Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
Ann Surg Oncol. 2017 Nov;24(12):3674-3682. doi: 10.1245/s10434-017-6076-z. Epub 2017 Sep 5.
There is debate regarding the definition and clinical significance of margin clearance in pancreatic ductal adenocarcinoma (PDA). A comprehensive archival analysis of surgical resection margins was performed to determine the effect on locoregional recurrence and survival, and the impact of adjuvant therapy in PDA.
We identified 105 patients with resected PDA. Pancreatic, anterior, bile duct, and posterior surgical resection margins (PM; posterior surface, uncinate and vascular groove) were identified. Three pathologists reviewed all archival surgical specimens and recategorized each margin as tumor at ink/transected, <0.5, 0.5-1, >1-2, or >2 mm from the inked surface. The impact of these and other clinical variables was assessed on local control, disease-free survival (DFS), and overall survival (OS).
Among all margins, PM clearance up to 2 mm was prognostic of DFS (p = 0.01) and OS (p = 0.01). Dichotomizing the PM at 2 mm revealed it to be an independent predictor of local recurrence-free survival [hazard ratio HR] 0.20, 95% confidence interval [CI] 0.048-0.881, p = 0.033), DFS (HR 0.46, 95% CI 0.22-0.96, p = 0.03), and OS (HR 0.31, 95% CI 0.14-0.74, p = 0.008). A margin status of >2 mm was also prognostic of OS in patients who received adjuvant chemotherapy (HR 0.31, 95% CI 0.11-0.89, p = 0.03), however this difference was mitigated in patients receiving adjuvant chemoradiotherapy (HR 0.40, 95% CI 0.10-1.58, p = 0.19).
These data highlight the clinical significance of the PM and the lack of significance of other resection margins. Clearance in excess of 2 mm should be considered to improve long-term clinical outcomes. The use of adjuvant radiotherapy should be strongly considered in patients with PMs <2 mm.
在胰腺导管腺癌 (PDA) 中，关于切缘清除的定义和临床意义存在争议。本研究对手术切缘进行了全面的存档分析，以确定其对局部复发和生存的影响，并评估辅助治疗在 PDA 中的作用。
我们共纳入 105 例接受胰腺切除术的 PDA 患者。确定胰腺、前、胆管和后手术切缘（PM；后表面、钩突和血管槽）。三位病理学家对所有存档的手术标本进行了复查，并将每个切缘重新分类为肿瘤位于墨汁/切断处、<0.5mm、0.5-1mm、1-2mm 或>2mm 处。评估这些和其他临床变量对局部控制、无病生存 (DFS) 和总生存 (OS) 的影响。
所有切缘中，PM 清除至 2mm 与 DFS（p=0.01）和 OS（p=0.01）相关。将 PM 分为 2mm 组显示其是局部无复发生存率 [风险比 HR] 0.20，95%置信区间 [CI] 0.048-0.881，p=0.033)、DFS（HR 0.46，95% CI 0.22-0.96，p=0.03）和 OS（HR 0.31，95% CI 0.14-0.74，p=0.008）的独立预测因子。在接受辅助化疗的患者中，>2mm 的切缘状态与 OS 相关（HR 0.31，95% CI 0.11-0.89，p=0.03），但在接受辅助放化疗的患者中，这种差异被缓解（HR 0.40，95% CI 0.10-1.58，p=0.19）。
这些数据突出了 PM 的临床意义，以及其他切缘无显著意义。PM 清除超过 2mm 应考虑改善长期临床结局。对于 PM<2mm 的患者，应强烈考虑使用辅助放疗。
