Competing risk nomogram predicting initial loco-regional recurrence in gastric cancer patients after D2 gastrectomy

Abstract

Background Lacking quantitative evaluations of clinicopathological features and the risk factors for loco-regional recurrence (LRR) in gastric cancer after D2 gastrectomy, we aimed to develop a competing risk nomogram to identify the risk predictors for initial LRR. Methods We retrospectively analysed 1105 patients who underwent radical gastrectomy with D2 resection for stage I-III gastric cancer. A nomogram predicting initial LRR of gastric cancer was conducted based on Fine and Grey’s competing risk analysis. The predictive accuracy and discriminative ability of the model were determined using the concordance index (C-index) and calibration curve. Decision tree analysis was performed for patient grouping. Results At a median follow-up of 28.4 months, 274 patients developed 373 first recurrence events (local, regional, and distant disease). The median recurrence-free survival (RFS) was 16.7 months. Multivariate competing risk analysis showed that age (SHR, 1.72; 95% CI, 1.10–2.83, p = 0.031), CEA (SHR, 1.94; 95% CI, 1.09–3.46, p = 0.024), pT4 (SHR, 2.77; 95% CI, 1.01–7.57, p = 0.047), lymph node metastasis (SHR 1.92, 95% CI: 1.09–3.38, p = 0.024) and LVI (SHR, 1.84; 95% CI, 1.06–3.20, p = 0.028) were independent risk factors for LRR (all p < 0.05). The nomogram incorporating these factors achieved good agreement between prediction and actual observation with a concordance index of 0.738 (95% CI, 0.767 to 0.709). In a subgroup analysis of node-positive patients, pN3b was associated with increased peritoneal and distant metastasis ( p = 0.048). The para-aortic lymph nodes were the most frequent sites ( n = 71) of LRR, and among them, the 16a2 and 16b1 nodes exhibited even more prevalence (90.1 and 81.7%). Conclusions Adjuvant radiotherapy might be recommended in gastric cancer patients ≥65 years old or those with pN+, pT4, LVI, or increased CEA levels, particularly in high-risk or pN1-3a patients. The competing risk nomograms may be considered as convenient and individualized predictive tools for LRR in gastric cancer after D2 gastrectomy. It is also recommended that the clinical target volume (CTV) include 16a2 and 16b1 regions of para-aortic lymph nodes.

A simple model established by blood markers predicting overall survival after radical resection of gastric cancer

“…CEA was an regular marker for screening the recurrence of cancer, our study verified that CEA was an independent risk marker, we need to take more attention for the patients with high CEA level. Age was also an insignificant factor, our result was consistent with previous study [21], the old patients has poor body function which can permit loco-regional recurrence, thus it can have an adverse on the prognosis of gastric cancer patients. In order to find early recurrence and metastasis of patients with high level of SII, old age, high CEA level and high TNM stage, they need more follow up and examination, and the surgeon should take comprehensive and make an appropriate treatment plan for these patients.…”

“…The possible mechanism is that the systemic inflammation caused by malignant tumors can releases a large number of pro-inflammatory mediators, such as CRP, fibrinogen, VEGF, TGF-a, and so on. These factors stimulate tumor growth and metastasis [21], meanwhile the anti-tumor immune response of T cells and natural killer cells in the system may are surrounded by a number of neutrophils, this may decrease the opportunity to contact with tumor cells and have adverse effect on the prognosis of patients [18,19], besides, platelets can also promote tumor growth by increasing angiogenesis via VEGF [20]. So SII should be included in the regular assessment index of gastric cancer patients.…”

A nomogram established by inflammatory markers predicting overall survival after radical resection of gastric cancer

“…CEA was a regular marker for screening the recurrence of cancer, our study veri ed that CEA was an independent risk marker; we need to take more attention for the patients with high CEA level. Age was also an signi cant factor, our result was consistent with previous study [23], the old patients may have poor body function which can permit loco-regional recurrence, and thus it can have an adverse on the prognosis of gastric cancer patients, so these signi cant variables need to take more attention in order to make a better prediction, and the nomogram may applied more widely in the clinic.…”

“…The possible mechanism is that the systemic in ammation caused by malignant tumors can releases a large number of pro-in ammatory mediators, such as CRP, brinogen, VEGF, TGF-a, and so on. These factors stimulate tumor growth and metastasis [23], meanwhile the anti-tumor immune response of T cells and natural killer cells in the system may are surrounded by a number of neutrophils, this may decrease the opportunity to contact with tumor cells and have adverse effect on the prognosis of patients [20,21], besides, platelets can also promote tumor growth by increasing angiogenesis via VEGF [22]. So SII should be included in the regular assessment index of gastric cancer patients.…”

Does frailty predict postoperative outcomes in geriatric patients receiving surgery for colorectal cancer? A systematic review and meta-analysis

“…Non-cancer-speci c mortality has been the main form of competing risk that occurs and leads to biased results when applying survival analysis [60]. Competing risk nomograms has been established for gastrointestinal cancer diseases in the recent years in order that overall survival (OS) and cancer-speci c survival (CSS) in patients with surgically resected tumours can be predicted [61,62]. As far as we know, only two studies previously explored discrimination between physiologically t and nont patients in cancer-related and non-cancer speci c mortality after curative resection for CRC [63,64].…”