Original article

Prognostic factors for survival in patients with pT1 N+ or

T2–3 N0 gastric cancer in Japan
M. Tokunaga1 , S. Ito2 , T. Yoshikawa3 , S. Nunobe4 , T. Fukagawa5 , K. Misawa2 , H. Cho3 , H. Katai5 ,
T. Sano4 and M. Terashima1
1 Divisionof Gastric Surgery, Shizuoka Cancer Centre, Shizuoka, 2 Department of Gastroenterological Surgery, Aichi Cancer Centre Hospital, Aichi,
3 Department of Gastrointestinal Surgery, Kanagawa Cancer Centre, Kanagawa, and 4 Department of Gastroenterological Surgery, Cancer Institute
Ariake Hospital, and 5 Department of Gastric Surgery, National Cancer Centre Hospital, Tokyo, Japan
Correspondence to: Dr M. Terashima, Division of Gastric Surgery, Shizuoka Cancer Centre, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka
411-8777, Japan (e-mail: m.terashima@scchr.jp)

Background: The outcome for pT1 N+ or pT2–3 N0 gastric cancer is favourable, but some patients
suffer from recurrent disease. The aim of this study was to identify prognostic factors in patients with
pT1 N+ or pT2–3 N0 gastric cancer.
Methods: This was a multicentre, retrospective cohort study. All patients with pT1 N+ or pT2–3 N0
gastric cancer who underwent curative gastrectomy at five high-volume, specialized cancer centres in
Japan between 2000 and 2008 were included. Demographic, clinical, surgical and pathological data were
collected. Independent prognostic factors were identified using a Cox proportional hazards regression
model.
Results: Some 1442 patients were included. The 5-year overall survival rate for patients with pT1 N+
or pT2–3 N0 gastric cancer was 92⋅0 per cent. Multivariable analysis for overall survival identified age
(hazard ratio (HR) 2⋅67, 95 per cent c.i. 2⋅09 to 3⋅43), sex (HR 0⋅57, 0⋅39 to 0⋅83) and clinical tumour
depth (cT) (HR 1⋅45, 1⋅06 to 1⋅98) as independent prognostic factors.
Conclusion: Survival of patients with pT1 N+ or pT2–3 N0 gastric cancer is good. Age 65 years or above,
male sex and cT2-4 category are associated with worse overall survival.

Paper accepted 13 January 2017

Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.10509

Introduction Gastric Infusional Chemotherapy) trial, 8⋅8 per cent were

Gastric cancer is common in East Asia and is the third lead-
ing cause of cancer-related death worldwide1 . In Eastern
countries, gastrectomy followed by adjuvant chemotherapy
is standard treatment for patients with advanced gastric
cancer, compared with gastrectomy with perioperative
chemotherapy or postoperative chemoradiotherapy in
Western countries2 – 5 . In Eastern countries, neoadjuvant
chemotherapy is given to selected patients with extensive
lymph node metastasis, with improvement in survival6,7 .
Hence, neoadjuvant chemotherapy for advanced gastric
cancer may become a worldwide standard treatment
for advanced gastric cancers that have poor prognostic
factors.
However, accurate staging and classification of gastric
cancer including advanced disease remains challenging.
Of gastric cancers included in the surgery-alone arm
of the MAGIC (Medical Research Council Adjuvant
pathological stage I, whereas the aim of the study was
to include advanced gastric cancers only4 . Therefore, it
remains to be determined which patients are appropriate
candidates for neoadjuvant chemotherapy. Most patients
with pathological stage II–III gastric cancer are candi-
dates for neoadjuvant chemotherapy, whereas those with
stage IA cancers probably do not benefit. It is unknown
whether surgery alone is suitable for patients with stage
IB (pT1 N1 or pT2 N0) and for some patients with stage
II (pT1 N2–3 or pT3 N0) disease. For patients in these
subgroups (pT1 N+ or pT2–3 N0), for whom current
Japanese gastric cancer treatment guidelines do not rec-
ommend any adjuvant treatment8,9 , administration of
neoadjuvant chemotherapy may be justified if they have a
high risk of recurrence and death.
The aim of this study was to identify independent prog-
nostic factors before the surgical treatment of patients

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 M. Tokunaga, S. Ito, T. Yoshikawa, S. Nunobe, T. Fukagawa, K. Misawa et al.

Patients with pT1 N+ or pT2–3 N0 gastric cancer

n = 1961

Patients with positive suprapancreatic nodes excluded n = 331

n = 1630

Excluded n = 188
Gastric stump cancer n = 49
Another active cancer n = 100
Received preoperative or postoperative chemotherapy n = 48

n = 1442

Fig. 1 Flow diagram for the study. Some patients were excluded for more than one reason

with pT1 N+ or pT2–3 N0 gastric cancer. If poor prog-
nostic factors could be identified, patients with these
factors might be potential candidates for neoadjuvant
chemotherapy.
Methods
The present study was designed as a multicentre, ret-
rospective cohort study. The institutional review board
of each participating institute approved the study pro-
tocol. Inclusion criteria were patients who underwent
curative gastrectomy from January 2000 to December
2008, and pathological examination of the resected spec-
imen showed pT1 N+ or pT2–3 N0 gastric cancer. The
participating hospitals were Aichi Cancer Centre, Can-
cer Institute Ariake Hospital, Kanagawa Cancer Centre,
National Cancer Centre and Shizuoka Cancer Centre.
Each institute performed more than 200 gastrectomies
per year.
Patients with positive suprapancreatic lymph nodes were
excluded. Patients who received neoadjuvant or adjuvant
chemotherapy, those with a history of gastrectomy, and
patients with another primary cancer under treatment were
also excluded.
Preoperative staging
Endoscopy and CT with contrast media were manda-
tory. Endoscopic ultrasonography and upper gastrointesti-
nal series were optional and varied among the participating
centres. Tumour infiltration depth was evaluated on the
basis of endoscopic and CT findings; any discrepancy
between the modalities was resolved at a multidisciplinary
team meeting. Nodal status was assessed on the basis
of CT findings. Each participating institute had mul-
tidisciplinary team meetings at which the clinical stage
of all patients was decided on using the aforementioned
criteria.
Clinical and pathological data regarding tumour depth
and nodal status were generally assigned according to
the seventh TNM classification. Histological type and
macroscopic type were classified according to the second
English edition of the Japanese Gastric Cancer Association
(JGCA) system9 . Tubular and papillary adenocarcinomas
were classified as differentiated-type adenocarcinomas,
and poorly differentiated adenocarcinomas, signet
ring cell carcinomas and mucinous adenocarcinomas
as undifferentiated-type adenocarcinomas.
Data collection
The following data were collected from the hospital
databases, or the individual patient medical record when
necessary: demographic and clinical data including sex,
age, clinical depth of tumour infiltration (cT), clinical
nodal status (cN), clinical stage, tumour location, tumour
diameter, macroscopic type and histological type. Surgical
details included type of surgical procedure, concomitant
resection of other organs, duration of operation and intra-
operative blood loss. Survival status, survival time, cause of
death, site of first recurrence and date of recurrence were
also recorded.
Surgical procedures
The surgical procedure and lymph node dissection were
determined according to the second English edition of
the JGCA classification system9 and Japanese gastric can-
cer treatment guideline8 . When the clinical stage was
IB or more advanced, total or distal gastrectomy with
D2 lymphadenectomy was performed. Patients with stage
IA gastric cancer underwent gastrectomy with D1 + β

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Prognostic factors in pT1 N+ or T2−3 N0 gastric cancer

Table 1 Patient characteristics and clinical tumour stage Table 2 Surgical procedures and pathology

No. of patients No. of patients

(n = 1442) (n = 1442)

Age (years)* 63 (26–92) Surgical procedure

Sex ratio (M : F) 973 : 469 Total gastrectomy 343
cT category Proximal gastrectomy 76
Mucosa 166 Pylorus-preserving gastrectomy 140
Submucosa 535 Distal gastrectomy 883
Lymphadenectomy
Muscularis propria 382
< D2 585
Subserosa 153
≥ D2 857
Serosa 203
Duration of operation (min)* 204 (80–545)
Adjacent structures 3
Intraoperative blood loss (mg)* 190 (0–1966)
cN category
Duration of postoperative hospital stay (days)* 12 (7–113)
cN0 1131
Tumour depth
cN+ 311 Mucosa 69
Stage of disease† Submucosa 415
IA 640 Muscularis propria 587
IB or higher 802 Subserosa 371
Location of primary tumour Pathological lymph node status
Upper third 325 pN0 958
Middle third 735 pN1 372
Lower third 381 pN2 98
Whole stomach 1 pN3 14
Diameter (mm)* 40 (6–220) Tumour stage†
Macroscopic type IA 0
0 929 IB 959
1 59 IIA 469
2 251 IIB 14
3 155 *Values are median (range). †Stage IB comprised T1 N1 (372 patients)
4 3 and T2 N0 (587); stage IIA comprised T1 N2 (98) and T3 N0 (371); stage
5 45 IIB comprised T1 N3 (14).
Histology
Differentiated type 682
examination and blood tests at every visit. Abdominal
Undifferentiated type 760
CT or ultrasonography was performed every 6 months in
*Values are median (range). †Stage IA comprised T1 N0 M0 tumours; the first 3 years and every year thereafter in patients with
stage IB or higher comprised T1 N1–3 M0 and T2–4 N0–3 M0 tumours.
advanced gastric cancer. Patients with early gastric cancer
Histological and macroscopic types were classified according to the
second English edition of the Japanese Gastric Cancer Association underwent CT every year.
system9 .
Statistical analysis
lymphadenectomy, which included lymph node dissection All continuous variables are presented as median (range).
of the perigastric and part of the suprapancreatic area. Five-year survival rates were calculated using the
Proximal gastrectomy and pylorus-preserving gastrectomy Kaplan–Meier method and the log rank test was used
were indicated in patients with upper- and middle-third to compare the groups. Independent prognostic factors
stage IA cancer respectively. were identified using a Cox proportional hazards regres-
sion model. Clinical variables that were available before
surgery were selected as co-variables. Continuous values
Follow-up
were converted to binary values, and the median value
Follow-up was according to the hospital policy. In general, was generally selected as the cut-off. For age, 65 years was
patients with early gastric cancer were seen at the out- selected as the cut-off value as the nearest round number
patient clinic every 6 months for the first 3 years, and to the median value. Factors with P < 0⋅100 (2-sided) in
then every year thereafter up to 5 years. For advanced the univariable analysis were included as co-variables in
gastric cancer, patients were seen every 3 months dur- the subsequent multivariable analysis. P < 0⋅050 (2-sided)
ing the first 3 years and every 6 months thereafter up to was considered significant. All statistical analyses were
5 years after gastrectomy. Patients underwent physical conducted using R Statistics version 3.2.110 .

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 M. Tokunaga, S. Ito, T. Yoshikawa, S. Nunobe, T. Fukagawa, K. Misawa et al.

Table 3 Univariable and multivariable Cox proportional hazards regression analyses to identify predictors of overall and relapse-free
survival
Univariable Multivariable
Hazard ratio P Hazard ratio P

Overall survival
Age (< 65 versus ≥ 65 years) 2⋅87 (2⋅24, 3⋅63) < 0⋅001 2⋅67 (2⋅09, 3⋅43) < 0⋅001
Sex (M versus F) 0⋅49 (0⋅34, 0⋅71) < 0⋅001 0⋅57 (0⋅39, 0⋅83) < 0⋅001
Histology (differentiated versus undifferentiated) 0⋅52 (0⋅39, 0⋅71) < 0⋅001 0⋅77 (0⋅56, 1⋅05) 0⋅097
cT (cT1 versus cT2–4) 1⋅79 (1⋅32, 2⋅44) < 0⋅001 1⋅45 (1⋅06, 1⋅98) 0⋅019
cN (cN0 versus cN+) 1⋅26 (0⋅90, 1⋅76) 0⋅175 –
Location (upper third/whole versus middle/lower third) 0⋅66 (0⋅48, 0⋅91) 0⋅010 0⋅78 (0⋅59, 1⋅08) 0⋅139
Diameter (< 40 versus ≥ 40 mm) 1⋅13 (0⋅92, 1⋅39) 0⋅253 –
Relapse-free survival
Age (< 65 versus ≥ 65 years) 2⋅60 (2⋅06, 3⋅27) < 0⋅001 2⋅38 (1⋅89, 3⋅01) < 0⋅001
Sex (M versus F) 0⋅49 (0⋅34, 0⋅70) < 0⋅001 0⋅58 (0⋅40, 0⋅84) 0⋅004
Histology (differentiated versus undifferentiated) 0⋅50 (0⋅37, 0⋅67) < 0⋅001 0⋅73 (0⋅53, 0⋅98) 0⋅039
cT (cT1 versus cT2–4) 1⋅93 (1⋅43, 2⋅62) < 0⋅001 1⋅54 (1⋅12, 2⋅13) 0⋅008
cN (cN0 versus cN+) 1⋅35 (0⋅98, 1⋅86) 0⋅067 1⋅06 (0⋅76, 1⋅48) 0⋅746
Location (upper third/whole versus middle/lower third) 0⋅57 (0⋅42, 0⋅77) < 0⋅001 0⋅69 (0⋅50, 0⋅93) 0⋅015
Diameter (< 40 versus ≥ 40 mm) 1⋅11 (0⋅91, 1⋅36) 0⋅307 –

Values in parentheses are 95 per cent confidence intervals.

1·0 1·0

0·8 0·8
Relapse-free survival
Overall survival

0·6 0·6

cT1
0·4 cT2–4 0·4

0·2 0·2

0 1 2 3 4 5 0 1 2 3 4 5
Time after surgery (years) Time after surgery (years)
No. at risk No. at risk
cT1 701 693 677 670 654 633 cT1 701 691 671 664 647 629
cT2–4 741 724 704 686 667 630 cT2–4 741 715 692 676 651 617

a Overall survival b Relapse-free survival

Fig. 2 a Overall and b relapse-free survival after surgery according to cT category. a,b P < 0⋅001 (log rank test)

Results recurrence were lymph nodes (22 patients), followed by

Some 1442 patients with pT1 N+ or T2–3 N0 gastric
cancer were included (Fig. 1). Patient characteristics and
clinical tumour stage are shown in Table 1, and surgical
procedures and pathological data in Table 2. The most
frequently performed operation was distal gastrectomy,
followed by total gastrectomy and pylorus-preserving
gastrectomy.
In all, 65 patients experienced recurrence during the
study interval. The most frequently observed sites of
liver (20), peritoneum (12) and bone (10). Of these 65
patients, 14 had multiple recurrence sites at the time of
detection of recurrent disease.
Survival
Some 1342 of 1442 patients (93⋅1 per cent) were fol-
lowed for 5 years after surgery or until death. The
median observation time of survivors was 75⋅6 months.
The 5-year overall survival (OS) and relapse-free

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Prognostic factors in pT1 N+ or T2−3 N0 gastric cancer
survival (RFS) rates were 92⋅0 and 90⋅6 per cent
respectively.
Table 3 shows the results of univariable and multivari-
able analyses for OS and RFS. Age, sex and cT category
were identified as independent prognostic factors for OS,
whereas histology and tumour location, as well as age, sex
and cT, were found to be independent prognostic factors
for RFS.
Fig. 2 shows OS and RFS curves stratified by cT category.
The 5-year OS rate for patients with cT2–4 tumours was
89⋅6 per cent, which was worse than that for patients with
cT1 tumours (94⋅6 per cent) (P < 0⋅001). The 5-year RFS
rate for patients with cT2–4 and cT1 disease was 87⋅6 and
93⋅6 per cent respectively (P < 0⋅001).
Discussion
In this multicentre study, the 5-year OS rate follow-
ing gastrectomy in patients with pT1 N+ or pT2–3 N0
gastric cancer was 92⋅0 per cent. This is slightly better
than the survival rate reported by the JGCA registration
programme11,12 . Age, sex and cT category were identified
as independent prognostic factors for OS in patients with
pT1 N+ or pT2–3 N0 gastric cancer. Tumour histology
and location, as well as age, sex and cT category, were
shown to be independent prognostic factors for RFS.
At present, the standard treatment for pT1 N+ or
pT2–3 N0 gastric cancer in Japan is gastrectomy with-
out adjuvant chemotherapy8 . However, survival is not
uniform for all patients, and some develop recurrent
disease. Previously, vascular invasion, number of metas-
tasized lymph nodes, histology and tumour location were
reported to be associated with poor survival in patients
with pT1 N+ or pT2–3 N0 gastric cancer13 – 17 . It has
also been reported that the survival outcome is different
between pT2 (invading mucularis propria) and pT3 (sub-
serosal) tumours18 – 20 . However, previous reports13,14,16 – 20
described single-centre studies recruiting a limited num-
ber of patients. In addition, co-variables in the analysis
included surgical and pathological characteristics, which
cannot be used to identify appropriate candidates for
neoadjuvant chemotherapy. Therefore, in the present
study, only variables that are available before surgery
were entered as co-variables in the multivariable analysis.
cT category was identified as one of the independent
prognostic factors for OS and RFS. The association
between depth of tumour infiltration and outcome has
been reported previously for pT2–3 tumours21 . An expla-
nation for the poor survival of patients with cT2 and more
advanced tumours in this study may be the larger preoper-
ative tumour volume compared with that of cT1 tumours
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(median 40 versus 35 mm respectively). Another explana-
tion is that cT2–T3 tumours have a different biological
behaviour that is associated with worse survival. Age and
sex were also independent prognostic factors. This may
reflect the natural history of a healthy population, because
the 5-year survival rate of patients included in this study
was favourable, at 92⋅0 per cent. Life expectancy for men
is shorter than that for women in Japan22 .
Controversy exists about perioperative chemo(radio)-
therapy of advanced gastric cancer. The quality of surgery
may be very important. Survival following surgery alone
differs among studies, but is generally better in Eastern
than in Western studies2 – 5 . Surgical quality control is
important, and must be monitored in future clinical trials.
Perioperative treatments can provide only a marginal ben-
efit. Therefore, other outcomes measures such as quality of
life must also be considered.
In Japan, the standard treatment for (advanced) gastric
cancer is gastrectomy and adjuvant chemotherapy. Neoad-
juvant chemotherapy is considered a promising treatment
option6,7 . The contamination of stage I (early) gastric can-
cer has been a major concern among surgeons. Taken that
the 5-year OS rate in patients with cT2–4 and pT1 N+ or
T2–3 N0 tumours was 89⋅6 per cent in this study, giving
neoadjuvant chemotherapy to all patients with cT2–4 gas-
tric cancer seems to be overtreatment. Including patients
with cT2–4 disease and enlarged lymph nodes are rea-
sonable selection criteria for neoadjuvant chemotherapy,
although cN was not an independent prognostic factor for
OS and disease-free survival here. This may be explained
by the limited accuracy of preoperative nodal staging23 .
Recently, the Japanese Clinical Oncology Group (JCOG)
initiated a prospective clinical trial aimed at identifying
the cut-off value for lymph node diameter, as measured
by preoperative CT, which offers the highest diagnostic
accuracy for node positivity. Chemotherapy may be justi-
fied for cT2–4 N+ gastric cancer; however, further studies
are needed to define more accurate selection criteria for
neoadjuvant chemotherapy.
It is still unclear whether recurrence in general, or of
particular types, is prevented by perioperative chemo-
therapy. Previous studies2 – 5 indicated that perioperative
chemotherapy is able to reduce any type of recurrence.
The site of recurrence in the present study was somewhat
different from that reported before2 – 5 . For example, the
incidence of peritoneal recurrence in the present study
was slightly lower than that of liver and lymph node
metastases. A possible reason for this could be the lower
incidence of serosa-positive gastric cancer in the present
study population.
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 M. Tokunaga, S. Ito, T. Yoshikawa, S. Nunobe, T. Fukagawa, K. Misawa et al.
The present study included five high-volume centres
from Japan. Surgeons from each institute met every
4 months at JCOG meetings, where members discussed
diagnostic and treatment strategies for gastric cancer and
showed surgical videos. Therefore, it is felt that interinsti-
tutional differences in diagnostic and surgical quality are
likely to be minimal. Although the retrospective design of
the present study is a potential drawback, each institute
had its own high-quality database.
Acknowledgements
This research was supported partially by the National
Cancer Centre Research and Development Fund (26-A-4)
and Practical Research for Innovative Cancer Control
(15ck0106043h0002) from the Japan Agency for Medical
Research and Development (AMED).
Disclosure: The authors declare no conflict of interest.
References
1 International Research Agency on Cancer. The GLOBOCAN
Project. http://globocan.iarc.fr/Pages/fact_sheets_cancer
.aspx [accessed 1 April 2016].
2 Sakuramoto S, Sasako M, Yamaguchi T, Kinoshita T, Fujii
M, Nashimoto A et al. Adjuvant chemotherapy for gastric
cancer with S-1, an oral fluoropyrimidine. N Engl J Med
2007; 357: 1810–1820.
3 Bang YJ, Kim YW, Yang HK, Chung HC, Park YK, Lee KH
et al. Adjuvant capecitabine and oxaliplatin for gastric cancer
after D2 gastrectomy (CLASSIC): a phase 3 open-label,
randomised controlled trial. Lancet 2012; 379: 315–321.
4 Cunningham D, Allum WH, Stenning SP, Thompson JN,
Van de Velde CJ, Nicolson M et al. Perioperative
chemotherapy versus surgery alone for resectable
gastroesophageal cancer. N Engl J Med 2006; 355: 11–20.
5 Macdonald JS, Smalley SR, Benedetti J, Hundahl SA, Estes
NC, Stemmermann GN et al. Chemoradiotherapy after
surgery compared with surgery alone for adenocarcinoma of
the stomach or gastroesophageal junction. N Engl J Med
2001; 345: 725–730.
6 Yoshikawa T, Sasako M, Yamamoto S, Sano T, Imamura H,
Fujitani K et al. Phase II study of neoadjuvant chemotherapy
and extended surgery for locally advanced gastric cancer. Br
J Surg 2009; 96: 1015–1022.
7 Tsuburaya A, Mizusawa J, Tanaka Y, Fukushima N,
Nashimoto A, Sasako M et al. Neoadjuvant chemotherapy
with S-1 and cisplatin followed by D2 gastrectomy with
para-aortic lymph node dissection for gastric cancer with
extensive lymph node metastasis. Br J Surg 2014; 101:
653–660.
8 Japanese Gastric Cancer Association. Japanese gastric cancer
treatment guidelines 2010 (ver. 3). Gastric Cancer 2011; 14:
113–123.
© 2017 BJS Society Ltd
Published by John Wiley & Sons Ltd
9 Japanese Gastric Cancer Association. Japanese Classification
of Gastric Carcinoma – 2nd English Edition. Gastric Cancer
1998; 1: 10–24.
10 R Core Team. R: A Language and Environment for Statistical
Computing. R Foundation for Statistical Computing: Vienna.
http://www.R-project.org/ [accessed 27 January 2017].
11 Isobe Y, Nashimoto A, Akazawa K, Oda I, Hayashi K,
Miyashiro I et al. Gastric cancer treatment in Japan: 2008
annual report of the JGCA nationwide registry. Gastric
Cancer 2011; 14: 301–316.
12 Japanese Gastric Cancer Association Registration
Committee, Maruyama K, Kaminishi M, Hayashi K, Isobe
Y, Honda I et al. Gastric cancer treated in 1991 in Japan:
data analysis of nationwide registry. Gastric Cancer 2006; 9:
51–66.
13 Saka M, Katai H, Fukagawa T, Nijjar R, Sano T.
Recurrence in early gastric cancer with lymph node
metastasis. Gastric Cancer 2008; 11: 214–218.
14 Araki I, Hosoda K, Yamashita K, Katada N, Sakuramoto S,
Moriya H et al. Prognostic impact of venous invasion in
stage IB node-negative gastric cancer. Gastric Cancer 2015;
18: 297–305.
15 Kunisaki C, Makino H, Kimura J, Takagawa R, Kosaka T,
Ono HA et al. Impact of lymphovascular invasion in patients
with stage I gastric cancer. Surgery 2010; 147: 204–211.
16 Aoyama T, Yoshikawa T, Fujikawa H, Hayashi T, Ogata T,
Cho H et al. Prognostic factors in stage IB gastric cancer.
World J Gastroenterol 2014; 20: 6580–6585.
17 Yokoyama T, Kamada K, Tsurui Y, Kashizuka H, Okano E,
Ogawa S et al. Clinicopathological analysis for recurrence of
stage Ib gastric cancer (according to the second English
edition of the Japanese classification of gastric carcinoma).
Gastric Cancer 2011; 14: 372–377.
18 Park do J, Kong SH, Lee HJ, Kim WH, Yang HK, Lee KU
et al. Subclassification of pT2 gastric adenocarcinoma
according to depth of invasion (pT2a vs pT2b) and lymph
node status (pN). Surgery 2007; 141: 757–763.
19 Nitti D, Marchet A, Mocellin S, Rossi GM, Ambrosi A,
Mencarelli R. Prognostic value of subclassification of T2
tumours in patients with gastric cancer. Br J Surg 2009; 96:
398–404.
20 Lu Y, Liu C, Zhang R, Li H, Lu P, Jin F et al. Prognostic
significance of subclassification of pT2 gastric cancer: a
retrospective study of 847 patients. Surg Oncol 2008; 17:
317–322.
21 Tokunaga M, Hiki N, Fukunaga T, Ohyama S, Yamada K,
Yamaguchi T. Better prognosis of T2 gastric cancer with
preoperative diagnosis of early gastric cancer. Ann Surg
Oncol 2009; 16: 1514–1519.
22 WHO. Global Health Observatory Data Repository: Life Tables
by Country: Japan. http://apps.who.int/gho/data/?
theme=main&vid=60820 [accessed 1 May 2016].
23 Tokunaga M, Sugisawa N, Tanizawa Y, Bando E, Kawamura
T, Terashima M. The impact of preoperative lymph node
size on long-term outcome following curative gastrectomy
for gastric cancer. Ann Surg Oncol 2013; 20: 1598–1603.
www.bjs.co.uk BJS