Annals of Surgical Oncology

, Volume 24, Issue 7, pp 2023–2030 | Cite as

Validation of the American Joint Commission on Cancer (AJCC) 8th Edition Staging System for Patients with Pancreatic Adenocarcinoma: A Surveillance, Epidemiology and End Results (SEER) Analysis

  • Sivesh K. Kamarajah
  • William R. Burns
  • Timothy L. Frankel
  • Clifford S. Cho
  • Hari Nathan
Hepatobiliary Tumors



The 8th edition of the AJCC staging system for pancreatic cancer incorporated several significant changes. This study sought to evaluate this staging system and assess its strengths and weaknesses relative to the 7th edition AJCC staging system.


Using the Surveillance, Epidemiology and End Results (SEER) database (2004–2013), 8960 patients undergoing surgical resection for non-metastatic pancreatic adenocarcinoma were identified. Overall survival was estimated using the Kaplan–Meier method and compared using log-rank tests. Concordance indices (c-index) were calculated to evaluate the discriminatory power of both staging systems. The Cox proportional hazards model was used to determine the impact of T and N classification on overall survival.


The c-index for the AJCC 8th staging system [0.60; 95% confidence interval (CI), 0.59–0.61] was comparable with that for the 7th edition AJCC staging system (0.59; 95% CI, 0.58–0.60). Stratified analyses for each N classification system demonstrated a diminishing impact of T classification on overall survival with increasing nodal involvement. The corresponding c-indices were 0.58 (95% CI, 0.55–0.60) for N0, 0.53 (95% CI, 0.51–0.55) for N1, and 0.53 (95% CI, 0.50–0.56) for N2 classification.


This is the first large-scale validation of the AJCC 8th edition staging system for pancreatic cancer. The revised system provides discrimination similar to that of the 7th-edition system. However, the 8th-edition system allows for finer stratification of patients with resected tumors according to extent of nodal involvement.


Pancreatic Cancer Staging System Pancreatic Adenocarcinoma Positive Regional Lymph Node Fine Stratification 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Conflict of interest

There are no conflicts of interest.

Supplementary material

10434_2017_5810_MOESM1_ESM.tif (161 kb)
Supplementary material 1 (TIFF 160 kb) Supplement 1: Overall survival of 8,960 patients who underwent resection for pancreatic adenocarcinoma (A) Overall survival by N classification according to AJCC 8th edition for all T classification
10434_2017_5810_MOESM2_ESM.tif (156 kb)
Supplementary material 2 (TIFF 155 kb) Supplement 1: Overall survival of 8,960 patients who underwent resection for pancreatic adenocarcinoma (B) Overall survival of N0 patients (AJCC 8th edition) stratified by T classification
10434_2017_5810_MOESM3_ESM.tif (160 kb)
Supplementary material 3 (TIFF 160 kb)Supplement 1: Overall survival of 8,960 patients who underwent resection for pancreatic adenocarcinoma (C) Overall survival of N1 patients (AJCC 8th edition) stratified by T classification
10434_2017_5810_MOESM4_ESM.tif (159 kb)
Supplementary material 4 (TIFF 158 kb) Supplement 1: Overall survival of 8,960 patients who underwent resection for pancreatic adenocarcinoma (D) Overall survival of N2 patients (AJCC 8th edition) stratified by T classification


  1. 1.
    Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin. 2016;66:7–30.CrossRefPubMedGoogle Scholar
  2. 2.
    Winter JM, Brennan MF, Tang LH, et al. Survival after resection of pancreatic adenocarcinoma: results from a single institution over three decades. Ann Surg Oncol. 2012;19:169–75.CrossRefPubMedGoogle Scholar
  3. 3.
    Conlon KC, Klimstra DS, Brennan MF. Long-term survival after curative resection for pancreatic ductal adenocarcinoma: clinicopathologic analysis of 5-year survivors. Ann Surg. 1996;223:273–9.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Hartwig W, Hackert T, Hinz U, et al. Pancreatic cancer surgery in the new millennium: better prediction of outcome. Ann Surg. 2011;254:311–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Werner J, Combs SE, Springfeld C, Hartwig W, Hackert T, Buchler MW. Advanced-stage pancreatic cancer: therapy options. Nat Rev Clin Oncol. 2013;10:323–33.CrossRefPubMedGoogle Scholar
  6. 6.
    Edge SB, Compton CC. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol. 2010;17:1471–4.Google Scholar
  7. 7.
    Adsay NV, Bagci P, Tajiri T, et al. Pathologic staging of pancreatic, ampullary, biliary, and gallbladder cancers: pitfalls and practical limitations of the current AJCC/UICC TNM staging system and opportunities for improvement. Semin Diagn Pathol. 2012;29:127–41.CrossRefPubMedGoogle Scholar
  8. 8.
    Allen PJ, Kuk D, Castillo CF, et al. Multi-institutional validation study of the American Joint Commission on Cancer (8th Edition): changes for T and N staging in patients with pancreatic adenocarcinoma. Ann Surg. 2017;265:185-191Google Scholar
  9. 9.
    Royston P, Altman DG. External validation of a Cox prognostic model: principles and methods. BMC Med Res Methodol. 2013;13:33.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Harrell FE Jr, Lee KL, Califf RM, Pryor DB, Rosati RA. Regression modelling strategies for improved prognostic prediction. Stat Med. 1984;3:143–52.CrossRefPubMedGoogle Scholar
  11. 11.
    Sohn TA, Yeo CJ, Cameron JL, et al. Resected adenocarcinoma of the pancreas—616 patients: results, outcomes, and prognostic indicators. J Gastrointest Surg. 2000;4:567–79.CrossRefPubMedGoogle Scholar
  12. 12.
    Sener SF, Fremgen A, Menck HR, Winchester DP. Pancreatic cancer: a report of treatment and survival trends for 100,313 patients diagnosed from 1985–1995 using the National Cancer Database. J Am Coll Surg. 1999;189:1–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Morganti AG, Brizi MG, Macchia G, et al. The prognostic effect of clinical staging in pancreatic adenocarcinoma. Ann Surg Oncol. 2005;12:145–51.CrossRefPubMedGoogle Scholar
  14. 14.
    Lee ES, Lee JM. Imaging diagnosis of pancreatic cancer: a state-of-the-art review. WJG World J Gastroenterol. 2014;20:7864–77.CrossRefPubMedGoogle Scholar
  15. 15.
    Saka B, Balci S, Basturk O, et al. Pancreatic ductal adenocarcinoma is spread to the peripancreatic soft tissue in the majority of resected cases, rendering the AJCC T-stage protocol (7th edition) inapplicable and insignificant: a size-based staging system (pT1: ≤2; pT2: >2 to ≤4; pT3: >4 cm) is more valid and clinically relevant. Ann Surg Oncol. 2016;23:2010–18.Google Scholar
  16. 16.
    Murakami Y, Uemura K, Sudo T, et al. Number of metastatic lymph nodes, but not lymph node ratio, is an independent prognostic factor after resection of pancreatic carcinoma. J Am Coll Surg. 2010;211:196–204.CrossRefPubMedGoogle Scholar
  17. 17.
    Riediger H, Keck T, Wellner U, et al. The lymph node ratio is the strongest prognostic factor after resection of pancreatic cancer. J Gastrointest Surg. 2009;13:1337–44.CrossRefPubMedGoogle Scholar
  18. 18.
    Strobel O, Hinz U, Gluth A, et al. Pancreatic adenocarcinoma: number of positive nodes allows to distinguish several N categories. Ann Surg. 2015;261:961–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Vuarnesson H, Lupinacci RM, Semoun O, et al. Number of examined lymph nodes and nodal status assessment in pancreaticoduodenectomy for pancreatic adenocarcinoma. Eur J Surg Oncol. 2013;39:1116–21.CrossRefPubMedGoogle Scholar
  20. 20.
    La Torre M, Nigri G, Petrucciani N, et al. Prognostic assessment of different lymph node staging methods for pancreatic cancer with R0 resection: pN staging, lymph node ratio, log odds of positive lymph nodes. Pancreatology. 2014;14:289–94.CrossRefPubMedGoogle Scholar
  21. 21.
    Nathan H, Pawlik TM. Staging of intrahepatic cholangiocarcinoma. Curr Opin Gastroenterol. 2010;26:269–73.CrossRefPubMedGoogle Scholar
  22. 22.
    Nathan H, Aloia TA, Vauthey JN, et al. A proposed staging system for intrahepatic cholangiocarcinoma. Ann Surg Oncol. 2009;16:14–22.CrossRefPubMedGoogle Scholar
  23. 23.
    Nathan H, Mentha G, Marques HP, et al. Comparative performances of staging systems for early hepatocellular carcinoma. HPB Oxford. 2009;11:382–90.CrossRefGoogle Scholar
  24. 24.
    Nathan H, Pawlik TM, Wolfgang CL, Choti MA, Cameron JL, Schulick RD. Trends in survival after surgery for cholangiocarcinoma: a 30-year population-based SEER database analysis. J Gastrointest Surg. 2007;11:1488–96; discussion 1496–1487.Google Scholar
  25. 25.
    de Jong MC, Nathan H, Sotiropoulos GC, et al. Intrahepatic cholangiocarcinoma: an international multi-institutional analysis of prognostic factors and lymph node assessment. J Clin Oncol. 2011;29:3140–5.CrossRefPubMedGoogle Scholar
  26. 26.
    Bilimoria KY, Bentrem DJ, Ko CY, et al. Validation of the 6th-edition AJCC Pancreatic Cancer Staging System: report from the National Cancer Database. Cancer. 2007;110:738–44.CrossRefPubMedGoogle Scholar
  27. 27.
    Balch CM, Soong SJ, Gershenwald JE, et al. Prognostic factors analysis of 17,600 melanoma patients: validation of the American Joint Committee on Cancer melanoma staging system. J Clin Oncol. 2001;19:3622–34.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2017

Authors and Affiliations

  • Sivesh K. Kamarajah
    • 1
  • William R. Burns
    • 2
  • Timothy L. Frankel
    • 2
  • Clifford S. Cho
    • 2
  • Hari Nathan
    • 2
  1. 1.College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
  2. 2.Department of SurgeryUniversity of MichiganAnn ArborUSA

Personalised recommendations