Comparison of three lymph node staging schemes for predicting outcome in patients with gastric cancer

Prognostic Performance of Three Lymph-Node Staging Systems on Gastric Signet-Ring-Cell Carcinoma

BACKGROUND

The lymph-node staging system can predict the prognosis of gastric signet-ring-cell carcinoma (SRCC). However, there are significant differences in lymph-node status between early SRCC and advanced SRCC. Additionally, the optimal system for early and advanced SRCC remains unknown.

METHODS

This study retrospectively analyzed 693 SRCC patients who underwent radical resection in the Department of Gastrointestinal Surgery, Harbin Medical University Cancer Hospital. The predicted performance of three lymph-node staging systems, including pN staging, lymph-node metastasis rate (LNR), and log odds of positive lymph nodes (LODDS), was compared using the receiver characteristic operating curve (ROC) and c-index. The Kaplan-Meier method and the log-rank test analyzed the overall survival of patients. The Cox risk regression model identified independent risk factors associated with patient outcomes. The nomogram was made by R studio.

RESULTS

The 693 SRCC included 165 early SRCC and 528 advanced SRCC. ROC showed that LODDS had better predictive performance than pN and LNR in predicting prognosis regardless of early or advanced SRCC. LODDS can be used to predict the prognosis of early and advanced SRCC and was an independent risk factor associated with patient outcomes (p = 0.002, p < 0.001). Furthermore, the nomogram constructed by LODDS and clinicopathological features had good predictive performance.

CONCLUSIONS

LODDS showed clear prognostic superiority over both pN and LNR in early and advanced SRCC.

Comparisons of different lymph node staging systems for predicting overall survival of node-positive patients with renal cell carcinoma: a retrospective cohort study using the Surveillance, Epidemiology and End Results database

OBJECTIVES

To compare the prognostic values of three lymph node staging systems in renal cell carcinoma (RCC), including the number of positive lymph nodes (NPLN), lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS).

DESIGN

A retrospective cohort study using data from the Surveillance, Epidemiology and End Results (SEER) database.

SETTING AND PARTICIPANTS

1904 patients with pathological N1 RCC, diagnosed from 2004 to 2015 and underwent nephrectomy combined with lymph node dissection, were identified from the SEER database.

PRIMARY OUTCOME MEASURE

The primary outcome of this study was overall survival (OS). Restricted cubic spline functions and multivariable Cox regression analyses were employed to characterise the associations of OS with NPLN, LNR and LODDS, respectively.

RESULTS

Data of 1904 eligible RCC patients were extracted from the SEER database. The mortality risks of RCC patients increased with the increasing of NPLN, LNR and LODDS. NPLN (NPLN3 vs NPLN1, HR 1.22, 95% CI 1.05 to 1.43, p=0.001), LNR (LNR3 vs LNR1, HR 1.46, 95% CI 1.28 to 1.67, p<0.001; LNR2 vs LNR1, HR 1.28, 95% CI 1.09 to 1.50, p=0.002) and LODDS (LODDS3 vs LODDS1, HR 1.48, 95% CI 1.28 to 1.72, p<0.001; LODDS2 vs LODDS1, HR 1.34, 95% CI 1.17 to 1.53, p<0.001) were all independent prognostic factors of OS. The predictive abilities of LNR (Akaike information criterion, AIC: 19576.3, optimism-corrected C-index: 0.677) and LODDS (AIC: 19579.2, optimism-corrected C-index: 0.676) were comparable, superior to NPLN (AIC: 19603.7, optimism-corrected C-index: 0.673). In subgroup analyses, the LODDS classification could better stratify survival of RCC patients, in particular for those with the number of dissected lymph nodes <13 or NPLN≤2.

CONCLUSIONS

NPLN, LNR and LODDS were all independent predictors of OS in RCC. When compared with NPLN and LNR, LODDS had a better performance in survival prediction and risk stratification. The three metrics all had the potential to be integrated into future versions of the American Joint Committee on Cancer staging manual.

Prognostic nomogram based on the lymph node metastasis indicators for patients with bladder cancer: A SEER population‐based study and external validation

PURPOSE

This study aimed to compare the prognostic value of multiple lymph node metastasis (LNM) indicators and to develop optimal prognostic nomograms for bladder cancer (BC) patients.

METHODS

BC patients were obtained from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015, and randomly partitioned into training and internal validation cohorts. Genomic and clinical data were collected from The Cancer Genome Atlas (TCGA) as external validation cohort. The predictive efficiency of LNM indicators was compared by constructing multivariate Cox regression models. We constructed nomograms on basis of the optimal models selected for overall survival (OS) and cause-specific survival (CSS). The performance of nomograms was evaluated with calibration plot, time-dependent area under the curve (AUC) and decision curve analysis (DCA) in three cohorts. We subsequently estimated the difference of biological function and tumor immunity between two risk groups stratified by nomograms in TCGA cohort.

RESULTS

Totally, 10,093 and 107 BC patients were screened from the SEER and TCGA databases. N classification, positive lymph nodes (PLNs), lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS) were all independent predictors for OS and CSS. The filtered models containing LODDS had minimal Akaike Information Criterion, maximal concordance indexes and AUCs. Age, LODDS, T and M classification were integrated into nomogram for OS, while nomogram for CSS included gender, tumor grade, LODDS, T and M classification. The nomograms were successfully validated in predictive accuracy and clinical utility in three cohorts. Additionally, the tumor microenvironment was different between two risk groups.

CONCLUSIONS

LODDS demonstrated superior prognostic performance over N classification, PLN and LNR for OS and CSS of BC patients. The nomograms incorporating LODDS provided appropriate prediction of BC, which could contribute to the tumor assessment and clinical decision-making.

Prognostic value of lymph node density on cancer staging system for gastric cancer without distal metastasis: a population-based analysis of SEER database

Background

Accurate tumor staging is the cornerstone of tumor treatment. Current tumor staging system for gastric cancer (GC) is based on regional positive lymph nodes while ignoring the total number of examined lymph nodes. We aim to assess the prognostic value of lymph node density (LND), the ratio of positive nodes to the total number examined nodes, in GC without distal metastasis.

Methods

Clinical information of patients with histologically confirmed GC and without distal metastasis was identified from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015. The X-Tile software was used to identify the ideal prognosis-related cutoff point for LND. The prognostic value of LND on cancer-specific survival (CSS) and overall survival (OS) was assessed in Cox regression models. Subgroup analysis stratified by LND was performed on current lymph node staging system to further explore the interaction between LND and current lymph node staging system.

Results

A total of 4281 participants were identified from the SEER database for the final analysis. The optimal prognosis-related cutoff values of LND were calculated as 0.1 and 0.4, and LND was divided into three levels: LND1 (< 0.1), LND2 (> = 0.1, < 0.4), and LND3 (> = 0.4). LND3 was associated with worse CSS and OS in GC patients. Compared to patients with LND1, those with LND2 and LND3 had 2.43 (HR = 2.43, 95% CI 2.09–2.84, P < 0.001) and 4.69 (HR = 4.69, 95% CI 4.02–5.48, P < 0.001) folds increase in mortality in CSS, respectively. Similar results were found in the evaluation of OS in GC patients. Subgroup analysis stratified by LND also found that patients in the same current lymph node stage still had different prognosis due to the different LND levels after adjustment for other prognosis-related covariates (all P values < 0.001).

Conclusion

LND is an independent prognostic factor for GC without distal metastasis. In the current lymph node staging system, LND has potential value in further accurately classifying GC patients without distal metastasis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02795-9.

Comparison of Four Lymph Node Staging Systems in Gastric Adenocarcinoma after Neoadjuvant Therapy – A Population-Based Study

Introduction

Neoadjuvant treatment leads in a reduction in positive lymph nodes and examined lymph nodes (ELN), which may affect assessment of lymph node staging and postoperative treatment. We aimed to compare the staging systems of lymph node ratio (LNR), the positive logarithm ratio of lymph nodes (LODDS), negative lymph nodes (NLN), and the 8th AJCC ypN stage for patients with gastric adenocarcinoma after neoadjuvant therapy.

Materials and Methods

Data was collected from the Surveillance, Epidemiology, and End Results database and 1,551 patients with gastric adenocarcinoma who underwent neoadjuvant therapy and radical surgery were enrolled. Harrell’s concordance index, the Receiver Operative Curve, the likelihood ratio test, and the Akaike information criterion were used to compare the predictive abilities of the different staging systems.

Results

Among the 1,551 patients, 689 (44.4%) had ELN < 16 and node-negative patients accounted for 395 (25.5%). When regarded as the categorical variable, LNR had better discrimination power, higher homogeneity, and better model fitness for CSS and OS compared to other stage systems, regardless of the status of ELN. When regarded as the continuos variable, LODDS outperformed others for CSS. Furthermore, the NLN staging system performed superior to others in node-negative patients.

Conclusions

LNR had a better predictive performance than ypN, LODDS and NLN staging systems regardless of the status of ELN when regarded as the categorical variable, whereas LOODS became the better predictive factor for CSS when regarded as the continuos variable. In node-negative patients, NLN might be a feasible option for evaluating prognosis. A combination of LNR and NLN should be considered as user-friendly method in the clinical prognostic assessment.

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.

N, LNR or LODDS: Which Is the Most Appropriate Lymph Node Classification Scheme for Patients with Radically Resected Pancreatic Cancer?

Simple Summary

To date, no data are available regarding the most appropriate alternative LN classification system with respect to prognostic power and discriminative ability in cases with resectable pancreatic ductal adenocarcinoma (PDAC). We compared different lymph node classification systems with regard to accurate evaluation of overall survival in 319 patients with resected PDAC. One LNR and one LODDS classification scheme were found to out-perform the N category in distinct patient subgroups. Only the LODDS classification exhibited statistically significant, gradually increasing HRs of their subcategories and, at the same time, significantly better discriminative potential in the subgroups of patients with PDAC of the head or corpus and in patients with tumor-free resection margins or M0 status, respectively.

Abstract

Background: Even though numerous novel lymph node (LN) classification schemes exist, an extensive comparison of their performance in patients with resected pancreatic ductal adenocarcinoma (PDAC) has not yet been performed. Method: We investigated the prognostic performance and discriminative ability of 25 different LN ratio (LNR) and 27 log odds of metastatic LN (LODDS) classifications by means of Cox regression and C-statistic in 319 patients with resected PDAC. Regression models were adjusted for age, sex, T category, grading, localization, presence of metastatic disease, positivity of resection margins, and neoadjuvant therapy. Results: Both LNR or LODDS as continuous variables were associated with advanced tumor stage, distant metastasis, positive resection margins, and PDAC of the head or corpus. Two distinct LN classifications, one LODDS and one LNR, were found to be superior to the N category in the complete patient collective. However, only the LODDS classification exhibited statistically significant, gradually increasing HRs of their subcategories and at the same time significantly higher discriminative potential in the subgroups of patients with PDAC of the head or corpus and in patients with tumor free resection margins or M0 status, respectively. On this basis, we built a clinically helpful nomogram to estimate the prognosis of patients after radically resected PDAC. Conclusion: One LNR and one LODDS classification scheme were found to out-perform the N category in terms of both prognostic performance and discriminative ability, in distinct patient subgroups, with reference to OS in patients with resected PDAC.

Evaluation of Four Lymph Node Classifications for the Prediction of Survival in Hilar Cholangiocarcinoma

BACKGROUND

An important prognostic indicator of hilar cholangiocarcinoma (HCCA) in patients after surgery is metastasis of lymph nodes (LN). However, there are many types of LN staging systems to the issue of a better determination of the prognosis of patients through the lymphatic staging system which needs research. Based on the above, we tried to re-evaluate the staging system of HCCA LNs. We compared the American Joint Committee on Cancer (AJCC), number of metastatic LNs (MLN), ratio of LN (LNR), and log odds of MLNs (LODDS) in individuals undergoing curative resection to determine the best LN staging system.

METHODS

In the current study, we retrospectively analyzed 229 patients undergoing curative resection. We evaluated the impact of the stage of AJCC pN, LNR, LODDS, and MLN on OS (overall survival) and RFS (recurrence-free survival). According to the curve of receiver operating characteristic (ROC), we compared the predictive capacity of different staging systems of LN for survival and recurrence.

RESULTS

Multivariate analysis results revealed that LODDS >  - 0.45 (95% CI = 1.115-2.709, P = 0.015; 95% CI = 1.187-2.780, P = 0.006) are independent risk factors affecting OS and RFS, respectively. Compared with LN status, AJCC pN stage, MLN, and LNR, the variable having the highest area under the ROC curve (AUC) was LODDS when predicting 1-year, 3-year, and 5-year OS and RFS.

CONCLUSION

This study shows that metastasis of LNs is a key indicator for predicting patient death and recurrence. Among them, LODDS is the best LN staging system for the prognostic evaluation of HCCA patients after surgery. Clinicians can incorporate LODDS into HCCA patient lymphatic staging system for a more accurate prognosis of HCCA patients post-surgery.

Prognostic Performance of Alternative Lymph Node Classification Systems for Patients with Medullary Thyroid Cancer: A Single Center Cohort Study

BACKGROUND

Lymph node ratio (LNR) and the log odds of positive lymph nodes (LODDS) have been proposed as alternative lymph node (LN) classification schemes. Various cut-off values have been defined for each system, with the question of the most appropriate for patients with medullary thyroid cancer (MTC) still remaining open. We aimed to retrospectively compare the predictive impact of different LN classification systems and to define the most appropriate set of cut-off values regarding accurate evaluation of overall survival (OS) in patients with MTC.

METHODS

182 patients with MTC who were operated on between 1985 and 2018 were extracted from our medical database. Cox proportional hazards regression models and C-statistics were performed to assess the discriminative power of 28 LNR and 28 LODDS classifications and compare them with the N category according to the 8th edition of the AJCC/UICC TNM classification in terms of discriminative power. Regression models were adjusted for age, sex, T category, focality, and genetic predisposition.

RESULTS

High LNR and LODDS are associated with advanced T categories, distant metastasis, sporadic disease, and male gender. In addition, among 56 alternative LN classifications, only one LNR and one LODDS classification were independently associated with OS, regardless of the presence of metastatic disease. The C-statistic demonstrated comparable results for all classification systems showing no clear superiority over the N category.

CONCLUSION

Two distinct alternative LN classification systems demonstrated a better prognostic performance in MTC patients than the N category. However, larger scale studies are needed to further verify our findings.

Comprehensive analysis of prognostic value of lymph node classifications in esophageal squamous cell carcinoma: a large real-world multicenter study

Background:

We aim to assess the prognostic ability of three common lymph node–based staging algorithms, namely, the number of positive lymph nodes (pN), the lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) in patients with esophageal squamous cell carcinoma (ESCC).

Methods:

A total of 3902 ESCC patients treated at 10 Chinese institutions between 2003 and 2013 were included, along with 2465 patients from the Surveillance, Epidemiology, and End Results (SEER) database. The prognostic ability of the aforementioned algorithms was evaluated using time-dependent receiver operating characteristic (tdROC) curves, R², Harrell’s concordance index (C-index), and the likelihood ratio chi-square score. The primary outcomes included cancer-specific survival (CSS), overall survival (OS), and CSS with a competing risk of death by non-ESCC causes.

Results:

LODDS had better prognostic performance than pN or LNR in both continuous and stratified patterns. In the multicenter cohort, the multivariate analysis showed that the model based on LODDS classification was superior to the others in predictive accuracy and discriminatory capacity. Two nomograms integrating LODDS classification and other clinicopathological risk factors associated with OS as well as cancer-specific mortality were constructed and validated in the SEER database. Finally, a novel TN_LODDS classification which incorporates the LODDS classification was built and categorized patients in to three new stages.

Conclusion:

Among the three lymph node–based staging algorithms, LODDS demonstrated the highest discriminative capacity and prognostic accuracy for ESCC patients. The nomograms and novel TN_LODDS classification based on LODDS classification could serve as precise evaluation tools to assist clinicians in estimating the survival time of individual patients and improving clinical outcomes postoperatively in the future.

Lymph Node Ratio Is an Independent Prognostic Factor for Patients with Siewert Type II Adenocarcinoma of Esophagogastric Junction: Results from a 10-Year Follow-up Study

PURPOSE

Emerging evidences suggest that lymph node ratio (LNR), the number of metastatic lymph node (LN) to the total number of dissected lymph nodes (NDLN), may predict survival in multiple types of solid tumor. However, the prognostic role of LNR in adenocarcinoma of the esophagogastric junction (AEG) remains uninvestigated. The present study is intended to determine the prognostic value of LNR in the patients with Siewert type II AEG.

METHODS

A total of 342 patients with Siewert type II AEG who underwent R0 resection were enrolled in this study. The optimal cutoff of LNR was stratified into tertiles using X-tile software. The log-rank test was used to evaluate the survival differences, and multivariate Cox regression analyses were performed to determine the independent prognostic variables.

RESULTS

The optimal cutoff of LNR were classified as LNR = 0, LNR between 0.01 and 0.40, and LNR > 0.41. Patients with high LNR had a shorter 5- and 10-year disease-specific survival (DSS) rate (8.5%, 1.4%) compared with those with moderate LNR (20.4%, 4.9%) and low LNR (58.0%, 27.5%) (P < 0.001). Multivariate Cox regression analysis indicated that LNR was an independent factor for DSS after adjusting for confounding variables (P < 0.05). Furthermore, after stratification by NDLN between NDLN < 15 group and NDLN ≥ 15 group, the LNR remained a significant predictor for DSS (P < 0.05).

CONCLUSIONS

LNR is an independent predictor for DSS in patients with Siewert type II AEG regardless of NDLN. Patients with higher LNR have significantly shorter DSS.

Prognostic Discrimination of Alternative Lymph Node Classification Systems for Patients with Radically Resected Non-Metastatic Colorectal Cancer: A Cohort Study from a Single Tertiary Referral Center

BACKGROUND

Lymph node ratio (LNR) and the Log odds of positive lymph nodes (LODDS) have been proposed as a new prognostic indicator in surgical oncology. Various studies have shown a superior discriminating power of LODDS over LNR and lymph node category (N) in diverse cancer entities, when examined as a continuous variable. However, for each of the classification systems various cut-off values have been defined, with the question of the most appropriate for patients with CRC still remaining open. The present study aimed to compare the predictive impact of different lymph node classification systems and to define the best cut-off values regarding accurate evaluation of overall survival in patients with resectable, non-metastatic colorectal cancer (CRC).

METHODS

CRC patients who underwent surgical resection from 1996 to 2018 were extracted from our medical data base. Cox proportional hazards regression models and C-statistics were performed to assess the discriminative power of 25 LNR and 26 LODDS classifications. Regression models were adjusted for age, sex, extent of the tumor, differentiation, tumor size and localization.

RESULTS

Our study group consisted of 654 consecutive patients with non-metastatic CRC. C-statistic revealed 2 LNR and 5 LODDS classifications that demonstrated superior prognostic performance in patients with UICC III CRC, compared to the N category. No clear advantage of one classification over another could be demonstrated in any other patient subgroup.

CONCLUSIONS

Distinct LNR and LODDS classifications demonstrate a prognostic superiority over the N category only in patients with Stage III radically resected CRC.

A Novel Nomogram Based on Log Odds of Metastatic Lymph Nodes to Predict Overall Survival in Patients With Perihilar Cholangiocarcinoma After Surgery

Background

Various lymph node staging strategies were reported to be significantly correlated with perihilar cholangiocarcinoma(pCCA) prognosis. This study aimed to evaluate their predictive abilities and construct an optimal model predicting overall survival (OS).

Methods

Patients with pCCA were collected as the training cohort from the Surveillance, Epidemiology, and End Results (SEER) database. Four models were constructed, involving four LNs staging strategies. The optimal model for predicting OS was evaluated by calculation of the concordance index (C-index) and Akaike information criterion (AIC), and validated by using the area under curve (AUC) and calibration curves. The clinical benefits of nomogram were evaluated by decision curve analysis (DCA). A Chinese cohort was collected to be an external validation cohort.

Results

There were 319 patients and 109 patients in the SEER database and Chinese cohort respectively. We developed an optimal model involving age, T stage, tumor size, LODDS, which showed better predictive accuracy than others. The C-index of the nomogram was 0.695, the time-dependent AUC exceeded 0.7 within 36 months which was significantly higher than that of the American Joint Committee on Cancer (AJCC) stage. The calibration curves for survival probability showed the nomogram prediction had good uniformity of the practical survival. The DCA curves exhibited our nomogram with higher clinical utility compared with the AJCC stage and single LOODS.

Conclusions

LODDS is a strong independent prognostic factor, and the nomogram has a great ability to predict OS, which helps assist clinicians to conduct personalized clinical practice.

The Prognostic Value of Log Odds of Positive Lymph Nodes in Early-Stage Esophageal Cancer Patients: A Study Based on the SEER Database and a Chinese Cohort

Objective

Early detection and timely treatment are important for improving the prognosis of esophageal cancer (EC). Identification of the prognostic risk factors could help us to discern the high-risk population. This study was aimed at exploring the prognostic significance of log odds of positive lymph nodes (LODDS) in early-stage EC patients.

Methods

Patients who underwent esophagectomy and diagnosed as pathologic T1-2 N0 EC were reviewed between January 2005 and December 2015 from the Surveillance, Epidemiology, and End Results (SEER) database (the development cohort, n = 1004). The X-tile software was used to determine the optimal cutoff values of LODDS. A separate Chinese cohort including 245 patients (the validation cohort) was used to externally validate the results of the SEER database.

Result

Patients were divided into two groups based on the cutoff points of LODDS: <-1.40 (LODDS1) and ≥-1.40 (LODDS2). In the development cohort, the 5-year overall survival (OS) rate was 75.3% for patients in the LODDS1 group, compared with 67.5% for those in the LODDS2 group (P=0.002). In multivariate Cox analysis, LODDS was associated with OS significantly (hazard ratio (HR), 1.48; 95% confidence intervals (CI), 1.19-1.85). In the validation cohort, the 5-year OS rate was 76.6% for patients in the LODDS1 group, compared with 64.4% for those in the LODDS2 group (P=0.006). The HR value in multivariate Cox analysis for OS was 2.00 (95% CI, 1.26-3.18).

Conclusion

LODDS was an important independent factor for survival in early-stage EC patients.

Development and validation of a novel staging system integrating the number and location of lymph nodes for gastric adenocarcinoma

Background

Evidence suggests that the anatomic extent of metastatic lymph nodes (MLNs) affects prognosis, as proposed by alternative staging systems. The aim of this study was to establish a new staging system based on the number of perigastric (PMLN) and extra-perigastric (EMLN) MLNs.

Methods

Data from a Chinese cohort of 1090 patients who had undergone curative gastrectomy with D2 or D2 plus lymphadenectomy for gastric cancer were retrospectively analysed. A Japanese validation cohort (n = 826) was included. Based on the Cox proportional hazards model, the regression coefficients of PMLN and EMLN were used to calculate modified MLN (MMLN). Prognostic performance of the staging systems was evaluated.

Results

PMLN and EMLN were independent prognostic factors in multivariate analysis (coefficients: 0.044, 0.115; all P < 0.001). MMLN was calculated as follows: MMLN = PMLN + 2.6 × EMLN. The MMLN staging system showed superior prognostic performance (C-index: 0.751 in the Chinese cohort; 0.748 in the Japanese cohort) compared with the five published LN staging systems when MMLN numbers were grouped as follows: MMLN0 (0), MMLN1 (1–4), MMLN2 (5–8), MMLN3 (9–20), and MMLN4 (>20).

Discussion

The MMLN staging system is suitable for assessing overall survival among patients undergoing curative gastrectomy with D2 or D2 plus lymphadenectomy.

Superiority of log odds of positive lymph nodes (LODDS) for prognostic prediction after gastric cancer surgery: a multi-institutional analysis of 7620 patients in China

PURPOSE

To compare the 8th pN system with ratio-based and Log odds of positive lymph nodes (LODDS) staging systems for predicting the overall survival (OS) of gastric cancer (GC) patients after curative gastric resection.

METHODS

We analyzed, retrospectively, clinicopathologic and prognostic data from three Chinese medical centers, on 7620 patients who underwent curative surgery for GC. We established a hypothetical tumor-LODDS-metastasis (TLM) and tumor-ratio-metastasis (TRM) staging system. The relative discriminative abilities of the different staging systems were assessed using Akaike's Information Criterion (AIC), a linear trend chi-square test, and a likelihood ratio chi-square test.

RESULTS

The cut-off points of the LODDS were set as: ≤ - 1.5, - 1.5 to - 1.0, - 1.0 to - 0.5, - 0.5 to 0, and > 0. There were significant differences in the survival of patients in different LODDS classifications for each pN or LNR group. When stratified by the LODDS classification, the prognosis was more homologous according to the pN or lymph-node ratio (LNR) classifications. The modified TLM staging system had better discriminatory ability and better optimistic prognostic stratification than the 8th TNM or the TRM staging systems for predicting the prognosis of patients with GC.

CONCLUSIONS

The LODDS staging system was superior to other lymph-node classifications for predicting the prognosis of patients undergoing gastrectomy GC. LODDS may be incorporated into a GC staging system if these results are confirmed by other studies.

Nomogram prediction of overall survival based on log odds of positive lymph nodes for patients with penile squamous cell carcinoma

Purpose

This study aimed to establish a nomogram to predict the long‐term overall survival (OS) for patients with penile squamous cell carcinoma (PSCC).

Method

The PSCC patients receiving regional lymph node dissection (RLND) were enrolled from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015. The dataset of all eligible patients were used to develop the predictive model. The significant independent predictors were identified through Cox regression modeling based on the Bayesian information criterion and then incorporated into a nomogram to predicted 1‐, 3‐, and 5‐year OS. Internal validation was performed using the bootstrap resampling method. The model performance was evaluated using Harrell's concordance index (C‐index), calibration plots, integrated discrimination improvement (IDI), net reclassification improvement (NRI), and decision curve analysis (DCA).

Results

Totally, 384 eligible PSCC patients were enrolled from the SEER database. A nomogram for OS prediction was developed, in which three clinical variables significantly associated with OS were integrated, including age, N classification, and log odds of positive lymph nodes (LODDS). The C‐index of the nomogram (0.746, 95% CI: 0.702‐0.790) was significantly higher than that of the American Joint Committee on Cancer (AJCC) staging system (0.692, 95% CI: 0.646‐0.738, P = .020). The bootstrap optimism‐corrected C‐index for the nomogram was 0.739 (95% CI: 0.690‐0.784). The bias‐corrected calibration plots showed the predicted risks were in good accordance with the actual risks. The results of NRI, IDI, and DCA exhibited superior predictive capability and higher clinical use of the nomogram compared with the AJCC staging system.

Conclusion

We successfully constructed a simple and reliable nomogram for OS prediction among PSCC patients receiving RLND, which would be beneficial to clinical trial design, patient counseling, and therapeutic modality selection.

Log odds of positive lymph nodes predicts survival in patients treated with neoadjuvant therapy followed by esophagectomy

BACKGROUND AND OBJECTIVES

We aimed to evaluate the efficacy of the log odds of positive lymph nodes (LODDS) in survival prediction of patients with esophageal carcinoma receiving neoadjuvant therapy, compared with N descriptor and positive lymph node ratio (LNR).

METHODS

Patients with esophageal carcinoma receiving neoadjuvant therapy from 2004 to 2015 were reviewed in Surveillance, Epidemiology, and End Results database. The receiver operating characteristics curve and area under the curve (AUC) were used to compare discriminatory power among N descriptor, LNR, and LODDS. The goodness of fit was measured using the -2 log-likelihood ratio (-2LLR).

RESULTS

About 2239 patients with a 22 months median follow-up and a 37.8% 5-year overall survival rate were included. LODDS had the best discriminatory power and goodness of fit (LODDS vs N descriptor, AUC 0.666 vs 0.626, -2LLR 15 680.402 vs 15 746.162; LODDS vs LNR, AUC 0.666 vs 0.635, -2LLR 15 680.402 vs 15 712.379; all P < .001). LODDS was the best for fewer than 15 lymph nodes retrieved (LODDS vs N descriptor, AUC 0.652 vs 0.618, P < .001; LODDS vs LNR, AUC 0.652 vs 0.625, P = .005). The prognosis of patients without metastatic nodes could be discriminated by LODDS.

CONCLUSIONS

LODDS could better predict survival of patients with esophageal carcinoma receiving neoadjuvant therapy.

Development and validation of prognostic nomogram based on log odds of positive lymph nodes for patients with gastric signet ring cell carcinoma

Objective

Our aims were to establish novel nomogram models, which directly targeted patients with signet ring cell carcinoma (SRC), for individualized prediction of overall survival (OS) rate and cancer-specific survival (CSS).

Methods

We selected 1,365 SRC patients diagnosed from 2010 to 2015 from Surveillance, Epidemiology and End Results (SEER) database, and then randomly partitioned them into a training cohort and a validation cohort. Independent predicted indicators, which were identified by using univariate testing and multivariate analyses, were used to construct our prognostic nomogram models. Three methods, Harrell concordance index (C-index), receiver operating characteristics (ROC) curve and calibration curve, were used to assess the ability of discrimination and predictive accuracy. Integrated discrimination improvement (IDI), net reclassification improvement (NRI) and decision curve analysis (DCA) were used to assess clinical utility of our nomogram models.

Results

Six independent predicted indicators, age, race, log odds of positive lymph nodes (LODDS), T stage, M stage and tumor size, were associated with OS rate. Nevertheless, only five independent predicted indicators were associated with CSS except race. The developed nomograms based on those independent predicted factors showed reliable discrimination. C-index of our nomogram for OS and CSS was 0.760 and 0.763, which were higher than American Joint Committee on Cancer (AJCC) 8th edition tumor-node-metastasis (TNM) staging system (0.734 and 0.741, respectively). C-index of validation cohort for OS was 0.757 and for CSS was 0.773. The calibration curves also performed good consistency. IDI, NRI and DCA showed the nomograms for both OS and CSS had a comparable clinical utility than the TNM staging system.

Conclusions

The novel nomogram models based on LODDS provided satisfying predictive ability of SRC both in OS and CSS than AJCC 8th edition TNM staging system alone.

A homogenized approach to classify advanced gastric cancer patients with limited and adequate number of pathologically examined lymph nodes

Background

The prognosis of gastric cancer patients with a limited number of pathologically examined lymph nodes (eLN, < 16) is dismal compared to those with adequately eLN (≥ 16), yet they are still classified within the same subgroups using the American Joint Committee on Cancer (AJCC) staging system. We aimed at formulating an easy-to-adopt and clinically reliable stratification approach to homogenize the classification for these two categories of patients.

Methods

Patients staged according to the 8th AJCC pathological nodal (N) and tumor-node-metastasis (TNM) classification were stratified into a Limited and Adequate eLN cohort based on their number of pathologically examined LNs. The statistical differences between the 5-year overall survival (OS) rates of both cohorts were determined and based on which, patients from the Limited eLN cohort were re-classified to a proposed modified nodal (N′) and TNM (TN′M) classification, by matching their survival rates with those of the Adequate eLN cohort. The prognostic performance of the N′ and TN′M classification was then compared to a formulated lymph-node-ratio-based nodal classification, in addition to the 8th AJCC N and TNM classification.

Results

Significant heterogeneous differences in 5-year OS between patients from the Limited and Adequate eLN cohort of the same nodal subgroups were identified (all P < 0.001). However, no significant differences in 5-year OS were observed between the subgroups N0, N1, N2, and N3a of the Limited eLN cohort when compared with N1, N2, N3a, and N3b from the Adequate eLN cohort, respectively (P = 0.853, 0.476, 0.114, and 0.230, respectively). A novel approach was formulated in which only patients from the Limited eLN cohort were re-classified to one higher nodal subgroup, denoted as the N′ classification. This re-classification demonstrated superior stratifying and prognostic ability as compared to the 8th AJCC N and lymph-node-ratio classification (Akaike information criterion values [AIC]: 12,276 vs. 12,358 vs. 12,283, respectively). The TN′M classification also demonstrated superior prognostic ability as compared to the 8th AJCC TNM classification (AIC value: 12,252 vs. 12,312).

Conclusion

The proposed lymph node classification approach provides a clinically practical and reliable technique to homogeneously classify cohorts of gastric cancer patients with limited and adequate number of pathologically examined lymph nodes.

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

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.

New metastatic lymph node classification for early gastric cancer should differ from those for advanced gastric adenocarcinoma: Results based on the SEER database

AIM

To establish an appropriate N classification system for early gastric cancer (EGC).

METHODS

Data from 10714 patients who underwent radical gastrectomy between 1988 and 2011 were retrieved from the National Cancer Institute’s Surveillance, Epidemiology, and End Result database. The overall survival (OS) based on the eighth edition and new tumor lymph node metastasis (TNM) staging systems were compared, and the analysis was repeated in an external validation set from the Fujian Medical University Union Hospital database.

RESULTS

There were no significant differences in OS between N1 and N2 cancers or between N3a and N3b cancers in cases of EGC. The X-tile program identified that the new staging system for EGC consisted of T1N0, T1N1’ [1-6 metastatic lymph nodes (LNs)], and T1N2’ ( ≥ 7 metastatic LNs). Compared with the eighth edition of the TNM staging system, the OS of patients in T1N1’ stage was similar to that of patients with stage IIA disease, whereas the OS of patients in T1N2’ stage was similar to that of patients with stage IIB disease. The new TNM staging system exhibited a slightly lower Akaike Information Criterion value and higher χ² and c-statistic compared with the eighth edition of the TNM classification system. Similar results were found in the external validation dataset from the external validation set.

CONCLUSION

We have developed an optional new TNM staging system with a better predictive ability that can be used to accurately predict the 5-year OS of patients with EGC.

Log Odds Could Better Predict Survival in Muscle-Invasive Bladder Cancer Patients Compared with pN and Lymph Node Ratio

Background: The aim of this study was to assess the prognostic value of lymph node-associated variables, pN, lymph node ratio (LNR) and log odds (LODDS), in patients with bladder cancer.

Methods: In the discovery cohort, 3358 patients with muscle-invasive bladder cancer (MIBC) and treated with radical cystectomy were identified from the Surveillance, Epidemiology, and End Results (SEER) database. A total of 173 patients with MIBC who underwent radical cystectomy at Shanghai Cancer Center between 2010 and 2013 were enrolled in the validation cohort. LNR and LODDS were calculated in two cohorts and prognostic value was compared between these two variables.

Results: In the two cohorts, survival differences between LODDS, LNR and pN (from the 7^th AJCC TNM system) cohorts were statistically significant. Univariate and multivariate analyses confirmed that LNR and LODDS were independent prognostic factors and LODDS was better at predicting prognosis than pN and LNR for patients with MIBC. Moreover, LODDS had a better discriminative ability and model fit, proven by the highest Harrell's concordance index and lowest AIC among the three variables. Furthermore, scatter plots of pN, LNR and LODDS revealed that several groups of LNR and pN were heterogeneous and could be better stratified by LODDS in terms of prognosis estimation.

Conclusion: LODDS has significant prognostic value for patients with MIBC. Moreover, LODDS is better at predicting prognosis for MIBC patients compared with pN and LNR.

Different lymph node staging systems for patients with adenocarcinoma of esophagogastric junction

OBJECTIVE

In addition to the traditional TNM N staging system, lymph node ratio (LNR) and log odds of metastatic lymph nodes (LODDS) staging methods were developed in cancers. This study aimed to examine their relative prognostic performance in patients with adenocarcinoma of the esophagogastric junction (AEG).

PATIENTS AND METHODS

Patients who underwent surgical resection for AEG were identified from the Surveillance, Epidemiology, and End Results (SEER) Program and the First Affiliated Hospital of Xi'an Jiaotong University as the training and validation sets, respectively. The Akaike's Information Criterion (AIC), Harrell's C statistic, and ROC curves were utilized for comparison.

RESULTS

A total of 735 patients were involved in the training set. LODDS and LNR staging systems had better prognostic performance than the TNM N staging systems (when considered as a categorical variable: C index = 0.728 and 0.712 vs 0.671; AIC: 6247.537 and 6265.996 vs 6320.045; AUC: 0.762 and 0.719 vs 0.692. For the continuous model: C index = 0.675 and 0.686 vs 0.658; AIC = 6243.740 and 6261.027 vs 6355.077; AUC = 0.778 and 0.733 vs 0.693). In the validation set of 183 patients, the TNM N staging scheme outperformed the LODDS and LNR staging systems (C index = 0.788 vs 0.779 and 0.767; AIC = 1014.702 vs 1026.899 and 1025.288; AUC = 0.806 vs 0.787 and 0.791) when considered a categorical variable. However, when considered a continuous variable, the LODDS and LNR staging systems were better than the TNM N staging system (C index = 0.724 and 0.733 vs 0.747; AIC = 1018.075 and 1025.803 vs 1026.085; AUC = 0.811 and 0.810 vs 0.806).

CONCLUSIONS

The LNR and LODDS staging schemes could be considered new options for prognostic prediction of AEG with respect to lymph node status, especially when considered as continuous variables.

Anatomical location of metastatic lymph nodes: an indispensable prognostic factor for gastric cancer patients who underwent curative resection

BACKGROUND

Although the numeric-based lymph node (LN) staging was widely used in the worldwide, it did not represent the anatomical location of metastatic lymph nodes (MLNs) and not reflect extent of LN dissection. Therefore, in the present study, we investigated whether the anatomical location of MLNs was still necessary to evaluate the prognosis of node-positive gastric cancer (GC) patients.

METHODS

We reviewed 1451 GC patients who underwent radical gastrectomy in our institution between January 1986 and January 2008. All patients were reclassified into several groups according to the anatomical location of MLNs and the number of MLNs. The prognostic differences between different patient groups were compared and clinicopathologic features were analyzed.

RESULTS

In the present study, both anatomical location of MLNs and the number of MLNs were identified as the independent prognostic factors (p < .01). The patients with extraperigastric LN involvement showed a poorer prognosis compared with the perigastric-only group (p < .001). For the N1-N2 stage patients, the prognostic discrepancy was still observed among them when the anatomical location of MLNs was considered (p < .05). For the N3-stage patients, although the anatomical location of MLNs had no significant effect on the prognosis of these patients, the higher number of MLNs in the extraperigastric area was correlated with the unfavorable prognosis (p < .05).

CONCLUSION

The anatomical location of MLNs was an important factor influencing the prognostic outcome of GC patients. To provide more accurate prognostic information for GC patients, the anatomical location of MLNs should not be ignored.

The prognostic value of different node staging systems in patients with ≤15 lymph nodes following surgery for gastric adenocarcinoma

AIM

Lymph node (LN) status is an important prognostic indicator in patients with gastric cancer (GC). Although American Joint Committee on Cancer/International Union against Cancer (AJCC/UICC) is the most widely used staging system, there is a challenge in predicting survival of patients when the number of total harvested LNs is ≤15. Our aim was to investigate the prognostic performances of seventh edition AJCC/UICC, lymph-node ratio (LNR), and log odds of metastatic lymph nodes (LODDS) on the overall survival (OS) of GC patients with ≤15 examined LNs after gastric resection.

MATERIAL AND METHOD

A total of 74 patients who underwent curative resection for gastric adenocarcinoma and had ≤15 LNs at the final histopathological examination were included in the study. The prognostic ability of three node staging models to predict OS was assessed using the area under the curve (AUC).

RESULTS

Of the 74 patients, 15 (20.3%) had no LN metastasis whereas 59 (79.7%) had nodal involvement. The median OS was 26 months. When assessed as a continuous variable, LNR was the strongest staging system to stratify GC patients on the basis of LN status. LODDS had superiority on other node staging models when the number of LNs retrieved was modeled as categorical variable.

CONCLUSIONS

LNR (continuous) and LODDS (categorical) were the strongest indicators of OS in GC when the number of LN harvested was ≤15. Therefore, they may be considered as an alternative nodal staging systems for GC.

Prognostic role of mesenteric lymph nodes involvement in patients undergoing posterior pelvic exenteration during radical or supra-radical surgery for advanced ovarian cancer

PURPOSE

The aim of this retrospective study is to analyze the prognostic role and the practical implication of mesenteric lymph nodes (MLN) involvements in advanced ovarian cancer (AOC).

METHODS

A total of 429 patients with AOC underwent surgery between December 2007 and May 2017. We included in the study 83 patients who had primary (PDS) or interval debulking surgery (IDS) for AOC with bowel resection. Numbers, characteristics and surgical implication of MLN involvement were considered.

RESULTS

Eighty-three patients were submitted to bowel resection during cytoreduction for AOC. Sixty-seven patients (80.7%) underwent primary debulking surgery (PDS). Sixteen patients (19.3%) experienced interval debulking surgery (IDS). 43 cases (51.8%) showed MLN involvement. A statistic correlation between positive MLN and pelvic lymph nodes (PLN) (p = 0.084), aortic lymph nodes (ALN) (p = 0.008) and bowel infiltration deeper than serosa (p = 0.043) was found. A longer overall survival (OS) and disease-free survival was observed in case of negative MLN in the first 20 months of follow-up. No statistical differences between positive and negative MLN in terms of operative complication, morbidity, Ca-125, type of surgery (radical vs supra-radical), length and site of bowel resection, residual disease and site of recurrence were observed.

CONCLUSIONS

An important correlation between positive MLN, ALN and PLN was detected; these results suggest a lymphatic spread of epithelial AOC similar to that of primary bowel cancer. The absence of residual disease after surgery is an independent prognostic factor; to achieve this result should be recommended a radical bowel resection during debulking surgery for AOC with bowel involvement.

Lymph node staging systems in patients with gastric cancer treated with D2 resection plus adjuvant chemotherapy

Background: The optimal nodal staging scheme for gastric cancer remains unsettled. We compared the prognostic performances of the metastatic lymph node, lymph node ratio, and log odds of metastatic lymph nodes based on nomograms among 801 patients with D2-resected gastric cancer treated with adjuvant chemotherapy.

Methods: When assessed as a continuous covariate, each nodal staging variable was incorporated into a prognostic nomogram with other significant prognosticators to predict the 5-year overall survival. The discriminatory abilities of the nomograms were compared using the concordance index. Patients were divided into subgroups using each nomogram, and the prognostic homogeneity of the nomograms was assessed using the Kaplan-Meier method with log-rank tests.

Results: The discriminatory abilities of the three nomograms were comparable (P > 0.05 for all pairwise comparisons). However, for patients within each lymph node ratio subgroup, overall survival was homogenous when stratified by subgroups of the other two staging schemes, while it differed significantly among the different lymph node ratio subgroups for patients within some of the other two staging subgroups.

Conclusion: The lymph node ratio-based staging scheme performs the best for the prediction of survival in patients with locally advanced gastric cancer treated with D2 resection followed by adjuvant chemotherapy.

Prognostic performance of three lymph node staging schemes for patients with Siewert type II adenocarcinoma of esophagogastric junction

The prognostic performance of different lymph node staging schemes for adenocarcinoma of esophagogastric junction (AEG) remains controversial. The objective of the present study was to compare the prognostic efficacy of the number of lymph node metastases (LNMs), the positive lymph node ratio (LNR) and the log odds of positive lymph nodes (LODDS). Patients diagnosed with Siewert type II AEG were included from the Surveillance, Epidemiology, and End Results database. Harrell's C-index statistic, Schemper's proportion of explained variation (PEV), the Akaike information criterion (AIC) and restricted cubic spine analyses were adopted to assess the predictive accuracy of LNM, LNR and LODDS. A total of 1302 patients with post-surgery Siewert type II AEG were included. LNM, LNR and LODDS all showed significant prognostic value in the multivariate Cox regression analyses. LODDS performed higher predictive accuracy than LNM and LNR, with relatively higher C-index, higher Schemper's PEV value and lower AIC value. For patients with no nodes involved, LODDS still performed significantly discriminatory utility. LODDS showed more accurate prognostic performance than LNM and LNR for post-surgery Siewert type II AEG, and it could help to detect survival heterogeneity for patients with no positive lymph nodes involved.

Comparison of prognostic nomograms based on different nodal staging systems in patients with resected gastric cancer

Purpose: Previous studies addressing the optimal nodal staging system in patients with resected gastric cancer have shown inconsistent results, and the optimal system for development of prognostic nomograms remains unclear. In this study, we compared prognostic nomograms based on the metastatic lymph node (MLN) count, lymph node ratio (LNR), and log odds of metastatic lymph nodes (LODDS) to predict the 5-year overall survival in patients with resected gastric cancer.

Methods: We analysed 15,320 patients with resected gastric cancer in the Surveillance, Epidemiology, and End Results (SEER) database between 1988 and 2010. Missing data were handled using multiple imputation. When assessed as a continuous covariate with restricted cubic splines, each MLN, LNR, and LODDS variable was incorporated into a nomogram with other significant prognosticators to predict the 5-year overall survival. A two-centre Chinese dataset (1,595 cases) was used as external validation data.

Results: The discriminatory abilities of the MLN-, LNR-, and LODDS-based nomograms were comparable (concordance indices: 0.744, 0.741, and 0.744, respectively, in the SEER set, P > 0.152 for all pairwise comparisons; 0.715, 0.712, and 0.713, respectively, in the Chinese set, P > 0.445 for all pairwise comparisons). The discriminatory abilities of the three nomograms were all superior to the American Joint Committee on Cancer (AJCC) TNM classification (concordance indices: 0.713, P < 0.001 for all in the SEER set; and 0.693, P < 0.001 for all in the Chinese set). The discriminatory abilities of the nomograms were comparable regardless of the number of nodes examined. Moreover, decision curve analyses indicated similar net benefits of using the nomograms.

Conclusion: MLN-, LNR-, and LODDS should be considered equally in the development of multivariate prognostic models and nomograms to refine the prediction of survival among patients with resected gastric cancer.

N staging: the role of the pathologist

Gastric cancer is the second cause of cancer-related mortality worldwide. Metastases, including lymph nodes ones, heavily influence the prognosis of this disease. The pathological detection of positive lymph nodes is pivotal for an optimal prognostication and clinical management of affected individuals. Several factors influence the pathological investigation of surgical specimens, ultimately affecting the number of retrieved lymph nodes and, with it, the reliability of N staging. The pathologist plays a central role in optimizing this process. Factors influencing lymph node retrieval and analysis will be herein reviewed, together with the procedures adopted for an optimal pathological analysis of lymph nodes in gastric cancer.

N staging system: tumor-node-metastasis and future perspectives

The correct staging of disease, with an exact definition of the extent of cancer at the diagnosis, is crucial in the planning of a specific treatment and in the assessment of real chances of cure. Cancer staging systems are expected to be accurate in the description of the severity of a patient's tumor on the basis of the extent of the primary neoplasm and of its spread, thus giving clinician tools to estimate prognosis and providing objective parameters to compare groups of patients in clinical studies. This last point is of wide importance in evaluating successful treatment strategies in oncology, and this is one of the issues that contributed to the development of stage-adapted therapies.

What is the most accurate lymph node staging method for perihilar cholangiocarcinoma? Comparison of UICC/AJCC pN stage, number of metastatic lymph nodes, lymph node ratio, and log odds of metastatic lymph nodes

BACKGROUND

We compared the prognostic performance of the International Union Against Cancer/American Joint Committee on Cancer (UICC/AJCC) 7th edition pN stage, number of metastatic LNs (MLNs), LN ratio (LNR), and log odds of MLNs (LODDS) in patients with perihilar cholangiocarcinoma (PCC) undergoing curative surgery in order to identify the best LN staging method.

METHODS

Ninety-nine patients who underwent surgery with curative intent for PCC in a single tertiary hepatobiliary referral center were included in the study. Two approaches were used to evaluate and compare the predictive power of the different LN staging methods: one based on the estimation of variable importance with prediction error rate and the other based on the calculation of the receiver operating characteristic (ROC) curve.

RESULTS

LN dissection was performed in 92 (92.9%) patients; 49 were UICC/AJCC pN0 (49.5%), 33 pN1 (33.3%), and 10 pN2 (10.1%). The median number of LNs retrieved was 8. The prediction error rate ranged from 42.7% for LODDS to 47.1% for UICC/AJCC pN stage. Moreover, LODDS was the variable with the highest area under the ROC curve (AUC) for prediction of 3-year survival (AUC = 0.71), followed by LNR (AUC = 0.60), number of MLNs (AUC = 0.59), and UICC/AJCC pN stage (AUC = 0.54).

CONCLUSIONS

The number of MLNs, LNR, and LODDS appear to better predict survival than the UICC/AJCC pN stage in patients undergoing curative surgery for PCC. Moreover, LODDS seems to be the most accurate and predictive LN staging method.

Comparison of different lymph node staging systems in prognosis of gastric cancer: a bi-institutional study from Hungary

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.

Seventh tumor-node-metastasis staging of gastric cancer: Five-year follow-up

Seventh tumor-node-metastasis (TNM) classification for gastric cancer, published in 2010, introduced changes in all of its three parameters with the aim to increase its accuracy in prognostication. The aim of this review is to analyze the efficacy of these changes and their implication in clinical practice. We reviewed relevant Literature concerning staging systems in gastric cancer from 2010 up to March 2016. Adenocarcinoma of the esophago-gastric junction still remains a debated entity, due to its peculiar anatomical and histological situation: further improvement in its staging are required. Concerning distant metastases, positive peritoneal cytology has been adopted as a criterion to define metastatic disease: however, its search in clinical practice is still far from being routinely performed, as staging laparoscopy has not yet reached wide diffusion. Regarding definition of T and N: in the era of multimodal treatment these parameters should more influence both staging and surgery. The changes about T-staging suggested some modifications in clinical practice. Differently, many controversies on lymph node staging are still ongoing, with the proposal of alternative classification systems in order to minimize the extent of lymphadenectomy. The next TNM classification should take into account all of these aspects to improve its accuracy and the comparability of prognosis in patients from both Eastern and Western world.

Influence of Total Lymph Node Count on Staging and Survival After Gastrectomy for Gastric Cancer: An Analysis From a Two-Institution Database in China

BACKGROUND

Although current guidelines suggest that 16 or more lymph nodes (LNs) are required for the appropriate staging of gastric cancer, the effect that the minimum number of examined LNs (eLNs) in the different types of gastrectomy has on survival remains unclear.

METHODS

This study retrospectively analyzed 2662 patients who underwent curative gastrectomy with D2 lymphadenectomy for gastric cancer at Fujian Medical University Union Hospital from January 2000 to December 2010 and randomly divided them into development (70 %, n = 1863) and validation (30 %, n = 799) data sets. An additional external validation was performed using the data set (n = 285) collected during the same period from the Sun Yat-sen University Cancer Center in Guangzhou, China. A hypothetical tumor-node-metastasis (TNM) classification (hTNM) was proposed based on eLNs and survival.

RESULTS

The mean numbers of nodes removed during radical distal and total gastrectomy were respectively 26 ± 9.6 and 29 ± 10.7 (p < 0.01). The optimal LN-count thresholds were determined to be 16 for patients who underwent curative distal gastrectomy and 21 for patients who underwent total gastrectomy. The hTNM staging system had higher linear trend and likelihood ratio χ ² scores and lower Akaike information criterion (AIC) values than the seventh American Joint Committee on Cancer (AJCC) TNM classification. Thus, the hTNM staging system exhibited superior prognostic stratification. Similar results were found in the two validation data sets.

CONCLUSION

A harvest of at least 21 LNs may represent a superior threshold for radical total gastrectomy (RTG) and could yield a better prognosis. For patients undergoing RTG, the hTNM staging system may predict survival more accurately and discriminatively. However, a validation from a Western institution is warranted.

Prognostic value of three different lymph node staging systems in the survival of patients with gastric cancer following D2 lymphadenectomy

The log odds of positive lymph nodes (LODDS) was defined as the log of the ratio between the number of positive lymph nodes and the number of negative lymph nodes, which is a novel and promising nodal staging system for gastric cancer. Here, we aimed to compare the prognostic effect of pN, lymph node ratio (LNR) and LODDS. The association between overall survival and pN, LNR and LODDS was retrospectively analysed. The discriminatory ability and monotonicity of gradients (linear trend χ (2) score), homogeneity ability (likelihood ratio test) and prognostic stratification ability (Akaike information criterion [AIC] and receiver operating characteristic [ROC] curve) were compared among three lymph node staging systems. The pN, LNR and LODDS were all identified as independent prognostic factors for gastric cancer patients in the multivariate analysis. LODDS showed the best prognostic performance (linear trend χ (2) score 266.743, likelihood ratio χ (2) test score 427.771, AIC value 5670.226, area under the curve (AUC) 0.793), followed by LNR and pN. In patients with different levels of retrieved lymph nodes (≤10, 11-14, 15-25 and >25), LODDS was the most powerful for prognostic prediction and discrimination of the heterogeneity among the subgroups. Significant differences in survival were observed among patients in different LODDS subgroups after being classified according to the pN and LNR classifications. LODDS appears to be a more powerful system for predicting the overall survival of gastric cancer patients, as compared to LNR and pN, and may serve as an alternative nodal staging system for gastric cancer.

Different lymph node staging systems in patients with gastric cancer from Korean: What is the best prognostic assessment tool?

To investigate whether the log odds of positive lymph nodes (LODDS) system is a more accurate prognostic tool than the number-based (pN) or ratio-based (rN) lymph node staging system in Korean patients with gastric cancer (GC).The LODDS is a recently proposed staging modality in surgical oncology. However, it is unclear whether LODDS is superior to the pN or rN system in terms of predicting the prognosis of GC patients who underwent radical gastrectomy with extended lymphadenectomy and had a greater number of retrieved lymph nodes.Clinicopathological data from 3929 patients who had undergone curative gastrectomy for GC were reviewed. In addition, overall survival rates according to pN and rN classification stratified by the LODDS were analyzed. A multivariate analysis of survival rate was performed using a Cox proportional hazard model.pN, rN, and LODDS were significantly correlated with 5-year survival rate. Spearman correlation test showed no correlation between LODDS and number of lymph nodes retrieved. The receiver operating characteristic (ROC) curves showed that the 3 staging systems had comparable prognostic accuracy (P < 0.05). Survival analysis according to pN and rN classification stratified by the LODDS staging system demonstrated that LODDS is superior to pN and rN.The LODDS is independently and significantly associated with the OS of Korean patients with GC, and its prognostic value is superior to that of the other lymph node staging systems in Korean patients.

Log Odds of Positive Lymph Nodes Predicts Survival in Patients After Resection for Esophageal Cancer

BACKGROUND

The number of lymph node metastases (LNMs) and the positive lymph node ratio (LNR) have been shown to be significant independent prognostic factors in predicting overall survival in patients with esophageal cancer. Our aim was to evaluate whether a novel prognostic indicator-the log odds of positive lymph nodes (LODDS)-predicts survival in esophageal cancer.

METHODS

Patients who underwent esophagectomy for esophageal cancer between 1988 and 2007 were identified from the Surveillance, Epidemiology, and End Results (SEER) database of 18 registries, and a Chinese patient cohort was subjected to validation. The prognostic efficacy of LNM, LNR, and LODDS was compared. Prognostic performance was measured using Harrell's C-index statistic, Schemper's proportion of explained variation, and the Akaike information criterion (AIC).

RESULTS

A total of 4,123 patients in the SEER database and 134 patients in the Chinese cohort met our criteria in this study. LODDS gave a better prognostic performance than either LNM or LNR in both the SEER database and the Chinese cohort. Multivariate analyses showed significant values for LNM, LNR, and LODDS as prognostic factors (p < 0.001). However, only LODDS was a significant prognostic factor regardless of the number of lymph nodes retrieved (p = 0.677). Furthermore, after stratification of patients with no nodes involved or all nodes involved, the values of LODDS still distinguished the heterogeneity efficiently.

CONCLUSIONS

LODDS predicts survival more accurately than either LNM or LNR in patients undergoing resection for esophageal cancer, especially for patients with an insufficient number of lymph nodes retrieved.

Prognostic Implications of Lymph Node Status for Patients With Gallbladder Cancer: A Multi-Institutional Study

BACKGROUND

Although the American Joint Committee on Cancer (AJCC) classification is the most accepted lymph node (LN) staging system for gallbladder adenocarcinoma (GBA), other LN prognostic schemes have been proposed. This study sought to define the performance of the AJCC LN staging system relative to the number of metastatic LNs (NMLN), the log odds of metastatic LN (LODDS), and the LN ratio (LNR).

METHODS

Patients who underwent curative-intent resection for GBA between 2000 and 2015 were identified from a multi-institutional database. The prognostic performance of various LN staging systems was compared by Harrell's C and the Akaike information criterion (AIC).

RESULTS

Altogether, 214 patients with a median age of 66.7 years (interquartile range [IQR] 56.5-73.1) were identified. A total of 1334 LNs were retrieved, with a median of 4 (IQR 2-8) LNs per patient. Patients with LN metastasis had an increased risk of death (hazard ratio [HR] 1.87; 95 % confidence interval [CI] 1.24-2.82; P = 0.003) and recurrence (HR 2.28; 95 % CI 1.37-3.80; P = 0.002). In the entire cohort, LNR, analyzed as either a continuous scale (C-index, 0.603; AIC, 803.5) or a discrete scale (C-index, 0.609; AIC, 802.2), provided better prognostic discrimination. Among the patients with four or more LNs examined, LODDS (C-index, 0.621; AIC, 363.8) had the best performance versus LNR (C-index, 0.615; AIC, 368.7), AJCC LN staging system (C-index, 0.601; AIC, 373.4), and NMLN (C-index, 0.613; AIC, 369.5).

CONCLUSIONS

Both LODDS and LNR performed better than the AJCC LN staging system. Among the patients who had four or more LNs examined, LODDS performed better than LNR. Both LODDS and LNR should be incorporated into the AJCC LN staging system for GBA.

Lymph node ratio as a novel and simple prognostic factor in advanced gastric cancer

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.

Prognostic Performance of Different Lymph Node Staging Systems After Curative Intent Resection for Gastric Adenocarcinoma

OBJECTIVE

To compare the prognostic performance of American Joint Committee on Cancer/International Union Against Cancer seventh N stage relative to lymph node ratio (LNR), log odds of metastatic lymph nodes (LODDS), and N score in gastric adenocarcinoma.

BACKGROUND

Metastatic disease to the regional LN basin is a strong predictor of worse long-term outcome following curative intent resection of gastric adenocarcinoma.

METHODS

A total of 804 patients who underwent surgical resection of gastric adenocarcinoma were identified from a multi-institutional database. The relative discriminative abilities of the different LN staging/scoring systems were assessed using the Akaike's Information Criterion (AIC) and the Harrell's concordance index (c statistic).

RESULTS

Of the 804 patients, 333 (41.4%) had no lymph node metastasis, whereas 471 (58.6%) had lymph node metastasis. Patients with ≥N1 disease had an increased risk of death (hazards ratio = 2.09, 95% confidence interval: 1.68-2.61; P < 0.001]. When assessed using categorical cutoff values, LNR had a somewhat better prognostic performance (C index: 0.630; AIC: 4321.9) than the American Joint Committee on Cancer seventh edition (C index: 0.615; AIC: 4341.9), LODDS (C index: 0.615; AIC: 4323.4), or N score (C index: 0.620; AIC: 4324.6). When LN status was modeled as a continuous variable, the LODDS staging system (C index: 0.636; AIC: 4304.0) outperformed other staging/scoring systems including the N score (C index: 0.632; AIC: 4308.4) and LNR (C index: 0.631; AIC: 4225.8). Among patients with LNR scores of 0 or 1, there was a residual heterogeneity of outcomes that was better stratified and characterized by the LODDS.

CONCLUSIONS

When assessed as a categorical variable, LNR was the most powerful manner to stratify patients on the basis of LN status. LODDS was a better predicator of survival when LN status was modeled as a continuous variable, especially among those patients with either very low or high LNR.

Effect of Lymph Node Count on Pathological Stage III Rectal Cancer with Preoperative Radiotherapy

Lymph node (LN) status after surgery for rectal cancer is affected by preoperative radiotherapy. The purpose of this study was to perform a population-based evaluation of the impact of pathologic LN status after neoadjuvant radiotherapy on survival. A total of 1,650 patients receiving neoadjuvant chemotherapy in Surveillance, Epidemiology, and End Results Program (SEER)-registered ypIII stage rectal cancer was analyzed. We identified the optimal cutoff for retrieved LNs as 10 (χ2 = 14.006, P < 0.001), which was validated as an independent prognosis factors in a Cox regression model. Further analysis showed that the LN count was only a prognosis factor with the number from 8 to 16(except for 13).After the number 16, the 5-year survival rate decreased gradually. Collectively, our results confirmed that the number of LNs in yp III stage rectal patients was a prognosis factor only with the numbers from 8 to 16(except for 13). Using the total mesorectal excision technique with an adequate pathologic examination, a large number of LNs retrieved (≥17) might indicate worse tumor response grade and poorer survival.

Overall Survival Is Impacted by Birthplace and Not Extent of Surgery in Asian Americans with Resectable Gastric Cancer

Survival from gastric cancer in the USA still lags behind Asia. Genetic, environmental, and tumor biology differences, along with extent of surgery have been implicated. Our aim was to evaluate survival outcomes in Asian-American gastric cancer patients undergoing surgical resection by comparing place of birth and clinicopathologic characteristics (including evaluation of 15 lymph nodes).The Surveillance, Epidemiology, and End Results database was queried to identify patients treated surgically for gastric cancer with curative intent in the USA (2000-2010). US-born versus foreign-born Asian-American patients were analyzed for survival. Secondary comparison was made to non-Asian patients. Stage IV and non-surgical patients were excluded. Of 10,089 patients identified, 1467 patients were Asian: 271 were born in the USA, and 1196 were born outside the USA. Median survival was 32 months for non-Asians and 29 months for US-born Asians versus 61 months for Asian immigrants (p < 0.001). On multivariable analysis of overall survival in Asian patients, only US birthplace, older age, and higher stage yielded a significantly poorer outcome. Asian-American patients have a worse prognosis if born in the USA. Anatomic and surgical differences do not explain this disparity; environmental factors may be responsible.

Increased number of negative lymph nodes is associated with improved cancer specific survival in pathological IIIB and IIIC rectal cancer treated with preoperative radiotherapy

Preoperative radiation significantly decreases the number of retrieved lymph nodes (LNs) in rectal cancer, but little is known with respect to the prognostic significance of negative LN (NLN) counts under these circumstances. In this study, Surveillance, Epidemiology, and End Results Program (SEER)-registered ypIII stage rectal cancer patients, and patients from Fudan University Shanghai Cancer Center (FDSCC) were combined and analyzed. The results showed that the survival rate of patients with n (cutoff) or more NLNs increased gradually when n ranged from two to nine. After n reached 10 or greater, survival rates were approximately equivalent. Furthermore, the optimal cutoff value of 10 was validated as an independent prognostic factor in stage ypIIIB and ypIIIC patients by both univariate and multivariate analysis (P < 0.001); the number of NLNs could also stratify the prognosis of ypN(+) patients in more detail. Patients in the FDSCC set validated these findings and confirmed that NLN count was not decreased in the good tumor regression group relative to the poor tumor regression group. These results suggest that NLN count is an independent prognostic factor for ypIIIB and ypIIIC rectal cancer patients, and, together with the number of positive LNs, this will provide better prognostic information than the number of positive LNs alone.

Usefulness of the log odds of positive lymph nodes to predict and discriminate prognosis in gastric carcinomas

BACKGROUND

The lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS) have been proposed to minimize the stage migration phenomenon. The value of the LODDS and LNR staging systems to predict and discriminate prognosis was assessed and compared to the International Union Against Cancer (UICC) TNM classification (pN).

METHODS

Three hundred and twenty-six patients with gastric carcinoma were retrospectively studied. Disease-specific survival rates were calculated for every pN, LNR, and LODDS category.

RESULTS

Four LNR categories (0, 1-25, 26-75, and >76 %) and four LODDS categories (-5 to -3, > -3 to -1, > -1 to 3, and >3 to 5) were established. In the multivariate analysis, only the stage pT3-4 versus pT1-2 (HR 1.88, 95 % CI 1.11-3.20, p=0.02) and LODDS as continuous variable (HR 1.40, 95 % CI 1.21-1.61, p<0.001) remained as independent prognostic factors. In patients with <16 lymph nodes retrieved, only the LODDS system could discriminate different disease-specific survival curves for every category. LODDS categories were able to discriminate subgroups with different prognoses in pN stages and LNR categories.

CONCLUSIONS

The LODDS staging system was superior to the pN classification and LNR system to discriminate risk prognosis especially in patients with an insufficient number of retrieved lymph nodes.

Prognostic value of metastatic lymph node ratio as an additional tool to the TNM stage system in gastric cancer

BACKGROUND

Gastric cancer is one of most common malignancies in the world. Currently the prognostic prediction is entirely based on the TNM staging system. In this study, we evaluated whether metastatic lymph node ratio (rN) at the time of surgery would improve the prognostic prediction in conjunction with the TNM staging system.

METHODS

This retrospective study includes 745 patients, who had been referred for surgery due to gastric cancer between 1995 and 2007 and had at least 15 lymph nodes examined at the time of surgery without preoperative treatment. Clinicopathologic features and overall survival were analyzed using univariate and multivariate modes to identify the risk factors for overall survival.

RESULTS

Median overall survival of all patients analyzed is 57.8 months and 5-year overall survival is 49.5%. Tumor site, macroscopic type, pTNM stage, and rN stage are identified as independent prognostic factors. Increased positive lymph node ratio correlates with shorter survival in all patients and in each T and N stage. In stage III gastric cancer patients, rN stage shows additional prognostic value on overall survival (p < 0.001).

CONCLUSIONS

rN stage is a simple and promising prognostic factor of gastric cancer after surgery in addition to the TNM stage system especially in stage III patients. But the independent prognostic value of rN stage in stage I, II and IV gastric cancer is yet to be determined.