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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: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Konstantinidis IT, Deshpande V, Zheng H, Wargo JA, Castillo CFD, Thayer SP, Androutsopoulos V, Lauwers GY, Warshaw AL, Ferrone CR. Does the mechanism of lymph node invasion affect survival in patients with pancreatic ductal adenocarcinoma? J Gastrointest Surg 2010; 14:261-7. [PMID: 19937477 PMCID: PMC3135335 DOI: 10.1007/s11605-009-1096-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 11/02/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lymph node metastases are prognostically significant in pancreatic ductal adenocarcinoma. Little is known about the significance of direct lymph node invasion. AIM The aim of this study is to find out whether direct lymph node invasion has the same prognostic significance as regional nodal metastases. METHODS Retrospective review of patients resected between 1/1/1993 and 7/31/2008. "Direct" was defined as tumor extension into adjacent nodes, and "regional" was defined as metastases to peripancreatic nodes. RESULTS Overall, 517 patients underwent pancreatic resection for adenocarcinoma, of whom 89 had one positive node (direct 26, regional 63), and 79 had two positive nodes (direct 6, regional 68, both 5). Overall, survival of node-negative patients was improved compared to patients with positive nodes (N0 30.8 months vs. N1 16.4 months; p < 0.001). There was no survival difference for patients with direct vs. regional lymph node invasion (p = 0.67). Patients with one positive node had a better overall survival compared to patients with >/=2 positive nodes (22.3 and 15 months, respectively; p < 0.001). The lymph node ratio (+LN/total LN) was prognostically significant after Cox regression (p < 0.001). CONCLUSIONS Isolated direct invasion occurs in 20% of patients with one to two positive nodes. Node involvement by metastasis or by direct invasion are equally significant predictors of reduced survival. Both the number of positive nodes and the lymph node ratio are significant prognostic factors.
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Affiliation(s)
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Hui Zheng
- Department of Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer A. Wargo
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Sarah P. Thayer
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Gregory Y. Lauwers
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew L. Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Cristina R. Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. Wang Ambulatory Care Center 460, 15 Parkman Street, Boston, MA 02114, USA
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