Annals of Surgical Oncology

, Volume 24, Issue 12, pp 3683–3691 | Cite as

Validation of the 8th Edition of the AJCC TNM Staging System for Gastric Cancer using the National Cancer Database

  • Haejin In
  • I. Solsky
  • B. Palis
  • M. Langdon-Embry
  • J. Ajani
  • T. Sano
Gastrointestinal Oncology



The 8th edition AJCC gastric cancer staging manual was refined using Japanese and Korean data from the International Gastric Cancer Association (IGCA). This study evaluated the eighth edition’s validity for U.S. populations.


National Cancer Database (NCDB) was used to obtain data on gastric cancer patients diagnosed from 2004 to 2008 who underwent surgery and to examine differences in stage grouping and survival between AJCC 7th and 8th editions. Discrimination of models derived from NCDB and IGCA data was compared.


Of 12,041 patients, median age was 65, 57.6% were male, median lymph nodes retrieved was 2 (0–76), 30.9% underwent distal/partial gastrectomy, and 49.8% received no adjuvant treatment. The 8th edition differed in that T1–T3 disease was upstaged with N3b, T4aN3a was downstaged from IIIC to IIIB, and T4bN0 and T4aN2 were downstaged from IIIB to IIIA. These changes resulted in increased patients in IIIA (1436 in the 7th edition to 2310 in the 8th) and IIIB (1737–1896) and decreased in IIIC (2100–1067). This also resulted in lower median survival for IIIA (28.7–25.0 months), IIIB (19.6–17.4), IIIC (13.7–11.8). The concordance index for the 8th edition applied to NCDB data was 0.719 [95% confidence interval (CI) 0.703–0.734), which is comparable to that for the 8th edition developed from IGCA data (0.775, 95% CI 0.770–0.780) and the 7th edition applied to NCDB data (0.720, 95% CI 0.704–0.735).


The 8th edition is valid for U.S. populations, showing clear separation of data with preservation of group order.



The authors have no disclosures to report. The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.


This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author Contributions

Analysis and interpretation of data—HI, BP, ML, JA, TS. Editing and drafting of the manuscript—ALL. Conception and design of study, and/or acquisition of data—HI, JA, TS. All authors gave final approval for the manuscript to be published.


  1. 1.
    Union for International Cancer Control. TNM History, Evolution, and Milestones. Accessed 22 Feb 2017.
  2. 2.
    American Joint Committee on Cancer. Desk References., 2016.
  3. 3.
    Sano T, Coit DG, Kim HH, Roviello F, Kassab P, Wittekind C, et al. Proposal of a new stage grouping of gastric cancer for TNM classification: International Gastric Cancer Association staging project. Gastric Cancer. 2016; 20:217–225.CrossRefPubMedGoogle Scholar
  4. 4.
    American College of Surgeons. National Cancer Database., 2016.
  5. 5.
    Bilimoria KY, Stewart AK, Winchester DP, Ko CY. The National Cancer Data Base: a powerful initiative to improve cancer care in the United States. Ann Surg Oncol. 2008;15(3):683–90.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    American College of Surgeons. Facility Oncology Registry Data Standars (FORDS): Revised for 2016. Accessed 5 Dec 2016.
  7. 7.
  8. 8.
    Collins GS, Reitsma JB, Altman DG, Moons KG. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): The TRIPOD Statement. Ann Intern Med. 2015;162:55–63. doi: 10.7326/M14-0697.CrossRefPubMedGoogle Scholar
  9. 9.
    McGhan LJ, Pockaj BA, Gray RJ, Bagaria SP, Wasif N. Validation of the updated 7th edition AJCC TNM staging criteria for gastric adenocarcinoma. J Gastrointest Surg. 2012; 16(1):53–61; discussion 61.CrossRefPubMedGoogle Scholar
  10. 10.
    Washington K. 7th edition of the AJCC cancer staging manual: stomach. Ann Surg Oncol. 2010;17(12):3077–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Ahn HS, Lee HJ, Hahn S, Kim WH, Lee KU, Sano T, et al. Evaluation of the seventh American joint committee on cancer/international union against cancer classification of gastric adenocarcinoma in comparison with the sixth classification. Cancer. 2010;116(24):5592–98.CrossRefPubMedGoogle Scholar
  12. 12.
    Marano L, Boccardi V, Braccio B, Esposito G, Grassia M, Petrillo M, et al. Comparison of the 6th and 7th editions of the AJCC/UICC TNM staging system for gastric cancer focusing on the “N” parameter-related survival: the monoinstitutional NodUs Italian study. World J Surg Oncol. 2015;13:215.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Bickenbach K, Strong VE. Comparisons of gastric cancer treatments: east vs. west. J Gastric Cancer. 2012;12(2):55–62.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Palma DA. National Cancer Data Base: An important research tool, but not population-based. J Clin Oncol. 2017;35(5):571.CrossRefGoogle Scholar
  15. 15.
    Deng J, Zhang R, Pan Y, Wang B, Wu L, Jiao X, et al. Comparison of the staging of regional lymph nodes using the sixth and seventh editions of the tumor-node-metastasis (TNM) classification system for the evaluation of overall survival in gastric cancer patients: findings of a case-control analysis involving a single institution in China. Surgery. 2014;156(1):64–74.CrossRefPubMedGoogle Scholar
  16. 16.
    Reim D, Loos M, Vogl F, Novotny A, Schuster T, Langer R, et al. Prognostic implications of the seventh edition of the international union against cancer classification for patients with gastric cancer: the Western experience of patients treated in a single-center European institution. J Clin Oncol. 2013;31(2):263–71.CrossRefPubMedGoogle Scholar
  17. 17.
    Datta J, Lewis RS Jr, Mamtani R, Stripp D, Kelz RR, Drebin JA, et al. Implications of inadequate lymph node staging in resectable gastric cancer: a contemporary analysis using the National Cancer Data Base. Cancer. 2014;120(18):2855–65.CrossRefPubMedGoogle Scholar
  18. 18.
    Dubecz A, Solymosi N, Schweigert M, Stadlhuber RJ, Peters JH, Ofner D, et al. Time trends and disparities in lymphadenectomy for gastrointestinal cancer in the United States: a population-based analysis of 326,243 patients. J Gastrointest Surg. 2013;17(4):611–18.CrossRefPubMedGoogle Scholar
  19. 19.
    Greenberg CC, Lipsitz SR, Neville B, In H, Hevelone N, Porter SA, et al. Receipt of appropriate surgical care for Medicare beneficiaries with cancer. Arch Surg. 2011;146(10):1128–34.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Chen S, Zhao BW, Li YF, Feng XY, Sun XW, Li W, et al. The prognostic value of harvested lymph nodes and the metastatic lymph node ratio for gastric cancer patients: results of a study of 1,101 patients. PLoS ONE. 2012;7(11):e49424.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Asoglu O, Karanlik H, Parlak M, Kecer M, Muslumanoglu M, Igci A, et al. Metastatic lymph node ratio is an independent prognostic factor in gastric cancer. Hepato-gastroenterology. 2009;56(91–92):908–13.PubMedGoogle Scholar
  22. 22.
    Wong J, Rahman S, Saeed N, Lin HY, Almhanna K, Shridhar R, et al. Prognostic impact of lymph node retrieval and ratio in gastric cancer: a U.S. single center experience. J Gastrointest Surg. 2013;17(12):2059–66.CrossRefPubMedGoogle Scholar
  23. 23.
    Lee JH, Kang JW, Nam BH, Cho GS, Hyung WJ, Kim MC, et al. Correlation between lymph node count and survival and a reappraisal of lymph node ratio as a predictor of survival in gastric cancer: a multi-instiutional cohort study. Eur J Surg Oncol. 2017;43(2):432–9.CrossRefPubMedGoogle Scholar
  24. 24.
    Yamashita H, Deng J, Liang H, Seto Y. Re-evaluating the prognostic validity of the negative to positive lymph node ratio in node-positie gastric cancer patients. Surgery. 2017;161:1588–96.CrossRefPubMedGoogle Scholar
  25. 25.
    Ajani JA, D’Amico TA, Almhanna K, Bentrem DJ, Chao J, Das P, et al. Gastric Cancer, Version 3.2016, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2016;14(10):1286–312.CrossRefPubMedGoogle Scholar
  26. 26.
    Amin MB, Edge S, Greene F, Byrd DR, Brookland RK, Washington MK, et al. (editors) AJCC cancer staging manual. 8th ed. Cham: Springer International Publishing; 2017.Google Scholar
  27. 27.
    Kattan MW, Hess KR, Amin MB, Lu Y, Moons KG, Gershenwald JE, et al. American Joint Committee on Cancer acceptance criteria for inclusion of risk models for individualized prognosis in the practice of precision medicine. CA Cancer J Clin. 2016;66(5):370–74.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Society of Surgical Oncology 2017

Authors and Affiliations

  • Haejin In
    • 1
  • I. Solsky
    • 1
  • B. Palis
    • 2
  • M. Langdon-Embry
    • 1
  • J. Ajani
    • 3
  • T. Sano
    • 4
  1. 1.Department of SurgeryMontefiore Medical Center/Albert Einstein College of MedicineBronxUSA
  2. 2.NCDB Research UnitAmerican College of SurgeonsChicagoUSA
  3. 3.Department of Gastrointestinal Medical OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  4. 4.Gastroenterological CenterCancer Institute HospitalTokyoJapan

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