The Influence of Metastatic Lymph Node Ratio on the Treatment Outcomes in the Adjuvant Chemoradiotherapy in Stomach Tumors (ARTIST) Trial: A Phase III Trial

Youjin Kim, Se Hoon Park, Kyoung-Mee Kim, Min Gew Choi, Jun Ho Lee, Tae Sung Sohn, Jae Moon Bae, Sung Kim, Su Jin Lee, Seung Tae Kim, Jeeyun Lee, Joon Oh Park, Young Suk Park, Ho Yeong Lim, Won Ki Kang, Youjin Kim, Se Hoon Park, Kyoung-Mee Kim, Min Gew Choi, Jun Ho Lee, Tae Sung Sohn, Jae Moon Bae, Sung Kim, Su Jin Lee, Seung Tae Kim, Jeeyun Lee, Joon Oh Park, Young Suk Park, Ho Yeong Lim, Won Ki Kang

Abstract

Purpose: In the Adjuvant Chemoradiotherapy in Stomach Tumors (ARTIST) trial, we investigated whether chemoradiotherapy after D2 gastrectomy reduces the rate of recurrence. Recently, the ratio of metastatic lymph nodes to examined lymph nodes (N ratio) has been proposed as an independent prognostic factor in gastric cancer (GC). The aim of this study was to investigate the relationship between the metastatic N ratio and prognosis of GC after curative D2 surgery.

Materials and methods: We retrospectively reviewed the data of 458 ARTIST patients who underwent D2 gastrectomy followed by adjuvant chemotherapy (XP, n=228) or chemoradiotherapy (XPRT, n=230). The disease-free survival (DFS) rates of patients were used to evaluate the influence of N ratio on the treatment outcome. To achieve this, 4 different N ratio categories (0%, 1%~9%, 10%~25%, and >25%) were compared on the basis of their influence on the treatment outcome.

Results: On multivariate analysis, the N ratio remained an independent prognostic factor for DFS. The hazard ratios (HRs) for the N ratio categories of 0%, 1%~9%, 10%~25%, and >25% were 1, 1.061, 1.202, and 3.571, respectively. In patients having N ratio >25%, the 5-year DFS rates were 55% and 28% for the XPRT and XP arms, respectively (HR, 0.527; 95% confidence interval, 0.307~0.904; P=0.020).

Conclusions: In patients with curatively resected GC, the N ratio was independently associated with DFS. Although this finding warrants further investigation in future prospective studies, the benefit of chemoradiotherapy for D2 resected GC appears to be more beneficial in cancers having N ratios >25%.

Keywords: Lymph node; Prognosis; Stomach neoplasms.

Conflict of interest statement

Conflicts of Interest: No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1. (A) Disease-free survival curves according…
Fig. 1. (A) Disease-free survival curves according to N ratio. (B) Overall survival curves according to N ratio. The cut-off values for the N ratios are as follows: solid (black) line, 0%; dashed line, 1~9%; dotted line, 10~25%; and solid (gray) line, >25%. N ratio = the ratio of metastatic lymph nodes to examined lymph nodes.
Fig. 2. (A) Disease-free survival curves for…
Fig. 2. (A) Disease-free survival curves for patients with N ratios of 0%~25%. (B) Overall survival curves for patients with N ratios of 0%~25%. Solid line, XPRT arm; dotted line, XP arm. XP = capecitabine plus cisplatin; XPRT = concurrent chemoradiotherapy with XP; N ratio = the ratio of metastatic lymph nodes to examined lymph nodes.
Fig. 3. (A) Disease-free survival curves for…
Fig. 3. (A) Disease-free survival curves for patients with N ratios >25% (B) Overall survival curves for patients with N ratios >25%. Solid line, XPRT arm; dotted line, XP arm. XP = capecitabine plus cisplatin; XPRT = concurrent chemoradiotherapy with XP; N ratio = the ratio of metastatic lymph nodes to examined lymph nodes.

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