应用两种定义标准判断胰头部导管腺癌切除标本R1切缘的临床研究

A clinical study about applying different R1 criteria to evaluate pancreatic head ductal adenocarcinoma specimens

目的 探讨用统一的方法处理标本后分别采用国际抗癌联盟和英国皇家病理学会两种R1切缘定义标准判断胰头癌切除标本R1切缘的发生情况.方法 前瞻性收集2010年11月至2013年10月在北京大学第三医院普通外科因胰头周围肿瘤行胰头十二指肠切除术患者的临床和病理资料,获得由病理证实为胰腺导管腺癌的患者70例.采用统一的方法对胰头十二指肠切除术标本进行取材,除胰颈断端、胆总管断端、胃体空肠断端外,用不同颜色标记胰头前表面、肠系膜上静脉沟切缘、肠系膜上动脉切缘与胰头后表面.每3个月通过门诊复查或电话对患者进行随访.结果 70例胰头部胰腺导管腺癌患者中,高、中、低分化分别为3、30、37例,pT1、pT2、pT3期患者分别有7、15、48例;40例（57.1％）有区域性淋巴结转移（pN1）,16例（22.9％）有腹主动脉旁淋巴结转移;13例（18.6％）同时行肠系膜上静脉或门静脉部分切除吻合术.采用UICC标准时,26例（26/70,37.1％）为R1切缘,总共33个切缘为R1切缘,肠系膜上静脉沟切缘和肠系膜上动脉切缘均占全部R1切缘的39.4％（13/33）.采用英国皇家病理学家学会标准时,39例（39/70,55.7％）为R1切缘,总共51个切缘为R1切缘,肠系膜上静脉沟切缘和肠系膜上动脉切缘分别占全部R1切缘的35.3％（18/51）和37.3％（19/51）.随访至2014年4月,中位随访时间为18个月（6～ 42个月）.结论 采用统一的方法处理胰头部胰腺导管腺癌切除标本时,环周切缘有较高的R1切缘发生率,并且R1切缘发生率与不同的R1切缘定义有关.肠系膜上血管切缘是R1发生率最主要的部位.

Objective To analyze the R1 rate of the pancreatic head carcinoma resection specimens which deh with a unified protocol by two different R1 criteria.Methods Between November 2011 and October 2013,a unified pathological protocol was prospectively used to handle 70 consecutive pancreatioduodenectomy specimens for pancreatic ductal adenocarcinoma.Apart from the pancreatic transection margin,the bile duct and stomach/jejunum margins,different colors were used to stain the anterior surface,the superior mesenteric vein （SMV） groove margin,the superior mesenteric artery （SMA） margin,and the posterior surface.Axial slicing technique was used to dissect the pancreatioduodenectomy specimens.Results Among the 70 patients,3,30 and 37 patients were classified as well,moderately and poorly differentiated respectively; 7,15 and 48 patients were classified as pT1,pT2 and pT3 respectively.Forty patients （57.1%） had metastases in regional lymph nodes （pN1）,and 16 patients （22.9%） had metastases in para-aortic nodes.Resection of the portal vein and/or the superior mesenteric vein was performed in 13 patients （18.6%）.When applying the UICC criteria,26 cancer resections were classified R1（37.1%）,33 margins were turned out to be R1.The SMV groove margin and SMA margin were infiltrated in 13 specimens（13/33,39.4%） respectively.When applying the Royal College of Pathologist＇s criteria,39 cancer resections were classified R1 （55.7%）,51 margins were turned out to be R1.The SMV groove margin and SMA margin were infiltrated in 18（18/51,35.3%） and 19（19/51,37.3%） specimen respectively.Until April 2014,the median follow-up was 18 （range 6-42） months.Conclusions Applying the unified protocol for pancreatic head ductal adenocarcinoma specimens results in an significant R1 rate of the resection margins,and the R1 rate is related to the R1 criterion.The SMV groove margin and SMA margin are the two most frequent sites of R1.