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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: 2.7] [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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Speichinger F, Dragomir MP, Schallenberg S, Loch FN, Degro CE, Baukloh AK, Hartmann L, Pozios I, Schineis C, Margonis GA, Lauscher JC, Beyer K, Kamphues C. Rethinking the TNM Classification Regarding Direct Lymph Node Invasion in Pancreatic Ductal Adenocarcinoma. Cancers (Basel) 2021; 14:cancers14010201. [PMID: 35008365 PMCID: PMC8750597 DOI: 10.3390/cancers14010201] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/25/2021] [Accepted: 12/29/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Due to the rising burden of pancreatic cancer and poor outcomes, a precise, post-operative cancer staging for further and individualized therapy is needed. In the latest cancer classification system, the lymph node invasion mechanism is not addressed. Due to different outcomes regarding the lymph node invasion, we suggest a rethinking of the current system. Abstract Mechanisms of lymph node invasion seem to play a prognostic role in pancreatic ductal adenocarcinoma (PDAC) after resection. However, the 8th edition of the TNM classification of the American Joint Committee on Cancer (AJCC) does not consider this. The aim of this study was to analyse the prognostic role of different mechanisms of lymph node invasion on PDAC. One hundred and twenty-two patients with resected PDAC were examined. We distinguished three groups: direct (per continuitatem, Nc) from the main tumour, metastasis (Nm) without any contact to the main tumour, and a mixed mechanism (Ncm). Afterwards, the prognostic power of the different groups was analysed concerning overall survival (OS). In total, 20 patients displayed direct lymph node invasion (Nc = 16.4%), 44 were classed as Nm (36.1%), and 21 were classed as Ncm (17.2%). The difference in OS was not statistically significant between N0 (no lymph node metastasis, n = 37) and Nc (p = 0.134), while Nm had worse OS than N0 (p < 0.001). Direct invasion alone had no statistically significant effect on OS (p = 0.885). Redefining the N0 stage by including Nc patients showed a more precise OS prediction among N stages (p = 0.001 vs. p = 0.002). Nc was more similar to N0 than to Nm; hence, we suggest a rethinking of TNM classification based on the mechanisms of lymph node metastases in PDAC. Overall, this novel classification is more precise.
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Affiliation(s)
- Fiona Speichinger
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt–Universität zu Berlin, Department of General and Visceral Surgery, Hindenburgdamm 30, 12203 Berlin, Germany; (F.N.L.); (C.E.D.); (A.-K.B.); (L.H.); (I.P.); (C.S.); (J.C.L.); (K.B.); (C.K.)
- Correspondence:
| | - Mihnea P. Dragomir
- Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Institute of Pathology, 10117 Berlin, Germany; (M.P.D.); (S.S.)
- German Cancer Consortium (DKTK), Partner Site Berlin, German Cancer Research Center (DKFZ), 69210 Heidelberg, Germany
- Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
| | - Simon Schallenberg
- Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Institute of Pathology, 10117 Berlin, Germany; (M.P.D.); (S.S.)
| | - Florian N. Loch
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt–Universität zu Berlin, Department of General and Visceral Surgery, Hindenburgdamm 30, 12203 Berlin, Germany; (F.N.L.); (C.E.D.); (A.-K.B.); (L.H.); (I.P.); (C.S.); (J.C.L.); (K.B.); (C.K.)
| | - Claudius E. Degro
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt–Universität zu Berlin, Department of General and Visceral Surgery, Hindenburgdamm 30, 12203 Berlin, Germany; (F.N.L.); (C.E.D.); (A.-K.B.); (L.H.); (I.P.); (C.S.); (J.C.L.); (K.B.); (C.K.)
| | - Ann-Kathrin Baukloh
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt–Universität zu Berlin, Department of General and Visceral Surgery, Hindenburgdamm 30, 12203 Berlin, Germany; (F.N.L.); (C.E.D.); (A.-K.B.); (L.H.); (I.P.); (C.S.); (J.C.L.); (K.B.); (C.K.)
| | - Lisa Hartmann
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt–Universität zu Berlin, Department of General and Visceral Surgery, Hindenburgdamm 30, 12203 Berlin, Germany; (F.N.L.); (C.E.D.); (A.-K.B.); (L.H.); (I.P.); (C.S.); (J.C.L.); (K.B.); (C.K.)
| | - Ioannis Pozios
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt–Universität zu Berlin, Department of General and Visceral Surgery, Hindenburgdamm 30, 12203 Berlin, Germany; (F.N.L.); (C.E.D.); (A.-K.B.); (L.H.); (I.P.); (C.S.); (J.C.L.); (K.B.); (C.K.)
| | - Christian Schineis
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt–Universität zu Berlin, Department of General and Visceral Surgery, Hindenburgdamm 30, 12203 Berlin, Germany; (F.N.L.); (C.E.D.); (A.-K.B.); (L.H.); (I.P.); (C.S.); (J.C.L.); (K.B.); (C.K.)
| | - Georgios Antonios Margonis
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA;
| | - Johannes C. Lauscher
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt–Universität zu Berlin, Department of General and Visceral Surgery, Hindenburgdamm 30, 12203 Berlin, Germany; (F.N.L.); (C.E.D.); (A.-K.B.); (L.H.); (I.P.); (C.S.); (J.C.L.); (K.B.); (C.K.)
| | - Katharina Beyer
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt–Universität zu Berlin, Department of General and Visceral Surgery, Hindenburgdamm 30, 12203 Berlin, Germany; (F.N.L.); (C.E.D.); (A.-K.B.); (L.H.); (I.P.); (C.S.); (J.C.L.); (K.B.); (C.K.)
| | - Carsten Kamphues
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt–Universität zu Berlin, Department of General and Visceral Surgery, Hindenburgdamm 30, 12203 Berlin, Germany; (F.N.L.); (C.E.D.); (A.-K.B.); (L.H.); (I.P.); (C.S.); (J.C.L.); (K.B.); (C.K.)
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Byun Y, Lee KB, Jang JY, Han Y, Choi YJ, Kang JS, Kim H, Kwon W. Peritumoral lymph nodes in pancreatic cancer revisited; is it truly equivalent to lymph node metastasis? JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:893-901. [PMID: 33735543 DOI: 10.1002/jhbp.940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/17/2021] [Accepted: 02/21/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Lymph node (LN) metastasis is a well-known poor prognostic factor of pancreatic cancer. LN metastasis, through direct invasion of tumor cell to peritumoral lymph nodes (PTLN), is treated as the same as those which spread through lymphatic channels. This study aimed to evaluate the impact of PTLN invasion on the oncologic outcome of pancreatic cancer. METHODS Five hundred and six patients who underwent operation for pancreatic ductal adenocarcinoma from 2012 to 2018 were reviewed. PTLN invasion was defined as direct invasion of tumor cells in contact with main tumor. RESULTS Among the 506 patients, 112 patients (22.1%) had PTLN invasion. PTLN invasion group (PTLNI) showed better disease-free survival than regional LN metastasis group (RLNM) and combined LN metastasis group (CLNM) (PTLNI 21 vs RLNM 11 vs CLNM 12 months, P = .003). There was no significant difference between N0 and PTLNI (PTLNI 21 vs N0 23 months, P = .999). In multivariate analysis, conventional LN metastasis was a significant factor compared to N0, but PTLN invasion was not (hazard ratio 0.786 [0.507-1.220], P = .283). CONCLUSION Because PTLN invasion does not adversely affect survival in the same way as LN metastasis does, pancreatic cancer-may be overstaged if PTLN invasion were dealt in the same manner as a metastatic LN. Therefore, PTLN invasion should be disregarded from current nodal staging system.
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Affiliation(s)
- Yoonhyeong Byun
- Division of Pancreatobiliary Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung-Bun Lee
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Division of Pancreatobiliary Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Youngmin Han
- Division of Pancreatobiliary Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yoo Jin Choi
- Division of Pancreatobiliary Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Kang
- Division of Pancreatobiliary Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hongbeom Kim
- Division of Pancreatobiliary Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Division of Pancreatobiliary Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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