title: Staging of pancreatic cancer based on the number of positive lymph nodes.
abstract: BACKGROUND
  The International Study Group on Pancreatic Surgery has stated that at least 12 lymph nodes should be evaluated for staging of pancreatic cancer. The aim of this population-based study was to evaluate whether the number of positive lymph nodes refines staging.
  
  
  METHODS
  Patients who underwent pancreatectomy for stage I-II pancreatic cancer between 2004 and 2012 were identified from the Surveillance, Epidemiology, and End Results database. The predictive value of the number of positive lymph nodes for survival was assessed by generalized receiver operating characteristic (ROC) curve analysis and propensity score-adjusted Cox regression analysis.
  
  
  RESULTS
  Some 5036 patients were included, with a median of 18 (i.q.r. 15-24) lymph nodes examined. Positive lymph nodes were found in 3555 patients (70·6 per cent). The median duration of follow-up was 15 (i.q.r. 8-28) months. ROC curve analysis revealed that two positive lymph nodes best discriminated overall survival. Patients with one or two positive lymph nodes (pN1a) and those with three or more positive lymph nodes (pN1b) had an increased risk of overall mortality compared with patients who were node-negative (pN0): hazard ratio (HR) 1·47 (95 per cent c.i. 1·33 to 1·64) and HR 2·01 (1·82 to 2·22) respectively. These findings were confirmed by propensity score-adjusted Cox regression analysis. The 5-year overall survival rates were 39·8 (95 per cent c.i. 36·5 to 43·3) per cent for patients with pN0, 21·0 (18·6 to 23·6) per cent for those with pN1a and 11·4 (9·9 to 13·3) per cent for patients with pN1b disease.
  
  
  CONCLUSIONS
  The number of positive lymph nodes in the resection specimen is a prognostic factor in patients with pancreatic cancer.
authors.affiliation: Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: I
authors.initials: I
authors.lastname: Tarantino
authors.affiliation: Institute of Medical Biometry and Informatics, Heidelberg University Hospital, Heidelberg, Germany.|Department of Surgery, Kantonsspital St Gallen, St Gallen, Switzerland.
authors.forename: R
authors.initials: R
authors.lastname: Warschkow
authors.affiliation: Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: T
authors.initials: T
authors.lastname: Hackert
authors.affiliation: Department of Surgery, Kantonsspital St Gallen, St Gallen, Switzerland.
authors.forename: B M
authors.initials: BM
authors.lastname: Schmied
authors.affiliation: Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: M W
authors.initials: MW
authors.lastname: Büchler
authors.affiliation: Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: O
authors.initials: O
authors.lastname: Strobel
authors.affiliation: Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Ulrich
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods*; D008198:Lymph Nodes / Q000473:pathology*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010179:Pancreas / Q000473:pathology*; D010180:Pancreatectomy / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery; D011379:Prognosis; D012372:ROC Curve; D015996:Survival Rate