Tumor-stroma ratio as prognostic factor for survival in rectal adenocarcinoma: A retrospective cohort study

AIM To evaluate the prognostic value of the tumor-stroma ratio (TSR) in rectal cancer. METHODS TSR was determined on hematoxylin and eosin stained histological sections of 154 patients treated for rectal adenocarcinoma without prior neoadjuvant treatment in the period 1996-2006 by two observers to assess reproducibility. Patients were categorized into three categories: TSR-high [carcinoma percentage (CP) >= 70%], TSR-intermediate (CP 40%, 50% and 60%) and TSR- low (CP <= 30%). The relation between categorized TSR and survival was analyzed using Cox proportional hazards model. RESULTS Thirty-six (23.4%) patients were scored as TSR- low, 70 (45.4%) as TSR- intermediate and 48 (31.2%) as TS-Rhigh. TSR had a good interobserver agreement (kappa = 0.724, concordance 82.5%). Overall survival (OS) and disease free survival (DFS) were significantly better for patients with a high TSR (P = 0.01 and P = 0.02, respectively). A similar association existed for disease specific survival (P = 0.06). In multivariate analysis, patients without lymph node metastasis and an intermediate TSR had a higher risk of dying from rectal cancer (HR = 5.27, 95% CI: 1.54-18.10), compared to lymph node metastasis negative patients with a high TSR. This group also had a worse DFS (HR = 6.41, 95% CI: 1.84-22.28). An identical association was seen for OS. These relations were not seen in lymph node metastasis positive patients. CONCLUSION The TSR has potential as a prognostic factor for survival in surgically treated rectal cancer patients, especially in lymph node negative cases.