# Prognostic value of lymph node ratio after neoadjuvant chemotherapy for gastric cancer: a systematic review and meta-analysis

## TL;DR

This study finds that a higher lymph node ratio after chemotherapy for gastric cancer is strongly linked to worse survival outcomes.

## Contribution

The study is the first to systematically evaluate the prognostic value of lymph node ratio after neoadjuvant chemotherapy in gastric cancer.

## Key findings

- High lymph node ratio is strongly associated with poorer overall survival (HR = 3.48).
- Lymph node ratio is linked to worse disease-free survival (HR = 1.94).
- Subgroup analysis showed significant interaction by lymph node ratio cutoff.

## Abstract

The prognostic value of the lymph node ratio (LNR) in gastric cancer treated with neoadjuvant chemotherapy (NACT) remains unclear, as conventional pathological nodal assessment after neoadjuvant therapy may be affected by treatment-induced changes. This meta-analysis evaluated whether LNR retains prognostic significance in patients undergoing neoadjuvant chemotherapy followed by curative gastrectomy.

PubMed, MEDLINE, CENTRAL, Web of Science, Embase, and ClinicalTrials.gov were searched from inception to October 20, 2025. Retrospective cohort studies reporting hazard ratios (HRs) for survival outcomes based on LNR after NACT were included. Overall survival was the primary outcome; disease-free survival was a secondary outcome. Prespecified subgroup analyses were performed by LNR cutoff (≥0.30 vs <0.30) and neoadjuvant regimen (chemotherapy vs chemo–immunotherapy).

Seven studies involving 2,437 patients met inclusion criteria. Six studies reported overall survival, one study reported disease-specific survival. High LNR was strongly associated with poorer overall survival (OS)(HR = 3.48, 95% CI: 2.27–5.33) and inferior disease-free survival(DFS) (HR = 1.94, 95% CI: 1.24–3.06). Subgroup analysis showed a significant interaction by LNR cutoff (p = 0.03), but no interaction by neoadjuvant treatment modality (p = 0.49). Sensitivity analyses confirmed the stability of results.

Higher LNR is a strong and independent predictor of poor survival after neoadjuvant chemotherapy in gastric cancer. LNR may improve postoperative risk stratification beyond pathological TNM staging after neoadjuvant therapy, but prospective studies are required to establish optimal cut-offs and determine how LNR should be integrated into clinical decision-making.

https://www.crd.york.ac.uk/prospero/, identifier CRD420251233582.