Prognostic impact of regional lymph node excision in T3-4N+M0 gastric cancer: a retrospective cohort study on nomogram development and external validation in China
In brief
Removing at least 18 lymph nodes cuts death risk by about half in advanced gastric cancer
In a combined US and Chinese cohort of T3-4N+M0 gastric cancer patients, excising 18 or more regional nodes reduced the hazard of death by roughly 50% and, when paired with postoperative radiotherapy, further improved survival. A newly validated nomogram predicts 5-year outcomes, but prospective trials are needed before mandating extensive node dissection.
- Journal
- International journal of surgery (London, England) (Q1)
- Published
- 12 March 2026
- Study design
- Prospective / inception cohort
- Evidence level
- Level 2, Moderate (CEBM 2b)
- Authors
- Chenrui Tian, Aiping Sun, Haodi Yu, Guozhen Song, Yongbin Wang, Qingyu Zhang, et al.
- PMID
- 42682307
- DOI
- 10.1097/JS9.0000000000004042
Why clinicians should know about it
- Picked for Surgical Oncology (paper of the day, 3 September 2026): Lymph node excision count impact on gastric cancer survival
Abstract
BACKGROUND: Locally advanced gastric cancer, especially T3-4N + M0 cancer, has been recognized as a significant clinical challenge among all kinds of gastric cancer. Although the surgery played a crucial role in the management of T3-4N + M0 gastric cancer, the number of regional nodes excision (RNE) exerted discernible impacts on the prognosis of this type of patients. This study aims to assess the potential survival benefit associated with excision of at least 18 lymph nodes and to develop a nomogram for predicting the 5-year survival rate in T3-4N + M0 gastric cancer patients. PATIENTS AND METHODS: This retrospective cohort study analyzed data from patients diagnosed with T3-4N + M0 gastric cancer between 2000 and 2019 from the Surveillance, Epidemiology, and End Results (SEER) database and our cohort (1 January 2015 to 2019). Participants were divided into train and test cohorts. The intervention included RNE, with exposure groups defined by lymph node count (≥18 vs <18) and postoperative radiotherapy. Primary outcome was overall survival (OS). Statistical analyses involved LASSO regression for variable selection, Cox proportional hazards models for identifying prognostic factors, restricted cubic spline (RCS) for modeling nonlinear relationships, and evaluation of the predictive nomogram using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA). RESULTS: Multivariable analysis identified ≥18 RNE and postoperative radiotherapy as independent favorable prognostic factors for OS (RNE≥18: HR = 0.47, P < 0.001; SRT: HR = 0.65, P = 0.03), while advanced nodal disease (N2/N3) and extended gastrectomy were associated with poorer outcomes. The nonlinear association between RNE and survival was statistically significant (P = 0.009) and predominantly nonlinear within the observed range. The developed nomogram demonstrated consistent discriminative ability, with AUCs of 0.722-0.765 in the train set and 0.713-0.801 in the external test set across 1, 3, and 5 years. CONCLUSIONS: This study establishes that resection of ≥18 lymph nodes and postoperative radiotherapy on those who underwent ≥18 lymph nodes significantly improves survival in T3-4N + M0 gastric cancer. We developed and validated a prognostic nomogram to guide individualized therapy. These findings advocate for standardized lymph node dissection in multimodal management, while prospective trials remain necessary to validate broader applicability. Besides, an online calculator is provided at https://yhd2314.shinyapps.io/huahuadan9_15/ to facilitate individual risk prediction.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.