Node Staging System Research Articles

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.

PS02.097: PROGNOSTIC IMPACT OF LYMPH NODE METASTASIS STATIONS IN PN1 STAGE ESOPHAGEAL SQUAMOUS CARCINOMA PATIENTS

Abstract Background Although numerically based lymph node staging system of UICC/AJCC of esophageal squamous cell carcinoma (ESCC) offers excellent prognostic performance, it doesn’t offer information on the anatomical extent of disease. The aim was to evaluate prognostic impact of lymph node metastasis (LNM) stations and regions in pN1 stage patients. Methods Among patients with ESCC undergone esophagectomy classified as R0 from January 2005 to December 2010, 185 patients diagnosed as pN1 were selected for analysis with univariate and multivariate Cox regression analysis. Results The most common metastasis areas in pN1 patients were middle and lower thoracic paraesophageal LN (28.6%), left gastric artery LN (27.6%) and paracardial LN (24.3%). Non- middle and lower paraesophageal LNM (P = 0.049), subcarinal LNM (P = 0.041) and multiple left gastric artery LNM (P = 0.010) were independent risk factors for worse survival. The median survival of the N1 (JES) group was significantly better than the N2 (JES) (40.1 months vs. 22.4 months, P = 0.012). However, no significant difference was found in median survival rate among intra-thoracic LNM, upper-abdominal LNM and both LNM. Conclusion Paraesophageal LNM, subcarinal LNM and left gastric artery LNM are predictive factors for survival and should be swept routinely in pN1 stage ESCC patients. On the basis of UICC/AJCC lymph node Classification system, anatomical lymphatic spread pattern analysis could further improve prognosis prediction. Disclosure All authors have declared no conflicts of interest.

Prognostic performance of various nodal staging systems for resected gallbladder cancer using a restricted cubic spline model: The results of multicenter study

Prognostic performance of various nodal staging systems for resected gallbladder cancer using a restricted cubic spline model: The results of multicenter study

Prognostic accuracy of different lymph node staging systems in rectal adenocarcinoma with or without preoperative radiation therapy.

A variety of different lymph node (LN) staging systems have been developed to describe the lymph node status accurately. We aim to compare the prognostic accuracy of American Joint Committee on Cancer seventh N stage relative to negative number of lymph node (nLN), lymph node ratio (LNR) and log odds of metastatic lymph nodes (LODDS) in rectal adenocarcinoma (RC). A total of 19 167 Stage II-III rectal cancer patients who underwent surgical resection of rectal adenocarcinoma were identified from Surveillance, Epidemiology and End Results database. Akaike's Information Criterion (AIC) and the Harrell's concordance index (c statistic) were used to evaluate the relative discriminative power of the different LN staging systems. Of the 19 167 patients, 10 958 received preoperative radiotherapy (pre-RT cohort) and 8209 patients were treated with surgical resection directly (SURG cohort). When assessed using categorical cutoff values, LNR has a somewhat better prognostic accuracy both in pre-RT (c-index: 0.62; AIC: 2988.6) and SURG groups (c-index: 0.60; AIC: 3359.8). Further analysis based on different total number of lymph node (TNLN) suggested that when less than 10 lymph nodes were retrieved, LNR exhibited significant superiority (pre-RT: c-index: 0.597, AIC: 1006.8; SURG: c-index: 0.560, AIC: 810.5). When analyzed as a continuous variable, the LODDS system performed the best and was not impacted by TNLN. When assessed as a categorical variable, LNR was the most powerful method to predict survival for Stage II-III RC patients with limited TNLN. Rather, LODDS was the most accurate staging system regardless of the TNLN when LN status was modeled as continuous variable.

Development of a novel salivary gland cancer lymph node staging system.

Current lymph node (LN) staging for salivary gland cancer (SGC) is extrapolated from mucosal head and neck squamous cell carcinoma. However, given its unique biology and clinical behavior, it is possible that a SGC-specific LN staging system would be more accurate. Patients from the National Cancer Data Base with nonmetastatic SGC of the head and neck who were diagnosed from 2004 through 2013 and underwent surgical resection and neck dissection removing at least 10 LNs were included. Multivariable models were constructed to assess the association between survival and LN factors, including number of metastatic LNs, extranodal extension, LN size, and lower LN involvement. Overall, 4520 patients met the inclusion criteria. An increasing number of metastatic LNs was found to be strongly associated with worse survival without plateau. The risk of death increased more rapidly up to 4 LNs (hazard ratio, 1.34; 95% confidence interval, 1.27-1.41 [P < .001]), and was more gradual for additional LNs >4 (hazard ratio, 1.02; 95% confidence interval, 1.01-1.03 [P < .001]). LN size, extranodal extension, and lower LN involvement appeared to have no impact on survival when accounting for the number of metastatic LNs. Recursive partitioning analysis was used to create a novel SGC LN staging system in which N0 indicates 0 positive LNs, N1 indicates 1 to 2 positive LNs, N2 indicates 3 to 21 positive LNs, and N3 indicates ≥ 22 positive LNs. This system exhibited greater concordance than the current American Joint Committee on Cancer (eighth edition) system. Quantitative LN burden is an important determinant of survival in patients with SGC. Use of this variable may improve SGC staging. Cancer 2018. © 2018 American Cancer Society.

The importance of lymph node ratio for patients with mandibular infiltration of oral squamous cell carcinoma

PurposeLymph node ratio (LNR) essentially improves assessment of prognosis and therapeutic decision making for patients with oral squamous cell carcinoma, as it considers both the number of positive lymph nodes and the number of dissected lymph nodes. Mandibular infiltration by oral squamous cell carcinoma is a vital clinicopathological feature, significantly worsens prognosis. However, to the best of our knowledge, data on the influence of LNR on prognosis for patients with OSCC and mandibular infiltration are not available. Materials and methodsA retrospective chart review of 89 patients with treatment-naive oral squamous cell carcinoma and histopathologically proven mandibular infiltration (pT4a) was performed. Exclusion criteria were primarily curative intended surgery (radical tumor resection, neck dissection and segmental mandibulectomy) with negative resection margins. Exclusion criteria were neoadjuvant chemoradiotherapy, erosive infiltration of the mandible, T4b classification, perioperative death, unresectable disease, synchronous malignancy, follow-up <3 months, and inadequate information to correctly determine clinicopathological characteristics. ResultsWe observed a significant correlation on univariate analysis between locoregional recurrence and pathologic N classification (p = 0.004), perineural invasion (p = 0.005) and lymph node ratio (p < 0.001). On multivariate analysis, lymph node ratio (p = 0.028) was shown to be an independent indicator for locoregional recurrence. ConclusionLNR predicted locoregional recurrence better than the conventional nodal staging system and therefore might serve as a more precise risk stratification tool. LNR >7% led to a 11.419-fold higher risk for locoregional recurrence of patients with mandibular infiltration due to OSCC.

Application value of the different lymph node staging system predicting prognosis of advanced gallbladder carcinoma

Application value of the different lymph node staging system predicting prognosis of advanced gallbladder carcinoma

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.

Strategies of nodal staging of the TNM system for esophageal cancer

The 8th edition of UICC/AJCC TNM staging for esophageal cancer will start in use since 2018. The nodal staging in this version of TNM system remains unchanged from the 7th edition that based on the number of lymph nodes (LN) involved, except the limited revision of the regional LN map. In this review, N staging revision was evaluated from its initially simple definition of negative (N0) and positive (N1) LN(s) to the current positive node number based proposal. Meanwhile the disadvantages of current N staging were discussed. The refined nodal staging system in view of the number of metastatic node stations was introduced; as well as the extent and station of metastatic node could better reflect the disease progression and prognosis. The controversy on N staging of esophagogastric junction cancer was also discussed. Other reported N staging associated elements including LN ratio and lymphatic vessel invasion were reviewed and evaluated.

Surgical management of periampullary adenocarcinoma: defining an optimal prognostic lymph node stratification schema.

Background: Lymph node (LN) metastasis is a strong predictor of unfavorable prognosis for patients with periampullary adenocarcinoma after surgical resection. We sought to assess the prognostic performance of several LN staging systems, including American Joint Committee on Cancer (AJCC)/ International Union Against Cancer (7th edition) N stage, the total number of LN (TLN), the number of metastatic LN (MLN), the lymph node ratio (LNR) and the log odds of MLNs (LODDS), in patients with periampullary adenocarcinoma after surgical resection and identify the optional LN staging system to accurately stratify patients with different prognoses.Methods: We retrospectively analyzed 205 patients with periampullary adenocarcinoma after surgical resection. The predictive effects of several LN staging systems on overall survival (OS) and progression free survival (PFS) for all included patients and patients with more than 12 TLNs examined were evaluated and compared using the time-dependent receive operating characteristic (ROC) curve and decision curve analysis (DCA), respectively.Results: Eighty-nine patients (43.4%) had LN metastasis and their survival was not significantly decreased compared with patients without LN metastasis. LODDS and LNR were able to stratify patients into various subgroups with significant differences of both OS and PFS. When assessed using ROC curve and DCA, LODDS outperformed LNR and other LN staging systems in predicting OS and PFS. In addition, when analyzed in patients with more than 12 TLNs examined, LODDS had a higher value of area under ROC curve (AUC) and showed better performance of DCA.Conclusion: LODDS performs better than other LN staging systems in predicting OS and PFS for patients with periampullary adenocarcinoma after surgical resection. Adequate LN dissection is necessary for curative surgery, as well as to achieve a more accurate staging of the disease and a more precise prediction of survival for these patients.

Lymph node staging systems in patients with gastric cancer treated with D2 resection plus adjuvant chemotherapy.

Background: The optimal nodal staging scheme for gastric cancer remains unsettled. We compared the prognostic performances of the metastatic lymph node, lymph node ratio, and log odds of metastatic lymph nodes based on nomograms among 801 patients with D2-resected gastric cancer treated with adjuvant chemotherapy.Methods: When assessed as a continuous covariate, each nodal staging variable was incorporated into a prognostic nomogram with other significant prognosticators to predict the 5-year overall survival. The discriminatory abilities of the nomograms were compared using the concordance index. Patients were divided into subgroups using each nomogram, and the prognostic homogeneity of the nomograms was assessed using the Kaplan-Meier method with log-rank tests.Results: The discriminatory abilities of the three nomograms were comparable (P > 0.05 for all pairwise comparisons). However, for patients within each lymph node ratio subgroup, overall survival was homogenous when stratified by subgroups of the other two staging schemes, while it differed significantly among the different lymph node ratio subgroups for patients within some of the other two staging subgroups.Conclusion: The lymph node ratio-based staging scheme performs the best for the prediction of survival in patients with locally advanced gastric cancer treated with D2 resection followed by adjuvant chemotherapy.

Predictive value of the 8th edition American Joint Commission Cancer (AJCC) nodal staging system for patients with cutaneous squamous cell carcinoma of the head and neck.

The 8th edition American Joint Committee on Cancer (AJCC8) provides the same nodal staging system for mucosal and cutaneous squamous cell carcinoma of the head and neck (HNcSCC) and includes extranodal extension (ENE) as an adverse prognostic criterion. This study evaluates the prognostic efficacy of the AJCC8 pathologic nodal staging system (pN) for HNcSCC. Univariate analysis of 382 patients with metastatic HNcSCC staged according to both the 7th (AJCC7) and the 8th edition staging systems. The AJCC7 pN3 category was associated with reduced disease specific survival (DSS HR 5.49; 95% CI: 1.83-16.53; P = 0.002) and overall survival (OS HR 3.42; 95% CI: 1.54-7.58; P = 0.002) as compared with pN1. However, no difference was observed between pN1, pN2, and pN3 categories as defined by the AJCC8. Also, when comparing Stages III and IV as defined by AJCC8, there was no difference in DSS (HR 0.75; 95% CI: 0.34-1.67; P = 0.478) or OS (HR 0.88; 95% CI: 0.51-1.51; P = 0.648). The AJCC8 performed poorly as a prognostic indicator for patients with metastatic HNcSCC in this cohort. HNcSCC would benefit from a staging system that accounts for its unique biologic characteristics distinct from mucosal SCC.

Evaluation of Pathology-Based Staging for HPV-Associated Squamous Cell Carcinoma of the Oropharynx in a Large National Sample

Metastatic node number ≥ 5 has been identified by small retrospective studies as a prognostic indicator of oncologic outcomes in human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV-A OPC). We aimed to validate the prognostic value of metastatic node number and the revised American Joint Committee on Cancer (AJCC) 8thedition pathologic and clinical nodal staging system in a large national sample. The National Cancer Database was used to identify patients with HPV-A OPC (any T, any N, M0) treated with curative-intent primary surgery +/- adjuvant therapy from 2010-2013. Demographic and clinicopathologic predictors of survival were analyzed by the chi-square test and logistic regression. OS was evaluated using Cox proportional hazard regression model, Kaplan-Meier method, log-rank statistic, and propensity score matching. Harrells’ concordance index (c-index) was determined to measure the discriminatory power across the AJCC 8thedition pathologic and clinical staging systems. We identified 2,347 patients. Median follow up was 33.6 months. 3-year OS of the AJCC 8th edition pathologic stage I, II, and III patients was 96.3%, 87.3% and 76.7%, respectively (log-rank p<.001). On multivariable logistic regression, patients with ≥ 5 metastatic nodes were more likely to have higher pT stage (odds ratio [OR] 2.14, 95% confidence interval [CI] 1.43-3.19, p<.001), pathologic extranodal extension (pENE) (OR 3.39, 95% CI 2.51-4.57, p<.001), and lymphovascular invasion (LVI) (OR 1.30, 95% CI 1.08-1.56, p.006). After adjusting for age, comorbidity, pT stage, pENE, surgical margins, LVI, adjuvant treatment, and insurance status, having ≥ 5 metastatic lymph nodes was associated with inferior OS compared to those with ≤ 4 nodes on multivariable Cox regression (HR 1.81; 95% CI 1.14-2.88; p=.011). Propensity score matching yielded a well-matched cohort of 486 patients and redemonstrated inferior OS in the ≥ 5 metastatic node group (HR 2.91, 95% CI 1.98-4.29, p<.001). The c-indices for the revised pathologic and clinical nodal staging in a multivariable model were 0.72 and 0.70, respectively. Using a large national sample, we have validated metastatic node number ≥ 5 as a significant prognostic marker in HPV-A OPC on multivariable and propensity score-matched analyses. The AJCC 8th edition revisions to both pathologic and clinical staging appear to reliably establish prognosis in this large patient cohort.

Metastatic Lymph Node Burden and Survival in Oral Cavity Cancer.

Purpose Current staging systems for oral cavity cancers incorporate lymph node (LN) size and laterality, but place less weight on the total number of positive metastatic nodes. We investigated the independent impact of numerical metastatic LN burden on survival. Methods Adult patients with oral cavity squamous cell carcinoma undergoing upfront surgical resection for curative intent were identified in the National Cancer Data Base between 2004 and 2013. A neck dissection of a minimum of 10 LNs was required. Multivariable models were constructed to assess the association between the number of metastatic LNs and survival, adjusting for factors such as nodal size, laterality, extranodal extension, margin status, and adjuvant treatment. Results Overall, 14,554 patients met inclusion criteria (7,906 N0 patients; 6,648 node-positive patients). Mortality risk escalated continuously with increasing number of metastatic nodes without plateau, with the effect most pronounced with up to four LNs (HR, 1.34; 95% CI, 1.29 to 1.39; P < .001). Extranodal extension (HR, 1.41; 95% CI, 1.20 to 1.65; P < .001) and lower neck involvement (HR, 1.16; 95% CI, 1.06 to 1.27; P < .001) also predicted increased mortality. Increasing number of nodes examined was associated with improved survival, plateauing at 35 LNs (HR, 0.98; 95% CI, 0.98 to 0.99; P < .001). In multivariable models accounting for the number of metastatic nodes, contralateral LN involvement (N2c status) and LN size were not associated with mortality. A novel nodal staging system derived by recursive partitioning analysis exhibited greater concordance than the American Joint Committee on Cancer (8th edition) system. Conclusion The number of metastatic nodes is a critical predictor of oral cavity cancer mortality, eclipsing other features such as LN size and contralaterality in prognostic value. More robust incorporation of numerical metastatic LN burden may augment staging and better inform adjuvant treatment decisions.

Numeric pathologic lymph node classification shows prognostic superiority to topographic pN classification in esophageal squamous cell carcinoma

The current eighth tumor node metastasis lymph node category pathologic lymph node staging system for esophageal squamous cell carcinoma is based solely on the number of metastatic nodes and does not consider anatomic distribution. We aimed to assess the prognostic capability of the eighth tumor node metastasis pathologic lymph node staging system (numeric-based) compared with the 11th Japan Esophageal Society (topography-based) pathologic lymph node staging system in patients with esophageal squamous cell carcinoma. We retrospectively reviewed the clinical records of 289 patients with esophageal squamous cell carcinoma who underwent esophagectomy with extended lymph node dissection during the period from January 2006 through June 2016. We compared discrimination abilities for overall survival, recurrence-free survival, and cancer-specific survival between these 2 staging systems using C-statistics. The median number of dissected and metastatic nodes was 61 (25% to 75% quartile range, 45to 79) and 1 (25% to 75% quartile range, 0 to 3), respectively. The eighth tumor node metastasis pathologic lymph node staging system had a greater ability to accurately determine overall survival (C-statistics: tumor node metastasis classification, 0.69, 95% confidence interval, 0.62-0.76; Japan Esophageal Society classification; 0.65, 95% confidence interval, 0.58-0.71; P=.014) and cancer-specific survival (C-statistics: tumor node metastasis classification, 0.78, 95% confidence interval, 0.70-0.87; Japan Esophageal Society classification; 0.72, 95% confidence interval, 0.64-0.80; P=.018). Rates of total recurrence rose as the eighth tumor node metastasis pathologic lymph node stage increased, while stratification of patients according to the topography-based node classification system was not feasible. Numeric nodal staging is an essential tool for stratifying the oncologic outcomes of patients with esophageal squamous cell carcinoma even in the cohort in which adequate numbers of lymph nodes were harvested.

The importance of log odds of positive lymph nodes for locoregional recurrence in oral squamous cell carcinoma

ObjectivesLog odds of positive lymph nodes (LODDS) has been demonstrated as a very promising staging model for multiple cancer sites, as it avoids singularity and predicts prognosis significantly better than conventional nodal staging and lymph node ratio. However, published studies on the influence of LODDS for patients with OSCC are very seldom. Material and methodsRetrospective chart review of 499 patients with treatment-naive oral squamous cell carcinoma. Exclusion criteria were neoadjuvant chemoradiotherapy, T4b classification, perioperative death, unresectable disease, synchronous malignancy, follow-up < 3 months and inadequate information to correctly determine nodal yield. Statistical analysis was performed using univariate and multivariate analysis. ResultsA significant correlation was found between locoregional recurrence and pathologic T classification (p=0.030), pathologic N classification p=0.013), extracapsular spread (p=0.034), grading (p=0.021), number of positive lymph nodes (p=0.042), lymph node ratio (p=0.009), LODDS (p=0.007) and treatment strategy (p=0.039). Multivariate analysis indicated lymph node ratio (p=0.029) and LODDS (p=0.015) as independent indicators for locoregional recurrence. Within the analyzed models, Nagelkerke R2 index and Someŕs D showed the strongest discrimination ability for LODDS. ConclusionFor patients with oral squamous cell carcinoma, log odds of positive lymph nodes and lymph node ratio are independent indicators for locoregional recurrence. LODDS predicts locoregional recurrence better than conventional nodal staging system, lymph node ratio and the number of positive lymph nodes.

The prognostic value of different node staging systems in patients with ≤15 lymph nodes following surgery for gastric adenocarcinoma

Aim: Lymph node (LN) status is an important prognostic indicator in patients with gastric cancer (GC). Although American Joint Committee on Cancer/International Union against Cancer (AJCC/UICC) is the most widely used staging system, there is a challenge in predicting survival of patients when the number of total harvested LNs is ≤15. Our aim was to investigate the prognostic performances of seventh edition AJCC/UICC, lymph-node ratio (LNR), and log odds of metastatic lymph nodes (LODDS) on the overall survival (OS) of GC patients with ≤15 examined LNs after gastric resection.Material and method: A total of 74 patients who underwent curative resection for gastric adenocarcinoma and had ≤15 LNs at the final histopathological examination were included in the study. The prognostic ability of three node staging models to predict OS was assessed using the area under the curve (AUC).Results: Of the 74 patients, 15 (20.3%) had no LN metastasis whereas 59 (79.7%) had nodal involvement. The median OS was 26 months. When assessed as a continuous variable, LNR was the strongest staging system to stratify GC patients on the basis of LN status. LODDS had superiority on other node staging models when the number of LNs retrieved was modeled as categorical variable.Conclusions: LNR (continuous) and LODDS (categorical) were the strongest indicators of OS in GC when the number of LN harvested was ≤15. Therefore, they may be considered as an alternative nodal staging systems for GC.

An objective nodal staging system for breast cancer patients undergoing neoadjuvant systemic treatment

BackgroundIn this study, we aimed to develop an objective staging system to determine the degree of nodal metastasis in breast cancer patients undergoing neoadjuvant systemic treatment (NST).MethodsWe reviewed the pretreatment computed tomography (CT) images of 392 breast cancer patients who received NST. The association between the patterns of the enlarged regional lymph nodes and treatment outcome was analyzed.ResultsIn the development cohort of 260 patients, 88 (33.8%) patients experienced tumor recurrence and had a significantly higher number of enlarged lymph nodes on the pretreatment CT compared to patients with no recurrence. When patients were classified according to the numbers and locations of enlarged lymph nodes on pretreatment CT, the number of lymph nodes larger than 1 cm was most significantly associated with tumor recurrence. The accuracy of the CT-based nodal staging system was validated in an independent cohort of 132 patients. The presence of the enlarged supraclavicular nodes was associated with worse outcome, but the effect seemed to originate from the accompanied extensive axillary nodal burden. The prognostic effect of the objectively measured axillary nodal metastasis was more pronounced in hormone receptor-negative tumors.ConclusionsWe have developed and validated an objective method of nodal staging in breast cancer patients who undergo NST based on the number of enlarged axillary lymph nodes. Our system can improve the current subjective approach, which uses physical examination alone.

Comparison of the current AJCC-TNM numeric-based with a new anatomical location-based lymph node staging system for gastric cancer: A western experience.

BackgroundIn gastric cancer, the current AJCC numeric-based lymph node staging does not provide information on the anatomical extent of the disease and lymphadenectomy. A new anatomical location-based node staging, proposed by Choi, has shown better prognostic performance, thus soliciting Western world validation.Study designData from 284 gastric cancers undergoing radical surgery at the Second University of Naples from 2000 to 2014 were reviewed. The lymph nodes were reclassified into three groups (lesser and greater curvature, and extraperigastric nodes); presence of any metastatic lymph node in a given group was considered positive, prompting a new N and TNM stage classification. Receiver-operating-characteristic (ROC) curves for censored survival data and bootstrap methods were used to compare the capability of the two models to predict tumor recurrence.ResultsMore than one third of node positive patients were reclassified into different N and TNM stages by the new system. Compared to the current staging system, the new classification significantly correlated with tumor recurrence rates and displayed improved indices of prognostic performance, such as the Bayesian information criterion and the Harrell C-index. Higher values at survival ROC analysis demonstrated a significantly better stratification of patients by the new system, mostly in the early phase of the follow-up, with a worse prognosis in more advanced new N stages, despite the same current N stage.ConclusionsThis study suggests that the anatomical location-based classification of lymph node metastasis may be an important tool for gastric cancer prognosis and should be considered for future revision of the TNM staging system.

The anatomy of the TNM for colon cancer.

To visualize the anatomy as revealed by dendrograms of the tumor, lymph node, and metastasis (TNM) staging system for colon cancer and compare it with the Dukes' system. A hierarchical clustering algorithm generated tree-structured dendrograms that stratified patients according to survival only. The dendrograms were constructed with the same prognostic variables used for the TNM. Because combinations of prognostic factors were stratified only on survival, additional factors of any number and type could be integrated into the TNM without changing the TNM categories. The algorithm provided a step-by-step visualization of the TNM and the Dukes' system for colon cancer. Dendrograms and associated 5-year survival rates were generated for the T category only, the N category only, the T, N combination, and combinations of the T, N, and M, and the T, N, M with histological grade. Dendrograms revealed visual differences between the structure of TNM and the Dukes' system of staging. Dendrograms also revealed how variations in prognostic factors changed survival. By cutting dendrograms along their dissimilarity axis, multiple prognostic subgroups could be created for colon cancer that may reflect outcomes that are more accurate to estimate. Dendrograms provide a new way to view cancer patient staging. They reveal a visual step-by-step hierarchical relationship between survival rates and combinations of prognostic variables. The dendrograms also revealed fundamental differences between the TNM and the Dukes system of staging. By stratifying on survival only, additional factors including molecular factors can be added to the TNM, because it classifies patients according to survival rates only and not according to pre-set rules of prognostic factors and stage groups. The clinical implications of stratifying only survival are discussed.