Microscopic margins and patterns of treatment failure in resected pancreatic adenocarcinoma.
OBJECTIVE
To correlate microscopic margin status with survival and local control in a large cohort of patients from a high-volume pancreatic cancer center.


METHODS
Retrospective database review. A uniform procedure for margin analysis was used with 4-color inking (neck, portal vein groove, uncinate, and posterior pancreatic margin) by the surgeon in the operating room.


METHODS
A tertiary care hospital.


METHODS
We reviewed patients who underwent pancreaticoduodenectomy between September 1, 1997, and December 31, 2008, from a prospective, institutional database.


METHODS
Using Cox regression models, we identified pathologic characteristics associated with local recurrence (LR) after controlling for potential confounding variables. Overall and LR-free survival curves were generated by the Kaplan-Meier method.


RESULTS
Of 285 patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma, 97 (34.0%) had 1 or more positive microscopic margins (uncinate, 16.5%; portal vein groove, 8.8%; neck, 7.7%; and posterior, 10.5%). A total of 198 patients (69.5%) recurred, with the first site of failure being LR only in 47 (23.7%), local plus distant recurrence in 42 (21.2%), and distant recurrence only in 109 (55.1%). Patients with LR only were significantly more likely to have lymph node involvement (adjusted hazard ratio, 2.66; 95% CI, 1.25-5.63) or a positive posterior margin (adjusted hazard ratio, 4.27; 95% CI, 2.07-8.81). Patients with a positive posterior margin had significantly poorer LR-free survival with (P < .001) or without (P = .01) lymph node involvement.


CONCLUSIONS
When systematically assessed, the incidence of positive microscopic margins is high. Positive posterior margins and lymph node involvement were each independently and significantly associated with LR.
Department of Surgery, Washington University School of Medicine, St Louis, Missouri 63110, USA.
Jennifer L
JL
Gnerlich
Samuel R
SR
Luka
Anjali D
AD
Deshpande
Bernard J
BJ
Dubray
Joshua S
JS
Weir
Danielle H
DH
Carpenter
Elizabeth M
EM
Brunt
Steven M
SM
Strasberg
William G
WG
Hawkins
David C
DC
Linehan
D000230:Adenocarcinoma / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D000368:Aged; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology / Q000473:pathology; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000379:methods; D017211:Treatment Failure