Optimal Intraoperative Assessment of Gastric Margins

Diffuse-Type Histology Is Prognostic for All Siewert Types of Gastroesophageal Adenocarcinoma

PURPOSE

The optimal treatment for gastroesophageal junction adenocarcinoma (GEJA) remains controversial. We evaluated the treatment patterns and outcomes of patients with locally advanced GEJA according to the histological type.

MATERIALS AND METHODS

We conducted a single-institution retrospective cohort study of patients with locally advanced GEJA who underwent curative-intent surgical resection between 2010 and 2020. Perioperative therapies as well as clinicopathologic, surgical, and survival data were collected. The results of endoscopy and histopathological examinations were assessed for Siewert and Lauren classifications.

RESULTS

Among the 58 patients included in this study, 44 (76%) were clinical stage III, and all received neoadjuvant therapy (72% chemoradiation, 41% chemotherapy, 14% both chemoradiation and chemotherapy). Tumor locations were evenly distributed by Siewert Classification (33% Siewert-I, 40% Siewert-II, and 28% Siewert-III). Esophagogastrectomy (EG) was performed for 47 (81%) patients and total gastrectomy (TG) for 11 (19%) patients. All TG patients received D2 lymphadenectomy compared to 10 (21%) EG patients. Histopathological examination showed the presence of 64% intestinal-type and 36% diffuse-type histology. The frequencies of diffuse-type histology were similar among Siewert groups (37% Siewert-I, 36% Siewert-II, and 33% Siewert-III). Regardless of Siewert type and compared to intestinal-type, diffuse histology was associated with increased intraabdominal recurrence rates (P=0.03) and decreased overall survival (hazard ratio, 2.33; P=0.02). With a median follow-up of 31.2 months, 29 (50%) patients had a recurrence, and the median overall survival was 50.5 months.

CONCLUSIONS

Present in equal proportions among Siewert types of esophageal and gastric cancer, a diffuse-type histology was associated with high intraabdominal recurrence rates and poor survival. Histopathological evaluation should be considered in addition to anatomic location in the determination of multimodal GEJA treatment strategies.

The correlation between the margin of resection and prognosis in esophagogastric junction adenocarcinoma

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.

BRAZILIAN GASTRIC CANCER ASSOCIATION GUIDELINES (PART 2): UPDATE ON TREATMENT

BACKGROUND

: The II Brazilian Consensus on Gastric Cancer of the Brazilian Gastric Cancer Association BGCA (Part 1) was recently published. On this occasion, countless specialists working in the treatment of this disease expressed their opinion in the face of the statements presented.

AIM

: To present the BGCA Guidelines (Part 2) regarding indications for surgical treatment, operative techniques, extension of resection and multimodal treatment.

METHODS

To formulate these guidelines, the authors carried out an extensive and current review regarding each declaration present in the II Consensus, using the Medline/PubMed, Cochrane Library and SciELO databases initially with the following descriptors: gastric cancer, gastrectomy, lymphadenectomy, multimodal treatment. In addition, each statement was classified according to the level of evidence and degree of recommendation.

RESULTS

: Of the 43 statements present in this study, 11 (25,6%) were classified with level of evidence A, 20 (46,5%) B and 12 (27,9%) C. Regarding the degree of recommendation, 18 (41,9%) statements obtained grade of recommendation 1, 14 (32,6%) 2a, 10 (23,3%) 2b e one (2,3%) 3.

CONCLUSION

: The guidelines complement of the guidelines presented here allows surgeons and oncologists who work to combat gastric cancer to offer the best possible treatment, according to the local conditions available.

Analysis of the Factors Affecting Survival in the Patients who Underwent Curative-Intent Gastrectomy due to Gastric Adenocarcinoma

Objectives:

Gastric cancer is the fifth most common cancer and the third most common cause of cancer-related deaths in the world. In this study, we aimed to evaluate the impact of clinicopathological factors on overall survival in the patients who underwent curative-intent gastrectomy due to gastric adenocarcinoma.

Methods:

The medical records of 644 patients who underwent gastrectomy between January 2007 and January 2017 in our clinic were retrospectively reviewed. Among these patients, 359 patients were included in this study. The impact of several prognostic factors on survival was investigated.

Results:

The mean age was 59.2±11.6 (29-83). Male/female ratio was 2.12. The median follow-up time was 19 months (CI=10.1-31.1). Median overall survival was 23±2.3 months (CI=18.3-27.6). Splenectomy, R1 (microscopically incomplete) resection, and advanced stage were independent risk factors for poor prognosis.

Conclusion:

R1 resection, splenectomy, and advanced TNM stage were associated with poor prognosis in gastric cancer. Splenectomy should be avoided in the absence of direct invasion of the tumour or metastasis of lymph nodes on splenic hilum to prevent postoperative infectious complication-related mortality.

Frozen section diagnosis of gastrointestinal poorly cohesive and signet-ring cell adenocarcinoma: useful morphologic features to avoid misdiagnosis

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.