Prediction of R Status in Resections for Pancreatic Cancer Using Simplified Radiological Criteria
Prediction of R Status in Resections for Pancreatic Cancer Using Simplified Radiological Criteria
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DOI：
10.1097/sla.0000000000005433
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发表时间：
2022-08-01
影响因子：
9
通讯作者：
Fernandez-del Castillo, Carlos
中科院分区：
文献类型：
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作者：
Bolm, Louisa;Pisuchpen, Nisanard;Fernandez-del Castillo, Carlos
目的：预测胰腺癌（PDAC）患者术前的R状态，进行前期手术和新辅助治疗。背景资料总结：手术切缘阴性（R 0）是PDAC长期预后的关键预测因子。方法：确定接受胰腺切除术的PDAC患者。使用诊断时的CT扫描，将2019年NCCN边界可切除性标准与新标准进行了比较：存在上级肠系膜-门静脉（SMPV）的任何改变和上级肠系膜动脉（SMA）的血管周围搁浅。两个标准的预测R状态的准确性进行了评价。对患者的基线特征、手术、组织病理学参数和切除术后的长期总生存率（OS）进行了评价。结果：2010年至2018年期间，共确定了593例因PDAC接受胰腺切除术的患者。325例（54.8%）患者接受了前期手术，而268例（45.2%）患者接受了新辅助治疗。在前期切除的患者中，SMA绞合阳性与56%的切缘阳性切除率相关，而SMA绞合阳性和SMPV改变共同显示切缘阳性切除率为75%。与这些标准相比，2019年NCCN边界标准未能预测保证金状态。在接受新辅助治疗的患者中，只有血管周围SMA绞窄仍然是切缘阳性切除的预测因素，导致33%的R+切除率。血管周围SMA绞合与较高的临床T分期（P = 0.003）和临床N分期（P = 0.043）以及神经周围浸润（P = 0.022）相关。SMA搁浅与接受前期手术（36 vs 22个月，P = 0.002）和新辅助治疗（47 vs 34个月，P = 0.050）的患者的生存率较差相关。结论：新标准是接受前期切除术的PDAC患者R状态的准确预测因子。新辅助治疗后，切缘阳性的可能性大约减半，只有血管周围SMA绞窄仍然是一个预测因素。
Objective: Predicting R status before surgery for pancreatic cancer (PDAC) patients with upfront surgery and neoadjuvant therapy. Summary Background Data: Negative surgical margins (R0) are a key predictor of long-term outcomes in PDAC. Methods: Patients undergoing pancreatic resection with curative intent for PDAC were identified. Using the CT scans from the time of diagnosis, the 2019 NCCN borderline resectability criteria were compared to novel criteria: presence of any alteration of the superior mesenteric-portal vein (SMPV) and perivascular stranding of the superior mesenteric artery (SMA). Accuracy of predicting R status was evaluated for both criteria. Patient baseline characteristics, surgical, histopathological parameters, and long-term overall survival (OS) after resection were evaluated. Results: A total of 593 patients undergoing pancreatic resections for PDAC between 2010 and 2018 were identified. Three hundred and twenty-five (54.8%) patients underwent upfront surgery, whereas 268 (45.2%) received neoadjuvant therapy. In upfront resected patients, positive SMA stranding was associated with 56% margin positive resection rates, whereas positive SMA stranding and SMPV alterations together showed a margin positive resection rate of 75%. In contrast to these criteria, the 2019 NCCN borderline criteria failed to predict margin status. In patients undergoing neoadjuvant therapy, only perivascular SMA stranding remained a predictor of margin positive resection, leading to a rate of 33% R+ resections. Perivascular SMA stranding was related to higher clinical T stage (P = 0.003) and clinical N stage (P = 0.043) as well as perineural invasion (P = 0.022). SMA stranding was associated with worse survival in both patients undergoing upfront surgery (36 vs 22 months, P = 0.002) and neoadjuvant therapy (47 vs 34 months, P = 0.050). Conclusions: The novel criteria were accurate predictors of R status in PDAC patients undergoing upfront resection. After neoadjuvant treatment, likelihood of positive resection margins is approximately halved, and only perivascular SMA stranding remained a predictive factor.