Ann Surg Treat Res.  2022 Jan;102(1):10-19. 10.4174/astr.2022.102.1.10.

Oncologic outcomes according to the location and status of resection margin in pancreas head cancer: role of radiation therapy in R1 resection

Affiliations
  • 1Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
  • 2Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
  • 3Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea

Abstract

Purpose
The clinical significance of margin status in pancreatic head cancer is still controversial due to the nonstandardized definition of R status and pathologic reporting. This study aims to evaluate the impact of the margin status including location and the role of radiation therapy in pancreatic head cancer.
Methods
A total of 314 patients who underwent curative-intent surgery for pancreatic head cancer between 2010 and 2017 were analyzed. Demographics, survival, and local recurrences were compared according to 2 definitions: 0-mm R1 as direct involvement and 1-mm R1 as close resection margin less than 1 mm. The specific margins were divided into 4 groups according to the location around the pancreas: pancreas transection, anterior surface, posterior surface, and vessel (superior mesenteric artery/superior mesenteric vein) margin.
Results
The 0-mm R1-rate was 15.6%, and increased to 36.3% in 1-mm R1. The median overall survival rate of 0-mm R0 vs. R1 was 26 months vs. 16 months (P = 0.052) and that of 1-mm R0 vs. R1 was 27 months vs. 18 months, respectively (P = 0.016). In individual margins, posterior, anterior surface, and pancreas transection margin involvement were associated with poor outcome, and the 1 mm posterior surface involvement was an independent risk factor for disease-free survival (hazard ratio, 1.63). Adjuvant radiation therapy had oncologic benefits, especially in R1 patients (P = 0.011) compared to R0 patients (P = 0.088).
Conclusion
Margin status, especially 1-mm R1 status is an important predictive factor, and involved posterior surface has a clinical impact. Patients with positive margins should be considered adjuvant radiation therapy.

Keyword

Disease-free survival; Margins of excision; Pancreatic neoplasms; Pancreaticoduodenectomy; Prognosis

Figure

  • Fig. 1 Schematic anatomy of pancreaticoduodenectomy specimen and description of specific pancreatic margins. SMV, superior mesenteric vein; SMA, superior mesenteric artery.

  • Fig. 2 R1 rates in each margin according to 2 definitions.

  • Fig. 3 Kaplan-Meier curves for resection margin status and survival. Only tendency was seen in 0-mm R0/R1 status in overall survival (A) (median survival of 26 months vs. 16 months, P = 0.052) but significant difference was seen 1-mm R0/R1 status (B) (27 months vs. 18 months, P = 0.016). In disease-free survival and local recurrence-free survival, both 0-mm and 1-mm R status showed significant survival difference. (C) Median survival of 12 months vs. 6 months, P = 0.045; (D) 13 months vs. 8 months, P = 0.009; (E) median survival of 15 months vs. 7 months, P = 0.036; (F) median survival of 16 months vs. 9 months, P = 0.006.

  • Fig. 4 Clinical impact of chemotherapy and radiation therapy on R0/R1 patients. Tendency of chemotherapy to survival difference in (A) R0 patients (27 months vs. 19 months, P = 0.303) and (B) R1 patients (21 months vs. 13 months, P = 0.056). Radiation therapy had survival benefit on both (C) R0 (30 months vs. 25 months, P = 0.034) and (D) R1 patients (29 months vs. 16 months, P = 0.009).


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