Combination of the ratio between metastatic and harvested lymph nodes and negative lymph node count as a prognostic indicator in advanced gastric cancer: a retrospective cohort study

Evaluation of three lymph node staging systems for prognostic prediction in gastric cancer: A systematic review and meta-analysis

BACKGROUND

Lymph node status is a critical prognostic factor in gastric cancer (GC), but stage migration may occur in pathological lymph nodes (pN) staging. To address this, alternative staging systems such as the positive lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS) were introduced.

AIM

To assess the prognostic accuracy and stratification efficacy of three nodal staging systems in GC.

METHODS

A systematic review identified 12 studies, from which hazard ratios (HRs) for overall survival (OS) were summarized. Sensitivity analyses, subgroup analyses, publication bias assessments, and quality evaluations were conducted. To enhance comparability, data from studies with identical cutoff values for pN, LNR, and LODDS were pooled. Homogeneous stratification was then applied to generate Kaplan-Meier (KM) survival curves, assessing the stratification efficacy of three staging systems.

RESULTS

The HRs and 95% confidence intervals for pN, LNR, and LODDS were 2.16 (1.72-2.73), 2.05 (1.65-2.55), and 3.15 (2.15-4.37), respectively, confirming all three as independent prognostic risk factors for OS. Comparative analysis of HRs demonstrated that LODDS had superior prognostic predictive power over LNR and pN. KM curves for pN (N0, N1, N2, N3a, N3b), LNR (0.1/0.2/0.5), and LODDS (-1.5/-1.0/-0.5/0) revealed significant differences (P < 0.001) among all prognostic stratifications. Mean differences and standard deviations in 60-month relative survival were 27.93% ± 0.29%, 41.70% ± 0.30%, and 26.60% ± 0.28% for pN, LNR, and LODDS, respectively.

CONCLUSION

All three staging systems are independent prognostic factors for OS. LODDS demonstrated the highest specificity, making it especially useful for predicting outcomes, while pN was the most effective in homogeneous stratification, offering better patient differentiation. These findings highlight the complementary roles of LODDS and pN in enhancing prognostic accuracy and stratification.

Overestimation of clinical N-staging in microsatellite instable gastric cancers is associated with VEGF-C signaling and CD8+ T-cell dynamics

BACKGROUND

Microsatellite instable (MSI) gastric cancers exhibit reduced lymph node (LN) metastasis and improved survival compared to microsatellite stable (MSS) counterparts. However, to our longstanding observation, clinical N-staging (cN) is frequently overestimated in MSI cases. The clinical implications and underlying mechanisms of this discrepancy warrant further investigation.

MATERIALS AND METHODS

We conducted a comprehensive review of clinicopathological data from a 141 MSI and 1119 MSS gastric cancer patients. Expression of vascular endothelial growth factor-C (VEGF-C) and its receptor VEGFR-3 were assessed using qPCR and immunohistochemistry. High-parameter flow cytometry was employed to analyze subsets of CD8+ T cells within the tumors.

RESULTS

Multivariate analysis revealed that MSI status was an independent prognostic factor, alongside the LN ratio and AJCC8 pathology staging. MSI gastric cancers exhibited a reduced LN ratio, particularly at advanced T-staging, compared to MSS counterparts, while maintaining an equivalent LN yield. Overestimation of cN by computed tomography preoperatively was frequent in MSI gastric cancers but was more commonly underestimated in MSS counterparts. VEGF-C and VEGFR-3 expression were lower in MSI tumors. MSI gastric cancers showed an increased total number of CD8+ T cells, albeit with a lower proportion of effector memory cells expressing CD45RA (EMRA) and CD8+ CXCR4+ T cells, compared to MSS counterparts.

CONCLUSION

Frequent overestimation of clinical N-staging in MSI gastric cancers is associated with VEGF-C signaling and CD8+ T-cell dynamics and should be cautiously interpreted, as it might misguide therapeutic options.

Combination of the Ratio Between Negative and Harvested Lymph Nodes and Metastatic Lymph Node Count as a Prognostic Indicator in Stage III Colon Cancer: A Retrospective Cohort Study

BACKGROUND

This study aimed to investigate the relationship between the ratio of negative lymph nodes (NLN) number to the number of metastatic lymph nodes (MLN) and the harvested lymph nodes (HLN) number ratio survival rate and compare its prognostic value.

METHODS

This retrospective cohort study included 207 stage III colon cancer patients between 2010 and 2018 at a single center. NLN/MLN and NLN/HLN cut-off values were determined with the receiver operating characteristic (ROC) curve according to 5-year survival. The patients were divided into high-risk and low-risk groups according to the cut-off value. These 2 groups were evaluated according to the clinicopathological data of the patients.

RESULT

The time-dependent ROC curve showed the optimal cut-off values of NLN as 3.86 and .79, respectively. These values show 83 patients in the high-risk group and 124 in the low-risk group. There was no difference between the groups in tumor localization and T stage. According to Kaplan-Meier survival analysis, mean survival was 35.88 months in the high-risk group and 50.18 months in the low-risk group. The risk of death in the high-risk group was 305% compared to the low-risk group (Hazard Ratio: 3.05, 95% 1.91 - 4.88) (P < .001).

CONCLUSION

NLNs are among the critical prognostic factors in colon cancer. Although NLNs have a positive correlation with the survival rate of the patients, there is no statistical difference in tumor T stage and localization.

The minimum number of examined lymph nodes was 24 for optimal survival of pathological T2-4 gastric cancer: a multi-center, hospital-based study covering 20 years of data

INTRODUCTION

The current National Comprehensive Cancer Network (NCCN) guidelines recommend that at least 16 lymph nodes should be examined for gastric cancer patients to reduce staging migration. However, there is still debate regarding the optimal management of examined lymph nodes (ELNs) for gastric cancer patients. In this study, we aimed to develop and test the minimum number of ELNs that should be retrieved during gastrectomy for optimal survival in patients with gastric cancer.

METHODS

We used the restricted cubic spline (RCS) to identify the optimal threshold of ELNs that should be retrieved during gastrectomy based on the China National Cancer Center Gastric Cancer (NCCGC) database. Northwest cohort, which sourced from the highest gastric cancer incidence areas in China, was used to verify the optimal cutoff value. Survival analysis was performed via Kaplan-Meier estimates and Cox proportional hazards models.

RESULTS

In this study, 12,670 gastrectomy patients were included in the NCCGC cohort and 4941 patients in the Northwest cohort. During 1999-2019, the average number of ELNs increased from 17.88 to 34.45 nodes in the NCCGC cohort, while the number of positive lymph nodes remained stable (5-6 nodes). The RCS model showed a U-curved association between ELNs and the risk of all-cause mortality, and the optimal threshold of ELNs was 24 [Hazard ratio (HR) = 1.00]. The ELN ≥ 24 group had a better overall survival (OS) than the ELN < 24 group clearly (P = 0.003), however, with respect to the threshold of 16 ELNs, there was no significantly difference between the two groups (P = 0.101). In the multivariate analysis, ELN ≥ 24 group was associated with improved survival outcomes in total gastrectomy patients [HR = 0.787, 95% confidence interval (CI): 0.711-0.870, P < 0.001], as well as the subgroup analysis of T2 patients (HR = 0.621, 95%CI: 0.399-0.966, P = 0.035), T3 patients (HR = 0.787, 95%CI: 0.659-0.940, P = 0.008) and T4 patients (HR = 0.775, 95%CI: 0.675-0.888, P < 0.001).

CONCLUSION

In conclusion, the minimum number of ELNs for optimal survival of gastric cancer with pathological T2-4 was 24.

Prognostic significance of metastatic lymph node ratio in gastric cancer: a Western-center analysis

BACKGROUND

Tumor-node-metastasis (TNM) staging is the central gastric cancer (GC) staging system, but it has some disadvantages. However, the lymph node ratio (LNR) can be used regardless of the type of lymphadenectomy and is considered an important prognostic factor. This study aimed to evaluate the relationship between LNR and survival in patients who underwent curative GC surgery.

METHODS

All patients who underwent radical gastric surgery between January 2014 and June 2022 were retrospectively evaluated. Clinicopathological features of tumors, TNM stage, and survival rates were analyzed. LNR was defined as the ratio between metastatic lymph nodes and total lymph nodes removed. The LNR groups were classified as follows: LNR0 = 0, 0.01 < LNR1 ≤ 0.1, 0.1 < LNR2 ≤ 0.25 and LNR3 > 0.25. Tumor characteristics and overall survival (OS) of the patients were compared between LNR groups.

RESULTS

After exclusion, 333 patients were analyzed. The mean age was 62 ± 14 years. According to the LNR classification, no difference was found between groups regarding age and sex. However, TNM stage III disease was significantly more common in LNR3 patients. Most patients (43.2%, n = 144) were in the LNR3 group. In terms of tumor characteristics (lymphatic, vascular, and perineural invasion), the LNR3 group had significantly poorer prognostic factors. The Cox regression model defined LNR3, TNM stage II-III disease, and advanced age as independent risk factors for survival. Patients with LNR3 demonstrated the lowest 5-year OS rate (35.7%) (estimated mean survival was 30 ± 1.9 months) compared to LNR 0-1-2.

CONCLUSION

Our study showed that a high LNR was significantly associated with poor OS in patients who underwent curative gastrectomy. LNR can be used as an independent prognostic predictor in GC patients.

Evaluation of the prognostic value of negative to positive lymph node ratio in gastric cancer: results from multi-institutional cohorts from western and eastern datasets - Cohort study

Lymph node (LN) stage is important for prognosis evaluation of gastric cancer (GC) patients. This study aimed to evaluate the prognostic value of the ratio of negative to positive LNs (Rnp) in GC.

METHODS

The authors evaluated the clinical significance of the Rnp stage in 7660 GC patients from three high-volume institutions in China. Meanwhile, the authors verified the value of the Rnp stage in 11 234 GC patients from the Surveillance, Epidemiology, and End Results (SEER) database.

RESULTS

The patients were stratified into different subgroups based on the N stage of the eighth edition of the TNM staging system, the ratio of positive to detected LNs (Rpd) and Rnp. The survival analysis showed clear differences between the three LN stages in both the China and Surveillance, Epidemiology, and End Results cohorts. In univariate and multivariate analyses, the Rnp stage provided smaller Akaike information criterion or Bayesian information criterion values and a larger likelihood ratio χ2 than the N or Rpd stages in both two cohorts. For patients with inadequate examined LNs (<16), the Rnp stage showed better prognostic evaluation performance than the other two stages. In addition, the 5-year disease-specific survival of GC patients showed a slight variation with increasing LNs in the same subgroup classified by the Rnp or Rpd stages compared to the N stage.

CONCLUSIONS

Along with the higher prognostic value, the Rnp stage has excellent universality with GC patients compared to the N or Rpd stages. Studies with larger sample sizes are needed to predict the prognosis and provide more precise treatment for GC patients.

Clinical significance of the largest histopathological metastatic lymph node size for postoperative course of patients undergoing surgery for gastric cancer

Aim

The aim of this study was to investigate the effect of the largest metastatic lymph node (MLN) size on postoperative outcomes of patients with stage II-III gastric cancer (GC).

Methods

A total of 163 patients with stage II/III GC who underwent curative surgery were included in this single-center retrospective study. The lymph nodes were counted, each lymph node was analyzed for metastatic involvement by histopathological examination, and the diameter of the largest metastatic lymph node was recorded. The severity of postoperative complications was assessed by Clavien-Dindo classification system. Two groups of 163 patients were defined according to ROC analysis with cut-off value of histopathologically maximum MLN diameter. A comparative analysis of demographic and clinicopathological characteristics of the patients and their postoperative outcomes were performed.

Results

The median hospital stay was significantly longer in patients with major complications compared to patients without major complications [18 days (IQR: 13-24) vs. 8 days (IQR: 7-11); (p < 0.001)]. The median MLN size was significantly larger in deceased patients compared to survived [1.3 cm (IQR: 0.8-1.6) vs. 0.9 cm (IQR: 0.6-1.2), respectively; (p < 0.001)]. The cut-off value of MLN size predicting mortality was found as 1.05 cm. MLN size ≥1.05 cm had nearly 3.5 times more negative impact on survival.

Conclusions

The largest metastatic lymph node size had a significant association with survival outcomes. Particularly, MLN size over 1.05 cm was associated with worse survival outcomes. However, the largest MLN was not shown to have any effect on major complications. Further prospective and large-scale studies are required to draw more precise conclusions.

Mapping Lymph Node during Indocyanine Green Fluorescence-Imaging Guided Gastric Oncologic Surgery: Current Applications and Future Directions

Huge strides have been made in the navigation of gastric cancer surgery thanks to the improvement of intraoperative techniques. For now, the use of indocyanine green (ICG) enhanced fluorescence imaging has received promising results in detecting sentinel lymph nodes (SLNs) and tracing lymphatic drainages, which make it applicable for limited and precise lymphadenectomy. Nevertheless, issues of the lack of specificity and unpredictable false-negative lymph nodes were encountered in gastric oncologic surgery practice using ICG-enhanced fluorescence imaging (ICG-FI), which restrict its application. Here, we reviewed the current application of ICG-FI and assessed potential approaches to improving ICG-FI.