Clinical nomogram for lymph node metastasis in pathological T1 esophageal squamous cell carcinoma: a multicenter retrospective study

Abstract

Background: Endoscopic resection is increasingly used to treat pathological T1 (pT1) esophageal cancer (EC) patients. However, the procedures are limited by lymph node metastasis (LNM) and remain controversial. We aimed to construct a nomogram to predict the risk of LNM in patients with pT1 esophageal squamous cell carcinoma (ESCC). Methods: A total of 243 patients with pT1 ESCC who underwent esophagectomy and lymph node dissection at two different institutes between February 2013 and June 2019 were analyzed retrospectively. Patients were categorized into the negative group and the positive group according to whether there was LNM. Risk factors for LNM were evaluated by univariate and multivariate analyses. The nomogram was used to estimate the individual risk of LNM.Results: Forty-six (18.9%) of the 243 patients with pT1 ESCC exhibited LNM. The LNM rate in patients with stage T1a disease was 5.7% (5/88), and the rate in patients with stage T1b disease was 26.5% (41/155).Multivariable logistic regression analysis showed that tumor differentiation [odds ratio (OR) =1.942, 95% confidence interval (CI): 1.067-3.536, P=0.030], the T1 sub-stage (OR =4.750, 95% CI: 1.658-13.611, P=0.004), the preoperative alanine aminotransferase/aspartate aminotransferase ratio (LSR) (OR =5.371, 95% CI: 1.676-17.210, P=0.005), and the high-density lipoprotein cholesterol (HDL-C) level (OR =5.894, 95% CI: 1.917-18.124, P=0.002) were independent risk factors for LNM. The nomogram had relatively high accuracy, with an area under the receiver operating characteristic curve (AUC) of 0.803 (95% CI: 0.732-0.873). The calibration curve showed that the predicted probability of LNM was in good agreement with the actual probability.Conclusions: Clinicopathological and hematological parameters of tumor differentiation, the T1 substage, the preoperative LSR, and the HDL-C level may predict the risk of LNM in T1 ESCC. The risk of LNM can be predicted by the nomogram.

Risk factors for lymph node metastasis in T1 esophageal squamous cell carcinoma: A systematic review and meta-analysis

“…Three[ 13 - 15 ] were multicenter studies, and fourteen[ 16 - 29 ] were single-center studies. All studies were conducted in Asian countries, including seven in China[ 14 , 15 , 20 , 21 , 23 , 26 , 29 ], seven in Japan[ 16 , 18 , 19 , 22 , 24 , 27 , 28 ] and three in South Korea[ 13 , 17 , 25 ]. All patients underwent open esophagectomy/thoracoscopy-assisted esophagectomy/ER and 2- or 3-field lymphadenectomy.…”

“…A total of 3775 patients were enrolled, of whom 914 had LNM and 2861 were non-LNM, with a metastasis rate of 24.2%. In terms of the assessment of the Newcastle-Ottawa Scale, 11 studies[ 8 , 13 , 16 - 22 , 25 , 27 ] scored 6, and 6 studies[ 14 , 15 , 23 , 24 , 26 , 28 ] scored 7.…”

“…Six studies[ 13 - 15 , 17 , 21 , 26 ] including 1482 patients, twelve studies[ 13 - 16 , 19 - 23 , 25 , 26 , 29 ] including 2751 patients, and six studies[ 13 , 18 , 21 , 22 , 25 , 27 ] including 1213 patients analyzed the relationship between LNM and tumor size, location and macroscopic type, respectively. The rates of LNM for tumor size ≤ 2 cm vs tumor size > 2 cm, upper-middle ESCC vs lower ESCC and nonflat type vs flat type were 8.9%-28.4% vs 17.5%-42.6%, 6.9%-41.5% vs 15.6%-36.8% and 23.5%-68.2% vs 8.2%-25.0%, respectively.…”

“…The relationship between T1 substage and LNM was analyzed in 17 studies[ 13 - 29 ], involving 3775 patients, and the relationship between differentiation and LNM was analyzed in 13 studies[ 13 - 15 , 18 - 21 , 23 - 26 , 28 , 29 ], involving 2599 patients. The rates of LNM in T1a vs T1b and well differentiated/moderately differentiated vs poorly differentiated were 1.5%-23.5% vs 20.9%-57.3% and 12.6%-43.3% vs 23.8%-63.6%, respectively.…”

Physician–Pharmacist Collaborative Clinic Model to Improve Anticoagulation Quality in Atrial Fibrillation Patients Receiving Warfarin: An Analysis of Time in Therapeutic Range and a Nomogram Development

“…Previous studies have also found that the coexistence of multiple diseases could significantly reduce the quality of INR control in AF patients receiving warfarin (Davis et al, 2005;Apostolakis et al, 2013), which can be explained by the increased number of hospitalizations required each year due to the Thromboembolic events, n (%) 3 (5.3%) 11 (5.3%) 1.000 Ischaemic stroke, n (%) 3 (5.3%) 9 (4.3%) 0.725 Myocardial infarction, n (%) 0 (0.0%) 1 (0.5%) 1.000 Peripheral venous thrombosis, n (%) 0 (0.0%) 1 (0.5%) 1.000 Bleeding events, n (%) 2 (3.5%) 9 (4.3%) 1.000 Epistaxis, n (%) 1 (1.8%) 0 (0.0%) 1.000 Hemoptysis, n (%) 0 (0.0%) 1 (0.5%) 0.251 Haematuria, n (%) 0 (0.0%) 3 (1.4%) 1.000 Gastrointestinal haemorrhage, n (%) 0 (0.0%) 3 (1.4%) 1.000 Subcutaneous hemorrhage, n (%) 1 (1.8%) 1 (0.5%) 0.385 Subconjunctival hemorrhage, n (%) 0 (0.0%) 1 (0.5%) 0.251 comorbidities, which, in turn, led to poor anticoagulation quality in AF patients receiving warfarin. Nomogram, as a graphical model calculating the probability of the outcome, has been improved as a feasible model in risk prediction and has been widely used in recent years (Lei et al, 2016;Serenari et al, 2020;Tian et al, 2020). To our knowledge, this study is the first to explore a feasible nomogram for predicting anticoagulation quality in Chinese AF patients receiving warfarin.…”