Xu-Feng Zhang1,2, Malcolm H Squires2, Fabio Bagante2, Cecilia G Ethun3, Ahmed Salem4, Sharon M Weber4, Thuy Tran5, George Poultsides5, Andre Y Son6, Ioannis Hatzaras6, Linda Jin7, Ryan C Fields7, Matthew Weiss8, Charles Scoggins9, Robert C G Martin9, Chelsea A Isom10, Kamron Idrees10, Harveshp D Mogal11, Perry Shen11, Shishir K Maithel3, Carl R Schmidt2, Timothy M Pawlik12,13,14. 1. Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China. 2. Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. 3. Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA. 4. Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. 5. Department of Surgery, Stanford University Medical Center, Stanford, CA, USA. 6. Department of Surgery, New York University, New York, NY, USA. 7. Department of Surgery, Washington University School of Medicine, St Louis, MO, USA. 8. Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA. 9. Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA. 10. Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA. 11. Department of Surgery, Wake Forest University, Winston-Salem, NC, USA. 12. Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. tim.pawlik@osumc.edu. 13. Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University, Wexner Medical Center, Columbus, OH, USA. tim.pawlik@osumc.edu. 14. Department of Oncology, Health Services Management and Policy, The Ohio State University, Wexner Medical Center, Columbus, OH, USA. tim.pawlik@osumc.edu.
Abstract
BACKGROUND: The impact of re-resection of a positive intraoperative bile duct margin on clinical outcomes for resectable hilar cholangiocarcinoma (HCCA) remains controversial. We sought to define the impact of re-resection of an initially positive frozen-section bile duct margin on outcomes of patients undergoing surgery for HCCA. METHODS: Patients who underwent curative-intent resection for HCCA between 2000 and 2014 were identified at 10 hepatobiliary centers. Short- and long-term outcomes were analyzed among patients stratified by margin status. RESULTS: Among 215 (83.7%) patients who underwent frozen-section evaluation of the bile duct, 80 (37.2%) patients had a positive (R1) ductal margin, 58 (72.5%) underwent re-resection, and 29 ultimately had a secondary negative margin (secondary R0). There was no difference in morbidity, 30-day mortality, and length of stay among patients who had primary R0, secondary R0, and R1 resection (all p > 0.10). Median and 5-year survival were 22.3 months and 23.3%, respectively, among patients who had a primary R0 resection compared with 18.5 months and 7.9%, respectively, for patients with an R1 resection (p = 0.08). In contrast, among patients who had a secondary R0 margin with re-resection of the bile duct margin, median and 5-year survival were 30.6 months and 44.3%, respectively, which was comparable to patients with a primary R0 margin (p = 0.804). On multivariable analysis, R1 margin resection was associated with decreased survival (R1: hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.0-1.7; p = 0.027), but secondary R0 resection was associated with comparable long-term outcomes as primary R0 resection (HR 0.9, 95% CI 0.4-2.3; p = 0.829). CONCLUSIONS: Additional resection of a positive frozen-section ductal margin to achieve R0 resection was associated with improved long-term outcomes following curative-intent resection of HCCA.
BACKGROUND: The impact of re-resection of a positive intraoperative bile duct margin on clinical outcomes for resectable hilar cholangiocarcinoma (HCCA) remains controversial. We sought to define the impact of re-resection of an initially positive frozen-section bile duct margin on outcomes of patients undergoing surgery for HCCA. METHODS:Patients who underwent curative-intent resection for HCCA between 2000 and 2014 were identified at 10 hepatobiliary centers. Short- and long-term outcomes were analyzed among patients stratified by margin status. RESULTS: Among 215 (83.7%) patients who underwent frozen-section evaluation of the bile duct, 80 (37.2%) patients had a positive (R1) ductal margin, 58 (72.5%) underwent re-resection, and 29 ultimately had a secondary negative margin (secondary R0). There was no difference in morbidity, 30-day mortality, and length of stay among patients who had primary R0, secondary R0, and R1 resection (all p > 0.10). Median and 5-year survival were 22.3 months and 23.3%, respectively, among patients who had a primary R0 resection compared with 18.5 months and 7.9%, respectively, for patients with an R1 resection (p = 0.08). In contrast, among patients who had a secondary R0 margin with re-resection of the bile duct margin, median and 5-year survival were 30.6 months and 44.3%, respectively, which was comparable to patients with a primary R0 margin (p = 0.804). On multivariable analysis, R1 margin resection was associated with decreased survival (R1: hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.0-1.7; p = 0.027), but secondary R0 resection was associated with comparable long-term outcomes as primary R0 resection (HR 0.9, 95% CI 0.4-2.3; p = 0.829). CONCLUSIONS: Additional resection of a positive frozen-section ductal margin to achieve R0 resection was associated with improved long-term outcomes following curative-intent resection of HCCA.
Authors: Tori Lenet; Richard W D Gilbert; Rory Smoot; Ching-Wei D Tzeng; Flavio G Rocha; Lavanya Yohanathan; Sean P Cleary; Guillaume Martel; Kimberly A Bertens Journal: Ann Surg Oncol Date: 2022-06-25 Impact factor: 4.339
Authors: T Peter Kingham; Victoria G Aveson; Alice C Wei; Jason A Castellanos; Peter J Allen; Daniel P Nussbaum; Yinin Hu; Michael I D'Angelica Journal: Curr Probl Surg Date: 2020-06-30 Impact factor: 1.909
Authors: Lynn E Nooijen; Rutger-Jan Swijnenburg; Heinz-Josef Klümpen; Joanne Verheij; Geert Kazemier; Thomas M van Gulik; Joris I Erdmann Journal: Visc Med Date: 2021-01-07