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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–≤4, pT3: >4 cm) is More Valid and Clinically Relevant

  • Pancreatic Tumors
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Abstract

Background

Most studies have failed to identify any prognostic value of the current T-stage protocol for pancreatic ductal adenocarcinoma (PDAC) by the American Joint Committee on Cancer and the Union for International Cancer Control unless some grouping was performed.

Methods

To document the parameters included in this T-stage protocol, 223 consecutive pancreatoduodenectomy specimens with PDAC were processed by a uniform grossing protocol.

Results

Peripancreatic soft tissue (PST) involvement, the main pT3 parameter, was found to be inapplicable and irreproducible due to lack of a true capsule in the pancreas and variability in the amount and distribution of adipose tissue. Furthermore, 91 % of the cases showed carcinoma in the adipose tissue, presumably representing the PST, and thus were classified as pT3. An additional 4.5 % were qualified as pT3 due to extension into adjacent sites. The T-stage defined as such was not found to have any correlation with survival (p = 0.4). A revised T-stage protocol was devised that defined pT1 as 2 cm or smaller, pT2 as >2–4 cm, and pT3 as larger than 4 cm. This revised protocol was tested in 757 consecutive PDACs. The median and 3-year survival rates of this size-based protocol were 26, 18, 13 months, and 40 %, 26 %, 20 %, respectively (p < 0.0001). The association between higher T-stage and shorter survival persisted in N0 cases and in multivariate modeling. Analysis of the Surveillance, Epidemiology, and End Results database also confirmed the survival differences (p < 0.0001).

Conclusions

This study showed that resected PDACs are already spread to various surfaces of the pancreas, leaving only about 4 % of PDACs to truly qualify as pT1/T2, and that the current T-stage protocol does not have any prognostic correlation. In contrast, as shown previously in many studies, size is an important prognosticator, and a size-based T-stage protocol is more applicable and has prognostic value in PDAC.

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Disclosure

Volkan Adsay has a Grant from National Institutes of Health (#5P50 CA62924). Lauren M. Postlewait has received funding from the Katz Foundation. For the remaining authors none were declared. This study is also supported in parts by funds generously donated by Monastra Foundation.

Author information

Author notes

  1. Olca Basturk MD

    Present address: Memorial Sloan Kettering Cancer Center, New York, NY, USA

Authors and Affiliations

  1. Department of Pathology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA

    Burcu Saka MD, Serdar Balci MD, Takashi Muraki MD, PhD, Irma Oliva MD, Gizem Akkas MD, Michelle D. Reid MD, MS, Alyssa Krasinskas MD, Rhonda Everett MPH, MLIS & Volkan Adsay MD

  2. Department of Pathology, Wayne State University and Karmanos Cancer Institute, Detroit, MI, USA

    Olca Basturk MD & Sudeshna Bandyopadhyay MD

  3. Department of Pathology, Marmara University, Istanbul, Turkey

    Pelin Bagci MD

  4. Department of Surgical Oncology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA

    Lauren M. Postlewait MD & Shishir Maithel MD

  5. Department of Epidemiology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA

    Jessica Knight MPH & Michael Goodman MD, PhD

  6. Department of Medical Oncology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA

    Bassel El-Rayes MD

  7. Department of General Surgery, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA

    David Kooby MD & Juan Sarmiento MD

  8. Istanbul Medipol University, Istanbul, Turkey

    Burcu Saka MD

  9. Yildirim Beyazit University, Ankara, Turkey

    Serdar Balci MD

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  1. Burcu Saka MD
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  2. Serdar Balci MD
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Corresponding author

Correspondence to Volkan Adsay MD.

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Burcu Saka and Serdar Balci have contributed equally to the study.

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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–≤4, pT3: >4 cm) is More Valid and Clinically Relevant. Ann Surg Oncol 23, 2010–2018 (2016). https://doi.org/10.1245/s10434-016-5093-7

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