Liu DY, Hu JJ, Zhou YQ, Tan AR. Analysis of lymph node metastasis and survival prognosis in early gastric cancer patients: A retrospective study. World J Gastrointest Surg 2024; 16(6): 1637-1646 [DOI: 10.4240/wjgs.v16.i6.1637]
Corresponding Author of This Article
Ai-Rong Tan, MM, Doctor, Department of Oncology, Qingdao Municipal Hospital, No. 5 Donghai Middle Road, Shinan District, Qingdao 266000, Shandong Province, China. airongtan0425@outlook.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Author contributions: Liu DY wrote the manuscript; Hu JJ and Zhou YQ collected the data; Tan AR guided the study; All authors reviewed, edited, and approved the final manuscript and revised it critically for important intellectual content, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work.
Institutional review board statement: This study has been approved by the Clinical medical Research Ethics Committee of Zhongshan Hospital of Fudan University.
Informed consent statement: This study has obtained the consent and signed informed consent of the patients and their families.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: The technical appendix, statistical code, and dataset are available from the corresponding author at airongtan0425@outlook.com.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ai-Rong Tan, MM, Doctor, Department of Oncology, Qingdao Municipal Hospital, No. 5 Donghai Middle Road, Shinan District, Qingdao 266000, Shandong Province, China. airongtan0425@outlook.com
Received: January 30, 2024 Revised: April 8, 2024 Accepted: May 6, 2024 Published online: June 27, 2024 Processing time: 151 Days and 10.8 Hours
Abstract
BACKGROUND
Early gastric cancer (EGC) is a common malignant tumor of the digestive system, and its lymph node metastasis and survival prognosis have been concerning. By retrospectively analyzing the clinical data of EGC patients, we can better understand the status of lymph node metastasis and its impact on survival and prognosis.
AIM
To evaluate the prognosis of EGC patients and the factors that affect lymph node metastasis.
METHODS
The clinicopathological data of 1011 patients with EGC admitted to our hospital between January 2015 and December 2023 were collected in a retrospective cohort study. There were 561 males and 450 females. The mean age was 58 ± 11 years. The patient underwent radical gastrectomy. The status of lymph node metastasis in each group was determined according to the pathological examination results of surgical specimens. The outcomes were as follows: (1) Lymph node metastasis in EGC patients; (2) Analysis of influencing factors of lymph node metastasis in EGC; and (3) Analysis of prognostic factors in patients with EGC. Normally distributed measurement data are expressed as mean ± SD, and a t test was used for comparisons between groups. The data are expressed as absolute numbers or percentages, and the chi-square test was used for comparisons between groups. Rank data were compared using a nonparametric rank sum test. A log-rank test and a logistic regression model were used for univariate analysis. A logistic stepwise regression model and a Cox stepwise regression model were used for multivariate analysis. The Kaplan-Meier method was used to calculate the survival rate and construct survival curves. A log-rank test was used for survival analysis.
RESULTS
Analysis of influencing factors of lymph node metastasis in EGC. The results of the multifactor analysis showed that tumor length and diameter, tumor site, tumor invasion depth, vascular thrombus, and tumor differentiation degree were independent influencing factors for lymph node metastasis in patients with EGC (odds ratios = 1.80, 1.49, 2.65, 5.76, and 0.60; 95%CI: 1.29–2.50, 1.11–2.00, 1.81–3.88, 3.87-8.59, and 0.48-0.76, respectively; P < 0.05). Analysis of prognostic factors in patients with EGC. All 1011 patients with EGC were followed up for 43 (0–13) months. The 3-year overall survival rate was 97.32%. Multivariate analysis revealed that age > 60 years and lymph node metastasis were independent risk factors for prognosis in patients with EGC (hazard ratio = 9.50, 2.20; 95%CI: 3.31-27.29, 1.00-4.87; P < 0.05). Further analysis revealed that the 3-year overall survival rates of gastric cancer patients aged > 60 years and ≤ 60 years were 99.37% and 94.66%, respectively, and the difference was statistically significant (P < 0.05). The 3-year overall survival rates of patients with and without lymph node metastasis were 95.42% and 97.92%, respectively, and the difference was statistically significant (P < 0.05).
CONCLUSION
The lymph node metastasis rate of EGC patients was 23.64%. Tumor length, tumor site, tumor infiltration depth, vascular cancer thrombin, and tumor differentiation degree were found to be independent factors affecting lymph node metastasis in EGC patients. Age > 60 years and lymph node metastasis are independent risk factors for EGC prognosis.
Core Tip: The clinical data of patients with early gastric cancer (EGC) were retrospectively analyzed to investigate the lymph node metastasis and its influence on survival and prognosis. We will focus on the incidence of lymph node metastasis in patients with EGC and the correlation between the number of metastatic lymph nodes and the survival of patients. The results of this study are helpful to further understand the pathological characteristics of EGC patients and their impact on prognosis, and provide scientific basis for developing personalized treatment and improving the quality of life of patients.
Citation: Liu DY, Hu JJ, Zhou YQ, Tan AR. Analysis of lymph node metastasis and survival prognosis in early gastric cancer patients: A retrospective study. World J Gastrointest Surg 2024; 16(6): 1637-1646
Early gastric cancer (EGC) is an adenocarcinoma that is limited to the gastric mucosa or submucosa, regardless of tumor size and lymph node metastasis[1-3]. In recent years, with the continuous improvement in the diagnosis and treatment of gastric cancer in our country, the detection rate of early-stage gastric cancer has been continuously increasing, and the 5-year survival rate is > 90%. Although the prognosis of EGC patients is good, the 5-year survival rate of EGC patients with lymph node metastasis is significantly lower than that of patients without lymph node metastasis[4]. The status of lymph node metastasis determines the treatment of EGC and affects the prognosis.
EGC research revealed that a large number of poorly differentiated cases involved the lower part of the stomach. This observation sparked our interest in a retrospective analysis of lymph node metastasis and survival outcomes in EGC patients. In clinical practice, low-differentiated cases typically show more aggressive characteristics, and their tendency to appear in the lower part of the stomach has attracted our attention[5]. There are several possible reasons. First, the lower part of the stomach has a more complex anatomical structure due to its anatomical location, close to the pylorus and gastric antrum, which may complicate the growth and spread of tumors in the lower part of the stomach. Additionally, the lower part of the stomach has more mucosal structure than the upper part. The submucosal tissue is also less dense, which may make it easier for tumor cells to enter lymphatic and blood vessels[6]. In addition, disease factors specific to the lower stomach, such as atrophic gastritis and Helicobacter pylori infection, may also be associated with low differentiation in gastric cancer and lymph node metastasis.
Early stomach cancer is the early stage of cancer, when the cancer cells are mostly confined to the stomach wall and have not yet spread to the lymph nodes or beyond[7]. Lymph node metastasis is an important sign of gastric cancer progression, which means that cancer cells enter lymphatic vessels from the primary site, reach lymph nodes, and continue to grow and spread. The occurrence and degree of lymph node metastasis have important influences on the prognosis of gastric cancer patients[8-10]. With the progress of medical technology, the diagnosis rate of EGC has improved, but lymph node metastasis is still a key factor affecting the prognosis of patients[11]. The presence of lymph node metastases in EGC can provide valuable information about the patient's prognosis and help physicians develop a more precise treatment plan. Studying the relationship between lymph node metastasis and the prognosis of EGC patients is helpful for further understanding the development of gastric cancer and providing clinicians with more targeted treatment recommendations to improve the survival rate and quality of life of patients[12-14]. Moreover, for patients with EGC with lymph node metastasis, effective treatments, such as surgery, chemotherapy, and radiotherapy, should be actively adopted to curb the spread of cancer cells and improve the cure rate[15].
Both anatomical pathways and tumor biology can help us understand the basic principle of lymph node metastasis, which is more concentrated in the first station. Anatomically, the lymphatic system forms specific channels in the body that direct tissue fluid and cellular waste from tissues to lymph nodes. When cancer cells invade lymphatic vessels and penetrate their walls, they usually first travel along an anatomical path to the nearest lymph node, the "first stop" of lymphatic metastasis. Tumor biology also influences this pattern; for example, tumor cells within lymphatic vessels may be influenced by specific factors that make them more inclined to stay and grow in specific lymph nodes along the anatomical path.
This study retrospectively analyzed the clinicopathological data of 1011 patients with EGC admitted to our department between January 2015 and December 2023 to explore the factors affecting lymph node metastasis and the prognosis of EGC patients.
MATERIALS AND METHODS
General clinical data analysis
The clinicopathological data of 1011 patients with EGC were collected in a prospective cohort study. There were 561 males and 450 females. The mean age was 58 ± 11 years. Among the 1011 patients, 577 had a tumor length ≤ 2 cm, and 434 had a length > 2 cm. The tumors were highly differentiated in 214 patients, moderately differentiated in 296 patients, and poorly differentiated in 501 patients. The tumors were located in the upper part of the stomach in 90 patients, the middle part of the stomach in 193 patients, and the lower part of the stomach in 728 patients. The depth of tumor invasion was mucosa (stage T1a) in 446 patients and submucosa (stage T1b) in 565 patients.
This study was approved by our hospital, and patients and their families signed informed consent forms.
Inclusion criteria: (1) A postoperative pathological examination confirmed EGC; (2) A radical gastrectomy was performed; (3) No antitumor therapy was administered before surgery; and (4) Complete clinicopathological data were available.
Exclusion criteria: (1) A postoperative pathological examination confirmed advanced gastric cancer; (2) Patients with a preoperative history of neoadjuvant therapy; (3) Other malignant tumors; (4) Gastric stump cancer; (5) Recurrent cancer; (6) Special types of gastric tumors, such as lymphoma, neuroendocrine tumors, and stromal tumors; and (7) Clinicopathological data were missing.
Research methods
The patient underwent radical gastrectomy. According to the pathological examination results of surgical specimens, lymph node metastasis in each group was determined according to the statistics of the 13th edition of the gastric cancer treatment protocol.
Observation indicators and evaluation criteria
Observation indicators: (1) Lymph node metastasis in EGC includes the lymph node metastasis rate, lymph node metastasis rate in different T stages, lymph node metastasis in different groups, and lymph node metastasis in different locations; (2) Analysis of influencing factors of lymph node metastasis in EGC: Sex, age, body mass index (BMI), family history of gastric cancer, smoking history, drinking history, tumor length, tumor site, tumor invasion depth, vascular cancer thrombus, nerve invasion, and tumor differentiation degree; and (3) Analysis of factors influencing the prognosis of patients with EGC: Number of patients with follow-up, follow-up time, and survival of patients. The clinicopathologic factors included sex, age, BMI, family history of gastric cancer, smoking history, drinking history, tumor length, tumor site, depth of tumor invasion, vascular cancer thrombus, nerve invasion, degree of tumor differentiation, and lymph node metastasis.
Evaluation criteria: The T and N stages were determined according to the American Joint Commission on Cancer (AJCC) 8th edition tumor-node-metastasis (TNM) staging criteria. The system classifies patients into different stages based on the primary tumor, lymph node metastasis, and distant metastasis status. Specifically, the T stage reflects the size and aggressiveness of the primary tumor in the stomach, the N stage reflects the presence of lymph node metastasis, and the M stage reflects the presence of distant metastasis. We retrospectively analyzed the patients' clinical data, classified them according to the AJCC-TNM staging system, and recorded the number of patients, clinical features, and lymph node metastasis in each stage group.
Follow-up visit
Follow-up was conducted by outpatient visits or telephone to determine the survival of patients, and the follow-up time was up to May 2023.
Statistical analysis
SPSS 25.0 statistical software was used for the analysis. Normally distributed measurement data are expressed as mean ± SD, and a t test was used for comparisons between groups. The data are expressed as absolute numbers or percentages, and the chi-square test was used for comparisons between groups. Rank data were compared using a nonparametric rank sum test. A log-rank test and a logistic regression model were used for univariate analysis. A logistic stepwise regression model and a Cox stepwise regression model were used for multivariate analysis. The Kaplan-Meier method was used to calculate the survival rate and construct survival curves. A log-rank test was used for survival analysis. P < 0.05 was considered to indicate statistical significance.
RESULTS
Lymph node metastasis in EGC
In 1011 patients with early-stage gastric cancer, the rate of lymph node metastasis was 23.64% (239/1011), among which the rate of lymph node metastasis was 11.88% (53/446) in patients with stage T1a disease and 32.92% (186/565) in patients with stage T1b disease. In 239 patients with lymph node metastasis, lymph node metastasis was mainly concentrated in the first-station lymph node, and in groups 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10, lymph node metastasis was 7, 11, 135, 59, 39, 91, 6, 8, 8, 8, and 6, respectively. The same patient may have multiple lymph node metastases. Lymph node metastasis at different tumor sites: 4, 2, and 1 patients were included in the 2nd, 3rd, and 5th groups of upper gastric tumors, respectively. There were 3, 7, 36, 15, 3, and 5 patients with lymph node metastasis in groups 1, 2, 3, 3, 6, 4, 4, and 6, respectively. There were 4, 97, 44, 35, and 86 patients with lymph node metastasis in groups 1, 3, 4, 5, and 6, respectively.
Analysis of influencing factors of lymph node metastasis in EGC
One-way analysis revealed that the factors that affected lymph node metastasis in EGC patients were tumor differentiation, tumor length, tumor location, tumor invasion depth, vascular thrombus, and tumor differentiation. Sex, age, BMI, family history of gastric cancer, smoking history, and drinking history were not correlated with lymph node metastasis in patients with EGC (P > 0.05; Table 1).
Table 1 Univariate analysis of lymph node metastasis in 1011 patients with early gastric cancer.
Clinicopathological factors
Assignment
Lymph node metastasis (n = 239)
No lymph node metastasis (n = 772)
χ²
P value
Sex
Male
1
131
430
0.06
0.809
Female
0
108
342
Age
≤ 60 yr old
0
131
432
0.10
0.755
> 60 yr old
1
108
340
BMI
≤ 24 kg/m²
1
162
539
0.56
0.511
> 24 kg/m²
0
77
233
Family history of gastric cancer
Yes
1
92
284
0.23
0.633
No
0
147
488
Smoking history
Yes
1
84
266
0.04
0.845
No
0
155
506
Drinking history
Yes
1
67
191
1.04
0.308
No
0
172
581
Tumor size
≤ 2 cm
0
99
478
31.29
< 0.001
> 2 cm
1
140
294
Tumor location
Upper part of the stomach
1
6
84
15.82
< 0.001
Mid-stomach
2
50
143
Lower part of the stomach
3
183
545
Tumor invasion depth
Mucosal lining
0
53
393
61.11
< 0.001
Submucosa
1
186
379
Vasculatogenic cancer thrombus
No
0
102
64
157.26
< 0.001
Yes
1
137
708
Nerve invasion
No
0
21
24
13.83
< 0.001
Yes
1
218
748
Degree of tumor differentiation
Low differentiation
1
125
376
Z = -2.45
0.014
Medium differentiation
2
88
208
High differentiation
3
26
188
The results of the multifactor analysis showed that tumor length, tumor location, tumor invasion depth, vascular cancer thrombus, and tumor differentiation degree were independent factors affecting lymph node metastasis in EGC patients (P < 0.05; Table 2).
Table 2 Multivariate analysis of lymph node metastasis in 1011 patients with early gastric cancer.
Clinicopathological factors
Regression coefficients
SE
Wald
OR
95%CI
P value
Tumor diameter
0.59
0.17
12.15
1.80
1.29-2.50
< 0.001
Tumor site
0.40
0.15
7.10
1.49
1.11-1.00
0.008
Depth of tumor invasion
0.97
0.20
24.84
2.65
1.81-3.88
< 0.001
Vasculatogenic cancer thrombus
1.75
0.20
73.99
5.76
3.87-8.59
< 0.001
Degree of tumor differentiation
-0.50
0.12
18.68
0.60
0.48-0.76
< 0.001
Analysis of factors influencing the prognosis of patients with EGC
All 1011 patients with EGC were followed up for 43 (0–13) months. The 3-year overall survival rate was 97.32%. Univariate analysis revealed that age, vascular thrombus, and lymph node metastasis were factors related to the prognosis of EGC patients (P < 0.05). Sex, BMI, family history of gastric cancer, smoking history, drinking history, tumor length, tumor site, depth of tumor invasion, nerve invasion, and degree of tumor differentiation were not correlated with the prognosis of EGC patients (P > 0.05; Table 3).
Table 3 Univariate analysis of prognosis in 1011 patients with early gastric cancer.
Clinicopathological factors
Assignment
Cases
3-year overall survival rate (%)
χ²
P value
Sex
Male
1
561
96.6
1.89
0.169
Female
0
450
98.0
Age
≤ 60 yr old
0
563
98.9
5.95
0.015
> 60 yr old
1
448
97.3
BMI
≤ 24 kg/m²
0
701
97.4
0.76
0.384
> 24 kg/m²
1
310
96.9
Family history of gastric cancer
Yes
1
376
96.6
1.69
0.193
No
0
635
99.3
Smoking history
Yes
1
350
97.9
1.42
0.233
No
0
661
98.8
Drinking history
Yes
1
258
98.8
1.09
0.297
No
0
753
98.4
Tumor length
≤ 2 cm
0
577
97.5
0.14
0.708
> 2 cm
1
434
96.9
Tumor location
Upper part of the stomach
1
90
97.4
0.57
0.752
Mid-stomach
2
193
98.1
Lower part of the stomach
3
728
98.2
Tumor invasion depth
Mucosal lining
0
446
98.0
3.39
0.066
Submucosa
1
565
96.6
Vasculatogenic cancer thrombus
No
0
166
97.8
5.26
0.022
Yes
1
845
94.4
Nerve invasion
No
0
45
98.8
0.30
0.587
Yes
1
966
95.1
Degree of tumor differentiation
Low differentiation
1
501
97.7
4.21
0.122
Medium differentiation
2
296
97.6
High differentiation
3
214
95.6
Lymph node metastases
No
0
772
97.9
7.11
0.008
Yes
1
239
95.0
The results of multivariate analysis showed that age > 60 years and lymph node metastasis were independent risk factors for the prognosis of EGC patients (P < 0.05; Table 4). Further analysis revealed that the 3-year overall survival rates of gastric cancer patients aged > 60 years and ≤ 60 years were 99.37% and 94.66%, respectively, and the difference was statistically significant (χ² = 25.33, P < 0.001; Figure 1A). The 3-year overall survival rates of patients with and without lymph node metastasis were 95.42% and 97.92%, respectively, and the difference was statistically significant (χ² = 5.69, P = 0.017; Figure 1B).
Figure 1 Overall survival curves of patients.
A: Postoperative overall survival curves of patients aged < 60 years and > 60 years with early gastric cancer; B: Overall survival curve of patients with early gastric cancer without lymph node metastasis and with lymph node metastasis.
Table 4 Multivariate analysis of prognosis in 1011 patients with early gastric cancer.
Clinicopathological factors
Regression coefficients
SE
Wald
RR
95%CI
P value
Age > 60 yr
2.25
0.54
17.47
9.5
3.31-27.29
< 0.001
Lymph node metastases
0.79
0.40
3.81
2.2
1.00-4.87
0.049
DISCUSSION
The main treatment methods for EGC include simple surgery and endoscopic resection[16]. Compared with surgical resection, endoscopic resection has the advantages of less trauma and a greater postoperative quality of life and is the preferred treatment for EGC[17]. However, the risk of tumor recurrence after endoscopic resection is greater than that after surgical resection because the lymph nodes cannot be removed. Therefore, for EGC patients with lymph node metastasis, surgical operations are still needed to achieve radical resection of the tumor[18-20]. Lymph node metastasis is also a key factor affecting the prognosis of patients with EGC. The results of this study showed that the 3-year overall survival rate of patients with lymph node metastasis was significantly lower than that of patients without lymph node metastasis[21]. Therefore, accurately predicting the risk of lymph node metastasis in EGC and understanding the law of lymph node metastasis in EGC are conducive to selecting appropriate surgical methods and improving therapeutic efficacy.
The results of this study showed that the lymph node metastasis rate of EGC patients was 23.64% (239/1011), which was similar to the findings of other studies[22]. There are many factors affecting lymph node metastasis in EGC, among which vascular invasion, depth of tumor invasion, and tumor size are recognized as influencing factors[23]. Multifactor analysis in this study showed that the length of the tumor, its location, its invasion depth, the presence of a vascular cancer thrombus, and its degree of differentiation were all separate factors that affected lymph node metastasis in EGC patients[24]. Among the many factors related to lymph node metastasis in EGC, the indicators that can be used for preoperative evaluation include tumor length, tumor site, and tumor invasion depth[25-27]. Preoperative operators can use endoscopic ultrasound and gastroscopy to accurately evaluate EGC and guide the selection of appropriate treatment[28].
The results of this study showed that lymph node metastasis in EGC patients was mainly concentrated in the first station lymph node[29]. The rate of lymph node metastasis differed among different tumor sites, and the rate of lymph node metastasis differed among groups[30]. Although the patterns of lymph node metastasis differed among the different sites of EGC, Group 3 lymph node metastasis was detected in all of the patients, which should be the focus of further studies. One study examined the clinical and pathological information of 33 people with EGC who had lymph node metastasis. Group 3 had the most lymph node metastasis, followed by Group 4. This is consistent with the results of this study. D2 lymph node dissection has become the standard surgical procedure for advanced gastric cancer[31-33].
The results showed that lymph node metastasis in gastric cancer was affected by the degree of tumor differentiation, the depth of invasion, and the extent of lymphatic vessel invasion. In particular, patients with low differentiation, deep invasion, and obvious lymphatic vessel invasion were more likely to have lymph node metastasis. In addition, the patient's age, sex, comorbidities, and other factors may also affect the incidence and prognosis of lymph node metastasis.
Lymph node metastasis in EGC is mainly concentrated in the first-station lymph node, and most patients with EGC may have excessive lymph node dissection[34]. In summary, this study revealed that we need to determine whether a patient has lymph node metastasis before surgery for early-stage gastric cancer, to ensure that the right lymph node dissection is performed to the greatest extent possible after radical treatment, and to improve the overall survival of patients[35]. The results of this study showed that age > 60 years and lymph node metastasis were independent risk factors affecting the prognosis of patients with EGC[36]. Further analysis revealed statistically significant differences in 3-year overall survival rates between patients aged > 60 years and those aged ≤ 60 years with and without lymph node metastasis[37]. Another study showed that vascular thrombus is an independent risk factor affecting the prognosis of patients with EGC and can be used as a reference index for postoperative adjuvant treatment. Age is an important predictor of the prognosis of gastric cancer patients, and there are significant differences in clinicopathological features and prognostic factors among different age groups[38]. Lymph node metastasis is an independent risk factor for the postoperative prognosis of gastric cancer patients and can better guide the diagnosis and treatment of postoperative patients[39-41]. This study revealed that people over 60 years old who have EGC and who undergo postoperative pathological examination that revealed lymph node metastasis should receive additional chemotherapy or radiotherapy after surgery to help them live longer.
CONCLUSION
In summary, the rate of lymph node metastasis in EGC patients was 23.64%. Tumor length, tumor site, tumor invasion depth, vascular cancer thrombin, and tumor differentiation degree were found to be independent factors affecting lymph node metastasis in EGC patients. Age > 60 years and lymph node metastasis are independent risk factors for EGC patients.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade C
Novelty: Grade B
Creativity or Innovation: Grade B
Scientific Significance: Grade C
P-Reviewer: Morya AK, India S-Editor: Li L L-Editor: A P-Editor: Che XX
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