Tumor grade as significant prognostic factor in pancreatic cancer: validation of a novel TNMG staging system

Aim of the study was to asses the tumor grade prognostic value in the Czech pancreatic cancer patients and to evaluate the accuracy of TNMG prognostic model. Retrospective analysis of 431 pancreatic cancer patients undergoing pancreatic resection in seven Czech oncological centers between 2003 and 2013 was performed. The impact of tumor grade and the accuracy of TNMG prognostic model were evaluated. Lymph node status, tumor size, tumor stage and grade were proved as statistically significant survival predictors. The lower tumor differentiation (grade 3 and 4) was associated with poorer prognosis in all stages (stage I: HR 2.23 [1.14; 4.36, CI 95%] p=0.019, stage II: HR 3.09 [2.01; 4.77, CI 95%] p=0.001, stage III and IV: HR 3.52 [1.73; 7.18, CI 95%] p=0.001). Kaplan-Meier analysis verified statistically significant impact of new TNMG stages on survival after resection for pancreatic cancer (p=0.001). In conclusion, we can state that the tumor grade was confirmed as statistically significant prognostic factor in pancreatic cancer. Its incorporation into the current TNM classification enables more accurate prognosis prediction within particular clinical stages. That is why an inclusion of the grade to the standard TNM classification should be discussed.

Feedback is the best way to see

A 60-year-old man with past history of acute mild pancreatitis (AP) in 1997 and 2005, recently with repeated attacks of AP 5 times in last 2 years. Repeated endoscopic ultrasonography (EUS) showed 20 mm cyst in pancreatic body with 5 mm nodule, main pancreatic duct (MPD) 4-6 mm, fine-needle aspiration malignant cell negative, mucin positive. Computed tomography and magnetic resonance imaging of branch duct intraductal papillary mucosal neoplasms with 10 mm branch duct. From 2011 to 2013, the cyst was without progression in size or character. Due to clinical course of repeated AP, endoscopic retrograde cholangiopancreatography was recommended. It revealed dilated MPD 5-7 mm and 15 mm × 13 mm cyst in pancreatic body. Distal pancreatectomy was indicated because of clinical course and "worrisome EUS features" - MPD size and intramural nodule. In terms of having feedback, endosonographer use to examine every resected specimen of pancreas in our hospital just after surgery. The resected body with "sand glass" appearance of the cyst of size 3 cm was totally different from what we saw previously. We rewinded the previous EUS documentation and made a new evaluation. EUS is unique method for pancreatic tumors, but only in combination with real image of specimen makes endosonographer to bow up.