Retrospective study of practices of pancreatic neck margin testing and their outcomes after pancreatoduodenectomy for PDAC

There is no consensus on the role of checking the pancreatic neck margin with frozen section (PNM-FS) during pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) to secure R0 resection and its impact on long-term outcomes. A retrospective study at the Cleveland Clinic (Cleveland, OH) investigated the impact of PNM-FS on survival outcomes after PD for PDAC. The study included 403 patients who underwent PD for PDAC. PNM-FS was checked in 361 patients (89.6%) and returned negative at first attempt in 285 of 361 patients (78.9%). A total of 76 patients had positive PNM-FS; 71 were revised and clearance achieved on repeat sampling in 49 (69.0%). Median pancreatic neck recurrence-free survival (PN-RFS; primary outcome) in patients with PNM-FS cleared with revision was significantly shorter compared with those with negative PNM-FS at first attempt (16.9 versus 23.1 months; p=0.048) but was not different from patients with PNM-FS not cleared (16.9 versus 16.0 months; p=0.961). Locoregional recurrence-free survival and distant recurrence-free survival were not different between the groups. Overall survival was marginally longer in patients with negative NPM-FS at first attempt (23.9 versus 19.4 months for PNM-FS cleared with revision; p=0.049; and 16.0 months for PNM-FS not cleared). Six patients underwent completion total pancreatectomy (TP) for margin clearance, four developed distant recurrence, one locoregional recurrence, and two died without disease at 1 and 11 months postoperatively. The authors conclude that PNM-FS is only a prognostic marker. Pursuing PNM-FS clearance does not improve PN-RFS, LR-RFS, D-RFS, or OS. Pursuing a completion TP may be associated with shorter OS either from disease progression or surgical morbidity.