The study results suggest a therapeutic benefit with removal of more lymph nodes that is limited to patients with intermediate-stage disease. In early disease, harvesting more nodes may not have survival gains because the risk of nodal metastases is low at the outset [3]. Also, nodes with both macro and micrometastases are limited and may not necessitate large number of nodes to be removed for complete clearance. In advanced stages, the risk of disease already being systemic is high so that clearance of more nodes potentially harboring micrometastasis is of minor therapeutic consequence. In intermediate-stage disease, however, harvesting of more lymph nodes with potential micrometastasis in a disease setting that is likely still locoregional may have a therapeutic impact. This may account for the statistically significant association with improved survival for stage IIIA disease and a favorable trend in stage IIB.
That survival benefit associated with the removal of more lymph nodes is limited to a particular intermediate-stage subgroup in this study is in line with other reports. In the Dutch trial, N2 subgroup had better survival with D2 dissection [8]. Karpeh et al. showed that examination of 15 or more nodes significantly influenced survival estimates for stage II and III gastric cancer [25]. In a prospective multicenter observational study, extent of lymphadenectomy, defined according to number of nodes removed (≤ 25 versus > 25), had an independent survival effect in stage II disease [34]. This effect persisted even after exclusion of patients with insufficient nodal dissection [34]. A South Korean high-volume center retrospective study showed that in patients with >15 nodes examined, there was no stage-specific survival differences according to nodal yield except for stage IIIB, an effect attributed to improved regional control with removal of lymph nodes with microinvolvement [35]. The lack of survival advantage with higher lymph node yield in early gastric cancer in this study is consistent with other reports [24, 35] and existing recommendations for limited lymphadenectomy (D1 or D1+) for early (cT1N0) gastric cancer [15, 16, 27], although the study is not designed adequately to provide strong conclusions to this effect. However, studies suggest that even in early node-negative disease, removal of at least 15 nodes remains important to improve survival [4]. Even with D1 lymphadenectomy retrieval of 15 nodes as a goal is achievable [6, 7, 9, 17]. In this study, 92% of D1 dissection cases had at least 15 nodes examined and 73% of patients with < 15 lymph nodes examined had node-negative disease. Additional analysis of T1 N0 patients (Additional file 5: Figure S4) showed no statistically significant difference in overall survival (p = 0.96) and disease-free survival (p = 0.79) between those who had < 15 and ≥ 15 lymph nodes examined. However, this may be due to the very small number of patients with < 15 nodes removed, comprising only 1.8% (33/1815) of patients with T1 N0 disease.
Worse survival outcomes were observed for patients with > 45 nodes examined when the entire patient cohort was analyzed. This may be due to the significant trend towards more nodes being removed with increasing pathologic stage and higher proportion of patients with > 45 nodes removed with advanced-stage disease. By looking at the entire patient cohort alone, it is unclear whether the poorer survival with removal of > 45 nodes is due to more advanced disease or removal of more nodes per se. Hence, analysis per stage category, was important to eliminate this concern.
This study’s findings are inconsistent with the results of a US population-based study using the Surveillance, Epidemiology, and End Results (SEER) database which showed that, for every stage, overall survival was found to be highly dependent on the number of nodes examined [5]. The different results could be explained by differences in methodology. The SEER study included low to high-volume gastric centers and excluded patients with N2–3 or T4 disease. Categories of number of removed lymph nodes and stage subgroupings were different. Additionally, 78% of patients had < 15 lymph nodes examined with a median of 8 nodes. In the present study, less than 2% of patients had < 15 nodes examined with a median of 41 nodes. Hence, in the SEER study, it is difficult to ascertain whether the survival benefit was an actual therapeutic benefit or the result of stage migration [5]. Another study using the National Cancer Database also showed positive association of OS with lymph node yield for both node-negative and node-positive disease but rate of adequate nodal retrieval was only 21–36% [22].
Distinguishing stage migration from therapeutic benefit confounds interpretation of studies demonstrating survival benefit of extended lymphadenectomy. Extensive lymphadenectomy results in higher nodal retrieval, higher probability of detecting nodal metastasis, and hence, more accurate pathologic staging [3, 4, 17,18,19,20, 27, 28, 35, 36]. Accurate staging leads to better stage-specific survival and may explain in part the benefit with D2 versus D1 dissection and better survival outcomes in Eastern versus Western centers [4, 29, 36]. Coburn et al. demonstrated poor survival for every stage with inadequate lymph node assessment [19]. Even in an Eastern high-volume center, a linear relationship between number of examine nodes and survival was demonstrated [24].
In this study, stage migration effect, while not completely eliminated, may have been reduced since most patients had D2 dissection and > 15 nodes examined. Nodal staging and stage-specific survival estimates are more accurate with at least 15 nodes examined [4, 25, 34, 35]. De Manzoni et al. suggested that D2 dissection is required for accurate gastric cancer staging given their findings that 62% of D1 dissection patients had < 15 nodes retrieved compared to 5.5% with D2 dissection [20].
Stage migration causing improved survival in other studies was suggested by positive correlation between number of examined and metastatic lymph nodes on linear regression analysis [24, 28]. Similar result was seen here but stage subgroup analysis revealed a stage-specific correlation. In stage IIIA where a survival benefit for greater nodal harvest was demonstrated, no significant correlation between number of nodal harvest and pathologic lymph nodes was found, suggesting that survival benefit in this intermediate stage may be an actual therapeutic benefit.
Nodal micrometastasis is one rationale for aggressive lymph node removal [33]. Immunohistochemical and molecular studies of resected nodes showed association of nodal micrometastasis with poor prognosis [30,31,32]. But, some studies on node-negative gastric cancer with 10–53% nodal micrometastasis rate failed to demonstrate survival difference between micrometastasis-positive and -negative groups [36, 37]. This may be due to the already favorable prognosis of early gastric cancer and because the micrometastasis-positive nodes were removed. The risk of nodal micrometastasis is correlated with tumor size and invasion depth and is more likely to occur in patients with lymph node metastases on conventional examination [32, 38, 39]. It is in the setting of intermediate-stage disease, therefore, where micrometastasis risk is high but systemic disease low that resection of more nodes may contribute to survival, as seen here.
A limitation in the clinical applicability of this study’s finding of improved survival with increased lymph node harvest in intermediate-stage disease is the accurate clinical identification of such patients. Preoperative and intraoperative assessment of nodal status is poorly correlated with pathologic nodal staging [40]. Hence, as mentioned in most gastric cancer guidelines, limited lymphadenectomy should be performed only in select group of T1N0 gastric cancer patients.
In our study, gastric cancer patients receiving neoadjuvant therapy were excluded from the analysis in an attempt to limit the potential confounding effect that neoadjuvant therapy may have on the ultimate number of lymph node harvested at the time of curative resection. However, there is no consensus in the literature as to whether or not the administration of neoadjuvant therapy for gastric cancer reduces the ultimate number of lymph nodes harvested at the time of curative resection [41, 42]. It is possible that our exclusion of gastric cancer patients receiving neoadjuvant therapy from our analysis could have been responsible for some portion of the survival advantage observed in intermediate stage disease patients with a greater number of lymph nodes harvested. This issue is of particular clinical interest in Western gastric cancer centers where neoadjuvant therapy is considered a standard of care for all patients except for those with very early stage disease [13, 14]. On the other hand, in Eastern gastric cancer centers, particularly in Japan and South Korea, where neoadjuvant therapy is not yet considered a standard of care, and for which only a small portion of gastric cancer patients receive neoadjuvant therapy, this issue is resultantly more difficult to assess.
This study’s strengths that allowed for good assessment of therapeutic impact of greater nodal harvest on survival and minimization of stage migration effect include the: 1) large number of cases, 2) completeness of data and follow-up, 3) performance in high-volume specialist center with standardized treatment protocols, 4) adequacy of lymph node retrieval for staging, and 5) subgroup categories according to AJCC stage. However, the limitation of the study to a single Eastern institution may preclude generalizability of results particularly in Western centers.