基于淋巴结分期评分的胰腺癌手术淋巴结清扫数目探讨(附四中心临床研究结果)
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摘要
目的探讨胰腺癌淋巴结准确分期所需清扫的淋巴结数目。方法回顾性分析美国SEER数据库中3989例切除的胰腺癌淋巴结阳性病人资料并进行建模,得到淋巴结分期评分达到90%时所需的淋巴结清扫数目作为推荐值,并利用SEER数据库2583例与国内93例淋巴结阴性病人进行生存分析验证结果。结果肿瘤最大径<2 cm是胰腺癌淋巴结清扫数量的影响因素。预期对阴性结果达到90%把握时,肿瘤最大径<2 cm的病人需要活检15枚淋巴结,而≥2 cm的病人需要活检20枚。校正假阴性病人后,淋巴结阳性率从60.7%升至71.0%。生存分析提示肿瘤最大径≥2 cm病人中,淋巴结分期评分与生存有相关性(P=0.002)。结论肿瘤最大径是决定胰腺癌淋巴结清扫数量的因素。根据淋巴结分期评分,推荐清扫更多淋巴结。
Objective To estimate the number of lymph nodes(LNs)needed to be examined for adequate LN staging via nodal staging score(NSS).Methods A model was fitted based on 3989 pN + patients with resected primary pancreatic adenocarcinoma in the Surveillance,Epidemiology and End Results(SEER)database.The number of nodes to examine to achieve an N SS of 90% was used as the optimal number.The results were validated in node negative patients from the SEER cohort(2583 patients)and a local multicenter cohort(93 patients).Results Tumor size is a determinant for the extent of lymphadenectomy.According to the tumor size<2 cm and ≥2 cm,15 and 20 LNs would need to be examined to achieve90% confidence in a pN0 patient.As a result of missing node-positive case,the prevalence of nodepositive was adjusted from 60.7% to 71.0%.In the survival analysis,more LNs examined was shown to be correlated with better prognosis in patients with tumor ≥2 cm.Conclusion The minimum number of LNs for adequate staging depends on the tumor size.The estimation provides a practical standard for evaluating the extent of LN yield for surgeons.
Objective To estimate the number of lymph nodes(LNs)needed to be examined for adequate LN staging via nodal staging score(NSS).Methods A model was fitted based on 3989 pN + patients with resected primary pancreatic adenocarcinoma in the Surveillance,Epidemiology and End Results(SEER)database.The number of nodes to examine to achieve an N SS of 90% was used as the optimal number.The results were validated in node negative patients from the SEER cohort(2583 patients)and a local multicenter cohort(93 patients).Results Tumor size is a determinant for the extent of lymphadenectomy.According to the tumor size<2 cm and ≥2 cm,15 and 20 LNs would need to be examined to achieve90% confidence in a pN0 patient.As a result of missing node-positive case,the prevalence of nodepositive was adjusted from 60.7% to 71.0%.In the survival analysis,more LNs examined was shown to be correlated with better prognosis in patients with tumor ≥2 cm.Conclusion The minimum number of LNs for adequate staging depends on the tumor size.The estimation provides a practical standard for evaluating the extent of LN yield for surgeons.
引文
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[12]G?nen M,Schrag D,Weiser MR.Nodal staging score:a tool to assess adequate staging of node-negative colon cancer[J].JClin Oncol,2009,27(36):6166-6171.
[13]Robinson TJ,Thomas S,Dinan MA,et al.Howmany lymph nodes are enough?assessing the adequacy of lymph node yield for papillary thyroid cancer[J].J Clin Oncol,2016,34(28):3434-3439.
[14]Yeo CJ,Cameron JL,Lillemoe KD,et al.Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma,part 2:randomized controlled trial evaluating survival,morbidity,and mortality[J].Ann Surg,2002,236(3):355-366.
[15]Nimura Y,Nagino M,Takao S,et al.Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas:long-term results of a Japanese multicenter randomized controlled trial[J].JHepatobiliary Pancreat Sci,2012,19(3):230-241.
[16]刘颖斌,吴文广.胰腺全系膜切除理念争议及评价[J].中国实用外科杂志,2016,36(8):836-838.
[17]吴文广,吴向嵩,李茂岚,等.胰头癌行胰腺全系膜切除75例报告[J].中国实用外科杂志,2013,33(10):859-862.
[18]Hirata K,Sato T,Mukaiya M,et al.Results of 1001 pancreatic resections for invasive ductal adenocarcinoma of the pancreas[J].Arch Surg,1997,132(7):771-777.
[19]Huebner M,Kendrick M,Reid-Lombardo KM,et al.Number of lymph nodes evaluated:prognostic value in pancreatic adenocarcinoma[J].J Gastrointest Surg,2012,16(5):920-926.
[20]洪德飞,刘颖斌,彭淑牖.如何提高胰头癌根治的彻底性和安全性[J].中华肝胆外科杂志,2010,16(2):88-91.
[21]Contreras CM,Lin CP,Oster RA,et al.Increased pancreatic cancer survival with greater lymph node retrieval in the National Cancer Data Base[J].Am J Surg,2017,214(3):442-449.
[2]赵玉沛.胰十二指肠切除术现状与展望[J].中国实用外科杂志,2016,36(8):817-820.
[3]Bochner BH,Hansel DE,Efstathiou JA,et al.AJCC Cancer Staging Manual[M].8th Edition.Chicago:Springer,2017:337-347.
[4]Tol JA,Gouma DJ,Bassi C,et al.Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma:a consensus statement by the International Study Group on Pancreatic Surgery(ISGPS)[J].Surgery,2014,156(3):591-600.
[5]Schwarz RE,Smith DD.Extent of lymph node retrieval and pancreatic cancer survival:information from a large US population database[J].Ann Surg Oncol,2006,13(9):1189-2000.
[6]Mirkin KA,Hollenbeak CS,Wong J.Greater lymph node retrieval and lymph node ratio impacts survival in resected pancreatic cancer[J].J Surg Res,2017,220:12-24.
[7]Showalter TN,Winter KA,Berger AC,et al.The influence of total nodes examined,number of positive nodes,and lymph node ratio on survival after surgical resection and adjuvant chemoradiation for pancreatic cancer:a secondary analysis of RTOG 9704[J].Int J Radiat Oncol Biol Phys,2011,81(5):1328-1335.
[8]Ashfaq A,Pockaj BA,Gray RJ,et al.Nodal counts and lymph node ratio impact survival after distal pancreatectomy for pancreatic adenocarcinoma[J].J Gastrointest Surg,2014,18(11):1929-1935.
[9]Tomlinson JS,Jain S,Bentrem DJ,et al.Accuracy of staging node-negative pancreas cancer:a potential quality measure[J].Arch Surg,2007,142(8):767-723.
[10]Valsangkar NP,Bush DM,Michaelson JS,et al.N0/N1,PNL,or LNR?The effect of lymph node number on accurate survival prediction in pancreatic ductal adenocarcinoma[J].J Gastrointest Surg,2013,17(2):257-266.
[11]刘颖斌,吴文广.胰腺癌淋巴结清扫范围的探讨[J].上海医学,2010,33(11):986-988.
[12]G?nen M,Schrag D,Weiser MR.Nodal staging score:a tool to assess adequate staging of node-negative colon cancer[J].JClin Oncol,2009,27(36):6166-6171.
[13]Robinson TJ,Thomas S,Dinan MA,et al.Howmany lymph nodes are enough?assessing the adequacy of lymph node yield for papillary thyroid cancer[J].J Clin Oncol,2016,34(28):3434-3439.
[14]Yeo CJ,Cameron JL,Lillemoe KD,et al.Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma,part 2:randomized controlled trial evaluating survival,morbidity,and mortality[J].Ann Surg,2002,236(3):355-366.
[15]Nimura Y,Nagino M,Takao S,et al.Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas:long-term results of a Japanese multicenter randomized controlled trial[J].JHepatobiliary Pancreat Sci,2012,19(3):230-241.
[16]刘颖斌,吴文广.胰腺全系膜切除理念争议及评价[J].中国实用外科杂志,2016,36(8):836-838.
[17]吴文广,吴向嵩,李茂岚,等.胰头癌行胰腺全系膜切除75例报告[J].中国实用外科杂志,2013,33(10):859-862.
[18]Hirata K,Sato T,Mukaiya M,et al.Results of 1001 pancreatic resections for invasive ductal adenocarcinoma of the pancreas[J].Arch Surg,1997,132(7):771-777.
[19]Huebner M,Kendrick M,Reid-Lombardo KM,et al.Number of lymph nodes evaluated:prognostic value in pancreatic adenocarcinoma[J].J Gastrointest Surg,2012,16(5):920-926.
[20]洪德飞,刘颖斌,彭淑牖.如何提高胰头癌根治的彻底性和安全性[J].中华肝胆外科杂志,2010,16(2):88-91.
[21]Contreras CM,Lin CP,Oster RA,et al.Increased pancreatic cancer survival with greater lymph node retrieval in the National Cancer Data Base[J].Am J Surg,2017,214(3):442-449.
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