title: Value of intraoperative neck margin analysis during Whipple for pancreatic adenocarcinoma: a multicenter analysis of 1399 patients.
abstract: BACKGROUND
  During pancreaticoduodenectomy (PD) for ductal adenocarcinoma, a frozen section (FS) neck margin is typically assessed, and if positive, additional pancreas is removed to achieve an R0 margin. We analyzed the association of this practice with improved overall survival (OS).
  
  
  METHODS
  Patients who underwent PD for pancreatic ductal adenocarcinoma from January 2000 to August 2012 at 8 academic centers were classified by neck margin status as negative (R0) or microscopically positive (R1) on the basis of FS and permanent section (PS). Impact on OS of converting an FS-R1-neck margin to a PS-R0-neck margin by additional resection was assessed.
  
  
  RESULTS
  A total of 1399 patients had FS neck margins analyzed. Median OS was 19.7 months. On FS, 152 patients (10.9%) were R1, and an additional 51 patients (3.6%) had false-negative FS-R0 margins. PS-R0-neck was achieved in 1196 patients (85.5%), 131 patients (9.3%) remained PS-R1, and 72 patients (5.1%) were converted from FS-R1-to-PS-R0 by additional resection. Median OS for PS-R0-neck patients was 21.1 months versus 13.7 months for PS-R1-neck patients (P < 0.001) and 11.9 months for FS-R1-to-PS-R0 patients (P < 0.001). Both FS-R1-to-PS-R0 and PS-R1-neck patients had larger tumors (P = 0.001), more perineural invasion (P = 0.02), and more node positivity (P = 0.08) than PS-R0-neck patients. On multivariate analysis controlling for adverse pathologic factors, FS-R1-to-PS-R0 conversion remained associated with significantly worse OS compared with PS-R0-neck patients (hazard ratio: 1.55; P = 0.009).
  
  
  CONCLUSIONS
  For patients who undergo pancreaticoduodenectomy for pancreatic ductal adenocarcinoma, additional resection to achieve a negative neck margin after positive frozen section is not associated with improved OS.
authors.affiliation: Departments of *Surgery †Pathology, and ‡Medical Oncology, Emory University School of Medicine, Atlanta, GA §Department of Surgery, University of Wisconsin School of Medicine, Madison, WI ¶Department of Surgery, Northwestern University Feinberg School of Medicine, Evanston, IL ‖Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH **Department of Surgery, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC ††Department of Surgery, University of Louisville School of Medicine, Louisville, KY ‡‡Department of Surgery, Vanderbilt University School of Medicine, Nashville, TN; and §§Department of Surgery, Washington University School of Medicine, St. Louis, MO.
authors.forename: David A
authors.initials: DA
authors.lastname: Kooby
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: Juan M
authors.initials: JM
authors.lastname: Sarmiento
authors.forename: Charles A
authors.initials: CA
authors.lastname: Staley
authors.forename: N Volkan
authors.initials: NV
authors.lastname: Adsay
authors.forename: Bassel F
authors.initials: BF
authors.lastname: El-Rayes
authors.forename: Sharon M
authors.initials: SM
authors.lastname: Weber
authors.forename: Emily R
authors.initials: ER
authors.lastname: Winslow
authors.forename: Clifford S
authors.initials: CS
authors.lastname: Cho
authors.forename: Kathryn A
authors.initials: KA
authors.lastname: Zavala
authors.forename: David J
authors.initials: DJ
authors.lastname: Bentrem
authors.forename: Mark
authors.initials: M
authors.lastname: Knab
authors.forename: Syed A
authors.initials: SA
authors.lastname: Ahmad
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Abbott
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Sutton
authors.forename: Hong Jin
authors.initials: HJ
authors.lastname: Kim
authors.forename: Jen Jen
authors.initials: JJ
authors.lastname: Yeh
authors.forename: Rachel
authors.initials: R
authors.lastname: Aufforth
authors.forename: Charles R
authors.initials: CR
authors.lastname: Scoggins
authors.forename: Robert C
authors.initials: RC
authors.lastname: Martin
authors.forename: Alexander A
authors.initials: AA
authors.lastname: Parikh
authors.forename: Jamie
authors.initials: J
authors.lastname: Robinson
authors.forename: Yassar M
authors.initials: YM
authors.lastname: Hashim
authors.forename: Ryan C
authors.initials: RC
authors.lastname: Fields
authors.forename: William G
authors.initials: WG
authors.lastname: Hawkins
authors.forename: Nipun B
authors.initials: NB
authors.lastname: Merchant
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005629:Frozen Sections; D006801:Humans; D007432:Intraoperative Period; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009361:Neoplasm Invasiveness; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D016577:Pancreaticoduodenectomy; D010502:Perineum / Q000473:pathology; D012189:Retrospective Studies; D016019:Survival Analysis