Skip to main content
SpringerLink
Log in

R1-Resektion beim Pankreaskarzinom

R1 resection for pancreatic carcinoma

  • Leitthema
  • Published:
Der Chirurg Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Die chirurgische Therapie ist das einzig potenziell kurative Therapieverfahren beim Pankreaskarzinom, eine R0-Situation wird aber nicht immer erreicht.

Fragestellung

Der Einfluss einer R1-Situation beim Pankreaskarzinom auf das Überleben und die Behandlungsmöglichkeiten (operativ/multimodal) bei nachgewiesener R1-Situation (intra-/postoperativ)

Ergebnisse

Bei intraoperativ nachgewiesener R1-Situation kann durch eine Nachresektion (Pankreasparenchym, Gallengang, Magen, venöse Gefäße) oftmals eine R0-Situation erreicht werden. Die Erweiterung der Operation mit arterieller Gefäßresektion bzw. die Resektion von Nachbarorganen ist manchmal technisch-chirurgisch durchführbar und kann im Einzelfall erwogen werden. Durch neue neoadjuvante und adjuvante Therapiekonzepte konnte sowohl die Rate an resezierbaren Pankreaskarzinomen erhöht, als auch das Überleben von Patienten mit einer R0/R1-Situation verbessert werden.

Schlussfolgerungen

Das Ziel der chirurgischen Therapie beim Pankreaskarzinom sollte die R0-Resektion sein, da die R1-Resektion mit einem verminderten Überleben einhergeht.

Abstract

Background

Surgery is the only potentially curative therapeutic approach in patients with pancreatic ductal adenocarcinoma (PDAC); however, achieving a negative (R0) resection margin is not always possible.

Objective

The impact of R1 resection margins on survival rates and treatment options (surgical and multimodal) for intraoperatively and postoperatively identified R1 resection margins.

Results

For intraoperatively diagnosed R1 resection margins, a re-resection (e.g. pancreas, main bile duct, stomach, superior mesenteric and portal vein) can be performed to achieve R0 resection margins. Arterial resections and the resection of additional organs are occasionally technically feasible and can be performed in an individual approach. New neoadjuvant and adjuvant treatment strategies have increased the rate of resectable PDAC and have improved the outcome of patients with R0/R1 resected PDACs.

Conclusion

An R0 resection is the primary goal of surgery in patients with PDAC as R1 resections are correlated with a poor outcome.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1

Literatur

  1. Verbeke CS et al (2006) Redefining the R1 resection in pancreatic cancer. Br J Surg 93:1232–1237

    Article  CAS  PubMed  Google Scholar 

  2. Gaedcke J et al (2010) The mesopancreas is the primary site for R1 resection in pancreatic head cancer: relevance for clinical trials. Langenbecks Arch Surg 395:451–458

    Article  CAS  PubMed  Google Scholar 

  3. Esposito I et al (2008) Most pancreatic cancer resections are R1 resections. Ann Surg Oncol 15:1651–1660

    Article  PubMed  Google Scholar 

  4. Campbell F et al (2009) Classification of R1 resections for pancreatic cancer: the prognostic relevance of tumour involvement within 1 mm of a resection margin. Histopathology 55:277–283

    Article  PubMed  Google Scholar 

  5. Kooby DA et al (2014) Value of intraoperative neck margin analysis during Whipple for pancreatic adenocarcinoma: a multicenter analysis of 1399 patients. Ann Surg 260:494–501 (discussion 501)

    Article  PubMed  Google Scholar 

  6. Butturini G et al (2008) Influence of resection margins and treatment on survival in patients with pancreatic cancer: meta-analysis of randomized controlled trials. Arch Surg 143:75–83 (discussion 83)

    Article  PubMed  Google Scholar 

  7. John BJ et al (2013) Redefining the R1 resection for pancreatic ductal adenocarcinoma: tumour lymph nodal burden and lymph node ratio are the only prognostic factors associated with survival. HPB (Oxford) 15:674–680

    Article  Google Scholar 

  8. Ferrone CR et al (2012) Pancreatic ductal adenocarcinoma: long-term survival does not equal cure. Surgery 152:43–49

    Article  Google Scholar 

  9. Konstantinidis IT et al (2013) Pancreatic ductal adenocarcinoma: is there a survival difference for R1 resections versus locally advanced unresectable tumors? What is a „true“ R0 resection. Ann Surg 257:731–736

    Article  PubMed  Google Scholar 

  10. Hamada Y et al (2014) Influence of microscopically positive resection margins on long-term (〉5-year) survival after resection of pancreatic ductal adenocarcinoma. JOP 15:455–458

    PubMed  Google Scholar 

  11. Nordby T et al (2013) Improved survival and quality of life in patients undergoing R1 pancreatic resection compared to patients with locally advanced unresectable pancreatic adenocarcinoma. Pancreatology 13:180–185

    Article  PubMed  Google Scholar 

  12. Tol JA et al (2015) Non-radical resection versus bypass procedure for pancreatic cancer – a consecutive series and systematic review. Eur J Surg Oncol 41:220–227

    Article  CAS  PubMed  Google Scholar 

  13. Verbeke CS, Menon KV (2009) Redefining resection margin status in pancreatic cancer. HPB (Oxford) 11:282–289

    Article  Google Scholar 

  14. Menon KV et al (2009) Impact of margin status on survival following pancreatoduodenectomy for cancer: the Leeds Pathology Protocol (LEEPP). HPB (Oxford) 11:18–24

    Article  Google Scholar 

  15. Neoptolemos JP et al (2017) 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 389:1011–1024

    Article  CAS  PubMed  Google Scholar 

  16. Chandrasegaram MD et al (2015) Meta-analysis of radical resection rates and margin assessment in pancreatic cancer. Br J Surg 102:1459–1472

    Article  CAS  PubMed  Google Scholar 

  17. Seufferlein T et al (2013) S3-guideline exocrine pancreatic cancer. Z Gastroenterol 51:1395–1440

    Article  CAS  PubMed  Google Scholar 

  18. Nimptsch U et al (2016) Nationwide in-hospital mortality following pancreatic surgery in Germany is higher than anticipated. Ann Surg 264:1082–1090

    Article  PubMed  Google Scholar 

  19. Huttner FJ et al (2016) Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev:. doi:10.1002/14651858.CD006053.pub6

    Google Scholar 

  20. Conroy T et al (2016) Current standards and new innovative approaches for treatment of pancreatic cancer. Eur J Cancer 57:10–22

    Article  PubMed  Google Scholar 

  21. Schorn S et al (2017) The impact of neoadjuvant therapy on the histopathological features of pancreatic ductal adenocarcinoma – a systematic review and meta-analysis. Cancer Treat Rev 55:96–106

    Article  CAS  PubMed  Google Scholar 

  22. Gillen S et al (2010) Preoperative/neoadjuvant therapy in pancreatic cancer: a systematic review and meta-analysis of response and resection percentages. PLoS Med 7:e1000267

    Article  PubMed  PubMed Central  Google Scholar 

  23. Schmidt CM et al (2007) Total pancreatectomy (R0 resection) improves survival over subtotal pancreatectomy in isolated neck margin positive pancreatic adenocarcinoma. Surgery 142:572–578 (discussion 578)

    Article  PubMed  Google Scholar 

  24. Hartwig W et al (2009) Multivisceral resection for pancreatic malignancies: risk-analysis and long-term outcome. Ann Surg 250:81–87

    Article  PubMed  Google Scholar 

  25. Yekebas EF et al (2008) En bloc vascular resection for locally advanced pancreatic malignancies infiltrating major blood vessels: perioperative outcome and long-term survival in 136 patients. Ann Surg 247:300–309

    Article  PubMed  Google Scholar 

  26. Chakravarty KD et al (2010) Prognosis and feasibility of en-bloc vascular resection in stage II pancreatic adenocarcinoma. World J Gastroenterol 16:997–1002

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Fukuda S et al (2007) Significance of the depth of portal vein wall invasion after curative resection for pancreatic adenocarcinoma. Arch Surg 142:172–179 (discussion 180)

    Article  PubMed  Google Scholar 

  28. Yu XZ et al (2014) Benefit from synchronous portal-superior mesenteric vein resection during pancreaticoduodenectomy for cancer: a meta-analysis. Eur J Surg Oncol 40:371–378

    Article  CAS  PubMed  Google Scholar 

  29. Grutzmann R et al (2014) Arterial reconstruction in pancreatic carcinoma – demonstration of surgical techniques. Zentralbl Chir 139:261–264

    Article  CAS  PubMed  Google Scholar 

  30. Mollberg N et al (2011) Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis. Ann Surg 254:882–893

    Article  PubMed  Google Scholar 

  31. Bachellier P et al (2011) Is the need for an arterial resection a contraindication to pancreatic resection for locally advanced pancreatic adenocarcinoma? A case-matched controlled study. J Surg Oncol 103:75–84

    Article  PubMed  Google Scholar 

  32. Shrikhande SV et al (2007) Pancreatic resection for M1 pancreatic ductal adenocarcinoma. Ann Surg Oncol 14:118–127

    Article  PubMed  Google Scholar 

  33. Werner J et al (2013) Advanced-stage pancreatic cancer: therapy options. Nat Rev Clin Oncol 10:323–333

    Article  CAS  PubMed  Google Scholar 

  34. Goto H et al (2014) Surgical resection and inferior vena cava reconstruction for treatment of the malignant tumor: technical success and outcomes. Ann Vasc Dis 7:120–126

    Article  PubMed  PubMed Central  Google Scholar 

  35. Fatima J et al (2010) Pancreatoduodenectomy for ductal adenocarcinoma: implications of positive margin on survival. Arch Surg 145:167–172

    Article  PubMed  Google Scholar 

  36. Nitschke P et al (2017) 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 265(6):1219–1225

    Article  PubMed  Google Scholar 

  37. Delpero JR et al (2014) Pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a French multicentre prospective evaluation of resection margins in 150 evaluable specimens. HPB (Oxford) 16:20–33

    Article  Google Scholar 

  38. Rau BM et al (2012) R1 resection in pancreatic cancer has significant impact on long-term outcome in standardized pathology modified for routine use. Surgery 152:S103–S111

    Article  PubMed  Google Scholar 

  39. Verbeke CS et al (2011) Tumour growth is more dispersed in pancreatic head cancers than in rectal cancer: implications for resection margin assessment. Histopathology 59:1111–1121

    Article  PubMed  Google Scholar 

  40. Wittekind C et al (2009) A uniform residual tumor (R) classification: integration of the R classification and the circumferential margin status. Cancer 115:3483–3488

    Article  PubMed  Google Scholar 

  41. Katz MH et al (2009) Long-term survival after multidisciplinary management of resected pancreatic adenocarcinoma. Ann Surg Oncol 16:836–847

    Article  PubMed  PubMed Central  Google Scholar 

  42. Oettle H et al (2013) Adjuvant chemotherapy with gemcitabine and long-term outcomes among patients with resected pancreatic cancer: the CONKO-001 randomized trial. JAMA 310(14):1473–1481

    Article  CAS  PubMed  Google Scholar 

  43. Krautz C et al (2017) Effect of Hospital Volume on In-hospital Morbidity and Mortality Following Pancreatic Surgery in Germany. Ann Surg. doi:10.1097/SLA.0000000000002248

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Chirurgische Klinik, Universitätsklinikum Erlangen, Krankenhausstraße 12, 91054, Erlangen, Deutschland

    G. F. Weber, S. Kersting & R. Grützmann

  2. Pathologisches Institut, Universitätsklinikum Erlangen, Erlangen, Deutschland

    F. Haller

Authors
  1. G. F. Weber
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. S. Kersting
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. F. Haller
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. R. Grützmann
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to G. F. Weber.

Ethics declarations

Interessenkonflikt

G. F. Weber, S. Kersting, F. Haller und R. Grützmann geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Weber, G.F., Kersting, S., Haller, F. et al. R1-Resektion beim Pankreaskarzinom. Chirurg 88, 764–770 (2017). https://doi.org/10.1007/s00104-017-0462-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00104-017-0462-8

Schlüsselwörter

Keywords

Search

Navigation