Lymph Node Ratio Staging System Research Articles

Different lymph node staging systems for predicting the prognosis of colorectal neuroendocrine neoplasms

BACKGROUND Colorectal neuroendocrine neoplasms (NENs) are a rare malignancy that primarily arises from the diffuse distribution of neuroendocrine cells in the colon and rectum. Previous studies have pointed out that the status of lymph node may be used to predict the prognosis. AIM To investigate the predictive values of lymph node ratio (LNR), positive lymph node (PLN), and log odds of PLNs (LODDS) staging systems on the prognosis of colorectal NENs treated surgically, and compare their predictive values. METHODS This cohort study included 895 patients with colorectal NENs treated surgically from the Surveillance, Epidemiology, and End Results database. The endpoint was mortality of patients with colorectal NENs treated surgically. X-tile software was utilized to identify most suitable thresholds for categorizing the LNR, PLN, and LODDS. Participants were selected in a random manner to form training and testing sets. The prognosis of surgically treating colorectal NENs was examined using multivariate cox analysis to assess the associations of LNR, PLN, and LODDS with the prognosis of colorectal NENs. C-index was used for assessing the predictive effectiveness. We conducted a subgroup analysis to explore the different lymph node staging systems’ predictive values. RESULTS After adjusting all confounding factors, PLN, LNR and LODDS staging systems were linked with mortality in patients with colorectal NENs treated surgically (P < 0.05). We found that LODDS staging had a higher prognostic value for patients with colorectal NENs treated surgically than PLN and LNR staging systems. Similar results were obtained in the different G staging subgroup analyses. Furthermore, the area under the receiver operating characteristic curve values for LODDS staging system remained consistently higher than those of PLN or LNR, even at the 1-, 2-, 3-, 4-, 5- and 6-year follow-up periods. CONCLUSION LNR, PLN, and LODDS were found to significantly predict the prognosis of patients with colorectal NENs treated surgically.

Evaluation of the prognostic performance of different cutoff values of lymph node ratio staging system for stage III colorectal cancer.

This study attempted to compare the prognostic performance of lymph node ratio (LNR) staging system with different cutoff values relative to American Joint Committee on Cancer (AJCC) pN staging system in stage III colorectal cancer (CRC). Overall, 45,069 patients from the SEER dataset and 69 patients from the Second Affiliated Hospital of Nanjing Medical University (the External set) who underwent surgical resection of the primary tumor and were diagnosed with stage III CRC by postoperative pathology were included. Patients were divided into three subgroups based on the LNR cutoff used in previous studies, Kaplan-Meier curves were plotted, and log-rank test was used to compare the differences among groups in terms of cancer-specific survival (CSS). Cox regression model was applied for survival analysis. To evaluate the discriminatory power of different lymph node staging systems, Harrell's C statistic(C-index) and Akaike's Information Criterion (AIC) were applied. A set of optimal cutoff values (0.11; 0.36; 0.66) of LNR staging system with the most considerable discriminatory power to the prognosis in patients with stage III CRC (SEER set: C-index = 0.714; AIC = 58,942.46, External set: C-index = 0.809; AIC = 164.36) were obtained, and both were superior to the AJCC pN staging system (SEER set: C-index = 0.708; AIC = 59,071.20, External set: C-index = 0.788; AIC = 167.06). For evaluating the prognostic efficacy of patients with stage III colorectal cancer, the cutoff value (0.11; 0.36; 0.66) of LNR staging system had the best discrimination and prognostic ability, which was superior to LNR staging system under other cutoff values and AJCC pN staging system.

[The relationship between the index of lymph node metastasis and the prognosis of pancreatic cancer patients after R0 resection].

Objective: To investigate the prognostic values of three different staging schemes including the number of lymph node metastasis (N stage), lymph node ratio (LNR) and log odd of positive lymph nodes (LODDS) in pancreatic cancer patients after R0 resection. Methods: The clinical and pathological data of 307 pancreatic cancer patients who underwent R0 resection at Cancer Hospital of Chinese Academy of Medical Sciences from January 2010 to December 2018 were retrospectively analyzed. Kaplan-Meier and Cox proportional hazard regression models were used to analyze the independent prognostic factors. The area under the receiver operator characteristic curve (AUC) was used to compare the prognostic efficacy of different lymph node staging systems. Results: The median survival was 24.0 months, 1-year, 3-year, and 5-year survival rates were 72.0%, 35.5% and 24.0%, respectively. Multivariate analysis showed that CA199, differentiation, T stage, adjuvant therapy, N stage, LNR stage, and LODDS stage were independent prognostic factors for pancreatic cancer patients after R0 resection (P<0.05). The AUC values of the 1-year survival rate for N stage, LNR stage, and LODDS stage were 0.591, 0.592 and 0.609, respectively. The AUC values of the 3-year survival rate for N stage, LNR stage, and LODDS stage were 0.585, 0.588 and 0.593, respectively. The AUC values of the 5-year survival rate for N stage, LNR stage, and LODDS stage were 0.554, 0.557 and 0.589, respectively. The AUC values of the LODDS stage were the highest while the N stage were the lowest, but there was no significant difference among these three systems (P>0.05). For all patients, the LODDS staging system was slightly better than the N and LNR staging systems, but the difference was not statistically significant (P>0.05). For patients with N0 stage, the LODDS staging system showed better prediction performance than the N stage and LNR staging systems (P<0.05). Conclusions: The N stage, LNR stage, and LODDS stage are independent prognostic factors for pancreatic cancer patients after R0 resection. For patients without lymph node metastasis, LODDS staging system is superior to N and LNR staging systems in predicting prognosis.

Different lymph node staging systems for patients with adenocarcinoma of esophagogastric junction

Objective: In addition to the traditional TNM N staging system, lymph node ratio (LNR) and log odds of metastatic lymph nodes (LODDS) staging methods were developed in cancers. This study aimed to examine their relative prognostic performance in patients with adenocarcinoma of the esophagogastric junction (AEG).Patients and methods: Patients who underwent surgical resection for AEG were identified from the Surveillance, Epidemiology, and End Results (SEER) Program and the First Affiliated Hospital of Xi’an Jiaotong University as the training and validation sets, respectively. The Akaike’s Information Criterion (AIC), Harrell’s C statistic, and ROC curves were utilized for comparison.Results: A total of 735 patients were involved in the training set. LODDS and LNR staging systems had better prognostic performance than the TNM N staging systems (when considered as a categorical variable: C index = 0.728 and 0.712 vs 0.671; AIC: 6247.537 and 6265.996 vs 6320.045; AUC: 0.762 and 0.719 vs 0.692. For the continuous model: C index = 0.675 and 0.686 vs 0.658; AIC = 6243.740 and 6261.027 vs 6355.077; AUC = 0.778 and 0.733 vs 0.693). In the validation set of 183 patients, the TNM N staging scheme outperformed the LODDS and LNR staging systems (C index = 0.788 vs 0.779 and 0.767; AIC = 1014.702 vs 1026.899 and 1025.288; AUC = 0.806 vs 0.787 and 0.791) when considered a categorical variable. However, when considered a continuous variable, the LODDS and LNR staging systems were better than the TNM N staging system (C index = 0.724 and 0.733 vs 0.747; AIC = 1018.075 and 1025.803 vs 1026.085; AUC = 0.811 and 0.810 vs 0.806).Conclusions: The LNR and LODDS staging schemes could be considered new options for prognostic prediction of AEG with respect to lymph node status, especially when considered as continuous variables.

The prognostic role of metastatic lymph node ratio-staging system in gastric cancer patients: Analysis of the National Cancer Database.

4044 Background: The NCCN recommends retrieval of at least 15 lymph nodes for adequate nodal staging in gastric cancer. There is an ongoing debate about the accuracy of the classification systems for nodal involvement based on the absolute number of positive nodes (AJCC-N) vs. the ratio of positive nodes (rN). In this study, we aim to assess the accuracy of each system in the prediction of 5-year survival using the National Cancer Data Base (NCDB) for gastric cancer. Methods: The database included 168,377 gastric cancer patients between 2004-2014. Patients who were approached with palliative intent, or had metastatic disease were excluded from the analysis. Only patients who had at least one regional node examined were included. A univariate and multivariate regression analysis were conducted to identify significant predictors of the 5-year survival among the perioperative patients’ characteristics. Bayesian Information Criterion (BIC) was used to compare the model fitting when the AJCC nodal staging is applied to that of the ratio nodal staging. Results: 48,126 patients were included in the final analysis. 23,102 (48%) patients had ≥15 nodes examined. The univariate and multivariate regression analysis identified age, male gender, Caucasian race, and presence of comorbidities as significant demographic predictors. TNM T-stage, N-stage, and rN-stage were significant predictors with worsening prognosis as the stage increases. Overall, BIC demonstrated that the model using rN had a better fit (rN = 30321 vs. AJCC-N = 30619). However, subgroup analysis showed that the AJCC-N functioned better when &lt; 15 nodes were examined (rN = 17367 vs. AJCC-N = 17311), whereas rN functioned better when ≥15 nodes were collected (rN = 16776 vs. AJCC-N = 16831). Conclusions: Both AJCC-N and rN are valid systems for nodal staging in terms of survival prediction in gastric cancer. When at least 15 nodes are resected in line with the current NCCN guidelines, the rN staging system for nodal metastasis appears to function more accurately in survival prediction. It might be advisable to consider the ratio of positive lymph nodes when a large number of nodes are collected to avoid over-staging and stage migration.

A Nomogram for Predicting Overall Survival of Gastric Cancer Patients with Insufficient Lymph Nodes Examined

Insufficient number of examined lymph nodes (eLNs) was considered to increase significantly the risk of stage migration in gastric cancer patients. The aim of our study is to establish a nomogram predicting the overall survival (OS) for patients with an insufficient number of eLNs. A total of 872 gastric cancer patients with extended lymphadenectomies were assigned randomly (2:1) to the development cohort and the validation cohort. The nomogram was established based on the Cox regression model using the development cohort. The concordance index (C-index) was used to evaluate the discriminative ability. We also compared our model with two other staging systems. Using multivariate analysis, age, sex, tumor location, depth of invasion, macroscopic type, lymphovascular invasion, the number of eLNs, and metastatic lymph nodes were selected and incorporated into the nomogram. The C-index of the nomogram was 0.742 and 0.743 in development and validation cohorts, respectively, which were significantly superior to the C-indices (range 0.705–0.712, all P < 0.001) of American Joint Committee on Cancer (AJCC) seventh edition and lymph node ratio staging systems in both cohorts. We established a nomogram which could predict accurately OS for gastric cancer patients with insufficient number of eLNs.

Usefulness of the Log Odds of Positive Lymph Nodes to Predict and Discriminate Prognosis in Gastric Carcinomas

BackgroundThe lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS) have been proposed to minimize the stage migration phenomenon. The value of the LODDS and LNR staging systems to predict and discriminate prognosis was assessed and compared to the International Union Against Cancer (UICC) TNM classification (pN). MethodsThree hundred and twenty-six patients with gastric carcinoma were retrospectively studied. Disease-specific survival rates were calculated for every pN, LNR, and LODDS category. ResultsFour LNR categories (0, 1–25, 26–75, and >76 %) and four LODDS categories (−5 to −3, > −3 to −1, > −1 to 3, and >3 to 5) were established. In the multivariate analysis, only the stage pT3-4 versus pT1-2 (HR 1.88, 95 % CI 1.11–3.20, p = 0.02) and LODDS as continuous variable (HR 1.40, 95 % CI 1.21–1.61, p < 0.001) remained as independent prognostic factors. In patients with <16 lymph nodes retrieved, only the LODDS system could discriminate different disease-specific survival curves for every category. LODDS categories were able to discriminate subgroups with different prognoses in pN stages and LNR categories. ConclusionsThe LODDS staging system was superior to the pN classification and LNR system to discriminate risk prognosis especially in patients with an insufficient number of retrieved lymph nodes.

[Prognostic value of lymph node ratio staging system in stage III( rectal cancer following 30 Gy/10 f preoperative radiotherapy].

To evaluate the prognostic value of the lymph node ratio(LNR) staging system for rectal cancer following 30 Gy/10 f preoperative radiotherapy. Clinical data of 282 patients with mid-lower locally advanced rectal cancer who received preoperative radiotherapy and curative surgery in the Peking University Cancer Hospital from August 2003 to August 2009 were retrospectively reviewed. The radiotherapy regimen was recommended by CACA. Total dose of 30 Gy was divided into 10 fragments (30 Gy/10 f), the biologically equivalent dose (BED) was 36 Gy, and 3D conformal radiotherapy(3D-CRT) was used. Surgery was performed 2-4 weeks after radiation. The prognostic effect of the lymph node ratio(LNR) staging system in addition to the 7th AJCC staging system were retrospectively analyzed and compared in stage III( cases with positive lymph node(s). Patients were divided into four groups by LNR quantiles: LNR1(<0.070), LNR2(0.070-0.142), LNR3(0.143-0.307) and LNR4(>0.307). A total of 108 eligible cases were included in the study. The 3-year disease-free survival (3-yr DFS) was 61.1%. On univariate analysis, circumferential resection margin involvement(P=0.034), tumor differentiation (P=0.002), N stage (P=0.001), TNM stage(P=0.000) and LNR(P=0.003) were significantly associated with 3-yr DFS. On multivariate analysis, abdominoperineal resection (P=0.006, HR=2.611, 95%CI:1.323-5.153), G3-4 differentiation (P=0.015, HR=2.208, 95%CI:1.163-4.192), ypN2a/N2b stage(as covariate: P=0.024, HR=2.568, 95%CI:1.135-5.810; P=0.001, HR=3.759, 95%CI:1.776-7.958) were independent risk factors for decreased 3-yr DFS. Other factors including LNR were excluded in Cox regression model. The 3-yr DFS was statistically different among subcategories of ypN stage. There was no statistical difference of 3-yr DFS in pair-wise comparison of LNR1 and LNR2, LNR2 and LNR3 and LNR3 and LNR4. Additional use of LNR over AJCC staging system did not improve the prediction of prognosis for III(B/C stages and for each stratum of ypN stages, despite the prognostic separation by LNR in III(A stage. The LNR staging system in addition to the 7th AJCC staging system does not provide further detailed stratification of the prognosis for stage III( rectal cancer following 30 Gy/10 f preoperative radiotherapy. Lymph node ratio is premature as a prognostic factor in clinical practice.

Prognostic value of the lymph node ratio in stage III gastric cancer patients undergoing radical resection.

ObjectiveThe aim of this study was to investigate the prognostic value of metastatic lymph node ratio (LNR) in patients having radical resection for stage III gastric cancer.MethodsA total of 365 patients with stage III gastric cancer who underwent radical resection between 2002 and 2008 at Tianjin Medical University Cancer Institute and Hospital were analyzed. The cut-point survival analysis was adopted to determine the appropriate cutoffs for LNR. Kaplan–Meier survival curves and log-rank tests were used for the survival analysis.ResultsBy cut-point survival analysis, the LNR staging system was generated using 0.25 and 0.50 as the cutoff values. Pearson's correlation test revealed that the LNR was related with metastatic lymph nodes but not related with total harvested lymph nodes. Cox regression analysis showed that depth of invasion and LNR were the independent predictors of survival (p<0.05). There was a significant difference in survival between each pN stages classified by the LNR staging, however no significant difference was found in survival rate between each LNR stages classified by the pN staging.ConclusionsThe LNR is an independent prognostic factor for survival in stage III gastric cancer and is superior to the pN category in TNM staging. It may be considered as a prognostic variable in future staging system.

Comparison of metastatic lymph node ratio staging system with the 7th AJCC system for colorectal cancer

To evaluate the prognostic value and staging accuracy of the metastatic lymph node ratio (rN) staging system for colorectal cancer. A total of 1,127 patients with colorectal cancer who underwent curative surgery between 2000 and 2011 at our institute were analyzed. Lymph nodes status was assigned according to American Joint Committee on Cancer (AJCC) pN system and rN system. Patients with colon cancer (group 1, n = 652) and rectal cancer (group 2, n = 475) were analyzed separately. The rN staging system was generated using 0.2 and 0.6 as the cutoff values of lymph node ratio and then compared with AJCC pN stages. Linear regression model revealed that the number of retrieved lymph node was related to number of metastatic lymph nodes. After a median follow-up of 46 months, the 5-year survival rates of patients with more than 12 lymph nodes (LNs) retrieved were better than cases with fewer than 12 LNs, while the differences were not obvious in rN classification. The rN category is a better prognostic tool than the AJCC pN category for colorectal cancer patients after curative surgery.

Lymph-node ratio staging system in gastric cancer

Background: The prognosis of gastric cancer is strictly related to lymph node metastasis, which is undoubtedly the strongest independent factor influencing survival of resectable gastric cancers after curative surgery. Recently, the ratio between metastatic and examined lymph nodes (N ratio) has been proposed as a new prognostic indicator. The aim of this study was to evaluate the prognostic value of the N ratio in patients with gastric cancer.

The evaluation of metastatic lymph node ratio staging system in gastric cancer

To evaluate the prognostic value and staging accuracy of the metastatic lymph node ratio (rN) staging system for gastric cancer. A total of 1,075 patients with gastric cancer who underwent curative surgery between 2000 and 2009 at our institute were analyzed. Lymph node status was assigned according to the American Joint Committee on Cancer (AJCC) pN system and rN system. Patients with >15 (group 1, n=691) and ≤15 lymph nodes (group 2, n=384) retrieved were analyzed separately. The rN staging system was generated using 0.2 and 0.5 as the cutoff values of lymph node ratio and then compared with AJCC pN stages. A linear regression model revealed that the number of retrieved lymph nodes was related to the number of metastatic lymph nodes, but not with rN. After a median follow-up of 47.66months, the 5-year survival rates of N0, N1, N2, and N3 patients of group 1 were significantly better than group 2, whereas the differences were not obvious in the rN classification. The rN category is a better prognostic tool than the AJCC pN category for gastric cancer patients after curative surgery regardless of the number of lymph node examined.

Comparison of the 2010 AJCC TNM staging system with a modified lymph node ratio staging system in 7,233 gastric cancer patients.

4023 Background: The 2010 AJCC staging system for gastric cancer modifies T and N definitions, but continues to base N stage on the absolute number of positive nodes (PN) regardless of the number of examined nodes (EN). With decreases in EN, the lymph node ratio (NR, ratio of PN to EN) may better stage patients. Methods: 7,233 gastric cancer patients who underwent gastrectomy between 1998 and 2006 were identified from the SEER database. Patients were classified into 5 NR groups according to a modified NR algorithm. TNRM staging system was constructed using the log-rank test. Overall survivals based on 2010 AJCC and TNRM staging systems were compared. Results: The median number of EN was 10 and 69% of patients had <16 EN. Both 2010 AJCC and TNRM staging systems were statistically significant prognostic factors (p<0.001). 5-year survivals (5YS) based on these systems are shown in the Table. When stratified by TNRM stage, 6 out of the 9 TNM stages (IA, IIA-B, IIIA-C) represented patients with statistically heterogeneous prognosis with the largest range of 5YS being 36% (stage IIB). In contrast, when stratified by AJCC stage, 3 of 8 TNRM stages (3, 7, 8) represented patients with statistically heterogeneous prognosis with the largest range being only 18% (stage 3). Using ±5% of estimated 5YS as a threshold for misclassification, 49% of patients were inaccurately staged by the AJCC system while this rate dropped to 7% with the TNRM system. Conclusions: The 2010 AJCC staging system does not optimally stratify survival in SEER gastric cancer patients given the majority of patients have <16 EN. A modified TNRM system is a more accurate means of staging these patients. TNRM 1 2 3 4 5 6 7 8 p value* AJCC TNM 5 YrS (#PTs) 81%(217) 67%(1,211) 52%(213) 40%(715) 28%(1212) 17%(1344) 6%(777) 2%(1,544) <0.001 0 76% (186) 82% 74% 0.12 IA 71% (647) 81% 68% <0.001 IB 60% (454) 66% 42% 50% 0.07 IIA 46% (915) 68% 60% 35% 36% <0.001 IIB 31% (892) 53% 46% 29% 17% <0.001 IIIA 19% (882) 28% 15% 8% <0.001 IIIB 14% (1387) 24% 18% 5% 5% <0.001 IIIC 8.0% (934) 29% 20% 10% 4% <0.001 IV 2.0% (936) 2% - p value* <0.001 0.97 0.25 <0.001 0.14 0.07 0.46 0.03 <0.001 * p value of testing the heterogeneity within each TNM or TNR M stage. No significant financial relationships to disclose.

The Lymph Node Ratio Staging System in Gastric Cancer

The Lymph Node Ratio Staging System in Gastric Cancer