Validation of the prognostic value of various lymph node staging systems for cervical squamous cell carcinoma following radical surgery: a single-center analysis of 3,732 patients

Application and subgroup analysis of competing risks model based on different lymph node staging systems in differentiated thyroid cancer

Differentiated thyroid cancer (DTC) is the most common endocrine malignancy, with a rising incidence worldwide. Accurate prognostic models are essential for effective patient management. This study evaluates the prognostic value of various lymph node staging systems in DTC using a competing risks model. We used SEER database records (1998-2016) of 16,527 DTC patients, analyzing N stage, positive lymph node numbers (PLNNs), metastatic lymph node ratio (MLNR), log odds of positive lymph nodes (LODDS), and log odds of the negative lymph node (NLN)/T stage ratio (LONT). Univariate and multivariate analyses in a competing risks model were performed, along with subgroup analyses based on demographic and clinical characteristics. In this study of 16,527 patients with DTC, different lymph node staging systems showed different prognostic correlations in univariate and multivariate analyses. In particular, PLNNs showed significant prognostic correlations in several subgroups. Additionally, PLNNs were more suitable as a lymph node staging system for DTC than LODDS and MLNR in N1 stage subgroups, with an optimal cut-off of 13. Receiver operating characteristic curves, calibration curves and nomograms improved the clinical utility of the prognostic model based on PLNNs. Using competing risks model and subgroup analyses, we found that PLNNs had the best prognostic discriminatory efficacy for patients with DTC, especially those with N1 stage disease, and had an optimal cut-off value of 13.

External beam radiotherapy boost versus surgical debulking followed by radiotherapy for the treatment of metastatic lymph nodes in cervical cancer: A systematic review and meta-analysis

OBJECTIVE

We aimed to assess disease-free survival (DFS), overall survival (OS) and treatment-related toxicity of two therapeutic strategies for treating bulky lymph nodes on imaging in patients with locally advanced cervical cancer (LACC): radiotherapy boost versus surgical debulking followed by radiotherapy.

METHODS

We performed a systematic review of studies published up to October 2023. We selected studies including patients with LACC treated by external beam radiotherapy (EBRT) boost or lymph node debulking followed by EBRT (with or without boost).

RESULTS

We included two comparative (included in the meta-analysis) and nine non-comparative studies. The estimated 3-year recurrence rate was 28.2% (95%CI:18.3-38.0) in the EBRT group and 39.9% (95%CI:22.1-57.6) in the surgical debulking plus EBRT group. The estimated 3-year DFS was 71.8% and 60.1%, respectively (p = 0.19). The estimated 3-year death rate was 22.2% (95%CI:11.2-33.2) in the EBRT boost group and 31.9% (95%CI:23.3-40.5) in the surgical debulking plus EBRT group. The estimated 3-year OS was 77.8% and 68.1%, respectively (p = 0.04). No difference in lymph node recurrence between the two comparative studies (p = 0.36). The meta-analysis of the two comparative studies showed no DFS difference (p = 0.13) but better OS in the radiotherapy boost group (p = 0.006). The incidence of grade≥3 toxicities (ranging 0-50%) was not different between the two approaches in the two comparative studies (p = 0.31).

CONCLUSION

No DFS and toxicity difference when comparing EBRT boost with surgical debulking of enlarged lymph nodes and EBRT in patients with cervical cancer was evident. Radiotherapy boost had better OS. Further investigation is required to better understand the prognostic role of surgical lymph node debulking in light of radiotherapy developments.

The impact of boost radiation therapy after hysterectomy on cervical cancer patients with close or positive resection margins

PURPOSE

We investigated the effect of boost radiation therapy (RT) in addition to whole pelvis RT (WPRT) on treatment outcome and safety of cervical cancer patients following hysterectomy with close/positive resection margins (RM).

METHODS

We retrospectively analyzed 51 patients with cervical cancer who received WPRT with or without boost-RT as adjuvant treatment between July 2006 and June 2022. Twenty patients (39.2%) were treated with WPRT-alone, and 31 (60.8%) received boost-RT after WPRT using brachytherapy or intensity-modulated RT.

RESULTS

The median follow-up period was 41 months. According to RT modality, the 4-year local control (LC) and locoregional control (LRC) rates of patients treated with WPRT-alone were 61% and 61%, respectively, whereas those in LC and LRC rates in patients who underwent WPRT with boost-RT were 93.2% and 75.3%, with p-values equal to 0.005 and 0.090, respectively. Seven patients (35.0%) had local recurrence in the WPRT-treated group compared to only two out of the 31 patients (6.5%) in the WPRT with boost-RT-treated counterparts (p = 0.025). Boost-RT was a significantly good prognostic factor for LC (p = 0.013) and LRC (p = 0.013). Boost-RT did not result in statistically-significant improvements in progression-free survival or overall survival. The acute and late toxicity rates were not significantly different between groups.

CONCLUSION

Boost RT following WPRT is a safe and effective treatment strategy to improve LC without increasing toxicity in patients with cervical cancer with close/positive RM after hysterectomy.

Amide proton transfer weighted combined with diffusion kurtosis imaging for predicting lymph node metastasis in cervical cancer

OBJECTIVE

To investigate the value of amide proton transfer weighted (APTw) combined with diffusion kurtosis imaging (DKI) in quantitative prediction of lymph node metastasis (LNM) in cervical carcinoma (CC).

METHODS

Data of 19 LNM(+) and 50 LNM(-) patients with CC were retrospectively analyzed. 3.0 T MRI scan was performed before the operation, including APTw and DKI. After post-processing, quantitative magnetization transfer ratio asymmetric at 3.5 ppm [MTRasym (3.5 ppm)], mean kurtosis (MK), and mean diffusivity (MD) maps were obtained. The MTRasym(3.5 ppm), MK, and MD values were respectively measured by two observers, and intra-class correlation coefficients (ICC) were used to test the consistency of the results. The independent samples t-test or Mann-Whitney U test was used to compare the differences in the values of each parameter. The ROC curve was used to analyze the predictive performance of parameters with significant differences and their combination parameter.

RESULTS

The two observers had good agreement in the measurement of each data (ICC > 0.75). The MTRasym(3.5 ppm) and MK values of the LNM(+) group(3.260 ± 0.538% and 0.531 ± 0.202) were higher than those of the LNM(-) group(2.698 ± 0.597% and 0.401 ± 0.148) (P < 0.05), while there was no significant difference in MD values between the two groups(P > 0.05). The area under the curves (AUCs) of MTRasym(3.5 ppm), MK value, and MTRasym(3.5 ppm) + MK value were 0.763, 0.716, and 0.813, respectively, when predicting LNM status of CC.

CONCLUSION

APTw and DKI can quantitatively predict LNM status of CC, which is of importance in clinical diagnosis and treatment.

Clinical Outcomes and Prognostic Factors in Stage III C Cervical Cancer Patients Treated with Radical Radiotherapy or Radiochemotherapy

Objective: Since the update of the 2018 International Federation of Gynecology and Obstetrics (FIGO) staging criteria, there have been few reports on the prognosis of stage III C cervical cancer. Moreover, some studies have drawn controversial conclusions, necessitating further verification. This study aims to evaluate the clinical outcomes and determine the prognostic factors for stage III C cervical cancer patients treated with radical radiotherapy or radiochemotherapy. Methods: The data of 117 stage III C cervical cancer patients (98 III C1 and 19 III C2) who underwent radical radiotherapy or radiochemotherapy were retrospectively analyzed. We evaluated 3-year overall survival (OS) and disease-free survival (DFS) using the Kaplan-Meier method. Prognostic factors were analyzed using the Log-rank test and Cox proportional hazard regression model. The risk of para-aortic lymph node metastasis (LNM) in all patients was assessed through Chi-squared test and logistic regression analysis. Results: For stage III C1 and III C2 patients, the 3-year OS rates were 77.6% and 63.2% (P = .042), and the 3-year DFS rates were 70.4% and 47.4% (P = .003), respectively. The pretreatment location of pelvic LNM, histological type, and FIGO stage was associated with OS (P = .033, .003, .042, respectively); the number of pelvic LNM and FIGO stage were associated with DFS (P = .015, .003, respectively). The histological type was an independent prognostic indicator for OS, and the numbers of pelvic LNM and FIGO stage were independent prognostic indicators for DFS. Furthermore, a pelvic LNM largest short-axis diameter ≥ 1.5 cm and the presence of common iliac LNM were identified as high-risk factors influencing para-aortic LNM in stage III C patients (P = .046, .006, respectively). Conclusions: The results of this study validated the 2018 FIGO staging criteria for stage III C cervical cancer patients undergoing concurrent chemoradiotherapy. These findings may enhance our understanding of the updated staging criteria and contribute to better management of patients in stage III C.

Predicting Lymph Node Metastasis From Primary Cervical Squamous Cell Carcinoma Based on Deep Learning in Histopathologic Images

We developed a deep learning framework to accurately predict the lymph node status of patients with cervical cancer based on hematoxylin and eosin-stained pathological sections of the primary tumor. In total, 1524 hematoxylin and eosin-stained whole slide images (WSIs) of primary cervical tumors from 564 patients were used in this retrospective, proof-of-concept study. Primary tumor sections (1161 WSIs) were obtained from 405 patients who underwent radical cervical cancer surgery at the Fudan University Shanghai Cancer Center (FUSCC) between 2008 and 2014; 165 and 240 patients were negative and positive for lymph node metastasis, respectively (including 166 with positive pelvic lymph nodes alone and 74 with positive pelvic and para-aortic lymph nodes). We constructed and trained a multi-instance deep convolutional neural network based on a multiscale attention mechanism, in which an internal independent test set (100 patients, 228 WSIs) from the FUSCC cohort and an external independent test set (159 patients, 363 WSIs) from the Cervical Squamous Cell Carcinoma and Endocervical Adenocarcinoma cohort of the Cancer Genome Atlas program database were used to evaluate the predictive performance of the network. In predicting the occurrence of lymph node metastasis, our network achieved areas under the receiver operating characteristic curve of 0.87 in the cross-validation set, 0.84 in the internal independent test set of the FUSCC cohort, and 0.75 in the external test set of the Cervical Squamous Cell Carcinoma and Endocervical Adenocarcinoma cohort of the Cancer Genome Atlas program. For patients with positive pelvic lymph node metastases, we retrained the network to predict whether they also had para-aortic lymph node metastases. Our network achieved areas under the receiver operating characteristic curve of 0.91 in the cross-validation set and 0.88 in the test set of the FUSCC cohort. Deep learning analysis based on pathological images of primary foci is very likely to provide new ideas for preoperatively assessing cervical cancer lymph node status; its true value must be validated with cervical biopsy specimens and large multicenter datasets.

Nomogram incorporating log odds of positive lymph nodes improves prognostic prediction for ovarian serous carcinoma: a real-world retrospective cohort study

OBJECTIVES

Ovarian serous carcinoma (OSC) is a major cause of gynaecological cancer death, yet there is a lack of reliable prognostic models. To address this, we developed and validated a nomogram based on conventional clinical characteristics and log odds of positive lymph nodes (LODDS) to predict the prognosis of OSC patients.

SETTING

A Real-World Retrospective Cohort Study from the Surveillance, Epidemiology and End Results programme.

PARTICIPANTS

We obtained data on 4192 patients diagnosed with OSC between 2010 and 2015. Eligibility criteria included specific diagnostic codes, OSC being the primary malignant tumour and age at diagnosis over 18 years. Exclusion criteria were missing information on various factors and unknown cause of death or survival time.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome were overall survival (OS) and ovarian cancer-specific survival (OCSS).

RESULTS

For OS and OCSS outcomes, we selected 7 and 5 variables, respectively, to establish the nomogram. In the training and validation cohorts, the C index for OS or OCSS was 0.716 or 0.718 and 0.731 or 0.733, respectively, with a 3-year time-dependent area under the curve (AUC) of 0.745 or 0.751 and a 5-year time-dependent AUC of 0.742 or 0.751. Calibration curves demonstrated excellent consistency between predicted and observed outcomes. The Net Reclassification Index, integrated discrimination improvement and decision curve analysis curves indicated that our nomogram performed better than the International Federation of Gynaecology and Obstetrics (FIGO) staging system in predicting OS and OCSS for OSC patients in both the training and validation cohorts.

CONCLUSION

Our nomogram, which includes LODDS, offers higher accuracy and reliability than the FIGO staging system and can predict overall and OCSS in OSC patients.

Rationality of FIGO 2018 IIIC restaging of cervical cancer according to local tumor size: A cohort study

INTRODUCTION

FIGO 2018 IIIC remains controversial for the heterogeneity of its prognoses. To ensure a better management of cervical cancer patients in Stage IIIC, a revision of the FIGO IIIC version classification is required according to local tumor size.

MATERIAL AND METHODS

We retrospectively enrolled cervical cancer patients of FIGO 2018 Stages I-IIIC who had undergone radical surgery or chemoradiotherapy. Based on the tumor factors from the Tumor Node Metastasis staging system, IIIC cases were divided into IIIC-T1, IIIC-T2a, IIIC-T2b, and IIIC-(T3a+T3b). Oncologcial outcomes of all stages were compared.

RESULTS

A total of 63 926 cervical cancer cases were identified, among which 9452 fulfilled the inclusion criteria and were included in this study. Kaplan-Meier pairwise analysis showed that: the oncology outcomes of I and IIA were significantly better than of IIB, IIIA+IIIB, and IIIC; the oncology outcome of IIIC-(T1-T2b) was significantly better than of IIIA+IIIB and IIIC-(T3a+T3b); no significant difference was noted between IIB and IIIC-(T1-T2b), or IIIC-(T3a+T3b) and IIIA+IIIB. Multivariate analysis indicated that, compared with IIIC-T1, Stages T2a, T2b, IIIA+IIIB and IIIC-(T3a+T3b) were associated with a higher risk of death and recurrence/death. There was no significant difference in the risk of death or recurrence/death between patients with IIIC-(T1-T2b) and IIB. Also, compared with IIB, IIIC-(T3a+T3b) was associated with a higher risk of death and recurrence/death. No significant differences in the risk of death and recurrence/death were noted between IIIC-(T3a+T3b) and IIIA+IIIB.

CONCLUSIONS

In terms of oncology outcomes of the study, FIGO 2018 Stage IIIC of cervical cancer is unreasonable. Stages IIIC-T1, T2a, and T2b may be integrated as IIC, and it might be unnecessary for T3a/T3b cases to be subdivided by lymph node status.

A Scoring System to Select the Candidates for Adjuvant Chemotherapy Alone in High-Risk Early-Stage Cervical Cancer Patients With Pelvic Lymph Node Metastases After Surgery

BACKGROUND

The aim was to build a risk scoring system to guide the adjuvant treatment for early-stage cervical cancer patients with pelvic lymph node (LN) metastases after surgery.

METHODS

A cohort of 1213 early-stage cervical cancer patients with pelvic LN metastases (T1-2aN1M0) were selected from the NCI SEER database, of which 1040 patients received adjuvant external beam radiotherapy concurrent with chemotherapy (EBRT+Chemo) and 173 patients received adjuvant chemotherapy alone. The Cox regression analysis was applied to identify the risk factors associated with worse survival. The exp (β) of each independent risk factors from multivariate analysis was assigned to develop the risk scoring system. The total cohort was divided into different risk subgroups accordingly and the efficacy of different adjuvant modalities in each risk subgroups was compared.

RESULTS

The patients were divided into 3 risk subgroups (Low-risk: total score <7.20, Middle-risk:7.20≤ total score≤ 8.40, High-risk: total score<8.40) based on the scoring system incorporating 5 independent risk factors. The survival analysis suggested that low-risk (hazard ratio [HR]=1.046, 95% CI: 0.586-1.867; P= 0.879) and middle-risk patients (HR=0.709, 95% CI: 0.459-1.096; P =0.122) could not benefit more from EBRT+Chemo than Chemo alone. However, EBRT+Chemo remained the superiority to Chemo alone in the high-risk subgroup (HR=0.482, 95% CI: 0.294-0.791; P =0.003).

CONCLUSION

A risk scoring system has been built to direct the adjuvant treatment for early-stage cervical cancer patients with pelvic LN metastases after surgery, where Chemo alone was totally enough for low-risk and middle-risk patients stratified by the model while EBRT+Chemo was still recommended for patients in the high-risk subgroup.

Validation of the 2018 FIGO Staging System for Predicting the Prognosis of Patients With Stage IIIC Cervical Cancer

Background

Risk stratification of patients with cervical cancer accompanied by positive lymph nodes (stage IIIC) (the 2018 International Federation of Gynecology and Obstetrics [FIGO] new staging system) yields a clinically heterogeneous group. In this study, we investigated the prognostic performance of the 2018 FIGO staging system for stage IIIC cervical cancer.

Methods

The study included patients with stage III cervical cancer based on the 2018 FIGO staging system, who visited Chongqing University Cancer Hospital between January 2011 and December 2014. Kaplan-Meier curves were generated to evaluate overall survival (OS), which was compared using the log-rank test. The Cox proportional hazard regression model was used for multivariable analysis.

Results

A total of 418 patients were eligible for analysis. The 5-year OS was 54.1% for stage IIIC1, 43.3% for stage IIIA, 40.6% for stage IIIB, and 23.1% for stage IIIC2 (P < .001). Multivariable analysis revealed that compared with stages IIIA (hazard ratio [HR] 1.432, 95% confidence interval [CI] 0.867-2.366, P = .161) and IIIB (HR 1.261, 95% CI 0.871-1.827, P = .219), stage IIIC1 cancer was not significantly associated with an increased mortality risk. Stage IIIC2 was independently associated with an increased mortality risk compared with stages IIIA (HR 2.958, 95% CI 1.757-4.983, P < .001) and IIIB (HR 2.606, 95% CI 1.752-3.877, P < .001). We stratified patients with stage IIIC1 based on the T stage. The 5-year OS was significantly longer in patients with stage IIIC1 (T1) than in those with stage IIIA (P = .004) or IIIB (P < .001). Analysis of multiple factors revealed that the mortality risk was 2.75-fold higher in patients with stage IIIC1pN>2 than in patients with stage IIIC1pN1-2 (HR 2.753, 95% CI 1.527-4.965, P = .001).

Conclusions

Patients with stage IIIC1 cervical cancer showed heterogeneous clinical characteristics that reflected variable prognoses, depending on the T stage and the extent of pelvic lymph node metastases.

Para-Aortic Lymph Node Dissection for Patients with Node-Negative Cervical Squamous Cell Carcinoma: A Retrospective Cohort Study

Objective. The current guidelines for cervical cancer are uncertain regarding whether the para-aortic lymph nodes (PALNs) need to be removed. For patients with negative PALNs, whether the addition of PALN dissection (PALND) can be translated into survival benefits is unknown. Methods. The medical records of 3,995 patients with FIGO stage IB-IIA cervical squamous cell carcinoma (CSCC) who underwent abdominal radical surgery between 2006 and 2014 at our center were retrospectively reviewed. Two groups were identified: PALN-negative patients who underwent PALND (+PALND) and those who did not (−PALND). The groups were matched by propensity score matching (PSM). Survival was analyzed using the Kaplan–Meier method and the Cox proportional hazards model. Subgroups were stratified by the variables known at the time of diagnosis. Results. After PSM, 313 patients were matched to the −PALND (cohort 1) and +PALND (cohort 2) groups. Cohort 2 patients had a poorer prognosis than cohort 1 patients in terms of overall survival (OS, $P=0.014$ ), and PALND was an independent prognostic factor for OS ( $P=0.021$ ). There were no differences in recurrence patterns between the groups. Subgroup analysis showed that cohort 2 patients had worse OS than cohort 1 patients when they were aged ≤47 years ( $P=0.033$ ), were premenopausal ( $P=0.032$ ), were in stage IB ( $P=0.009$ ), or had preoperative SCC-Ag<6.5 ( $P=0.009$ ). Conclusions. PALND negatively impacts OS in early-stage PALN-negative CSCC patients. For CSCC patients who are clinically PALN-negative, especially those who are young, are premenopausal, have tumors confined to the cervix, and have relatively low SCC-Ag values, PALND may “rub salt on the wound.”

The prognostic value of the number of positive lymph nodes and the lymph node ratio in early-stage cervical cancer

INTRODUCTION

To establish the impact of the number of lymph node metastases (nLNM) and the lymph node ratio (LNR) on survival in patients with early-stage cervical cancer after surgery.

MATERIAL AND METHODS

In this nationwide historical cohort study, all women diagnosed between 1995 and 2020 with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IA2-IIA1 cervical cancer and nodal metastases after radical hysterectomy and pelvic lymphadenectomy from the Netherlands Cancer Registry were selected. Optimal cut-offs for prognostic stratification by nLNM and LNR were calculated to categorize patients into low-risk or high-risk groups. Kaplan-Meier overall survival analysis and flexible parametric relative survival analysis were used to determine the impact of nLNM and LNR on survival. Missing data were imputed.

RESULTS

The optimal cut-off point was ≥4 for nLNM and ≥0.177 for LNR. Of the 593 women included, 500 and 501 (both 84%) were categorized into the low-risk and 93 and 92 (both 16%) into the high-risk groups for nLNM and LNR, respectively. Both high-risk groups had a worse 5-year overall survival (p < 0.001) compared with the low-risk groups. Being classified into the high-risk groups is an independent risk factor for relative survival, with excess hazard ratios of 2.4 (95% confidence interval 1.6-3.5) for nLNM and 2.5 (95% confidence interval 1.7-3.8) for LNR.

CONCLUSIONS

Presenting a patient's nodal status postoperatively by the number of positive nodes, or by the nodal ratio, can support further risk stratification regarding survival in the case of node-positive early-stage cervical cancer.

Comparison of 4 lymph node staging systems for the prognostic prediction of esophagogastric junction adenocarcinoma with ≤15 retrieved lymph nodes

BACKGROUND

Directly applying the 8th American Joint Committee on Cancer (AJCC) Tumor Node Metastasis (TNM) staging system to evaluate the prognosis of patients with esophagogastric junction adenocarcinoma (AEG) might lead to under-staging, when insufficient lymph nodes were retrieved during surgery. The prognostic value of 4 lymph nodes staging systems, 8th AJCC TNM N stage, lymph node ratio (LNR), log odds of positive lymph nodes (LODDS), and negative lymph nodes (NLN), in AEG patients having ≤15 retrieved lymph nodes were compared.

METHODS

869 AEG patients diagnosed between 2004 and 2012 with ≤15 retrieved lymph nodes were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate Cox regression analyses were conducted to assess the association of cancer-specific survival (CSS) and overall survival (OS) with 8th AJCC TNM N stage, LNR, LODDS, and NLN respectively. Predictive survival ability was assessed and compared using linear trend χ2 score, likelihood ratio (LR) test, Akaike information criterion (AIC), Harrell concordance index (C-index), and Receiver Operative Curve (ROC).

RESULTS

The N stage, LNR, LODDS, and NLN were all independent prognostic predictors for CSS and OS in multivariate Cox models. Comparatively, LODDS demonstrated higher linear trend χ2 score, LR test score, C-index and integrated area under the curve (iAUC) value, and lower AIC in CSS compared to the other three systems. Moreover, for patients without regional lymph node metastasis, NLN showed higher C-index and lower AIC.

CONCLUSIONS

LODDS showed better predictive performance than N, LNR, and NLN among patients with node-positive patients while NLN performed better in node-negative patients. A combination of LODDS and NLN has the potential to provide more prognostic information than the current AJCC TNM classification.

Development and external validation of a novel nomogram for predicting cancer-specific survival in patients with ascending colon adenocarcinoma after surgery: a population-based study

Background

This study aimed to develop and validate a novel nomogram to predict the cancer-specific survival (CSS) of patients with ascending colon adenocarcinoma after surgery.

Methods

Patients with ascending colon adenocarcinoma were enrolled from the Surveillance, Epidemiology, and End Results (SEER) database from 1973 to 2015 and randomly divided into a training set (5930) and a validation set (2540). The cut-off values for age, tumour size and lymph node ratio (LNR) were calculated via X-tile software. In the training set, independent prognostic factors were identified using univariate and multivariate Cox analyses, and a nomogram incorporating these factors was subsequently built. Data from the validation set were used to assess the reliability and accuracy of the nomogram and then compared with the 8th edition of the American Joint Committee on Cancer (AJCC) tumour-node-metastasis (TNM) staging system. Furthermore, external validation was performed from a single institution in China.

Results

A total of 8470 patients were enrolled from the SEER database, 5930 patients were allocated to the training set, 2540 were allocated to the internal validation set and a separate set of 473 patients was allocated to the external validation set. The optimal cut-off values of age, tumour size and lymph node ratio were 73 and 85, 33 and 75 and 4.9 and 32.8, respectively. Univariate and multivariate Cox multivariate regression revealed that age, AJCC 8th edition T, N and M stage, carcinoembryonic antigen (CEA), tumour differentiation, chemotherapy, perineural invasion and LNR were independent risk factors for patient CSS. The nomogram showed good predictive ability, as indicated by discriminative ability and calibration, with C statistics of 0.835 (95% CI, 0.823–0.847) and 0.848 (95% CI, 0.830–0.866) in the training and validation sets and 0.732 (95% CI, 0.664–0.799) in the external validation set. The nomogram showed favourable discrimination and calibration abilities and performed better than the AJCC TNM staging system.

Conclusions

A novel validated nomogram could effectively predict patients with ascending colon adenocarcinoma after surgery, and this predictive power may guide clinicians in accurate prognostic judgement.

Development and Validation of Novel Nomograms to Predict the Overall Survival and Cancer-Specific Survival of Cervical Cancer Patients With Lymph Node Metastasis

Objective

The objective of this study was to establish and validate novel individualized nomograms for predicting the overall survival (OS) and cancer-specific survival (CSS) in cervical cancer patients with lymph node metastasis.

Methods

A total of 2,956 cervical cancer patients diagnosed with lymph node metastasis (American Joint Committee on Cancer, AJCC N stage=N1) between 2000 and 2018 were included in this study. Univariate and multivariate Cox regression models were applied to identify independent prognostic predictors, and the nomograms were established to predict the OS and CSS. The concordance index (C-index), calibration curves, and receiver operating characteristic (ROC) curves were applied to estimate the precision and discriminability of the nomograms. Decision-curve analysis (DCA) was used to assess the clinical utility of the nomograms.

Results

Tumor size, log odds of positive lymph nodes (LODDS), radiotherapy, surgery, T stage, histology, and grade resulted as significant independent predictors both for OS and CSS. The C-index value of the prognostic nomogram for predicting OS was 0.788 (95% CI, 0.762–0.814) and 0.777 (95% CI, 0.758–0.796) in the training and validation cohorts, respectively. Meanwhile, the C-index value of the prognostic nomogram for predicting CSS was 0.792 (95% CI, 0.767–0.817) and 0.781 (95% CI, 0.764–0.798) in the training and validation cohorts, respectively. The calibration curves for the nomograms revealed gratifying consistency between predictions and actual observations for both 3- and 5-year OS and CSS. The 3- and 5-year area under the curves (AUCs) for the nomogram of OS and CSS ranged from 0.781 to 0.828. Finally, the DCA curves emerged as robust positive net benefits across a wide scale of threshold probabilities.

Conclusion

We have successfully constructed nomograms that could predict 3- and 5-year OS and CSS of cervical cancer patients with lymph node metastasis and may assist clinicians in decision-making and personalized treatment planning.

Treatment Strategies and Prognostic Factors of 2018 FIGO Stage IIIC Cervical Cancer: A Review

Cervical cancer is the fourth most common malignant tumor globally in terms of morbidity and mortality. The presence of lymph node metastasis (LNM) is an independent prognostic factor for progression-free survival (PFS) and overall survival (OS) in cervical cancer patients. The International Federation of Gynecology and Obstetrics (FIGO) staging system was revised in 2018. An important revision designates patients with regional LNM as stage IIIC, pelvic LNM only as stage IIIC1, and para-aortic LNM as stage IIIC2. However, the current staging system is only based on the anatomical location of metastatic lymph nodes (LNs). It does not consider other LN status parameters, which may limit its prognostic significance to a certain extent and needs further exploration and confirmation in the future. The purpose of this review is to summarize the choice of treatment for stage IIIC cervical cancer and the effect of different LN status parameters on prognosis.

Construction and validation of a prognostic model for stage IIIC endometrial cancer patients after surgery

BACKGROUND

To explore the most predictive lymph node (LN) scheme for stage IIIC endometrial cancer (EC) patients after hysterectomy and develop a scheme-based nomogram.

METHODS

Data from 2626 stage IIIC EC patients, diagnosed between 2010 and 2014, were extracted from the Surveillance, Epidemiology, and End Results (SEER) registry. The predictive ability of four LN schemes was assessed using C-index and Akaike information criterion (AIC). A nomogram based on the most predictive LN scheme was constructed and validated. The comparison of the predictive ability between nomogram and FIGO stage was conducted using the area under the receiver operating characteristic curve (AUC) and decision curve analysis (DCA).

RESULTS

FIGO stage (stage IIIC1/stage IIIC2) was not an independent risk factor for OS in stage IIIC EC patients (P = 0.672) and log odds of positive lymph nodes (LODDS) had the best predictive ability (C-index: 0.742; AIC: 8228.95). A nomogram based on LODDS was constructed and validated, which had a decent C-index of 0.742 (0.723-0.762). The nomogram showed a better predictive ability than that of the FIGO staging system.

CONCLUSION

FIGO IIIC1/FIGO IIIC2 could not differentiate the prognosis for stage IIIC EC patients. We developed and validated a nomogram based on LODDS to predict OS for post-operative patients with stage IIIC EC.

The role of lymph nodes in cervical cancer: incidence and identification of lymph node metastases-a literature review

Correct identification of patients with lymph node metastasis from cervical cancer prior to treatment is of great importance, because it allows more tailored therapy. Patients may be spared unnecessary surgery or extended field radiotherapy if the nodal status can be predicted correctly. This review captures the existing knowledge on the identification of lymph node metastases in cervical cancer. The risk of nodal metastases increases per 2009 FIGO stage, with incidences in the pelvic region ranging from 2% (stage IA2) to 14-36% (IB), 38-51% (IIA) and 47% (IIB); and in the para-aortic region ranging from 2 to 5% (stage IB), 10-20% (IIA), 9% (IIB), 13-30% (III) and 50% (IV). In addition, age, tumor size, lymph vascular space invasion, parametrial invasion, depth of stromal invasion, histological type, and histological grade are reported to be independent prognostic factors for the risk of nodal metastases. Furthermore, biomarkers can contribute to predict a patient's nodal status, of which the squamous cell carcinoma antigen (SCC-Ag) is currently the most widely used in squamous cell cervical cancer. Still, pre-treatment lymph node assessment is primarily performed by imaging, of which diffusion-weighted magnetic resonance imaging has the highest sensitivity and 2-deoxy-2-[¹⁸F]fluoro-D-glucose positron emission computed tomography the highest specificity. Imaging results can be combined with clinical parameters in nomograms to increase the accuracy of predicting positives nodes. Despite all the progress regarding pre-treatment prediction of lymph node metastases in cervical cancer in recent years, prediction rates are not robust enough to safely abandon surgical staging of the pelvic or para-aortic region yet.

Comparison of Different Lymph Node Staging Schemes for Predicting Survival Outcomes in Node-Positive Endometrioid Endometrial Cancer Patients

Objective: To compare the prognostic predictive performance of six lymph node (LN) staging schemes: American Joint Committee on Cancer (AJCC) N stage, number of retrieved lymph nodes (NRLN), number of positive lymph nodes (NPLN), number of negative lymph nodes (NNLN), lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) among node-positive endometrioid endometrial cancer (EEC) patients. Methods: A total of 3,533 patients diagnosed with node-positive EEC between 2010 and 2016 from the Surveillance, Epidemiology, and End Results (SEER) database were retrospectively analyzed. We applied X-tile software to identify the optimal cutoff value for different staging schemes. Univariate and multivariate Cox regression models were used to assess the relationships between different LN schemes and survival outcomes [disease-specific survival (DSS) and overall survival (OS)]. Moreover, Akaike information criterion (AIC) and Harrell concordance index (C-index) were used to evaluate the predictive performance of each scheme in both continuous and categorical patterns. Results: N stage (N1/N2) was not an independent prognostic factor for node-positive EEC patients based on multivariate analysis (DSS: p = 0.235; OS: p = 0.145). Multivariate model incorporating LNR demonstrated the most superior goodness of fit regardless of continuous or categorical pattern. Regarding discrimination power of the models, LNR outperformed other models in categorical pattern (OS: C-index = 0.735; DSS: C-index = 0.737); however, LODDS obtained the highest C-index in continuous pattern (OS: 0.736; DSS: 0.739). Conclusions: N stage (N1/N2) was unable to differentiate the prognosis for node-positive EEC patients in our study. However, LNR and LODDS schemes seemed to have a better predictive performance for these patients than other number-based LN schemes whether in DSS or OS, which revealed that LNR and LODDS should be more helpful in prognosis assessment for node-positive EEC patients than AJCC N stage.

Should the Number of Metastatic Pelvic Lymph Nodes be Integrated into the 2018 Figo Staging Classification of Early Stage Cervical Cancer?

Introduction: Lymph node status has become part of the new staging system for cervical cancer (CC). It has been shown that patients staged as IIIC1 had heterogeneous prognoses and, in some cases, experienced better outcomes than patients with lower stages. We evaluated the impact of the number of metastatic pelvic lymph nodes (MPLNs) among patients with stage IIIC1 cervical cancer. Methods: Survival analyses were conducted in order to identify the best cut-off prognostic value relative to the number of MPLNs. Disease free survival (DFS) was considered the main outcome. Results: 541 patients were included in the study. Eighty-nine patients were of stage IIIC1. The best prognostic cut-off value of the number of MPLNs was 2. Patients with >2 MPLNs (n > 2 group) had worse DFS compared with those having <2 (N1-2 group) (5 yr DFS: 54.7% vs. 78.1%, p value = 0.006). Multivariate analyses demonstrated that the extent of MPLNs had little impact on DFS and that replacement of IIIC1 staging with N1-2 and n > 2 grouping provided a better, statistically significant model (p value = 0.006). Discussion: Using a cut-off value of 2, the number of MPLNs could better predict prognostic outcomes within stage IIIC1 cervical cancer and have potential implications for therapeutic decision-making in the treatment of patients with stage IIIC1 CC.