ratio, lymphocyte count, serum albumin, CEA, CA153, CA199, BMI, tumor size, nerve invasion, and vascular invasion were prognostic factors for gastric cancer (all, P < 0.05). However, merely tumor staging, tumor location, positive lymph node ratio, CA199, BMI, tumor size, nerve invasion, and vascular invasion were independent risk factors, based on the results of the multivariate Cox regression analysis (all, P < 0.05). The nomogram based on eight independent prognostic factors revealed a well-degree of differentiation with a concordance index of 0.76 (95% CI: 0.72-0.79, P < 0.001), which was better than the AJCC-7 staging system (concordance index = 0.68).

CONCLUSION

The present study established a nomogram based on eight independent prognostic factors to predict long-term survival in gastric cancer patients. The nomogram would be beneficial for more accurately predicting the prognosis of gastric cancer, and provide important basis for making individualized treatment plans following surgery.

Essential updates 2017/2018: Recent topics in the treatment and research of gastric cancer in Japan

Recent developments in diagnostic technology, accumulated clinical effort and established evidence have boosted early detection and drastically improved early and long-term outcomes of gastric cancer. However, gastric cancer continues to be one of the most aggressive and life-threatening malignancies among all cancers and is a global health problem. Between January 2017 and December 2018, various fascinating reports of managements and research were published, including the new 15th Japanese Classification of Gastric Carcinoma reflecting the 8th American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) tumor, node and metastasis (TNM) classification (October 2017) and the new Gastric Cancer Treatment Guidelines version 5 (January 2018). Moreover, pivotal molecular features of gastric cancer were clarified by the worldwide cancer genome project, and various treatment targets and biomarkers such as circulating DNAs and microRNAs were detected. Novel treatment options using programmed cell death protein 1 immune checkpoint inhibitors have been started. In this review, we summarize the recent topics of classification, guidelines, and clinical and basic research in order to bring new insights to gastric cancer treatment.

Tumor-infiltrating CD8+ T cells combined with tumor-associated CD68+ macrophages predict postoperative prognosis and adjuvant chemotherapy benefit in resected gastric cancer

Background

Tumor-infiltrating immune cells are present in various malignant tumors, but their clinical significance in gastric cancer (GC) remains unclear. This study aimed to investigate the prognostic significance of tumor-infiltrating lymphocytes (TILs) and tumor-associated macrophages (TAMs).

Methods

Using a prospective database containing 401 cases of GC, we evaluated TIL (cluster of differentiation 8 (CD8) expression) and TAM (cluster of differentiation 68 (CD68) expression) statuses via immunohistochemical staining.

Results

Compared with CD8+ TIL-negative cases (n = 196, 48.6%), CD8+ TIL-positive cases (n = 205, 51.1%) showed significantly better recurrence-free survival (RFS) [log-rank p<0.001; multivariate HR: 0.372; 95% confidence interval (CI): 0.239–0.579, p<0.001]. In contrast, compared with CD68+ TAM-negative cases (n = 217, 54.1%), CD68+ TAM-positive cases (n = 184, 45.9%) had significantly poor RFS [log-rank p<0.001; multivariate HR: 2.182; 95% CI: 1.435–3.318, p<0.001]. Thus, patients with a positive CD8+ TIL and negative CD68+ TAM status exhibited significantly increased RFS. Multivariate analysis demonstrated that CD8+ TILs and CD68+ TAMs may serve as independent prognostic markers for RFS. Incorporating CD8+ TIL and CD68+ TAM statuses into the AJCC TNM system generated a predictive model with better predictive accuracy for RFS. More importantly, patients with a positive TIL and negative TAM status showed a tendency of improved RFS after postoperative adjuvant chemotherapy (PAC). Similar results were obtained by overall survival (OS) analysis.

Conclusions

CD8+ TIL and CD68+ TAM statuses were identified as independent prognostic factors that may be integrated into the current TNM staging system to refine risk stratification and to better predict the survival benefit from PAC in patients with GC.

Trial registration

The current controlled trial was registered at ClinicalTrials.gov (ID: NCT02327481) on December 30, 2014.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-6089-z) contains supplementary material, which is available to authorized users.

A novel TNM staging system for gastric cancer based on the metro-ticket paradigm: a comparative study with the AJCC-TNM staging system

BACKGROUND

The metro-ticket prognostic tool for hepatocellular carcinoma has been proven to predict outcome, but a similar concept has not been investigated for GC. The objective of the current study was to apply the principles of the metro-ticket paradigm to develop a novel TNM staging system (nTNM) for gastric cancer (GC).

METHODS

The nTNM considered the distance from the origin on a Cartesian plane incorporating the pN (x-axis) and pT (y-axis) stages. GC patients undergoing radical resection at Fujian Medical University Union Hospital (FMUUH) (n = 4267) were included. The nTNM was validated using 2 external cohorts from the Sun Yat-sen University Cancer Center (SYSUCC) (n = 1800) and Surveillance, Epidemiology, and End Results (SEER) (n = 3227) databases.

RESULTS

nTNM classes with the same distance from the origin have same stage; the stage increases with this distance. Among all patients, 48.0% (n = 2049) were restaged in the nTNM compared with the 7th edition of the AJCC-TNM classification; 26.2% (n = 1116) were downstaged in the nTNM compared with the 8th edition. The nTNM provides significant survival differences between stages (all P < 0.001). The survival difference between stages IB and IIA was especially large for the nTNM (P < 0.001) compared to the 7th and 8th editions (P = 0.073). The concordance index and hazard ratio increased successively with the nTNM stage. Similar findings were observed in both external cohorts.

CONCLUSION

Compared with the AJCC-TNM classification, the nTNM for GC is easier to remember and provides some improvements; therefore, the nTNM may be considered for adoption in future editions of the AJCC-TNM classification.

A novel prognosis prediction model after completion gastrectomy for remnant gastric cancer: Development and validation using international multicenter databases

BACKGROUND

Examined lymph node counts of remnant gastric cancer patients are often insufficient, and the prognostic ability of tumor-node-metastasis staging is therefore limited. This study aimed to create a simple and universally applicable prediction model for RGC patients after completion of gastrectomy.

METHODS

A 5-year overall survival prediction model for remnant gastric cancer patients was developed using a test dataset of 148 consecutive patients. Model coefficients were obtained based on the Cox analysis of clinicopathological factors. Prognostic performance was assessed with the concordance index (C-index) and decision curve analysis. For internal validation, the bootstrap method and calibration assessment were used. The model was validated using 2 external cohorts from China (First Affiliated Hospital of Fujian Medical University, n = 46) and the United States (Mayo Clinic, n = 20).

RESULTS

Depth of tumor invasion, number of metastatic lymph nodes, distant metastasis, and operative time were independent prognostic factors. Our model's C-index (0.761) showed better discriminatory power than that of the eighth tumor-node-metastasis staging system (0.714, P = .001). The model calibration was accurate at predicting 5-year survival. Decision curve analysis showed that the model had a greater benefit, and the results were also confirmed by bootstrap internal validation. In external validation, the C-index and decision curve analysis showed good prognostic performances in patient datasets from 2 participating institutions. Moreover, we verified the reliability of the model in an analysis of patients with different examined lymph node counts (>15 or ≤15).

CONCLUSION

Utilizing clinically practical information, we developed a universally applicable prediction model for accurately determining the 5-year overall survival of remnant gastric cancer patients after completion of gastrectomy. Our predictive model outperformed tumor-node-metastasis staging in diverse international datasets regardless of examined lymph node counts.

Development and validation of a new staging system for node-negative gastric cancer based on recursive partitioning analysis: An international multi-institutional study

BACKGROUND

Whether the tumor-node-metastasis (TNM) staging system is appropriate for patients with node-negative gastric cancer (GC) is still inconclusive. The modified staging system developed by recursive partitioning analysis (RPA) showed good prognostic performance in a variety of cancers. The application of RPA has not been reported in the prognostic prediction of GC.

METHODS

Node-negative GC patients who underwent radical resection at Fujian Medical University Union Hospital (n = 862) and Sun Yat-sen University Cancer Center (n = 311) with at least 5 years of follow-up were selected as the training set. RPA was used to develop a modified staging system. Patients from the Surveillance, Epidemiology, and End Results database (n = 1415) were selected as the validation set.

RESULTS

The 5-year overall survival (OS) rates of patients with 8th AJCC-TNM stage IA-IIIA in the training set were IA 95.2%, IB 87.1%, IIA 78.3%, IIB 75.8%, and IIIA 72.6%. Multivariate analysis (MVA) showed that larger tumor size, elder age, and deeper depth of invasion were independent predictors for OS in patients with node-negative GC (all P < 0.05). Patients were reclassified into RPA I, RPA II, RPA III, and RPA IV stages based on RPA; the 5-year OS rates were 96.1%, 87.2%, 81.0%, and 64.3%, respectively, with significant difference (P < 0.05). Two-step MVA showed that the RPA staging system was an independent predictor of OS (P < 0.05). Compared with the 8th AJCC-TNM staging system, the RPA staging system had a smaller AIC value (2544.9 vs 2576.2), higher χ2 score (104.2 vs 69.6) and higher Harrell's C-index (0.697 vs 0.669, P = 0.007). The similar results were found in the validation set.

CONCLUSIONS

A new prognostic predictive system based on RPA was successfully developed and validated, which may be suggested for staging node-negative GC in future.

Comparison of the 7th and the 8th AJCC Staging System for Non-metastatic D2-Resected Lymph Node-Positive Gastric Cancer Treated with Different Adjuvant Protocols

PURPOSE

The purpose of this study was to compare prognostic differentiation performances of the 7th and the 8th edition of American Joint Commission on Cancer (AJCC) staging system for gastric cancer (GC) patients.

Materials and Methods

A total of 1,633 GC patients who underwent curative D2 resection followed by adjuvant chemotherapy alone (CA) or concurrent chemo-radiotherapy (CCRT) from 2004 to 2013 were included. Concordance index (c-index) was applied to compare the discriminatory ability.

RESULTS

In the 8th edition, migration of stage was detected in 248 patients (15.2%). Among them, 121 patients were up-staged while 127 patients were down-staged. Overall, there was no statistically significant difference in the discriminatory ability between the 7th and 8th editions. The new edition of staging system, however, showed a trend of better prognostic performance not only in recurrence-free survival (c-index=0.734; 95% confidence interval [CI], 0.706 to 0.762 in the 7th edition vs. c-index=0.740; 95% CI, 0.712 to 0.768 in the 8th edition; p=0.14), but also in overall survival (c-index=0.717; 95% CI, 0.688 to 0.745 in the 7th edition vs. c-index=0.722; 95% CI, 0.694 to 0.751 in the 8th edition; p=0.19), especially in stage III. This finding was repeated in the subgroup analysis regardless of adjuvant CA or CCRT.

CONCLUSION

Generally, the 8th edition of AJCC staging system had failed to show a superior discriminatory ability for curatively D2 resected GC patients than the 7th edition, although there was a trend of better prognostic performance of the new edition, regardless of adjuvant treatment method.