An Increased Total Resected Lymph Node Count Benefits Survival following Pancreas Invasive Intraductal Papillary Mucinous Neoplasms Resection: An Analysis Using the Surveillance, Epidemiology, and End Result Registry Database
and End Result Registry Database. PLoS ONE 9(9):
e107962. doi:10.1371/journal.pone.0107962
An Increased Total Resected Lymph Node Count Benefits Survival following Pancreas Invasive Intraductal Papillary Mucinous Neoplasms Resection: An Analysis Using the Surveillance, Epidemiology, and End Result Registry Database
Wenming Wu." 0
Xiafei Hong." 0
Rui Tian 0
Lei You 0
Menghua Dai 0
Quan Liao 0
Taiping Zhang 0
Yupei Zhao 0
Xin-Yuan Guan, The University of Hong Kong, China
0 Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences , Beijing , China; and Peking Union Medical College , Beijing , China
Background: The therapeutic effect of lymph node dissection for pancreas invasive intraductal papillary mucinous neoplasms (IPMN) remains unclear. The study investigated whether cancer-specific survival (CSS) and overall survival (OS) rates among invasive IPMN patients improve when more lymph nodes are harvested during surgery. Study Design: The study cohort was retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. The lymph node count was categorized into quartiles. The relationship between lymph node count and survival was analyzed using Kaplan-Meier curves and a Cox proportional-hazards model. The stage migration was assessed by Chi-square tests. Propensity score matching (PSM) was used to minimize confounding variables between groups. Results: In total, 1,080 patients with resected invasive IPMNs from 1992 to 2011 were included. Univariate and multivariate Cox models indicated that an increased lymph node count independently improves survival. The Kaplan-Meier and log-rank tests identified 16 nodes as an optimal cut-off value that yielded a significant survival benefit for all invasive IPMN patients. The stage migration effect existed in this cohort. After PSM, the 5-year CSS increased from 36% to 47%, and the median survival rate increased from 30 months to 40 months by increasing the lymph node count to over 16, alone. The 5-year OS rate also provided additional support for this result. Conclusion: Increased lymph node counts were associated with improved survival in invasive IPMN patients. One cut-off value of lymph node count was 16 for this improvement.
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Data Availability: The authors confirm that all data underlying the findings are fully available without restriction. All relevant data are within the paper and its
Supporting Information files.
Funding: The authors have no support or funding to report.
Competing Interests: The authors have declared that no competing interests exist.
. These authors contributed equally to this work.
" These authors are co-first authors on this work.
Intraductal papillary mucinous neoplasms (IPMN) have been
increasingly recognized as an intraductal mucin-producing
pancreatic neoplasms with tall, columnar mucin-containing
epithelium and a lack of ovarian stroma, according to the World Health
Organization definition [1,2]. The estimated IPMN prevalence is
around 26 per 100,000 people, and the prevalence of this disease is
roughly 99 per 100,000 people in the population over 60 years old
[3,4]. Approximately 5% of all pancreatic cancers are invasive
IPMNs from an analysis from the Surveillance, Epidemiology, and
End Result (SEER) database [5].
IPMN can be classified into adenoma, borderline dysplasia,
carcinoma in situ and invasive lesions based on the cellular atypia
degree [6]. The three major IPMN types are the main duct-type,
branch duct-type, and the mixed-type, based on their relationships
with the main pancreatic duct [7]. The common main duct-type
IPMN features include main pancreatic duct obstruction and
dilatation [8]. Approximately 40%80% of main duct-type
IPMNs are invasive lesions [912]. Branch duct-type IPMNs
reside in the branches of the pancreatic duct. Approximately
10%30% of branch duct-type IPMNs are invasive lesions and are
much less frequent than main duct-type IPMNs [914]. The
International Consensus Guidelines recommended resection for all
main duct-type IPMNs and certain branch duct-type IPMNs with
suspicious malignant features [15,16]. The prognosis is poorer for
invasive IPMNs compared with their non-invasive counterparts.
The five-year survival rate was estimated to be nearly 31%41%
for invasive IPMNs and 77%94.5% for non-invasive IPMNs [17
19]. The recurrence rate is also higher for invasive IPMNs (30%
65%) compared with non-invasive IPMNs (614%) [17,1921].
Distance metastases are common for invasive IPMN recurrences
and usually involve the liver, peritoneum, and other abdominal
organs. Local recurrences in the remnant pancreas are seen in
some patients who had a partial pancreatectomy as an initial
treatment.
The lymph node status has long been recognized as the
prognostic indicator for invasive IPMNs. Survival is even worse for
those with positive nodes compared with negative ones [9,22].
Moreover, a higher lymph node ratio is associated with a poorer
prognosi (...truncated)