Resection margins and R1 rates in pancreatic cancer--are we there yet?

Department of Histopathology, St James's University Hospital, Leeds, UK.
Histopathology (Impact Factor: 3.3). 07/2008; 52(7):787-96. DOI: 10.1111/j.1365-2559.2007.02935.x
Source: PubMed

ABSTRACT The prognosis of pancreatic cancer is poor, even for those patients who undergo surgical resection. The rate of local recurrence is high, despite the fact that in most series complete ('R0') resection is reported to be achieved in the majority of patients. The discrepancy between pathological assessment and clinical outcome indicates that microscopic margin involvement (R1) is frequently underreported, and potential causes for this are discussed in this review. Special emphasis is given to the variation that exists between currently used dissection techniques and their impact on the assessment of the resection margins in pancreatoduodenectomy specimens.

  • [Show abstract] [Hide abstract]
    ABSTRACT: ZusammenfassungBeim Pankreaskarzinom zeigt sich eine auffällige Diskrepanz zwischen der angegebenen R0-Resektionsrate und dem klinischen Langzeitergebnis. Deshalb erscheint es notwendig, hier zusätzliche Parameter zu finden, die besseren prognostischen Wert besitzen. Auffällig ist die innerhalb der Studien unterschiedliche Anwendung der R-Klassifikation. Wichtig erscheint, die Standards der histopathologischen Aufarbeitung zu überprüfen und zu der klassischen R-Klassifikation zurückzukehren, gegebenenfalls entsprechend den Erfahrungen beim Rektumkarzinom einen «zirkumferentiellen Resektionsrand» einzuführen. Um ein optimales Langzeitüberleben zu erzielen, ist ein Abstand zwischen Tumor und Resektionsrand von >1,0 oder gar >1,5 mm erforderlich. Zu wenige Patienten mit Gefäßinvasion werden operativ saniert, obwohl die Infiltration der Pfortader und der Vena mesenterica superior nach den S3-Leitlinien kein Ausschlusskriterium ist. Mit «High-Volume»-Pankreaszentren könnte eine Qualitätsverbesserung erreicht werden. Der Stellenwert der Radiochemotherapie (RCT) in der perioperativen Situation wird derzeit in mehreren großen Studien überprüft. Die adjuvante Chemotherapie ist Standard und im klinischen Alltag etabliert.
    Onkologie 01/2010; 33(4):31-35. DOI:10.1159/000308453 · 0.84 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Curative resection has been shown to be one of the key factors influencing survival of pancreatic ductal adenocarcinoma (PDAC) patients. Although general guidelines for the processing of pancreatic specimens have been established, there is currently no widely accepted standardized protocol for pathological examination, especially with respect to resection margins. Here we present a single-center experience with 111 consecutive macroscopic complete pancreatic head resections for PDAC carried out between 2005 and 2006 by using standardized pathological processing and reporting. The pancreatic transection margin, as well as the bile duct and stomach/duodenum margins and the circumferential soft tissue margins (medial, anterior surface, superior, and posterior), were inked and analyzed. R1 was defined as a distance of the tumor from the resection margin of < or = 1 mm. One hundred eighty-eight consecutive macroscopic complete pancreatic head resections carried out for PDAC without a standardized protocol between 2002 and 2004 were used as a control group. The R1 rate for resections carried out with the standardized protocol was 76%. The medial (68%) and the posterior (47%) margins were most commonly involved, and in 32% of the cases, more than one margin was affected. The R1 resection rate in the period without standardized pathological reporting was 14%. This study highlights the importance of pathological reporting and suggests that tumor growth patterns and thorough examination but not surgical technique determine R1 resection rates in PDAC.
    Annals of Surgical Oncology 06/2008; 15(6):1651-60. DOI:10.1245/s10434-008-9839-8 · 3.94 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The volume-outcome relationship has been repeatedly demonstrated for pancreatectomy, but identifying underlying reasons for this association has been challenging. Some have suggested that differences in surgical technique may affect longterm survival, but it is unknown whether margin-positive resection rates vary by hospital volume. Our objective was to evaluate the effect of hospital pancreatectomy volume on margin status. Patients who underwent pancreaticoduodenectomy for localized pancreatic adenocarcinoma were identified from the National Cancer Data Base (1998 to 2004). Regression modeling adjusting for patient, tumor, and hospital factors was used to assess predictors of margin involvement and to evaluate the effect of margin status on survival. Volume quintiles were based on average annual hospital pancreatectomy volume. Of 12,101 patients, 24.4% had positive resection margins (14.6% microscopic/R1; 9.8% macroscopic/R2). From 1998 to 2004, there was not a significant change in margin-positive resection rates (p=0.43). On multivariable analysis, patients were more likely to have a margin-positive resection if they had a higher T classification or nodal involvement, were uninsured or living in lower-income areas, or underwent resection at lowest-volume hospitals compared with highest-volume hospitals (25.9% versus 22.6%, p < 0.0001; odds ratio, 1.21; 95% confidence interval, 1.01 to 1.43). On multivariable analysis, margin involvement was associated with a higher risk of longterm mortality compared with margin-negative resections (p < 0.0001). Involved resection margins are a poor prognostic factor after a pancreaticoduodenectomy. Patients undergoing pancreaticoduodenectomy at low-volume centers are more likely to have margin-positive resections. Standardization of pathologic evaluation for pancreatectomy specimens is needed.
    Journal of the American College of Surgeons 10/2008; 207(4):510-9. DOI:10.1016/j.jamcollsurg.2008.04.033 · 4.45 Impact Factor


1 Download