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Lymph Node Ratio Predicts for Survival in Gastric Cancer; A SEER Database Analysis

Lymph Node Ratio Predicts for Survival in Gastric Cancer; A SEER Database Analysis. George W. Dombi, PhD 1 and Ravi Shridhar, MD-PhD 2 1 Epidemiology Division and 2 Gershenson Radiation Oncology Center Barbara Ann Karmanos Cancer Institute Detroit Medical Center Wayne State University

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Lymph Node Ratio Predicts for Survival in Gastric Cancer; A SEER Database Analysis

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  1. Lymph Node Ratio Predicts for Survival in Gastric Cancer; A SEER Database Analysis George W. Dombi, PhD1 and Ravi Shridhar, MD-PhD2 1 Epidemiology Division and 2 Gershenson Radiation Oncology Center Barbara Ann Karmanos Cancer Institute Detroit Medical Center Wayne State University Detroit, MI

  2. Gastric Cancer Epidemiology • 870,000 new cases gastric cancer/year worldwide. • 650,000 deaths/year worldwide, (75%). • 22,000 new cases/year in US in 2006. • 11,430 deaths/year, (52%) Lower ratio in US. • Gastric Cancer is 14th in incidence in US. • Worldwide top 3 cancers are lung, breast, colon. • Top 3 deaths from cancer are lung, gastric, and liver.

  3. Gastric Cancer Epidemiology • Location of gastric tumors are most common in the antrum. • Antrum or distal stomach 40% • Fundus, cardia, GEJ 35% • Body 25%

  4. Gastric Cancer Epidemiology • Worldwide decline over past few decades • 1930-1980 • Decrease from 38 to 10/100,000 men, • Decrease from 30 to 5/100,000 women. • Identification and treatment of Heliobacter pylori. • Dietary factors • Fresh fruits and vegetables (antioxidants) • Introduction of refrigeration • Less salt based preservation (includes nitrates) • Less bacterial and fungal contamination

  5. Patterns of Spread • Direct • Omenta, pancreas, diaphragm, colon, duodenum, jejunum, vessels, adrenals, kidney • Lymphatic • Paracardial, lesser and greater curvature, pyloric, celiac, SMA, hepatic, splenic, paraaortic • Hematogenous • Via portal system • Peritoneal • Often diffuse process

  6. Staging – Japanese • N1 – stations 1-6 • Paracardial, greater and lesser curvature, pyloric • N2 – stations 7-11 • Left gastric, common hepatic, splenic art and hilum, celiac • N3-4 – stations 12-16 • Hepatic, retropancreatic, mesenteric root, middle colic, paraaortic

  7. T1: invasion of the lamina propria T2a: invasion of the muscularis T2b: invasion of the subserosa T3: penetration of the serosa (visceral peritoneum) T4: invasion of adjacent structures N1: 1-6 lymph nodes N2: 7-15 lymph nodes N3: >15 lymph nodes Gastric Cancer AJCC Staging

  8. Gastric Cancer AJCC Staging } 1 } 2 } 3 } 4 } 5 • Stage IA T1 N0 • Stage IB T1 N1 • T2 N0 • Stage II T1 N2 • T2 N1 • T3 N0 • Stage IIIA T2 N2 • T3 N1 • T4 N0 • Stage IIIB T3 N2 • Stage IV T4 N1-3 • T1-3 N3 • M1

  9. Lymph Node Ratio • Lymph Node ratio = (LNR = LN pos /LN exam) • - LN pos = number lymph nodes positive • - LN exam = number nodes examined • Nodal ratio has become an important prognostic tool • Studies showing importance of nodal ratio in rectal, pancreatic, and gastric cancer • Nodal ratio in breast cancer predicts for survival, recurrence and who benefits from Radiation Therapy. • No large US lymph node ratio gastric studies.

  10. Lymph Node Ratio - Italian

  11. Lymph Node Ratio - Italian

  12. Lymph Node Ratio - Japanese

  13. Lymph Node Ratio - Japanese

  14. Lymph Node Ratio - Japanese

  15. Lymph Node Ratio - Japanese

  16. Aims • The first aim of this study was to compare three measures of lymph node involvement as a predictor of gastric cancer survival • Number of Total nodes examined, • Number of Total metastatic nodes, and • Lymph Node Ratio (LNR) (metastatic nodes)/(nodes examined). • The second aim was to examine the effect of removing 15 or more lymph nodes on survival outcomes for N0-N2 and 30 or more for N3

  17. Methods • Data contained 13,745 cases of gastric cancer taken from the Surveillance, Epidemiology and End Results (SEER) 1990-2003 public access data tapes. • Data were grouped by N0, N1, N2, and N3 stages (AJCC) as well as Lymph Nodes Examined, Lymph Nodes Positive and Lymph Node Ratio (LNR); (LNR = LN pos /LN exam). • Survival analysis was conducted with SAS ver 9.1 utilizing proc lifetest for the Kaplan-Meier analysis and proc phreg for Cox proportional hazard analysis.

  18. Patient Characteristics

  19. Patient Characteristics

  20. Patient Characteristics

  21. Patient Characteristics

  22. Patient Characteristics

  23. Patient Characteristics

  24. Results r=0.8 P<0.0001

  25. Results r=0

  26. Gastric Cancer Survival by Lymph Node Ratio Groups.

  27. Results

  28. Results

  29. Results AC - Adenocarcinoma

  30. Results

  31. Conclusion • LNR is a simple, significant predictor for survival. • Removing >15 lymph nodes provided a survival benefit across stages N0, N1 and N2. • LNR as a predictor of survival was nearly identical whether <15 or >15 lymph nodes were removed. • LNR should be considered in the staging system.

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