Prognostic role of nodal ratio, LODDS, pN in patients with pancreatic cancer with venous involvement

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Abstract

Background

The UICC/AJCC TNM staging system classifies lymph nodes as N0 and N1 in pancreatic cancer. Aim of the study is to determine whether the number of examine nodes, the nodal ratio (NR) and the logarithm odds of positive lymph nodes (LODDS) may better stratify the prognosis of patients undergoing pancreatectomy combined with venous resection for pancreatic cancer with venous involvement.

Methods

A multicenter database of 303 patients undergoing pancreatectomy in 9 Italian referral centers was analyzed. The prognostic impact of number of retrieved and examined nodes, NR, LODDS was analyzed and compared with ROC curves analysis, Pearson test, univariate and multivariate analysis.

Results

The number of metastatic nodes, pN, the NR and LODDS was significantly correlated with survival at multivariate analyses. The corresponding AUC for the number of metastatic nodes, pN, the NR and LODDS were 0.66, 0.69, 0.63 and 0.65, respectively. The Pearson test showed a significant correlation between the number of retrieved lymph nodes and number of metastatic nodes, pN and the NR. LODDS had the lower coefficient correlation. Concerning N1 patients, the NR, the LODDS and the number of metastatic nodes were able to significantly further stratify survival ( p = 0.040; p = 0.046; p = 0.038, respectively).

Conclusions

The number of examined lymph nodes, the NR and LODDS are useful for further prognostic stratification of N1 patients in the setting of pancreatectomy combined with PV/SMV resection. No superiority of one over the others methods was detected.

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Most cited references 18

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Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS).

Johanna Tol, Dirk Gouma, Claudio Bassi … (2014)

The lymph node (Ln) status of patients with resectable pancreatic ductal adenocarcinoma is an important predictor of survival. The survival benefit of extended lymphadenectomy during pancreatectomy is, however, disputed, and there is no true definition of the optimal extent of the lymphadenectomy. The aim of this study was to formulate a definition for standard lymphadenectomy during pancreatectomy.

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Impact of total lymph node count and lymph node ratio on staging and survival after pancreatectomy for pancreatic adenocarcinoma: a large, population-based analysis.

Mark B Slidell, David Chang, John L. Cameron … (2008)

Based on data from other malignancies, the number of lymph nodes evaluated and the ratio of metastatic to examined lymph nodes (LNR) may be important predictors of survival. LNR has never been investigated in a large population-based study of patients with pancreatic adenocarcinoma. The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 4005 patients who underwent resection for pancreatic adenocarcinoma from 1988 to 2003. The effect of total lymph node count and LNR on survival was examined using univariate and multivariate analyses. The median number of lymph nodes examined was seven; 390 (10.1%) patients had no lymph nodes examined. Of those patients who had at least one lymph node examined, 1507 (43.3%) had no lymph node metastases (N0) and 1971 (56.7%) had metastatic nodal disease (N1). Overall median survival was 13 months, and 5-year survival was 6.8%. N1 disease was associated with a worse 5-year survival compared with N0 disease (4.3 vs 11.3%, respectively, P 0-0.2, 15 months; LNR > 0.2-0.4, 12 months; LNR > 0.4, 10 months) (P < .001). Most patients have an inadequate number of lymph nodes evaluated following pancreatic surgery. N0 patients who have fewer than 12 lymph nodes examined may be understaged. In patients with N1 disease, LNR may better substratify patients with regard to prognosis.

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The lymph node ratio is the strongest prognostic factor after resection of pancreatic cancer.

Hartwig Riediger, Tobias Keck, Ulrich Wellner … (2009)

Survival after surgery of pancreatic cancer is still poor, even after curative resection. Some prognostic factors like the status of the resection margin, lymph node (LN) status, or tumor grading have been identified. However, only few data have been published regarding the prognostic influence of the LN ratio (number of LN involved to number of examined LN). We, therefore, evaluated potential prognostic factors in 182 patients after resection of pancreatic cancer including assessment of LN ratio. Since 1994, 204 patients underwent pancreatic resection for ductal pancreatic adenocarcinoma. Survival was evaluated in 182 patients with complete follow-up evaluations. Of those 182 patients, 88% had cancer of the pancreatic head, 5% of the body, and 7% of the pancreatic tail. Patients underwent pancreatoduodenectomy (85%), distal resection (12%), or total pancreatectomy (3%). Survival was analyzed by the Kaplan-Meier and Cox methods. In all 204 resected patients, operative mortality was 3.9% (n = 8). In the 182 patients with follow-up, 70% had free resection margins, 62% had G1- or G2-classified tumors, and 70% positive LN. Median tumor size was 30 (7-80) mm. The median number of examined LN was 16 and median number of involved LN 1 (range 0-22). Median LN ratio was 0.1 (0-0.79). Cumulative 5-year survival (5-year SV) in all patients was 15%. In univariate analysis, a LN ratio > or = 0.2 (5-year SV 6% vs. 19% with LN ratio or = 0.3 (5-year SV 0% vs. 18% with LN ratio or = 0.2 (p or = 0.3 (p < 0.001; RR 2.2), positive margins (p < 0.02; RR 1.7), and poor differentiation (p < 0.03; RR 1.5) were independent factors predicting a poorer outcome. The conventional nodal status or the number of examined nodes (in all patients and in the subgroups of node positive or negative patients) had no significant influence on survival. Patients with one metastatic LN had the same outcome as patients with negative nodes, but prognosis decreased significantly in patients with two or more LN involved. Not the lymph node involvement per se but especially the LN ratio is an independent prognostic factor after resection of pancreatic cancers. In our series, the LN ratio was even the strongest predictor of survival. The routine estimation of the LN ratio may be helpful not only for the individual prediction of prognosis but also for the indication of adjuvant therapy and herein related outcome and therapy studies.

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Author and article information

Contributors

Giovanni Ramacciato: Giovanni.ramacciato@uniroma1.it

Giuseppe Nigri:

ORCID: http://orcid.org/0000-0002-7656-7789

00390633775632 , giuseppe.nigri@uniroma1.it , http://w3.uniroma1.it/nigri

Niccolo’ Petrucciani: nicpetrucciani@hotmail.it

Antonio Daniele Pinna: antoniodaniele.pinna@unibo.it

Matteo Ravaioli: matteo.ravaioli@aosp.bo.it

Elio Jovine: elio.jovine@ausl.bologna.it

Francesco Minni: francesco.minni@unibo.it

Gian Luca Grazi: grazi@ifo.it

Piero Chirletti: piero.chirletti@Uniroma1.it

Giuseppe Tisone: tisone@med.uniroma2.it

Fabio Ferla: Fabio.Ferla@OspedaleNiguarda.it

Niccolo’ Napoli: nicco.napo@gmail.com

Ugo Boggi: u.boggi@med.unipi.it

Journal

Journal ID (nlm-ta): BMC Surg

Journal ID (iso-abbrev): BMC Surg

Title: BMC Surgery

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2482

Publication date (Electronic): 23 November 2017

Publication date PMC-release: 23 November 2017

Publication date Collection: 2017

Volume: 17

Electronic Location Identifier: 109

Affiliations

[1 ]GRID grid.7841.a, Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, , St Andrea Hospital, Sapienza University, General Surgery Unit, ; Via di Grottarossa 1037, 00189 Rome, Italy

[2 ]ISNI 0000 0004 1757 1758, GRID grid.6292.f, Department of Medical and Surgical Sciences-DIMEC, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, , University of Bologna, General Surgery and Transplantation Unit, ; Bologna, Italy

[3 ]ISNI 0000 0004 1759 7093, GRID grid.416290.8, General Surgery Unit, ‘Maggiore’ Hospital, ; Bologna, Italy

[4 ]ISNI 0000 0004 1757 1758, GRID grid.6292.f, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, S. Orsola-Malpighi Hospital, , University of Bologna, General Surgery Unit, ; Bologna, Italy

[5 ]ISNI 0000 0004 1760 5276, GRID grid.417520.5, Regina Elena National Cancer Institute IFO, Hepato-pancreato-biliary Surgery Unit, ; Rome, Italy

[6 ]GRID grid.7841.a, Department of Surgical Sciences, Sapienza University of Rome, Policlinico Umberto I Hospital, General Surgery Unit, ; Rome, Italy

[7 ]ISNI 0000 0001 2300 0941, GRID grid.6530.0, Department of Experimental Medicine and Surgery, Liver Unit, , Tor Vergata University of Rome, ; Rome, Italy

[8 ]GRID grid.416200.1, Division of General Surgery and Transplantation Surgery, Niguarda Hospital, ; Milan, Italy

[9 ]ISNI 0000 0004 1756 8209, GRID grid.144189.1, Division of General Surgery and Transplantation Surgery, Pisa University Hospital, ; Pisa, Italy

Author information

Giuseppe Nigri http://orcid.org/0000-0002-7656-7789

Article

Publisher ID: 311

DOI: 10.1186/s12893-017-0311-1

PMC ID: 5701499

PubMed ID: 29169392

SO-VID: b960b9a0-59ac-4f73-b334-9f95c33660b4

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 4 September 2017

Date accepted : 15 November 2017

Custom metadata

ScienceOpen disciplines: Surgery

Keywords: pancreatic cancer,tnm,nodal ratio,lodds,prognosis,nodal staging,venous invasion,portal vein,superior mesenteric vein,pancreatectomy

Data availability:

ScienceOpen disciplines: Surgery

Keywords: pancreatic cancer, tnm, nodal ratio, lodds, prognosis, nodal staging, venous invasion, portal vein, superior mesenteric vein, pancreatectomy

Prognostic role of nodal ratio, LODDS, pN in patients with pancreatic cancer with venous involvement

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Abstract

Background

Methods

Results

Conclusions

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Karger: Oncology

Most cited references 18

Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS).

Impact of total lymph node count and lymph node ratio on staging and survival after pancreatectomy for pancreatic adenocarcinoma: a large, population-based analysis.

The lymph node ratio is the strongest prognostic factor after resection of pancreatic cancer.

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