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Intraoperative Pancreatic Neck Margin Assessment During Pancreaticoduodenectomy for Pancreatic Adenocarcinoma in the Era of Neoadjuvant Therapy: A Multi-institutional Analysis from the Central Pancreatic Consortium

  • Pancreatic Tumors
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Data regarding the survival impact of converting frozen-section (FS):R1 pancreatic neck margins to permanent section (PS):R0 by additional resection (i.e., converted-R0) during upfront pancreaticoduodenectomy for pancreatic ductal adenocarcinoma (PDAC) are conflicting. The impact of neoadjuvant therapy on this practice and its relationship with overall survival (OS) is incompletely understood.

Methods

We reviewed PDAC patients (80% borderline resectable/locally advanced [BR/LA]) undergoing pancreaticoduodenectomy after neoadjuvant therapy at seven, academic, high-volume centers (2010–2018). Multivariable models examined the association of PS:R0, PS:R1, and converted-R0 margins with OS.

Results

Of 272 patients receiving at least 2 (median 4) cycles of neoadjuvant chemotherapy (71% mFOLFIRINOX or gemcitabine/nab-paclitaxel) and undergoing pancreaticoduodenectomy with intraoperative frozen-section assessment of the transected pancreatic neck margin, PS:R0 (n = 220, 80.9%) was observed in a majority of patients; 18 patients (6.6%) had converted-R0 margins following additional resection, whereas 34 patients (12.5%) had persistently positive PS:R1 margins. At a median follow-up of 42 months, PS:R0 resection was associated with improved OS compared with either converted-R0 or PS:R1 resection (median 25 vs. 14 vs. 16 months, respectively; p = 0.023), with no survival difference between the converted-R0 and PS:R1 groups (p = 0.9). On Cox regression, SMA margin positivity (hazard ratio 2.2, p = 0.012), but not neck margin positivity (hazard ratio 1.2, p = 0.65), was associated with worse OS.

Conclusions

In this multi-institutional cohort of predominantly BR/LA PDAC patients undergoing pancreaticoduodenectomy following modern neoadjuvant therapy, pursuing a negative neck margin intraoperatively if the initial margin is positive does not appear to be associated with improved survival.

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Authors and Affiliations

  1. Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA

    Kristin N. Kelly MD, MPH, Francisco I. Macedo MD, Max Seaton MD, Nipun B. Merchant MD & Jashodeep Datta MD

  2. Department of Surgery, Upstate Medical University, Syracuse, NY, USA

    Kristin N. Kelly MD, MPH

  3. Department of Surgery, University of Central Florida, Gainesville, FL, USA

    Francisco I. Macedo MD

  4. Department of Surgery, University of Cincinnati, Cincinnati, OH, USA

    Gregory Wilson MD & Syed A. Ahmad MD

  5. Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA

    Chet Hammill MD

  6. Department of Surgery, University of Louisville, Louisville, KY, USA

    Robert C. Martin MD

  7. Department of Surgery, University of North Carolina, Chapel Hill, NC, USA

    Ugwuji N. Maduekwe MD & Hong J. Kim MD

  8. Department of Surgery, Emory University, Atlanta, GA, USA

    Shishir K. Maithel MD & David A. Kooby MD

  9. Department of Surgery, University of Wisconsin, Madison, WI, USA

    Daniel E. Abbott MD

Authors
  1. Kristin N. Kelly MD, MPH
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  2. Francisco I. Macedo MD
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  4. Gregory Wilson MD
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  7. Ugwuji N. Maduekwe MD
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  9. Shishir K. Maithel MD
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  11. Syed A. Ahmad MD
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  12. David A. Kooby MD
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  13. Nipun B. Merchant MD
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  14. Jashodeep Datta MD
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Correspondence to Jashodeep Datta MD.

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Kelly, K.N., Macedo, F.I., Seaton, M. et al. Intraoperative Pancreatic Neck Margin Assessment During Pancreaticoduodenectomy for Pancreatic Adenocarcinoma in the Era of Neoadjuvant Therapy: A Multi-institutional Analysis from the Central Pancreatic Consortium. Ann Surg Oncol 29, 6004–6012 (2022). https://doi.org/10.1245/s10434-022-11804-w

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