title: Re-evaluating the impact of tumor size on survival following pancreaticoduodenectomy for pancreatic adenocarcinoma.
abstract: OBJECTIVE
  Following resection of pancreatic adenocarcinoma, tumor size has been considered a key prognostic feature; however, this remains controversial. We sought to examine the association of size with outcomes following resection of pancreatic adenocarcinoma.
  
  
  METHODS
  Between 1970 and 2010, 1,697 patients with pancreatic adenocarcinoma at the Johns Hopkins Hospital underwent curative intent pancreaticoduodenectomy. Prognostic factors were identified by univariate and multivariate analyses.
  
  
  RESULTS
  Of 1,697 patients, tumor size was ≤ 2 cm in 418 (24.6%) patients, 2-5 cm in 1,070 (63.1%) patients, and ≥ 5 cm in 209 (12.3%) patients. On univariate analyses, 5-year survival was inversely proportional to tumor size (≤ 2 cm: 28.8% vs. 2-5 cm: 19.4% vs. ≥ 5 cm: 14.2%; P < 0.001). Size correlated with the risk of other adverse factors, with larger tumors being more likely to be associated with nodal disease and poor differentiation (both P < 0.05). On multivariate analysis, the 2 cm cut-off was not associated with survival, while nodal disease (HR = 1.59; P = 0.006) and poor differentiation (HR = 1.59; P = 0.04) remained predictive of outcome, regardless of size.
  
  
  CONCLUSIONS
  The cut-off value of 2 cm is not independently associated with outcome, however, tumor size was strongly associated with the risk of other adverse prognostic factors. The effect of size on prognosis was largely attributable to these other biologic factors rather than tumor size itself.
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
authors.forename: Mechteld C
authors.initials: MC
authors.lastname: de Jong
authors.forename: Fuyu
authors.initials: F
authors.lastname: Li
authors.forename: John L
authors.initials: JL
authors.lastname: Cameron
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Wolfgang
authors.forename: Barish H
authors.initials: BH
authors.lastname: Edil
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Herman
authors.forename: Michael A
authors.initials: MA
authors.lastname: Choti
authors.forename: Frederick
authors.initials: F
authors.lastname: Eckhauser
authors.forename: Kenzo
authors.initials: K
authors.lastname: Hirose
authors.forename: Richard D
authors.initials: RD
authors.lastname: Schulick
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D018784:Abdominal Abscess / Q000453:epidemiology; D000230:Adenocarcinoma / Q000401:mortality* / Q000473:pathology* / Q000601:surgery; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D007902:Length of Stay; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D010185:Pancreatic Fistula / Q000453:epidemiology; D010190:Pancreatic Neoplasms / Q000401:mortality* / Q000473:pathology* / Q000601:surgery; D016577:Pancreaticoduodenectomy; D011183:Postoperative Complications; D011446:Prospective Studies; D013530:Surgical Wound Infection / Q000453:epidemiology; D016019:Survival Analysis; D055815:Young Adult