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Eda Caliskan Yildirim,1 Yusuf Acikgoz,2 Yakup Ergun,2 Efnan Algin,2 Oznur Bal2 1Dokuz Eylul University, Department of Internal Medicine, Division of Medical Oncology, Izmir, Turkey; 2Health Sciences University Ankara City Hospital, Department of Medical Oncology, Ankara, TurkeyCorrespondence: Eda Caliskan Yildirim, Dokuz Eylul University, Department of Internal Medicine, Division of Medical Oncology, Izmir, 35340, Turkey, Tel +905545070442, Email caliskan_eda@yahoo.comPurpose: N3 gastric cancer is characterized by a fairly high lymph node metastasis burden and poor outcome despite optimal therapy. Given the limitations of TNM classification, a comprehensive evaluation tool is necessary to predict the prognosis of patients with N3 gastric cancer who underwent curative surgery. This study aims to explore the outcomes and clinicopathologic prognostic factors affecting the overall survival (OS) of patients with N3 gastric cancer after surgery.Methods: Data on patients with N3 gastric cancer who underwent (sub)total gastrectomy and regional lymph node dissection between November 2005 and September 2018 (n = 169) were analyzed by Cox regression to determine the independent prognostic factors for OS.Results: The multivariable analysis established that gender, patient performance status, metastatic lymph node ratio (MLNR), tumor grade, and adjuvant chemotherapy are significantly associated with OS. The five-year OS of the study population was 15%. Adjuvant chemoradiotherapy was applied to 72% of the patients, which resulted in an improvement in recurrence-free survival but not OS. Recurrence occurred in 103 (75%) patients, in which the most frequent recurrence site was distant metastasis.Conclusion: Male gender, poor performance status, grade 3 tumor, MLNR > 0.37, and not receiving adjuvant chemotherapy are predictors of poor prognosis in N3 gastric cancer after curative resection. Considering the high recurrence rates of this group, prospective studies are needed to optimize treatment strategies.Keywords: gastric cancer, prognosis, N3, lymph node ratio, recurrence pattern