The Impact of Positive Resection Margin in Perihilar Cholangiocarcinoma, Ductal Margin vs Radial Margin

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Introduction: Resection margin status is the most important prognostic factor in resected perihilar cholangiocarcinoma (pCCA). Although the impact of ductal margin (DM) was reported in many studies, the influence of radial margin (RM) is unclear. This study aims to investigate the incidence and the effect of positive RM on survival. Methods: Patients with pCCA who underwent curative resection between October 2013 to December 2018 were retrospectively reviewed. Resection margin status were divided into negative resection margin (R0) and positive resection margin (R1); positive RM alone (RM+) and positive DM with or without positive RM (DM+). Results: Of the 170 pCCA patients, 63 (37%) had R1 margin. Among 63 R1 patients; 18 (28.6%) had positive DM alone, 20 (31.7%) had positive RM alone and 25 (39.7%) had both positive DM and RM. The R1 patients had a significantly greater number of LN metastasis and advanced tumor staging than R0 patients, however there was no difference between the RM+ and DM+ patients. The median survival time of patients with RM+ was significantly poorer than R0 patients (13.8 vs 24.7 months; p<0.001, respectively) and similar to the DM+ patients (9.1 months, p=0.561). In multivariable analysis, positive resection margin and lymph node metastasis were independently prognostic factors. Conclusion: Positive resection margin remains the most important prognostic factors and positive RM is common in these patients. Positive RM also had a comparable effect on survival as positive DM. As a result, in pCCA, surgical resection should target both RM and DM. Tabled 1EP03A-039CharacteristicsUnivariableMultivariableNMST (months)p-valueHR95%CIp-valueBismuth type0.0441.3770.838-2.2620.207 1-314416.8 42310.6Portal vein invasion0.0291.0920.212-5.6130.916 Absence8418.4 Present6714.8Hepatic artery invasion0.0410.8560.465-1.5780.619 Absence10018.4 Present5114.2pT stage (AJCC 8th)0.0190.9970.211-4.7090.997 pT 1-29818.4 pT 3-46914.2pN stage (AJCC 8th)<0.0012.2931.437-3.6620.001 pN09025.7 pN1/2778.0Staging (AJCC 8th)<0.0011.3630.729-2.5490.332 Stage 1-24930.7 Stage 3-411810.6Surgical margin status<0.001 R010524.711.613-4.180<0.001 DM+429.12.5971.231-3.8510.008 RM+2013.82.177Surgical margin status<0.001 R010524.70.3850.239-0.620<0.001 DM+429.110.463-1.5190.561 RM+2013.80.838 Open table in a new tab