淋巴结转移率对淋巴结清扫不足15枚胃癌患者预后评估的价值

目的 评价淋巴结转移率(MLR)对淋巴结清扫不足15枚胃癌患者预后评估的价值.方法 回顾性分析天津医科大学附属肿瘤医院2003年1月到2007年7月间收治的610例胃癌患者的临床资料.其中淋巴结清扫数目不足15枚者320例,15枚以上者290例,比较两组患者在不同病理N分期(pN分期)和不同淋巴结转移度分期(rN分期)中预后的差异.结果 通过Log-rank检验,确定MLR的界值,按此界值可分为rN1(MLR小于或等于10％)、rN2(MLR大于10％,但小于或等于30％)、rN3(MLR大于30％,但小于或等于60％)和rN4(MLR大于60％)4期.对于淋巴结清扫数目不足15枚者,上述不同rN分期患者的生存差异均无统计学意义(均P＞0.05);在同一rN分期中,不同pN分期之间生存差异亦均无统计学意义(均P＞0.05).对于pN2和pN3a期患者,淋巴结清扫数目不足15枚者与15枚以上者的生存差异有统计学意义(均P＜0.05);但在各个rN分期中,两者间差异均无统计学意义(均P＞0.05).多因素预后分析证实,rN分期是淋巴结清扫数目不足15枚胃癌患者的独立预后因素(P=0.012,RR=1.617,95％CI:1.111～2.354).结论 rN分期能很好地对淋巴结清扫不足15枚胃癌患者的预后进行预测.     

淋巴结转移率对胃癌患者预后的评估价值

目的 探讨淋巴结转移率（rN）对胃癌根治术患者预后的评估价值.方法 回顾性分析1980-2006年间中国医科大学附属第一医院肿瘤外科收治的接受根治性手术的710例胃癌患者的临床资料.按淋巴结捡取数目将710例患者分为少于15枚组（327例）和15枚以上（含15枚）组（383例）.按淋巴结转移率进行rN分期;按淋巴结转移数量进行pN分期.分别采用Logrank检验和Cox比例风险模型来进行单因素和多因素预后分析.结果 少于15枚组和15枚以上组胃癌患者中位生存时间分别为74个月（95％ CI：55.6～92.4个月）和96个月（95％ CI：77.8～119.2个月）,差异无统计学意义（P＞0.05）.多因素预后分析显示,rN分期既是少于15枚组（P＜0.01,RR=1.225,95％ CI：1.102～1.362）,又是15枚以上组（P＜0.01,RR=1.421,95％ CI：1.269～1.592）胃癌患者的独立预后因素;而pN分期仅仅是少于15枚组胃癌患者的独立预后因素（P＜0.01,RR=1.475,95％ CI：1.168～1.863）.采用rN分期系统,相同分期的两组胃癌患者生存时间的差异均无统计学意义（P＞0.05）;而采用pN分期系统,在pN1期患者中少于15枚组患者生存时间明显短于15枚以上组（P＜0.01）.结论 淋巴结转移率是影响胃癌预后的独立因素.在判断胃癌预后中,按淋巴结转移率的rN分期不受检出淋巴结数目的限制,较pN分期系统更为可靠.     

淋巴结转移率对胃癌患者预后的评估价值

目的 评估淋巴结转移率(MLR)对胃癌患者预后的预测价值.方法 回顾性分析2005-2009年间在南京医科大学第一附属医院接受根治性切除(pT4期患者除外)并具有完整随访资料的1247例胃癌患者的临床资料,从准确性、均一性和适用性3个方面比较MLR分期和pN分期的预后价值.结果 MLR和pN均与送检淋巴结数目呈正相关(均P<0.01).不同MLR分期及不同pN分期患者5年累计生存率(5-YCSR)的差异均有统计学意义(均P<0.01);进一步经多因素预后分析显示,MLR分期和pN分期均可作为独立的预后因素(均P<0.01).ROC曲线显示,MLR分期预测预后所对应的曲线下面积大于pN分期,但差异并未达到统计学意义(p>0.05).相同MLR组中不同pN组间5-YCSR的差异无统计学意义(P>0.05);而相同pN组中不同MLR组间5-YCSR的差异有统计学意义(P<0.05).同一pN分期患者,送检淋巴结数目不同,其5-YCSR的差异均有统计学意义(P<0.05);而同一MLR分期患者5-YCSR则与送检淋巴结数目无关(P>0.05).结论 MLR是预测胃癌生存的独立预后因素;MLR分期评估胃癌预后的准确性与pN分期相当,但均一性和适用性均优于pN分期.

Abstract：

Objective To evaluate the prognostic value of metastatic lymph node ratio (MLR) for patients with gastric cancer. Methods Data collected from 1247 patients with gastric cancer who underwent radical surgery (pT4 cases were excluded) at the First Affiliated Hospital of Nanjing Medical University between 2005 and 2009 were analyzed retrospectively. MLR was compared to pathological N staging (pN) in terms of prognostic accuracy, homogenicity, and applicability. Results MLR and pN were both positively correlated with the number of retrieved lymph nodes (both P<0.01). Significant differences were found in 5-year cumulative survival rate (5-YCSR) among different pN stages and MLR classification (all P<0.01). Multivariable analysis showed that both pN and MLR were independent prognostic factors (both P<0.01). The area under ROC curve (AUC) of MLR was larger than pN, however the difference was not statistically significant (P>0.05). There were significant differences in 5-YCSR among different MLR stages within the same pN stages (P<0.05), but not among different pN stages within the same MLR stage (P>0.05). Significant differences in 5-YCSR were also found among different retrieved-node groups within the same pN stage (P<0.05), but not within the same MLR stages (P>0.05). Conclusions MLR is an independent prognostic factor for patients with gastric cancer. The prognostic homogenicity and applicability of MLR are better than those of pN, however the prediction accuracy is not favorable.     

病理N3期胃癌310例预后分析

目的探讨UICC第7版TNM分期标准中病理N3（pN3）期胃癌患者的预后特征及预后影响因素。方法回顾性分析2000年1月至2006年12月间天津医科大学附属肿瘤医院收治的实施胃癌根治术或扩大根治术的310例pN3期胃癌患者的临床病理和随访资料,分别采用Logrank检验和Cox比例风险模型进行单因素和多因素预后分析。结果310例患者均获随访,随访时间为2～103（平均35．7）月,术后5年生存率为14．6％。其中pN3a期201例,pN3b期109例,5年生存率分别为16．8％和10．3％,差异有统计学意义（P=0．013）。单因素预后分析显示,肿瘤部位、Borrmann分型、pT分期、pN分期、淋巴结转移率及手术方式与患者预后有关（均P〈0．05）。多因素分析显示,浸润深度、手术方式及淋巴结转移率是影响预后的独立危险因素（均P〈0．01）,而pN分期并不是独立的预后影响因素（P=0．658）。按浸润深度对患者进行分层分析显示,对于210例pT4a期患者,pN3a和pN3b亚组5年生存率分别为16．1％和12．8％,差异有统计学意义（P=0．001）;但对于88例pT4b期患者,pN3a和pN,b亚组5年生存率的差异则无统计学意义（8．6％比3．1％,P=0．137）。结论pM期胃癌患者预后较差,肿瘤浸润深度和不同手术方式是影响其预后的重要因素,淋巴结转移率对判断pM期胃癌预后有重要意义。第7版TNM分期中pN3分期能较好反映患者的预后情况。     

淋巴结取材方法对胃癌淋巴结分期的影响

目的探讨淋巴结取材方法对胃癌淋巴结检查数目及分期的影响。方法 36例接受根治性切除手术的进展期胃癌病例,根据淋巴结取材方法分为新鲜组(n=9)、固定组(n=9)和脱脂组(n=18);记录每例患者的淋巴结数目,分别计算全组及亚组患者的淋巴结总数和平均值,比较亚组患者的淋巴结数目、转移淋巴结数目及pN分期。结果本组36例总体淋巴结转移率72%。新鲜组检出淋巴结(22.11±10.28)枚/例,固定组检出淋巴结(21.89±6.57)枚/例(t=0.052,P=0.960),故合并为传统组(n=18);脱脂组检出淋巴结(55.83±16.77)枚/例(t=14.129,P0.001)。传统组检出47枚(2~11枚/例)淋巴结转移,脱脂组检出223枚(2~77枚/例)淋巴结转移(t=2.295,P=0.035)。与传统组相比较,脱脂组pN0-pN2病例明显减少,pN3a和pN3b病例明显增加(x~2=9.602,P=0.040)。结论脱脂法可以获取更多的淋巴结,淋巴结转移数目也随之增加,pN分期上移。     

早期胃癌微转移的研究进展

早期胃癌（early gastric carcinoma，EGC）是指肿瘤局限于黏膜或黏膜下层，无论是否存在淋巴结的转移。EGC的5年存活率达90％以上，但仍有少数病人发生复发转移。影响EGC预后的因素很多，以肿瘤浸润深度和淋巴结转移最为重要。国际抗癌联盟UICC和美国抗癌联合会AJCC的胃癌第5版TNM分期中，推荐淋巴结转移的分期以转移阳性的数目为基础，它比以往按照淋巴结转移部位分期有优越性。研究表明，送检的淋巴结越多，判定淋巴结转移的准确性越大，送检的淋巴结数不足以诊断时，淋巴结分期将不被考虑，即所谓“分期移动”（stage migration）。为了准确确定淋巴结转移的分期，应明确最少的淋巴结检出数。UICC和AJCC提出对胃癌pNO检出数定为15个以上，多学者亦认同此观点，但并未阐明为何取15个作为分界点。陈波等研究表明．pNO最少的淋巴结检出数应由原来的15个减至10个，有淋巴结转移者，至少应送检15个以上，Ⅱ期病例最好送20个以上，Ⅲ、Ⅳ期病例最好送30个以上。近年来，淋巴结微转移在肿瘤转移、复发和治疗中的作用引起重视。本文就微转移的概念、检测方法及临床意义等方面作一综述，增强对早期胃癌微转移的诊断意识，提高诊断水平及检出率，提高早期胃癌的治愈率。     

胃癌新TNM分期与其生物学行为及预后的关系

目的　分析胃癌新TNM分期的临床应用价值。　方法　对比分析 334例胃癌患者新、旧TNM分期中区域淋巴结转移 (pN)分级与患者预后及反映胃癌生物学行为的病理因素间的相关性。　结果　旧pN分级中pN1组术后 5年生存率为 49 6 % ,pN2 组为 33 5 % ,2组差异有显著性意义 (P <0 0 1) ;新pN分级中pN1组术后 5年生存率为 48 5 % ,pN2 组为 2 4 1% ,pN3 组为 5 6 %。 3组患者术后生存率差异有极显著意义 (P <0 0 1) ;新pN分级与患者胃癌的浸润深度、大体类型、浆膜分型和生长方式相关 (P <0 0 1) ;COX模型分析表明新pN分级是反映胃癌预后最主要的独立指标。　结论　与旧TNM分期相比 ,新TNM分期系统是估计胃癌预后更为合理的指标 ,并且较旧分期更简单、客观 ,具可重复性 ,易于推广应用。     

胃癌淋巴结转移CT诊断指标与病理N分期对照研究

目的探讨可用于评价胃癌淋巴结转移及术前N分期的影像学指标。方法利用PACS工作站软件对89例胃癌患者的CT淋巴结检出情况进行回顾性分析。记录CT检出淋巴结的大小和数目,并计算每例检出淋巴结的径线和：并将各CT指标与肿瘤的病理N分期进行比较。结果CT检出淋巴结数、最大淋巴结径线及径线和在肿瘤组织不同病理N分期的差异有统计学意义（P〈0．05）;淋巴结转移和非转移两组间上述3个指标的差异也均有统计学意义（P〈0．05）。CT检出淋巴结数在pN1与pN3和pN2与pN1分期间比较,差异有统计学意义（P〈0．01）;淋巴结最大径线在淋巴结转移阳性组各病理分期间比较,差异无统计学意义（P〉0．05）;径线和在pN1与pN2和pN1与pN3分期间比较,差异有统计学意义（P〈0．01）。结论 CT检出淋巴结数目联合淋巴结径线和可为术前肿瘤N分期的评价提供参考。     

转移的淋巴数目:最新TNM分级评价胃癌预后的指标

日本Aichi肿瘤治疗中心自1983～1992年间收治胃癌病人1913例。其中,伴有淋巴结转移但未侵及邻近组织及无远处转移者493例,对这些病例分别用新的TNM分期（pN──据转移的淋巴结数目分级）和日本的胃癌分期法（JCGC）进行了回顾性的随访研究,对5年生存率进行分析和比较。新的pN分级法（TNMClassification,5thed,1997）：pNO,无区域淋巴结转移;PNI,1～6个淋巴结;pN2,7～15个淋巴结;pN3,大于15个淋巴结;pM1,有远处转移。本组患者均行手术切除：全胃切除153例,近端切除ZI冽,远端切除319例。其中行DZ式淋巴结清扫者414…     

淋巴结转移率对食管胃交界部腺癌患者的预后评估价值

目的 比较AJCC/UICC胃癌淋巴结（pN）分期与淋巴结转移率（MLR）分期及以其为基础的TNM与TRM分期系统对食管胃交界部腺癌患者的预后评估价值.方法 回顾性分析天津市肿瘤医院2000年1月至2007年6月间行根治性切除手术的414例食管胃交界部腺癌的临床资料.采用Spearman相关分析检验 pN、MLR与送检淋巴结数3者之间的相关性;应用单因素KaplanMeier生存分析和多因素Cox回归分析检验pN、MLR、TNM及TRM分期与患者预后的关系;通过ROC曲线下面积（AUC）比较它们对患者5年生存率的预测价值.结果 414例患者中位淋巴结清扫数目17（4～71）枚/例,中位转移淋巴结数目4（0～67）枚/例.阳性淋巴结数与淋巴结清扫数目呈正相关 （P＜0.01）,MLR与淋巴结清扫数目无相关性（P＞0.05）.单因素和多因素预后分析结果表明,pN和MLR均可单独作为食管胃交界部腺癌患者的独立预后因素（均P＜0.01）,且MLR的相对危险度（HR）值高于pN（1.573比1.382）;但当pN与MLR共同纳入多因素分析时,MLR仍是独立预后因素（P＜0.01）,而pN不再是其独立预后因素（P＞0.05）.MLR和pN预测患者预后所对应的AUC分别为0.726和 0.714,TRM分期和TNM分期所对应的AUC分别为0.747和0.736,差异均无统计学意义（均P＞0.05）.结论 MLR是食管胃交界部腺癌患者的独立预后因素,MLR及以其为基础的TRM分期对食管胃交界部腺癌患者预后的评估价值或优于pN及以其为基础的TNM分期.     

Minimum number of lymph nodes that should be examined for the International Union Against Cancer/American Joint Committee on Cancer TNM classification of gastric carcinoma

Abstract The classification of lymph node metastasis based on the number of positive nodes has been adopted in the International Union Against Cancer/American Joint Committee on Cancer (UICC/AJCC) TNM classification of gastric carcinoma. However, the N classification (for condition of the regional lymph nodes) would be underestimated when the number of examined nodes were too small. To determine the minimum number of lymph nodes to examine for a correct classification, we analyzed 926 patients undergoing curative resection for gastric carcinoma. The number of metastatic lymph nodes correlated significantly with the number of examined lymph nodes. The pN0 patients with 10 to 14 examined nodes showed a significantly higher survival rate than did those with 5 to 9 examined nodes, and they had as good a prognosis as those with 15 or more examined nodes. In the pN1 and pN2 categories, patients with 29 or fewer examined nodes tended toward lower survival rates than did patients with 30 or more examined nodes. Among the patients who were classified as stage IA, the survival rate for those with 5 to 9 examined nodes was significantly lower than that for patients with 30 or more examined nodes. Among the patients classified as stage III, those with 10 to 19 examined nodes and those with 20 to 29 examined nodes had lower survival rates than did patients with 30 or more examined nodes. In conclusion, the minimum number of lymph nodes examined for a correct pN0 classification can be reduced from 15 to 10. For pN1–3 classifications, 20 or more nodes should be examined, and examining 30 or more lymph nodes may be desirable. Electronic Publication     

Influence of the number of lymph nodes examined on staging of gastric cancer

BACKGROUND: Nodal staging for gastric cancer according to the 1997 Union Internacional Contra la Cancrum tumour node metastasis classification is based on the number of metastatic lymph nodes. The aim of this study was to evaluate whether the number of lymph nodes examined affected staging of gastric cancer. METHODS: A retrospective study was performed in 4789 consecutive patients with gastric cancer, who had undergone curative resection (R0) from 1986 to 1995. Patients were classified according to the number of nodes examined. The number of metastatic lymph nodes and stage-stratified survival were compared. RESULTS: There were significant differences in the number of metastatic lymph nodes and survival in stage IIIA between patients with 15 or more lymph nodes and those with fewer than 15 nodes. In analysis restricted to patients with 15 or more nodes, stage-stratified survival did not vary significantly with lymph node yields for any stage except IIIB, in which there was a significant difference between the subgroup with fewer than 20 examined lymph nodes and patients with 35 or more nodes. CONCLUSION: The number of lymph nodes examined did not significantly affect node staging of gastric cancer as long as at least 15 nodes were examined. For stage IIIB, more than 15 lymph nodes may be required for optimal staging.     

Accuracy of staging node-negative pancreas cancer: a potential quality measure

OBJECTIVE: To determine the optimal number of lymph nodes to examine for accurate staging of node-negative pancreatic adenocarcinoma after pancreaticoduodenectomy. DESIGN, SETTING, AND PATIENTS: Data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program (1988-2002) were used to identify 3505 patients who underwent pancreaticoduodenectomy for adenocarcinoma of the pancreas, including 1150 patients who were pathologically node negative (pN0) and 584 patients with a single positive node (pN1a). Perioperative deaths were excluded. Univariate and multivariate survival analyses were performed. MAIN OUTCOME MEASURE: Examination of 15 lymph nodes appears to be optimal for accurate staging of node-negative adenocarcinoma of the pancreas after pancreaticoduodenectomy. RESULTS: The number of nodes examined ranged from 1 to 54 (median, 7 examined nodes). Univariate survival analysis demonstrated that dichotomizing the pN0 cohort on 15 or more examined lymph nodes resulted in the most statistically significant survival difference (log-rank chi(2) = 14.49). Kaplan-Meier survival curves demonstrated a median survival difference of 8 months (P < .001) in favor of the patients who had 15 or more examined nodes compared with patients with fewer than 15 examined nodes. Multivariate analysis validated that having 15 or more examined nodes was a statistically significant predictor of survival (hazard ratio, 0.63; 95% confidence interval, 0.49-0.80; P < .0001). Furthermore, a multivariate model based on the survival benefit of each additional node evaluated in the pN0 cohort demonstrated only a marginal survival benefit for analysis of more than 15 nodes. Approximately 90% of the pN1a cohort was identified with examination of 15 nodes. CONCLUSIONS: Examination of 15 lymph nodes appears to be optimal to accurately stage node-negative adenocarcinoma of the pancreas after pancreaticoduodenectomy. Furthermore, evaluation of at least 15 lymph nodes of a pancreaticoduodenectomy specimen may serve as a quality measure in the treatment of pancreatic adenocarcinoma.     

Lymph node staging in gastric cancer: is location more important than Number? An analysis of 1,038 patients

OBJECTIVE: To compare the impact of staging systems on the survival of 1,038 patients with gastric cancer undergoing resection for cure in a North American center. SUMMARY BACKGROUND DATA: In 1997, the American Joint Committee on Cancer (AJCC) and the Union Internationale Contre le Cancer redefined N stage in gastric cancer. The number of involved nodes rather than their location defines N, and a minimum of 15 examined lymph nodes is recommended for adequate staging. In the 1988 AJCC N-staging system, N1 and N2 node metastases were defined as within 3 cm or more than 3 cm of the primary; the 1997 AJCC N stages were defined as N1 = 1 to 6 positive nodes, N2 = 7 to 15 positive nodes, and N3 = more than 15 positive nodes. METHODS: Between 1985 and 1999, 1,038 patients underwent an R0 resection. Median and 5-year survival rates were compared and the Kaplan-Meier method was used to estimate median survival. RESULTS: The location of positive nodes did not significantly affect median survival when analyzed by the number of positive nodes. In contrast, the number of positive lymph nodes had a profound influence on survival. The new N categories served as a better discriminator of median survival when 15 or more nodes were examined. Survival estimates for stages II, IIIA, and IIIB were significantly influenced by examining 15 or more nodes. CONCLUSION: The number of positive nodes best defines the prognostic influence of metastatic lymph nodes in gastric cancer. Survival estimates based on the number of involved nodes are better represented when at least 15 nodes are examined.     

Log Odds of Positive Lymph Nodes (LODDS): What Are Their Role in the Prognostic Assessment of Gastric Adenocarcinoma?

Background

Nodal status is an important prognostic factor for patients with gastric cancer. Log odds of positive nodes (LODDS) (log of the ratio between the number of positive nodes and the number of negative nodes) are a new effective indicator of prognosis. The aim of the study is to evaluate if LODDS are superior to N stage and lymph nodal ratio (LNR).

Methods

Prognostic efficacy of pN, nodal ratio, and LODDS was analyzed and compared in a group of 177 patients with gastric adenocarcinoma who underwent curative gastrectomy.

Results

pT, pN, LNR, and LODDS were all significantly correlated with 5-year survival. Multivariate analyses showed significant values as prognostic factor for pN, LNR, and LODDS. A Pearson test demonstrated no significant correlation between LODDS and retrieved nodes. In patients with less than 15 examined nodes, LODDS classification and pN were significantly correlated with survival, whereas LNR classification was not significantly related.

Conclusions

LODDS are not correlated with the extension of the lymphadenectomy and are able to predict survival even if less than 15 nodes are examined. They permit an effective prognostic stratification of patients with a nodal ratio approaching 0 and 1. Further studies are needed to clarify their role and if they are capable of guaranteeing some advantages over pN and LNR.     

淋巴结转移率对胃癌患者预后的影响

目的 探讨淋巴结转移率(rN)在胃癌患者预后评估中的价值.方法 对比分析319例接受胃癌根治术且清扫的淋巴结总数大于或等于15枚胃癌患者的临床资料,探讨rN与胃癌预后的关系.结果 本研究中将rN按0、<30%、30%～60%及>60%分为4组,各组2年生存率分别为84.4%、66.1%、35.0%、15.1%;3年生存率分别为80.5%、45.0%、15.0%、5.5%;4年生存率分别为71.4%、33.0%、5.0%、1.4%,差异均有统计学意义(P<0.05),与预后有良好的一致性.将同一pN分期组与rN分组比较,各组预后之间的差异均无统计学意义.COX多因素分析结果显示rN是影响胃癌预后的独立指标,其与肿瘤浸润深度、手术方式及肿瘤部位有相关性.结论 rN分级可更好地指导胃癌的治疗和预后判断,有助于完善胃癌的TNM分期体系.