Prognostic factors in patients with node-negative gastric cancer: an Indian experience.

Abstract

The status of the regional nodes is the most important prognostic factor in gastric cancer. There are subgroups of patients with different prognosis even in node-negative patients of gastric cancer. The aim of this study is to analyze the factors influencing the prognosis in Indian patients with node-negative gastric cancer.
This was a retrospective analysis of patients who underwent radical gastrectomy in a tertiary cancer centre in India between 1991 and 2007. The study group included only patients with histologically node-negative disease. Various clinical, pathological and treatment related factors in this group of patients were analyzed to determine their prognostic ability by univariate and multivariate analyses.
Among the 417 patients who underwent gastrectomy during this period, 122 patients had node-negative disease. A major proportion of the patients had advanced gastric cancer. The 5-year overall survival and disease-free survival in all node-negative gastric cancer patients was 68.2% and 67.5% respectively. The overall recurrence rate in this group was 27.3%. On univariate analysis, the factors found to significantly influence the disease-free survival were the size, location and presence or absence of serosal invasion of the primary tumor. However, on multivariate analysis, only tumor size more than 3 cm and serosal invasion were found to be independently associated with an inferior survival.
Serosal invasion and primary tumor size more than 3 cm independently predict a poor outcome in patients with node-negative gastric cancer.

Full text

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RESEARCH Open Access
Prognostic factors in patients with node-negative
gastric cancer: an Indian experience
Ramakrishnan A Seshadri1*, Sunil B Jayanand1and Rama Ranganathan2
Abstract
Background: The status of the regional nodes is the most important prognostic factor in gastric cancer. There are
subgroups of patients with different prognosis even in node-negative patients of gastric cancer. The aim of this
study is to analyze the factors influencing the prognosis in Indian patients with node-negative gastric cancer.
Methods: This was a retrospective analysis of patients who underwent radical gastrectomy in a tertiary cancer
centre in India between1991 and 2007. The study group included only patients with histologically node-negative
disease. Various clinical, pathological and treatment related factors in this group of patients were analyzed to
determine their prognostic ability by univariate and multivariate analyses.
Results: Among the 417 patients who underwent gastrectomy during this period, 122 patients had node-negative
disease. A major proportion of the patients had advanced gastric cancer. The 5-year overall survival and disease-
free survival in all node-negative gastric cancer patients was 68.2% and 67.5% respectively. The overall recurrence
rate in this group was 27.3%. On univariate analysis, the factors found to significantly influence the disease-free
survival were the size, location and presence or absence of serosal invasion of the primary tumor. However, on
multivariate analysis, only tumor size more than 3 cm and serosal invasion were found to be independently
associated with an inferior survival.
Conclusion: Serosal invasion and primary tumor size more than 3 cm independently predict a poor outcome in
patients with node-negative gastric cancer.
Background
The status of the regional lymph nodes is the most
important prognostic factor in gastric cancer and
patients with node-negative gastric cancer have a better
survival compared to those with nodal metastasis [1,2].
However, even among the node-negative patients, there
are certain subgroups of patients who fare better than
the others [3-13]. Identification of the poor risk category
among the node-negative patients may help in planning
adjuvant therapy for this group. Although the incidence
of gastric cancer in India is less than other Asian coun-
tries like Japan, Korea and China, the age-standardized
(world) incidence of gastric cancer in Chennai (12.2 and
6.0/100,000 population in males and females respec-
tively) is among the highest in India [14]. While many
previous studies on node-negative gastric cancer have
included a large proportion of patients with early gastric
cancer, we wished to study the factors influencing the
survival in Indian patients with node-negative gastric
cancer, most of whom have advanced gastric cancer.
This will help in the optimal utilization of treatment
resources for better patient care.
Methods
We undertook a retrospective analysis of patients diag-
nosed with gastric cancer who underwent radical gas-
trectomy with a curative intent in our institution
between 1991 and 2007. Prior to 1993, most patients
underwent a D1 dissection. From 1993, D2 dissection
was the standard treatment for patients with gastric can-
cer and a D1 dissection was performed only in special
situations (patients above 70 years, severely malnour-
ished patients or the occasional patient who underwent
emergency surgery for bleeding from the tumor). Only
patients in whom routine histological examination
(hematoxylin-eosin staining) of the dissected regional
* Correspondence: ram_a_s@yahoo.com
1Department of Surgical Oncology, Cancer Institute (WIA), Chennai-600036,
India
Full list of author information is available at the end of the article
Seshadri et al. World Journal of Surgical Oncology 2011, 9:48
http://www.wjso.com/content/9/1/48
WORLD JOURNAL OF
SURGICAL ONCOLOGY
© 2011 Seshadri et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.

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lymph nodes did not reveal evidence of nodal metastasis
were included in the study group. The UICC TNM 6th
edition staging system was used for staging the disease
[15]. Patients in whom all examined lymph nodes were
negative for metastasis regardless of the number of
nodes dissected were still designated as pN0 according
to the UICC TNM guidelines [15] and were included in
the analysis. Patients with carcinoma-in-situ were
excluded from the study, since the risk of nodal metas-
tasis is very low in these patients and they cannot be
compared with invasive malignancies.
Adjuvant chemotherapy was not administered to any
of the patients. The tumors were divided into proximal
or distal by an imaginary line between the incisura and
the mid-point of the greater curve. The patients were
followed 3-monthly for the first three years, 6-monthly
for the next two years and then annually thereafter.
Clinical examination was performed at each visit and
abdominal imaging studies (computerized tomography
scan or an ultrasound) was requested every year for the
first five years. An endoscopy was performed once a
year for three years. Local recurrence identified on
endoscopy was always confirmed by a biopsy. Nodal or
distant recurrences were identified on imaging and a
biopsy was not attempted unless the imaging result was
equivocal. The median duration of follow-up of all
patients in this study (including 5 patients who had a
30-day mortality) was 58 months (range 1 to 202
months). Univariate analysis of various prognostic fac-
tors influencing the disease-free survival (DFS) was per-
formed using log-rank test. Factors identified to be
significant in univariate analysis were included in the
multivariate analysis, which was performed using the
Cox proportional hazard model. The survival estimates
were calculated by life-table method. Statistical signifi-
cance was considered when p value was < 0.05. The
SPSS v11.0.1 software was used for statistical analysis
Results
Among the 417 patients who underwent radical gas-
trectomy during the study period, 122 patients had his-
tologically node-negative disease. After excluding one
patient with carcinoma-in-situ, the study population had
121 patients (29%). Table 1 enlists the patient, surgical
and pathological details of the node-negative patients.
More than 80% of the patients had advanced gastric
cancer (predominantly T3 disease) and D2 lymphade-
nectomy was performed in 81% of the patients.
On follow-up, recurrence was detected in 33 patients
(27.3%). Of this, distant metastasis was seen in 24
patients (19.8%), isolated locoregional recurrence in 6
patients (4.9%) and combined locoregional and distant
recurrence was seen in 3 patients (2.4%). The 3-year
and 5-year overall survival in node-negative patients
were 76% and 68.2% respectively, whereas the 3-year
and 5-year disease-free survival were 73.6% and 67.5%
respectively. In contrast, the 5-year overall survival of
the 295 patients who had node-positive disease was
29.1%, which was significantly lower than that of node-
negative patients (p < 0.001).
On univariate analysis, the only factors which were
found to be significantly associated with a poor disease-
free survival in patients with node-negative gastric can-
cer were tumor size >3 cm, proximal tumor location
and the presence of serosal invasion in the primary
tumor (Table 2). The age of the patient, gender, histol-
ogy and grade of the tumor did not correlate signifi-
cantly with survival. There was a non-significant trend
towards better survival in patients in whom >15 nodes
were dissected when compared to those with fewer
number of dissected nodes. Similarly, although there
Table 1 Clinical, pathological and treatment details of
node negative patients
VariableNo. (%)
Gender
Male
Female
86
35
Median age (range)53 years (27-76)
Depth of invasion
pT1
pT2
pT3
pT4
22 (18.2)
33 (27.3)
64 (52.9)
2 (1.7)
Size of primary tumor
≤3 cm
>3 cm
18 (14.9)
85 (70.2)
Grade
1
2
3
12 (9.9)
39 (32)
70 (57.9)
Histology
Adenocarcinoma
Mucin secreting carcinoma
Signet-ring cell carcinoma
102 (84.3)
13 (10.7)
6 (5)
Type of gastrectomy
Distal
Total
Proximal
97 (80.2)
21 (17.4)
3 (2.5)
Extent of lymphadenectomy
D1
D2
23 (19)
98 (81)
Median no. of dissected nodes (range)22 (4-77)
No. of nodes dissected
≤15
>15
39 (32.2)
82 (67.8)
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was a trend towards improved survival in patients
undergoing D2 lymphadenectomy when compared to
D1, we could not demonstrate any statistical signifi-
cance. On multivariate analysis, only the primary tumor
size >3 cm and presence of serosal invasion were found
to be independently associated with an inferior disease-
free survival (Table 3). The survival curves in patients
with node-negative gastric cancers according to tumor
size and serosal invasion are presented in Figures 1 and 2
respectively.
Discussion
The status of regional nodes is the most important
prognostic factor in gastric cancer [1,2]. Node-negative
patients have a significantly better survival when com-
pared to node-positive patients. The 5-year and 10-year
overall survival in node-negative patients have been
reported to vary from 72% to 91.7% [2-10] and 88% to
93% [3,6,11] respectively. The recurrence rates vary
from 13.7% to 29.4% in this favorable subset of patients
[7,8,10,12]. Most of these series come from East Asian
countries and include a sizeable proportion of early gas-
tric cancer. Our series, which reflects the Indian sce-
nario, has a majority of patients diagnosed with
advanced gastric cancer and hence the 5-year survival
rates reported by us (68.2%) is slightly less than that
quoted in the literature. However, in one of the largest
series, comprising more than 1500 patients with node
negative gastric cancer, Kim et al [13] reported a com-
parable 5-year survival (66.9%) in patients with advanced
gastric cancer.
The proportion of node-negative patients in our study,
although less than that reported from many East Asian
countries [5,11,13], is comparable to that reported in
some western centers [4,9]. There are two reasons for
this. First, aggressive screening programmes, as practiced
Table 2 Univariate analysis of factors predicting disease-
free survival in node negative gastric cancer
Variable5-year Disease free
survival
p value
1. Gender
Male
Female
68.2%
65.4%
0.78(NS)
2. Age
≤53 years 63.5%0.557
(NS)
>53 years 71.5%
3. Haemoglobin
≤9 gm%
>9 gm%
59.03%
70.6%
0.42(NS)
4. Patient Weight
≤50 kg
>50 kg
68.7%
66.5%
0.44(NS)
5. Location of tumor
Distal
Proximal
71.8%
48.6%
0.05
6. Multi-organ resection
None
Pancreaticosplenectomy
Others
68.2%
55.4%
100%
0.69(NS)
7. Dissection
D153.5%0.100
(NS)
D270.1%
8. Histology
Adenocarcinoma
Mucinous carcinoma
Signet ring cell
carcinoma
65.5%
84.6%
62.5%
0.30(NS)
9. Grade
1
2
3
80%
76.8%
60%
0.14(NS)
10. Tumor size
≤3 cm
>3 cm
94.3%
55.9%
0.003
11. Serosal invasion
Absent
Present
86.4%
51.9%
0.0002
12. No of nodes dissected
≤15
>15
59.6%
71.3%
0.07(NS)
13. Gastric outlet obstruction
Absent
Present
70.3%
60.7%
0.27(NS)
14. Blood loss
≤400 ml
>400 ml
72.9%
64.3%
0.17(NS)
NS- not significant.
Table 3 Multivariate analysis of prognostic factors in
node negative gastric cancer
VariableHazard
ratio
95% confidence
interval
p
value
1. Location of
tumor
Distal
Proximal
1*
1.430.73-2.790.36
(NS)
2. Tumor size
≤3 cm
>3 cm
1*
7.971.08-59.06
0.04
3. Serosal invasion
Absent
Present
1*
2.13 1.04-4.35
0.04
*Reference value NS- not significant.
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in Japan leads to early detection of gastric cancer whereas
in India, many patients present in an advanced stage due
to the lack of such screening programmes. Second, it has
been observed that node-negative gastric cancer is fre-
quently associated with small tumor size (usually <4 cm)
[3,5,11], less poorly differentiated tumors [3] and are
usually confined to the muscularis propria [3,11]. In the
entire population of 417 gastric cancer patients treated in
our institution, the mean size of the primary tumor was
5.3 cm, 69% of the patients had high grade tumors and
75% of the patients had disease extending beyond the
muscularis propria (data not shown) - all of which
probably account for a high proportion of nodal metasta-
sis among Indian patients.
Various clinico-pathological factors have been
reported to influence the survival and recurrence rates
in node-negative gastric cancer. The size of the primary
tumor has been reported to be a significant prognostic
factor for survival in earlier studies [5,6,10,13,16], and
has been confirmed in our study as well. The presence
of serosal invasion, which emerged as an independent
prognostic factor in our study has been documented by
other authors [4,8,10,12,13,16]. The depth of invasion of
the primary tumor has also been reported as a prognos-
tic factor [3,11,17-19]. Proximal location of the tumor
was significant only on univariate analysis in our study,
but lost significance on multivariate analysis. Similarly,
distal tumor location did not emerge as an independent
prognostic factor in other studies [3,19]. In contrast,
Deng et al. [8] found that patients who underwent sub-
total gastrectomy had a significantly longer median
overall survival when compared to those who underwent
a total gastrectomy (116 vs 91 months, p = 0.03), which
indirectly reflected the influence of tumor location on
survival. Lauren’s histological classification has been
reported to be an independent prognostic factor in
node-negative gastric cancer, with the intestinal type
having a better prognosis than the diffuse type [12,19].
Even though we did not use the Lauren’s classification
in our study, the histological subtype of the tumor
according to the WHO classification did not emerge as
a significant prognostic factor in our analysis. The other
factors which have been found to influence survival in
patients with node-negative gastric cancer include pre-
sence of lympho-vascular invasion [3,12,16,18,20], age
[11,17,18,21], gender [8], vascular invasion [5,22], S-
phase fraction [23] and proliferating cell nuclear antigen
(PCNA) labeling index [24]. Poorly differentiated tumors
also have a poor prognosis [4,10], although in our analy-
sis we were not able to demonstrate a significant asso-
ciation between the histological grade of the tumor
(which denotes the tumor differentiation) and survival.
Extended lymphadenectomy has been reported to be
an independent prognostic factor for survival in node-
negative gastric cancer by few authors [6,21,25] whereas
others have reported that this survival benefit is limited
only to patients withT3 disease [9,17]. It is recom-
mended that a minimum of 15 nodes be dissected for
proper staging in gastric cancer [15]. The number of
node to be dissected in patients with node-negative gas-
tric cancer is unclear, although Giuliani et al recom-
mended examination of at least 23 nodes in these
patients for identifying prognostic indicators [26].
Huang et al. [7] found that the number of dissected
lymph nodes was an independent prognostic factor for
survival in patients with node-negative gastric cancer
Months
120 96 7248240
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.1
0.0
Tumor Size
>3 cm
<=3 cm
Figure 1 Survival in node negative gastric cancer patients
according to tumor size. The disease-free survival of patients with
tumor size ≤3 cm was higher than that of patients with tumors size
>3 cm.
Months
120 967248240
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.1
.0
Serosal invasion
Present
Absent
Figure 2 Survival in node negative gastric cancer patients
according to serosal invasion. The disease-free survival of patients
with serosal invasion was lower than that of patients without
serosal invasion.
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and that there was a negative correlation between the
number of dissected nodes and recurrence rates. By cut-
point analysis, these authors reported better survival in
pT1-2 patients in whom ≥15 nodes were dissected, in
pT3-4 patients in whom ≥20 nodes were dissected and
in the entire group of patients if ≥15 nodes were dis-
sected. In a retrospective analysis, Biffi et al reported
that the disease-free and overall survival of node-nega-
tive gastric cancer patients was significantly improved
when at least 15 nodes were dissected regardless of the
pT stage and that the risk of distant metastasis
decreased with increase in the number of dissected
nodes [27]. Shen et al. [28] reported that there was a
positive association between the number of nodes dis-
sected and the chance of identifying nodal metastasis in
pT3 but not pT1 or pT2 gastric cancer (HR = 1.014,
95% CI 1.006-1.021). However, they failed to demon-
strate an independent prognostic value of the number of
nodes dissected in pT3N0 patients. In another study [8],
it was observed that patients in whom more than 20
nodes were dissected had a longer median disease-free
survival than patients in whom fewer than 20 nodes
were dissected (47.5 versus 21.4 months, p = 0.01). In
our study, although there was a definite trend towards
better survival in patients who underwent D2 dissection
and in patients in whom >15 nodes were examined, we
were not able to demonstrate a statistically significant
association between these factors and patient survival.
This is probably due to the small sample size.
The benefit of extended lymphadenectomy seems to
be due to the eradication of potential micrometastatic
disease [7]. Using reverse transcription polymerase chain
reaction assay, Wu et al. [29] detected micrometastasis
in 20% of patients who were determined to be node
negative on routine hematoxylin-eosin stains. Immuno-
histochemical studies have also been used to detect
micrometastasis in 10-32% patients with gastric cancer
[30-33]. The presence of micrometastasis significantly
impacts the prognosis of patients with node-negative
gastric cancer. Patients who do not harbour microme-
tastasis have been found to have a significantly better
survival than those who harbour micrometastasis in the
nodes [29,31-35]. The type of micrometastasis also
seems to have an impact on the outcome. Yasuda et al.
observed that patients with ≥4 micrometastasis have a
significantly worse outcome when compared to those
with fewer micrometastasis and also that those with
micrometastasis in extragastric nodes fare poorly [32].
In another study, Cao et al reported that the cluster-
type micrometastasis had a significantly poor survival
when compared to the single-cell type micrometastasis
[31]. The presence of micrometastasis in the nodes has
been correlated with loss of E-cadherin expression in
the primary tumor as well as the size, depth of invasion
and differentiation of the primary tumor [30-35]. It is
interesting to note that most of the variables are them-
selves independent prognostic factors in node-negative
gastric cancer, and therefore, their prognostic impor-
tance may be attributed to the presence of micrometas-
tasis. Thus, identifying micrometastasis in node-negative
gastric cancer patients may help in prognostication as
well as determining the need for adjuvant therapy.
The prognostic value of adjuvant therapy in node-nega-
tive gastric cancer has not been reported in the English lit-
erature. Adjuvant chemotherapy has been shown to
improve the survival in gastric cancer in general [36,37].
However, it is difficult to say whether adjuvant chemother-
apy will add to the already favourable prognosis of node-
negative gastric cancer. This can be answered only by a
multicenter randomized trial of adjuvant chemotherapy
exclusively in patients with node-negative gastric cancer.
Conclusion
Although patients with node-negative gastric cancers had
a favorable survival in our study, the subgroup of patients
with a tumor size more than 3 cm or tumors invading
the serosa had a worse prognosis when compared to
those having smaller tumors or those without serosal
invasion. The low rate of locoregional recurrence in our
study may be related to the extended nodal dissection
performed in most patients. An attempt should be made
in all node-negative patients to identify lymph node
micrometastasis since it may further help in prognostica-
tion. The available evidence from literature suggests that
an extended lymphadenectomy with dissection of at least
15 nodes must be performed even in patients with clini-
cally negative nodes. However, surgical treatment alone
is unlikely to prevent distant recurrences, even in node-
negative gastric cancer. Hence, systemic therapy may
have a role in node-negative gastric cancer patients. In a
country like India, where it is essential to utilize the avail-
able treatment resources judiciously, patients with node-
negative gastric cancer with a tumor >3 cm or invading
the serosa or with lymph node micrometastasis should be
considered for more aggressive adjuvant therapy in the
form of systemic chemotherapy.
Acknowledgements
We wish to acknowledge the immense help rendered by Mr. Sivakumar M
and Mrs. Lakshmi Dhanasekar in retrieving the case records and updating
the patient follow-up status.
Author details
1Department of Surgical Oncology, Cancer Institute (WIA), Chennai-600036,
India.2Department of Biostatistics and Tumor Registry, Cancer Institute (WIA),
Chennai-600036, India.
Authors’ contributions
RAS was involved in the conception and design of the study, extraction of
data, interpretation of data, literature search and critical appraisal and
Seshadri et al. World Journal of Surgical Oncology 2011, 9:48
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