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Wu Z, Zhao P, Wang Z, Huang X, Wu C, Li M, Wang L, Tian B. Adjusting CA19-9 values with clinical stage and bilirubin to better predict survival of resectable pancreatic cancer patients: 5-year-follow-up of a single center. Front Oncol 2022; 12:966256. [PMID: 35965560 PMCID: PMC9372400 DOI: 10.3389/fonc.2022.966256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background Pancreatic cancer mortality is growing every year, and radical resection is the most essential therapy strategy. It is critical to evaluate the long-term prognosis of individuals receiving radical surgery. CA19-9 is a biomarker for patient recurrence and survival, however obstructive jaundice has a significant impact on this index. Researchers have attempted to modify the index using various modification methods, but the results have been unsatisfactory. In this study, we adjusted CA19-9 values based on clinical stage and bilirubin and found that it provided better prediction than CA19-9 alone in assessing patients. Methods We analyzed over 5 years follow-up records of patients who underwent radical pancreatic cancer surgery between August 2009 and May 2017 in a single center. We investigated the association of risk factors with overall survival (OS) as well as disease-free survival (DFS) after surgery. Threshold values for high-risk features associated with poor prognosis in resectable pancreatic cancer were determined. The hazard ratios of the indicators were eventually examined under the stratification of patients’ clinical stages. Results A total of 202 patients were involved in the study. The optimum cut-off values for CA19-9 and CA19-9/TB for predicting overall survival were 219.4 (p = 0.0075) and 18.8 (p = 0.0353), respectively. CA19-9>219.4 increased the risk of patient mortality by 1.70 times (95% CI 1.217-2.377, p = 0.002), and tumor poor differentiation raised the risk by 1.66 times (95% CI 1.083-2.553, P = 0.02). Based on clinical stage stratification, we found discrepancies in the predictive efficacy of CA19-9 and CA19-9/TB. CA19-9 was a better predictor in clinical stage 1 (HR = 2.056[CI 95%1.169-3.616], P = 0.012), whereas CA19-9/TB indications were better in stages 2 (HR = 1.650[CI 95%1.023-2.662], P = 0.040) and 3 (HR = 3.989[CI95%1.145-13.896], P = 0.030). Conclusions CA19-9, CEA, and tumor differentiation are predictors for patients with resectable PDAC. CA19-9 values can be adjusted based on clinical stage and bilirubin levels to better predict overall survival in patients with resectable PDAC. CA19-9>219.4 predicted poor survival in individuals in clinical stage 1, whereas CA19-9/TB>18.8 predicted poor survival for individuals in stages 2 and 3.
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Liu W, Ma Y, Tang B, Qu C, Chen Y, Yang Y, Tian X. Predictive Model of Early Death of Resectable Pancreatic Ductal Adenocarcinoma After Curative Resection: A SEER-Based Study. Cancer Control 2022; 29:10732748221084853. [PMID: 35262432 PMCID: PMC8918973 DOI: 10.1177/10732748221084853] [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] [Indexed: 11/25/2022] Open
Abstract
Objective This study aims to determine the factors that predict early death and establish a predictive model for early death by analyzing clinical characteristics of patients with resectable pancreatic ductal adenocarcinoma (R-PDAC) who die early after radical surgery. Materials and Methods This was a retrospective study of patients who underwent radical surgical resection for R-PDAC in the Surveillance, Epidemiology, and End Results (SEER) database. Patients with overall survival ≤ 12 months were assigned as early death group and above 1 year as the late death group. Univariate and multivariate logistic regression was conducted to identify factors significantly associated with early death. An early death predictive model was constructed based on the identified independent risk factors. Results A total of 9695 patients were analyzed, and the total incidence of early death was 30.72%. Multivariable analysis showed that factors significantly associated with early death included age at diagnosis, race, marital status, tumor location, tumor size, tumor grade, number of positive lymph nodes, number of examined lymph nodes, positive lymph node ratio, chemotherapy, and radiotherapy. The predictive model showed good discrimination with a C-index of 0.722 (95% confidence interval: 0.711-0.733) and convincing calibration. Conclusions We developed a predictive model that may be easily applied to patients with R-PDAC after radical resection to predict the chance of death within 1 year. For patients with high risk of early death, neoadjuvant therapy should be considered. Even after radical resection, more aggressive adjuvant chemotherapy (with or without combined radiotherapy) must be used to minimize the chance of early death.
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Affiliation(s)
- Weikang Liu
- 26447Peking University First Hospital, Beijing, China
| | - Yongsu Ma
- 26447Peking University First Hospital, Beijing, China
| | - Bingjun Tang
- 26447Peking University First Hospital, Beijing, China
| | - Chang Qu
- 26447Peking University First Hospital, Beijing, China
| | - Yiran Chen
- 26447Peking University First Hospital, Beijing, China
| | - Yinmo Yang
- 26447Peking University First Hospital, Beijing, China
| | - Xiaodong Tian
- 26447Peking University First Hospital, Beijing, China
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Relationship between the tumor location and clinicopathological features in left-sided pancreatic ductal adenocarcinoma. Surg Today 2020; 51:814-820. [PMID: 32970195 DOI: 10.1007/s00595-020-02151-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Although the same distal pancreatectomy (DP) is performed regardless of the location of left-sided pancreatic ductal adenocarcinoma (PDAC), the clinicopathological features may differ depending on the tumor location. The present study investigated the relationship between the tumor location and clinicopathological features in patients with left-sided PDAC. METHODS The records of 59 patients who underwent DP for PDAC were enrolled. The relationship between the tumor location and clinicopathological features was investigated. The tumor location was classified into three groups according to the 7th AJCC/UICC TNM classification: body (Pb), body and tail (Pbt), and tail (Pt). RESULTS Tumors were located at the Pb in 26 patients, Pbt in 15, and Pt in 18. There was no metastasis to the lymph nodes around the common hepatic artery in Pt. The rate of peritoneal dissemination in the Pt was higher than that in the Pb (P = 0.034) or Pbt (P = 0.002). There were no significant differences in the overall survival among the three groups. CONCLUSION There was no metastasis to the lymph nodes around the common hepatic artery, and peritoneal dissemination was the most common site of recurrence in Pt tumors.
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Shyr BU, Shyr BS, Chen SC, Shyr YM, Wang SE. Mesopancreas level 3 dissection in robotic pancreaticoduodenectomy. Surgery 2020; 169:362-368. [PMID: 32896373 DOI: 10.1016/j.surg.2020.07.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 06/28/2020] [Accepted: 07/22/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND There are no reports of performing mesopancreas dissections in robotic pancreaticoduodenectomy. This study evaluated the feasibility and justification for mesopancreas level 3 dissection in robotic pancreaticoduodenectomy. METHODS Surgical outcomes after robotic pancreaticoduodenectomy and open pancreaticoduodenectomy were evaluated and compared. RESULTS There were 289 robotic pancreaticoduodenectomy and 162 open pancreaticoduodenectomy patients included in the study. Postoperative diarrhea occurred in 34.5% of mesopancreas level 3 dissection cases and was higher than in levels 2 and 1 dissection cases, P < .001. Blood loss in the robotic pancreaticoduodenectomy group was higher for mesopancreas level 3 dissection, with a median loss of 263 mL (P = .015). The rate of R0 resection with margin >1 mm was higher for mesopancreas level 3 dissection (93.8%) than for level 2 dissection (72.2%) (P < .001). The lymph node yield was higher for mesopancreas level 3 dissection in robotic pancreaticoduodenectomy; the median lymph node yield was 21 for level 3, 18 for level 2, and 14 for level 1 (P < .001). Compared with mesopancreas levels 1 and 2 dissections in the robotic pancreaticoduodenectomy groups, level 3 dissection did not show increased surgical mortality or postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, postpancreatectomy hemorrhage, chyle leakage, bile leakage, or wound infection. Compared with open pancreaticoduodenectomy, mesopancreas level 3 dissection in robotic pancreaticoduodenectomy had less blood loss, no delayed gastric emptying, and lower chyle leakage. CONCLUSION Mesopancreas level 3 dissection in robotic pancreaticoduodenectomy is feasible without compromising surgical safety. Therefore, robotic pancreaticoduodenectomy can be recommended as a safe alternative to open pancreaticoduodenectomy for mesopancreas level 3 dissection.
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Affiliation(s)
- Bor-Uei Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Bor-Shiuan Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Shih-Chin Chen
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Yi-Ming Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Shin-E Wang
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan.
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Zheng ZJ, Wang MJ, Tan CL, Chen YH, Ping J, Liu XB. Prognostic impact of lymph node status in patients after total pancreatectomy for pancreatic ductal adenocarcinoma: A strobe-compliant study. Medicine (Baltimore) 2020; 99:e19327. [PMID: 32080152 PMCID: PMC7034702 DOI: 10.1097/md.0000000000019327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The optimal number of examined lymph nodes (ELN) for staging and impact of nodal status on survival following total pancreatectomy (TP) for pancreatic ductal adenocarcinoma (PDAC) is unclear. The aim of this study was to evaluate the prognostic impact of different lymph node status after TP for PDAC.The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients who underwent TP for PDAC from 2004 to 2015. We calculated overall survival (OS) of these patients using Kaplan-Meier analysis and Cox proportional hazards model.Overall, 1291 patients were included in the study, with 869 node-positive patients (49.5%). A cut-off points analysis revealed that 19, 19, and 13 lymph nodes best discriminated OS for all patients, node-negative patients, and node-positive patients, respectively. Higher number of ELN than the corresponding cut-off points was an independent predictor for better prognosis [all patients: hazard ratios (HR) 0.786, P = .002; node-negative patients: HR 0.714, P = .043; node-positive patients: HR 0.678, P < .001]. For node-positive patients, 1 to 3 positive lymph nodes (PLN) correlated independently with better survival compared with those with 4 or more PLN (HR 1.433, P = .002). Moreover, when analyzed in node-positive patients with less than 13 ELN, neither the number of PLN nor lymph node ratio (LNR) was associated with survival. However, when limited node-positive patients with at least 13 ELN, univariate analyses showed that both the number of PLN and LNR were associated with survival, whereas multivariate analyses demonstrated that only number of PLN was consistently associated with survival (HR 1.556, P = .004).Evaluation at least 19 lymph nodes should be considered as quality metric of surgery in patients who underwent TP for PDAC. For node-negative patients, a minimal number of 19 lymph nodes is adequate to avoid stage migration. For node-positive patients, PLN is superior to LNR in predicting survival after TP, predominantly for those with high number of ELN.
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Affiliation(s)
| | - Mo-Jin Wang
- Department of Gastrointestinal Surgery, Institute of Digestive Surgery and State key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | | | | | - Jie Ping
- Division of Epidemiology, Vanderbilt University Medical Center, Nashville, USA
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Prognostic factors for disease-free survival in patients with pancreatic ductal adenocarcinoma after surgery: a single center experience. JOURNAL OF PANCREATOLOGY 2019. [DOI: 10.1097/jp9.0000000000000011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Lowder CY, Metkus J, Epstein J, Kozak GM, Lavu H, Yeo CJ, Winter JM. Clinical Implications of Extensive Lymph Node Metastases for Resected Pancreatic Cancer. Ann Surg Oncol 2018; 25:4004-4011. [PMID: 30225835 DOI: 10.1245/s10434-018-6763-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Outcomes of patients with resected pancreatic ductal adenocarcinoma (PDA) and extensive lymph node metastases have not been fully characterized. METHODS A total of 637 patients underwent resection for pancreatic ductal adenocarcinoma (PDA) between 2002 and 2014 at the Thomas Jefferson University. Positive lymph node count (LNC) and positive lymph node ratio (LNR) were analyzed as predictors of cancer-specific outcomes, with a focus on outcomes of patients with extensive lymph node burden. RESULTS Resected patients with regional lymph node metastases had a median survival of 17.1 months (n = 425, 70%) compared with 25.5 months (n = 185, 30%) for patients without lymph node spread (N0) (hazard ratio [HR] = 1.9, p < 0.001). Overall survival decremented with increased lymph node spread, but plateaued for LNC ≥ 4 (HR 2.4 vs. N0, p < 0.001) and LNR ≥ 0.4 (HR 2.2, p < 0.001). Compared with historical cohorts with macroscopic metastatic disease, as opposed to microscopic, superior long-term survival was achieved in patients with extensive lymph node metastases (LNC ≥ 4); 24- and 36-month survivals were 25% (vs. 16%, p < 0.001) and 12% (vs. 6%, p < 0.001), respectively. Extensive lymph node burden was associated with increased baseline postoperative serum CA 19-9 (p = 0.044) and systemic recurrence (p < 0.001). CONCLUSIONS The prognostic impact of extensive lymph node spread after resection for PDA plateaus above a specific threshold (LNC ≥ 4 or LNR ≥ 0.4), supporting the new 8th edition AJCC criteria for N2 disease. Clinically, lymph node spread above this threshold seems to correlate with occult systemic disease (elevated postoperative CA 19-9 and systemic pattern of failure).
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Affiliation(s)
- Cinthya Y Lowder
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA.,Department of Surgery, Albert Einstein Healthcare Network, Philadelphia, PA, USA
| | - James Metkus
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jeffrey Epstein
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Geoffrey M Kozak
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Harish Lavu
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Charles J Yeo
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jordan M Winter
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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Cui Y, Li ZW, Li XT, Gao SY, Li Y, Li J, Zhu HC, Tang L, Cao K, Sun YS. Dynamic enhanced CT: is there a difference between liver metastases of gastroenteropancreatic neuroendocrine tumor and adenocarcinoma. Oncotarget 2017; 8:108146-108155. [PMID: 29296230 PMCID: PMC5746132 DOI: 10.18632/oncotarget.22554] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 06/18/2017] [Indexed: 12/26/2022] Open
Abstract
This study proposed to evaluate the feasibility of dynamic enhanced CT in differentiation of liver metastases of gastroenteropancreatic well-differentiated neuroendocrine tumors (GEP NETs) from GEP adenocarcinomas based on their characteristic features. CT images of 23 well-differentiated (G1 or G2) GEP NETs and 23 GEP adenocarcinomas patients with liver metastases were retrospectively reviewed. The distribution type, shape, intra-tumoral neovascularity, enhancement on hepatic artery phase, dynamic enhancement pattern and lymphadenopathy were subjective analyzed. Meanwhile, the size, number, CT value of tumor and adjacent normal liver parenchyma were measured and the metastasis-to-liver ratios were calculated objectively. Compared with GEP adenocarcinomas, the liver metastases of GEP NETs more frequently demonstrated a hyper enhancement on hepatic artery phase, washout dynamic enhancement pattern, absence of lymphadenopathy and higher metastasis-to-liver ratios on both hepatic artery phase and portal venous phase (P=0.017, P<0.001, P =0.038, P <0.001 and P =0.008, respectively). Logistic regression analysis showed that the dynamic enhancement pattern (P=0.012), and the metastasis-to-liver ratios on hepatic artery phase (P=0.009) were independent CT predictors for liver metastases of GEP NETs. The sensitivity and specificity of combing the two predictors in differentiation of liver metastases of GEP adenocarcinomas from GEP NET were 82.6% (19 of 23) and 91.3% (21 of 23), respectively. CT features are helpful in differentiating liver metastases of well-differentiated GEP NETs from that of GEP adenocarcinomas.
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Affiliation(s)
- Yong Cui
- Department of Radiology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Zhong-Wu Li
- Department of Pathology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Xiao-Ting Li
- Department of Radiology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Shun-Yu Gao
- Department of Radiology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Ying Li
- Department of Radiology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jie Li
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Hui-Ci Zhu
- Department of Radiology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Lei Tang
- Department of Radiology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Kun Cao
- Department of Radiology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Ying-Shi Sun
- Department of Radiology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
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Lin R, Han CQ, Wang WJ, Liu J, Qian W, Ding Z, Hou XH. Analysis on survival and prognostic factors in patients with resectable pancreatic adenocarcinoma. ACTA ACUST UNITED AC 2017; 37:612-620. [PMID: 28786050 DOI: 10.1007/s11596-017-1780-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 04/25/2017] [Indexed: 12/17/2022]
Abstract
Survival after pancreatic cancer surgery is extremely unfavorable even after curative resection. Prognostic factors have been explored but remain largely undefined. The present study was to identify the role of clinical and laboratory variables in the prognostic significance of resectable pancreatic adenocarcinoma. A total of 96 patients who underwent curative resection for pancreatic cancer were included. Survival was evaluated based on complete follow-up visits and was associated with potential prognostic factors using the Kaplan-Meier method and Cox proportional hazard model survival analyses. The results showed that prognostic variables significantly reduced survival, including old age, poorly differentiated tumors, elevated tumor markers and positive lymph node metastasis (LNM). Age of older than 60 years (HR=1.83, P=0.04), LNM (HR=2.22, P=0.01), lymph node ratio (0<LNR≤0.2, HR=1.38, P=0.042; LNR>0.2, HR=1.92, P=0.017), initial CA199 (HR=4.80, P=0.004), and CEA level (HR=2.59, P=0.019) were identified as independent prognostic factors by multivariate analysis. It was concluded that LNR may be potent predictor of survival and suggests that surgeons and the pathologists should thoroughly assess lymph nodes prior to surgery.
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Affiliation(s)
- Rong Lin
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Chao-Qun Han
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Wei-Jun Wang
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jun Liu
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Wei Qian
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Zhen Ding
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Xiao-Hua Hou
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
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Contreras CM, Lin CP, Oster RA, Reddy S, Wang T, Vickers S, Heslin M. Increased pancreatic cancer survival with greater lymph node retrieval in the National Cancer Data Base. Am J Surg 2017; 214:442-449. [PMID: 28687101 DOI: 10.1016/j.amjsurg.2017.06.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 04/23/2017] [Accepted: 06/14/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND We evaluated the role of lymph node (LN) retrieval in pancreatic adenocarcinoma (PA) patients undergoing pancreaticoduodenectomy (PD). METHODS We utilized the National Cancer Data Base; Cox regression models and logistic regression models were used for statistical evaluation. RESULTS We evaluated 26,792 patients with PA who underwent PD. The mean LN retrieved in LN(-) patients was 10.8 vs 14.4 for LN(+) patients (P < 0.0001). Greater LN retrieval is an independent predictor of a negative microscopic margin and decreased length of stay. The median survival of LN(-) patients exceeded that of LN(+) patients (24.5 vs 15.1 months, P < 0.0001). Increasing LN retrieval is a significant predictor of survival in all patients, and in LN(-) patients. The relationship of increased LN retrieval and enhanced survival is a nearly linear trend. CONCLUSIONS Rather than demonstrating an inflection point that defines the extent of adequate lymphadenectomy, this dataset demonstrates an incremental relationship between LN retrieval and survival.
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Affiliation(s)
- Carlo M Contreras
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL, USA.
| | - Chee Paul Lin
- University of Alabama at Birmingham, Center for Clinical and Translational Science, Birmingham, AL, USA
| | - Robert A Oster
- University of Alabama at Birmingham, Department of Preventive Medicine, Birmingham, AL, USA
| | - Sushanth Reddy
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL, USA
| | - Thomas Wang
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL, USA
| | - Selwyn Vickers
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL, USA
| | - Martin Heslin
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL, USA
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11
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Eskander MF, de Geus SWL, Kasumova GG, Ng SC, Al-Refaie W, Ayata G, Tseng JF. Evolution and impact of lymph node dissection during pancreaticoduodenectomy for pancreatic cancer. Surgery 2017; 161:968-976. [PMID: 27865602 DOI: 10.1016/j.surg.2016.09.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/11/2016] [Accepted: 09/24/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Insufficient examination of lymph nodes after pancreaticoduodenectomy can lead some pancreatic cancer patients with N1 disease to be misclassified as N0. We examined trends in lymph node dissection throughout time and investigated how these changes affect lymph node status and its prognostic value. METHODS The National Cancer Data Base was queried for patients with nonmetastatic pancreatic adenocarcinoma (2004-2013) who underwent classic pancreaticoduodenectomy with antrectomy. Logistic regression was performed for odds of node positivity. Kaplan-Meier curves and Cox proportional hazards models were used to assess the impact of lymph node status on overall survival for patients diagnosed during 2-year intervals from 2004-2012. RESULTS Median number of examined lymph nodes was 10 (interquartile range 6-15) in 2004 vs 17 (interquartile range 12-24) in 2013. Number of lymph nodes examined was a significant predictor of N1 disease (P < .0001), with a plateau at 30 nodes. N1 disease increased from 64.4% to 68.0% (P < .0001). Survival for both N1 and N0 subgroups improved. In successive multivariate models, N0 versus N1 status was consistently protective for overall survival (P < .0001), but there was no change in the magnitude of its hazard ratio over time (overall hazard ratio 0.691; 95% confidence interval 0.660-0.723). CONCLUSION Contemporary patients have an adequate number of nodes examined during standard pancreaticoduodenectomy. This, along with rising rates of N1 cancer detection and improved survival for both node-positive and node-negative patients, suggest more accurate classification of lymph node status. However, no increased benefit is achieved beyond 30 nodes. Overall, lymph node status remains a strong prognosticator for overall survival.
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Affiliation(s)
- Mariam F Eskander
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Susanna W L de Geus
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Gyulnara G Kasumova
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sing Chau Ng
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Waddah Al-Refaie
- Department of Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Gamze Ayata
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jennifer F Tseng
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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12
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Burke EE, Marmor S, Virnig BA, Tuttle TM, Jensen EH. Lymph Node Evaluation for Pancreatic Adenocarcinoma and Its Value as a Quality Metric. J Gastrointest Surg 2015; 19:2162-70. [PMID: 26453357 DOI: 10.1007/s11605-015-2969-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 09/24/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Adequate lymph node evaluation (LNE) is recommended for surgically treated pancreatic adenocarcinoma because studies have shown an association between improved survival and adequate LNE. This study aimed to understand the mechanism of this association and determine whether LNE is a valuable quality metric. METHODS Using the linked Surveillance Epidemiology End Results Medicare database, we identified patients with surgically treated pancreatic adenocarcinoma from 2000 to 2010. Adequate LNE was defined as evaluation of ≥15 nodes. Survival was determined using Kaplan-Meier and Cox proportional hazards. RESULTS We identified 2629 patients who underwent resection for pancreatic adenocarcinoma. Overall, 33 % had adequate LNE. Adequate LNE was significantly associated with receipt of postoperative chemotherapy. A significant decrease in hazard of death was associated with adequate LNE (HR 0.86, p < 0.05). Receipt of postoperative chemotherapy was also significantly associated with decreased hazard of death (HR 0.77, p < 0.05). On unadjusted analysis, the survival benefit associated with adequate LNE was lost when stratified by receipt of postoperative chemotherapy. CONCLUSION The survival benefit associated with LNE is in part derived from the fact that patients who receive adequate LNE are also more likely to receive chemotherapy. Thus, the use of lymph node counts has limitations as a quality metric.
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Affiliation(s)
- Erin E Burke
- Department of Surgery, University of Minnesota, 420 Delaware Street SE, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Schelomo Marmor
- Department of Surgery, University of Minnesota, 420 Delaware Street SE, Mayo Mail Code 195, Minneapolis, MN, 55455, USA.,School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Beth A Virnig
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Todd M Tuttle
- Department of Surgery, University of Minnesota, 420 Delaware Street SE, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Eric H Jensen
- Department of Surgery, University of Minnesota, 420 Delaware Street SE, Mayo Mail Code 195, Minneapolis, MN, 55455, USA.
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