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Substaging of Lymph Node Status in Resected Pancreatic Ductal Adenocarcinoma Has Strong Prognostic Correlations: Proposal for a Revised N Classification for TNM Staging

  • Pancreatic Tumors
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Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

The current tumor-node-metastasis staging system for the pancreas does not incorporate the number of lymph nodes (LNs) with metastasis.

Methods

Among 1649 pancreaticoduodenectomies, 227 stringently defined pancreatic ductal adenocarcinomas (PDACs) that had undergone a specific approach of LN harvesting were analyzed for the prognostic value of LN substaging protocols used for other gastrointestinal (GI) organs.

Results

The median number of LNs harvested was 18, and the median number of LNs with metastasis was 3. Lymph node metastasis was detected in 175 cases (77 %). The number of LNs involved correlated significantly with clinical outcome. When cases were substaged with the protocol already in use for the upper GI organs (N0: no metastasis, N1: metastasis to 1–2 LNs; N2: metastasis to ≥3 LNs), the median overall survival times were 35, 21, and 18 months, and the respective 3-year survival rates were 46, 34, and 20 % (p = 0.004). Analysis of the Surveillance, Epidemiology and End Results (SEER) database also confirmed the survival differences between these substages (median overall survival times of 23, 15, and 14 months and respective 3-year survival rates of 37, 22, and 18 %; p < 0.0001). The substaging protocol for the lower GI organs (N0: no metastasis; N1: metastasis to 1–3 LNs; N2: metastasis to ≥4 LNs) also was significant, with median overall survival times of 35, 21, 18 months and respective 3-year survival rates of 46, 26, and 23 %; p = 0.009). The association between higher N stage and shorter survival persisted with multivariate modeling for both protocols, although the prognostic value of the upper GI protocol appeared to be slightly stronger according to the Akaike Information Criterion method.

Conclusion

In conclusion, with proper LN harvesting, the LN metastasis rate in PDACs is very high (77 %). Substaging of LN metastasis has significant prognostic value and needs to be considered in the N staging of PDACs. The protocol already in use for other upper GI tract organs, which currently also is proven significant for ampulla, would be preferable, although the lower GI tract protocol also is applicable.

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Acknowledgments

This study was supported in part by a grant from National Institutes of Health (#5P50 CA62924) awarded to Volkan Adsay. Lauren M. Postlewait has received funding from the Katz Foundation. For the remaining authors, no support was declared.

Conflict of interest

There are no conflicts of interest.

Author information

Author notes

  1. Olca Basturk MD

    Present address: Memorial Sloan Kettering Cancer Center, New York, NY, USA

Authors and Affiliations

  1. Department of Pathology, New York University, New York, NY, USA

    Olca Basturk MD

  2. Department of Pathology, Istanbul Medipol University, Istanbul, Turkey

    Burcu Saka MD

  3. Department of Pathology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA

    Serdar Balci MD, Hyejeong Choi MD, Pelin Bagci MD, Alyssa Krasinskas MD, Brian Quigley MD, Michelle D. Reid MD, Gizem Akkas MD & Volkan Adsay MD

  4. Department of Surgical Oncology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA

    Lauren M. Postlewait MD, David Kooby MD & Shishir K. Maithel MD

  5. Department of Epidemiology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA

    Jessica Knight MPH & Michael Goodman MD, PhD

  6. Department of General Surgery, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA

    Juan M. Sarmiento MD

  7. Department of Medical Oncology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA

    Bassel El-Rayes MD

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  1. Olca Basturk MD
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Corresponding author

Correspondence to Volkan Adsay MD.

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Basturk, O., Saka, B., Balci, S. et al. Substaging of Lymph Node Status in Resected Pancreatic Ductal Adenocarcinoma Has Strong Prognostic Correlations: Proposal for a Revised N Classification for TNM Staging. Ann Surg Oncol 22 (Suppl 3), 1187–1195 (2015). https://doi.org/10.1245/s10434-015-4861-0

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