Impact of Resection Status on Pattern of Failure and Survival After Pancreaticoduodenectomy for Pancreatic Adenocarcinoma

Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
Annals of Surgery (Impact Factor: 8.33). 08/2007; 246(1):52-60. DOI: 10.1097/01.sla.0000259391.84304.2b
Source: PubMed


To better understand the impact of a microscopically positive margin (R1) on patterns of disease recurrence and survival after pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma.
A positive resection margin after PD is considered to be a poor prognostic factor, and some have proposed that an R1 margin may be a biologic predictor of more aggressive disease. The natural history of patients treated with contemporary multimodality therapy who underwent a positive margin PD has not been described.
We analyzed our experience from 1990 to 2004, which included the prospective use of a standardized system for pathologic analysis of all PD specimens. All patients who underwent PD met objective computed tomographic criteria for resection. Standard pathologic evaluation of the PD specimen included permanent section analysis of the final bile duct, pancreatic, and superior mesenteric artery (SMA) margins. First recurrences (all sites) were defined as local, regional, or distant. Survival and follow-up were calculated from the date of initial histologic diagnosis to the dates of first recurrence or death and last contact, respectively.
PD was performed on 360 consecutive patients with pancreatic adenocarcinoma. Minimum follow-up was 12 months (median, 51.9 months). The resection margins were negative (R0) in 300 patients (83.3%) and positive (R1) in 60 (16.7%); no patients had macroscopically positive (R2) margins. By multivariate analysis (MVA), high mean operative blood loss and large tumor size were independent predictors of an R1 resection. Patients who underwent an R1 resection had a median overall survival of 21.5 months compared with 27.8 months in patients who underwent an R0 resection. After controlling for other variables on MVA, resection status did not independently affect survival. By MVA, only lymph node metastases, major perioperative complications, and blood loss adversely affected survival.
There was no statistically significant difference in patient survival or recurrence based on R status. However, this series is unique in the incorporation of a standardized surgical technique for the SMA dissection, the prospective use of a reproducible system for pathologic evaluation of resection margins, the absence of R2 resections, and the frequent use of multimodality therapy.

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Available from: Chandrajit P Raut, May 02, 2014
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    • "identified that predict survival in PC patients, such as tumour size, histologic grade, vascular invasion, lymph node metastases and perineural invasion (Griffanti-Bartoli et al, 1994; Fortner et al, 1996; Ozaki et al, 1999; Raut et al, 2007). Nevertheless, the majority of these established histological predictors is only amenable for assessment after surgery. "
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    ABSTRACT: Background: Recent evidence indicates that the host inflammatory response has an important role in the tumour progression. Elevated C-reactive protein (CRP) levels have been previously associated with poor prognosis in several cancer types including small-scale studies in pancreatic cancer (PC) patients. The purpose of the present study was to validate the prognostic impact of plasma CRP levels at date of diagnosis on cancer-specific survival (CSS) in a large cohort of PC patients. Methods: Data from 474 consecutive patients with adenocarcinoma of the pancreas, treated between 2004 and 2012 at a single centre, were evaluated retrospectively. CSS was analysed using the Kaplan–Meier method. To evaluate the prognostic significance of plasma CRP levels, univariate and multivariate Cox analyses were applied. Results: High plasma CRP levels at diagnosis were significantly associated with well-established prognostic factors, including high tumour stage and tumour grade and the administration of chemotherapy (P<0.05). In univariate analysis, we observed that a high plasma CRP level was a consistent factor for poor CSS in PC patients (hazard ratio (HR)=2.21; 95% confidence interval (CI)=1.68–2.92, P<0.001). In multivariate analysis, tumour stage, grade, administration of chemotherapy, a high neutrophil–lymphocyte ratio and the highest quartile of CRP levels (HR=1.60, 95% CI=1.16–2.21; P=0.005) were identified as independent prognostic factors in PC patients. Conclusion: In conclusion, we confirmed a significant association of elevated CRP levels with poor clinical outcome in PC patients. Our results indicate that the plasma CRP level might represent a useful marker for patient stratification in PC management.
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    • "The reported microscopic tumor infiltration (R1) rates show a surprisingly high variation ranging from 17% to 85% (Table 1). In divergence with low reported R1 rates, local recurrence is a current problem for PDAC and concerns up to 87% of patients [9,10,11,12]. This obvious discrepancy is well shown by a recent retrospective study including 360 patients with a local recurrence rate of more than 66% of initially R0 diagnosed patients. "
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