Annals of Surgical Oncology

, Volume 17, Issue 5, pp 1267–1277 | Cite as

New Metastatic Lymph Node Ratio System Reduces Stage Migration in Patients Undergoing D1 Lymphadenectomy for Gastric Adenocarcinoma

  • Ugwuji N. Maduekwe
  • Gregory Y. Lauwers
  • Carlos Fernandez-del-Castillo
  • David L. Berger
  • Charles M. Ferguson
  • David W. Rattner
  • Sam S. Yoon
Gastrointestinal Oncology



The American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC) staging system for gastric cancer incorporates the absolute number of metastatic lymph nodes (N status) and is optimally used when ≥15 nodes are examined. The ratio of metastatic to examined nodes (N ratio) is an effective prognostic tool, but has not been examined in Western patients undergoing primarily D1 lymphadenectomy.


Two hundred and fifty seven patients with gastric adenocarcinoma who underwent gastric resection between 1995 and 2005 at our institution were examined. Novel N ratio intervals were determined using the best cutoff approach (Nr0: N ratio = 0 and ≥15 nodes examined; Nr1: 0 ≤ N ratio ≤ 0.3; Nr2: 0.3 < N ratio ≤ 0.7; and Nr3: N ratio > 0.7). Overall survival was examined according to N status and N ratio.


83% of patients underwent D1 lymphadenectomy with a median of 14 lymph nodes examined. Overall survival stratified by N status was significantly different in patients with <15 nodes examined compared with those with ≥15 nodes examined. When we stratified by N ratio intervals, there was no significant difference in overall survival in patients with <15 versus ≥ 15 nodes examined. On multivariate analysis, N ratio but not N status was retained as an independent prognostic factor.


The use of N status for staging patients undergoing primarily D1 lymphadenectomy results in significant stage migration due to varying numbers of nodes examined. Use of N ratio reduces stage migration and may be a more reliable method of staging these patients.



The authors would like to thank Carol Venuti of the Massachusetts General Hospital Cancer Data Registry. Dr. Maduekwe was supported by the Scholars in Clinical Science Program at Harvard Medical School under National Institutes of Health grant no. 1 KL2 RR025757-0 1, Harvard Clinical and Translational Science Center (KL1).


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Copyright information

© Society of Surgical Oncology 2010

Authors and Affiliations

  • Ugwuji N. Maduekwe
    • 1
  • Gregory Y. Lauwers
    • 2
  • Carlos Fernandez-del-Castillo
    • 1
  • David L. Berger
    • 1
  • Charles M. Ferguson
    • 1
  • David W. Rattner
    • 1
  • Sam S. Yoon
    • 1
    • 3
  1. 1.Department of SurgeryMassachusetts General Hospital, Harvard Medical SchoolBostonUSA
  2. 2.Department of PathologyMassachusetts General Hospital, Harvard Medical SchoolBostonUSA
  3. 3.Departments of Surgery and Cancer BiologyUniversity of Pennsylvania School of MedicinePhiladelphiaUSA

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