Intra-Operative Frozen Section Histology of the Pancreatic Resection Margins and Clinical Outcome of Patients with Adenocarcinoma of the Head of the Pancreas Undergoing Pancreaticoduodenectomy

Intraoperative Positive Pancreatic Parenchymal Resection Margin: Is It a True Indication of Completion Total Pancreatectomy after Partial Pancreatectomy for Pancreatic Ductal Adenocarcinoma?

Background: Total pancreatectomy (TP) can be performed in cases with positive resection margin after partial pancreatectomy for pancreatic cancer. However, despite complete removal of the residual pancreatic parenchyme, it is questionable whether an actual R0 resection and favorable survival can be achieved. This study aimed to identify the R0 resection rate and postoperative outcomes, including survival, following completion TP (cTP) performed due to intraoperative positive margin. Methods: From 1995 to 2015, 1096 patients with pancreatic ductal adenocarcinoma underwent elective pancreatectomy at the Samsung Medical Center. Among these, 25 patients underwent cTP, which was converted during partial pancreatectomy because of a positive resection margin. To compare survival after R0 resection between the cTP R0 and pancreaticoduodenectomy (PD) R0 cases, propensity score matching was conducted to balance the baseline characteristics. Results: The R0 rate of cTP performed due to intraoperative positive margin was 84% (21/25). The overall 5-year survival rate (5YSR) in the 25 cTP cases was 8%. There was no difference in the 5YSR between the cTP R0 and cTP R1 groups (9.5% versus 0.0%, p = 0.963). However, the 5YSR of the cTP R0 group was significantly lower than that of the PD R0 group (9.5% versus 20.0%, p = 0.022). There was no distinct difference in postoperative complications between the cTP R0 versus cTP R1 and cTP R0 versus PD R0 groups. Conclusions: In cases with intraoperative positive pancreatic parenchymal resection margin, survival after cTP was not favorable. Careful patient selection is needed to perform cTP in such cases.

Korean Surgical Practice Guideline for Pancreatic Cancer 2021: A summary of evidence-based surgical approaches

Pancreatic cancer is the eighth most common cancer and the fifth most common cause of cancer-related deaths in Korea. Despite the increasing incidence and high mortality rate of pancreatic cancer, there are no appropriate surgical practice guidelines for the current domestic medical situation. To enable standardization of management and facilitate improvements in surgical outcome, a total of 10 pancreatic surgical experts who are members of Korean Association of Hepato-Biliary-Pancreatic Surgery have developed new recommendations that integrate the most up-to-date, evidence-based research findings and expert opinions. This is an English version of the Korean Surgical Practice Guideline for Pancreatic Cancer 2021. This guideline includes 13 surgical questions and 15 statements. Due to the lack of high-level evidence, strong recommendation is almost impossible. However, we believe that this guideline will help surgeons understand the current status of evidence and suggest what to investigate further to establish more solid recommendations in the future.

Pancreatic Frozen Section Guides Operative Management With Few Deferrals and Errors

CONTEXT.—

Pancreatic adenocarcinoma is the third leading cause of cancer death in the United States. Surgery remains the mainstay of treatment, and frozen section analysis is used to confirm diagnosis and determine resectability and margin status.

OBJECTIVE.—

To evaluate use and accuracy of frozen section and how diagnosis impacts surgical procedure.

DESIGN.—

We reviewed patients with planned pancreatic resections between January 2014 and March 2019 with at least 1 frozen section. Pathology reports including frozen sections, preoperative cytology, and operative notes were reviewed. Frozen sections were categorized by margin, primary pancreatic diagnosis, metastasis, or vascular resectability. The deferral and error rates and surgeons' response were noted.

RESULTS.—

We identified 898 planned pancreatic resections and 221 frozen sections that were performed on 152 cases for 102 margins, 94 metastatic lesions, 20 primary diagnoses, and 5 to confirm vascular resectability. The diagnosis was deferred to permanent sections in 13 of 152 cases (8.6%) on 16 of 221 frozen sections (7.2%): 6 for metastasis, 8 for margins, and 2 for primary diagnosis. Discrepancies/errors were identified in 4 of 152 cases (2.6%) and 4 of 221 frozen sections (1.8%). Surgeon's response was different than expected in 8 of 221 frozen sections (3.6%), but their actions were explained by other intraoperative findings in 6 of 8.

CONCLUSIONS.—

Frozen section remains an important diagnostic tool used primarily for evaluation of margins and metastasis during pancreatectomy. In most cases, a definitive diagnosis is rendered, with occasional deferrals and few errors. Intraoperative findings explain most cases where surgeons act differently than expected based on frozen section diagnosis.