1
|
Mayer M, Wolber P, Prinz J, Jansen L, Esser J, Shabli S, Quaas A, Klußmann JP, Sharma SJ, Nachtsheim L, Arolt C. The extent of androgen receptor and HER2 expression allows for targeted therapy in most cases of salivary duct carcinoma: analysis of clinical and histopathological data in a tertiary care center. Eur Arch Otorhinolaryngol 2024; 281:3779-3789. [PMID: 38587651 PMCID: PMC11211117 DOI: 10.1007/s00405-024-08627-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/18/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE The incidence of salivary duct carcinoma (SDC) seems to be underestimated due to inaccurate classification. Further, the frequency of SDC patients with targeted therapy options according to current guidelines is unclear. Therefore, this study aimed at (a) describing the proportion of SDC among salivary gland carcinoma (SGC) before and after reclassification of cases initially classified as adenocarcinoma, not otherwise specified (ANOS); and (b) quantifying the frequency of SDC patients with targeted therapy options. METHODS All patients with SDC or ANOS treated in a tertiary care center between 1996 and 2023 were identified. Histopathological diagnosis was verified for patients primarily diagnosed with SDC and reviewed for patients initially diagnosed with ANOS. Clinical data for SDC patients were retrieved from clinical charts. Immunohistochemical (IHC) androgen receptor (AR) and HER2 staining was performed. RESULTS Among 46 SDC, 34 were primarily diagnosed as SDC and 12 had initially been classified as ANOS. The proportion of SDC among SGC was 12.1% and was rising when comparing the time periods 2000-2015 (7.1-11.5%) versus 2016-2023 (15.4-18.1%). Nuclear AR staining in > 70% of tumor cells was found in 56.8% and HER2 positivity (IHC 3 +) in 36.4% of cases. 70.5% of patients showed AR staining in > 70% of tumor cells and/or HER2 positivity and therefore at least one molecular target. 5-year overall and disease-free survival (DFS) were 62.8% and 41.0%. Multivariate Cox regression revealed positive resection margins (HR = 4.0, p = 0.03) as independent negative predictor for DFS. CONCLUSIONS The results suggest a rising SDC incidence and show that the extent of the AR and HER2 expression allows for targeted therapy in most SDC cases.
Collapse
Affiliation(s)
- Marcel Mayer
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany.
- Center for Molecular Medicine Cologne (CMMC), Medical Faculty, University of Cologne, Cologne, Germany.
| | - Philipp Wolber
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Medical Faculty, University of Cologne, Cologne, Germany
| | - Johanna Prinz
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany
| | - Louis Jansen
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Medical Faculty, University of Cologne, Cologne, Germany
| | - Julia Esser
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Medical Faculty, University of Cologne, Cologne, Germany
| | - Sami Shabli
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Medical Faculty, University of Cologne, Cologne, Germany
| | - Alexander Quaas
- Institute of Pathology, Medical Faculty, University of Cologne, Cologne, Germany
| | - Jens Peter Klußmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Medical Faculty, University of Cologne, Cologne, Germany
| | - Shachi Jenny Sharma
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Medical Faculty, University of Cologne, Cologne, Germany
| | - Lisa Nachtsheim
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Medical Faculty, University of Cologne, Cologne, Germany
| | - Christoph Arolt
- Institute of Pathology, Medical Faculty, University of Cologne, Cologne, Germany
| |
Collapse
|
2
|
Pang T, Nie M, Yin K. The correlation between the margin of resection and prognosis in esophagogastric junction adenocarcinoma. World J Surg Oncol 2023; 21:316. [PMID: 37814242 PMCID: PMC10561513 DOI: 10.1186/s12957-023-03202-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/30/2023] [Indexed: 10/11/2023] Open
Abstract
Adenocarcinoma of the gastroesophageal junction (AEG) has become increasingly common in Western and Asian populations. Surgical resection is the mainstay of treatment for AEG; however, determining the distance from the upper edge of the tumor to the esophageal margin (PM) is essential for accurate prognosis. Despite the relevance of these studies, most have been retrospective and vary widely in their conclusions. The PM is now widely accepted to have an impact on patient outcomes but can be masked by TNM at later stages. Extended PM is associated with improved outcomes, but the optimal PM is uncertain. Academics continue to debate the surgical route, extent of lymphadenectomy, preoperative tumor size assessment, intraoperative cryosection, neoadjuvant therapy, and other aspects to further ensure a negative margin in patients with gastroesophageal adenocarcinoma. This review summarizes and evaluates the findings from these studies and suggests that the choice of approach for patients with adenocarcinoma of the esophagogastric junction should take into account the extent of esophagectomy and lymphadenectomy. Although several guidelines and reviews recommend the routine use of intraoperative cryosections to evaluate surgical margins, its generalizability is limited. Furthermore, neoadjuvant chemotherapy and radiotherapy are more likely to increase the R0 resection rate. In particular, intraoperative cryosections and neoadjuvant chemoradiotherapy were found to be more effective for achieving negative resection margins in signet ring cell carcinoma.
Collapse
Affiliation(s)
- Tao Pang
- Department of Gastrointestinal Tract Surgery, First Affiliated Hospital of Naval Military Medical University, Shanghai, China
| | - Mingming Nie
- Department of Gastrointestinal Tract Surgery, First Affiliated Hospital of Naval Military Medical University, Shanghai, China
| | - Kai Yin
- Department of Gastrointestinal Tract Surgery, First Affiliated Hospital of Naval Military Medical University, Shanghai, China.
| |
Collapse
|
3
|
Kim TH, Kim IH, Kang SJ, Choi M, Kim BH, Eom BW, Kim BJ, Min BH, Choi CI, Shin CM, Tae CH, Gong CS, Kim DJ, Cho AEH, Gong EJ, Song GJ, Im HS, Ahn HS, Lim H, Kim HD, Kim JJ, Yu JI, Lee JW, Park JY, Kim JH, Song KD, Jung M, Jung MR, Son SY, Park SH, Kim SJ, Lee SH, Kim TY, Bae WK, Koom WS, Jee Y, Kim YM, Kwak Y, Park YS, Han HS, Nam SY, Kong SH. Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach. J Gastric Cancer 2023; 23:3-106. [PMID: 36750993 PMCID: PMC9911619 DOI: 10.5230/jgc.2023.23.e11] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 01/22/2023] [Accepted: 01/25/2023] [Indexed: 02/09/2023] Open
Abstract
Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.
Collapse
Affiliation(s)
- Tae-Han Kim
- Department of Surgery, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - In-Ho Kim
- Division of Medical Oncology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center Seoul, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency (NECA), Seoul, Korea
| | - Baek-Hui Kim
- Department of Pathology, Korea University Guro Hospital, Seoul, Korea
| | - Bang Wool Eom
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Bum Jun Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
| | - Byung-Hoon Min
- Department of Medicine, Samsung Medical Center, Seoul, Korea
| | - Chang In Choi
- Department of Surgery, Pusan National University Hospital, Pusan, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seungnam, Korea
| | - Chung Hyun Tae
- Department of Internal Medicine, Ewha Woman’s University College of Medicine, Seoul, Korea
| | - Chung sik Gong
- Division of Gastrointestinal Surgery, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Jin Kim
- Department of Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | | | - Eun Jeong Gong
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Geum Jong Song
- Department of Surgery, Soonchunhyang University, Cheonan, Korea
| | - Hyeon-Su Im
- Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Hye Seong Ahn
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Hyun Lim
- Department of Gastroenterology, Hallym University Sacred Heart Hospital, University of Hallym College of Medicine, Anyang, Korea
| | - Hyung-Don Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Joon Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Jeong Won Lee
- Department of Nuclear Medicine, Catholic Kwandong University, College of Medicine, Incheon, Korea
| | - Ji Yeon Park
- Department of Surgery, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jwa Hoon Kim
- Division of Oncology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Kyoung Doo Song
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea
| | - Minkyu Jung
- Division of Medical Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Mi Ran Jung
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Sang-Yong Son
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Shin-Hoo Park
- Department of Surgery, Korea University Anam Hospital, Seoul, Korea
| | - Soo Jin Kim
- Department of Radiology, National Cancer Center, Goyang, Korea
| | - Sung Hak Lee
- Department of Hospital Pathology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae-Yong Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Woo Kyun Bae
- Division of Hematology-Oncology, Department of Internal Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Yeseob Jee
- Department of Surgery, Dankook University Hospital, Cheonan, Korea
| | - Yoo Min Kim
- Department of Surgery, Severance Hospital, Seoul, Korea
| | - Yoonjin Kwak
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
| | - Young Suk Park
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hye Sook Han
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea.
| | - Su Youn Nam
- Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital and Seoul National University College of Medicine Cancer Research Institute, Seoul, Korea.
| | | |
Collapse
|
4
|
Watanabe A, Adamson H, Lim H, McFadden AF, McConnell YJ, Hamilton TD. Intraoperative frozen section analysis of margin status as a quality indicator in gastric cancer surgery. J Surg Oncol 2023; 127:66-72. [PMID: 36177786 DOI: 10.1002/jso.27107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/12/2022] [Accepted: 09/15/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Positive pathologic margins following gastric cancer (GC) resection carries a poor prognosis. We evaluated intraoperative frozen section (IFS) analysis of resection margins (RMs) as a quality indicator in GC surgery. METHODS Patients referred to a provincial cancer agency with surgically resected non-metastatic GC between 2004 and 2012 were included. Associations between IFS analysis, other baseline characteristics, RMs, and overall survival (OS) were assessed using logistic regression, Kaplan-Meier analyses, and Cox proportional hazards modeling. RESULTS Among 377 patients, median age was 67 years, 68% were male, and 16% had +RMs. Thirty-four percent of patients underwent IFS analysis, which protected against +RMs (odds ratio [OR]: 0.34, 95% confidence interval [CI]: 0.16-0.73, p = 0.006) and improved OS (hazards ratio [HR]: 0.72, 95% CI: 0.54-0.98, p = 0.037). OS following re-resection of IFS positive patients was similar to IFS negative patients (69 vs. 54 months, p = 0.317). Stage III disease (OR: 12.8, 95% CI: 3.00-55.0, p = 0.001) and gastroesophageal junction tumors (OR: 2.25, 95% CI: 1.05-4.78, p = 0.036) predicted +RMs. Stage III disease led to worse OS (HR: 2.89, 95% CI: 1.92-4.34, p < 0.001) while intestinal histology improved OS (HR: 0.67, 95% CI: 0.50-0.90, p = 0.007). CONCLUSIONS IFS analysis reduce +RMs and improve OS and should be incorporated in curative intent GC surgery for patients with locally advanced GC.
Collapse
Affiliation(s)
- Akie Watanabe
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hannah Adamson
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Howard Lim
- BC Cancer Agency, Vancouver, British Columbia, Canada
| | - Andrew F McFadden
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Trevor D Hamilton
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
5
|
Zhang X, Zhao L, Niu P, Wang T, Wang W, Sun C, Li Z, Chen Y, Zhao D. Adjuvant Chemotherapy Might Be Recommended to Patients With Positive Margin After Gastrectomy: A 20-Year Retrospective Analysis in a Single Center. Front Oncol 2022; 11:794032. [PMID: 35186712 PMCID: PMC8847385 DOI: 10.3389/fonc.2021.794032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/30/2021] [Indexed: 12/12/2022] Open
Abstract
Background Margin positivity after gastric cancer resection is associated with poorer outcomes. However, the prognostic factors and the choice of postoperative adjuvant treatment of patients with positive margin (PM) after gastrectomy are still being debated. Methods A single-center, retrospective analysis was conducted for patients with PM after gastrectomy from the China National Cancer Center Gastric Cancer Database (NCCGCDB) from 1998 to 2018. Univariate and multivariate Cox regression analyses were performed to identify prognostic factors of overall survival (OS) and recurrence-free survival (RFS). Results A total of 449 patients were included in the study, including 192 (42.8%) in the proximal PM group (PPM), 205 (45.7%) in the distal PM group (DPM), and 52 (11.6%) in the bilateral PM group (BPM). The 3- and 5-year OS rates for the PM patients investigated were 47.5% and 39.3%, respectively, and the 3- and 5-year RFS rates were 60.0% and 53.6%, respectively. Multivariate Cox regression analysis proved total gastrectomy (hazard ratio (HR): 1.783, 95%CI: 1.133–2.805, p = 0.012), pT4 (HR: 5.264, 95%CI: 1.493–18.565, p = 0.01), pN2 (HR: 2.263, 95%CI: 1.164–4.397, p = 0.016), pN3 (HR: 2.327, 95%CI: 1.233–4.393, p = 0.009), and combined resection (HR: 1.952, 95%CI: 1.256–3.034, p = 0.003) to be independent risk factors of OS, and pT3 (HR: 9.257, 95%CI: 1.152–74.386, p = 0.036) and pT4 (HR: 11.361, 95%CI: 1.469–87.847, p = 0.020) to be independent risk factors for RFS. Adjuvant chemotherapy prolonged OS in the PPM group (p = 0.032) and prolonged RFS in the PPM group (p < 0.001) and the DPM group (p = 0.035) compared with surgery alone. Conclusions Advanced pathologic stage was associated with poor prognosis, and postoperative adjuvant chemotherapy might be recommended in PM patients after gastrectomy. Still, further prospective trials are warranted to verify and support our conclusions.
Collapse
Affiliation(s)
- Xiaojie Zhang
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lulu Zhao
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Penghui Niu
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tongbo Wang
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wanqing Wang
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chongyuan Sun
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zefeng Li
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yingtai Chen
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dongbing Zhao
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
6
|
Simões IBP, Pereira MA, Ramos MFKP, Ribeiro Junior U, Zilberstein B, Nahas SC, Dias AR. SALVAGE SURGERY IN GASTRIC CANCER. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2022; 34:e1629. [PMID: 35107491 PMCID: PMC8846409 DOI: 10.1590/0102-672020210002e1629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/29/2021] [Indexed: 02/08/2023]
Abstract
AIM Salvage surgery (SS) is defined as surgical resection after the failure of the first treatment with curative intent. The aim of this study was to report the experience of a reference center with SS for stomach adenocarcinoma. METHODS This is a retrospective study of patients with gastric cancer (GC) operated on between 2009 and 2020. RESULTS Notably, 40 patients were recommended for salvage gastrectomy with curative-intent treatment. For analysis purpose, patients were divided into two groups: 23 patients after endoscopic resection and 17 patients after gastrectomy. In the first group, all patients underwent R0 resection, their average hospital length of stay (LOS) was 15.7 days, and 2 (8.6%) patients had major complications. During the average follow-up of 37.2 months, there was only one recurrence. The median overall survival (OS) was 46 months. In the postgastrectomy group, 9 (52.9%) patients were rescued with curative intent, the average hospital LOS was 12.2 days, and 3 (17.6%) had major complications. In a mean follow-up of 22 months, five patients relapsed. Median OS and disease-free survival were 24 and 16.5 months, respectively. CONCLUSION SS in GC offers the possibility of long-term disease control and increased survival rate with an acceptable complication rate.
Collapse
Affiliation(s)
- Italo Beltrão Pereira Simões
- Trabalho realizado no Instituto do Câncer, Hospital de Clínicas - HCFMUSP, Universidade de São Paulo, Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo - USP - SP - São Paulo - Brasil
| | - Marina Alessandra Pereira
- Trabalho realizado no Instituto do Câncer, Hospital de Clínicas - HCFMUSP, Universidade de São Paulo, Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo - USP - SP - São Paulo - Brasil
| | - Marcus Fernando Kodama Pertille Ramos
- Trabalho realizado no Instituto do Câncer, Hospital de Clínicas - HCFMUSP, Universidade de São Paulo, Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo - USP - SP - São Paulo - Brasil
| | - Ulysses Ribeiro Junior
- Trabalho realizado no Instituto do Câncer, Hospital de Clínicas - HCFMUSP, Universidade de São Paulo, Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo - USP - SP - São Paulo - Brasil
| | - Bruno Zilberstein
- Trabalho realizado no Instituto do Câncer, Hospital de Clínicas - HCFMUSP, Universidade de São Paulo, Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo - USP - SP - São Paulo - Brasil
| | - Sergio Carlos Nahas
- Trabalho realizado no Instituto do Câncer, Hospital de Clínicas - HCFMUSP, Universidade de São Paulo, Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo - USP - SP - São Paulo - Brasil
| | - Andre Roncon Dias
- Trabalho realizado no Instituto do Câncer, Hospital de Clínicas - HCFMUSP, Universidade de São Paulo, Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo - USP - SP - São Paulo - Brasil
| |
Collapse
|
7
|
Jiang Z, Liu C, Cai Z, Shen C, Yin Y, Yin X, Zhao Z, Mu M, Yin Y, Zhang B. Impact of Surgical Margin Status on Survival in Gastric Cancer: A Systematic Review and Meta-Analysis. Cancer Control 2021; 28:10732748211043665. [PMID: 34569315 PMCID: PMC8482729 DOI: 10.1177/10732748211043665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND It is inconclusive whether R1 margin determined by postoperative pathological examination indicates worse long-term survival in gastric cancer (GC) patients after curative intent resection (CIR). Hence, we aimed to systematically pool the conflicting evidence to fill this gap. METHODS The present study was performed according to the published protocol and Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Published studies examining the impact of microscopic margin status on overall survival (OS) and 5-year OS rate in GC were systematically searched in PubMed, Embase, and Cochrane Library databases. RevMan 5.3 was used to conduct statistical analysis, and the Grading of Recommendations, Assessment, Development, and Evaluations approach was used to assess the certainty of evidence for each outcome. RESULTS Twenty-three retrospective cohort studies including 19 992 patients were analyzed. The pooled hazard ratio for OS of 14 studies was 2.06 (95% confidence interval [CI]: 1.61-2.65, low certainty), indicating that R1 margin predicted inferior OS. Subgroup and sensitivity analyses upheld the statistical stability of this finding. The pooled odds ratio (OR) of 14 studies was .21 (95% CI: .17-.26, moderate certainty), demonstrating that the presence of R1 margins was associated with a poorer 5-year OS rate. Sensitivity analyses and most of the subgroup analyses confirmed this finding, except the "esophagogastric junction (EGJ) cancers" subgroup, which included two studies with a pooled OR of .41 (95% CI: .10-1.61). CONCLUSION R1 margin detected by pathological examination might exhibit a high correlation with poorer OS and 5-year OS rate in GC (except EGJ cancers) patients who underwent CIR. To figure out the effect of R1 margin on survival of different stages and histological types need prospective studies with large sample sizes and standardized methods. What is the best treatment for R1 margin patients also need more in-depth and special research.
Collapse
Affiliation(s)
- Zhiyuan Jiang
- Department of Gastrointestinal Surgery, West China Hospital, 34753Sichuan University, Chengdu, China
| | - Chunyu Liu
- Department of Pharmacy, West China Second University Hospital, 34753Sichuan University, Chengdu, China.,Evidence-Based Pharmacy Center, West China Second University Hospital, 34753Sichuan University, Chengdu, China.,Ministry of Education, Key Laboratory of Birth Defects and Related Diseases of Women and Children, 34753Sichuan University, Chengdu, China.,West China School of Pharmacy, 34753Sichuan University, Chengdu, China
| | - Zhaolun Cai
- Department of Gastrointestinal Surgery, West China Hospital, 34753Sichuan University, Chengdu, China
| | - Chaoyong Shen
- Department of Gastrointestinal Surgery, West China Hospital, 34753Sichuan University, Chengdu, China
| | - Yuan Yin
- Department of Gastrointestinal Surgery, West China Hospital, 34753Sichuan University, Chengdu, China
| | - Xiaonan Yin
- Department of Gastrointestinal Surgery, West China Hospital, 34753Sichuan University, Chengdu, China
| | - Zhou Zhao
- Department of Gastrointestinal Surgery, West China Hospital, 34753Sichuan University, Chengdu, China
| | - Mingchun Mu
- Department of Gastrointestinal Surgery, West China Hospital, 34753Sichuan University, Chengdu, China
| | - Yiqiong Yin
- Department of Gastrointestinal Surgery, West China Hospital, 34753Sichuan University, Chengdu, China
| | - Bo Zhang
- Department of Gastrointestinal Surgery, West China Hospital, 34753Sichuan University, Chengdu, China
| |
Collapse
|
8
|
Muneoka Y, Ohashi M, Kurihara N, Fujisaki J, Makuuchi R, Ida S, Kumagai K, Sano T, Nunobe S. Short- and long-term oncological outcomes of totally laparoscopic gastrectomy versus laparoscopy-assisted gastrectomy for clinical stage I gastric cancer. Gastric Cancer 2021; 24:1140-1149. [PMID: 33723719 DOI: 10.1007/s10120-021-01181-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/07/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Totally laparoscopic gastrectomy (TLG), which involves a complete intracorporeal gastric transection and the creation of an anastomosis, has been gradually adopted. However, a potential limitation of intracorporeal transection is the lack of tactile feedback, and whether this limitation influences oncological outcomes is unclear. The aim of this study is to evaluate the short- and long-term oncological safety of TLG using endoscopy-guided intracorporeal gastric transection for clinical stage (cStage) I gastric cancer. METHODS A total of 1875 consecutive patients who underwent laparoscopic gastrectomy for cStage I gastric cancer between January 2007 and March 2015 were enrolled in this study. Marking clips were preoperatively placed and a transection line was determined by perceiving it tactually in laparoscopy-assisted gastrectomy (LAG) or endoscopically in TLG. After propensity score matching, 1366 patients (683 each for LAG and TLG groups) were selected to primarily test the non-inferiority of TLG to that of LAG for relapse-free survival (RFS). RESULTS In the propensity-matched population, the 5-year RFS rates of the LAG and TLG groups were 94.3% (95% confidence interval (CI) 92.2-95.8%), and 95.6% (95% CI 93.8-96.9%), respectively. The hazard ratio (TLG/LAG) was 0.77 (95% CI 0.48-1.24, P for non-inferiority < 0.01). There were no significant differences in the recurrence profiles. The incidence of the remnant of marking clips or tumor tissue did not differ (LAG: 1.0% vs. TLG: 1.9%, P = 0.177). CONCLUSIONS TLG using preoperative markings and intraoperative endoscopic guidance provides cStage I gastric cancer patients with comparable oncological outcomes to the conventional method.
Collapse
Affiliation(s)
- Yusuke Muneoka
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Manabu Ohashi
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Nozomi Kurihara
- Department of Clinical Trial Planning and Management, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Junko Fujisaki
- Department of Gastroenterology, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Rie Makuuchi
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Satoshi Ida
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Koshi Kumagai
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takeshi Sano
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Souya Nunobe
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| |
Collapse
|
9
|
Abstract
Surgery is an essential component of curative-intent treatment strategies for gastric cancer. However, the care of each patient with gastric cancer must be individualized based on patient and tumor characteristics. It is important that all physicians who will be caring for patient with gastric cancer understand the current best practices of surgical management to provide patients with the highest quality of care. This article aims to provide this information while acknowledging areas of surgical management that are still controversial.
Collapse
Affiliation(s)
- Ian Solsky
- Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 1300 Morris Park Avenue Block Building #112, New York, NY 10461, USA
| | - Haejin In
- Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 1300 Morris Park Avenue Block Building #112, New York, NY 10461, USA; Department of Surgery, Albert Einstein College of Medicine, New York, NY, USA; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York, NY, USA.
| |
Collapse
|
10
|
Juez LD, Barranquero AG, Priego P, Cuadrado M, Blázquez L, Sánchez-Picot S, Fernández-Cebrián JM, Galindo J. Influence of positive margins on tumour recurrence and overall survival after gastrectomy for gastric cancer. ANZ J Surg 2021; 91:E465-E473. [PMID: 34013576 DOI: 10.1111/ans.16937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 04/24/2021] [Accepted: 04/27/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Incidence of positive surgical margins after curative gastrectomy ranges from 1% to 20%. It has been suggested that positive surgical margin is an adverse prognosis factor, with a higher local recurrence and worse overall survival (OS). However, the management of these patients remains unclear. METHODS A total of 267 patients who underwent gastrectomy with curative intent between January 2010 and December 2018 in our centre were enrolled in this study. Post-operative histological analysis revealed positive resection margins in 18 patients (8%). Clinicopathological features and outcome of patients undergoing gastrectomy with negative and positive margins were compared. RESULTS Patients with positive margins were associated with higher American Joint Committee on Cancer (AJCC) stage, T stage, N stage, median number of positive nodes, diffuse Lauren type, whole stomach involved and poorly differentiated tumours. Local recurrence was described in 50% of cases with positive margins. The multivariate analysis demonstrated that the TNM stage was the only independent prognostic factor associated with recurrence. OS for positive margins at 1, 3 and 5 years was 75%, 57% and 26%, respectively. The median survival in patients with positive margins was 38.33 versus 81.17 months for R0 patients (p = 0.027). Multivariate analysis showed that age (hazard ratio [HR] 1.041, 95% confidence interval [CI] 1.02-1.07, sex (HR 2.00, 95% CI 1.22-3.30) and TNM stage (p < 0.001) were independent factors of OS. CONCLUSION Positive resection margin was an indication of advanced and more aggressive disease rather than an independent prognosis factor for OS or recurrence in gastric cancer.
Collapse
Affiliation(s)
- Luz Divina Juez
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain.,Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Alberto G Barranquero
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain.,Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Pablo Priego
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain.,Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Marta Cuadrado
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain.,Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Luis Blázquez
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain.,Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Silvia Sánchez-Picot
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain.,Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - José María Fernández-Cebrián
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain.,Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Julio Galindo
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain.,Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
| |
Collapse
|
11
|
Jiang Z, Cai Z, Yin Y, Shen C, Huang J, Yin Y, Zhang B. Impact of surgical margin status on the survival outcome after surgical resection of gastric cancer: a protocol for systematic review and meta-analysis. BMJ Open 2020; 10:e040282. [PMID: 33148760 PMCID: PMC7643516 DOI: 10.1136/bmjopen-2020-040282] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Generally, complete resection with cancer cell negative (R0) margin has been accepted as the most effective treatment of gastric cancer and positive resection (R1/R2) margin has been associated with decreased survival to varied degrees. However, the independent impact of microscopical positive (R1) margin on long-term survival may be confounded. No meta-analysis has worked at the association between R1 margin and outcomes of gastric cancer and the available evidence are scant. Therefore, we plan to conduct a systematic review and meta-analysis to quantitatively explore the role of R1 margin on gastric (including oesophagogastric junction) cancer survival after curative intent resection. METHODS AND ANALYSIS The protocol was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guideline. A systematic search of PubMed, Embase and the Cochrane Central Register of Controlled Trials databases will be performed from their inceptions to 30 April 2020 to identify randomised controlled trials (RCTs), cohort studies and case-control studies focusing on the impact of R1 margin on survival of gastric cancer after curative intent resection. The primary outcome will be the overall survival (OS) and disease-free survival (DFS) and the secondary outcomes will be 5-year OS rate and 5-year DFS rate. The Cochrane tool for bias assessment in randomised trials and Risk Of Bias In Non-randomised Studies-I for the assessment of bias in non-randomised studies (NRS) will be used. Statistical heterogeneity will be assessed by visual inspection of forest plots and measured using the I2 statistics. A fixed-effect model will be used when heterogeneity is low, otherwise, a random-effect model will be chosen. Publication bias will be assessed by funnel plots, subgroup analysis and sensitivity analysis will be performed in the right context. For each outcome, we will perform data synthesis separately for RCTs and NRS using Rev Man V.5.3 software and compile 'summary of findings' tables separately for RCTs and NRS using GRADEpro software. Grading of Recommendations, Assessment, Development and Evaluations considerations will also be used to make an overall assessment of the quality of evidence. ETHICS AND DISSEMINATION There is no requirement for ethics approval because no patient data will be collected at an individual level in this systematic review and meta-analysis.The results of this systematic review will be published in a peer-reviewed journal and presented at relevant conferences, any deviations from the protocol will be clearly documented and explained in its final report. PROSPERO REGISTRATION NUMBER CRD42020165110.
Collapse
Affiliation(s)
- Zhiyuan Jiang
- Department of Gastrointestinal Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Zhaolun Cai
- Department of Gastrointestinal Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Yuan Yin
- Department of Gastrointestinal Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Chaoyong Shen
- Department of Gastrointestinal Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Jinming Huang
- Department of Rehabilitation Medicine, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Yiqiong Yin
- Department of Gastrointestinal Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Bo Zhang
- Department of Gastrointestinal Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| |
Collapse
|
12
|
Zhu X, Bledsoe JR. Frozen section diagnosis of gastrointestinal poorly cohesive and signet-ring cell adenocarcinoma: useful morphologic features to avoid misdiagnosis. Virchows Arch 2020; 477:497-506. [PMID: 32215719 DOI: 10.1007/s00428-020-02799-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 02/25/2020] [Accepted: 03/17/2020] [Indexed: 01/01/2023]
Abstract
Frozen section examination of adenocarcinomas with poorly cohesive growth, including signet-ring cell carcinoma, is challenging. Due to their diffuse morphology, the tumor cells may be indistinct and difficult to distinguish from inflammatory or stromal cells. Misdiagnosis may result in significant adverse clinical outcome. We performed a detailed retrospective analysis of such cases to identify features that are helpful to avoid misdiagnosis at the time of frozen section. We reviewed the original frozen section slides from 50 patients with poorly cohesive carcinoma (PCC) including 32 with positive and 18 with negative frozen section slides. Tumor cells and inflammatory cells were evaluated for 17 distinct cytologic and nine architectural or stromal features. Features with 100% specificity and positive predictive value (PPV) for carcinoma included the presence of cells with a single distinct cytoplasmic mucin vacuole, focal gland formation, and perineural invasion. Features with high specificity, sensitivity, PPV, and negative predictive value (NPV) (all > 75%) included irregular nuclear contours, large nuclear size with many nuclei > 4× the size of a small lymphocyte, and disruption/obliteration of normal structures. Other features with high specificity and PPV (both ≥ 85%) but relatively low sensitivity and NPV-included crescent-shaped/indented nuclei, prominent nucleoli, anisonucleosis (> 4:1 difference in nuclear size), multinucleation, and the presence of mitotic figures. We characterized useful histologic features of poorly cohesive carcinoma that may serve to distinguish carcinoma cells from benign inflammatory or stroma cells. Knowledge of the relatively specific features in particular may help surgical pathologists avoid false-negative interpretation resulting in significant clinical morbidity.
Collapse
Affiliation(s)
- Xiaoqin Zhu
- Department of Pathology, UMass Memorial Medical Center, University of Massachusetts, One Innovation Drive, Biotech 3, Worcester, MA, 01605, USA
| | - Jacob R Bledsoe
- Department of Pathology, UMass Memorial Medical Center, University of Massachusetts, One Innovation Drive, Biotech 3, Worcester, MA, 01605, USA.
| |
Collapse
|
13
|
Surgery for Gastric Cancer: State of the Art. Indian J Surg 2020. [DOI: 10.1007/s12262-019-02061-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
|
14
|
Zhao B, Lu H, Bao S, Luo R, Mei D, Xu H, Huang B. Impact of proximal resection margin involvement on survival outcome in patients with proximal gastric cancer. J Clin Pathol 2019; 73:470-475. [PMID: 31879270 DOI: 10.1136/jclinpath-2019-206305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 12/26/2022]
Abstract
AIM The aim of this study was to evaluate the risk factors for proximal resection margin involvement and its impact on survival outcome in patients with proximal gastric cancer. METHODS A total of 488 patients who underwent potentially curative resection for proximal gastric cancer were retrospectively reviewed. Clinicopathological characteristics and survival differences between patients with positive and negative resection margins were compared and prognostic factors were determined by Cox multivariate analysis. RESULTS In this study, 7.6% (37/488) of patients with proximal gastric cancer had a positive proximal resection margin after postoperative histopathological examination. Positive resection margins were significantly associated with advanced tumour stage and more aggressive biological features including larger tumour size, serosal invasion and lymphovascular invasion. Serosal invasion (OR 4.543, 95% CI 2.201 to 9.380, p<0.001) and lymphovascular invasion (OR 2.279, 95% CI 1.129 to 4.600, p<0.05) were independent risk factors for positive proximal resection margins. In terms of survival outcome, positive resection margins had an adverse impact on the prognosis of patients with proximal gastric cancer (median DFS: 20.7 vs 30.2 months, p<0.001). The multivariate analysis indicated that positive resection margins (HR 1.494, 95% CI 1.042 to 2.142, p=0.029), T stage (T3-T4, HR 2.264, 95% CI 1.484 to 3.454, p<0.001) and N stage (N1-N2 stage, HR 1.696, 95% CI 1.279 to 2.248, p<0.001; N3 stage, HR 2.691, 95% CI 1.967 to 3.681, p<0.001) were independent prognostic factors for patients with proximal gastric cancer. CONCLUSION Proximal resection margin involvement was an indicator of more aggressive tumours and an independent prognostic factor for patients with proximal gastric cancer. Aggressive efforts should be made to achieve a negative resection margin if gastric cancer was deemed to be potentially resectable.
Collapse
Affiliation(s)
- Bochao Zhao
- Department of Surgical Oncology, First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China.,Department of General Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, Liaoning, China
| | - Huiwen Lu
- Department of Surgical Oncology, First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Shiyang Bao
- Department of Surgical Oncology, First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Rui Luo
- Department of Surgical Oncology, First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Di Mei
- Department of Surgical Oncology, First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Huimian Xu
- Department of Surgical Oncology, First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Baojun Huang
- Department of Surgical Oncology, First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| |
Collapse
|
15
|
van der Werf LR, Cords C, Arntz I, Belt EJT, Cherepanin IM, Coene PPLO, van der Harst E, Heisterkamp J, Langenhoff BS, Lamme B, van Berge Henegouwen MI, Lagarde SM, Wijnhoven BPL. Population-Based Study on Risk Factors for Tumor-Positive Resection Margins in Patients with Gastric Cancer. Ann Surg Oncol 2019; 26:2222-2233. [PMID: 31011900 PMCID: PMC6545177 DOI: 10.1245/s10434-019-07381-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Indexed: 12/16/2022]
Abstract
Background Radical gastrectomy is the cornerstone of the treatment of locally advanced gastric cancer. This study was designed to evaluate factors associated with a tumor-positive resection margin after gastrectomy and to evaluate the influence of hospital volume. Methods In this Dutch cohort study, patients with junctional or gastric cancer who underwent curative gastrectomy between 2011 and 2017 were included. The primary outcome was incomplete tumor removal after the operation defined as the microscopic presence of tumor cells at the resection margin. The association of patient and disease characteristics with incomplete tumor removal was tested with multivariable regression analysis. The association of annual hospital volume with incomplete tumor removal was tested and adjusted for the patient- and disease characteristics. Results In total, 2799 patients were included. Incomplete tumor removal was seen in 265 (9.5%) patients. Factors associated with incomplete tumor removal were: tumor located in the entire stomach (odds ratio (OR) [95% confidence interval (CI): 3.38 [1.91–5.96] reference: gastroesophageal junction), cT3, cT4, cTx (1.75 [1.20–2.56], 2.63 [1.47–4.70], 1.60 [1.03–2.48], reference: cT0-2), pN+ (2.73 [1.96–3.80], reference: pN−), and diffuse and unknown histological subtype (3.15 [2.14–4.46] and 2.05 [1.34–3.13], reference: intestinal). Unknown differentiation grade was associated with complete tumor removal (0.50 [0.30–0.83], reference: poor/undifferentiated). Compared with a hospital volume of < 20 resections/year, 20–39, and > 39 resections were associated with lower probability for incomplete tumor removal (OR 0.56 [0.42–0.76] and 0.34 [0.18–0.64]). Conclusions Tumor location, cT, pN, histological subtype, and tumor differentiation are associated with incomplete tumor removal. The association of incomplete tumor removal with an annual hospital volume of < 20 resections may underline the need for further centralization of gastric cancer care in the Netherlands. Electronic supplementary material The online version of this article (10.1245/s10434-019-07381-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Leonie R van der Werf
- Department of Surgery, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands.
| | - Charlotte Cords
- Department of Surgery, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ivo Arntz
- Department of Surgery, Bravis Hospital, Roosendaal, The Netherlands
| | - Eric J T Belt
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | | | | | - Joos Heisterkamp
- Department of Surgery, Elisabeth Tweesteden Hospital, Tilburg, The Netherlands
| | | | - Bas Lamme
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Sjoerd M Lagarde
- Department of Surgery, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
16
|
Clinical usefulness of extending the proximal margin in total gastrectomies for gastric adenocarcinoma. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2018.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
17
|
Celli R, Barbieri AL, Colunga M, Sinard J, Gibson JA. Optimal Intraoperative Assessment of Gastric Margins. Am J Clin Pathol 2018; 150:353-363. [PMID: 30020407 DOI: 10.1093/ajcp/aqy062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Intraoperative pathology consultation (IOC) to assess margins is frequently requested during surgery of the stomach and gastroesophageal junction. METHODS We studied 110 consecutive patients undergoing gastrectomy with IOC margin assessment. RESULTS Gastric margins at IOC utilized the most blocks but were least often positive. In 64% of patients, the entire gastric margin was examined using average six blocks; representative sections were examined in 25% of patients using two blocks. There was no difference in patient outcome between those who had entire vs representative sections of margin examined. Gross variables showing strongest associations with positive margins were tumor size and tumor distance to margin. Tumors sized greater than 2.3 cm had significantly increased risk of positive margin, and tumor distance greater than 4.5 cm to margin was associated with negative margins. CONCLUSIONS We conclude representative sections of the closest gastric margin are sufficient to ensure R0 resection in the majority of cases.
Collapse
Affiliation(s)
- Romulo Celli
- Department of Pathology, Yale University School of Medicine, New Haven, CT
| | - Andrea L Barbieri
- Department of Pathology, Yale University School of Medicine, New Haven, CT
| | | | - John Sinard
- Department of Pathology, Yale University School of Medicine, New Haven, CT
| | - Joanna A Gibson
- Department of Pathology, Yale University School of Medicine, New Haven, CT
| |
Collapse
|
18
|
Morgagni P, La Barba G, Colciago E, Vittimberga G, Ercolani G. Resection line involvement after gastric cancer treatment: handle with care. Updates Surg 2018; 70:213-223. [DOI: 10.1007/s13304-018-0552-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 06/01/2018] [Indexed: 02/06/2023]
|
19
|
Clemente-Gutiérrez U, Sánchez-Morales G, Santes O, Medina-Franco H. Clinical usefulness of extending the proximal margin in total gastrectomies for gastric adenocarcinoma. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2018; 84:136-142. [PMID: 29753577 DOI: 10.1016/j.rgmx.2018.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/03/2018] [Accepted: 03/14/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION AND AIMS Surgical resection with negative margins is part of the curative treatment of gastric adenocarcinoma. Positive surgical margins are associated with worse outcome. The aim of the present study was to determine the clinical usefulness of extending the proximal surgical margin in patients undergoing total gastrectomy for gastric adenocarcinoma. MATERIALS AND METHODS A retrospective analysis of patients that underwent total gastrectomy within the time frame of 2002 and 2017 was conducted. Patients diagnosed with adenocarcinoma that underwent curative surgery were included. Patients were divided into three groups, depending on proximal surgical margin status: negative margin (R0), positive margin with additional resection to achieve negative margin (R1-R0), and positive margin (R1). Demographic and clinical variables were analyzed. The outcome measures to evaluate were recurrence, disease-free survival, and overall survival. RESULTS Forty-eight patients were included in the study. Thirty-seven were classified as R0, 9 as R1-R0, and 2 as R1. Fifty-two percent of the patients had clinical stage III disease. The overall surgical mortality rate was 2% and the morbidity rate was higher than 29%. The local recurrence rate was 0% in the R1-R0 group vs. 50% in the R1 group (p = 0.02). Disease-free survival was 49 months in the R1-R0 group vs. 32 months in the R1 group (p = 0.6). Overall survival was 51 months for the R1-R0 group vs. 35 months for the R1 group (p = 0.5). CONCLUSIONS Intraoperative extension of the positive surgical margin improved the local recurrence rate but was not associated with improvement in overall survival or disease-free survival and could possibly increase postoperative morbidity.
Collapse
Affiliation(s)
- U Clemente-Gutiérrez
- Cirugía General, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Ciudad de México, México.
| | - G Sánchez-Morales
- Cirugía General, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Ciudad de México, México
| | - O Santes
- Cirugía General, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Ciudad de México, México
| | - H Medina-Franco
- Cirugía General, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Ciudad de México, México
| |
Collapse
|
20
|
|
21
|
Makris EA, Poultsides GA. Surgical Considerations in the Management of Gastric Adenocarcinoma. Surg Clin North Am 2017; 97:295-316. [PMID: 28325188 DOI: 10.1016/j.suc.2016.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Since Theodor Billroth and César Roux perfected the methods of postgastrectomy reconstruction in as early as the late nineteenth century, surgical management of gastric cancer has made incremental progress. The longstanding and contentious debate on the optimal extent of lymph node dissection for gastric cancer seems to have settled in favor of D2 dissection. Pylorus-preserving distal (central) gastrectomy has emerged as a less invasive, function-preserving option for T1N0 middle-third gastric cancers. Frozen section analysis of margins seems partially helpful in this direction. Last, the role of palliative gastrectomy in patients with metastatic seems less important than initially thought.
Collapse
Affiliation(s)
- Eleftherios A Makris
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, H3680, Stanford, CA 94305, USA
| | - George A Poultsides
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, H3680, Stanford, CA 94305, USA.
| |
Collapse
|
22
|
Brenkman HJF, Correa-Cote J, Ruurda JP, van Hillegersberg R. A Step-Wise Approach to Total Laparoscopic Gastrectomy with Jejunal Pouch Reconstruction: How and Why We Do It. J Gastrointest Surg 2016; 20:1908-1915. [PMID: 27561635 PMCID: PMC5078159 DOI: 10.1007/s11605-016-3235-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 08/02/2016] [Indexed: 02/06/2023]
Abstract
Laparoscopic gastrectomy (LG) is a safe alternative compared to open gastrectomy for cancer. To increase the uptake of minimally invasive approaches and facilitate their analysis and improvement a stepwise approach is warranted. This study describes our technique and experiences total laparoscopic gastrectomy (TLG) with jejunal pouch reconstruction for gastric cancer. Technical modifications throughout the years were described. In patients with anastomotic leakage, the CT-scan and reoperation report were reviewed to identify the location and cause of the leak. A total of 47 patients who underwent laparoscopic total gastrectomy with extracorporeal jejunal pouch reconstruction and stapled circular esophagojejunostomy from May 2007 to August 2015 were prospectively analyzed. A stepwise approach of 10 steps was designed based on video and case analysis. Median operation time was 301 (148-454) minutes and median blood loss was 300 (30-900) milliliters. Anastomotic leakage occurred in six (12.8 %) patients; additionally, one (2.12 %) jejunal-pouch staple line leak was identified. An important modification in our technique was a purse-string suture around the anvil of the circular stapler to prevent esophageal mucosa to slip away. After this modification, the leakage rate was reduced to 7 % in the last 15 procedures. In conclusion, TLG with jejunal pouch reconstruction is a feasible procedure in a selected group of patients. Our stepwise approach and technique may help surgeons to introduce jejunal pouch reconstruction during laparoscopic gastrectomy in their center.
Collapse
Affiliation(s)
- Hylke J. F. Brenkman
- Department of Surgery, University Medical Center Utrecht, PO BOX 85500, 3508 GA Utrecht, The Netherlands
| | - Juan Correa-Cote
- Department of Surgical Oncology, Hospital Pablo Tobón Uribe, Calle 78 B #, 69 - 240 Medellín, Colombia ,Department of Surgical Oncology, University of Toronto, Room 3-130, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Jelle P. Ruurda
- Department of Surgery, University Medical Center Utrecht, PO BOX 85500, 3508 GA Utrecht, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, PO BOX 85500, 3508 GA Utrecht, The Netherlands
| |
Collapse
|
23
|
Postlewait LM, Maithel SK. The importance of surgical margins in gastric cancer. J Surg Oncol 2015; 113:277-82. [DOI: 10.1002/jso.24110] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 11/14/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Lauren M. Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute; Emory University; Atlanta Georgia
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute; Emory University; Atlanta Georgia
| |
Collapse
|
24
|
Woo JW, Ryu KW, Park JY, Eom BW, Kim MJ, Yoon HM, Park SR, Kook MC, Choi IJ, Kim YW, Park YI. Prognostic impact of microscopic tumor involved resection margin in advanced gastric cancer patients after gastric resection. World J Surg 2014; 38:439-46. [PMID: 24132828 DOI: 10.1007/s00268-013-2301-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The prognosis of patients with positive surgical resection margins is dismal in gastric cancer. However, the influence of positive margin itself on prognosis is still uncertain, especially in advanced gastric cancer (AGC). The aims of the present study were to evaluate the prognostic impact of microscopic tumor involved resection margins in stage III-IV AGC after gastric resection in comparison with other well-known factors. METHODS Among 1,536 consecutive gastric cancer patients who received intentional curative resection for stage III-IV AGC between April 2001 and December 2011 at the National Cancer Center, 35 patients (2.28 %) had positive resection margins on their final histology. A comparison of clinicopathologic characteristics, recurrence pattern, overall survival (OS), and disease-free survival (DFS) was made between positive margin (PM) patients and negative margin (NM) patients. RESULTS Among the 35 PM patients, 15 (42.9 %) had proximal involved margins, 21 (60.0 %) had distal involved margins, and one (2.9 %) had both involved margins. Twenty-eight PM patients (80.0 %) were stage III, and 7 (20.0 %) were stage IV. Recurrence was significantly higher in PM than NM (63.6 % vs. 39.7 %, respectively; p = 0.005). The OS and DFS rates were significantly lower in the PM group than in the NM group (14.9 vs. 36.3 months, p < 0.001 and 11.6 vs. 27.1 months, p = 0.005, respectively). The presence of PM was an independent risk factor for both OS and DFS. CONCLUSIONS The presence of PM is an independent risk factor for OS and DFS. Considering the prognostic impact of PM, a sufficient resection margin should be ensured when determining the resection line in gastrectomy with curative intent. The reoperation to secure clear resection margins should be considered as a treatment of choice in the case of PM.
Collapse
Affiliation(s)
- Jung-Woo Woo
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea,
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Squires MH, Kooby DA, Pawlik TM, Weber SM, Poultsides G, Schmidt C, Votanopoulos K, Fields RC, Ejaz A, Acher AW, Worhunsky DJ, Saunders N, Jin LX, Levine E, Cho CS, Bloomston M, Winslow E, Cardona K, Staley CA, Maithel SK. Utility of the proximal margin frozen section for resection of gastric adenocarcinoma: a 7-Institution Study of the US Gastric Cancer Collaborative. Ann Surg Oncol 2014; 21:4202-10. [PMID: 25047464 DOI: 10.1245/s10434-014-3834-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The proximal gastric margin dictates the extent of resection for gastric adenocarcinoma (GAC). The value of achieving negative margins via additional gastric resection after a positive proximal margin frozen section (FS) is unknown. METHODS The US Gastric Cancer Collaborative includes all patients who underwent resection of GAC at seven institutions from 2000-2012. Intraoperative proximal margin FS data and final permanent section (PS) data were classified as R0 or R1, respectively; positive distal margins were excluded. The primary aim was to evaluate the impact on local recurrence of converting a positive proximal FS-R1 margin to a PS-R0 final margin by additional resection. Secondary endpoints were recurrence-free survival (RFS) and overall survival (OS). RESULTS Of 860 patients, 520 had a proximal margin FS and 67 were positive. Of these, 48 were converted to R0 on PS by additional resection. R0 proximal margin was achieved in 447 patients (86 %), PS-R1 in 25 (5 %), and converted FS-R1-to-PS-R0 in 48 (9 %). The median follow-up was 44 months. Local recurrence was significantly decreased in the converted FS-R1-to-PS-R0 group compared to the PS-R1 group (10 vs. 32 %; p = 0.01). Median RFS was similar between the FS-R1-to-PS-R0 and PS-R1 cohorts (25 vs. 20 months; p = 0.49), compared to 37 months for the PS-R0 group. Median OS was similar between the FS-R1-to-PS-R0 conversion and PS-R1 groups (36 vs. 26 months; p = 0.14) compared to 50 months for the PS-R0 group. On multivariate analysis, increasing T-stage and N-stage were associated with worse OS; the FS-R1-to-PS-R0 proximal margin conversion was not significantly associated with improved RFS (p = 0.68) or OS (p = 0.44). CONCLUSION Conversion of a positive intraoperative proximal margin frozen section during gastric cancer resection may decrease local recurrence, but it is not associated with improved RFS or OS. This may guide decisions regarding the extent of resection.
Collapse
Affiliation(s)
- Malcolm H Squires
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Stiekema J, Trip AK, Jansen EPM, Boot H, Cats A, Ponz OB, Verheij M, van Sandick JW. The Prognostic Significance of an R1 Resection in Gastric Cancer Patients Treated with Adjuvant Chemoradiotherapy. Ann Surg Oncol 2013; 21:1107-14. [DOI: 10.1245/s10434-013-3397-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Indexed: 12/19/2022]
|