Survival impact of the number of lymph node dissection on stage I–III node-negative gastric cancer

It is well known that lymph node (LN) status is the most important prognostic factor in localized gastric adenocarcinoma (GC) (1-4). Curative resection including adequate lymphadenectomy provided the chance of a cure for stage I–III disease (1,4,5). Unfortunately, a subgroup of patients with node-negative GC who underwent radical surgery including extensive LN dissection still experiences tumor recurrence, distant metastasis and subsequently died from the disease (6,7). In the issue of Annals of Surgery, Jin et al. indicated that in node-negative GC patients undergoing curative intent surgery, T3/T4 tumors, presence of lymphovascular invasion and signet ring histology independently affected overall survival suggesting that these patients may benefit from more aggressive adjuvant therapies (8). However, it should be noted that recurrence rates were 8.4% and 10.5% in T1 and stage I GC, respectively and 35.0% and 37.5% in T4 and stage III cancer, respectively in their study. The median number of nodes examined for patients with recurrence was 14 (range, 6–22), which might result in the possibility of underestimation of nodal involvement and understaging. In addition, tumor recurrence rates did not differ regardless of the extent of lymphadenectomy or the total nodes examined. The overall 5-year survival rate was 53% for the whole cohort.