Minimum number of removed and examined lymph nodes is essential in gastric cancer patients: reply to letter.

The lymph node ratio has been extensively studied in gastric cancer, and several articles reported it as a more accurate prognostic factor with respect to the current UICC and JGCA classifications. However, most of these studies were performed at institutions with fair or good experience with gastric cancer surgery and pathologic assessment. In a recent report from the Italian Research Group for Gastric Cancer, we confirmed these results in a large cohort of gastric cancer patients operated on in six specialized Italian centers, where the quality of lymph node dissection, nodal retrieval, and pathologic assessment had been standardized for years. The current TNM staging system (6th edition) had poor prognostic value when only a few lymph nodes are removed. Indeed, this classification requires that the pathologic assessment of the regional lymph nodes should entail removal of a sufficient number of nodes for correct classification in the pN category. This suggestion has not been changed in the recent 7th edition of the AJCC/UICC staging system, which divides the pN stage into four groups: 1–2, 3–6, 7–15, and[15 metastatic lymph nodes. We emphasize that an adequate number is important not only for the classification of node-positive cases but also to ensure that a pN0 assignment is truly a node-negative patient. In our opinion the number of removed and examined lymph nodes is essential in gastric cancer patients, and the possibility of using a system to overcome poor surgical or pathologic quality should not look away from the need to perform an adequate lymphadenectomy and lymph node retrieval to cure the patient or, at least, stage the tumor.