Equipping the 8th Edition American Joint Committee on Cancer Staging for Gastric Cancer with the 15-Node Minimum: a Population-Based Study Using Recursive Partitioning Analysis

The recently proposed 8th American Joint Committee on Cancer (AJCC) staging for gastric cancer (GC) did not include the evaluated lymph node (ELN) count as a prognostic indicator. In this study, we performed recursive partitioning analysis (RPA) to objectively combine the 15-ELN threshold and 8th AJCC stage to refine the staging for GC. We analyzed 19,018 patients with non-metastatic GC from the Surveillance, Epidemiology, and End Results database. The dataset was randomly divided into training and validation sets. For each 8th AJCC stage, survival was significantly better for patients with ≥15 ELNs versus those with <15 ELNs ( P  < 0.001 for all). RPA divided non-metastatic GC into seven stages: RPA-IA (8th AJCC IA with ≥15 ELNs), RPA-IB (IA with <15 ELNs and IB/IIA with ≥15 ELNs), RPA-IIA (IB with <15 ELNs and IIB with ≥15 ELNs), RPA-IIB (IIA with <15 ELNs and IIIA with ≥15 ELNs), RPA-IIIA (IIB with <15 ELNs), RPA-IIIB (IIIA with <15 ELNs and IIIB ≥15 ELNs), and RPA-IIIC (IIIB with <15 ELNs and IIIC). The corresponding 5-year survival rates were 84.1, 70.3, 52.8, 41.4, 32.9, 21.7, and 10.2%, respectively ( P  < 0.001 for all pairwise comparisons). The RPA staging outperformed the 8th AJCC staging in terms of discrimination and homogeneity among the SEER training and validation sets, as well as an independent Chinese cohort. By equipping the 8th AJCC stage with the 15-ELN threshold, the proposed RPA staging is superior to the 8th AJCC staging without overcomplicating.