{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T02:28:48Z","timestamp":1786328928338,"version":"build-2736575974"},"reference-count":26,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,8,8]],"date-time":"2026-08-08T00:00:00Z","timestamp":1786147200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: The relative prognostic information provided by different nodal metrics and the independent role of primary tumor size remain unclear in gastric cancer. This study evaluated the association of metastatic lymph node count and primary tumor size with disease-free survival (DFS) in stage II\u2013III gastric cancer (GC) treated with a surgery-first approach. Materials and Methods: This retrospective single-center study included 128 patients who underwent curative-intent gastrectomy between 2003 and 2019 without neoadjuvant treatment. A multivariable Cox model with clinically prespecified covariates was fitted. Metastatic lymph node count, pathological N (pN) category, lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) were each added separately to the same base clinical model and compared using the Akaike information criterion (AIC). Results: During a median follow-up of 114.3 months, 86 DFS events occurred. Each additional metastatic lymph node was independently associated with a higher hazard of a DFS event (HR, 1.049; 95% CI, 1.022\u20131.076; p &lt; 0.001), and this association persisted across four sensitivity analyses. Primary tumor size was not independently associated with DFS. All four nodal metrics improved model fit, with LNR yielding the lowest AIC. Conclusions: Metastatic lymph node count was independently and robustly associated with DFS, whereas primary tumor size was not. Although LNR provided the best relative model fit, these within-cohort comparisons do not establish clinical superiority, and external validation is required.<\/jats:p>","DOI":"10.3390\/medicina62081528","type":"journal-article","created":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T01:20:03Z","timestamp":1786324803000},"page":"1528","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Association of Metastatic Lymph Node Count and Primary Tumor Size with Disease-Free Survival in Stage II\u2013III Gastric Cancer: A Retrospective Cohort Study"],"prefix":"10.3390","volume":"62","author":[{"given":"Emine","family":"Kanats\u0131z","sequence":"first","affiliation":[{"name":"Department of Gastroenterology and Hepatology, \u00dcmraniye Training and Research Hospital, \u0130stanbul 34764, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4122-8389","authenticated-orcid":false,"given":"Yasin","family":"Sezgin","sequence":"additional","affiliation":[{"name":"Department of Medical Oncology, Medical Faculty, Van Y\u00fcz\u00fcnc\u00fc Y\u0131l University, Van 65080, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6686-0300","authenticated-orcid":false,"given":"Yonca","family":"Y\u0131lmaz \u00dcr\u00fcn","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology and Hepatology, Medical Faculty, Van Y\u00fcz\u00fcnc\u00fc Y\u0131l University, Van 65080, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,8]]},"reference":[{"key":"ref_1","first-page":"e70090","article-title":"Global Cancer Statistics 2024: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 34 Cancers in 186 Countries","volume":"76","author":"Sung","year":"2026","journal-title":"CA Cancer J. Clin."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1948","DOI":"10.1016\/S0140-6736(18)32557-1","article-title":"FLOT4-AIO Investigators. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): A randomised, phase 2\/3 trial","volume":"393","author":"Homann","year":"2019","journal-title":"Lancet"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1005","DOI":"10.1016\/j.annonc.2022.07.004","article-title":"Gastric cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up","volume":"33","author":"Lordick","year":"2022","journal-title":"Ann. Oncol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"10732748221099227","DOI":"10.1177\/10732748221099227","article-title":"Recent Estimates and Predictions of 5-Year Survival in Patients with Gastric Cancer: A Model-Based Period Analysis","volume":"29","author":"Li","year":"2022","journal-title":"Cancer Control"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"635","DOI":"10.1016\/S0140-6736(20)31288-5","article-title":"Gastric cancer","volume":"396","author":"Smyth","year":"2020","journal-title":"Lancet"},{"key":"ref_6","first-page":"5107","article-title":"Clinical value and application of a novel nomogram containing inflammatory, nutritional and clinical markers in predicting overall survival of stage II\/III gastric cancer patients after radical resection: A bi-centered retrospective study of 2,443 patients","volume":"14","author":"Liang","year":"2022","journal-title":"Am. J. Transl. Res."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"391","DOI":"10.1007\/s10120-017-0770-1","article-title":"Validation of the American Joint Committee on Cancer (AJCC) 8th edition stage system for gastric cancer patients: A population-based analysis","volume":"21","author":"He","year":"2018","journal-title":"Gastric Cancer"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Grigorie, T.R., Verdea, C., Chiriac, T.D., Gramaticu, I.M., Iliesiu, A., Popescu, G.A., Popescu, M., and Alexandrescu, S.T. (2026). Improving Prognostic Stratification in Gastric Cancer: The Role of Lymph Node Staging Systems. Medicina, 62.","DOI":"10.3390\/medicina62010085"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Tsai, Y.-C., Lin, H.-C., Hsu, C.-Y., Wu, F.-H., Luo, S.-C., and Shih, Y.-H. (2025). Lymph Node Ratio as a Risk Factor for Early Recurrence in Older Patients with Stage II\/III Gastric Cancer: A Retrospective Study. J. Clin. Med., 14.","DOI":"10.3390\/jcm14186609"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"4235","DOI":"10.1245\/s10434-020-08616-1","article-title":"Association Between Lymph Node Ratio and Survival in Patients with Pathological Stage II\/III Gastric Cancer","volume":"27","author":"Kano","year":"2020","journal-title":"Ann. Surg. Oncol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2571","DOI":"10.1002\/cncr.24989","article-title":"Log odds of positive lymph nodes: A novel prognostic indicator superior to the number-based and the ratio-based N category for gastric cancer patients with R0 resection","volume":"116","author":"Sun","year":"2010","journal-title":"Cancer"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1016\/j.amsu.2020.04.002","article-title":"Recurrence outcome of lymph node ratio in gastric cancer after underwent curative resection: A retrospective cohort study","volume":"54","author":"Supsamutchai","year":"2020","journal-title":"Ann. Med. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e38809","DOI":"10.1016\/j.heliyon.2024.e38809","article-title":"Positive Lymph Node Ratio as a new prognostic score in Geriatric patients with operated gastric cancer","volume":"10","author":"Acar","year":"2024","journal-title":"Heliyon"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Miciak, M., Jurkiewicz, K., Dzierzek, P., Rudno-Rudzinska, J., and Kielan, W. (2025). Prognostic Significance of Lymph Node Ratio (LNR) in Gastric Cancer in Predicting Postoperative Complications and Survival: A Single-Center Study. Cancers, 17.","DOI":"10.3390\/cancers17050743"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"You, W., Cai, Z., Sheng, N., Yan, L., Wan, H., Wang, Y., Ouyang, J., Xie, L., Wu, X., and Wang, Z. (2022). Construction and Validation of Convenient Clinicopathologic Signatures for Predicting the Prognosis of Stage I-III Gastric Cancer. Front. Oncol., 12.","DOI":"10.3389\/fonc.2022.848783"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"194","DOI":"10.1007\/s00268-019-05198-2","article-title":"Tumor size\u226550 mm as an Independent Prognostic Factor for Patients with Stage II or III Gastric Cancer After Postoperative S-1 Monotherapy: Analysis of a Multi-institution Dataset","volume":"44","author":"Tsutsuyama","year":"2020","journal-title":"World J. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Xu, M., Huang, C.M., Zheng, C.H., Li, P., Xie, J.W., Wang, J.B., Lin, J.X., and Lu, J. (2014). Does tumor size improve the accuracy of prognostic predictions in node-negative gastric cancer (pT1-4aN0M0 stage)?. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0101061"},{"key":"ref_18","first-page":"478","article-title":"The prognostic role of tumor size in patients with gastric cancer","volume":"88","author":"Viani","year":"2017","journal-title":"Ann. Ital. Chir."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Zu, H., Wang, F., Ma, Y., and Xue, Y. (2013). Stage-Stratified Analysis of Prognostic Significance of Tumor Size in Patients with Gastric Cancer. PLoS ONE, 8.","DOI":"10.1371\/journal.pone.0054502"},{"key":"ref_20","first-page":"1299","article-title":"Comparison of the 8th Union for International Cancer Control lymph node staging system for gastric cancer with two other lymph node staging systems","volume":"17","author":"Cao","year":"2019","journal-title":"Oncol. Lett."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"513","DOI":"10.1080\/0284186X.2021.1874619","article-title":"Prognosis after surgery for gastric adenocarcinoma in the Swedish Gastric Cancer Surgery Study (SWEGASS)","volume":"60","author":"Asplund","year":"2021","journal-title":"Acta Oncol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"3361","DOI":"10.1245\/s10434-017-5992-2","article-title":"Survival rates for patients with resected gastric adenocarcinoma finally have increased in the United States","volume":"24","author":"Arsoniadis","year":"2017","journal-title":"Ann. Surg. Oncol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"424","DOI":"10.1002\/bjs5.50270","article-title":"Nationwide study of the impact of D2 lymphadenectomy on survival after gastric cancer surgery","volume":"4","author":"Kung","year":"2020","journal-title":"BJS Open"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1613","DOI":"10.3748\/wjg.v26.i14.1613","article-title":"Lifestyle factors and long-term survival of gastric cancer patients: A large bidirectional cohort study from China","volume":"26","author":"Zhao","year":"2020","journal-title":"World J. Gastroenterol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"2404","DOI":"10.1158\/1055-9965.EPI-13-0805-T","article-title":"Impact of postdiagnosis smoking on long-term survival of cancer patients: The Shanghai cohort study","volume":"22","author":"Tao","year":"2013","journal-title":"Cancer Epidemiol. Biomark. Prev."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1073","DOI":"10.28982\/josam.816374","article-title":"Prognostic factors for survival among gastric cancer patients receiving neoadjuvant chemotherapy: A cross sectional study from Turkey","volume":"4","author":"Uzun","year":"2020","journal-title":"J. Surg. Med."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/8\/1528\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T01:48:35Z","timestamp":1786326515000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/8\/1528"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,8]]},"references-count":26,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["medicina62081528"],"URL":"https:\/\/doi.org\/10.3390\/medicina62081528","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,8]]}}}