The prognostic role of metastatic lymph node ratio in colon cancer: a retrospective cohort study on 241 patients in a single center.

BACKGROUND: The detection of nodal status is based on examination of lymph nodes (LN) after the tumor surgical resection and the current guidelines recommend examining at least 12 regional LN. An inadequate number of examined LN may lead to a lower N stage or to a false-negative nodal disease. To overcome these issues, many authors proposed to consider the metastatic lymph node ratio (mLNR). MLNR is the ratio of the number of metastatic LN to the number of examined LN. METHODS: Two hundred forty-one colon cancer (CC) specimens from patients who had undergone surgical resection between January 2010 and December 2015 at the General Surgery Unit of Parma University Hospital were analyzed. mLNR, which is defined as the ratio of the number of positive LN to the number of examined LN, was calculated in CCs with LN metastasis. In this study we focused on the following mLRN cutoffs: <0.15, 0.15-0.3 and >3 and we evaluated the prognostic implication of mLNRs. RESULTS: Regarding the impact of examined LN on involved LN in CC, our results showed that the number of involved LN increased with the increasing number of examined LN (P=0.03). We found a significant correlation between OS and RFS rate of patients with CCs and mLNR. Patients with mLNR<0.15 were associated with better OS and RFS rate whereas patients with mLNR>0.3 were associated with worse OS and RFS rate. OS rate for patients with a mLNR<0.15 was 95.24% (89-100%) at 1 year, 83.27% (72.7-95.4%) at 3 years and 68.07% (55.1-84.1%) at 5 years whereas patients with a mLNR>0.3 had an OS rate of 51.7% (34.6-77.3%) at 1 year, 36.55% (20.08-64.3%) at 3 years and 31.33% (16.5-59.4%) at 5 years. RFS rate for patients with a mLNR<0.15 was 100% (100-100%) at 1 year, 92.2% (84-100%) at 3 years and 85.2% (73.8-98.31%) at 5 years whereas patients with a mLNR>0.3 had a RFS of 63.2% (42.8-93.58%) at 1 year and 54.2% (33.1-88.93%) at 3 and 5 years. CONCLUSIONS: The prognostic value of pN stage could be more accurate if we consider both the number of LN metastasis and harvested LN. This can be achieved by using the mLNR that can be a useful tool in daily practice to predict the prognosis of patients who undergone surgery for CC.

Towards standardization of lymph-node ratio classifications: Validation and comparison of different lymph node ratio classifications for predicting prognosis of patients with resected gastric cancer.

INTRODUCTION: The TNM staging system is the main prognostic tool for GC, but the number of metastatic lymph nodes (LN) can be affected by surgical, pathological, tumor or host factors. Several authors have shown that lymph node ratio (LNR) may be superior to TNM staging in GC. However, cut-off values vary between studies and LNR assessment is not standardized. MATERIAL AND METHODS: Retrospective study of all GC resected in a western tertiary center (N = 377). Clinical features were collected and pathological features were assessed by two independent pathologists. Eight LNR classifications were selected and applied to our patients. Statistical analyses were performed. RESULTS: 315 patients were included. Most tumors were T3 (49.2%) N+ (59.3%). During follow-up, 36.7% of patients progressed and 27.4% died due to tumor. All LNR classifications were significantly associated with clinicopathological features such as Laurén subtype, lymphovascular invasion, perineural infiltration, T stage, tumor progression or death. All LNR classifications were independent prognostic factors for OS and DFS, and ROC analyses calculated similar AUC values for all staging systems. Kaplan-Meier curves showed that Pedrazzani, Wang, Liu and Huang classifications stratified patients better into three (Pedrazzani) or four categories. These classifications tended to downstage TNM N2 and N3 tumors. In cases with less than 16 LNs resected, Pedrazzani and Wang classifications showed the best prognostic performance. CONCLUSIONS: Pedrazzani, Wang, Liu and Huang classifications showed good prognostic performance in western GC patients. Larger studies in other cohorts are needed to identify the most consistent LNR classification for GC.

The Prognostic Significance of Lymph Node Status and Lymph Node Ratio (LNR) on Survival of Right Colon Cancer Patients: a Tertiary Center Experience.

BACKGROUND: Colon cancer is a major health problem and is one of the most frequent cancers all over the world. In Egypt, the incidence of colon cancer is relatively low, but its mortality rate is high. Lymphatic spread of colon cancer is one of the most important factors affecting the prognosis of patients. Recently, the lymph node ratio (LNR) has been evaluated as a prognostic parameter for survival. This study aimed at evaluation of nodal status of resected specimens and LNR, as well as its impact on the disease-free survival (DFS) and overall survival (OS) after curative resection of right colon cancer. METHODS: The institutional registry of the Oncology Center Mansoura University (OCMU) was revised for node-positive right colon cancer cases that were operated in the period between January 2010 and January 2015. Fifty-three patients met the inclusion criteria and were followed up till January 2020. RESULTS: A total of 766 lymph nodes were excised from the patients. Thirty-two patients (60.4%) had a LN yield of ≥12 LNs with a mean LNR of 0.257 ± 0.27. Multivariate analysis of outcomes showed that LNR was significantly correlated with both DFS (p = 0.015) and OS (p = 0.024). Moreover, the number of resected LNs was also associated with statistically significant relationship with the DFS and OS. CONCLUSION: Our study confirms the validity of LNR as a prognostic tool that correlates with the survival of patients. Moreover, LNR cutoff values may help predict those of high chance of tumor recurrence. TRIAL REGISTRATION: MS/20.03.1087 (Institutional IRB), date of registration: March 10, 2020, "retrospectively registered".

Neoadjuvant chemoradiation is associated with decreased lymph node ratio in borderline resectable pancreatic cancer: A propensity score matched analysis.

BACKGROUND: Lymph node ratio (LNR) and margin status have prognostic significance in pancreatic cancer. Herein we examined the pathologic and clinical outcomes in patients with borderline resectable pancreatic cancer (BRPC) following neoadjuvant therapy (NAT) and pancreaticoduodenectomy. METHODS: Patients who underwent treatment between January 1, 2012 and June 30, 2017 were included. Sequential patients in the BRPC group were compared to a propensity score matched cohort of patients with radiographically resectable pancreatic cancer who underwent upfront surgical resection. The BRPC group was also compared to sequential patients with radiographically resectable pancreatic cancer who required vein resection (VR) during upfront surgery. RESULTS: There were 50 patients in the BRPC group, 50 patients in the matched control group, and 38 patients in the VR group. Negative margins (R0) were seen in 72%, 64%, and 34% of the BRPC, control, and VR groups, respectively (P = 0.521 for BRPC vs. control; P = 0.002 for BRPC vs. VR), with 24% of the BRPC group requiring a vascular resection. Nodal stage was N0 in 64%, 20%, and 18% of the BRPC, control, and VR groups, respectively (P < 0.001 for BRPC vs. control or VR). When nodal status was stratified into four groups (N0, or LNR ≤ 0.2, 0.2-0.4, ≥ 0.4), the BRPC group had a more favorable distribution (P < 0.001). The median overall survival were 28.8, 38.6, and 19.0 months for the BRPC, control, and VR groups, respectively (log-rank P = 0.096). CONCLUSIONS: NAT in BRPC was associated with more R0 and N0 resections and lower LNR compared to patients undergoing upfront resection for resectable disease.

Lymph Node Ratio Is an Independent Prognostic Factor for Patients with Siewert Type II Adenocarcinoma of Esophagogastric Junction: Results from a 10-Year Follow-up Study.

PURPOSE: Emerging evidences suggest that lymph node ratio (LNR), the number of metastatic lymph node (LN) to the total number of dissected lymph nodes (NDLN), may predict survival in multiple types of solid tumor. However, the prognostic role of LNR in adenocarcinoma of the esophagogastric junction (AEG) remains uninvestigated. The present study is intended to determine the prognostic value of LNR in the patients with Siewert type II AEG. METHODS: A total of 342 patients with Siewert type II AEG who underwent R0 resection were enrolled in this study. The optimal cutoff of LNR was stratified into tertiles using X-tile software. The log-rank test was used to evaluate the survival differences, and multivariate Cox regression analyses were performed to determine the independent prognostic variables. RESULTS: The optimal cutoff of LNR were classified as LNR = 0, LNR between 0.01 and 0.40, and LNR > 0.41. Patients with high LNR had a shorter 5- and 10-year disease-specific survival (DSS) rate (8.5%, 1.4%) compared with those with moderate LNR (20.4%, 4.9%) and low LNR (58.0%, 27.5%) (P < 0.001). Multivariate Cox regression analysis indicated that LNR was an independent factor for DSS after adjusting for confounding variables (P < 0.05). Furthermore, after stratification by NDLN between NDLN < 15 group and NDLN ≥ 15 group, the LNR remained a significant predictor for DSS (P < 0.05). CONCLUSIONS: LNR is an independent predictor for DSS in patients with Siewert type II AEG regardless of NDLN. Patients with higher LNR have significantly shorter DSS.

Development of a simplified tumor-lymph node ratio classification system for patients with resected gastric cancer: A western study.

INTRODUCTION: Gastric cancer (GC) shows high recurrence and mortality rates. The AJCC TNM staging system is the best prognostic predictor, but lymph node assessment is a major source of controversy. Recent studies have found that lymph node ratio (LNR) may overcome TNM limitations. Our aim is to develop a simplified tumor-LNR (T-LNR) classification for predicting prognosis of resected GC. METHODS: Retrospective study of all GC resected in a tertiary center in Spain (N = 377). Clinicopathological features were assessed, LNR was classified into N0:0%, N1:1-25%, N2:>25%, and a T-LNR classification was developed. Statistical analyses were performed. RESULTS: 317 patients were finally included. Most patients were male (54.6%) and mean age was 72 years. Tumors were intestinal (61%), diffuse (30.8%) or mixed (8.1%). During follow-up, 36.7% and 27.4% of patients progressed and died, respectively. T-LNR classification divided patients into five prognostic categories (S1-S5). Most cases were S1-S4 (26.2%, 19.9%, 22.6% and 23.6%, respectively). 7.6% of tumors were S5. T-LNR classification was significantly associated with tumor size, depth, macroscopical type, Laurén subtype, signet ring cells, histologic grade, lymphovascular invasion, perineural infiltration, infiltrative growth, patient progression and death. Kaplan-Meier curves for OS showed an excellent patient stratification with evenly spaced curves. As for DFS, T-LNR classification also showed good discriminatory ability with non-overlapping curves. T-LNR classification was independently related to both OS and DFS. CONCLUSIONS: T-LNR classifications can successfully predict prognosis of GC patients. Larger studies in other geographic regions should be performed to refine this classification and to validate its prognostic relevance.

Stage III and Metastatic Lymph Node Ratio Are the only Independent Prognostic Factors in Colorectal Signet-ring Cell Carcinoma Patients.

BACKGROUND/AIM: Signet-ring cell carcinoma (SRCC) is an uncommon histological variant of colorectal cancer (CRC). Knowledge is scarce due to its rarity. Our aim was to better evaluate the clinicopathologic and prognostic features of this little-known malignancy. PATIENTS AND METHODS: Thirty-nine consecutive patients with non-metastatic colorectal SRCC undergoing curative resection at University Hospital of Parma between 2000 and 2018 were examined in this retrospective analysis. RESULTS: Mean overall (OS) and disease-free survival (DFS) were 33.6 and 31.5 months, respectively. At univariate analysis, the lymph-related parameters (nodal status, Stage III, metastatic lymph node ratio and lymphovascular invasion) were significantly associated with shorter OS and poorer DFS. At multivariate analysis, Stage III and a metastatic lymph node ratio ≥25% were found to be the only independent prognostic factors significantly correlated with worse OS and DFS. CONCLUSION: Nodal and lymphatic status should be carefully pondered when planning the most appropriate management of patients with colorectal SRCC.

Lymph node yield and lymph node ratio in oral cavity and oropharyngeal carcinoma: Preliminary results from a prospective, multicenter, international cohort.

OBJECTIVES: Recently, Lymph Node Yield (LNY) and Lymph Node Ratio (LNR) have emerged as prognostic indicators in head and neck cancer. However, there is a lack of data regarding the LNY and LNR values in the specific neck levels dissected and regarding the factors that influence these values. MATERIALS AND METHODS: Preliminary results of the NCT03534778 trial are reported. LNY and LNR values were estimated for 100 patients with oral or oropharynx carcinoma, from November 1, 2018 to September 30, 2019. RESULTS: Overall, the mean number of lymph nodes retrieved was 34.4 (95% confidence interval [CI] 31.6-37.3). LNY means and CI per single neck level were as follows: level I 5.5 lymph nodes harvested (95% CI 3.5-7.5), level II 15.4 (95% CI 10.6-20.2), level III 8.0 (95% CI 4.6-11.3), level IV 6.3 (95% CI 3.4-9.15), level V 6.3 (95% CI 3.6-9.0). cN+ patients had a higher number of lymph nodes retrieved, odds ratio (OR) 1.2 (95% CI 1.05-1.36). Smokers had less lymph nodes harvested, OR 0.78 (95% CI, 0.71-0.87). Mean LNR was 0.063 (95% CI 0.047-0.078). A multiple regression analysis showed that anatomic site, pN, smoking status and LNY statistically significantly predicted the LNR (p < 0.05) CONCLUSIONS: The LNY and LNR values are influenced by various demographic and pathological characteristics of the patient, such as the number of dissected levels, primary site, cN positivity, and smoking status.

Does lymph node ratio have any prognostic significance in maximally cytoreduced node-positive low-grade serous ovarian carcinoma?

PURPOSE: To determine the prognostic impact of the lymph node ratio (LNR) in node-positive low-grade serous ovarian cancer (LGSOC). METHODS: We retrospectively reviewed women with LGSOC who had undergone maximal cytoreduction followed by standard chemotherapy in 11 centers from Turkey during a study period of 20 years. Sixty two women with node-positive LGSOC were identified. LNR was defined as the number of metastatic lymph nodes (LNs) divided by the number of total LNs removed. We grouped patients pursuant to the LNR as LNR ≤ 0.09 and LNR > 0.09. The prognostic value of LNR was investigated by employing the univariate log-rank test and multivariate Cox-regression model. RESULTS: With a median follow-up of 45 months, the 5-year progression-free survival (PFS) rates were 61.7% for women with LNR ≤ 0.09 and 32.0% for those with LNR > 0.09 (p = 0.046) whereas, the 5-year overall survival (OS) rates were 72.8% for LNR ≤ 0.09 and 54.7% for LNR > 0.09 (p = 0.043). On multivariate analyses, lymphovascular space invasion (LVSI) (Hazard Ratio [HR] 4.18, 95% confidence interval [CI] 1.88-9.27; p < 0.001), omental involvement (HR 3.48, 95% CI 1.36-8.84; p = 0.009) and LNR > 0.09 (HR 3.51, 95% CI 1.54-8.03; p = 0.003) were adverse prognostic factors for PFS. Additionally, LVSI (HR 6.56, 95% CI 2.33-18.41; p < 0.001), omental involvement (HR 6.34, 95% CI 1.86-21.57; p = 0.003) and LNR > 0.09 (HR 7.20, 95% CI 2.33-22.26; p = 0.001) were independent prognostic factors for decreased OS. CONCLUSION: LNR > 0.09 seems to be an independent prognosticator for decreased survival outcomes in LGSOC patients who received maximal cytoreduction followed by standard adjuvant chemotherapy.

Significance of lymph node ratio on survival of women with borderline ovarian tumors.

PURPOSE: To assess the qualitative and quantitative measures of the effect of pelvic lymph node involvement on survival of women with borderline ovarian tumors (BOTs). METHODS: This is a retrospective study examining the Surveillance, Epidemiology, and End Results Program between 1988 and 2003. Women with stage T1-3 BOTs who had results of pelvic lymph node status at surgery were included. The effect of lymph node involvement on cause-specific survival (CSS) was evaluated using multivariable analysis with the following approaches: (1) any involvement, (2) involvement of multiple nodes (≥ 2 nodes), and (3) lymph node ratio (LNR), defined as the ratio of the number of tumor-containing lymph nodes to the total number of harvested lymph nodes. RESULTS: A total of 1524 women were examined for analysis. Median count of sampled nodes was 8 (interquartile range 3-15), and there were 81 (5.3%, 95% confidence interval [CI] 4.2-6.4) women who had lymph node involvement. Median follow-up was 15.8 (interquartile range 13.8-18.9) years, and 83 (5.4%) women died of BOTs. After controlling for age, histology, stage, and tumor size, only LNR remained an independent prognostic factor for decreased CSS (adjusted hazard ratio [HR] per percentage unit 1.015, 95% CI 1.003-1.026, P = 0.014), whereas any involvement (adjusted HR 1.700, 95% CI 0.843-3.430, P = 0.138) and involvement of multiple nodes (adjusted HR 1.644, 95% CI 0.707-3.823, P = 0.249) did not. On cutoff analysis, LNR ≥ 13% had the largest magnitude of significance on multivariable analysis of CSS (adjusted HR 2.399, 95% CI 1.163-4.947, P = 0.018). CONCLUSION: Our study suggests that high pelvic LNR may be a prognostic factor associated with decreased CSS in women with BOTs.

Prognostic Value of Lymph Node Ratio in Breast Cancer Patients with Adequate Pathologic Evidence After Neoadjuvant Chemotherapy.

BACKGROUND The prognostic role of axillary lymph node ratio (LNR) after neoadjuvant chemotherapy (NAC) in breast cancer has not been illuminated. This study was designed to investigate the prognostic role of LNR in breast cancer compared with traditional ypN stage. MATERIAL AND METHODS A total of 306 breast cancer patients diagnosed with positive axillary lymph nodes from January 2007 to December 2014 were eligible for this retrospective analysis. All enrolled patients were treated with a median of 4 cycles of NAC followed by mastectomy and level I, II, and III axillary lymph node dissection (ALND). RESULTS The median duration of follow-up was 78 months (range, 7-147 months). Univariate analysis indicated that both the LNR category (P<0.001) and ypN stage (P<0.001) were significant associated with event-free survival (EFS) and overall survival (OS). However, multivariate analysis indicated that the LNR category was independently associated with EFS (P<0.001) and OS (P<0.001), while the ypN stage showed no statistical effect on EFS (P=0.391) or OS (P=0.081). On additional analyses stratified by molecular subtypes, we found that the prognosis of triple negative breast cancer could be better discriminated when the cutoff value of LNR was set at 0.15. CONCLUSIONS LNR showed a superior predictive value in evaluating prognosis of breast cancer patients after NAC. In addition, the LNR cutoff point 0.15 can accurately discriminate survival outcomes for different triple negative breast cancer subtypes.

Prognostic nomogram based on the metastatic lymph node ratio for gastric neuroendocrine tumour: SEER database analysis.

OBJECTIVE: The prediction of survival of gastric neuroendocrine tumours (g-NETs) is controversial. Prognostic effects of the metastatic lymph node ratio (LNR) in patients with g-NET were explored, and a nomogram was plotted to predict the survival rates of patients. METHODS: A longitudinal study conducted on the basis of the Surveillance, Epidemiology, and End Results database. The association between LNR and survival were investigated by using Pearson correlation and Cox regression. Overall survival (OS) and cancer-specific survival (CSS) rates were predicted with the help of nomograms. RESULTS: A total of 315 patients with g-NET diagnosed from 2004 to 2015 were included in this study. LNR was discovered to have a negative correlation with OS and CSS (Pearson correlation coefficients: 0.343 (p<0.001) and 0.389 (p<0.001), respectively). The multivariate analyses indicated age, tumour site, differentiation, T staging, M staging, chemotherapy and LNR to be independent prognostic factors for both OS and CSS. Surgery was also a prognostic determinant for CSS (p=0.003). Concordance indices of the nomograms for OS and CSS were higher than those of the TNM classification (0.772 vs 0.730 and 0.807 vs 0.768, respectively). As per the area under the receiver operating characteristic curve, predictive ability of the nomograms for survival of 1, 3 and 5 years was all better than that of TNM classification. CONCLUSIONS: LNR is an independent predictor of g-NETs. The nomograms plotted in this study have a satisfying predictive ability of survival risks and are capable of guiding tailored treatment strategies for patients with g-NET.

Prognostic value of lymph node ratio in non-small-cell lung cancer: a meta-analysis.

BACKGROUND: This meta-analysis aimed to investigate the prognostic value of lymph node ratio in non-small-cell lung cancer. METHODS: We searched systematically for eligible studies in PubMed, Web of Science, Medline (via Ovid) and Cochrane library through 6 November 2018. The primary outcome was overall survival. Disease-free survival and cancer-specific survival were considered as secondary outcomes. Hazard ratio with corresponding 95% confidence interval were pooled. Quality assessment of included studies was conducted. Subgroup analyses were performed based on N descriptors, types of tumor resection, types of lymphadenectomy and study areas. Sensitivity analysis and evaluation of publication bias were also performed. RESULTS: Altogether, 20 cohorts enrolling 76 929 patients were included. Mean Newcastle-Ottawa Scale was 7.65 ± 0.59, indicating the studies' quality was high. The overall result showed non-small-cell lung cancer patients with lower lymph node ratio was associated with better overall survival (HR: 1.946; 95% CI: 1.746-2.169; P < 0.001), disease-free survival (HR: 2.058; 95% CI: 1.717-2.467; P < 0.001) and cancer-specific survival (HR: 2.149; 95% CI: 1.864-2.477; P < 0.001). Subgroup analysis prompted types of lymphadenectomy and the station of positive lymph node have an important effect on the prognosis. No significant discovery was found in sensitivity analysis. CONCLUSION: Patients with lower lymph node ratio was associated with better survival, indicating that lymph node ratio may be a promising prognostic predictor in non-small-cell lung cancer. The type of lymphadenectomy, an adequate examined number and the removed stations should be considered for more accurate prognosis assessment.

Prognostic Implication of pN Stage Subdivision Using Metastatic Lymph Node Ratio in Resected Pancreatic Ductal Adenocarcinoma.

In this meta-analysis, we aimed to evaluate the prognostic implication of the metastatic lymph node ratio (mLNR) and its optimal criterion in pancreatic ductal adenocarcinoma (PDAC) with lymph node metastasis (LNM). The present study included 3735 patients with PDAC who had LNM, from 11 eligible studies. We carried out a meta-analysis to determine the correlation between a high mLNR and PDAC prognosis. The estimated mean numbers of examined and metastatic lymph nodes were 22.396 (95% confidence interval [CI] = 19.681-25.111) and 6.496 (95% CI = 4.646-8.345), respectively. A high mLNR was significantly correlated with worse overall survival (hazard ratio = 1.344, 95% CI = 1.276-1.416). In 3 subgroups based on high mLNR criteria (>0 and <0.2, ≥0.2 and <0.4, and ≥0.4), there were significant correlations between a high mLNR and worse survival. A cutoff of 0.200 showed the highest hazard ratio (1.391, 95% CI = 1.268-1.525), which was statistically significant. Our results showed that mLNR is a useful prognostic factor for PDAC with LNM. Although the optimal criterion of high mLNR may be 0.200, further cumulative studies are required before this can be applied in daily practice.

Metastatic Lymph Node Ratio (mLNR) is a Useful Parameter in the Prognosis of Colorectal Cancer; A Meta-Analysis for the Prognostic Role of mLNR.

Background and objectives: The presenting study aimed to elucidate the prognostic role of the metastatic lymph node ratio (mLNR) in patients with colorectal cancer (CRC), using a meta-analysis. Materials and Methods: Using data from 90,274 patients from 14 eligible studies, we performed a meta-analysis for the correlation between mLNR and survival rate. Besides, subgroup analyses were performed, based on tumor stage, tumor location, and mLNR. Results: A high mLNR showed significant correlation with worse overall survival and disease-free survival rates in CRC patients (hazard ratio (HR), 1.617, 95% confidence interval (CI) 1.393-1.877, and HR 2.345, 95% CI 1.879-2.926, respectively). In patients with stage III, who had regional LN metastasis, the HRs were 1.730 (95% CI 1.266-2.362) and 2.451 (95% CI 1.719-3.494) for overall and disease-free survival, respectively. According to tumor location, rectal cancer showed a worse survival rate when compared to colon cancer. In the analysis for overall survival, when mLNR was 0.2, HR was the highest across the different subgroups (HR 5.040, 95% CI 1.780-14.270). However, in the analysis for disease-free survival, the subgroup with an mLNR < 0.2 had a higher HR than the other subgroups (HR 2.878, 95% CI 1.401-5.912). Conclusions: The mLNR may be a useful prognostic factor for patients with CRC, regardless of the tumor stage or tumor location. Further studies are necessary for the detailed criteria of mLNR before its application in daily practice.

Clinical Value of Lymph Node Ratio Integration with the 8th Edition of the UICC TNM Classification and 2015 ATA Risk Stratification Systems for Recurrence Prediction in Papillary Thyroid Cancer.

Recently, the 2015 American Thyroid Association (ATA) risk stratification and the 8th edition of the American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) TNM staging system were released. This study was conducted to assess the clinical value of the lymph node ratio (LNR) as a predictor of recurrence when integrated with these newly released stratification systems, and to compare the predictive accuracy of the modified systems with that of the newly released systems. The optimal LNR threshold value for predicting papillary thyroid cancer (PTC) recurrence was 0.17857 using the Contal and O'Quigley method. The 8th edition of the AJCC/UICC TNM staging system with the LNR and the 2015 ATA risk stratification system with the LNR were significant predictors of recurrence. Furthermore, calculation of the proportion of variance explained (PVE), the Akaike information criterion (AIC), Harrell's c index, and the incremental area under the curve (iAUC) revealed that the 8th edition of the TNM staging system with the LNR, and the 2015 ATA risk stratification system with the LNR, showed the best predictive performance. Integration of the LNR with the TNM staging and the ATA risk stratification systems should improve prediction of recurrence in patients with PTC.

Lymph node ratio as prognostic variable in oral squamous cell carcinomas: Systematic review and meta-analysis.

Lymph node ratio (LNR) has been shown to be an independent prognostic factor for oral squamous cell carcinoma (OSCC) in various centre-based studies recently. A range of cut-off values have been suggested. A meta-analysis was performed to evaluate the prognostic effects of LNR and to investigate the cut-off value. Electronic search on Pubmed, Embase and Cochrane library and manual search were performed for studies up to January 2018. The outcomes were overall survival (OS), disease specific survival (DSS), disease free survival (DFS), local recurrence free survival (LF), locoregional disease free survival (LRF), and distant metastasis disease free survival (DM). 19 studies between 2009 and 2017 were included. The total number of patients was 14,254 (range 19-3958). Data was grouped into Group A (with pathological nodal disease, pN+) and Group B (with and without pathological nodal disease, pN+ and pN-). In the meta-analysis, the high LNR was significantly related to short OS (A = HR 1.902; 95%CI: 1.453-2.488, B = HR 2.76; 95%CI: 2.13-3.59), DSS (A = HR 1.728; 95%CI: 1.159-2.579; B = HR 2.83; 95%CI: 1.8-4.44) and DFS (A = HR 2.27; 95%CI: 1.74-2.96; B = HR 2.01; 95%CI: 1.44-2.82) in both groups; and shorter LRF in Group B (HR 5.013; 95%CI: 3.584-7.011). In the analysis, all cut-off values were shown to be significant and there was no strong evidence to consider a possibility of a second significant value. Based on our results, LNR is an independent prognostic factor in OSCC and may be considered in future oncologic staging systems.