Habib Joseph R, Rompen Ingmar F, Kinny-Köster Benedict, Campbell Brady A, Andel Paul C M, Sacks Greg D, Billeter Adrian T, van Santvoort Hjalmar C, Daamen Lois A, Javed Ammar A, Müller-Stich Beat P, Besselink Marc G, Büchler Markus W, He Jin, Wolfgang Christopher L, Molenaar I Quintus, Loos Martin
New York University Langone Health, Department of Surgery, New York, USA.
Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Department of Surgery, Utrecht, the Netherlands.
Ann Surg. 2024 Sep 12. doi: 10.1097/SLA.0000000000006532.
To assess the prognostic impact of margin status in patients with resected intraductal papillary mucinous neoplasms (IPMN)-derived pancreatic ductal adenocarcinoma (PDAC) and to inform future intraoperative decision-making on handling differing degrees of dysplasia on frozen section.
The ideal oncologic surgical outcome is a negative transection margin with normal pancreatic epithelium left behind. However, the prognostic significance of reresecting certain degrees of dysplasia or invasive cancer at the pancreatic neck margin during pancreatectomy for IPMN-derived PDAC is debatable.
Consecutive patients with resected and histologically confirmed IPMN-derived PDAC (2002-2022) from six international high-volume centers were included. The prognostic relevance of a positive resection margin (R1) and degrees of dysplasia at the pancreatic neck margin were assessed by log-rank test and multivariable Cox-regression for overall survival (OS) and recurrence-free survival (RFS).
Overall, 832 patients with IPMN-derived PDAC were included with 322 patients (39%) having an R1-resection on final pathology. Median OS (mOS) was significantly longer in patients with an R0 status compared to those with an R1 status (65.8 vs. 26.3 mo P<0.001). Patients without dysplasia at the pancreatic neck margin had similar OS compared to those with low-grade dysplasia (mOS: 78.8 vs. 66.8 months, P=0.344). However, high-grade dysplasia (mOS: 26.1 mo, P=0.001) and invasive cancer (mOS: 25.0 mo, P<0.001) were associated with significantly worse OS compared to no or low-grade dysplasia. Patients who underwent conversion of high-risk margins (high-grade or invasive cancer) to a low-risk margin (low-grade or no dysplasia) after intraoperative frozen section had significantly superior OS compared to those with a high-risk neck margin on final pathology (mOS: 76.9 vs. 26.1 mo P<0.001).
In IPMN-derived PDAC, normal epithelium or low-grade dysplasia at the neck have similar outcomes while pancreatic neck margins with high-grade dysplasia or invasive cancer are associated with poorer outcomes. Conversion of a high-risk to low-risk margin after intraoperative frozen section is associated with survival benefit and should be performed when feasible.
评估手术切除的导管内乳头状黏液性肿瘤（IPMN）衍生的胰腺导管腺癌（PDAC）患者切缘状态的预后影响，并为未来术中关于处理冰冻切片上不同程度发育异常的决策提供依据。
理想的肿瘤外科手术结果是切缘阴性且保留正常胰腺上皮。然而，在IPMN衍生的PDAC胰腺切除术中，再次切除胰腺颈部切缘一定程度的发育异常或浸润性癌的预后意义存在争议。
纳入来自六个国际大型中心的连续手术切除且经组织学证实为IPMN衍生的PDAC患者（2002 - 2022年）。通过对数秩检验和多变量Cox回归评估阳性切缘（R1）及胰腺颈部切缘发育异常程度对总生存期（OS）和无复发生存期（RFS）的预后相关性。
总体而言，纳入832例IPMN衍生的PDAC患者，322例（39%）最终病理为R1切除。R0状态患者的中位OS（mOS）显著长于R1状态患者（65.8个月对26.3个月，P<0.001）。胰腺颈部切缘无发育异常的患者与低级别发育异常患者的OS相似（mOS：78.8个月对66.8个月，P = 0.344）。然而，高级别发育异常（mOS：26.1个月，P = 0.001）和浸润性癌（mOS：25.0个月，P<0.001）与OS显著较差相关，与无或低级别发育异常相比。术中冰冻切片后将高风险切缘（高级别或浸润性癌）转为低风险切缘（低级别或无发育异常）的患者，其OS显著优于最终病理为高风险颈部切缘的患者（mOS：76.9个月对26.1个月，P<0.001）。
在IPMN衍生的PDAC中，颈部正常上皮或低级别发育异常的预后相似，而胰腺颈部切缘有高级别发育异常或浸润性癌的预后较差。术中冰冻切片后将高风险切缘转为低风险切缘与生存获益相关，可行时应进行。
