Age and axillary lymph node ratio in postmenopausal women with T1-T2 node positive breast cancer

Analyzing Cardiovascular Characteristics of Patients Initially Diagnosed with Breast Cancer in Saudi Arabia

Introduction Cancer is a condition where abnormal cells proliferate uncontrollably, leading to metastasis, which can be related to death. Breast cancer is the most prevalent type among women worldwide. Early detection with screening mammography has contributed to the decline in breast cancer incidence and mortality. Breast cancer patients are more likely to develop cardiovascular disease, with elderly patients dying from complications. Understanding the patients' cardiovascular status prior to treatment is essential. The study's objective was to evaluate the cardiovascular characteristics of women with breast cancer at diagnosis within the designated time frame of one year. Methodology This was a retrospective study that focused on patients in Taif City, Saudi Arabia, who were initially diagnosed with primary breast cancer over a span of one year. The inclusion criteria encompassed eligible patients, while those not meeting the criteria were excluded. Data extraction from patients' records was conducted, and the analysis was executed using IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, New York, United States). Results This study analyzed the cardiovascular attributes of breast cancer patients, focusing on 136 female cases. The study found significant patterns concerning cardiovascular risk factors in breast cancer patients, categorized by menopausal status. Premenopausal female cases had a mean age of 43.09 ± 8.31 years, while postmenopausal patients had an average age of 58.07 ± 11.70 years. Postmenopausal patients had a higher prevalence of overweight/obesity, irregular menstrual cycles, type II diabetes, hypertension, and hyperlipidemia compared to their premenopausal counterparts. No significant differences were found between the two groups regarding low-density lipoprotein (LDL) cholesterol levels, axillary lymph node metastasis, or distant metastasis. This study emphasized the importance of regular check-ups for menopausal women to detect potential health complications early. Conclusion In summary, breast cancer is a global health concern, and understanding its impact on the cardiovascular system is crucial for comprehensive patient care. A study in Saudi Arabia found associations between cardiovascular risk factors and menopausal status in breast cancer patients. Postmenopausal patients had more prevalent risk factors, emphasizing the need for proactive assessment and management. Age-appropriate screenings and interventions are essential. Integrated healthcare approaches should consider the interplay between breast cancer and cardiovascular health, with medical professionals vigilant in evaluating and addressing risk factors to mitigate complications and optimize long-term outcomes.

Axillary lymph node status and invasive lobular breast cancer : Analysis of the Clinical Tumor Register of the AGO Austria

BACKGROUND

Invasive lobular carcinoma (ILC) represents the second most common type of invasive breast cancer (BC). Although ILC generally have good prognostic properties (positive estrogen receptor, ER, low tumor grade), they are generally diagnosed at a more advanced stage. The data on the axillary lymph node status in ILC compared to invasive ductal carcinoma (IDC) are considered controversial. Therefore, the aim of this study was to compare the pathological node stage (pN) between ILC and IDC in an Austria-wide register.

METHODS

Data of the Clinical Tumor Register (Klinisches TumorRegister, KTR) of the Austrian Association for Gynecological Oncology (AGO) were retrospectively analyzed. Patients with primary early BC, invasive lobular or ductal, diagnosed between January 2014 and December 2018, and primary surgery were included. A total of 2127 tumors were evaluated and compared in 2 groups, ILC n = 303, IDC n = 1824.

RESULTS

A total of 2095 patients were analyzed in the study. In the multivariate analysis, pN2 and pN3 were observed significantly more frequently in ILC compared with IDC (odds ratio, OR 1.93; 95% confidence interval, CI 1.19-3.14; p = 0.008 and OR 3.22; 95% CI: 1.47-7.03; p = 0.003; respectively). Other factors associated with ILC were tumor grades 2 and 3, positive ER, and pathological tumor stage (pT) 2 and pT3. In contrast, concomitant ductal carcinoma in situ, overexpression of the human epidermal growth factor receptor 2 (HER2), and a moderate and high proliferation rate (Ki67) were found less frequently in ILC.

CONCLUSION

The data show an increased risk of extensive axillary lymph node metastasis (pN2/3) in ILC.

Breast Cancer Patients With Positive Apical or Infraclavicular/Ipsilateral Supraclavicular Lymph Nodes Should Be Excluded in the Application of the Lymph Node Ratio System

Aim: Increasing studies have demonstrated lymph node ratio (LNR) to be an accurate prognostic indicator in breast cancer and an alternative to pN staging; however, the AJCC-TNM staging system classified apical or infraclavicular/ipsilateral supraclavicular lymph node-positive (APN(+)) patients with a worse prognosis as the pN3 stage. Until now, different reports on LNR in breast cancer have ignored this possibility. Consequently, it is necessary to discuss the role of APN(+) patients in the LNR system to obtain a precise LNR that predicts the prognosis accurately.

Materials and Methods: We collected data on 10,120 breast cancer patients, including 3,936 lymph node-positive patients (3,283 APN(−) and 653 APN(+) patients), who visited our hospital from 2007 to 2012. Then we applied X-tile analysis to calculate cut-off values and conduct survival analysis and multivariate analysis to evaluate patients’ prognosis.

Results: We confirmed that some APN(+) patients were mis-subgrouped according to previously reported LNR, indicating that APN(+) patients should be excluded in the application of LNR to predict prognosis. Then we applied X-tile analysis to calculate two cut-off values (0.15 and 0.34) for LNR-APN(−) patients and conducted survival analysis and found that LNR-APN(−) staging was superior to pN staging in predicting the prognosis of APN(−) breast cancer patients.

Conclusion: From this study, we conclude that excluding APN(+) patients is the most necessary condition for effective implementation of the LNR system. LNR-APN(−) staging could be a more comprehensive approach in predicting prognosis and guiding clinicians to provide accurate and appropriate treatment.

Nomograms for prediction of overall and cancer-specific survival in young breast cancer

PURPOSE

To assess the prognostic risk factors and establish prognostic nomograms based on lymph node ratio (LNR) to predict the survival of young patients with breast cancer (BC).

METHODS

Patients aged < 40 years and diagnosed with BC between 2010 and 2016 from the Surveillance, Epidemiology and End Results database were assessed. Nomograms incorporating LNR were constructed to predict overall survival (OS) and breast cancer-specific survival (BCSS) based on Cox proportional hazards model. The performance of the nomograms was assessed by C-index, calibration curves, receiver operating characteristic (ROC) curves, decision curve analysis (DCA), and risk group stratification and compared with the TNM staging system.

RESULTS

Based on the univariate and multivariate Cox regression analysis, significant prognostic factors were identified and integrated to create the nomograms for OS and BCSS. The calibration curves indicated optimal agreement between model predictions and actual observations. The nomograms showed favorable sensitivity with a C-index of 0.8351 (95% CI 0.8234-0.8469) for OS and 0.8474 (95% CI 0.8355-0.8594) for BCSS. The ROC curves of the nomograms showed better predictive ability than those of the TNM staging system for OS (AUC: 0.8503 vs. 0.7819) and BSCC (AUC: 0.8607 vs. 0.8081). Significant differences in Kaplan-Meier curves were observed in patients stratified into different risk groups (p < 0.001).

CONCLUSIONS

These nomograms provided more accurate individualized risk prediction of OS and BCSS and may assist clinicians in making decisions for young patients with BC.

The prognostic value of lymph node ratio in survival of non-metastatic breast carcinoma patients

PURPOSE

This study was conducted to assess the correlation between lymph node ratio (LNR) and prognosis of non-metastatic invasive breast carcinoma.

METHOD

This retrospective study examined 455 patients who were diagnosed with non-metastatic, unilateral invasive breast carcinoma and underwent either breast conservative surgery (BCS) or modified radical mastectomy (MRM) with axillary lymph node dissection (ALND) with at least one lymph node identified in the ALND specimen. Receiver operating characteristics (ROC) curve analysis was used to find out predictive cut-off values of the LNR and negative lymph nodes (NLN).

RESULTS

The median follow-up duration was 38 months. The median DFS and OS were 68 months and 72 months, respectively. 25.1% of patients had reported recurrence. The optimal cut-off value of LNR was 0.40. LNR was found to correlate significantly with pathological T (p < 0.001), pathological N (p < 0.001), and NLN (p < 0.001). Univariate analysis of the patients showed that the age group ≤ 35 years, menstrual status, pathological T, nodal status, lymphovascular invasion (LVI), perineural invasion (PNI), tumor grade, estrogen receptor (ER), progesterone receptor (PR), molecular subtypes, LNR, and NLN can affect disease-free survival (DFS) (p < 0.05) and OS (p < 0.05). Multivariate analysis showed that the pathological T (p < 0.001), menstrual status (p = 0.030), and LNR (p < 0.001) were the independent prognostic factors for DFS. Pathological T (p < 0.001) and LNR (p < 0.001) were the independent prognostic factors affecting OS.

CONCLUSION

LNR is the independent prognostic factor of DFS and OS for non-metastatic breast carcinoma.

Prognostic value of the metastatic lymph node ratio in patients with pancreatic cancer

The purpose of the study was to analyze the prognostic value of metastatic lymph node ratio (LNR) in pancreatic cancer (PC) patients undergoing surgical operation. We retrospectively reviewed 615 patients with PC who underwent surgical operation. The clinic-pathologic factors related to lymph node metastasis (LNM) were analyzed. There are 251 patients with LNM (40.8%), 364 cases of patients without LNM (59.2%). We found that overall survival (OS) of PC was significantly correlated to histological type, degree of differentiation, clinical staging, LNM, and LNR (all P < 0.05). Multivariate Cox regression analysis demonstrated that LNR was an independent risk factor for postoperative survival rate of patients with PC (P=0.006), and the presence of LNM was not an independent factor for predicting poor prognosis. When age and gender were included in multivariate Cox proportional hazards, LNR was still the independent prognostic factor for the OS of patients with PC (P=0.013). The value of LNR in the prediction of the prognosis of PC was better than the number and presence of LNM. It provided some helpful advice for clinicians to formulating a reasonable treatment strategy.

Lymph node ratio (LNR) as a complementary staging system to TNM staging in salivary gland cancer

Purpose

The role of lymph node ratio (LNR, ratio of metastatic to examined nodes) in the staging of multiple human malignancies has been reported. We aim to evaluate its value in salivary gland cancer (SGC).

Methods

Records of SGC patients from Surveillance, Epidemiology, and End Results database (SEER, training set, N = 4262) and Fudan University Shanghai Cancer Center (FUSCC, validating set, N = 154) were analyzed for the prognostic value of LNR. Kaplan–Meier survival estimates, the Log-rank χ² test and Cox proportional hazards model were used for univariate and multivariate analysis. Optimal LNR cutoff points were identified by X-tile.

Results

Optimal LNR cutoff points classified patients into four risk groups, R0, R1 (≤ 0.17), R2 (0.17–0.56) and R3 (> 0.56), corresponding to 5-year cause-specific survival in SEER patients of 88.6%, 57.2%, 53.1% and 39.7%, disease-free survival in FUSCC patients of 69.2%, 63.3%, 34.6% and 0%, and disease-specific survival in FUSCC patients of 92.3%, 90.0%, 71.4% and 0%, respectively. Compared with TNM staging, TNM + R staging showed smaller AIC values and higher C-index values in the Cox regression model in both patient sets.

Conclusions

LNR classification should be considered as a complementary system to TNM staging and LNR classification based clinical trials deserve further research.

Electronic supplementary material

The online version of this article (10.1007/s00405-019-05597-0) contains supplementary material, which is available to authorized users.

Old age at diagnosis increases risk of tumor progression in nasopharyngeal cancer

Age at diagnosis has been found to be a prognostic factor of outcomes in various cancers. However, the effect of age at diagnosis on nasopharyngeal cancer (NPC) progression has not been explored. We retrospectively evaluated the relationship between age and disease progression in 3,153 NPC patients who underwent radiotherapy, chemotherapy, or chemoradiotherapy between 2007 and 2009. Patients were randomly assigned to either a testing cohort or a validation cohort by computer-generated random assignment. X-tile plots determined the optimal cut-point of age based on survival status to be ≤61 vs. >61 years. Further correlation analysis showed that age >61 years was significantly correlated with the tumor progression and therapeutic regimen in both testing and validation cohorts (P <0.05). In the present study, we observed that older age (>61 years) was a strong and independent predictor of poor disease-free survival (DFS) and cancer-specific survival (CSS), in both univariate and multivariate analyses. Age was also found to be a significant prognostic predictor as well (P <0.05) when evaluating patients with the same disease stage. ROC analysis confirmed the predictive value of age on NPC-specific survival in both cohorts (P <0.001) and suggested that age may improve the ability to discriminate outcomes in NPCs, especially regarding tumor progression. In conclusion, our study suggests that older age at NPC diagnosis is associated with a higher incidence of tumor progression and cancer-specific mortality. Age is a strong and independent predictor of poor outcomes and may allow for more tailored therapeutic decision-making and individualized patient counseling.

Lymph Node Ratio in Sentinel Lymph Node Biopsy Era: Are We Losing Prognostic Information?

BACKGROUND

The number of involved axillary lymph nodes (LNs) found pathologically is regarded as a significant prognostic factor in early-stage breast cancer (EBC). Recently, there is speculation that LN ratio (LNR) may be a better surrogate at predicting cancer-specific outcome than number of involved LNs. This study investigated prognostic value of LNR, using predetermined cutoff values.

METHODS

Data included all women diagnosed with node-positive EBC between January 1, 2001, and December 31, 2010 (N = 553). Retrospective evaluation for clinical, demographic, and pathologic data was performed. Most had axillary node clearance (ANC) (548/553; 99.1%). Cohorts were divided by LNR risk groups (low: ≤ 0.20; intermediate: 0.21-0.65; high: >0.65). Proportional hazard modeling was undertaken to evaluate whether LNR was associated with overall survival (OS).

RESULTS

Median follow-up was 59.8 months. LNR distribution was as follows: low, 303/553 (54.8%); intermediate, 160/553 (28.9%); high, 90/553 (16.3%). Kaplan-Meier estimates for OS were stratified by LNR: low-risk group had better outcome for OS (P < .001). Overall 5- and 10-year OS was 63% and 58%, respectively. Number of positive LNs correlated with 10-year OS (66%, 48%, and 48% for patients with N1, N2, and N3 stage, respectively; P < .001). LNR also correlated with 5-year OS (69%, 48%, and 41% for low-, intermediate-, and high-risk groups, respectively; P < .001). Significantly, LNR on multivariate analysis also formed a prognostic model when combined with age, estrogen receptor status, PgR status and, HER2 status (P < .001).

CONCLUSION

The Findings support LNR as a predictor for OS in EBC. LNR should be considered an independent prognostic variable to current prognostic instruments already in use.

Breast cancer at extreme ages--a comparative analysis in Chile

BACKGROUND

Young onset breast cancer (BC) has a worse outcome as compared to in the elderly. However, some studies have shown that BC in the elderly, despite indolent features, does also cause increase in mortality. In an attempt to compare clinic-pathological characteristics, BC subtypes and survival in patients with BC presenting at extremes of age, we performed a retrospective study.

MATERIALS AND METHODS

Patients were either ≤40 or ≥70 years old. Subtypes were defined using immunohistochemistry and histological grade. Chi-Square test was used for evaluation of categorical variables, and Kaplan-meier and log-rank for disease-specific survival (DSS) and disease free survival (DFS) .

RESULTS

We analyzed 256 patients ≤40 and 366 patients ≥70. Younger patients presented with more aggressive disease, with less luminal A but more luminal B and triple negative (TN) subtype. With a median follow-up of 57.5 months, DFS at 5 years in younger patients was 72.3% vs 84.6% in the elderly (p=0.007). Luminal A and B disease presented with worse DFS in younger patients. The opposite was seen in the TN subgroup. Although we found no significant differences in DSS, older patients with TN tumors died of BC more frequently. This group also received less chemotherapy.

CONCLUSIONS

Young patients present with more aggressive disease, this translating into worse DFS. However, elderly patients with TN disease represent a particular subpopulation with worse DFS and DSS, suggesting that chemotherapy should not be withheld only because of age.

Association between Lymph Node Ratio and Disease Specific Survival in Breast Cancer Patients with One or Two Positive Lymph Nodes Stratified by Different Local Treatment Modalities

PURPOSE

Results of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial indicated that complete axillary node dissection (ALND) may not be warranted in some breast cancer patients with low tumor burden who are undergoing breast-conserving surgery following whole-breast irradiation. However, this study did not address patients undergoing mastectomy or those undergoing breast-conserving surgery without whole-breast radiotherapy. Given that lymph node ratio (LNR; ratio of positive lymph nodes to the total number removed) has been shown to be a prognostic factor in breast cancer, we first sought to determine the prognostic value of LNR in a low risk population comparable to that of the Z0011 trial and further to investigate whether the prognostic significance differs with local treatment modality.

METHOD

We used the Surveillance Epidemiology and End Results (SEER) database to identify breast cancer patients with T1-T2 tumor and 1-2 positive nodes. Patients were subclassified by the local therapy they underwent for the primary tumor. The prognostic value of LNR in predicting disease-specific survival (DSS) was examined in each treatment group.

RESULTS

A total of 53,109 patients were included. In the subgroup of 20,602 patients who underwent lumpectomy following radiotherapy, LNR was not found to be significantly associated with DSS in both the univariate and multivariate model. For the 4,664 patients treated with mastectomy following radiotherapy, 6,811 treated with lumpectomy without radiotherapy and 21,031 with mastectomy without radiotherapy, LNR independently predict DSS in each of these subgroups.

CONCLUSIONS

Our results add evidence to the concept that axillary dissection could be omitted in patients with one or two positive nodes following breast-conserving surgery and whole breast radiation.

Prognostic value of the lymph node ratio for lymph-node-positive breast cancer- is it just a denominator problem?

Purpose

To examine the prognostic value of lymph node ratio (LNR) for patients with node-positive breast cancer with varying numbers of minimum nodes removed (>5, > 10 and > 15 total node count).

Methods

This study examined the original histopathological reports of 332 node-positive patients treated in the state of New South Wales (NSW), Australia between 1 April 1995 and 30 September 1995. The LNR was defined as the number of positive lymph nodes (LNs) over the total number of LNs removed. The LNR cutoffs were defined as low-risk, 0.01–0.20; intermediate-risk, 0.21– 0.65; and high-risk, LNR >0.65.

Results

The median follow-up was 10.3 years. In multivariate analysis, LNR was an independent predictor of 10-year breast cancer specific survival when > 5 nodes were removed. However, LNR was not an independent predictor when > 15 nodes were removed. In a multivariate analysis the relative risk of death (RR) decreased from 2.20 to 1.05 for intermediate-risk LNR and from 3.07 to 2.64 for high-risk while P values increased from 0.027 to 0.957 for intermediate-risk LNR and 0.018 to 0.322 for high-risk with the number of nodes removed increasing from > 5 to > 15.

Conclusions

Although LNR is important for patients with low node denominators, for patients with macroscopic nodal metastases in several nodes following an axillary dissection who have more than 15 nodes dissected, the oncologist can be satisfied that prognosis, selection of adjuvant chemotherapy and radiotherapy fields can be based on the numerator of the positive nodes.

Electronic supplementary material

The online version of this article (doi:10.1186/s40064-015-0865-2) contains supplementary material, which is available to authorized users.

Recursive partitioning analysis of lymph node ratio in breast cancer patients

Lymph node ratio (LNR) is a powerful prognostic factor for breast cancer. We conducted a recursive partitioning analysis (RPA) of the LNR to identify the prognostic risk groups in breast cancer patients. Records of newly diagnosed breast cancer patients between 2002 and 2006 were searched in the Taiwan Cancer Database. The end of follow-up was December 31, 2009. We excluded patients with distant metastases, inflammatory breast cancer, survival <1 month, no mastectomy, or missing lymph node status. Primary outcome was 5-year overall survival (OS). For univariate significant predictors, RPA were used to determine the risk groups. Among the 11,349 eligible patients, we identified 4 prognostic factors (including LNR) for survival, resulting in 8 terminal nodes. The LNR cutoffs were 0.038, 0.259, and 0.738, which divided LNR into 4 categories: very low (LNR ≤ 0.038), low (0.038 < LNR ≤ 0.259), moderate (0.259 < LNR ≤ 0.738), and high (0.738 < LNR). Then, 4 risk groups were determined as follows: Class 1 (very low risk, 8,265 patients), Class 2 (low risk, 1,901 patients), Class 3 (moderate risk, 274 patients), and Class 4 (high risk, 900 patients). The 5-year OS for Class 1, 2, 3, and 4 were 93.2%, 83.1%, 72.3%, and 56.9%, respectively (P< 0.001). The hazard ratio of death was 2.70, 4.52, and 8.59 (95% confidence interval 2.32-3.13, 3.49-5.86, and 7.48-9.88, respectively) times for Class 2, 3, and 4 compared with Class 1 (P < 0.001). In conclusion, we identified the optimal cutoff LNR values based on RPA and determined the related risk groups, which successfully predict 5-year OS in breast cancer patients.

Additional prognostic value of lymph node ratio over pN staging in different breast cancer subtypes based on the results of 1,656 patients

PURPOSE

Although the impact of lymph node ratio (LNR: ratio of metastatic to resected LNs) in breast cancer (BC) has been investigated, its prognostic value in molecular subtypes remains unclear. Our aim was to evaluate the impact of LNR compared to pN-stage in BC subtypes.

PATIENTS/METHODS

We analyzed the impact of LNR and pN-stage on disease-free (DFS) and overall survival (OS) in 1,656 patients with primary BC who underwent primary axillary surgery (removal of ≥10 LNs) between 1998 and 2011. The cut-off points for LNR were previously published. Using immunohistochemical parameters tumors were grouped in luminalA, luminalB/HER2-, luminalB/HER2+, HER2+ and triple negative (TNBC).

RESULTS

For the entire cohort 5/10-year DFS and OS rates were 88/77% and 88/75%, respectively. LNR and pN-stage were independent prognostic parameters for DFS/OS in multivariate analysis in the entire cohort and each molecular subgroup (p < 0.001). However, increasing LNR seemed to discriminated 10-year DFS slightly better than pN-stage in luminalA (intermediate/high LNR 65/44% versus pN2/pN3 71/53%), luminalB/HER2- (intermediate/high LNR 48/24% versus pN2/pN3 41/42%), and TNBC patients (intermediate/high LNR 49/24% versus pN2/pN3 56/33%).

CONCLUSIONS

LNR is an important prognostic parameter for DFS/OS and might provide potentially more information than pN-stage in different molecular subtypes.

Lymph node ratio for postoperative staging of laryngeal squamous cell carcinoma with lymph node metastasis

BACKGROUND

Lymph node metastasis has a significant impact on laryngeal cancer prognosis. The role of lymph node ratio (LNR, ratio of metastatic to examined nodes) in the staging of laryngeal cancer was not reported.

PATIENTS AND METHODS

Records of laryngeal cancer patients with lymph node involvement from Surveillance, Epidemiology, and End Results database (SEER, training set, N = 1963) and Fudan University Shanghai Cancer Center (FDSCC, validating set, N = 27) were analyzed for the prognostic value of LNR. Kaplan-Meier survival estimates, the Log-rank χ² test and Cox proportional hazards model were used for univariate and multivariate analysis. Optimal LNR cutoff points were identified by X-tile.

RESULTS

Optimal LNR cutoff points classified patients into three risk groups R1 (≤0.09), R2 (0.09-0.20) and R3 (>0.20), corresponding to 5-year cause-specific survival and overall survival in SEER patients of 55.1%, 40.2%, 28.8% and 43.1%, 31.5%, 21.8%, 2-year disease free survival and disease specific survival in FDSCC patients of 74.1%, 62.5%, 50.0%, and 67.7%, 43.2%, 25.0%, respectively. R3 stratified more high risk patients than N3 with the same survival rate, and R classification clearly separated N2 patients to 3 risk groups and N1 patients to 2 risk groups (R1-2 and R3).

CONCLUSIONS

R classification is a significant prognostic factor of laryngeal cancer and should be used as a complementary staging system of N classification.

The number of lymph nodes dissected in breast cancer patients influences the accuracy of prognosis

BACKGROUND

Recent trials have suggested that axillary node dissection may not be warranted in some breast cancer patients with one to two positive nodes. Given that lymph node ratio (LNR; number of positive lymph nodes divided by the total examined) has been shown to be a significant prognostic factor, we sought to determine whether the number of nodes removed in this low risk population predicted survival.

METHODS

The National Cancer Database is a comprehensive clinical surveillance resource capturing 70% of newly diagnosed malignancies in the United States; 309,216 breast cancer patients diagnosed between 1998 and 2005, with tumors ≤5 cm and one to two positive nodes, formed the cohort of interest.

RESULTS

Median age at diagnosis was 57 (range 18-90) years. Median tumor size was 2 (range 0.1-5) cm; 215,382 patients (69.7%) had one positive node, and 93,834 (30.3%) had two. The median number of lymph nodes examined was 11 (range 1-84). Patients were categorized into low (≤0.2), medium (0.21-0.65), or high (>0.65) LNR groups, with 228,822 (74%), 55,797 (18%), and 24,597 (8%) patients in each of these categories, respectively. Median follow-up was 54.1 months. Median overall survival (OS) for low, intermediate, and high LNR was 66.1, 61.1, and 56.5 months, respectively (p < 0.001). In a Cox model controlling for clinicopathologic and therapy covariates, LNR category remained a significant predictor of OS (p < 0.001).

CONCLUSIONS

LNR is an independent predictor of OS in a low-risk population with one to two positive nodes and tumors ≤5 cm. Therefore, the number of lymph nodes excised may influence prognostic stratification.

Impact of lymph node ratio on the survival of patients with hypopharyngeal squamous cell carcinoma: a population-based analysis

Objective

To analyze the impact of the lymph node ratio (LNR, ratio of metastatic to examined nodes) on the prognosis of hypopharyngeal cancer patients.

Methods

SEER (Surveillance, Epidemiology and End Results)-registered hypopharyngeal cancer patients with lymph node metastasis were evaluated using multivariate Cox regression analysis to identify the prognostic role of the LNR. The categorical LNR was compared with the continuous LNR and pN classifications to predict cause-specific survival (CSS) and overall survival (OS) rates of hypopharyngeal cancer patients.

Results

Multivariate analysis of 916 pN+ hypopharyngeal cancer cases identified race, primary site, radiation sequence, T classification, N classification, M classification, the number of regional lymph nodes examined, the continuous LNR (Hazard ratio 2.415, 95% CI 1.707–3.416, P<0.001) and age as prognostic variables that were associated with CSS in hypopharyngeal cancer. The categorical LNR showed a higher C-index and lower Akaike information criterion (AIC) value than the continuous LNR. When patients (n = 1152) were classified into four risk groups according to LNR, R0 (LNR = 0), R1 (LNR ≤0.05), R2 (LNR 0.05–0.30) and R3 (LNR >0.30), the Cox regression model for CSS and OS using the R classification had a higher C-index value and lower AIC value than the model using the pN classification. Significant improvements in both CSS and OS were found for R2 and R3 patients with postoperative radiotherapy.

Conclusions

LNR is a significant prognostic factor for the survival of hypopharyngeal cancer patients. Using the cutoff points 0.05/0.30, the R classification was more accurate than the pN classification in predicting survival and can be used to select high risk patients for postoperative treatment.

Impact of age on the cancer-specific survival of patients with localized renal cell carcinoma: martingale residual and competing risks analysis

Background

Age at diagnosis has been shown to be an independent prognostic factor of localized renal cell carcinoma (RCC) in several studies. We used contemporary statistical methods to reevaluate the effect of age on the cancer-specific survival (CSS) of localized RCC.

Methods and Findings

1,147 patients with localized RCC who underwent radical nephrectomy between 1993 and 2009 were identified in our four institutions. The association between age and CSS was estimated, and the potential threshold was identified by a univariate Cox model and by martingale residual analysis. Competing risks regression was used to identify the independent impact of age on CSS. The median age was 52 years (range, 19–84 years). The median follow-up was 61 months (range, 6–144 months) for survivors. A steep increasing smoothed martingale residual plot indicated an adverse prognostic effect of age on CSS. The age cut-off of 45 years was most predictive of CSS on univariate Cox analysis and martingale residual analysis (p = 0.005). Age ≤45 years was independently associated with a higher CSS rate in the multivariate Cox regression model (HR = 1.59, 95% CI = 1.05–2.40, p = 0.027) as well as in competing risks regression (HR = 3.60, 95% CI = 1.93–6.71, p = 0.001).

Conclusions

Increasing age was associated with a higher incidence of cancer-specific mortality of localized RCC. Age dichotomized at 45 years would maximize the predictive value of age on CSS, and independently predict the CSS of patients with localized RCC.