Prognostic assessment of different metastatic lymph node staging methods for gastric cancer after D2 resection

AIM: To compare the prognostic assessment of lymph node ratio and absolute number based staging system for gastric cancer after D2 resection. METHODS: The clinical, pathologic, and long-term follow-up data of 427 patients with gastric cancer that underwent D2 curative gastrectomy were retrospectively analyzed. The relationships between the metastatic lymph node ratio (MLR), log odds of positive lymph nodes (LODDS), and positive lymph nodes (pN) staging methods and the long-term prognoses of the patients were compared. In addition, the survival curves, accuracy, and homogeneity were compared with stratification to evaluate the prognostic assessment of the 3 methods when the number of tested lymph nodes was insufficient (< 10 and 10-15). RESULTS: MLR [hazard ratio (HR) = 1.401, P = 0.012], LODDS (HR = 1.012,P = 0.034), and pN (HR = 1.376, P = 0.005) were independent risk factors for gastric cancer patients. The receiver operating characteristic (ROC) curves showed that the prognostic accuracy of the 3 methods was comparable (P > 0.05). Spearman correlation analysis confirmed that MLR, LODDS, and pN were all positively correlated with the total number of tested lymph nodes. When the number of tested lymph node was < 10, the value of survival curves staged by MLR and LODDS was superior to those of pN staging. However, the difference in survival curves between adjacent stages was not significant. In addition, the survival rate of stage 4 patients using the MLR and LODDS staging methods was 26.7% and 27.3% with < 10 lymph node, respectively which were significantly higher than the survival rate of patients with > 15 tested lymph nodes (< 4%). The ROC curve showed that the accuracy of the prognostic assessment of MLR, LODDS, and pN staging methods was comparable (P > 0.05), and the area under the ROC curve of all 3 methods were increased progressively with the enhanced levels of examined lymph nodes. In addition, the homogeneity of the 3 methods in patients with ≤ 15 tested lymph nodes also showe     

胃癌淋巴结转移的分期与影像学诊断研究进展

［摘要］　淋巴结转移是影响胃癌患者预后的重要危险因素之一。病理活检是目前现有的检查手段中唯一可以确诊淋巴结转移阳性的方式,而胃周淋巴结分布广泛且解剖位置多变,术前对淋巴结进行活检较为困难。现有的检查方式中,无论是超声内镜(EUS)、多排螺旋CT（MDCT）还是核磁共振成像（MRI）,对于淋巴结转移的诊断目前都是停留在形态学方面。该文对胃癌淋巴结转移的分期与影像学诊断研究进展进行综述。     

Prognostic value of lateral lymph node metastasis for advanced low rectal cancer

AIM： To evaluate the risk factors for lateral lymph node metastasis in patients with advanced low rectal cancer, in order to make the effective selection of patients who could benefit from lateral lymph node dissection, as well as the relationship of lateral lymph node metastasis with local recurrence and survival of patients with advanced low rectal cancer. METHODS： A total of 96 consecutive patients who underwent curative surgery with lateral pelvic lymphadenectomy for advanced lower rectal cancer were retrospectively analyzed. The relation of lateral lymph node metastasis with clinicopathologic characteristics, local recurrence and survival of patients was identified. RESULTS： Lateral lymph node metastasis was observed in 14.6% （14/96） of patients with advanced low rectal cancer. Lateral lymph node metastasis was detected in 10 （25.0%） of 40 patients with tumor diameter ≥ 5 cm and in 4 （7.1%） of 56 patients with tumor diameter 〈 5 cm. The difference between the significant （X^2 = 5.973, P = two groups was statistically 0.015）. Lateral lymph node metastasis was more frequent in patients with 4/4 diameter of tumor infiltration （7 of 10 cases, 70.0%）, compared with patients with 3/4, 2/4 and 1/4 diameter of tumor infiltration （3 of 25 cases, 12.0%; 3 of 45 cases, 6.7%; 1 of 16 cases, 6.3%） （X^2 = 27.944, P = 0.0001）. The lateral lymph node metastasis rate was 30.0% （9 of 30 cases）, 9.1% （4 of 44 cases） and 4.5% （1 of 22cases） for poorly, moderately and well-differentiated carcinoma, respectively. The difference between the three groups was statistically significant （X^2 = 8.569, P = 0.014）. Local recurrence was 18.8% （18 of 96 cases）, 64.3% （9 of 14 cases）, and 11.0% （9 of 82 cases） in patients with advanced low rectal cancer, in those with and without lateral lymph node metastasis, respectively. The difference between the two groups was statistically significant （X^2 = 22.308, P = 0.0001）. Kaplan-Meier survival analysis showed significant impr     

Prognostic assessment of different lymph node staging methods for pancreatic cancer with R0 resection: pN staging,lymph node ratio,log odds of positive lymph nodes

Background and aimsSurvival after surgical resection of pancreatic adenocarcinoma is poor. Several prognostic factors such as the status of the resection margin, lymph node status, or tumour grading have been identified. The aims of the present study were to evaluate and compare the prognostic assessment of different lymph nodes staging methods: standard lymph node (pN) staging, metastatic lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) in pancreatic cancer after pancreatic resection.Materials and methodsData were retrospectively collected from 143 patients who had undergone R0 pancreatic resection for pancreatic ductal adenocarcinoma. Survival curves (Kaplan–Meier and Cox proportional hazard models), accuracy, and homogeneity of the 3 methods (LNR, LODDS, and pN) were compared to evaluate the prognostic effects.ResultsMultivariate analysis demonstrated that LODDS and LNR were an independent prognostic factors, but not pN classification. The scatter plots of the relationship between LODDS and the LNR suggested that the LODDS stage had power to divide patients with the same ratio of node metastasis into different groups. For patients in each of the pN or LNR classifications, significant differences in survival could be observed among patients in different LODDS stages.ConclusionLODDS and LNR are more powerful predictors of survival than the lymph node status in patients undergoing pancreatic resection for ductal adenocarcinoma. LODDS allows better prognostic stratification comparing LNR in node negative patients.     

Prognostic impact of dissected lymph node count on patients with node-negative gastric cancer

AIM： To investigate the long-term effect of the number of resected lymph nodes （LNs） on the prognosis of patients with node-negative gastric cancer. METHODS： Clinical data of 211 patients with gastric cancer, without nodal involvement, were analyzed retrospectively after D2 radical operation. We analyzed the relationship between the number of resected LNs with the 5-year survival, the recurrence rate and the post-operative complication rate. RESULTS： The 5-year survival of the entire cohort was 82.2%. The total number of dissected LNs was one of the independent prognostic factors. Among patients with comparable depth of invasion, the larger the number of resected LNs, the better the survival （P 〈 0.05）. A cut-point analysis provided the possibility to detect a significant survival difference among subgroups. Patients had a better long-term survival outcomes with LN counts ≥ 15 for pT1-2, ≥ 20 for pT3-4, and ≥ 15 for the entire cohort. The overall recurrence rate was 29.4% within 5 years after surgery. There was a statistically significant, negative correlation between the number of resected LNs and the recurrence rate （P 〈 0.01）. The post-operative complication rate was 10.9% and was not significantly correlated with the number of dissected LNs （P 〉 0.05）.CONCLUSION： For node-negative gastric cancer, sufficient number of dissected LNs is recommended during D2 lymphadenectomy, to improve the long-term survival and reduce the recurrence. Suitable increments of the dissected LN count would not increase the postoperative complication rate.     

Sentinel lymph node concept in gastric cancer with solitary lymph node metastasis

AIM: To study the localization of the solitary metastases in relation to the primary gastric cancers and the feasibility of sentinel lymph node (SLN) concept in gastric cancer. METHODS: Eighty-six patients with gastric cancer, who had only one lymph node involved, were regarded retrospectively as patients with a possible sentinel node metastasis, and the distribution of these nodes were assessed. Thirteen cases with jumping metastases were further studied and followed up. RESULTS: The single nodal metastasis was found in the nearest perigastric nodal area in 65.1% (56/86) of the cases and in 19.8% (17/86) of the cases in a fairly remote perigastric area. Out of 19 middle-third gastric cancers,3 tumors at the lesser or greater curvatures had transverse metastases. There were also 15.1% (13/86) of patients with a jumping metastasis to N2-N3 nodes without N1 involved. Among them, the depth of invasion was mucosal (M) in 1 patient, submucosal (SM) in 2, proper-muscular (MP) in 4, subserosal (SS) in 5, and serosa-exposed (SE) in 1. Five of these patients died of gastric cancer recurrence at the time of this report within 3 years aftersurgery. CONCLUSION: These results suggest that nodal metastases occur in a random and multidirectional process in gastric cancer and that not every first metastatic node is located in the perigastric region near the primary tumor. The rate of “jumping metastasis” in gastric cancer is much higher than expected, which suggests that the blind examination of the nodal area close to the primary tumor can not be a reliable method to detect the SLN and that a extended lymph node dissection (ELND) should be performed if the preoperative examination indicates submucosal invasion.     

中老年人胃癌前哨淋巴结术中定位的临床研究

目的　探讨胃癌前哨淋巴结 (SLN)术中定位和检测应用的可行性及其预测胃癌淋巴转移的准确性。方法　应用 1 %亚甲蓝染色剂 ,对 2 8例 (T1、T2期 )胃癌病人进行术中SLN定位 ,切除蓝染淋巴结〔平均每例病人 (2 6± 1 7)个〕 ,随后对患者均行胃癌扩大根治术。SLNs和非前哨淋巴结 (nSLNs)均行苏木精 伊红 (HE)染色。结果　 2 8例中有 2 7例 (96 4% )成功检出SLN ,1 0例患者有淋巴结转移 ,其中 6例存在SLN及n SLN转移 ,3例存在SLN转移 ,1例只有n SLN转移。由SLN状态预测胃周淋巴结转移情况的敏感性为 90 % (9/ 1 0 ) ,特异性为 1 0 0 % (1 7/ 1 7) ,准确率为 96 3 % (2 6/ 2 7)。T1组 (1 2例 )与T2组 (1 6例 )敏感性分别为 1 0 0 %和 88%。结论　应用亚甲蓝染色剂对胃癌SLN定位检测成功率高 ,SLN状态 ,尤其是T1期胃癌 ,能够准确预测胃癌患者的淋巴结转移状况。     

Prognostic accuracy of different lymph node staging system in predicting overall survival in stage IV colon cancer

International Journal of Colorectal Disease - With emphasis of surgical management, the lymph node (LN) status has been advocated to predict prognosis in colon cancer with distant metastatic....     

Prognostic impact of metastatic lymph node ratio on gastric cancer after curative distal gastrectomy

AIM:To investigate the prognostic impact of metastatic lymph node ratio(rN) on gastric cancer after curative distal gastrectomy.METHODS:A total of 634 gastric cancer patients who underwent curative resection(R0) of lymph nodes at distal gastrectomy in 1995-2004.Correlations between positive nodes and retrieved nodes,between rN and retrieved nodes,and between rN and negative lymph node(LN) count were analyzed respectively.Prognostic factors were identif ied by univariate and multivariate analyses.Staging acc...     

Prognostic impact of metastatic lymph node ratio in advanced gastric cancer from cardia and fundus

AIM： To investigate the prognostic impact of the metastatic lymph node ratio （MLR） in advanced gastric cancer from the cardia and fundus. METHODS： Two hundred and thirty-six patients with gastric cancer from the cardia and fundus who underwent D2 curative resection were analyzed ret- rospectively. The correlations between MLR and the total lymph nodes, positive nodes and the total lymph nodes were analyzed respectively. The influence of MLR on the survival time of patients was determined with univariate Kaplan-Meier survival analysis and mul- tivariate Cox proportional hazard model analysis. And the multiple linear regression was used to identify the relation between MLR and the 5-year survival rate of the patients. RESULTS： The MLR did not correlate with the total lymph nodes resected （r = -0.093, P = 0.057）. The 5-year overall survival rate of the whole cohort was 37.5%. Kaplan-Meier survival analysis identified that the following eight factors influenced the survival time of the patients postoperatively： gender （χ2 = 4.26, P = 0.0389）, tumor size （χ2 = 18.48, P 〈 0.001）, Borrmann type （χ2 = 7.41, P = 0.0065）, histological grade （χ2 = 5.07, P = 0.0243）, pT category （χ2 = 49.42, P 〈 0.001）, pN category （χ2 = 87.7, P 〈 0.001）, total number of re- trieved lymph nodes （χ2 = 8.22, P = 0.0042） and MLR （χ2 = 34.3, P 〈 0.001）. Cox proportional hazard model showed that tumor size （χ2 = 7.985, P = 0.018）, pTcategory （χ2 = 30.82, P 〈 0.001） and MLR （χ2 = 69.39, P 〈 0.001） independently influenced the prognosis. A linear correlation between MLR and the 5-year survival was statistically significant based on the multiple lin- ear regression （β = -0.63, P 〈 0.001）. Hypothetically, the 5-year survival would surpass 50% when MLR was lower than 10%. CONCLUSION： The MLR is an independent prognostic factor for patients with advanced gastric cancer from the cardia and fundus. The decrease of MLR due to adequate number of total resected lymph     

Reappraisal of the new UICC staging system for gastric cancer: problem in lymph node stage

BACKGROUND/AIMS: The International Union Against Cancer (UICC) TNM staging system defined a new system for classifying gastric cancer, based on the number of metastatic nodes (1997). However, the advantage of the new system is still a matter of debate. The aim of the present study is to compare the new system with the old one (1987), which is based on the location of positive lymph nodes. METHODOLOGY: We analyzed the survival of 608 patients with curative resection of their gastric cancer. The average number of resected and involved lymph nodes for each resected patient was 31.4 and 7.7. Comparison of these two systems was carried out to determine which classification was more effective. The prognostic value of different lymph node staging systems was also analyzed. RESULTS: One hundred and thirty-five patients (22.2%) had different N classification and 109 (17.9%) had different TNM staging. There was a significant stepwise decrease of slope of survival curve for each stage, but the new system did not cleanly separate stage II with IIIa at 3 years and stage IIIb with IV at 5 years. Although different lymph node staging systems were able to predict survival, the ratio rather than the number of involved nodes had a more cleanly separated stepwise decrease of slope of survival curve. CONCLUSIONS: The new UICC staging system is not better than the old system for the staging of gastric cancer. The reason is that the category of node number seems not to be appropriate and will be influenced by the extent of lymph node dissection. To overcome this problem, the frequency of involved nodes can be adopted instead of the number.     

Prognostic value of number of examined lymph nodes in patients with node-negative gastric cancer

AIM:To elucidate the potential impact of examined lymph nodes(eLNs)on long-term survival of nodenegative gastric cancer patients after curative surgery.METHODS:A total of 497 node-negative gastric cancer patients who underwent curative gastrectomy between January 2000 and December 2008 in our center were enrolled in this study.Patients were divided into4 groups according to eLNs through cut-point analysis.Clinicopathological features were compared between≤15 eLNs group and>15 eLNs group and potential prognostic factors were analyzed.The Log-rank test was used to assess statistical differences between the groups.Independent prognostic factors were identifiedusing the Cox proportional hazards regression model.Stratified analysis was performed to investigate the impact of eLNs on patient survival in each stage.Overall survival was also compared among the four groups.Finally,we explored the recurrent sites associated with eLNs.RESULTS:Patients with eLNs>15 had a better survival compared with those with eLNs≤15 for the entire cohort.By the multivariate survival analysis,we found that the depth of invasion and the number of eLNs were the independent predictors of overall survival(OS)of patients with node-negative gastric cancer.According to the cut-point analysis,T2-T4 patients with 11-15 eLNs had a significantly longer mean OS than those with 4-10 eLNs or 1-3 eLNs.Patients with≤15 eLNs were more likely to experience locoregional and peritoneal recurrence than those with>15eLNs.CONCLUSION:Number of eLNs could predict the prognosis of node-negative gastric cancer,and dissection of>15 eLNs is recommended during lymphadenectomy so as to improve the long-term survival.     

结直肠癌淋巴结的分期

目的:分析结直肠癌淋巴结转移状况与预后的关系,提出新的结直肠癌淋巴结分期方案.方法:122例病理资料完整的结直肠癌病例,比较不同删分期(AJCC/UICC)病例的5年生存率:将淋巴结转移数目≥10枚和顶端淋巴结转移拟定为N,期,比较AJCC/UICC的TNM分期中No、N1、N2与N3期病例的5年生存率;按Kaplan-Meier方法计算生存率,绘制生存曲线,并对生存率进行Log-rank检验.结果:随着TNM分期的上升,5年生存率逐渐下降(Ⅰ期为100%;Ⅱ期为81.82%;ⅢAB期为69-39%,ⅢC期为15%:Ⅳ期为0,P<0.01),随着N分期的上升,5年生存率也逐渐下降(N0Ⅰ期为100%、N0Ⅱ期为89.82%、N1期69.39%,N2期为15%,P<0.01).N3期病例5年生存率为0,与TNM的Ⅳ期预后相似.结论:建议将结直肠癌TNM中的N分期定为:无淋巴结转移为N0,1-3枚淋巴结转移为N1,4-9枚淋巴结转移为N2,≥10枚淋巴结转移和/或顶端淋巴结转移为N3.N3期患者的5年生存率为0,与M1期结果相似,可以定为亚临床转移.     

Unveiling lymph node metastasis in early gastric cancer

With respect to gastric cancer treatment,improvements in endoscopic techniques and novel therapeutic modalities[such as endoscopic mucosal resection(EMR)and endoscopic submucosal dissection(ESD)]have been developed.Currently,EMR/ESD procedures are widely accepted treatment modalities for early gastric cancer(EGC).These procedures are most widely accepted in Asia,including in Korea and Japan.In the present era of endoscopic resection,accurate prediction of lymph node(LN)metastasis is a critical component of selecting suitable patients for EMR/ESD.Generally,indications for EMR/ESD are based on large Japanese datasets,which indicate that there is almost no risk of LN metastasis in the subgroup of EGC cases.However,there is some controversy among investigators regarding the validity of these criteria.Further,there are currently no accurate methods to predict LN metastasis in gastric cancer(for example,radiologic methods or methods based on molecular biomarkers).We recommend the use of a 2-step method for the management of early gastric cancer using endoscopic resection.The first step is the selection of suitable patients for endoscopic resection,based on endoscopic and histopathologic findings.After endoscopic resection,additional surgical intervention could be determined on the basis of a comprehensive review of the endoscopic mucosal resection/endoscopic submucosal dissection specimen,including lymphovascular tumor emboli,tumor size,histologic type,and depth of invasion.However,evaluation of clinical application data is essential for validating this recommendation.Moreover,gastroenterologists,surgeons,and pathologists should closely collaborate and communicate during these decisionmaking processes.     

Superiority of metastatic lymph node ratio to the 7th edition UICC N staging in gastric cancer

AIM:To compare and evaluate the appropriate prog-nostic indicators of lymph node basic staging in gastric cancer patients who underwent radical resection.METHODS:A total of 1042 gastric cancer patients who underwent radical resection and D2 lymphadenectomy were staged using the 6th and 7th edition International Union Against Cancer(UICC)N staging methods and the metastatic lymph node ratio(MLNR)staging.Ho-mogeneity,discriminatory ability,and gradient mono-tonicity of the various staging methods were compare...     

胃癌术中前哨淋巴结的定位检测研究

目的 探讨胃癌术中前哨淋巴结(SLN)定位检测的可行性及意义.方法 在106例胃癌手术中,将亚甲蓝注射至肿瘤周围1 cm的胃壁上,循蓝染的淋巴管找寻第一个蓝染淋巴结,即SLN.结果 106例胃癌患者获得SLN 者103例 (97.17%).根据SLN预测胃周淋巴结转移的准确率、敏感性、假阴性率、特异性在Ⅰ、Ⅱ期胃癌分别为94.74%(36/38)、90%(18/20)、10% (2/20)、100% (18/18),Ⅲ、Ⅳ期胃癌分别为68.33%(41/60)、67.24%(39/58)、32.76% (19/58)、100% (2/2). 结论 使用亚甲蓝染色术中定位胃癌SLN是可行的.在Ⅰ、Ⅱ期胃癌中SLN能准确预测淋巴结转移的情况.