Comparison of Predictive Performance of Three Lymph Node Staging Systems in Colorectal Signet Ring Cell Carcinoma Based on Machine Learning Model

Resumen

This study evaluates prognostic systems for colorectal signet-ring cell carcinoma patients using machine learning models and competing risk analyses. It identifies log odds of positive lymph nodes as a superior predictor compared to pN staging, demonstrating strong predictive performance and aiding clinical decision-making through robust survival prediction tools.

Resumen

Lymph node status is a critical prognostic predictor for patients; however, the prognosis of colorectal signet-ring cell carcinoma (SRCC) has garnered limited attention. This study investigates the prognostic predictive capacity of the log odds of positive lymph nodes (LODDS), lymph node ratio (LNR), and pN staging in SRCC patients using machine learning models (Random Forest, XGBoost, and Neural Network) alongside competing risk models. Relevant data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. For the machine learning models, prognostic factors for cancer-specific survival (CSS) were identified through univariate and multivariate Cox regression analyses, followed by the application of three machine learning methods-XGBoost, RF, and NN-to ascertain the optimal lymph node staging system. In the competing risk model, univariate and multivariate competing risk analyses were employed to identify prognostic factors, and a nomogram was constructed to predict the prognosis of SRCC patients. The area under the receiver operating characteristic curve (AUC-ROC) and calibration curves were utilized to assess the model's performance. A total of 2,409 SRCC patients were included in this study. To validate the effectiveness of the model, an additional cohort of 15,122 colorectal cancer patients, excluding SRCC cases, was included for external validation. Both the machine learning models and the competing risk nomogram exhibited strong performance in predicting survival outcomes. Compared to pN staging, the LODDS staging systems demonstrated superior prognostic capability. Upon evaluation, machine learning models and competing risk models achieved excellent predictive performance characterized by good discrimination, calibration, and interpretability. Our findings may assist in informing clinical decision-making for patients.

Introducción

Colorectal cancer (CRC) ranks as the third most prevalent malignant tumor globally^1,2,3. Signet ring cell carcinoma (SRCC), a rare subtype of CRC, comprises approximately 1% of cases and is characterized by abundant intracellular mucin displacing the cell nucleus^1,2,4. SRCC is often associated with younger patients, has a higher prevalence in females, and has advanced tumor stages at diagnosis. Compared to colorectal adenocarcinoma, SRCC shows poorer differentiation, a higher risk of distant metastasis, and a 5-year survival rate of only 12%-20%^5,6. Developing an accurate and effective prognostic model for SRCC is crucial for optimizing treatment strategies and improving clinical outcomes.

This study aims to construct a robust prognostic model for SRCC patients using advanced statistical approaches, including machine learning (ML) and competing risk models. These methodologies can accommodate complex relationships in clinical data, offering individualized risk assessments and surpassing traditional methods in predictive accuracy. Machine learning models, such as Random Forest, XGBoost, and Neural Networks, excel in processing high-dimensional data and identifying intricate patterns. Studies have shown that AI models effectively predict survival outcomes in colorectal cancer, emphasizing ML's potential in clinical applications^7,8. Complementing ML, competing risk models address multiple event types, such as cancer-specific mortality versus other causes of death, to refine survival analysis. Unlike traditional methods like the Kaplan-Meier estimator, competing risk models accurately estimate the marginal probability of events in the presence of competing risks, providing more precise survival assessments⁸. Integrating ML and competing risk analysis enhances predictive performance, offering a powerful framework for personalized prognostic tools in SRCC^9,10,11.

Lymph node metastasis significantly influences prognosis and recurrence in CRC patients. While N-stage assessment in the TNM classification is critical, inadequate lymph node examination -- reported in 48%-63% of cases -- can lead to disease underestimation. To address this, alternative approaches like the lymph node ratio (LNR) and the log odds of positive lymph nodes (LODDS) have been introduced. LNR, the ratio of positive lymph nodes (PLNs) to total lymph nodes (TLNs), is less affected by TLN count and serves as a prognostic factor in CRC. LODDS, the logarithmic ratio of PLNs to negative lymph nodes (NLNs), has shown superior predictive ability in both gastric SRCC and colorectal cancer^10,11. Machine learning has been increasingly applied in oncology, with models improving risk stratification and prognostic predictions across various cancers, including breast, prostate, and lung cancers^12,13,14. However, its application in colorectal SRCC remains limited.

This study seeks to bridge this gap by integrating LODDS with ML and competing risk models to create a comprehensive prognostic tool. By evaluating the prognostic value of LODDS and leveraging advanced predictive techniques, this research aims to enhance clinical decision-making and improve outcomes for SRCC patients.

Protocolo

This study does not refer to ethical approval and consent to participate. The data used in this study was obtained from databases. We included patients diagnosed with colorectal signet-ring cell carcinoma from 2004 to 2015, as well as other types of colorectal cancer. Exclusion criteria included patients with a survival time of less than one month, those with incomplete clinicopathological information, and cases where the cause of death was unclear or unspecified.

1. Data acquisition

1. Download SEER. Obtain statistics 8.4.3 software from the SEER database website (http://seer.cancer.gov/about/overview.html). After logging into the software, click Case List Session > Data and select the Incidence SEER Research Plus Data, 17 Registries, Nov 2021 Sub (2000-2019) database.
2. Click on Selection > Edit and choose {Race, Sex, Year Dx. Year of diagnosis} = '2004', '2005', '2006', '2007', '2008', '2009', '2010', '2011', '2012', '2013', '2014', '2015' AND {Site and Morphology. Site recode ICD-O-3/WHO 2008} = '8490/3'.
3. Then click on Table, and in the available variables interface, select Age recode with single ages and 100+, Sex, Marital, Site recode ICD-O-3/WHO 2008, CS tumor size, Regional nodes_examined(1988+), Regional nodes_positive(1988+), Derived AJCC Stage Group, 6th ed (2004-2015), Derived AJCC T, 6th ed (2004-2015), Derived AJCC N, 6th ed (2004-2015), Derived AJCC M, 6th ed (2004-2015), CEA, Radiation recode, Chemotherapy recode (yes, no/unk), SEER cause-specific death classification, Vital status recode (study cutoff used), Survival months, Year of diagnosis.
4. Finally, click on Output, name the data, and click on Execute to output and save the data. The detailed inclusion process is shown in Figure 1.
5. Download data from colorectal cancer patients, excluding SRCC cases, for subsequent external validation. Click on Selection > Edit and choose {Race, Sex, Year Dx. Year of diagnosis} = '2004', '2005', '2006', '2007', '2008', '2009', '2010', '2011', '2012', '2013', '2014', '2015' AND {Primary Site - labeled} = 'C18-C20'. Repeat steps 1.3 and 1.4 to obtain clinical pathological information and exclude samples with {Site and Morphology. Site recode ICD-O-3/WHO 2008} = '8490/3' from the downloaded file.
6. For comparative purposes, process several variables. Classify lymph node status using both Lymph Node Ratio (LNR) and Logarithm of the Odds of Positive Lymph Nodes (LODDS).
   1. Define LNR as the ratio of positive lymph nodes (PLNs) to total lymph nodes (TLNs). Calculate the LODDS value using the formula:
      loge(number of PLNs + 0.5) / (number of negative lymph nodes (NLNs) + 0.5)
      where 0.5 was added to prevent an infinite result. The cut-off values for LNR, LODDS, and tumor size were determined using X-tile software (version 3.6.1) based on the minimum P-value method.
7. Open the X-tile software, click on File > Open, and select the data file to import it into the software. Once the data is loaded, map the variables: Censor corresponds to survival status, Survival time corresponds to survival time, and marker1 is the variable to be analyzed, ensuring the data matches correctly.
8. Then, click on Do > Kaplan-Meier > Marker1 to perform the Kaplan-Meier survival analysis and generate the survival curve. Based on the separation of the Kaplan-Meier survival curves, statistical significance (e.g., p-value), and clinical relevance, determine the optimal cut-off value, and finally record or export the analysis results.
   1. Divide LNR into three groups: LNR 1 (≤0.16), LNR 2 (0.16 - 0.78), and LNR 3 (≥ 0.78). Categorize patients into three groups based on LODDS: LODDS 1 (≤ -1.44), LODDS 2 (-1.44 - 0.86), and LODDS 3 (≥ 0.86).
   2. Classify tumor size into three categories: ≤ 3.5 cm, 3.5 - 5.5 cm, and ≥ 5.5 cm. Convert age from a continuous to a categorical variable. Categorize patients' ages at the time of initial diagnosis as ≥60 years and <60 years. Classify tumor location based on the distribution of signet-ring cell carcinoma (SRCC) tumors as right colon, left colon, and rectum. The right colon includes the cecum, ascending colon, hepatic flexure, and transverse colon, while the left colon includes the splenic flexure, descending colon, sigmoid colon, and rectosigmoid junction.
9. For this study, randomly assign a total of 2409 eligible patient data with SRCC to a training cohort (N = 1686) and a validation cohort (N = 723) in a 7:3 ratio. Use the following code for random splitting, and source data.csv from the SEER database. The files generated after random splitting will be used for further analysis.
   library(caret)
   data <- read.csv("data.csv")
   set.seed(123)
   train_indices <- createDataPartition(data$variable, p = 0.7, list = FALSE)
   train_data <- data[train_indices, ]
   test_data <- data[-train_indices, ]
   write.csv(train_data, "traindata.csv", row.names = FALSE)
   write.csv(test_data, "testdata.csv", row.names = FALSE)

2. ML models development and verification

1. Download RStudio (2024.04.2+764) and R software (4.4.1). Open RStudio to run R software. Click on New File and select R Script to create a new R programming interface. Enter the relevant code in the code editor and click on Run to execute the code.
2. Use the following code to screen the variables included in the ML models by Cox regression analysis. Additionally, explore the impact of LODDS, LNR, and pN staging on cancer-specific survival (CSS) in SRCC patients. The traindata.csv is data obtained from the SEER database.
   library("survival")
   library("survminer")
   library("rms")
   library("dplyr")
   data <- read.csv("traindata.csv")
   data$time=as.numeric(data$time)
   data$status=as.numeric(data$status)
   variables <- c("Sex", "Age", "Race", "Marital", "Stage", "T", "N", "M","Tumor_size", "LNR", "LODDS", "CEA","Radiation", "Chemotherapy", "Site")
   data <- data %>%
   mutate(across(all_of(variables), as.factor))
   cox=coxph(Surv(time, status) ~ data$T, data = data)
   cox$coefficients
   pval=anova(cox)$Pr[2]
   clean_data=data[,c(1:12, 14:18)]
   get_coxVariable=function(your_data,index){cox_list=c() k=1
   for (i in 1:index) {mod=coxph(Surv(time, status) ~ your_data[,i],data=your_data) pval=anova(mod)$Pr[2] print(pval) print(colnames(your_data)[i]) if (pval<0.05) {cox_list[k]=colnames(your_data)[i] k=k+1}}return(cox_list)}
   variable_select=get_coxVariable(clean_data,15)
   for(i in 1:15){print(variable_select[i])}
   for (var in variable_select) {formula <- as.formula(paste("Surv(time, status) ~", var))cox_model <- coxph(formula, data = data) print(summary(cox_model))
   ggforest(cox)
   variables <- c("Sex", "Age", "Race", "Marital", "Stage", "T", "N", "M", "Tumor_size", "LNR", "LODDS", "Chemotherapy")
   data <- data %>%
   mutate(across(all_of(variables), as.factor))
   cox=coxph(Surv(time, status) ~ Sex+Age+Race+Marital+T+N+M+Tumor_size+LNR+
   LODDS+Chemotherapy,data = data)
   ggforest(cox,data = data)
   ggplot_forest <- ggforest(cox, data = data)
3. Use the following code to compare the prognostic prediction abilities of three LN systems (LODDS, LNR, and pN staging) across the training, validation, and external validation cohorts.
   library(rms)
   library(survival)
   library(survminer)
   library(riskRegression)
   library(gt)
   train_data <- read.csv("train_data123.csv")
   validation_data <- read.csv("test_data123.csv")
   dd <- datadist(train_data)
   options(datadist = "dd")
   model_LNR <- cph(Surv(time, status) ~ LNR, data = train_data, x = TRUE, y = TRUE)
   model_LODDS <- cph(Surv(time, status) ~ LODDS, data = train_data, x = TRUE, y = TRUE)
   model_pN <- cph(Surv(time, status) ~ N, data = train_data, x = TRUE, y = TRUE)
   calculate_performance <- function(model, data) {pred <- predict(model, newdata = data) c_index_result <- concordance(Surv(data$time, data$status) ~ pred) c_index <- c_index_result$concordance aic <- AIC(model) bic <- BIC(model) return(c(C_index = round(c_index, 3), AIC = round(aic, 2), BIC = round(bic, 2)))}
   calculate_performance <- function(model, data) {pred <- predict(model, newdata = data, type = "lp") concordance_result <- concordancefit(Surv(data$time, data$status), x = pred) c_index <- concordance_result$concordance ci_lower <- c_index - 1.96 * sqrt(concordance_result$var) ci_upper <- c_index + 1.96 * sqrt(concordance_result$var) aic <- AIC(model) bic <- BIC(model) return(c(C_Index = round(c_index, 3), CI_Lower = round(ci_lower, 3), CI_Upper = round(ci_upper, 3), AIC = round(aic, 2), BIC = round(bic, 2)))}
   train_LNR <- calculate_performance(model_LNR, train_data)
   train_LODDS <- calculate_performance(model_LODDS, train_data)
   train_pN <- calculate_performance(model_pN, train_data)
   model_LNR_val <- cph(Surv(time, status) ~ LNR, data = validation_data, x = TRUE, y = TRUE)
   model_LODDS_val <- cph(Surv(time, status) ~ LODDS, data = validation_data, x = TRUE, y = TRUE)
   model_pN_val <- cph(Surv(time, status) ~ N, data = validation_data, x = TRUE, y = TRUE)
   val_LNR <- calculate_performance(model_LNR_val, validation_data)
   val_LODDS <- calculate_performance(model_LODDS_val, validation_data)
   val_pN <- calculate_performance(model_pN_val, validation_data)
   results <- data.frame(Variable = c("LNR", "LODDS", "pN"), Training_C_Index = c(paste(train_LNR["C_Index"], "(", train_LNR["CI_Lower"], ", ", train_LNR["CI_Upper"], ")", sep = ""), paste(train_LODDS["C_Index"], "(", train_LODDS["CI_Lower"], ", ", train_LODDS["CI_Upper"], ")", sep = ""), paste(train_pN["C_Index"], "(", train_pN["CI_Lower"], ", ", train_pN["CI_Upper"], ")", sep = "")), Training_AIC = c(train_LNR["AIC"], train_LODDS["AIC"], train_pN["AIC"]), Training_BIC = c(train_LNR["BIC"], train_LODDS["BIC"], train_pN["BIC"]), Validation_C_Index = c(paste(val_LNR["C_Index"], "(", val_LNR["CI_Lower"], ", ", val_LNR["CI_Upper"], ")", sep = ""), paste(val_LODDS["C_Index"], "(", val_LODDS["CI_Lower"], ", ", val_LODDS["CI_Upper"], ")", sep = ""), paste(val_pN["C_Index"], "(", val_pN["CI_Lower"], ", ", val_pN["CI_Upper"], ")", sep = "")), Validation_AIC = c(val_LNR["AIC"], val_LODDS["AIC"], val_pN["AIC"]), Validation_BIC = c(val_LNR["BIC"], val_LODDS["BIC"], val_pN["BIC"]))
   results_table <- gt(results) %>%
   tab_header(title = "Prediction Performance of the Three Lymph Nodal Staging Systems") %>%
   cols_label(Variable = "Variable",Training_C_Index = "C-index (95% CI) (Training)", Training_AIC = "AIC (Training)", Training_BIC = "BIC (Training)", Validation_C_Index = "C-index (95% CI) (Validation)", Validation_AIC = "AIC (Validation)", Validation_BIC = "BIC (Validation)")
   write.csv(results, "prediction_performance.csv", row.names = FALSE)
4. Use the following code to build an XGBoost model and generate bar graphs of the relative importance of variables, thus, to compare the importance of the three LN systems. Similarly, generate ROC curves and calibration curves. The data is obtained from the SEER database.
   library(xgboost)
   library(caret)
   library(pROC)
   train_data <- read.csv("train_data.csv")
   test_data <- read.csv("test_data.csv")
   train_matrix <- xgb.DMatrix(data = as.matrix(train_data[, c('Age', 'T', 'N', 'M', 'LODDS', 'Chemotherapy')]), label = train_data$status)
   test_matrix <- xgb.DMatrix(data = as.matrix(test_data[, c('Age', 'T', 'N', 'M', 'LODDS', 'Chemotherapy')]), label = test_data$status)
   params <- list(booster = "gbtree", objective = "binary:logistic", eval_metric = "auc", eta = 0.1, max_depth = 6, subsample = 0.8, colsample_bytree = 0.8)
   xgb_model <- xgb.train(params = params, data = train_matrix, nrounds = 100, watchlist= list(train = train_matrix), verbose = 1)
   pred_probs <- predict(xgb_model, newdata = test_matrix)
   pred_labels <- ifelse(pred_probs > 0.5, 1, 0)
   conf_matrix <- confusionMatrix(as.factor(pred_labels), as.factor(test_data$status))
   roc_curve <- roc(test_data$status, pred_probs)
   auc_value <- auc(roc_curve)
   ci_auc <- ci.auc(roc_curve)
   sensitivity <- conf_matrix$byClass["Sensitivity"]
   specificity <- conf_matrix$byClass["Specificity"]
   accuracy <- conf_matrix$overall["Accuracy"]
   ppv <- conf_matrix$byClass["Pos Pred Value"]
   npv <- conf_matrix$byClass["Neg Pred Value"]
   result_table <- data.frame(Model = "XGBoost", AUC = sprintf("%.3f (%.3f-%.3f)", auc_value, ci_auc[1], ci_auc[3]), Sensitivity = sprintf("%.3f", sensitivity), Specificity = sprintf("%.3f", specificity), Accuracy = sprintf("%.3f", accuracy), PPV = sprintf("%.3f", ppv), NPV = sprintf("%.3f", npv))
   write.csv(result_table, "xgboost_model_performance.csv", row.names = FALSE)
   roc_df <- data.frame(FPR = 1 - roc_curve$specificities, TPR = roc_curve$sensitivities)
   roc_plot <- ggplot(roc_df, aes(x = FPR, y = TPR)) +geom_line(color = "steelblue", size = 1.2) + geom_abline(intercept = 0, slope = 1, linetype = "dashed", color = "gray") + annotate("text", x = 0.9, y = 0.2, label = paste("AUC =", round(auc_value, 3)), size = 5, color = "black") + labs(title = "ROC Curve for XGBoost Model", x = "False Positive Rate", y = "True Positive Rate") + theme_minimal() + theme(panel.border = element_rect(color = "black", fill = NA, size = 1))
   calibration_data <- data.frame(Status = as.factor(test_data$status), pred_probs = pred_probs)
   calib_model <- calibration(Status ~ pred_probs, data = calibration_data, class = "1", cuts = 5)
   ggplot(calib_model$data, aes(x = midpoint, y = Percent)) + geom_line(color = "steelblue", size = 1) + geom_point(color = "red", size = 2) + geom_abline(intercept = 0, slope = 1, linetype = "dashed", color = "black") +labs(title = "Calibration Curve for XGBoost Model", x = "Predicted Probability", y = "Observed Proportion") + theme_minimal() + theme(panel.border = element_rect(color = "black", fill = NA, size = 0.5))
5. Use the following code to build an RF model and generate bar graphs of the relative importance of variables, thus comparing the importance of the three LN systems. Similarly, generate ROC curves and calibration curves. The data is obtained from the SEER database.library(randomForest)
   library(dplyr)
   library(ggplot2)
   library(pROC)
   library(caret)
   library(rms)
   trainset <- read.csv("train_data.csv")
   testsed <- read.csv("test_data.csv")
   trainset$status=factor(trainset$status)
   variables1 <- c("Age", "T", "N", "M", "LODDS", "Chemotherapy")
   trainset <- trainset %>%
   mutate(across(all_of(variables1), as.numeric))
   testsed$status=factor(testsed$status)
   testsed <- testsed %>%
   mutate(across(all_of(variables1), as.numeric))
   RF=randomForest(trainset$status ~ Age + T + N + M + LODDS + Chemotherapy, data=trainset,ntree=100,importance=TRUE,proximity=TRUE)
   imp=importance(RF)
   varImpPlot(RF)
   impvar=rownames(imp)[order(imp[,4],decreasing = TRUE)]
   importance_df <- as.data.frame(imp)
   importance_df$Variables <- rownames(importance_df)
   importance_plot <- ggplot(importance_df, aes(x = reorder(Variables, MeanDecreaseAccuracy), y = MeanDecreaseAccuracy)) +geom_bar(stat = "identity", fill = "steelblue") +coord_flip() + labs(title = "Variable Importance", x = "Variables", y = "Mean Decrease Accuracy") + theme_minimal()
   pred_probs <- predict(RF, testset, type = "prob")[,2]
   roc_obj <- roc(testset$status, pred_probs)
   auc_value <- auc(roc_obj)
   roc_plot <- ggplot() +geom_line(aes(x = 1 - roc_obj$specificities, y = roc_obj$sensitivities), color = "steelblue", size = 1.2) +geom_abline(intercept = 0, slope = 1, linetype = "dashed", color = "gray") + annotate("text", x = 0.8, y = 0.2, label = paste("AUC =", round(auc_value, 3)), color = "black", size = 5, hjust = 0) + labs(title = "ROC Curve for Random Forest Model", x = "False Positive Rate", y = "True Positive Rate") +theme_minimal() + theme(panel.border = element_rect(color = "black", fill = NA, size = 1))
   calibration_data <- data.frame(pred_probs = pred_probs, status = testsed$status)
   calib_model <- calibration(status ~ pred_probs, data = calibration_data, class = "1", cuts = 5)
   calib_df <- as.data.frame(calib_model[["data"]])
   calib_df$mid <- calib_df$midpoint
   calib_df$Percent <- calib_df$Percent
   calibration_plot <- ggplot(calib_df, aes(x = mid, y = Percent)) + geom_line(color = "steelblue", size = 1.2) + geom_point(color = "steelblue", size = 3) + geom_abline(intercept = 0, slope = 1, linetype = "dashed", color = "black", size = 0.8) + labs(title = "Calibration Curve for Random Forest", x = "Predicted Probability", y = "Actual Probability") + theme_minimal() + theme(panel.border = element_rect(color = "black", fill = NA, size = 1), plot.title = element_text(hjust = -0.05, vjust = -1.5, face = "bold", size = 12) )
   rf_probs <- predict(RF, newdata=testsed, type="prob")[, 2]
   rf_auc <- roc(testsed$status, rf_probs)
   auc_value <- auc(rf_auc)
   ci_auc <- ci.auc(rf_auc)
   rf_predictions <- predict(RF, newdata=testsed)
   conf_matrix <- confusionMatrix(rf_predictions, testsed$status)
   sensitivity <- conf_matrix$byClass["Sensitivity"]
   specificity <- conf_matrix$byClass["Specificity"]
   accuracy <- conf_matrix$overall["Accuracy"]
   ppv <- conf_matrix$byClass["Pos Pred Value"]
   npv <- conf_matrix$byClass["Neg Pred Value"]
   result_table <- data.frame(Model = "RF", AUC = sprintf("%.3f (%.3f-%.3f)", auc_value, ci_auc[1], ci_auc[3]), Sensitivity = sprintf("%.3f", sensitivity), Specificity = sprintf("%.3f", specificity), Accuracy = sprintf("%.3f", accuracy), PPV = sprintf("%.3f", ppv), NPV = sprintf("%.3f", npv))
   write.csv(result_table, "RF_model_performance.csv", row.names = FALSE)
6. Use the following code to build an NN model and generate bar graphs of the relative importance of variables, thus comparing the importance of the three LN systems. Similarly, generate ROC curves and calibration curves. The data is obtained from the SEER database.library(nnet)
   library(caret)
   library(pROC)
   library(ggplot2)
   train_data <- read.csv("train_data.csv")
   test_data <- read.csv("test_data.csv")
   train_data$status <- as.factor(train_data$status)
   test_data$status <- as.factor(test_data$status)
   features <- c("Age", "T", "N", "M", "LODDS", "Chemotherapy")
   x_train <- train_data[, features]
   y_train <- train_data$status
   x_test <- test_data[, features]
   y_test <- test_data$status
   nn_model <- nnet(status ~ Age + T + N + M + LODDS + Chemotherapy, data = train_data, size = 5, decay = 0.01, maxit = 200)
   pred_probs <- predict(nn_model, newdata = x_test, type = "raw")
   pred_labels <- ifelse(pred_probs > 0.5, 1, 0)
   roc_curve <- roc(as.numeric(y_test), pred_probs)
   auc_value <- auc(roc_curve)
   auc_ci <- ci.auc(roc_curve)
   auc_text <- paste0(round(auc_value, 3), " (", round(auc_ci[1], 3), "-", round(auc_ci[3], 3), ")")
   conf_matrix <- confusionMatrix(as.factor(pred_labels), y_test)
   accuracy <- conf_matrix$overall["Accuracy"]
   sensitivity <- conf_matrix$byClass["Sensitivity"]
   specificity <- conf_matrix$byClass["Specificity"]
   ppv <- conf_matrix$byClass["Pos Pred Value"]
   npv <- conf_matrix$byClass["Neg Pred Value"]
   performance_table <- data.frame(Metric = c("AUC (95% CI)", "Accuracy", "Sensitivity", "Specificity", "PPV", "NPV"),Value = c(auc_text, round(accuracy, 3), round(sensitivity, 3), round(specificity, 3), round(ppv, 3), round(npv, 3)))
   write.csv(performance_table, "NN_performance_table.csv", row.names = FALSE)
   roc_curve <- roc(y_test, pred_probs)
   auc_value <- auc(roc_curve)
   roc_plot <- ggplot() + geom_line(aes(x = 1 - roc_curve$specificities, y = roc_curve$sensitivities), color = "steelblue", size = 1.2) +geom_abline(intercept = 0, slope = 1, linetype = "dashed", color = "gray") + annotate("text", x = 0.8, y = 0.2, label = paste("AUC =", round(auc_value, 3)), color = "black", size = 5, hjust = 0) + labs(title = "ROC Curve for Neural Network Model", x = "False Positive Rate", y = "True Positive Rate") + theme_minimal() + theme(panel.border = element_rect(color = "black", fill = NA, size = 1))
   calibration_data <- data.frame(pred_probs = pred_probs, status = as.numeric(y_test) - 1)
   calibration_data$pred_probs <- as.numeric(calibration_data$pred_probs)
   calibration_data$calibration_bin <- cut(calibration_data$pred_probs, breaks = seq(0, 1, by = 0.2), include.lowest = TRUE)
   calibration_summary <- aggregate(status ~ calibration_bin, data = calibration_data, FUN = mean)
   calibration_summary$pred_mean <- aggregate(pred_probs ~ calibration_bin, data = calibration_data, FUN = mean)$pred_probs
   calibration_plot <- ggplot(calibration_summary, aes(x = pred_mean, y = status)) + geom_line(color = "steelblue", size = 1.2) + geom_point(color = "red", size = 3) + geom_abline(intercept = 0, slope = 1, linetype = "dashed", color = "black", size = 0.8) + labs(title = "Calibration Curve for Neural Network", x = "Predicted Probability", y = "Actual Probability") + theme_minimal() + theme(panel.border = element_rect(color = "black", fill = NA, size = 1))
   nn_var_importance <- varImp(nn_model)
   importance_df <- data.frame(Feature = rownames(nn_var_importance), Importance = nn_var_importance$Overall )
   importance_plot <- ggplot(importance_df, aes(x = reorder(Feature, Importance), y = Importance)) + geom_bar(stat = "identity", fill = "steelblue") + coord_flip() + labs(title = "Variable Importance for Neural Network", x = "Features", y = "Importance") + theme_minimal()

3. Competing risk model development and verification

1. Use the following code to perform univariate analysis and plot the cumulative incidence function (CIF) curve. The data.csv is data obtained from the SEER database. The method for saving subsequent images will be the same as in this step. Replace Site in the code one by one with other factors to perform univariate analysis for all factors.
   library(tidycmprsk)
   library(gtsummary)
   library(ggplot2)
   library(ggsurvfit)
   library(ggprism)
   aa <- read.csv("data.csv")
   cif2 <- tidycmprsk::cuminc(Surv(time, Status1) ~Site, data = aa)
   tidy(cif2,times = c(12,24,36,48,60))
   tbl_cuminc(cif2, times =c(12,24,36,48,60), outcomes = c("CSS", "OSS"),estimate_fun = NULL, label_header = "**{time/12}-year cuminc**") %>%
   add_p() %>%
   add_n(location = "level")
   cuminc_plot <- ggcuminc(cif2, outcome = c("CSS", "OSS"), size = 1.5) + labs(x = "time") +add_quantile(y_value = 0.20, size = 1) + scale_x_continuous(breaks = seq(0, 84, by = 12), limits = c(0, 84)) +scale_y_continuous(label = scales::percent, breaks = seq(0, 1, by = 0.2), limits = c(0, 1)) + theme_prism() + theme(legend.position = c(0.2, 0.8), panel.grid = element_blank(),panel.grid.major.y = element_line(colour = "grey80")) + theme(legend.spacing.x = unit(0.1, "cm"), legend.spacing.y = unit(0.01, "cm")) + theme(axis.ticks.length.x = unit(-0.2, "cm"), axis.ticks.x = element_line(color = "black", size = 1, lineend = 1)) + theme(axis.ticks.length.y = unit(-0.2, "cm"), axis.ticks.y = element_line(color = "black", size = 1, lineend = 1))
2. Use the following code to perform multivariate analysis and visualization. The data1.csv comes from the results of the previous code. After running the code, click on Export, then click Save as PDF, and finally click Save to save the image.
   library(tidycmprsk)
   library(gtsummary)
   aa <-read.csv('data1.csv')
   for (i in names(aa)[c(1:16, 19)]){aa[,i] <- as.factor(aa[,i])}
   mul1<tidycmprsk::crr(Surv(time,Status1)~Sex+Age+Race+Marital+T+N+M+Tumor_size+LNR+LODDS+Radiation+Chemotherapy+Site,data=aa, failcode=1,cencode=0)
   table2 <- mul1 %>%
   gtsummary::tbl_regression(exponentiate = TRUE) %>%
   add_n(location = "level");table2
   table_df <- as_tibble(table2)
   tab <- table2$table_body
   tab1 <- tab[,c(12,19,20,22:29)]
3. Use the following code to plot the nomogram, ROC curve, and calibration curve. After training the model using data from the training cohort, use the validation and external validation cohorts data to validate the model.library(QHScrnomo). The external cohort data consists of samples of colorectal cancer other than ring cell carcinoma, which were selected in step 1.4.
   library(rms)
   library(timeROC)
   library(survival)
   aa <-read.csv('data3.csv')
   for (i in names(aa)[c(1:16, 19)]){aa[,i] <- as.factor(aa[,i])}
   dd <- datadist(aa)
   options(datadist = "dd")
   mul <- cph(Surv(time, Status1 == 1) ~ T + N + M + LODDS + Site, data = aa, x = TRUE, y = TRUE, surv = TRUE)
   m3 <- crr.fit(mul, failcode = 1, cencode = 0)
   nomo <-Newlabels(fit = m3, labels =c(T="T", N= "N", M = "M", LODDS = "LODDS", Site = "Site"))
   nomo<Newlevels(fit=nomo,list(T=c("T1","T2","T3","T4"),N=
   c("N0","N1","N2"),M=c("M0","M1"),LODDS=c
   ("LODDS1","LODDS2","LODDS3"),Site=
   c("RSC","LSC","Rectum")))
   nomogram.crr(fit =nomo , lp = F, xfrac = 0.3, fun.at =seq(from=0, to=1, by= 0.1) , failtime =c(12,36,60), funlabel = c("1-year CSS Cumulative Incidence","3-year CSS Cumulative Incidence","5-year CSS Cumulative Incidence"))
   time_points <- c(12, 36, 60)
   pred_risks_list <- lapply(time_points, function(time_point) {predict(m3, newdata = aa, type = "risk", time = time_point)})
   pred_risks_df <- data.frame(do.call(cbind, pred_risks_list))
   colnames(pred_risks_df) <- paste("risk_at", time_points, "months", sep = "_")
   roc_1year <- timeROC(T = aa$time, delta = ifelse(aa$Status1 == "CSS", 1, 0), marker = pred_risks_df$risk_at_12_months, cause = 1, times = 12, iid = TRUE)
   roc_3year <- timeROC(T = aa$time, delta = ifelse(aa$Status1 == "CSS", 1, 0), marker = pred_risks_df$risk_at_36_months, cause = 1, times = 36, iid = TRUE)
   roc_5year <- timeROC(T = aa$time, delta = ifelse(aa$Status1 == "CSS", 1, 0), marker = pred_risks_df$risk_at_60_months, cause = 1,times = 60, iid = TRUE)
   legend("bottomright",legend = c("1 year CSS", "3 year CSS", "5 year CSS"), col = c("#BF1D2D", "#262626", "#397FC7"), lwd = 2)
   sas.cmprsk(m3,time = 36)
   set.seed(123)
   aa$pro <- tenf.crr(m3,time = 36)
   cindex(prob = aa$pro, fstatus = aa$Status1, ftime = aa$time, type = "crr", failcode = 1, cencode = 0, tol = 1e-20)
   groupci(x=aa$pro, ftime = aa$time, fstatus = aa$Status1, failcode = 1, cencode = 0, ci = TRUE, g = 5, m = 1000, u = 36, xlab = "Predicted Probability ", ylab = "Actual Probability", lty=1, lwd=2, col="#262626",xlim=c(0,1.0), ylim=c(0,1.0), add =TRUE)

Resultados

Patients characteristics
This study focused on patients diagnosed with colorectal SRCC, using data from the SEER database spanning 2004 to 2015. Exclusion criteria included patients with a survival time of less than one month, those with incomplete clinicopathological information, and cases where the cause of death was unclear or unspecified. A total of 2409 colorectal SRCC patients who met the inclusion criteria were randomly divided into a training cohort (N = 1686) and a validation cohort (N = 7...

Discusión

Colorectal cancer (CRC) SRCC is a rare and special subtype of colorectal cancer with a poor prognosis. Therefore, greater attention needs to be paid to the prognosis of SRCC patients. Accurate survival prediction for SRCC patients is crucial for determining their prognosis and making individualized treatment decisions. In this study, we explored the relationship between clinical features and prognosis in SRCC patients and identified the optimal LN staging system for SRCC patients from the SEER database. To our knowledge,...

Materiales

Name	Company	Catalog Number	Comments
SEER database	National Cancer institiute at NIH
X-tile software	Yale school of medicine
R-studio	Posit