Searching a robust prognostic factor, the report by Fukudaet al. [1] in the 2009 November issue of World Journal ofSurgery evaluates whether lymph node ratio could be usedas an optimal predictor of survival in gastric cancer.Metastases to lymph nodes in gastric cancer have beenthe most important prognostic factor in gastric cancer. Inday-to-day clinical practice for decision-making aboutadjuvant systemic treatment after a complete surgicalresection (R0), two factors dominantly guide this decision:lymph node status (pN), and tumor depth invasion into thegastric wall (pT).More currently, there is a debate between the scientificcommunityinthewesternworldandJapanorAsiancountries.Whichisthemorereliableprognosticfactor:theabsolutetotalnumber of metastatic lymph nodes proposed by the Interna-tional Union Against Cancer/American Joint Committee onCancer (UICC/AJCC) or the location and number of meta-static nodes proposed by the Japanese Gastric Cancer Asso-ciation (JGCA)? Both systems have strengthens andlimitations.Toimprovetheprognosticpowerofbothsystems,researchers recently evaluated whether the presence of mi-crometastases or isolated tumor cells in patients with node-negative disease could further improve prognosis and adju-vant treatment decisions in these patients.Based on the results of their retrospective study, Fukudaet al. [1] concluded that the metastatic lymph node ratio(MLR) is an important prognostic factor that should beconsidered. In this study, multivariate analyses revealedthat the MLR was the most significant prognostic factorcompared with UICC/AJCC or JGCA staging systems.Although MLR has already been demonstrated to be aprognostic marker, this study has several weaknesses tosupport the superiority of MLR vs. UICC and JGCA sys-tems. It is a small study (n