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Reconsidering the absence of extrapancreatic extension in T staging for pancreatic adenocarcinoma in the AJCC (8th ed) Staging Manual using the National Cancer Database

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Purpose

Although the concept of extrapancreatic extension (EPEx) was removed in the eighth edition of the American Joint Committee on Cancer pancreatic cancer staging system, several studies have supported the prognostic significance of EPEx. This study aimed to investigate the significance of EPEx in pancreatic ductal adenocarcinoma (PDAC) using the National Cancer Database (NCDB).

Methods

Data of patients who underwent resection for PDAC between 2006 and 2016 were extracted and analyzed from the NCDB. Cases arising from premalignant lesions, those with metastases, and those treated with neoadjuvant therapy were excluded.

Results

Among 37,634 patients, the median overall survival was 23 months and the 5-year survival rate was 22.7%. The EPEx prevalence was the lowest for T1 stage (63.2%) and increased with each T-stage (T2:83.4%, T3:85.8%). The overall survival was better in EPEx-negative patients than in EPEx-positive patients (median 33.7 vs. 21.5 months; p<0.001). When the T-stages were stratified by EPEx, EPEx-positive patients showed worse survival in all T-stages than EPEx-negative patients. Survival was comparable between T1 EPEx-positive and T2 or T3 EPEx-negative patients (p=0.088 and p=0.178, respectively). Furthermore, T2 and T3 EPEx-negative patients had similar survival to each other (p=0.877), and distinctly superior survival compared to T2 and T3 EPEx-positive patients (p<0.001).

Conclusions

EPEx was an important prognostic factor in the overall cohort and in differentiating between T stages. This study strongly suggests that staging systems should reinstate EPEx and apply it to all T-stages, especially in T1, where EPEx was absent in 36% of patients.

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Data Availability

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

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Author notes

  1. Mirang Lee and Alexander S. Thomas contributed equally to this work as first authors.

Authors and Affiliations

  1. Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 03080, South Korea

    Mirang Lee, Young Jae Cho, Hye-Sol Jung, Won-Gun Yun, Youngmin Han, **-Young Jang & Wooil Kwon

  2. Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, USA

    Alexander S. Thomas & Michael D. Kluger

  3. Department of Mathematics and Statistics, Sejong University College of Natural Sciences, Seoul, Republic of Korea

    Seung Yeoun Lee

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  1. Mirang Lee
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Lee, M., Thomas, A.S., Lee, S.Y. et al. Reconsidering the absence of extrapancreatic extension in T staging for pancreatic adenocarcinoma in the AJCC (8th ed) Staging Manual using the National Cancer Database. J Gastrointest Surg 27, 2484–2492 (2023). https://doi.org/10.1007/s11605-023-05850-2

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