The Relationship Between Lymph Node Ratio and Survival Benefit With Adjuvant Chemotherapy in Node-positive Esophageal Adenocarcinoma

Lymph Node Ratio as a Predictor of Survival for Colon Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Lymph node ratio is the number of lymph nodes with evidence of metastases on pathological review compared to the total number of lymph nodes harvested during oncologic resection. Lymph node ratio is a proven predictor of long-term survival. These data have not been meta-analyzed to determine the prognosis associated with different lymph node ratio cut-offs in colon cancer.

METHODS

Medline, Embase, and CENTRAL were systematically searched. Articles were included if they compared 5-year overall survival (OS) or disease-free survival (DFS) between different lymph node ratios for patients undergoing oncologic resection for stages I-III colon cancer. Pairwise meta-analyses using inverse variance random effects were performed.

RESULTS

From 2587 citations, nine studies with 97,631 patients (female: 51.9%, median age: 61.65 years) were included. A lymph node ratio above .1 resulted in a 49% decrease in the odds of 5-year OS (2 studies; OR: 0.51, 95% CI: 0.49-.53, P < .00001). A lymph node ratio above .25 resulted in a 56% decrease in the odds of 5-year OS (3 studies; OR: 0.44, 95% CI: 0.43-.45, P < .00001). A lymph node ratio above .5 resulted in a 65% decrease in the odds of 5-year OS (3 studies; OR: 0.35, 95% CI: 0.33-.37, P < .00001).

CONCLUSIONS

Lymph node ratios from .1 to .5 are effective predictors of 5-year OS for colon cancer. There appears to be an inverse dose-response relationship between lymph node ratio and 5-year OS. Further study is required to determine whether there is an optimal lymph node ratio cut-off for prognostication and whether it can inform which patients may benefit from more aggressive adjuvant therapy and follow-up protocols.

The Prognostic Significance of Lymph Node Ratio for Esophageal Cancer: A Meta-Analysis

INTRODUCTION

This meta-analysis aimed to investigate the prognostic significance of positive lymph node ratio (LNR) in patients with esophageal cancer.

MATERIALS AND METHODS

The meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We conducted a systematic search of relevant literature published until April 2022 in PubMed, EMBASE, and the Cochrane Library. The primary and secondary outcomes were overall survival (OS) and disease-free survival (DFS), with corresponding hazard ratios (HR) and 95% confidence intervals (CI). The included studies were subgrouped based on age, study area, adjuvant therapy, sensitivity analysis, and assessment of publication bias. We analyzed and discussed the results.

RESULTS

We included 21 studies with 29 cohorts and 11,849 patients. The Newcastle-Ottawa Scale scores of the included studies were no less than six, indicating high research quality. The combined results of HR and 95% CI showed that patients with esophageal cancer with a lower LNR had better OS (HR, 2.58; 95% CI, 2.15-3.11; P < 0.001) and DFS (HR, 3.07; 95% CI, 1.85-5.10; P < 0.001). The subgroup analysis suggested that geographic region, age, and adjuvant therapy affected OS. When any cohort was excluded, no significant changes were observed in the pooled HR of the OS group, indicating reliable and robust results. Egger's and Begg's tests showed no potential publication bias in the studies that used OS as an outcome measurement index, indicating reliable results. Sensitivity analyses and assessments of publication bias (<10) were not performed because of an insufficient number of DFS studies.

CONCLUSION

Patients with a lower positive LNR had a higher survival rate, suggesting that positive LNR may be a promising predictor of EC prognosis in esophageal cancer. After radical resection of esophageal cancer, the ratio of the number of dissected lymph nodes to the number of positive lymph nodes in patients with esophageal cancer should be considered to accurately evaluate the prognosis.

The Effect of Center Esophagectomy Volume on Outcomes in Clinical Stage I to III Esophageal Cancer

OBJECTIVE

To determine the threshold annualized esophagectomy volume that is associated with improved survival, oncologic resection, and postoperative outcomes.

BACKGROUND

Esophagectomy at high-volume centers is associated with improved outcomes; however, the definition of high-volume remains debated.

METHODS

The 2004 to 2016 National Cancer Database was queried for patients with clinical stage I to III esophageal cancer undergoing esophagectomy. Center esophagectomy volume was modeled as a continuous variable using restricted cubic splines. Maximally selected ranks were used to identify an inflection point of center volume and survival. Survival was compared using multivariable Cox proportional hazards methods. Multivariable logistic regression was used to examine secondary outcomes.

RESULTS

Overall, 13,493 patients met study criteria. Median center esophagectomy volume was 8.2 (interquartile range: 3.2-17.2) cases per year. On restricted cubic splines, inflection points were identified at 9 and 30 cases per year. A multivariable Cox model was constructed modeling annualized center surgical volume as a continuous variable using 3 linear splines and inflection points at 9 and 30 cases per year. On multivariable analysis, increasing center volume up to 9 cases per year was associated with a substantial survival benefit (hazard ratio: 0.97, 95% confidence interval, 0.95-0.98, P ≤0.001). On multivariable logistic regression, factors associated with undergoing surgery at a high-volume center (>9 cases per year) included private insurance, care at an academic center, completion of high school education, and greater travel distance.

CONCLUSIONS

This National Cancer Database study utilizing multivariable analysis and restricted cubic splines suggests the threshold definition of a high-volume esophagectomy center as one that performs at least 10 operations a year.

Development and validation of prognostic model based on extragastric lymph nodes metastasis and lymph node ratio in node-positive gastric cancer: a retrospective cohort study based on a multicenter database

BACKGROUND

Regional lymph node metastasis (LNM) is a competent and the most intensive predictor for the prognostic evaluation of patients after curative surgery. This study is based on the databases of two large medical centers in North and South China. It aims to establish a prognostic model based on extragastric LNM (ELNM) and lymph node ratio (LNR) in node-positive gastric cancer (GC).

METHODS

Clinical data of 874 GC patients with pathologically confirmed LNM in a large medical center in southern China, were included as the training cohort. In addition, the clinical data of 674 patients with pathologically confirmed LNM from a large medical center in northern China were used as the validation cohort.

RESULTS

In the training cohort, a modified N staging system (mNstage) based on ELNM and LNR was established; it has a significantly higher prognostic accuracy than the pN, LNR and ELNM staging system (Akaike Information Criterion, pN stage vs. LNR stage vs. ELNM stage vs. mN stage=5498.479 vs. 5537.815 vs. 5569.844 vs. 5492.123; Bayesian Information Criterion, pN stage vs. LNR stage vs. ELNM stage vs. mN stage=5512.799 vs. 5547.361 vs. 5574.617 vs. 5506.896; likelihood-ratio χ2 , pN stage vs. LNR stage vs. ELNM stage vs. mN stage=177.7 vs. 149.8 vs. 115.79 vs. 183.5). In the external validation, mNstage also has higher prognostic accuracy than the pN, LNR and ELNM staging system. Cox multivariate regression analysis showed that age, mNstage, pT stage, and perineural invasion were independent factors. A nomogram model was established according to the four factors (age, mNstage, pT stage, and perineural invasion). The nomogram model was greater than the traditional tumor-node-metastasis (TNM) staging in the training cohort [1-year area under the curve (AUC), American Joint Commission for Cancer (AJCC) 8th TNM vs. nomogram=0.692 vs. 0.746, 3-year AUC: AJCC 8th TNM vs. nomogram=0.684 vs. 0.758, 5-year AUC: AJCC 8th TNM vs. nomogram=0.725 vs. 0.762]. In the external validation, the nomogram also showed better prognostic value and greater prediction accuracy than the traditional TNM staging.

CONCLUSION

The prognostic model based on ELNM and LNR has good prognostic prediction in patients with node-positive GC.

Clinical Understaging, Treatment Response, and Survival Among Esophageal Adenocarcinoma Patients

INTRODUCTION

Selecting appropriate management for patients with esophageal adenocarcinoma (EA) is predicated on accurate clinical staging information. Inaccurate information could lead to inappropriate treatment and suboptimal survival. We investigated the relationship between staging accuracy, treatment, and survival.

METHODS

This was a national cohort study of EA patients in the National Cancer Data Base (2006-2015) treated with upfront resection or neoadjuvant therapy (NAT). Clinical and pathological staging information was used to ascertain staging concordance for each patient. For NAT patients, Bayesian analysis was used to account for potential downstaging. We evaluated the association between staging concordance, receipt of NAT, and survival through hierarchical logistic regression and multivariable Cox regression.

RESULTS

Among 7635 EA patients treated at 877 hospitals, 3038 had upfront resection and 4597 NAT followed by surgery. Relative to accurately staged patients, understaging was associated with a lower likelihood (odds ratio [OR] 0.04 95% confidence interval [CI] 0.02-0.05) while overstaging was associated with a greater likelihood of receiving NAT (OR 1.98 [1.53-2.56]). Relative to upfront surgery, treatment of cT1N0 patients with NAT was associated with a higher risk of death (HR 3.08 [2.36-4.02]). For accurately or overstaged cT3-T4 patients, NAT was associated with a lower risk of death whether downstaging occurred (ypN0 disease-HR 0.67 [0.49-0.92]; N+ disease-HR 0.55 [0.45-0.66]) or not (ypN + disease-HR 0.78 [95% CI 0.65-0.93]).

CONCLUSIONS

Clinical understaging is associated with receipt of NAT which in turn may have a stage-specific impact on patients' survival regardless of treatment response. Guidelines should account for the possibility of inaccurate clinical staging.

The Construction and Validation of Nomogram to Predict the Prognosis with Small-Cell Lung Cancer Followed Surgery

Simple Summary

The therapeutic effect of postoperative radiotherapy for small-cell lung cancer (SCLC) patients with limited stage remained unclear. The aim of this retrospective study was to construct and validate a nomogram to assess the prognosis of small-cell lung cancer patients followed surgery in a large cohort (882 patients) which involved patients from Shanghai Pulmonary Hospital and the Surveillance, Epidemiology and End Results database. The nomogram derived from the training cohort achieved good predictive ability and could discriminate low- and high-risk subgroups in four cohorts. Postoperative radiotherapy promoted survival for high-risk patients but had little effect on low-risk patients. Moreover, by subgroup analysis based on the N stage, we suggested that N2 patients in the high-risk subgroup could benefit more from postoperative radiotherapy. Therefore, our nomogram might help with clinical decisions on the strategy of postoperative radiotherapy for SCLC patients.

Abstract

This study constructed and validated a prognostic model to evaluate the survival of small-cell lung cancer (SCLC) patients following surgery, and shed light on the strategy of postoperative radiotherapy. A total of 882 patients from Shanghai Pulmonary Hospital and the Surveillance, Epidemiology and End Results database after lung resection were selected. Multivariable Cox analysis was used to identify the indicators affecting long-term survival in patients. A nomogram was constructed to predict the prognosis of eligible patients. Indices of concordance (C-index) was used to access the predictive ability of cancer-specific survival (CSS) for the prognostic model. CSS discrimination in the prognostic model was comparable in the training and validation cohorts (C-index = 0.637[NORAD-T], 0.660[NORAD-V], 0.656[RAD] and 0.627[our hospital], respectively. Stratification based on the cutoff value of the nomogram yielded low- and high-risk subgroups in four cohorts. For patients in the high-risk group, postoperative radiotherapy was considered a survival-promoting strategy (unadjusted HR 0.641, 95% CI 0.469–0.876, p = 0.0046). In the low-risk group, however, the implementation of radiotherapy barely had an influence on CSS. In conclusion, the nomogram we constructed and validated could predict the prognosis of SCLC patients followed surgery and identify high-risk patients who were likely to benefit from postoperative radiotherapy.

Inclusion of the Number of Metastatic Lymph Nodes in the Staging System for Medullary Thyroid Cancer: Validating a Modified American Joint Committee on Cancer Tumor-Node-Metastasis Staging System

Background: The current American Joint Committee on Cancer (AJCC) staging system (8th edition) for medullary thyroid cancer (MTC) was originally extrapolated from the staging system for differentiated thyroid cancer. However, the current staging system does not accurately predict the prognosis of patients with MTC. Patients and Methods: The present study was based on data from the Surveillance, Epidemiology, and End Results (SEER) database and validated by multicenter data from the Shanghai Tenth People's Hospital, Tongji University School of Medicine, Xuzhou City Central Hospital, and Suzhou Ninth People's Hospital. Hazard ratio with its 95% confidence interval [CI] was estimated by Cox proportional hazards regression analysis. The concordance index (C-index) was used to evaluate the discrimination accuracy of the current AJCC tumor-node-metastasis (TNM) staging system and the modified AJCC (mAJCC) TNM staging system. Results: A total of 1175 MTC patients were selected from the SEER database and 312 from the three hospitals in China. We redefined the N category according to the number of metastatic lymph nodes (LNs) as follows: N'0 category (0 metastatic LNs), N'1 category (1-9 metastatic LNs), and N'2 category (≥10 metastatic LNs). The four distinct tumor stages were reclassified in the mAJCC staging system as follows: stage I (T1-4N'0M0, T1N'1M0), stage II (T2-3N'1M0, T1N'2M0), stage III (T4N'1M0, T2-4N'2M0), and stage IV (TanyN'anyM1). The C-index of the current AJCC staging system and the mAJCC staging system was 0.72 [CI, 0.67-0.78] and 0.78 [CI, 0.73-0.84], respectively. Similar results were observed in the survival analysis of the multicenter data set. Conclusions: The mAJCC staging system could discriminate the prognosis of MTC patients more effectively than the current AJCC staging system, indicating that it is feasible and appropriate to modify the current AJCC staging system by introducing the number of metastatic LNs instead of the location of LNs. These findings might be adopted in the next edition of the AJCC staging system and be used to guide clinical practice.

Esophagectomy versus definitive chemoradiotherapy as initial treatment for clinical stage I esophageal cancer: a systematic review and meta-analysis

BACKGROUND

Esophagectomy and definitive chemoradiotherapy are commonly used in the treatment of stage I esophageal cancer (EC). The present study aims to compare the efficacy and safety of esophagectomy and definitive chemoradiotherapy as the initial treatment for clinical stage I EC.

METHODS

This study was registered with the International Prospective Register of Systematic Reviews (CRD42020197203). Relevant studies were identified through PubMed, Web of Science, EMBASE, and Cochrane Library from database inception to June 30, 2020. Hazard ratio (HR) with 95% confidence intervals (CI) was employed to compare overall survival (OS) and progression-free survival (PFS). Odds ratio (OR) with 95% CI was employed to compare treatment-related death, complications, and tumor recurrence.

RESULTS

A total of 13 non-randomized controlled studies involving 3,346 patients were included. Compared with definitive chemoradiotherapy, esophagectomy showed an improved OS (HR 0.69, 95% CI 0.55-0.86; P < 0.001), PFS (HR 0.47, 95% CI 0.33-0.67; P < 0.001), and a lower risk of tumor recurrence (OR 0.43, 95% CI 0.30-0.61; P < 0.001). There was no significant difference in the incidence of complications (OR 1.11, 95% CI 0.75-1.65; P = 0.60) and treatment-related death (OR 1.15, 95% CI 0.31-4.30; P = 0.84) between the two treatments.

CONCLUSIONS

Current evidence shows esophagectomy has superior survival benefits as the initial treatment for clinical stage I EC. It is still the preferred choice for patients with clinical stage I EC. However, future high-quality randomized controlled trials are needed to validate this conclusion.

Perioperative CRP: A novel inflammation-based classification in gastric cancer for recurrence and chemotherapy benefit

Background

Perioperative C‐reactive protein (CRP) levels have effects on the prognosis of cancer patients. We intended to determine the prognostic value of combining the two for gastric cancer (GC).

Methods

Data were extracted from a clinical trial. By calculating the area under the curve (AUC) and the C‐index, the predictive value of CRPs among different time points, including preoperative (pre‐CRP), postoperative days 1, 3, and 5 (post‐CRPs), and postoperative maximum CRP (post‐CRP_max), was derived. Multivariate analysis was performed to further explore the independent variates for recurrence‐free survival (RFS).

Results

Finally, 401 patients were available in the present study. For RFS, higher AUC (0.692) and concordance index (0.678) of pre‐CRP were observed when compared with those of post‐CRPs. Further, among post‐CRPs, post‐CRP_max had the highest predictive values (AUC: 0.591; concordance index: 0.585) among the other post‐CRPs. The threshold values in predicting RFS for pre‐CRP and post‐CRP_max were 3.1 mg/L and 77.1 mg/L. Multivariate analysis showed both pre‐CRP≥3.1 mg/L (high‐pre‐CRP) and post‐CRP_max≥77.1 mg/L (high‐post‐CRP_max) were risk factors for RFS. Postoperative chemotherapy benefit was further analyzed for patients with stage II/III GC and indicated that patients with pre‐CRP<3.1 mg/L had better prognosis without benefit from postoperative adjuvant chemotherapy (ACT), p = 0.557. In high‐pre‐CRP patients, only patients with post‐CRP_max≥77.1 mg/L but not post‐CRP_max<77.1 mg/L benefited from postoperative ACT (RFS: 33.2% vs 49.9% for non‐chemotherapy group and chemotherapy group, respectively, p = 0.037). Analyses for overall survival obtained the similar outcomes.

Conclusions

Both high‐pre‐CRP and high‐post‐CRP_max are associated with worse prognosis in GC. ACT seems to only improve the prognosis for stage II/III GC with pre‐CRP≥3.1 mg/L and post‐CRP_max≥77.1 mg/L after radical gastrectomy. Further studies are needed to confirm these findings and explore the potential mechanism.