Association Between Lymph Node Ratio and Survival in Patients with Pathological Stage II/III Gastric Cancer

Prognostic value of a modified pathological staging system for gastric cancer based on the number of retrieved lymph nodes and metastatic lymph node ratio

Aim

The prognosis for gastric cancer (GC) remains grim, underscoring the importance of accurate staging and treatment. Given the potential benefits of using lymph node ratio (LNR) for improved prognostication and treatment planning, it is critical to incorporate examined lymph nodes (ELN) count in an integrated GC staging system.

Methods

Patients data from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015 was utilized as training set. The Mantel-Cox survival test was used to calculate chi-square values for 40 LNR segments with a 0.025 interval, defining a novel LNR-based N (rN) classification based on the cutoff points. A revised AJCC (rAJCC) staging system was established by replacing the 8th AJCC N staging with a rN classification. The relationship between the ELN count and prognosis or positive lymph node detection was conducted by using multivariable models. The series of the odds ratios and hazard ratios were fitted with a locally weighted scatterplot smoothing (LOWESS) smoother, and the structural break points were determined by Chow test to clarify an optimal minimum ELN count. The integrated GC staging system incorporated both rAJCC system and the ideal ELN count. Discriminatory ability and prognostic homogeneity of the rAJCC and integrated staging system was compared with AJCC staging system in the SEER validation set (2016-2017), the Cancer Genome Atlas Program (TCGA) database, and the Third Affiliated Hospital of Sun Yat-sen University database.

Results

The current study found that LNR and ELN count are both significantly associated with the prognosis of GC patients (HR = 0.98, p < 0.001 and HR = 2.51, p < 0.001). Four peaks of the chi-square value were identified as LNR cut-off points at 0.025, 0.175, 0.45 and 0.6 to define a novel rN stage. In comparison to the 8th AJCC staging system, the rAJCC staging system demonstrated significant prognostic advantages and discriminatory ability in the training set (5-Y OS AUC: 71.7 vs. 73.0; AIC: 57,290.7 vs. 57,054.9). The superiority of the rAJCC staging system was confirmed in all validation sets. Using a LOWESS smoother and Chow test, a threshold ELN count of 30 was determined to maximum improvement in the prognosis of node-negative patients without downgrading due to potential metastasis, while also maximizing the detection efficiency of at least one involved lymph node. The integrated staging system, combining the refined rAJCC classification with an optimized ELN count threshold, has demonstrated superior discriminatory performance compared to the standalone rAJCC or the traditional AJCC system.

Conclusion

The development of a novel GC staging system, which integrated the LNR-based N classification and the minimum ELN count, has exhibited superior prognostic accuracy, holding promise as a valuable asset in the clinical management of GC. However, it is crucial to recognize the limitations from the retrospective database, which should be addressed in subsequent analyses.

Caudal-Type Homeobox Transcription Factor 2 is a Favorable Prognostic Indicator in Stage II and III Gastric Cancer Following Curative Surgery

Background

The study explored the prognostic value of caudal-type homeobox transcription factor 2 (CDX2) in stage II and III gastric cancer.

Methods

This study evaluated the expression level of CDX2 in gastric cancer in a hospital cohort (n=197) using immunohistochemistry. According to a semiquantitative score used to determine CDX2 expression, the cases were divided into a low CDX2 group (116 cases) and a high CDX2 group (81 cases). The RNA-seq expression data from 291 patients with stage II and III gastric cancer from The Cancer Genome Atlas (TCGA) cohort were used to verify the immunohistochemistry results. Based on the median CDX2 expression value, the TCGA patients were divided into a low CDX2 group (145 cases) and a high CDX2 group (146 cases). The relationships among CDX2 expression and clinicopathological features were determined using the Chi-square test. Cox proportional hazards regression models were applied to estimate the independent prognostic factors. The probability of survival was determined using the Kaplan-Meier method and Log rank tests.

Results

Based on the Cox multivariate analysis, CDX2 was the independent prognostic factor in the hospital and TCGA cohorts. In the hospital cohort, CDX2 expression was associated with an improved DFS (hazard ratio [HR] = 0.4076, 95% CI, 0.2675-0.6210, P = 0.0001) and OS (HR = 0.4183, 95% CI, 0.2744-0.6375, P = 0.0002). In the TCGA cohort, CDX2 expression also was associated with an improved DFS (HR = 0.5948, 95% CI, 0.4153-0.8521, P = 0.0054) and OS (HR = 0.5976, 95% CI, 0.4172-0.8561, P = 0.0058). Furthermore, the CDX2 expression level was correlated with an improved DFS (P = 0.0025) and OS (P = 0.0015) using the Kaplan-Meier Plotter database for gastric cancer.

Conclusion

CDX2 is a potential prognostic biomarker for stage II and III gastric cancer. In addition, CDX2 positive cancer patients are more likely to have resectable tumors and exhibit better survival rates.

RATIO OF METASTATIC LYMPH NODES VS. RESECTED LYMPH NODES (N-RATIO) HAS PROGNOSTIC IMPLICATIONS IN GASTRIC CANCER

BACKGROUND

Lymph node status is vital for gastric cancer (GC) prognosis, but the conventional pN stage may be limited by variations in lymphadenectomy and stage migration. The N-Ratio, which assesses the ratio of metastatic to resected lymph nodes, emerges as a promising prognostic tool.

AIMS

To assess N-Ratios prognostic value in GC, particularly in patients with <25 resected lymph nodes.

METHODS

Patients who underwent gastrectomy with curative intent for GC were retrospectively evaluated. The N-Ratio categories were determined using the ROC curve method, and the area under the curve (AUC) was used as a measure of performance in predicting recurrence/death.

RESULTS

A total of 561 GC patients were included in the study, 57% had pN+ status, and 17.5% had <25 resected lymph nodes. N-Ratio, with a mean of 0.12, predicted survival with 74% accuracy (AUC=0.74; 95%CI 0.70-0.78, p<0.001). N-Ratio categories included: N-Ratio 0 (43%); N-Ratio 1 (12.3%); N-Ratio 2 (31.6%); and N-Ratio 3 (13.2%). Disease-free survival (DFS) varied among all N-Ratio groups, with N-Ratio 3 showing worse survival than pN3 cases (DFS=21.8 vs. 11 months, p=0.022, p<0.05). In cases with <25 resected lymph nodes, DFS was not significantly worse in N-Ratio 0 (68.8 vs. 81.9%, p=0.061, p>0.05) and N-Ratio 1 (66.2 vs. 50%, p=0.504, p>0.05) groups. The DFS of N-Ratio-0 cases with <25 lymph nodes was similar to N-Ratio 1 cases.

CONCLUSIONS

N-Ratio influenced survival in GC patients, especially in advanced lymph node disease (N-Ratio 3). Considering that N-Ratio does not impact pN0 cases, individualized prognosis assessment is essential for patients with <25 resected lymph nodes.

Histopathologic response in patients with curative resection with D2 dissection following neoadjuvant treatment for locally advanced gastric and esophagogastric junction adenocarcinoma

AIM

This study evaluated pathologic response rate, overall survival (OS), and postoperative complications in locally advanced gastric cancer (GC) and esophagogastric junction (EGJ) adenocarcinoma patients who underwent curative gastric resection D2 lymph node dissection with neoadjuvant treatment.

METHODS

We reviewed the medical records of 122 patients with locally advanced GC and EGJ adenocarcinoma who had neoadjuvant treatment and curative resection with D2 dissection between January 2014 and December 2022. Patients were divided into responders and nonresponders. Grades 1a-1b were responders, while 2-3 were non-responders. Patients' clinicopathological features, pathologic response rate, survival, and postoperative complications were evaluated. We assessed complications using the Clavien-Dindo (CD) classification. Total survival was assessed using the Kaplan-Meier model. Overall survival was assessed using univariate and multivariate Cox regression analysis.

RESULTS

The mean age of the study participants was 61 (N = 89 males; N = 33 females). There were 79 GC and 43 EGJ adenocarcinomas. Overall postoperative complications (CD ≥ II) were 27 %. Postoperative complications were similar in responders and non-responders (p = 0.316). YpT0N0 had a 2.5 % pathological complete response rate. Responders had better overall survival, but there was no statistical difference.

CONCLUSIONS

Both responder and non-responder groups have similar postoperative complications. A complete pathologic response is discouraging for assessing neoadjuvant chemotherapy for locally advanced gastric cancer, but a positive treatment response is acceptable. Pathologic response rate helps stage and predict gastric cancer prognosis. Responder groups survive slightly better.

Deep learning model for predicting postoperative survival of patients with gastric cancer

Background

Prognostic prediction for surgical treatment of gastric cancer remains valuable in clinical practice. This study aimed to develop survival models for postoperative gastric cancer patients.

Methods

Eleven thousand seventy-five patients from the Surveillance, Epidemiology, and End Results (SEER) database were included, and 122 patients from the Chinese database were used for external validation. The training cohort was created to create three separate models, including Cox regression, RSF, and DeepSurv, using data from the SEER database split into training and test cohorts with a 7:3 ratio. Test cohort was used to evaluate model performance using c-index, Brier scores, calibration, and the area under the curve (AUC). The new risk stratification based on the best model will be compared with the AJCC stage on the test and Chinese cohorts using decision curve analysis (DCA), the net reclassification index (NRI), and integrated discrimination improvement (IDI).

Results

It was discovered that the DeepSurv model predicted postoperative gastric cancer patients' overall survival (OS) with a c-index of 0.787; the area under the curve reached 0.781, 0.798, 0.868 at 1-, 3- and 5- years, respectively; the Brier score was below 0.25 at different time points; showing an advantage over the Cox and RSF models. The results are also validated in the China cohort. The calibration plots demonstrated good agreement between the DeepSurv model's forecast and actual results. The NRI values (test cohort: 0.399, 0.288, 0.267 for 1-, 3- and 5-year OS prediction; China cohort:0.399, 0.288 for 1- and 3-year OS prediction) and IDI (test cohort: 0.188, 0.169, 0.157 for 1-, 3- and 5-year OS prediction; China cohort: 0.189, 0.169 for 1- and 3-year OS prediction) indicated that the risk score stratification performed significantly better than the AJCC staging alone (P < 0.05). DCA showed that the risk score stratification was clinically useful and had better discriminative ability than the AJCC staging. Finally, an interactive native web-based prediction tool was constructed for the survival prediction of patients with postoperative gastric cancer.

Conclusion

In this study, a high-performance prediction model for the postoperative prognosis of gastric cancer was developed using DeepSurv, which offers essential benefits for risk stratification and prognosis prediction for each patient.

The pathological roles and potential mechanisms of vascular endothelial growth factor receptor-3 in gastric cancer

OBJECTIVE

To investigate the roles and underlying mechanisms of vascular endothelial growth factor receptor-3 (VEGFR-3) in gastric cancer (GC).

METHODS

VEGFR-3 gene expression profiles in human gastric adenocarcinoma (GAC) tissues were analysed using The Cancer Genome Atlas database. Human GC cell lines and were used for in vitro studies. Mouse models of GC and distant metastasis were used for in vivo studies. Silencing of VEGFR-3 gene expression was achieved using small interfering RNA.

RESULTS

VEGFR-3 gene expression was significantly elevated in GAC tissues and GC cells. Higher VEGFR-3 expression was positively correlated with more advanced stages and a greater number of metastatic lymph nodes. In vitro studies in GC cells showed that knockdown of VEGFR-3 gene expression significantly suppressed cell proliferation and migration, but promoted apoptosis. In vivo investigations revealed that silencing of VEGFR-3 gene expression exhibited significant inhibition on tumour growth and metastasis. Further mechanistic studies showed that VEGFR-3 exerted its pathological roles by affecting the key molecules in the apoptotic and epithelial-mesenchymal transition pathways.

CONCLUSION

The molecular pathways associated with VEGFR-3-mediated pathological effects could be targets in the development of novel approaches for the diagnosis, prognosis and treatment of GC.

Impact of tumor stage and neoadjuvant chemotherapy in fluorescence-guided lymphadenectomy during laparoscopic gastrectomy for gastric cancer: A propensity score-matched study in a western center

BACKGROUND

The use of indocyanine green fluorescence has been shown to be a safe and effective method for improving lymph node retrieval in patients with gastric cancer. However, previous studies have focused on early-stage tumors and/or the Asian population and excluded patients who received neoadjuvant treatment.

METHODS

In this study, 142 patients with gastric adenocarcinoma underwent laparoscopic gastrectomy at a Spanish hospital between January 2017 and December 2022. Of these, 42 patients received preoperative indocyanine green injection to guide lymphadenectomy. Their outcomes were compared to a retrospective cohort of 42 patients after 1:1 propensity score matching.

RESULTS

The feasibility of indocyanine green lymphatic mapping was 95.5%. No complications associated with indocyanine green injection were observed. The indocyanine green group had a significantly higher number of retrieved lymph nodes than the non-indocyanine green group (32.67 vs 25.14; P = .013). This statistically significant difference was maintained across subgroups of neoadjuvant treatment, non-obese patients, pT0 to 2 stage, and pN0 stage. In 47.6% of patients from the indocyanine green group, lymphadenectomy was extended outside the standard D2 dissection area based on indocyanine green uptake, but none of the retrieved lymph nodes were metastatic. There were no differences in postoperative complications and length of hospital stay between the 2 groups.

CONCLUSION

Indocyanine green-guided lymphadenectomy is safe and feasible and increases the number of retrieved lymph nodes compared to conventional lymphatic dissection, as well as in patients receiving neoadjuvant chemotherapy. The use of indocyanine green should be routine if available for guiding lymph node dissection in gastric cancer, regardless of tumor stage or previous neoadjuvant treatment. However, further studies are needed to determine the impact of this technique on disease-free and overall survival.

Prognostic value of lymph node ratio in stage III non-small-cell lung cancer: A retrospective cohort study

A growing number of studies have found that the lymph node ratio (LNR) is an important indicator of prognosis in non-small-cell lung cancer (NSCLC). Impact analysis for LNR was performed for survival in patients undergoing surgery for stage III NSCLC compared to the surveillance, epidemiology and end results databank. Clinicopathological variables, such as cancer-specific survival (CSS), were taken from the surveillance epidemiology and end result databank of stage III NSCLC patients who underwent surgery, and the LNR threshold stratification of NSCLC patients was computed by X-tile. CSS was assessed by the Kaplan-Meier method with CSS-independent risk factors calculated by multivariate Cox regression analysis. In total, 7011 lung cancer patients were included. Multifactorial analysis showed that LNR and positive node category had predictive value for stage III NSCLC. In patients with stage IIIA NSCLC, Kaplan-Meier analysis demonstrated that patients with T1-2N2 stage had clearly superior CSS than those with T3-4N1 stage (P < .001), which conflicted with the results from the assessment of primary tumor, lymph nodes, and metastasis/N stage. The cutoff values for LNR were 0.31 and 0.59. Kaplan-Meier analysis demonstrated that the CSS was substantially better in patients with LNR-low than in those with LNR-medium or LNR-high (P < .001), which was also proven by multivariate competing risk regression. Subgroup analysis suggested that the survival advantage of a lower LNR was achieved in all subgroups (sex, race, etc). In stage III NSCLC, the LNR is a valuable factor for assessing prognosis, in which a higher LNR indicates a worse prognosis.

Treatment Outcomes and Prognostic Factors in N3 Stage Gastric Cancer After Curative Resection: A Real World Data

Purpose

N3 gastric cancer is characterized by a fairly high lymph node metastasis burden and poor outcome despite optimal therapy. Given the limitations of TNM classification, a comprehensive evaluation tool is necessary to predict the prognosis of patients with N3 gastric cancer who underwent curative surgery. This study aims to explore the outcomes and clinicopathologic prognostic factors affecting the overall survival (OS) of patients with N3 gastric cancer after surgery.

Methods

Data on patients with N3 gastric cancer who underwent (sub)total gastrectomy and regional lymph node dissection between November 2005 and September 2018 (n = 169) were analyzed by Cox regression to determine the independent prognostic factors for OS.

Results

The multivariable analysis established that gender, patient performance status, metastatic lymph node ratio (MLNR), tumor grade, and adjuvant chemotherapy are significantly associated with OS. The five-year OS of the study population was 15%. Adjuvant chemoradiotherapy was applied to 72% of the patients, which resulted in an improvement in recurrence-free survival but not OS. Recurrence occurred in 103 (75%) patients, in which the most frequent recurrence site was distant metastasis.

Conclusion

Male gender, poor performance status, grade 3 tumor, MLNR > 0.37, and not receiving adjuvant chemotherapy are predictors of poor prognosis in N3 gastric cancer after curative resection. Considering the high recurrence rates of this group, prospective studies are needed to optimize treatment strategies.

Gastric Cancer: Correlation of Histologic Type with Commonly Used Prognostic Variables

Background: Gastric cancer is one of the most common cancers among Iranian men and women. Objectives: The aim here was to investigate different histopathologic types and features of this cancer in association with selected prognostic variables. Methods: A retrospective cross-sectional study was performed to reevaluate the pathologic samples of 100 cases of gastric cancer referred to Shohadaye Tajrish Hospital, Tehran, Iran from 2017 to 2022. Results: We evaluated 100 cases of gastric cancer in this study. They had a mean age of 62.4 ± 13.44 years old (range 28 - 84 years) and were mostly men (n = 66, 66 %). On histopathologic evaluation, tubular carcinoma was the most common type (n = 45, 45%). We found a statistically significant correlation between the histologic type and perineural invasion (P-value = 0.024), lymphovascular invasion (P-value < 0.001), tumoral involvement of surgical margin (P-value = 0.012 ), infiltration depth of the primary tumor (pT) (P-value = 0.049) , number of metastatic lymph nodes (pN) (P-value = < 0.001) , tumor location in the antrum (P-value=0.033) and body (P-value = 0.013) , and tumor size (P-value = 0.002 and P-value = 0.031 in small and large size groups respectively). Conclusions: According to the findings, histologic type of gastric cancer correlates with perineural invasion, lymphovascular invasion, tumoral involvement of the surgical margin, pT, pN, and tumor location and size.

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.

Analysis of factors associated with the prognosis of papillary thyroid cancer and the construction of a survival model

OBJECTIVE

To study the survival prediction value of lymph node ratio (LNR) and preoperative thyroglobulin (Tg) in the prognosis of thyroid papillary carcinoma (PTC).

METHODS

A total of 495 patients with PTC and lymph node metastasis treated at the Cancer Hospital of Xinjiang Medical University were selected for a retrospective study. The disease-free survival (DFS) of patients was the follow-up endpoint. DFS was calculated for all patients. The Cox proportional risk regression model and nomogram were used to predict the survival prognosis of PTC with lymph node metastasis by index. LNR and preoperative Tg level cutoff values were obtained using ROC curves. To express DFS, Kaplan-Meier survival curves were created. Using 3- and 5-year calibration curves and AUC values, the prognostic models' precision and discrimination were assessed. Clinical decision curve analysis was used to forecast clinical benefitability. Finally, the results were validated using internal cross-validation.

RESULTS

The cutoff values of LNR and preoperative Tg level were 0.295 and 50.24, respectively, and they were divided into two groups according to the cutoff values. Multifactorial Cox regression models showed that NLNM, LNR, and preoperative Tg level (all p < 0.05) were independent risk factors affecting the prognosis of PTC with lymph node metastasis. Kaplan-Meier curves showed higher DFS rates in the group with low NLNM (<10), LNR (<0.295), and preoperative Tg level (<50.24) groups. The 3-year and 5-year calibration curves showed good agreement. A ROC curve analysis was performed on the nomogram model, and its AUC values at 3 and 5 years were, respectively, 0.805 and 0.793. Clinical decision curves indicate good clinical benefit. Finally, internal cross-validation demonstrated the legitimacy of the prognostic model.

CONCLUSION

The LNR and preoperative Tg levels, in combination with other independent factors, were effective in predicting the survival prognosis for patients with PTC.

UICC Staging after Neoadjuvant/Perioperative Chemotherapy Reveals No Significant Survival Differences Compared to Primary Surgery for Locally Advanced Gastric Cancer

Background: The applicability of UICC TNM staging for gastric cancer (GC) patients treated with neoadjuvant chemotherapy (nCTX) and surgery was not yet analyzed in comparison to patients undergoing primary surgery (PS). The purpose of this analysis was to analyze if the prognostic impact of TNM staging after nCTx is comparable with PS. Methods: Data for patients having been treated for GC with or without nCTx between 1990 and 2016 were analyzed. Uni-(URA) and multivariable regression analyses (MRA) were performed to identify predictors. Survival according to the UICC 8th edition stages was analyzed by the Kaplan−Meier method and cox regression analysis. Propensity score matching (PSM) was performed to balance for confounders. Results: 1149 patients with GC were eligible for primary analysis. URA demonstrated age (p < 0.0001), tumor localization (p < 0.0001), clinical UICC-stage, complications, UICC stage 0, IIB-IIIC, Lauren subtype, grading, and R-stage to be significantly associated with OS. MRA revealed that age, distal tumor localization, more than 25 dissected lymph nodes, UICC stage 0, IIB-IIIC, and Lauren subtype were significantly and independently related to OS. After PSM, survival analyses revealed only a significant difference for pN2/ypN2 (p = 0.03), while all other T and N stages were comparable. Conclusion: UICC dependent survival stages do not change significantly after nCTx treatment for GC. Therefore, UICC staging in its present version is applicable to patients undergoing nCTx.

Prognostic impact of number of examined lymph nodes on survival of patients with appendiceal neuroendocrine tumors

BACKGROUND

The prognosis of patients with appendiceal neuroendocrine tumors (ANETs) is related to lymph node (LN) metastasis and other factors. However, it is unclear how the number of examined LNs (ELNs) impact on survival.

AIM

To determine the factors affecting the cancer-specific survival (CSS) of patients with ANET and to evaluate the impact of the number of ELNs on survival.

METHODS

A total of 4583 ANET patients were analyzed in the Surveillance, Epidemiology, and End Results database. Univariate survival analysis was used to identify factors related to survival and the optimal number of ELNs and lymph node ratio (LNR) were determined by the Kaplan–Meier method. The survival difference was determined by CSS.

RESULTS

Except for sex, the other factors, such as age, year, race, grade, histological type, stage, tumor size, ELNs, LNR, and surgery type, were associated with prognosis. The 3-, 5-, and 10-year CSS rates of ANET patients were 91.2%, 87.5, and 81.7%, respectively (median follow-up period of 31 mo and range of 0-499 mo). There was no survival difference between the two surgery types, namely, local resection and colectomy or greater, in both stratifications of tumor size ≥ 2 cm (P = 0.523) and < 2 cm (P = 0.068). In contrast to patients with a tumor size < 2 cm, those with a tumor size ≥ 2 cm were more likely to have LN metastasis (χ² = 378.16, P < 0.001). The optimal number of ELNs was more than 11, 7, and 18 for all patients, node-negative patients, and node-positive patients, respectively. CSS rates of patients with a larger number of ELNs were significantly improved (≤ 10 vs ≥ 11, χ² = 20.303, P < 0.001; ≤ 6 vs ≥ 7, χ² = 11.569, P < 0.001; ≤ 17 vs ≥ 18, χ² = 21.990, P < 0.001; respectively). ANET patients with an LNR value ≤ 0.16 were more likely to have better survival than those with values of 0.17-0.48 (χ² = 48.243, P < 0.001) and 0.49-1 (χ² = 168.485, P < 0.001).

CONCLUSION

ANET ≥ 2 cm are more likely to develop LN metastasis. At least 11 ELNs are required to better evaluate the prognosis. For patients with positive LN metastasis, 18 or more LNs need to be detected and lower LNR values (LNR ≤ 0.16) indicate a better survival prognosis.

Mapping Lymph Node during Indocyanine Green Fluorescence-Imaging Guided Gastric Oncologic Surgery: Current Applications and Future Directions

Huge strides have been made in the navigation of gastric cancer surgery thanks to the improvement of intraoperative techniques. For now, the use of indocyanine green (ICG) enhanced fluorescence imaging has received promising results in detecting sentinel lymph nodes (SLNs) and tracing lymphatic drainages, which make it applicable for limited and precise lymphadenectomy. Nevertheless, issues of the lack of specificity and unpredictable false-negative lymph nodes were encountered in gastric oncologic surgery practice using ICG-enhanced fluorescence imaging (ICG-FI), which restrict its application. Here, we reviewed the current application of ICG-FI and assessed potential approaches to improving ICG-FI.

Efficacy of indocyanine green fluorescence imaging-guided lymphadenectomy in radical gastrectomy for gastric cancer: A systematic review and meta-analysis

Background

Indocyanine green (ICG) imaging-guided lymphadenectomy has been introduced in gastric cancer (GC) surgery and its clinical value remains controversial. The aim of this study is to evaluate the efficacy of ICG fluorescence imaging-guided lymphadenectomy in radical gastrectomy for GC.

Methods

Studies comparing lymphadenectomy in radical gastrectomy between use and non-use of ICG fluorescence imaging up to July 2022 were systematically searched from PubMed, Web of Science, Embase and Cochrane Library. A pooled analysis was performed for the available data regarding the baseline features, the number of retrieved lymph nodes (LNs), the number of metastatic LNs and surgical outcomes as well as oncological outcomes. RevMan 5.3 software was used to perform the statistical analysis. Quality evaluation and publication bias were also conducted.

Results

17 studies with a total of 2274 patients (1186 in the ICG group and 1088 in the control group) undergoing radical gastrectomy and lymphadenectomy were included. In the pooled analysis, the baseline features were basically comparable. However, the number of retrieved LNs in the ICG group was significantly more than that in the control group (MD = 7.41, 95% CI = 5.44 to 9.37, P < 0.00001). No significant difference was found between the ICG and control groups in terms of metastatic LNs (MD = -0.05, 95% CI = -0.25 to 0.16, P = 0.65). In addition, the use of ICG could reduce intraoperative blood loss (MD = -17.96, 95% CI = -27.89 to -8.04, P = 0.0004) without increasing operative time (P = 0.14) and overall complications (P = 0.10). In terms of oncological outcomes, the use of ICG could reduce the overall recurrence rate (OR = 0.50; 95% CI 0.28-0.89; P = 0.02) but could not increase the 2-year overall survival rate (OR = 1.25; 95% CI 0.72-2.18; P = 0.43).

Conclusions

ICG imaging-guided lymphadenectomy is valuable for complete LNs dissection in radical gastrectomy for GC. However, more high-quality randomized controlled trials are needed to confirm this benefit.

V-set and immunoglobulin domain containing 1 (VSIG1) as an emerging target for epithelial-mesenchymal transition of gastric cancer

V-set and Immunoglobulin domain containing 1 (VSIG1) is a cell–cell adhesion molecule which role in the genesis and evolution of gastric cancer (GC) is not understood. Only three Medline-indexed papers have focused on the role of VSIG1 in GC. The clinicopathological features of 94 GCs were examined in association with immunohistochemical (IHC) patterns of VSIG1, E-cadherin, and β-catenin which were assessed in the tumor core (central) vs. invasive edge. Cases were classified depending on the VSIG1 expression: membrane/membrane in both core and invasive front; null/negative staining in both core and invasive front; and cases with translocational patterns: membrane core/cytoplasmic buds and cytoplasmic core/null buds. Most of the tumors showed null pattern (n = 54). Cases with translocational patterns (n = 20) were GCs with a high lymph node ratio value (≥ 0.26) and advanced Dukes-MAC-like stage. Of the 20 total cases, 9 showed membrane-to-nuclear translocation of β-catenin and loss of E-cadherin, as indicators of epithelial–mesenchymal transition. All cases with membrane/membrane pattern (n = 20) involved the distal stomach. The poorest overall survival was registered in patients with subcellular translocation of VSIG1, compared to those with either membrane/membrane or null patterns (p = 0.002). In GC, VSIG1 acts as an adhesion membrane protein but its membrane-cytoplasmic translocation can be an indicator of epithelial–mesenchymal transition due to cytoplasmic VSIG1-mediated activation of canonical Wnt/β-catenin signaling pathway.

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.

Survival Nomogram for Young Breast Cancer Patients Based on the SEER Database and an External Validation Cohort

Background

Young breast cancer (YBC) patients are more prone to lymph node metastasis than other age groups. Our study aimed to investigate the predictive value of lymph node ratio (LNR) in YBC patients and create a nomogram to predict overall survival (OS), thus helping clinical diagnosis and treatment.

Methods

Patients diagnosed with YBC between January 2010 and December 2015 from the Surveillance, Epidemiology, and End Results (SEER) database were enrolled and randomly divided into a training set and an internal validation set with a ratio of 7:3. An independent cohort from our hospital was used for external validation. Univariate and least absolute shrinkage and selection operator (LASSO) regression were used to identify the significant factors associated with prognosis, which were used to create a nomogram for predicting 3- and 5-year OS.

Results

We selected seven survival predictors (tumor grade, T-stage, N-stage, LNR, ER status, PR status, HER2 status) for nomogram construction. The C-indexes in the training set, the internal validation set, and the external validation set were 0.775, 0.778 and 0.817, respectively. The nomogram model was well calibrated, and the time-dependent ROC curves verified the superiority of our model for clinical usefulness. In addition, the nomogram classification could more precisely differentiate risk subgroups and improve the discrimination of YBC prognosis.

Conclusions

LNR is a strong predictor of OS in YBC patients. The novel nomogram based on LNR is a reliable tool to predict survival, which may assist clinicians in identifying high-risk patients and devising individual treatments.

A Novel Prognostic Index Model for Adult Hemophagocytic Lymphohistiocytosis: A Multicenter Retrospective Analysis in China

Hemophagocytic lymphohistiocytosis (HLH) is an immune disorder with rapid progression and poor survival. Individual treatment strategy is restricted, due to the absence of precise stratification criteria. In this multicenter retrospective study, we aimed to develop a feasible prognostic model for adult HLH in China. A total of 270 newly diagnosed patients of adult HLH were retrieved from the Huaihai Lymphoma Working Group (HHLWG), of whom 184 from 5 medical centers served as derivation cohort, and 86 cases from 3 other centers served as validation cohort. X-Tile program and Maxstat analysis were used to identify optimal cutoff points of continuous variables; univariate and multivariate Cox analyses were used for variable selection, and the Kaplan–Meier curve was used to analyze the value of variables on prognosis. The C-index, Brier Score, and calibration curve were used for model validation. Multivariate analysis showed that age, creatinine, albumin, platelet, lymphocyte ratio, and alanine aminotransferase were independent prognostic factors. By rounding up the hazard ratios from 6 significant variables, a maximum of 9 points was assigned. The final scoring model of HHLWG-HPI was identified with four risk groups: low risk (≤3 pts), low-intermediate risk (4 pts), high-intermediate risk (5-6 pts), and high risk (≥7 pts), with 5-year overall survival rates of 68.5%, 35.2%, 21.3%, and 10.8%, respectively. The C-indexes were 0.796 and 0.758 in the derivation and validation cohorts by using a bootstrap resampling program. In conclusion, the HHLWG-HPI model provides a feasible and accurate stratification system for individualized treatment strategy in adult HLH.

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.

Lymph Node Evaluation after Neoadjuvant Chemotherapy for Patients with Gastric Cancer

BACKGROUND

Adequate lymphadenectomy with at least 16 nodes retrieved at the time of gastrectomy is a quality measure recommended to ensure adequate staging. The minimum nodal retrieval recommended after receipt of neoadjuvant chemotherapy (NACT) is less defined.

METHODS

Patients with clinical stages 1 to 3 gastric adenocarcinoma who received NACT and surgical resection were identified from the 2004-2015 National Cancer Database. The optimal nodal harvest number was calculated with Cox spline regression modeling. Cohorts with a nodal harvest higher or lower than this number were 1:1 propensity score-matched. Overall survival (OS) was analyzed using Kaplan-Meier survival estimates.

RESULTS

Among 4337 patients receiving NACT, the optimal minimal nodal harvest at gastrectomy was 23 nodes. Compared with the patients who had fewer than 23 nodes retrieved, the patients with at least 23 nodes examined (n = 1073, 24.7%) were more likely to be female (26.1% vs 22%; p = 0.006) and non-white (29.3% vs 18.5%; p < 0.0001), to have a Charlson-Deyo score of 0 (71.5% vs 66.8%; p = 0.005), and to have undergone resection at an academic facility (67.9% vs 51.5%; p < 0.0001). The patients with at least 23 nodes examined had higher proportions of high-grade tumor (62% vs 57.4%; p = 0.030), pT3 or pT4 tumor (56.3% vs 48.7%; p < 0.0001), body tumor (21.3% vs 12.5%; p < 0.0001), or antrum/pylorus tumor (15.3% vs 11.4%; p < 0.0001). The patients with at least 23 nodes were more likely to have lymph node metastases identified (61% vs 51%; p < 0.0001). After matching, the patients with at least 23 nodes (n = 990) demonstrated an improved 5-year OS (57.9% vs 49%; p = 0.001).

CONCLUSIONS

The extent of lymphadenectomy during gastrectomy for gastric adenocarcinoma should not be reduced after NACT because adequate lymph node retrieval remains important for prognostication.

Evaluation of dual-energy CT derived radiomics signatures in predicting outcomes in patients with advanced gastric cancer after neoadjuvant chemotherapy

BACKGROUND

To investigate the prognostic value of dual-energy CT (DECT) based radiomics to predict disease-free survival (DFS) and overall survival (OS) for patients with advanced gastric cancer (AGC) after neoadjuvant chemotherapy (NAC).

METHODS

From January 2014 to December 2018, a total of 156 AGC patients were enrolled and randomly allocated into a training cohort and a testing cohort at a ratio of 2:1. Volume of interest of primary tumor was delineated on eight image series. Four feature sets derived from pre-NAC and delta radiomics were generated for each survival arm. Random survival forest was used for generating the optimal radiomics signature (RS). Statistical metrics for model evaluation included Harrell's concordance index (C-index) and the average cumulative/dynamic AUC throughout follow-up. A clinical model and a combined Rad-clinical model were built for comparison.

RESULTS

The pre-IU (derived from iodine uptake images before NAC) RS performed best for DFS and OS in the testing cohort (C-indices, 0.784 and 0.698; the average cumulative/dynamic AUCs, 0.80 and 0.77). When compared with the clinical model, the radiomics model had significantly higher C-index to predict DFS in the testing cohort (0.784 vs. 0.635, p < 0.001), but no statistical difference was found for OS (0.698 vs. 0.680, p = 0.473). The combined Rad-clinical models showed improved performance in the testing cohort, with C-indices of 0.810 and 0.710 for DFS and OS, respectively.

CONCLUSION

DECT-derived radiomics serves as a promising non-invasive biomarker to predict survival for AGC patients after NAC, providing an opportunity for transforming proper treatment.

The Prognostic Value of Lymph Node Ratio in Locally Advanced Esophageal Cancer Patients Who Received Neoadjuvant Chemotherapy

BACKGROUND

The lymph node (LN) ratio (LNR) has been proposed as a sensitive prognosticator in patients with esophageal squamous cell carcinoma (ESCC), especially when the number of LNs harvested is insufficient. We investigated the association between the LNR and survival in patients with locally advanced ESCC who received neoadjuvant chemotherapy (NAC) and explored whether the LNR is a prognosticator in these patients when stratified by their response to NAC.

METHODS

We retrospectively reviewed 199 locally advanced ESCC patients who received curative resection after NAC between January 2011 and December 2019. The predictive accuracy of the adjusted X-tile cut-off values for LNR of 0 and 0.13 was compared with that in the Union for International Cancer Control pathological N (UICC pN) categories. The association between survival rate and clinicopathological features was examined.

RESULTS

Multivariate analysis identified that the LNR was an independent risk factor for recurrence-free survival [RFS; hazard ratio (HR) 6.917, p < 0.001] and overall survival (OS) (HR 4.998, p < 0.001). Moreover, even when stratified by response to NAC, the LNR was a significant independent risk factor for RFS and OS (p < 0.001). The receiver operating characteristic curves identified that the prognostic accuracy of the LNR tended to be better than that of the UICC pN factor in all cases and responders.

CONCLUSION

The LNR had a significant prognostic value in patients with locally advanced ESCC, including in those who received NAC.

Stage migration resulting from inadequate number of examined lymph nodes impacts prognosis in stage II colon cancer after radical surgery

PURPOSE

We evaluated the impact of examined lymph node (ELN) number on the prognosis of stage II colon cancer after radical surgery and developed a novel prognostic scoring system by combining primary tumor extension (pT) and ELN number for reclassification of stage II colon cancer.

METHODS

Three cohorts of patients diagnosed with colon cancer between 2004 and 2010 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate analyses were performed to evaluate the relationship between factors and patients' survival including cause-specific survival (CSS) and overall survival (OS). Survival curves from subgroups were plotted by the Kaplan-Meier method and compared by the log-rank test.

RESULTS

Cohort 1 and cohort 2 consisted of 13,960 and 5312 stage II colon cancer patients, respectively. Cohort 3 consisted of 4713 stage III patients. Factors including ELN, age, and pT were found to be associated with patients' survival in cohorts 1 and 2. Patients who were older or with smaller tumors were more likely to experience inadequate ELN. Patients with a higher score, as calculated by the novel scoring system, showed worse survival. Compared with stage III colon cancer patients, stage II patients with high scores had a comparable or even worse survival than stage IIIA and IIIB patients.

CONCLUSION

Inadequate ELN leads to understaging in stage II colon cancer and predicts inferior prognosis. Our analyses show that the novel prognostic scoring system, consisting of combined pT and ELN, quantified stage migration effect and can be applied to the reclassification of stage II colon cancer.

Angiogenesis-Related Gene Expression Signatures Predicting Prognosis in Gastric Cancer Patients

Simple Summary

To elucidate the role of angiogenesis as a prognostic signature in gastric cancer, we analyzed the expression level of 36 angiogenesis-related genes (ARGs) from Stomach Adenocarcinoma (STAD) from The Cancer Genome Atlas (TCGA). Consensus clustering analysis showed two major angiogenesis-related types: one related to more aggressive clinicopathological characteristics and worse survival, and the other related to lower tumor, lymph node, metastasis (TNM) stage and better outcomes. Our analysis of TCGA with a least absolute shrinkage and selection operator (LASSO) regression model identified 10 genes associated with overall survival in gastric cancer patients. With this gene signature, we computed angiogenesis-related gene signature risk scores for individual cancer patients that predicted overall and disease-free survival, which were further validated in the independent dataset Asian Cancer Research Group (ACRG). Moreover, an overall survival (OS)-related nomogram was established and had better performance in prognosis prediction than TNM stage. Our analysis provides a comprehensive map of ARGs that can be serve as useful biomarkers for gastric cancer.

Abstract

Increasing evidence indicates that angiogenesis is crucial in the development and progression of gastric cancer (GC). This study aimed to develop a prognostic relevant angiogenesis-related gene (ARG) signature and a nomogram. The expression profile of the 36 ARGs and clinical information of 372 GC patients were extracted from The Cancer Genome Atlas (TCGA). Consensus clustering was applied to divide patients into clusters 1 and 2. Least absolute shrinkage and selection operator (LASSO) Cox regression analyses were used to identify the survival related ARGs and establish prognostic gene signatures, respectively. The Asian Cancer Research Group (ACRG) (n = 300) was used for external validation. Risk score of ARG signatures was calculated, and a prognostic nomogram was developed. Gene set enrichment analysis of the ARG model risk score was performed. Cluster 2 patients had more advanced clinical stage and shorter survival rates. ARG signatures carried prognostic relevance in both cohorts. Moreover, ARG-risk score was proved as an independent prognostic factor. The predictive value of the nomogram incorporating the risk score and clinicopathological features was superior to tumor, lymph node, metastasis (TNM) staging. The high-risk score group was associated with several cancer and metastasis-related pathways. The present study suggests that ARG-based nomogram could serve as effective prognostic biomarkers and allow a more precise risk stratification.