Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
Department of Epidemiology, University of Texas MD Anderson Cancer Center, Houston, TX.
Ann Surg. 2023 Jun 1;277(6):e1239-e1246. doi: 10.1097/SLA.0000000000005450. Epub 2022 Jul 6.
This study aimed to propose a revised ypN (r-ypN) classification based on lymph node ratio (LNR) and to examine its prognostic value in postneoadjuvant esophageal cancer.
A new postneoadjuvant pathologic (ypTNM) staging classification has been introduced for esophageal cancer. However, the ypN classification currently defined by the number of positive lymph nodes is influenced by the extent of lymphadenectomy.
Data on 7195 esophageal cancer patients receiving neoadjuvant chemoradiation were extracted from the National Cancer Database (NCDB). Four r-ypN stages were defined by 3 LNR thresholds (0%, 10%, and 20% using X-tile software). A revised ypTNM (r-ypTNM) classification was developed by solely changing N categories. Kaplan-Meier method and Cox proportional hazards models were used for survival analyses. Akaike information criterion (AIC) and Harrell's concordance index ( C -index) were used to compare the predictive performance of the current and the revised classification. External validation was performed using an independent cohort from the NEOCRTEC5010 clinical trial.
Both ypN ( P <0.001) and r-ypN ( P <0.001) were independent prognostic factors of overall survival (OS) for esophageal cancer patients. Kaplan-Meier curves demonstrated a better discrimination with r-ypN than ypN categories. Within each ypN category (except ypN3), OS was significantly different comparing r-ypN strata; however, there were no differences between ypN strata within each r-ypN category (except r-ypN3). r-ypN (AIC: 60752 vs 60782; C -index: 0.591 vs 0.587) and r-ypTNM (AIC: 60623 vs 60628; C -index: 0.613 vs 0.610) showed better predictive performance than the current staging system, with a lower AIC (better calibration) and higher C -index (improved discrimination). This advantage was also confirmed by external validation using the NEOCRTEC5010 cohort.
LNR showed better performance than ypN in predicting OS of esophageal cancer patients after neoadjuvant chemoradiation and may be an improvement on the current staging system.
本研究旨在提出一种基于淋巴结比率（LNR）的修订后 ypN（r-ypN）分类，并检验其在新辅助治疗后食管癌中的预后价值。
已经引入了一种新的食管癌新辅助病理（ypTNM）分期分类。然而，目前通过阳性淋巴结数量定义的 ypN 分类受到淋巴结清扫程度的影响。
从国家癌症数据库（NCDB）中提取了 7195 名接受新辅助放化疗的食管癌患者的数据。使用 X-tile 软件定义了 4 个 r-ypN 分期，使用 3 个 LNR 阈值（0%、10%和 20%）。通过仅改变 N 类别来开发修订后的 ypTNM（r-ypTNM）分类。使用 Kaplan-Meier 方法和 Cox 比例风险模型进行生存分析。使用赤池信息量准则（AIC）和哈雷尔一致性指数（C-指数）比较当前和修订分类的预测性能。使用来自 NEOCRTEC5010 临床试验的独立队列进行外部验证。
ypN（P<0.001）和 r-ypN（P<0.001）均是食管癌患者总生存（OS）的独立预后因素。Kaplan-Meier 曲线表明 r-ypN 比 ypN 分类具有更好的区分能力。在每个 ypN 分类内（ypN3 除外），比较 r-ypN 分层，OS 有显著差异；然而，在每个 r-ypN 分类内（r-ypN3 除外），ypN 分层之间没有差异。r-ypN（AIC：60752 与 60782；C-指数：0.591 与 0.587）和 r-ypTNM（AIC：60623 与 60628；C-指数：0.613 与 0.610）比当前分期系统具有更好的预测性能，AIC 更低（更好的校准），C-指数更高（改善区分）。使用 NEOCRTEC5010 队列进行的外部验证也证实了这一优势。
LNR 在预测新辅助放化疗后食管癌患者的 OS 方面优于 ypN，可能是对当前分期系统的改进。
