The Lymph Node Ratio Optimizes Staging in Patients with Small Intestinal Neuroendocrine Tumors

Background: The effectiveness of the current Tumor, Lymph node, Metastases (TNM) staging system in small intestinal neuroendocrine tumors (SiNETs) is unsatisfactory. Current N classification only distinguishes between node-negative and node-positive status. We aim to refine the N classification for updated TNM stage. Methods: During the period from 1988 to 2012, patients with non-metastatic SiNETs were enrolled in the Surveillance, Epidemiology, and End Results database. Using the X-tile program, we calculated an optimal cutoff value for lymph node ratio (LNR) and proposed a novel Nr category. Survival outcomes were estimated using the Kaplan-Meier method and Cox regression model. Adjusted hazard ratio (HR) and cluster analysis were performed to differentiate TNrM stages. Results: Patients with existing TNM stage I and II had equivalent survival prognosis (p = 0.214). Current N classification was not a significant predictor of patient survival (p = 0.372). Multivariate analyses identified the revised Nr classification, based on LNR of 0.6 optimal cutoff value, as an independent prognostic factor (p = 0.020). By incorporating the Nr classification, a revised TNrM, which categorized patients into 3 new stages was proposed: stage I (T1–2Nr0–1), stage II (T3Nr0–1), and stage III (TxNr2 or T4Nrx). TNrM stage had better stratification according to the survival outcome (primary cohort: stage I: reference, II: HR 3.852, 95% CI 1.731–8.575; III: HR 7.169, 95% CI 3.220–15.963, p < 0.001; validation cohort: stage I: reference, II: HR 2.034; III: HR 3.815; p < 0.001). Conclusions: The Nr classification more accurately stratifies SiNET patients than current N classification. The new TNrM staging system could improve the ability to predict survival outcome of SiNET patients.

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The Lymph Node Ratio Optimizes Staging System while Adjuvant Chemotherapy Plays an Invalid Role for Patients with Nonmetastatic Colorectal Neuroendocrine Carcinomas: A Propensity Score Matching Analysis of Patients from the Surveillance, Epidemiology, and End-Results Database

10.21203/rs.3.rs-682298/v1 ◽

2021 ◽

Author(s):

Xiaoxiao Chen ◽

Hongjuan Zheng ◽

Xia Zhang ◽

Wanfen Tang ◽

Shishi Zhou ◽

...

Keyword(s):

Lymph Node ◽

Adjuvant Chemotherapy ◽

Propensity Score ◽

Survival Benefit ◽

Lymph Node Ratio ◽

Cutoff Value ◽

Survival Difference ◽

N Classification ◽

Node Ratio ◽

End Results

Abstract Objective: Colorectal neuroendocrine carcinoma (CRNEC) is rare and little is known about survival benefit between lymph node ratio (LNR) and improved overall survival (OS), and so is the adjuvant chemotherapy (AC). We aim to evaluate the survival benefit of LNR and AC in patients with nonmetastatic CRNEC following resection. Methods: Patients with resected nonmetastatic CRNECs were identified in Surveillance, Epidemiology, and End Results (SEER) during year 1992 to 2016. A Log-rank test was conducted to determine the survival difference. The survival benefit was evaluated using a competing-risks regression model and propensity score-matched (PSM) techniques were used to reduce the selection bias.Results: A total of 251 patients met the inclusion criteria, of which, 152 patients (60.56%) received AC. The age of 60 (P=0.848) and number of 12 of resected regional lymph nodes (P=0.082) acted as an optimal cutoff value in terms of survival, failing to reach a significance. Chemotherapy failed to bring survival benefit (hazard ratio [HR], 0.959; 95% confidence interval [CI], 0.649-1.416; P=0.832). Current N classification was not a significant predictor of patient survival (N1: P = 0.174; N2: P=0.028, compared to N0, respectively). Multivariate analyses explored the revised Nr classification, based on LNR of 0.30 and 0.75 as cutoff value (Nr0: LNR£0.30; Nr1: 0.3<LNR£0.75; Nr2: LNR >0.75), as an independent prognostic factor (Nr1: P = 0. 003; Nr2: P<0.001, compared to Nr0, respectively). With the foundation of revised Nr classification, a revised TNrM was proposed for nonmetastatic CRNEC: stage I (T1–2Nr0), stage II (T1-2Nr1 or T3Nr0–1 or T4Nr0), and stage III (TxNr2 or T4Nr1). TNrM stage had better stratification according to Kaplan-Meier survival curves (P <0.001). Conclusions: AC seems invalid for improving the survival of patients with nonmetastatic CRNECs following resection. The LNR more accurately predict survival of CRNEC patients than current N classification.

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Positive lymph node ratio is an index in predicting prognosis for remnant gastric cancer with insufficient retrieved lymph node in R0 resection

Scientific Reports ◽

10.1038/s41598-021-81663-0 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Honghu Wang ◽

Hao Qi ◽

Xiaofang Liu ◽

Ziming Gao ◽

Iko Hidasa ◽

...

Keyword(s):

Gastric Cancer ◽

Lymph Node ◽

Lymph Nodes ◽

Lymph Node Ratio ◽

Prognostic Index ◽

Staging System ◽

R0 Resection ◽

Remnant Gastric Cancer ◽

Curative Intent ◽

Node Ratio

AbstractThe staging system of remnant gastric cancer (RGC) has not yet been established, with the current staging being based on the guidelines for primary gastric cancer. Often, surgeries for RGC fail to achieve the > 15 lymph nodes needed for TNM staging. Compared with the pN staging system, lymph node ratio (NR) may be more accurate for RGC staging and prognosis prediction. We retrospectively analyzed the data of 208 patients who underwent R0 gastrectomy with curative intent and who have ≤ 15 retrieved lymph nodes (RLNs) for RGC between 2000 and 2014. The patients were divided into four groups on the basis of the NR cutoffs: rN0: 0; rN1: > 0 and ≤ 1/6; rN2: > 1/6 and ≤ 1/2; and rN3: > 1/2. The 5-year overall survival (OS) rates for rN0, rN1, rN2, and rN3 were 84.3%, 64.7%, 31.5%, and 12.7%, respectively. Multivariable analyses revealed that tumor size (p = 0.005), lymphovascular invasion (p = 0.023), and NR (p < 0.001), but not pN stage (p = 0.682), were independent factors for OS. When the RLN count is ≤ 15, the NR is superior to pN as an important and independent prognostic index of RGC, thus predicting the prognosis of RGC patients more accurately.

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Metastatic Lymph Node Ratio: A New Staging System for Gastric Cancer

World Journal of Surgery ◽

10.1007/s00268-009-0157-5 ◽

2009 ◽

Vol 33 (10) ◽

pp. 2106-2111 ◽

Cited By ~ 21

Author(s):

Roberto Persiani ◽

Stefano Rausei ◽

Vincenzo Antonacci ◽

Alberto Biondi ◽

Francesco Casella ◽

...

Keyword(s):

Gastric Cancer ◽

Lymph Node ◽

Lymph Node Ratio ◽

Metastatic Lymph Node ◽

Staging System ◽

Metastatic Lymph ◽

Node Ratio

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Comparison of prognostic prediction between nomogram based on lymph node ratio and AJCC 8th staging system for patients with resected pancreatic head carcinoma: a SEER analysis

Cancer Management and Research ◽

10.2147/cmar.s157940 ◽

2018 ◽

Vol Volume 10 ◽

pp. 227-238 ◽

Cited By ~ 14

Author(s):

Ning Pu ◽

Jianang Li ◽

Yaolin Xu ◽

Wanling Lee ◽

Yuan Fang ◽

...

Keyword(s):

Lymph Node ◽

Lymph Node Ratio ◽

Pancreatic Head ◽

Staging System ◽

Node Ratio ◽

Pancreatic Head Carcinoma ◽

Prognostic Prediction

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A novel simplified approach to incorporating lymph node ratio into gastric cancer staging.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.4_suppl.24 ◽

2013 ◽

Vol 31 (4_suppl) ◽

pp. 24-24

Author(s):

Sarah B. Fisher ◽

Malcolm Hart Squires ◽

Sameer H. Patel ◽

David A. Kooby ◽

Kenneth Cardona ◽

...

Keyword(s):

Gastric Cancer ◽

Lymph Node ◽

Lymph Node Ratio ◽

Staging System ◽

Cancer Staging ◽

Lymph Node Staging ◽

Cox Regression Analysis ◽

Simplified Approach ◽

Staging Systems ◽

Node Ratio

24 Background: Previous investigators have reported on the value of lymph node ratio (LNR, defined as the number of positive nodes divided by the total number of nodes assessed) in gastric adenocarcinoma (GAC) staging. Given the complexity of previously proposed staging systems, it has not gained widespread acceptance. The aim of our study was to offer a novel simplified approach to incorporating LNR into gastric cancer staging. Methods: 131 patients who underwent curative intent resection with lymphadenectomy for GAC between 1/00-6/11 were identified. Clinicopathologic factors were assessed. Primary outcome was overall survival (OS). Results: Median age was 64 yrs, 51% were male. Median tumor size was 3.5 cm, 67% were poorly differentiated, 20% had perineural invasion, 31% had lymphovascular invasion, and 6% had a positive margin. Locoregional nodal metastases were present in 59% (n=77, N0: 41%, N1: 18%, N2: 22%, N3a: 14%, N3b: 5%). Median number of lymph nodes (LN) assessed was 15.5. Mean FU was 27.3 mos, median OS was 29.3 mos. Median LNR was 0.4 (.04-1). Patients with LNR ≥0.4 had decreased OS as compared to patients with LNR <0.4 (15.1 vs 41.5 mos, p<0.0001); the survival of patients with LNR <0.4 was similar to that of node negative pts (48 mos, p=0.882). On Cox regression analysis, LNR ≥0.4 was more strongly associated with decreased OS (HR 3.09, 95%CI: 1.81-5.26; p<0.0001) compared to the AJCC 7th edition N stage (HR 1.36, 95%CI: 1.11-1.68; p=0.004). In the subset of patients who were inadequately staged and had <16 nodes examined, a LNR ≥0.4 was associated with reduced survival compared to a LNR <0.4 (17.3 vs 41.5 mos, p=.04). Conclusions: Compared to the current lymph node staging system, a lymph node ratio using 0.4 as the cutoff may more accurately predict survival outcomes. It seems to be particularly useful in patients who have inadequate nodal assessment. This simplified approach to lymph node ratio may be a more valuable staging tool than the current AJCC nodal staging system for gastric cancer and needs to be validated.

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