A nomogram to predict overall survival and disease-free survival after curative-intent gastrectomy for gastric cancer

AbstractAn individual prediction of DFS and OS may be useful after surgery for gastric cancer to inform patients and to guide the clinical management. Patients who underwent curative-intent resection for gastric cancer between January 2010 and May 2020 at a single Italian institution were identified. Variables associated with OS and DFS were recorded and analysed according to univariable and multivariable Cox models. Nomograms predicting OS and DFS were built according to variables resulting from multivariable Cox models. Discrimination ability was calculated using the Harrell’s Concordance Index. Overall, 168 patients underwent curative-intent resection. Nomograms to predict OS were developed including age, tumor size, tumor location, T stage, N stage, M stage and post-operative complications, while nomogram to predict DFS includes Lauren classification, and lymph node ratio (LNR). On internal validation, both nomograms demonstrated a good discrimination with a Harrell’s C-index of 0.77 for OS and 0.71 for DFS. The proposed nomogram to predict DFS and OS after curative-intent surgery for gastric cancer showed a good discrimination on internal validation, and may be useful to guide clinician decision-making, as well help identify patients with high-risk of recurrence or with a poor estimated survival.

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Positive lymph node ratio is an index in predicting prognosis for remnant gastric cancer with insufficient retrieved lymph node in R0 resection

Scientific Reports ◽

10.1038/s41598-021-81663-0 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Honghu Wang ◽

Hao Qi ◽

Xiaofang Liu ◽

Ziming Gao ◽

Iko Hidasa ◽

...

Keyword(s):

Gastric Cancer ◽

Lymph Node ◽

Lymph Nodes ◽

Lymph Node Ratio ◽

Prognostic Index ◽

Staging System ◽

R0 Resection ◽

Remnant Gastric Cancer ◽

Curative Intent ◽

Node Ratio

AbstractThe staging system of remnant gastric cancer (RGC) has not yet been established, with the current staging being based on the guidelines for primary gastric cancer. Often, surgeries for RGC fail to achieve the > 15 lymph nodes needed for TNM staging. Compared with the pN staging system, lymph node ratio (NR) may be more accurate for RGC staging and prognosis prediction. We retrospectively analyzed the data of 208 patients who underwent R0 gastrectomy with curative intent and who have ≤ 15 retrieved lymph nodes (RLNs) for RGC between 2000 and 2014. The patients were divided into four groups on the basis of the NR cutoffs: rN0: 0; rN1: > 0 and ≤ 1/6; rN2: > 1/6 and ≤ 1/2; and rN3: > 1/2. The 5-year overall survival (OS) rates for rN0, rN1, rN2, and rN3 were 84.3%, 64.7%, 31.5%, and 12.7%, respectively. Multivariable analyses revealed that tumor size (p = 0.005), lymphovascular invasion (p = 0.023), and NR (p < 0.001), but not pN stage (p = 0.682), were independent factors for OS. When the RLN count is ≤ 15, the NR is superior to pN as an important and independent prognostic index of RGC, thus predicting the prognosis of RGC patients more accurately.

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Nomogram to predict overall survival for patients with pseudomyxoma peritonei of appendiceal origin: A retrospective cohort study

10.21203/rs.3.rs-39824/v3 ◽

2020 ◽

Author(s):

Mingjian Bai ◽

Shilong Wang ◽

Ruiqing Ma ◽

Ying Cai ◽

Yiyan Lu ◽

...

Keyword(s):

Overall Survival ◽

Pseudomyxoma Peritonei ◽

Roc Analysis ◽

Prediction Models ◽

Radical Surgery ◽

Individual Risk ◽

Good Discrimination ◽

Internal Validation ◽

Discrimination Ability ◽

First Time

Abstract Background Pseudomyxoma peritonei (PMP) is a rare disease, the prognosis of overall survival (OS) is affected by many factors, present study aim to define independent prediction indicators and establish a nomogram for PMP patients.Methods 119 PMP patients received cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) in our center for the first time were included between 01/06/2013 and 22/11/2019 . The log-rank test was used to compare the OS rate among groups, subsequently, variables with P<0.10 were subjected to multivariate Cox model for defining independent prediction indicators. Finally, the nomogram prediction models will be established and for internal validation.Results Multivariate analysis showed Sex, D-Dimer, CA125, CA19-9, PCI, and degree of radical surgery were independently associated with OS in PMP patients. A nomogram was plotted based on the independent predictive factors and undergone internal validation, ROC analysis was performed to calculate discrimination ability of the nomogram, the C-index was 0.880 (95%CI: 0.806- 0.933) and calibration plots showed good performance. Conclusions Six independent prognostic factor for predicting survival in PMP patients were difined, the nomogram has a good discrimination ability for individual risk predition, more researches are needed to verify and improve the prediction model.

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Personalizing the Prediction of Colorectal Cancer Prognosis by Incorporating Comorbidities and Functional Status into Prognostic Nomograms

Cancers ◽

10.3390/cancers11101435 ◽

2019 ◽

Vol 11 (10) ◽

pp. 1435 ◽

Cited By ~ 4

Author(s):

Daniel Boakye ◽

Lina Jansen ◽

Martin Schneider ◽

Jenny Chang-Claude ◽

Michael Hoffmeister ◽

...

Keyword(s):

Colorectal Cancer ◽

Functional Status ◽

Significant Risk ◽

Disease Free Survival ◽

Stage Iv ◽

Tumor Location ◽

Cancer Prognosis ◽

Prognostic Models ◽

Cox Models ◽

Validation Set

Despite consistent evidence that comorbidities and functional status (FS) are strong prognostic factors for colorectal cancer (CRC) patients, these important characteristics are not considered in prognostic nomograms. We assessed to what extent incorporating these characteristics into prognostic models enhances prediction of CRC prognosis. CRC patients diagnosed in 2003–2014 who were recruited into a population-based study in Germany and followed over a median time of 4.7 years were randomized into training (n = 1608) and validation sets (n = 1071). In the training set, Cox models with predefined variables (age, sex, stage, tumor location, comorbidity scores, and FS) were used to construct nomograms for relevant survival outcomes. The performance of the nomograms, compared to models without comorbidity and FS, was evaluated in the validation set using concordance index (C-index). The C-indexes of the nomograms for overall and disease-free survival in the validation set were 0.768 and 0.737, which were substantially higher than those of models including tumor stage only (0.707 and 0.701) or models including stage, age, sex, and tumor location (0.749 and 0.718). The nomograms enabled significant risk stratification within all stages including stage IV. Our study suggests that incorporating comorbidities and FS into prognostic nomograms could substantially enhance prediction of CRC prognosis.

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Flow cytometry as a predictive indicator in patients with operable gastric cancer.

Journal of Clinical Oncology ◽

10.1200/jco.1989.7.8.1105 ◽

1989 ◽

Vol 7 (8) ◽

pp. 1105-1112 ◽

Cited By ~ 44

Author(s):

D M Nanus ◽

D P Kelsen ◽

D Niedzwiecki ◽

D Chapman ◽

M Brennan ◽

...

Keyword(s):

Gastric Cancer ◽

Dna Content ◽

Disease Free Survival ◽

Tumor Location ◽

The Body ◽

Biological Difference ◽

Free Survival ◽

Flow Cytometric ◽

Disease Free ◽

Predictive Indicator

Adenocarcinoma of the proximal portion of the stomach (gastroesophageal [GE] junction and cardia) is increasing in incidence. The inferior survival of patients with GE-cardia lesions as compared with patients with tumors located in the body and antrum has been attributed to anatomic features. To determine if a biological difference could explain the varying prognosis, flow cytometric studies were performed prospectively in 50 patients with operable gastric cancer and analyzed for association with site, histology, gender, age, stage, and disease-free survival. DNA aneuploidy significantly correlated with tumor location: 96% of GE-cardia carcinomas were aneuploid as compared with 48% of body-antrum tumors (P = .0008). Nodal involvement was more common in aneuploid tumors (P = .0548), and women were more likely to have diploid tumors than were men (P = .0233). The median disease-free survival for patients with diploid tumors was 18.5 months as compared with 5.4 months for patients with aneuploid carcinomas (P = .076). Furthermore, within the body-antrum of the stomach, patients with diploid tumors had a significantly better disease-free survival than did those with aneuploid tumors from the same site (18.4 v 4.7 months, P = .0185). These results indicate there is a difference in the DNA content of gastric tumors located in different sites within the stomach and that DNA content correlates with prognosis.

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The Efficacy and Safety of (Neo)Adjuvant Therapy for Gastric Cancer: A Network Meta-analysis

Cancers ◽

10.3390/cancers11010080 ◽

2019 ◽

Vol 11 (1) ◽

pp. 80 ◽

Cited By ~ 8

Author(s):

Tom van den Ende ◽

Emil ter Veer ◽

Mélanie Machiels ◽

Rosa Mali ◽

Frank Abe Nijenhuis ◽

...

Keyword(s):

Gastric Cancer ◽

Curative Resection ◽

Meta Analysis ◽

Treatment Strategies ◽

Disease Free Survival ◽

Perioperative Chemotherapy ◽

Curative Intent ◽

Radio Therapy ◽

Credible Intervals ◽

Resectable Gastric Cancer

Background: Alternatives in treatment-strategies exist for resectable gastric cancer. Our aims were: (1) to assess the benefit of perioperative, neoadjuvant and adjuvant treatment-strategies and (2) to determine the optimal adjuvant regimen for gastric cancer treated with curative intent. Methods: PubMed, EMBASE, CENTRAL, and ASCO/ESMO conferences were searched up to August 2017 for randomized-controlled-trials on the curative treatment of resectable gastric cancer. We performed two network-meta-analyses (NMA). NMA-1 compared perioperative, neoadjuvant and adjuvant strategies only if there was a direct comparison. NMA-2 compared different adjuvant chemo(radio)therapy regimens, after curative resection. Overall-survival (OS) and disease-free-survival (DFS) were analyzed using random-effects NMA on the hazard ratio (HR)-scale and calculated as combined HRs and 95% credible intervals (95% CrIs). Results: NMA-1 consisted of 9 direct comparisons between strategies for OS (14 studies, n = 4187 patients). NMA-2 consisted of 16 direct comparisons between adjuvant chemotherapy/chemoradiotherapy regimens for OS (37 studies, n = 10,761) and 14 for DFS (30 studies, n = 9714 patients). Compared to taxane-based-perioperative-chemotherapy, surgery-alone (HR = 0.58, 95% CrI = 0.38–0.91) and perioperative-chemotherapy regimens without a taxane (HR = 0.79, 95% CrI = 0.58–1.15) were inferior in OS. After curative-resection, the doublet oxaliplatin-fluoropyrimidine (for one-year) was the most efficacious adjuvant regimen in OS (HR = 0.47, 95% CrI = 0.28–0.80). Conclusions: For resectable gastric cancer, (1) taxane-based perioperative-chemotherapy was the most promising treatment strategy; and (2) adjuvant oxaliplatin-fluoropyrimidine was the most promising regimen after curative resection. More research is warranted to confirm or reproach these findings.

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Use of lymph node ratio improves staging and selection criteria for adjuvant therapy of gastric cancer

Journal of Clinical Oncology ◽

10.1200/jco.2006.24.18_suppl.4051 ◽

2006 ◽

Vol 24 (18_suppl) ◽

pp. 4051-4051 ◽

Cited By ~ 1

Author(s):

N. G. Coburn ◽

C. J. Swallow ◽

A. Kiss ◽

C. Law

Keyword(s):

Gastric Cancer ◽

Lymph Node ◽

Adjuvant Therapy ◽

Lymph Node Ratio ◽

North American Population ◽

Cox Models ◽

Node Negative ◽

Survival Difference ◽

Node Ratio ◽

Resected Gastric Cancer

4051 Background: Despite 1997 American Joint Commission on Cancer (AJCC) guidelines stipulating assessment of ≥15 lymph nodes (LN) for staging of gastric cancer, only one third of patients in the Surveillance, Epidemiology and End Results (SEER) database from 1998–2002 had ≥15 LN assessed (ASCO 2005 #4004), with resultant understaging and probable under-treatment. In series from Asia and Europe, Lymph Node Ratio (LNR), the ratio of positive to total LN assessed, has been shown to be more accurate for staging than number of positive LN. However, most of these excluded cases with <15 LN assessed. We examined the utility of LNR in a North American population. Methods: Using SEER data, we identified 9503 M0 resected gastric cancer cases from 1988–2002. LNR was categorized as 0%, 1–10%, 11–30%, 31–50% and >50%. For node negative cases (LNR = 0%, n = 3652), we stratified by number of LN assessed (A=1–4; B = 5–9; C = 10–14; D≥15). For each AJCC stage or LNR strata, the degree of understaging in patients with inadequate LN assessment was measured by survival difference on Kaplan-Meier curves. Cox proportional hazard ratio (HR) models determined the effect of stratifying node negative patients and the accuracy of LNR for prognostication. Results: 27% of patients had a LNR > 50%, a high proportion compared to Asian series. Fewer nodes assessed resulted in a higher likelihood of being node negative. In node negative cases, the HR of death increased for those with fewer LN assessed (vs. Group D, with 95% CI): A: HR=1.6 (1.5–1.8); B: HR = 1.3 (1.1–1.5); C: HR = 1.3 (1.1–1.5). Understaging was observed for patients with inadequate LN assessment when AJCC criteria were used (p < 0.0001); this effect significantly decreased by using LNR. LNR had superior prognostic accuracy in Cox models. Conclusions: This study examines LNR in the largest series of resected gastric cancer in the literature, and the only one in which the majority of cases were inadequately staged. LNR significantly decreases understaging and improves prognostic ability. Node negative patients, nearly one third of cases, should be risk stratified by number of LN assessed, and considered for adjuvant therapy on this basis. LNR should be used to stratify node positive patients in clinical trials, and to provide more accurate staging and prognostication. No significant financial relationships to disclose.

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Real-world outcomes of first-line U.S. patients with unresectable advanced or metastatic gastroesophageal adenocarcinoma by primary tumor location.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.4_suppl.304 ◽

2020 ◽

Vol 38 (4_suppl) ◽

pp. 304-304

Author(s):

Veena Shankaran ◽

Hong Xiao ◽

David Bertwistle ◽

Ying Zhang ◽

Pranav Abraham ◽

...

Keyword(s):

Gastric Cancer ◽

Real World ◽

Gastroesophageal Junction ◽

Tumor Location ◽

Rank Test ◽

First Line ◽

Eligibility Criteria ◽

Cox Models ◽

Significant Difference ◽

Gastroesophageal Adenocarcinoma

304 Background: Gastric cancer clinical trials are inconsistent in their inclusion of esophageal adenocarcinoma (EAC). Thus it is uncertain if outcomes are similar among subgroups of gastroesophageal adenocarcinoma. The aim of this study was to compare baseline characteristics and clinical outcomes of US patients with EAC versus Gastroesophageal Junction Cancer (GEJC) and Gastric Cancer (GC) treated in real world clinical settings. Methods: Adult patients with unresectable, advanced or metastatic GC, GEJC, or EAC diagnosed between January 2011 and November 2018 were identified from the Flatiron Health database. Patients with a positive HER2 test, or who received trastuzumab, were excluded. Overall survival (OS) was defined as time from first-line (1L) treatment initiation to death or loss of follow-up. Survival analyses were conducted using Kaplan-Meier methods with log-rank test and Cox models. Results: A total of 3052 patients (969 EAC and 2083 GEJC/GC) met eligibility criteria. Out of all EAC patients, 90% were males and 76% were white. Within the GEJC/GC patients, 67% were males and 57% were white. Median age was 66 years for both cohorts while proportion with ECOG PS of 0 or 1 was 78% for EAC and 84% for GEJC/GC among patients with ECOG scores. The proportion of patients receiving 1L treatment was comparable (78% for EAC, 76% for GEJC/GC) across groups with FOLFOX being the most frequent treatment (25% for EAC and 29% for GEJC/GC). There was no significant difference in OS between the two groups, with median OS of 9.1 and 9.6 months for EAC and GEJC/GC, respectively (HR 0.957, 95% CI: 0.863 - 1.062, p = 0.41). Conclusions: In this US real-world analysis, OS did not differ significantly between patients with EAC and patients with GEJC/GC who received 1L treatment, suggesting that these two populations may have comparable survival benefit from systemic therapy.

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Randomized phase III trial of standard D2 versus D2 + para-aortic lymph node (PAN) dissection (D) for clinically M0 advanced gastric cancer: JCOG9501

Journal of Clinical Oncology ◽

10.1200/jco.2006.24.18_suppl.lba4015 ◽

2006 ◽

Vol 24 (18_suppl) ◽

pp. LBA4015-LBA4015 ◽

Cited By ~ 9

Author(s):

M. Sasako ◽

T. Sano ◽

S. Yamamoto ◽

A. Nashimoto ◽

A. Kurita ◽

...

Keyword(s):

Gastric Cancer ◽

Advanced Gastric Cancer ◽

Disease Free Survival ◽

Operation Time ◽

Hazard Ratio ◽

Phase Iii ◽

Rank Test ◽

R0 Resection ◽

Eligibility Criteria ◽

Curative Intent

LBA4015 Background: The INT-0116 study proved the efficacy of radiochemotherapy after R0 resection for gastric cancer and thus the importance of the local control and the insufficiency of D0/1 surgery. Recently D2 surgery was for the first time proven to improve the survival compared with D1 in a Taiwanese RCT (Lancet Oncol 2006). In our study, D2+PAND was compared with D2 in a RCT. Low operative mortality has been reported (Sano et al. J Clin Oncol 2004) and we now present the survival results. Methods: Eligibility criteria included; histologically proven adenocarcinoma, cT2b-T4, cM0, no macroscopic metastasis to the PAN, negative lavage cytology, adequate organ function, and age <76. Linitis plastica was excluded. Eligible pts were randomly assigned to D2 with or without PAND during surgery. All patients were followed without adjuvant therapy until recurrence. The primary endpoint was overall survival (OS) to be compared by stratified log-rank test. Assuming 256 eligible pts in each arm, the study had 75% power to detect 0.73 hazard ratio for D2+PAND to D2 in OS at 0.05 one-sided alpha. Results: Between 07/1995 and 04/2001, 523 pts were randomized (263 to D2 and 260 to D2+PAND). Baseline characteristics were well balanced between the arms. At the time of the final analysis on 23/03/06, 191 (96 and 95, in D2 and D2+PAND, respectively) had died. The 3- and 5-year OS were 76% and 69% in D2 and 76% and 70% in D2+PAND, respectively (p = 0.57, Hazard ratio was 1.03 (95% CI: 0.77–1.37)). Disease free survival did not show any difference between the groups as well. Median operation time was 63 minutes longer and median blood loss was 230 ml larger in D2+PAND than in D2. There was no difference in the incidence of major surgical complications and hospital mortality (0.8% in both arms). Conclusions: D2 or D2+PAND could be carried out safely and showed excellent survival for advanced gastric cancer treated with curative intent. PAND could not improve the survival achieved by D2. General use of PAND should be avoided. No significant financial relationships to disclose.

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Effect of body mass index in patients undergoing resection for gastric cancer: A single-center U.S. experience.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.4_suppl.25 ◽

2013 ◽

Vol 31 (4_suppl) ◽

pp. 25-25

Author(s):

Joyce Wong ◽

Shams Rahman ◽

Nadia Saeed ◽

Hui-Yi Lin ◽

Khaldoun Almhanna ◽

...

Keyword(s):

Gastric Cancer ◽

Body Mass Index ◽

Body Mass ◽

Disease Free Survival ◽

Technical Difficulty ◽

Tumor Location ◽

Normal Weight ◽

Lymph Node Count ◽

Clinicopathologic Factors ◽

The Impact

25 Background: With the rise of obesity in the U.S., the impact of body mass index (BMI) on surgical outcomes and survival in gastric cancer remains undetermined. Methods: An IRB-approved, prospectively-maintained institutional database of patients referred for surgical evaluation of gastric cancer was reviewed. Patients were stratified according to BMI: <18.5 (underweight), 18.5-25 (normal weight), 25.1-30 (overweight), and >30 (obese). Clinicopathologic factors and overall survival (OS) were analyzed using polytomous regression, Pearsons correlation and Kaplan Meier when appropriate. Results: From 1997-2012, 222 patients underwent exploration for gastric adenocarcinoma. Of these, 186 (84%) patients had BMI recorded: 9 (5%) with BMI<18.5, 72 (39%) 18.5-25, 62 (33%) 25.1-30, and 43 (23%) >30. 135 (73%) ultimately underwent resection. Operative factors including American Society of Anesthesiology (ASA) score and blood loss were not significantly associated with BMI. Increased BMI was associated with longer operative time, P=0.02. Pathologic factors including proximal tumor location, perineural invasion (PNI), lymphovascular invasion (LVI), positive surgical margins, and positive lymph nodes (LN+) were all associated with a worse OS. Although increased BMI was associated with a lower total lymph node count, P=0.004, the number of LN+ was not associated with BMI. Tumor location, PNI, LVI, margin status, and final pathologic stage were not significantly associated with BMI. Additionally, the use of neoadjuvant or adjuvant chemotherapy was not associated with BMI. Median OS for the group was 22 months. When stratified by BMI, median OS was improved with increased BMI: 21 months for <18.5, 13 months for 18.5-25, 28 months for 25-30, and 34 months for >30, P=0.02. Similarly, disease free survival (DFS) improved with increasing BMI: 2 months for <18.5, 7 months for 18.5-25, 15 months for 25.1-30, and 15 months for >30, P=0.02. Conclusions: Although BMI may impact the technical difficulty of resection for gastric cancer, increasing BMI is not associated with more aggressive disease. In this experience, increased BMI does not adversely impact OS or DFS.

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Prognostic impact of lymph node retrieval and ratio in gastric cancer: A single-center U.S. experience.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.4_suppl.17 ◽

2013 ◽

Vol 31 (4_suppl) ◽

pp. 17-17

Author(s):

Joyce Wong ◽

Shams Rahman ◽

Nadia Saeed ◽

Hui-Yi Lin ◽

Khaldoun Almhanna ◽

...

Keyword(s):

Gastric Cancer ◽

Lymph Node ◽

Lymph Nodes ◽

Lymph Node Ratio ◽

Disease Free Survival ◽

Prognostic Impact ◽

Free Survival ◽

Lymph Node Retrieval ◽

Node Ratio ◽

Disease Free

17 Background: Recommendations for extended lymphadenectomy in gastric cancer is thought to be associated with improved overall survival (OS), although defining adequate lymphadenectomy remains controversial. Methods: A single-institution, prospectively-maintained database of patients referred for surgical care of gastric cancer was reviewed. Patients were stratified by number of examined lymph nodes (eLN): <5, 6-10, 11-15, and >15 and positive LNs (LN+) stratified by 0, 1-2, 3-6, 7-15, and >15. Lymph node ratio (LN+:eLN) was evaluated, stratified by 0, 0.01-0.2, 0.21-0.5, and >0.5. Disease-free-survival (DFS) and OS were the primary endpoints, determined by Kaplan-Meier analyses. Results: From 1997-2012, 222 patients were included; most were male (N=122, 55%) with median age 67 (range 17-92) years. Of 220 (99%) patients surgically explored, 164 (74%) ultimately underwent resection. Median OS of the entire cohort was 22 months. Gender, ethnicity, and smoking status did not impact OS. Pathologic factors such as perineural invasion, lymphovascular invasion, and poor differentiation adversely affected OS, P<0.05. A median 14 lymph nodes (LN) were retrieved (range 0-45), with a median of one positive LN (range 0-31). No OS or disease-free survival (DFS) difference was observed when comparing <5, 6-10, 11-15, and >15 eLN, P=0.30. LN+ affected both OS and DFS: median OS was 52 months for 0 LN+ and decreased to 21 months with 1-2 LN+, 34 months 3-6 LN+, 25 months 7-15 LN+, and 11.5 months with >15 LN+. Similarly, median DFS decreased from 35 months with 0 LN+ to 19 months with 1-2 LN+, 9 months with 3-6 LN+, 13.5 months with 7-15 LN+, and 7.5 months with >15 LN+. Lymph node ratio demonstrated worse median OS with increasing ratio: 49 months for ratio of 0, 37 months for 0.01-0.2, 27 months for 0.21-0.5, and 12 months for >0.5, P<0.0001. DFS was similar: 35months for ratio of 0, 22 months for 0.01-0.2, 13 months for 0.21-0.5, and 7 months for >0.5, P<0.0001. Conclusions: Extent of lymphadenectomy does not impact OS or DFS. Presence of LN+ adversely impacts OS and DFS. Lymph node ratio may be a better prognostic indicator than number of eLN or LN+ in gastric cancer.

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