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Comparison of a Lymph Node Ratio–Based Staging System With the 7th AJCC System for Gastric Cancer: Analysis of 18,043 Patients From the SEER Database

Wang, Jiping MD, PhD; Dang, Ping MD, MSc; Raut, Chandrajit P. MD; Pandalai, Prakash K. MD; Maduekwe, Ugwuji N. MD, MMSc; Rattner, David W. MD; Lauwers, Gregory Y. MD; Yoon, Sam S. MD

doi: 10.1097/SLA.0b013e31824857e2
Original Articles

Objectives: The American Joint Committee on Cancer (AJCC) staging system for gastric cancer bases N status on absolute number of metastatic nodes, regardless of the number of examined nodes. We examined a modified staging system utilizing node ratio (Nr), the ratio of metastatic to examined nodes.

Methods: A total of 18,043 gastric cancer patients who underwent gastrectomy were identified from the US Surveillance, Epidemiology, and End Results (SEER) database. A training set was divided into 5 Nr groups, and a TNrM staging system was constructed. Median survival and overall survival, based on 7th edition AJCC and TNrM staging systems, were compared, and the analysis was repeated in a validation set.

Results: Median examined nodes were 10 to 11. For the training set, overall survival for all 5 AJCC N categories was significantly different when subgrouped into 15 or fewer versus more than 15 examined nodes, but overall survival was similar regardless of the number of examined nodes in 4 of 5 Nr categories. Seven AJCC stages had statistically different overall survival between subgroups, whereas only 1 TNrM stage had statistically different overall survival between subgroups. When misclassification was defined as any subgroup in which median survival fell outside the 95% confidence interval of the group's overall median survival, AJCC staging misclassified 57% of patients and TNrM staging misclassified only 12%. Similar results were found in the validation set.

Conclusions: The AJCC system classifies SEER gastric cancer patients into stages in which subgroups often have wide variations in survival. For patients undergoing limited lymph node analysis, the proposed TNrM system may predict survival more accurately.

A training set of 7,233 gastric cancer patients from the SEER database was used to construct a staging system in which AJCC N status was replaced with node ratio (Nr), the ratio of metastatic nodes to examined nodes. TNrM staging was then compared to 2010 AJCC staging, and results were then confirmed in a validation set of 10,810 patients.

*Department of Surgery, Brigham and Women's Hospital and Harvard Medical School

Departments of Surgery

Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Reprints: Jiping Wang, MD, PhD, Department of Surgery, Brigham and Women's Hospital, 353 Carrie Hall, 75 Francis St, Boston, MA 02115. E-mail:; or Sam S. Yoon, MD, Department of Surgery, Massachusetts General Hospital, Yawkey 7, 55 Fruit St, Boston, MA 02114. E-mail:

The results of the training set data were presented at the American Society of Clinical Oncology Annual Meeting, Chicago, IL, June 2010.

Disclosure: The authors declare that they have nothing to disclose.

Copyright © 2012 Wolters Kluwer Health, Inc. All rights reserved.