Recurrence/prognosis estimation using a molecularly positive surgical margin-based model calls for alternative curative strategies in pIIIA/N2 NSCLC

Stage pIIIA/N2 non-small cell lung cancer (NSCLC) is primarily treated by complete surgical resection combined with neoadjuvant/adjuvant therapies. However, up to 40% of patients experience tumor recurrence. Here, we studied 119 stage pIIIA/N2 NSCLC patients who received complete surgery plus adjuvant chemotherapy (CT) or chemoradiotherapy (CRT). The paired tumor and resection margin samples were analyzed using next-generation sequencing (NGS). Although all patients were classified as negative resection margins by histologic methods, NGS revealed that 47.1% of them had molecularly positive surgical margins. Patients who tested positive for NGS-detected residual tumors had significantly shorter disease-free survival (DFS) (P = 0.002). Additionally, metastatic lymph node ratio, erb-b2 receptor tyrosine kinase 2 (ERBB2) mutations, and SWI/SNF-related, matrix-associated, actin-dependent regulator of chromatin, subfamily a, member 4 (SMARCA4) mutations were also independently associated with DFS. We used these four features to construct a COX model that could effectively estimate recurrence risk and prognosis. Notably, mutational profiling through broad-panel NGS could more sensitively detect residual tumors than the conventional histologic methods. Adjuvant CT and adjuvant CRT exhibited no significant difference in eliminating locoregional recurrence risk for stage pIIIA/N2 NSCLC patients with molecularly positive surgical margins.

Development and external validation of a nomogram predicting overall survival for Gastric adenocarcinoma patients with radical gastrectomy

PURPOSE

The aim of this study was to develop and externally validate a nomogram to accurately predict the overall survival (OS) of patients with gastric adenocarcinoma who underwent radical gastrectomy.

MATERIALS AND METHODS

A total of 3492 patients with gastric adenocarcinoma who underwent radical gastrectomy from 2012 to 2017 were included as the training cohort. Survival analysis was performed via Kaplan Meier method and log-rank test. Independent postoperative prognostic factors in patients with gastric adenocarcinoma were analyzed using univariate and multifactorial COX analysis methods. The prognosis nomogram was established in the training cohort and verified externally in the Surveillance, Epidemiology and End Results (SEER) database.

RESULTS

According to the univariate and multifactorial COX analyses, metastatic lymph node ratio (MLNR) and five other independent prognostic factors (age at surgery, type of gastrectomy, tumor size, T stage, and pathological grade) were included in the prognostic nomogram. The nomogram had better prognostic predictive ability than the American Joint Committee on Cancer (AJCC) TNM staging in both the training (C-index: 0.736 VS. 0.668) and external validation cohort (C-index: 0.712 VS. 0.627). The calibration plots showed that the predicted survival rate was in good agreement with the actual survival rate. And the decision curve analysis (DCA) curves revealed that nomogram showed stronger ability in predicting 1-year, 3-year, and 5-year OS.

CONCLUSION

This study estimated the excellent prognostic predictive power and clinical application potential of the MLNR-based nomogram, which may be used to facilitate postoperative clinical treatment decisions and potentially improve patient survival outcomes.

The Prognostic Utility of the Metastatic Lymph Node Ratio and the Number of Regional Lymph Nodes Removed from Patients with Small Bowel Adenocarcinomas

Background and Objectives: Small bowel adenocarcinomas (SBAs) are rare tumors of the gastrointestinal system. Lymph node metastasis in patients with curatively resected SBAs is associated with poor prognosis. In this study, we determined the prognostic utility of the number of removed lymph nodes and the metastatic lymph node ratio (the N ratio). Materials and Methods: The data of 97 patients who underwent curative SBA resection in nine hospitals of Turkey were retrospectively evaluated. Univariate and multivariate analyses of potentially prognostic factors including the N ratio and the numbers of regional lymph nodes removed were evaluated. Results: Univariate analysis showed that perineural and vascular invasion, metastatic lymph nodes, advanced TNM stage, and a high N ratio were significant predictors of poor survival. Multivariate analysis revealed that the N ratio was a significant independent predictor of disease-specific survival (DSS). The group with the lowest N ratio exhibited the longest disease-free survival (DFS) and DSS; these decreased significantly as the N ratio increased (both, p < 0.001). There was no significant difference in either DFS or DSS between groups with low and high numbers of dissected lymph nodes (i.e., <13 and ≥13) (both, p = 0.075). Conclusions: We found that the N ratio was independently prognostic of DSS in patients with radically resected SBAs. The N ratio is a convenient and accurate measure of the severity of lymph node metastasis.

Superiority of metastatic lymph node ratio over number of node metastases and TNM/AJCC N classification in predicting cancer-specific survival in medullary thyroid cancer

BACKGROUND

In medullary thyroid cancer (MTC), it is unclear which nodal classification system, metastatic lymph node ratio (MLNR), number of node metastases, or TNM/AJCC N classification, predicts cancer-specific survival best.

METHODS

Kaplan-Maier analysis of cancer-specific survival after operation at a tertiary center.

RESULTS

Included were 505 MTC patients. The spread of the survival curves was greatest after stratification by MLNR (in 0.20 increments), followed by number of node metastases (in 10-node and 20-node increments) and TNM/AJCC classification (N0, N1a, N1b). After collapsing overlapping survival curves, all adjacent curves (MLNRs ≤0.20 vs. 0.21-0.60 vs. >0.60; 0 vs. 1-20 vs. >20 node metastases; and TNM/AJCC N classification N0/N1a vs. N1b) significantly differed between each other.

CONCLUSIONS

In MTC, MLNR, reflecting intensity of lymphatic spread, predicts cancer-specific survival better than number of node metastases or TNM/AJCC N classification. The applicability of these findings to patients with limited neck dissection requires more research.

Prognostic significance of the metastatic lymph node ratio compared to the TNM classification in stage III gastric cancer

Background

We aimed to evaluate a comparative analysis of the prognostic value of the metastatic lymph node ratio (LNR) and pN (TNM) in stage III gastric cancer.

Patients and Methods

A total of 159 stage III gastric cancer patients with curative gastrectomy were retrospectively analyzed. Cutoff values for LNR were designated according to 25%, 50% and 75% percentiles, 0.07, 0.20 and 0.44 respectively. The LNR was divided into four groups as 0 > LNR1 ≤ 0.07; 0.07 > LNR2 ≤0.20; 0.20 > LNR3 ≤0.44; 0.44 > LNR4 ≤1.

Results

The mean age of the patients was 61.1 ± 11.3 years. Male predominance was apparent (73.6%). The 1-year overall survival and recurrence rates were 73.6% and 33.6%, respectively. The univariate cox regression analysis demonstrated age and LNR were the main variables that affected overall survival (OS) (p < 0.05). Harvested lymph nodes less than 16 did not affect OS (p = 0.255). The results of the multivariate cox regression analysis revealed that only LNR was an independent prognostic factor (P < 0.001), while pN was not (p > 0.05). Similar results, as with overall survival, could not be revealed clearly for disease free survival (DFS).

Conclusions

LNR was an independent significant prognostic factor and superior to pN staging in predicting OS but not for DFS in stage III gastric cancer patients. The high LNR levels in our research were found to be associated with poor survival rates. The percentile system we used to determine cutoff values may be considered as a reliable method. Similarly, LNR also provides a reliable prognostic parameter in future staging systems to help guide treatment algorithm plans.

Prognostic Significance of Metastatic Lymph Nodes Ratio (MLNR) Combined with Protein-Tyrosine Phosphatase H1 (PTPH1) Expression in Operable Breast Invasive Ductal Carcinoma

Purpose

The metastatic lymph node ratio (MLNR) is one of the most important factors in prognostic analysis of breast cancer. The objective of this study was to determine if MLNR combined with protein-tyrosine phosphatase H1 (PTPH1) pathological expression can be used to predict the prognosis of patients with breast invasive ductal carcinoma (IDC) better than one factor only.

Patients and Methods

A total of 136 patients with invasive ductal carcinoma (IDC) of breast who underwent modified radical mastectomy and were treated with chemotherapy after operation at Qilu Hospital of Shandong University from December 2008 to October 2011 were included. PTPH1 expression was evaluated by immunohistochemistry in surgical specimens retrospectively collected from patients with histologically proven invasive ductal breast cancer. Kaplan–Meier survival analysis and Cox regression analysis were performed to assess the prognostic significance of PTPH1 expression. A prognostic factor for disease-free survival (DFS) was identified by univariate and multivariate analyses. ROC analysis was used to evaluate the performance of single factors and combined feature.

Results

One hundred and thirty-six patients were included in the analysis. By cut-point survival analysis, MLNR cut-off was designed as 0.2. On multivariate analysis, a MLNR>0.2 was associated with a worse DFS (HR=2.581, 95% CI=1.303–5.113, P=0.007). PTPH1 overexpression is correlated with a better DFS (HR=0.391, 95% CI=0.162–0.945, P=0.037). In addition, MLNR and PTPH1 combined feature had better performance in predicting clinical outcomes after surgery long before recurrence had occurred (Area under the curve=0.795 [95% CI=0.694–0.896], P<0.001).

Conclusion

These findings indicate that both PTPH1 and MLNR are accurate independent prognostic parameters in patients with IDC of the breast. Better information on IDC prognosis could be obtained from the combined feature.

Prognostic Implication of Metastatic Lymph Node Ratio in Colorectal Cancers: Comparison Depending on Tumor Location

Background: The proportion of the number of involved lymph nodes (LNs) to the number of examined LNs—defined as metastatic LN ratio (mLNR)—has been considered as a prognostic parameter. This study aims to elucidate the prognostic implication of the mLNR in colorectal cancer (CRC) according to the tumor location. Methods: We evaluated the correlation between prognoses and the involved and examined LNs as well as mLNR according to the tumor location in 266 surgically resected human CRCs. Besides, to evaluate the optimal cutoff for high and low mLNRs, we investigated the correlation between mLNR and survival according to the various cutoffs. Results: LN metastasis was found in 146 cases (54.9%), and colon and rectal cancers were found in 116 (79.5%) and 30 (20.5%) of the cases, respectively. The mean mLNRs were significantly higher in rectal cancer than in colon cancer (0.38 ± 0.28 vs. 0.21 ± 0.24, P = 0.003). Besides this, the number of involved LNs in rectal cancer was significantly high compared to colon cancer (11.83 ± 10.92 vs. 6.37 ± 7.78, P = 0.014). However, there was no significant difference in the examined LNs between the rectal and colon cancers (31.90 ± 12.28 vs. 36.60 ± 18.11, P = 0.181). In colon cancer, a high mLNR was significantly correlated with worse survival for all cutoffs (0.1, 0.2, 0.3, and 0.4). However, rectal cancer only showed a significant correlation between high mLNR and worse survival in the subgroup with a cutoff of 0.2. Conclusions: Our results showed that high mLNR was significantly correlated with worse survival. The number of involved LNs and mLNRs were significantly higher in rectal cancer than in colon cancer. The cutoff of 0.2 can be useful for the differentiation of prognostic groups, regardless of tumor location.

Metastatic Lymph Node Ratio (mLNR) is a Useful Parameter in the Prognosis of Colorectal Cancer; A Meta-Analysis for the Prognostic Role of mLNR

Background and objectives: The presenting study aimed to elucidate the prognostic role of the metastatic lymph node ratio (mLNR) in patients with colorectal cancer (CRC), using a meta-analysis. Materials and Methods: Using data from 90,274 patients from 14 eligible studies, we performed a meta-analysis for the correlation between mLNR and survival rate. Besides, subgroup analyses were performed, based on tumor stage, tumor location, and mLNR. Results: A high mLNR showed significant correlation with worse overall survival and disease-free survival rates in CRC patients (hazard ratio (HR), 1.617, 95% confidence interval (CI) 1.393-1.877, and HR 2.345, 95% CI 1.879-2.926, respectively). In patients with stage III, who had regional LN metastasis, the HRs were 1.730 (95% CI 1.266-2.362) and 2.451 (95% CI 1.719-3.494) for overall and disease-free survival, respectively. According to tumor location, rectal cancer showed a worse survival rate when compared to colon cancer. In the analysis for overall survival, when mLNR was 0.2, HR was the highest across the different subgroups (HR 5.040, 95% CI 1.780-14.270). However, in the analysis for disease-free survival, the subgroup with an mLNR < 0.2 had a higher HR than the other subgroups (HR 2.878, 95% CI 1.401-5.912). Conclusions: The mLNR may be a useful prognostic factor for patients with CRC, regardless of the tumor stage or tumor location. Further studies are necessary for the detailed criteria of mLNR before its application in daily practice.

Grade-lymph node ratio predicts the survival of breast cancer in different molecular types: A surveillance, epidemiology, and end results population-based analysis

The prognostic value and conflicting results of metastatic lymph node ratio (mLNR) on breast cancer have aroused an increasing concern. We aimed to evaluate the imperative of mLNR classification and prognostic factors in breast cancer with molecular subtypes.This study uses the database of surveillance, epidemiology, and end results (SEER) to investigate the imperative for reliable mLNR classification and critical prognostic factors in breast cancer with different molecular subtypes.The prognostic characteristics for disease-specific survival (DSS) of breast cancer were investigated in the SEER cohort (n = 3651). mLNR (P = .017) and histology grade (P < .001) were independent factors. A novel grade-lymph node ratio (G-R) staging system was proposed for breast cancer prognosis. The receiver operating characteristic curves revealed that the G-R staging system had an accurate 1-, 3-, and 5-year DSS prediction. Further stratification analysis with molecular subtypes of breast cancer (Luminal and TNBC) first proved robust prognostic values of the G-R staging system among molecular subtypes.The current population-based cohort demonstrated the capacity of mLNR serving as a critical prognostic factor. Also, G-R staging system has the potential to be regarded as reliable classification for breast cancer patients with different molecular subtypes.

Comparison of the 8th union for international cancer control lymph node staging system for gastric cancer with two other lymph node staging systems

The log odds of positive lymph nodes (LODDS) and the metastatic lymph node ratio (MLR) staging systems have previously been demonstrated to exhibit advantages compared with the tumor-node-metastasis (TNM) staging system in predicting the prognosis of gastric cancer. The current study compared the prognostic significance of the newest Union for International Cancer Control Node classification with the LODDS and MLR staging systems. From September 2010 to December 2012, all medical records for patients with gastric cancer at the Third Affiliated Hospital of Soochow University were retrospectively analyzed and the clinicopathologic characteristics were reviewed. Cut-off points were selected to divide the patients with gastric cancer into different groups. Univariate and multivariate analyses were performed to identify the prognostic risk factors for gastric cancer. The Harrell's concordance index (C-index) was adopted to compare the prognostic value of the three staging systems. A total of 877 patients with gastric cancer who met the inclusion criteria were analyzed in the current study. The patients were classified according to the three MLR subgroups as follows: MLR0 (MLR=0), MLR1 (0<MLR≤0.28) and MLR2 (0.28<MLR<1). The patients were classified according to the LODDS subgroups as follows: LODDS1 (LODDS≤-0.5), LODDS2 (-0.5<LODDS≤0), LODDS3 (0<LODDS≤0.5) and LODDS4 (LODDS>0.5). Based on multivariate analysis, LODDS, MLR and pathological node (pN) stage could significantly predict survival rates of patients with gastric cancer. According to the C-index, the LODDS staging system more accurately predicted the 5-year overall survival for patients with gastric cancer compared with the other two staging systems. In summary, the current study has identified that LODDS may be superior to the MLR and pN staging systems in predicting the prognosis of patients with gastric cancer. However MLR may exhibit advantages compared with LODDS for patients who have undergone adequate lymphadenectomies.

Metastatic lymph node ratio and Lauren classification are independent prognostic markers for survival rates of patients with gastric cancer

The long-term prognosis for patients with gastric cancer (GC) following radical resection remains poor. It is important to identify prognostic markers to predict survival. In the present retrospective study, the association between the metastatic lymph node ratio (rN) and the Lauren classification on predicting overall survival (OS) was investigated. Furthermore, a subgroup analysis was performed on the Lauren classification, using rN score as an independent prognostic marker. In total, 261 pathologically confirmed patients with GC were retrospectively reviewed. Kaplan-Meier curves and Cox's proportional hazards modeling were applied to analyze the OS of patients, and were utilized in the subgroup analysis. Receiver operating characteristic (ROC) curves were used to compare the accuracy of prognosis between the rN score and lymph node staging (N stage). The χ² test was used to analyze the association between the rN score and Lauren classification. Univariate survival and multivariate analysis demonstrated that the rN score and Lauren classification were significant prognostic markers for patients with GC. The ROC analysis confirmed that the rN score was more effective than N staging for OS prediction. Subgroup analysis indicated that rN was more accurate at predicting OS time in patients with diffuse type GC. The rN score and the Lauren classification were independent prognostic factors for the OS of patients with GC following radical resection, and the rN score was more accurate than the N stage for predicting the prognosis. Overall, the rN may be suitable as an independent predictor for OS in patients with diffuse type GC.

Lymph node ratio-based staging system as an alternative to the current TNM staging system to assess outcome in adenocarcinoma of the esophagogastric junction after surgical resection

This study aimed to assess the prognostic value of the hypothetical tumor-N-ratio (rN)-metastasis (TrNM) staging system in adenocarcinoma of the esophagogastric junction (AEG). The clinical data of 387 AEG patients who received surgical resection were retrospectively reviewed. The optimal cut-off point of rN was calculated by the best cut-off approach using log-rank test. Kaplan-Meier plots and Cox regressions model were applied for univariate and multivariate survival analyses. A TrNM staging system based on rN was proposed. The discriminating ability of each staging was evaluated by using an adjusted hazard ratio (HR) and a −2log likelihood. The prediction accuracy of the model was assessed by using the area under the curve (AUC) and the Harrell's C-index. The number of examined lymph nodes (LNs) was correlated with metastatic LNs (r = 0.322, P < 0.001) but not with rN (r = 0.098, P > 0.05). The optimal cut-points of rN were calculated as 0, 0~0.3, 0.3~0.6, and 0.6~1.0. Univariate analysis revealed that pN and rN classifications significantly influenced patients’ RFS and OS (P < 0.001). Multivariate analysis adjusted for significant factors revealed that rN was recognized as an independent risk factor. A larger HR, a smaller −2log likelihood and a larger prediction accuracy were obtained for rN and the modified TrNM staging system. Taken together, our study demonstrates that the proposed N-ratio-based TrNM staging system is more reliable than the TNM staging system in evaluating prognosis of AEG patients after curative resection.

Quality indicators for thyroid cancer surgery: current perspective

INTRODUCTION

While the disease specific mortality of differentiated thyroid cancer has remained low with current treatments, its incidence has been steadily rising over the past several decades, and cancer related recurrence and morbidity have remained a significant problem. Quality indicators currently employed are relevant to the surgical intervention, but do not necessarily reflect oncological outcomes. Therefore, thyroid cancer specific surgical quality indicators, that offer insight into risk of cancer related morbidity and mortality are needed.

AREAS COVERED

This review aims to discuss the role of measuring quality in thyroid surgical oncology and carry out a comprehensive review of potential quality indicators for thyroid cancer operations. The three quality indicators reviewed here are the postoperative radioactive iodine update by remnant thyroid tissue, the proportion of resected lymph nodes with evidence of metastases, and the post-operative serum thyroglobulin level. Expert commentary: Together, these quality indicators may be utilized to guide improvement of the quality of surgical care for this unique patient population. A critical future step in establishing the role of quality indicators for thyroid cancer surgery is the determination of cutoff values of each indicator in an evidence-based manner.

Prognostic significance of metastatic lymph node ratio in squamous cell carcinoma of the cervix

Purpose

Metastatic lymph node ratio (MLNR) was reported to be an important prognostic factor in several tumors. However, depth of primary tumor invasion is also important in cervical cancer prognostic analysis. In this study, the objective was to determine if MLNR can be used to define a high-risk category of patients with squamous cell carcinoma of the cervix (SCC). And we combined MLNR and depth of invasion to investigate whether prognosis of SCC can be predicted better.

Patients and methods

We performed a retrospective review of patients with SCC who underwent radical hysterectomy and pelvic lymphadenectomy at QiLu Hospital of Shandong University from January 2007 to December 2009. Prognostic factors for disease-free survival (DFS) and overall survival (OS) were identified by univariate and multivariate analyses.

Results

One hundred and ninety-eight patients met the inclusion criteria and were included in the analysis. By cut-point survival analysis, MLNR cutoff was designed as 0.2. On multivariate analysis, an MLNR >0.2 was associated with a worse OS (hazard ratio [HR] =2.560, 95% CI 1.275–5.143, P=0.008) and DFS (HR =2.404, 95% CI 1.202–4.809, P=0.013). Depth of invasion cutoff was designed as invasion >1/2 cervix wall and was associated with a worse OS (HR =1.806, 95% CI 1.063–3.070, P=0.029) and DFS (HR =1.900, 95% CI 1.101–3.279, P=0.021). In addition, subgroup analysis revealed significant difference in OS and DFS rates between different MLNR categories within the same depth of invasion category (P<0.05), however, not between different depth of invasion categories within the same MLNR category (P>0.05).

Conclusion

MLNR may be used as the independent prognostic parameter in patients with SCC. Combined MLNR and depth of invasion can predict both OS and DFS better in SCC than one factor. Besides, MLNR appears to be a better prognostic value than depth of invasion for SCC.

Effect of number and ratio of positive lymph nodes in hypopharyngeal cancer

BACKGROUND

The number and ratio of positive lymph nodes are important prognostic factors in gastric cancer, but there is little data reported in hypopharyngeal cancer.

METHODS

Medical data from 81 patients with hypopharyngeal cancer undergoing radical hypopharyngectomy and cervical lymph node dissection were reviewed.

RESULTS

The median survival time was 84, 54, 30, and 13 months in patients with N0, N1, N2, and N3, respectively, and 84, 51, and 17 months with positive lymph node ratios (N ratio) 0, <10%, and >10%, respectively. Of the 24 N1 patients, the 20 patients that had an N ratio <10% had a better prognosis than the 4 patients with an N ratio >10%. Similar data was seen for the N2 patients. Tumor (T) classification, adjuvant therapy, and N ratio were independent prognostic factors in multivariate analysis.

CONCLUSION

The positive lymph node ratio is complementary to the current N classification system.

Can metastatic lymph node ratio (LNR) predict survival in oral cavity cancer patients?

OBJECTIVES

To evaluate the prognostic role of the lymph node ratio (LNR; ratio of total positive nodes to total dissected nodes) in oral squamous cell carcinoma (OSCC) as compared to pN staging with an aim to provide an optimal cut-off value.

METHODS

1,408 OSCC previously untreated patients who underwent treatment (surgery + neck dissection + adjuvant treatment). LNR sensitivity with respect to survival was calculated using receiver operating characteristic (ROC) curves and Cox regression method. LNR and TNM staging variables were subjected to multivariate analysis.

RESULTS

LNR (0.088) showed significant association with survival outcomes. For patients with LNR ≤0.088, the OS, DFS, local control, regional control and distant metastasis rates were 64%, 70%, and 89%; for LNR >0.088 it was 22%, 19%, and 52%, respectively (P < 0.001). On multivariate analysis LNR of 0.088 was seen to be an independent prognostic factor for 5-year regional control (p, hazard ratio [95% confidence interval]; 0.044, 2.016 (1.019-3.990), DFS, 0.032, 1.858 (1.054-3.276), and OS, 0.040, 1.195 (1.033-1.144). On multivariate analysis LNR categorization showed a statistically significant [0.032, 1.858, (1.054-3.276)] advantage over pN staging [0.527, 1.208 (1.054-3.276)] in predicting survival.

CONCLUSIONS

LNR is a better prognostic marker than the current N staging of TNM classification.

Lymph node ratio predicts local recurrence for periampullary tumours

BACKGROUND

To better define the prognostic role of nodal disease, evaluation of metastatic lymph node ratio (MLR) has been performed, and this method has recently gained prominence in various gastrointestinal cancers. The present study attempts to identify prognostic factors and evaluate the independent prognostic influence of MLR in patients who have undergone curative pancreaticoduodenectomy.

METHODS

In our institution within the study period, 111 patients received curative pancreaticoduodenectomy for periampullary cancers. Clinicopathologic data were collected and MLR was calculated for each of the patients. Patients were then divided into four groups based on MLR value: MLR 1 = 0; MLR 2 = 0.01-0.2; MLR 3 0.21-0.4; and MLR 4 >0.4.

RESULTS

Increasing MLR correlates with high recurrence rate and lower overall survival (OS) with significance (P < 0.001, P < 0.001). The recurrent group showed significantly lower OS than the non-recurrent group (P < 0.001). In the multivariate analysis for recurrence, MLR was identified as the only independent prognostic factor (P < 0.001).

CONCLUSIONS

The simple and easily obtainable MLR is well qualified as a prognostic factor in patients who undergo curatively radical resection for periampullary cancer. Furthermore, MLR can overcome the limitations of evaluation of lymph nodes status, allowing it to be used as a potential prognostic factor.