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Wang G, Tan Y, Jiang Y, Liu J, Su Y, Sun Z, Liu B. Prognostic Model of D2 Radical Gastrectomy Combined with Neoadjuvant Chemotherapy for Gastric Cancer. Risk Manag Healthc Policy 2023; 16:1259-1271. [PMID: 37456825 PMCID: PMC10348377 DOI: 10.2147/rmhp.s413052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023] Open
Abstract
Purpose The AJCC (the American Joint Committee on Cancer) ypTNM (post-neoadjuvant pathologic stage group) staging was established based on patients with lymphadenectomy scope less than D2 and did not include ypT0N0 patients with pathologically complete response (PCR). The purpose of this study was to construct a survival predictive model for gastric cancer patients after neoadjuvant chemotherapy and gastrectomy combined with D2 lymphadenectomy. Patients and Methods The multicenter data of 838 gastric cancer patients who received neoadjuvant chemotherapy and gastrectomy combined with D2 lymphadenectomy were analyzed retrospectively. These dual center patients were divided into training (n = 671, the Affiliated Hospital of Qingdao University) and validation (n = 167, Qingdao West Coast New Area Central Hospital) cohorts. Based on training cohort, univariate and multivariable COX regression analyses were performed to select the clinicopathological characteristics significantly correlating with overall survival and construct a nomogram. Based on training and validation cohorts, the distinguishing and calibrating capabilities of nomogram was evaluated by the receiver operating characteristic (ROC) curve, Harrell's concordance index (C-index), decision curve analysis (DCA) curve and calibration curve. Results Platelet-to-lymphocyte ratio (PLR), pathologic stage after neoadjuvant treatment: ypT and ypN stage, tumor regression grade (TRG) became independent variables intimately related to the prognosis and was used to construct nomograms of 3/5-year prognosis. The nomograms showed an accuracy in predicting OS (overall survival) rate, with area under the ROC curve (AUC) of 0.818 (95% CI = 0.753~0.883) and C-index of 0.801 (95% CI = 0.744~0.858) in validation cohort. Calibration curves showed satisfactory agreement between nomogram prediction and actual result, and DCA curves indicated the large positive net benefit and excellent clinical usefulness of nomogram. Conclusion This study successfully developed a nomogram to predict overall survival of gastric cancer patients after neoadjuvant chemotherapy and gastrectomy combined with D2 lymphadenectomy, which might have excellent predictive performance and clinical application value.
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Affiliation(s)
- Guangjun Wang
- Department of General Surgery, Qingdao West Coast New Area Central Hospital, Qingdao, Shandong, People’s Republic of China
| | - Yinghua Tan
- Department of Paediatrics, Qingdao West Coast New Area Central Hospital, Qingdao, Shandong, People’s Republic of China
| | - Yongjie Jiang
- Department of General Surgery, Qingdao West Coast New Area Central Hospital, Qingdao, Shandong, People’s Republic of China
| | - Jia Liu
- Department of General Surgery, Qingdao West Coast New Area Central Hospital, Qingdao, Shandong, People’s Republic of China
| | - Yuanhui Su
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, People’s Republic of China
| | - Zhengang Sun
- Department of Spine Surgery, Qingdao West Coast New Area Central Hospital, Qingdao, Shandong, People’s Republic of China
| | - Bo Liu
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, People’s Republic of China
- Department of Gastrointestinal Surgery, the Affiliated Hospital of Qingdao University, Qingdao, Shandong, People’s Republic of China
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Zhang M, Ding C, Xu L, Ou B, Feng S, Wang G, Wang W, Liang Y, Chen Y, Zhou Z, Qiu H. Comparison of a Tumor-Ratio-Metastasis Staging System and the 8th AJCC TNM Staging System for Gastric Cancer. Front Oncol 2021; 11:595421. [PMID: 34307116 PMCID: PMC8297973 DOI: 10.3389/fonc.2021.595421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 05/21/2021] [Indexed: 12/29/2022] Open
Abstract
Background Despite the implementation of the 8th American Joint Committee on Cancer (AJCC) TNM staging system for gastric cancer (GC) in 2017, it still holds a significant level of stage migration which affects patients’ proper classification and accurate prognosis. Here, to reduce this effect, we evaluated the prognostic value of a lymph node ratio (LNR) and established a novel tumor–ratio–metastasis (TRM) staging system. Method The data of 15,206 GC patients from the Sun Yat-sen University Cancer Center (Training set; n=2,032) and the US Surveillance, Epidemiology, and End Results (SEER) database (Validation set; n=13,174) were analyzed. The training set was classified into 5 LNR categories, based on which the novel TRM staging system was constructed. The overall survival (OS) between the TRM and AJCC TNM systems was compared in the training set and validated in the validation set. The likelihood ratio x2, liner trend x2, C-index, and Akaike information criterion (AIC) values were used to measure the discriminatory ability between the two different staging systems. Decision curve analyses (DCAs) were conducted to test the clinical value of the two staging systems. Result The patients were classified into the following categories: LNR0: 0%, LNR1: 0%<LNR ≤ 10%, LNR2: 10%<LNR ≤ 25%, LNR 3a: 25%<LNR ≤ 60%, and LNR 3b: LNR>60%. Univariate analyses demonstrated that the log-rank x2 of the LNR stage (Training/Validation set: x2 = 463.1/2880.8) was larger than the AJCC pN stage (Training/Validation set: x2 = 281.5/2240.8). For both the training set and validation set, stratified analyses using the Kaplan-Meier method identified significantly heterogeneous OS in every pN category but only one using the LNR. The TRM staging system had higher likelihood ratio x2, liner trend x2, C-index and smaller AIC values than the TNM system. Conclusion The TRM staging system demonstrated improved homogeneity and discriminatory ability in predicting the prognosis of GC patients compared with the AJCC TNM staging system.
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Affiliation(s)
- Miaoquan Zhang
- Department of Gastric Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Chao Ding
- Department of Gastric Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Lin Xu
- School of Public Health (Shenzhen), Sun Yat-Sen University, Guangzhou, China
| | - Biyi Ou
- Department of Gastric Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Shoucheng Feng
- Department of Gastric Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Guoqiang Wang
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wei Wang
- Department of Gastric Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yao Liang
- Department of Gastric Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yingbo Chen
- Department of Gastric Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Zhiwei Zhou
- Department of Gastric Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Haibo Qiu
- Department of Gastric Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
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da Costa PM, Lages P, Onofre S, Ribeiro RM. The impact of negative lymph nodes in the survival outcomes of pN+ patients following radical gastrectomy: the inverse lymph node ratio as a better score to study negative lymph nodes. Updates Surg 2020; 72:1031-1040. [PMID: 32388806 DOI: 10.1007/s13304-020-00757-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/24/2020] [Indexed: 12/12/2022]
Abstract
The impact of negative lymph nodes (LNs) on survival of pN+ patients has been recognized. The weight of negative LNs in an inverse lymph node ratio (nR) should be related to its prognostic impact. Five hundred and two consecutive gastric cancer patients, who underwent radical gastrectomy, were included. Patients were split into groups according to the number of harvested nodes and a cross-tabulation with pTNM stages was performed to test differences in the tumor burden. pN+ patients (n = 296) were split into groups of negative LNs harvested. We tested an alternative formula for computing a lymph node ratio: nR = total number of harvested nodes/total number of positive nodes. The median number of negative LNs was significantly different (p < 0.01) between dissection groups, but not the median of positive nodes (p > 0.05). No difference in pTNM percentage distribution was found between these groups (p > 0.05). When tested, the overall survival improved significantly for groups with larger numbers of negative LNs (p < 0.001). A cutoff of nR ≥ 6 was an independent prognostic factor for survival (p = 0.001), and the survival of pN+ patients with nR ≥ 6 was not different from pN0 patients. The impact of the number of negative LNs on the survival of the pN+ patients was demonstrated. The higher numbers in the numerator of the nR was due to the disproportion between harvested negative LNs and metastatic LNs. Larger ratios imply more negative lymph nodes in relation to positive lymph nodes, which was significantly associated with survival. We believe that the proposed nR is a friendlier to use format because of its intuitive interpretation.
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Affiliation(s)
- Paulo Matos da Costa
- Serviço de Cirurgia Geral, Hospital Garcia de Orta, Almada, Portugal.
- Centro Académico de Medicina de Lisboa, Lisboa, Portugal.
- Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal.
| | - Patrícia Lages
- Serviço de Cirurgia Geral, Hospital Garcia de Orta, Almada, Portugal
- Centro Académico de Medicina de Lisboa, Lisboa, Portugal
- Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Susana Onofre
- Serviço de Cirurgia Geral, Hospital Garcia de Orta, Almada, Portugal
- Centro Académico de Medicina de Lisboa, Lisboa, Portugal
- Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Ruy M Ribeiro
- Laboratório de Biomatemática, Lisboa, Portugal
- Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
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Wohnrath DR, Araujo RLC. Positive node-ratio in curative-intent treatment for gastric cancer is a strong independent prognostic factor for 5-year overall survival. J Surg Oncol 2019; 121:777-783. [PMID: 31691299 DOI: 10.1002/jso.25755] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/20/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION This study addressed whether the positive node-ratio (N-ratio) for patients who underwent curative-intent treatment was an independent prognostic factor of overall survival (OS) for gastric adenocarcinoma (GA). METHODS Consecutive patients who underwent gastrectomy for GA with at least 15 harvested nodes were evaluated for 5-year OS. The best threshold was determined using the area under an receiver operating characteristic (ROC) curve. Univariate and multivariate models were assessed looking for independent prognostic factors for OS. RESULTS From 1994 to 2015, 398 consecutive patients were evaluated. The N-ratio ≥11% had an accuracy of 0.764, the sensitivity of 71.1%, the specificity of 81.7%, positive predictive value (PPV) of 91.7%, and odds ratio (OR) of 11. After multivariate analysis for OS, age ≥70 years (HR 1.44), need for total gastrectomy (HR 1.45), need for extended resection (HR 1.7), and N-ratio ≥11% (HR 3.7) were unfavorable prognostic factors. D2 lymphadenectomy (HR 0.53) was a protective factor. The median OS according to N-ratio was 14 months for N-ratio >11 vs 58 months for N-ratio <11%. CONCLUSION The N-ratio ≥11% was an independent negative prognostic factor for patients who underwent treatment for GA with curative intent. The N-ratio ≥11% presented high specificity, high PPV and high OR for risk of death for 5 years after surgery.
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Affiliation(s)
- Durval R Wohnrath
- Department of Upper Gastrointestinal and Hepato-Pancreato-Billiary Surgery, Barretos Cancer Hospital, Barretos, SP, Brazil
| | - Raphael L C Araujo
- Department of Upper Gastrointestinal and Hepato-Pancreato-Billiary Surgery, Barretos Cancer Hospital, Barretos, SP, Brazil.,Department of Digestive Surgery, Escola Paulista de Medicina - UNIFESP, São Paulo, SP, Brazil.,Department of Oncology, Americas Medical Service/Brazil, United Health Group, São Paulo, SP, Brazil.,Department of Oncology, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Amit M, Tam S, Boonsripitayanon M, Cabanillas ME, Busaidy NL, Grubbs EG, Lai SY, Gross ND, Sturgis EM, Zafereo ME. Association of Lymph Node Density With Survival of Patients With Papillary Thyroid Cancer. JAMA Otolaryngol Head Neck Surg 2019; 144:108-114. [PMID: 29192312 DOI: 10.1001/jamaoto.2017.2416] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Importance Lymph node metastases are common in papillary thyroid cancer (PTC), yet the impact of nodal metastases on survival remains unclear. Lymph node density (LND) is the ratio between the number of positive lymph nodes excised and the total number of excised lymph nodes. Lymph node density has been suggested as a prognostic factor in many types of cancer. Objective To evaluate the prognostic role of LND in PTC. Design, Setting, and Participants This cohort study reviewed medical records of patients with PTC who were treated at the University of Texas MD Anderson Cancer Center between January 1, 2000, and December 31, 2015. Survival and recurrence outcomes were calculated by using the Kaplan-Meier method. Significant variables on univariate analysis were subjected to a Cox proportional hazards regression multivariate model. Main Outcomes and Measures Primary study outcome was disease-specific survival (DSS); other measurements included overall survival (OS). Results The study cohort included data for 2542 patients (1801 [71%] male; median age, 48 years [range, 18-97 years]) with a median follow-up of 55 months (range, 4-192 months). The 10-year disease-specific survival rate was 98% for patients with LND of 0.19 or less, compared with 90% for those with LND greater than 0.19 (effect size, 8%; 95% CI, 4%-15%). The 10-year overall survival was 87% for patients with LND of 0.19 or less, compared with 79% for patients with LND greater than 0.19 (effect size, 8%; 95% CI, 3%-15%). Multivariable analysis revealed that LND greater than 0.19 was independently associated with an adverse DSS (hazard ratio [HR], 4.11; 95% CI, 2.11-8.97) and OS (HR, 1.96; 95% CI, 1.24-4.11). Subgroup analysis of patients with 18 or more lymph nodes analyzed revealed that LND greater than 0.19 remained a significant marker for DSS (HR, 2.94; 95% CI, 1.36-9.81) and OS (HR, 2.26; 95% CI, 1.12-5.34). Incorporating LND into the current American Joint Committee on Cancer staging system successfully stratified risk groups compared with the traditional TNM staging system. Conclusions and Relevance This single-institute study demonstrates the reproducibility of LND as a predictor of outcomes in PTC. Lymph node density can potentially assist in identifying patients with poorer survival who may benefit from more aggressive adjuvant therapy.
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Affiliation(s)
- Moran Amit
- Division of Surgery, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Samantha Tam
- Division of Surgery, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Mongkol Boonsripitayanon
- Division of Surgery, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Maria E Cabanillas
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Houston
| | - Naifa L Busaidy
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Houston
| | - Elizabeth Gardner Grubbs
- Division of Surgery, Department of Endocrine Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Stephen Y Lai
- Division of Surgery, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Neil D Gross
- Division of Surgery, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Erich M Sturgis
- Division of Surgery, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Mark E Zafereo
- Division of Surgery, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
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Lymph node yield and lymph node density for elective level II-IV neck dissections in laryngeal squamous cell carcinoma patients. Eur Arch Otorhinolaryngol 2019; 276:2923-2927. [PMID: 31317320 DOI: 10.1007/s00405-019-05560-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 07/11/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE To determine the minimum lymph node yield (LNY) in patients with laryngeal squamous cell carcinoma (LSCCs). METHODS This retrospective study was performed in a tertiary care hospital setting and included 42 LSCC patients aged 39-81 years (females, n = 2; males, n = 40) who underwent a total or partial laryngectomy and elective bilateral level II-IV neck dissections (unilateral neck dissections: n = 84). RESULTS The average LNY in the unilateral level II-IV lymph node dissections was 25.9 ± 10, and the average metastatic LNY was 0.9 ± 1.9. The unilateral neck dissections were grouped according to the number of lymph nodes. There was no significant difference between the groups in terms of the metastatic LNY (p = 0.5). The metastatic lymph node density (LND) (metastatic lymph node yield/LNY) was 0.043 for unilateral neck level II-IV neck dissections. A Cox regression analysis revealed no significant relationship between survival and the LNY and LND in bilateral neck dissections (p = 0.4 and p = 0.8, respectively). CONCLUSIONS The results revealed no minimum number of lymph nodes that could reliably detect metastatic lymph nodes in LSCC patients.
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Lymph-node ratio is an important clinical determinant for selecting the appropriate adjuvant chemotherapy regimen for curative D2-resected gastric cancer. J Cancer Res Clin Oncol 2019; 145:2157-2166. [PMID: 31273512 DOI: 10.1007/s00432-019-02963-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 06/28/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE Adjuvant chemotherapy for gastric cancer, particularly stage III, improves survival after curative D2 gastrectomy. We investigated the clinical value of the lymph-node ratio (LNR; number of metastatic lymph nodes/number of lymph nodes examined) for selecting the appropriate adjuvant chemotherapy regimen in patients with D2-resected stage II/III gastric cancer. METHODS We reviewed the data of 819 patients who underwent curative D2 gastrectomy followed by adjuvant chemotherapy. Of them, 353 patients received platinum-based chemotherapy and 466 received TS-1. The patients were categorized into three groups according to their LNR (LNR 1, 0-0.1; LNR 2, > 0.1-0.25; and LNR 3, > 0.25), and their disease-free survival (DFS) was evaluated. RESULTS The DFS curves of the patients were well separated according to stage and LNR. In multivariate analyses, an LNR > 0.1 was strongly associated with the 3-year DFS (hazard ratio 2.402, 95% confidence interval 1.607-3.590, P < 0.001). Platinum-based chemotherapy improved the 3-year DFS compared to TS-1 in patients with LNR 3 group in stage III gastric cancer (platinum vs. TS-1, median DFS 26.87 vs. 16.27 months, P = 0.028). An LNR > 0.1 was associated with benefiting from platinum-based adjuvant chemotherapy in stage III gastric cancer patients with lymphovascular invasion (platinum vs. TS-1, median DFS 47.57 vs. 21.77 months, P = 0.011). CONCLUSIONS The LNR can be used to select the appropriate adjuvant chemotherapy regimen for patients with D2-resected gastric cancer, particularly in stage III.
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Agnes A, Biondi A, Cananzi FM, Rausei S, Reddavid R, Laterza V, Galli F, Quagliuolo V, Degiuli M, D'Ugo D, Persiani R. Ratio-based staging systems are better than the 7th and 8th editions of the TNM in stratifying the prognosis of gastric cancer patients: A multicenter retrospective study. J Surg Oncol 2019; 119:948-957. [PMID: 30742308 DOI: 10.1002/jso.25411] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 01/18/2019] [Accepted: 01/30/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The current and the previous editions of the tumor-node-metastasis (TNM) system for gastric cancer (GC; TNM8 and TNM7) have a high risk of stage-migration bias when the node count after gastrectomy is suboptimal. Hence, they are possibly not the optimal staging systems for GC patients. This study aims to compare the TNM with two systems less affected by the stage-migration bias, namely, the lymph nodes ratio (LNR) and the log odds of positive lymph nodes (LODDS), to assess which one is the best in stratifying the prognosis of GC patients. METHODS The sample study included 1221 GC patients. Two 7-cluster staging systems based on the combination of pT categories and LNR and LODDS categories (TLNR and TLODDS) were compared with the two last editions of TNM, using the Akaike information criteria, the Bayesian information criteria, and the receiver operating characteristic (ROC) curve graphs. Further validation on an independent sample of 251 patients was carried out. RESULTS The univariable and multivariable analyses and the ROC curves detected an advantage of the TLNR and TLODDS systems over the TNM. The TLNR and TLODDS showed the best accuracy both in the subgroup of patients with ≥16 nodes examined. The results were confirmed in the validation analysis. CONCLUSIONS TLNR and TLODDS staging systems should be considered a valid implementation of the TNM for the prognostic stratification of GC patients. If these results are confirmed in further studies, the future implementation of the TNM should consider the introduction of the LNR or the LODDS along with the number of metastatic nodes.
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Affiliation(s)
- Annamaria Agnes
- Dipartimento Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Department of Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alberto Biondi
- Dipartimento Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Department of Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ferdinando M Cananzi
- Department of Surgery, Surgical Oncology Unit, Humanitas Clinical and Research Center, Milan, Italy
| | | | - Rossella Reddavid
- Department of Oncology, Surgical Oncology, and Digestive Surgery, San Luigi University Hospital (S.L.U.H.), University of Turin, Turin, Italy
| | - Vito Laterza
- Department of Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Vittorio Quagliuolo
- Department of Surgery, Surgical Oncology Unit, Humanitas Clinical and Research Center, Milan, Italy
| | - Maurizio Degiuli
- Department of Oncology, Surgical Oncology, and Digestive Surgery, San Luigi University Hospital (S.L.U.H.), University of Turin, Turin, Italy
| | - Domenico D'Ugo
- Dipartimento Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Department of Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberto Persiani
- Dipartimento Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Department of Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
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9
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Zhu J, Xue Z, Zhang S, Guo X, Zhai L, Shang S, Zhang Y, Lu H. Integrated analysis of the prognostic role of the lymph node ratio in node-positive gastric cancer: A meta-analysis. Int J Surg 2018; 57:76-83. [PMID: 30103072 DOI: 10.1016/j.ijsu.2018.08.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/25/2018] [Accepted: 08/06/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The lymph node ratio (LNR) as a prognostic parameter for gastric cancer has yet to be fully validated in the current tumor node metastasis staging system. We assessed the prognostic role of LNR in lymph node-positive gastric cancer through a meta-analysis. MATERIALS AND METHODS PubMed and EMBASE were searched for relevant studies up until December 2016. The effect measure for meta-analysis of primary outcomes was the hazard ratio (HR) for overall survival. Pooled HRs and 95% confidence intervals were calculated using random effects models. The I2 statistic was used to measure heterogeneity. Subgroup analysis and meta-regression were chosen to illustrate the potential heterogeneity of the risk factors of outcomes. Publication bias was assessed using Egger's test and Begg's funnel plots. Sensitivity analysis was applied to evaluate the origin of the heterogeneity. RESULTS We included 27 studies in this meta-analysis. Higher LNRs were significantly associated with a shorter overall survival (OS). High heterogeneity among the studies was identified (I2 = 85.6), and the publication bias was moderate. Subgroup analysis showed similar results, and elevated LNR was associated with late-stage gastric cancer and indicative of a worse prognosis. Univariate meta-regression analysis of OS indicated that both treatment type and ethnicity may be causes of heterogeneity in patients with gastric cancer (p values were 0.005 and 0.008, respectively). CONCLUSION LNR was associated with a significantly poorer OS and LNR was an independent predictor of survival in patients with gastric cancer. LNR should be added as one of the parameters to be used in future tumor staging classification systems.
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Affiliation(s)
- Jiang Zhu
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, 150081, China
| | - Zhao Xue
- Department of Gastrointestinal Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, 150040, China
| | - Shumei Zhang
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, 150081, China
| | - Xinxin Guo
- Department of Gastrointestinal Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, 150040, China
| | - Laihui Zhai
- Department of Gastrointestinal Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, 150040, China
| | - Shipeng Shang
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, 150081, China
| | - Yan Zhang
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, 150081, China.
| | - Haibo Lu
- Department of Gastrointestinal Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, 150040, China.
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10
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Woo Y, Goldner B, Son T, Song K, Noh SH, Fong Y, Hyung WJ. Western Validation of a Novel Gastric Cancer Prognosis Prediction Model in US Gastric Cancer Patients. J Am Coll Surg 2017; 226:252-258. [PMID: 29277711 DOI: 10.1016/j.jamcollsurg.2017.12.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 12/09/2017] [Accepted: 12/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND A novel prediction model for accurate determination of 5-year overall survival of gastric cancer patients was developed by an international collaborative group (G6+). This prediction model was created using a single institution's database of 11,851 Korean patients and included readily available and clinically relevant factors. Already validated using external East Asian cohorts, its applicability in the American population was yet to be determined. STUDY DESIGN Using the Surveillance, Epidemiology, and End Results (SEER) dataset, 2014 release, all patients diagnosed with gastric adenocarcinoma who underwent surgical resection between 2002 and 2012, were selected. Characteristics for analysis included: age, sex, depth of tumor invasion, number of positive lymph nodes, total lymph nodes retrieved, presence of distant metastasis, extent of resection, and histology. Concordance index (C-statistic) was assessed using the novel prediction model and compared with the prognostic index, the seventh edition of the TNM staging system. RESULTS Of the 26,019 gastric cancer patients identified from the SEER database, 15,483 had complete datasets. Validation of the novel prediction tool revealed a C-statistic of 0.762 (95% CI 0.754 to 0.769) compared with the seventh TNM staging model, C-statistic 0.683 (95% CI 0.677 to 0.689), (p < 0.001). CONCLUSIONS Our study validates a novel prediction model for gastric cancer in the American patient population. Its superior prediction of the 5-year survival of gastric cancer patients in a large Western cohort strongly supports its global applicability. Importantly, this model allows for accurate prognosis for an increasing number of gastric cancer patients worldwide, including those who received inadequate lymphadenectomy or underwent a noncurative resection.
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Affiliation(s)
- Yanghee Woo
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Bryan Goldner
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Taeil Son
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kijun Song
- Department of Biostatistics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Hoon Noh
- Department of Surgery, City of Hope National Medical Center, Duarte, CA; Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Woo Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea; Gastric Cancer Center, Yonsei Cancer Hospital, Seoul, Republic of Korea; Robot and MIS Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.
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11
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Kim Y, Squires MH, Poultsides GA, Fields RC, Weber SM, Votanopoulos KI, Kooby DA, Worhunsky DJ, Jin LX, Hawkins WG, Acher AW, Cho CS, Saunders N, Levine EA, Schmidt CR, Maithel SK, Pawlik TM. Impact of lymph node ratio in selecting patients with resected gastric cancer for adjuvant therapy. Surgery 2017; 162:285-294. [PMID: 28578142 PMCID: PMC6036903 DOI: 10.1016/j.surg.2017.03.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 01/14/2017] [Accepted: 03/02/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND The impact of adjuvant chemotherapy and chemo-radiation therapy in the treatment of resectable gastric cancer remains varied. We sought to define the clinical impact of lymph node ratio on the relative benefit of adjuvant chemotherapy or chemo-radiation therapy among patients having undergone curative-intent resection for gastric cancer. METHODS Using the multi-institutional US Gastric Cancer Collaborative database, 719 patients with gastric adenocarcinoma who underwent curative-intent resection between 2000 and 2013 were identified. Patients with metastasis or an R2 margin were excluded. The impact of lymph node ratio on overall survival among patients who received chemotherapy or chemo-radiation therapy was evaluated. RESULTS Median patient age was 65 years, and the majority of patients were male (56.2%). The majority of patients underwent either subtotal (40.6%) or total gastrectomy (41.0%), with the remainder undergoing distal gastrectomy or wedge resection (18.4%). On pathology, median tumor size was 4 cm; most patients had a T3 (33.0%) or T4 (27.9%) lesion with lymph node metastasis (59.7%). Margin status was R0 in 92.5% of patients. A total of 325 (45.2%) patients underwent resection alone, 253 (35.2%) patients received 5-FU or capecitabine-based chemo-radiation therapy, whereas the remaining 141 (19.6%) received chemotherapy. Median overall survival was 40.9 months, and 5-year overall survival was 40.3%. According to lymph node ratio categories, 5-year overall survival for patients with a lymph node ratio of 0, 0.01-0.10, >0.10-0.25, >0.25 were 54.1%, 53.1 %, 49.1 % and 19.8 %, respectively. Factors associated with worse overall survival included involvement of the gastroesophageal junction (hazard ratio 1.8), T-stage (3-4: hazard ratio 2.1), lymphovascular invasion (hazard ratio 1.4), and lymph node ratio (>0.25: hazard ratio 2.3; all P < .05). In contrast, receipt of adjuvant chemo-radiation therapy was associated with an improved overall survival in the multivariable model (versus resection alone: hazard ratio 0.40; versus chemotherapy: hazard ratio 0.45, both P < .001). The benefit of chemo-radiation therapy for resected gastric cancer was noted only among patients with lymph node ratio >0.25 (versus resection alone: hazard ratio R 0.34; versus chemotherapy: hazard ratio 0.45, both P < .001). In contrast, there was no noted overall survival benefit of chemotherapy or chemo-radiation therapy among patients with lymph node ratio ≤0.25 (all P > .05). CONCLUSION Adjuvant chemotherapy or chemo-radiation therapy was utilized in more than one-half of patients undergoing curative-intent resection for gastric cancer. Lymph node ratio may be a useful tool to select patients for adjuvant chemo-radiation therapy, because the benefit of chemo-radiation therapy was isolated to patients with greater degrees of lymphatic spread (ie, lymph node ratio >0.25).
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Affiliation(s)
- Yuhree Kim
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Malcolm H Squires
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | | | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - David J Worhunsky
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Linda X Jin
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - William G Hawkins
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Alexandra W Acher
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Clifford S Cho
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Neil Saunders
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Edward A Levine
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Carl R Schmidt
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD; Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH.
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12
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Galizia G, Lieto E, Auricchio A, Cardella F, Mabilia A, Diana A, Castellano P, De Vita F, Orditura M. Comparison of the current AJCC-TNM numeric-based with a new anatomical location-based lymph node staging system for gastric cancer: A western experience. PLoS One 2017; 12:e0173619. [PMID: 28380037 PMCID: PMC5381862 DOI: 10.1371/journal.pone.0173619] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/23/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In gastric cancer, the current AJCC numeric-based lymph node staging does not provide information on the anatomical extent of the disease and lymphadenectomy. A new anatomical location-based node staging, proposed by Choi, has shown better prognostic performance, thus soliciting Western world validation. STUDY DESIGN Data from 284 gastric cancers undergoing radical surgery at the Second University of Naples from 2000 to 2014 were reviewed. The lymph nodes were reclassified into three groups (lesser and greater curvature, and extraperigastric nodes); presence of any metastatic lymph node in a given group was considered positive, prompting a new N and TNM stage classification. Receiver-operating-characteristic (ROC) curves for censored survival data and bootstrap methods were used to compare the capability of the two models to predict tumor recurrence. RESULTS More than one third of node positive patients were reclassified into different N and TNM stages by the new system. Compared to the current staging system, the new classification significantly correlated with tumor recurrence rates and displayed improved indices of prognostic performance, such as the Bayesian information criterion and the Harrell C-index. Higher values at survival ROC analysis demonstrated a significantly better stratification of patients by the new system, mostly in the early phase of the follow-up, with a worse prognosis in more advanced new N stages, despite the same current N stage. CONCLUSIONS This study suggests that the anatomical location-based classification of lymph node metastasis may be an important tool for gastric cancer prognosis and should be considered for future revision of the TNM staging system.
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Affiliation(s)
- Gennaro Galizia
- Division of Surgical Oncology, Department of Surgical Sciences, University of Campania 'Luigi Vanvitelli', School of Medicine, Naples, Italy
| | - Eva Lieto
- Division of Surgical Oncology, Department of Surgical Sciences, University of Campania 'Luigi Vanvitelli', School of Medicine, Naples, Italy
| | - Annamaria Auricchio
- Division of Surgical Oncology, Department of Surgical Sciences, University of Campania 'Luigi Vanvitelli', School of Medicine, Naples, Italy
| | - Francesca Cardella
- Division of Surgical Oncology, Department of Surgical Sciences, University of Campania 'Luigi Vanvitelli', School of Medicine, Naples, Italy
| | - Andrea Mabilia
- Division of Surgical Oncology, Department of Surgical Sciences, University of Campania 'Luigi Vanvitelli', School of Medicine, Naples, Italy
| | - Anna Diana
- Division of Medical Oncology, "F. Magrassi" Department of Clinical and Experimental Medicine and Surgery, University of Campania 'Luigi Vanvitelli', School of Medicine, Naples, Italy
| | - Paolo Castellano
- Division of Surgical Oncology, Department of Surgical Sciences, University of Campania 'Luigi Vanvitelli', School of Medicine, Naples, Italy
| | - Ferdinando De Vita
- Division of Medical Oncology, "F. Magrassi" Department of Clinical and Experimental Medicine and Surgery, University of Campania 'Luigi Vanvitelli', School of Medicine, Naples, Italy
| | - Michele Orditura
- Division of Medical Oncology, "F. Magrassi" Department of Clinical and Experimental Medicine and Surgery, University of Campania 'Luigi Vanvitelli', School of Medicine, Naples, Italy
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Koh J, Lee HE, Kim WH, Lee HS. Clinicopathologic implication of meticulous pathologic examination of regional lymph nodes in gastric cancer patients. PLoS One 2017; 12:e0174814. [PMID: 28362845 PMCID: PMC5376083 DOI: 10.1371/journal.pone.0174814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 03/15/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We aimed to investigate effect of increased number of examined lymph nodes (LNs) to pN category, and compare various N categories in gastric cancer: American Joint Committee on Cancer (AJCC) 7th edition, metastatic LN ratio (MLR), and log odds of positive LNs (LODDS). METHODS Four cohorts with a total of 2,309 gastric cancer patients were enrolled. For cohort 1 and 2, prognostic significance of each method by disease-specific survival was analyzed using Akaike and Bayesian information criterion (AIC and BIC). RESULTS The total LNs in four cohorts significantly differed [median (range), 28 (6-97) in cohort 1, 37 (8-120) in cohort 2, 48 (7-122) in cohort 3, and 54 (4-221) in cohort 4; p<0.001]. The numbers of negative LNs increased with increase of total LN (p<0.001), but the numbers of metastatic LNs did not increase from cohort 1 to 4. MLR and LODDS in four cohorts had decreasing tendency with increase of total LNs in each pT3 and pT4 category (p<0.001), while the numbers of metastatic LNs did not differ significantly in any pT category (p>0.05). The AIC and BIC varied according to different cut-off values for MLR; model by cut-offs of 0.2 and 0.5 being better for cohort 1, while cut-offs 0.1 and 0.25 was better for cohort 2. CONCLUSION Our study showed that the number of metastatic LNs did not increase with maximal pathologic examination of regional LNs. AJCC 7th system is suggested as the simplest method with single cut-off value, but prognostic significance of MLR may be influenced by various cut-offs.
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Affiliation(s)
- Jiwon Koh
- Department of Pathology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hee Eun Lee
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America
| | - Woo Ho Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hye Seung Lee
- Department of Pathology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- * E-mail:
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Tóth D, Bíró A, Varga Z, Török M, Árkosy P. Comparison of different lymph node staging systems in prognosis of gastric cancer: a bi-institutional study from Hungary. Chin J Cancer Res 2017; 29:323-332. [PMID: 28947864 PMCID: PMC5592820 DOI: 10.21147/j.issn.1000-9604.2017.04.05] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective The Union for International Cancer Control (UICC) Node (N) classification is the most common used staging method for the prognosis of gastric cancer. It demands adequate, at least 16 lymph nodes (LNs) to be dissected; therefore different staging systems were invented. Methods Between March 2005 and March 2010, 164 patients were evaluated at the Department of General Surgery in the Kenézy Gyula Hospital and at the Department of General, Thoracic and Vascular Surgery in the Kaposi Mór Hospital. The 6th, 7th and 8th UICC N-staging systems, the number of examined LNs, the number of harvested negative LNs, the metastatic lymph node ratio (MLR) and the log odds of positive LNs (LODDS) were determined to measure their 5-year survival rates and to compare them to each other. Results The overall 5-year survival rate for all patients was 55.5% with a median overall survival time of 102 months. The tumor stage, gender, UICC N-stages, MLR and the LODDS were significant prognostic factors for the 5-year survival with univariate analysis. The 6th UICC N-stage did not follow the adequate risk in comparing N2 vs. N0 and N3 vs. N0 with multivariate investigation. Comparison of performances of the residual N classifications proved that the LODDS system was first in the prediction of prognosis during the evaluation of all patients and in cases with less than 16 harvested LNs. The MLR gave the best prognostic prediction when adequate (more than or equal to 16) lymphadenectomy was performed.
Conclusions We suggest the application of LODDS system routinely in western patients and the usage of MLR classification in cases with extended lymphadenectomy.
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Affiliation(s)
- Dezső Tóth
- Department of General Surgery, Kenézy Gyula Teaching Hospital, Debrecen 4031, Hungary
| | - Adrienn Bíró
- Department of General Surgery, Kenézy Gyula Teaching Hospital, Debrecen 4031, Hungary
| | - Zsolt Varga
- Department of General Surgery, Kenézy Gyula Teaching Hospital, Debrecen 4031, Hungary
| | - Miklós Török
- Department of General Surgery, Kenézy Gyula Teaching Hospital, Debrecen 4031, Hungary
| | - Péter Árkosy
- Department of General Surgery, Kenézy Gyula Teaching Hospital, Debrecen 4031, Hungary
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15
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Imre A, Pinar E, Dincer E, Ozkul Y, Aslan H, Songu M, Tatar B, Onur I, Ozturkcan S, Aladag I. Lymph Node Density in Node-Positive Laryngeal Carcinoma: Analysis of Prognostic Value for Survival. Otolaryngol Head Neck Surg 2016; 155:797-804. [PMID: 27221573 DOI: 10.1177/0194599816652371] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 05/10/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We investigated the value of lymph node density (LND) as a predictor of survival in patients with laryngeal squamous cell carcinoma (SCC) and positive neck node (pN+) after laryngectomy. STUDY DESIGN Case series with chart review. SETTING Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey. SUBJECTS AND METHODS We reviewed the records of 289 patients with newly diagnosed primary laryngeal carcinomas who underwent partial or total laryngectomy and combined neck dissection at a tertiary referral center between June 2006 and December 2014. Patients with pN+ laryngeal SCC (n = 101) were included in the study. Overall survival (OS) and disease-free survival (DFS) were used to evaluate the prognostic significance of LND. RESULTS In 101 patients with pN+ laryngeal SCC, LND ≥0.09 and number of metastatic lymph nodes >4 were significantly associated with OS and DFS but not the overall tumor, node, and metastasis stage. Forward stepwise Cox regression analysis revealed that LND ≥0.09 was the only independent predictor of both DFS and OS. Furthermore, the odds ratio of LND ≥0.09 was 10 times higher in patients with regional recurrence when compared patients without regional recurrence. CONCLUSIONS LND was the only independent prognostic predictor of OS and DFS in patients with pN+ laryngeal SCC. Moreover, patients with LND ≥0.09 were significantly associated with high risk of regional recurrence. Thus, patients with LND ≥0.09 are at high risk of regional recurrence and death and may be considered for adjuvant chemoradiation.
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Affiliation(s)
- Abdulkadir Imre
- Department of Otorhinolaryngology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
| | - Ercan Pinar
- Department of Otorhinolaryngology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
| | - Elif Dincer
- Department of Otorhinolaryngology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
| | - Yılmaz Ozkul
- Department of Otorhinolaryngology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
| | - Hale Aslan
- Department of Otorhinolaryngology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
| | - Murat Songu
- Department of Otorhinolaryngology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
| | - Bekir Tatar
- Department of Otorhinolaryngology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
| | - Irem Onur
- Department of Pathology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
| | - Sedat Ozturkcan
- Department of Otorhinolaryngology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
| | - Ibrahim Aladag
- Department of Otorhinolaryngology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
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Mihmanli M, Ilhan E, Idiz UO, Alemdar A, Demir U. Recent developments and innovations in gastric cancer. World J Gastroenterol 2016; 22:4307-20. [PMID: 27158199 PMCID: PMC4853688 DOI: 10.3748/wjg.v22.i17.4307] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 03/14/2016] [Accepted: 03/30/2016] [Indexed: 02/06/2023] Open
Abstract
Gastric cancer has an important place in the worldwide incidence of cancer and cancer-related deaths. It can metastasize to the lymph nodes in the early stages, and lymph node metastasis is an important prognostic factor. Surgery is a very important part of gastric cancer treatment. A D2 lymphadenectomy is the standard surgical treatment for cT1N+ and T2-T4 cancers, which are potentially curable. Recently, the TNM classification system was reorganized, and the margins for gastrectomy and lymphadenectomy were revised. Endoscopic, laparoscopic and robotic treatments of gastric cancer have progressed rapidly with development of surgical instruments and techniques, especially in Eastern countries. Different endoscopic resection techniques have been identified, and these can be divided into two main categories: endoscopic mucosal resection and endoscopic submucosal dissection. Minimally invasive surgery has been reported to be safe and effective for early gastric cancer, and it can be successfully applied to advanced gastric cancer with increasing experience. Cytoreductive surgery and hyperthermıc intraperıtoneal chemotherapy were developed as a combined treatment modality from the results of experimental and clinical studies. Also, hyperthermia increases the antitumor activity and penetration of chemotherapeutics. Trastuzumab which is a monoclonal antibody interacts with human epidermal growth factor (HER) 2 and is related to gastric carcinoma. The anti-tumor mechanism of trastuzumab is not clearly known, but mechanisms such as interruption of the HER2-mediated cell signaling pathways and cell cycle progression have been reported previously. H. pylori is involved in 90% of all gastric malignancies and Japanese guidelines strongly recommend that all H. pylori infections should be eradicated regardless of the associated disease. In this review, we present innovations discussed in recent studies.
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Yamashita K, Hosoda K, Ema A, Watanabe M. Lymph node ratio as a novel and simple prognostic factor in advanced gastric cancer. Eur J Surg Oncol 2016; 42:1253-60. [PMID: 27017273 DOI: 10.1016/j.ejso.2016.03.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 01/02/2016] [Accepted: 03/01/2016] [Indexed: 12/14/2022] Open
Abstract
TNM staging is no doubt the most critical prognostic factors, representing tumor (T)/lymph node metastasis (N)/distant metastasis (M) in gastric cancer. Lymph node ratio-based N system (Nr) has been repeatedly reported to be of prognostic relevance in advanced gastric cancer independent of stage in the multivariate analysis world-wide, and proposed as more sophisticated than N with regard to predicting accurate prognosis. As a result, proposed TNrM system may predict survival more accurately than the present TNM staging system for patients undergoing limited lymph node analysis. It could adjust stage migration when the lymph node number was used as staging factor. Although correlation of the number of metastatic lymph nodes and lymph node ratio is obvious, biological characteristics other than that could also have been reflected on. It may indicate how successful the operation of lymph node dissection was, or it may be revealing the potential of the patient's lymph node immune-reaction. Recently, high lymph node ratio is closely associated with EGFR expression in advanced gastric cancer. When efficiency of applying lymph node ratio as a biomarker is verified and confirmed in an expansive research, and when cancer causing molecules are identified, as well as the competence as a treatment target is studied, the new biomarker, namely, lymph node ratio, could find itself in a limelight in gastric cancer treatment in the future.
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Affiliation(s)
- K Yamashita
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kangawa 252-0374, Japan.
| | - K Hosoda
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kangawa 252-0374, Japan
| | - A Ema
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kangawa 252-0374, Japan
| | - M Watanabe
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kangawa 252-0374, Japan
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Tang X, Chen Y, Guo L, Zhang J, Wang C. Prognostic significance of metastatic lymph node number, ratio and station in gastric neuroendocrine carcinoma. J Gastrointest Surg 2015; 19:234-41. [PMID: 25394386 DOI: 10.1007/s11605-014-2691-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 10/25/2014] [Indexed: 02/06/2023]
Abstract
The objective of this study was to analyze the prognostic significance of metastatic lymph node status in gastric neuroendocrine carcinoma (GNEC) patients following radical gastrectomy. A consecutive series of 73 patients who underwent gastrectomy between 1999 and 2011 for GNEC was retrospectively reviewed. Indexes of lymph node involvement (the pN classification, metastatic lymph node number [MLNn], ratio [MLNr], and station [MLNs]) and other clinicopathological data were analyzed. Fifty-four patients met the inclusion criteria and were enrolled in the study. Among them, 44 patients (81 %) were found to have lymph node metastases. The median survival time of the entire cohort was 63.2 (range, 14-153) months with 3- and 5-year survival rates of 88.9 and 47.9 %, respectively. The median total number of lymph nodes, MLNn, and MLNr were 19 (range, 10-56), 5 (range, 1-21), and 25 % (6-100 %), respectively. Cox regression analysis revealed pN classification = 1, MLNn >2, MLNr >0.1, and MLNs = 2, and distant metastases influenced prognosis independently (P = 0.0266, 0.0091, 0.0031, 0.0119, and 0.0021, respectively). In addition to the pN classification, indexes of metastatic lymph node involvement, including MLNn, MLNr, and MLNs, were all significant predictors of survival in GNEC patients. Distant metastasis was also a significant prognostic factor. These indexes proved to be accurate and important supplements to survival factors, which may improve risk classification of GNEC patients.
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Affiliation(s)
- Xiaolong Tang
- Department of Abdominal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No.17, South of Pan Jiayuan Street, Chaoyang District, Beijing, China
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Costa Junior WLD, Coimbra FJF, Batista TP, Ribeiro HSDC, Diniz AL. Evaluation of N-ratio in selecting patients for adjuvant chemoradiotherapy after d2-gastrectomy. ARQUIVOS DE GASTROENTEROLOGIA 2014; 50:257-63. [PMID: 24474226 DOI: 10.1590/s0004-28032013000400004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 07/17/2013] [Indexed: 01/28/2023]
Abstract
CONTEXT Whether adjuvant chemoradiotherapy may contribute to improve survival outcomes after D2-gastrectomy remains controversial. OBJECTIVE To explore the clinical utility of N-Ratio in selecting gastric cancer patients for adjuvant chemoradiotherapy after D2-gastrectomy. METHODS A retrospective cohort study was carried out on gastric cancer patients who underwent D2-gastrectomy alone or D2-gastrectomy plus adjuvant chemoradiotherapy (INT-0116 protocol) at the Hospital A. C. Camargo from September 1998 to December 2008. Statistical analysis were performed using multiple conventional methods, such as c-statistic, adjusted Cox's regression and stratified survival analysis. RESULTS Our analysis involved 128 patients. According to c-statistic, the N-Ratio (i.e., as a continuous variable) presented "area under ROC curve" (AUC) of 0.713, while the number of metastatic nodes presented AUC of 0.705. After categorization, the cut-offs provide by Marchet et al. displayed the highest discriminating power - AUC value of 0.702. This N-Ratio categorization was confirmed as an independent predictor of survival using multivariate analyses. There also was a trend of better survival by adding of adjuvant chemoradiotherapy only for patients with milder degrees of lymphatic spread - 5-year survival of 23.1% vs 66.9%, respectively (HR = 0.426, 95% CI 0.150-1.202; P = 0.092). CONCLUSIONS This study confirms the N-Ratio as a tool to improve the lymph node metastasis staging in gastric cancer and suggests the cut-offs provided by Marchet et al. as the best way for its categorization after a D2-gastrectomy. In these settings, the N-Ratio appears a useful tool to select patients for adjuvant chemoradiotherapy, and the benefit of adding this type of adjuvancy to D2-gastrectomy is suggested to be limited to patients with milder degrees of lymphatic spread (i.e., NR2, 10%-25%).
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Affiliation(s)
- Wilson Luiz da Costa Junior
- Departamento de Cirurgia Abdominal, Hospital Antônio Cândido de Camargo (A. C. Camargo), São PauloSP, Brasil
| | | | - Thales Paulo Batista
- Departamento de Cirurgia/Oncologia, Faculdade Pernambucana de Saúde, Instituto de Medicina Integral, RecifePE, Brasil
| | | | - Alessandro Landskron Diniz
- Departamento de Cirurgia Abdominal, Hospital Antônio Cândido de Camargo (A. C. Camargo), São PauloSP, Brasil
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Zilberstein B, Malheiros C, Lourenço LG, Kassab P, Jacob CE, Weston AC, Bresciani CJC, Castro O, Gama-Rodrigues J, Borin AA, Buchpiegel C, Montagnini A, Leite CV, Deutsch CR, Kruel CDP, Mucerino D, Wohnrath D, Ilias E, Mrué F, Maluf-Filho F, Rocha F, de Souza F, Tomasich FS, Ishak G, Laporte G, de Souza HP, Cecconello I, Eisig J, Ohana J, Sabagga J, del Grande JC, de Jesus JP, Soares J, Dias LAN, Moreira LF, Correa M, Carvalho M, Andreollo NA, Áquila ND, Czeczko NG, Kruel N, Forones NM, da Motta OM, Malafaia O, Assumpção P, Leonardi P, Sakai P, Rocha PRS, Colleoni R, Gurgel R, Coral RP, Chalub S, Ribeiro- Junior U, Alves VAF, Vasquez VDL, Nadalin V. Brazilian consensus in gastric cancer: guidelines for gastric cancer in Brazil. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2014; 26:2-6. [PMID: 23702862 DOI: 10.1590/s0102-67202013000100002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 11/16/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND In Brazil, gastric cancer is the fourth most common malignancy among men and sixth among women. The cause is multivariate and the risks are well known. It has prognosis and treatment defined by the location and staging of the tumor and number of lymph nodes resected and involved. AIM The Brazilian Consensus on Gastric Cancer promoted by ABCG was designed with the intention to issue guidelines that can guide medical professionals to care for patients with this disease. METHODS Were summarized and answered 43 questions reflecting consensus or not on diagnosis and treatment that may be used as guidance for its multidisciplinary approach. The method involved three steps. Initially, 56 digestive surgeons and related medical specialties met to formulate the questions that were sent to participants for answers on scientific evidence and personal experience. Summaries were presented, discussed and voted in plenary in two other meetings. They covered 53 questions involving: diagnosis and staging (six questions); surgical treatment (35 questions); chemotherapy and radiotherapy (seven questions) and anatomopathology, immunohistochemistry and perspective (five questions). It was considered consensus agreement on more than 70% of the votes in each item. RESULTS All the answers were presented and voted upon, and in 42 there was consensus. CONCLUSION It could be developed consensus on most issues that come with the care of patients with gastric cancer and they can be transformed in guidelines.
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Kong F, Li H, Fan Y, Zhang X, Cao S, Yu J, Ren X, Hao X. Overweight patients achieve ideal body weight following curative gastrectomy resulting in better long-term prognosis. Obes Surg 2013; 23:650-6. [PMID: 23371777 DOI: 10.1007/s11695-012-0847-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The relationship between body mass index (BMI) and long-term outcome in gastric cancer patients following radical gastrectomy continues to be debated. We investigated the association between BMI, clinicopathological features, and prognosis in Chinese gastric carcinoma patients. METHODS A retrospective consecutive cohort study was performed on 1,296 patients who underwent gastrectomy with curative intent at the Tianjin Cancer Institute Hospital between 1999 and 2004. The clinicopathological characteristics, overall 5-year survival rate (OS), and preoperative and six-month postoperative BMIs of both overweight (BMI ≥ 25 kg/m(2); H-BMI; n = 364) and non-overweight (BMI <25 kg/m(2); N-BMI; n = 932) patients were compared. RESULTS Among these patients, 364 (28.1 %) were overweight. The OS was significantly higher in the H-BMI than N-BMI group (33.2 vs. 24.1 %, respectively; p < 0.001). Preoperative and six-month postoperative BMIs were 27.1 ± 2.0 and 24.8 ± 2.0 kg/m(2), respectively, in the H-BMI group (p < 0.001), whereas they were 21.7 ± 2.2 and 20.7 ± 2.2 kg/m(2), respectively, in the N-BMI group (p = 0.007). There was significantly better differentiation (p = 0.034), less distant metastases (p = 0.006), and a lower metastatic lymph node ratio (p = 0.014) observed in the H-BMI groups. Multivariate analyses indicated age, BMI, pathological tumor depth, distant metastases, metastatic lymph node ratio, and tumor size as independent prognostic factors. CONCLUSIONS Our findings suggest that overweight patients were less likely to have tumors with aggressive features and can achieve ideal body weight following curative gastrectomy, possibly resulting in better long-term prognosis.
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Affiliation(s)
- Fanming Kong
- Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Huanhuxi Road, Hexi District, Tianjin, China
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Lymph node density in oral cavity cancer: results of the International Consortium for Outcomes Research. Br J Cancer 2013; 109:2087-95. [PMID: 24064974 PMCID: PMC3798966 DOI: 10.1038/bjc.2013.570] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 08/22/2013] [Accepted: 08/26/2013] [Indexed: 01/05/2023] Open
Abstract
Background: Lymph node density (LND) has previously been reported to reliably predict recurrence risk and survival in oral cavity squamous cell carcinoma (OSCC). This multicenter international study was designed to validate the concept of LND in OSCC. Methods: The study included 4254 patients diagnosed as having OSCC. The median follow-up was 41 months. Five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), locoregional control and distant metastasis rates were calculated using the Kaplan–Meier method. Lymph node density (number of positive lymph nodes/total number of excised lymph nodes) was subjected to multivariate analysis. Results: The OS was 49% for patients with LND⩽0.07 compared with 35% for patients with LND>0.07 (P<0.001). Similarly, the DSS was 60% for patients with LND⩽0.07 compared with 41% for those with LND>0.07 (P<0.001). Lymph node density reliably stratified patients according to their risk of failure within the individual N subgroups (P=0.03). A modified TNM staging system based on LND ratio was consistently superior to the traditional system in estimating survival measures. Conclusion: This multi-institutional study validates the reliability and applicability of LND as a predictor of outcomes in OSCC. Lymph node density can potentially assist in identifying patients with poor outcomes and therefore for whom more aggressive adjuvant treatment is needed.
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Peng CW, Wang LW, Zeng WJ, Yang XJ, Li Y. Evaluation of the staging systems for gastric cancer. J Surg Oncol 2013; 108:93-105. [PMID: 23813573 DOI: 10.1002/jso.23360] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Accepted: 05/13/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Some staging systems for gastric cancer (GC) have been developed as alternatives to the 6th and 7th TNM staging systems, including the Hybrid, tumor-ratio-metastasis (TRM), and Kiel staging systems. This study evaluated the overall performance of these systems for GC. METHODS A total of 540 GC patients undergoing surgical resection were staged using these five systems. Homogeneity, discrimination power, predictive accuracy, and complexity of these systems were compared. RESULTS Multivariate analyses showed that all of 7th pT, pN, and pM classifications were independent factors for GC prognosis (P < 0.001 for all). Compared with the other four systems, 7th TNM system had improved stage groups homogeneity (7 of 8 stage groups homogeneous), enhanced discrimination power (4 of 5, 5 of 7, 4 of 7, 3 of 7, and 1 of 4 adjacent stage groups were differentiated by the 6th, 7th TNM, Hybrid, TRM, and Kiel systems, respectively), and better prediction value for GC patients' outcome (AUC = 0.801, P < 0.001). In addition, the 7th TNM system did not increase the staging complexity (9 groups and 21 subgroups). CONCLUSIONS The 7th TNM staging system represents advancement in GC staging system for better prediction of clinical outcomes.
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Affiliation(s)
- Chun-Wei Peng
- Department of Oncology, Zhongnan Hospital of Wuhan University, Hubei Key Laboratory of Tumor Biological Behaviors & Hubei Cancer Clinical Study Center, Wuhan, PR China
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Liu H, Deng J, Zhang R, Hao X, Jiao X, Liang H. The RML of lymph node metastasis was superior to the LODDS for evaluating the prognosis of gastric cancer. Int J Surg 2013; 11:419-24. [DOI: 10.1016/j.ijsu.2013.03.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/11/2013] [Accepted: 03/18/2013] [Indexed: 12/19/2022]
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Reim D, Loos M, Vogl F, Novotny A, Schuster T, Langer R, Becker K, Höfler H, Siveke J, Bassermann F, Friess H, Schuhmacher C. Prognostic implications of the seventh edition of the international union against cancer classification for patients with gastric cancer: the Western experience of patients treated in a single-center European institution. J Clin Oncol 2012; 31:263-71. [PMID: 23213098 DOI: 10.1200/jco.2012.44.4315] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Validity of the seventh edition of the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) staging systems for gastric cancer has been evaluated in several studies, mostly in Asian patient populations. Only few data are available on the prognostic implications of the new classification system on a Western population. Therefore, we investigated its prognostic ability based on a German patient cohort. PATIENTS AND METHODS Data from a single-center cohort of 1,767 consecutive patients surgically treated for gastric cancer were classified according to the seventh edition and were compared using the previous TNM/UICC classification. Kaplan-Meier analyses were performed for all TNM stages and UICC stages in a comparative manner. Additional survival receiver operating characteristic analyses and bootstrap-based goodness-of-fit comparisons via Bayesian information criterion (BIC) were performed to assess and compare prognostic performance of the competing classification systems. RESULTS We identified the UICC pT/pN stages according to the seventh edition of the AJCC/UICC guidelines as well as resection status, age, Lauren histotype, lymph-node ratio, and tumor grade as independent prognostic factors in gastric cancer, which is consistent with data from previous Asian studies. Overall survival rates according to the new edition were significantly different for each individual's pT, pN, and UICC stage. However, BIC analysis revealed that, owing to higher complexity, the new staging system might not significantly alter predictability for overall survival compared with the old system within the analyzed cohort from a statistical point of view. CONCLUSION The seventh edition of the AJCC/UICC classification was found to be valid with distinctive prognosis for each stage. However, the AJCC/UICC classification has become more complex without improving predictability for overall survival in a Western population. Therefore, simplification with better predictability of overall survival of patients with gastric cancer should be considered when revising the seventh edition.
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Affiliation(s)
- Daniel Reim
- Klinikum Rechts der Isar der Technischen Universität München, Ismaninger Strasse 22, D-81675 Munich, Germany
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