Lymph Node Ratio: Role in the Staging of Node-Positive Colon Cancer

Department of Surgery, University at Buffalo, State University of New York, Buffalo, New York, USA.
Annals of Surgical Oncology (Impact Factor: 3.93). 07/2008; 15(6):1600-8. DOI: 10.1245/s10434-007-9716-x
Source: PubMed


Recent literature has shown that lymph node ratio (LNR) is superior to the number of positive lymph nodes (pLNs) in predicting the prognosis in several malignances other than colon cancer. We hypothesize that LNR may play a similar role in stage III colon cancer.
We included 24,477 stage III colon cancer cases from the Surveillance, Epidemiology, and End Results cancer registry. Patients were categorized into four groups, LNR1 to 4, according to cutoff points 1/14, 0.25, and 0.50. Kaplan-Meier and Cox proportional hazard model were used to evaluate the prognostic effect and estimate the relative risk (RR) and 95% confidence interval (CI) of LNR.
The 5-year survival for patients with stage IIIA, IIIB, and IIIC was 71.3%, 51.7%, and 34.0%, respectively (P < .0001). There was no survival difference among LNR1 to LNR4 for stage IIIA patients. In stage IIIB patients, the 5-year survival for those with LNR1 to LNR4 was 63.5%, 54.7%, 44.4%, and 34.2%, respectively (P < .0001). In stage IIIC patients, the 5-year survival for those with LNR2 to LNR4 was 49.6%, 41.7%, and 25.2%, respectively (P < .0001). LNR is an independent predictor of survival after adjusting patient's age, tumor size, tumor grade, race, number of pLNs, and total number of LNs harvested. (RR 2.30, 95% CI 2.08-2.55).
Patients with stage IIIB and IIIC colon cancer represent a heterogeneous group of patients with the majority either overstaged or understaged. LNR is a more accurate prognostic method for stage III colon cancer patients. We propose an algorithm to incorporate LNR into current AJCC staging system.

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    • "There were several limitations in this study. Firstly, the current study did not consider the regional lymph node ratio which was identified as one of the major prognostic factors in longitudinal studies [4,33-35]. Secondly, rates of all-cause mortality and recurrence reported in current study may be higher than those in other studies conducted in Chinese population [36,37], especially in studies of CRC patients undergoing curative open or laparoscopic resections. Patients in current study were recruited at specialist outpatient clinic where they were followed up at one year after diagnosis rather than a short period away from diagnosis or surgery. "
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    ABSTRACT: Background The study aimed to examine the association between health-related quality of life (HRQOL) assessed with overall survival (OS) and recurrence after diagnosis of colorectal cancer (CRC). Methods Overall 160 patients with advanced stage CRC were recruited in an observational study and completed the generic and condition-specific HRQOL questionnaires at the colorectal specialist outpatient clinic in Hong Kong, between 10/2009 and 07/2010. Socio-demographic and clinical characteristics including duration since diagnosis, primary tumor location and treatment modality, were collected to serve as predictor variables in regression models. All-cause death or CRC recurrence was the event of interest. Association between HRQOL with OS was assessed using Cox regression. Association between HRQOL and CRC recurrence was further modeled by competing-risks regression adjusted for the competing-risks of death from any cause. Results After a median follow-up of 23 months, there were 22 (16.1%) incidents of CRC recurrence and 15 (9.4%) deaths. Decreased physical functioning (hazard ratios, HR = 0.917, 95% CI:0.889-0.981) and general health of domains in SF-12 (HR = 0.846, 95% CI:0.746-0.958) or SF-6D scores (HR = 0.010, 95% CI:0.000-0.573) were associated with an increased risk of death, with adjustment of patients’ characteristics. Increased vitality (HR = 1.151, 95% CI:1.027-1.289) and mental health (HR = 1.128, 95% CI:1.005-1.265) were associated with an increased likelihood of death. In models adjusted for competing-risk of death, those with worse HRQOL was not associated with increased risk of CRC recurrence. Conclusions Although self-reported HRQOL was not a significant prognostic factor for CRC recurrence, the HRQOL provided independent prognostic value about mortality in patients with advanced stage of CRC.
    Full-text · Article · May 2014 · BMC Cancer
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    • "The LNR has been demonstrated to have prognostic value in colon cancer in various studies (33–35). Data for rectal cancer were limited but Rosenberg et al reported that, following subgroup analysis, the LNR was an independent prognostic factor for cause-specific survival in patients with rectal cancer (36). "
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    ABSTRACT: Lymph node status is the most significant prognostic factor of colorectal cancer. However, there is a risk of disease understaging if the extent of lymph node assessment is sub-optimal. Preoperative C-reactive protein (CRP) is known to be a useful tool in predicting postoperative outcomes in patients with colorectal cancer. We retrospectively evaluated whether CRP adds to prognosis information in stage I-III colorectal cancer patients with poor lymph node assessment. In stages I-III, multivariate analysis revealed that CRP-positive status and advanced T-stage were factors that independently affected survival. In stage III, univariate analysis revealed that lymph node number retrieval and lymph node ratio were factors that affected survival. However, CRP positivity was the only independent factor for survival. CRP positivity did not predict poor prognosis in stage II or III patients with adequate lymph node retrieval. By contrast, the prognosis of CRP-positive patients was poorer than that of CRP-negative patients in stage II and III, with inadequate lymph node retrieval. CRP is an independent prognostic marker in patients with stage I-III, II or III colorectal cancer. The evaluation of CRP may provide useful information on prognosis in curative patients with an inadequate examination of lymph nodes.
    Full-text · Article · Jun 2013 · Oncology letters
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    • "This figure seems to be superior to the absolute number of metastatic lymph nodes in predicting the prognosis and to be useful in reducing stage migration in types of solid cancers such as cancers of the stomach [8-10], breast [11], bladder [12], pancreas [13], and lung [14]. Many clinical studies on colorectal cancer patients have been performed to investigate the significance of the LNR as a prognostic factor [13, 15-20]. However, the clinical significance of the LNR in rectal cancer patients' survival is still controversial. "
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    ABSTRACT: Lymph-node metastasis is the most important predictor of survival in stage III rectal cancer. The number of metastatic lymph nodes may vary depending on the level of specimen dissection and the total number of lymph nodes harvested. The aim of this study was to evaluate whether the lymph node ratio (LNR) is a prognostic parameter for patients with rectal cancer. A retrospective review of a database of rectal cancer patients was performed to determine the effect of the LNR on the disease-free survival (DFS) and the overall survival. Of the total 228 patients with rectal cancer, 55 patients with stage III cancer were eligible for analysis. Survival curves were estimated using the Kaplan-Meier method. Cox regression analyses, after adjustments for potential confounders, were used to evaluate the relationship between the LNR and survival. According to the cutoff point 0.15 (15%), the 2-year DFS was 95.2% among patients with a LNR < 0.15 compared with 67.6% for those with LNR ≥ 0.15 (P = 0.02). In stratified and multivariate analyses adjusted for age, gender, histology and tumor status, a higher LNR was independently associated with worse DFS. This study showed the prognostic significance of ratio-based staging for rectal cancer and may help in developing better staging systems. LNR 0.15 (15%) was shown to be a cutoff point for determining survival and prognosis in rectal cancer cases.
    Full-text · Article · Jun 2013 · Annals of Coloproctology
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