Value of Intraoperative Neck Margin Analysis During Whipple for Pancreatic Adenocarcinoma

Kooby, David A.; Lad, Neha L.; Squires, Malcolm H.; Maithel, Shishir K.; Sarmiento, Juan M.; Staley, Charles A.; Adsay, Volkan; El‐Rayes, Bassel F.; Weber, Sharon M.; Winslow, Emily R.; Cho, Clifford S.; Zavala, Kathryn; Bentrem, David J.; Knab, Mark; Ahmad, Syed A.; Abbott, Daniel E.; Sutton, Jeffrey M.; Kim, Hee Jin; Yeh, Jen Jen; Aufforth, Rachel; Scoggins, Charles R.; Martin, Robert C.G.; Parikh, Alexander A.; Robinson, Jamie R.; Hashim, Yassar; Fields, Ryan C.; Hawkins, William G.; Merchant, Nipun B.

doi:10.1097/sla.0000000000000890

Cited by 96 publications

(92 citation statements)

References 27 publications

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“…One of the major factors that brought attention to the issue of margin status in PDAC was the dramatic variability in the reported margin positivity rate, which ranges from 10% to 84% in the literature [4,[6][7][8]11,26]. Although margin status in general is classically associated with the quality of surgery, in the context of PDAC, margin positivity is complex and multifactorial.…”

Section: Margin Positivitymentioning

confidence: 99%

“…Several tumor-specific factors have been identified as predictors of outcome following resection for PDAC, including tumor size, location within the pancreas, surgical margin status, lymphovascular and perineural invasion, histologic grade, and nodal disease [6][7][8][9][10]. Margin status, in particular, has garnered increased attention in recent years, as conflicting data regarding the basic concepts of margin involvement, pathologic assessment, and prognostic value in PDAC have emerged [6,7,[11][12][13]. This article will elaborate on these concepts and examine how their variability has led to a critical reevaluation of margin status and its implications for treatment and outcome in patients with PDAC.…”

Section: Introductionmentioning

confidence: 99%

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The importance of surgical margins in pancreatic cancer

Ethun

Kooby

2015

Journal of Surgical Oncology

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Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive disease with a grim prognosis. Surgical resection offers the best chance for long-term survival, yet recurrence rates are high and outcomes are poor. The influence of margin status in PDAC is controversial, as conflicting data have been plagued by a lack of standardization in margin definitions, pathologic analysis, and reporting. Despite recent efforts, international consensus is still needed for this disease.

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Section: Margin Positivitymentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

The importance of surgical margins in pancreatic cancer

Ethun

Kooby

2015

Journal of Surgical Oncology

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“…Although the ‘Whipple At The Splenic Artery’ or ‘WATSA’,26 advocated by Strasberg, appears sensible and also permits better control of the splenic vein in such patients, the role of additional resection dependent on frozen section biopsy is disputed. Kooby et al,27 and others,19 determined that involvement of this margin reflected adverse pathological factors such as tumor size, lymph node involvement and perineural infiltration, with an overwhelming effect on survival despite additional pancreatic resection with clear margins.…”

Section: Discussionmentioning

confidence: 99%

Vein resection in patients with adenocarcinoma of the head of pancreas adherent to the portomesenteric venous axis is beneficial despite a high rate of R1 resection

Cherukuru

Govil

Vij

et al. 2018

Ann Hepatobiliary Pancreat Surg

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Backgrounds/AimsEn-bloc vein resection (VR) for pancreatic ductal adenocarcinoma (PDAC) of the head of pancreas adherent to the portomesenteric axis benefits patients when the vein wall is not infiltrated by tumour and an R0 resection is achieved, albeit at the expense of greater morbidity and mortality.MethodsA retrospective review of pancreaticoduodenectomy for PDAC over 6 years was conducted. Patients were divided into a standard resection group (Group SR) and simultaneous vein resection group (Group VR) and compared for outcome.ResultsThe study group consisted of 41 patients (Group SR 15, Group VR 26). VR was performed by end-to-end reconstruction in 12 patients and with interposition grafts in 13 cases (autologous vein in 10, PTFE in 3). R1 resections occurred in 49% patients, with the superior mesenteric artery margin most commonly involved. Patients with Ishikawa grade III and IV vein involvement were more likely to carry a positive SMA margin (p=0.04). Involvement of the splenoportal junction was associated with a significantly greater risk of pancreatic transection margin involvement. No difference in morbidity was seen between the groups. Median survival in the entire group of patients was 17 months and did not vary significantly between the groups. The only significant predictor of survival was lymph node status.ConclusionsVenous involvement by proximal PDAC is indicative of tumor location rather than tumor biology. VR improves outcomes in patients with tumor adhesion to the portomesenteric venous axis despite a high incidence of R1 resections and greater operative mortality.

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“…Generally, bile duct margin, duodenal margins, retroperitoneal soft tissue margin, and pancreatic neck margin must be examined intraoperatively. However, the bile duct and duodenal margins are rarely R1 resections 38 . The retroperitoneal margin, if taken correctly, has a finite extent from the pancreas 8 .…”

Section: Methodsmentioning

confidence: 99%

Identifying the neck margin status of ductal adenocarcinoma in the pancreatic head by multiphoton microscopy

Chen

et al. 2017

Sci Rep

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Complete surgical resection is the only option for improving the survival of patients with ductal adenocarcinoma in the pancreatic head. After resection, determining the status of resection margins (RMs) is crucial for deciding on the nature of the follow-up treatment. The purpose of this study was to evaluate whether multiphoton microscopy (MPM) could be considered a reliable tool for determining the status of pancreatic neck margins by identifying tumour cells of ductal adenocarcinoma in these margins in the pancreatic head, and our results were affirmative. In particular, MPM could identify tumour cells in the nerves. It was also found that the quantification of the difference between normal duct cells and tumour cells was possible. In addition, the content of collagen could be quantified and used as a marker for differentiating ductal adenocarcinoma in the pancreatic head from normal pancreatic tissues, eventually leading to the identification of R0 and R1 resections of the pancreatic neck margin. With the development of the clinical applications of the multiphoton endoscope, MPM has the potential to provide in vivo real-time identification of RM status during surgery.

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Value of Intraoperative Neck Margin Analysis During Whipple for Pancreatic Adenocarcinoma

Abstract: For patients who undergo pancreaticoduodenectomy for pancreatic ductal adenocarcinoma, additional resection to achieve a negative neck margin after positive frozen section is not associated with improved OS.

Cited by 96 publications

References 27 publications

The importance of surgical margins in pancreatic cancer

The importance of surgical margins in pancreatic cancer

Vein resection in patients with adenocarcinoma of the head of pancreas adherent to the portomesenteric venous axis is beneficial despite a high rate of R1 resection

Identifying the neck margin status of ductal adenocarcinoma in the pancreatic head by multiphoton microscopy

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