A New Metastatic Lymph Node Classification-based Survival Predicting Model in Patients With Small Bowel Adenocarcinoma: A Derivation and Validation Study

Abstract

Background

Current methods of lymph node (LN) staging are controversial in predicting the survival of SBA. We aimed to develop an alternative LN-classification-based nomogram to individualize SBA prognosis.

Methods

Based on the data from the Surveillance, Epidemiology, and End Results (SEER) database of patients diagnosed with SBA between 2004 and 2014, we identified the cut-off points for the number of LNs examined and the number found to be metastatic using the K-adaptive partitioning (KAPS) algorithm. Using metastatic LNs, a nomogram predicting the survival of SBA was derived, internally and externally validated, and measured by calibration curve, C-index, and decision curve analysis (DCA), and compared to the 8th TNM stage.

Results

A total of 1516 patients were included. The cut-off of 17 was the optimal examined LN number. For metastatic LN numbers, the cut-off points were 0, 2, and 8. The C-index for the nomogram was higher than the 8th TNM staging (internal: 0.734; 95% CI, 0.693 to 0.775 vs. 0.677; 95% CI, 0.652 to 0.702, P < 0.001; external: 0.715; 95% CI, 0.674 to 0.756 vs. 0.648; 95% CI, 0.602 to 0.693, P < 0.001). Also, the nomogram showed good calibration in internal and external validation and larger net benefit than TNM staging.

Conclusion

We modified current N staging into a 4-level staging system based on the number of metastatic LNs: N0, no LN metastasis; N1, 1–2 metastatic LNs; N2, 3–8 metastatic LNs, and N3, >8 metastatic LNs and set the least examined LN number to 17. A nomogram based on this staging showed great clinical usability than TNM staging for predicting the survival of SBA patients.

Highlights

• •

  The least examined number of lymph nodes was 16 in small bowel adenocarcinoma patients.

• •

  A new 4-level metastatic LNs staging was recommended: N0, no metastasis; N1, 1–2 LNs; N2, 3–8 LNs and N3, >8 LNs.

• •

  A nomogram with new staging showed great clinical usability than TNM staging for predicting survival of SBA patients.

The number of examined and metastatic lymph nodes (LNs) is correlated inversely with survival of patients with small bowel adenocarcinoma (SBA). However, there was no verdict on the number of examined LNs and current staging of metastatic LNs was controversial in predicting survival of SBA. In this study, based on survival data of 6440 adults diagnosed SBA, we modified the examined LN number of 16 and introduced a new 4-level metastatic LN staging. Based on this new staging, we developed and validated a nomogram with greater clinical usability than traditional TNM staging for predicting survival of SBA patients.