Reappraising the Role of Intraoperative Neck Margin Revision in Postneoadjuvant Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma: A Multi-institutional Analysis

Objective: To investigate whether revision of pancreatic neck margin based on intraoperative frozen section analysis has oncologic value in postneoadjuvant pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma. Background: The role of intraoperative neck margin revision has been controversial, with little information specific to postneoadjuvant PD. Methods: Patients who underwent postneoadjuvant PD (2013-2019) for conventional pancreatic ductal adenocarcinoma with frozen section analysis of neck margin at 3 academic institutions were included. Overall survival (OS) and recurrence-free survival were compared across 3 groups: complete resection achieved en bloc (CR-EB), complete resection achieved non-en bloc (CR-NEB), and incomplete resection (IR). Results: Among the 671 patients included, 524 (78.1%) underwent CR-EB, 119 (17.7%) CR-NEB and 28 (4.2%) IR. Patients undergoing CR-NEB and IR exhibited larger tumors and lower rates of "Response Evaluation Criteria in Solid Tumors" response, requiring vascular resections more often. Likewise, CR-NEB and IR were associated with a worse pathologic profile than CR-EB. The incidence of postoperative complications and access to adjuvant treatment were comparable among groups. A CR-EB was associated with the longest OS duration (34.3 months). In patients with positive neck margin, obtaining a CR-NEB through reexcision was associated with a comparable OS relative to patients with an IR (26.9 vs 27.1 months, P = 0.901). Similar results were observed for recurrence-free survival. At multivariable analysis, neck margin status was not independently associated with survival and recurrence. Conclusions: Conversion of an initially positive pancreatic neck margin by additional resection is not associated with oncologic benefits in postneoadjuvant PD and cannot be routinely recommended.