Clinical data combined with radiological imaging improves the accuracy of TNM staging of pancreatic body and tail adenocarcinoma

Figures & data

Table 1 Patients’ clinical profile: pre- and postoperative stages

Factor	Case number	Pre-TNM stage					pTNM stage
		Undefined (n=13)	IA (1) + IB (4) (n=5)	IIA (8) + IIB (5) (n=13)	III (n=8)	IV (n=52)	IIA (5) + IIB (1) (n=6)	III (n=13)	IV (n=72)
Gender, M/F	63/28	10/3	1/0	6/2	5/3	34/18	5/0	8/5	49/23
			3/1	4/1			1/0
Age (years)
≤50	10	1	1/0/0	1/4/3	1	6	1/0/4	2	7
51–60	32	3	0/0/4	0/3/2	2	20	0/1/0	3	28
≥60	49	9			5	26		8	37
Duration (months)a	2.4	1.5	1.4	3.0	5.7	2.1	1.5	4.7	2.3
			4.2	3.5			0.9
Weight loss >5 kg, yes/no	41/50	4/9	0/1	4/4	7/1	23/29	1/4	5/8	35/37
			0/4	3/2			0/1
Preoperative blood sugar >6.1 mmol/L, yes/no	47/44	9/4	0/1	6/2	2/6	27/25	4/1	5/8	38/34
			1/3	2/3			0/1
With diabetes, yes/no	4/87	0/13	0/1	0/8	1/7	3/49	0/5	0/13	4/68
			0/4	0/5			0/1
With acute pancreatitis, yes/no	5/86	1/12	0/1	2/6	0/8	1/51	0/5	1/12	4/68
			0/4	1/4			0/1
Main pancreatic duct dilation >0.3 cm, yes/no	11/80	2/11	0/1	0/8	0/8	8/44	0/5	0/13	11/61
			0/4	1/4			0/1
With chronic pancreatitis, yes/no	27/64	6/7	0/1	3/5	3/5	14/38	1/4	6/7	20/52
			0/4	1/4			0/1
With pancreatic duct stones, yes/no	1/90	1/12	0/1	0/8	0/8	0/52	0/5	0/13	1/71
			0/4	0/5			0/1
Preoperative ascites, yes/no	23/68	1/12	0/1	1/7	1/7	17/35	0/5	1/12	22/50
			1/3	2/3			0/1
Tumor size (cm)a,b	5.1	5.3	2.0	4.8	4.2	5.2	3.1	4.1	5.5
			3.5	8.3			10.2
ALT (U/L)	14.10	13.40	11.40	9.95	16.40	16.65	11.10	10.00	17.50
			12.50	20.20			13.70
AST (U/L)	30.5	30.5	14.0	21.9	24.5	34.1	25.5	22.9	31.3
			33.0	26.0			19.0
TBIL ≥34.0 μmol/L, yes/no	10/81	1/12	0/1	1/7	0/8	6/46	2/3	0/13	8/64
			2/2	0/5			0/1
Serum amylase (U/L)	51.2	55.3	94.3	41.5	46.1	49.3	104.2	41.5	54.2
			71.7	93.8			68.7
ALB (g/L)
≤30	5	0	0/0/1	0/1/7	0	4	0/1/4	0	5
30–35	21	2	0/0/4	1/2/2	1	15	0/0/1	0	20
≥35	65	11			7	33		13	47
WBC (×10^9/L)a	7.0	6.6	4.6	6.2	5.3	8.1	4.9	6.3	7.2
			6.1	7.1			10.3
Neutrophils (%)a	70.6	69.6	66.5	71.2	60.7	72.1	68.5	66.5	70.8
			70.7	68.7			82.3
Lymphocytes (%)a	19.7	22.8	28.4	19.6	25.7	18.3	22.8	23.7	19.4
			22.7	22.3			10.9
NLRa	3.6	2.9	2.4	3.7	2.3	3.9	2.9	2.9	3.6
			3.2	3.1			7.5
PLT (×10^9/L)	143.0	131.0	91.0	113.5	126.0	151.0	119.0	116.0	144.0
			155.0	140.0			324.0
ALP (U/L)	98.5	88.9	47.7	85.6	97.7	125.2	66.0	82.9	108.4
			90.5	95.0			109.7
ALP/TBIL cutoff
≤6.8	28	4	0/0/1	4/0/4	3	13	1/1/3	10	17
6.8–7.1	3	1	3/0/1	1/0/4	1	1	0/0/1	0	2
≥7.1	60	8			4	38		3	53
CEA >5.0 μg/L, yes/no	41/50	3/10	0/1	1/7	3/5	28/24	1/4	4/9	35/37
			3/1	3/2			1/0
CA19-9 (U/L)
≤37.0	19	5	0/1/0	2/3/3	1	10	4/1/0	5	10
37.0–955.0	26	6	1/3/0	0/1/4	1	11	0/0/1	7	18
≥955.0	46	2			6	31		1	44

Notes:

a Median.

b Tumor size was defined as the maximum tumor diameter.

Abbreviations: ALB, albumin; ALP, alkaline phosphatase; ALT, glutamic pyruvic transaminase; AST, aspartate aminotransferase; CA19-9, carcinoembryonic antigen 19-9; CEA, carcinoembryonic antigen; F, female; M, male; NLR, neutrophils/lymphocyte ratio; PA, prealbumin; PLT, platelet; pTNM, postoperative tumor staging; TBIL, total bilirubin; WBC, white blood cell.

Table 2 Univariate analysis of factors associated with pTNM stage

Factor	Estimate	SE	Wald	df	Sig	95% confidence interval
						Lower bound	Upper bound
Gender
Female	0.369	0.584	0.399	1	0.528	−0.776	1.513
Male	0			0
Age (years)
≤50	−0.275	0.755	0.133	1	0.716	−1.754	1.204
51–60	0.844	0.629	1.797	1	0.180	−0.390	2.077
≥61	0			0
Disease course (months)	−0.036	0.069	0.281	1	0.596	−0.171	0.098
Weight loss >5 kg
No	−0.785	0.547	2.059	1	0.151	−1.856	0.287
Yes	0			0
TBIL ≥34.0 μmol/L
No	−0.145	0.849	0.029	1	0.864	−1.810	1.519
Yes	0			0
Preoperative blood sugar >6.1 mmol/L
No	0.120	0.540	0.049	1	0.825	−0.940	1.179
Yes	0			0
With acute pancreatitis
No	0.734	0.714	1.057	1	0.304	−0.666	2.134
Yes	0			0
With chronic pancreatitis
No	0.333	0.543	0.376	1	0.540	−0.732	1.398
Yes	0			0
Preoperative ascites
No	−2.087	1.064	3.848	1	0.050	−4.171	−0.002
Yes	0			0
Tumor size (cm)a
Indefinite	−0.818	0.588	1.933	1	0.164	−1.971	0.335
≤2	−0.452	1.233	0.135	1	0.714	−2.869	1.964
2–4	−0.679	0.763	0.791	1	0.374	−2.175	0.818
≥4	0			0
ALT (U/L)	0.016	0.012	1.747	1	0.186	−0.008	0.039
AST (U/L)	0.030	0.017	2.966	1	0.085	−0.004	0.063
ALB (g/L)	−0.141	0.064	4.795	1	0.029*	−0.267	−0.015
Serum amylase (IU/L)	0.001	0.008	0.032	1	0.858	−0.014	0.016
WBC (×10^9/L)	0.120	0.105	1.318	1	0.251	−0.085	0.325
HGB (g/L)	0.000	0.013	0.001	1	0.975	−0.026	0.027
Neutrophils (%)	0.012	0.023	0.245	1	0.621	−0.034	0.058
Lymphocytes (%)	−0.035	0.028	1.578	1	0.209	−0.090	0.020
NLR	0.102	0.095	1.151	1	0.283	−0.084	0.288
PLT	0.001	0.004	0.055	1	0.814	−0.007	0.009
PA	−0.018	0.008	5.012	1	0.025*	−0.034	−0.002
ALP (U/L)	0.012	0.006	4.319	1	0.038*	0.001	0.024
ALP/TBIL ratio
≤6.8	−1.404	0.554	6.412	1	0.011*	−2.490	−0.317
6.8–7.1	−1.714	1.192	2.069	1	0.150	−4.050	0.622
≥7.1	0			0
ALP/TBIL ratio	0.123	0.054	5.219	1	0.022*	0.018	0.230
CEA >5.0 μg/L
No	−0.668	0.555	1.446	1	0.229	−1.756	0.421
Yes	0			0
CA19-9 (U/mL)	0.001	0.001	3.007	1	0.083	−0.000	0.002
CA19-9 ≥955.0 U/mL
No	−2.316	0.788	8.633	1	0.003*	−3.861	−0.771
Yes	0			0

Notes:

* P<0.05.

a Tumor size was defined as the maximum tumor diameter.

Abbreviations: ALB, albumin; ALP, alkaline phosphatase; ALT, glutamic pyruvic transaminase; AST, aspartate aminotransferase; CA19-9, carcinoembryonic antigen 19-9; CEA, carcinoembryonic antigen; HGB, hemoglobin; NLR, neutrophils/lymphocyte ratio; PA, prealbumin; PLT, platelet; pTNM, postoperative tumor staging; TBIL, total bilirubin; WBC, white blood cell.

Table 3 Multivariate analysis of factors associated with pTNM stage

Factor	Estimate	SE	Wald	df	Sig	95% confidence interval
						Lower bound	Upper bound
ALB (g/L)	−0.140	0.068	4.209	1	0.042*	−0.274	−0.006
ALP	0.035	0.024	2.127	1	0.145	−0.012	0.081
ALP/TBIL ratio	0.224	0.109	4.218	1	0.039*	0.010	0.438
ALP/TBIL ratio cutoff
≤6.8	−0.647	0.849	0.581	1	0.446	−2.312	1.018
6.8–7.1	−1.388	1.431	0.940	1	0.332	−4.192	1.417
≥7.1	0			0
CA19-9 ≥955.0 (U/L)
No	−2.258	0.875	6.664	1	0.010*	−3.972	−0.544
Yes	0			0

Note:

* P<0.05.

Abbreviations: ALB, albumin; ALP, alkaline phosphatase; CA19-9, carcinoembryonic antigen 19-9; pTNM, postoperative tumor staging; TBIL, total bilirubin.

Table 4 Cross-validation of pre- and postoperative TNM stages classified by radiological TNM staging system

pTNM stage	Predicted group membership				Total
	IIA	IIB	III	IV
Original
Count
IIA	0	4	1	0	5
IIB	0	1	0	0	1
III	1	2	7	3	13
IV	0	6	4	62	72
IIA	0	80	20	0	100
IIB	0	100	0	0	100
III	7.7	15.4	53.8	23.1	100
IV	0	8.3	5.6	86.1	100
Cross-validated
Count
IIA	0	4	1	0	5
IIB	1	0	0	0	1
III	1	2	7	3	13
IV	0	6	4	62	72
IIA	0	80	20	0	100
IIB	100	0	0	0	100
III	7.7	15.4	53.8	23.1	100
IV	0	8.5	5.6	85.9	100

Abbreviation: pTNM, postoperative tumor staging.

Table 5 Cross-validation of pre- and postoperative TNM stages classified by radiological TNM staging after excluding patients with a preoperative TNM stage IV disease

pTNM stage	Predicted group membership				Total
	IIA	IIB	III	IV
Original
Count
IIA	0	4	1	0	5
IIB	0	1	0	0	1
III	1	2	2	8	13
IV	0	6	1	13	20
IIA	0	80	20	0	100
IIB	0	100	0	0	100
III	7.7	15.4	15.4	61.5	100
IV	0	30	5	65	100
Cross-validated
Count
IIA	0	4	1	0	5
IIB	1	0	0	0	1
III	1	2	2	8	13
IV	0	6	1	13	20
IIA	0	80	20	0	100
IIB	100	0	0	0	100
III	7.7	15.4	15.4	61.5	100
IV	0	30	5	65	100

Abbreviation: pTNM, postoperative tumor staging.

Table 6 Cross-validation of pre- and postoperative TNM stages classified by Bayesian discriminant functions

pTNM stage	Predicted group membership				Total
	IIA	IIB	III	IV
Original
Count
IIA	4	0	0	0	4
IIB	0	1	0	0	1
III	1	0	11	0	12
IV	2	2	3	61	68
IIA	100	0	0	0	100
IIB	0	100	0	0	100
III	8.3	0	91.7	0	100
IV	2.9	2.9	4.4	89.8	100
Cross-validated
Count
IIA	3	0	1	0	4
IIB	1	0	0	0	1
III	1	0	10	1	12
IV	3	3	2	60	68
IIA	75	0	25	0	100
IIB	100	0	0	0	100
III	8.3	0	83.4	8.3	100
IV	4.4	4.4	2.9	88.3	100

Abbreviation: pTNM, postoperative tumor staging.

Table 7 Cross-validation of pre- and postoperative TNM stages classified by Bayesian discriminant functions after excluding patients with a preoperative TNM stage IV disease

pTNM stage	Predicted group membership				Total
	IIA	IIB	III	IV
Original
Count
IIA	4	0	0	0	4
IIB	0	1	0	0	1
III	1	0	10	1	12
IV	1	1	1	16	19
IIA	100	0	0	0	100
IIB	0	100	0	0	100
III	8.3	0	83.3	8.4	100
IV	5.3	5.3	5.3	84.1	100
Cross-validated
Count
IIA	3	0	1	0	4
IIB	0	0	0	1	1
III	1	0	10	1	12
IV	2	1	2	14	19
IIA	75	0	25	0	100
IIB	0	0	0	100	100
III	8.3	0	83.3	8.4	100
IV	10.5	5.3	10.5	73.7	100

Abbreviation: pTNM, postoperative tumor staging.

Table 8 Cross-validation of pre- and postoperative TNM stages classified by Bayesian discriminant functions after excluding patients with preoperative diagnosis of TNM stage IV and undefined PBTA

pTNM stage	Predicted group membership				Total
	IIA	IIB	III	IV
Original
Count
IIA	2	0	0	2	2
III	0	9	1	10	0
IV	0	1	13	14	0
IIA	100	0	0	100	100
III	0	90	10	100	0
IV	0	7.1	92.9	100	0
Cross-validated
Count
IIA	2	0	0	2	2
III	0	9	1	10	0
IV	0	1	13	14	0
IIA	100	0	0	100	100
III	0	90	10	100	0
IV	0	7.1	92.9	100	0

Abbreviations: PBTA, pancreatic body and tail adenocarcinoma; pTNM, postoperative tumor staging.