Justifying vein resection with pancreatoduodenectomy

Does revision of resection margins based on frozen section improve overall survival following pancreatoduodenectomy for pancreatic ductal adenocarcinoma? A meta-analysis

BACKGROUND

Margin status is the main surgical determinant of long-term outcome in pancreatic cancer. Intraoperative frozen section (IOFS) detects microscopic positive margins at a stage when margin revision is possible. The aim of this study was to determine if IOFS driven-revision of pancreatic resection margin(s) improves overall survival (OS) in pancreatic cancer.

METHODS

A systematic review of major reference databases was undertaken. Patients were divided into 3 groups based on initial FS (FSR0 for negative margin and FSR1 for positive microscopic margin) and final Permanent Section report (PSR0 for negative margin and PSR1 for positive microscopic margin): Group 1 (FSR0 → PSR0), Group 2 (FSR1 → PSR0), and Group 3 (FSR1 → PSR1). Patients in Groups 2 and 3 had surgical revision of the FSR1 margin. Data was meta-analysed.

RESULTS

4 studies included in the final analysis. No difference in OS and incidence of lymph node metastases between Groups 2 and 3 (P = 0.590 and P = 0.410).

CONCLUSIONS

IOFS-based revision of R1 pancreatic resection margin does not improve OS, even when it results in an R0 margin. This suggests that any benefit of margin revision based on FS is over-ridden by markers of more advanced or aggressive disease.

The concept of 'borderline resectable' pancreatic cancer: limited foundations and limited future?

Pancreatic ductal adenocarcinoma (PDAC) is traditionally treated by a surgery-first approach. The development and adoption of the concept of borderline resectable PDAC, which extends the role of surgery, is based on the proposition that neoadjuvant therapy (NAT) will increase the resection rate, margin negative rate and overall survival. There are a number of issues with this concept and a critical review of these suggests that it is based on limited foundations and likely has a limited future.