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Hayami M, Ohashi M, Kurihara N, Nunobe S. Adequate gross resection margin length ensuring pathologically complete resection in gastrectomy for gastric cancer: A systematic review and meta-analysis. Ann Gastroenterol Surg 2024; 8:202-213. [PMID: 38455483 PMCID: PMC10914694 DOI: 10.1002/ags3.12761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 11/12/2023] [Accepted: 11/21/2023] [Indexed: 03/09/2024] Open
Abstract
Aim A positive resection margin (RM) is associated with poor survival after gastrectomy for gastric cancer (GC). However, the adequate RM length to avoid a positive RM remains controversial. We performed a systematic review to examine the RM length required to avoid a positive RM in gastrectomy for GC. Methods This systematic review involved all relevant articles identified in PubMed, the Cochrane Library, Web of Science, and ClinicalTrials.gov until August 2023. The incidence of a positive RM related to the RM length and the possible incidence of a positive RM estimated from the discrepancy between the gross and pathological RM length were evaluated. The Newcastle-Ottawa Scale was used to quantify study quality. Results Thirteen studies involving 8983 patients were analyzed. Investigation of the incidence of a positive RM in relation to the RM length showed that a proximal RM length of 6 cm guaranteed a negative RM in gastrectomy. Analyses of the possible incidence of a positive RM revealed that a negative RM would be guaranteed if the proximal RM length was 6 cm in distal gastrectomy, if the esophageal resection length was 2 cm in total gastrectomy for GC without esophageal invasion and 2.5 cm in total or proximal gastrectomy for GC with esophageal invasion or esophagogastric junction cancer, and if the distal RM length was 4 cm in proximal gastrectomy for early GC. Conclusions The adequate RM lengths to ensure a pathologically negative RM in each type of gastrectomy for GC were herein suggested.
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Affiliation(s)
- Masaru Hayami
- Department of Gastroenterological Surgery, Gastroenterological CenterCancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Manabu Ohashi
- Department of Gastroenterological Surgery, Gastroenterological CenterCancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Nozomi Kurihara
- Department of Clinical Trial Planning and StrategyCancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Souya Nunobe
- Department of Gastroenterological Surgery, Gastroenterological CenterCancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
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Takashima Y, Komatsu S, Nishibeppu K, Ohashi T, Kosuga T, Konishi H, Shiozaki A, Kubota T, Fujiwara H, Otsuji E. A shorter distal resection margin is a surrogate marker of nodal metastasis and poor prognosis in distal gastrectomy for advanced gastric cancer. BMC Cancer 2023; 23:1075. [PMID: 37936119 PMCID: PMC10629168 DOI: 10.1186/s12885-023-11570-2] [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: 01/12/2023] [Accepted: 10/26/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Although a 3-5 cm surgical margin distance is recommended for advanced gastric cancer (GC) in Japanese guidelines, little is known about the clinical effects of the surgical margin, especially the distal resection margin (DM). This study aims to clarify the clinical significance of DM in GC. METHODS A total of 415 GC patients who underwent curative distal gastrectomy between 2008 and 2018 were analyzed retrospectively. RESULTS The DM significantly stratified recurrence-free survival (P = 0.002), and a DM < 30 mm was an independent factor of a poor prognosis (P = 0.023, hazard ratio: 1.91). Lymphatic recurrence occurred significantly more frequently in the DM < 30 mm group than in the DM ≥ 30 mm group (P = 0.019, 6.9% vs. 1.9%). Regarding the station No.6 lymph node metastases in advanced GC (DM < 30 mm vs. 30 mm ≤ DM ≤ 50 mm vs. DM > 50 mm), the number (P < 0.001, 1.42 ± 1.69 vs. 1.18 ± 1.80 vs. 0.18 ± 0.64), the positive rate (P < 0.001, 59.0% vs. 46.7% vs. 11.3%) and therapeutic value index (43.3 vs. 14.5 vs. 8.0) were significantly higher in the DM < 30 mm group. By subdivision using the DM distance of 30 mm, more segmented prognostic stratifications were possible (P < 0.001). CONCLUSIONS A DM of less than 30 mm could be a surrogate marker of poor RFS, especially increasing nodal recurrence. More intensive treatment strategies, including lymphadenectomy and chemotherapy, are needed for patients with this condition.
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Affiliation(s)
- Yusuke Takashima
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachihirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Shuhei Komatsu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachihirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan.
| | - Keiji Nishibeppu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachihirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Takuma Ohashi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachihirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Toshiyuki Kosuga
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachihirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Hirotaka Konishi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachihirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Atsushi Shiozaki
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachihirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Takeshi Kubota
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachihirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Hitoshi Fujiwara
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachihirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Eigo Otsuji
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachihirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
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Hirata Y, Agnes A, Estrella JS, Blum Murphy M, Das P, Minsky BD, Ajani JA, Badgwell BD, Mansfield P, Ikoma N. Clinical Impact of Positive Surgical Margins in Gastric Adenocarcinoma in the Era of Preoperative Therapy. Ann Surg Oncol 2023; 30:4936-4945. [PMID: 37106276 DOI: 10.1245/s10434-023-13495-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/27/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Microscopically positive (R1) surgical margins after gastrectomy increase gastric cancer recurrence risk, but optimal management after R1 gastrectomy is controversial. We sought to identify the impact of R1 margins on recurrence patterns and survival in the era of preoperative therapy for gastric cancer. METHODS Patients who underwent gastrectomy for adenocarcinoma during 1998-2017 at a major cancer center were enrolled. Clinicopathologic factors associated with positive margins were examined, and incidence, sites, and timing of recurrence and survival outcomes were compared between patients with positive and negative margins. RESULTS Of 688 patients, 432 (63%) received preoperative therapy. Thirty-four patients (5%) had R1 margins. Compared with patients with negative margins, patients with R1 margins more frequently had aggressive clinicopathologic features, such as linitis plastica (odds ratio [OR] 7.79, p < 0.001) and failure to achieve cT downstaging with preoperative treatment (OR 5.20, p = 0.005). The 5 year overall survival (OS) rate was lower in patients with R1 margins (6% vs 60%; p < 0.001), and R1 margins independently predicted worse OS (hazard ratio 2.37, 95% CI 1.51-3.75, p < 0.001). Most patients with R1 margins (58%) experienced peritoneal recurrence, and locoregional recurrence was relatively rare in this group (14%). Median time to recurrence was 8.5 months for peritoneal dissemination and 15.7 months for locoregional recurrence. CONCLUSION R1 margins after gastrectomy were associated with aggressive tumor biology, high incidence of peritoneal recurrence after a short interval, and poor OS. In patients with R1 margins, re-resection to achieve microscopically negative margins has to be considered with caution.
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Affiliation(s)
- Yuki Hirata
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Annamaria Agnes
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeannelyn S Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela Blum Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Liao N, Xu C, Zheng S, Wang R. Effect of Double-Channel Anastomosis and Esophagojejunal Anastomosis on Postoperative Recovery and Complications of Laparoscopic D2 Radical Gastrectomy for Gastric Cancer. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:8281558. [PMID: 35368937 PMCID: PMC8967533 DOI: 10.1155/2022/8281558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/18/2022] [Indexed: 11/17/2022]
Abstract
The aim of this study was to investigate the effects of double-channel anastomosis versus esophagojejunostomy on postoperative recovery and complications after laparoscopic D2 radical gastrectomy for early proximal gastric cancer. The cases were collected from 100 patients with early proximal gastric cancer admitted to our hospital from January 2017 to January 2021. According to different surgical methods, they were divided into control group (total gastrectomy + esophagojejunal anastomosis) and experimental group (D2 radical resection + double-channel anastomosis). The two groups were compared in terms of clinical outcomes (operative time, intraoperative blood loss, number of lymph nodes dissected, digestive tract anastomosis time, postoperative exhaust, and hospitalization days), postoperative complications, and nutritional status; the expression of T lymphocyte subsets in peripheral blood of the two groups was detected to reflect the recovery of immune ability. There was no significant difference between the observation group and the control group in clinical operation effect indexes (P < 0.05). The incidence of complications of dumping syndrome and reflux esophagitis in the observation group was significantly lower than that in the control group (P < 0.05). In terms of postoperative nutritional status, the ratio of plasma albumin level and body weight restored to operation at 12 and 24 weeks after operation in the observation group was significantly higher than that in the control group (P < 0.05). 3 months after the operation, the levels of CD3 +, CD4 + cell subsets, and CD4+/CD8+ index reflecting the recovery of immune ability in the observation group were significantly higher than those in the observation group (P < 0.05). The application of double-channel anastomosis in laparoscopic D2 radical gastrectomy for early proximal gastric cancer has a better effect on reducing complications and promoting postoperative recovery, which is of great application value.
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Affiliation(s)
- Nansheng Liao
- Department of General Surgery, Taizhou First People's Hospital, Taizhou 318020, China
| | - Chaowei Xu
- Department of General Surgery, Taizhou First People's Hospital, Taizhou 318020, China
| | - Shuang Zheng
- Department of General Surgery, Taizhou First People's Hospital, Taizhou 318020, China
| | - Rongguo Wang
- Department of General Surgery, Taizhou First People's Hospital, Taizhou 318020, China
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Maspero M, Sposito C, Benedetti A, Virdis M, Di Bartolomeo M, Milione M, Mazzaferro V. Impact of Surgical Margins on Overall Survival after Gastrectomy for Gastric Cancer: A Validation of Japanese Gastric Cancer Association Guidelines on a Western Series. Ann Surg Oncol 2022; 29:3096-3108. [PMID: 34973091 PMCID: PMC8989928 DOI: 10.1245/s10434-021-11010-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/12/2021] [Indexed: 12/24/2022]
Abstract
Purpose No consensus exists on the resection extent needed to ensure oncological safety in gastrectomy for gastric adenocarcinoma (GAC). This study aims to assess the impact of margin adequacy according to Japanese Gastric Cancer Association (JGCA) guidelines on overall survival (OS). Patients and Methods Patients who underwent surgery for stage I–III GAC at our institution between 2010 and 2017 were included. Margin adequacy according to JGCA, National Comprehensive Cancer Network (NCCN), and European Society for Medical Oncology (ESMO) guidelines was assessed, and their predictive value on OS was evaluated with Harrell’s C-index. Patients were analyzed according to their margins’ adherence to JGCA guidelines, and a propensity score matching (PSM) was run. Indication to either total gastrectomy (TG) or distal gastrectomy (DG) according to each guideline was also assessed. Results A total of 279 patients were included, of whom 220 (79%) underwent DG. Adequate margins according to JGCA were obtained in 209 patients (75%). On multivariate analysis, JGCA margin adequacy was independently associated with OS, together with American Society of Anesthesiologist class, neoadjuvant chemotherapy, lymphadenectomy extent, R0 resection, and postoperative N stage. After PSM, patients with JGCA adequate margins showed better OS, recurrence-free survival (RFS), and local RFS than patients with JGCA inadequate margins. For 220 DG, JGCA guidelines would have recommended TG in 25 patients (11%), NCCN in 30 (14%), and ESMO in 90 (41%) (p < 0.001). Conclusion Adequacy of surgical resection margins to JGCA guidelines leads to improved survival outcomes and allows for a more organ-preserving approach than Western guidelines.
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Affiliation(s)
- Marianna Maspero
- Upper GI and HPB Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Carlo Sposito
- Upper GI and HPB Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Antonio Benedetti
- Upper GI and HPB Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Matteo Virdis
- Upper GI and HPB Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | | | - Massimo Milione
- Pathology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Vincenzo Mazzaferro
- Upper GI and HPB Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy. .,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
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Prognostic impact of a microscopic positive margin in patients undergoing gastrectomy for gastric cancer: a propensity score‑matched analysis of a multi‑institutional dataset. Surg Today 2021; 52:559-566. [PMID: 34436686 DOI: 10.1007/s00595-021-02365-8] [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: 03/15/2021] [Accepted: 07/03/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE We analyzed the effect of a microscopic positive margin on survival outcomes after gastrectomy for gastric cancer METHODS: We analyzed a multi-institutional dataset to study patients who underwent gastrectomy with curative intent between 2010 and 2014. We used propensity score matching to strictly balance the patients' oncological features, backgrounds, and postoperative treatment to compare the survival outcomes of those with microscopic positive margins and those with negative margins. RESULTS Among 3029 patients, 32 (1.1%) had positive margins. After matching, we enrolled 128 patients in this retrospective analysis: 32 with a positive margin and 96 with a negative margin. The recurrence-free survival of the positive-margin group was significantly shorter than that of the negative-margin group (hazard ratio [HR], 1.62, 95% confidence interval, 1.00-2.63, p = 0.0485). Consistent results were observed for patients with pStages I-III disease (HR, 1.65, p = 0.0835), whereas the survival curves overlapped in those with pStage IV disease (HR, 1.29, p = 0.5934). The prevalence of overall recurrence in the positive-margin group was higher than that in the negative-margin group (75% vs 58%, p = 0.0917). This trend was consistent with locoregional recurrence (9% vs 3%) and distant recurrence (69% vs 55%). CONCLUSIONS The survival of patients after curative gastrectomy for gastric cancer was worse in those with microscopic positive margins than in those with negative margins.
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