Nomograms predicting survival and recurrence in colonic cancer in the era of complete mesocolic excision

Abstract

Background: More extensive lymphadenectomy may improve survival after resection of colonic cancer. Nomograms were created predicting overall survival and recurrence for patients who undergo D2-D3 lymph node dissection, and their validity determined.

Methods: This was a multicentre study of patients with colonic cancer who underwent resection with D2-D3 lymph node dissection in Japan. Inclusion criteria included R0 resection. A training cohort of patients operated on from 2007 to 2008 was analysed to construct prognostic models predicting survival and recurrence. Discrimination and calibration were performed using an external validation cohort from the Japanese colorectal cancer registry (procedures in 2005-2006).

Results: The training cohort consisted of 2746 patients. Predictors of survival were: age (hazard ratio (HR) 1·04), female sex (HR 0·71), depth of tumour invasion (HR 1·15, 1·22, 2·96 and 3·14 for T2, T3, T4a and T4b respectively versus T1), lymphatic invasion (HR 1·11, 1·15 and 2·95 for ly1, ly2 and ly3 versus ly0), preoperative carcinoembryonic antigen (CEA) level (HR 1·21, 1·59 and 1·99 for 5·1-10·0, 10·1-20·0 and 20·1 and over versus 0-5·0 ng/ml), number of metastatic lymph nodes (HR 1·07), number of lymph nodes examined (HR 0·98) and extent of lymphadenectomy (HR 0·23, 0·13 and 0·11 for D1, D2 and D3 versus D0). Predictors of recurrence were: female sex (HR 0·82), macroscopic type (HR 3·82, 4·56, 6·66, 7·74 and 3·22 for types I, II, III, IV and V versus type 0), depth of invasion (HR 1·25, 2·66, 5·32 and 6·43 for T2, T3, T4a and T4b versus T1), venous invasion (HR 1·43, 3·05 and 4·79 for v1, v2 and v3 versus v0), preoperative CEA level (HR 1·39, 1·43, 1·56 and 1·85 for 5·1-10·0, 10·1-20·0, 20·1-40·0 and 40·1 or more versus 0-5 ng/ml), number of metastatic lymph nodes (HR 1·07) and number of lymph nodes examined (HR 0·98). The validation cohort comprised 4446 patients. The internal and external validated Harrell's C-index values for the nomogram predicting survival were 0·75 and 0·74 respectively. Corresponding values for recurrence were 0·78 and 0·75.

Conclusion: These nomograms could predict survival and recurrence after curative resection of colonic cancer.

Figure 1

Prognostic nomogram for predicting overall survival of patients with colonic cancer. The nomogram can assign the probability of survival by adding up the scores identified on the points scale for each variable. The total score projected to the bottom scale indicates the probability of 3‐ and 5‐year survival. CEA, carcinoembryonic antigen; LN, lymph node

Figure 2

Prognostic nomogram for predicting recurrence‐free survival of patients with colonic cancer. The nomogram can assign the probability of survival by adding up the scores identified on the points scale for each variable. The total score projected to the bottom scale indicates the probability of 3‐ and 5‐year survival. CEA, carcinoembryonic antigen; LN, lymph node

Figure 3

Calibration of the nomogram in the training cohort. a Five‐year overall survival (OS) and b 5‐year recurrence‐free survival (RFS). Actual survival rates with 95 per cent confidence intervals were calculated by Kaplan–Meier analysis. The dotted line represents the ideal reference line where predicted survival corresponds to actual survival

Figure 4

Calibration of the nomogram in the validation cohort. a Five‐year overall survival (OS) and b 5‐year recurrence‐free survival (RFS). Actual survival rates with 95 per cent confidence intervals were calculated by Kaplan–Meier analysis. The dotted line represents the ideal reference line where predicted survival corresponds to actual survival

Figure 5

Predicted stage‐specific recurrence‐free survival based on the eighth AJCC classification. Median value (bold line), box (i.q.r.), and range (error bars) excluding outliers (circles) are shown