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Increased Pancreatic Cancer Survival with Greater Lymph Node Retrieval in the National Cancer Data Base
Carlo M. Contreras*1, Chee P. Lin2, Robert Oster2, Sushanth M. Reddy1, Thomas N. Wang1, Selwyn M. Vickers1, Martin M. Heslin1
1Surgery, University of Alabama at Birmingham, Birmingham, AL; 2Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL

Introduction: Robust lymph node (LN) retrieval during resection has been associated with increased survival in the setting of various gastrointestinal malignancies. The purpose of this study is to evaluate the role of LN retrieval in patients undergoing pancreaticoduodenectomy (PD) for pancreatic cancer.
Methods: The National Cancer Data Base was utilized which captures tumor, patient, and facility data from academic and community medical centers. Cox regression models were used to assess bivariate & multivariate predictors of time to death, and logistic regression models were used to assess bivariate & multivariate predictors of mortality. Group mean comparisons were performed using the two-group t-test.
Results: 30,180 patients with pancreatic adenocarcinoma underwent PD between the years 1998-2011 from 1,268 institutions; 62% (18,862/30,180) had LN metastasis. The mean number of LN retrieved in LN(-) patients was 10.7 vs 14.4 for LN(+) patients (p<0.0001). Patients with <10 LN retrieved had a mean of 1.1 vs 2.8 positive LN for patients with >10 LN retrieved (p<0.0001). Clinically irrelevant differences in the number of LN retrieved were observed related to PD with/without antrectomy, or receipt of neoadjuvant therapy. There were minor associations between pathologic margin status, postoperative days until hospital discharge, or 30-day readmission rate and the number of LN retrieved. The median survival of LN(-) patients exceeded that of LN(+) patients (24.9 vs 15.2 months, p<0.0001). Increasing LN retrieval is a multivariate predictor of survival in all patients, and in node-negative patients. The mean number of LN retrieved at academic centers is greater than at non-academic centers (14 vs 11.5, p<0.0001). The relationship of increased LN retrieval and enhanced survival is a nearly linear trend (see Figure).
Conclusions: Greater LN retrieval is associated with increased survival in patients with pancreatic cancer, even in the node-negative subset. Increased nodal retrieval does not correlate with a significant increase in morbidity. Rather than demonstrating an inflection point that defines the extent of adequate lymphadenectomy, this dataset demonstrates an incremental relationship between LN retrieval and survival.

Figure. Hazard ratio of lymph node retrieval on survival for node-negative patients undergoing pancreaticoduodenectomy for adenocarcinoma (n=11,318).


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