Survival After Pancreaticoduodenectomy is not Improved by Extending Resections to Achieve Negative Margins

Abstract

Survival after pancreaticoduodenectomy is not improved by extending pancreatic resections to achieve negative margins after initially positive intraoperative frozen sections. Tumor-specific factors beyond the presence of disease at a surgical margin are responsible for the abbreviated survival seen in patients undergoing R1 resections.

Frozen section of the pancreatic neck margin in pancreatoduodenectomy for pancreatic adenocarcinoma is of limited utility

“…This finding is in line with the previous studies indicating that frozen section analysis increases the rate of complete excision by 6.0-8.4%. 1,5,14 However, the question of whether this definite increase in the R0 excision rate actually results in an improved outcome is less straightforward. In our study there was worse survival in the R0(s) group (16 months) versus the R0(p) group (31 months); p ¼ 0.04.…”

“…[2][3][4] Whilst frozen section has been shown to increase the rate of R0 excision, two large retrospective studies have suggested that it does not improve overall survival. 1,5 A major area of contention in the recent literature has been over the prognostic significance of positive resection margins in pancreatic cancer. Whilst some groups have reported that excision margin status does not hold prognostic significance, others have reported that it does.…”

Pancreatic Adenocarcinoma: Complete Tumor Extirpation Improves Survival Benefit Despite Larger Tumors for Patients Who Undergo Distal Pancreatectomy and Splenectomy

“…Complete tumor extirpation and pathologically negative microscopic margins continue to prove to be an independent predictor of survival. [7][8][9] Therefore, this study was undertaken to investigate if resectable tumors of the distal pancreas have equivalent survival when compared proximal counterparts. This is a retrospective study of prospectively collected data of patients undergoing pancreaticoduodenectomy or distal pancreatectomy and splenectomy for pancreatic adenocarcinoma who were deemed "resectable" with thorough preoperative evaluations.…”

“…If negative margins were not achieved, then subsequent resections and frozen sections were undertaken to achieve negative margins, when possible. 7 Final pathologic examination was undertaken with serial sectioning of the uninked specimen placed in formalin with specific examination of the distal common bile duct and pancreatic neck margin, while superior mesenteric artery margins are not routinely undertaken. Portovenous resections were undertaken in patients who were found intraoperatively to have the potential for negative margins only when segmental portovenous resection was undertaken and preoperative evaluation revealed no evidence of portovenous thrombosis.…”

Can the new RCP R0/R1 classification predict the clinical outcome in ductal adenocarcinoma of the pancreatic head?

“…Beyond the presence of disease at a surgical margin also tumor biological factors exhibit prognostic relevance and are responsible that PDAC becomes a systemic disease early for the majority of patients [29].…”