AIM: To investigate the prognostic impact of the metastatic lymph node ratio (MLR) in advanced gastric cancer from the cardia and fundus. METHODS: Two hundred and thirty-six patients with gastric cancer from the cardia and fundus who underwent D2 curative resection were analyzed ret- rospectively. The correlations between MLR and the total lymph nodes, positive nodes and the total lymph nodes were analyzed respectively. The influence of MLR on the survival time of patients was determined with univariate Kaplan-Meier survival analysis and mul- tivariate Cox proportional hazard model analysis. And the multiple linear regression was used to identify the relation between MLR and the 5-year survival rate of the patients. RESULTS: The MLR did not correlate with the total lymph nodes resected (r = -0.093, P = 0.057). The 5-year overall survival rate of the whole cohort was 37.5%. Kaplan-Meier survival analysis identified that the following eight factors influenced the survival time of the patients postoperatively: gender (X2 = 4.26, P = 0.0389), tumor size (X2 = 18.48, P < 0.001), Borrmann type (X2 = 7.41, P = 0.0065), histological grade (X2 =5.07, P = 0.0243), pT category (X2 = 49.42, P < 0.001), pN category (X2 = 87.7, P < 0.001), total number of re- trieved lymph nodes (X2 = 8.22, P = 0.0042) and MLR (X2 = 34.3, P < 0.001). Cox proportional hazard model showed that tumor size (X2 = 7.985, P = 0.018), pT category (X2 = 30.82, P < 0.001) and MLR (X2 = 69.39, P < 0.001) independently influenced the prognosis. A linear correlation between MLR and the 5-year survival was statistically significant based on the multiple lin- ear regression (β = -0.63, P < 0.001). Hypothetically, the 5-year survival would surpass 50% when MLR was lower than 10%. CONCLUSION: The MLR is an independent prognostic factor for patients with advanced gastric cancer from the cardia and fundus. The decrease of MLR due to adequate number of total resected lymph nodes can improve the survival.