Prognostic significance of the metastatic lymph node ratio in gastric cancer patients

Prognostic Significance of Lymph Node Ratio (LNR) in Gastric Cancer in Predicting Postoperative Complications and Survival: A Single-Center Study

BACKGROUND/OBJECTIVES

The Lymph Node Ratio (LNR) index is the proportion of lymph nodes with present metastases to lymph nodes removed and examined. This is an additionally established parameter for predicting the prognosis of gastric cancer patients. The most popular cancer classification, TNM, describes only the number of affected lymph nodes. It can result in a negative overestimation of the prognosis of patients with gastric cancer if the number of nodes examined is relatively limited.

METHODS

In this study, we retrospectively analyzed 194 patients diagnosed with gastric cancer operated on between 2017 and 2021 at the Clinical Department of Oncological Surgery, University Centre of General and Oncological Surgery of the University Clinical Hospital in Wroclaw. In total, 133 patients underwent gastrectomy with D2 lymphadenectomy and 61 remaining patients had the resection procedure abandoned due to an unresectable lesion. The LNR index was calculated based on histopathological examination, and postoperative complications were assessed using the Clavien-Dindo (C-D) scale. Statistical analysis was performed regarding the dependence of LNR on the following patient characteristics: sex, age, TNM features, tumor stage, tumor location, performed procedure, chemotherapy application, C-D complication rate, and survival rate.

RESULTS

The value of the LNR index significantly depends on TNM features (p < 0.05), clinical tumor stage (p < 0.05), and patient survival (p < 0.05), while no statistically significant relationship with C-D complication rate was demonstrated.

CONCLUSIONS

The LNR index is a relevant parameter in predicting prognosis and survival time in gastric cancer patients, but future studies on larger and differentiated groups of patients could further confirm its usefulness in the development of guidelines.

Reliability of the Lymph Node Ratio in the Prediction of Gastric Cancer Survival

Background. Lymph node metastasis is the major determinant factor in the prognosis of gastric cancer. There is still no definite consensus on the lymph node number that should be harvested during gastric cancer surgery. Lymph Node Ratio (LNR) is defined as the ratio of metastatic nodes to the total number of pathologically examined lymph nodes. LNR has been proposed to be a sensitive prognostic factor in patients with gastric cancer. In this study the reliability of the LNR is tested for being a prognostic factor in gastric cancer survival. Methods. Medical records of 244 patients, with neither distant metastases nor neoadjuvant treatment underwent curative gastrectomy, were analyzed retrospectively in terms of survival according to the lymph node ratio (LNR). Patients were divided in two groups by using LNR cut-off value. Results. LNR of 0.4 was proved to be the best cut-off value to predict the prognosis of patients with gastric cancer. Univariate and multivariate analysis revealed that age over 65 (p < 0.001), and LNR ≥ 0.4 (p = 0.02) were independent factors in gastric cancer survival. Patients with LNR ≥ 0.4 presented with worse outcomes regarding other prognostic parameters (tumor differentiation, tumor diameter, lymphovascular invasion or perineural invasion), despite similar numbers of lymph nodes being harvested in both groups during surgery. Conclusion. Lymph node ratio is a reliable parameter to predict the survival in gastric cancer.

What is the Role of Nodal Ratio as a Prognostic Factor for Gastric Cancer Nowadays? Comparison with New TNM Staging System and Analysis According to the Number of Resected Nodes

Nodal ratio (NR) has been demonstrated to be an important prognostic factor in patients with gastric cancer. The aim of this study is to evaluate the prognostic role of nodal ratio comparing it with the new TNM (2010) classification. One hundred forty-two patients were submitted to potentially curative gastrectomy for cancer. Patients with low performance status underwent D1.5 lymphadenectomy, whereas the other patients underwent D2–D2.5 lymphadenectomy. Nodal staging was classified according to 2010 International Union Against Cancer/American Joint Committee on Cancer classification. Kaplan-Meier method was used to evaluate survival, stratified for nodal classes and nodal status. Total gastrectomy was performed in 39 per cent of cases and distal gastrectomy in 61 per cent. Mean number of resected nodes was 25.5. Whereas N status was strictly related to the number of resected nodes, the NR was independent from the extension of the lymphadenectomy. Overall five-year survival was 81 per cent for N0 patients, 72 per cent for N1, and 26 and 23 per cent for N2 and N3, respectively. Patients with NR0 had 81 per cent five-year survival, whereas NR1 67 per cent, NR2 51 per cent, and NR3 22 per cent. NR seems to be a simple method to predict the prognosis of patients with gastric cancer; unlike N status, it is independent from the number of resected nodes, and therefore it is particularly useful in case of inadequate lymphadenectomy.

The significance of preoperative serum carcinoembryonic antigen levels in the prediction of lymph node metastasis and prognosis in locally advanced gastric cancer: a retrospective analysis

Background

In this study, we aimed to investigate the preoperative serum carcinoembryonic antigen (CEA) in the diagnosis of positive lymph node metastasis (LNM), and to evaluated the relationship between CEA and survival in patients with locally advanced gastric cancer (LAGC).

Methods

The significance of the preoperative serum CEA level for the diagnose of LAGC and prediction of LNM was determined using the receiver operating characteristic (ROC) curve. The areas under the ROC of CEA were compared with those of other tumor markers or imaging examination including CT and MRI. Logistic regression was utilized to identify the risk factors predicting positive LNM. Independent prognosis factors were evaluated using univariate and multivariate COX regression analyses.

Results

The ROC curves showed that the AUCs of CEA, CA199, and CA125 for diagnosing LAGC were 0.727, 0.594, and 0.566. When used to predict LNM, the AUC of CEA, CA199 and CA125 were 0.696, 0.531, and 0.588. Logistic regression analysis demonstrated that preoperative serum CEA were significantly associated with positive LNM. On combining imaging examination with CEA, the sensitivity and specificity were 85.3 and 79.4%, respectively, with the AUC equal to 0.853. The combination of CEA and imaging examination preformed the highest levels of AUC and sensitivity for diagnosing LNM, which is significantly higher than using either of them alone. Although patients with abnormal CEA have a poor prognosis, two models of multivariate analysis showed that CEA was not the independent prognosis factor for survival.

Conclusions

CEA can be used to diagnose gastric cancer and determine whether it has LNM. Moreover, combined with CEA could improve the diagnostic sensitivity of imaging examination for lymph node involvement.

Study of Survival in Gastric Cancer with Emphasis on Lymph Node Status as an Independent Prognostic Factor

Background: Lymph node status in gastric cancer is known as an independent prognostic factor that guides the surgical and oncological treatment and independently influences long-term survival. Several studies suggest that the lymph node ratio has a greater importance in survival than the number of metastatic lymph nodes.

Aim: The aim of this study was to evaluate the clinical and morphological factors that can influence the survival of gastric cancer patients, with an emphasis on nodal status and the lymph node ratio.

Material and methods: We conducted a retrospective study in which 303 patients with gastric cancer admitted to the Department of Surgery of the Mureș County Hospital between 2008 and 2018 were screened for study enrolment. Data were obtained from the records of the department and from the histopathological reports. The examined variables included: age, gender, tumor localization, T stage, histological type, grade of differentiation, surgical procedure, lympho-vascular invasion, excised lymph nodes, metastatic lymph nodes, lymph node ratio. After screening, the study included a total number of 100 patients, for which follow-up data was available.

Results: The mean age of the study population was 66.43 ± 10 years, and 71% were males. The average survival period was 21.42 months. Statistical analysis showed that the localization of the tumor (p = 0.021), vascular invasion (p ---lt---0.001), T (p = 0.004) and N (p ---lt---0.001) stages, type of surgery (partial gastrectomy 59% vs. total gastrectomy 41%, p = 0.005), as well as the lymph node ratio (p ---lt---0.001) were prognostic factors for survival in patients with gastric cancer undergoing surgical therapy.

Conclusions: The survival of gastric cancer patients is significantly influenced by tumor localization, T stage, vascular invasion, type of surgery, N stage and the lymph node ratio based on univariate analysis. Also, the lymph node ratio proved to be an independent prognostic factor for survival.

Prognostic Significance of Lymph Node Ratio in Ovarian Cancer

Lymphadenectomy is critical in the clinical prognosis of ovarian cancer patients. Therefore, we assessed whether lymph node ratio (LNR) has predictive value on overall survival (OS) of patients with serous epithelial ovarian cancer (SEOC). A total of 7,815 eligible SEOC patients were identified from the Surveillance, Epidemiology, and End Results (SEER) database, who underwent surgical resection between 1973 and 2013. We used the time-dependent receiver operating characteristic (ROC) curve and the area under curve to determine the optimal cut-off value of LNR. The predictive role of LNR was analyzed by Cox proportional hazards regression model. The effects of LNR and positive lymph nodes (PLN) on OS were evaluated by comparing the time-dependent ROC curves. The time-dependent ROC curves showed that the optimal LNR cut-off value was 42.0% for nodal-positive SEOC. As shown in Kaplan-Meier survival curves, survival was significantly poorer for all patients with LNR≥42.0% (log-rank test: P<0.0001), regardless of the stage. In the multivariate Cox analysis, LNR≥42.0% remained a significant and independent predictor of mortality risk for all patients [hazards ratio: 1.526, 95% confidence interval: 1.415-1.647; P<0.0001], compared with those LNR<42.0%. These results suggest that LNR, rather than the number of PLN or stage, could be regarded as a promising predictor of mortality risk, particularly in stage-III SEOC patients.

Which method is more suitable for advanced gastric cancer with enlarged lymph nodes, laparoscopic radical gastrectomy or open gastrectomy?

BACKGROUND

The oncologic outcome of laparoscopic radical gastrectomy (LG) with open radical gastrectomy (OG) for gastric cancer with preoperative enlarged lymph nodes (LNs) remains ambiguous.

METHODS

The long-term outcomes of LG (n = 855) versus OG (n = 154) in gastric adenocarcinoma patients were analyzed retrospectively. Patients were stratified according to enlarged (> 10 mm) and small (≤ 10 mm) LNs (ELN and SLN) based on the long-axis diameter of the LNs.

RESULTS

The violin plot indicates that the distribution of ELN size was similar between two groups. Survival curves demonstrated that the overall survival (OS) in LG is enhanced compared with OG (p = 0.034). A stratified analysis revealed that the OS was better in the LG group compared with the OG group for patients with ELNs (p = 0.038). In a forest map analysis, the actual 3-year OS rate for LG was significantly increased compared with OG in enlarged suprapancreatic LN (ESLNs) patients. Stratified analysis based on different diameters of ESLNs revealed that the actual 3-year OS and cancer-specific survival (CSS)rate for LG was significant increased compared to OG with a diameter from 1.0 to 1.9 cm for pII or pIII stage patients. However, the actual 3-year OS and CSS rate for LG was significantly reduced compared with OG when the size exceeded 2.5 cm.

CONCLUSIONS

For advanced gastric cancer with an ESLN diameter from 1.0 to 1.9 cm, LG could be chosen preferentially; nevertheless, LG is not safe if ESLN are > 2.5 cm.

Integrated analysis of the prognostic role of the lymph node ratio in node-positive gastric cancer: A meta-analysis

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.

The H19-PEG10/IGF2BP3 axis promotes gastric cancer progression in patients with high lymph node ratios

We previously demonstrated that the lymph node ratio (LNR) is a prognostic factor associated with EGFR expression, among first priority genes amplified or overexpressed in cancer. Here, we investigated the associations between high LNR and second, third, and fourth priority genes. We performed mRNA expression microarray analysis of tumor tissue from patients with stage III gastric cancer and high or low LNRs. Candidate high LNR-associated genes were further evaluated in 39 patients with stage III gastric cancer. The functional relevance of these genes was evaluated in gastric cancer cell lines. We focused on five genes: H19,PEG10, IGF2BP3, CD177, and PGA3. H19 and PEG10 were confirmed as high LNR-associated genes. H19, PEG10, and IGF2BP3 were found to promote each other’s expression. Knocking down H19 or PEG10 using RNAi decreased cell proliferation, invasion, anchorage-independent growth, and chemoresistance. These genes had a mutual relationship in MKN7 cells. H19 knockdown decreased expression of epithelial-mesenchymal transition-associated genes in MKN74 cells to suppress transformation. Thus, H19 promotes epithelial-mesenchymal transition in gastric cancer and is a potential therapeutic target.

Value and impact factors of multidetector computed tomography in diagnosis of preoperative lymph node metastasis in gastric cancer: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Multidetector computed tomography (MDCT) exhibited wide ranges of sensitivities and specificities for lymph node assessment of gastric cancer (GC) in several individual studies. This present meta-analysis was carried out to evaluate the value of MDCT in diagnosis of preoperative lymph node metastasis (LNM) and to explore the impact factors that might explain the heterogeneity of its diagnostic accuracy in GC.

METHODS

A comprehensive search was conducted to collect all the relevant studies about the value of MDCT in assessing LNM of GC within the PubMed, Cochrane library and Embase databases up to Feb 2, 2016. Two investigators independently screened the studies, extracted data, and evaluated the quality of included studies. The sensitivity, specificity, and area under ROC curve (AUC) were pooled to estimate the overall accuracy of MDCT. Meta-regression and subgroup analysis were carried out to identify the possible factors influencing the heterogeneity of the accuracy.

RESULTS

A total of 27 studies with 6519 subjects were finally included. Overall, the pooled sensitivity, specificity, and AUC were 0.67 (95% CI: 0.56-0.77), 0.86 (95% CI: 0.81-0.90), and 0.86 (95% CI: 0.83-0.89), respectively. Meta-regression revealed that MDCT section thickness, proportion of serosal invasion, and publication year were the main significant impact factors in sensitivity, and MDCT section thickness, multiplanar reformation (MPR), and reference standard were the main significant impact factors in specificity. After the included studies were divided into 2 groups (Group A: studies with proportion of serosa-invasive GC subjects ≥50%; Group B: studies with proportion of serosa-invasive GC subjects <50%), the pooled sensitivity in Group A was significantly higher than in Group B (0.84 [95% CI: 0.75-0.90] vs 0.55 [95% CI: 0.41-0.68], P < .01). For early gastric cancer (EGC), the pooled sensitivity, specificity, and AUC were 0.34 (95% CI: 0.15-0.61), 0.91 (95% CI: 0.84-0.95), and 0.83 (95% CI: 0.80-0.86), respectively.

CONCLUSION

To summarize, MDCT tends to be adequate to assess preoperative LNM in serosa-invasive GC, but insufficient for non-serosa-invasive GC (particularly for EGC) owing to its low sensitivity. Proportion of serosa-invasive GC subjects, MDCT section thickness, MPR, and reference standard are the main factors influencing its diagnostic accuracy.

Lymph node ratio as a prognostic factor in gastric cancer patients following D1 resection. Comparison with the current TNM staging system

INTRODUCTION

Nodal ratio (NR) has been demonstrated to be an independent prognostic factor in patients with gastric cancer. We evaluated the prognostic role of NR comparing it with the current TNM (2010) classification in gastric cancer patients treated with curative (R0) D1 resection.

MATERIALS AND METHODS

We retrospectively reviewed 110 patients who underwent R0 resection for gastric cancer at University Hospital of Larissa between 2002 and 2011. All patients had a D1 lymphadenectomy plus the nodes along the left gastric artery. Factors affecting survival as well as correlations between the N status, NR status and resected nodes were investigated.

RESULTS

In univariate analysis the N and NR status but not the numbers of retrieved nodes were significant prognostic factors. Inside N1 and N2 categories, patients with different NR groups were present and survival of some of these subpopulations was statistically different at long-rank test. There was a correlation between the nodes retrieved and N status but not with the NR category. In multivariate analysis both N status (HR=1.45; 95% C.I. = 1.19-1.89) and NR (HR=4.53; 95% C.I. = 1.86-11.03) found to be independent prognostic factors of survival.

CONCLUSION

Prognostic significance of N status and NR status was comparable. Unlike N status, NR is independent by the number of resected nodes, and therefore it is particularly useful in case of conventional lymphadenectomy.

Do preoperative enlarged lymph nodes affect the oncologic outcome of laparoscopic radical gastrectomy for gastric cancer?

BACKGROUND

To investigate the long-term outcome of laparoscopic radical gastrectomy (LAG) for gastric cancer (GC) with preoperative enlarged lymph nodes (LNs).

MATERIALS AND METHODS

We retrospectively collected data on 855 patients who underwent LAG for GC. The patients were divided into large (>10 mm) and small (≤10 mm) LN groups (LG and SG) based on the preoperative size of the LNs. The outcomes were compared using a 1:1 propensity score-matching method. The enlarged LNs were divided into five areas according to their location.

RESULTS

Before matching, the LG was associated with more retrieved LNs than the SG, whereas after matching, the numbers of LNs retrieved were similar. These numbers remained similar as the number of areas with enlarged LNs increased. Before matching, patients in the LG demonstrated a significantly lower 3-year overall survival rate than those in the SG (p < 0.001). Additionally, in the LG, 3-year overall survival rates were similar among patients with different total numbers of areas with enlarged LNs. After matching, the 3-year overall survival rate of the LG was close to that of the SG (81.1% vs. 72.4%, p = 0.066). A stratified analysis according to the only independent prognostic factor (pTNM stage) demonstrated that the 3-year overall survival rates at each stage were similar between the LG and SG.

CONCLUSIONS

LAG has similar oncologic outcomes for GC with or without preoperative enlarged LNs in the same tumor stage. Furthermore, the total number of areas with enlarged LNs has no impact on the long-term outcome.

A long non-coding RNA signature to improve prognosis prediction of gastric cancer

BACKGROUND

Increasing evidence suggests long non-coding RNAs (lncRNAs) are frequently aberrantly expressed in cancers, however, few related lncRNA signatures have been established for prediction of cancer prognosis. We aimed at developing alncRNA signature to improve prognosis prediction of gastric cancer (GC).

METHODS

Using a lncRNA-mining approach, we performed lncRNA expression profiling in large GC cohorts from Gene Expression Ominus (GEO), including GSE62254 data set (N = 300) and GSE15459 data set (N = 192). We established a set of 24-lncRNAs that were significantly associated with the disease free survival (DFS) in the test series.

RESULTS

Based on this 24-lncRNA signature, the test series patients could be classified into high-risk or low-risk subgroup with significantly different DFS (HR = 1.19, 95 % CI = 1.13-1.25, P < 0.0001). The prognostic value of this 24-lncRNA signature was confirmed in the internal validation series and another external validation series, respectively. Further analysis revealed that the prognostic value of this signature was independent of lymph node ratio (LNR) and postoperative chemotherapy. Gene set enrichment analysis (GSEA) indicated that high risk score group was associated with several cancer recurrence and metastasis associated pathways.

CONCLUSIONS

The identification of the prognostic lncRNAs indicates the potential roles of lncRNAs in GC biogenesis. Our results may provide an efficient classification tool for clinical prognosis evaluation of GC.

Serum fibrinogen levels are positively correlated with advanced tumor stage and poor survival in patients with gastric cancer undergoing gastrectomy: a large cohort retrospective study

BACKGROUND

Platelet and blood coagulation abnormalities frequently occur in cancer patients. Fibrinogen is an important hemostatic factor that regulates the hemostatic pathway. Hyperfibrinogenemia is increasing recognized as an important risk factor influencing cancer development and outcome. However, few reports have investigated the prognostic potential of fibrinogen for predicting the survival of gastric cancer (GC) patients. The primary aim of this study was to evaluate the usefulness of preoperative serum fibrinogen as a biomarker for predicating tumor progression and survival of patients with GC.

PATIENTS AND METHODS

This retrospective study was conducted in GC patients who underwent gastrectomy from 2005 to 2007. Patient demographics, clinicopathological characteristics, preoperative plasma fibrinogen levels and median survival time (MST) were analyzed. Univariate and multivariate proportional hazard analysis of risk factors were used.

RESULTS

This study included 1196 patients (885 males and 311 females) with GC, more than half of whom had advanced GCs. Radical lymph node dissection was performed in 71.6 % of these patients. MST was 41.9 ± 32.4 months. Patient survival was significantly affected by family GC history (p <0.05), lymph node dissection mode (p <0.001), tumor size (≥5 cm; p <0.001), tumor location (p < 0.001), poor tumor differentiation (p <0.001), tumor histologic classification (p <0.001), extent of tumor invasion (p <0.001), number of metastatic lymph nodes (p <0.001), advanced stage of disease (p <0.001), extended operation duration (>150 min; p <0.001), higher operative bleeding volume (>200 ml; p <0.001), postoperative transfusion, preoperative serum fibrinogen levels, CEA levels and CA 19-9 levels (p <0.001). Multivariate analysis indicated that the independent prognostic factors significantly associated with poor survival included non-radical lymph node dissection, palliative lymph node dissection, multi-organ involvement, advanced TNM stages, poor tumor differentiation, higher preoperative serum fibrinogen levelsand higher CA19-9 levels.

CONCLUSIONS

Serum fibrinogen levels are positively correlated with advanced tumor stages and poor survival in GC patients undergoing gastrectomy. Preoperative plasma fibrinogen levels are an independent risk factor for survival in these patients. Serum fibrinogen is a useful biomarker for patients with clinically advanced GC.

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.

Inverse association between visceral obesity and lymph node metastasis in gastric cancer

BACKGROUND

The relationship between fat distribution and lymph node metastasis has not been well studied. The goal of this study was to determine the impact of visceral obesity on lymph node metastasis in gastric cancer.

MATERIALS AND METHODS

Metastatic lymph node ratio (MLR) was defined as the number of involved nodes by tumor divided by the total number of resected lymph nodes. Visceral (VFA) and subcutaneous fat areas (SFA) were determined by measuring abdominal fat volume distribution via CT scan, and visceral obesity was defined as a VFA to total fat area ratio (V/T) >0.29.

RESULTS

With lymph node metastasis as a dependent variable, the following factors were significant in multivariate analysis among 495 patients: pathologic T stage (P < 0.001), lympho-vascular invasion (P < 0.001), and V/T (hazard ratio (HR) = 0.455, 95 % confidence interval (CI) = 0.263-0.786, P = 0.005). Similarly, when MLR was the dependent variable in multivariate analysis, MLR was significantly associated with lympho-vascular invasion (HR = 2.222, 95 % CI = 1.149-4.296, P = 0.018), and V/T (HR = 0.247, 95 % CI = 0.133-0.458, P < 0.001).

CONCLUSIONS

Visceral obesity defined by higher visceral to total fat area ratio was significantly associated with decreased MLR.

Accuracy of multidetector-row CT in diagnosing lymph node metastasis in patients with gastric cancer

OBJECTIVES

The purpose of this study was to determine the optimal cut-off value of lymph node size for diagnosing metastasis in gastric cancer with multidetector-row computed tomography (MDCT) after categorizing perigastric lymph nodes into three regions.

METHODS

The study included 90 gastric cancer patients who underwent gastrectomy. The long-axis diameter (LAD) and short-axis diameter (SAD) of all visualized lymph nodes were measured with transverse MDCT images. The locations of lymph nodes were categorized into three regions: lesser curvature, greater curvature, and suprapancreatic. The diagnostic value of lymph node metastasis was assessed with receiver operating characteristic (ROC) analysis.

RESULTS

The area under the curve was larger for SAD than LAD in all groups. The optimal cut-off values of SAD were determined as follows: overall, 9 mm; differentiated type, 9 mm; undifferentiated type, 8 mm; lesser curvature region, 7 mm; greater curvature region, 6 mm; and suprapancreatic region, 9 mm. The diagnostic accuracies for lymph node metastasis using individual cut-off values were 71.1% based on histological type and 76.6% based on region of lymph node location.

CONCLUSIONS

The diagnostic accuracy of lymph node metastasis in gastric cancer was improved by using individual cut-off values for each lymph node region.

KEY POINTS

• Multidetector-row computed tomography is widely used to predict pathological nodal status. • An optimal cut-off value of lymph node size has not been determined. • Cut-off values were assessed according to histology and nodal location. • The optimal cut-off values differed based on histology and nodal location. • Diagnostic accuracy was improved by using individual cut-off values for each region.

Prognostic impact of lymph node retrieval and ratio in gastric cancer: a U.S. single center experience

INTRODUCTION

Increased lymph node (LN) retrieval for gastric cancer has been associated with improved overall survival (OS). This study examines the impact of number of examined LN (eLN) and lymph node ratio.

METHODS

Patients referred for surgical care of gastric cancer were stratified by number of eLN, positive LNs (LN+), and lymph node ratio (LN+/eLN). Clinicopathologic factors were compared; OS and disease-free survival (DFS) were the primary endpoints.

RESULTS

From 1997 to 2012, 222 patients, median age 67 (range, 17-92) years, were analyzed. Of 220 (99 %) explored, 164 (74 %) underwent resection. Median OS was 22 (range, 0.3-140) months. Perineural and lymphovascular invasion and poor differentiation adversely affected OS, p < 0.05. A median 14 eLN (range, 0-45), with median 1 LN+ (range, 0-31), was observed. There were no OS or DFS differences when comparing the eLN groups. Both OS and DFS were impacted by LN+. Lymph node ratio demonstrated worse median OS with increasing ratio: 49 months (0) to 37 months (0.01-0.2), 27 months (0.21-0.5), and 12 months (>0.5), p < 0.0001. DFS was similar: 35 months (0), decreasing to 22 months (0.01-0.2), 13 months (0.21-0.5), and 7 months (>0.5), p < 0.0001.

CONCLUSION

Number of eLN did not impact survival, while LN+ adversely affected survival. Lymph node ratio may predict prognosis better than number of eLN or LN+ in gastric cancer.

Ratio between negative and positive lymph nodes is suitable for evaluation the prognosis of gastric cancer patients with positive node metastasis

OBJECTIVE

To date, there is no consensus to evaluate the most appropriate category of the nodal metastasis for precise predication the prognosis of gastric cancer patients with positive node metastasis after curative surgery.

METHODS

We retrospectively analyzed the clinicopathologic characteristics and overall survival (OS) of 299 gastric cancer patients with positive node metastasis after curative surgery for evaluation the optimal category of the nodal metastasis.

RESULTS

With the univariate and multivariate survival analyses, the depth of primary tumor invasion was identified as the independent predicators with the OS of 299 gastric cancer patients with nodal metastasis postoperatively, as were the number of positive lymph nodes (PLNs), the number of negative lymph nodes (NLNs), and the ratio between negative and positive lymph nodes (RNPL). The RNPL was identified to be more suitable for predication the OS of gastric cancer patients with positive node metastasis than the ratio between positive and dissected lymph nodes (RPDL) by using the stratum procedure of survival analysis. Besides, we found both PLNs and NLNs were independently correlated with OS of gastric cancer patients with nodal metastasis when RNPL, instead of RPDL, was controlled in the partial correlation model.

CONCLUSIONS

RNPL, a new category of the nodal metastasis, was suitable for predication the OS of gastric cancer patients with nodal metastasis after curative resection, as were the PLNs, and NLNs.

Metastatic lymph node ratio versus number of metastatic lymph nodes as a prognostic factor in gastric cancer

OBJECTIVE

Knowledge of prognostic factors in gastric cancer is essential to decide on single patient management. We aim to establish the value of lymph node ratio compared to lymph node involvement in the prediction of gastric cancer survival and treatment approach.

METHODS

Charts of ninety-six consecutive patients undergoing gastrectomy for resectable gastric cancer were reviewed between January 1996 and December 2005. Receiver operating characteristic (ROC) curves were plotted to verify the accuracy of metastatic lymph node ratio (MLNR) and number of metastatic lymph node (NMLN) cut-off values for survival prediction. Patients were divided into two groups according to ROC curve cut-offs and accuracy in prognosis was reviewed.

RESULTS

ROC curves showed that 5 metastatic nodes and a node ratio value of 20% had the best survival prognostic correlation. The median survival of patients with MLNR and NMLN were similar according to cut-off determinations (≤ 5/> 5 metastatic nodes and ≤20/>20% lymph node ratio). Five-year survival rates were 70.9% vs 17.1% and 72.4% vs 15.6%, respectively (p < 0.001). Positive correlation coefficient was found between the number of excised nodes and the number of metastatic nodes.

CONCLUSION

Number of metastatic lymph nodes showed greater accuracy than lymph node ratio for survival prediction in gastric cancer.

Comparison of the prognostic value of tumour and patient related factors in patients undergoing potentially curative resection of gastric cancer

BACKGROUND

There is increasing evidence that the patient-related systemic inflammatory response is a powerful prognostic factor. The aim of the present study was to compare the prognostic value of selected markers of the systemic inflammatory response in patients undergoing resection of gastric cancer.

METHODS

One hundred twenty patients undergoing resection of gastric cancer, had measurements of various systemic inflammatory markers in addition to tumor-related factors. From these, the modified Glasgow Prognostic Score (mGPS), neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and metastatic lymph node ratio were calculated.

RESULTS

On multivariate analysis, only the ratio of positive to total lymph nodes (hazard ratio, 2.29%; 95% confidence interval, 1.57%-3.33%; P < .001) and the mGPS (hazard ratio, 2.23%; 95% confidence interval, 1.40%-3.54%; P = .001) were independently associated with cancer-specific survival in patients with gastric cancer. An increase in the mGPS was associated with a higher neutrophil/lymphocyte ratio (P < .05) and poorer survival (P < .001).

CONCLUSIONS

The present study indicates that the mGPS, an acute-phase, protein-based prognostic score, is a superior predictor of cancer survival compared with the cellular components of the systemic inflammatory response in patients undergoing resection of gastric cancer.

Hypoxia, tumour-associated macrophages, microvessel density, VEGF and matrix metalloproteinases in human gastric cancer: interaction and impact on survival

INTRODUCTION

Hypoxia is a key feature of the microenvironment of cancer cells actively participating in tumour progression. Our study was aimed to evaluate the impact of hypoxia and hypoxia-associated factors on tumour progression and survival of patients with gastric cancer.

MATERIAL AND METHODS

One hundred and five resected specimens were used. The level of tumour hypoxia was evaluated using (31)P NMR spectroscopy, CD68 (tumour-associated macrophages), CD34 (microvessel density, MVD) and VEGF expression, immunohistochemistry, MMP-2 and MMP-9 activity, zymography. Statistical analysis was conducted using Pearson's test, Kaplan-Meier survival analysis, log-rank test and Cox proportional hazards model.

RESULTS

Intratumoral hypoxia level has been significantly correlated with VEGF expression, TAM number and total protease activity. The overall survival rate of patients with strong tumour hypoxia, high level of MVD, VEGF expression, TAM and MMP activity was significantly lower than that of the patients without the mentioned tumour characteristics.

CONCLUSIONS

The hypoxia-associated signalling that is activated in tumours promotes tumour progression through the recruitment of macrophages, remodelling of extracellular matrix and neoangiogenesis.

Evaluation of the 7th UICC TNM Staging System of Gastric Cancer

Since January of 2010, the seventh edition of UICC tumor node metastasis (TNM) Classification, which has recently been revised, has been applied to almost all cases of malignant tumors. Compared to previous editions, the merits and demerits of the current revisions were analyzed. Many revisions have been made for criteria for the classification of lymph nodes. In particular, all the cases in whom the number of lymph nodes is more than 7 were classified as N3 without being differentiated. Therefore, the coverage of the N3 was broad. Owing to this, there was no consistency in predicting the prognosis of the N3 group. By determining the positive cases to a distant metastasis as TNM stage IV, the discrepancy in the TNM stage IV compared to the sixth edition was resolved. In regard to the classification system for an esophagogastric (EG) junction carcinoma, it was declared that cases of an invasion to the EG junction should follow the classification system for esophageal cancer. A review of clinical cases reported from Asian patients suggests that it would be more appropriate to follow the previous editions of the classification system for gastric cancer. In addition, in the classification of the TNM stages in the overall cases, the discrepancy in the prognosis between the different stages and the consistency in the prognosis between the same TNM stages were achieved to a lesser extent as compared to that previously. Accordingly, further revisions are needed to develop a purposive classification method where the prognosis can be predicted specifically to each variable and the mode of the overall classification can be simplified.

The prognostic impact of the ratio of positive lymph nodes on survival of epithelial ovarian cancer patients

BACKGROUND AND OBJECTIVES

To study the prognostic significance of ratio of positive to examined lymph nodes (LNR) on survival of patients with node positive epithelial ovarian cancer (NPEOC).

METHODS

Data were obtained from Surveillance, Epidemiology, and End Results Program (SEER) from 1988 to 2006, and analyzed using Kaplan-Meier survival and Cox regression proportional hazard methods. Patients were divided into: stage IIIC group 1 (no macroscopic peritoneal disease), stage IIIC group 2 (macroscopic peritoneal disease), and stage IV.

RESULTS

A total of 6,310 women were included. The 5-year survival for stage IIIC groups 1, 2, and stage IV was 55.4%, 35.5%, and 20.3%, respectively (P < 0.001). Increasing LNR (<10%, 10-50%, and >50%) was associated with decreased survival from 51.5% to 38.1% to 27.0%, respectively, (P < 0.001). On multivariate analysis, LNR was an independent prognostic factor for survival after adjusting for extent of peritoneal disease, stage, grade, race, age, extent of lymphadenectomy and absolute number of positive nodes.

CONCLUSIONS

The impact of increasing LNR was strongly related to survival, especially in patients with no macroscopic peritoneal disease. Stratification of this subpopulation of node positive EOC based on nodal burden provides a significant prognostic value that may be considered in future staging and aid in management decisions.

Size of the largest lymph node visualized on multi-detector-row computed tomography (MDCT) is useful in predicting metastatic lymph node status of gastric cancer

This study was designed to investigate whether the size of the largest lymph node (long-axis diameter [LAD] and short-axis diameter [SAD]) visualized using multi-detector-row computed tomography (MDCT) was useful for predicting the metastatic lymph node (MLN) status of gastric cancer. A retrospective analysis of 305 gastric cancer patients who underwent pre-operative MDCT was performed, followed by a prospective study in 61 gastric cancer patients to determine the diagnostic effectiveness of LAD and SAD. In the retrospective study, the accuracy of LAD and SAD for predicting the MLN status of gastric cancer was 51.1% and 45.9%, respectively. In the prospective study, the accuracy of LAD and SAD measurement and the traditional MDCT method of counting MLNs was 52.5%, 49.2% and 57.4%, respectively; the differences were not significant. In conclusion, the size of the largest lymph node in terms of LAD and SAD visualized on MDCT was useful for predicting the MLN status of gastric cancer, with accuracy comparable to the traditional MDCT method of counting the total number of MLNs detected.

Prognostic impact of metastatic lymph node ratio on gastric cancer after curative distal gastrectomy

AIM

To investigate the prognostic impact of metastatic lymph node ratio (rN) on gastric cancer after curative distal gastrectomy.

METHODS

A total of 634 gastric cancer patients who underwent curative resection (R0) of lymph nodes at distal gastrectomy in 1995-2004. Correlations between positive nodes and retrieved nodes, between rN and retrieved nodes, and between rN and negative lymph node (LN) count were analyzed respectively. Prognostic factors were identified by univariate and multivariate analyses. Staging accuracy of the pN category (5th UICC/TNM system) and the rN category was compared according to the survival rates of patients. A linear regression model was used to identify the relation between rN and 5-year survival rate of the patients.

RESULTS

The number of dissected LNs was related with metastatic LNs but not related with rN. Cox regression analysis showed that depth of invasion, pN and rN category were the independent predictors of survival (P < 0.05). There was a significant difference in survival between LN stages classified by the rN category or by the pN category (P < 0.05). However, no significant difference was found in survival rate between LN stages classified by the pN category or by the rN category (P > 0.05). Linear regression model showed a significant linear correlation between rN and the 5-year survival rate of gastric cancer patients (beta = 0.862, P < 0.001). Pearson's correlation test revealed that negative LN count was negatively correlated with rN (P < 0.001).

CONCLUSION

rN category is a better prognostic tool than the 5th UICC pN category for gastric cancer patients after curative distal gastrectomy. Increased negative LN count can reduce rN and improve the survival rate of gastric cancer patients.