CLINICAL AND PATHOLOGIC (SURGICAL) STAGING
A standardized system for the clinical and pathologic staging of pancreatic cancer does not currently exist in the United States. The system modified from the American Joint Committee on Cancer and the TNM Committee of the International Union Against Cancer appears in Table 32.4-4 (Table Not Available) . However, this staging system is rarely used because it is difficult to apply, the stages do not directly correlate with treatment or prognosis, and lymph node status cannot be determined without surgical treatment. Pathologic staging can be applied only to patients who undergo pancreatectomy; in all other patients, only clinical staging, based on radiographic examinations, can be done. Treatment and prognosis are based on whether the tumor is potentially resectable, locally advanced, or metastatic, definitions that do not directly correlate with TNM status. For example, both potentially resectable and locally advanced tumors may be stage T3. Further, because lymph node metastases are often small (2 to 4 mm) and not accurately assessed by preoperative imaging, many patients who undergo complete negative-margin pancreaticoduodenectomy are found to have positive regional lymph nodes on permanent-section pathologic analysis of the resected specimen. Such patients would then be classified as having stage III disease. However, a patient with unresectable, locally advanced disease is usually classified as having stage II (T3, N0) disease because operative (pathologic) staging is not performed.

Tumors of the pancreas are unlike other solid tumors of the gastrointestinal tract in that accurate diagnosis, clinical staging, and pathologic evaluation of resected specimens require extensive interaction and cooperation between physicians of different specialties. Accurate clinical staging requires high-quality computed tomography (CT) to accurately define the relationship of the tumor to the celiac axis and superior mesenteric vessels. The development of objective radiographic criteria for preoperative tumor staging allows physicians to develop detailed treatment plans for their patients, avoid unnecessary laparotomy in patients with locally advanced or metastatic disease, and improve resectability rates.
Similar standardized criteria are needed for the pathologic analysis of pancreaticoduodenectomy specimens to allow accurate interpretation of survival statistics.

 Retrospective pathologic analysis of archival material does not allow accurate assessment of margins of resection or number of lymph nodes retrieved. However, these are the most accurate predictors of outcome. In the recent study by Yeo and colleagues, resection margin, lymph node status, and tumor size and DNA content were the tumor characteristics that most strongly predicted survival by multivariate analysis. To determine which patient subsets may benefit from the most aggressive treatment strategies, accurate pathologic staging and histologic assessment of response are mandatory.