Prognosis of resected pancreatic cancer: is the refined resection margin status dispensable?
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Pancreatic cancer is a tumor entity which is generally characterized by a poor prognosis. The only hope for cure lies in the radical resection of circumscribed tumors, or even better in the resection of precursor lesions, such as not-yet malignant intraductal papillary mucinous neoplasmns. Despite radical resection, patients with supposedly completely resected pancreatic carcinomas encounter local recurrences in many cases. The high recurrence rate does not correspond with the high R0 resection rates, which were reported to be about 70 % for pancreatoduodenectomies in most large surgical series. Some specialized pathologists for pancreatic diseases established a detailed 3-dimensional analysis of pancreatic resection specimen combined with a new R1 resection status, as defined as microscopic evidence of tumor within 1 mm from a resection margin [1, 2]. Just recently, our group confirmed the relevance of the refined R1 definition in a series of 1,071 consecutive patients with resected primary pancreatic adenocarcinomas . Whereas R0 and R1 resections were associated with similar prognosis in the time period prior to the revised R1 definition, the revised R0 status was one of three independent positive predictors of patient survival (the others were Tis/T1/T2 status and G1 grading).
How to proceed from here? Refining the pancreatic specimen assessment, the Glasgow group further stratified resection margins into so-called mobilization margins along the anterior or posterior aspect of the pancreas, which have no influence on survival, and transection margins of the pancreas and mesopancreas, which do influence survival . Since cut-off levels for resection margin clearance are controversial , the inclusion of the minimal distance between tumor and resection margin into the R classification, as known from rectal cancer, may be a further option. Importantly, therapeutic regimens to prevent or adequately respond to tumor positive transection margins located along the mesenteric vessels, e.g., by the “artery first”  or “uncinate first”  approach or possibly by adjuvant chemoradiation therapy, will demand our future attention to improve survival of patients with resectable pancreatic cancer.
Conflicts of interest
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