Document Type : Research articles


1 Department of Surgical Oncology, Faculty of Medicine, Cukurova University, Cukurova, Adana, Turkey

2 Department of General Surgery, Faculty of Medicine, Cukurova University, Cukurova, Adana, Turkey

3 Department of Anesthesiology and Reanimation, School of Medicine, Baskent University, Adana, Turkey


Background: Gastric cancer is the fifth most common cancer worldwide.Objectives: This study investigated the risk factors associated with mediastinal lymph node metastases due to proximal gastric cancer.Methods: The study included patients with curative surgical resection and transcural lymphadenectomy for proximal gastric tumors between January 2012 and January 2020. The patients (n=88) were divided into Group 1 (n=54, negative) and Group 2 (n=34, positive) according to the positivity of mediastinal lymph nodes. The diagnostic value of composite immunonutritional and inflammatory indices in predicting lymph node positivity was examined.Results: It was found that only C-reactive protein (CRP) (P=0.044), the rate of postoperative respiratory complications (P=0.002), tumor size (P=0.0001), the total number of lymph nodes, and the number of metastatic lymph nodes were higher in Group 2. Moreover, pT stage (P=0.008) and pN stage (P<0.001) were more advanced in Group 2. Among the composite indices, only the neutrophil-to-lymphocyte ratio (NLR) had a diagnostic value, with a sensitivity of 67.65% and a specificity of 55.56% at a cut-off point of > 2.19. According to the multivariate analysis, a tumor size of > 3 cm, a CRP value of > 7, and tumor localization were independent risk factors.Conclusion: Our study found that mediastinal lymph node positivity was associated with elevated CRP and that these patients had more advanced tumors and poor histopathological characteristics. Mediastinal lymph node positivity was also associated with increased postoperative respiratory complications. We established the diagnostic value of the NLR in predicting lymph node positivity. It is helpful to establish the relationship between clinicopathological characteristics and mediastinal lymph node positivity in proximal gastric tumors since it can be useful in determining the surgical strategy for esophagogastric junction tumors.


  1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209-249. doi: 10.3322/caac.21660. [PubMed: 33538338].
  2. Committee of Korean Gastric Cancer Association. Korean gastric Cancer association Nationwide survey on gastric Cancer in 2014. J Gastric Cancer. 2016;16(3):131–40. doi: 10.5230/jgc.2016.16.3.131. [PubMed: 27752390].
  3. Han WH, Eom BW, Yoon HM, Reim D, Kim YW, Kim MS et al The optimal extent of lymph node dissection in gastroesophageal junctional cancer: retrospective case control study. BMC Cancer. 2019;19(1):719. doi: 10.1186/s12885-019-5922-8. [PubMed: 31331305].
  4. Chen XD, He FQ, Chen M, Zhao FZ. Incidence of lymph node metastasis at each station in Siewert types Ⅱ/Ⅲ adenocarcinoma of the esophagogastric junction: A systematic review and meta-analysis. Surg Oncol. 2020;35:62-70. doi: 10.1016/j.suronc.2020.08.001. [PubMed: 32835903].
  5. Matsuda T, Takeuchi H, Tsuwano S, Nakamura R, Takahashi T, Wada N et al. Optimal surgical management for esophagogastric junction carcinoma. Gen Thorac Cardiovasc Surg. 2014;62(9):560-6. doi: 10.1007/s11748-014-0381-2. [PubMed: 24570201].
  6. Lee IS, Ahn JY, Yook JH, Kim BS. Mediastinal lymph node dissection and distal esophagectomy is not essential in early esophagogastric junction adenocarcinoma. World J Surg Oncol. 2017;15(1):28. doi: 10.1186/s12957-016-1088-x. [PubMed: 28100248].
  7. Kurokawa Y, Hiki N, Yoshikawa T, Kishi K, Ito Y, Ohi M et al. Mediastinal lymph node metastasis and recurrence in adenocarcinoma of the esophagogastric junction. Surgery. 2015;157(3):551–55. doi: 10.1016/j.surg.2014.08.099. [PubMed: 25532434].
  8. Hosoda K, Yamashita K, Katada N, Moriya H, Mieno H, Sakuramoto S et al. Impact of lower mediastinal lymphadenectomy for the treatment of esophagogastric junction carcinoma. Anticancer Res. 2015;35(1):445–56.
  9. [PubMed: 25550586].
  10. Koyanagi K, Kato F, Kanamori J, Daiko H, Ozawa S, Tachimori Y. Clinical signifcance of esophageal invasion length for the prediction of mediastinal lymph node metastasis in Siewert type II adenocarcinoma: a retrospective single-institution study. Ann Gastroenterological Surg. 2018;2(3):187–96. doi: 10.1002/ags3.12069. [PubMed: 29863189].
  11. Shiraishi O, Yasuda T, Kato H, Iwama M, Hiraki Y, Yasuda A, et al. Risk factors and prognostic impact of mediastinal lymph node metastases in patients with esophagogastric junction cancer. Ann Surg Oncol. 2020;27(11):4433–40. doi: 10.1245/s10434-020-08579-3. [PubMed: 32409967].
  12. Sugita S, Kuwata T, Tokunaga M, Kaito A, Watanabe M, Tonouchi A, et al. Clinical signifcance of lymphatic invasion in the esophageal region in patients with adenocarcinoma of the esophagogastric junction. J Surg Oncol. 2020;122(3):433–41. doi: 10.1002/jso.25964. [PubMed: 32359219].
  13. Maatouk M, Ben Safta Y, Kbir GH, Mabrouk A, Ben Dhaou A, Daldoul S et al. Can we predict mediastinal lymph nodes metastasis in esophagogastric junction cancer? Results of a systematic review and meta-analysis. Gen Thorac Cardiovasc Surg. 2021;69(8):1165-73. doi: 10.1007/s11748-021-01665-7. [PubMed: 34109538].
  14. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines (ver. 4). Gastric Cancer.2017;20(1):1–19. doi: 10.1007/s10120-016-0622-4. [PubMed: 27342689].
  15. Amin MB, Greene FL, Edge SB, Compton CC, Gershenwald JE, Brookland RK et al. The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more "personalized" approach to cancer staging. CA Cancer J Clin. 2017;67(2):93-9. doi: 10.3322/caac.21388. [PubMed: 28094848].
  16. Edge SB, Compton CC. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol. 2010;17(6):1471-4. doi: 10.1245/s10434-010-0985-4. [PubMed: 20180029].
  17. Hart PC, Rajab IM, Alebraheem M, Potempa LA. C-Reactive Protein and Cancer-Diagnostic and Therapeutic Insights. Front Immunol. 2020;11:595835. doi: 10.3389/fimmu.2020.595835. [PubMed: 33324413].
  18. Csendes JA, Muñoz ChA, Burgos L. Blood count and C-reactive protein evolution in gastric cancer patients with total gastrectomy surgery. Arq Bras Cir Dig. 2014;27(4):234-6. doi: 10.1590/S0102-67202014000400002. [PubMed: 25626929].
  19. Yu Q, Yu XF, Zhang SD, Wang HH, Wang HY, Teng LS. Prognostic role of C-reactive protein in gastric cancer: a meta-analysis. Asian Pac J Cancer Prev. 2013;14(10):5735-40. doi: 10.7314/apjcp.2013.14.10.5735. [PubMed: 24289571].
  20. Matsumoto Y, Kosuga T, Konishi T, Kudou M, Shoda K, Arita T et al. [Prognostic Value of Preoperative Serum C-Reactive Protein Level in Gastric Cancer]. Gan To Kagaku Ryoho. 2019;46(10):1623-25. [PubMed: 31631155].
  21. Urabe M, Yamashita H, Watanabe T, Seto Y. Comparison of prognostic abilities among preoperative laboratory data indices in patients with resectable gastric and esophagogastric junction adenocarcinoma. World J Surg. 2018;42(1):185–94. doi: 10.1007/s00268-017-4146-9. [PubMed: 28741195].
  22. Sisic L, Blank S, Nienhüser H, Haag GM, Jäger D, Bruckner T, et al. The postoperative part of perioperative chemotherapy fails to provide a survival benefit in completely resected esophagogastric adenocarcinoma. Surg Oncol. 2020;33:177-88. doi: 10.1016/j.suronc.2017.06.001. [PubMed: 28684226].
  23. Sisic L, Strowitzki MJ, Blank S, Nienhueser H, Dorr S, Haag GM et al. Postoperative follow-up programs improve survival in curatively resected gastric and junctional cancer patients: a propensity score matched analysis. Gastric Cancer. 2018;21(3):552-68. doi: 10.1007/s10120-017-0751-4. [PubMed: 28741059].