A Critical Appraisal of Circumferential Resection Margins in Esophageal Carcinoma

Abstract

BackgroundIn esophageal cancer, circumferential resection margins (CRMs) are considered to be of relevant prognostic value, but a reliable definition of tumor-free CRM is still unclear. The aim of this study was to appraise the clinical prognostic value of microscopic CRM involvement and to determine the optimal limit of CRM.MethodsTo define the optimal tumor-free CRM we included 98 consecutive patients who underwent extended esophagectomy with microscopic tumor-free resection margins (R0) between 1997 and 2006. CRMs were measured in tenths of millimeters with inked lateral margins. Outcome of patients with CRM involvement was compared with a statistically comparable control group of 21 patients with microscopic positive resection margins (R1).ResultsA cutoff point of CRM at ≤1.0 mm and >1.0 mm appeared to be an adequate marker for survival and prognosis (both P < 0.001). The outcome in patients with CRMs ≤1.0 and >0 mm was equal to that in patients with CRM of 0 mm (P = 0.43). CRM involvement was an independent prognostic factor for both recurrent disease (P = 0.001) and survival (P < 0.001). Survival of patients with positive CRMs (≤1 mm) did not significantly differ from patients with an R1 resection (P = 0.12).ConclusionInvolvement of the circumferential resection margins is an independent prognostic factor for recurrent disease and survival in esophageal cancer. The optimal limit for a positive CRM is ≤1 mm and for a free CRM is >1.0 mm. Patients with unfavorable CRM should be approached as patients with R1 resection with corresponding outcome.

Prognostic role of initial pan-endoscopic tumor length at diagnosis in operable esophageal squamous cell carcinoma undergoing esophagectomy with or without neoadjuvant concurrent chemoradiotherapy

“…Consistent with the reported literature, CRM invasion did contribute to shorter survival in ESCC patients, either in surgery group or in nCCRT-surgery group (Tables 3,4) (18,30,31). When divided into sub-groups I, II and III (≤3, 3-5, >5 cm), the CRM invasion rates in surgery group raised from 3.2% to 4.5% and then 31.3% progressively, however, they remained around 10% in nCCRT-surgery group (Table 5).…”

Does the Margin Matter in Esophageal Cancer

“…However, they were not able to detect any significant differences in regards to CRM involvement (p = 0.192) [32]. In another study by Pultrum et al [33], the type of surgery did not influence the extension of CRM involvement (p = 0.693) at all. …”

“…Few studies have investigated the direct impact on margin involvement. Two studies found higher positive CRMs after transhiatal resections while another failed to demonstrate any differences between surgical approaches [23,31,33]. A higher rate of CRM involvement might be due to failed en bloc resections, which are known to improve patients' prognosis [44].…”

Impact of incremental circumferential resection margin distance on overall survival and recurrence in oesophageal adenocarcinoma

“…The prognostic value of the oesophageal CRM has been demonstrated in many studies4 8, 10 11, 14, 15, 16 25, 26, 27, 28. A large multicentre study in 2016 9 demonstrated that the CAP definition of CRM positivity was independently predictive of poor survival, whereas a meta‐analysis29 suggested that, although the CAP definition identified the highest‐risk group, the RCP definition encompassed patients still at risk of poor survival.…”

“…The College of American Pathologists (CAP) defines a positive CRM as tumour at the cut margin (TAM), which has been advocated in some studies4, 5, 6, 7, 8, 9, whereas the Royal College of Pathologists (RCP) defines a positive CRM as tumour within 1 mm, preferred in other studies10, 11, 12, 13. Some studies have found the CRM to be independently prognostically significant4 7, 9 10, 13, 14, 15, 16, and others have not5 6, 11 12, 17, 18, 19. A positive margin may increase the likelihood of locoregional and systemic tumour recurrence9 20, although it is unclear whether the latter is simply a reflection of a larger, more advanced tumour.…”