Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida.
Sylvester Comprehensive Cancer Center, Miami, Florida.
JAMA Surg. 2021 May 1;156(5):489-495. doi: 10.1001/jamasurg.2020.5676.
Although margin-negative (R0) resection is the gold standard for surgical management of localized pancreatic ductal adenocarcinoma (PDAC), the question of how to manage the patient with a microscopically positive intraoperative neck margin (IONM) during pancreaticoduodenectomy remains controversial.
In the absence of randomized clinical trials, we critically evaluated high-quality retrospective studies examining the oncologic utility of re-resecting positive IONMs during pancreaticoduodenectomy for PDAC (2000-2019). Several studies have concluded that additional pancreatic resection to achieve an R0 margin in IONM-positive cases does not influence survival. The largest is a multi-institutional study of 1399 patients undergoing pancreaticoduodenectomy, which demonstrated that in comparison with patients undergoing R0 resection (n = 1196; median survival, 21 months), those with either final R1 resections (n = 131) or undergoing margin conversion from IONM-positive to R0 resection on permanent section (n = 72) demonstrated similar median survival times (13.7 and 11.9 months, respectively). Conversely, recent reports suggest that the conversion of IONM to R0 resection with additional resection or even total pancreatectomy may be associated with improved survival. The discordance between these conflicting studies could be explained in part by the influence of biologic and physiologic selection on the association of IONM re-resection and survival. Since most studies did not include patients receiving modern combination chemotherapy regimens, the intersection between margin status, tumor biology, and chemoresponsiveness remains unclear. Furthermore, there are no dedicated data to guide surgical management in IONM-positive pancreaticoduodenectomy for patients receiving neoadjuvant chemotherapy.
Although data regarding the oncologic utility of additional resection to achieve a tumor-free margin following initial IONM positivity during pancreaticoduodenectomy for PDAC are conflicting, they suggest that IONM positivity may be a surrogate for biologic aggressiveness that is unlikely to be mitigated by the extent of surgical resection. The complex relationship between margin status and chemoresponsiveness warrants exploration in studies including patients receiving increasingly effective neoadjuvant chemotherapy.
虽然边缘阴性（R0）切除是局部胰腺导管腺癌（PDAC）手术治疗的金标准，但在胰十二指肠切除术中如何处理术中颈部边缘微阳性（IONM）的患者仍然存在争议。
在缺乏随机临床试验的情况下，我们批判性地评估了 2000 年至 2019 年间检查 PDAC 胰十二指肠切除术中重新切除阳性 IONM 的肿瘤学实用性的高质量回顾性研究。几项研究得出结论，在 IONM 阳性病例中进行额外的胰腺切除以达到 R0 切缘不会影响生存。最大的是一项对 1399 例接受胰十二指肠切除术的患者进行的多机构研究，该研究表明，与接受 R0 切除的患者（n=1196；中位生存期 21 个月）相比，接受最终 R1 切除的患者（n=131）或在永久性切片上将 IONM 阳性转换为 R0 切除的患者（n=72）的中位生存期相似（分别为 13.7 个月和 11.9 个月）。相反，最近的报告表明，通过额外切除甚至全胰切除术将 IONM 转换为 R0 切除可能与改善生存相关。这些相互矛盾的研究之间的差异部分可以用 IONM 重新切除与生存的关联的生物学和生理学选择的影响来解释。由于大多数研究都没有包括接受现代联合化疗方案的患者，因此边缘状态、肿瘤生物学和化疗反应之间的交点仍不清楚。此外，没有专门的数据来指导接受新辅助化疗的 IONM 阳性胰十二指肠切除术中的手术管理。
尽管关于在 PDAC 胰十二指肠切除术中初始 IONM 阳性后进行额外切除以达到无肿瘤切缘的肿瘤学实用性的数据存在争议，但它们表明 IONM 阳性可能是生物学侵袭性的替代指标，不太可能通过手术切除的范围来减轻。边缘状态和化疗反应之间的复杂关系需要在包括接受越来越有效的新辅助化疗的患者的研究中进行探索。
