title: Is it time to stop checking frozen section neck margins during pancreaticoduodenectomy?
abstract: BACKGROUND
  Residual disease after pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) adversely impacts survival. The value of taking additional neck margin after a positive frozen section (FS) to achieve a negative margin remains uncertain.
  
  
  METHODS
  All patients who underwent PD for PDAC from January 2000 August 2012 were identified and classified as negative (R0) or positive (R1) based on final neck margin. We examined factors for association with a positive FS neck margin and overall survival (OS). We assessed the value of converting an R1 neck margin to R0 via additional parenchymal resection.
  
  
  RESULTS
  A total of 382 patients had FS neck margin analysis, of which 53 (14 %) were positive. Positive FS neck margin was associated with decreased OS (11.1 vs. 17.3 months, p = 0.01) on univariate analysis. On multivariate analysis poor histologic grade (p = 0.007), increased tumor size (p = 0.003), and a positive retroperitoneal margin (p = 0.009) were independently associated with decreased OS, but positive FS neck margin was not. Of the 53 patients with positive FS, 41 underwent additional neck resection and 23 were converted to R0. On permanent section, R0 neck margin was achieved in 322 patients (84 %), R1 in 37 patients (10 %), and R1 converted to R0 in 23 patients (6 %). Both the converted and the R1 groups had significantly poorer OS than the R0 group (11.3 vs. 11.1 vs. 17.3 months respectively; p = 0.04).
  
  
  CONCLUSIONS
  Positive FS margin at the pancreatic neck during PD for PDAC is associated with poor survival. Extending the neck resection after a positive FS to achieve R0 margin status does not appear to improve OS.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: Neha L
authors.initials: NL
authors.lastname: Lad
authors.forename: Malcolm H
authors.initials: MH
authors.lastname: Squires
authors.forename: Shishir K
authors.initials: SK
authors.lastname: Maithel
authors.forename: Sarah B
authors.initials: SB
authors.lastname: Fisher
authors.forename: Vishes V
authors.initials: VV
authors.lastname: Mehta
authors.forename: Kenneth
authors.initials: K
authors.lastname: Cardona
authors.forename: Maria C
authors.initials: MC
authors.lastname: Russell
authors.forename: Charles A
authors.initials: CA
authors.lastname: Staley
authors.forename: N Volkan
authors.initials: NV
authors.lastname: Adsay
authors.forename: David A
authors.initials: DA
authors.lastname: Kooby
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality* / Q000473:pathology / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D021441:Carcinoma, Pancreatic Ductal / Q000401:mortality* / Q000473:pathology / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D005629:Frozen Sections; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D018365:Neoplasm, Residual / Q000401:mortality* / Q000473:pathology / Q000601:surgery; D010190:Pancreatic Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery; D016577:Pancreaticoduodenectomy / Q000401:mortality*; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate