Abstract
BACKGROUND: Lymph node metastases evaluation is important for assessing gastric cancer prognosis. In patients not undergoing adequate lymph node biopsy, lymph node stage migration occurs with the use of the existing staging system. This study established a prediction model to improve prognostication in patients undergoing fewer than 16 lymph nodes biopsy. PATIENTS AND METHODS: In total, 3036 eligible patients from the Surveillance, Epidemiology, and End Results Program database were evaluated. They were randomized into development and validation sets in a 1:1 ratio (n=1520 and 1516, respectively). To avoid model overfitting and loss of important factors, prognostic factors related to overall survival (OS) were screened according to the Akaike information criterion. The nomogram was assessed using discrimination and consistency tests in the development and validation sets; the concordance index (C-index), calibration curves, and receiver operating characteristic (ROC) curves were also evaluated. Comparison with the 7th American Joint Committee on Cancer (AJCC) staging system was based on Kaplan-Meier curves, ROC, risk stratification, and decision curve analysis (DCA). RESULTS: Age, race, degree of differentiation, invasion depth, chemotherapy, radiotherapy, and lymph node ratio were independent prognostic factors in OS. C-indices of the development and validation sets were 0.759 (95% CI: 0.741-0.777) and 0.742 (95% CI: 0.713-0.771), respectively; calibration curves were approximately 45° diagonal, indicating good predictive ability of the nomogram. In contrast to the 7th AJCC staging system, the Kaplan-Meier curves and risk stratification of the nomogram had better discrimination ability, the ROC curves of the nomogram achieved more predictive accuracy, and the DCA indicated that the nomogram conferred higher net benefit. CONCLUSION: Our constructed nomogram predicts the prognosis of patients with resectable gastric cancer undergoing biopsy of fewer than 16 lymph nodes more precisely and has better clinical applicability than the 7th AJCC staging system.