Cancer Res Treat.  2019 Oct;51(4):1639-1652. 10.4143/crt.2019.023.

Validation of the 8th AJCC Cancer Staging System for Pancreas Neuroendocrine Tumors Using Korean Nationwide Surgery Database

  • 1Department of Surgery, Konkuk University Choongju Hospital, Konkuk University School of Medicine, Chungju, Korea.
  • 2Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.
  • 3Department of Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea.
  • 4Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.
  • 5Department of Surgery, Gangnam Severance Hospital, Yonsei University, Seoul, Korea.
  • 6Department of Surgery, Chonnam National University Hwasun Hospital, Hwasun, Korea.
  • 7Department of Surgery and Center for Liver Cancer, National Cancer Center, Goyang, Korea.
  • 8Department of Surgery, Chonbuk National University Medical School and Hospital, Jeonju, Korea.
  • 9Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
  • 10Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
  • 11Department of Surgery, Keimyung University Dongsan Medical Center, Daegu, Korea.
  • 12Department of Surgery, Gyeongsang National University School of Medicine, Jinju, Korea.
  • 13Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea.
  • 14Department of Surgery, Chung-Ang University Hospital, Chung-Ang University, College of Medicine, Seoul, Korea.
  • 15Department of Surgery, Dong-A University College of Medicine, Busan, Korea.
  • 16Department of Surgery, Chonnam National University Hospital, Gwangju, Korea.
  • 17Department of Surgery, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea.
  • 18Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.


The 8th edition of the American Joint Committee on Cancer (AJCC) staging system for pancreatic neuroendocrine tumor (PNET) included several significant changes. We aim to evaluate this staging system compared to the 7th edition AJCC staging system and European Neuroendocrine Tumors Society (ENETS) system.
We used Korean nationwide surgery database (2000-2014). Of 972 patients who had undergone surgery for PNET, excluding patients diagnosed with ENETS/World Health Organization 2010 grade 3 (G3), only 472 patients with accurate stage were included.
Poor discrimination in overall survival rate (OSR) was noted between AJCC 8th stage III and IV (p=0.180). The disease-free survival (DFS) curves of 8th AJCC classification were well separated between all stages. Compared with stage I, the hazard ratio of II, III, and IV was 3.808, 13.928, and 30.618, respectively (p=0.007, p < 0.001, and p < 0.001). The curves of OSR and DFS of certain prognostic group in AJCC 7th and ENETS overlapped. In ENETS staging system, no significant difference in DFS between stage IIB versus IIIA (p=0.909) and IIIA versus IIIB (p=0.291). In multivariable analysis, lymphovascular invasion (p=0.002), perineural invasion (p=0.003), and grade (p < 0.001) were identified as independent prognostic factors for DFS.
This is the first large-scale validation of the AJCC 8th edition staging system for PNET. The revised 8th system provides better discrimination compared to that of the 7th edition and ENETS TNM system. This supports the clinical use of the system.


Validation; Neoplasm staging; Pancreatic neuroendocrine tumor

MeSH Terms

Discrimination (Psychology)
Disease-Free Survival
Neoplasm Staging*
Neuroectodermal Tumors, Primitive
Neuroendocrine Tumors*
Survival Rate


  • Fig. 1. Kaplan-Meier survival analysis of disease-free survival (DFS) according to T category of American Joint Committee on Cancer (AJCC) 7th edition (A), T category of AJCC 8th edition (B), 7th AJCC prognostic group (C), 8th AJCC prognostic group (D), European Neuroendocrine Tumors Society (ENETS) prognostic group (E), N category (F), 7th M category (G), 8th M category (H), and Grade (ENETS/World Health Organization [WHO] 2010) (I).

  • Fig. 2. Kaplan-Meier survival analysis of overall survival rate (OSR) according to T category of American Joint Committee on Cancer (AJCC) 7th edition (A), T category of AJCC 8th edition (B), 7th AJCC prognostic group (C), 8th AJCC prognostic group (D), European Neuroendocrine Tumors Society (ENETS) prognostic group (E), N category (F), 7th M category (G), 8th M category (H), and grade (ENETS/World Health Organization [WHO] 2010) (I).



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