Influence of standardized histopathological workup on reporting of the resection margin status in pancreatic head cancer

Background Resection margin (RM) status in pancreatic head adenocarcinoma is assessed histologically, but pathological examination is not standardized. Our aim was to determine the influence of the 'standardized histopathological workup' of pancreaticoduodenectomy specimens on the reporting of the RM status using a 'surgical quality protocol'. Patients and methods Starting October 2009, 42 patients underwent pancreaticoduodenectomy using the 'surgical quality protocol' for pancreatic ductal adenocarcinoma and were examined using 'standardized histopathological workup'. We prospectively evaluated and validated its results for 50 months. We evaluated different sites of R1 at 0 and 1 mm resections according to the color code and determined the most frequent site of incomplete tumor resection. Results Patients included 14 women and 28 men. Their age ranged from 46 to 74 years, with a median of 60 years. Changing to 'standardized histopathological workup' from traditional pathological examination procedures resulted in an increase in the R1 rate from 14.3 to 64.3% in this prospective series. Fifteen percent of R1 resections showed multifocal margin involvement (i.e. more than one margin involved in a single specimen) for the 0 mm in contrast to 33% for the 1.0 mm margin. The uncinate margin represents the most frequent site with residual tumor mass by far (42% at 0 mm and 43% at 1 mm), followed by the posterior margin. When R1 resection was defined by a positive margin of 0 mm, 48% of the present patients achieved R1 resection. In contrast to when R1 resection was defined by the presence of tumor cells within 1.0 mm, 64% of the present patients achieved R1 resection. Conclusion Standardization of the histopathological examination of pancreaticoduodenectomy specimens influences the reporting of RM status. The RM involvement is significantly more frequent than commonly reported. Complete and meticulous surgical resection of the uncinate process en bloc with all the peripancreatic tissues between the artery and the pancreatic parenchyma must become the standard surgical approach in pancreatic head resection as it is the most frequent site for residual tumor by far.