# Improving Prognostic Stratification in Gastric Cancer: The Role of Lymph Node Staging Systems

## TL;DR

This study shows that lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS) improve survival prediction in gastric cancer patients compared to traditional staging.

## Contribution

Demonstrates that LNR and LODDS provide better prognostic stratification than N staging in gastric cancer patients with curative surgery.

## Key findings

- LNR and LODDS were identified as independent prognostic factors for overall survival.
- Cut-offs for LNR and LODDS stratified patients into three subgroups with distinct survival outcomes.
- The findings suggest LNR and LODDS improve accuracy even with more than 15 retrieved lymph nodes.

## Abstract

Background and Objectives: The tumor-node-metastasis (TNM) classification system is the standard for staging gastric cancer and predicting survival. However, its accuracy can be compromised by insufficient lymph node (LN) dissection during surgery or inadequate pathologic examination. Alternative staging systems, such as the lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS), may provide better prognostic value when LN examination is suboptimal. Because the current N staging system was not able to accurately stratify patients relative to their survival outcomes in our series, this study assessed the prognostic impact of LNR and LODDS on overall survival (OS) of patients who underwent radical gastrectomy for cancer. Materials and Methods: Between March 2005 and June 2025, the authors performed gastrectomy for gastric carcinoma in 114 patients. Out of these patients, 39 were excluded (19 had stage IV, while 20 underwent palliative gastrectomy with D1 lymphadenectomy). Thus, the study cohort included 75 patients who underwent curative gastrectomy, with 4 (5.3%) of them dying postoperatively. Potential prognostic factors associated with OS (including age, sex, tumor location, T stage, N stage, TNM stage, LNR, and LODDS) were evaluated by univariate and multivariate analysis. Because the recurrence data were missing in 41 patients, the disease-free survival (DFS) analysis would not be meaningful. Results: The OS analysis was based on the 71 patients surviving postoperatively. Because successive N stage groups could not accurately stratify patients according to their OS, we used X-tile software version 3.6.1 to identify two cut-offs (both for LNR and LODDS) that were able to stratify patients in three subgroups with significantly distinct survival outcomes. Multivariate analysis found that both LODDS and LNR systems were independent prognostic factors for OS. Conclusions: LNR and LODDS provide more detailed insights into lymph node status and have demonstrated potential for enhancing prognostic accuracy compared to N staging, even in patients who underwent curative gastrectomy with D2 lymphadenectomy. Although LNR and LODDS are usually useful in patients who underwent suboptimal lymphadenectomy, the current study demonstrated that these systems could improve prognostic stratification even in patients with more than 15 retrieved LNs. However, due to the small sample size, the current observations and proposed cut-offs of LNR and LODDS have to be validated in larger studies including such patients.