J Gastric Cancer.  2019 Sep;19(3):329-343. 10.5230/jgc.2019.19.e33.

Proposal of a New TNM Classification for Gastric Cancer: Focusing on pN3b and Cytology-Positive (CY1) Disease

• Kim SH
• Lee HJ
• Park JH
• Choi JH
• Park SH
• Choe HN
• Oh SY
• Suh YS
• Kong SH
• Park DJ
• Yang HK

• KMID: 2458832
• DOI: http://doi.org/10.5230/jgc.2019.19.e33

Abstract

PURPOSE
Gastric cancer with lymph node metastasis (LNM) more than 15 (N3b) was defined as stage IV until the 6th AJCC system. However, it has been reclassified as a localized disease (stage IIb or III) since the 7th system. The aim of this study is to demonstrate that the survival of N3b is comparable to cytology-only positive (CY1-only) stage IV and to propose a new TNM system interpreting N3b as an eligibility criterion for receiving more intensive chemotherapy regimens.
MATERIALS AND METHODS
1,430 patients who underwent gastric cancer surgery at Seoul National University Hospital from 2007 to 2012 were retrospectively analyzed. The 5-year survival rate (5YSR) and 3-year recurrence-free survival (RFS) were evaluated according to the 7th and 8th systems, as well as a new categorization based on N-classification; N0-2 (LNM<7), N3a (LNM 7-15), or N3b (LNM>15).
RESULTS
The survival of N3b is comparable to that of CY1-only stage IV (log rank test, P=0.671) and is distinct from that of grossly stage IV (log rank test, P<0.001). The survival of the remaining stage IIIc (T4bN3a) was comparable to those of N3b and CY1-only stage IV. Most N3b patients had significantly shorter 3-year RFS and mean RFS than those with IIb-IIIc, as if N3b itself was a higher TNM stage.
CONCLUSIONS
In terms of survival, T4bN3a, N3b, and CY1-only stage IV were unified as stage IVa, while grossly stage IV was defined as stage IVb. N3b can be regarded as an eligibility criterion for undergoing more intensive chemotherapy regimens.

Keyword

Classification; Surgery

MeSH Terms

Classification*
Drug Therapy
Humans
Lymph Nodes
Neoplasm Metastasis
Retrospective Studies
Seoul
Stomach Neoplasms*
Survival Rate

Figure

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  Fig. 1 AJCC staging systems. Shown are the 6th (top), 7th (middle), and 8th (bottom) AJCC staging system. AJCC = American Joint Committee on Cancer; LN = lymph node.

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  Fig. 2 Patients extraction. TNM = tumor, node, metastasis. *The patient count number can be duplicated when extracted; †Ten of 32 patients had cytology-only positive (CY1-only) disease.

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  Fig. 3 OS curves. Shown are the OS curves of the (A) 7th and (B) 8th systems, as well as the new categorization based on (C) the N classification; N3b patients separated from (D) other stages and (E) T1–T4bN3b. OS = overall survival.

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  Fig. 4 RFS curves. Shown are the RFS curves reported in the (A) 7th and (B) 8th systems, as well as the new categorization based on (C) the N classification; N3b patients separated from (D) other stages and (E) T1–T4bN3b. RFS = recurrence-free survival.

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  Fig. 5 New staging system. Shown are the newly suggested stages, IVa and IVb. LN = lymph node.

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