Survival After Margin-Positive Resection in the Era of Modern Chemotherapy for Pancreatic Cancer: Do Patients Still Benefit?

Pancreatic cancer is a highly aggressive disease with poor survival. The only effective therapy offering long-term survival is complete surgical resection. In the setting of nonmetastatic disease, locally advanced tumors constitute a technical challenge to the surgeon and may result in margin-positive resection margins. Few studies have evaluated the implications of the latter in depth. The aim of this study was to compare the margin-positive situation to palliative bypass procedures and margin-negative resections in terms of perioperative and long-term outcome. By retrospective analysis of prospectively maintained data from 360 patients operated for pancreatic cancer at our institution, we provide evidence that margin-positive resection still yields a significant survival benefit over palliative bypass procedures. At the same time, perioperative severe morbidity and mortality are not significantly increased. Our observations suggest that pancreatic cancer should be resected whenever technically feasible, including, cases of locally advanced disease.

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Value of surgical resection and timing of therapy in patients with pancreatic cancer at high risk for positive margins

ESMO Open ◽

10.1136/esmoopen-2017-000282 ◽

2018 ◽

Vol 3 (1) ◽

pp. e000282 ◽

Cited By ~ 12

Author(s):

Anna Torgeson ◽

Ignacio Garrido-Laguna ◽

Randa Tao ◽

George M Cannon ◽

Courtney L Scaife ◽

...

Keyword(s):

Pancreatic Cancer ◽

Surgical Resection ◽

Proportional Hazards ◽

Clinical Stage ◽

Positive Margin ◽

Cox Proportional Hazards ◽

Stage Iii ◽

Term Survival ◽

Additional Therapy ◽

Margin Positive

BackgroundSurgical resection remains the best chance at long-term survival in pancreatic cancer, though margin-positive resections are associated with diminished survival. We examined the effect of margin-positive resection on survival, as well as the role and timing of additional therapies through the National Cancer Database (NCDB).Patients and methodsPatients with stage IIA–III pancreatic adenocarcinoma diagnosed from 2004 to 2013 were identified in NCDB. Survival was compared using univariate and multivariate Cox proportional hazards modelling for patients who underwent surgery with negative (R0), microscopically positive (R1) and macroscopically positive (R2) margins or non-surgical treatment. We further analysed patients by margin status, timing of additional therapy (neoadjuvant therapy (NAT) vs adjuvant therapy (AT) vs none) and clinical stage.ResultsWe analysed 44 852 patients. Median survival (MS) for patients who did not undergo surgery was 10.3 months, compared with 19.7 months for R0 (P<0.001), 14.3 months for R1 (P<0.001) and 9.8 months (P=0.07) for R2 resections. NAT (MS 23.2 months) was associated with improved survival compared with AT (MS 21.5 months) in negative-margin patients and equivalent (MS 17.6 months) to AT (MS 16.8 months) in positive-margin patients. Survival for stage III NAT positive-margin patients (MS 19.8 months) was equivalent to AT after negative margins (MS 18.4 months, P=1.00). Improved R0 rates were seen with NAT (88% vs 81%, P<0.001), especially in stage III patients (85% vs 59%, P<0.001).ConclusionR1 resections portend poorer survival than R0 but do not negate the benefit of surgery when additional therapy is given. NAT was associated with improved R0 rates and improved survival for stage III positive-margin patients.

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ASO Author Reflections: Impact of Neoadjuvant Therapy on Survival After Margin-Positive Resection for Pancreatic Cancer

Annals of Surgical Oncology ◽

10.1245/s10434-021-10177-w ◽

2021 ◽

Author(s):

Asmita Chopra ◽

Joal D. Beane

Keyword(s):

Pancreatic Cancer ◽

Neoadjuvant Therapy ◽

Margin Positive

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Cyberknife Radiotherapy Extends Survival for Patients with Margin-Positive, Resected Pancreatic Cancer

Journal of Surgical Research ◽

10.1016/j.jss.2009.11.624 ◽

2010 ◽

Vol 158 (2) ◽

pp. 396-397

Author(s):

C.M. Vollmer ◽

A. Mahadevan ◽

T.S. Kent ◽

M.P. Callery

Keyword(s):

Pancreatic Cancer ◽

Margin Positive

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Adjuvant Treatment for Resectable Pancreatic Cancer

Journal of Clinical Oncology ◽

10.1200/jco.2005.17.954 ◽

2005 ◽

Vol 23 (20) ◽

pp. 4532-4537 ◽

Cited By ~ 53

Author(s):

Yu Jo Chua ◽

David Cunningham

Keyword(s):

Pancreatic Cancer ◽

Adjuvant Chemotherapy ◽

Adjuvant Treatment ◽

Meta Analysis ◽

Neoadjuvant Treatment ◽

Adjuvant Chemoradiotherapy ◽

Resectable Pancreatic Cancer ◽

Randomized Studies ◽

The Subject ◽

Margin Positive

There are relatively few randomized studies of adjuvant chemoradiotherapy and chemotherapy in patients with resected pancreatic adenocarcinoma. The European Study Group for Pancreatic Cancer 1 (ESPAC1) trial is the largest study of adjuvant treatment to date. The results of ESPAC1 are discussed in the context of other evidence from previous randomized studies, which have also been combined in a meta-analysis. Overall, the existing data show a clear benefit for postoperative adjuvant chemotherapy, which has not been demonstrated for adjuvant chemoradiotherapy. The subgroup of patients with resection margin positive disease did seem to benefit less from adjuvant chemotherapy, and showed a trend towards improved survival with chemoradiotherapy. Adjuvant chemoradiotherapy should be evaluated further in this latter group of patients. The optimal chemotherapy regimen for use as adjuvant treatment is the subject of ongoing trials. Other strategies which should be explored include neoadjuvant treatment and the incorporation of novel targeted agents into management.

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