Risk factor analysis for involvement of resection margins in gastric and esophagogastric junction cancer: an Italian multicenter study

Abstract

Background Resection margin (RM) involvement is associated with negative prognosis after gastrectomy. Intraoperative frozen section (IFS) analysis allows radical resection to be achieved in a single operation but is timeconsuming and resource-consuming. The aim of this study was to assess risk factors associated with RM involvement to identify patients who would benefit from IFS analysis. Methods We retrospectively analyzed patients who underwent gastrectomy with curative intent for gastric or esophagogastric junction (EGJ) cancer from 2000 to 2014 in six Italian hospitals. RM status was assessed by IFS analysis and/or definitive histopathology examination. A set of 21 potential risk factors were compared in a multivariate analysis between patients with positive RMs on IFS analysis or definitive histopathology examination and a control cohort of similar patients with negative RMs, with the samples stratified into three subgroups (T1, T2-T4 Lauren intestinal pattern, T2-T4 Lauren diffuse/mixed pattern). Results One hundred forty-five patients had positive RMs. Survival was significantly worse in positive RM patients than in negative RM patients (89.5 months vs 28.9 months). Multivariate analysis showed that in T1 cancers a margin distance of less than 2 cm is a risk factor for RM involvement (odds ratio 15.7), in T2-T4 intestinal pattern cancers, serosa invasion (odds ratio 6.0), EGJ location (odds ratio 4.1), and a margin distance of less than 3 cm (odds ratio 4.0) are independent risk factors, and in T2-T4 diffuse/mixed pattern cancers, lymphatic infiltration (odds ratio 4.2), tumor diameter greater than 4 cm (odds ratio 3.5), EGJ location (odds ratio 2.8), and serosa invasion (odds ratio 2.2) are independent risk factors. Conclusions Survival after gastrectomy is negatively affected by positive RMs. IFS analysis should be routinely used in patients with a high risk of positive RMs, especially in diffuse pattern cancers.

S3-Leitlinie Magenkarzinom – Diagnostik und Therapie der Adenokarzinome des Magens und des ösophagogastralen Übergangs – Langversion 2.0 – August 2019. AWMF-Registernummer: 032/009OL

“…Die operative Strategie sollte generell so gewählt werden, dass zu Operationsbeginn die kritischen Resektionsränder geklärt werden, um das definitive Operationsverfahren festzulegen. Positive Schnittränder oral und aboral sollten intraoperativ durch einen Schnellschnitt möglichst vermieden werden [512,513]. Bei einem positiven intraoperativen Schnellschnitt sollte möglichst nachreseziert oder das OP-Verfahren gewechselt werden, wobei das Risiko der Eingriffserweiterung mit dem onkologischen Vorteil abgewogen werden sollte [475,512,514].…”

“…Die R1-Situation ist oft Ausdruck eines weit fortgeschrittenen Tumorstadiums und einer ungünstigen Tumorbiologie [510,513,514]. Meist erleiden Patienten mit R1-Situation einen systemischen Progress mit Fernmetastasen und kein Lokalrezidiv [510,512] Die Experten würdigen mit der Empfehlung für die perioperative Chemotherapie bzw.…”

Distant nodal metastasis: is it always an unresectable disease?

“…We are observing an interesting phenomenon from a historical point of view; while 30 years ago the Japanese surgeons sustained an aggressive surgical approach to gastric cancer, which was subsequently accepted in the rest of the world, Western surgeons are actually more aggressive in this dissection nowadays than their Eastern counterpart. Other recently published papers, investigating Krukenberg tumors, margin infiltration and surgery in old patients, included as subgroup analysis number of patients with distant positive nodes, whose survival was not statistically different (when lymphadenectomy was done) from patients without nodal metastases in those basins (16)(17)(18).…”

Risk factors analysis and stratification for microscopically positive resection margin in gastric cancer patients

“…The demographic and clinicopathological characteristics of the patients are shown in Table 1 Previous studies have similarly reported that advanced T category, advanced N category, total gastrectomy, larger tumor, EGJ location, diffuse histology, and linitis plastica, which is also referred to as macroscopic type 4, [3,17,18] are risk factors for positive RM. On the basis of these studies, we chose candidate risk factors for preoperatively predicting clinicopathological features.…”

“…However, the estimated risk would change depending on the actual secured margin distance. A multicenter Italian study reported that a RM distance of less than 2 cm was a risk factor for T1 tumors, and a RM distance of less than 3 cm was a risk factor for T2 to T4 Lauren intestinal pattern tumors [18]. The required margin distance should be evaluated in patients who have high-risk factors for positive RM in future studies.…”