Validation of at least 1 mm as cut-off for resection margins for pancreatic adenocarcinoma of the body and tail

Hank, Thomas; Hinz, Ulf; Tarantino, Ignazio; Kaiser, Jörg; Niesen, Willem; Bergmann, Frank; Hackert, Thilo; Büchler, Markus W.; Strobel, Oliver

doi:10.1002/bjs.10842

Cited by 83 publications

(56 citation statements)

References 27 publications

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“…R0 (>1 mm) resections were achieved in 23.5% of these resections. Median overall survival times for patients with R0 (1 mm), R1 (≤1 mm) and R1 (direct) status were 62.4, 24.6 and 17.2 months respectively, with 5‐year survival rates of 62.6%, 16.8% and 13.0% . In both studies, the R‐status was demonstrated to be an independent predictor of survival …”

Section: Resection Margin Status and Survival In Pancreatic Cancermentioning

confidence: 85%

“…While the authors of this meta‐analysis clearly demonstrated that resection margin data originating from contexts with different definitions and work‐up are not at all comparable, they were unable to draw valid conclusions as to the prognostic significance of the R‐status due to heterogeneity in reporting of survival . Two large cohort studies based on the new protocol for margin assessment and the 1‐mm rule clearly established a considerable impact of the resection margin status on overall survival after pancreatoduodenectomy for pancreatic head cancers and after total pancreatectomy or distal pancreatectomy for pancreatic body and tail cancers, respectively . In 561 patients with pancreatoduodenectomies for pancreatic head adenocarcinoma, 112 (20%) had a “true” R0 resection (>1‐mm tumor‐free margin), 123 (22%) patients had R1 (≤1 mm, but no direct margin involvement) status and 326 (58%) patients had R1 with direct margin involvement.…”

Section: Resection Margin Status and Survival In Pancreatic Cancermentioning

confidence: 89%

“…The notion reflected in the NCCN (USA) guidelines stating that survival benefits from R1 resections may be comparable to definitive chemoradiation without surgery is based on outdated studies that report median overall survival times of only 12.3 months for R1 resections and are clearly inconsistent with recent data obtained in the context of the current state of the art of surgery and adjuvant chemotherapy (Table ) . Of note, the 5‐year overall survival rate after R1 resection with direct margin involvement can still be as high as 20%‐25% and is, therefore, much better than frequently discussed.…”

Section: Resection Margin Status and Survival In Pancreatic Cancermentioning

confidence: 95%

“…The 5‐year overall survival rate for the favorable subgroup of “true R0” without lymph node metastases (pN0, R0) was as high as 62.2% . In a second study on 455 patients, the prognostic impact of the R‐status was confirmed for tumors located in the pancreatic tail and body treated by distal pancreatectomy (n = 218) or total pancreatectomy (n = 237) . R0 (>1 mm) resections were achieved in 23.5% of these resections.…”

Section: Resection Margin Status and Survival In Pancreatic Cancermentioning

confidence: 98%

“…Recent clinical trials and observational studies that present data on resection margins and survival are summarized in Table . These studies show that with modern surgery and adjuvant chemotherapy, median survival times are around 40 months after R0 and 25 months after R1 resections and 5‐year survival rates are around 35% and 10%, respectively.…”

Section: Resection Margin Status and Survival In Pancreatic Cancermentioning

confidence: 99%

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Local radicality and survival outcome of pancreatic cancer surgery

Niesen

Hank

Büchler

et al. 2019

Annals of Gastroent Surgery

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Pancreatic cancer remains a therapeutic challenge. Surgical resection in combination with systemic chemotherapy is the only option promising long‐term survival and potential cure. However, only about 20% of patients are diagnosed with tumors that are still in a resectable stage. Even after potentially curative resection and modern regimens for adjuvant chemotherapy, the majority of patients develop local and systemic recurrence resulting in median overall survival times of 28‐54 months. The predominance of systemic recurrence and its impact on survival may lead to the assumption that surgical radicality and local control play only minor roles in the treatment of pancreatic cancer. This review provides an overview of the recent literature on surgical radicality and survival outcome in pancreatic cancer. The current evidence on the extent of lymphadenectomy, the prognostic impact of the extent of lymph node involvement, and the impact of the resection margin status on postresection survival are reviewed. Data from recent studies performed in the context of modern surgery and adjuvant therapy provide good evidence of a considerable impact of local radicality on survival after pancreatic cancer surgery. Surgical techniques that have been developed to refine oncological resections and to increase local control as well as resectability are highlighted. These techniques include artery‐first approaches, level‐3 dissection with removal of the periarterial nerve plexus, the triangle operation, and extended resections. Local radicality and quality of surgical resection remain among the most important parameters that determine the chances for survival in patients with non‐metastatic pancreatic cancer.

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Section: Resection Margin Status and Survival In Pancreatic Cancermentioning

confidence: 85%

Section: Resection Margin Status and Survival In Pancreatic Cancermentioning

confidence: 89%

Section: Resection Margin Status and Survival In Pancreatic Cancermentioning

confidence: 95%

Section: Resection Margin Status and Survival In Pancreatic Cancermentioning

confidence: 98%

Section: Resection Margin Status and Survival In Pancreatic Cancermentioning

confidence: 99%

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Local radicality and survival outcome of pancreatic cancer surgery

Niesen

Hank

Büchler

et al. 2019

Annals of Gastroent Surgery

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Contemporary Reappraisal of Intraoperative Neck Margin Assessment During Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma

et al. 2021

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IMPORTANCE Although margin-negative (R0) resection is the gold standard for surgical management of localized pancreatic ductal adenocarcinoma (PDAC), the question of how to manage the patient with a microscopically positive intraoperative neck margin (IONM) during pancreaticoduodenectomy remains controversial. OBSERVATIONS In the absence of randomized clinical trials, we critically evaluated high-quality retrospective studies examining the oncologic utility of re-resecting positive IONMs during pancreaticoduodenectomy for PDAC (2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018)(2019). Several studies have concluded that additional pancreatic resection to achieve an R0 margin in IONM-positive cases does not influence survival. The largest is a multi-institutional study of 1399 patients undergoing pancreaticoduodenectomy, which demonstrated that in comparison with patients undergoing R0 resection (n = 1196; median survival, 21 months), those with either final R1 resections (n = 131) or undergoing margin conversion from IONM-positive to R0 resection on permanent section (n = 72) demonstrated similar median survival times (13.7 and 11.9 months, respectively). Conversely, recent reports suggest that the conversion of IONM to R0 resection with additional resection or even total pancreatectomy may be associated with improved survival. The discordance between these conflicting studies could be explained in part by the influence of biologic and physiologic selection on the association of IONM re-resection and survival. Since most studies did not include patients receiving modern combination chemotherapy regimens, the intersection between margin status, tumor biology, and chemoresponsiveness remains unclear. Furthermore, there are no dedicated data to guide surgical management in IONM-positive pancreaticoduodenectomy for patients receiving neoadjuvant chemotherapy. CONCLUSIONS AND RELEVANCEAlthough data regarding the oncologic utility of additional resection to achieve a tumor-free margin following initial IONM positivity during pancreaticoduodenectomy for PDAC are conflicting, they suggest that IONM positivity may be a surrogate for biologic aggressiveness that is unlikely to be mitigated by the extent of surgical resection. The complex relationship between margin status and chemoresponsiveness warrants exploration in studies including patients receiving increasingly effective neoadjuvant chemotherapy.

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