Impact of lymph node ratio on survival of colorectal cancer patients

Impact of Metastatic Lymph Node Ratio on Survival and Prognosis in Rectal Carcinoma: A Retrospective Cohort Study

Objective This study aimed to evaluate the impact of the metastatic lymph node ratio (mtLNR) on survival outcomes and prognosis in patients with rectal carcinoma, in comparison with other clinicopathological factors. Methods A retrospective cohort analysis was conducted on 97 patients with rectal adenocarcinoma who underwent surgical treatment at Erol Olçok Training and Research Hospital between January 2017 and December 2022. The inclusion criteria consisted of patients over 18 years of age and the absence of hematological disorders or concurrent inflammatory conditions. The patients' demographic data, tumor characteristics, surgical details, lymph node (LN) status, mtLNR, and survival outcomes were analyzed. The optimal cutoff value of mtLNR for predicting mortality was determined using receiver operating characteristic (ROC) curve analysis. Kaplan-Meier survival analysis was employed to estimate overall survival (OS) and disease-free survival (DFS), and differences between groups were evaluated using the log-rank test. The Cox proportional hazards model was used to calculate hazard ratios (HRs) for all-cause mortality. Statistical significance was set at p<0.05. Results The mean age of the patients was 70.31 ± 11.57 years, with 65.98% being male. Low anterior resection (LAR) was performed in 83.51% of the patients, and laparoscopic surgery was conducted in 26.8%. The median OS for the entire cohort was 24 months (range: 3-60). Patients were divided into two groups based on mtLNR, with the cutoff value set at 0.2183. A high mtLNR was significantly associated with poorer DFS and OS (p=0.021 and p=0.003, respectively). Moreover, patients with an mtLNR>0.2183 exhibited significantly higher rates of recurrence, lymphovascular invasion (LVI), and perineural invasion (PNI) compared to those with a lower mtLNR (all p<0.001). The optimal cutoff value of mtLNR predicted mortality with a specificity of 81.4% and a sensitivity of 48.1% (area under the curve (AUC) 0.662, p=0.012). Kaplan-Meier analysis showed a significant difference in survival between the two groups; the risk of all-cause mortality was 3.71 times higher in patients with mtLNR>0.2183 (p=0.002). Conclusion The mtLNR is a strong determinant of survival and prognosis in patients with rectal carcinoma. High mtLNR values are associated with worse survival outcomes and more aggressive tumor characteristics. The findings suggest that mtLNR should be considered in clinical decision-making processes. These results indicate that mtLNR could be a valuable prognostic tool in clinical decision-making.

Diagnostic performance of Node Reporting and Data System (Node-RADS) for assessing mesorectal lymph node in rectal cancer by CT

BACKGROUND

To compare the diagnostic performance of the Node-RADS scoring system and lymph node (LN) size in preoperative LN assessment for rectal cancer (RC), and to investigate whether the selection of size as the primary criterion whereas morphology as the secondary criterion for LNs can be considered the preferred method for clinical assessment.

METHODS

Preoperative CT data of 146 RC patients treated with radical resection surgery were retrospectively analyzed. The Node-RADS score and short-axis diameter of size-prioritized LNs and the morphology-prioritized LNs were obtained. The correlations of Node-RADS score to the pN stage, LNM number and lymph node ratio (LNR) were investigated. The performances on assessing pathological lymph node metastasis were compared between Node-RADS score and short-axis diameter. A nomogram combined the Node-RADS score and clinical features was also evaluated.

RESULTS

Node-RADS score showed significant correlation with pN stage, LNM number and LNR (Node-RADS of size-prioritized LN: r = 0.600, 0.592, and 0.606; Node-RADS of morphology-prioritized LN: r = 0.547, 0.538, and 0.527; Node-RADSmax: r = 0.612, 0.604, and 0.610; all p < 0.001). For size-prioritized LN, Node-RADS achieved an AUC of 0.826, significantly superior to short-axis diameter (0.826 vs. 0.743, p = 0.009). For morphology-prioritized LN, Node-RADS exhibited an AUC of 0.758, slightly better than short-axis diameter (0.758 vs. 0.718, p = 0.098). The Node-RADS score of size-prioritized LN was significantly better than that of morphology-prioritized LN (0.826 vs. 0.758, p = 0.038). The nomogram achieved the best diagnostic performance (AUC = 0.861) than all the other assessment methods (p < 0.05).

CONCLUSIONS

The Node-RADS scoring system outperforms the short-axis diameter in predicting lymph node metastasis in RC. Size-prioritized LN demonstrates superior predictive efficacy compared to morphology-prioritized LN. The nomogram combined the Node-RADS score of size-prioritized LN with clinical features exhibits the best diagnostic performance. Moreover, a clear relationship was demonstrated between the Node-RADS score and the quantity-dependent pathological characteristics of LNM.

Five-year follow-up mortality prognostic index for colorectal patients

PURPOSE

To identify 5-year survival prognostic variables in patients with colorectal cancer (CRC) and to propose a survival prognostic score that also takes into account changes over time in the patient's health-related quality of life (HRQoL) status.

METHODS

Prospective observational cohort study of CRC patients. We collected data from their diagnosis, intervention, and at 1, 2, 3, and 5 years following the index intervention, also collecting HRQoL data using the EuroQol-5D-5L (EQ-5D-5L), European Organization for Research and Treatment of Cancer's Quality of Life Questionnaire-Core 30 (EORTC-QLQ-C30), and Hospital Anxiety and Depression Scale (HADS) questionnaires. Multivariate Cox proportional models were used.

RESULTS

We found predictors of mortality over the 5-year follow-up to be being older; being male; having a higher TNM stage; having a higher lymph node ratio; having a result of CRC surgery classified as R1 or R2; invasion of neighboring organs; having a higher score on the Charlson comorbidity index; having an ASA IV; and having worse scores, worse quality of life, on the EORTC and EQ-5D questionnaires, as compared to those with higher scores in each of those questionnaires respectively.

CONCLUSIONS

These results allow preventive and controlling measures to be established on long-term follow-up of these patients, based on a few easily measurable variables.

IMPLICATIONS FOR CANCER SURVIVORS

Patients with colorectal cancer should be monitored more closely depending on the severity of their disease and comorbidities as well as the perceived health-related quality of life, and preventive measures should be established to prevent adverse outcomes and therefore to ensure that better treatment is received.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02488161.

The number of cycles of adjuvant chemotherapy in stage III and high-risk stage II rectal cancer: a nomogram and recursive partitioning analysis

Objective

The prognostic role of the number of cycles of adjuvant chemotherapy (ACT) after total mesorectal excision in stage III and high-risk stage II rectal cancer is unknown. As a result of this, our study was designed to assess the effect of the number of cycles of ACT on the prediction of cancer-specific survival.

Methods

Four hundred patients that were diagnosed as stage III and high-risk stage II rectal cancer from January 2012 to January 2018 and who had received total mesorectal excision were enrolled in this study. A nomogram incorporating the number of cycles of ACT was also developed in this study. For internal validation, the bootstrap method was used and the consistency index was used to evaluate the accuracy of the model. The patients were stratified into risk groups according to their tumor characteristics by recursive partitioning analysis.

Results

We found that the risk of death was decreased by 26% (HR = 0.74, 95% CI: 0.61–0.89, P = 0.0016) with each increasing ACT cycle. The N stage, positive lymph node ratio (PLNR), carcinoembryonic antigen, neutrophil-to-lymphocyte ratio, and the number of cycles of ACT were chosen and entered into the nomogram model. Recursive partitioning analysis-based risk stratification revealed a significant difference in the prognosis in rectal cancer patients with high-risk, intermediate-risk, and low-risk (3-year cancer-specific survival: 0.246 vs. 0.795 vs. 0.968, P < 0.0001). Seven or more cycles of ACT yielded better survival in patients with PLNR ≥ 0.28 but not in patients with PLNR < 0.28.

Conclusion

In conclusion, the nomogram prognosis model based on the number of cycles of ACT predicted individual prognosis in rectal cancer patients who had undergone total mesorectal excision. These findings further showed that in patients with PLNR ≥ 0.28, no fewer than 7 cycles of ACT are needed to significantly reduce the patient’s risk of death.

Prognostic implications of ENE and LODDS in relation to lymph node-positive colorectal cancer location

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This is the first study on LODDS and ENE together. The current study showed that LODDS and ENE are liable prognostic parameters of CRC or CC.

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ENE is an independent influencing factor on the prognosis of both CRC and CC, and the prognostic impact of ENE was observed in both CRC and CC.

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The frequency of ENE increases from the proximal (right) to the distal (left) colon as well as the rectum.

Background

Extranodal extension (ENE) and log odds of positive lymph nodes (LODDS) are associated with the aggressiveness of both colon and rectal cancers. The current study evaluated the clinicopathological significance and the prognostic impact of ENE and LODDS in the colon and rectal patients independently.

Methods

The clinical and histological records of 389 colorectal cancer (CRC) patients who underwent curative surgery were reviewed.

Results

For the ENE system, 244 patients were in the ENE1 group and 145 in the ENE2 system. Compared with the ENE1 system, the patients included in the ENE2 system were prone to nerve invasion (P < 0.001) and vessel invasion (P < 0.001) with higher TNM (P = 0.009), higher T category (P = 0.003), higher N category (P < 0.001), advanced differentiation (P = 0.013), more number of positive lymph nodes (NPLN) (P < 0.001), more lymph node ratio (LNR) (P < 0.001), and a higher value of LODDS (P < 0.001). ENE was more frequent in patients with left and rectal than right cancer. For the LODDS system, 280 patients were in the LODDS1 group, and 109 in the LODDS2 group. Compared to the LODDS1 group, the patients included in the LODDS2 group were more prone to nerve invasion (P = 0.0351) and vessel invasion (P < 0.001) with a higher rate of N2 stage, less NDLN (P < 0.001), more NPLN (P < 0.001), more LNR (P < 0.001), and a higher value of ENE (P < 0.001). Based on the results in the univariable analysis, the N, NPLN, LNR, LODDS, and ENE were separately incorporated into five different Cox regression models combined with the same confounders. The multivariable Cox regression analysis demonstrated that all the five staging systems were independent prognostic factors for overall survival.

Conclusion

The current study confirmed that the LODDS stage is an independent influence on the prognosis of both CRC and CC patients. ENE is an independent influencing factor on the prognosis of both CRC and CC patients, and the prognostic impact of extracapsular lymph node was observed in both CRC and CC. The frequency of ENE increases from the proximal (right) to the distal (left) colon as well as the rectum. Therefore, combining ENE and LODDS into the current TNM system to compensate for the inadequacy of pN staging needs further investigation.

A Modified Tumor-Node-Metastasis Staging System for Colon Cancer Patients with Fewer than Twelve Lymph Nodes Examined

BACKGROUND

To construct a modified tumor-node-metastasis (TNM) staging system for stage I-III colon cancer patients with lymph nodes examined (LNE) < 12.

METHODS

The clinicopathological and survival data of 3870 stage I-III colon cancer patients with LNE < 12 from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015 (development cohort) and 126 stage I-III patients with LNE < 12 from the Second Affiliated Hospital of Harbin Medical University between 2011 and 2015 (validation cohort) were identified. The optimal stratification of LNR for cancer-specific survival (CSS) was achieved using X-tile software. The predictive accuracy of the modified stage (mStage) was determined by the concordance index (C-index).

RESULTS

The modified N stage (mN stage) was built based on the LNR (mN0: LNR = 0, mN1: 0 < LNR < 0.4 or cancer nodule formation and mN2: 0.4 ≤ LNR ≤ 1). Preferable C-indices could be found for mStage compared with TNM stage in both development (0.750 vs 0.727) and validation cohorts (0.682 vs 0.646). Besides, patients with mStage A and B diseases could not benefit from adjuvant chemotherapy, while in patients with mStage C-F diseases, those receiving radical surgery plus adjuvant chemotherapy presented better CSS than those with radical surgery alone.

CONCLUSIONS

The mStage system could predict the prognosis of colon cancer patients with LNE < 12 accurately and showed superior predictive power compared with conventional TNM staging system. Moreover, adjuvant chemotherapy might play inequable roles in patients with different mStage diseases.

Metastatic lymph node ratio as a better prognostic tool than the TNM system in colorectal cancer

Background: The minimum number of lymph nodes that should be evaluated in colon cancer to adequately categorize lymph node status is still controversial. The lymph node ratio (LNR) may be a better prognostic indicator. Materials & methods: We studied 1065 patients treated from 1 January 2000 to 31 August 2012. Results: Significant differences in survival were detected according to regional lymph nodes (pN) (p < 0.001) and LNR (p < 0.001). LRN and pN are independent prognostic factors. Spearman correlation analysis showed a significant correlation between the total number of dissected lymph nodes and pN (rs = 0.167; p < 0.001), but the total number of dissected lymph nodes is not significantly correlated with LNR (rs = -0.019; p = 0.550). Interpretation: In this study, LNR seems to demonstrate a superior prognostic value compared with the pN categories, in part due to its greater independence regarding the extent of lymphadenectomy.

Lymph Node Ratio Versus TNM System As Prognostic Factor in Colorectal Cancer Staging. a Single Center Experience

Objective

This study aims to establish the actual validity of the lymph node ratio (LNR) as a prognostic factor for colorectal cancer patients, and to verify differences of survival and disease-free interval.

Methods

Patients referred with colorectal cancer who underwent potentially curative surgery between January 1997 and December 2011 were included. Lymph node ratio, TNM staging and survival were extracted from surgical, histological and follow-up records.

Results

Two hundred eigthy six patients with different stages of colorectal cancer underwent surgery, with comparison of survival prediction based on lymph node ratio and TNM staging. The overall survival rate was 78.3%, the recurrence rate was 11.9% and the mortality rate was estimated as 21.7%. Univariate analysis in relation to survival was significant for the following variables: serum level of CEA, CA 19.9 value, degree of histological differentiation, and tumor growth. There weren’t any statistically significant differences for the LNR (LNR </ ≥0.16: p = 0.116). The TNM system was effective both in discriminating between survival stages (Stage II vs. Stage III: p = 0.05) and in differentiating sub-groups (p = 0.05).

Conclusions

LNR alone could not be considered a better prognostic factor than the TNM system. However, future studies are needed in a larger number of patients with a standardized surgical, pathological and medical protocol.

The lymph node ratio does not provide additional prognostic information compared with the N1/N2 classification in Stage III colon cancer

AIM

The ratio of positive nodes to total nodes, the lymph node ratio (LNR), is a proposed alternative to the current N1/N2 classification of nodal disease. The true clinical benefit of adopting the LNR, however, has not been definitively demonstrated. This study compared the LNR with the current N1/N2 classification of Stage III colon cancer.

METHOD

Patients with Stage III colon cancer were identified from a prospectively maintained database (1996-2012). The specificity and sensitivity of the N1/N2 classification in the prediction of overall survival were determined using R. A cut-off point for the LNR was determined by setting the specificity the same as for the N1/N2 classification. The sensitivity of the two methods was then compared, and bootstrapping 1000-fold was performed. This was then repeated for disease-specific survival.

RESULTS

The specificity and sensitivity of the N1/N2 classification in predicting 3-year overall survival in this cohort (n = 402) was 62.2% and 52.1%, respectively. The cut-off point for the LNR was determined to be 0.27 for these data. On comparing LNR with the N1/N2 classification showed that for a given specificity, the LNR did not provide a statistically significant improvement in sensitivity (52.8% vs 52.1%, P = 0.31). For disease-specific death at 3 years, the specificity and sensitivity were 60.8% and 54.6%, respectively. The LNR did not provide a statistically significant improvement (55.4% vs 54.6%, P = 0.44).

CONCLUSION

Both the N1/N2 system and the LNR predict survival in colon cancer, but both have low specificity and sensitivity. The LNR does not provide additional prognostic value to current staging for overall or disease-specific survival for a given cut-off point.