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Impact of intraoperative margin clearance on survival following pancreatoduodenectomy for pancreatic cancer: a systematic review and meta-analysis.

ABSTRACT: The use of intraoperative margin revision to achieve margin clearance in patients undergoing pancreatoduodenectomy for pancreatic cancer is controversial. We performed a systematic review and meta-analysis to summarize the evidence of intraoperative margin revisions of the pancreatic neck and its impact on overall survival (OS). Nine studies with 4501 patients were included. Patient cohort was stratified in an R0R0-group (negative margin on frozen and permanent section), R1R0-group (revised positive margin on frozen section which turned negative on permanent section), and R1R1-group (positive margin on frozen and permanent section despite margin revision). OS was higher in the R1R0-group (HR 0.83, 95% CI 0.72-0.96, P?=?0.01) compared to the R1R1-group but lower compared to the R0R0-group (HR 1.20; 95% CI 1.05-1.37, P?=?0.008), respectively. Subgroup analyses on the use of different margin clearance definitions confirmed an OS benefit in the R1R0-group compared to the R1R1-group (HR 0.81; 95% CI 0.65-0.99, P?=?0.04). In conclusion, intraoperative margin clearance of the pancreatic neck margin is associated with improved OS while residual tumor indicates aggressive tumor biology. Consensus definitions on margin terminologies, clearance, and surgical techniques are required.

SUBMITTER: Birgin E

PROVIDER: S-EPMC7746710 | biostudies-literature | 2020 Dec

REPOSITORIES: biostudies-literature

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Impact of intraoperative margin clearance on survival following pancreatoduodenectomy for pancreatic cancer: a systematic review and meta-analysis.

Birgin Emrullah E Rasbach Erik E Téoule Patrick P Rückert Felix F Reissfelder Christoph C Rahbari Nuh N NN

Scientific reports 20201217 1

The use of intraoperative margin revision to achieve margin clearance in patients undergoing pancreatoduodenectomy for pancreatic cancer is controversial. We performed a systematic review and meta-analysis to summarize the evidence of intraoperative margin revisions of the pancreatic neck and its impact on overall survival (OS). Nine studies with 4501 patients were included. Patient cohort was stratified in an R0R0-group (negative margin on frozen and permanent section), R1R0-group (revised posi ...[more]

PMID: 33335201

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Project description:BackgroundIt is inconclusive whether R1 margin determined by postoperative pathological examination indicates worse long-term survival in gastric cancer (GC) patients after curative intent resection (CIR). Hence, we aimed to systematically pool the conflicting evidence to fill this gap.MethodsThe present study was performed according to the published protocol and Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Published studies examining the impact of microscopic margin status on overall survival (OS) and 5-year OS rate in GC were systematically searched in PubMed, Embase, and Cochrane Library databases. RevMan 5.3 was used to conduct statistical analysis, and the Grading of Recommendations, Assessment, Development, and Evaluations approach was used to assess the certainty of evidence for each outcome.ResultsTwenty-three retrospective cohort studies including 19 992 patients were analyzed. The pooled hazard ratio for OS of 14 studies was 2.06 (95% confidence interval [CI]: 1.61-2.65, low certainty), indicating that R1 margin predicted inferior OS. Subgroup and sensitivity analyses upheld the statistical stability of this finding. The pooled odds ratio (OR) of 14 studies was .21 (95% CI: .17-.26, moderate certainty), demonstrating that the presence of R1 margins was associated with a poorer 5-year OS rate. Sensitivity analyses and most of the subgroup analyses confirmed this finding, except the "esophagogastric junction (EGJ) cancers" subgroup, which included two studies with a pooled OR of .41 (95% CI: .10-1.61).ConclusionR1 margin detected by pathological examination might exhibit a high correlation with poorer OS and 5-year OS rate in GC (except EGJ cancers) patients who underwent CIR. To figure out the effect of R1 margin on survival of different stages and histological types need prospective studies with large sample sizes and standardized methods. What is the best treatment for R1 margin patients also need more in-depth and special research.

Project description:IntroductionGenerally, complete resection with cancer cell negative (R0) margin has been accepted as the most effective treatment of gastric cancer and positive resection (R1/R2) margin has been associated with decreased survival to varied degrees. However, the independent impact of microscopical positive (R1) margin on long-term survival may be confounded. No meta-analysis has worked at the association between R1 margin and outcomes of gastric cancer and the available evidence are scant. Therefore, we plan to conduct a systematic review and meta-analysis to quantitatively explore the role of R1 margin on gastric (including oesophagogastric junction) cancer survival after curative intent resection.Methods and analysisThe protocol was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guideline. A systematic search of PubMed, Embase and the Cochrane Central Register of Controlled Trials databases will be performed from their inceptions to 30 April 2020 to identify randomised controlled trials (RCTs), cohort studies and case-control studies focusing on the impact of R1 margin on survival of gastric cancer after curative intent resection. The primary outcome will be the overall survival (OS) and disease-free survival (DFS) and the secondary outcomes will be 5-year OS rate and 5-year DFS rate. The Cochrane tool for bias assessment in randomised trials and Risk Of Bias In Non-randomised Studies-I for the assessment of bias in non-randomised studies (NRS) will be used. Statistical heterogeneity will be assessed by visual inspection of forest plots and measured using the I2 statistics. A fixed-effect model will be used when heterogeneity is low, otherwise, a random-effect model will be chosen. Publication bias will be assessed by funnel plots, subgroup analysis and sensitivity analysis will be performed in the right context. For each outcome, we will perform data synthesis separately for RCTs and NRS using Rev Man V.5.3 software and compile 'summary of findings' tables separately for RCTs and NRS using GRADEpro software. Grading of Recommendations, Assessment, Development and Evaluations considerations will also be used to make an overall assessment of the quality of evidence.Ethics and disseminationThere is no requirement for ethics approval because no patient data will be collected at an individual level in this systematic review and meta-analysis.The results of this systematic review will be published in a peer-reviewed journal and presented at relevant conferences, any deviations from the protocol will be clearly documented and explained in its final report.Prospero registration numberCRD42020165110.

Dataset Information

Impact of intraoperative margin clearance on survival following pancreatoduodenectomy for pancreatic cancer: a systematic review and meta-analysis.

Publications

Impact of intraoperative margin clearance on survival following pancreatoduodenectomy for pancreatic cancer: a systematic review and meta-analysis.

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