title: The prognostic value of lymph node ratio and updated TNM classification in rectal cancer patients with adequate versus inadequate lymph node dissection.
abstract: BACKGROUND
  The aim of this study was to clarify whether the lymph node ratio (LNR) is superior to the updated TNM classification regarding the prognosis of stage III rectal cancer patients who have not undergone neoadjuvant therapy. The TNM system is based on the absolute number of lymph nodes involved, and the LNR takes into account involved and examined nodes.
  
  
  METHODS
  In 237 patients with stage III rectal cancer, we evaluated prognostic factors for 5-year overall survival (OS), disease-free survival (DFS), and risk of distant metastases (DM) using the Kaplan-Meier method, with patients divided based on adequate versus inadequate lymph node dissection (≥12 vs. <12 lymph nodes examined). The updated TNM divides patients into four groups (1, 2-3, 4-6, and ≥7 involved nodes), while LNR divides patients into quartiles. Multivariate Cox regression analyses were performed.
  
  
  RESULTS
  Among patients with adequate lymph node dissection, the distributions within the two systems were in agreement in 141/178 (79.2 %, kappa 0.721), and the predictive values for OS, DFS, and DM were similar. In patients with inadequate lymph node dissection, the classifications of both systems were concordant in only 13/59 (22 %, kappa 0.021). The pN system significantly under-staged patients, while the LNR classification was a better predictor of OS, DFS, and DM.
  
  
  CONCLUSIONS
  In patients with adequate lymph node dissection, LNR staging does not add substantial information to the predictions of updated TNM lymph node staging. However, in patients with inadequate lymph node harvesting, the LNR compensates for the under-staging of the TNM classification and provides a better estimation of prognosis than the updated TNM system.
authors.affiliation: Department of General and Abdominal Surgery, University Medical Centre of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany, junginger@uni-mainz.de.
authors.forename: T
authors.initials: T
authors.lastname: Junginger
authors.forename: U
authors.initials: U
authors.lastname: Goenner
authors.forename: A
authors.initials: A
authors.lastname: Lollert
authors.forename: D
authors.initials: D
authors.lastname: Hollemann
authors.forename: M
authors.initials: M
authors.lastname: Berres
authors.forename: M
authors.initials: M
authors.lastname: Blettner
mesh_terms: D000230:Adenocarcinoma / Q000556:secondary* / Q000601:surgery*; D000368:Aged; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008197:Lymph Node Excision / Q000592:standards*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging / Q000379:methods*; D011237:Predictive Value of Tests; D012004:Rectal Neoplasms / Q000473:pathology* / Q000601:surgery*; D015996:Survival Rate