Value of Intraoperative Neck Margin Analysis During Whipple for Pancreatic Adenocarcinoma: A Multicenter Analysis of 1399 Patients
David A Kooby*1, Neha L Lad*1, Malcolm H Squires, III*1, Shishir K Maithel*1, Sharon M Weber2, Emily R Winslow*2, David J Bentrem*3, Syed A Ahmad*4, Daniel E Abbott*4, Hong Jin Kim*5, Charles R Scoggins*6, Robert C Martin6, Alexander A Parikh*7, Yassar M Hashim*8, Nipun B Merchant7
1Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA;2Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI;3Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL;4Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH;5Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC;6Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, KY;7Department of Surgery, Vanderbilt University School of Medicine, Nashville, TN;8Department of Surgery, Washington University School of Medicine, St. Louis, MO
During pancreaticoduodenectomy (PD) for ductal adenocarcinoma (PDAC) a frozen section (FS) neck margin is typically assessed, and if positive, additional pancreas is removed to achieve an R0 margin. We analyzed the overall survival (OS) benefit of this practice.
Patients who underwent PD for PDAC from 1/2000-8/2012 at eight academic centers were classified by neck margin status as negative (R0) or positive (R1) based on FS and permanent section (PS). Impact on OS of converting a FS-R1 neck margin to a PS-R0 by additional resection was assessed.
1399 patients had FS neck margins analyzed. Median OS was 19.7 months. On FS, 152 patients (10.9%) were R1, and 48 patients (3.8%) had false-negative FS-R0 margins. PS-R0 was achieved in 1201 patients (85.9%), 121 patients (8.6%) remained PS-R1, and 77 patients (5.5%) were converted from FS-R1-to-PS-R0. Median OS for PS-R0 patients was 21.1mos, versus 13.6mos for PS-R1 patients (p<0.001) and 13.0mos for FS-R1-to-PS-R0 patients (p<0.001; Figure). Both FS-R1-to-PS-R0 and PS-R1 patients had larger tumors (p=0.001), more perineural invasion (p=0.02), and more node positivity (p=0.04) than PS-R0 patients. On multivariate analysis controlling for adverse pathologic factors, FS-R1-to-PS-R0 conversion lacked association with improved OS (HR 0.97; p-value=0.90).
For patients who undergo pancreaticoduodenectomy for PDAC, additional resection to achieve a negative neck margin after positive frozen section fails to improve OS, questioning the utility of this practice.
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