Youqing Zhan

Tumor–ratio–metastasis staging system as an alternative to the 7th edition UICC TNM system in gastric cancer after D2 resection—results of a single-institution study of 1343 Chinese patients

BACKGROUND In this study, we assessed the prognostic value of the lymph node ratio (LNR), established a hypothetical tumor-ratio-metastasis (TRM) staging system and compared it with the 7th edition International Union Against Cancer pathological N (pN) and tumor-node-metastasis (TNM) system. PATIENTS AND METHODS A total of 1343 gastric cancer patients undergoing D2 resection were staged using the TRM staging system and the 7th edition TNM system. Optimal cut points of LNR were calculated using X-tile software and validated by bootstrapping. Homogeneity, discriminatory ability, and monotonicity of gradients of the TRM and TNM systems were compared using linear trend χ(2), likelihood ratio χ(2) statistics, and Akaike information criterion (AIC) calculations. RESULTS Optimal cut points classified patients into LNR0 (0%), LNR1 (1%-30%), LNR2 (31%-60%), and LNR3 (61%-100%) groups. In univariate, multivariate and stratified analyses, the LNR staging showed superiority to the 7th edition pN staging. The TRM staging system had higher linear trend and likelihood ratio χ(2) scores and smaller AIC values compared with those for the TNM system, which represented the optimum prognostic stratification. CONCLUSIONS The novel TRM staging system predicts survival of gastric cancer more accurately than the 7th edition TNM system. It may be considered as an alternative to TNM system.

Preoperative C-Reactive Protein/Albumin Ratio Predicts Prognosis of Patients after Curative Resection for Gastric Cancer.

BACKGROUND: An elevated preoperative C-reactive protein/albumin (CRP/Alb) ratio has been reported to be associated with a poor prognosis for hepatocellular carcinoma. The aim of the present study was to investigate the prognostic value of the preoperative CRP/Alb ratio and compare it with other systemic inflammatory response markers in patients with gastric cancer (GC). METHODS: A retrospective study was performed in 455 patients with GC undergoing curative resection. We investigated the correlations between the preoperative CRP/Alb ratio and overall survival (OS). Kaplan-Meier and Cox regression models were used to assess independent prognostic factors. The area under the curve was used to compare the prognostic value of different markers. RESULTS: On multivariate analysis, the CRP/Alb ratio were independently associated with OS in patients with GC (hazard ratio: 1.626; 95% confidence interval: 1.191-2.219; P = .002), along with age (P = .003), preoperative body weight loss (P = .001), tumor location (P = .008), metastatic lymph node ratio (P < .001), and seventh tumor-nodes-metastasis stage (American Joint Committee on Cancer) (P = .007). However, several other systemic inflammation–based prognostic scores (neutrophil lymphocyte ratio, platelet lymphocyte ratio and systemic immune-inflammation index, Glasgow Prognostic Score, modified Glasgow prognostic score, and high-sensitivity modified Glasgow prognostic score) were not. In addition, the CRP/Alb ratio had a higher area under the curve value (0.625) compared with several other systemic inflammation–based prognostic scores (P < .001). CONCLUSION: The preoperative CRP/Alb ratio, a system inflammation-based prognostic score, is a superior predictor of OS in patients undergoing curative resection for GC and may help to identify the high-risk patients for treatment decisions.

Effect of lymph node number on survival of patients with lymph node-negative gastric cancer according to the 7th edition UICC TNM system

Background For the patients with node-negative gastric cancer, the 7th edition classification does not define the minimum number of lymph nodes necessary. We aimed to explore the prognostic significance of examined lymph nodes and determine how many nodes must be examined. Methodology/Principal Findings 435 patients underwent D2 gastrectomy with node-negative gastric cancer between December 1992 and December 2006 were obtained. Patients were classified into 4 groups by the number of negative LNs examined during surgery (1-6LNs, 7-10 LNs, 11-15 LNs, and > = 16 LNs). Stratified and Cox regression analyses were used to evaluate the association between survival and the number of negative LNs. Survival was significantly better in the > = 16 LNs, compared with the 1-5 LNs, 6-10 LNs and 11-15 LNs group in T2-4 patients; Multivariate analysis demonstrated tumor size, depth of invasion, 7th UICC stage and the number of examined nodes are strongly independent predictors of survival. Conclusions This study first demonstrates that patients with lymph node-negative gastric cancer underwent D2 dissection should have at least 16 LNs examined, especially in advanced gastric cancer. These results are a reasonable supplement to our previous tumor-ratio-metastasis staging system and a stratification criterion in clinical pratice.

Vitamin Intake Reduce the Risk of Gastric Cancer: Meta-Analysis and Systematic Review of Randomized and Observational Studies

Aim The association between vitamin intake and gastric cancer (GC) has been widely debated due to the relatively weak evidence. In this study, a meta-analysis of prospective and well designed observational studies were performed to explore this association. Methods MEDLINE, Cochrane Library, and Sciencedirect were searched for studies of vitamin consumption and gastric cancer. This produced 47 relevant studies covering 1,221,392 human subjects. Random effects models were used to estimate summary relative risk (RR). Dose-response, subgroup, sensitivity, meta-regression, and publication bias analyses were conducted. Results The RR of gastric cancer in the group with the highest vitamin intake was compared to that of the lowest intake group. Total vitamin intake was 0.78 (95% CI, 0.71−0.83). In 9 studies that individuals were given doses at least 4 times above the tolerable upper intake (UL) vitamins, the RR was 1.20 (95% CI, 0.99−1.44). However, in 17 studies that individuals received doses below the UL, the RR was 0.76 (95% CI, 0.68−0.86). Dose-response analysis was conducted on different increments in different types of vitamins (vitamin A: 1.5 mg/day, vitamin C: 100 mg/day, vitamin E: 10 mg/day) intake with a significant reduction in the risk of gastric cancer, respectively, 29% in vitamin A, 26% in vitamin C, and 24% in vitamin E. Conclusion This meta-analysis clearly demonstrated that low doses of vitamins can significantly reduce the risk of GC, especially vitamin A, vitamin C, vitamin E.

Incorporation of extranodal metastasis of gastric carcinoma into the 7th edition uicc tnm staging system

Background To assess the clinical significance and prognostic impact of extranodal metastasis (EM) in gastric carcinoma and establish an optimal classification in the staging system. Methodology/Principal Findings A total of 1343 patients with gastric carcinoma who underwent surgical resection were recruited to determine the frequency and prognostic significance of EMs. EMs were divided into two groups (EM1 and EM2) and then incorporated into the 7th edition UICC TNM staging system. EMs was detected in 179 (13.3%) of 1343 patients who underwent radical resection. Multivariate analysis identified EMs as an independent prognostic factor (HR = 1.412, 95%CI = 1.151–1.731, P<0.001). After curative operation, the overall survival rate were worse in patients with ≥3 cases of EM (EM2) than those with the number of 1 and 2 cases (EM1) (P<0.001). Survival of patients with EM1 was found almost comparable to that of N3 stage (P = 0.437). Survival of patients with EM2 showed similar to that of stage IV patients (P = 0.896). By using the linear trend X2, likelihood ratio X2, and Akaike information criterion (AIC) test, EM1 treated as N3 stage and EM2 treated as M1 stage performed higher linear trend X2 scores, likelihood ratio X2 scores, and lower AIC value than the 7th edition UICC TNM staging system, which represented the optimum prognostic stratification, together with better homogeneity, discriminatory ability, and monotonicity of gradients. Conclusions/Significance EMs might be classified based on their number and prognostic information and should incorporate into the TNM staging system.

Development and external validation of a prognostic nomogram for gastric cancer using the national cancer registry

A nomogram based on both western and eastern populations to estimate the Disease Specific Survival (DSS) of resectable gastric cancer (RGC) has not been established. In current study, we retrospectively analyzed 4,379 RGC patients who underwent curative resection from the Surveillance, Epidemiology, and End Results (SEER) database. Patients diagnosed between 1998 and 2009 were assigned as training set (n= 2,770), and the rest were selected as SEER validation set (n= 1,609). An external validation was performed by a set of independent 1,358 RGC patients after D2 resection from Sun Yat–sen University Cancer Center (SYSUCC) in China. The nomogram was constructed based on the training set. The multivariate analysis identified that patients age at diagnosis, race, tumor location, grade, depth of invasion, metastatic lymph node stage (mLNS) and total number of examined lymph node (TLN) were associated with patients DSS. The discrimination of this nomogram was superior to that of the 7th edition of AJCC staging system in SEER validation set and SYSUCC validation set (0.73 versus 0.70, p=0.005; 0.76 versus 0.72, p=0.005; respectively). Calibration plots of the nomogram showed that the probability of DSS corresponded to actual observation closely. In conclusion, our nomogram resulted in more–reliable prognostic prediction for RGC patients in general population.

Combined preoperative concentrations of CEA, CA 19-9, and 72-4 for predicting outcomes in patients with gastric cancer after curative resection

In many cancers, prognostic factors are useful for identifying high-risk patients and in individualizing treatment. We sought to determine whether a combination of tumor markers (CTM) would improve prognostic accuracy in patients with gastric cancer (GC). The CTM score, which is derived from serum concentrations of carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9), and carbohydrate antigen 72-4 (CA 72-4), was tested retrospectively in 1134 patients with GC undergoing curative resection between October 2000 and December 2012. The CTM score was 2 for patients with two or three elevated markers, 1 for those with one elevated marker, and 0 for those no elevated markers. Overall survival (OS) in patients with CTM scores 0, 1, and 2 was 61.8%, 31.4%, and 15.1%, respectively (P<.001). The CTM score independently predicted OS on multivariate analysis (HR, 1.95; 95% CI, 1.73 to 2.21; P<.001). Moreover, the area under the receiver operating characteristics curve of the CTM score (0.67; 95% CI, 0.64 to 0.70) was higher than the values of any individual marker (0.63, 0.57, 0.57; P<.001 for all comparisons). The CTM score independently predicted postoperative survival in GC, and it may have better clinical utility than individual tumor markers for identifying high-risk patients with GC.

Time trends of clinicopathologic features and surgical treatment for gastric cancer: Results from 2 high-volume institutions in southern China.

BACKGROUND The objective of this study was to evaluate the time-related trends of tumor characteristics and postoperative survival of patients with gastric cancer (GC) in 2 high-volume centers in high incidence areas of southern China. METHODS Based on the meticulously collected data from 5,327 patients with GC treated with operative intervention at Sun Yat-sen University Cancer Center and Fujian Medical University Union Hospital, we analyzed the differences in clinicopathologic features and postoperative survival over the following 4 consecutive periods: 1991-1995 (period 1), 1996-2000 (period 2), 2001-2005 (period 3), and 2006-2010 (period 4). RESULTS Tumor size decreased (P = .001), but the proportion of poorly differentiated tumors increased (P < .001) over the study periods. Early GC was diagnosed more often in later periods, gradually increasing from 7 to 15% (P < .001). A surprising improvement was observed in the mean number of retrieved lymph nodes, ranging from 10.36 to 26.22 (P < .001). The radical resection rate increased from 88 to 93%. The overall 5-year survival rate improved steadily over the 4 periods, from 39 to 53% (P < .001). Multivariate analysis revealed that age, tumor location, histologic type, tumor size, depth of invasion, lymphatic invasion, number of retrieved lymph nodes, radical resection, and time periods were independent prognostic factors. CONCLUSION The clinicopathologic features of tumors changed during the observation period in our region. The increasingly early detection of patients with GC and more standardized regimens for operative management, including routinely performed D2 lymphadenectomy, most likely resulted in the increase in overall survival.

Nomogram based on systemic inflammatory response markers predicting the survival of patients with resectable gastric cancer after D2 gastrectomy

This study aimed to construct a nomogram to predict survival of patients with resectable gastric cancer (RGC) based on both clinicopathology characteristics and systemic inflammatory response markers (SIRMs). Of 3,452 RGC patients after D2 gastrectomy at the Sun Yat-sen University Cancer Center, 1058 patients who met the inclusion criterion were analyzed. The patients operated on from January 1, 2005 to December 31, 2009 were assigned to the training set (817 patients) to establish a nomogram, and the rest (241 patients) were selected as validation set. Based on the training set, seven independent risk factors were selected in the nomogram. The calibration curves for probability of 1-year, 3-year and 5-year overall survival (OS) showed satisfactory accordance between nomogram prediction and actual observation. When the metastatic lymph node stage (mLNS) is replaced by metastasis lymph node ratio (mLNR) in validation set, the C-index in predicting OS rise from 0.77 to 0.79, higher than that of 7th American Joint Committee on Cancer 7th (AJCC) staging system (0.70; p<0.001). In conclusions, the proposed nomogram which including mLNR and routine detected SIRMs resulted in optimal survival prediction for RGC patients after D2 gastrectomy.

Prognostic value of pretreatment albumin–globulin ratio in predicting long-term mortality in gastric cancer patients who underwent D2 resection

Background Several studies have highlighted the prognostic value of the albumin–globulin ratio (AGR) in various kinds of cancers. Our study was designed to assess whether AGR is associated with the prognosis of gastric cancer patients. Patients and methods A total of 507 gastric cancer patients between 2005 and 2012 were included. The AGR was defined as the ratio of serum albumin to nonalbumin and calculated by the equation: albumin/(total protein − albumin). Furthermore, AGR was divided into two groups (low and high) using the X-tile software. Survival analysis stratified by AGR groups was performed. Results The mean survival time for each group was 36.62 months (95% CI: 33.92–39.32) for the low AGR group and 48.95 months (95% CI: 41.93–55.96, P=0.003) for the high AGR group. Patients in the high group (AGR ≥1.93) had a significantly lower 5-year mortality in comparison with the low group (AGR <1.93) (52.4% vs 78.5%, P=0.003). The high AGR group showed obviously better overall survival than the low AGR group according to Kaplan–Meier curves (P=0.003). Multivariate analysis showed that AGR was an independent predictive factor of prognosis in gastric patients. Conclusion Pretreatment AGR is a significant and independent predictive factor of prognosis.