Prognostic Performance of Different Lymph Node Staging Systems After Curative Intent Resection for Gastric Adenocarcinoma

Spolverato, Gaya; Ejaz, Aslam; Kim, Yuhree; Squires, Malcolm H.; Poultsides, George A.; Fields, Ryan C.; Bloomston, Mark; Weber, Sharon M.; Votanopoulos, Konstantinos I.; Acher, Alexandra W.; Jin, Linda X.; Hawkins, William G.; Schmidt, Carl; Kooby, David A.; Worhunsky, David J.; Saunders, Neil; Cho, Clifford S.; Levine, Edward A.; Maithel, Shishir K.; Pawlik, Timothy M.

doi:10.1097/sla.0000000000001040

Cited by 88 publications

(86 citation statements)

References 45 publications

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“…20–26,28,39 The present study confirmed that LNR was a strong, independent prognostic indicator of tumor prognosis relative to other risk factors. Two previous studies had also reported the potential role of LNR to select patients for adjuvant cXRT after gastric surgery with D2 lymphadenectomy.…”

Section: Discussionsupporting

confidence: 82%

Impact of lymph node ratio in selecting patients with resected gastric cancer for adjuvant therapy

Kim

Squires

Poultsides

et al. 2017

Surgery

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Background: The impact of adjuvant chemotherapy (CTx) and chemo-radiation therapy (cXRT) in the treatment of resectable gastric cancer remains varied. We sought to define the clinical impact of lymph node ratio (LNR) on the relative benefit of adjuvant CTx or cXRT among patients having undergone curative-intent resection for gastric cancer. Methods: Using the multi-institutional U.S. Gastric Cancer Collaborative database, 719 patients with gastric adenocarcinoma who underwent curative-intent resection between 2000 and 2013 were identified. Patients with metastasis or an R2 margin were excluded. The impact of LNR on overall survival (OS) among patients who received CTx or cXRT was evaluated. Results: Median patient age was 65 years, and the majority of patients were male (56.2%). The majority of patients underwent either subtotal (40.6%) or total gastrectomy (41.0%), with the remainder undergoing distal gastrectomy or wedge resection (18.4%). On pathology, median tumor size was 4 cm; most patients had a T3 (33.0%) or T4 (27.9%) lesion with lymph node metastasis (59.7%). Margin status was R0 in 92.5% of patients. A total of 325 (45.2%) patients underwent resection alone, 253 (35.2%) patients received 5-FU or capecitabine-based cXRT, whereas the remaining 141 (19.6%) received CTx. Median OS was 40.9 months, and 5-year OS was 40.3%. According to LNR categories, 5-year OS for patients with a LNR of 0, 0.1–0.10, >0.10–0.25, >0.25 were 54.1%, 53.1 %, 49.1 % and 19.8 %, respectively. Factors associated with worse OS included involvement of the gastroesophageal junction (hazard ratio [HR] 1.8), T-stage (3–4: HR 2.1), lymphovascular invasion (HR 1.4), and LNR (>0.25: HR 2.3) (all P<0.05). In contrast, receipt of adjuvant cXRT was associated with an improved OS in the multivariable model (vs. resection alone: HR 0.40; vs. CTx: HR 0.45, both P<0.001). The benefit of cXRT for resected gastric cancer was noted only among patients with LNR >0.25 (vs. resection alone: HR 0.34; vs. CTx: HR 0.45, both P<0.001). In contrast, there was no noted OS benefit of CTx or cXRT among patients with LNR ≤0.25 (all P>0.05). Conclusion: Adjuvant CTx or cXRT was utilized in over one-half of patients undergoing curative-intent resection for gastric cancer. LNR may be a useful tool to select patients for adjuvant cXRT, because the benefit of cXRT therapy was isolated to patients with greater degrees of lymphatic spread (i.e., LNR >0.25).

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Section: Discussionsupporting

confidence: 82%

Impact of lymph node ratio in selecting patients with resected gastric cancer for adjuvant therapy

Kim

Squires

Poultsides

et al. 2017

Surgery

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“…In addition, different prognostic significances of the subgroups of N3 (N3a and N3b) was not reflected in the final staging [1011]. The metastatic lymph node ratio was suggested to be a complementary measure by many authors [12131415], and others noted that there was heterogeneity in the survival of subgroups in a certain stage of the 7th AJCC/UICC staging system [16]. These controversies have highlighted the need for a new staging system [17].…”

Section: Introductionmentioning

confidence: 99%

Validation of the 7th AJCC/UICC staging system for gastric cancer and a proposal for a new TNM system based on a prognostic score: a retrospective multicenter study

et al. 2016

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PurposeWe validate the 7th American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) staging system for gastric cancer and propose a new staging system that reflects the prognostic significances of each of T and N category.MethodsData from 5,957 patients who underwent curative gastrectomies from 2000 to 2007 at 4 university hospitals in Daegu Metropolitan city in Korea were analyzed for the validation of the 7th AJCC/UICC staging system for gastric cancer. The hazard ratios of the respective T and N categories were estimated and converted to weightings and summated to make prognostic score (P-score). Homogeneity and stage grouping were determined according to the P-scores.ResultsIn the 7th AJCC/UICC staging system for gastric cancer, poor discrimination was noted between stages IIB and IIIA (P = 0.152). In addition, heterogeneity in stage IIB (P = 0.021) and a small gap in 5-year survival rates (1.7%) between stages IA and IB were noted. A new proposed staging system was generated on the basis of P-scores and demonstrated more discrimination between stages and more homogeneity within stages. The new staging system reflects the different prognostic impacts of N3a and N3b.ConclusionSeveral controversial issues of the 7th AJCC/UICC staging system for gastric cancer were reconfirmed in the present analysis. The TNM system based on P-score appears to be more scientifically accurate than the 7th AJCC/UICC staging system for gastric cancer.

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“…The LNR, which weights for the total number of nodes examined, has the same limit of the N classification in not being able to stratify the prognosis of patients with all metastatic (LNR = 1) or no metastatic (LNR = 0) nodes. For this reason, another solution proposed to minimize the limits of the N and LNR classifications was the use of the log odds of positive lymph nodes (LODDS), namely, the logarithm of the ratio between metastatic nodes and non metastatic nodes, which carries all the adjunctive information and the advantages of the LNR system and further discriminates among patients with edge LNR values (LNR 0 to 1) …”

Section: Introductionmentioning

confidence: 99%

“…To date, the prognostic advantage of alternative staging systems has been investigated in a significant number of studies, which mostly compared the difference between the sole nodal classification systems (N, LNR e LODDS), with discordant results . Most of these studies have been conducted in Asia and, so far, no study has compared the prognostic value of a full TNM classification system based on the LNR and LODDS classification with the TNM 8th edition.…”

Section: Introductionmentioning

confidence: 99%

Ratio‐based staging systems are better than the 7th and 8th editions of the TNM in stratifying the prognosis of gastric cancer patients: A multicenter retrospective study

Agnes

Biondi

Cananzi

et al. 2019

Journal of Surgical Oncology

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Background The current and the previous editions of the tumor‐node‐metastasis (TNM) system for gastric cancer (GC; TNM8 and TNM7) have a high risk of stage‐migration bias when the node count after gastrectomy is suboptimal. Hence, they are possibly not the optimal staging systems for GC patients. This study aims to compare the TNM with two systems less affected by the stage‐migration bias, namely, the lymph nodes ratio (LNR) and the log odds of positive lymph nodes (LODDS), to assess which one is the best in stratifying the prognosis of GC patients. Methods The sample study included 1221 GC patients. Two 7‐cluster staging systems based on the combination of pT categories and LNR and LODDS categories (TLNR and TLODDS) were compared with the two last editions of TNM, using the Akaike information criteria, the Bayesian information criteria, and the receiver operating characteristic (ROC) curve graphs. Further validation on an independent sample of 251 patients was carried out. Results The univariable and multivariable analyses and the ROC curves detected an advantage of the TLNR and TLODDS systems over the TNM. The TLNR and TLODDS showed the best accuracy both in the subgroup of patients with ≥16 nodes examined. The results were confirmed in the validation analysis. Conclusions TLNR and TLODDS staging systems should be considered a valid implementation of the TNM for the prognostic stratification of GC patients. If these results are confirmed in further studies, the future implementation of the TNM should consider the introduction of the LNR or the LODDS along with the number of metastatic nodes.

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Prognostic Performance of Different Lymph Node Staging Systems After Curative Intent Resection for Gastric Adenocarcinoma

Abstract: When assessed as a categorical variable, LNR was the most powerful manner to stratify patients on the basis of LN status. LODDS was a better predicator of survival when LN status was modeled as a continuous variable, especially among those patients with either very low or high LNR.

Cited by 88 publications

References 45 publications

Impact of lymph node ratio in selecting patients with resected gastric cancer for adjuvant therapy

Impact of lymph node ratio in selecting patients with resected gastric cancer for adjuvant therapy

Validation of the 7th AJCC/UICC staging system for gastric cancer and a proposal for a new TNM system based on a prognostic score: a retrospective multicenter study

Ratio‐based staging systems are better than the 7th and 8th editions of the TNM in stratifying the prognosis of gastric cancer patients: A multicenter retrospective study

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