Negative lymph node count is a significant prognostic factor in patient with stage IV gastric cancer after palliative gastrectomy

Prognostic role of the number of resected and negative lymph nodes in Spanish patients with gastric cancer

INTRODUCTION

Lymph node (LN) involvement is one of the most critical prognostic factors in resected gastric cancer (GC). Some analyses, mainly conducted in Asian populations, have found that patients with a higher number of total lymph nodes (NTLN) and/or negative lymph nodes (NNLN) have a better prognosis, although other authors have failed to confirm these results.

MATERIALS AND METHODS

Retrospective study including all patients with GC resected in a tertiary hospital in Spain between 2001 and 2019 (n = 315). Clinicopathological features were collected and patients were categorized according to the NTLN and the NNLN. Statistical analyses were performed.

RESULTS

Mean NNLN was 17. The NNLN was significantly related to multiple clinicopathological variables, including recurrence and tumor-related death. The classification based on the NNLN (N1: ≥16, N2: 8-15, N3: ≤7) effectively stratified the entire cohort into three distinct prognostic groups and maintained its prognostic value within both the pN0 and pN+ patient subsets. Furthermore, it was an independent prognostic indicator for both overall and disease-free survival. Conversely, the mean NTLN was 21.9. Patients with ≤16 LN retrieved exhibited distinct clinicopathological features compared to those with >16 LN, but no significant differences were observed in terms of recurrence or disease-associated death. The application of alternative cut-off points for NTLN (10, 20, 25, 30, and 40) showed no prognostic significance.

CONCLUSIONS

In Spanish patients with resected GC the NNLN hold prognostic significance, while the NTLN does not appear to be prognostically significant. Incorporating the NNLN into GC staging may enhance the accuracy of the TNM system.

Effect of the number of negative lymph nodes removed on the survival and recurrence rate after gastrectomy in patients with gastric cancer: a multicenter retrospective cohort study

BACKGROUND

Various factors affect the survival rate of Gastric cancer (GC) patients after gastrectomy. This study aimed to investigate the effect of the number of negative lymph nodes (NLNs) removed on GC patients' survival and recurrence rate after gastrectomy.

METHODS

In this retrospective, multicenter cohort study, we reviewed the medical profile of 639 patients with a definite diagnosis of GC who underwent gastrectomy from 2010 to 2022 in one of the medical centers affiliated with the Iran University of Medical Sciences. Based on the number of NLNs removed, patients were divided into three groups, including (0-9NLNs), (10-15 NLNs), and (≥ 16 NLNs), including 155, 231, and 253 GC patients, respectively. Demographic characteristics, tumor characteristics, and pathological findings of the patients were extracted by referring to the patient's files.

RESULTS

The 5-year survival rate of patients was estimated at 48.2%. The 5-year tumor recurrence rate in patients with the number of NLNs 1-9, NLNs 10-15, and ≥ 16 NLNs were 79.4%, 51.1%, and 30.8%, respectively. (Log-rank = 9.24, P 0.001) The multivariate analysis showed that the 5-year survival rate in patients with fewer NLNs removed ≥ 16 was significantly higher than in the other two groups. In addition, age, BMI, tumor size, tumor stage, metastasis, and tumor differentiation were significantly related to the survival of GC patients after gastrectomy. (p < 0.05) CONCLUSION: Paying attention to the number of NLNs removed during gastrectomy can be a key factor in improving the survival prediction of GC patients.

Establishment and Validation of a Nomogram Based on Negative Lymph Nodes to Predict Survival in Postoperative Patients with non-Small Cell Lung Cancer

Background: The importance of the negative lymph node (NLN) count has recently attracted attention. This study aimed to determine the prognostic value of NLN count in patients with non-small cell lung cancer (NSCLC) after radical surgery by constructing NLN-based prognostic models. Methods: This study included 33 756 patients pooled from the case listing session of the US Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2015 and 545 patients collected from The First Affiliated Hospital of Shandong First Medical University between 2012 and 2016. X-tile software was used to calculate the optimal cutoff value for the NLN count. The associated clinical factors were determined using univariate and multivariate Cox analyses. Nomograms were developed using the SEER database and validated using hospital data. Results: The training cohort was divided into high and low NLN count subgroups based on the cancer-specific survival (CSS) and overall survival (OS), respectively. Multivariate analysis showed that NLN count was an independent prognostic factor, and the high NLN count subgroup had better CSS and OS than those of the low NLN count subgroup (HR = 0.632, 95% CI 0.551-0.724, P < .001 for CSS and HR = 0.641, 95% CI 0.571-0.720, P < .001 for OS). Nomograms were established, exhibiting good discrimination ability with a C-index of 0.789 (95% CI 0.778 −0.798) for CSS and 0.704 (95% CI, 0.694 −0.714) for OS. The calibration plots of the validation cohorts showed optimal agreement with the training cohort, with a C-index of 0.681 (95% CI 0.646 −0.716) for CSS and 0.645 (95% CI 0.614 −0.676) for OS. Conclusions: NLN count is a strong prognostic factor for OS and CSS in NSCLC patients and the prognostic model provides a useful risk stratification for NSCLC patients when applied to clinical practice.

Impact of the extent of negative lymph nodes in gastric adenocarcinoma undergoing primary surgical resection: An institutional report

BACKGROUND

Sub-total/total gastrectomy with lymph node dissection (LND) remains an effective therapeutic strategy for resectable gastric adenocarcinomas (GACs). Despite the prognostic significance of positive lymph nodes (PLNs) defined in N-status, few have appraised the impacts of negative lymph nodes (NLNs) and the percentage of NLN (=number of NLNs/number of total lymph nodes [TLNs], %), as well as the extent of TLNs to be dissected in GACs.

METHODS

We retrospectively analyzed 62 GAC patients (mean age of 67.1 years; 41 men) undergoing primary sub-total/total gastrectomy from a single institute. Candidate variables, including the number of NLNs (≤9 and >9) and the percentage of NLN (≤37.5, 37.5-80.6 and >80.6, %), were evaluated to determine their prognostic impacts and hazard ratios (HRs).

RESULTS

Under the multivariate Cox proportional-hazards regression model, tumor length exceeding 4 cm (p = 0.017; HR = 2.828), perineural invasion (p = 0.037; HR = 3.182), and lower percentage of NLN (p = 0.016 and p = 0.060; HRs = 1.000, 0.327, and 0.333 for subgroups ≤37.5, 37.5-80.6, and >80.6, respectively) were three independent predictors with elevated HRs for poor prognosis. GAC patients with the percentage of NLN > 80.6 were highly related to those with NLNs > 9 (p < 0.001), and GAC patients with NLNs > 9 were highly related to those with TLNs > 15 (p < 0.001). For all 62 GAC or 42 N(+) GAC patients, those who underwent LND with TLNs>15 tended to have more PLNs (p = 0.018, p = 0.003) and more NLNs (p < 0.001, p = 0.029) than did those with TLNs ≤ 15. Among the 42 GAC patients with TLNs > 15, a lower percentage of NLN (p = 0.026 and p = 0.015; HRs = 1.000, 0.272, and 0.180 for subgroups ≤37.5, 37.5-80.6, and >80.6, respectively) remained an independent predictor of poor prognosis.

CONCLUSION

The percentage of NLN could predict the prognosis of GAC patients properly. However, an accurate percentage of NLN needs a minimal requirement of TLNs > 15 to detect an adequate number of PLNs and sufficient number of NLNs.

Impact of negative lymph nodes on colon cancer survival and exploring relevant transcriptomics differences through real-world data analyses

Background

The prognostic role and underlying heterogeneity of negative lymph nodes (NLNs) on colon cancer is not well understood. The purpose of this study was to construct NLN-based prognostic models and reveal relevant mechanisms affecting NLNs by analyzing omic data.

Methods

This inception cohort study included 314,398 colon cancer patients from the US Surveillance, Epidemiology, and End Results (SEER) database. Receiver operating characteristic (ROC) curve was used to determine the cut-off of NLNs. Nomograms were constructed and validated using SEER data and the Cancer Genome Atlas (TCGA) data, respectively. The differentially expressed genes (DEGs) were analyzed using edgeR. Enrichment analyses were performed by Metascape.

Results

Multivariate analysis confirmed the high NLN had improved cancer-specific survival (CSS) and overall survival (OS) compared to low NLN [hazard ratio (HR) =0.610, 95% confidence interval (CI), 0.601-0.620] for CSS and (HR =0. 682, 95% CI, 0.674-0.690) for OS. Nomograms were established for CSS and OS with the c-statistic 0.790 (95% CI, 0.788-0.792) for CSS and 0.734 (95% CI, 0.732-0.736) for OS. High NLN was associated with less B cell (P=0.002) and macrophage infiltration (P<0.0001), high microsatellite instability (MSI) (OR =4.325, P=0.001), and hypermutation (OR =4.285, P=0.001; high vs. low). Transcriptomics analysis demonstrated histone modifiers were the most significant different biological processes between the high and low NLN group.

Conclusions

The NLN-based models can aid in personalized risk stratification for colon cancer. This study postulates that high NLN may represent a biological subtype with less macrophage infiltration, high MSI status, hypermutation, and histone modifier gene enriched expression, and thus warrants further investigation.

Involvement of SLC39A6 in gastric adenocarcinoma and correlation of the SLC39A6 polymorphism rs1050631 with clinical outcomes after resection

BACKGROUND

The single-nucleotide polymorphism SLC39A6 rs1050631 is strongly implicated in esophageal squamous cell carcinoma, leading us to question whether it may also play a role in gastric adenocarcima (GA).

METHODS

We genotyped the SLC39A6 rs1050631 in 512 patients who underwent GA resection. All study subjects lived in an area of China with high GA incidence. Genotypes were examined for possible correlation with survival and recurrence. The potential involvement of SLC39A6 in gastric cancer was explored in clinical samples and cell culture studies.

RESULTS

Multivariable analysis showed that patients with the CT + TT genotype at SLC39A6 rs1050631 were at greater risk of recurrence (hazard ratio, HR 1.387, p = 0.004) and death (HR 1.429, p = 0.002) than patients with CC genotype. Median recurrence-free and overall survival were significantly shorter in patients with the CT + TT genotype (20, 27 months) than in patients with the CC genotype (36, 43 months, p = 0.001, p < 0.001). Patients with the CT + TT genotype who were male or ≥ 60 years, or who had a tumor ≥5 cm or a moderately differentiated tumor were at significantly higher risk of recurrence and death. SLC39A6 was overexpressed in tissues from GA patients and in GA cell lines, and SLC39A6 knockdown in GA cell lines inhibited their proliferation, migration and invasion.

CONCLUSION

SLC39A6 rs1050631 correlates with post-resection prognosis of GA patients and SLC39A6 may participate in GA onset or progression.

Nomograms for predicting survival in patients with metastatic gastric adenocarcinoma who undergo palliative gastrectomy

BACKGROUND

Recently, evidence has emerged that palliative gastrectomy in patients with stage IV gastric cancer may offer some survival benefits. However, the decision whether to perform primary tumor surgery remains challenging for surgeons, and investigations into models that are predictive of prognosis are scarce. Current study aimed to develop and validate prognostic nomograms for patients with metastatic gastric adenocarcinoma treated with palliative gastrectomy.

METHODS

The development dataset comprised 1186 patients from the Surveillance, Epidemiology, and End Results Program who were diagnosed with metastatic gastric adenocarcinoma in 2004-2011, while the validation dataset included 407 patients diagnosed in 2012-2015. Variables were incorporated into a Cox proportional hazards model to identify independent risk factors for survival. Both pre- and postoperative nomograms for predicting 1- or 2-year survival probabilities were constructed using the development dataset. The concordance index (c-index) and calibration curves were plotted to determine the accuracy of the nomogram models. Finally, the cut-off value of the calculated total scores based on preoperative nomograms was set and validated by comparing survival with contemporary cases without primary tumor surgery.

RESULTS

Age, tumor size, location, grade, T stage, N stage, metastatic site, scope of gastrectomy, number of examined lymph node(s), chemotherapy and radiotherapy were risk factors of survival and were included as variables in the postoperative nomogram; the c-indices of the development and validation datasets were 0.701 (95% confidence interval [CI]: 0.693-0.710) and 0.699 (95% CI: 0.682-0.716), respectively. The preoperative nomogram incorporated age, tumor size, location, grade, depth of invasion, regional lymph node(s) status, and metastatic site. The c-indices for the internal (bootstrap) and external validation sets were 0.629 (95% CI: 0.620-0.639) and 0.607 (95% CI: 0.588-0.626), respectively. Based on the preoperative nomogram, patients with preoperative total score > 28 showed no survival benefit with gastrectomy compared to no primary tumor surgery.

CONCLUSIONS

Our survival nomograms for patients with metastatic gastric adenocarcinoma undergoing palliative gastrectomy can assist surgeons in treatment decision-making and prognostication.

Metastatic lymph node ratio as a prognostic indicator in patients with stage IV colon cancer undergoing resection

Background: It has been shown that the metastatic lymph node ratio (LNR, metastatic LNs divided by the total number of retrieved LNs) significantly affects the prognosis of patients with non-stage IV and some curative stage IV colon cancer undergoing curative resection. In this study, we aimed to evaluate the role of the LNR as a predictor of prognosis in patients with stage IV colon cancer undergoing curative or palliative resection. Patients and Methods: We conducted a retrospective study of 424 patients who were initially diagnosed with stage IV colon cancer at the Sun Yat-Sen University Cancer Center from 2003 to 2014. The patients were divided into the curative and palliative primary tumor resection groups with regional lymph nodes harvest. The median value was used as the cutoff for the LNR. Overall survival (OS) was assessed with the Kaplan-Meier method and log-rank test. Multivariate analysis was performed to identify the prognostic factors for OS. Results: The cutoff value for the LNR was 0.2. A total of 71 and 353 patients were classified as being in the curative and palliative resection groups, respectively. Patients in the palliative resection group showed higher pretreatment levels of carbohydrate antigen 19-9 (CA199; P = 0.014), a deeper infiltration of the primary tumor (P = 0.049), a lower regional lymph node harvest (i.e., total lymph node yield [TLN] ≤ 11; P = 0.001), and more extensive metastasis (P = 0.006). Among all patients, initial elevated CA199 levels, a TLN≤11, a negative lymph nodes (NLN) ≤7, and a LNR ≤0.2 were significantly associated with an unfavorable prognosis. OS was significantly longer in patients with a low LNR in both groups (P = 0.008 and P = 0.001, respectively). The LNR was an independent prognostic indicator in patients with stage IV colon cancer, with a hazard ratio (HR) of 1.47 (95% confidence interval [CI] 1.14-1.91; P = 0.003) in total population, and an HR of 1.43 (95% CI 1.09-1.86; P = 0.009) in patients with palliative resection. Conclusion: The LNR can be used as an independent prognostic factor in patients with stage IV colon cancer patients undergoing resection.

Prognostic Significance of the Lymph Node Ratio in Surgical Patients With Distal Cholangiocarcinoma

BACKGROUND

The aim of this study was to compare the prognostic impact of the lymph node ratio (LNR) versus positive lymph node count (PLNC) in patients who had undergone resection for distal cholangiocarcinoma.

METHODS

We identified 448 patients with resected distal cholangiocarcinoma from the Surveillance, Epidemiology, and End Results database. The X-Tile program was used to calculate the cutoff values for the LNR and PLNC that discriminate survival. The overall survival and cancer-specific survival rates were calculated. Relationships between clinicopathological factors and patient survival were assessed using univariate and multivariate analyses.

RESULTS

The optimal cutoff values for the LNR and PLNC were 0.45 and 3, respectively. Univariate analysis revealed that tumor size, the American Joint Committee on Cancer stage, T stage, the LNR and PLNC were significantly associated with prognosis (P < 0.05). Multivariate analysis demonstrated that the LNR, T stage, and tumor size were independent prognostic factors for cancer-specific and overall survival, whereas PLNC was not. In the subgroup of patients with positive lymph nodes, patients with an LNR of greater than 0.45 had significantly worse cancer-specific survival (hazard ratio, 2.418; 95% confidence interval, 1.588 to 3.682; P < 0.001) and overall survival (hazard ratio, 2.149; 95% CI, 1.421 to 3.249; P < 0.001) than those with an LNR of 0.45 or less.

CONCLUSIONS

The LNR was a better predictor of long-term prognosis than PLNC in patients with distal cholangiocarcinoma.

MicroRNA-214 promotes the proliferation, migration and invasion of gastric cancer MKN28 cells by suppressing the expression of Dact2

The present study examined the expression of Dapper, antagonist of β-catenin 2 (Dact2) and microRNA (miR)-214 in gastric cancer at tissue and cellular levels, and to understand their biological roles. A total of 42 gastric cancer patients were enrolled in the present study. Bioinformatics tool was used to predict the miR molecule that potentially regulates Dact2 expression. To measure the expression of miR-214 and Dact2, reverse transcription-quantitative polymerase chain reaction was employed. Mixed gastric adenocarcinoma type MKN28 cells were transfected with negative control (NC), miR-214 mimics or inhibitor. The CCK-8 assay was used to investigate the proliferation of mixed gastric adenocarcinoma type MKN28 cells. To study migration and invasion abilities of mixed gastric adenocarcinoma type MKN28 cells, the Transwell assay was performed. To determine the expression of Dact2 protein, western blotting was conducted and the rescue assay was utilized to study the biological roles of miR-214 and Dact2 in mixed gastric adenocarcinoma type MKN28 cells. To test whether Dact2 is a direct target of miR-214, the dual luciferase reporter assay was performed. Results indicated that the expression of miR-214 was elevated, but expression of Dact2 mRNA was decreased in gastric cancer tissues, which was closely correlated with the invasion, metastasis, occurrence and development of gastric cancer. Notably, miR-214 promoted the proliferation of mixed gastric adenocarcinoma type MKN28 cells in vitro, whereas but Dact2 inhibited the proliferation of these cells. Downregulation of miR-214 expression or upregulation of Dact2 expression inhibited the migration and invasion of mixed gastric adenocarcinoma type MKN28 cells. Furthermore, miR-214 regulated the expression of Dact2 protein and its downstream β-catenin protein in mixed gastric adenocarcinoma type MKN28 cells. Dact2 reversed the effect of miR-214 on the proliferation, migration and invasion of mixed gastric adenocarcinoma type MKN28 cells. In addition, miR-214 directly targeted the 3'-UTR seeding region of Dact2 mRNA to regulate its expression. The present study demonstrated that expression of miR-214 was upregulated in gastric cancer tissues, and positively correlated with lymphatic metastasis and clinical staging. In addition, expression of Dact2 was downregulated in gastric cancer tissues and negatively correlated with lymphatic metastasis and clinical staging. Notably, the present findings suggest that miR-214 promoted the proliferation, migration and invasion of mixed gastric adenocarcinoma type MKN28 cells by suppressing the expression of Dact2.

An increased number of negative lymph nodes is associated with a higher immune response and longer survival in colon cancer patients

Background

The purpose of the present study was to examine the relationship among the number of negative lymph nodes (LNs), the local and systemic immune response, and survival in patients with colon cancer.

Patients and methods

One thousand one hundred and fifty-seven patients with colon cancer who underwent surgery at Sun Yat-sen University Cancer Center between 2009 and 2014 were included. We examined negative LNs in relation to the local and systemic immune response, including percentage carcinoma, neutrophil and lymphocyte infiltration, Crohn's-like reaction, neutrophil to lymphocyte ratio, platelets, and C-reactive protein (CRP). Disease-free survival and overall survival were also examined. We performed subgroup analysis based on the distribution of negative LNs.

Results

An increased number of negative LNs was associated with greater neutrophil invasion (p=0.001), more lymphocyte invasion (p=0.001), and more Crohn's-like reaction (p=0.001). No significant correlation was observed between negative LNs and the neutrophil to lymphocyte ratio. More than 12 negative LNs were associated with increased platelets and CRP levels. A higher number of negative LNs was independently associated with longer disease-free survival in stage I+II patients (p=0.004) and stage III patients (p=0.015), while negative LNs were also independent prognostic factors in stage IV patients (p=0.007).

Conclusion

Our study suggests that negative LNs are indicators of the immune response and are associated with a better prognosis in patients with colon cancer.

The retrieval of at least 25 lymph nodes should be essential for advanced gastric cancer patients with lymph node metastasis: A retrospective analysis of single-institution database study design: Cohort study

BACKGROUND

Recently, increased evidence have shown that the better prognosis of gastric cancer (GC) patients was associated with the larger number of retrieved lymph nodes (RLNs), but the optimal number of RLNs remains controversial. In the present study, we investigated whether adequate LN retrieval (≥15) was necessary to evaluate the prognosis of patients and attempted to propose an appropriate cutoff-point for the number of RLNs.

METHODS

We reviewed 2246 GC patients who underwent radical gastrectomy in our research institution between January 1986 and January 2008. All patients were divided into several groups based on the number of RLNs. The prognostic outcomes of different patient groups were compared and clinicopathologic features were analyzed.

RESULTS

In the present study, our results indicated that ≥15 RLNs showed a better survival outcome than inadequate LN retrieval (<15), regardless of the node-negative or node-positive GC patients (P < 0.001). For the more advanced GC patients (T2-T4 stage, N1-N3 stage, and stage II-stage III), the retrieval of 25-29 LNs could provide a better survival benefit compared with <25 or ≥30 RLNs (P < 0.05). In addition, for the patients who underwent proximal or total gastrectomy, the superior prognosis was still observed in the patient group with 25-29 RLNs.

CONCLUSION

The minimal goal of 15 RLNs may not be enough to accurately evaluate prognosis of all patients and at least 25 RLNs should be necessary for advanced GC patients with lymph node metastasis.

The appropriate number of ELNs for lymph node negative breast cancer patients underwent MRM: a population-based study

Whether number of examed lymph nodes (ELNs) would bring survival benefit for patients with negative lymph nodes after modified radical mastectomy (MRM) is uncertain. In our study, using the Surveillance Epidemiology and End Results (SEER) database between 2004 and 2009, we screened the appropriate patients with negative lymph nodes underwent MRM. The Cox proportional hazard analysis was used to determine the effect of number of ELNs on cancer specific survival (CSS). The results showed that the number of ELNs was not an independent prognostic factor on CSS (P = 0.940). Then the X-tile mode was used to determine the appropriate threshold for ELNs count. The results showed that 9 was the appropriate cut-off point. Next, the log-rank χ² test was used to analyze the CSS based on different subgroup variables. The results showed that some subgroup variables including age < 50/ ≥ 50, grade I/III, AJCC T1/T2, ER positive/negative and PR positive/negative ,demonstrated significant CSS benefits among the patients with the number of ELNs ≤ 9 (all, P < 0.05). However, three subgroup variables including grade II, AJCC T3 and AJCC T4, the patients with the number of ELNs ≤ 9 did not bring significant CSS benefits (all, P > 0.1). In conclusion, our study demonstrated that the number of ELNs was not an independent prognostic factor on CSS, and 9 can be selected as the appropriate cut-off point of ELNs for patients with negative lymph nodes who underwent MRM.