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RE-RESECTION OF A POSITIVE PANCREATIC MARGIN IS ASSOCIATED WITH PROLONGED SURVIVAL AMONG PATIENTS WITH PANCREATIC CANCER TREATED WITH PREOPERATIVE THERAPY AND PANCREATODUODENECTOMY
Michael E. Egger*, Laura R. Prakash, Jordan M. Cloyd, Huamin Wang, Michael P. Kim, Ching-Wei Tzeng, Thomas Aloia, Jean Nicolas Vauthey, Jason B. Fleming, Jeffrey E. Lee, Matthew Katz
Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
Introduction: The role of re-resection of a positive pancreatic transection margin on the basis of intraoperative assessment in patients undergoing de novo pancreatoduodenectomy for cancer has recently been debated. Preoperative therapy may improve margin-negative resection rates and select patients with “favorable tumor biology” for surgery. We therefore hypothesized that re-resection of a positive pancreatic transection margin to a negative one prolongs survival following preoperative therapy.
Methods: The records of consecutive patients who underwent pancreatoduodenectomy following the administration of chemotherapy and/or chemoradiation between 2000-2014 at a single center were reviewed. The intraoperative assessment of each patient’s pancreatic margin was compared to its final status, which was categorized as negative, converted by re-resection to negative, or positive. The superior mesenteric artery (SMA) margin was defined as negative if ≥ 1mm. Kaplan-Meier survival analysis and multivariable Cox proportional hazard modeling was performed for overall survival (OS) and recurrence-free survival (RFS).
Results: A positive pancreatic transection margin was identified intraoperatively in 52 (11%) of 471 patients. The final pancreatic margin was reported as negative in 415 (88%), converted by re-resection to negative in 39 (8%), and positive in 17 (4%) patients. 28 (72%) patients in whom the pancreatic margin was converted from positive to negative had a negative SMA margin and 18 (46%) had negative lymph nodes. Patients in whom the pancreatic margin was converted to negative had a longer OS than those in whom the final margin was positive, even after controlling for other factors (multivariable HR 0.48, 95%CI 0.24-0.97; Figure). However, conversion was not associated with a prolongation of RFS (multivariable HR 0.67, 95% CI 0.30-1.27). The five year OS rate was 24% in the converted margin group and 31% in the negative margin group; there were no five year survivors in the positive margin group.
Conclusion: In patients with pancreatic cancer treated with preoperative therapy and pancreatoduodenectomy, the status of the pancreatic transection margin should be determined intraoperatively, and re-resection of a positive margin should be performed when technically feasible.
Figure. Overall survival from pancreatoduodenectomy for pancreatic ductal adenocarcinoma following neoadjuvant therapy, stratified by the pancreas neck margin status.
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