Objective: Survival after gastric cancer surgery is largely attributed to tumor biology, neoadjuvant chemotherapy (NAC), and surgical approach, yet other prognostic factors have been reported, including pre-operative systemic inflammatory response (SIR), and Morbidity Severity Score (MSS). The hypothesis tested was that a SIR, MMS, and pathological composite score, would be associated with disease-free (DFS) and overall survival (OS). Methods: Consecutive 358 patients undergoing potentially curative gastrectomy for adenocarcinoma were studied. Complications were defined as a MSS of Clavien-Dindo classification (CDSC) >1. Serum SIR measurements were performed on the day before surgery, and a composite score (CIMpN) (0-3) was developed based on CRP, morbidity, and pN-stage. Primary outcome measures were DFS and OS. Results: Post-operative complications occurred in 138 (38.5%) patients, (8 (2.2%) deaths), and was associated with higher CRP (28.3% vs. 15.5%, p=0.003), vascular invasion (55.8% vs. 36.8%, p<0.001), and R1 status (26.1% vs. 9.5%, p=0.001). Five-year DFS and OS were 32.9% and 33.3% for patients with post-operative complications compared with 62.5% and 64.0% in controls (p<0.001). Five-year DFS and OS were 31.4% and 37.3% in patients with raised CRPs compared with 58.5% and 59.5% in controls (p=0.005, p=0.001, respectively). Five-year DFS for CIMpN scores of 0, 1, 2, and 3 were 85.9%, 50.0%, 26.2%, and 15.4% (p<0.001) respectively. On multivariable analysis CIMpN score was independently associated with DFS [HR 3.00, 95% Confidence Interval (CI) 1.90-4.73, p<0.001] and OS [1.93 (1.43-2.59), p<0.001]. Conclusion: A novel composite score, CIMpN, based on SIR, MSS and pN-stage, offers important prognostic signals.
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