Abstract
Background
Microscopic tumor involvement (R1) in different surgical resection margins after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) has been debated.
Methods
Clinico-pathological data for 258 patients who underwent PD between 2001 and 2010 were retrieved from a prospective database. The rates of R1 resection in the circumferential resection margin (pancreatic transection, medial, posterior, and anterior surfaces) and their prognostic influence on survival were assessed.
Results
For PDAC, the R1 rate was 57.1 % (48/84) for any margin, 31.0 % (26/84) for anterior surface, 42.9 % (36/84) for posterior surface, 29.8 % (25/84) for medial margin, and 7.1 % (3/84) for pancreatic transection margin. Overall and disease-free survival for R1 resections were significantly worse than those for R0 resection (17.2 vs. 28.7 months, P = 0.007 and 12.3 vs. 21.0 months, P = 0.019, respectively). For individual margins, only medial positivity had a significant impact on survival (13.8 vs. 28.0 months, P < 0.001), as opposed to involvement in the anterior (19.7 vs. 23.3 months, P = 0.187) or posterior margin (17.5 vs. 24.2 months, P = 0.104). Multivariate analysis demonstrated R0 medial margin was an independent prognostic factor (P = 0.002, HR = 0.381; 95 % CI 0.207–0.701).
Conclusion
The medial surgical resection margin is the most important after PD for PDAC, and an R1 resection here predicts poor survival.
Similar content being viewed by others
References
Jemal A, Siegel R, Xu J, Ward E (2010) Cancer statistics, 2010. CA Cancer J Clin 60: 277-300.
Vincent A, Herman J, Schulick R, Hruban RH, Goggins M (2011) Pancreatic cancer. Lancet 378: 607-620.
Carpelan-Holmstrom M, Nordling S, Pukkala E, Sankila R, Luttges J, et al. (2005) Does anyone survive pancreatic ductal adenocarcinoma? A nationwide study re-evaluating the data of the Finnish Cancer Registry. Gut 54: 385-387.
Alexakis N, Halloran C, Raraty M, Ghaneh P, Sutton R, et al. (2004) Current standards of surgery for pancreatic cancer. Br J Surg 91: 1410-1427.
Ghaneh P, Costello E, Neoptolemos JP (2007) Biology and management of pancreatic cancer. Gut 56: 1134-1152.
Pancreatic Section BSoG (2005) Guidelines for the management of patients with pancreatic cancer periampullary and ampullary carcinomas. Gut 54 Suppl 5: v1-16.
Fatima J, Schnelldorfer T, Barton J, Wood CM, Wiste HJ, et al. (2010) Pancreatoduodenectomy for ductal adenocarcinoma: implications of positive margin on survival. Arch Surg 145: 167-172.
Chang DK, Johns AL, Merrett ND, Gill AJ, Colvin EK, et al. (2009) Margin clearance and outcome in resected pancreatic cancer. J Clin Oncol 27: 2855-2862.
Winter JM, Cameron JL, Campbell KA, Arnold MA, Chang DC, et al. (2006) 1423 pancreaticoduodenectomies for pancreatic cancer: A single-institution experience. J Gastrointest Surg 10: 1199-1210; discussion 1210-1191.
Raut CP, Tseng JF, Sun CC, Wang H, Wolff RA, et al. (2007) Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma. Ann Surg 246: 52-60.
Schmidt CM, Powell ES, Yiannoutsos CT, Howard TJ, Wiebke EA, et al. (2004) Pancreaticoduodenectomy: a 20-year experience in 516 patients. Arch Surg 139: 718-725; discussion 725-717.
Neoptolemos JP, Stocken DD, Friess H, Bassi C, Dunn JA, et al. (2004) A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer. N Engl J Med 350: 1200-1210.
Neoptolemos JP, Stocken DD, Bassi C, Ghaneh P, Cunningham D, et al. (2010) Adjuvant chemotherapy with fluorouracil plus folinic acid vs gemcitabine following pancreatic cancer resection: a randomized controlled trial. JAMA 304: 1073-1081.
Verbeke CS (2008) Resection margins and R1 rates in pancreatic cancer--are we there yet? Histopathology 52: 787-796.
Yeo CJ, Cameron JL, Lillemoe KD, Sitzmann JV, Hruban RH, et al. (1995) Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients. Ann Surg 221: 721-731; discussion 731-723.
Khalifa MA (2007) Intraoperative assessment of the Whipple resection specimen. J Clin Pathol 60: 975-980.
Verbeke CS, Leitch D, Menon KV, McMahon MJ, Guillou PJ, et al. (2006) Redefining the R1 resection in pancreatic cancer. Br J Surg 93: 1232-1237.
Esposito I, Kleeff J, Bergmann F, Reiser C, Herpel E, et al. (2008) Most pancreatic cancer resections are R1 resections. Ann Surg Oncol 15: 1651-1660.
(2003) Japanese Pancreatic Society: Classification of Pancreatic Cancer. Tokyo: Kanahara Publishing Co.
Hruban RH, Pitman MB, Klimstra DS (2007) Tumors of the pancreas. Atlas of tumor pathology. Washington DC: Armed Forces Institute of Pathology.
Jamieson NB, Foulis AK, Oien KA, Going JJ, Glen P, et al. (2010) Positive mobilization margins alone do not influence survival following pancreatico-duodenectomy for pancreatic ductal adenocarcinoma. Ann Surg 251: 1003-1010.
Schmidt CM, Glant J, Winter JM, Kennard J, Dixon J, et al. (2007) Total pancreatectomy (R0 resection) improves survival over subtotal pancreatectomy in isolated neck margin positive pancreatic adenocarcinoma. Surgery 142: 572-578; discussion 578-580.
Hernandez J, Mullinax J, Clark W, Toomey P, Villadolid D, et al. (2009) Survival after pancreaticoduodenectomy is not improved by extending resections to achieve negative margins. Ann Surg 250: 76-80.
Williamson R (1994) The pancreas. In: Keen G, Farndon J, editors. Operative surgery and management. Oxford, England: Butterworth Heinemann.
Sommerville CA, Limongelli P, Pai M, Ahmad R, Stamp G, et al. (2009) Survival analysis after pancreatic resection for ampullary and pancreatic head carcinoma: an analysis of clinicopathological factors. J Surg Oncol 100: 651-656.
Pathologists TRCo (2010) Standards and Minimum Datasets for Reporting Cancers. Minimum Dataset for the Histopathological Reporting of Pancreatic, Ampulla of Vater and Bile Duct Carcinoma. London, UK.
Verbeke CS, Menon KV (2009) Redefining resection margin status in pancreatic cancer. HPB (Oxford) 11: 282-289.
Angst E, Kim-Fuchs C, Kuruvilla YC, Inderbitzin D, Montani M, et al. (2012) How to counter the problem of R1 resection in duodenopancreatectomy for pancreatic cancer? J Gastrointest Surg 16: 673.
Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, et al. (2010) American Joint Committee on Cancer (AJCC) cancer staging manual. Chicago: Springer.
Howard TJ, Krug JE, Yu J, Zyromski NJ, Schmidt CM, et al. (2006) A margin-negative R0 resection accomplished with minimal postoperative complications is the surgeon’s contribution to long-term survival in pancreatic cancer. J Gastrointest Surg 10: 1338-1345; discussion 1345-1336.
Nagakawa T, Sanada H, Inagaki M, Sugama J, Ueno K, et al. (2004) Long-term survivors after resection of carcinoma of the head of the pancreas: significance of histologically curative resection. J Hepatobiliary Pancreat Surg 11: 402-408.
Tsuchiya R, Noda T, Harada N, Miyamoto T, Tomioka T, et al. (1986) Collective review of small carcinomas of the pancreas. Ann Surg 203: 77-81.
Westgaard A, Tafjord S, Farstad IN, Cvancarova M, Eide TJ, et al. (2008) Resectable adenocarcinomas in the pancreatic head: the retroperitoneal resection margin is an independent prognostic factor. BMC Cancer 8: 5.
Chua TC, Saxena A (2010) Extended pancreaticoduodenectomy with vascular resection for pancreatic cancer: a systematic review. J Gastrointest Surg 14: 1442-1452.
Nakagohri T, Kinoshita T, Konishi M, Inoue K, Takahashi S (2003) Survival benefits of portal vein resection for pancreatic cancer. Am J Surg 186: 149-153.
Author information
Authors and Affiliations
Corresponding author
Additional information
Yaojun Zhang and Adam E. Frampton contributed equally.
Electronic Supplementary Materials
Below is the link to the electronic supplementary material.
Table S1
Logistic regression for covariates associated with R1 medial resection margin. PPPD pylorus-preserving pancreaticoduodenectomy. (DOC 31 kb)
Rights and permissions
About this article
Cite this article
Zhang, Y., Frampton, A.E., Cohen, P. et al. Tumor Infiltration in the Medial Resection Margin Predicts Survival After Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma. J Gastrointest Surg 16, 1875–1882 (2012). https://doi.org/10.1007/s11605-012-1985-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11605-012-1985-4