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

• Sohn HJ
• Kim H
• Kim SJ
• Lee KB
• Han Y
• Lee JM
• Kang JS
• Kwon W
• Chie EK
• Kim H
• Jang JY

• KMID: 2523765
• DOI: http://doi.org/10.4174/astr.2022.102.1.10

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

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

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

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  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.

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  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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