The impact of negative lymph nodes in the survival outcomes of pN+ patients following radical gastrectomy: the inverse lymph node ratio as a better score to study negative lymph nodes


The impact of negative lymph nodes (LNs) on survival of pN+ patients has been recognized. The weight of negative LNs in an inverse lymph node ratio (nR) should be related to its prognostic impact. Five hundred and two consecutive gastric cancer patients, who underwent radical gastrectomy, were included. Patients were split into groups according to the number of harvested nodes and a cross-tabulation with pTNM stages was performed to test differences in the tumor burden. pN+ patients (n = 296) were split into groups of negative LNs harvested. We tested an alternative formula for computing a lymph node ratio: nR = total number of harvested nodes/total number of positive nodes. The median number of negative LNs was significantly different (p < 0.01) between dissection groups, but not the median of positive nodes (p > 0.05). No difference in pTNM percentage distribution was found between these groups (p > 0.05). When tested, the overall survival improved significantly for groups with larger numbers of negative LNs (p < 0.001). A cutoff of nR ≥ 6 was an independent prognostic factor for survival (p = 0.001), and the survival of pN+ patients with nR ≥ 6 was not different from pN0 patients. The impact of the number of negative LNs on the survival of the pN+ patients was demonstrated. The higher numbers in the numerator of the nR was due to the disproportion between harvested negative LNs and metastatic LNs. Larger ratios imply more negative lymph nodes in relation to positive lymph nodes, which was significantly associated with survival. We believe that the proposed nR is a friendlier to use format because of its intuitive interpretation.

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Author information




All authors contributed to the study conception and design. Material preparation and data collection were performed by PC, PL and SO. Statistical analysis was planned and performed by RR. The first draft of the manuscript was written by PC and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Paulo Matos da Costa.

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The authors have no conflicting of financial interest or other regarding the present study.

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All procedures in this study were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964. The study was approved by the Ethical Committee of the Lisbon Academic Medical Center. The Centro Hospitalar Lisboa Norte is the academic hospital of this Center and Hospital Garcia de Orta is an Affiliated Hospital to this Academic Center.

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da Costa, P.M., Lages, P., Onofre, S. et al. The impact of negative lymph nodes in the survival outcomes of pN+ patients following radical gastrectomy: the inverse lymph node ratio as a better score to study negative lymph nodes. Updates Surg 72, 1031–1040 (2020).

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  • Gastrectomy for cancer
  • Lymph nodes (LNs)
  • Negative LNs and outcomes
  • Inverse lymph node ratio
  • Gastric cancer survival