Development and validation of a nomogram to predict overall survival of T1 esophageal squamous cell carcinoma patients with lymph node metastasis

PURPOSE: To develop a nomogram for predicting the prognosis of T1 esophageal squamous cell carcinoma (ESCC) patients with positive lymph node. METHODS: T1 ESCC patients with lymph node metastasis diagnosed between 2010 and 2015 were selected from the Surveillance, Epidemiology, and Final Results (SEER) database. The entire cohort was randomly divided in the ratio of 7:3 into a training group (n=457) and validation group (n=192), respectively. Prognostic factors were identified by univariate and multivariate Cox regression models. Harrell's concordance index (C-index), receiver operating characteristic (ROC) curve, and calibration curve were used to evaluate the discrimination and calibration of the nomogram. The accuracy and clinical net benefit of the nomogram compared with the 7(th) AJCC staging system were evaluated using net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis (DCA). RESULTS: The nomogram consisted of eight factors: insurance, T stage, summary stage, primary site, radiation code, chemotherapy, surgery, and radiation sequence with surgery. In the training and validation cohorts, the AUCs exceeded 0.700, and the C-index scores were 0.749 and 0.751, respectively, indicating that the nomogram had good discrimination. The consistency between the survival probability predicted by the nomogram and the actual observed probability was indicated by the calibration curve in the training and validation cohorts. For NRI>0 and IDI>0, the predictive power of the nomogram was more accurate than that of the 7(th) AJCC staging system. Furthermore, the DCA curve indicated that the nomogram achieved better clinical utility than the traditional system. CONCLUSIONS: Unlike the 7(th) AJCC staging system, the developed and validated nomogram can help clinical staff to more accurately, personally and comprehensively predict the 1-year and 3-year OS probability of T1 ESCC patients with lymph node metastasis.