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

Abstract

Background: Cancer cells are often found postoperatively at surgical resection margins (RM) in patients with gastric cancer because of submucosal infiltration or hesitation to secure adequate RM. This study was designed to evaluate risk factors for microscopic positive RM and to clarify which patients should undergo intraoperative frozen section diagnosis (IFSD). Methods: Patients who underwent R0/1 gastrectomy for gastric adenocarcinoma between 2000 and 2018 in a single cancer center in Japan were studied. We divided the patients into a positive RM group and negative RM group according to the results of definitive histopathological examinations. We performed multivariate analysis to analyze risk factors for positive RM by and used the identified risk factors to risk stratify the patients. Results: A total of 2757 patients were studied, including 49 (1.8%) in the positive RM group. The risk factors significantly associated with positive RM were remnant gastric cancer (odds ratio [OR] 4.7), esophageal invasion (OR 6.3), tumor size ≥80 mm (OR 3.9), and a histopathological diagnosis of undifferentiated type (OR 3.6), macroscopic type 4 (OR 3.7), or pT4 disease (OR 4.6). On risk stratification analysis, the incidence of positive RM was 0.1% without any risk factors, increasing to 0.4% with one risk factor, 3.1% with two risk factors, 5.3% with three risk factors, 21.3% with four risk factors, and 85.7% with five risk factors. Conclusions: The risk of macroscopically positive RM increased in patients who have risk factors. IFSD should be performed in patients who have four or more risk factors.

Is proximal gastrectomy indicated for locally advanced cancer in the upper third of the stomach?

“… 6 Large tumors and pathologically advanced T stage are reportedly risk factors for a positive resection margin in gastric cancer surgery, similar to the characteristics of patients with pathological tumor invasion to the M region in this study. 25 , 26 , 27 However, this study suggested that more than half of the stomach might be preserved even with locally advanced gastric cancer, provided that the lesion is located within the cardia and/or the fornix.…”

Adequate gross resection margin length ensuring pathologically complete resection in gastrectomy for gastric cancer: A systematic review and meta‐analysis

“…Numerous authors have identified risk factors for positive RMs; these risk factors are mainly associated with more aggressive tumor biology, including a larger tumor size, higher tumor location, advanced TNM status, undifferentiated or diffuse histological type, higher Borrmann type, and lymphovascular invasion. 2,4,[6][7][8][32][33][34][35][36][37][38][39] Thus, IFS analysis should be routinely performed in patients who A proximal RM length of 6 cm to ensure a negative pathological RM in gastrectomy for GC obtained in the present systematic review may be a reliable result because four of the 13 studies and the meta-analyses of the secondary outcome produced this same finding. 20,24,25,30 However, 6 cm is relatively long when GC is located in the middle to upper third of the stomach.…”

“…Numerous authors have identified risk factors for positive RMs; these risk factors are mainly associated with more aggressive tumor biology, including a larger tumor size, higher tumor location, advanced TNM status, undifferentiated or diffuse histological type, higher Borrmann type, and lymphovascular invasion. 2 , 4 , 6 , 7 , 8 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 Thus, IFS analysis should be routinely performed in patients who have such risk factors to reduce the incidence of positive RMs and determine the ideal gastric or esophageal transection line. Although shorter RM lengths seem to increase the risk of positive RMs, specific RM lengths for avoiding positive RMs have not yet been sufficiently discussed.…”

Prevention and treatment of a positive proximal margin after gastrectomy for cardia cancer

“…They observed a positive resection margin in 21.3% of their patients when four risk factors were present and 85.7% when five factors were identified. This led to their recommendation to perform a frozen section analysis in patients with four or more risk factors [29].…”