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Introduction: The extent of lymphadenectomy and protocol design in gastric cancer trials limit the interpretation of survival benefit of adjuvant therapy for those who undergo surgery with adequate nodal evaluation. We examined the impact of surgery alone with adequate nodal evaluation (≥ 15 lymph nodes) on survival in non-metastatic gastric cancer.Methods: Using the 2001-08 California Cancer Registry, we identified 2,229 patients who underwent gastrectomy with adequate nodal evaluation (≥ 15 lymph nodes) for American Joint Committee on Cancer stage (6th edition) I-IVM0 gastric adenocarcinoma. Patient, tumor and treatment-variables were compared by type of adjuvant therapy. Cox proportional hazard analysis models were used to evaluate the impact of surgery alone on overall survival (OS) and cancer specific mortality (CSM) adjusting for covariates. Results: Of our total cohort, 70% had T1/T2 disease and 30% had N0 disease. Up to 49% of our cohort underwent surgery alone. Those patients were more likely to be older, black, carriers of Medicare coverage, with T1, and N0 disease (p ≤ 0.05). Overall, persons who underwent surgery alone experienced worse OS and CSM than those who received adjuvant chemoradiotherapy. However, when stratified by AJCC-stage and nodal involvement, persons with AJCC stage I or N0 disease who had adequate nodal evaluation experienced more favorable survival outcomes with surgery alone than those who received adjuvant chemoradiotherapy. These results persisted on our Cox regression analysis to show that in AJCC stage I or N0 disease, surgery alone predicted more favorable OS and CSM than when combined with adjuvant therapies (Table). Conclusion: Surgery alone with adequate nodal evaluation may have a role in the treatment of localized gastric cancer. To corroborate these findings, surgery alone with adequate nodal evaluation (as a treatment arm) deserves consideration in the design of future gastric cancer trials to provide patients effective yet resource-conserving, rather than maximally tolerated, treatments.

Table : Multivariate analysis of surgery alone with adequate nodal evaluation on OS and CSM*.

Surgery alone and Mortality (stratified by AJCC stage)
	Stage I HR (95% CI)	Stage II HR (95% CI)	Stage III HR (95% CI)	Stage IV HR (95% CI)
	Cancer Specific Mortality
Surgery alone	0.28 (0.15-0.53)	1.69 (1.14-2.53)	1.56 (1.17-2.07)	1.78 (1.31-2.40
Surgery + Chemotherapy	0.70 (0.25-1.92)	0.90 (0.51-1.58)	1.12 (0.81-1.55)	1.05 (0.74-1.49)
Surgery + Chemoradiotherapy	Ref.	Ref.	Ref.	Ref.
	Overall Mortality
Surgery alone	0.45 (0.26-0.77)	1.68 (1.21-2.35)	1.51 (1.17-1.95)	1.95 (1.49-2.54)
Surgery + Chemotherapy	0.74 (0.31-1.73)	0.97 (0.63-1.50)	1.07 (0.79-1.44)	1.12 (0.83-1.52)
Surgery + Chemoradiotherapy	Ref.	Ref.	Ref.	Ref.
Surgery alone and Mortality(stratified by AJCC-N status)**
	Node negative		Node Positive
	Cancer specific Mortality	Overall Mortality	Cancer specific Mortality	Overall Mortality
Surgery alone	0.49 (0.26-0.92)	0.66 (0.39-1.12)	1.71 (1.42-2.04)	1.71 (1.46-2.00)
Surgery + Chemotherapy	0.65 (0.27-1.60)	0.56 (0.25-1.26)	1.20 (0.97-1.49)	1.22(1.01-1.47)
Surgery + Chemoradiotherapy	Ref.	Ref.	Ref.	Ref.

*After adjusting for age, race, year of diagnosis, insurance, tumor grade, and extent of gastrectomy. ** We also adjusted for AJCC T-stage. Abbreviations: HR, hazard ratio; CI, confidence intervals; ref, referent.