Abstract
Background
The impact of resecting positive margins during pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDA) remains debated. Additionally, the survival benefit of resecting multiple positive margins is unknown.
Methods
We identified patients with PDA who underwent PD from 2006 to 2015. Pancreatic neck, bile duct, and uncinate frozen section margins were assessed before and after resection of positive margins. Survival curves were compared with log-rank tests. Multivariable Cox regression assessed the effect of margin status on overall survival.
Results
Of 501 patients identified, 17.3%, 5.3%, and 19.7% had an initially positive uncinate, bile duct, or neck margin, respectively. Among initially positive bile duct and neck margins, 77.8% and 67.0% were resected, respectively. Although median survival was decreased among patients with any positive margins (15.6 vs. 20.9 months; p = 0.006), it was similar among patients with positive bile duct or neck margins with or without R1 to R0 resection (17.0 vs. 15.6 months; p = 0.20). Median survival with and without positive uncinate margins was 13.8 vs. 19.7 months (p = 0.04). Uncinate margins were never resected. Resection of additional margins when the uncinate was concurrently positive was not associated with improved survival (p = 0.37). Patients with positive margins who received adjuvant therapy had improved survival, regardless of margin resection (p = 0.03). Adjuvant therapy was independently protective against death (hazard ratio 0.6, 95% CI 0.5–0.7).
Conclusions
Positive PD margins at any position are associated with reduced overall survival; however, resection of additional margins may not improve survival, particularly with concurrently positive uncinate margins. Adjuvant chemotherapy improves survival with positive margins, regardless of resection.
Similar content being viewed by others
References
Vincent A, Herman J, Schulick R, Hruban RH, Goggins M. Pancreatic cancer. Lancet. 2011;378(9791):607–620.
Hernandez J, Mullinax J, Clark W, Toomey P, Villadolid D, Morton C, et al. Survival after pancreaticoduodenectomy is not improved by extending resections to achieve negative margins. Ann Surg. 2009;250(1):76–80.
Ghaneh P, Kleeff J, Halloran CM, Raraty M, Jackson R, Melling J, et al. The impact of positive resection margins on survival and recurrence following resection and adjuvant chemotherapy for pancreatic ductal adenocarcinoma. Ann Surg. 2019;269(3):520–529.
Yeo CJ, Cameron JL, Lillemoe KD, Sitzmann JV, Hruban RH, Goodman SN, et al. Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients. Ann Surg. 1995;221(6):721–31; (discussion 731).
Zhang B, Lee GC, Qadan M, Fong ZV, Mino-Kenudson M, Desphande V, et al. Revision of pancreatic neck margins based on intraoperative frozen section analysis is associated with improved survival in patients undergoing pancreatectomy for ductal adenocarcinoma. Ann Surg. Epub 5 Dec 2019. https://doi.org/10.1097/sla.0000000000003503.
Nitschke P, Volk A, Welsch T, Hackl J, Reissfelder C, Rahbari M, et al. Impact of intraoperative re-resection to achieve R0 status on survival in patients with pancreatic cancer: a single-center experience with 483 patients. Ann Surg. 2017;265(6):1219–1225.
Zhang X-F, Squires MH, Bagante F, Ethun CG, Salem A, Weber SM, et al. The impact of intraoperative re-resection of a positive bile duct margin on clinical outcomes for hilar cholangiocarcinoma. Ann Surg Oncol. 2018;25(5):1140–1149.
Park Y, Hwang DW, Kim JH, Hong S-M, Jun S-Y, Lee JH, et al. Prognostic comparison of the longitudinal margin status in distal bile duct cancer: R0 on first bile duct resection versus R0 after additional resection. J Hepatobiliary Pancreat Sci. 2019;26(5):169–178.
Ethun CG, Kooby DA. The importance of surgical margins in pancreatic cancer. J Surg Oncol. 2016;113(3):283–288.
Barreto SG, Pandanaboyana S, Ironside N, Windsor JA. Does revision of resection margins based on frozen section improve overall survival following pancreatoduodenectomy for pancreatic ductal adenocarcinoma? A meta-analysis. HPB (Oxford). 2017;19(7):573–579.
Hermanek P, Wittekind C. Residual tumor (R) classification and prognosis. Semin Surg Oncol. 1994;10(1):12–20.
Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138(1):8–13.
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology–Pancreatic Adenocarcinoma (Version 1.2020). https://www2.tri-kobe.org/nccn/guideline/pancreas/english/pancreatic.pdf. Accessed Jun 2020.
Allen PJ, Kuk D, Fernandez-Del Castillo C, et al. Multi-institutional validation study of the american joint commission on cancer (8th Edition) Changes for T and N staging in patients with pancreatic adenocarcinoma. Ann Surg. 2017;265:185–191.
Sohal DPS, Walsh RM, Ramanathan RK, Khorana AA. Pancreatic adenocarcinoma: treating a systemic disease with systemic therapy. J Natl Cancer Inst. 2014;106(3):dju011.
Yamamoto T, Yagi S, Kinoshita H, Sakamoto Y, Okada K, Uryuhara K, et al. Long-term survival after resection of pancreatic cancer: a single-center retrospective analysis. World J Gastroenterol. 2015;21(1):262–268.
Jamieson NB, Foulis AK, Oien KA, Going JJ, Glen P, Dickson EJ, et al. Positive mobilization margins alone do not influence survival following pancreatico-duodenectomy for pancreatic ductal adenocarcinoma. Ann Surg. 2010;251(6):1003–1010.
Petrucciani N, Nigri G, Debs T, Giannini G, Sborlini E, Antolino L, et al. Frozen section analysis of the pancreatic margin during pancreaticoduodenectomy for cancer: does extending the resection to obtain a secondary R0 provide a survival benefit? Results of a systematic review. Pancreatology. 2016;16(6):1037–1043.
Kooby DA, Lad NL, Squires MH, Maithel SK, Sarmiento JM, Staley CA, et al. Value of intraoperative neck margin analysis during Whipple for pancreatic adenocarcinoma: a multicenter analysis of 1399 patients. Ann Surg. 2014;260(3):494–501; (discussion 501).
Lad NL, Squires MH, Maithel SK, Fisher SB, Mehta VV, Cardona K, et al. Is it time to stop checking frozen section neck margins during pancreaticoduodenectomy? Ann Surg Oncol. 2013;20(11):3626–3633.
Fatima J, Schnelldorfer T, Barton J, Wood CM, Wiste HJ, Smyrk TC, et al. Pancreatoduodenectomy for ductal adenocarcinoma: implications of positive margin on survival. Arch Surg. 2010;145(2):167–172.
Pang TCY, Wilson O, Argueta MA, Hugh TJ, Chou A, Samra JS, et al. Frozen section of the pancreatic neck margin in pancreatoduodenectomy for pancreatic adenocarcinoma is of limited utility. Pathology. 2014;46(3):188–192.
Mathur A, Ross SB, Luberice K, Kurian T, Vice M, Toomey P, et al. Margin status impacts survival after pancreaticoduodenectomy but negative margins should not be pursued. Am Surg. 2014;80(4):353–360.
Keane FK, Wo JY, Ferrone CR, Clark JW, Blaszkowsky LS, Allen JN, et al. Intraoperative radiotherapy in the era of intensive neoadjuvant chemotherapy and chemoradiotherapy for pancreatic adenocarcinoma. Am J Clin Oncol. 2018;41(6):607–612.
Otsuka S, Ebata T, Yokoyama Y, Mizuno T, Tsukahara T, Shimoyama Y, et al. Clinical value of additional resection of a margin-positive distal bile duct in perihilar cholangiocarcinoma. Br J Surg. 2019;106(6):774–782.
Osipov A, Nissen N, Rutgers J, Dhall D, Naziri J, Chopra S, et al. Redefining the positive margin in pancreatic cancer: impact on patterns of failure, long-term survival and adjuvant therapy. Ann Surg Oncol. 2017;24(12):3674–3682.
Zheng R, Bonaroti J, Ng B, et al. Is the use of intraoperative frozen section during pancreaticoduodenectomy justified? J Gastrointest Surg. Epub 17 Mar 2020. https://doi.org/10.1007/s11605-020-04564-z.
Campbell F, Foulis AK, Verbeke CC. Dataset for the Histopathological Reporting of Carcinomas of the Pancreas, Ampulla of Vater and Common Bile Duct. London: The Royal College of Pathologists; 2010.
Nitta T, Nakamura T, Mitsuhashi T, Asano T, Okamura K, Tsuchikawa T, et al. The impact of margin status determined by the one-millimeter rule on tumor recurrence and survival following pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. Surg Today. 2017;47(4):490–497.
Delpero JR, Jeune F, Bachellier P, Regenet N, Le Treut YP, Paye F, et al. Prognostic value of resection margin involvement after pancreaticoduodenectomy for ductal adenocarcinoma: updates from a french prospective multicenter study. Ann Surg. 2017;266(5):787–796.
van Roessel S, Kasumova GG, Tabatabaie O, Ng SC, van Rijssen LB, Verheij J, et al. Pathological margin clearance and survival after pancreaticoduodenectomy in a US and European pancreatic center. Ann Surg Oncol. 2018;25(6):1760–1767.
Pine JK, Haugk B, Robinson SM, Darne A, Wilson C, Sen G, et al. Prospective assessment of resection margin status following pancreaticoduodenectomy for pancreatic ductal adenocarcinoma after standardisation of margin definitions. Pancreatology. 2020;20(3):537–544.
Conroy T, Hammel P, Hebbar M, et al. FOLFIRINOX or gemcitabine as adjuvant therapy for pancreatic cancer. N Engl J Med. 2018;379(25):2395–2406. https://doi.org/10.1056/nejmoa1809775.
Neoptolemos JP, Palmer DH, Ghaneh P, et al. Comparison of adjuvant gemcitabine and capecitabine with gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label, randomised, phase 3 trial. Lancet. 2017;389(10073):1011–1024. https://doi.org/10.1016/s0140-6736(16)32409-6.
Oettle H, Neuhaus P, Hochhaus A, et al. Adjuvant chemotherapy with gemcitabine and long-term outcomes among patients with resected pancreatic cancer: the CONKO-001 randomized trial. JAMA. 2013;310(14):1473–1481. https://doi.org/10.1001/jama.2013.279201.
Schmidt CM, Glant J, Winter JM, Kennard J, Dixon J, Zhao Q, et al. Total pancreatectomy (R0 resection) improves survival over subtotal pancreatectomy in isolated neck margin positive pancreatic adenocarcinoma. Surgery. 2007;142(4):572–578; (discussion 578).
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
Richard Zheng, David Nauheim, Jonathan Bassig, Matthew Chadwick, Christopher Schultz, Geoffrey Krampitz, Harish Lavu, Jordan R. Winter, Charles J. Yeo, and Adam C. Berger have no relevant financial disclosures to declare and have not received any funding or material support on behalf of this study.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Zheng, R., Nauheim, D., Bassig, J. et al. Margin-Positive Pancreatic Ductal Adenocarcinoma during Pancreaticoduodenectomy: Additional Resection Does Not Improve Survival. Ann Surg Oncol 28, 1552–1562 (2021). https://doi.org/10.1245/s10434-020-09000-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-020-09000-9