title: Prognostic relevance of lymph node ratio and total lymph node count for small bowel adenocarcinoma.
abstract: BACKGROUND
  Nodal metastasis is a known prognostic factor for small bowel adenocarcinoma. The goals of this study were to evaluate the number of lymph nodes (LNs) that should be retrieved and the impact of lymph node ratio (LNR) on survival.
  
  
  METHODS
  Surveillance, Epidemiology, and End Results was queried to identify patients with small bowel adenocarcinoma who underwent resection from 1988 to 2010. Survival was calculated with the Kaplan-Meier method. Multivariate analysis identified predictors of survival.
  
  
  RESULTS
  A total of 2,772 patients underwent resection with at least one node retrieved, and this sample included equal numbers of duodenal (n = 1,387) and jejunoileal (n = 1,386) adenocarcinomas. There were 1,371 patients with no nodal metastasis (N0, 49.4%), 928 N1 (33.5%), and 474 N2 (17.1%). The median numbers of LNs examined for duodenal and jejunoileal cancers were 9 and 8, respectively. Cut-point analysis demonstrated that harvesting at least 9 for jejunoileal and 5 LN for duodenal cancers resulted in the greatest survival difference. Increasing LNR at both sites was associated with decreased overall median survival (LNR = 0, 71 months; LNR 0-0.02, 35 months; LNR 0.21-0.4, 25 months; and LNR >0.4, 16 months; P < .001). Multivariate analysis confirmed number of LNs examined, T-stage, LN positivity, and LNR were independent predictors of survival.
  
  
  CONCLUSIONS
  LNR has a profound impact on survival in patients with small bowel adenocarcinoma. To achieve adequate staging, we recommend retrieving a minimum of 5 LN for duodenal and 9 LN for jejunoileal adenocarcinomas.
authors.affiliation: Department of Surgery, Division of Surgical Oncology, Stanford University, Stanford, CA.
authors.forename: Thuy B
authors.initials: TB
authors.lastname: Tran
authors.affiliation: Department of Surgery, Division of Surgical Oncology, Stanford University, Stanford, CA.
authors.forename: Motaz
authors.initials: M
authors.lastname: Qadan
authors.affiliation: Department of Surgery, Division of Surgical Oncology, Stanford University, Stanford, CA.
authors.forename: Monica M
authors.initials: MM
authors.lastname: Dua
authors.affiliation: Department of Surgery, Division of Surgical Oncology, Stanford University, Stanford, CA.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Norton
authors.affiliation: Department of Surgery, Division of Surgical Oncology, Stanford University, Stanford, CA.
authors.forename: George A
authors.initials: GA
authors.lastname: Poultsides
authors.affiliation: Department of Surgery, Division of Surgical Oncology, Stanford University, Stanford, CA. Electronic address: bvisser@stanford.edu.
authors.forename: Brendan C
authors.initials: BC
authors.lastname: Visser
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D000328:Adult; D000368:Aged; D004379:Duodenal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007078:Ileal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D007580:Jejunal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000473:pathology* / Q000601:surgery; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D011379:Prognosis; D018426:SEER Program; D015996:Survival Rate; D016896:Treatment Outcome