The impact of contour maps on estimating the risk of gastrointestinal stromal tumor recurrence: indications for adjuvant therapy: an analysis of the Kinki GIST registry.

INTRODUCTION: Contour maps enable risk classification of GIST recurrence in individual patients within 10 postoperative years. Although contour maps have been referred to in Japanese guidelines, their usefulness and role in determining indications for adjuvant therapy is still unclear in Japanese patients. The aims of this study are to investigate the validity of contour maps in Japanese patients with GIST and explore the new strategy for adjuvant therapy. MATERIALS AND METHODS: A total of 1426 Japanese GIST patients who were registered to the registry by the Kinki GIST Study Group between 2003 and 2012 were analyzed. Patients who had R0 surgery without perioperative therapy were included in this study. The accuracy of contour maps was validated. RESULTS: Overall, 994 patients have concluded this study. Using contour maps, we validated the patients. The 5-year recurrence-free survival rates of patients within the GIST classification groups of 0-10%, 10-20%, 20-40%, 40-60%, 60-80%, 80-90%, and 90-100% were 98.1%, 96.6%, 92.3%, 48.0%, 37.3%, 41.0% and 42.4%, respectively. We confirmed that this classification by contour maps was well reflected recurrence prediction. Further, in the high-risk group stratified by the modified National Institutes of Health consensus criteria (m-NIHC), the 10-year RFS rate was remarkably changed at a cutoff of 40% (0-40% group vs. 40-100% group: 88.7% vs. 50.3%, p < 0.001). CONCLUSION: Contour maps are effective in predicting individual recurrence rates. And it may be useful for the decision of individual strategy for high-risk patients combined with m-NIHC.

Risk factors of "loss of independence" in elderly patients who received gastrectomy for gastric cancer.

OBJECTIVE: The aim of this study was to clarify the risk of loss of independence (LOI) following gastrectomy in elderly patients with gastric cancer (GC). METHODS: In this prospective study, frailty was assessed preoperatively by a frailty index (FI) in 243 patients aged ≥ 65 years who underwent gastrectomy for GC between August 2016 and December 2020. Patients were assigned into two groups (high FI vs. low FI) to investigate frailty and the risk of LOI after gastrectomy for GC. RESULTS: Overall and minor (Clavien-Dindo classification [CD] 1, 2) complication rates were significantly higher in the high FI group, but the two groups had similar rates of major (CD ≥ 3) complications. The frequency of pneumonia was significantly higher in the high FI group. In univariate and multivariate analyses for LOI after surgery, high FI, older age (≥ 75 years), and major (CD ≥ 3) complications were independent risk factors. A risk score assigning 1 point for each of these variables was useful in predicting postoperative LOI (LOI: score 0, 7.4%; score 1, 18.2%; score 2, 43.9%; score 3, 100%; area under the curve [AUC] = 0.765.) CONCLUSIONS: LOI after gastrectomy was independently associated with high FI, older age (≥ 75 years), and major (CD ≥ 3) complications. A simple risk score assigning points for these factors was an accurate predictor of postoperative LOI. We propose that frailty screening should be applied for all elderly GC patients before surgery.

The Cancer Cachexia Index Can Be Used to Prognostically Predict Patients with Gastric Cancer Undergoing Gastrectomy.

INTRODUCTION: Cancer cachexia occurs in cancer patients more frequently as the cancer progresses, with a negative impact on treatment outcomes. In this study, we sought to clarify the clinical impact of a cancer cachexia index (CXI) in patients with gastric cancer (GC) undergoing gastrectomy. METHODS: Between January 2013 and December 2018, we reviewed data from 556 patients treated for GC at our hospital. CXI was calculated using skeletal muscle index (SMI), serum albumin, and neutrophil-lymphocyte ratios (NLR). Patients were divided into high (n = 414) or low CXI (n = 142) groups. We investigated the clinical impact of CXI in patients with GC undergoing gastrectomy. RESULTS: Multivariate analyses of 5-year overall survival (OS) and cancer-specific survival (CSS) rates indicated that a low CXI was independently associated with unfavorable outcomes for patients with GC. In multivariate analyses, SMI was independent predictor of OS but not CSS. NLR was not an independent predictor of either OS or CSS. Complication incidences (≥ Clavien Dindo 3) were non-significantly higher in the low (vs. high) CXI group. CONCLUSION: CXI was a more valuable prognostic biomarker when compared with SMI or NLR in GC patients undergoing gastrectomy. We suggest that patients with low CXI values should be given more comprehensive treatment, including exercise and nutritional therapy to improve clinical outcomes.

[Surgical Technique for Mesorectal Division in the Robotic Anterior Resection for Rectal Cancer].

Since April 2018, robot-assisted rectal resection has been approved as an insurance medical treatment, and robot- assisted rectal resection is rapidly becoming widespread. Even in robot-assisted laparoscopic surgery, mesorectal division is difficult in a narrow pelvic cavity. At the beginning of the operation, Vessel Sealer ExtendTM(price 89,250 yen)was used, but as the procedure became stable, the mesorectal division was started with bipolar forceps and monopolar scissors. The purpose of this study was to investigate the mesorectal division time and postoperative complications associated with changes in the procedure. 36 patients who underwent robot-assisted anterior resection for rectal cancer by the same surgeon from January 2019 to December 2021. We compared mesorectal division time and postoperative complication. Median operation time were 267 minutes, median console time were 132 minutes. There were no complications such as intestinal obstruction or anastomotic leakage. There was no difference in mesorectal division time time between Vessel Sealer groups and Scissors groups(14 min 55 sec vs 16 min 5 sec). The mesorectal division with bipolar forceps and monopolar scissors could be performed without extending the operation time, and could be performed with cost-benefit and safely.

Less Severe Intra-Abdominal Infections in Robotic Surgery for Gastric Cancer Compared with Conventional Laparoscopic Surgery: A Propensity Score-matched Analysis.

BACKGROUND: The impact of robotic gastrectomy (RG) for gastric cancer (GC) on the incidence of postoperative complication is debatable and unclear. METHODS: This study enrolled 200 patients with GC who were surgically treated and consisted of 100 RG and 100 laparoscopic gastrectomy (LG) cases using an ultrasonic scalpel. The short-term outcomes were compared between the two groups. These outcomes were compared using a 1:1 propensity score (PS)-matching analysis. RESULTS: After PS matching, 76 cases in each group were well matched. Mean surgical time was significantly longer in the RG group than in the LG group (393 vs. 342 min, p < 0.005), whereas mean blood loss during surgery was significantly lower in the RG group than in the LG group (30.1 vs. 50.1 mL, p = 0.023). The median number of surgeons who attend the main part of the surgery was significantly less in the RG group than in the LG group (2.0 vs. 3.0, p = 0.01). The rate of severe intra-abdominal infectious complication was significantly lower in the RG group than in the LG group (0% vs. 9.2%, p = 0.014). The duration from surgery to adjuvant chemotherapy was significantly shorter in the RG group than in the LG group (29.6 ± 11.0 vs. 45.2 ± 27.8 days, p = 0.046). CONCLUSIONS: RG using an ultrasonic scalpel may be a viable alternative to LG because of the improvement in the rate of postoperative intra-abdominal infectious complications after curative surgery for GC.

[Locally Advanced Pancreatic Cancer Treated with Two-Staged Pancreaticoduodenectomy after Laparoscopic Median Arcuate Ligament Section-A Case Report].

A 76-year-old male was diagnosed as locally advanced pancreatic cancer because abdominal CT scan revealed a pancreatic head tumor with involvement of the proper hepatic artery. Gemcitabine plus nab-paclitaxel was initiated, but was discontinued because interstitial pneumonia was occurred. The treatment was switched to S-1 therapy and achieved stable disease for 22 months. Therefore, conversion surgery was scheduled. Because stenosis of the celiac artery origin due to median arcuate ligament(MAL)compression and dilatation of pancreatoduodenal artery arcade were observed, laparoscopic MAL section was performed. The patient was discharged on postoperative day 5 without complications. Postoperative CT scan revealed no stenosis of the celiac artery origin and disappearance of dilatation of pancreatoduodenal artery arcade. On postoperative day 14, subtotal stomach-preserving pancreaticoduodenectomy(PD)with portal vein resection was performed. The patient was discharged on postoperative day 19 without complications. Two-staged PD after MAL section make possible to evaluate blood flow accurately and select an appropriate operative method. Laparoscopic MAL section is minimally invasive and may be useful for two-staged PD in patients with celiac axis stenosis.

[Impact of Sarcopenia on Patients with Advanced Gastric Cancer Who Underwent Surgery].

This study aimed to investigate the short- and long-term outcomes in patients with sarcopenia who underwent surgery for advanced gastric cancer. We included 76 patients with pStage Ⅱ or Ⅲ gastric cancer who underwent gastrectomy between January 2017 and June 2021. Patients with pT3N0 cancer were excluded. Using the Asian Working Group for Sarcopenia( AWGS)2019 criteria, the patients were divided into the sarcopenia group(S group)and the non-sarcopenia group (NS group). The surgical outcomes, effects on postoperative adjuvant chemotherapy, and prognosis of the 2 groups were evaluated and compared. No significant differences were observed in the operative time, blood loss, postoperative hospital stays, or incidence of postoperative complications with a grade higher than Clavien-Dindo Grade Ⅱ. The number of patients who received postoperative adjuvant chemotherapy was 5(26.3%)in the S group and 38(66.7%)in the NS group which was significantly lower in the S group(p=0.003). The 3-year overall survival rate was 45.7% in the S group and 71.0% in the NS group(p=0.302). There was no significant difference but survival rate was lower in the S group. The results suggest that postoperative adjuvant chemotherapy is not always available for patients with advanced gastric cancer, and that may worsen the prognosis.

[A Case of Robotic Surgery for Local and Peritoneal Recurrence of Colorectal Cancer].

A 35-year-old women with sigmoid cancer(pT4aN1aM0, pStage Ⅲb)underwent laparoscopic sigmoidectomy. She had 8 courses of CapeOX for adjuvant chemotherapy, but follow up CT scan 1 year after the operation detected intraabdominal nodules in anastomotic site and in left lower quadrant of abdomen. After 10 courses of IRIS plus bevacizumab, the both intraabdominal nodules decreased in size. Robot assisted laparoscopic lower anterior resection and laparoscopic disseminated nodule resection were performed. The patient had no postoperative complications and the postoperative course was good. She remains alive without recurrence at 6 months after the second operation.

[A Case of pStage IB Gastric Cancer Relapsed on Both Pleura and Peritoneum Eight Year after Radical Gastrectomy].

An 86-year-old man presented with upper abdominal pain and was diagnosed with type 0-Ⅲ gastric cancer located at the posterior wall of the upper stomach by upper gastrointestinal endoscopy. Laparoscopic total gastrectomy(D1+)was performed for gastric cancer of cStage Ⅰ. As final pathological diagnosis was pT2N0(0/27)M0H0P0CY0, pStage ⅠB, adjuvant chemotherapy was not administrated. The patient has been alive with no recurrence for 5 years after surgery. 8 years and 1 month after procedure, he visited our hospital with chief complaint of abdominal distention and anorexia. Chest and abdominal CT showed pleural fluid and ascites, but PET-CT could not detect any sites of recurrence. Cytopathology and cell blocks by immunohistochemical staining of ascites proved recurrence of previous gastric cancer. Any treatment was rejected, and the patient died 3 months after recurrence and 8 years and 4 months after gastrectomy. Late recurrence on both pleura and peritoneum of gastric cancer is very rare. We report a case of pStage ⅠB gastric cancer relapsed on both pleura and peritoneum 8 year after radical gastrectomy.

[A Case of Recurrent Gastric Cancer of Multiple Organ Metastasis with Long-Term Survival Due to Multimodal Treatment].

A 67-year-old man was introduced to examine for abnormal findings in physical examination. Upper gastrointestinal endoscopy detected the 3 lesions and diagnosed multiple gastric cancers with biopsy. Laparoscopic total gastrectomy was performed and final pathological diagnosis was pT2N1M0, pStage ⅡA with HER2 positive(3+). Adjuvant chemotherapy was not administrated. CT findings 6 months after procedure showed 2 liver metastases(S6, S7)and laparoscopic partial liver resection was performed. Pathological findings proved the metastasis of previous gastric cancer. Although adjuvant chemotherapy of S-1 was started 2 months after hepatectomy, CT findings showed second recurrences in liver and right adrenal gland. Chemotherapy was changed to S-1 plus cisplatin(SP)plus trastuzumab. AS these recurrence sites and ascites could not be detected by CT after 6 courses, therapeutic effect was judged as clinical CR(cCR)and SP plus trastuzumab was stopped due to side effect. Since then, regular follow-up CT showed preservation of status of cCR without chemotherapy and he has been alive without recurrence for 8 years and 9 months after gastrectomy. We report a case of recurrent gastric cancer of multiple organ metastasis with long-term survival due to multimodal treatment.

Asporin Expression on Stromal Cells and/or Cancer Cells Might Be A Useful Prognostic Marker in Patients with Diffuse-Type Gastric Cancer.

BACKGROUND: Asporin (ASPN), a member of the proteoglycan family, has been shown to have a close correlation with cancer progression. It is not known whether ASPN is an oncogenic driver or a tumor suppressor in human gastric cancer. We sought herein to determine the relationship between ASPN expression and clinicopathological features of gastric cancer. PATIENTS AND METHODS: A total of 296 gastric cancer patients (diffuse type, n = 144; intestinal type, n = 152) were enrolled. The ASPN expression level in each case was analyzed by immunohistochemistry. RESULTS: ASPN was mainly found on stromal cells, especially on fibroblasts in tumor stroma, i.e., cancer-associated fibroblasts. The ASPN expression on either cancer cells or stromal cells was significantly high in macroscopic scirrhous-type tumors (p < 0.001) and histologically abundant stroma-type tumors (p < 0.001). Interestingly, a Kaplan-Meier survival curve of the 144 cases of diffuse-type gastric cancer revealed a significantly poorer prognosis in patients with ASPN-positive expression (p = 0.043; log rank) compared to those with ASPN-negative expression, but the prognoses were not significantly different in these subgroups of the 152 cases of intestinal-type gastric cancer. A multivariate analysis with respect to overall survival showed that ASPN expression on stromal cells and/or cancer cells was significantly correlated with overall survival in patients with diffuse-type gastric cancer (p = 0.041). CONCLUSION: In gastric cancer, ASPN was expressed mainly on stromal cells and partially on cancer cells. ASPN expression on stromal cells and/or cancer cells might be a useful prognostic marker in patients with diffuse-type gastric cancer.

Preoperative C-reactive protein to albumin ratio predicts anastomotic leakage after esophagectomy for thoracic esophageal cancer: a single-center retrospective cohort study.

BACKGROUND: Postoperative anastomotic leakage (AL) is associated with not only prolonged hospital stay and increased medical costs, but also poor prognosis in esophageal cancer. Several studies have addressed the utility of various inflammation-based and/or nutritional markers as predictors for postoperative complications. However, none have been documented as specific predictors for AL in esophageal cancer. We aimed to identify predictors of AL after esophagectomy for thoracic esophageal cancer, focusing on preoperative inflammation-based and/or nutritional markers. METHODS: We retrospectively analyzed 295 patients who underwent radical esophagectomy for thoracic esophageal squamous cell carcinoma between June 2007 and July 2020. As inflammation-based and/or nutritional markers, Onodera prognostic nutritional index, C-reactive protein (CRP)-to-albumin ratio (CAR) and modified Glasgow prognostic score were investigated. Optimal cut-off values of inflammation-based and/or nutritional markers for AL were determined by receiver operating characteristic curves. Predictors for AL were analyzed by logistic regression modeling. RESULTS: AL was observed in 34 patients (11.5%). In univariate analyses, preoperative body mass index (≥ 22.1 kg/m2), serum albumin level (≤ 3.8 g/dL), serum CRP level (≥ 0.06 mg/dL), CAR (≥ 0.0139), operation time (> 565 min) and blood loss (≥ 480 mL) were identified as predictors of AL. Multivariate analyses revealed higher preoperative CAR (≥ 0.0139) as an independent predictor of AL (p = 0.048, odds ratio = 3.02, 95% confidence interval 1.01-9.06). CONCLUSION: Preoperative CAR may provide a useful predictor of AL after esophagectomy for thoracic esophageal squamous cell carcinoma.

[Prognostic Analysis of Colorectal Cancer Patients by the Controlling Nutritional Status(CONUT)Score].

We examined the controlling nutritional status(CONUT)score and the long-term prognosis of colorectal cancer surgery cases. We retrospectively examined the prognosis of colorectal cancer patients who underwent surgery between January 2013 and December 2015. We targeted 449 patients who were able to calculate the CONUT score. A total of 266 patients (59.2%)had normal nutritional status(1 or less)and 183 patients(40.8%)had mildly poor or worse nutritional status (2 or more). The CONUT score was calculated through preoperative blood tests. The relationship between the CONUT score and overall survival was examined in the low and high groups. Overall survival was significantly shorter in the high group but relapse-free survival did not differ significantly between the 2 groups. There was no difference in cancer-specific survival between the 2 groups, but the survival time due to death from other diseases was significantly shorter in the high group. The CONUT score obtained from preoperative blood sampling suggested that the overall survival time was short in the malnourished group, and that it could be used as an index of prognosis due to death from other diseases.

[Short-Term Clinical Outcome of Robotic Surgery for Advanced Rectal Cancer after Neoadjuvant Therapy].

We examined 14 cases who underwent robotic rectal resection with neoadjuvant chemotherapy(NAC)or neoadjuvant chemoradiation therapy(NACRT)for local advanced rectal cancer in our hospital from 2018 June to 2020 December. Two patients underwent NACRT, 12 patients underwent NAC. Sex was 10 males and 4 females. The median age was 66. The surgical procedure was ISR 2 cases, LAR 8 cases, APR 4 cases. The median operation time was 397 minutes and the median blood loss was 73 mL. The histological response grade were Grade 3: 1 case, 2: 7 cases, 1b: 3 cases, and 1a: 3 cases. Surgical margin was negative in all cases. Postoperative complications(≥Clavien-Dindo Grade Ⅲ)required reoperation due to intestinal obstruction in 1 case. Urinary dysfunction was nothing in all cases. Although long-term results such as prognosis and function preservation need to be examined, short-term results of robot-assisted rectal resection after NAC or NACRT were generally good.

[A Case of Robot Assisted Low Anterior Resection for a Patient with Persistent Descending Mesocolon].

Persistent descending mesocolon(PDM)is caused by absence of fusion of the descending colon to the retroperitoneum. A 67-year-old man with bloody stools was diagnosed with rectal cancer on colonoscopy. A computed tomography showed a medial displacement of his descending colon. The preoperative clinical diagnosis was rectal cancer with PDM, and robot assisted low anterior resection was performed. We found that the left-sided colon was shifted to the midline and adhered the cecum and the mesentery of small intestine. Robot assisted surgery enables surgery with the precise adhesiotomy in a stable field. PDM is a relatively rare anatomic abnormality. Character of PDM is adhesion between the left-sided colon and other organs and radially branch from the inferior mesenteric artery. It is important to understand the anatomical characteristics of PDM and to improve on existing surgical procedures to ensure safe robot assisted surgery these patients.

[A Case of Advanced Gastric Cancer-Recurrence of Skin Metastasis Nine Years after Surgery and Rectal Stenosis Due to Peritoneal Dissemination Ten Years Later].

A 70-year-old man previously underwent laparoscopic total gastrectomy for gastric cancer in 2010 and pathological diagnoses were pT4a, pN3, M0, pStage ⅢC. The postoperative adjuvant chemotherapy was interrupted due to nausea, but the patient had no apparent recurrence within 5 years after gastrectomy. In 2019, a swelling appeared from the left inguinal region to the scrotum, and MRI scan showed subcutaneous edematous changes in the same region. Biopsy showed adenocarcinoma and we diagnosed a recurrence of gastric cancer with skin metastasis. In November 2020, the patient complained of defecation disorder, and CT scan showed a circumferential wall thickening with contrast effect in the rectum. Although colonoscopy revealed rectal stenosis, biopsy specimen showed no malignant findings. We suspected rectal stenosis due to peritoneal dissemination of gastric cancer and performed a colostomy. Intraoperative findings showed that the rectal wall was remarkably thickened with serosal erythema. Adenocarcinoma cells were found from the cytology of ascites. The patient was treated with nab-paclitaxel plus ramucirumab, then treated with nivolumab after failure of first-line therapy.

[Short- and Long-Term Surgical Outcomes for Patients with Colorectal Cancer Aged 80 Years or Older].

This study aimed to assess short-term and long-term outcomes and to identify the factors that affect outcomes for patients with colorectal cancer aged 80 years or older. Two hundred patients with colorectal cancer who were underwent resection of the primary tumor between January 2013 and December 2018 were enrolled. Short-term outcomes of elderly patients with poor PS and of those who take antithrombotic agents and of those who were underwent open surgery were poor. Long-term outcomes of elderly patients with high GNRI and of those who were underwent D3 lymph nodes dissection were better. Laparoscopic surgery with D3 lymph nodes dissection for elderly patients who were more than 80 years old should be useful to improve short- and long-term outcomes. GNRI might be a prognostic predictive factor for patients with colorectal cancer aged 80 years or older.

[A Case of Double Colorectal Cancer Diagnosed by Preoperative CT Colonography].

A 66‒year‒old man was admitted to our hospital because of anemia and a positive fecal occult blood test in the medical examination. Colonoscopy revealed a type 2 advanced sigmoid colon cancer with circular stenosis. Computed tomography (CT)colonography was performed to examine the oral colon. The apple core signs were found both in the sigmoid and transverse colon. We diagnosed a double colon cancer and performed a laparoscopic left hemicolectomy and sigmoidectomy. The tumor was histopathologically diagnosed as a multiple cancer including a transverse and a sigmoid colon cancer. Although evaluations of the intestine for colon cancer with stenosis are performed by enema examination or endoscopic examination after colon stent placement, both examinations are invasive. CT colonography is considered to be a minimally invasive and an effective preoperative examination for colorectal cancer with stenosis.

The duration of systemic inflammatory response syndrome is a reliable indicator of long-term survival after curative esophagectomy for esophageal squamous cell carcinoma.

BACKGROUND: We focused on the Systemic Inflammatory Response Syndrome (SIRS) duration after surgery for esophageal squamous cell carcinoma (ESCC) as the prognostic marker. METHODS: We enrolled a total of 222 patients with local ESCC, who underwent curative esophagectomy between 2005 and 2015. SIRS was diagnosed according to the criteria as a condition involving two or more of the following factors after surgery: (a) body temperature of > 38 °C or < 36 °C; (b) heart rate > 90 beats/min; (c) respiratory rate > 20 breaths/min (d) WBC count > 12,000 or < 4000 cells/mm3. We defined SIRS duration as the total sum of the days defined as SIRS conditions during 7 days after surgery. The SIRS duration was analyzed by Cox hazards modeling to determine the independent prognostic factors for overall survival (OS) and Cancer-specific survival (CSS). RESULTS: The cutoff point of SIRS duration was determined to be set at 5.0 days according to the receiver operating characteristic (ROC) curve, which was plotted using 5-year OS as the endpoint. Of the 222 patients, 165 (74.4%) and 57 (25.6%) were classified as having short (< 5.0) and long (≥ 5.0) SIRS, respectively. The long SIRS was significantly associated with postoperative pneumonia (Hazard Ratio (HR):9.07; P < 0.01), great amount of blood loss during surgery (HR: 2.20: P = 0.04), preoperative high CRP value (HR: 2.45: P = 0.04) and preoperative low albumin (HR: 2.79: P = 0.03) by logistic-regression multivariate analysis. Cox Hazard Multivariate analyses revealed that long SIRS was a worse prognostic factor for OS (HR: 2.36; 95% Confidence Interval (CI):1.34-4.20, P < 0.01) and CSS (HR: 2.07; 95% CI:1.06-4.06, P = 0.03), while postoperative pneumonia and postoperative high CRP value were not worse prognostic factors for OS and CSS. CONCLUSION: SIRS duration is a more reliable prognostic marker than the development of pneumonia and high postoperative CRP value after surgery for ESCC. The surgeons should aim to reduce the SIRS duration to improve the prognosis of ESCC patients.

Clinical significance of prognostic inflammation-based and/or nutritional markers in patients with stage III gastric cancer.

BACKGROUND: Although many studies have identified several inflammation-based and/or nutritional markers with prognostic value for patients with various types of cancer, the optimal markers and cut-off values for these markers remain obscure. Therefore, this retrospective study aimed to identify optimal markers and their cutoffs. METHODS: We compared prognostic values among established preoperative inflammation-based and/or nutritional markers in 225 patients who underwent R0 resection for stage III gastric cancer. Inflammation-based and/or nutritional markers comprised C-reactive protein to albumin ratio (CAR), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), prognostic nutritional index (PNI), Glasgow prognostic score (GPS), and prognostic index (PI). Time-dependent receiver operating characteristic curves were analyzed to assess predictive ability and to determine the optimal cut-off values. Prognostic factors predicting overall survival (OS) and cancer specific survival (CSS) were analyzed using Cox proportional hazards models. RESULTS: Multivariate analyses revealed that CAR and PLR cut-off values of 0.47 and 172, respectively, were independent prognostic factors for overall survival (OS) (HR, 2.257; 95% CI, 1.180-4.319; p = 0.014 and HR, 1.478; 95% CI, 1.025-2.133; p = 0.037, respectively) and cancer-specific survival (CSS) (HR, 2.771; 95% CI, 1.398-5.493; p = 0.004 and HR, 1.552; 95% CI, 1.029-2.341; p = 0.036, respectively). These results were different from those we previously reported in patients with stage II. CONCLUSIONS: Among inflammation-based and/or nutritional markers, CAR and PLR were independent prognostic factors of OS and CSS in patients with stage III gastric cancer. The optimal markers and their cut-off values should be determined in specific populations.