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Seufferlein T, Mayerle J, Boeck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie Exokrines Pankreaskarzinom – Version 3.1. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1724-1785. [PMID: 39389105 DOI: 10.1055/a-2338-3716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Affiliation(s)
| | | | | | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Gastroenterologie und Endokrinologie Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik und Poliklinik für Allgemein-, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Medizinische Klinik und Poliklinik II Onkologie und Hämatologie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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Seufferlein T, Mayerle J, Boeck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie Exokrines Pankreaskarzinom – Version 3.1. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:e874-e995. [PMID: 39389103 DOI: 10.1055/a-2338-3533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Affiliation(s)
| | | | | | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Gastroenterologie und Endokrinologie Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik und Poliklinik für Allgemein-, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Medizinische Klinik und Poliklinik II Onkologie und Hämatologie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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Munding J, Tannapfel A. [Pathological processing in pancreatic ductal adenocarcinoma-What is new?]. Chirurg 2022; 93:453-460. [PMID: 35290470 DOI: 10.1007/s00104-022-01615-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/25/2022]
Abstract
The macroscopic and microscopic assessments of pancreatic cancer resection specimens belong to the standard repertoire of any department of pathology. In recent years standards have been developed regarding both macroscopic and microscopic assessments, which are laid down in international and national guidelines and classifications and are regularly updated. In this way the reporting of results and interdisciplinary communication are facilitated. These classifications and guidelines are influenced by current studies and the data from them provide information on which histopathological factors are particularly relevant for the prognosis and treatment. Due to the increasing use of neoadjuvant therapy the assessment of tumor regression in histopathological specimens is also gaining in importance. Finally, individual targeted treatments are also now available for pancreatic cancer, which require extended molecular pathological diagnostics.
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Affiliation(s)
- Johanna Munding
- Institut für Pathologie, Georgius Agricola Stiftung Ruhr, Ruhr-Universität Bochum, Bürkle-de-la-Camp-Platz 1, 44879, Bochum, Deutschland.
| | - Andrea Tannapfel
- Institut für Pathologie, Georgius Agricola Stiftung Ruhr, Ruhr-Universität Bochum, Bürkle-de-la-Camp-Platz 1, 44879, Bochum, Deutschland
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Role of lymphadenectomy in resectable pancreatic cancer. Langenbecks Arch Surg 2020; 405:889-902. [PMID: 32902706 DOI: 10.1007/s00423-020-01980-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 08/31/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatic cancer (PC) remains one of the most devastating malignant diseases, predicted to become the second leading cause of cancer-related death by 2030. Despite advances in surgical techniques and in systemic therapy, the 5-year relative survival remains a grim 9% for all stages combined. The extent of lymphadenectomy has been discussed intensively for decades, given that even in early stages of PC, lymph node (LN) metastasis can be detected in approximately 80%. PURPOSE The primary objective of this review was to provide an overview of the current literature evaluating the role of lymphadenectomy in resected PC. For this, we evaluated randomized controlled studies (RCTs) assessing the impact of extent of lymphadenectomy on OS and studies evaluating the prognostic impact of anatomical site of LN metastasis and the impact of the number of resected LNs on OS. CONCLUSIONS Lymphadenectomy plays an essential part in the multimodal treatment algorithm of PC and is an additional therapeutic tool to increase the chance for surgical radicality and to ensure correct staging for optimal oncological therapy. Based on the literature from the last decades, standard lymphadenectomy with resection of at least ≥ 15 LNs is associated with an acceptable postoperative complication risk and should be recommended to obtain local radicality and accurate staging of the disease. Although radical surgery including appropriate lymphadenectomy of regional LNs remains the only chance for long-term tumor control, future studies specifically assessing the impact of neoadjuvant therapy on extraregional LNs are warranted.
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Karjol U, Chandranath A, Jonnada P, Cherukuru S, Annavarjula V, Morla SA. Lymph Node Ratio as a Prognostic Marker in Pancreatic Cancer Survival: A Systematic Review and Meta-Analysis. Cureus 2020; 12:e9597. [PMID: 32789099 PMCID: PMC7417066 DOI: 10.7759/cureus.9597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Introduction The lymph node ratio (LNR) is defined as the ratio of number of positive lymph nodes to the total number of lymph nodes harvested during surgery. The objective of this article is to investigate the efficacy of LNR as a prognostic indicator of survival in pancreatic cancer patients who have undergone surgery by meta-analysis. Methods A systematic database search was performed in MEDLINE, Embase, and Google Scholar for relevant studies that reported LNR in pancreatic cancer. Two authors independently screened the relevant articles for selection and to extract data. All studies published in English up to April 2020 were obtained, and a total of 17,128 node-positive patients in 14 studies were included in this meta-analysis. RevMan software 5.3 (Cochrane Collaboration, the Nordic Cochrane Centre, Copenhagen, Denmark) was used for conducting all statistical analyses. Results This meta-analysis demonstrated that LNR > 0.2 significantly correlated with worse survival (hazard ratio [HR]: 1.84; 95% CI: 1.74-1.94; p ≤ 0.00001) in node-positive pancreatic cancer patients. Conclusions Our findings have demonstrated that a higher LNR is a predictor of poor survival and that LNR serves as an independent prognostic marker for assessing survival using a cut-off of 20%.
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Affiliation(s)
- Uday Karjol
- Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, IND
| | - Ajay Chandranath
- Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, IND
| | - Pavan Jonnada
- Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, IND
| | | | - Vinitha Annavarjula
- Oral and Maxillofacial Surgery, Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, IND
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Warschkow R, Tsai C, Köhn N, Erdem S, Schmied B, Nussbaum DP, Gloor B, Müller SA, Blazer D, Worni M. Role of lymphadenectomy, adjuvant chemotherapy, and treatment at high-volume centers in patients with resected pancreatic cancer-a distinct view on lymph node yield. Langenbecks Arch Surg 2020; 405:43-54. [PMID: 32040705 DOI: 10.1007/s00423-020-01859-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 01/27/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE While the importance of lymphadenectomy is well-established for patients with resectable pancreatic cancer, its direct impact on survival in relation to other predictive factors is still ill-defined. METHODS The National Cancer Data Base 2006-2015 was queried for patients with resected pancreatic adenocarcinoma (stage IA-IIB). Patients were dichotomized into the following two groups, those with 1-14 resected lymph nodes and those with ≥ 15. Optimal number of resected lymph nodes and the effect of lymphadenectomy on survival were assessed using various statistical modeling techniques. Mediation analysis was performed to differentiate the direct and indirect effect of lymph node resection on survival. RESULTS A total of 21,912 patients were included; median age was 66 years (IQR 59-73), 48.9% were female. Median number of resected lymph nodes was 15 (IQR 10-22), 10,163 (46.4%) had 1-14 and 11,749 (53.6%) had ≥ 15 lymph nodes retrieved. Lymph node positivity increased by 4.1% per lymph node up to eight examined lymph nodes, and by 0.6% per lymph node above eight. Five-year overall survival was 17.9%. Overall survival was better in the ≥ 15 lymph node group (adjusted HR 0.91, CI 0.88-0.95, p < 0.001). On a continuous scale, survival improved with increasing LNs collected. Patients who underwent adjuvant chemotherapy and were treated at high-volume centers had improved overall survival compared with their counterparts (adjusted HR 0.59, CI 0.57-0.62, p < 0.001; adjusted HR 0.86, CI 0.83-0.89, p < 0.001, respectively). Mediation analysis revealed that lymphadenectomy had only 18% direct effect on improved overall survival, while 82% of its effect were mediated by other factors like treatment at high-volume hospitals and adjuvant chemotherapy. DISCUSSION While higher number of resected lymph nodes increases lymph node positivity and is associated with better overall survival, most of the observed survival benefit is mediated by chemotherapy and treatment at high-volume centers.
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Affiliation(s)
- Rene Warschkow
- Department of Surgery, Kantonsspital St. Gallen, Gallen, Switzerland
| | - Catherine Tsai
- Department of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Nastassja Köhn
- Department of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Suna Erdem
- Department of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Bruno Schmied
- Department of Surgery, Kantonsspital St. Gallen, Gallen, Switzerland
| | - Daniel P Nussbaum
- Berner Viszeralchirurgie, Klinik Beau-Site, Hirslanden, Bern, Switzerland
| | - Beat Gloor
- Department of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Sascha A Müller
- Berner Viszeralchirurgie, Klinik Beau-Site, Hirslanden, Bern, Switzerland
| | - Dan Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mathias Worni
- Department of Surgery, Duke University Medical Center, Durham, NC, USA. .,Swiss Institute for Translational and Entrepreneurial Medicine, Stiftung Lindenhof, Campus SLB, Bern, Switzerland. .,Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, CH-4058, Basel, Switzerland.
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The value of 18F-FDG PET/CT and carbohydrate antigen 19-9 in predicting lymph node micrometastases of pancreatic cancer. Abdom Radiol (NY) 2019; 44:4057-4062. [PMID: 31570958 DOI: 10.1007/s00261-019-02248-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE This study aimed to assess the value of 18F-FDG PET/CT and carbohydrate antigen 19-9 (CA 19-9) levels in predicting lymph node micrometastases in patients with pancreatic cancer. PATIENTS AND METHODS A total of 160 patients with pancreatic carcinoma were included in the study from 2012 to 2017. All patients underwent surgical treatment and PET/CT scans as well as tests to measure CA 19-9 levels before surgery. The PET/CT scans were evaluated by 2 nuclear medicine physicians who were blinded to the clinical information and were compared to the postsurgical pathological findings. Logistic regression analysis was performed to determine the variables that could predict lymph node micrometastases. Receiver operating characteristic (ROC) curves were utilized to find the best cutoff value of the variables related to predicting lymph node micrometastases. RESULTS The maximum standardized uptake value (SUVmax) of the primary tumor and CA 19-9 level were potent predictors for determining the lymph node status. The best SUVmax and CA 19-9 cutoff values for predicting lymph node micrometastases were 7.05 (sensitivity = 71.2%, specificity = 76.6%) and 240.55 U/ml (sensitivity = 62.1%, specificity = 79.8%), respectively. CONCLUSION Patients with pancreatic cancer with a tumor SUVmax ≥ 7.05 or a CA 19-9 value ≥ 240.55 are likely to have lymph node micrometastases.
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Macedo FI, Picado O, Hosein PJ, Dudeja V, Franceschi D, Mesquita-Neto JW, Yakoub D, Merchant NB. Does Neoadjuvant Chemotherapy Change the Role of Regional Lymphadenectomy in Pancreatic Cancer Survival? Pancreas 2019; 48:823-831. [PMID: 31210664 DOI: 10.1097/mpa.0000000000001339] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The objective of this study was to evaluate the role of lymph node (LN) dissection and staging in outcomes of patients with pancreatic adenocarcinoma (PDAC) who underwent neoadjuvant chemotherapy (NAC). METHODS National Cancer Database was queried for patients with stages I to III PDAC diagnosed between 2004 and 2014. Overall survival (OS) was derived from Kaplan-Meier methods, and Cox-regression model was used to evaluate associations between the number of LN examined, number of positive nodes, and LN ratio with OS. RESULTS A total 35,599 patients were included, 3395 (9%) underwent NAC, 19,865 (56%) received adjuvant chemotherapy (AC), and 12,299 (35%) underwent surgery alone. Cox-regression showed superior OS in NAC compared with AC and surgery alone (26 vs 23 vs 14 months, P < 0.001). Minimum number of LN examined affecting OS was 8 LNs in NAC (23.8 vs 26.6 months, P = 0.029), and 12 LNs in AC group (22 vs 23.1 months, P = 0.028). Lymph node ratio cutoff of greater than 0.2 was associated with decreased OS (19.4 vs 24.4 months, P < 0.001). CONCLUSIONS Neoadjuvant chemotherapy is associated with improved survival in PDAC. Lymph node yield remains a significant prognostic factor after NAC, whereas the minimum number of harvested LNs associated with sufficient staging and survival is decreased.
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Affiliation(s)
| | | | | | | | | | - Jose Wilson Mesquita-Neto
- Department of Surgery, Karmanos Comprehensive Cancer Center, Wayne State University School of Medicine, Detroit, MI
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Panaro F, Kellil T, Vendrell J, Sega V, Souche R, Piardi T, Leon P, Cassinotto C, Assenat E, Rosso E, Navarro F. Microvascular invasion is a major prognostic factor after pancreatico-duodenectomy for adenocarcinoma. J Surg Oncol 2019; 120:483-493. [PMID: 31197842 DOI: 10.1002/jso.25580] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/03/2019] [Accepted: 05/18/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Microvascular invasion (MVI) has been proved to be poor prognostic factor in many cancers. To date, only one study published highlights the relationship between this factor and the natural history of pancreatic cancer. The aim of this study was to assess the impact of MVI, on disease-free survival (DFS) and overall survival (OS), after pancreatico-duodenectomy (PD) for pancreatic head adenocarcinoma. Secondarily, we aim to demonstrate that MVI is the most important factor to predict OS after surgery compared with resection margin (RM) and lymph node (LN) status. MATERIALS AND METHODS Between January 2015 and December 2017, 158 PD were performed in two hepato-bilio-pancreatic (HBP) centers. Among these, only 79 patients fulfilled the inclusion criteria of the study. Clinical-pathological data and outcomes were retrospectively analyzed from a prospectively maintained database. RESULTS Of the 79 patients in the cohort, MVI was identified in 35 (44.3%). In univariate analysis, MVI (P = .012 and P < .0001), RM (P = .023 and P = .021), and LN status (P < .0001 and P = .0001) were significantly associated with DFS and OS. A less than 1 mm margin clearance did not influence relapse (P = .72) or long-term survival (P = .48). LN ratio > 0.226 had a negative impact on OS (P = .044). In multivariate analysis, MVI and RM persisted as independent prognostic factors of DFS (P = .0075 and P = .0098, respectively) and OS (P < .0001 and P = .0194, respectively). Using the likelihood ratio test, MVI was identified as the best fit to predict OS after PD for ductal adenocarcinomas compared with the margin status model (R0 vs R1) (P = .0014). CONCLUSION The MVI represents another major prognostic factor determining long-term outcomes.
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Affiliation(s)
- Fabrizio Panaro
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Saint Eloi Hospital, School of Medicine, Montpellier University Hospital, Montpellier, France
| | - Tarek Kellil
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Saint Eloi Hospital, School of Medicine, Montpellier University Hospital, Montpellier, France
| | - Julie Vendrell
- Department of Pathology and Onco-Biology/Solid Tumors Biology Lab, Arnaud de Villeneuve Hospital, School of Medicine, Montpellier University Hospital, Montpellier, France
| | - Valentina Sega
- Division of Surgical Oncology, Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Regis Souche
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Saint Eloi Hospital, School of Medicine, Montpellier University Hospital, Montpellier, France
| | - Tullio Piardi
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Reims University Hospital-School of Medicine, Reims, France
| | - Piera Leon
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Saint Eloi Hospital, School of Medicine, Montpellier University Hospital, Montpellier, France
| | - Christophe Cassinotto
- Department of Radiology, Saint Eloi Hospital, School of Medicine, Montpellier University Hospital, Montpellier, France
| | - Eric Assenat
- Division of Medical Oncology, Department of Medicine, Saint Eloi Hospital, School of Medicine, Montpellier University Hospital, Montpellier, France
| | - Edoardo Rosso
- Department of Pathology and Onco-Biology/Solid Tumors Biology Lab, Arnaud de Villeneuve Hospital, School of Medicine, Montpellier University Hospital, Montpellier, France
| | - Francis Navarro
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Saint Eloi Hospital, School of Medicine, Montpellier University Hospital, Montpellier, France
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Zhou L, Lu J, Liang ZY, Zhou WX, Yuan D, Li BQ, You L, Guo JC, Zhao YP. High nuclear Survivin expression as a poor prognostic marker in pancreatic ductal adenocarcinoma. J Surg Oncol 2018; 118:1115-1121. [PMID: 30261114 DOI: 10.1002/jso.25253] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 09/04/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Survivin, one of the key regulators of mitosis and apoptosis, has long been well recognized to play important biological roles in many neoplasms, including pancreatic ductal adenocarcinoma (PDAC). However, its prognostic value in PDAC remains controversial. PATIENTS AND METHODS Nuclear expression of Survivin was detected, using tissue microarray-based immunohistochemistry, in paired-tumor and nontumor samples from 306 patients with radically resected PDAC. The staining H scores were further correlated with clinicopathologic features and disease-specific survival (DSS). RESULTS Nuclear Survivin expression was much higher in tumor than in nontumor tissues (P < 0.001). No significant association between tumoral Survivin expression and clinicopathologic variables was found. For prognosis, high Survivin expression was associated with shortened DSS in all eligible patients and four subgroups, that is, male and nondiabetic patients as well as those with head-located and G1-2 tumors, shown by univariate analyses. In addition, a statistically marginal significance was revealed in eight subgroups. For the entire cohort and two subgroups, nuclear Survivin expression was also multivariate identified as an independent predictor for DSS. For patients with G1-2 tumors, it was the single prognostic marker. CONCLUSION Our data suggest an association between high nuclear Survivin expression and poor prognosis in PDAC. However, further confirmation might be necessary.
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Affiliation(s)
- Li Zhou
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Jun Lu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Zhi-Yong Liang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Wei-Xun Zhou
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Da Yuan
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Bing-Qi Li
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Lei You
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Jun-Chao Guo
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Yu-Pei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
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12
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Liu WJ, Zhou L, Liang ZY, Zhou WX, You L, Zhang TP, Zhao YP. High expression of GRK3 is associated with favorable prognosis in pancreatic ductal adenocarcinoma. Pathol Res Pract 2017; 214:228-232. [PMID: 29254792 DOI: 10.1016/j.prp.2017.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/06/2017] [Accepted: 11/16/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND It was found that G-protein-coupled receptor kinase 3 (GRK3) played key biological roles in some cancers. However, its associations with clinicopathologic features and prognosis in pancreatic ductal adenocarcinoma (PDAC) remain unknown. METHODS AND METHODS Expression of GRK3 was detected, using tissue microarray-based immunohistochemistry, in paired formalin-fixed paraffin-embedded tumor and non-tumor samples from 165 patients with PDAC after curative resection, and was further correlated with clinicopathologic parameters and cancer-specific survival (CSS). RESULTS It was shown that GRK3 expression was much lower in tumor than in non-tumor tissues. Moreover, expression of GRK3 in tumor tissues was significantly associated with gender and T stage. Univariately, high GRK3 expression was predictive for favorable CSS, along with some conventional clinicopathologic variables. In multivariate Cox regression test, GRK3 expression remained to be a significant prognostic marker for PDAC. Finally, combination of GRK3 with some clinicopathologic variables, especially N stage, obtained more precise prediction for CSS. CONCLUSIONS Our data suggested that expression of GRK3 was down-regulated in PDAC and was an independent prognostic factor.
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Affiliation(s)
- Wen-Jing Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Li Zhou
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Zhi-Yong Liang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Wei-Xun Zhou
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Lei You
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Tai-Ping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China.
| | - Yu-Pei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China.
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Tarantino I, Warschkow R, Hackert T, Schmied BM, Büchler MW, Strobel O, Ulrich A. Staging of pancreatic cancer based on the number of positive lymph nodes. Br J Surg 2017; 104:608-618. [PMID: 28195303 DOI: 10.1002/bjs.10472] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 08/10/2016] [Accepted: 11/28/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND The International Study Group on Pancreatic Surgery has stated that at least 12 lymph nodes should be evaluated for staging of pancreatic cancer. The aim of this population-based study was to evaluate whether the number of positive lymph nodes refines staging. METHODS Patients who underwent pancreatectomy for stage I-II pancreatic cancer between 2004 and 2012 were identified from the Surveillance, Epidemiology, and End Results database. The predictive value of the number of positive lymph nodes for survival was assessed by generalized receiver operating characteristic (ROC) curve analysis and propensity score-adjusted Cox regression analysis. RESULTS Some 5036 patients were included, with a median of 18 (i.q.r. 15-24) lymph nodes examined. Positive lymph nodes were found in 3555 patients (70·6 per cent). The median duration of follow-up was 15 (i.q.r. 8-28) months. ROC curve analysis revealed that two positive lymph nodes best discriminated overall survival. Patients with one or two positive lymph nodes (pN1a) and those with three or more positive lymph nodes (pN1b) had an increased risk of overall mortality compared with patients who were node-negative (pN0): hazard ratio (HR) 1·47 (95 per cent c.i. 1·33 to 1·64) and HR 2·01 (1·82 to 2·22) respectively. These findings were confirmed by propensity score-adjusted Cox regression analysis. The 5-year overall survival rates were 39·8 (95 per cent c.i. 36·5 to 43·3) per cent for patients with pN0, 21·0 (18·6 to 23·6) per cent for those with pN1a and 11·4 (9·9 to 13·3) per cent for patients with pN1b disease. CONCLUSION The number of positive lymph nodes in the resection specimen is a prognostic factor in patients with pancreatic cancer.
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Affiliation(s)
- I Tarantino
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - R Warschkow
- Institute of Medical Biometry and Informatics, Heidelberg University Hospital, Heidelberg, Germany.,Department of Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - B M Schmied
- Department of Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - O Strobel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - A Ulrich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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14
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Hsu CP, Hsu JT, Liao CH, Kang SC, Lin BC, Hsu YP, Yeh CN, Yeh TS, Hwang TL. Three-year and five-year outcomes of surgical resection for pancreatic ductal adenocarcinoma: Long-term experiences in one medical center. Asian J Surg 2016; 41:115-123. [PMID: 28010955 DOI: 10.1016/j.asjsur.2016.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 08/31/2016] [Accepted: 11/15/2016] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Pancreatic ductal adenocarcinoma is one of the most malignant types of cancer. This study evaluated the 3-year and 5-year surgical outcomes associated with the cancer and determined whether statistically identified factors can be used to predict survival. METHODS This retrospective review was conducted from 1995 to 2010. Patients who had resectable pancreatic ductal adenocarcinoma and received surgical treatment were included. Cases of hospital mortality were excluded. The relationships between several clinicopathological factors and the survival rate were analyzed. RESULTS A total of 223 patients were included in this study. The 3-year and 5-year survival rates were 21.4% and 10.1%, respectively, and the median survival was 16.1 months. Tumor size, N status, and resection margins were independent predictive factors for 3-year survival. Tumor size independently predicted 5-year survival. CONCLUSION Tumor size is the most important independent prognostic factor for 3-year and 5-year survival. Lymph node status and the resection margins also independently affected the 3-year survival. These patient outcomes might be improved by early diagnosis and radical resection. Future studies should focus on the tumor biology of this aggressive cancer.
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Affiliation(s)
- Chih-Po Hsu
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Jun-Te Hsu
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chien-Hung Liao
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Shih-Ching Kang
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Being-Chuan Lin
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yu-Pao Hsu
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chun-Nan Yeh
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ta-Sen Yeh
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsann-Long Hwang
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
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15
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Elshaer M, Gravante G, Kosmin M, Riaz A, Al-Bahrani A. A systematic review of the prognostic value of lymph node ratio, number of positive nodes and total nodes examined in pancreatic ductal adenocarcinoma. Ann R Coll Surg Engl 2016; 99:101-106. [PMID: 27869496 DOI: 10.1308/rcsann.2016.0340] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma is the most common pancreatic cancer. Five-year overall survival is currently 3.3-6.0%. The aim of this review was to evaluate the prognostic value of lymph node ratio, number of positive nodes and total nodes examined on overall survival rate following pancreatic resection. MATERIALS AND METHODS A literature search was conducted of MEDLINE, EMBASE, the Cochrane Library and Central Register of Controlled Trials and the Cochrane Database of Systematic Review databases, from January 1996 to January 2016. RESULTS Overall, 19 studies including 4,883 patients examined the relationship between lymph node ratio and overall survival. A high lymph node ratio was associated with decreased overall survival in 17 studies. A total of 12 studies examined the relationship between the number of positive nodes and overall survival, and 11 studies revealed that an increase in the number of positive nodes was associated with decreased overall survival. In 15 studies examining the relationship between the total nodes examined and overall survival, there was no association with overall survival in 12 studies. CONCLUSIONS Lymph node ratio and number of positive nodes are factors associated with overall survival in pancreatic ductal adenocarcinoma, but not total nodes examined.
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Affiliation(s)
- M Elshaer
- Department of Surgery, Broomfield Hospital, Chelmsford , Essex , UK
| | - G Gravante
- Department of Surgery, Leicester Royal Infirmary, University Hospitals of Leicester , Leicester , UK
| | - M Kosmin
- Department of Oncology, Mount Vernon Cancer Centre, East and North Hertfordshire NHS Trust , Northwood, Middlesex , UK
| | - A Riaz
- Department of Surgery, Watford General Hospital , Watford , UK
| | - A Al-Bahrani
- Department of Surgery, Watford General Hospital , Watford , UK
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16
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Riediger H, Kulemann B, Wittel U, Adam U, Sick O, Neeff H, Höppner J, Hopt UT, Makowiec F. Prognostic Role of Log Odds of Lymph Nodes After Resection of Pancreatic Head Cancer. J Gastrointest Surg 2016; 20:1707-15. [PMID: 27384432 DOI: 10.1007/s11605-016-3200-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 06/23/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Nodal status is a strong prognostic factor after resection of pancreatic cancer. The lymph node ratio (LNR) has been shown to be superior to the pN status in several studies. The role of log odds of the ratio between positive and negative nodes (LODDS) as a suggested new indicator of prognosis, however, has been hardly evaluated in pancreatic cancer. METHODS Prognostic factors for overall survival after resection for cancer of the pancreatic head were evaluated in 409 patients from two institutions (prospectively maintained databases). The lymph node status, LNR, and LODDS were separately analyzed and independently compared in multivariate survival analysis. RESULTS The median numbers of examined and positive lymph nodes were 16 and 2, respectively. Actuarial 3- and 5-year survival rates were 29 and 16 %. All three classifications of nodal disease significantly predicted survival in the entire group (n = 409), in patients with free resection margins (n = 297), and in patients with <12 examined nodes. In multivariate analysis, however, both LNR and LODDS were equally superior to the nodal status. In node-negative patients (n = 110), LODDS could not identify subgroups with different prognosis. CONCLUSION Both LNR and LODDS are superior to the classical nodal status in predicting prognosis in resected pancreatic cancer. However, LODDS has not shown any advantage over LNR in our series, neither in the entire patient group nor in the subgroups with free margins, negative nodes or a low number of examined nodes. Therefore, the use of LODDS to predict the outcome after resection of pancreatic head cancer cannot be recommended.
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Affiliation(s)
- Hartwig Riediger
- Department of Surgery, University of Freiburg, Hugstetterstrasse 55, D-79106, Freiburg, Germany.,Department of Surgery, Vivantes-Humboldt-Klinikum, Berlin, Germany
| | - Birte Kulemann
- Department of Surgery, University of Freiburg, Hugstetterstrasse 55, D-79106, Freiburg, Germany
| | - Uwe Wittel
- Department of Surgery, University of Freiburg, Hugstetterstrasse 55, D-79106, Freiburg, Germany
| | - Ulrich Adam
- Department of Surgery, Vivantes-Humboldt-Klinikum, Berlin, Germany
| | - Olivia Sick
- Department of Surgery, University of Freiburg, Hugstetterstrasse 55, D-79106, Freiburg, Germany
| | - Hannes Neeff
- Department of Surgery, University of Freiburg, Hugstetterstrasse 55, D-79106, Freiburg, Germany
| | - Jens Höppner
- Department of Surgery, University of Freiburg, Hugstetterstrasse 55, D-79106, Freiburg, Germany
| | - Ulrich T Hopt
- Department of Surgery, University of Freiburg, Hugstetterstrasse 55, D-79106, Freiburg, Germany
| | - Frank Makowiec
- Department of Surgery, University of Freiburg, Hugstetterstrasse 55, D-79106, Freiburg, Germany.
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17
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Lahat G, Lubezky N, Gerstenhaber F, Nizri E, Gysi M, Rozenek M, Goichman Y, Nachmany I, Nakache R, Wolf I, Klausner JM. Number of evaluated lymph nodes and positive lymph nodes, lymph node ratio, and log odds evaluation in early-stage pancreatic ductal adenocarcinoma: numerology or valid indicators of patient outcome? World J Surg Oncol 2016; 14:254. [PMID: 27687517 PMCID: PMC5041551 DOI: 10.1186/s12957-016-0983-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 08/13/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND We evaluated the prognostic significance and universal validity of the total number of evaluated lymph nodes (ELN), number of positive lymph nodes (PLN), lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) in a relatively large and homogenous cohort of surgically treated pancreatic ductal adenocarcinoma (PDAC) patients. METHODS Prospectively accrued data were retrospectively analyzed for 282 PDAC patients who had pancreaticoduodenectomy (PD) at our institution. Long-term survival was analyzed according to the ELN, PLN, LNR, and LODDS. RESULTS Of these patients, 168 patients (59.5 %) had LN metastasis (N1). Mean ELN and PLN were 13.5 and 1.6, respectively. LN positivity correlated with a greater number of evaluated lymph nodes; positive lymph nodes were identified in 61.4 % of the patients with ELN ≥ 13 compared with 44.9 % of the patients with ELN < 13 (p = 0.014). Median overall survival (OS) and 5-year OS rate were higher in N0 than in N1 patients, 22.4 vs. 18.7 months and 35 vs. 11 %, respectively (p = 0.008). Mean LNR was 0.12; 91 patients (54.1 %) had LNR < 0.3. Among the N1 patients, median OS was comparable in those with LNR ≥ 0.3 vs. LNR < 0.3 (16.7 vs. 14.1 months, p = 0.950). Neither LODDS nor various ELN and PLN cutoff values provided more discriminative information within the group of N1 patients. CONCLUSIONS Our data confirms that lymph node positivity strongly reflects PDAC biology and thus patient outcome. While a higher number of evaluated lymph nodes may provide a more accurate nodal staging, it does not have any prognostic value among N1 patients. Similarly, PLN, LNR, and LODDS had limited prognostic relevance.
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Affiliation(s)
- G Lahat
- Department of Surgery, Tel Aviv Sourasky Medical Center, 6th Weitzman St., Tel Aviv, Israel. .,Sackler Faculty of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel Aviv, Israel.
| | - N Lubezky
- Department of Surgery, Tel Aviv Sourasky Medical Center, 6th Weitzman St., Tel Aviv, Israel.,Sackler Faculty of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel Aviv, Israel
| | - F Gerstenhaber
- Department of Surgery, Tel Aviv Sourasky Medical Center, 6th Weitzman St., Tel Aviv, Israel.,Sackler Faculty of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel Aviv, Israel
| | - E Nizri
- Department of Surgery, Tel Aviv Sourasky Medical Center, 6th Weitzman St., Tel Aviv, Israel.,Sackler Faculty of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel Aviv, Israel
| | - M Gysi
- Sackler Faculty of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel Aviv, Israel
| | - M Rozenek
- Sackler Faculty of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel Aviv, Israel
| | - Y Goichman
- Department of Surgery, Tel Aviv Sourasky Medical Center, 6th Weitzman St., Tel Aviv, Israel.,Sackler Faculty of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel Aviv, Israel
| | - I Nachmany
- Department of Surgery, Tel Aviv Sourasky Medical Center, 6th Weitzman St., Tel Aviv, Israel.,Sackler Faculty of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel Aviv, Israel
| | - R Nakache
- Department of Surgery, Tel Aviv Sourasky Medical Center, 6th Weitzman St., Tel Aviv, Israel.,Sackler Faculty of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel Aviv, Israel
| | - I Wolf
- Sackler Faculty of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel Aviv, Israel.,Department of Oncology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - J M Klausner
- Department of Surgery, Tel Aviv Sourasky Medical Center, 6th Weitzman St., Tel Aviv, Israel.,Sackler Faculty of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel Aviv, Israel
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18
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Åkerberg D, Ansari D, Andersson R. Re-evaluation of classical prognostic factors in resectable ductal adenocarcinoma of the pancreas. World J Gastroenterol 2016; 22:6424-6433. [PMID: 27605878 PMCID: PMC4968124 DOI: 10.3748/wjg.v22.i28.6424] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/24/2016] [Accepted: 06/15/2016] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma carries a poor prognosis with annual deaths almost matching the reported incidence rates. Surgical resection offers the only potential cure. Yet, even among patients that undergo tumor resection, recurrence rates are high and long-term survival is scarce. Various tumor-related factors have been identified as predictors of survival after potentially curative resection. These factors include tumor size, lymph node disease, tumor grade, vascular invasion, perineural invasion and surgical resection margin. This article will re-evaluate the importance of these factors based on recent publications on the topic, with potential implications for treatment and outcome in patients with pancreatic cancer.
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19
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Pancreatic cancer metastatic to a limited number of lymph nodes has no impact on outcome. HPB (Oxford) 2016; 18:523-8. [PMID: 27317957 PMCID: PMC4913131 DOI: 10.1016/j.hpb.2016.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 02/14/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The purpose of this study was to determine the association of the extent of metastatic lymph node involvement with survival in pancreatic cancer. METHODS This is a retrospective review of a prospectively maintained database of patients who underwent resection for pancreatic adenocarcinoma, 1999-2011. RESULTS 165 patients were identified and divided into 3 groups based on the number of positive lymph nodes - 0 (group A), 1-2 (B), >3 (C). Each group had 55 patients. Those in group C were more likely to have a higher T stage, poorly differentiated grade, lymphovascular invasion (LVI), higher mean intraoperative blood loss, positive margins, tumor location involving the uncinate process, and a higher likelihood of undergoing a pancreaticoduodenectomy. Median overall survival (OS) for group A, B and C was 25.5 months (mo), 21 mo and 12.3 mo, respectively (p < 0.001). No survival difference was noted for survival between groups A and B (p = 0.86). The ratio of involved lymph nodes <0.2 was predictive of improved survival (p < 0.001). CONCLUSIONS Resected pancreatic cancer patients with only 1-2 positive lymph nodes or less than 20% involvement have a similar prognosis to patients without nodal disease. Current staging should consider stratification based on the extent of nodal involvement.
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20
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Kang CM, Lee SH, Hwang HK, Yun M, Lee WJ. Preoperative Volume-Based PET Parameter, MTV2.5, as a Potential Surrogate Marker for Tumor Biology and Recurrence in Resected Pancreatic Cancer. Medicine (Baltimore) 2016; 95:e2595. [PMID: 26945350 PMCID: PMC4782834 DOI: 10.1097/md.0000000000002595] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
This study aims to evaluate the role of volume-based positron emission tomography parameters as potential surrogate markers for tumor recurrence in resected pancreatic cancer. Between January 2008 and October 2012, medical records of patients who underwent surgical resection for pancreatic ductal adenocarcinoma and completed ¹⁸F-fluorodeoxyglucose positron emission tomography/CT as a part of preoperative staging work-up were retrospectively reviewed. Not only clinicopathologic variables but also positron emission tomography parameters such as SUVmax, MTV2.5 (metabolic tumor volume), and TLG (total lesion glycolysis) were obtained. Twenty-six patients were women and 31 were men with a mean age of 62.9 ± 9.1 years. All patients were preoperatively determined to resectable pancreatic cancer except 1 case with borderline resectability. R0 resection was achieved in all patients and 45 patients (78.9%) received postoperative adjuvant chemotherapy with or without radiation therapy. Median overall disease-free survival was 12.8 months with a median overall disease-specific survival of 25.1 months. SUVmax did not correlate with radiologic tumor size (P = 0.501); however, MTV2.5 (P = 0.001) and TLG (P = 0.009) were significantly associated with radiologic tumor size. In addition, MTV2.5 (P < 0.001) and TLG (P < 0.001) were significantly correlated with a tumor differentiation. There were no significant differences in TLG and SUVmax according to lymph node ratio; only MTV2.5 was related to lymph node ratio with marginal significance (P = 0.055). In multivariate analysis, lymph node ratio (Exp [β] = 2.425, P = 0.025) and MTV2.5 (Exp[β] = 2.273, P = 0.034) were identified as independent predictors of tumor recurrence following margin-negative resection. Even after tumor size-matched analysis, MTV2.5 was still identified as significant prognostic factor in resected pancreatic cancer (P < 0.05). However, preoperative neoadjuvant treatment attenuated adverse oncologic impact of high preoperative MTV2.5 (P = 0.210). Preoperatively determined volume-based PET parameter, MTV2.5, can potentially be used as a surrogate marker to estimate tumor biology and tumor recurrence. Individual treatment strategies for pancreatic cancer can be suggested based on patients' preoperative MTV2.5.
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Affiliation(s)
- Chang Moo Kang
- From the Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery (CMK, SHL, HKH, WJL); Nuclear Medicine (MY), Yonsei University College of Medicine; and Pancreaticobiliary Cancer Clinic (CMK, SHL, HKH, MY, WJL), Institute of Gastroenterology, Severance Hospital, Seoul, Korea
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21
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Fink DM, Steele MM, Hollingsworth MA. The lymphatic system and pancreatic cancer. Cancer Lett 2015; 381:217-36. [PMID: 26742462 DOI: 10.1016/j.canlet.2015.11.048] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 11/16/2015] [Accepted: 11/30/2015] [Indexed: 02/06/2023]
Abstract
This review summarizes current knowledge of the biology, pathology and clinical understanding of lymphatic invasion and metastasis in pancreatic cancer. We discuss the clinical and biological consequences of lymphatic invasion and metastasis, including paraneoplastic effects on immune responses and consider the possible benefit of therapies to treat tumors that are localized to lymphatics. A review of current techniques and methods to study interactions between tumors and lymphatics is presented.
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Affiliation(s)
- Darci M Fink
- Eppley Institute, University of Nebraska Medical Center, Omaha, NE 68198-5950, USA
| | - Maria M Steele
- Eppley Institute, University of Nebraska Medical Center, Omaha, NE 68198-5950, USA
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22
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Lim YJ, Kim K, Chie EK, Kim B, Ha SW. Role of Adjuvant Radiotherapy in Left-Sided Pancreatic Cancer-Population-Based Analysis with Propensity Score Matching. J Gastrointest Surg 2015; 19:2183-91. [PMID: 26376994 DOI: 10.1007/s11605-015-2941-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 09/08/2015] [Indexed: 01/31/2023]
Abstract
This population-based study evaluated the survival impact of postoperative radiotherapy (PORT) in left-sided pancreatic cancer. The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients with surgically resected left-sided pancreatic adenocarcinoma from 2004 to 2010. Propensity score matching was conducted to compare PORT and non-PORT groups. A total of 445 patients were identified, and PORT was performed in 180 (40 %) patients. In the unmatched population, there were no significant differences in overall survival (OS) (P = 0.197) and cause-specific survival (CSS) (P = 0.379) between the PORT and non-PORT groups. After propensity score matching, the patients treated with PORT had longer median OS (P = 0.012) and CSS (P = 0.039) than the non-PORT group. In propensity-adjusted multivariate analysis, non-receipt of PORT was a poor prognostic factor in OS (hazard ratio [HR] 1.39, 95 % confidence interval [CI] 1.08-1.79), and CSS (HR 1.31, 95 % CI 1.01-1.71). The log odds of positive lymph nodes (LOODS) (≥-0.73) was also associated with worse OS (P = 0.003) and CSS (P = 0.001). In left-sided pancreatic cancer, considering the addition of PORT is a reasonable option as in pancreatic head cancer. The LOODS was suggested as a strong predictive indicator of the patients' prognoses.
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Affiliation(s)
- Yu Jin Lim
- Department of Radiation Oncology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.,Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, Republic of Korea
| | - BoKyong Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Sung W Ha
- Department of Radiation Oncology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.,Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, Republic of Korea
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23
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Basturk O, Saka B, Balci S, Postlewait LM, Knight J, Goodman M, Kooby D, Sarmiento JM, El-Rayes B, Choi H, Bagci P, Krasinskas A, Quigley B, Reid MD, Akkas G, Maithel SK, Adsay V. 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 2015; 22 Suppl 3:S1187-95. [PMID: 26362048 DOI: 10.1245/s10434-015-4861-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Indexed: 01/09/2023]
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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Affiliation(s)
- Olca Basturk
- Department of Pathology, New York University, New York, NY, USA.,Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Burcu Saka
- Department of Pathology, Istanbul Medipol University, Istanbul, Turkey
| | - Serdar Balci
- Department of Pathology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Lauren M Postlewait
- Department of Surgical Oncology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Jessica Knight
- Department of Epidemiology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Michael Goodman
- Department of Epidemiology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - David Kooby
- Department of Surgical Oncology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Juan M Sarmiento
- Department of General Surgery, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Bassel El-Rayes
- Department of Medical Oncology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Hyejeong Choi
- Department of Pathology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Pelin Bagci
- Department of Pathology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Alyssa Krasinskas
- Department of Pathology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Brian Quigley
- Department of Pathology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Michelle D Reid
- Department of Pathology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Gizem Akkas
- Department of Pathology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Shishir K Maithel
- Department of Surgical Oncology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Volkan Adsay
- Department of Pathology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA.
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Roland CL, Katz MHG, Tzeng CWD, Lin H, Varadhachary GR, Shroff R, Javle M, Fogelman D, Wolff RA, Vauthey JN, Crane CH, Lee JE, Fleming JB. The Addition of Postoperative Chemotherapy is Associated with Improved Survival in Patients with Pancreatic Cancer Treated with Preoperative Therapy. Ann Surg Oncol 2015; 22 Suppl 3:S1221-8. [PMID: 26350371 DOI: 10.1245/s10434-015-4854-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Preoperative/neoadjuvant therapy (NT) is increasingly utilized for the treatment of pancreatic ductal adenocarcinoma (PDAC). However, little data exist regarding information on the use of additional postoperative therapy following NT. The lymph node ratio (LNR) is a prognostic marker of oncologic outcomes after NT and resection. In this study, we evaluated the effectiveness of postoperative therapy following NT, stratified by LNR. METHODS A prospective tumor registry database was queried to identify patients with PDAC who underwent resection following NT from 1990 to 2008. Clinicopathologic factors were compared to identify associations with overall survival (OS) and time to recurrence (TTR) based on postoperative chemotherapy status. RESULTS Thirty-six (14 %) of the 263 patients received additional postoperative therapy. No differences were observed in the pathologic characteristics between patients who received postoperative chemotherapy and those who did not. The median LNR was 0.12 for patients with N + disease. Following NT, the administration of postoperative therapy was associated with improved median OS (72 vs. 33 months; p = 0.008) for patients with an LNR < 0.15. There was no association between postoperative chemotherapy and OS for patients with LNR ≥ 0.15. Multivariate analysis demonstrated that the administration of postoperative systemic therapy in patients with a low LNR was associated with a reduced risk of death (hazard ratio 0.49; p = 0.02). CONCLUSION Postoperative chemotherapy after NT in patients with low LNR is associated with improved oncologic outcomes.
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Affiliation(s)
- Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Heather Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gauri R Varadhachary
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rachna Shroff
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Milind Javle
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Fogelman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert A Wolff
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean N Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher H Crane
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jason B Fleming
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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25
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Guo JC, Li J, Zhao YP, Zhou L, Cui QC, Zhou WX, Zhang TP, You L, Shu H. N-wasp in pancreatic ductal adenocarcinoma: associations with perineural invasion and poor prognosis. World J Surg 2015; 38:2126-31. [PMID: 24718883 DOI: 10.1007/s00268-014-2500-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) has long been acknowledged to have a dismal prognosis. Therefore, prognostic markers, especially molecular ones, are of interest. So far, expression of Neural Wiskott-Aldrich syndrome protein (N-WASP) and its associations with clinicopathologic variables and prognosis for patients with PDAC remain unknown. METHODS N-WASP expression was detected by immunohistochemical staining in a tissue microarray consisted of tumor and nontumor samples from 86 patients with PDAC. The correlations of N-WASP expression with clinicopathologic features and overall survival were evaluated. In addition, risk factors of perineural invasion (PNI) were identified. RESULTS High expression of N-WASP was more frequent in tumor than in nontumor tissues of PDAC patients (45.3 vs. 19.8%, p < 0.001). The rank of N-WASP grading was significantly higher in tumor tissues than in nontumor tissues (p = 0.048). Also, high expression of N-WASP in tumor tissues was significantly associated with PNI, and lymph node status had a marginally significant relation to tumoral N-WASP expression. Univariate analyses showed that, in addition to conventional clinicopathologic variables, including sex, histologic grade, PNI and lymph node metastasis, high tumoral N-WASP expression was an independent marker of PNI and served as a significant predictor of poor overall survival. The prognostic implication of N-WASP expression was not proven In the multivariate analysis. CONCLUSIONS Our data showed highly up-regulated expression of N-WASP in PDAC tissues, its correlations with PNI, and its association with an unfavorable prognosis.
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Affiliation(s)
- Jun-Chao Guo
- Department of General Surgery, Peking Union Medical College Hospital, National Laboratory of Medical Molecular Biology, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, 100730, China
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26
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Fischer LK, Katz MH, Lee SM, Liu L, Wang H, Varadhachary GR, Wolff RA, Lee JE, Maitra A, Roland CL, Fleming JB, Estrella J, Rashid A, Wang H. The number and ratio of positive lymph nodes affect pancreatic cancer patient survival after neoadjuvant therapy and pancreaticoduodenectomy. Histopathology 2015; 68:210-20. [PMID: 25945396 DOI: 10.1111/his.12732] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 05/01/2015] [Indexed: 02/06/2023]
Abstract
AIMS This study is to examine the significance of the number and ratio of positive nodes in post-neoadjuvant therapy pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). METHODS AND RESULTS Our study population consisted of 398 consecutive PDAC patients, who completed neoadjuvant therapy and PD between 1999 and 2012. Lymph node status was classified as ypN0 (node-negative), ypN1 (1-2 positive nodes) and ypN2 (≥3 positive nodes) and correlated with disease-free survival (DFS) and overall survival (OS). The ypN0, ypN1 and ypN2 was present in 183 (46.0%), 117 (29.4%) and 98 (24.6%) patients, respectively. Additionally, 162 (40.7%) had a lymph node ratio (LNR) ≤0.19 and 53 (13.3%) had a LNR >0.19. Patients with ypN1 disease had shorter DFS and OS than those with ypN0 disease, but better DFS and OS than those with ypN2 disease (P < 0.05). Similarly, patients with a LNR ≤ 0.19 had better DFS and OS than those with a LNR > 0.19 (P < 0.001). In multivariate analysis, both the number of positive nodes and LNR were independent prognostic factors for DFS and OS. CONCLUSIONS Subclassification of post-therapy node-positive group into ypN1 (1-2 positive nodes) and ypN2 (≥3 positive nodes) should be incorporated into the American Joint Committee on Cancer (AJCC) staging of PDAC patients.
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Affiliation(s)
- Laurice K Fischer
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew H Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sun M Lee
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Li Liu
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hua Wang
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gauri R Varadhachary
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert A Wolff
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anirban Maitra
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jason B Fleming
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeannelyn Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Asif Rashid
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Huamin Wang
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abstract
OBJECTIVE To determine the prognostic value of PLN and LNR based on a large series with standardized lymphadenectomy and pathological workup. BACKGROUND Lymph node (LN) involvement is a major prognostic factor in pancreatic adenocarcinoma. However, the distinction N0/N1 is not sufficient to accurately predict prognosis. To improve prognostic accuracy in N1 tumors, different LN parameters have been tested. Previous studies were based on series with variable numbers of examined lymph nodes (ELN) and came to inconsistent conclusions as to the value of the number of positive lymph nodes (PLN) and the lymph node ratio (LNR). METHODS 811 patients who underwent pancreatoduodenectomy for pancreatic adenocarcinoma between October 2001 and June 2012 were identified from a prospective database. Clinicopathological parameters included LN status (N0/N1), ELN, PLN, and LNR. Univariate and multivariate survival analyses were performed. RESULTS The median number of ELN was 24 (interquartile range: 18-32). By univariate analysis, both PLN and LNR were significantly associated with survival in N1 tumors. However, by multivariate analysis, only the number of PLN was confirmed as independent predictor of survival. Median survival in patients with only 1 PLN was 31.1 months and comparable to the survival in N0 (33.2 months). With increasing numbers of PLN median survival significantly decreased (2-3 PLN: 26.1 months, 4-7 PLN: 21.9 months, ≥8 PLN: 18.3 months, P < 0.0001). CONCLUSIONS This study demonstrates that, based on high numbers of ELN, PLN is superior to LNR in predicting survival and allows to distinguish several N-categories that improve prognostic accuracy in LN-positive resectable pancreatic adenocarcinoma.
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Expression of c-fos was associated with clinicopathologic characteristics and prognosis in pancreatic cancer. PLoS One 2015; 10:e0120332. [PMID: 25789763 PMCID: PMC4366380 DOI: 10.1371/journal.pone.0120332] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 01/30/2015] [Indexed: 01/28/2023] Open
Abstract
It has long been regarded that pancreatic cancer (PC) is a life-threatening malignant tumor. Thus, much attention has been paid for factors, especially relative molecules, predictive for prognosis of PC. However, c-fos expression in PC was less investigated. In addition, its association with clinicopathologic variables and prognosis remains unknown. In the present study, expression of c-fos was detected by tissue microarray-based immunohistochemical staining in cancer and adjacent tissues from 333 patients with PC. The staining results were correlated with clinicopathologic parameters and overall survival. Furthermore, prognostic significance of c-fos in subsets of PC was also evaluated. It was shown that low expression of c-fos was more often in cancer than in adjacent tissues of PC (P<0.001). Besides, high cancerous c-fos expression was significantly associated with tumor site and T stage, whereas peri-neural invasion was of a borderline significant relevance. Log-rank test revealed that high expression of c-fos in cancer tissues was a significant marker of poor overall survival, accompanied by some conventional clinicopathologic variables, such as sex, grade, peri-neural invasion, T and N stages. More importantly, cancerous c-fos expression was identified as an independent prognosticator in multivariate analysis. Finally, the prognostic implication of c-fos expression was proven in four subsets of patients with PC. These data suggested that c-fos expression was of relationships with progression and dismal prognosis of PC.
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29
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Liu ZQ, Xiao ZW, Luo GP, Liu L, Liu C, Xu J, Long J, Ni QX, Yu XJ. Effect of the number of positive lymph nodes and lymph node ratio on prognosis of patients after resection of pancreatic adenocarcinoma. Hepatobiliary Pancreat Dis Int 2014; 13:634-41. [PMID: 25475867 DOI: 10.1016/s1499-3872(14)60264-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The prognostic factors related to lymph node involvement [lymph node status, the number of positive lymph nodes, lymph node ratio (LNR)] and the number of nodes evaluated in patients with pancreatic adenocarcinoma after pancreatectomy are poorly defined. METHODS A total of 167 patients who had undergone resection of pancreatic adenocarcinoma from February 2010 to August 2011 were included in this study. Histological examination was performed to evaluate the tumor differentiation and lymph node involvement. Univariate and multivariate analyses were made to determine the relationship between the variables related to nodal involvement and the number of nodes and survival. RESULTS The median number of total nodes examined was 10 (range 0-44) for the entire cohort. The median number of total nodes examined in node-negative (pN0) patients was similar to that in node-positive (pN1) patients. Patients with pN1 diseases had significantly worse survival than those with pN0 ones (P=0.000). Patients with three or more positive nodes had a poorer prognosis compared with those with the negative nodes (P=0.000). The prognosis of the patients with negative nodes was similar to that of those with one to two positive nodes (P=0.114). The median survival of patients with an LNR ≥0.4 was shorter than that of patients with an LNR <0.4 in the pN1 cohort (P=0.014). No significance was found between the number of total nodes examined and the prognosis, regardless of the cutoff of 10 or 12 and in the entire cohort or the pN0 and pN1 groups. Based on the multivariate analysis of the entire cohort and the pN1 group, the nodal status, the number of positive nodes and the LNR were all associated with survival. CONCLUSIONS In addition to the nodal status, the number of positive nodes and the LNR can serve as comprehensive factors for the evaluation of nodal involvement. This approach may be more effective for predicting the survival of patients with pancreatic adenocarcinoma after pancreatectomy.
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Affiliation(s)
- Zu-Qiang Liu
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University; Pancreatic Cancer Institute, Fudan University, Shanghai 200032, China.
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30
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Roland CL, Yang AD, Katz MHG, Chatterjee D, Wang H, Lin H, Vauthey JN, Pisters PW, Varadhachary GR, Wolff RA, Crane CH, Lee JE, Fleming JB. Neoadjuvant therapy is associated with a reduced lymph node ratio in patients with potentially resectable pancreatic cancer. Ann Surg Oncol 2014; 22:1168-75. [PMID: 25352267 DOI: 10.1245/s10434-014-4192-6] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND The use of neoadjuvant therapy (NAC) for the treatment of potentially resectable pancreatic cancer remains controversial. In this study, we sought to evaluate cancer-specific endpoints in patients undergoing a NAC versus a surgery-first (SF) approach with specific emphasis on lymph node metastases. METHODS A total of 222 patients who underwent NAC and 85 patients who underwent SF were identified from 1990 to 2008 and compared for cancer-related endpoints. Peripancreatic lymph nodes from 135 neoadjuvant therapy patients were evaluated for histologic tumor regression. RESULTS Patients who underwent NAC followed by surgery had improved overall survival and time to local recurrence compared with the SF approach. NAC patients were less likely to have lymph node metastases (p = 0.001), lymphovascular invasion (LVI), and had smaller tumors. On multivariate analysis, lymph node positivity was associated with SF, tumor size, and the presence of LVI. NAC patients with N0 disease had equivalent outcomes to patients with a low-LNR (0.01-0.15), whereas patients with a LNR >0.15 had reduced survival, and time to local and distant recurrence. Ten of 135 (7.4 %) NAC patients had evidence of tumor regression in at least one lymph node. CONCLUSIONS Patients with potentially resectable PDAC selected to undergo NAC had improved survival and longer time to recurrence. Although some of these differences may be related to improvements in multimodality therapy completion rates, tumor regression in lymph node metastases exists and may demonstrate a biologic benefit of NAC compared with a SF approach.
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Affiliation(s)
- Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
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Abstract
BACKGROUND Recent studies have shown the clinical significance of epidermal growth factor-like domain 7 (EGFL7) in a variety of cancers. However, the relationship between EGFL7 and the prognosis of pancreatic cancer (PC) remains unclear. The present study was undertaken to investigate the role of EGFL7 in the prognosis of PC. METHODS The expression of EGFL7 in nine PC cell lines was first determined by Western blotting analysis. Tissue microarray-based immunohistochemical staining was performed in paired formalin-fixed paraffin-embedded tumor and non-tumor samples from 83 patients with PC. Finally, correlations between EGFL7 expression and clinicopathological variables as well as overall survival were evaluated. RESULTS EGFL7 was widely expressed in all PC cell lines tested. EGFL7 expression in tumor tissues was significantly higher than that in non-tumor tissues (P=0.040). In addition, univariate analysis revealed that high EGFL7 expression in tumor tissues was significantly associated with poor overall survival, accompanied by several conventional clinicopathological variables, such as gender, histological grade and lymph node metastasis. In a multivariate Cox regression test, EGFL7 expression was identified as an independent marker for long-term outcome of PC. CONCLUSION Our data showed that EGFL7 is extensively expressed in PC and that EGFL7 is associated with poor prognosis.
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The Association between Survival and the Pathologic Features of Periampullary Tumors Varies over Time. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2014; 2014:890530. [PMID: 25104878 PMCID: PMC4102018 DOI: 10.1155/2014/890530] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 06/15/2014] [Indexed: 02/07/2023]
Abstract
Introduction. Several histopathologic features of periampullary tumors have been shown to be correlated with prognosis. We evaluated their association with mortality at multiple time points. Methods. A retrospective chart review identified 207 patients with periampullary adenocarcinomas who underwent pancreaticoduodenectomy between January 1, 2001 and December 31, 2009. Clinicopathologic features were assessed, and the data were analyzed using univariate and multivariate methods. Results. In univariate analysis, perineural invasion had a strong association with 1-year mortality (OR 3.03, CI 1.42–6.47), and one lymph node (LN) increase in the LN ratio (LNR) equated with a 5-fold increase in mortality. In contrast, LN status (OR 6.42, CI 3.32–12.41) and perineural invasion (OR 5.44, CI 2.81–10.52) had the strongest associations with mortality at 3 years. Using Cox proportional hazards, perineural invasion (HR 2.61, CI 1.77–3.85) and LN status (HR 2.69, CI 1.84–3.95) had robust associations with overall mortality. Recursive partitioning analysis identified LNR as the most important risk factor for mortality at 1 and 3 years. Conclusions. Overall mortality was closely related to the LNR within the first year, while longer follow-up periods demonstrated a stronger association with perineural invasion and overall LN status. Therefore, the current staging for periampullary tumors may need to be updated to include the LNR.
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Prognostic assessment of different lymph node staging methods for pancreatic cancer with R0 resection: pN staging, lymph node ratio, log odds of positive lymph nodes. Pancreatology 2014; 14:289-94. [PMID: 25062879 DOI: 10.1016/j.pan.2014.05.794] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 05/22/2014] [Accepted: 05/24/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Survival after surgical resection of pancreatic adenocarcinoma is poor. Several prognostic factors such as the status of the resection margin, lymph node status, or tumour grading have been identified. The aims of the present study were to evaluate and compare the prognostic assessment of different lymph nodes staging methods: standard lymph node (pN) staging, metastatic lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) in pancreatic cancer after pancreatic resection. MATERIALS AND METHODS Data were retrospectively collected from 143 patients who had undergone R0 pancreatic resection for pancreatic ductal adenocarcinoma. Survival curves (Kaplan-Meier and Cox proportional hazard models), accuracy, and homogeneity of the 3 methods (LNR, LODDS, and pN) were compared to evaluate the prognostic effects. RESULTS Multivariate analysis demonstrated that LODDS and LNR were an independent prognostic factors, but not pN classification. The scatter plots of the relationship between LODDS and the LNR suggested that the LODDS stage had power to divide patients with the same ratio of node metastasis into different groups. For patients in each of the pN or LNR classifications, significant differences in survival could be observed among patients in different LODDS stages. CONCLUSION LODDS and LNR are more powerful predictors of survival than the lymph node status in patients undergoing pancreatic resection for ductal adenocarcinoma. LODDS allows better prognostic stratification comparing LNR in node negative patients.
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Weber CE, Bock EA, Hurtuk MG, Abood GJ, Pickleman J, Shoup M, Aranha GV. Clinical and pathologic features influencing survival in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma. J Gastrointest Surg 2014; 18:340-7. [PMID: 24272772 DOI: 10.1007/s11605-013-2388-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 10/07/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of the study was to determine the clinicopathological features that influence survival in patients with resected pancreatic ductal adenocarcinoma (PDA). METHODS The study used a single institution retrospective review of patients undergoing pancreaticoduodenectomy (PD) for PDA from 1993 to 2010. RESULTS Two hundred forty-six consecutive cases of resected PDA were identified: 128 males (52 %), median age 68 years. Median hospital length of stay was 8 days and 30-day mortality rate was 2.4 %. There were 101 (41.1 %) postoperative complications, 77 % of which were Dindo-Clavien Grade 3 or less. Overall survival was 85, 63, 25, and 15 % at 6 months, 1 year, 3 years, and 5 years, respectively, with a median survival of 17 months. Multivariate Cox proportional hazard modeling demonstrated lymph node ratio was negatively correlated with survival at all time points. Preoperative hypertension was a poor prognostic factor at 6 months, 3 years, and 5 years. The absence of postoperative complications was protective at 6 months whereas pancreatic leaks were associated with worse survival at 6 months. Abdominal pain on presentation, operative time, and estimated blood loss were also associated with decreased survival at various time points. CONCLUSION The strongest prognostic variable for short- and long-term survival after PD for PDA is lymph node ratio. Short-term survival is influenced by the postoperative course.
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Affiliation(s)
- Cynthia E Weber
- Department of Surgery, Division of Surgical Oncology, Loyola University, Maywood, IL, USA
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35
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Kang MJ, Jang JY, Chang YR, Kwon W, Jung W, Kim SW. Revisiting the concept of lymph node metastases of pancreatic head cancer: number of metastatic lymph nodes and lymph node ratio according to N stage. Ann Surg Oncol 2014; 21:1545-51. [PMID: 24419758 DOI: 10.1245/s10434-013-3473-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Some suggest that metastatic lymph node ratio (LNR) may be prognostic of survival in patients with pancreatic cancer. However, this phenomenon was confused by inclusion of node-negative patients in the analysis. The present study was designed to evaluate the prognostic impact of metastatic LNR and the absolute number of metastatic LNs in patients resected for pancreatic cancer. METHODS Data were collected from 398 patients who underwent curative surgery for pancreatic head cancer at Seoul National University Hospital. Long-term survival was analyzed according to LNR and absolute number of metastatic LNs. RESULTS Of the patients, 227 (57.0 %) had LN metastasis. The mean numbers of total retrieved and metastatic LNs were 19.5 and 1.9, respectively, and the mean LNR was 0.11. Median overall survival (OS) of patients was significantly higher in N0 than in N1 patients after curative resection (25.4 vs. 14.8 months, p < 0.001). Median OS was significantly lower in patients with 1 than in those with 0 positive LNs (17.3 vs. 25.4 months, p = 0.001). Among N1 patients, those with 0 < LNR ≤ 0.2 had comparable prognosis than those with >0.2 LNR (median OS 17.2 vs. 12.8 months, p = 0.096), and the number of metastatic LNs did not correlate with median OS (p = 0.365). CONCLUSIONS The presence of a single positive metastatic LN was associated with significantly poorer OS in patients with pancreatic cancer. When LN metastasis was present, the number of metastatic LNs and LNR had limited prognostic relevance.
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Affiliation(s)
- Mee Joo Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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36
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La Torre M, Nigri G, Lo Conte A, Mazzuca F, Tierno SM, Salaj A, Marchetti P, Ziparo V, Ramacciato G. Is a preoperative assessment of the early recurrence of pancreatic cancer possible after complete surgical resection? Gut Liver 2013; 8:102-8. [PMID: 24516708 PMCID: PMC3916679 DOI: 10.5009/gnl.2014.8.1.102] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 02/27/2013] [Accepted: 04/07/2013] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND/AIMS The prognosis of pancreatic adenocarcinoma (PAC) is poor. The serum carbohydrate antigen 19-9 (CA 19-9) level has been identified as a prognostic indicator of recurrence and reduced overall survival. The aim of this study was to identify preoperative prognostic factors and to create a prognostic model able to assess the early recurrence risk for patients with resectable PAC. METHODS A series of 177 patients with PAC treated surgically at the St. Andrea Hospital of Rome between January 2003 and December 2011 were reviewed retrospectively. Univariate and multivariate analyses were utilized to identify preoperative prognostic indicators. RESULTS A preoperative CA 19-9 level >228 U/mL, tumor size >3.1 cm, and the presence of pathological preoperative lymph nodes statistically correlated with early recurrence. Together, these three factors predicted the possibility of an early recurrence with 90.4% accuracy. The combination of these three preoperative conditions was identified as an independent parameter for early recurrence based on multivariate analysis (p=0.0314; hazard ratio, 3.9811; 95% confidence interval, 1.1745 to 15.3245). CONCLUSIONS PAC patient candidates for surgical resection should undergo an assessment of early recurrence risk to avoid unnecessary and ineffective resection and to identify patients for whom palliative or alternative treatment may be the treatment of choice.
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Affiliation(s)
- Marco La Torre
- Department of General Surgery, Biomedical Technologies and Translational Medicine, St. Andrea Hospital, University of Rome La Sapienza Faculty of Medicine and Psychology, Rome, Italy
| | - Giuseppe Nigri
- Department of Hepato-Biliary and Pancreatic Surgery, Biomedical Technologies and Translational Medicine, St. Andrea Hospital, University of Rome La Sapienza Faculty of Medicine and Psychology, Rome, Italy
| | - Annalisa Lo Conte
- Department of General Surgery, Biomedical Technologies and Translational Medicine, St. Andrea Hospital, University of Rome La Sapienza Faculty of Medicine and Psychology, Rome, Italy
| | - Federica Mazzuca
- Department of Oncology, Biomedical Technologies and Translational Medicine, St. Andrea Hospital, University of Rome La Sapienza Faculty of Medicine and Psychology, Rome, Italy
| | - Simone Maria Tierno
- Department of General Surgery, Biomedical Technologies and Translational Medicine, St. Andrea Hospital, University of Rome La Sapienza Faculty of Medicine and Psychology, Rome, Italy
| | - Adelona Salaj
- Department of General Surgery, Biomedical Technologies and Translational Medicine, St. Andrea Hospital, University of Rome La Sapienza Faculty of Medicine and Psychology, Rome, Italy
| | - Paolo Marchetti
- Department of Oncology, Biomedical Technologies and Translational Medicine, St. Andrea Hospital, University of Rome La Sapienza Faculty of Medicine and Psychology, Rome, Italy
| | - Vincenzo Ziparo
- Department of General Surgery, Biomedical Technologies and Translational Medicine, St. Andrea Hospital, University of Rome La Sapienza Faculty of Medicine and Psychology, Rome, Italy
| | - Giovanni Ramacciato
- Department of Hepato-Biliary and Pancreatic Surgery, Biomedical Technologies and Translational Medicine, St. Andrea Hospital, University of Rome La Sapienza Faculty of Medicine and Psychology, Rome, Italy
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Standard Retrograde Pancreatosplenectomy versus Radical Antegrade Modular Pancreatosplenectomy for Body and Tail Pancreatic Adenocarcinoma. Am Surg 2013. [DOI: 10.1177/000313481307901117] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Pancreatic surgery remains the only established curative treatment for pancreatic cancer. Radical antegrade pancreatosplenectomy (RAMPS) is a modification of the standard retrograde pancreatosplenectomy (SRPS) developed to achieve a complete N1 node resection and R0 resection (posterior extent). The aim of this study is to compare the short-, mid-, and long-term outcomes of RAMPS and SRPS. From a database that included 143 consecutive patients who underwent resection for pancreatic carcinoma at the St. Andrea Hospital, University of Rome, 25 patients who underwent pancreatosplenectomy were retrospectively reviewed. Among these 25 patients, eight (32%) underwent RAMPS (Group 1) and 17 (68%) underwent SRPS (Group 2). Clinicopathologic and oncological characteristics of the RAMPS group were compared with those of the SRPS group. RAMPS was longer than SRPS (315 vs 265 minutes, respectively, P < 0.001). No differences were encountered for perioperative outcomes (estimated blood loss, intraoperative blood transfusions, postoperative morbidity and mortality, and hospital stay). The margin status rates were similar: noteworthy, the two patients with positive tangential margins belonged to Group 2. No between-group differences in survival were encountered: the actuarial 5-year overall survival for Groups 1 and 2 were 26 and 29 per cent, respectively ( P = 0.6608; hazard ratio, 1.2621; 95% confidence interval, 0.4462 to 3.5699). RAMPS and SRPS did not differ statistically in terms of perioperative outcomes. RAMPS seems to allow better control of tangential margins; however, no difference was found in actuarial survival compared with standard pancreatosplenectomy.
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Wang LP, Wang HY, Cao R, Zhu C, Wu XZ. Proposal of a new classification for stage III colorectal cancer based on the number and ratio of metastatic lymph nodes. World J Surg 2013. [PMID: 23385643 DOI: 10.1007/s00268013-1940-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The objective of this retrospective study was to determine whether the current staging system for stage III colorectal cancer (CRC) is appropriate and to assess the value of the metastatic lymph node ratio (LNR) in predicting the prognosis of patients with stage III CRC. METHODS From 2000 to 2006 inclusively, 245 patients with stage III CRC underwent curative resection. The follow-up was closed in March 2012. Kaplan-Meier survival curves and log-rank tests were used for the survival analysis. RESULTS Survival time of patients with T3N1M0 was significantly better than that for patients in other subgroups of stage IIIB and similar to that of patients with stage IIIA disease. The greatest survival difference was found with 0.30 as the LNR cutoff point for patients with current stage III CRC. Survival time of patients with LNR ≤ 0.30 was significantly better than that of those with LNR > 0.30. rN1 included stage III patients with LNR ≤ 0.30, and rN2 included patients with LNR > 0.30. Survival time of patients with T4aN1(rN2)M0 staging was significantly worse than that for patients with T4aN1(rN1)M0 staging and similar to that of patients with stage IIIC CRC. CONCLUSIONS We propose an algorithm to incorporate LNR into the current American Joint Committee on Cancer staging system. In it the patients with T3N1M0 are excluded from the current stage IIIB and included in the stage IIIA group. Also, patients with T4aN1(rN2)M0 are excluded from the current stage IIIB group and included in the stage IIIC group.
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Affiliation(s)
- Li-Ping Wang
- Department of Zhong-Shan-Men In-patient, Tianjin Medical University Cancer Institute and Hospital, Huan-Hu-Xi Road, He-Xi District, Tianjin 300171, China
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Wang LP, Wang HY, Cao R, Zhu C, Wu XZ. Proposal of a new classification for stage III colorectal cancer based on the number and ratio of metastatic lymph nodes. World J Surg 2013; 37:1094-102. [PMID: 23385643 DOI: 10.1007/s00268-013-1940-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The objective of this retrospective study was to determine whether the current staging system for stage III colorectal cancer (CRC) is appropriate and to assess the value of the metastatic lymph node ratio (LNR) in predicting the prognosis of patients with stage III CRC. METHODS From 2000 to 2006 inclusively, 245 patients with stage III CRC underwent curative resection. The follow-up was closed in March 2012. Kaplan-Meier survival curves and log-rank tests were used for the survival analysis. RESULTS Survival time of patients with T3N1M0 was significantly better than that for patients in other subgroups of stage IIIB and similar to that of patients with stage IIIA disease. The greatest survival difference was found with 0.30 as the LNR cutoff point for patients with current stage III CRC. Survival time of patients with LNR ≤ 0.30 was significantly better than that of those with LNR > 0.30. rN1 included stage III patients with LNR ≤ 0.30, and rN2 included patients with LNR > 0.30. Survival time of patients with T4aN1(rN2)M0 staging was significantly worse than that for patients with T4aN1(rN1)M0 staging and similar to that of patients with stage IIIC CRC. CONCLUSIONS We propose an algorithm to incorporate LNR into the current American Joint Committee on Cancer staging system. In it the patients with T3N1M0 are excluded from the current stage IIIB and included in the stage IIIA group. Also, patients with T4aN1(rN2)M0 are excluded from the current stage IIIB group and included in the stage IIIC group.
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Affiliation(s)
- Li-Ping Wang
- Department of Zhong-Shan-Men In-patient, Tianjin Medical University Cancer Institute and Hospital, Huan-Hu-Xi Road, He-Xi District, Tianjin 300171, China
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Ricci C, Casadei R, Taffurelli G, Buscemi S, D'Ambra M, Monari F, Santini D, Campana D, Tomassetti P, Minni F. The role of lymph node ratio in recurrence after curative surgery for pancreatic endocrine tumours. Pancreatology 2013; 13:589-93. [PMID: 24280574 DOI: 10.1016/j.pan.2013.09.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 09/04/2013] [Accepted: 09/11/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND The prognostic role of lymph nodes metastasis in pancreatic neuroendocrine tumours is unclear. METHODS Retrospective study of 53 patients who underwent a curative standard resection for pancreatic neuroendocrine tumours. The endpoint was to define the role of the lymph nodes ratio in recurrence after curative surgery. The following data were considered as possible factors for predicting the risk of recurrence: gender, age, presence of symptoms, hormonal status, site of tumours, type of resection, size of the tumours, radical resection, pathological T, N and M stage, the Ki67 index, the number of lymph nodes harvested, the number of metastatic lymph nodes and the lymph node ratio. Recurrence rate and time of recurrence were evaluated. RESULTS Twelve (26.4%) patients developed a recurrence with a median time of 42.8 (1-305) months. At multivariate analysis, the only factors related to recurrence were: size of lesions (HR 1.1, C.I. 95% 1.0-1.1, P = 0.011), Ki67 ≥ 5% (HR 3.6, C.I. 95% 1.3-10, P = 0.014) and LNR > 0.07 (HR 5.2, C.I. 95% 1.1-25, P = 0.045). CONCLUSIONS Our study confirmed that the lymph nodes ratio played an important role in the recurrence rate and suggested that a low number of metastatic lymph nodes reduced the disease free survival.
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Affiliation(s)
- Claudio Ricci
- Department of Internal Medicine, Emergency and Surgery (DIMES), Alma Mater Studiorum, University of Bologna, S.Orsola-Malpighi Hospital, Italy.
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La Torre M, Mazzuca F, Ferri M, Mari FS, Botticelli A, Pilozzi E, Lorenzon L, Osti MF, Marchetti P, Enrici RM, Ziparo V. The importance of lymph node retrieval and lymph node ratio following preoperative chemoradiation of rectal cancer. Colorectal Dis 2013; 15:e382-8. [PMID: 23581854 DOI: 10.1111/codi.12242] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 02/05/2013] [Indexed: 12/13/2022]
Abstract
AIM Preoperative chemoradiation (CRT) for rectal cancer decreases the number of examined lymph nodes (NELN) found in the resected specimen. However, the prognostic role of lymph node evaluation including overall numbers and the lymph node ratio (LNR) in patients having preoperative CRT have not yet been defined. The study has assessed the influence of CRT on the NELN and on lymph node number and LNR on the survival of patients with rectal cancer. METHOD Between 2003 and 2011, 508 patients with nonmetastatic rectal cancer underwent mesorectal excision. Of these 123 (24.2%) received preoperative CRT. Univariate and multivariate analysis was performed to define the role of NELN and LNR as prognostic indicators of survival. RESULTS Neoadjuvant CRT significantly reduced the NELN (P < 0.0001). Disease-free survival (DFS) and overall survival (OS) of patients with fewer or more than 12 nodes retrieved did not differ statistically. Node-negative patients with six or fewer lymph nodes were significantly associated with a poor DFS and OS on univariate analysis (P = 0.03 and P = 0.03). LNR significantly influenced the DFS and OS on multivariate analysis [DFS, P = 0.0473, hazard ratio (HR) 2.4980, 95% confidence interval (CI) 1.2631-9.4097; OS, P = 0.0419, HR 1.1820, 95% CI 1.1812-10,710]. CONCLUSION The cut-off of 12 lymph nodes does not influence survival and should not be considered for cancer-specific prediction of patients having neoadjuvant CRT. In contrast LNR is an independent prognostic predictor of DFS and OS in such patients.
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Affiliation(s)
- M La Torre
- Surgical Department of Clinical Sciences, Faculty of Medicine and Psychology, Biomedical Technologies and Translational Medicine 'La Sapienza', Sant'Andrea Hospital, University of Rome 'La Sapienza', Rome, Italy.
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La Torre M, Ramacciato G, Nigri G, Balducci G, Cavallini M, Rossi M, Ziparo V. Post-operative morbidity and mortality in pancreatic surgery. The role of surgical Apgar score. Pancreatology 2013; 13:175-9. [PMID: 23561976 DOI: 10.1016/j.pan.2013.01.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 11/21/2012] [Accepted: 01/26/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Morbidity and mortality rates after pancreatic resection still remain high. The surgical Apgar score (SAS) has been recently introduced as predictive value of perioperative outcomes after pancreatic surgery. Aim of the study was to detect significant parameters affecting post-operative outcomes in pancreatic surgery, and to evaluate the role of SAS in predicting morbidity, pancreatic fistulas and mortality. MATERIALS AND METHODS Data were collected from 143 patients who had undergone pancreatic resection for pancreatic and periampullary adenocarcinoma. Pre-operative and intra-operative parameters were statistically analyzed to evaluate their potential prognostic effects. RESULTS A low SAS (p = 0.001), hypo-albuminemia (p = 0.003), and the need for blood transfusions (p = 0.05) were significant independent predictors of postoperative morbidity. The SAS was demonstrated to significantly predict major complications (p = 0.001) surgical site infections (p = 0.001) and mortality (p = 0.001). CONCLUSION The SAS provides a simple, immediate, and objective means of measuring patient outcomes in surgery. This score should be used to identify patients at high risk of major complications and death after pancreatic surgery and may be useful to optimize the use of postoperative critical care beds and hospital resources.
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Affiliation(s)
- Marco La Torre
- Department of General Surgery, Surgical Department of Clinical Sciences, Biomedical Technologies and Translational Medicine, Faculty of Medicine and Psychology, University of Rome La Sapienza, St. Andrea Hospital, Via di Grottarossa, 1035-39, 00189 Rome, Italy.
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The lymph node ratio has limited prognostic significance in melanoma. J Surg Res 2013; 179:10-7. [DOI: 10.1016/j.jss.2012.08.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 07/30/2012] [Accepted: 08/24/2012] [Indexed: 11/19/2022]
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Pomianowska E, Westgaard A, Mathisen Ø, Clausen OPF, Gladhaug IP. Prognostic relevance of number and ratio of metastatic lymph nodes in resected pancreatic, ampullary, and distal bile duct carcinomas. Ann Surg Oncol 2012; 20:233-41. [PMID: 22893118 DOI: 10.1245/s10434-012-2592-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Lymph node ratio (LNR) may be more useful than nodal (N) status in prognostic subclassification of adenocarcinomas after pancreatoduodenectomy. Ampullary (AC), biliary (DBC), and pancreatic (PC) adenocarcinomas are biologically distinct, and nodal involvement may have different prognostic importance among these separate cancers. METHODS We included 179 consecutive pancreatoduodenectomies for PC, AC, or DBC, and performed standardized histopathologic evaluation, including prospective registration and retrospective reevaluation of the cancer origin. Associations between histopathologic variables and LNR, N status, and number of metastatic nodes were evaluated. Unadjusted and adjusted survival analysis was performed. RESULTS Overall 5 year survival was 6% for PC (n=72), 26% for DBC (n=46), and 46% for AC (n=61). Lymph node involvement was more frequent in PC (75%) than in AC (48%) and DBC (57%). In PC, N status did not discriminate between prognostic groups (N1 vs. N0; p=0.31). However, increasing LNR was associated with poorer survival in unadjusted analysis, as well as when adjusting for margin involvement, degree of differentiation, and tumor diameter (p=0.032; hazard ratio 1.87, 95% confidence interval 1.06-3.31). In AC and DBC, N status clearly discriminated between subgroups of patients with different long-term survival in unadjusted and adjusted survival analysis (N1 vs. N0; p<0.001), whereas number of metastatic nodes and LNR did not predict survival among node-positive resections. CONCLUSIONS The predictive value of nodal involvement depends on the type of cancer within the pancreatic head. In AC and DBC, N status adequately discriminates between good and poor prognosis. In PC, LNR may be more powerful in prognostic subclassification.
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Affiliation(s)
- Ewa Pomianowska
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, and Department of Hepato-pancreato-biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
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Bhamidipati CM, Stukenborg GJ, Thomas CJ, Lau CL, Kozower BD, Jones DR. Pathologic lymph node ratio is a predictor of survival in esophageal cancer. Ann Thorac Surg 2012; 94:1643-51. [PMID: 22621876 DOI: 10.1016/j.athoracsur.2012.03.078] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 03/16/2012] [Accepted: 03/21/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND A ratio between pathologic and examined lymph nodes may have predictive relevance in esophageal cancer. We sought to determine the prognostic value of lymph node ratio (LNR) compared with TNM and N stage using the seventh edition American Joint Commission on Cancer and International Union Against Cancer criteria. METHODS We abstracted data from 347 consecutive patients undergoing esophagectomy for esophageal cancer between 1999 and 2010 at our institution. Patients were stratified into surgery alone or induction therapy followed by surgery. Kaplan-Meier and Cox proportional hazard models estimated the survival function using LNR as a continuous variable or categorized into 0, more than 0.0 to less than 0.1, 0.1 to less than 0.2, 0.2 to less than 0.3, and 0.3 or greater. The influence of LNR on survival was assessed by the Wald χ(2) statistic and survival plots. RESULTS A total of 173 patients (49.9%) underwent induction therapy. The pathologic complete response rate was 55 of 173 (32%). The median number of examined nodes in surgery alone was 14 (interquartile range, 8 to 21), and induction was 12 (interquartile range, 7 to 17). Patients with nodal disease (n = 137) had a median LNR of 0.2 with equivalent survival regardless of induction therapy. Examination of LNR as a continuous variable demonstrated that LNR is an independent predictor of survival in both groups. After categorization, LNR contributed more toward estimating survival than pN stage in both groups. CONCLUSIONS Lymph node ratio is an independent predictor of survival in patients undergoing esophagectomy for esophageal cancer. The LNR makes a greater contribution in estimating overall survival than pN stage, regardless of the utilization of induction therapy.
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Affiliation(s)
- Castigliano M Bhamidipati
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA 22908-0679, USA
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La Torre M, Nigri G, Cavallini M, Mercantini P, Ziparo V, Ramacciato G. The glasgow prognostic score as a predictor of survival in patients with potentially resectable pancreatic adenocarcinoma. Ann Surg Oncol 2012; 19:2917-23. [PMID: 22488099 DOI: 10.1245/s10434-012-2348-9] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND Survival rates after resection of pancreatic adenocarcinoma are poor; however, several tumor-related prognostic factors have been identified. There is increasing evidence that additional patient-related prognostic factors, such as ongoing systemic inflammatory response, are associated with poor outcomes in patients with common solid tumors. The purpose of this study was to evaluate the prognostic significance of the modified glasgow prognostic score (mGPS) in resected pancreatic ductal adenocarcinoma. METHODS Data were collected from 101 patients who had undergone pancreatic resection for ductal adenocarcinoma. Tumor and host factors were analyzed by Kaplan-Meier and Cox proportional hazard models to evaluate their potential prognostic effects. RESULTS An elevated mGPS was associated with lower overall survival rate after pancreatic resection. The median actuarial survival rate for patients with an mGPS of 0, 1, or 2 was 37.2, 11.5, and 7.3, respectively (p = 0.0001). The Cox proportional hazards model, including all the parameters statistically significant at univariate analysis, demonstrated that mGPS, lymph node ratio (LNR), and positive resection margins were independent negative prognostic factors CONCLUSIONS Margin involvement, LNR, and the preoperative mGPS were identified as independent predictors of survival in patients undergoing potentially curative pancreatic resection. Based on the present results and existing validation literature, the mGPS should be included in the routine assessment of patients with pancreatic cancer to better stratify patients for entry into therapeutic trials.
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Affiliation(s)
- Marco La Torre
- Department of General Surgery, University of Rome La Sapienza, Rome, Italy.
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