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@ARTICLE{Huang:144568,
      author       = {L. Huang$^*$ and L. Jansen$^*$ and Y. Balavarca$^*$ and L.
                      van der Geest and V. Lemmens and B. Groot Koerkamp and H. C.
                      van Santvoort and R. Grützmann and M. G. Besselink and P.
                      Schrotz-King$^*$ and H. Brenner$^*$},
      title        = {{S}ignificance of {E}xamined {L}ymph {N}ode {N}umber in
                      {A}ccurate {S}taging and {L}ong-term {S}urvival in
                      {R}esected {S}tage {I}-{II} {P}ancreatic {C}ancer-{M}ore is
                      {B}etter? {A} {L}arge {I}nternational {P}opulation-based
                      {C}ohort {S}tudy.},
      journal      = {Annals of surgery},
      volume       = {274},
      number       = {6},
      issn         = {0003-4932},
      address      = {[S.l.]},
      publisher    = {Ovid38850},
      reportid     = {DKFZ-2019-02011},
      pages        = {e554-e563},
      year         = {2021},
      note         = {2021 Dec 1;274(6):e554-e563 / #EA:C070#LA:C070#},
      abstract     = {This large international cohort study aimed to investigate
                      the associations of examined lymph node (ELN) number with
                      accurate staging and long-term survival in pancreatic
                      adenocarcinoma (PaC) and to robustly determine the minimal
                      and optimal ELN thresholds.ELN number is an important
                      quality metric in cancer care. The recommended minimal ELN
                      number in PaC to accurately stage cancer varies greatly
                      across guidelines, and the optimal number especially to
                      adequately stratify patient survival has not yet been
                      established.Population-based data on patients with stage I
                      to II PaC resected in 2003 to 2015 from the US Surveillance,
                      Epidemiology, and End Results (SEER)-18 Program and
                      Netherlands National Cancer Registry (NCR) were analyzed.
                      Associations of ELN number with stage migration and survival
                      were evaluated using multivariable-adjusted logistic and Cox
                      regression models, respectively. The series of odds ratios
                      (ORs) for negative-to-positive node stage migration and
                      hazard ratios (HRs) for survival with more ELNs were fitted
                      using a LOWESS smoother, and structural breakpoints were
                      determined by Chow test.Overall 16,241 patients were
                      analyzed. With increasing ELN number, both cohorts exhibited
                      significant proportional increases from node-negative to
                      node-positive disease [ORSEER-18=1.05, $95\%$ confidence
                      interval (CI) = 1.04-1.05; ORNCR = 1.10, $95\%$ CI =
                      1.08-1.12] and serial improvements in survival (HRSEER-18 =
                      0.98, $95\%$ CI = 0.98-0.99; HRNCR = 0.98, $95\%$ CI =
                      0.97-0.99) per additional ELN after controlling for
                      confounders. Associations for stage migration and survival
                      remained significant in most stratifications by patient,
                      tumor, and treatment factors. Cut-point analyses suggested a
                      minimal threshold ELN number of 11 and an optimal number of
                      19, which were validated both internally in the derivative
                      US cohort and externally in the Dutch cohort with the
                      ability to well discriminate different probabilities of both
                      survival and stage migration.In stage I to II PaC, more ELNs
                      are associated with more precise nodal staging, which might
                      largely explain the survival association. Our observational
                      study does not suggest causality, and does not encourage
                      more extended lymphadenectomy before further randomized
                      evidence is obtained. Our results robustly conclude 11 ELNs
                      as the minimal and suggest 19 ELNs as the optimal
                      cut-points, for evaluating quality of lymph node examination
                      and possibly for stratifying postoperative prognosis.},
      cin          = {C070 / C120 / HD01},
      ddc          = {610},
      cid          = {I:(DE-He78)C070-20160331 / I:(DE-He78)C120-20160331 /
                      I:(DE-He78)HD01-20160331},
      pnm          = {313 - Krebsrisikofaktoren und Prävention (POF4-313)},
      pid          = {G:(DE-HGF)POF4-313},
      typ          = {PUB:(DE-HGF)16},
      pubmed       = {pmid:31425290},
      doi          = {10.1097/SLA.0000000000003558},
      url          = {https://inrepo02.dkfz.de/record/144568},
}