Frozen section analysis of the pancreatic margin during pancreaticoduodenectomy for cancer: Does extending the resection to obtain a secondary R0 provide a survival benefit? Results of a systematic review Niccolo' Petrucciani a, b, * , Giuseppe Nigri a , Tarek Debs b , Giulia Giannini a , Elena Sborlini a , Laura Antolino a , Paolo Aurello a , Francesco D'Angelo a , Jean Gugenheim b , Giovanni Ramacciato a a Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, UOC Chirurgia Generale 3, St Andrea Hospital, Rome, Italy b Division of Digestive Surgery and Liver Transplantation, Archet II Hospital, University of Nice-Sophia-Antipolis,151 Route de Saint-Antoine, 06200, Nice, France article info Article history: Received 28 March 2016 Received in revised form 6 September 2016 Accepted 8 September 2016 Available online xxx Keywords: Pancreatic carcinoma Pancreaticoduodenectomy Frozen section Pancreatic margin Survival abstract Background: During pancreaticoduodenectomy, frozen section pancreatic margin analysis permits to extend the resection in case of a positive margin, to achieve R0 margin. We aim to assess if patients having an R0 margin following the extension of the pancreatectomy after a positive frozen section (secondary R0) have different survival compared to those with R1 resection or primary R0 resection. Methods: A systematic search was performed to identify all studies published up to March 2016 analyzing the survival of patients undergoing pancreaticoduodenectomy according to the results of frozen section pancreatic margin examination. Clinical effectiveness was synthetized through a narrative review with full tabulation of results. Results: Four studies published between 2010 and 2014 were retrieved, including 2580 patients. A pri- mary R0 resection was obtained in a percentage of patients ranging from 36.2% to 85.5%, whereas sec- ondary R0 in 9.4%e57.8% of cases and R1 in 5.1%e9.2%. Median survival ranged from 19 to 29 months in R0 patients, from 11.9 to 18 months in secondary R0, and from 12 to 23 months in R1 patients. None of the study demonstrated a survival benefit of extending the resection to obtain a secondary R0 pancreatic margin. Conclusions: All the studies were concordant, and failed to demonstrate the survival benefit of additional pancreatic resection to obtain a secondary R0. However, inadequate surgery should not be advocated. This review suggests that re-resection of the pancreatic margin may have limited impact on patients' survival. © 2016 Published by Elsevier B.V. on behalf of IAP and EPC. Introduction Pancreatic cancer represents the fourth-leading cause of cancer- related death in the United States. In 2015, 48960 new cases have been reported in the US, with 40560 deaths [1]. In Europe, 103773 new cases were reported in 2012 [2]. Complete surgical resection represents the only potentially curative treatment for pancreatic adenocarcinoma: 5-year survival for patients undergoing complete surgical resection approaches 25% [3]. To achieve a complete sur- gical resection, several strategies were developed during the last decades. En-bloc pancreatic and portal and mesenteric vein re- sections are nowadays recommended in most cases of venous in- vasion [4e6]. Furthermore, the use of neoadjuvant therapies has emerged, with several potential theoretical benefits including the reduction of tumor volume and a subsequent possible increase in * Corresponding author. Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, St Andrea Hospital, via di Grottarossa 1035-1039, 00189, Rome, Italy E-mail address: nicpetrucciani@hotmail.it (N. Petrucciani). Contents lists available at ScienceDirect Pancreatology journal homepage: www.elsevier.com/locate/pan http://dx.doi.org/10.1016/j.pan.2016.09.004 1424-3903/© 2016 Published by Elsevier B.V. on behalf of IAP and EPC. Pancreatology xxx (2016) 1e7 Please cite this article in press as: Petrucciani N, et al., Frozen section analysis of the pancreatic margin during pancreaticoduodenectomy for cancer: Does extending the resection to obtain a secondary R0 provide a survival benefit? Results of a systematic review, Pancreatology (2016), http://dx.doi.org/10.1016/j.pan.2016.09.004