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Wang ZM, Ma HB, Meng Y. Impact of chemoradiotherapy on the survival of unresectable locally advanced pancreatic cancer: a retrospective cohort analysis. BMC Gastroenterol 2023; 23:107. [PMID: 37020202 PMCID: PMC10077630 DOI: 10.1186/s12876-023-02739-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/22/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND The role of chemoradiotherapy in unresectable locally advanced pancreatic cancer is still unclear. METHODS Data from patients with unresectable locally advanced pancreatic cancer were extracted from the Surveillance, Epidemiology, and End Results Program database. Univariate and multivariate Cox regression analyses were conducted to identify the independent prognostic factors of survival. Propensity score matching was carried out to minimize the interference of confounding factors. Subgroup analysis was performed to screen the characteristics of patients who would benefit from chemoradiotherapy. RESULTS A total of 5002 patients with unresectable locally advanced pancreatic cancer were included. Among them, 2423 (48.4%) received chemotherapy, and 2579 (51.6%) received chemoradiotherapy. The median overall survival of all patients was 11 months. Multivariate Cox analysis showed that age (p < 0.001), marital status (p < 0.001), tumor size (p = 0.001), N stage (p = 0.015) and radiotherapy (p < 0.001) were independent prognostic factors of survival. Both before (HR, 0.817; 95% CI, 0.769-0.868; p < 0.001) and after (HR, 0.904; 95% CI, 0.876-0.933; p < 0.001) propensity score matching, chemoradiotherapy significantly improved the median overall survival of patients from 10 to 12 months. Subgroup analysis showed that chemoradiotherapy was significantly associated with improved survival regardless of sex, primary site or N stage. In addition, the following subgroups all significantly benefited from chemoradiotherapy: age ≥ 50 years, not divorced, grade 2-4, tumor size > 2 cm, adenocarcinoma, mucinous adenocarcinoma and white race. CONCLUSIONS Chemoradiotherapy is highly recommended for patients with unresectable locally advanced pancreatic cancer.
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Affiliation(s)
- Zi-Meng Wang
- Department of Radiation Oncology, Third Affiliated Hospital of Naval Medical University (Eastern Hepatobiliary Surgery Hospital), Shanghai, 200438, China
| | - Hong-Bin Ma
- Department of Radiation Oncology, Third Affiliated Hospital of Naval Medical University (Eastern Hepatobiliary Surgery Hospital), Shanghai, 200438, China
| | - Yan Meng
- Department of Radiation Oncology, Third Affiliated Hospital of Naval Medical University (Eastern Hepatobiliary Surgery Hospital), Shanghai, 200438, China.
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Kang H, Kim SS, Sung MJ, Jo JH, Lee HS, Chung MJ, Park JY, Park SW, Song SY, Park MS, Bang S. Evaluation of the 8th Edition AJCC Staging System for the Clinical Staging of Pancreatic Cancer. Cancers (Basel) 2022; 14:cancers14194672. [PMID: 36230595 PMCID: PMC9563770 DOI: 10.3390/cancers14194672] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/15/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
The 8th edition of the American Joint Committee on Cancer (AJCC) staging system for pancreatic cancer (PC) has been validated for pathological staging; however, its significance for clinical staging remains uncertain. We validated the prognostic performance and suitability of the current staging system for the clinical staging of PC. We identified 1043 patients from our PC registry who were staged by imaging according to the 8th edition staging system and conducted analysis, including overall survival (OS) comparison. Gradual prognostic stratification according to stage hierarchy yielded significant OS differences between stage groups, except between stage I and II (p = 0.193). A substage comparison revealed no survival differences between IB (T2N0) and IIA (T3N0), which were divided by the T3 criterion only (p = 0.278). A higher N stage had significantly shorter OS than a lower N stage (all pairwise p < 0.05). However, among the 150 patients who received upfront surgery, the pathological stage was more advanced than the clinical stage in 86 (57.3%), mostly due to a false-negative cN0 (70.9%). Our results suggest that the new definition of T3 and the number-based N criteria in the 8th edition AJCC staging system may be not adequate for clinical staging. Establishing separate criteria more suitable for clinical staging should be considered.
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Affiliation(s)
- Huapyong Kang
- Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon 21565, Korea
- Department of Medicine, Yonsei University Graduate School, Seoul 03722, Korea
| | - Seung-seob Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Min Je Sung
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam 13496, Korea
| | - Jung Hyun Jo
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Hee Seung Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Moon Jae Chung
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Jeong Youp Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Seung Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Si Young Song
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Mi-Suk Park
- Department of Radiology, Yonsei University College of Medicine, Seoul 03722, Korea
- Correspondence: (M.-S.P.); (S.B.); Tel.: +82-2-2228-1995 (S.B.); Fax: +82-2-393-6884 (S.B.)
| | - Seungmin Bang
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
- Correspondence: (M.-S.P.); (S.B.); Tel.: +82-2-2228-1995 (S.B.); Fax: +82-2-393-6884 (S.B.)
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Schouten TJ, Daamen LA, Dorland G, van Roessel SR, Groot VP, Besselink MG, Bonsing BA, Bosscha K, Brosens LAA, Busch OR, van Dam RM, Fariña Sarasqueta A, Festen S, Groot Koerkamp B, van der Harst E, de Hingh IHJT, Intven M, Kazemier G, de Meijer VE, Nieuwenhuijs VB, Raicu GM, Roos D, Schreinemakers JMJ, Stommel MWJ, van Velthuysen MF, Verdonk RC, Verheij J, Verkooijen HM, van Santvoort HC, Molenaar IQ. Nationwide Validation of the 8th American Joint Committee on Cancer TNM Staging System and Five Proposed Modifications for Resected Pancreatic Cancer. Ann Surg Oncol 2022; 29:5988-5999. [PMID: 35469113 PMCID: PMC9356941 DOI: 10.1245/s10434-022-11664-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 03/06/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The prognostic value of four proposed modifications to the 8th American Joint Committee on Cancer (AJCC) TNM staging system has yet to be evaluated. This study aimed to validate five proposed modifications. METHODS Patients who underwent pancreatic ductal adenocarcinoma resection (2014-2016), as registered in the prospective Dutch Pancreatic Cancer Audit, were included. Stratification and prognostication of TNM staging systems were assessed using Kaplan-Meier curves, Cox proportional hazard analyses, and C-indices. A new modification was composed based on overall survival (OS). RESULTS Overall, 750 patients with a median OS of 18 months (interquartile range 10-32) were included. The 8th edition had an increased discriminative ability compared with the 7th edition {C-index 0.59 (95% confidence interval [CI] 0.56-0.61) vs. 0.56 (95% CI 0.54-0.58)}. Although the 8th edition showed a stepwise decrease in OS with increasing stage, no differences could be demonstrated between all substages; stage IIA vs. IB (hazard ratio [HR] 1.30, 95% CI 0.80-2.09; p = 0.29) and stage IIB vs. IIA (HR 1.17, 95% CI 0.75-1.83; p = 0.48). The four modifications showed comparable prognostic accuracy (C-index 0.59-0.60); however, OS did not differ between all modified TNM stages (ns). The new modification, migrating T3N1 patients to stage III, showed a C-index of 0.59, but did detect significant survival differences between all TNM stages (p < 0.05). CONCLUSIONS The 8th TNM staging system still lacks prognostic value for some categories of patients, which was not clearly improved by four previously proposed modifications. The modification suggested in this study allows for better prognostication in patients with all stages of disease.
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Affiliation(s)
- Thijs J. Schouten
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Lois A. Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht, The Netherlands
| | - Galina Dorland
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Stijn R. van Roessel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent P. Groot
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | | | - Olivier R. Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ronald M. van Dam
- Department of Surgery, Maastricht UMC+, Maastricht, The Netherlands
- GROW - School for Oncology & Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of General and Visceral Surgery, University Hospital Aachen, Aachen, Germany
| | - Arantza Fariña Sarasqueta
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | | | - Ignace H. J. T. de Hingh
- GROW - School for Oncology & Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Martijn Intven
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht, The Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Vincent E. de Meijer
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | | | - G. Mihaela Raicu
- Department of Pathology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Group, Delft, The Netherlands
| | | | | | | | - Robert C. Verdonk
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Helena M. Verkooijen
- Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands
- Utrecht University, Utrecht, The Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - The Dutch Pancreatic Cancer Group
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht, The Netherlands
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
- Department of Pathology, UMC Utrecht Cancer Center, Utrecht, The Netherlands
- Department of Surgery, Maastricht UMC+, Maastricht, The Netherlands
- GROW - School for Oncology & Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of General and Visceral Surgery, University Hospital Aachen, Aachen, Germany
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, OLVG, Amsterdam, The Netherlands
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
- Department of Surgery, Isala, Zwolle, The Netherlands
- Department of Pathology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Surgery, Reinier de Graaf Group, Delft, The Netherlands
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pathology, Erasmus MC, Rotterdam, Netherlands
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
- Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands
- Utrecht University, Utrecht, The Netherlands
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Zhu X, Chen D, Cao Y, Zhao X, Ju X, Shen Y, Cao F, Qing S, Fang F, Jia Z, Zhang H. Validation of the eighth edition of the AJCC staging system for patients with pancreatic adenocarcinoma initially receiving chemoradiotherapy and proposal of modifications. Cancer Biol Med 2021; 17:492-500. [PMID: 32587784 PMCID: PMC7309473 DOI: 10.20892/j.issn.2095-3941.2019.0101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 04/18/2019] [Indexed: 12/31/2022] Open
Abstract
Objective: To validate the eighth edition of the AJCC staging system in patients with pancreatic adenocarcinoma receiving only stereotactic body radiation therapy and chemotherapy, and to propose modifications to improve prognostic accuracy. Methods: Patients with pathologically confirmed pancreatic adenocarcinoma without metastasis who were undergoing only chemoradiotherapy were included and staged according to the seventh and eighth editions of the AJCC staging system. Meanwhile, another group of stage T4 patients from the above enrollment with only portal vein involvement with or without tumor thrombi (PV ± PVTT) were retrieved for survival comparisons. Modifications were proposed according to the survival comparisons. A cohort from the SEER database was used for external validation of the modified staging system. Results: A total of 683 patients were included. Patients with N2 or N1 but different T stages had significantly different survival outcomes according to the eighth edition. The survival of patients with PV ± PVTT was comparable to that of patients with T4 tumors. The concordance index of the seventh and eighth editions, and the modified staging system was 0.744 (95%CI: 0.718–0.769), 0.750 (95%CI: 0.725–0.775), and 0.788 (95%CI: 0.762–0.813), respectively. For external validation, the concordance index was 0.744 (95%CI: 0.718–0.770), 0.750 (95%CI: 0.724–0.776), and 0.788 (95%CI: 0.762–0.814), respectively. Conclusions: The modified staging system is suggested to have the most accurate prognostic value. Hence, PV ± PVTT should be added to the definition of T4 tumors regardless of tumor size. Patients with N2 or N1 in different T stages could be regrouped into different substages. Additionally, stage III should be subclassified into IIIA (T3N2 and T4N0) and IIIB (T4N1-2).
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Affiliation(s)
- Xiaofei Zhu
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai 200433, China
| | - Di Chen
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai 200433, China
| | - Yangsen Cao
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai 200433, China
| | - Xianzhi Zhao
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai 200433, China
| | - Xiaoping Ju
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai 200433, China
| | - Yuxin Shen
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai 200433, China
| | - Fei Cao
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai 200433, China
| | - Shuiwang Qing
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai 200433, China
| | - Fang Fang
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai 200433, China
| | - Zhen Jia
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai 200433, China
| | - Huojun Zhang
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai 200433, China
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Hu H, Qu C, Tang B, Liu W, Ma Y, Chen Y, Xie X, Zhuang Y, Gao H, Tian X, Yang Y. Validation and modification of the AJCC 8th TNM staging system for pancreatic ductal adenocarcinoma in a Chinese cohort: A nationwide pancreas data center analysis. Chin J Cancer Res 2021; 33:457-469. [PMID: 34584371 PMCID: PMC8435826 DOI: 10.21147/j.issn.1000-9604.2021.04.03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 07/18/2021] [Indexed: 12/11/2022] Open
Abstract
Objective To validate the 8th edition of the American Joint Committee on Cancer (AJCC) staging system for pancreatic ductal adenocarcinoma (PDAC) in a Chinese cohort of radically resected patients and to develop a refined staging system for PDAC. Methods Data were collected from the China Pancreas Data Center (CPDC) for patients with resected PDAC in 2016 and 2017, and cancer-specific survival (CSS) was evaluated using the Kaplan-Meier method and log-rank test. Univariate and multivariate analyses based on Cox regression were performed to identify prognostic factors. The recursive partitioning analysis (RPA), Kaplan-Meier method, and log-rank test were performed on the training dataset to generate a proposed modification for the 8th TNM staging system utilizing the preoperative carbohydrate antigen (CA)19-9 level. Validation was performed for both staging systems in the validation cohort. Results A total of 1,676 PDAC patients were retrieved, and the median CSS was significantly different between the 8th TNM groupings, with no significant difference in survival between stage IB and IIA. The analysis of T and N stages demonstrated a better prognostic value in the N category. Multivariate analysis showed that the preoperative serum CA19-9 level was the strongest prognostic indicator among all the independent risk factors. All patients with CA19-9 >500 U/mL had similar survival, and we proposed a new staging system by combining IB and IIA and stratifying all patients with high CA19-9 into stage III. The modified staging system had a better performance for predicting CSS than the 8th AJCC staging scheme. Conclusions The 8th AJCC staging system for PDAC is suitable for a Chinese cohort of resected patients, and the N category has a better prognostic value than the T category. Our modified staging system has superior accuracy in predicting survival than the 8th AJCC TNM staging system.
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Affiliation(s)
- Hao Hu
- Department of General Surgery, Peking University First Hospital, Beijing 100034, China.,Department of Hepatobiliary Surgery, Aerospace Center Hospital, Beijing 100049, China
| | - Chang Qu
- Department of General Surgery, Peking University First Hospital, Beijing 100034, China
| | - Bingjun Tang
- Department of General Surgery, Peking University First Hospital, Beijing 100034, China
| | - Weikang Liu
- Department of General Surgery, Peking University First Hospital, Beijing 100034, China
| | - Yongsu Ma
- Department of General Surgery, Peking University First Hospital, Beijing 100034, China
| | - Yiran Chen
- Department of General Surgery, Peking University First Hospital, Beijing 100034, China
| | - Xuehai Xie
- Department of General Surgery, Peking University First Hospital, Beijing 100034, China
| | - Yan Zhuang
- Department of General Surgery, Peking University First Hospital, Beijing 100034, China
| | - Hongqiao Gao
- Department of General Surgery, Peking University First Hospital, Beijing 100034, China
| | - Xiaodong Tian
- Department of General Surgery, Peking University First Hospital, Beijing 100034, China
| | - Yinmo Yang
- Department of General Surgery, Peking University First Hospital, Beijing 100034, China
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Lymph Node Metastatic Patterns and Survival Predictors Based on Tumor Size in Pancreatic Ductal Adenocarcinoma. Adv Ther 2021; 38:4258-4270. [PMID: 34176089 DOI: 10.1007/s12325-021-01819-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/05/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignancies. Larger tumor size is widely acknowledged to be associated with increased lymph node (LN) metastatic potential. However, the quantitative relationships between tumor size and LN metastasis or survival remain unclear. This study aims to quantify the objective relationship between tumor size and the prevalence of LN metastases across a spectrum primary tumor size. METHODS The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 9958 patients with resected PDAC without distant metastasis. The prevalence of LN metastases, LN ratio (LNR), and N2/N1 ratio were assessed amongst different tumor sizes, and the relationships were displayed by matched curves. RESULTS In the enrolled cohort, age, tumor site, grade, American Joint Committee on Cancer (AJCC) 8th node staging, tumor size, chemotherapy, and radiotherapy were identified as significant independent predictors for overall survival (OS) and cancer-specific survival (CSS). For tumors within 1-40 mm in size, the prevalence of node-positive disease is closely modelled using a logarithmic formula [0.249 × ln (size) + 0.452] × 100%. The prevalence plateaued between 70% and 80% beyond 40 mm. The mean LNR increased in a stepwise manner as tumor size increased from 1-5 mm (LNR = 0.024) to 41-45 mm (LNR = 0.177); then, beyond 45 mm, it plateaued near 0.170. N2/N1 ratio gradually increased along with tumor size from 1-5 mm (N2/N1 = 0.286) to 41-45 mm (N2/N1 = 1.016), and when tumor size reached to 41-45 mm or more, the ratio stabilized around 1.000. In addition, significant survival prediction by AJCC N staging was observed when tumors ranging between 16 and 45 mm in size. CONCLUSION Regional LN involvement demonstrated a logarithmic growth with increasing tumor sizes in patients with resected PDAC . The probability of metastasis in each regional LN for resected PDAC with tumors greater than 40 mm in size was near 17.0% and their overall prevalence of LN metastasis was 70-80%. Among which, 50% of patients had an N2 stage. Such prediction may be a potential and promising tool for guiding lymphadenectomy in PDAC surgery.
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Li G, Liao CY, Chen JZ, Huang L, Yang C, Tian YF, Wang YT, Du Q, Zhan Q, Chen YL, Chen S. Construction and Validation of Novel Nomograms for Predicting Prognosis of Pancreatic Ductal Adenocarcinoma After Surgery According to Different Primary Cancer Locations. Front Oncol 2021; 11:646082. [PMID: 33968745 PMCID: PMC8103839 DOI: 10.3389/fonc.2021.646082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/06/2021] [Indexed: 11/22/2022] Open
Abstract
Background/Aims Pancreatic ductal adenocarcinoma (PDAC) can occur in different parts of the pancreas. This study aimed to identify clinicopathological characteristics independently correlated with the prognosis of PDAC of the pancreatic head/uncinate (PHC) or body-tail (PBTC), and to develop novel nomograms for predicting cancer-specific survival (CSS) according to different primary cancer locations. Methods 1160 PDAC patients were retrospectively enrolled and assigned to training and test sets with each set divided into PHC and PBTC groups. Comparative analysis of clinicopathologic characteristics, survival analysis, and multivariate analysis were performed. Independent factors were identified and used for constructing nomograms. The performance of the nomograms was validated in the test set. Results Primary tumor location was an independent risk factor for prognosis of PDAC after surgery. Specially, gender, fasting blood glucose, and preoperative cancer antigen 19-9 were significantly associated with prognosis of PHC, whereas age, body mass index, and lymph nodes were significantly correlated with the prognosis of PBTC. A significant difference in prognosis was found between PHC and PBTC in stage Ia and stage III. Three nomograms were established for predicting the prognosis for PDAC, PHC, and PBTC. Notably, these nomograms were calibrated modestly (c-indexes of 0.690 for PDAC, 0.669 for PHC, and 0.704 for PBTC), presented better accuracy and reliability than the 8th AJCC staging system, and achieved clinical validity. Conclusions PHC and PBTC share the differential clinical-pathological characteristics and survival. The nomograms show good performance for predicting prognosis in PHC and PBTC. Therefore, these nomograms hold potential as novel approaches for predicting survival of PHC and PBTC patients after surgery.
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Affiliation(s)
- Ge Li
- Department of Hepatobiliary Surgery and Fujian Institute of Hepatobiliary Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Key Laboratory of The Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Cheng-Yu Liao
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Jiang-Zhi Chen
- Department of Hepatobiliary Surgery and Fujian Institute of Hepatobiliary Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Key Laboratory of The Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Long Huang
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Can Yang
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Yi-Feng Tian
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Yi-Ting Wang
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qiang Du
- Department of Hepatobiliary Surgery and Fujian Institute of Hepatobiliary Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Key Laboratory of The Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Qian Zhan
- Pancreatic Disease Center, Department of General Surgery, Ruijin Hospital, Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan-Ling Chen
- Department of Hepatobiliary Surgery and Fujian Institute of Hepatobiliary Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Key Laboratory of The Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Shi Chen
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
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8
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Equipping the American Joint Committee on Cancer Staging for Resectable Pancreatic Ductal Adenocarcinoma with Tumor Grade: A Novel Staging System. JOURNAL OF ONCOLOGY 2020; 2020:9093729. [PMID: 33014058 PMCID: PMC7525311 DOI: 10.1155/2020/9093729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 08/29/2020] [Accepted: 09/05/2020] [Indexed: 12/13/2022]
Abstract
Background The 8th American Joint Committee on Cancer (AJCC) staging system for pancreatic ductal adenocarcinoma (PDAC) outperforms its previous version in reproducibility but not in survival discrimination. Tumor grade, an indicator of the aggressive biology of PDAC, has been suggested as a reliable prognostic factor. This study aimed to construct a novel staging system with greater prognostication for resectable PDAC by incorporating tumor grade into the 8th AJCC system. Methods A total of 9966 patients with resectable PDAC from the Surveillance Epidemiology and End Results (SEER) database were randomly separated into training and interval validation sets. Another 324 patients from our center were included as an external validation set. We proposed a novel staging system by sorting the substages yielded by a combination of T, N, and tumor grade based on their overall survival (OS) and grouping them into several stages. Prognostic homogeneity and discrimination were determined using the likelihood ratio χ 2 and the linear trend χ 2 test, respectively. Prognostic accuracies were evaluated by the area under the receiver operating characteristics curve (AUC). Results Using the 8th AJCC system, the prognosis of patients within the same stage was quite heterogeneous among different substages. The multivariate Cox model identified the tumor grade (hazard ratio 1.333, 95% confidence interval 1.250-1.423, p < 0.001) was an independent prognostic factor of the OS. In the training set, the AUC, homogeneity, and discriminatory ability were superior for the novel staging system than for the 8th AJCC system (0.642 vs. 0.615, 403.4 vs. 248.6, and 335.1 vs. 218.0, respectively). Similar results were observed in the internal and external validation sets. Conclusions The novel staging system incorporating tumor grade into the 8th AJCC system was associated with better prognostic accuracy, homogeneity, and discriminatory ability among resectable PDAC patients. Moreover, the novel staging system also allowed possibly adjuvant chemotherapy decisions.
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You MS, Ryu JK, Huh G, Chun JW, Paik WH, Lee SH, Kim YT. Comparison of efficacy between adjuvant chemotherapy and chemoradiation therapy for pancreatic cancer: AJCC stage-based approach. World J Clin Oncol 2020; 11:747-760. [PMID: 33033696 PMCID: PMC7522542 DOI: 10.5306/wjco.v11.i9.747] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 08/05/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The adjuvant treatment for patients with resected pancreatic cancer (PC) is not yet standardized. Because the prognosis differs according to the American Joint Committee on Cancer (AJCC) stage, a tailored approach to establish more aggressive treatment plans in high-risk patients is necessary. However, studies comparing the efficacy of adjuvant treatment modalities according to the AJCC stage are largely lacking.
AIM To compare the efficacy of chemotherapy and chemoradiation therapy according to AJCC 8th staging system in patients with PC who underwent surgical resection.
METHODS A total of 335 patients who underwent surgical resection and adjuvant treatment for PC were included. Patients were divided into three groups: Chemoradiation therapy (CRT) group, systemic chemotherapy (SCT) group and combined treatment of chemoradiation plus chemotherapy therapy (CRT-SCT) group. The primary outcomes were differences in overall survival (OS) between the three groups. The secondary outcomes were differences in recurrence-free survival, recurrence pattern and adverse events between the three groups.
RESULTS Patients received CRT (n = 65), SCT (n = 62) and CRT-SCT (n = 208). Overall median OS was 33.3 mo (95% confidence interval (CI): 27.4-38.6). In patients with stage I/II, the median OS was 27.0 mo (95%CI: 2.06-89.6) in the CRT group, 35.8 mo (95%CI: 26.9-NA) in the SCT group and 38.6 mo (95%CI: 33.3-55.7) in the CRT-SCT group. Among them, there was no significant difference in OS between the three groups. In 59 patients with stage III, median OS in the SCT group [19.0 mo (95%CI: 12.6-NA)] and the CRT-SCT group [23.4 mo (95%CI: 22.0-44.4)] was significantly longer than that in the CRT group [17.7 mo (95%CI: 6.8-NA); P = 0.011 and P < 0.001, respectively]. There were no significant differences in incidence of locoregional and distant recurrences between the three groups (P = 0.158 and P = 0.205, respectively). Incidences of grade 3 or higher hematologic adverse events were higher in the SCT and CRT-SCT groups than in the CRT group.
CONCLUSION SCT and CRT-SCT showed significantly longer OS and recurrence-free survival than CRT in patients with AJCC stage III, while there was no significant difference in OS between the CRT, SCT and CRT-SCT groups in patients with AJCC stage I/II. Different adjuvant therapy according to AJCC stage can be applied in patients with PC.
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Affiliation(s)
- Min Su You
- Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul 110-744, South Korea
| | - Ji Kon Ryu
- Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul 110-744, South Korea
| | - Gunn Huh
- Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul 110-744, South Korea
| | - Jung Won Chun
- Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul 110-744, South Korea
| | - Woo Hyun Paik
- Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul 110-744, South Korea
| | - Sang Hyub Lee
- Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul 110-744, South Korea
| | - Yong-Tae Kim
- Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul 110-744, South Korea
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Shin DW, Hwang JH. Reply to the letter to the editor: ‘AJCC 8th edition staging system for pancreatic ductal adenocarcinoma: A controversial step forward?’. Eur J Surg Oncol 2020; 46:704-705. [DOI: 10.1016/j.ejso.2019.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 10/17/2019] [Indexed: 11/29/2022] Open
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Rowan DJ, Hartley CP, Aldakkak M, Christians KK, Evans DB, Tsai S, Hagen CE. Gross tumor size using the AJCC 8th ed. T staging criteria does not provide prognostic stratification for neoadjuvant treated pancreatic ductal adenocarcinoma. Ann Diagn Pathol 2020; 46:151485. [PMID: 32172219 DOI: 10.1016/j.anndiagpath.2020.151485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/25/2020] [Indexed: 10/28/2022]
Abstract
The 8th edition AJCC T stage criteria for pancreatic ductal adenocarcinoma (PDAC) are now size based. These criteria provide better prognostic stratification in patients without neoadjuvant therapy. Our aim was to determine if gross tumor size is prognostically significant using the 8th ed. staging criteria for neoadjuvant treated PDAC. The study included 289 patients who underwent resection for PDAC following neoadjuvant therapy. By AJCC 7th ed., there were 12 (4.2%) ypT0, 32 (11.1%) ypT1, 64 (22.1%) ypT2, and 181 (62.6%) ypT3 patients. By AJCC 8th ed., there were 12 (4.2%) ypT0, 74 (25.6%) ypT1 (6 ypT1a, 1 ypT1b, 67 ypT1c), 161 (55.7%) ypT2, and 42 (14.5%) ypT3 patients. 182 patients had negative lymph nodes and 107 had positive lymph nodes. 77 patients were ypN1 and 30 were ypN2 by 8th ed. criteria. 7th ed. T stage significantly correlated with OS (p = 0.048), while 8th ed. T stage did not correlate with OS (p = 0.13). In ypN0 patients, neither the 7th ed. or 8th ed. T stages significantly correlated with patient OS (p = 0.065 and 0.26, respectively). Higher 7th ed. T stage correlated with lymph node status (p ≤ 0.001) more strongly than 8th ed. T stage (p = 0.04). 7th ed. and 8th ed. N stage correlated with OS (p = 0.004 and p = 0.0002, respectively). By 8th ed. AJCC staging criteria, gross tumor size does not provide good prognostic stratification in neoadjuvant therapy PDAC. Mapped grossing techniques combining gross and microscopic examination to determine tumor size may provide more accurate staging of neoadjuvant treated tumors.
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Affiliation(s)
- Daniel J Rowan
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Mohammed Aldakkak
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Susan Tsai
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Catherine E Hagen
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA.
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Pu N, Yin L, Habib JR, Gao S, Hu H, Zhu Y, Wu Y, Yu J, Lou W. Optimized modification of the eighth edition of AJCC TNM staging system for resected pancreatic ductal adenocarcinoma. Future Oncol 2019; 15:3457-3465. [PMID: 31460788 DOI: 10.2217/fon-2019-0264] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Aim: To reassess the prognostic performance of the American Joint Committee on Cancer (AJCC) 8th edition for pancreatic ductal adenocarcinoma (PDAC) and optimize the categorization of PDAC staging. Patients & methods: A total of 11,858 patients with resected PDAC from the Surveillance, Epidemiology and End Results database were retrospectively enrolled by sequential analyses. Results: There was no statistical significance between stage IIA and IIB tumors with hazard ratios of 2.065 and 2.184 (p = 0.620) for stages IIA and IIB, respectively. With the proposed modification, there was a significant difference between the hazard ratios of stages IIIA and IIIB which were 2.481 and 2.715, respectively (p = 0.009). The C-index of modified system was 0.609, slightly higher than AJCC 8th staging system 0.604. Conclusion: We proposed a modified eighth edition of the AJCC staging system by combining stage IIA with IIB and further subclassifying stage III patients in order to lead to better discriminative power.
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Affiliation(s)
- Ning Pu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, PR China
- Department of Surgery & The Pancreatic Cancer Precision Medicine Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Lingdi Yin
- Department of Surgery & The Pancreatic Cancer Precision Medicine Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, & Pancreas Institute of Nanjing Medical University, Nanjing, PR China
| | - Joseph R Habib
- Department of Surgery & The Pancreatic Cancer Precision Medicine Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Shanshan Gao
- Department of Surgery & The Pancreatic Cancer Precision Medicine Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, PR China
| | - Haijie Hu
- Department of Surgery & The Pancreatic Cancer Precision Medicine Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Biliary Surgery, West China Hospital of Sichuan University, Sichuan, PR China
| | - Yayun Zhu
- Department of Surgery & The Pancreatic Cancer Precision Medicine Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Liver Cancer Institute, Zhongshan Hospital, & Key Laboratory of Carcinogenesis & Cancer Invasion (Ministry of Education), Fudan University, Shanghai, PR China
| | - Yong Wu
- Department of Surgery & The Pancreatic Cancer Precision Medicine Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of General Surgery, The Second Affiliated Hospital of Soochow University, Jiangsu, PR China
| | - Jun Yu
- Department of Surgery & The Pancreatic Cancer Precision Medicine Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Wenhui Lou
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, PR China
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Sapalidis K, Kosmidis C, Funtanidou V, Katsaounis A, Barmpas A, Koimtzis G, Mantalobas S, Alexandrou V, Aidoni Z, Koulouris C, Pavlidis E, Giannakidis D, Surlin V, Pantea S, Strambu V, Constantina RO, Amaniti A, Zarogoulidis P, Mogoantă S, Kesisoglou I, Sardeli C. Update on current pancreatic treatments: from molecular pathways to treatment. J Cancer 2019; 10:5162-5172. [PMID: 31602269 PMCID: PMC6775621 DOI: 10.7150/jca.36300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 07/29/2019] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cancer is still diagnosed at a late stage although we have novel diagnostic tools. Pancreatic cancer chemotherapy treatment resistance is observed and therefore novel treatments are in need. Anti-cancer stem cell therapy, combination of chemotherapy and/or radiotherapy with immunotherapy, proteins/enzymes and gene therapy are currently under evaluation. Targeted treatment with tyrosine kinase inhibitors is also administered and novel inhibitors are also under evaluation. In the current review we present recent data from our search within the year 2018.
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Affiliation(s)
- Konstantinos Sapalidis
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Christoforos Kosmidis
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Varvara Funtanidou
- Anesthesiology Department, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Athanasios Katsaounis
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Amastasios Barmpas
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Georgios Koimtzis
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Stylianos Mantalobas
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Vyron Alexandrou
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Zoi Aidoni
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Charilaos Koulouris
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Efstathios Pavlidis
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Dimitrios Giannakidis
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Valeriu Surlin
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | | | - Victor Strambu
- General Surgery Department, "Dr Carol Davila", University of Medicine and Pharmacy, Bucuresti, Romania
| | | | - Aikaterini Amaniti
- Anesthesiology Department, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Paul Zarogoulidis
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
- Anesthesiology Department, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Stelian Mogoantă
- Department of Pharmacology and Department of Surgery, Faculty of Dentistry, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Isaak Kesisoglou
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Chrysanthi Sardeli
- Clinical Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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