Lymph Node Ratio-based Staging System Outperforms the Seventh AJCC System for Gastric Cancer

Lee, Yueh-Chang; Yang, Po‐Jen; Zhong, Yi; Clancy, Thomas E.; Lin, Jaw–Town; Wang, Jiping

doi:10.1097/coc.0000000000000110

Cited by 39 publications

(28 citation statements)

References 25 publications

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“…In this present study, Nr stage was shown to have better discriminatory ability and more accurately prediction than N. Although there was no predictive difference for patients with retrieved lymph nodes ≥ 15, Nr stage revealed superiority in survival prediction for patients with retrieved lymph nodes < 15, demonstrating that Nr stage would better compensate for N stage shortcomings in gastric cancer patients, which is consistent with previous studies [10, 22, 23]. Additionally, a modified staging system, TNrM staging system based on Nr stage, predicted more accurately on overall survival by comparison of the current TNM staging system according to the findings in our study (Figure 3), which was consistent with the findings mentioned in previous investigations [6, 11, 16, 17, 24]. To show the improvement we got in this study, we also validated the various cutoff points produced in previous studies, which was not commonly done by previous authors, and found that the Nr stage, categorized by our cutoff points: 0, 0.15, 0.40 could produce the best prognostic discriminatory ability and predictive accuracy.…”

Section: Discussionsupporting

confidence: 93%

Superiority of lymph node ratio-based staging system for prognostic prediction in 2575 patients with gastric cancer: validation analysis in a large single center

Zhao

Jia

et al. 2016

Oncotarget

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This study aimed to evaluate the prognostic significance of node ratio (Nr), the ratio of metastatic to retrieved lymph nodes, and to investigate whether a modified staging system based on Nr can improve prognostic ability for gastric cancer patients following gastrectomy. A total of 2572 patients were randomly divided into training set and validation set, and the cutoff points for Nr were produced using X-tile. The relationships between Nr and other clinicopathologic factors were analyzed, while survival prognostic discriminatory ability and accuracy were compared among different staging systems by AIC and C-index in R program. Patients were categorized into four groups as follows: Nr0, Nr1: 0.00–0.15, Nr2: 0.15–0.40 and Nr3: > 0.40. Nr was significantly associated with clinicopathologic factors including macroscopic type, tumor differentiation, lymphovascular invasion, perineural invasion, tumor size, T stage, N stage and TNM stage. Besides, for all patients, Nr and TNrM staging system showed a smaller AIC and a larger C-index than that of N and TNM staging system, respectively. Moreover, in subgroup analysis for patients with retrieved lymph nodes < 15, Nr was demonstrated to have a smaller AIC and a larger C-index than N staging system. Furthermore, in validation analysis, Nr, categorized by our cutoff points, showed a larger C-index and a smaller AIC value than those produced in previous studies. Nr could be considered as a reliable prognostic factor, even in patients with insufficient (< 15) retrieved lymph nodes, and TNrM staging system may improve the prognostic discriminatory ability and accuracy for gastric cancer patients undergoing radical gastrectomy.

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Section: Discussionsupporting

confidence: 93%

Superiority of lymph node ratio-based staging system for prognostic prediction in 2575 patients with gastric cancer: validation analysis in a large single center

Zhao

Jia

et al. 2016

Oncotarget

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“…For example, in 2 different reports from Japan, 13,20 median TNLE was 11 in a series of 320 patients and, amazingly, in a separate series of 110 patients undergoing surgery for PHCC, the median TNLE was 24. 12,19 The current study consisted of 437 patients with PHCC with a median TNLE of 3 (IQR 1 to 7), which was similar to other published experiences from Western centers. 18,45 Specifically, we noted that 117 (26.8%) patients had only 1 to 2 LNs examined, 64 (14.6%) had 3 to 4 LNs, and 185 (42.3%) patients had ≥4 LNs examined.…”

Section: Discussionmentioning

confidence: 76%

Perihilar Cholangiocarcinoma: Number of Nodes Examined and Optimal Lymph Node Prognostic Scheme

Bagante

Tran

Spolverato

et al. 2016

Journal of the American College of Surgeons

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BACKGROUND The role of routine lymphadenectomy for perihilar cholangiocarcinoma is still controversial and no study has defined the minimum number of lymph nodes examined (TNLE). We sought to assess the prognostic performance of American Joint Committee on Cancer/Union Internationale Contre le Cancer (7th edition) N stage, lymph node ratio, and log odds (LODDS; logarithm of the ratio between metastatic and nonmetastatic nodes) in patients with perihilar cholangiocarcinoma and identify the optimal TNLE to accurately stage patients. METHODS A multi-institutional database was queried to identify 437 patients who underwent hepatectomy for perihilar cholangiocarcinoma between 1995 and 2014. The prognostic abilities of the lymph node staging systems were assessed using the Harrell’s c-index. A Bayesian model was developed to identify the minimum TNLE. RESULTS One hundred and fifty-eight (36.2%) patients had lymph node metastasis. Median TNLE was 3 (interquartile range, 1 to 7). The LODDS had a slightly better prognostic performance than lymph node ratio and American Joint Committee on Cancer, in particular among patients with <4 TNLE (c-index = 0.568). For 2 TNLE, the Bayesian model showed a poor discriminatory ability to distinguish patients with favorable and poor prognosis. When TNLE was >2, the hazard ratio for N1 patients was statistically significant and the hazard ratio for N1 patients increased from 1.51 with 4 TNLE to 2.10 with 10 TNLE. Although the 5-year overall survival of N1 patients was only slightly affected by TNLE, the 5-year overall survival of N0 patients increased significantly with TNLE. CONCLUSIONS Perihilar cholangiocarcinoma patients undergoing radical resection should ideally have at least 4 lymph nodes harvested to be accurately staged. In addition, although LODDS performed better at determining prognosis among patients with <4 TNLE, both lymph node ratio and LODDS outperformed compared with American Joint Committee on Cancer N stage among patients with ≥4 TNLE.

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“…28 In patients with the same N stage, Nr stage improved discrimination of patients' survival. [29][30][31] However, the efficacy of radiotherapy for patients with different N or Nr stage remains unclear.…”

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confidence: 99%

Lymph Node Burden as a Predictive Factor for Selective Chemoradiotherapy in Patients With Locally Advanced Gastric Cancer After a D2 Dissection

Li¹,

Palmer

et al. 2017

American Journal of Clinical Oncology

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Lymph Node Ratio-based Staging System Outperforms the Seventh AJCC System for Gastric Cancer

Abstract: Lymph node ratio significantly decreases the stage migration caused by inadequate examined lymph nodes. The advantage of TNrM was validated with a patient cohort from the Eastern medical center.

Cited by 39 publications

References 25 publications

Superiority of lymph node ratio-based staging system for prognostic prediction in 2575 patients with gastric cancer: validation analysis in a large single center

Superiority of lymph node ratio-based staging system for prognostic prediction in 2575 patients with gastric cancer: validation analysis in a large single center

Perihilar Cholangiocarcinoma: Number of Nodes Examined and Optimal Lymph Node Prognostic Scheme

Lymph Node Burden as a Predictive Factor for Selective Chemoradiotherapy in Patients With Locally Advanced Gastric Cancer After a D2 Dissection

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