Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
Institute for Pathology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
Ann Surg. 2018 Dec;268(6):1058-1068. doi: 10.1097/SLA.0000000000002345.
The aim of this study was to decipher the true importance of R0 versus R1 resection for survival in pancreatic ductal adenocarcinoma (PDAC).
PDAC is characterized by poor survival, even after curative resection. In many studies, R0 versus R1 does not result in different prognosis and does not affect the postoperative management.
Pubmed, Embase, and Cochrane databases were screened for prognostic studies on the association between resection status and survival. Hazard ratios (HRs) were pooled in a meta-analysis. Furthermore, our prospective database was retrospectively screened for curative PDAC resections according to inclusion criteria (n = 254 patients) between July 2007 and October 2014.
In the meta-analysis, R1 was associated with a decreased overall survival [HR 1.45 (95% confidence interval, 95% CI 1.37-1.52)] and disease-free survival [HR 1.44 (1.30-1.59)] in PDAC when compared with R0. Importantly, this effect held true only for pancreatic head resection both in the meta-analysis [R0 ≥0 mm: HR 1.21 (1.05-1.39) vs R0 ≥1 mm: HR 1.66 (1.46-1.89)] and in our cohort (R0 ≥0 mm: 31.8 vs 14.5 months, P < 0.001; R0 ≥1 mm, 41.2 vs 16.8 months; P < 0.001). Moreover, R1 resections were associated with advanced tumor disease, that is, larger tumor size, lymph node metastases, and extended resections. Multivariable Cox proportional hazard model suggested G3, pN1, tumor size, and R1 (0 mm/1 mm) as independent predictors of overall survival.
Resection margin is not a valid prognostic marker in publications before 2010 due to heterogeneity of cohorts and lack of standardized histopathological examination. Within standardized pathology protocols, R-status' prognostic validity may be primarily confined to pancreatic head cancers.
本研究旨在阐明胰腺导管腺癌（PDAC）中 R0 与 R1 切除对生存的真正重要性。
PDAC 患者的生存预后较差，即使接受根治性切除术也是如此。在许多研究中，R0 与 R1 之间的差异并不影响预后，也不会影响术后管理。
通过 Pubmed、Embase 和 Cochrane 数据库，筛选与切除状态和生存相关的预后研究。采用荟萃分析对风险比（HRs）进行合并。此外，我们回顾性地从 2007 年 7 月至 2014 年 10 月期间，根据纳入标准（n=254 例患者）筛选了前瞻性数据库中可治愈的 PDAC 切除术。
荟萃分析显示，与 R0 相比，R1 与 PDAC 患者的总生存[HR 1.45（95%置信区间，95%CI 1.37-1.52）]和无病生存[HR 1.44（1.30-1.59）]降低有关。重要的是，这种影响仅在胰头切除术时才成立，荟萃分析中 [R0≥0mm：HR 1.21（1.05-1.39）比 R0≥1mm：HR 1.66（1.46-1.89）]和我们的队列中 [R0≥0mm：31.8 个月比 14.5 个月，P<0.001；R0≥1mm：41.2 个月比 16.8 个月，P<0.001] 也是如此。此外，R1 切除术与晚期肿瘤疾病相关，即肿瘤更大、淋巴结转移和扩大切除。多变量 Cox 比例风险模型表明，G3、pN1、肿瘤大小和 R1（0mm/1mm）是总生存的独立预测因子。
由于队列的异质性和缺乏标准化的组织病理学检查，2010 年之前的研究中，切除边缘并不是一个有效的预后标志物。在标准化病理方案中，R 状态的预后有效性可能主要局限于胰头癌。
