Abstract
BackgroundThe present study aimed to examine the impact of microscopically tumour-infiltrated resection margins (R1) in pancreatic ductal adenocarcinoma (PDAC) patients with advanced lymphonodular metastasis (pN1–pN2) on overall survival (OS).MethodsThis retrospective, multi-institutional analysis included patients undergoing surgical resection for PDAC at three tertiary university centres between 2005 and 2018. Subcohorts of patients with lymph node status pN0–N2 were stratified according to the histopathological resection status using Kaplan-Meier survival analysis.ResultsThe OS of the entire cohort (n = 620) correlated inversely with the pN status (26 [pN0], 18 [pN1], 11.8 [pN2] months, P < 0.001) and R status (21.7 [R0], 12.5 [R1] months, P < 0.001). However, there was no statistically significant OS difference between R0 versus R1 in cases with advanced lymphonodular metastases: 19.6 months (95% CI: 17.4–20.9) versus 13.6 months (95% CI: 10.7–18.0) for pN1 stage and 13.7 months (95% CI: 10.7–18.9) versus 10.1 months (95% CI: 7.9–19.1) for pN2, respectively. Accordingly, N stage–dependent Cox regression analysis revealed that R status was a prognostic factor in pN0 cases only. Furthermore, there was no significant survival disadvantage for patients with R0 resection but circumferential resection margin invasion (≤ 1 mm; CRM+; 10.7 months) versus CRM-negative (13.7 months) cases in pN2 stages (P = 0.5).ConclusionsAn R1 resection is not associated with worse OS in pN2 cases. If there is evidence of advanced lymph node metastasis and a re-resection due to an R1 situation (e.g. at venous or arterial vessels) may substantially increase the perioperative risk, margin clearance in order to reach local control might be avoided with respect to the OS.
Highlights
Current multimodal treatment strategies of pancreatic ductal adenocarcinoma (PDAC) have resulted in a significant survivalRobert Grützmann, Tobias Keck and Thilo Welsch shared senior authorship.Besides R status, regional lymph node metastases are a strong prognostic survival determinant after resection of Langenbecks Arch Surg (2021) 406:1481–1489PDAC
Considering the entire cohort, pN0 status was significantly associated with the longest median overall survival (OS) of 26 months, followed by 18 months for the pN1 stage and 11.8 months for the pN2 stage
Resection margin status seems to lose prognostic relevance in patients with advanced lymphatic tumour cell spread. This is relevant because the analyzed data when obtained from an era when multimodal treatment with neo- or adjuvant chemotherapy for PDAC was standard, and advanced lymph node metastasis stages according to current guidelines were considered
Summary
Current multimodal treatment strategies of pancreatic ductal adenocarcinoma (PDAC) have resulted in a significant survival. There is evidence that both the R and pN stage are significant prognostic factors, the question remains of whether local control (R0 status) matters in advanced lymphonodular positive disease (e.g. pN2 according to the new N classification). The present study aimed to examine the impact of microscopically tumour-infiltrated resection margins (R1) in pancreatic ductal adenocarcinoma (PDAC) patients with advanced lymphonodular metastasis (pN1–pN2) on overall survival (OS). Methods This retrospective, multi-institutional analysis included patients undergoing surgical resection for PDAC at three tertiary university centres between 2005 and 2018. Subcohorts of patients with lymph node status pN0–N2 were stratified according to the histopathological resection status using Kaplan-Meier survival analysis
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