Development and validation of a nomogram for predicting survival on the base of modified lymph node ratio in breast cancer patients |
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| Affiliation: | 1. Department of Breast Oncology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China;2. Department of Obstetrics and Gynecology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China;3. Department of Breast Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China;11. Unidad de Investigación, Hospital Galdakao-Usansolo, Galdakao-Bizkaia/Red de Investigación en Servicios de Salud en Enfermedades Crónicas, REDISSEC, Spain;12. Epidemiologia Clínica y Cribado de Cancer, Corporació Sanitaria Parc Taulí, Sabadell/Red de Investigación en Servicios de Salud en Enfermedades Crónicas, REDISSEC, Spain;13. Servicio de Laboratorio. Hospital Costa del Sol, Málaga/REDISSEC, Spain;14. Unidad de Epidemiología. Distrito Sevilla, Servicio Andaluz de Salud, Spain;15. Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid/REDISSEC, Spain;p. Unidad de Investigación, Hospital Universitario Donostia/Instituto de Investigación Sanitaria Biodonostia, Donostia, REDISSEC, Spain;q. Unidad de Investigación, Hospital Universitario Basurto, Bilbao/REDISSEC, Spain;r. Servicio de Epidemiología, Hospital Costa del Sol, Málaga – REDISSEC, Spain;s. Department of Preventive Medicine and Public Health, Univesity of Valencia/CIBER de Epidemiología y Salud Pública (CIBERESP)/CSISP-FISABIO, Valencia, Spain;t. Unidad de Evaluación de Tecnologías Sanitarias, Agencia Laín Entralgo, Madrid, Spain;u. Unidad Apoyo a Docencia-Investigación. Dirección Técnica Docencia e Investigación, Gerencia Adjunta Planificación, Gerencia de Atención Primaria de la Consejería de Sanidad de la Comunidad Autónoma de Madrid, Spain;v. Departamento de Matemática Aplicada, Estadística e Investigación Operativa, UPVe REDISSEC, Spain;w. Epidemiologia Clínica y Cribado de Cancer, Corporació Sanitaria Parc Taulí, Sabadell/REDISSEC, Spain;x. Servicio de Oncología. Hospital Universitario Basurto, Bilbao, Spain;y. Servicio de Cirugía General. Hospital Universitario Basurto, Bilbao, Spain;z. Servicio de Anatomía Patológica, Hospital Galdakao-Usansolo, Galdakao, Spain;11. Servicio de Cirugía General, Hospital Universitario Araba, Vitoria-Gasteiz, Spain;12. Servicio de Gastroenterología, Hospital Universitario de Canarias, La Laguna, Spain;13. Servicio de Cirugía General, Hospital Galdakao-Usansolo, Galdakao, Spain;14. IMAS-Hospital del Mar, Barcelona, Spain;15. Servicio de Cirugía General y Digestiva. Hospital Universitario Donostia, Spain;16. Instituto de Investigación Sanitaria Biodonostia, Donostia, Spain;17. Servicio de Cirugía General y Digestiva, Hospital de Mendaro, Spain;18. Servicio de Cirugía General y Digestiva, Hospital de Zumárraga, Spain;19. Servicio de Cirugía General y Digestiva, Hospital del Bidasoa, Spain;110. Servicio de Oncología Médica. Hospital Universitario Donostia, Spain;111. Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío, Sevilla, Spain;112. Servicio de Cirugía. Hospital Universitario Virgen de Valme, Sevilla, Spain;113. Servicio de Cirugía General y Aparato Digestivo, Hospital Dr. Pesset, Valencia, Spain;114. Servicio de Cirugía General y Aparato Digestivo. Agencia Sanitaria Costa del Sol, Marbella, Spain;115. Servicio de Oncología Médica, Agencia Sanitaria Costa del Sol, Marbella, Spain;1p. Servicio de Cirugía, Hospital de Antequera, Spain;1q. Coloproctology Unit, General and Digestive Surgery Service, Corporació Sanitaria Parc Taulí, Sabadell, Spain;1r. Digestive Diseases Department, Corporació Sanitaria Parc Taulí, Sabadell, Spain;1s. Pathology Service, Corporació Sanitaria Parc Taulí, Sabadell, Spain;1t. Medical Oncology Department, Corporació Sanitaria Parc Taulí, Sabadell/REDISSEC, Spain;1u. General and Digestive Surgery Service, Parc de Salut Mar, Barcelona, Spain;1v. General and Digestive Surgery Service, Althaia- Xarxa Assistencial Universitaria, Manresa, Spain;1w. Catalonian Cancer Strategy Unit, Department of Health, Institut Català d’Oncología, Spain;1x. Medical Oncology Department, Institut Català d’Oncología, Spain;1y. Agency for Health Quality and Assessment of Catalonia –AquAS- and REDISSEC, Spain;1z. Agency for Health Quality and Assessment of Catalonia –AQuAS, CIBER de Epidemiología y Salud Pública eCIBERESP, Spain;21. Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Fundación Alcorcón, Madrid, Spain;22. Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Clínico San Carlos, Madrid, Spain;23. Servicio Cirugía General y del Aparato Digestivo, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain;24. Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario La Paz, Madrid, Spain;25. REDISSEC. Unidad de Apoyo a la Investigación, Gerencia Asistencial de Atención Primaria de la Comunidad de Madrid, Madrid, Spain;26. REDISSEC. Unidad de Gestión Sanitaria, Hospital del Alto Deba, Mondragon-Arrasate, Spain;1. Unidad de Investigación, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain;2. Servicio de Cirugía General, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain;3. Unidad de Epidemiología Clínica, Corporació Parc Taulí, Sabadell, Barcelona, Spain;4. Centro Nacional de Epidemiología, ISCIII, Madrid, Spain;5. Unidad de Investigación, Hospital Costa del Sol, Málaga, Spain;6. Unidad de Epidemiología. Distrito Sanitario Sevilla, Sevilla, Spain;7. Unidad de Investigación, Hospital U. Basurto, Bilbao, Bizkaia, Spain;8. Unidad de Investigación, Hospital U. Donostia/BIODONOSTIA, Donostia-San Sebastian, Gipuzkoa, Spain;9. Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC);10. CIBER Epidemiología y Salud Pública (CIBERESP);1. General Surgery and Hepato-pancreato-biliary Unit, Sapienza University of Rome, Sant’Andrea Hospital, Rome, Italy;2. General Surgery and Transpantation Unit, University of Bologna, Policlinico Sant’Orsola Malpighi, Bologna, Italy;3. General Surgery Unit, Ospedale Maggiore di Bologna, Italy;4. General Surgery Unit, Policlinico Sant’Orsola Malpighi, Bologna, Italy;5. Hepato-pancreato-biliary Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy;6. General Surgery Unit, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy;7. Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy;8. Department of General Surgery and Transplantation, Niguarda Ca'' Granda Hospital, Milan, Italy;9. Transplantation Unit, University of Tor Vergata, Policlinico Tor Vergata, Roma, Italy;10. General Surgery and Transplantation Unit, University of Pisa, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy;1. Center for Fire, Rescue, and EMS Health Research, Institute for Biobehavioral Health Research, National Development and Research Institutes, Leawood, KS, USA;2. University of Texas Health Science Center at Houston, Houston, TX, USA;1. Department of Radiation Oncology, Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, South Korea;2. Department of Radiation Oncology, Chungnam National University Hospital, Munhwaro 282, Jungku, Daejeon, South Korea;3. Department of Radiation Oncology, Ewha Womans University School of Medicine, Anyangcheon-ro, Yangcheon-gu, Seoul, South Korea;4. Department of Surgery, Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, South Korea;5. Department of Internal Medicine, Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, South Korea |
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| Abstract: | BackgroundAxillary lymph node status is one of the most important prognostic factors in breast cancer and previous studies indicated that lymph node ratio (LNR) could better predict the outcome than the counting of positive lymph nodes. In the current study, we evaluated the prognostic effect of modified LNR in breast cancer patients.MethodsA total of 3339 breast cancer patients undergoing axillary lymph nodes dissection were enrolled and respectively analyzed. Seventy five percent of participants were randomly selected as training cohort and the remaining 25% were as validation cohort. Univariate and multivariate analyses were performed and the prognostic impact of mLNR was compared with pN staging. A prognostic nomogram was established and externally validated in the validation cohort.ResultIn multivariate analysis, both the mLNR and pN staging were independent prognostic factors for breast cancer patients, and the mLNR manifested superior discrimination power than the pN stages regardless of the total number of lymph nodes retrieved and the lymph node status. The nomogram was built including the identified independent prognostic factors and the calibration curves indicated optimal agreement between nomogram prediction and actual observation. The Concordance index (C-index) of the nomogram was statistically higher than that of the TNM system (0.747 vs. 0.711 in training cohort, 0.789 vs. 0.760 in validation cohort, both p < 0.05).ConclusionModified LNR is an important prognostic parameter and can predict survival more accurately than pN staging. The novel nomogram could provide individual prediction for breast cancer patients and help clinicians in treatment option making and prognosis evaluation. |
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| Keywords: | Modified lymph node ratio Breast cancer Prognosis Nomogram LN" },{" #name" :" keyword" ," $" :{" id" :" kwrd0035" }," $$" :[{" #name" :" text" ," _" :" lymph nodes LNR" },{" #name" :" keyword" ," $" :{" id" :" kwrd0045" }," $$" :[{" #name" :" text" ," _" :" lymph node ratio mLNR" },{" #name" :" keyword" ," $" :{" id" :" kwrd0055" }," $$" :[{" #name" :" text" ," _" :" modified lymph node ratio pN" },{" #name" :" keyword" ," $" :{" id" :" kwrd0065" }," $$" :[{" #name" :" text" ," _" :" pathologic positive lymph node C-index" },{" #name" :" keyword" ," $" :{" id" :" kwrd0075" }," $$" :[{" #name" :" text" ," _" :" Concordance index ALND" },{" #name" :" keyword" ," $" :{" id" :" kwrd0085" }," $$" :[{" #name" :" text" ," _" :" axillary lymph node dissection IDC" },{" #name" :" keyword" ," $" :{" id" :" kwrd0095" }," $$" :[{" #name" :" text" ," _" :" invasive ductal carcinoma ILC" },{" #name" :" keyword" ," $" :{" id" :" kwrd0105" }," $$" :[{" #name" :" text" ," _" :" invasive lobular carcinoma ER" },{" #name" :" keyword" ," $" :{" id" :" kwrd0115" }," $$" :[{" #name" :" text" ," _" :" Estrogen receptor PR" },{" #name" :" keyword" ," $" :{" id" :" kwrd0125" }," $$" :[{" #name" :" text" ," _" :" Progesterone receptor HER-2" },{" #name" :" keyword" ," $" :{" id" :" kwrd0135" }," $$" :[{" #name" :" text" ," _" :" human epithelial growth factor receptor-2 CSS" },{" #name" :" keyword" ," $" :{" id" :" kwrd0145" }," $$" :[{" #name" :" text" ," _" :" cancer-specific survival CIs" },{" #name" :" keyword" ," $" :{" id" :" kwrd0155" }," $$" :[{" #name" :" text" ," _" :" confidence intervals AIC" },{" #name" :" keyword" ," $" :{" id" :" kwrd0165" }," $$" :[{" #name" :" text" ," _" :" Akaike's information criterion LR chi2" },{" #name" :" keyword" ," $" :{" id" :" kwrd0175" }," $$" :[{" #name" :" text" ," _" :" Likelihood ratio chi-square AUC" },{" #name" :" keyword" ," $" :{" id" :" kwrd0185" }," $$" :[{" #name" :" text" ," _" :" area under curve HR" },{" #name" :" keyword" ," $" :{" id" :" kwrd0195" }," $$" :[{" #name" :" text" ," _" :" hazard ratio |
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