Journal of Gastric Cancer

The Korean Gastric Cancer Association (대한위암학회)
권호 표지
DOI QR코드

DOI QR Code

The Prognostic Value of Lymph Node Ratio after Neoadjuvant Chemotherapy in Patients with Locally Advanced Gastric Adenocarcinoma

  • Zhu, Kankai (Department of Gastrointestinal Surgery, The First Affiliated Hospital Zhejiang University School of Medicine) ;
  • Jin, Hailong (Department of Gastrointestinal Surgery, The First Affiliated Hospital Zhejiang University School of Medicine) ;
  • Li, Zhijian (Department of Gastrointestinal Surgery, The First Affiliated Hospital Zhejiang University School of Medicine) ;
  • Gao, Yuan (Department of Gastrointestinal Surgery, The First Affiliated Hospital Zhejiang University School of Medicine) ;
  • Zhang, Qing (Department of Gastrointestinal Surgery, The First Affiliated Hospital Zhejiang University School of Medicine) ;
  • Liu, Xiaosun (Department of Gastrointestinal Surgery, The First Affiliated Hospital Zhejiang University School of Medicine) ;
  • Yu, Jiren (Department of Gastrointestinal Surgery, The First Affiliated Hospital Zhejiang University School of Medicine)
  • Received : 2020.09.06
  • Accepted : 2021.02.21
  • Published : 2021.03.31
Download PDF
⟨ Previous Next ⟩

Abstract

Purpose: This study aimed to investigate the prognostic value of lymph node ratio (LNR) in patients with locally advanced gastric cancer who received neoadjuvant chemotherapy. Materials and Methods: We retrospectively enrolled gastric cancer patients treated with neoadjuvant chemotherapy and curative surgery at the First Affiliated Hospital of Zhejiang University from 2004 to 2015 as the study cohort. Patients with the same inclusion criteria treated in 2016-2017 were enrolled as the validation cohort. Kaplan-Meier curves were assessed using the log-rank test to analyze the differences in overall survival (OS). Multivariate survival analysis was performed using the Cox proportional hazards model. The areas under the receiver operating characteristic curve of ypN and LNR categories for predicting the actual 3-year OS were compared. Results: A total of 265 patients were included in the proposal cohort. The median number of retrieved lymph nodes (rLNs) was 32. The number of positive lymph nodes (pLNs) increased as rLN increased (P=0.037), but the LNR remained relatively constant (P=0.462). The LNR was categorized into 4 groups according to the prognosis: ypNr0, node-negative with rLN>25; ypNr1, node-negative with rLN≤25 or 00.3. In the validation cohort of 43 enrolled patients, there was a clear distinction in OS that significantly (P<0.001) varied depending on the LNR values and LNR was the only independent prognostic factor in multivariate analysis (P<0.001). Conclusions: LNR was an independent prognostic factor for survival of patients with gastric cancer after preoperative chemotherapy and might be an alternative predictor for ypN stage.

Keywords

References

  1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424. https://doi.org/10.3322/caac.21492
  2. Cunningham D, Allum WH, Stenning SP, Thompson JN, Van de Velde CJ, Nicolson M, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 2006;355:11-20. https://doi.org/10.1056/NEJMoa055531
  3. Al-Batran SE, Homann N, Pauligk C, Goetze TO, Meiler J, Kasper S, et al. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet 2019;393:1948-1957. https://doi.org/10.1016/S0140-6736(18)32557-1
  4. Amin MB, Edge S, Greene F, Byrd DR, Brookland RK, Washington MK, et al. AJCC Cancer Staging Manual. 8th ed. New York: Springer; 2016.
  5. Schmidt T, Sicic L, Blank S, Becker K, Weichert W, Bruckner T, et al. Prognostic value of histopathological regression in 850 neoadjuvantly treated oesophagogastric adenocarcinomas. Br J Cancer 2014;110:1712-1720. https://doi.org/10.1038/bjc.2014.94
  6. Pedrazzani C, Sivins A, Ancans G, Marrelli D, Corso G, Krumins V, et al. Ratio between metastatic and examined lymph nodes (N ratio) may have low clinical utility in gastric cancer patients treated by limited lymphadenectomy: results from a single-center experience of 526 patients. World J Surg 2010;34:85-91. https://doi.org/10.1007/s00268-009-0288-8
  7. Kong SH, Lee HJ, Ahn HS, Kim JW, Kim WH, Lee KU, et al. Stage migration effect on survival in gastric cancer surgery with extended lymphadenectomy: the reappraisal of positive lymph node ratio as a proper N-staging. Ann Surg 2012;255:50-58. https://doi.org/10.1097/SLA.0b013e31821d4d75
  8. Wang J, Dang P, Raut CP, Pandalai PK, Maduekwe UN, Rattner DW, et al. Comparison of a lymph node ratio-based staging system with the 7th AJCC system for gastric cancer: analysis of 18,043 patients from the SEER database. Ann Surg 2012;255:478-485. https://doi.org/10.1097/SLA.0b013e31824857e2
  9. Rawicz-Pruszynski K, Cisel B, Mlak R, Mielko J, Skórzewska M, Kwietniewska M, et al. The role of the lymph node ratio in advanced gastric cancer after neoadjuvant chemotherapy. Cancers (Basel) 2019;11:1914. https://doi.org/10.3390/cancers11121914
  10. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer 2011;14:113-123. https://doi.org/10.1007/s10120-011-0042-4
  11. Zhang H, Shang X, Chen C, Gao Y, Xiao X, Tang P, et al. Lymph node ratio-based staging system as an alternative to the current TNM staging system to assess outcome in adenocarcinoma of the esophagogastric junction after surgical resection. Oncotarget 2016;7:74337-74349. https://doi.org/10.18632/oncotarget.11188
  12. Zhu J, Xue Z, Zhang S, Guo X, Zhai L, Shang S, et al. Integrated analysis of the prognostic role of the lymph node ratio in node-positive gastric cancer: a meta-analysis. Int J Surg 2018;57:76-83. https://doi.org/10.1016/j.ijsu.2018.08.002
  13. Agnes A, Biondi A, Cananzi FM, Rausei S, Reddavid R, Laterza V, et al. 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. J Surg Oncol 2019;119:948-957. https://doi.org/10.1002/jso.25411
  14. Li Z, Li S, Bu Z, Zhang L, Wu X, Shan F, et al. The effect of preoperative treatments on lymph node counts after total gastrectomy in esophagogastric adenocarcinoma. J Surg Oncol 2018;118:657-663. https://doi.org/10.1002/jso.25188
  15. Woo Y, Goldner B, Ituarte P, Lee B, Melstrom L, Son T, et al. Lymphadnectomy with optimum of 19 lymph nodes retrieved associated with improve survival in advanced gastric cacner: a 25,000-patient international database study. J Am Coll Surg 2017;224:546-555. https://doi.org/10.1016/j.jamcollsurg.2016.12.015
  16. Liu YY, Fang WL, Wang F, Hsu JT, Tsai CY, Liu KH, et al. Does a higher cutoff value of lymph node retrieval substantially improve survival in patients with advanced gastric cancer?-Time to embrace a new digit. Oncologist 2017;22:97-106. https://doi.org/10.1634/theoncologist.2016-0239
  17. Hou Y, Wang X, Chen J. Prognostic significance of metastatic lymph node ratio: the lymph node ratio could be a prognostic indicator for patients with gastric cancer. World J Surg Oncol 2018;16:198. https://doi.org/10.1186/s12957-018-1504-5
  18. Wohnrath DR, Araujo RL. Positive node-ratio in curative-intent treatment for gastric cancer is a strong independent prognostic factor for 5-year overall survival. J Surg Oncol 2020;121:777-783. https://doi.org/10.1002/jso.25755
  19. Chu X, Yang ZF. Impact on survival of the number of lymph nodes resected in patients with lymph node-negative gastric cancer. World J Surg Oncol 2015;13:192. https://doi.org/10.1186/s12957-015-0602-x
  20. Hsu JT, Lin CJ, Sung CM, Yeh HC, Chen TH, Chen TC, et al. Prognostic significance of the number of examined lymph nodes in node-negative gastric adenocarcinoma. Eur J Surg Oncol 2013;39:1287-1293. https://doi.org/10.1016/j.ejso.2013.07.183
  21. Kulig J, Sierzega M, Kolodziejczyk P, Popiela T; Polish Gastric Cancer Study Group. Ratio of metastatic to resected lymph nodes for prediction of survival in patients with inadequately staged gastric cancer. Br J Surg 2009;96:910-918. https://doi.org/10.1002/bjs.6653
  22. Marchet A, Mocellin S, Ambrosi A, Morgagni P, Garcea D, Marrelli D, et al. The ratio between metastatic and examined lymph nodes (N ratio) is an independent prognostic factor in gastric cancer regardless of the type of lymphadenectomy: results from an Italian multicentric study in 1853 patients. Ann Surg 2007;245:543-552. https://doi.org/10.1097/01.sla.0000250423.43436.e1
  23. Alatengbaolide LD, Lin D, Li Y, Xu H, Chen J, Wang B, et al. Lymph node ratio is an independent prognostic factor in gastric cancer after curative resection (R0) regardless of the examined number of lymph nodes. Am J Clin Oncol 2013;36:325-330. https://doi.org/10.1097/COC.0b013e318246b4e9
  24. Komatsu S, Ichikawa D, Nishimura M, Kosuga T, Okamoto K, Konishi H, et al. Evaluation of prognostic value and stage migration effect using positive lymph node ratio in gastric cancer. Eur J Surg Oncol 2017;43:203-209. https://doi.org/10.1016/j.ejso.2016.08.002

Cited by

  1. Lymph Node Ratio System for N Staging of Gastric Cancer: Challenging for Universal Application But Useful for the Prognostic Prediction of Individual Patients vol.21, pp.1, 2021, https://doi.org/10.5230/jgc.2021.21.e10