High Lymph Node Ratio Research Articles

Role of Adjuvant Radiation in pN2 Non-Small Cell Lung Cancer (NSCLC) Patients

Past studies have shown mixed results of postoperative radiation (PORT) for pN2 NSCLC patients and the recent LungART trial has shown no disease free survival or overall survival (OS) benefits with PORT for pN2 NSCLC patients. High lymph node ratio (LNR = number of positive lymph nodes in the resected specimen/number of total lymph nodes resected) has been shown to correlate with worse outcomes. We hypothesize that PORT can improve survival outcomes in pN2 NSCLC patients with high LNR.The National Cancer Database was queried for cases of NSCLC from 2004-2016. Patients without neoadjuvant treatment, with at least a lobectomy with resection of at least 10 lymph nodes, with pN2 disease, with histology of squamous cell carcinoma, adenocarcinoma, adenosquamous carcinoma and large cell carcinoma were included. Exclusion criteria were neoadjuvant therapy, lack of pathological confirmation or lack of information about chemotherapy and metastatic disease. For patients with PORT, RT was directed to thorax with dose≥30Gy. Log-rank test and Cox proportional hazards models were used to compare survival adjusted for age, sex, CCI, pT, grade, chemotherapy, LNR, and PORT. Predictors for overall survival (OS) were identified.Among 10272 patients, 6266 (61%) did not have PORT, and 4006 (39%) had PORT. Median follow up was over 5 years. PORT was given to 51.3% and 37.7% patients with non-R0 and R0 resection, respectively (P < 0.001). PORT was given to 48.4% and 9.91% of patients with and without adjuvant chemotherapy, respectively (P < 0.001). The average LNR for patients with and without PORT were 0.33 and 0.29 (P < 0.001), respectively. In multivariate analysis (MVA) of patients with R0 resection, predictors of OS were listed in Table 1. PORT was not associated with better OS (HR, 1.04, P = 0.63) for patients with LNR of 1-15%. However, PORT was associated with better survival in patients with higher LNRs (HR, 0.90, P = 0.23 for LNR of 15-29% and HR, 0.82, P = 0.01 for LNR ≥ 30%). In MVA of patients with non-R0 resection, PORT was associated with better survival (HR, 0.56, P = 0.01).High LNR after R0 surgery in pN2 NSCLC patients portends worse survival. PORT is associated with better survival for pN2 NSCLC patients after R0 resection with high LNR after accounting for multiple confounders including adjuvant chemotherapy. PORT is also associated with better survival in pN2 NSCLC patients after R1 or R2 surgery.

Prognostic Value of Lymph Node Characteristics in Patients with Cervical Cancer Treated with Radical Hysterectomy.

ObjectiveThis study evaluated the prognostic value of various lymph node (LN) characteristics, including the lymph node ratio (LNR), in patients with cervical cancer treated with radical hysterectomy.MethodsIn this retrospective study, 260 patients with cervical cancer who had undergone radical hysterectomy with pelvic or paraaortic lymphadenectomies were included. LN characteristics related to several LN statuses included total LN counts, LN metastasis, total positive LN counts, LNR, and levels of lymphadenectomy. LNR was defined as the number of metastatic LNs divided by the total number of LNs harvested. Univariate and multivariate analyses for disease-free survival (DFS) and overall survival (OS) were performed using the clinicopathological and LN characteristics.ResultsBased on receiver-operating characteristics curve analysis, the cut-off value of LNR was 0.0625. Multivariate analysis revealed that high LNR was significantly related to tumor recurrence (hazard ratio [HR], 5.182; 95% confidence interval [CI], 2.424–11.075; p < 0.0001). After adjusting for clinicopathological factors, LNR was also independent prognostic factor for predicting tumor recurrence (HR, 5.930; 95% CI, 2.114–16.634; p = 0.0007). However, total retrieved LN counts and level of lymphadenectomy were not associated with survival outcomes.ConclusionLNR may be a prognostic biomarker for predicting disease recurrence in cervical cancer treated with radical hysterectomy.

How to select the most appropriate adjuvant treatment after neoadjuvant treatment and resection for locally advanced pancreatic cancer?

Adjuvant chemotherapy (ACT) significantly improves survival of patients undergoing upfront surgery for resectable pancreatic cancer. After introducing the concept of neoadjuvant therapy (NAT) with potent chemotherapy regimens, long term survival has been achieved even in patients with borderline and locally advanced pancreatic cancer (BR/LAPC) following radical resection. The observed pathologic tumor response is strongly predictive of survival and provides a unique opportunity to visualize to what extent the cancer has been sensitive to the administered chemotherapy regimen and may potentially give hint how to personalize further oncologic treatment. Current literature provides only limited and heterogeneous data as to whether and what type of ACT is beneficial after NAT and resection for BR/LAPC. Larger studies suggest that ACT may bring survival advantage and should be attempted particularly in node-positive disease and preferably with more potent regimen such as FOLFIRINOX, if tolerable. In case of complete pathologic response, particularly after FOLFIRINOX, it does not seem beneficial to deescalate the treatment during ACT, but whether continuation on the same regimen is worthwhile needs to be further examined. In case of gemcitabine-based treatment as NAT, continuation with more cycles seems to be of value unless tumor biology proves to be too aggressive, with high lymph node ratio. Whether switch to a different regimen should be sought, if tolerability allows it, needs to be further studied. Whether it is the exact treatment sequence (NAT, ACT or both) of the potent chemotherapy regimens like FOLFIRINOX and gemcitabine-nab-paclitaxel or the total dose of chemotherapy that has impact on survival in BR/LAPC, is unknown.

The prognostic value of lymph node ratio in comparison to positive lymph node count in penile squamous cell carcinoma

PurposePenile cancer is a rare male neoplasm with a wide variation in its global incidence. In this study, the prognostic value of lymph node ratio (LNR) was compared to that of positive lymph node count (PLNC) in penile squamous cell carcinoma.MethodsA total of 249 patients with penile squamous cell carcinoma were enrolled from The Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015. The X-tile program was used to calculate the optimal cut-off values of LNR and PLNC that discriminate survival. We used the χ2 or the Fisher exact probability test to assess the association between clinical-pathological characteristics and LNR or PLNC. Univariate and multivariate Cox regression analyses were performed to identify independent prognostic factors for survival. Spearman correlation analysis was used to determine the correlation between LNR and PLNC.ResultsWe found that patients with high LNR tended to have advanced N stage, the 7th AJCC stage, and higher pathological grade, while patients with high PLNC had advanced N stage and the 7th AJCC stage. Univariate Cox regression analysis revealed that the N stage, M stage, the 7th AJCC stage, lymph-vascular invasion, LNR, and PLNC were significantly associated with prognosis. Multivariate Cox regression analysis demonstrated that LNR rather than PLNC was an independent prognostic factor for cancer-specific survival. Subgroup analysis of node-positive patients showed that LNR was associated with CSS, while PLNC was not.ConclusionLNR was a better predictor for long-term prognosis than PLNC in patients with penile squamous cell carcinoma.

Lymph node ratio is a strong prognostic factor after minimally invasive surgery radical hysterectomy of early-stage cervical cancer

<h3>Objectives:</h3> To determine whether prognostic impact of lymph node ratio (LNR), defined as the ratio between the number of positive lymph nodes and removed lymph nodes, is different by the surgical approach of radical hysterectomy (RH) in node-positive, early-stage cervical cancer. <h3>Methods:</h3> We retrospectively identified 2009 FIGO stage IB1-IIA2 patients who underwent primary Type C RH between 2010 and 2018 at two tertiary hospitals. Among them, only those with pathologically proven lymph node metastases and received adjuvant radiation therapy were included. Each patient's LNR was calculated, and its prognostic significance was investigated according to the two surgical approaches, open surgery, and minimally invasive surgery (MIS). <h3>Results:</h3> In total, 55 patients were included in this analysis. All patients received concurrent chemoradiation therapy after surgery, and the median LNR (%) was 9.524 (range, 2.083-62.500). Based on receiver operating characteristic-curve analysis, the cut-off value for LNR (%) was determined as 8.831. Overall, patients with high LNR (≥8.831%; n=29) showed worse disease-free survival (DFS) than those with low LNR (<8.831%, n=26) (P=0.027), whereas no difference in overall survival was observed. Multivariate analyses adjusting clinicopathologic factors revealed that DFS was adversely affected by both MIS (HR, 8.132; P=0.038) and high LNR (HR, 10.837; P=0.045). In a subgroup of open RH, LNR was not associated with disease recurrence. However, in a subgroup of MIS, high LNR was identified as an independent poor prognostic factor for DFS (adjusted HR, 14.578; P=0.034). <h3>Conclusions:</h3> In patients with node-positive, early-stage cervical cancer, high LNR was associated with a significantly higher disease recurrence rate. This relationship was further consolidated among patients who received MIS RH.

The prognostic value of lymph node ratio in patients with surgically resected stage I-III small-cell lung cancer: a propensity score matching analysis of the SEER database.

Due to the lack of prospective studies, the role of the lymph node ratio (LNR) in small-cell lung cancer (SCLC) remains unknown. This study aimed to assess the prognostic effect of LNR in surgically resected stage I-III SCLC patients. Clinical data of stage I-III (excluding N3 and NX) SCLC patients diagnosed between 1998 and 2016 were extracted from the Surveillance, Epidemiology and End Results database. Patients were divided into low-risk and high-risk subsets based on the LNR cut-off value of 0.15 using X-tile software. Propensity score matching analysis was employed to reduce bias in baseline characteristics. Kaplan-Meier analysis was performed to determine the overall survival (OS) and lung cancer-specific survival (LCSS). Cox regression analysis was performed to evaluate the effects of multiple variables. A total of 978 patients were identified, of whom 669 (68.40%) had LNR ≤0.15. Patients with LNR ≤0.15 showed better OS (P < 0.001) and LCSS (P < 0.001) both before and after propensity score matching. Multivariable analyses of the matched population confirmed LNR as an independent prognostic factor. Patients with LNR >0.15 showed poorer OS [hazard ratio (HR) 1.55, 95% confidence interval (CI) 1.09-2.19; P = 0.015] and LCSS (HR 1.65, 95% CI 1.13-2.43; P = 0.010). Subgroup analyses revealed that LNR ≤0.15 was associated with favourable OS (P = 0.009 and 0.197, respectively) and LCSS (P = 0.010 and 0.169, respectively) in N1 and N2 patients. LNR was determined as an independent predictor for surgically resected stage I-III SCLC, indicating that higher LNR is associated with reduced survival. The predictive value of LNR should to be further validated in prospective studies.

Comparing prognostic utility between the 8th edition of TNM staging system and the lymph node ratio for oral squamous cell carcinoma.

Lymph node metastasis in oral squamous cell carcinoma (OSCC) is associated with poor prognosis. The 8th edition of TNM has implemented new nodal staging criteria. We assess the prognostic utility of the lymph node ratio (LNR) and compare it to that of pN in the TNM 8th edition. One hundred and forty-two patients with OSCC were retrospectively studied. Nodal staging was performed using the TMN 8th edition and the prognostic value of the LNR in terms of overall survival (OS) and disease-free survival (DFS) was evaluated. Fifty-seven patients were eligible for inclusion. The LNR was independently prognostic of OS (p=0.02). Instead N classification was not significantly predictive of OS (p=0.10). High LNRs resulted in decreases in OS of approximately 40% within 6months after surgery. The LNR identifies patients with poor outcomes better than N classification. The lack of reliable LNR cutoffs compromises its utility in clinical practice.

Accurate Prediction of Prognosis by Integrating Clinical and Molecular Characteristics in Colon Cancer.

Various factors affect the prognosis of patients with colon cancer. Complicated factors are found to be conducive to accurate assessment of prognosis. In this study, we developed a series of prognostic prediction models for survival time of colon cancer patients after surgery. Analysis of nine clinical characteristics showed that the most important factor was the positive lymph node ratio (LNR). High LNR was the most important clinical factor affecting 1- and 3-year survival; M0&age < 70 was the most important feature for 5 years. The performance of the model was improved through the integration of clinical characteristics and four types of molecule features (mRNA, lncRNA, miRNA, DNA methylation). The model provides guidance for clinical practice. According to the high-risk molecular features combined with age ≥ 70&T3, poorly differentiated or undifferentiated, M0&well differentiated, M0&T2, LNR high, T4&poorly differentiated, or undifferentiated, the survival time may be less than 1 year; for patients with high risk of molecular features combined with M0&T2, M0&T4, LNR 0& M0, LNR median &T3, and LNR high, the survival is predicted less than 3 years; and the survival of patients with M1&T3, M0 and high risk molecular features is less than 5 years. Using multidimensional and complex patient information, this study establishes potential criteria for clinicians to evaluate the survival of patients for colon cancer.

Chemoradiotherapy or chemotherapy as adjuvant treatment for resected gastric cancer: should we use selection criteria?

The management of gastric adenocarcinoma is essentially based on surgery followed by adjuvant treatment. Adjuvant chemotherapy (CT) as well as chemoradiotherapy (CTRT) have proven their effectiveness in survival outcomes compared to surgery alone. However, there is little data comparing the two adjuvant approaches. This study aimed to compare the prognosis and survival outcomes of patients with gastric adenocarcinoma operated and treated by adjuvant radio-chemotherapy or chemotherapy. We retrospectively evaluated 80 patients with locally advanced gastric cancer (LGC) who received adjuvant treatment. We compared survival outcomes and patterns of recurrence of 53 patients treated by CTRT and those of 27 patients treated by CT. After a median follow-up of 38.48 months, CTRT resulted in a significant improvement of the 5-year PFS (60.9% vs. 36%, p = 0.03) and the 5-year OS (55.9% vs. 33%, p = 0.015) compared to adjuvant CT. The 5-year OS was significantly increased by adjuvant CTRT (p = 0.046) in patients with lymph node metastasis, and particularly those with advanced pN stage (p = 0.0078) and high lymph node ratio (LNR) exceeding 25% (p = 0.012). Also, there was a significant improvement of the PFS of patients classified pN2-N3 (p = 0.022) with a high LNR (p = 0.018). CTRT was also associated with improved OS and PFS in patients with lymphovascular and perineural invasion (LVI and PNI) compared to chemotherapy. There is a particular survival benefit of adding radiotherapy to chemotherapy in patients with selected criteria such as lymph node involvement, high LNR LVI, and PNI.

Laparoscopic gastrectomy plus D2 lymphadenectomy is as effective as open surgery in terms of long-term survival: a single-institution study on gastric cancer

BackgroundLaparoscopic surgery has been widely accepted to treat early-stage gastric cancer. However, it is still controversial to perform laparoscopic gastrectomy plus D2 lymphadenectomy for locally advanced gastric cancer. We performed the present study to compare the long-term outcomes of patients after laparoscopic or open gastrectomy plus D2 lymphadenectomy.MethodsThe clinicopathological data of 182 gastric cancer patients receiving gastrectomy plus D2 lymphadenectomy between January 2011 and December 2015 at Shenzhen Traditional Chinese Medicine Hospital were retrospectively retrieved. The overall survival (OS) and disease-free survival (DFS) of these 182 patients were compared. Then, the prognostic significance of positive lymph node ratio (LNR) was assessed.ResultsAs a whole, OS (P = 0.789) and DFS (P = 0.672) of patients receiving laparoscopic gastrectomy plus D2 lymphadenectomy were not significantly different from those of patients receiving open surgery. For stage I patients, laparoscopic gastrectomy plus D2 lymphadenectomy was not significantly different from open surgery in terms of OS (P = 0.573) and DFS (P = 0.157). Similarly, for stage II patients, laparoscopic gastrectomy plus D2 lymphadenectomy was not significantly different from open surgery in terms of OS (P = 0.567) and DFS (P = 0.830). For stage III patients, laparoscopic gastrectomy plus D2 lymphadenectomy was not significantly different from open surgery in terms of OS (P = 0.773) and DFS (P = 0.404). Laparoscopic or open gastrectomy plus D2 lymphadenectomy was not proven by Cox regression analysis to be an independent prognostic factor for OS and DFS. High LNR was significantly associated with worse OS (P < 0.001) and DFS (P < 0.001). Surgical type did not significantly affect prognosis of patients with low LNR or survival of patients with high LNR.ConclusionsFor patients with gastric cancer, laparoscopic gastrectomy plus D2 lymphadenectomy was not inferior to open surgery in terms of long-term outcomes. LNR is a useful prognostic marker for GC patients.

Clinical study on the effects of neoadjuvant chemotherapy on lymph node ratio, prognosis, and survival analysis of stage ⅢA-N2 non-small cell lung cancer

Objective: To investigate the effect of neoadjuvant chemotherapy (NCT) on the lymph node ratio (LNR) of patients with stage ⅢA-N2 non-small cell lung cancer (NSCLC), and analyze the relationship between LNR and prognosis. Methods: The data of 128 patients with stage ⅢA-N2 NSCLC admitted to the Department of Cardiothoracic Surgery of the First Affiliated Hospital of Hebei North University from January 2013 to December 2018 were retrospectively collected. The patients were divided into two groups according to the treatment method. The patients in the observation group (64 cases) were treated with NCT and surgery, and the patients in the control group (64 cases) were treated with surgery. Lymph node metastasis and survival were observed in the two groups. Subgroups were divided according to LNR and N2 lymph node status, and survival analysis was performed for each subgroup. Univariate and multivariate analysis were conducted for the observation group. Results: The number of metastatic lymph nodes, the proportion of patients with positive lymph nodes, and the rate of lymph node metastasis in the observation group were lower than those in the control group,3.8±2.1 vs 4.9±2.4,92.2% vs 100%,19.1% vs 22.4% respectively (all P<0.05). Progression-free survival (PFS) and overall survival (OS) in the observation group were better than those in the control group (both P<0.05). Both the observation and control subgroups with low LNR had better PFS and OS than the subgroups with high LNR (both P<0.05). Patients in the observation group with non-multi-site N2 lymph node metastasis had better PFS and OS (both P<0.05). Univariate analysis of observation group showed that patients with low LNR had better 2-year PFS and OS(both P<0.05). Multivariate analysis showed that the higher the LNR, the greater the risk of death (HR=2.178,95%CI: 1.025-4.626,P=0.043) and progression (HR=2.130,95%CI: 1.123-4.038,P=0.021). Conclusion: NTC could improve the prognosis and reduce LNR of patients with stage ⅢA-N2 NSCLC, and LNR was expected to be a prognostic indicator.

Intra-pancreatic distal cholangiocarcinoma and pancreatic ductal adenocarcinoma: a common short and long-term prognosis?

The aim of the study was to compare histological features, postoperative outcomes, and long-term prognostic factors after pancreaticoduodenectomy for distal cholangiocarcinoma and pancreatic ductal adenocarcinoma. From 2005 to 2017, 188 pancreaticoduodenectomies (pancreatic ductal adenocarcinoma n = 151, distal cholangiocarcinoma n = 37) were included. Postoperative outcomes were compared after matching on pancreatic gland texture and main pancreatic duct size. Matching according to tumor size, lymph node invasion and resection margin was used to compare overall and disease-free survival. Distal cholangiocarcinoma patients had more often "soft" pancreatic gland (P = 0.002) and small size main pancreatic duct (P = 0.001). Pancreatic ductal adenocarcinoma patients had larger tumors (P = 0.009), and higher lymph node ratio (P = 0.017). Severe morbidity (P = 0.023) and clinically relevant pancreatic fistula (P = 0.018) were higher in distal cholangiocarcinoma patients. After matching on gland texture and main pancreatic duct diameter, clinically relevant postoperative pancreatic fistula was still more frequent in distal cholangiocarcinoma patients (P = 0.007). Tumor size > 20mm was predictive of impaired overall survival (P = 0.024) and disease-free survival (P = 0.003), tumor differentiation (P = 0.027) was predictive of impaired overall survival. Survival outcomes for distal cholangiocarcinoma and pancreatic ductal cholangiocarcinoma were similar after matching patients according to tumor size, lymph node invasion and resection margin. Long-term outcomes after pancreaticoduodenectomy for distal cholangiocarcinoma and pancreatic ductal adenocarcinoma patients are similar. Postoperative course is more complicated after pancreaticoduodenectomy for distal cholangiocarcinoma than pancreatic ductal adenocarcinoma. After pancreaticoduodenectomy, patients with distal cholangiocarcinoma and pancreatic ductal adenocarcinoma have similar long-term oncological outcomes.

The lymph node ratio predicts cancer-specific survival of node-positive non-small cell lung cancer patients: a population-based SEER analysis

BackgroundLymph node ratio (LNR) has been suggested to be an effective prognostic tool for stratifying non-small cell lung cancer (NSCLC) cases. In this study, we sought to determine cancer-specific survival (CCS) of NSCLC cases from the SEER registry and used the X-tile method to optimize CCS-based LNR cut-off points for prognostic stratification of node-positive NSCLC.MethodsCSS and other clinicopathologic variables were retrieved from the SEER registry. Kaplan-Meier methods were used to calculate CSS. The optimal cut-off points for LNR classification were determined by the X-tile approach. Multivariate Cox regression analysis was performed to identify independent risks of CSS.ResultsTotally 11,341 lung cancer patients were included. Their median CSS was 22 months (range 0,143). The median LNR was 0.22 (Q1,Q3: 0.11, 0.50). X-tile analysis showed that the optimal LNR cut-off points were 0.28 and 0.81, dividing the cohort into low (LNR1 ≤ 0.28; n = 6580, 58%), middle (0.28 < LNR2 < 0.81; n = 3025, 26.7%), and high (LNR3 > 0.81; n = 1736, 15.3%) subsets. Kaplan-Meier analysis showed that patients with a low LNR had a significantly higher CCS versus patients with middle or high LNR (P < 0.001). Multivariate competing risks regression analysis revealed that LNR was an independent and significant adverse predictor of CSS (LNR2 vs. LNR1: SHR: 1.56, 95%CI: 1.47,1.67, P < 0.001; LNR3 vs. LNR1: SHR: 2.54, 95%CI: 2.30,2.80, P < 0.001).ConclusionsLNR is an independent prognostic factor of node-positive NSCLC and its optimal cut-off values established using the robust x-tile method effectively define subpopulations of node-positive NSCLC cases, which is important in guiding selection of treatment strategies clinically.

Lymph Node Ratio Is a Strong Prognostic Factor in Patients with Early-Stage Cervical Cancer Undergoing Minimally Invasive Radical Hysterectomy.

PurposeTo determine whether the prognostic impact of lymph node ratio (LNR), defined as the ratio between the number of positive lymph nodes and removed lymph nodes, differs between open and minimally invasive surgical approaches for radical hysterectomy (RH) in node-positive, early-stage cervical cancer.Materials and MethodsWe retrospectively identified 2009 International Federation of Gynecology and Obstetrics stage IB1-IIA2 patients who underwent primary type C RH between 2010 and 2018. Among them, only those with pathologically proven lymph node metastases who received adjuvant radiation therapy were included. The prognostic significance of LNR was investigated according to open surgery and minimally invasive surgery (MIS).ResultsIn total, 55 patients were included. The median LNR (%) was 9.524 (range, 2.083–62.500). Based on receiver operating characteristic curve analysis, the cut-off value for LNR (%) was determined as 8.831. Overall, patients with high LNR (≥8.831%; n=29) showed worse disease-free survival (DFS) than those with low LNR (<8.831%, n=26) (p=0.027), whereas no difference in overall survival was observed. Multivariate analyses adjusting for clinicopathologic factors revealed that DFS was adversely affected by both MIS [adjusted hazard ratio (HR), 8.132; p=0.038] and high LNR (adjusted HR, 10.837; p=0.045). In a subgroup of open surgery cases, LNR was not associated with disease recurrence. However, in a subgroup of MIS cases, high LNR was identified as an independent poor prognostic factor for DFS (adjusted HR, 14.578; p=0.034).ConclusionIn patients with node-positive, early-stage cervical cancer, high LNR was associated with a significantly higher disease recurrence rate. This relationship was further consolidated among patients who received MIS RH.

Long-term survival trend after primary total laryngectomy for patients with locally advanced laryngeal carcinoma.

Purpose: To evaluate long-term survival trends after primary total laryngectomy (TL) for locally advanced laryngeal carcinoma (LC).Methods: A total of 2094 patients diagnosed with locally advanced LC and underwent primary TL (1992-2011, at least 5-year follow-up) in the Surveillance, Epidemiology, and End Results (SEER) database were included in this study. Besides the traditional overall survival (OS) and cancer-specific survival (CSS) by using Kaplan-Meier curves, the 3-year conditional survival analysis was also performed to describe the long-term trends in these patients. Time-dependent multivariate competing-risk models were constructed to assess the persistent sub-distribution hazard of prognostic factors. Finally, a nomogram was developed to predict conditional cancer-specific survival.Results: The curves of overall hazard and cancer-specific hazard both quickly reached the apex within the first year since TL, then decreased thereafter. In general, the CS3 steadily increased from within 5 years after TL. In the stratified CS3 analysis, the increments in patients with adverse characteristics were more pronounced. 4 years after TL, the probability of surviving the next year exceeded 90%. The time-dependent multivariate competing-risk models indicated that age and lymph node ratio (LNR) persistently contributed to the cancer-specific outcome. The nomogram based on the competing-risk model was constructed to estimate CSS probability conditional upon 3 years for advanced LC patients having survived 1, 2, and 3 years.Conclusion: Most patients achieved a substantially improved survival rate after surviving a long period after primary TL. Patients diagnosed at older age and with higher LNR should receive more effective follow-up. The predictive nomogram can provide significant evidence for clinical research and practice.

Lymph Node Ratio Rather Than Positive Lymph Node Counts Has Better Prognostic Value in Patients With Testicular Germ Cell Tumors.

Background:Testicular cancer represents the most common malignancy in young adult men. In the current study, we sought to analyze and compare the prognostic value of lymph node ratio (LNR) as well as positive lymph node counts (LNC) to understand its clinical significance in testicular germ cell tumors.Methods:We employed eligibility criteria to recruit a total of 931 patients, with testicular cancer, from 2010 to 2015 from The Surveillance, Epidemiology, and End Results (SEER) database. We then used the X-Tile program to calculate LNR and LNC cutoff values and discriminate survival. We then calculated the overall and cancer specific survival rates and analyzed the association between LNR/LNC and clinical pathological characteristics using the χ2 test. Finally, we assessed the relationships between clinical pathological factors and patient survival using univariate Cox proportional hazard analysis.Results:Univariate analysis revealed a significant association between prognosis with age (HR, 5.169; 95% CI, 1.758-15.200; P = 0.003), AJCC stage (III vs I: HR, 9.298; 95% CI, 2.691-32.131; P < 0.001), M stage (HR, 7.897; 95% CI, 3.417-18.251; P < 0.001) and LNR (HR, 3.009; 95% CI, 1.275-7.098; P = 0.012). On the other hand, LNC (HR, 1.743; 95% CI, 0.687-4.420; P = 0.242) was not significantly associated with prognosis. Analysis of the association between LNR/LNC and clinical pathological characteristics showed that high LNR patients tended to have significantly larger tumor sizes (χ2 = 7.877, P = 0.005), as well as advanced T (χ2 = 13.195, P = 0.004), N ( χ2 = 86.775, P < 0.001), M (χ2 = 19.948, P < 0.001) and 7th AJCC (χ2 = 103.074, P < 0.001) stages. In addition, high LNC patients were significantly associated with T (χ2 = 8.799, P = 0.032), N (χ2 = 74.390, P < 0.001) and 7th AJCC (χ2 = 111.759, P < 0.001) stages.Conclusion:LNR was a better predictor for long-term prognosis and was closely associated with clinical pathological characteristics than LNC in patients with testicular germ cell tumors.

Treatment of persistent/recurrent nodal disease in nasopharyngeal cancer.

Persistent or recurrent disease in the neck lymphatics is an unusual pattern of failure in nasopharyngeal carcinoma (NPC) after definitive radiotherapy or chemoradiotherapy. The purpose of this review is to critically synthesize the current knowledge regarding salvage treatment of this unique form of failure in NPC. Surgery in the form of radical neck dissection has been established as the standard salvage treatment with 5-year regional control of 60--86%. Recent shift in paradigm has resulted in the use of modified or selective neck dissection as salvage surgery in some centers. Risk factors for poor survival outcome include recurrent nodal disease, number of involved lymph nodes, extracapsular extension, high lymph node ratio, and positive resection margin. There are no well controlled studies on the role of additional radiotherapy or chemotherapy to improve local control or survival after salvage neck dissection in this group of patients with regional failure. There is limited literature regarding the extent of surgical dissection in treating nodal persistent or recurrent disease. Prospective studies are also needed to determine whether adjuvant therapy improves treatment outcomes.

Deaths of colon neuroendocrine tumors are associated with increasing metastatic lymph nodes and lymph node ratio.

Colon neuroendocrine tumors (NETs) are uncommon. Currently, the impact of the number of metastatic lymph nodes (LNs) and lymph node ratio (LNR) on survival has been well investigated in other colon malignancies, but both remain nebulous for patients with colon NETs. Surgically resected patients with histologically proven nonmetastatic colon NETs were queried from the Surveillance, Epidemiology, and End Results database between 1988 and 2011. Patients with lymph nodes involved were investigated and categorized into four LNs-based classifications (≤4, >4-10, >10-13, and >13) or three LNR-based subgroups (≤0.51, >0.51-0.71, and >0.71) according to the threshold, determined by Harrell's C statistic. Univariate and multivariate survival analyses were performed by log-rank test and Cox stepwise regression analysis, respectively. Eight hundred fifty-one patients met the inclusion criteria. Among them, higher LNR and LNs classification are associated with a worse prognosis. The 10-year NETs-specific survival rate was 78.3% (74.2-82.6%), 61.3% (52.4-71.7%), 40.8% (20.7-80.7%) for patients in the ≤4, >4-10, and 10-13 LNs groups, respectively. When patients were classified with LNR, the observed 10-year NETs-specific survival rate was 79.9% (74.8-85.5%) for ≤0.51, 57.4% (43.8-75.2%) for >0.51-0.71, and 40.0% (31.0-51.5%) for >0.71. In stratified analysis, higher LNs and LNR groups have worse prognosis only in patients with advanced T stage (T3-T4). Regarding stage migration, the LNR-based system did not show superiority to LNs-based classification. Current TNM staging classification could be improved by considering the count of metastatic nodes and LNR instead of a simple record of lymph node status (N1 or N0) for colon NETs.

Prognostic significance of lymph node ratio after neoadjuvant chemoradiation therapy for esophageal squamous cell carcinoma

PurposeWe retrospectively evaluated the prognostic significance of lymph node ratio (LNR) in patients with esophageal squamous cell carcinoma who underwent neoadjuvant concurrent chemoradiation therapy (NCRT) followed by surgery.Materials and MethodsIn total, 270 patients who underwent NCRT followed by surgery between August 2005 and December 2015 were included. They were divided into three groups: LNR 0 (n = 196), LNR low (0 < LNR ≤ 0.1; n = 63), and LNR high (>0.1; n = 11). The primary endpoint was overall survival (OS), and the secondary endpoints were freedom from local recurrence (FFLR), distant metastasis-free survival (DMFS), and disease-free survival (DFS). ResultsThe median number of retrieved lymph nodes per patient was 33. Pathologically, 74 patients had positive lymph nodes. The median follow-up duration was 36.1 months, and the median survival period was 68.4 months. There was a significant correlation between LNR and the number of positive lymph nodes (correlation coefficient = 0.763, p < 0.001). There was a substantial difference in the OS among the LNR groups, with 2-year survival rates of 79.0%, 54.0%, and 9.1% in the LNR 0, LNR low, and LNR high groups, respectively (p < 0.001). A marked decrease in FFLP, DMFS, and DFS was observed with the increasing LNR. In subgroup analysis, the survival results of patients with clinically positive lymph node were similar from those of entire cohort.ConclusionLNR is a significant prognostic factor in patients with esophageal squamous cell carcinoma who underwent NCRT followed by surgery. Additional treatment and closer follow-up would be necessary for patients with a high LNR.

Prognostic outcomes of treatment naïve oral tongue squamous cell carcinoma (OTSCC): a comprehensive analysis of 14 years

To analyze the factors predicting survival outcomes in treatment naive oral tongue squamous cell carcinoma (OTSCC). A comprehensive review of 531 oral tongue carcinoma patients treated with upfront surgery followed by adjuvant radiotherapy or chemoradiotherapy was conducted from 2004–2018. The mean age of presentation was 53 years (11–86) with a male to female ratio of 1.3:1. The associated risk factors were smoking (21%), betel nut (16%), naswar (9%) and alcohol (1%). Most of the cases were either well (45.1%) or moderately (46.2%) differentiated. Surgery was performed in 164 patients alone while 368 were treated with surgery in combination with adjuvant modalities. Overall (OS) and disease free survival (DFS) were 66 and 71%, respectively, with a median follow up of 2.5 years. Cox regression analysis showed nodal positivity, increased depth of invasion (DOI) and higher lymph node ratio (LNR) as significant prognosticators impacting OS and DSS. Nodal volume, DOI and LNR are the most consistent predictors of poor outcome in OTSCC. Nodal positivity, depth of invasion > 5 mm and lymph node ratio > 0.04 adversely affect OS and DSS.