Lymph Node Ratio-Based Staging System for Gallbladder Cancer With Fewer Than Six Lymph Nodes Examined

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.

Modified staging system of positive lymph nodes based nomogram in intrahepatic cholangiocarcinoma

BACKGROUND

Intrahepatic cholangiocarcinoma (iCCA) presents the similar trend and prevalence of lymph node metastasis to other biliary tract cancer. There is still a necessity and possibility for the current classification of lymph node in the 8th TNM of iCCA, which is the same as the criteria of hepatoma carcinoma (HCC), to further improve the prognostic capacity. We aim to explore the optimal positive lymph nodes cutoff value that could predict the survival outcomes of patients with iCCA and further establish a prognostic nomogram.

METHOD

Clinical characteristics were retrospectively collected in 292 patients with iCCA from Sun Yat-sen University Cancer Center (SYSUCC) for preliminary analysis. A retrospective analysis of 107 patients with iCCA in the First Hospital of Dalian Medical University (FHDMU) was performed for verification. R software was used to determine the optimal cutoff value of positive lymph nodes (PLN) and further establish the nomogram with the Cox regression model in the primary cohort.

RESULTS

In those patients who were graded into the N1 stage in 8th TNM staging system, the patients with PLN between 1 and 3 showed significantly better overall survival than those patients with more than 4 PLN (P < 0.0001). Moreover, there was a significant correlation between the new PLN classification and adverse clinical characteristic including Micro Invasion (P = 0.001), Lymph Vessel Invasion (P = 0.040), Satellite Sites (P < 0.001), and Tumor Size (P = 0.005). The PLN and ELN were both independent prognostic factors for survival outcomes in the multivariate analysis, and further showed large contribution to the nomogram. The nomogram achieved a satisfied C-index of 0.813 for overall survival (OS), 0.869 for progression-free survival (PFS) in the primary cohort, and 0.787 for OS, 0.762 for PFS in the validation cohort.

CONCLUSION

The modified classification of PLN in iCCA could accurately stratify the N1 stage patients in 8th TNM staging system into two groups with significantly different overall survival. The development of this nomogram can offer new evidence to precisely post-operative management of iCCA patients.

Progress in gallbladder cancer with lymph node metastasis

Gallbladder cancer (GBC) is a malignant tumor that originates from the mucosal lining of the gallbladder. It is distinctly regional and is common in certain geographic regions of developing countries. GBC has a high degree of insidiousness as well as a high propensity for metastatic spread, resulting in the majority of patients being diagnosed at an advanced stage. Lymph node metastasis (LNM) is fairly common in GBC patients and is an independent risk factor for a poor prognosis. This article is focused on the lymph node pathways and metastatic directions of GBC. Furthermore, it summarizes the different lymph node groupings, disease stages and treatments. In the future, it is of great significance to develop individualized treatment and predict the outcomes of GBC patients with different lymph node conditions.

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.

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

OBJECTIVE

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

DESIGN

A registry-based retrospective cohort study.

SETTING

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

PARTICIPANTS

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

PRIMARY OUTCOME MEASURE

Cancer-specific survival (CSS).

RESULTS

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

CONCLUSIONS

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

Lymph Node Ratio is an Important Prognostic Factor in Curatively Resected Gallbladder Carcinoma, Especially in Node-positive Patients: An Experience from Endemic Region in a Developing Country

Background

Metastasis to lymph nodes is a bad prognostic factor in patients with gallbladder carcinoma who undergo radical cholecystectomy. During the past decade, studies have brought focus on lymph node ratio (LNR) as an additional valuable prognostic factor in these cases.Our research studied the factors that predicted the recurrence of disease and survival of patients with gallbladder carcinoma who were treated with surgical resection, concentrating especially on the lymph nodal status as a prognostic factor and LNR in node-positive T1-T3 cases.

Methods

In our hospital, Mahavir Cancer Institute and Research Centre, we reviewed retrospective data, from 2009 to 2014, of 60 patients who had undergone radical cholecystectomy for gallbladder carcinoma. We staged the patients as per the AJCC eight edition. Predictive factors that affect disease-free survival (DFS), like age, gender, postoperative complications, lymphovascular invasion (LVI) and perineural invasion (PVI), lymph node dissection, differentiation, T stage, N stage, number of lymph nodes involved, and LNR, were examined statistically.

Results

Lymph nodal involvement was found to be a principal predictive factor in cases in whom radical cholecystectomy was done. The number of lymph nodes dissected determined the prognosis in N0 cases. LNR was a strong prognostic factor for DFS in cases of curatively resected gallbladder cancer.

Conclusion

LNR is a strong predictive factor in radically resected gallbladder carcinoma cases.

How to cite this article

Naveed S, Qari H, Thau CM, et al. Lymph Node Ratio is an Important Prognostic Factor in Curatively Resected Gallbladder Carcinoma, Especially in Node-positive Patients: An Experience from Endemic Region in a Developing Country. Euroasian J Hepato-Gastroenterol 2021;11(1):1-5.