External validation of three lymph node ratio-based nomograms predicting survival using an international cohort of patients with resected pancreatic head ductal adenocarcinoma

Michael Schneider, Ismail Labgaa, Dionisios Vrochides, Alessandro Zerbi, Gennaro Nappo, Julie Perinel, Mustapha Adham, Stijn van Roessel, Marc Besselink, J. Sven D. Mieog, Jesse V. Groen, Nicolas Demartines, Markus Schäfer, Gaëtan-Romain Joliat

Research output: Contribution to JournalArticleAcademicpeer-review

2 Citations (Scopus)


Introduction: Lymph node ratio (LNR) is an important prognostic factor of survival in patients with pancreatic ductal adenocarcinoma (PDAC). This study aimed to validate three LNR-based nomograms using an international cohort. Materials and methods: Consecutive PDAC patients who underwent upfront pancreatoduodenectomy from six centers (Europe/USA) were collected (2000–2017). Patients with metastases, R2 resection, missing LNR data, and who died within 90 postoperative days were excluded. The updated Amsterdam nomogram, the nomogram by Pu et al., and the nomogram by Li et al. were selected. For the validation, calibration, discrimination capacity, and clinical utility were assessed. Results: After exclusion of 176 patients, 1′113 patients were included. Median overall survival (OS) of the cohort was 23 months (95% CI: 21–25). For the three nomograms, Kaplan-Meier curves showed significant OS diminution with increasing scores (p < 0.01). All nomograms showed good calibration (non-significant Hosmer-Lemeshow tests). For the Amsterdam nomogram, area under the ROC curve (AUROC) for 3-year OS was 0.64 and 0.67 for 5-year OS. Sensitivity and specificity for 3-year OS prediction were 65% and 59%. Regarding the nomogram by Pu et al., AUROC for 3- and 5-year OS were 0.66 and 0.70. Sensitivity and specificity for 3-year OS prediction were 68% and 53%. For the Li nomogram, AUROC for 3- and 5-year OS were 0.67 and 0.71, while sensitivity and specificity for 3-year OS prediction were 63% and 60%. Conclusion: The three nomograms were validated using an international cohort. Those nomograms can be used in clinical practice to evaluate survival after pancreatoduodenectomy for PDAC.

Original languageEnglish
Pages (from-to)2002-2007
Number of pages6
JournalEuropean journal of surgical oncology
Issue number9
Early online date2022
Publication statusPublished - Sep 2022


  • Mortality
  • Pancreas cancer
  • Pancreatoduodenectomy
  • Prediction
  • Prognosis

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