Metastatic lymph nodes and prognosis assessed by the number of retrieved lymph nodes in gastric cancer

BACKGROUND The prognostic value of quantitative assessments of the number of retrieved lymph nodes(RLNs)in gastric cancer(GC)patients needs further study.AIM To discuss how to obtain a more accurate count of metastatic lymph nodes(MLNs)based on RLNs in different pT stages and then to evaluate patient prognosis.METHODS This study retrospectively analyzed patients who underwent GC radical surgery and D2/D2+LN dissection at the Cancer Hospital of Harbin Medical University from January 2011 to May 2017.Locally weighted smoothing was used to analyze the relationship between RLNs and the number of MLNs.Restricted cubic splines were used to analyze the relationship between RLNs and hazard ratios(HRs),and X-tile was used to determine the optimal cutoff value for RLNs.Patient survival was analyzed with the Kaplan-Meier method and log-rank test.Finally,HRs and 95%confidence intervals were calculated using Cox proportional hazards models to analyze independent risk factors associated with patient outcomes.RESULTS A total of 4968 patients were included in the training cohort,and 11154 patients were included in the validation cohort.The smooth curve showed that the number of MLNs increased with an increasing number of RLNs,and a nonlinear relationship between RLNs and HRs was observed.X-tile analysis showed that the optimal number of RLNs for pT1-pT4 stage GC patients was 26,31,39,and 45,respectively.A greater number of RLNs can reduce the risk of death in patients with pT1,pT2,and pT4 stage cancers but may not reduce the risk of death in patients with pT3 stage cancer.Multivariate analysis showed that RLNs were an independent risk factor associated with the prognosis of patients with pT1-pT4 stage cancer(P=0.044,P=0.037,P=0.003,P<0.001).CONCLUSION A greater number of RLNs may not benefit the survival of patients with pT3 stage disease but can benefit the survival of patients with pT1,pT2,and pT4 stage disease.For the pT1,pT2,and pT4 stages,it is recommended to retrieve 26,31 and 45 LNs,respectively.

Targeted delivery of docetaxel to the metastatic lymph nodes:A comparison study between nanoliposomes and activated carbon nanoparticles

The objective of this study is to compare the targeting ability of activated carbon nanoparticles and nanoliposomes,which are used as carriers for delivering docetaxel(DTX)to the metastatic lymph nodes.In this study,we first prepared the DTX-loaded activated carbon nanoparticles(DTX-AC-NPs)by modifying the activated carbon with nitric acid oxidation and absorbing DTX in the concentrated nitro-oxide nanocarbon.We then prepared DTX-loaded nanoliposomes(DTX-LPs)by the proliposome method.The physiochemical properties of DTX-AC-NPs and DTX-LPs were carefully evaluated in vitro.The metastatic lymph node uptake and the injection site retention were investigated by analyzing the DTX concentration in metastatic lymph nodes and injection sites.The result showed that DTX-AC-NPs and DTX-LPs with suitable and stable physicochemical properties could be used for in vivo lymph node targeting studies.DTX-AC-NPs significantly increased DTX-AUC_((0-24)) and prolonged DTX-retention in metastatic lymph nodes compared to DTX-LPs and non-modified activate carbon in vivo.This study demonstrated activated carbon nanoparticles may be potential intralymphatic drug delivery system to preferentially target regional metastatic lymph nodes.

Deep neural network-assisted computed tomography diagnosis of metastatic lymph nodes from gastric cancer

Background:Artificial intelligence-assisted image recognition technology is currently able to detect the target area of an image and fetch information to make classifications according to target features.This study aimed to use deep neural netAVorks for computed tomography(CT)diagnosis of perigastric metastatic lymph nodes(PGMLNs)to simulate the recognition of lymph nodes by radiologists,and to acquire more accurate identification results.Methods:A total of 1371 images of suspected lymph node metastasis from enhanced abdominal CT scans were identified and labeled by radiologists and were used with 18,780 original images for faster region-based convolutional neural networks(FR-CNN)deep learning.The identification results of 6000 random CT images from 100 gastric cancer patients by the FR-CNN were compared with results obtained from radiologists in terms of their identification accuracy.Similarly,1004 CT images with metastatic lymph nodes that had been post-operatively confirmed by pathological examination and 11,340 original images were used in the identification and learning processes described above.The same 6000 gastric cancer CT images were used for the verification,according to which the diagnosis results were analyzed.Results:In the initial group,precision-recall curves were generated based on the precision rates,the recall rates of nodule classes of the training set and the validation set;the mean average precision(mAP)value was 0.5019.To verify the results of the initial learning group,the receiver operating characteristic curves was generated,and the corresponding area under the curve(AUC)value was calculated as 0.8995.After the second phase of precise learning,all the indicators were improved,and the mAP and AUC values were 0.7801 and 0.9541,respectively.Conclusion:Through deep learning,FR-CNN achieved high judgment effectiveness and recognition accuracy for CT diagnosis of PGMLNs.

Differential diagnosis of metastasis from non-metastatic lymph nodes in cervical cancers： pilot study of diffusion weighted imaging with background suppression at 3T magnetic resonance

Background Diffusion weighted imaging with background suppression （DWIBS） is potentially useful in detecting metastatic lymph nodes. This study aimed to evaluate the efficacy of DWIBS at 3T magnetic resonance （MR） for diagnosing metastatic lymph nodes in cervical cancer.Methods This retrospective study included 25 patients with cervical cancer who underwent MR examination and were treated by hysterectomy and lymphadenectomy. The metastatic and non-metastatic lymph nodes were histologically proven by operation. Apparent diffusion coefficient （ADC） values, long-axis diameters, short-axis diameters, ratio of short- to long-axis diameters of all the identifiable lymph nodes were measured and compared.Results Twenty-five primary tumor lesions, 17 metastatic lymph nodes and 140 non-metastatic lymph nodes were pathologically confirmed in 25 cases with cervical cancer. The difference of ADC values between primary tumor lesions,metastatic and non-metastatic lymph nodes were statistically significant （F=7.93, P=0.001）. There was no statistically significant difference between primary tumor lesions of cervical cancer and metastatic lymph nodes （t=-0.75, P=-0.456）,and the difference between primary tumor lesions and non-metastatic lymph nodes was statistically significant （t =4.68, P〈0.001）. The ADC values, long-axis diameters, short-axis diameters, ratio of short- to long-axis diameters of metastatic and non-metastatic lymph nodes were （0.86±0.36）×10-3 mm2/s vs. （1.12±0.34）×10-3 mm2/s, （1.51±0.41） cm vs.（1.19±0.36） cm, （1.16±0.35） cm vs. （0.77±0.22） cm, 0.78±0.17 vs. 0.68±0.19 respectively, and statistically significant difference existed between two groups.Conclusions DWIBS at 3T MR has the distinct advantages in detecting pelvic lymph nodes of cervical cancer.Quantitative measurement of ADC values could reflect the degree of restriction of diffusion of metastatic and non-metastatic lymph nodes. The combination of size and ADC value would be useful in the accurate diagnosis of metastatic lymph nodes.

Prognostic impact of metastatic lymph node ratio on gastric cancer after curative distal gastrectomy

AIM:To investigate the prognostic impact of metastatic lymph node ratio(rN) on gastric cancer after curative distal gastrectomy.METHODS:A total of 634 gastric cancer patients who underwent curative resection(R0) of lymph nodes at distal gastrectomy in 1995-2004.Correlations between positive nodes and retrieved nodes,between rN and retrieved nodes,and between rN and negative lymph node(LN) count were analyzed respectively.Prognostic factors were identif ied by univariate and multivariate analyses.Staging accuracy of the pN category(5th UICC/TNM system) and the rN category was compared according to the survival rates of patients.A linear regression model was used to identify the relation between rN and 5-year survival rate of the patients.RESULTS:The number of dissected LNs was related with metastatic LNs but not related with rN.Cox regression analysis showed that depth of invasion,pN and rN category were the independent predictors of survival(P < 0.05).There was a signif icant difference in survival between LN stages classif ied by the rN category or by the pN category(P < 0.05).However,no signif icant difference was found in survival rate between LN stages classif ied by the pN category or by the rN category(P > 0.05).Linear regression model showed a signif icant linear correlation between rN and the 5-year survival rate of gastric cancer patients(β = 0.862,P < 0.001).Pearson's correlation test revealed that negative LN count was negatively correlated with rN(P < 0.001).CONCLUSION:rN category is a better prognostic tool than the 5th UICC pN category for gastric cancer patients after curative distal gastrectomy.Increased negative LN count can reduce rN and improve the survival rate of gastric cancer patients.

Superiority of metastatic lymph node ratio to the 7th edition UICC N staging in gastric cancer

AIM:To compare and evaluate the appropriate prog-nostic indicators of lymph node basic staging in gastric cancer patients who underwent radical resection.METHODS:A total of 1042 gastric cancer patients who underwent radical resection and D2 lymphadenectomy were staged using the 6th and 7th edition International Union Against Cancer(UICC)N staging methods and the metastatic lymph node ratio(MLNR)staging.Ho-mogeneity,discriminatory ability,and gradient mono-tonicity of the various staging methods were compared using linear trend χ2,likelihood ratio χ2 statistics,and Akaike information criterion(AIC)calculations.The area under the curve(AUC)was calculated to compare the predictive ability of the aforementioned three stag-ing methods.RESULTS:Optimal cut-points of the MLNR were cal-culated as MLNR0(0),MLNR1(0.01-0.30),MLNR2(0.31-0.50),and MLNR3(0.51-1.00).In univariate,multivariate,and stratified analyses,MLNR staging was superior to the 6th and 7th edition UICC N stag-ing methods.MLNR staging had a higher AUC,higher linear trend and likelihood ratio χ2 scores and lower AIC values than the other two staging methods.CONCLUSION:MLNR staging predicts survival after gastric cancer more precisely than the 6th and 7th edi-tion UICC N classif ications and should be considered as an alternative to current pathological N staging.

Prognostic impact of metastatic lymph node ratio in advanced gastric cancer from cardia and fundus

AIM: To investigate the prognostic impact of the metastatic lymph node ratio (MLR) in advanced gastric cancer from the cardia and fundus. METHODS: Two hundred and thirty-six patients with gastric cancer from the cardia and fundus who underwent D2 curative resection were analyzed ret- rospectively. The correlations between MLR and the total lymph nodes, positive nodes and the total lymph nodes were analyzed respectively. The influence of MLR on the survival time of patients was determined with univariate Kaplan-Meier survival analysis and mul- tivariate Cox proportional hazard model analysis. And the multiple linear regression was used to identify the relation between MLR and the 5-year survival rate of the patients. RESULTS: The MLR did not correlate with the total lymph nodes resected (r = -0.093, P = 0.057). The 5-year overall survival rate of the whole cohort was 37.5%. Kaplan-Meier survival analysis identified that the following eight factors influenced the survival time of the patients postoperatively: gender (χ2 = 4.26, P = 0.0389), tumor size (χ2 = 18.48, P < 0.001), Borrmann type (χ2 = 7.41, P = 0.0065), histological grade (χ2 = 5.07, P = 0.0243), pT category (χ2 = 49.42, P < 0.001), pN category (χ2 = 87.7, P < 0.001), total number of re- trieved lymph nodes (χ2 = 8.22, P = 0.0042) and MLR (χ2 = 34.3, P < 0.001). Cox proportional hazard model showed that tumor size (χ2 = 7.985, P = 0.018), pTcategory (χ2 = 30.82, P < 0.001) and MLR (χ2 = 69.39, P < 0.001) independently influenced the prognosis. A linear correlation between MLR and the 5-year survival was statistically significant based on the multiple lin- ear regression (β = -0.63, P < 0.001). Hypothetically, the 5-year survival would surpass 50% when MLR was lower than 10%. CONCLUSION: The MLR is an independent prognostic factor for patients with advanced gastric cancer from the cardia and fundus. The decrease of MLR due to adequate number of total resected lymph nodes can improve the survival.

A clinical analysis of risk factor with lymph node metastatic recurrence in patients with N0 esophageal cancer after Ivor-Lewis Esophagectomy

Objective To investigate the risk factors with lymph node metastatic recurrence in patients with N0 esophageal cancer after Ivor-Lewis Esophagectomy. Methods The subjects were 82 patients with pN0 esophagea cancer who underwent Ivor-Lewis esophagectomy from January 2001 to January 2005. By using RT-PCR,VEGF C mRNA was detected in tumor issues,and Mucin (MUC1) mRNA was detected in lymph nodes. The Kaplan-Meier method was used to calculate the survival

Distribution of solitary Iymph nodes in primary gastric cancer:A retrospective study and clinical implications

AIM： To investigate the distribution pathway of metastatic lymph nodes in gastric carcinoma as a foundation for rational lymphadenectomy. METHODS： We investigated 173 cases with solitary or single station metastatic lymph nodes （LN） from among 2476 gastric carcinoma patients. The location of metastatic LN, histological type and growth patterns were analyzed retrospectively. RESULTS： Of 88 solitary node metastases cases, 65 were limited to perigastric nodes （N1）, while 23 showed skipping metastasis. Among 8 tumors in the upper third stomach, 3 involved right paracardial LN （station number： No.1）, and one in the greater curvature was found in No.1. In the 28 middle third stomach tumors, 10 were found in LN of the lesser curvature （No.3） and 6 in LN of the left gastric artery （No.7）; 5 of the 20 cases on the lesser curvature spread to No.7, while 2 of the 8 on the greater curvature metastasized to LN of the spleen hilum （No.10）. Of 52 lower third stomach tumors, 13 involved in No.3 and 19 were detected in inferior pyloric LN （No.6）; 9 of the 29 cases along the lesser curvature were involved in No.6. CONCLUSION： Transversal and skipping metastases of sentinel lymph nodes （SLN） are notable, and rational lymphadenectomy should, therefore, be performed.

Comparative genomic hybridization analysis of genetic aberrations associated with development of esophageal squamous cell carcinoma in Henan, China

AIM: To characterize cytogenetic alterations in esophageal squamous cell carcinoma (ESCC) and its metastasis. METHODS: A total of 37 cases of primary ESCC and 15 pairs of primary ESCC tumors and their matched metastatic lymph nodes cases were enrolled from Linzhou, the high incidence area for ESCC in Henan, northern China. The comparative genomic hybridization (CGH) was applied to determine the chromosomal aberrations on the DNA extracted from the frozen ESCC and metastatic lymph node samples from these patients. RESULTS: CGH showed chromosomal aberrations in all the cases. In 37 cases of primary ESCC, chromosomal profile of DNA copy number was characterized by frequently detected gains at 8q (29/37, 78%), 3q (24/37, 65%), 5p (19/37, 51%); and frequently detected losses at 3p (21/37, 57%), 8p and 9q (14/37, 38%). In 15 pairs of primary ESCC tumors and their matched metastatic lymph node cases, the majority of the chromosomal aberrations in both primary tumor and metastatic lymph node lesions were consistent with the primary ESCC cases, but new candidate regions of interest were also detected. The most significant finding is the gains of chromosome 6p with a minimum high-level amplification region at 6p12-6q12 in 7 metastatic lymph nodes butonly in 2 corresponding primary tumors (P = 0.05) and 20p with a minimum high-level amplification region at 20p12 in 11 metastatic lymph nodes but only in 5 corresponding primary tumors (P < 0.05). Another interesting finding is the loss of chromosome 10p and 10q in 8 and 7 metastatic lymph nodes but only in 2 corresponding primary tumors (P < 0.05). CONCLUSION: Using the CGH technique to detect chromosomal aberrations in both the primary tumor and its metastatic lymph nodes of ESCC, gains of 8q, 3q and 5p and loss of 3p, 8p, 9q and 13q were specifically implicated in ESCC in Linzhou population. Gains of 6p and 20p and loss of 10pq may contribute to the lymph node metastasis of ESCC. These findings suggest that the gains and losses of chromosomal regions may contain ESCC-related oncogenes and tumor suppressor genes and provide important theoretic information for identifying and cloning novel ESCC-related oncogenes and tumor suppressor genes.

Retrieved lymph nodes from different anatomic groups in gastric cancer:a proposed optimal number,comparison with other nodal classification strategies and its impact on prognosis

Background:The optimal number of retrieved lymph nodes(LNs)in gastric cancer(GC)is still debatable and previ-ous studies proposing new classification alternatives mostly focused on the number of retrieved LNs without proper consideration on the anatomic nodal groups’location.Here,we assessed the impact of retrieved LNs from different nodal location groups on the survival of GC patients.Methods:Stage I-III gastric cancer patients who had radical gastrectomy were investigated.LN grouping was deter-mined according to the 13th edition of the JCGC.The optimal cut-off values of retrieved LNs in different LN groups(Group 1 and 2)were calculated,based on which a proposed nodal classification(rN)simultaneously accounting the optimal number and location of retrieved LNs was proposed.The performance of rN was then compared to that of LN ratio,log-odds of metastatic LNs(LODDs)and the 8th edition of the Union for International Cancer Control/American Joint Committee on Cancer(UICC/AJCC)N classification.Results:The optimal cut-off values for Group 1 and 2 were 13 and 9,respectively.The 5-year overall survival(OS)was higher for patients in retrieved Group 1 LNs>13(vs.Group 1 LNs≤13,63.2%vs.57.9%,P=0.005)and retrieved Group 2 LNs>9(vs.Group 2 LNs≤9,72.5%vs.60.7%,P=0.009).Patients staged as pN0-3b were sub classified using this Group 1 and 2 nodal analogy.The OS of pN0-N2 patients in retrieved Group 1 LNs>13 or Group 2 LNs>9 were superior to those in retrieved Group 1 LNs≤13 and Group 2 LNs≤9(All P<0.05);except for pN3 patients.The rN clas-sification was formulated and demonstrated better 5-year OS prognostication performance as compared to the LNR,LODDs,and the 8th UICC/AJCC N staging system.Conclusions:The retrieval of>13 and>9 LNs for Group 1 and Group 2,respectively,could represent an alternative lymph node retrieval approach in radical gastrectomy for more precise survival prognostication and minimizing staging migration,especially if>16 LNs is found to be difficult.

Overexpression of the cholesterol-binding protein MLN64 induces liver damage in the mouse

AIM： To examine the in vivo phenotype associated with hepatic metastatic lymph node 64 （MLN64） overexpression.METHODS： Recombinant-adenovirus-mediated MLN64 gene transfer was used to overexpress MLN64 in the livers of C57BL/6 mice. We measured the effects of MLN64 overexpression on hepatic cholesterol content, bile flow, biliary lipid secretion and apoptosis markers. For in vitro studies cultured CHO cells with transient MLN64 overexpression were utilized and apoptosis by TUNEL assay was measured.RESULTS： Livers from Ad.MLN64-infected mice exhibited early onset of liver damage and apoptosis. This response correlated with increases in liver cholesterol content and bilian/bile acid concentration, and impaired bile flow. We investigated whether liver MLN64 expression could be modulated in a murine model of hepatic injury. We found increased hepatic MLN64 mRNA and protein levels in mice with chenodeoxycholic acid-induced liver damage. In addition, cultured CliO cells with transient MLN64 overexpression showed increased apoptosis.CONCLUSION： In summary, hepatic MLN64 overexpression induced damage and apoptosis in murine livers and altered cholesterol metabolism. Further studies are required to elucidate the relevance of these findings under physiologic and disease conditions.