Comparison of different lymph node staging systems in prognosis of gastric cancer:a bi-institutional study from Hungary

Objective： The Union for International Cancer Control （UICC） Node （N） classification is the most common used staging method for the prognosis of gastric cancer. It demands adequate, at least 16 lymph nodes （LNs） to be dissected; therefore different staging systems were invented. Methods： Between March 2005 and March 2010, 164 patients were evaluated at the Department of General Surgery in the Ken^zy Gyula Hospital and at the Department of General, Thoracic and Vascular Surgery in the Kaposi M6r Hospital. The 6th, 7th and 8th UICC N-staging systems, the number of examined LNs, the number of harvested negative LNs, the metastatic lymph node ratio （MLR） and the log odds of positive LNs （LODDS） were determined to measure their 5-year survival rates and to compare them to each other. Results： The overall 5year survival rate for all patients was 55.5% with a median overall survival time of 102 months. The tumor stage, gender, UICC N-stages, MLR and the LODDS were significant prognostic factors for the 5-year survival with univariate analysis. The 6th UICC N-stage did not follow the adequate risk in comparing N2 vs. NO and N3 vs. NO with multivariate investigation. Comparison of performances of the residual N classifications proved that the LODDS system was first in the prediction of prognosis during the evaluation of all patients and in cases with less than 16 harvested LNs. The MLR gave the best prognostic prediction when adequate （more than or equal to 16） lymphadenectomy was performed. Conclusions： We suggest the application of LODDS system routinely in western patients and the usage of MLR classification in cases with extended lymphadenectomy.

Do the existing staging systems for primary liver cancer apply to combined hepatocellular carcinoma-intrahepatic cholangiocarcinoma?

Background:The incidence of combined hepatocellular carcinoma-intrahepatic cholangiocarcinoma(cHCC-ICC)is relatively low,and the knowledge about the prognosis of cHCC-ICC remains obscure.In the study,we aimed to screen existing primary liver cancer staging systems and shed light on the prognosis and risk factors for cHCC-ICC.Methods:We retrospectively reviewed 206 cHCC-ICC patients who received curative surgical resection from April 1999 to March 2017.The correlation of survival measures with the histological types or with tumor staging systems was determined and predictive values of tumor staging systems with cHCC-ICC prognosis were compared.Results:The histological type was not associated with overall survival(OS)(P=0.338)or disease-free survival(DFS)(P=0.843)of patients after curative surgical resection.BCLC,TNM for HCC,and TNM for ICC stages correlated with both OS and DFS in cHCC-ICC(all P<0.05).The predictive values of TNM for HCC and TNM for ICC stages were similar in terms of predicting postoperative OS(P=0.798)and DFS(P=0.191)in cHCC-ICC.TNM for HCC was superior to BCLC for predicting postoperative OS(P=0.022)in cHCC-ICC.Conclusion:The TNM for HCC staging system should be prioritized for clinical applications in predicting cHCC-ICC prognosis.

Proposal of a new and simple staging system of colorectal liver metastasis

AIM： To create a new, simple and useful staging system for colorectal liver metastasis analogous to the Tumor Node Metastasis classification system of International Union Against Cancer. METHODS： A retrospective review was undertaken of 81 consecutive patients who underwent partial hepatectomy for colorectal liver metastases （group 1）. Clinical and pathological features of both primary and metastatic liver cancers were entered into a multivariate analysis to determine independent variables helpful in accurately predicting long-term prognosis after hepatectomy. Using selected variables, we created a new staging system like TNM classification. The usefulness of the new staging system was examined in a series of 92 patients from another hospital （group 2）. RESULTS： Multivariate analysis showed that 81 patients in group 1 had significant multiple hepatic tumors with the largest tumor being more than 5 cm in diameter, resectable extrahepatic distant metastases, and independent prognostic factors for poor survival after hepatectomy. Using these three variables, we created a new staging system to classify patients with colorectal liver metastases. Finally, our new staging system classified the patients both in group 1 and in group 2. CONCLUSION： Our new staging system of colorecta liver metastasis is simple and useful for staging patients.

Usefulness of staging systems and prognostic scores for hepatocellular carcinoma treatments

Therapeutic management of hepatocellular carcinoma(HCC) is quite complex owing to the underlying cirrhosis and portal vein hypertension. Different scores or classification systems based on liver function and tumoral stages have been published in the recent years. If none of them is currently "universally" recognized, the Barcelona Clinic Liver Cancer(BCLC) staging system has become the reference classification system in Western countries. Based on a robust treatment algorithm associated with stage stratification, it relies on a high level of evidence. However, BCLC stage B and C HCC include a broad spectrum of tumors but are only matched with a single therapeutic option. Some experts have thus suggested to extend the indications for surgery or for transarterial chemoembolization. In clinical practice, many patients are already treated beyond the scope of recommendations. Additional alternative prognostic scores that could be applied to any therapeutic modality have been recently proposed. They could represent complementary tools to the BCLC staging system and improve the stratification of HCC patients enrolled in clinical trials, as illustrated by the NIACE score. Prospective studies are needed to compare these scores and refine their role in the decision making process.

Validation of the eighth edition of the AJCC staging system for patients with pancreatic adenocarcinoma initially receiving chemoradiotherapy and proposal of modifications

Objective:To validate the eighth edition of the AJCC staging system in patients with pancreatic adenocarcinoma receiving only stereotactic body radiation therapy and chemotherapy,and to propose modifications to improve prognostic accuracy.Methods:Patients with pathologically confirmed pancreatic adenocarcinoma without metastasis who were undergoing only chemoradiotherapy were included and staged according to the seventh and eighth editions of the AJCC staging system.Meanwhile,another group of stage T4 patients from the above enrollment with only portal vein involvement with or without tumor thrombi(PV±PVTT)were retrieved for survival comparisons.Modifications were proposed according to the survival comparisons.A cohort from the SEER database was used for external validation of the modified staging system.Results:A total of 683 patients were included.Patients with N2 or N1 but different T stages had significantly different survival outcomes according to the eighth edition.The survival of patients with(PV±PVTT)was comparable to that of patients with T4 tumors.The concordance index of the seventh and eighth editions,and the modified staging system was 0.744(95%CI:0.718—0.769),0.750(95%CI:0.725—0.775),and 0.788(95%CI:0.762-0.813),respectively.For external validation,the concordance index was 0.744(95%CI:0.718-0.770),0.750(95%CI:0.724-0.776),and 0.788(95%CI:0.762-0.814),respectively.Conclusions:The modified staging system is suggested to have the m ost accurate prognostic value.Hence,PV土PVTT should be added to the definition of T4 tumors regardless of tumor size.Patients with N2 or N1 in different T stages could be regrouped into different substages.Additionally,stage III should be subclassified into IIIA(T3N 2 and T4N 0)and IIIB(T4N 1-2).

Prognostic factors and survival after surgical resection of pancreatic neuroendocrine tumor with validation of established and modified staging systems

Background: Pancreatic neuroendocrine tumors(PNETs) display wide heterogeneity with highly variable prognosis. This study aimed to identify variables related to survival after surgical resection of PNET.Methods: A total of 143 patients were identified from a prospectively maintained database. Patient characteristics were analyzed and prognostic factors for overall survival and progression-free survival were evaluated. The WHO, ENETS and AJCC scoring systems were applied to the cohort, and their ability to predict patient outcomes were compared.Results: Multivariate analysis found that female gender, lymph node metastases and increasing WHO2010 grade to be independently associated with reduced overall survival(P < 0.05). Patients requiring multi-visceral resection or debulking surgery found to be associated with shortest survival. ROC analysis found the ENETS and AJCC scoring systems to be similarly predictive of 5-year overall survival. Modified Ki67 significantly improved its accuracy in predicting 5-year overall survival(AUROC: 0.699 vs 0.605;P < 0.01).Conclusions: Multi-visceral or debulking surgery is associated with poor outcomes. There seems to be no significant difference between enucleation and anatomical segmental resection. Available scoring systems have reasonable accuracy in stratifying disease severity, with no system identified as being superior.Prognostic stratification with modified grading systems needs further validation before applied in clinical practice.

A retrospective prognostic evaluation analysis using the 8th edition of American Joint Committee on Cancer(AJCC)cancer staging system for luminal A breast cancer

Objective： We retrospectively analyzed the clinical prognostic value of the 8th edition of the American Joint Committee on Cancer （AJCC） staging system for luminal A breast cancer. Methods： Using both the anatomic and prognostic staging in the 8th edition of AJCC cancer staging system, we restaged patients with luminal A breast cancer treated at the Breast Disease Center, Peking University First Hospital from 2008 to 2014. Follow-up data including 5-year disease free survival （DFS）, overall survival （OS） and other clinic-pathological data were collected to analyze the differences between the two staging subgroups. Results： This study included 421 patients with luminal A breast cancer （median follow-up, 61 months）. The 5- year DFS and OS rates were 98.3% and 99.3%, respectively. Significant differences in 5-year DFS but not OS were observed between different anatomic disease stages. Significant differences were observed in both 5-year DFS and O S between different prognostic stages. Application of the prognostic staging system resulted in assignment of 175 of 421 patients （41.6%） to a different group compared to their original anatomic stages. In total, 102 of 103 patients with anatomic stage IlA changed to prognostic stage IB, and 24 of 52 patients with anatomic stage lib changed to prognostic stage IB, while 1 changed to prognostic stage liIB. Twenty-two of 33 patients with anatomic stage IliA were down-staged to IlA when staged by prognostic staging system, and the other 11 patients were down-staged to liB. Two patients with anatomic stage IIIB were down-staged to IliA. Among seven padents with anatomic stage IIIC cancer, two were down-staged to IliA and four were down-staged to stage I]IB. Conclusions： The 8th edition of AJCC prognostic staging system is an important supplement to the breast cancer staging system. More clinical trials are needed to prove its ability to guide selection of proper systemic therapy and predict prognosis of breast cancer.

The 7th lung cancer TNM classification and staging system:Review of the changes and implications

Lung cancer is the most common cause of death from cancer in males,accounting for more than 1.4 million deaths in 2008.It is a growing concern in China,Asia and Africa as well.Accurate staging of the disease is an important part of the management as it provides estimation of patient’s prognosis and identifies treatment sterategies.It also helps to build a database for future staging projects.A major revision of lung cancer staging has been announced with effect from January 2010.The new classification is based on a larger surgical and non-surgical cohort of patients,and thus more accurate in terms of outcome prediction compared to the previous classification.There are several original papers regarding this new classification which give comprehensive description of the methodology,the changes in the staging and the statistical analysis.This overview is a simplified description of the changes in the new classification and their potential impact on patients’ treatment and prognosis.

Staging systems of hepatocellular carcinoma:A review of literature

Hepatocellular carcinoma(HCC)is a major health problem with a high incidence and mortality all over the world.Natural history of HCC is severe and extremely variable,and prognostic factors influencing outcomes are incompletely defined.Over time,many staging and scoring systems have been proposed for the classification and prognosis of patients with HCC.Currently,the non-ideal predictive performance of existing prognostic systems is secondary to their inherent limitations,as well as to a non-universal reproducibility and transportability of the results in different populations.New serological and histological markers are still under evaluation with promising results,but they require further evaluation and external validation.The aim of this review is to highlight the main tools for assessing the prognosis of HCC and the main concerns,pitfalls and warnings regarding its staging systems currently in use.

Staging systems for hepatocellular carcinoma: Current status and future perspectives

Hepatocellular carcinoma(HCC) is a major health concern worldwide and the third cause of cancer-related death. Despite advances in treatment as well as careful surveillance programs, the mortality rates in most countries are very high. In contrast to other cancers, the prognosis and treatment of HCC depend on the tumor burden in addition to patient's underlying liver disease and liver functional reserve. Moreover, thereis considerable geographic and institutional variation in both risk factors attributable to the underlying liver diseases and the management of HCC. Therefore, although many staging and/or scoring systems have been proposed, there is currently no globally accepted system for HCC due to the extreme heterogeneity of the disease. The aim of this review is to focus on currently available staging systems as well as those newly reported in the literatures since 2012. Moreover, we describe problems with currently available staging systems and attempts to modify and/or add variables to existing staging systems.

Staging systems for predicting survival of patients with hepatocellular carcinoma after surgery

AIM: To compare the staging systems for stratifying and predicting the prognosis of patients with hepatocel-lular carcinoma (HCC) after partial hepatectomy (PH). METHODS: Clinical data about 438 HCC patients who underwent PH from January 1991 to December 2004 at our hospital were retrospectively analyzed. Tumor stage was evaluated following the Chinese tumor node me-tastasis (TNM) and barcelona clinic liver cancer (BCLC) staging systems, respectively. Survival curves for the HCC patients were plotted using the Kaplan-Meier method and differences were compared by the log-rank test. The accuracy of each system for predicting death of HCC patients was evaluated by calculating the area under the receiver operating characteristic curve. RESULTS: The HCC patients were classified into stag-es Ⅰ-Ⅲ, stages Ⅰ-Ⅳ and stages A-C, according to the 3 staging systems, respectively. Log-rank test showed that the cumulative survival rate was significantly dif-ferent for the HCC patients at 3 Chinese system stag-es, TNM stages Ⅰ and Ⅱ, TNM stages Ⅲ and Ⅳ, and 3 BCLC stages (P < 0.05). However, no significant differ-ence was found in the HCC patients at TNM stages Ⅱ and Ⅲ. The accuracy of the Chinese and BCLC staging systems was higher than that of the TNM staging sys-tem for predicting the survival rate of HCC patients. CONCLUSION: The Chinese and BCLC staging systems are better for stratifying and predicting the prognosis of HCC patients after PH than the TNM staging system.

Validation and modification of the AJCC 8th TNM staging system for pancreatic ductal adenocarcinoma in a Chinese cohort:A nationwide pancreas data center analysis

Objective:To validate the 8 th edition of the American Joint Committee on Cancer(AJCC)staging system for pancreatic ductal adenocarcinoma(PDAC)in a Chinese cohort of radically resected patients and to develop a refined staging system for PDAC.Methods:Data were collected from the China Pancreas Data Center(CPDC)for patients with resected PDAC in 2016 and 2017,and cancer-specific survival(CSS)was evaluated using the Kaplan-Meier method and log-rank test.Univariate and multivariate analyses based on Cox regression were performed to identify prognostic factors.The recursive partitioning analysis(RPA),Kaplan-Meier method,and log-rank test were performed on the training dataset to generate a proposed modification for the 8 th TNM staging system utilizing the preoperative carbohydrate antigen(CA)19-9 level.Validation was performed for both staging systems in the validation cohort.Results:A total of 1,676 PDAC patients were retrieved,and the median CSS was significantly different between the 8 th TNM groupings,with no significant difference in survival between stage IB and IIA.The analysis of T and N stages demonstrated a better prognostic value in the N category.Multivariate analysis showed that the preoperative serum CA19-9 level was the strongest prognostic indicator among all the independent risk factors.All patients with CA19-9>500 U/mL had similar survival,and we proposed a new staging system by combining IB and IIA and stratifying all patients with high CA19-9 into stage III.The modified staging system had a better performance for predicting CSS than the 8 th AJCC staging scheme.Conclusions:The 8 th AJCC staging system for PDAC is suitable for a Chinese cohort of resected patients,and the N category has a better prognostic value than the T category.Our modified staging system has superior accuracy in predicting survival than the 8 th AJCC TNM staging system.

Hepatocellular carcinoma staging systems: Hong Kong liver cancer vs Barcelona clinic liver cancer in a Western population

BACKGROUND Despite being the world’s most widely used system for staging and therapeutic guidance in hepatocellular carcinoma(HCC)treatment,the Barcelona clinic liver cancer(BCLC)system has limitations,especially regarding intermediate-grade(BCLC-B)tumors.The recently proposed Hong Kong liver cancer(HKLC)staging system appears useful but requires validation in Western populations.AIM To evaluate the agreement between BCLC and HKLC staging on the management of HCC in a Western population,estimating the overall patient survival.METHODS This was a retrospective study of HCC patients treated at a university hospital in southern Brazil between 2011 and 2016.Demographic,clinical,and laboratory data were collected.HCC staging was carried out according to the HKLC and BCLC systems to assess treatment agreement.Overall survival was estimated based on the treatment proposed in each system.RESULTS A total of 519 HCC patients were assessed.Of these,178(34.3%)were HKLC-I;95(18.3%)HKLC-IIA;47(9.1%)HKLC-IIB;29(5.6%)HKLC-IIIA;30(5.8%)HKLCIIIB;75(14.4%)HKLC-IV;and 65(12.5%)HKLC-V.According to the BCLC,25(4.9%)were BCLC-0;246(47.4%)BCLC-A;107(20.6%)BCLC-B;76(14.6%)BCLCC;and 65(12.5%)BCLC-D.The general agreement between the two systems was 80.0%-BCLC-0 and HKLC-I(100%);BCLC-A and HKLC-I/HKLC-II(96.7%);BCLC-B and HKLC-III(46.7%);BCLC-C and HKLC-IV(98.7%);BCLC-D and HKLC-V(41.5%).When sub-classifying BCLC-A,HKLC-IIB,HKLC-IIIA and HKLC-IIIB stages according to the up-to-7 in/out criterion,13.4,66.0,100 and 36.7%,respectively,of the cases were classified as up-to-7 out.CONCLUSION In a Western population,the general agreement between the two systems was 80.0%,although in BCLC-B cases the agreement was low,suggesting that some individuals could be candidates for the curative treatment recommended by the HKLC.The authors suggest that the BCLC system should be routinely employed,although for BCLC-B cases it should be associated with the HKLC system.

Sixth and seventh tumor-node-metastasis staging system compared in gastric cancer patients

AIM: To investigate the clinical relevance and prognosis regarding survival according to the changes of the tumor-node-metastasis(TNM) in gastric cancer patients. METHODS: We retrospectively studied 347 consecutive subjects who underwent surgery for gastric adenocarcinoma at the Division of General Surgery, Hospital of Busto Arsizio, Busto Arsizio, Italy between June 1998 and December 2009. Patients who underwent surgery without curative intent, patients with tumors of the gastric stump and patients with tumors involving the esophagus were excluded for survival analysis. Patients were staged according to the 6thand 7thedition TNM criteria; 5-year overall survival rates were investigated, and the event was defined as death from any cause. RESULTS: After exclusion, our study population included 241 resected patients with curative intent for gastric adenocarcinoma. The 5-year overall survival(5-year OS) rate of all the patients was 52.8%. Thediagnosed stage differed in 32% of 241 patients based on the TNM edition used for the diagnosis. The patients in stage Ⅱ according to the 6thedition who were reclassified as stage Ⅲ had significantly worse prognosis than patients classified as stage Ⅱ(5-year OS, 39% vs 71%). According to the 6thedition, 135 patients were classifed as T2, and 75% of these patients migrated to T3 and exhibited a significantly worse prognosis than those who remained T2, regardless of lymph node involvement(37% vs 71%). The new N1 patients exhibited a better prognosis than the previous N1 patients(67% vs 43%). CONCLUSION: 7thTNM allows new T2 and N1 patients to be selected with better prognosis, which leads to different staging. New stratification is important in multimodal therapy.

Application of the revised Tumour Node Metastasis （TNM） staging system of clear cell renal cell carcinoma in eastern China： advantages and limitations

This study was designed to evaluate whether the revised 2010 Tumour Node Metastasis （TNM） staging system could lead to a more accurate prediction of the prognosis of renal cell carcinoma （RCC） patients. A total of 1216 patients who had undergone radical nephrectomy or partial nephrectomy for RCC from 2003 to 2011 were enrolled. All of the patients had pathologically confirmed clear cell RCC （ccRCC）. All cases were staged by both the 2002 and 2010 TNM staging systems after pathological review, and survival data were collected. Univariate and multivariate Cox regression models were used to evaluate cancer-specific survival （CSS） and progression-free survival （PFS） after surgery. Continuous variables, such as age and tumour diameter, were calculated as mean values and standard deviations （s.d.） or as median values. Survival was calculated by the Kaplan-Meier method, and the log-rank test assessed differences between groups. Statistically significant differences in CSS and PFS were noted among patients in T3 subgroups using the new 2010 staging system. Therefore, the revised 2010 TNM staging system can lead to a more accurate prediction of the prognosis of ccRCC patients. However, when using the revised 2010 staging system, we found that more than 92% of patients （288/313） with T3 tumours were staged in the T3a subgroup, and their survival data were not significantly different from those of patients with T2b tumours. In addition, T2 subclassification failed to independently predict survival in RCC patients.

Health-related quality of life evaluated by tumor node metastasis staging system in patients with hepatocellular carcinoma

AIM: To investigate and evaluate the change in healthrelated quality of life (HRQoL) by tumor node metastasis (TNM) staging system in patients with hepatocellular carcinoma (HCC). METHODS: A total of 140 patients diagnosed with HCC between June 2008 and April 2009 in our department were enrolled to this study. One hundred and thirty-five (96.5%) patients had liver cirrhosis secondary to hepatitis B virus (HBV) infection, 73 (54.07%) of them being HBV DNA positive; the other etiologies of liver cirrhosis were alcoholic liver disease (1.4%), hepatitis C (1.4%) or cryptogenic (0.7%). All subjects were fully aware of their diagnosis and provided informed consent. HRQoL was assessed before treatment using the functional assessment of cancer therapy-hepatobiliary (FACT-Hep) questionnaire. Descriptive statistics were used to evaluate demographics and disease-specific characteristics of the patients. One-way analysis of variance and independent samples t tests were used to compare the overall FACT-Hep scores and clinically distinct TNM stages. Scores for all FACT-Hep items were analyzed by frequency analyses. The mean scores obtained from the FACT-Hep in different Child-Pugh classes were also evaluated. RESULTS: The mean FACT-Hep scores were reduced significantly from TNM StageⅠto Stage Ⅱ, Stage ⅢA, Stage ⅢB group (687 ± 39.69 vs 547 ± 42.57 vs 387 ± 51.24 vs 177 ± 71.44, P = 0.001). Regarding the physical and emotional well-being subscales, scores decreased gradually from Stage Ⅰ to Stage ⅢB (P = 0.002 vs Stage Ⅰ; P = 0.032 vs Stage Ⅱ; P = 0.033 vs Stage ⅢA). Mean FACT-Hep scores varied by Child-Pugh class, especially in the subscales of physical well-being, functional well-being and the hepatobiliary cancer (P = 0.001 vs Stage I; P = 0.036 vs Stage Ⅱ; P = 0.032 vs Stage ⅢA). For the social and family well-being subscale, only Stage ⅢB scores were significantly lower as compared with Stage Ⅰ scores (P = 0.035). For the subscales of functional well-being and hepatobiliary cancer, there were significant differences for Stages ⅡΙ, ⅢA and ⅢB (P = 0.002vs StageⅠ). CONCLUSION: HRQoL of patients with HCC worsens gradually with progression of TNM stages. The most impaired subscales of HRQoL, as measured by FACT-Hep, were physical and emotional well-being.

Lymph node ratio-based staging system for esophageal squamous cell carcinoma

AIM: To analyze a modified staging system utilizing lymph node ratio(LNR) in patients with esophageal squamous cell carcinoma(ESCC).METHODS: Clinical data of 2011 patients with ESCC who underwent surgical resection alone between January 1995 and June 2010 at the Cancer Hospital of Shantou University Medical College were reviewed. The LNR, or node ratio(Nr) was defined as the ratio of metastatic LNs ompared to the total number of resected LNs. Overall survival between groups was compared with the log-rank test. The cutoff point of LNR was established by grouping patients with 10% increment in Nr, and then combining the neighborhood survival curves using the log-rank test. A new TNr M staging system, was constructed by replacing the American Joint Committee on Cancer(AJCC) N categories with the Nr categories in the new TNM staging system. The time-dependent receiver operating characteristic curves were used to evaluate the predictive performance of the seventh edition AJCC staging system and the TNr M staging system.RESULTS: The median number of resected LNs was 12(range: 4-44), and 25% and 75% interquartilerangeswere8 and 16. Patients were classified into four Nr categories with distinctive survival differences(Nr0: LNR = 0; Nr1: 0% < LNR ≤ 10%; Nr2: 10% < LNR ≤ 20%; and Nr3: LNR > 20%). From N categories to Nr categories, 557 patients changed their LN stage. The median survival time(MST) for the four Nr categories(Nr0-Nr3) was 155.0 mo, 39.0 mo, 28.0 mo, and 19.0 mo, respectively, and the 5-year overall survival was 61.1%, 41.1%, 33.0%, and 22.9%, respectively(P < 0.001). Overall survival was significantly different for the AJCC N categories when patients were subgrouped into 15 or more vs fewer than 15 examined nodes, except for the N3 category(P = 0.292). However, overall survival was similar when the patients in all four Nr categories were subgrouped into 15 or more vs fewer than 15 nodes. Using the time-dependent receiver operating characteristic, we found that the Nr category and TNr M stage had higher accuracy in predicting survival than the AJCC N category and TNM stage. CONCLUSION: A staging system based on LNR may have better prognostic stratification of patients with ESCC than the current TNM system, especially for those undergoing limited lymphadenectomy.

Mesenterico-portal vein invasion should be an important factor in TNM staging for pancreatic ductal adenocarcinoma: Proposed modification of the 8th edition of the American Joint Committee on Cancer staging system

BACKGROUND The 8^th edition of the American Joint Committee on Cancer(AJCC)staging system for pancreatic ductal adenocarcinoma(PDAC)excludes extrapancreatic extension from the assessment of T stage and restages tumors with mesenterico-portal vein(MPV)invasion into T1-3 diseases according to tumor size.However,MPV invasion is believed to be correlated with a poor prognosis.AIM To analyze whether the inclusion of MPV invasion can further improve the 8th edition of the AJCC staging system for PDAC.METHODS This study retrospectively included 8th edition AJCC T1-3N0-2M0 patients undergoing pancreaticoduodenectomy/total pancreatectomy from two cohorts and analyzed survival outcomes.In the first cohort,a total of 7539 patients in the surveillance,epidemiology,and end results database was included,and in the second cohort,689 patients from the West China Hospital database were enrolled.RESULTS Cox regression analysis showed that MPV invasion is an independent prognostic factor in both databases.In the MPV-group,all pairwise comparisons between the survival functions of patients with different stages were significant except for the comparison between patients with stage IIA and those with stage IIB.However,in the MPV+group,pairwise comparisons between the survival functions of patients with stage IA,stage IB,stage IIA,stage IIB,and stage III were not significant.T1-3N0 patients in the MPV+group were compared with the T1N0,T2N0,and T3N0 subgroups of the MPV-group;only the survival of MPV-T3N0 and MPV+T1-3N0 patients had no significant difference.Further comparisons of patients with stage IIA and subgroups of stage IIB showed(1)no significant difference between the survival of T2N1 and T3N0 patients;(2)a longer survival of T1N1 patients that was shorter than the survival of T2N0 patients;and(3)and a shorter survival of T3N1 patients that was similar to that of T1-3N2 patients.CONCLUSION The modified 8th edition of the AJCC staging system for PDAC proposed in this study,which includes the factor of MPV invasion,provides improvements in predicting prognosis,especially in MPV+patients.

BCLC staging system and liver transplantation:From a stage to a therapeutic hierarchy

The Barcelona Clinic Liver Cancer(BCLC)system was proposed in 1999 with the intent to improve a therapeutic algorithm for the management of patients with hepatocellular carcinoma(HCC)[1].Both the European and the American Guidelines on the Treatment of HCC have endorsed the BCLC as the standard staging algorithm with prognostic and therapeutic implications[2,3].The BCLC staging system stratifies HCC patients into five stages(0,A,B,C and D).According to the algorithm,liver transplantation(LT)is indicated only in patients in the stages BCLC 0 and A,special situations provided.

Incorporation of perigastric tumor deposits into the TNM staging system for primary gastric cancer

BACKGROUND The current prognostic significance of perigastric tumor deposits(TDs)in gastric cancer(GC)remains unclear.AIM To assess the prognostic value of perigastric TDs and put forward a new TNM staging framework involving TDs for primary GC.METHODS This study retrospectively analyzed the pathological data of 6672 patients with GC who underwent gastrectomy or surgery for GC with other diseases from January 1,2012 to December 31,2017 at the Chinese PLA General Hospital.According to the presence of perigastric TDs or not,the patients were divided into TD-positive and TD-negative groups by using the method of propensity score matching.The differences between TD-positive and TD-negative patients were analyzed using binary logistic regression modeling.The Kaplan-Meier method was used to plot survival curves.Multivariate Cox regression modeling and the log-rank test were used to analyze the data.RESULTS Perigastric TDs were found to be positive in 339(5.09%)of the 6672 patients with GC,among whom 237 were men(69.91%)and 102 were women(30.09%)(2.32:1).The median age was 59 years(range,27 to 78 years).Univariate and multivariate survival analyses indicated that TD-positive GC patients had a poorer prognosis than TD-negative patients(P<0.05).The 1-,3-,and 5-year overall survival rates of GC patients with TDs were 68.3%,19.6%,and 11.2%,respectively,and these were significantly poorer than those without TDs of the same stages.There was significant variation in survival according to TD locations among the GC patients(P<0.05).A new TNM staging framework for GC was formulated according to TD location.When TDs appear in the gastric body,the original stages T1,T2,and T3 are classified as T4a with the new framework,and the original stages T4a and T4b both are classified as T4b.When TDs appear in the lesser curvature,the previous stages N0,N1,N2,and N3 now both are classified as N3.When TDs appear in the greater curvature or the distant tissue,the patient should be categorized as having M1.With the new GC staging scheme including TDs,the survival curves of patients in the lower grade TNM stage with TDs were closer to those of patients in the higher grade TNM stage without TDs.CONCLUSION TDs are a poor prognostic factor for patients with primary GC.The location of TDs is associated with the prognosis of patients with primary GC.Accordingly,we developed a new TNM staging framework involving TDs that is more appropriate for patients with primary GC.