Prognostic value of site-specific metastases in pancreatic adenocarcinoma: A Surveillance Epidemiology and End Results database analysis

To evaluate the prognostic value of site-specific metastases among patients with metastatic pancreatic carcinoma registered within the Surveillance, Epidemiology and End Results (SEER) database.METHODSSEER database (2010-2013) has been queried through SEER*Stat program to determine the presentation, treatment outcomes and prognostic outcomes of metastatic pancreatic adenocarcinoma according to the site of metastasis. In this study, metastatic pancreatic adenocarcinoma patients were classified according to the site of metastases (liver, lung, bone, brain and distant lymph nodes). We utilized chi-square test to compare the clinicopathological characteristics among different sites of metastases. We used Kaplan-Meier analysis and log-rank testing for survival comparisons. We employed Cox proportional model to perform multivariate analyses of the patient population; and accordingly hazard ratios with corresponding 95%CI were generated. Statistical significance was considered if a two-tailed P value < 0.05 was achieved.RESULTSA total of 13233 patients with stage IV pancreatic cancer and known sites of distant metastases were identified in the period from 2010-2013 and they were included into the current analysis. Patients with isolated distant nodal involvement or lung metastases have better overall and pancreatic cancer-specific survival compared to patients with isolated liver metastases (for overall survival: lung vs liver metastases: P < 0.0001; distant nodal vs liver metastases: P < 0.0001) (for pancreatic cancer-specific survival: lung vs liver metastases: P < 0.0001; distant nodal vs liver metastases: P < 0.0001). Multivariate analysis revealed that age < 65 years, white race, being married, female gender; surgery to the primary tumor and surgery to the metastatic disease were associated with better overall survival and pancreatic cancer-specific survival.CONCLUSIONPancreatic adenocarcinoma patients with isolated liver metastases have worse outcomes compared to patients with isolated lung or distant nodal metastases. Further research is needed to identify the highly selected subset of patients who may benefit from local treatment of the primary tumor and/or metastatic disease.

Epidemiology and outcome of individuals with intraductal papillary neoplasms of the bile duct

BACKGROUND Intraductal papillary neoplasm of the bile duct(IPNB)is a rare distinct subtype of precursor lesions of biliary carcinoma.IPNB is considered to originate from luminal biliary epithelial cells,typically displays mucin-hypersecretion or a papillary growth pattern,and results in cystic dilatation[1].IPNB develops anywhere in the intrahepatic and extrahepatic biliary tracts,and can occur in various pathological stages from low-grade dysplasia to invasive carcinoma.IPNBs have similar phenotypic changes in the occurrence and development of all subtypes,and the prognosis is significantly better than that of traditional(nonpapillary)cholangiocarcinoma.AIM To evaluate the clinicopathological features of IPNB to provide evidence-based guidance for treatment.METHODS Invasive IPNB,invasive intraductal papillary mucinous neoplasm of the pancreas(IPMN),and traditional cholangiocarcinoma data for affected individuals from 1975 to 2016 were obtained from the Surveillance,Epidemiology,and End Results(SEER)database.Annual percentage changes(APCs)in the incidence and incidence-based(IB)mortality were calculated.We identified the independent predictors of overall survival(OS)and cancer-specific survival(CSS)in indivi duals with invasive IPNB.RESULTS The incidence and IB mortality of invasive IPNB showed sustained decreases,with an APC of-4.5%(95%CI:-5.1%to-3.8%)and-3.3%(95%CI:-4.1%to-2.6%)(P<0.001),respectively.Similar decreases in incidence and IB mortality were seen for invasive IPMN but not for traditional cholangiocarcinoma.Both OS and CSS for invasive IPNB were better than for invasive IPMN and traditional cholangiocarcinoma.A total of 1635 individuals with invasive IPNB were included in our prognosis analysis.The most common tumor sites were the pancreaticobiliary ampulla(47.9%)and perihilar tract(36.7%),but the mucin-related subtype of invasive IPNB was the main type,intrahepatically(approximately 90%).In the univariate and multivariate Cox regression analysis,age,tumor site,grade and stage,subtype,surgery,and chemotherapy were associated with OS and CSS(P<0.05).CONCLUSION Incidence and IB mortality of invasive IPNB trended steadily downward.The heterogeneity of IPNB comprises site and the tumor’s mucin-producing status.

Risk stratification in gastric cancer lung metastasis: Utilizing an overall survival nomogram and comparing it with previous staging

BACKGROUND Gastric cancer(GC)is prevalent and aggressive,especially when patients have distant lung metastases,which often places patients into advanced stages.By identifying prognostic variables for lung metastasis in GC patients,it may be po-ssible to construct a good prediction model for both overall survival(OS)and the cumulative incidence prediction(CIP)plot of the tumour.AIM To investigate the predictors of GC with lung metastasis(GCLM)to produce nomograms for OS and generate CIP by using cancer-specific survival(CSS)data.METHODS Data from January 2000 to December 2020 involving 1652 patients with GCLM were obtained from the Surveillance,epidemiology,and end results program database.The major observational endpoint was OS;hence,patients were se-parated into training and validation groups.Correlation analysis determined va-rious connections.Univariate and multivariate Cox analyses validated the independent predictive factors.Nomogram distinction and calibration were performed with the time-dependent area under the curve(AUC)and calibration curves.To evaluate the accuracy and clinical usefulness of the nomograms,decision curve analysis(DCA)was performed.The clinical utility of the novel prognostic model was compared to that of the 7th edition of the American Joint Committee on Cancer(AJCC)staging system by utilizing Net Reclassification Improvement(NRI)and Integrated Discrimination Improvement(IDI).Finally,the OS prognostic model and Cox-AJCC risk stratification model modified for the AJCC system were compared.RESULTS For the purpose of creating the OS nomogram,a CIP plot based on CSS was generated.Cox multivariate regression analysis identified eleven significant prognostic factors(P<0.05)related to liver metastasis,bone metastasis,primary site,surgery,regional surgery,treatment sequence,chemotherapy,radiotherapy,positive lymph node count,N staging,and time from diagnosis to treatment.It was clear from the DCA(net benefit>0),time-de-pendent ROC curve(training/validation set AUC>0.7),and calibration curve(reliability slope closer to 45 degrees)results that the OS nomogram demonstrated a high level of predictive efficiency.The OS prediction model(New Model AUC=0.83)also performed much better than the old Cox-AJCC model(AUC difference between the new model and the old model greater than 0)in terms of risk stratification(P<0.0001)and verification using the IDI and NRI.CONCLUSION The OS nomogram for GCLM successfully predicts 1-and 3-year OS.Moreover,this approach can help to ap-propriately classify patients into high-risk and low-risk groups,thereby guiding treatment.

Analysis of cancer-specific survival in patients with metastatic colorectal cancer: A evidence-based medicine study

BACKGROUND Metastatic colorectal cancer(mCRC)is a common malignancy whose treatment has been a clinical challenge.Cancer-specific survival(CSS)plays a crucial role in assessing patient prognosis and treatment outcomes.However,there is still li-mited research on the factors affecting CSS in mCRC patients and their corre-lation.AIM To predict CSS,we developed a new nomogram model and risk grading system to classify risk levels in patients with mCRC.METHODS Data were extracted from the United States Surveillance,Epidemiology,and End Results database from 2018 to 2023.All eligible patients were randomly divided into a training cohort and a validation cohort.The Cox proportional hazards model was used to investigate the independent risk factors for CSS.A new nomogram model was developed to predict CSS and was evaluated through internal and external validation.RESULTS A multivariate Cox proportional risk model was used to identify independent risk factors for CSS.Then,new CSS columns were developed based on these factors.The consistency index(C-index)of the histogram was 0.718(95%CI:0.712-0.725),and that of the validation cohort was 0.722(95%CI:0.711-0.732),indicating good discrimination ability and better performance than tumor-node-metastasis staging(C-index:0.712-0.732).For the training set,0.533,95%CI:0.525-0.540;for the verification set,0.524,95%CI:0.513-0.535.The calibration map and clinical decision curve showed good agreement and good potential clinical validity.The risk grading system divided all patients into three groups,and the Kaplan-Meier curve showed good stratification and differentiation of CSS between different groups.The median CSS times in the low-risk,medium-risk,and high-risk groups were 36 months(95%CI:34.987-37.013),18 months(95%CI:17.273-18.727),and 5 months(95%CI:4.503-5.497),respectively.CONCLUSION Our study developed a new nomogram model to predict CSS in patients with synchronous mCRC.In addition,the risk-grading system helps to accurately assess patient prognosis and guide treatment.

Application of geographical information system technology to epidemiological surveillance and prevention and cure decision-making for SARS

Objective:To expound geographical information system (GIS) technology is a very important tool when it was employed to assist to present the distribution by time and place and the model of transmission of infectious disease. Methods: We illustrated the assistant decision-making support function of GIS with an example of the spatial decision support system for SARS controlling in Shaanxi province of China which was developed by us. Results: The spatial decision support system established by applying GIS technology fulfilled the needs of real-time collection and management and dissemination SARS information and of surveillance and analysis the epidemic situation of SARS. Conclusion: Occurrence and epidemic of diseases, implement prevention and intervention measures and collocation hygienic resources are all with the characteristic of the variation of time and space, therefore, GIS technology has become a powerful tool for identifying risk factors of diseases, providing clues of causation of diseases , evaluating the effects of intervention measures and drawing a health management plan.

Case-by-Case Surveillance for Bacterial Meningitis in Benin: Data Analysis, 2016 to 2018

Background: Bacterial meningitis is an inflammation of the meninges caused mainly by three bacterial species Neisseria meningitidis, Streptococcus pneumoniae and Haemophilus influenzae that are transmitted by nasopharyngeal secretions emitted by carriers. Meningitis is a public health problem in Benin, like all countries in the African meningitis belt. This study aims to analyze the epidemiological surveillance data of meningitis in Benin from 2016 to 2018. Methods: Each suspect case of meningitis was recorded and Cerebrospinal Fluid (CSF) samples were collected. CSF collection was accompanied by the Integrated Disease Surveillance and Response form. This sheet provides information on the patient’s social-demographic and epidemiological data. CSF specimens were sent to the laboratory for analysis and identification (Gram stain, biochemical parameters, and latex agglutination test) of pathogens according to the WHO standards. Results: Of the 2992 patients with suspected meningitis, 2893 were hospitalized with a death rate of 9.4% (281/2992). The sex ratio of registered patients was 1.29 in favor of men. The median age was 4 years (min: 0;max: 90). Patients younger than five years were the most represented (44.8%). During the study period, there was a decrease in the incidence of meningitis per 100,000 inhabitants (6.3 to 3.2 from 2016 to 2018). Of 2928 CSF samples collected we were able to identify 899 pathogenic bacterial species. The most represented species are S. pneumoniae (63.4%), N. meningitidis (24.4%) and H. influenzae (12.2%). Conclusion: The burden of disease is disproportionate in the northern departments as in others. The frequency of bacterial meningitis in the northern region increased during the study period. However, deaths have been recorded in the departments of the South (“Atlantic”, “Plateau”). This suggests an improvement in epidemiological surveillance and case management throughout the national territory.

Phylogenetic and epidemiological characteristics of H9N2 avian influenza viruses in Shandong Province, China from 2019 to 2021

H9N2 avian influenza virus(AIV) has widely circulated in poultry worldwide and sporadic infections in humans and mammals. During our surveillance of chicken from 2019 to 2021 in Shandong Province, China, we isolated 11 H9N2AIVs. Phylogenetic analyses showed that the eight gene segments of the 11 isolates were closely related to several sublineages of Eurasian lineage: BJ/94-like clades(HA and NA genes), G1-like clades(PB2 and M genes), and SH/F/98-like clades(PB1, PA, NP and NS genes). The isolates showed mutation sites that preferentially bind to humanlike receptors(HA) and mammalian fitness sites(PB2, PB1 and PA), as well as mutations in antigen and drug resistance sites. Moreover, studies with mice revealed four isolates with varying levels of pathogenicity. The average antibody titer of the H9N2 AIVs was 8.60 log2. Based on our results, the epidemiological surveillance of H9N2 AIVs should be strengthened.

Survival benefits and disparities in radiation therapy for elderly patients with pancreatic ductal adenocarcinoma

BACKGROUND Older patients represent a unique subgroup of the cancer patient population,for which the role of cancer therapy requires special consideration.However,the outcomes of radiation therapy(RT)in elderly patients with pancreatic ductal adenocarcinoma(PDAC)are not well-defined in the literature.AIM To explore the use and effectiveness of RT in the treatment of elderly patients with PDAC in clinical practice.METHODS Data from patients with PDAC aged≥65 years between 2004 and 2018 were collected from the Surveillance,Epidemiology,and End Results database.Multivariate logistic regression analysis was performed to determine factors associated with RT administration.Overall survival(OS)and cancer-specific survival(CSS)were evaluated using the Kaplan–Meier method with the log-rank test.Univariate and multivariate analyses with the Cox proportional hazards model were used to identify prognostic factors for OS.Propensity score matching(PSM)was applied to balance the baseline characteristics between the RT and non-RT groups.Subgroup analyses were performed based on clinical characteristics.RESULTS A total of 12245 patients met the inclusion criteria,of whom 2551(20.8%)were treated with RT and 9694(79.2%)were not.The odds of receiving RT increased with younger age,diagnosis in an earlier period,primary site in the head,localized disease,greater tumor size,and receiving chemotherapy(all P<0.05).Before PSM,the RT group had better outcomes than did the non-RT group[median OS,14.0 vs 6.0 mo;hazard ratio(HR)for OS:0.862,95%confidence interval(CI):0.819–0.908,P<0.001;and HR for CSS:0.867,95%CI:0.823–0.914,P<0.001].After PSM,the survival benefit associated with RT remained comparable(median OS:14.0 vs 11.0 mo;HR for OS:0.818,95%CI:0.768–0.872,P<0.001;and HR for CSS:0.816,95%CI:0.765–0.871,P<0.001).Subgroup analysis revealed that the survival benefits(OS and CSS)of RT were more significant in patients aged 65 to 80 years,in regional and distant stages,with no surgery,and receiving chemotherapy.CONCLUSION RT improved the outcome of elderly patients with PDAC,particularly those aged 65 to 80 years,in regional and distant stages,with no surgery,and who received chemotherapy.Further prospective studies are warranted to validate our results.

Risk factors,prognostic predictors,and nomograms for pancreatic cancer patients with initially diagnosed synchronous liver metastasis

BACKGROUND Liver metastasis(LM)remains a major cause of cancer-related death in patients with pancreatic cancer(PC)and is associated with a poor prognosis.Therefore,identifying the risk and prognostic factors in PC patients with LM(PCLM)is essential as it may aid in providing timely medical interventions to improve the prognosis of these patients.However,there are limited data on risk and prognostic factors in PCLM patients.AIM To investigate the risk and prognostic factors of PCLM and develop corresponding diagnostic and prognostic nomograms.METHODS Patients with primary PC diagnosed between 2010 and 2015 were reviewed from the Surveillance,Epidemiology,and Results Database.Risk factors were identified using multivariate logistic regression analysis to develop the diagnostic mode.The least absolute shrinkage and selection operator Cox regression model was used to determine the prognostic factors needed to develop the prognostic model.The performance of the two nomogram models was evaluated using receiver operating characteristic(ROC)curves,calibration plots,decision curve analysis(DCA),and risk subgroup classification.The Kaplan-Meier method with a logrank test was used for survival analysis.RESULTS We enrolled 33459 patients with PC in this study.Of them,11458(34.2%)patients had LM at initial diagnosis.Age at diagnosis,primary site,lymph node metastasis,pathological type,tumor size,and pathological grade were identified as independent risk factors for LM in patients with PC.Age>70 years,adenocarcinoma,poor or anaplastic differentiation,lung metastases,no surgery,and no chemotherapy were the independently associated risk factors for poor prognosis in patients with PCLM.The C-index of diagnostic and prognostic nomograms were 0.731 and 0.753,respectively.The two nomograms could accurately predict the occurrence and prognosis of patients with PCLM based on the observed analysis results of ROC curves,calibration plots,and DCA curves.The prognostic nomogram could stratify patients into prognostic groups and perform well in internal validation.CONCLUSION Our study identified the risk and prognostic factors in patients with PCLM and developed corresponding diagnostic and prognostic nomograms to help clinicians in subsequent clinical evaluation and intervention.External validation is required to confirm these results.

Comparison of clinicopathological characteristics and survival outcomes between gallbladder mucinous adenocarcinoma and gallbladder adenocarcinoma:A propensity score-matched study

BACKGROUND Gallbladder mucinous adenocarcinoma(GBMAC)is a rare subtype of gallbladder adenocarcinoma(GBAC),with limited knowledge of its survival outcomes from small case series and single-center retrospective analysis.AIM To compare the clinicopathological characteristics of GBMAC with typical GBAC and its prognostic factors to gain insights into this field.METHODS This study was conducted using data from the Surveillance,Epidemiology,and End Results database,including cases of GBMAC and typical GBAC diagnosed from 2010 to 2017.The Pearson chi-square test or Fisher exact test was used to examine the differences in clinicopathological features between these two cohorts.In addition,propensity score matching(PSM)analysis was performed to balance the selection biases.Univariate and multivariate Cox hazards regression analyses were performed to determine independent prognostic factors for cancer-speci
c survival(CSS)and overall survival(OS).The Kaplan–Meier curves and log-rank tests were used to assess the OS and CSS of GBMAC and typical GBAC patients.RESULTS The clinicopathological and demographic characteristics of GBMAC were different from typical GBAC.They included a larger proportion of patients with unmarried status,advanced American Joint Committee on Cancer(AJCC)stage,higher T stage,higher N1 stage rate and lower N0 and N2 stage rates(P<0.05).Multivariate analyses demonstrated that surgery[OS:Hazard ratio(HR)=2.27,P=0.0037;CSS:HR=2.05,P=0.0151],chemotherapy(OS:HR=6.41,P<0.001;CSS:HR=5.24,P<0.001)and advanced AJCC stage(OS:Stage IV:HR=28.99,P=0.0046;CSS:Stage III:HR=12.31,P=0.015;stage IV:HR=32.69,P=0.0015)were independent prognostic indicators for OS and CSS of GBMAC patients.Furthermore,after PSM analysis,there was no significant difference between GBMAC and matched typical GBAC patients regarding OS(P=0.82)and CSS(P=0.69).CONCLUSION The biological behaviors of GBMAC are aggressive and significantly different from that of typical GBAC.However,they show similar survival prognoses.Surgery,chemotherapy,and lower AJCC stage were associated with better survival outcomes.Further research is needed in the future to verify these results.

Advantage of log odds of positive lymph nodes in prognostic evaluation of patients with early-onset colon cancer

BACKGROUND Colon cancer(CC)is one of the most common cancers of the digestive tract,the third most common cancer worldwide,and the second most common cause of cancer-related deaths.Previous studies have demonstrated a higher risk of lymph node metastasis(LNM)in young patients with CC.It might be reasonable to treat patients with early-onset locally advanced CC with extended lymph node dissection.However,few studies have focused on early-onset CC(ECC)patients with LNM.At present,the methods of predicting and evaluating the prognosis of ECC patients with LNM are controversial.From the data of patients with CC obtained from the Surveillance,Epidemiology,and End Results(SEER)database,data of young patients with ECC(≤50 years old)was screened.Patients with unknown data were excluded from the study,while the remaining patients were included.The patients were randomly divided into a training group(train)and a testing group(test)in the ratio of 7:3,while building the model.The model was constructed by the training group and verified by the testing group.Using multiple Cox regression models to compare the prediction efficiency of LNM indicators,nomograms were built based on the best model selected for overall survival(OS)and cause-specific survival(CSS).In the two groups,the performance of the nomogram was evaluated by constructing a calibration plot,time-dependent area under the curve(AUC),and decision curve analysis.Finally,the patients were grouped based on the risk score predicted by the prognosis model,and the survival curve was constructed after comparing the survival status of the high and low-risk groups.RESULTS Records of 26922 ECC patients were screened from the SEER database.N classification,positive lymph nodes(PLN),lymph node ratio(LNR)and log odds of PLN(LODDS)were considered to be independent predictors of OS and CSS.In addition,independent risk factors for OS included gender,race,marital status,primary site,histology,grade,T,and M classification,while the independent prognostic factors for CSS included race,marital status,primary site,grade,T,and M classification.The prediction model including LODDS is composed of minimal Akaike information criterion,maximal concordance indexes,and AUCs.Factors including gender,race,marital status,primary site,histology,grade,T,M classification,and LODDS were integrated into the OS nomogram,while race,marital status,primary site,grade,T,M classification,and LODDS were included into the CSS nomogram.The nomogram representing both cohorts had been successfully verified in terms of prediction accuracy and clinical practicability.CONCLUSION LODDS is superior to N-stage,PLN,and LNR of ECC.The nomogram containing LODDS might be helpful in tumor evaluation and clinical decision-making,since it provides an appropriate prediction of ECC.

Epidemiologic characteristics and risk factors associated with overall survival for patients with mucinous colorectal cancer:A population-based study

BACKGROUND Mucinous adenocarcinoma(MC)has attracted much attention as a distinct histologic subtype of colorectal cancer in recent years.However,data about its epidemiologic and prognostic characteristics are limited.Therefore,patient data extracted from the National Cancer Institute’s Surveillance,Epidemiology,and End Results Program were collected to analyze the epidemiologic and clinicopathological characteristics of MC.AIM To determine the epidemiologic and clinicopathological characteristics of MC.METHODS The incidence trend of MC was calculated through the Joinpoint Regression Program.Cox regression analyses were performed to identify prognostic factors associated with overall survival(OS).A nomogram was established to predict the survival probability of individual patients with MC.RESULTS We found that rates of MC decreased from 4.50/100000 in 2000 to 1.54/100000 in 2018.Rates of MCs in patients aged≤50 years decreased 2.27%/year during 2000-2018.The incidence of appendiceal MCs increased from 0.14/100000 in 2000 to 0.24/100000 in 2018,while the incidence in other anatomic subsites continued to decrease.On multivariable Cox analyses,age,race,tumor site,T stage,N stage,M stage,surgery,and chemotherapy were associated with OS.A nomogram was developed based on these factors,and the area under the curve for 1-year,3-year,and 5-year OS in the training cohort was 0.778,0.778,and 0.768,respectively.CONCLUSION Our results demonstrated that MC incidence decreased in almost all anatomic subgroups except for the appendix.A nomogram predicting the survival probability of patients with MCs showed good performance.

Surveillance, epidemiology, and pathogen spectrum of hand, foot, and mouth disease in mainland of China from 2008 to 2017

Hand,foot and mouth disease(HFMD)was reported in May 2,2008 to be the 38th legally notifiable disease in China's National Notifiable Disease Reporting and Surveillance System.In order to solve the infection,an extensive three-level HFMD surveillance laboratory network was established.In this study,the framework of that network is assessed and the incidence of HFMD in China from 2008 to 2017 is reported using a descriptive epidemiologic method.During these 10 years,a series of techniques have been widely applied in all the network laboratories.Using information and material obtained from the network,a virus bank and database containing 18,238 viruses were established.Nationally,18,184,834 HFMD cases,including 152,436 severe cases and 3633 fatal cases,were reported in mainland of China.The average annual incidence in the population was 133.99/100,000 people,with a maximum incidence of 205.06/100,000 people in 2014.The incidence and mortality rates of HFMD were the highest in children aged 1–2 years.The numbers of reported cases fluctuated,with a high incidence observed every 2 years.An overall increase in the number of reported cases was also observed throughout the study period.Despite this,the incidence of severe cases and the mortality rate have been decreasing.High-risk regions are located in southern,eastern,and central China.Two peaks of HFMD infection cases were observed annually except for Northeast China.Different proportions of enterovirus serotypes were observed during the studied years.The predominant enterovirus varies from year to year,but the disease severity is always closely related to the specific serotype.EV-A71 is the dominant serotype associated with severe and fatal cases,with constituent ratios of 70.03%and 92.23%,respectively.The studied highly sensitive and efficient surveillance network provides information that is critical for prevention and control of the disease.It is extremely necessary and important to continuously conduct extensive virological surveillance for HFMD.

Development and validation of a prognostic nomogram for colorectal cancer after surgery

BACKGROUND A nomogram is a diagram that aggregates various predictive factors through multivariate regression analysis,which can be used to predict patient outcomes intuitively.Lymph node(LN)metastasis and tumor deposit(TD)conditions are two critical factors that affect the prognosis of patients with colorectal cancer(CRC)after surgery.At present,few effective tools have been established to predict the overall survival(OS)of CRC patients after surgery.AIM To screen out suitable risk factors and to develop a nomogram that predicts the postoperative OS of CRC patients.METHODS Data from a total of 3139 patients diagnosed with CRC who underwent surgical removal of tumors and LN resection from 2010 to 2015 were collected from the Surveillance,Epidemiology,and End Results program.The data were divided into a training set(n=2092)and a validation set(n=1047)at random.The Harrell concordance index(C-index),Akaike information criterion(AIC),and area under the curve(AUC)were used to assess the predictive performance of the N stage from the American Joint Committee Cancer tumor-node-metastasis classification,LN ratio(LNR),and log odds of positive lymph nodes(LODDS).Univariate and multivariate analyses were utilized to screen out the risk factors significantly correlating with OS.The construction of the nomogram was based on Cox regression analysis.The C-index,receiver operating characteristic(ROC)curve,and calibration curve were employed to evaluate the discrimination and prediction abilities of the model.The likelihood ratio test was used to compare the sensitivity and specificity of the final model to the model with the N stage alone to evaluate LN metastasis.RESULTS The predictive efficacy of the LODDS was better than that of the LNR based on the C-index,AIC values,and AUC values of the ROC curve.Seven independent predictive factors,namely,race,age at diagnosis,T stage,M stage,LODDS,TD condition,and serum carcinoembryonic antigen level,were included in the nomogram.The C-index of the nomogram for OS prediction was 0.8002(95%CI:0.7839-0.8165)in the training set and 0.7864(95%CI:0.7604-0.8124)in the validation set.The AUC values of the ROC curve predicting the 1-,3-,and 5-year OS were 0.846,0.841,and 0.825,respectively,in the training set and 0.823,0.817,and 0.835,respectively,in the validation test.Great consistency between the predicted and actual observed OS for the 1-,3-,and 5-year OS in the training set and validation set was shown in the calibration curves.The final nomogram showed a better sensitivity and specificity than the nomogram with N stage alone for evaluating LN metastasis in both the training set(-4668.0 vs-4688.3,P<0.001)and the validation set(-1919.5 vs-1919.8,P<0.001)through the likelihood ratio test.CONCLUSION The nomogram incorporating LODDS,TD,and other risk factors showed great predictive accuracy and better sensitivity and specificity and represents a potential tool for therapeutic decision-making.

National trends in resection of the distal pancreas

AIM:To investigate national trends in distal pancreatectomy(DP) through query of three national patient care databases.METHODS:From the Nationwide Inpatient Sample(NIS,2003-2009),the National Surgical Quality Improvement Project(NSQIP,2005-2010),and the Surveillance Epidemiology and End Results(SEER,2003-2009) databases using appropriate diagnostic and procedural codes we identified all patients with a diagnosis of a benign or malignant lesion of the body and/or tail of the pancreas that had undergone a partial or distal pancreatectomy.Utilization of laparoscopy was defined in NIS by the International Classification of Diseases,Ninth Revision correspondent procedure code;and in NSQIP by the exploratory laparoscopy or unlisted procedure current procedural terminology codes.In SEER,patients were identified by the International Classification of Diseases for Oncology,Third Edition diagnosis codes and the SEER Program Code Manual,third edition procedure codes.We analyzed the databases with respect to trends of inpatient outcome metrics,oncologic outcomes,and hospital volumes in patients with lesions of the neck and body of the pancreas that underwent operative resection.RESULTS:NIS,NSQIP and SEER identified 4242,2681 and 11 082 DP resections,respectively.Overall,laparoscopy was utilized in 15%(NIS) and 27%(NSQIP).No significant increase was seen over the course of the study.Resection was performed for malignancy in 59%(NIS) and 66%(NSQIP).Neither patient Body mass index nor comorbidities were associated with operative approach(P = 0.95 and P = 0.96,respectively).Mortality(3% vs 2%,P = 0.05) and reoperation(4% vs 4%,P = 1.0) was not different between laparoscopy and open groups.Overall complications(10% vs 15%,P < 0.001),hospital costs [44 741 dollars,interquartile range(IQR) 28 347-74 114 dollars vs 49 792 dollars,IQR 13 299-73 463,P = 0.02] and hospital length of stay(7 d,IQR 4-11 d vs 7 d,IQR 6-10,P < 0.001) were less when laparoscopy was utilized.One and two year survival after resection for malignancy were unchanged over the course of the study(ductal adenocarinoma 1-year 63.6% and 2-year 35.1%,P = 0.53;intraductal papillary mucinous neoplasm and nueroendocrine 1-year 90% and 2-year 84%,P = 0.25).The majority of resections were performed in teaching hospitals(77% NIS and 85% NSQIP),but minimally invasive surgery(MIS) was not more likely to be used in teaching hospitals(15% vs 14%,P = 0.26).Hospitals in the top decile for volume were more likely to be teaching hospitals than lower volume deciles(88% vs 43%,P < 0.001),but were no more likely to utilize MIS at resection.Complication rate in teaching and the top decile hospitals was not significantly decreased when compared to non-teaching(15% vs 14%,P = 0.72) and lower volume hospitals(14% vs 15%,P = 0.99).No difference was seen in the median number of lymph nodes and lymph node ratio in N1 disease when compared by year(P = 0.17 and P = 0.96,respectively).CONCLUSION:There appears to be an overall underutilization of laparoscopy for DP.Centralization does not appear to be occurring.Survival and lymph node harvest have not changed.

Long-term survival of patients with stage Ⅱ and Ⅲgastric cancer who underwent gastrectomy with inadequate nodal assessment

BACKGROUND Gastric cancer is an aggressive disease with frequent lymph node(LN)involvement.The NCCN recommends a D2 lymphadenectomy and the harvesting of at least 16 LNs.This threshold has been the subject of great debate,not only for the extent of surgery but also for more appropriate staging.The reclassification of stage IIB through IIIC based on N3b nodal staging in the eighth edition of the American Joint Committee on Cancer(AJCC)staging system highlights the efforts to more accurately discriminate survival expectancy based on nodal number.Furthermore,studies have suggested that pathologic assessment of 30 or more LNs improve prognostic accuracy and is required for proper staging of gastriccancer.AIM To evaluate the long-term survival of advanced gastric cancer patients who deviated from expected survival curves because of inadequate nodal evaluation.METHODS Eligible patients were identified from the Surveillance,Epidemiology,and End Results database.Those with stage II-III gastric cancer were considered for inclusion.Three groups were compared based on the number of analyzed LNs.They were inadequate LN assessment(ILA,<16 LNs),adequate LN assessment(ALA,16-29 LNs),and optimal LN assessment(OLA,≥30 LNs).The main outcomes were overall survival(OS)and cancer-specific survival.Data were analyzed by the Kaplan-Meier product-limit method,log-rank test,hazard risk,and Cox proportional univariate and multivariate models.Propensity score matching(PSM)was used to compare the ALA and OLA groups.RESULTS The analysis included 11607 patients.Most had advanced T stages(T3=48%;T4=42%).The pathological AJCC stage distribution was IIA=22%,IIB=18%,IIIA=26%,IIIB=22%,and IIIC=12%.The overall sample divided by the study objective included ILA(50%),ALA(35%),and OLA(15%).Median OS was 24 mo for the ILA group,29 mo for the ALA group,and 34 mo for the OLA group(P<0.001).Univariate analysis showed that the ALA and OLA groups had better OS than the ILA group[ALA hazard ratio(HR)=0.84,95%confidence interval(CI):0.79-0.88,P<0.001 and OLA HR=0.73,95%CI:0.68-0.79,P<0.001].The OS outcome was confirmed by multivariate analysis(ALA HR=0.68,95%CI:0.64-0.71,P<0.001 and OLA:HR=0.48,95%CI:0.44-0.52,P<0.001).A 1:1 PSM analysis in 3428 patients found that the OLA group had better survival than the ALA group(OS:OLA median=34 mo vs ALA median=26 mo,P<0.001,which was confirmed by univariate analysis(HR=0.81,95%CI:0.75-0.89,P<0.001)and multivariate analysis:(HR=0.71,95%CI:0.65-0.78,P<0.001).CONCLUSION Proper nodal staging is a critical issue in gastric cancer.Assessment of an inadequate number of LNs places patients at high risk of adverse long-term survival outcomes.

Factors associated with 5-year survival of combined hepatocellular and cholangiocarcinoma

BACKGROUND Combined hepatocellular and cholangiocarcinoma(HCC/CC)is a rare primary hepatic malignancy which carries a poor prognosis due to its aggressive nature.Few centers have enough cases to draw definitive conclusions and there is limited understanding of prognosis.Given the rarity of HCC/CC,an analysis of large national cancer database was needed to obtain larger number of HCC/CC cases.AIM To identify associated factors for 5-year survival of HCC/CC.METHODS We conducted a retrospective study of The Surveillance,Epidemiology,and End Results(SEER)database obtained from SEER*Stat 8.3.6 software.Previously defined histology code 8180 for the International Classification of Disease for Oncology,3rd edition was used to identify HCC/CC cases from 2004 to 2015.We collected demographics,American Joint Committee on Cancer(AJCC)stage,treatment,tumor size,and survival data.These data were converted to categorical variables.The Shapiro-Wilk normality test was used to assess normal distribution.Mann-Whitney U test was used to compare continuous variables without normal distribution,and t-test was used to compare continuous variables with a normal distribution.The Kaplan-Meier survival curve analyzed 5-year survival.Univariate and multivariate logistic regression model was used to analyze factors associated with 5-year survival.Multivariate Cox proportional hazard regression was done on 5-year survival.We defined P<0.05 was statistically significant.RESULTS We identified 497 patients with the following characteristics:Mean age 62.4 years(SD:11.3),149(30.0%)were female,racial distribution was:276(55.5%)white,53(10.7%)black,84(16.9%)Asian and Pacific Islander(API),77(15.5%)Hispanic,and 7(1.4%)others or unknown.Stage I/II disease occurred in 41.5%and tumor size<50 mm was seen in 35.6%of patients.Twenty-four(4.8%)received locoregional therapy(LRT),119(23.9%)underwent resection,and 50(10.1%)underwent liver transplantation.The overall median survival was 6 mo[Interquartile range(IQR):1-22].After multivariate logistic regression,tumor size<50 mm[Odds ratios(OR):2.415,P=0.05],resection(OR:12.849,P<0.01),and transplant(OR:27.129,P<0.01)showed significance for 5-year survival.Age>60,sex,race,AJCC stages,metastasis,and LRT were not significant.However,API vs white showed significant OR of 2.793(CI:1.120-6.967).Cox proportional hazard regression showed AJCC stages,tumor size<50 mm,LRT,resection,and transplant showed significant hazard ratio.CONCLUSION HCC/CC patients with tumor size<50 mm,resection,and transplant were associated with an increase in 5-year survival.API showed advantageous OR and hazard ratios over white,black.

Adenosquamous carcinoma may have an inferior prognosis to signet ring cell carcinoma in patients with stages Ⅰ and Ⅱ gastric cancer

BACKGROUND Primary gastric adenosquamous carcinoma(ASC)is an exceedingly rare histological subtype.Gastric signet ring cell carcinoma(SRC)is a unique subtype with distinct tumor biology and clinical features.The prognosis of gastric ASC vs SRC has not been well established to date.We hypothesized that further knowledge about these distinct cancers would improve the clinical management of such patients.AIM To investigate the clinicopathological characteristics and prognosis of gastric ASC vs SRC.METHODS A cohort of gastric cancer patients was retrospectively collected from the Surveillance,epidemiology,and end results program database.The 1:4 propensity score matching was performed among this cohort.The clinicopathological features and prognosis of gastric ASC were compared with gastric SRC by descriptive statistics.Kaplan-Meier method was utilized to calculate the median survival of the two groups of patients.Cox proportional hazard regression models were used to identify prognostic factors.RESULTS Totally 6063 patients with gastric ASC or SRC were identified.A cohort of 465 patients was recruited to the matched population,including 370 patients with SRC and 95 patients with ASC.Gastric ASC showed an inferior prognosis to SRC after propensity score matching.In the post-matching cohort,the median cancer specific survival was 13.0(9.7-16.3)mo in the ASC group vs 20.0(15.7-24.3)mo in the SRC group,and the median overall survival had a similar trend(P<0.05).ASC and higher tumor-node-metastasis stage were independently associated with a poor survival,while radiotherapy and surgery were independent protective factors for improved prognosis.Subgroup survival analysis revealed that the prognosis of ASC was inferior to SRC only in stages I and II patients.CONCLUSION ASC may have an inferior prognosis to SRC in patients with stages I and II gastric cancer.Our study supports radiotherapy and surgery for the future management of this clinically rare entity.

Critical prognostic value of the log odds of negative lymph nodes/tumor size in rectal cancer patients

BACKGROUND The number of negative lymph nodes(NLNs)and tumor size are associated with prognosis in rectal cancer patients undergoing surgical resection.However,little is known about the prognostic significance of the NLN count after adjusting for tumor size.AIM To assess the prognostic impact of the log odds of NLN/tumor size(LONS)in rectal cancer patients.METHODS Data of patients with stage I–III rectal cancer were extracted from the Surveillance,Epidemiology,and End Results Program database.These patients were randomly divided into a training cohort and a validation cohort.Univariate and multivariate Cox regression analyses were used to determine the prognostic value of the LONS.The optimal cutoff values of LONS were calculated using the"X-tile"program.Stratified analysis of the effect of LONS on cancer-specific survival(CSS)and overall survival(OS)were performed.The Kaplan-Meier method with the log-rank test was used to plot the survival curve and compare the survival data among the different groups.RESULTS In all,41080 patients who met the inclusion criteria were randomly divided into a training cohort(n=28775,70%)and a validation cohort(n=12325,30%).Univariate and multivariate analyses identified the continuous variable LONS as an independent prognostic factor for CSS[training cohort:Hazard ratio(HR)=0.47,95%confidence interval(CI):0.44–0.51,P<0.001;validation cohort:HR=0.46,95%CI:0.41-0.52,P<0.001]and OS(training cohort:HR=0.53,95%CI:0.49-0.56,P<0.001;validation cohort:HR=0.52,95%CI:0.42-0.52,P<0.001).The Xtile program indicated that the difference in CSS was the most significant for LONS of-0.8,and the cutoff value of-0.4 can further distinguish patients with a better prognosis in the high LONS group.Stratified analysis of the effect of the categorical variable LONS on CSS and OS revealed that LONS was also an independent predictor,independent of pN stage,pT stage,tumor-node-metastasis stage,site,age,sex,the number of examined lymph nodes,race,preoperative radiotherapy and carcinoembryonic antigen level.CONCLUSION LONS is associated with improved survival of rectal cancer patients independent of other clinicopathological factors.

Colorectal adenocarcinoma patients with M1a diseases gain more clinical benefits from palliative primary tumor resection than those with M1b diseases: A propensity score matching analysis

BACKGROUND Surgical resection is regarded as the only potentially curative treatment option for patients with metastatic colorectal cancer(CRC).The National Comprehensive Cancer Network clinical practice guidelines do not recommend palliative surgery unless there is a risk of severe symptoms.However,accumulating evidence has shown that palliative surgery is associated with more favorable outcomes for patients with metastatic CRC.AIM To investigate the separate role of palliative primary tumor resection for patients with stage IVA(M1a diseases)and stage IVB(M1b diseases)colorectal adenocarcinoma(CRA).METHODS CRA patients diagnosed from 2010 to 2015 with definite M1a and M1b categories according to the 8th edition of American Joint Committee on Cancer staging system were selected from the Surveillance Epidemiology and End Results(SEER)database.To minimize potential selection bias,the data were adjusted by propensity score matching(PSM).Baseline characteristics,including gender,year of diagnosis,age,marital status,primary site,surgical information,race,grade,chemotherapy,and radiotherapy,were recorded and analyzed.Univariate and multivariate analyses were performed to explore the separate role of palliative surgery for patients with M1a and M1b diseases.RESULTS A total of 19680 patients with metastatic CRA were collected from the SEER database,including 10399 cases of M1a diseases and 9281 cases of M1b diseases.Common independent prognostic factors for both M1a and M1b patients included year of diagnosis,age,race,marital status,primary site,grade,surgery,and chemotherapy.After PSM adjustment,3732 and 3568 matched patients in the M1a and M1b groups were included,respectively.Patients receiving palliative primary tumor resection had longer survival time than those without surgery(P<0.001).For patients with M1a diseases,palliative resection could increase the median survival time by 9 mo;for patients with M1b diseases,palliative resection could prolong the median survival time by 7 mo.For M1a diseases,patients with lung metastasis had more clinical benefit from palliative resection than those with liver metastasis(15 mo for lung metastasis vs 8 mo for liver metastasis,P<0.001).CONCLUSION CRA patients with M1a diseases gain more clinical benefits from palliative primary tumor resection than those with M1b diseases.Those patients with M1a(lung metastasis)have superior long-term outcomes after palliative primary tumor resection.