- Open Access
Impact of retrieved lymph node count on short-term complications in patients with gastric cancer
World Journal of Surgical Oncology volume 18, Article number: 224 (2020)
It is well established that retrieved lymph node (RLN) counts were positively correlated with better overall survival in gastric cancer (GC). But little is known about the relationship between RLN count and short-term complications after radical surgery.
A total of 1487 consecutive GC patients between January 2016 and December 2018 at Nanjing Drum Tower Hospital were retrospectively analyzed. Univariate analyses were performed to elucidate the association between RLN count and postoperative complications. We further identified clinical factors that might affect the RLN count.
Among all of the patients, postoperative complications occurred in 435 (29.3%) patients. The mean RLN count was 25.1, and 864 (58.1%) patients were diagnosed with lymph node metastasis. Univariate analyses showed no significant difference between RLN count and postoperative complications (both overall and stratified by CDC grade). Univariate and multivariate analyses further revealed that type of resection, tumor invasion, and lymph node metastasis were associated with RLN count.
The current study demonstrated that RLN count was not associated with postoperative short-term complications following gastrectomy of GC, which provided a rationale for the determination of a proper RLN count of curative gastrectomy.
There are approximately one million new cases of gastric cancer (GC) each year worldwide, and half of them occur in Eastern Asia, including China, Japan, and South Korea . Despite advances in early screening and comprehensive treatment of GC, it remains the third most common cause of cancer-related death in the world . For advanced GC, a consensus has been reached of radical gastrectomy with D2 lymphadenectomy . However, there is still controversy over the number of retrieved lymph nodes (RLNs) for accurate pathological staging.
Several studies have reported that RLN count was positively correlated with better overall survival in GC, even in lymph node-negative GC [4,5,6,7]. An RLN count of ≥ 16 has been recommended by the 8th edition TNM classification for GC to guarantee the accurate pN stage . Moreover, Okajima et al. suggested an optimal RLN count of ≥ 25 for nodal staging . Recently, by stratum analysis of 7620 patients, Deng et al. proposed an optimal RLN count of ≥ 16 for lymph node-negative GC and > 30 for lymph node-positive GC . These above studies are all conducted by comparing the RLN count with long-term survival. But little is known about the relationship between the RLN count and short-term complications after radical surgery.
Postoperative complications of GC pose a significant impact on the length of postoperative stay and hospital charges, which further affect the quality of life . Therefore, investigating the relationship between RLN count and postoperative short-term complications would provide more comprehensive evidence for selecting the appropriate RLN count.
A total of 1487 consecutive GC patients between January 2016 and December 2018 at Nanjing Drum Tower Hospital were retrospectively reviewed. All patients underwent curative (R0) gastrectomy and were histologically confirmed. The exclusion criteria were as follows: (1) multivisceral resection, (2) patients accepting preoperative radiotherapy or chemotherapy, (3) patients with previous stomach surgery, and (4) patients with incomplete clinical data. This study was approved by the Ethics Committee of Nanjing Drum Tower Hospital.
Data for preoperative characteristics, intraoperative index, and postoperative features were extracted. Preoperative characteristics included age, gender, body mass index (BMI), comorbidities, and laboratory data. The intraoperative index involved the American Society of Anesthesiologists (ASA) grade, surgical approach, type of resection, operation time, and blood loss. Postoperative features included depth of tumor invasion, tumor site, retrieved lymph node count, lymph node metastasis, lymph node ratio (LNR), log odds of positive lymph nodes (LODDS), pTNM stage, Lauren subtype, short-term complications, postoperative stay, and total hospital charges. LNR was defined as the ratio of positive to retrieved lymph nodes. LODDS was calculated by log [(positive lymph nodes + 0.5)/(total lymph nodes − positive lymph nodes + 0.5)] . The postoperative short-term complications occurring in the hospital or within 30 days were collected. All complications were evaluated according to the Clavien-Dindo classification system .
Statistical analyses were conducted by SPSS 19.0 (Chicago, IL, USA). Continuous variables were shown as means ± SD. Student’s t test was applied for normally distributed data; Mann-Whitney U test was applied for non-normally distributed data. Categorical variable data were presented as numbers and analyzed using the chi-squared test or the Fisher exact test. Univariate and multivariate analyses were performed to analyze the risk factors associated with the postoperative complications or retrieved lymph node count. The optimal cutoff values of LNR and LODDS were determined by receiver operating characteristic (ROC) analysis. All statistical tests were conducted two-sided, and statistical differences were termed as P value < 0.05.
The background characteristics of the patients enrolled in this study were presented in Table 1. There were 1487 GC patients in all, including 1089 (73.2%) men and 398 (26.8%) women. The median age was 60 years with a range from 21 to 96 years. A total of 1411 (94.9%) patients underwent open gastrectomy while 76 (5.1%) underwent laparoscopic surgery. The type of resection was distal gastrectomy in 617 (41.5%) patients, proximal gastrectomy in 163 (11.0%), and total gastrectomy in 707 (47.5%). The mean operation time was 232 min, and the mean intraoperative blood loss was 221 ml. Pathological results were stage I/II/III/IV in 506/368/597/16 patients, respectively. The mean RLN count was 25.1 (range, 2–84), and 864 (58.1%) patients were tested with lymph node metastasis. Overall, postoperative short-term complications occurred in 435 (29.3%) patients. The mean postoperative stay was 12 days, and the mean total hospital charges were 7.5 × 104¥.
Association between perioperative characteristics and postoperative complications
As presented in Table 2, univariate and multivariate analyses indicated that postoperative short-term complications were significantly correlated with age, gender, level of preoperative serum albumin, and operation time. Stratified analyses by type of resection revealed that complications occurred frequently in proximal gastrectomy compared with total gastrectomy, while there was no significant difference between distal gastrectomy and total gastrectomy. No significant association was observed between RLN count and overall postoperative complications.
Impact of RLN count on postoperative complications
Of the 1487 patients, 435 (29.3%) developed complications: 74% (323 of 435) encountered a single complication, and 26% (112 of 435) encountered multiple complications. The details of patients with short-term complications based on the Clavien-Dindo classification are 15.5% for grade I, 9.2% for grade II, 4.0% for grade III, 0.3% for grade IV, and 0.2% for grade V. The rate of major complications (CDC grade ≥ III) was 4.5%. The median RLN count in this study was 24. So, we divided all patients into two groups based on the median RLN count. Univariate analyses showed no significant difference between RLN count and postoperative complications (both overall and stratified by CDC grade) (Table 3).
Factors associated with RLN count
We further explored the potential factors associated with RLN count. Univariate analyses revealed that preoperative serum albumin, type of resection, tumor invasion, lymph node metastasis, and pTNM stage were associated with RLN count (P < 0.05; Table 4). Stratification by type of resection showed that RLN count in either distal gastrectomy or proximal gastrectomy was significantly lower than that in total gastrectomy. Multivariate analyses further indicated that type of resection, tumor invasion, and lymph node metastasis were still significantly associated with RLN count (P < 0.05; Table 4).
Nodal involvement significantly affected the prognosis of GC patients because it is the major root of tumor relapse after surgery [14, 15]. Thus, standardized lymph node dissection is the basic requirement for curative (R0) gastrectomy. Curative gastrectomy with D2 lymphadenectomy has been considered as the standard fashion for decades in Eastern Asia, especially in Japan [16, 17]. This procedure has been gradually accepted by Western countries in recent years [18, 19]. As for the RLN count, the 8th edition TNM classification for GC recommended dissecting at least 16 lymph nodes. Moreover, emerging evidence revealed the positive correlations between RLN count and overall survival of GC patients [4, 5, 20]. By comparing RLN count to survival time, Okajima et al. suggested an optimal RLN count of ≥ 25 ; Deng et al. proposed an optimal RLN count of ≥ 16 for lymph node-negative GC and > 30 for lymph node-positive GC by stratum analysis of 7620 patients ; Sano et al. reported that RLN count preferably achieved 30 or more by a multicenter study enrolling 25,411 patients . Additionally, LNR and LODDS were also reported to be associated with GC prognosis [21,22,23]. These above studies mainly focused on the relationship between RLN count and long-term prognosis. However, little is known about its effects on postoperative short-term complications.
In this study, we concentrated on the association between RLN count and short-term prognosis. Univariate analyses showed no significant difference between RLN count and postoperative complications (both overall and stratified by CDC grade). Therefore, more lymph nodes were encouraged to be dissected from the perspective of short-term prognosis.
Although curative gastrectomy with D2 lymphadenectomy is considered a pivotal strategy for advanced GC, there are international and institutional differences in the number of RLN count [24, 25]. Various factors were reported to influence the RLN count, including the confidence and enthusiasm of doctors (both surgeons and pathologists), surgical situation, and innate lymph node count in each patient [7, 9]. In our study, we concluded that RLN count was related to the type of resection, tumor invasion, and lymph node metastasis. Of note, RLN count was positively correlated with the lymph node metastasis rate, which underlined the importance of RLN count for accurate staging.
Actually, for a thorough pathological examination, RLNs should be individually divided from a complete tissue sample after surgery. Owing to much time and effort was required during this procedure, it has not been widely implemented clinically. Therefore, the examined lymph node count by pathologists might be lower than the dissected lymph node count. Multiple attempts have been conducted to improve the detection rate of lymph nodes [26,27,28]. Li et al. elucidated that the mean number of RLNs could be significantly elevated by injecting carbon nanoparticles before surgery compared with controls (38.33 vs 28.27) . Markl and colleagues reported a twofold lymph node pick up rate utilizing methylene blue staining than unstained groups (35 vs 17) . Several dye materials were also used to increase the number of lymph nodes dissected during surgery, such as fluorescent indocyanine green (ICG) and 5-aminolevulinic acid (5-ALA) [29, 30].
We acknowledge that this study had some potential limitations. First, it was a retrospective, single-center study, so the results might be flawed because of residual confounding factors. Second, the RLN count was closely related to the quality of surgeons and pathologists. The perioperative variables might differ in different doctors. Therefore, multicenter studies are needed to confirm our results.
In conclusion, the current study demonstrated that RLNs\ count was not associated with postoperative short-term complications following gastrectomy of GC. Therefore, our analysis encouraged more lymph nodes to be dissected for accurate pathologic staging.
Availability of data and materials
Access to the data and the calculation method can be obtained from the authors by email (firstname.lastname@example.org).
Body mass index
American Society of Anesthesiologists
Retrieved lymph nodes
Lymph node ratio
Log odds of positive lymph nodes
Stewart B, Wild CP: World cancer report 2014. Public Health 2019.
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424.
Van Cutsem E, Sagaert X, Topal B, Haustermans K, Prenen H. Gastric cancer. Lancet. 2016;388(10060):2654–64.
Zhang W, Zhangyuan G, Wang J, Jin K, Liu Y, Wang F, et al. Effect of lymph nodes count in node-positive gastric cancer. J Cancer. 2019;10(23):5646–53.
Chu X, Yang ZF. Impact on survival of the number of lymph nodes resected in patients with lymph node-negative gastric cancer. World J Surg Oncol. 2015;13:192.
Jiang L, Yang KH, Guan QL, Zhao P, Chen Y, Tian JH. Survival and recurrence free benefits with different lymphadenectomy for resectable gastric cancer: a meta-analysis. J Surg Oncol. 2013;107(8):807–14.
Deng J, Yamashita H, Seto Y, Liang H. Increasing the number of examined lymph nodes is a prerequisite for improvement in the accurate evaluation of overall survival of node-negative gastric cancer patients. Ann Surg Oncol. 2017;24(3):745–53.
Amin MB, Greene FL, Edge SB, Compton CC, Gershenwald JE, Brookland RK, et al. The eighth edition AJCC cancer staging manual: continuing to build a bridge from a population-based to a more “personalized” approach to cancer staging. CA Cancer J Clin. 2017;67(2):93–9.
Okajima W, Komatsu S, Ichikawa D, Kosuga T, Kubota T, Okamoto K, et al. Prognostic impact of the number of retrieved lymph nodes in patients with gastric cancer. J Gastroenterol Hepatol. 2016;31(9):1566–71.
Deng J, Liu J, Wang W, Sun Z, Wang Z, Zhou Z, et al. Validation of clinical significance of examined lymph node count for accurate prognostic evaluation of gastric cancer for the eighth edition of the American joint committee on cancer (AJCC) TNM staging system. Chin J Cancer Res. 2018;30(5):477–91.
Kim TH, Suh YS, Huh YJ, Son YG, Park JH, Yang JY, et al. The comprehensive complication index (CCI) is a more sensitive complication index than the conventional Clavien-Dindo classification in radical gastric cancer surgery. Gastric Cancer. 2018;21(1):171–81.
Wang J, Hassett JM, Dayton MT, Kulaylat MN. The prognostic superiority of log odds of positive lymph nodes in stage III colon cancer. J Gastrointest Surg. 2008;12(10):1790–6.
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13.
Hirabayashi S, Kosugi S, Isobe Y, Nashimoto A, Oda I, Hayashi K, et al. Development and external validation of a nomogram for overall survival after curative resection in serosa-negative, locally advanced gastric cancer. Ann Oncol. 2014;25(6):1179–84.
Tóth D, Bíró A, Varga Z, Török M, Árkosy P. Comparison of different lymph node staging systems in prognosis of gastric cancer: a bi-institutional study from Hungary. Chin J Cancer Res. 2017;29(4):323.
De Steur WO, Dikken JL, Hartgrink HH. Lymph node dissection in resectable advanced gastric cancer. Dig Surg. 2013;30(2):96–103.
Maruyama K, Kaminishi M, Hayashi K-I, Isobe Y, Honda I, Katai H, et al. Gastric cancer treated in 1991 in Japan: data analysis of nationwide registry. Gastric Cancer. 2006;9(2):51–66.
Liang H, Deng J. Evaluation of rational extent lymphadenectomy for local advanced gastric cancer. Chin J Cancer Res. 2016;28(4):397.
Degiuli M, Sasako M, Ponti A, Vendrame A, Tomatis M, Mazza C, et al. Randomized clinical trial comparing survival after D1 or D2 gastrectomy for gastric cancer. Br J Surg. 2014;101(2):23–31.
Sano T, Coit DG, Kim HH, Roviello F, Kassab P, Wittekind C, et al. Proposal of a new stage grouping of gastric cancer for TNM classification: international gastric cancer association staging project. Gastric Cancer. 2017;20(2):217–25.
Zhao E, Zhou C, Chen S. Prognostic nomogram based on log odds of positive lymph nodes for gastric carcinoma patients after surgical resection. Future Oncol. 2019;15(36):4207–22.
Alatengbaolide, Lin D, Li Y, Xu H, Chen J, Wang B, Liu C, Lu P: Lymph node ratio is an independent prognostic factor in gastric cancer after curative resection (R0) regardless of the examined number of lymph nodes. Am J Clin Oncol 2013, 36(4):325-330.
Wang J, Dang P, Raut CP, Pandalai PK, Maduekwe UN, Rattner DW, et al. Comparison of a lymph node ratio-based staging system with the 7th AJCC system for gastric cancer analysis of 18,043 patients from the SEER database. Ann Surg. 2012;255(3):478–85.
Degiuli M, De Manzoni G, Di Leo A, ’Ugo DD, Galasso E, Marrelli D, et al. Gastric cancer: current status of lymph node dissection. World J Gastroenterol. 2016;22(10):2875–93.
Son T, Hyung WJ, Lee JH, Kim YM, Kim HI, An JY, et al. Clinical implication of an insufficient number of examined lymph nodes after curative resection for gastric cancer. Cancer. 2012;118(19):4687–93.
Li Z, Ao S, Bu Z, Wu A, Wu X, Shan F, et al. Clinical study of harvesting lymph nodes with carbon nanoparticles in advanced gastric cancer: a prospective randomized trial. World J Surg Oncol. 2016;14:88.
Markl B, Kerwel TG, Jahnig HG, Oruzio D, Arnholdt HM, Scholer C, et al. Methylene blue-assisted lymph node dissection in colon specimens: a prospective, randomized study. Am J Clin Pathol. 2008;130(6):913–9.
Aoyama T, Yoshikawa T, Morita S, Shirai J, Fujikawa H, Iwasaki K, et al. Methylene blue-assisted technique for harvesting lymph nodes after radical surgery for gastric cancer: a prospective randomized phase III study. BMC Cancer. 2014;14(1):155.
He M, Jiang Z, Wang C, Hao Z, An J, Shen J. Diagnostic value of near-infrared or fluorescent indocyanine green guided sentinel lymph node mapping in gastric cancer: a systematic review and meta-analysis. J Surg Oncol. 2018;118(8):1243–56.
Koizumi N, Harada Y, Murayama Y, Harada K, Beika M, Yamaoka Y, et al. Detection of metastatic lymph nodes using 5-aminolevulinic acid in patients with gastric cancer. Ann Surg Oncol. 2013;20(11):3541–8.
The authors gratefully acknowledge all the investigators for their contributions to the trial.
There is no funding supporting this work.
Ethics approval and consent to participate
This retrospective study was approved by the ethics committee of Nanjing Drum Tower Hospital, Medical School of Nanjing University. Due to the retrospective nature, the requirement for informed consent was waived by the IRBs from Nanjing Drum Tower Hospital, Medical School of Nanjing University.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Sun, F., Liu, S., Song, P. et al. Impact of retrieved lymph node count on short-term complications in patients with gastric cancer. World J Surg Onc 18, 224 (2020). https://doi.org/10.1186/s12957-020-02000-9
- Retrieved lymph nodes
- Postoperative complications
- Gastric cancer