Abstract
Background
The impact of margin status on resection of primary pancreatic neuroendocrine tumors
has been poorly defined. The objectives of the present study were to determine the
impact of margin status on long-term survival of patients with pancreatic neuroendocrine
tumors after curative resection and evaluate the impact of reresection to obtain a
microscopically negative margin.
Methods
Patients who underwent curative-intent resection for pancreatic neuroendocrine tumors
between 2000 and 2016 were identified at 8 hepatobiliary centers. Overall and recurrence-free
survival were analyzed relative to surgical margin status using univariable and multivariable
analyses.
Results
Among 1,020 patients, 866 (84.9%) had an R0 (>1 mm margin) resection, whereas 154
(15.1%) had an R1 (≤1 mm margin) resection. R1 resection was associated with a worse
recurrence-free survival (10-year recurrence-free survival, R1 47.3% vs R0 62.8%,
hazard ratio 1.8, 95% confidence interval 1.2–2.7, P = .002); residual tumor at either the transection margin (R1t) or the mobilization margin
(R1m) was associated with increased recurrence versus R0 (R1t versus R0: hazard ratio
1.8, 95% confidence interval 1.0–3.0, P = .033; R1m versus R0: hazard ratio 1.3, 95% confidence interval 1.0–1.7, P = .060). In contrast, margin status was not associated with overall survival (10-year
overall survival, R1 71.1% vs R0 71.8%, P = .392). Intraoperatively, 539 (53.6%) patients had frozen section evaluation of the
surgical margin; 49 (9.1%) patients had a positive margin on frozen section analysis;
38 of the 49 patients (77.6%) had reresection, and a final R0 (secondary R0) margin
was achieved in 30 patients (78.9%). Extending resection to achieve an R0 status remained
associated with worse overall survival (hazard ratio 3.1, 95% confidence interval
1.6–6.2, P = .001) and recurrence-free survival (hazard ratio 2.6, 95% confidence interval 1.4–5.0,
P = .004) compared with primary R0 resection. On multivariable analyses, tumor-specific
factors, such as cellular differentiation, perineural invasion, Ki-67 index, and major
vascular invasion, rather than surgical margin, were associated with long-term outcomes.
Conclusion
Margin status was not associated with long-term survival. The reresection of an initially
positive surgical margin to achieve a negative margin did not improve the outcome
of patients with pancreatic neuroendocrine tumors. Parenchymal-sparing pancreatic
procedures for pancreatic neuroendocrine tumors may be appropriate when feasible.
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Article info
Publication history
Published online: September 29, 2018
Accepted:
August 8,
2018
Received in revised form:
August 1,
2018
Received:
April 24,
2018
Footnotes
Xu-Feng Zhang was supported by the Clinical Research Award of the First Affiliated Hospital of Xi'an Jiaotong University of China (No. XJTU1AF-CRF-2017-004).
Identification
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© 2018 Elsevier Inc. All rights reserved.
