Influence of the Proximal Margin Length on Local Anastomotic Recurrence in Adenocarcinoma of the Gastroesophageal Junction: A Single-center Experience

Document Type : Research/Original Article

Authors

Department of General Surgery, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Abstract

Background: Curative resection with adequate margins is a treatment principle in gastroesophageal junction cancers. There is still no comprehensive agreement on the length of the negative proximal margin after total gastrectomy in Siewert II and III tumors. Extending the proximal negative margin in this anatomical region is very difficult in some cases and can cause more complications for the patients. This study aimed to investigate the influence of the negative proximal margin length on the local anastomotic recurrence in gastroesophageal junction (GEJ) adenocarcinoma in a referral cancer center in Iran.
Methods: In a prospective cross-sectional study, 35 patients with GEJ Sievert II and III adenocarcinomas who underwent total radical gastrectomy from 2017 to 2020 were included. Proximal margin length was measured immediately after resection in the operation room. Then, patients were evaluated for local recurrence at the anastomosis site after two years by endoscopic examination. The relationship between negative proximal margin length, local recurrence rate, and overall survival was evaluated.
Results: From 35 patients 29 (82.9%) cases had negative proximal margins, and 6 (17.1%) cases had positive proximal margins. The least negative proximal margin length was 0.1 cm, and the most were 5 cm. The mean margin was 2±1.6 cm. Based on the endoscopic and pathologic findings, the local recurrence at the anastomosis site was 20% in two years of follow-up. The incidence of local tumor recurrence was higher in patients with positive margins versus patients with negative ones (11.4% vs. 8.6%, P=0.007). There was no significant relationship between the negative proximal margin length and the incidence of local anastomotic recurrence.
Conclusion: According to our findings, the length of the negative proximal margin has no effect on the rate of local recurrence at the anastomosis site, however it is suggested  to reach the negative proximal margin in all tumor stages in total gastrectomy for Siewert II and III gastric cardia tumors. 

Keywords

References

  1. Devesa SS, Blot WJ, Fraumeni JF, Jr. Changing patterns in the incidence of esophageal and gastric carcinoma in the United States. Cancer. 1998;83(10):2049-53.
  2. Bollschweiler E, Wolfgarten E, Gutschow C, Hölscher AH. Demographic variations in the rising incidence of esophageal adenocarcinoma in white males. Cancer. 2001;92(3):549-55.
  3. Steevens J, Botterweck AA, Dirx MJ, van den Brandt PA, Schouten LJ. Trends in incidence of oesophageal and stomach cancer subtypes in Europe. European journal of gastroenterology & hepatology. 2010;22(6):669-78.
  4. Siewert JR, Hölscher AH, Becker K, Gössner W. [Cardia cancer: attempt at a therapeutically relevant classification]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 1987;58(1):25-32.
  5. Siewert JR, Stein HJ. Classification of adenocarcinoma of the oesophagogastric junction. The British journal of surgery. 1998;85(11):1457-9.
  6. Hosokawa Y, Kinoshita T, Konishi M, Takahashi S, Gotohda N, Kato Y, et al. Clinicopathological features and prognostic factors of adenocarcinoma of the esophagogastric junction according to Siewert classification: experiences at a single institution in Japan. Annals of surgical oncology. 2012;19(2):677-83.
  7. Rüdiger Siewert J, Feith M, Werner M, Stein HJ. Adenocarcinoma of the esophagogastric junction: results of surgical therapy based on anatomical/topographic classification in 1,002 consecutive patients. Annals of surgery. 2000;232(3):353-61.
  8. Suh YS, Han DS, Kong SH, Lee HJ, Kim YT, Kim WH, et al. Should adenocarcinoma of the esophagogastric junction be classified as esophageal cancer? A comparative analysis according to the seventh AJCC TNM classification. Annals of surgery. 2012;255(5):908-15.
  9. Chen JD, Yang XP, Shen JG, Hu WX, Yuan XM, Wang LB. Prognostic improvement of reexcision for positive resection margins in patients with advanced gastric cancer. European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 2013;39(3):229-34.
  10. Nagata T, Ichikawa D, Komatsu S, Inoue K, Shiozaki A, Fujiwara H, et al. Prognostic impact of microscopic positive margin in gastric cancer patients. Journal of surgical oncology. 2011;104(6):592-7.
  11. Cho BC, Jeung HC, Choi HJ, Rha SY, Hyung WJ, Cheong JH, et al. Prognostic impact of resection margin involvement after extended (D2/D3) gastrectomy for advanced gastric cancer: a 15-year experience at a single institute. Journal of surgical oncology. 2007;95(6):461-8.
  12. Wang SY, Yeh CN, Lee HL, Liu YY, Chao TC, Hwang TL, et al. Clinical impact of positive surgical margin status on gastric cancer patients undergoing gastrectomy. Annals of surgical oncology. 2009;16(10):2738-43.
  13. Sun Z, Li DM, Wang ZN, Huang BJ, Xu Y, Li K, et al. Prognostic significance of microscopic positive margins for gastric cancer patients with potentially curative resection. Annals of surgical oncology. 2009;16(11):3028-37.
  14. Bickenbach KA, Gonen M, Strong V, Brennan MF, Coit DG. Association of positive transection margins with gastric cancer survival and local recurrence. Annals of surgical oncology. 2013;20(8):2663-8.
  15. Woo JW, Ryu KW, Park JY, Eom BW, Kim MJ, Yoon HM, et al. Prognostic impact of microscopic tumor involved resection margin in advanced gastric cancer patients after gastric resection. World journal of surgery. 2014;38(2):439-46.
  16. Postlewait LM, Squires MH, 3rd, Kooby DA, Poultsides GA, Weber SM, Bloomston M, et al. The importance of the proximal resection margin distance for proximal gastric adenocarcinoma: A multi-institutional study of the US Gastric Cancer Collaborative. Journal of surgical oncology. 2015;112(2):203-7.
  17. Bissolati M, Desio M, Rosa F, Rausei S, Marrelli D, Baiocchi GL, et al. Risk factor analysis for involvement of resection margins in gastric and esophagogastric junction cancer: an Italian multicenter study. Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association. 2017;20(1):70-82.
  18. Kim BS, Oh ST, Yook JH, Kim HS, Lee IS, Kim BS. Appropriate gastrectomy resection margins for early gastric carcinoma. Journal of surgical oncology. 2014;109(3):198-201.
  19. Kim Y, Squires MH, Poultsides GA, Fields RC, Weber SM, Votanopoulos KI, et al. Impact of lymph node ratio in selecting patients with resected gastric cancer for adjuvant therapy. Surgery. 2017;162(2):285-94.
  20. Jiang Z, Liu C, Cai Z. Impact of Surgical Margin Status on Survival in Gastric Cancer: A Systematic Review and Meta-Analysis. 2021;28:10732748211043665.
  21. Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association. 2017;20(1):1-19.
  22. Ajani JA, Barthel JS, Bekaii-Saab T, Bentrem DJ, D’Amico TA, Das P, et al. Gastric cancer. Journal of the National Comprehensive Cancer Network : JNCCN. 2010;8(4):378-409.
  23. Feng F, Tian Y, Xu G, Liu S, Liu Z, Zheng G, et al. The length of proximal margin does not influence the prognosis of Siewert type II/III adenocarcinoma of esophagogastric junction after transhiatal curative gastrectomy. SpringerPlus. 2016;5:588.
  24. Kim MG, Lee JH, Ha TK, Kwon SJ. The distance of proximal resection margin dose not significantly influence on the prognosis of gastric cancer patients after curative resection. Annals of surgical treatment and research. 2014;87(5):223-31.
  25. Lee CM, Jee YS, Lee JH, Son SY, Ahn SH, Park DJ, et al. Length of negative resection margin does not affect local recurrence and survival in the patients with gastric cancer. World journal of gastroenterology. 2014;20(30):10518-24.
  26. Ohe H, Lee WY, Hong SW, Chang YG, Lee B. Prognostic value of the distance of proximal resection margin in patients who have undergone curative gastric cancer surgery. World journal of surgical oncology. 2014;12:296.
  27. Jang YJ, Park MS, Kim JH, Park SS, Park SH, Kim SJ, et al. Advanced gastric cancer in the middle one-third of the stomach: Should surgeons perform total gastrectomy? Journal of surgical oncology. 2010;101(6):451-6.
  28. Correa P, Chen VW. Gastric cancer. Cancer surveys. 1994;19-20:55-76.
  29. Leers JM, DeMeester SR, Chan N, Ayazi S, Oezcelik A, Abate E, et al. Clinical characteristics, biologic behavior, and survival after esophagectomy are similar for adenocarcinoma of the gastroesophageal junction and the distal esophagus. The Journal of thoracic and cardiovascular surgery. 2009;138(3):594-602; discussion 1-2.
  30. Squires MH, 3rd, Kooby DA, Poultsides GA, Pawlik TM, Weber SM, Schmidt CR, et al. Is it time to abandon the 5-cm margin rule during resection of distal gastric adenocarcinoma? A multi-institution study of the U.S. Gastric Cancer Collaborative. Annals of surgical oncology. 2015;22(4):1243-51.
  31. Kim JH, Park SS, Kim J, Boo YJ, Kim SJ, Mok YJ, et al. Surgical outcomes for gastric cancer in the upper third of the stomach. World journal of surgery. 2006;30(10):1870-6; discussion 7-8.
  32. 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 gastroenterologia de Mexico (English). 2019;84(2):136-42.
  33. Mine S, Sano T, Hiki N, Yamada K, Kosuga T, Nunobe S, et al. Proximal margin length with transhiatal gastrectomy for Siewert type II and III adenocarcinomas of the oesophagogastric junction. The British journal of surgery. 2013;100(8):1050-4.
  34. Schoenfeld JD, Wo JY, Mamon HJ, Kwak EL, Mullen JT, Enzinger PZ, et al. The Impact of Positive Margins on Outcome Among Patients With Gastric Cancer Treated With Radiation. American journal of clinical oncology. 2016;39(3):243-7.
  35. Koumarianou A, Krivan S, Machairas N, Ntavatzikos A, Pantazis N, Schizas D, et al. Ten-year survival outcomes of patients with potentially resectable gastric cancer: impact of clinicopathologic and treatment-related risk factors. Annals of gastroenterology. 2019;32(1):99-106.
  36. Niclauss N, Jung MK, Chevallay M, Mönig SP. Minimal length of proximal resection margin in adenocarcinoma of the esophagogastric junction: a systematic review of the literature. Updates in surgery. 2019;71(3):401-9.
  37. Kim A, Kim BS, Yook JH, Kim BS. Optimal proximal resection margin distance for gastrectomy in advanced gastric cancer. World journal of gastroenterology. 2020;26(18):2232-46.
  38. Aurello P, Magistri P, Nigri G, Petrucciani N, Novi L, Antolino L, et al. Surgical management of microscopic positive resection margin after gastrectomy for gastric cancer: a systematic review of gastric R1 management. Anticancer research. 2014;34(11):6283-8.
  39. Squires MH, 3rd, Kooby DA, Pawlik TM, Weber SM, Poultsides G, Schmidt C, et al. Utility of the proximal margin frozen section for resection of gastric adenocarcinoma: a 7-Institution Study of the US Gastric Cancer Collaborative. Annals of surgical oncology. 2014;21(13):4202-10.
  40. Kasakura Y, Fujii M, Mochizuki F, Imai S, Kanamori N, Suzuki T. Clinicopathological features of the superficial spreading type of early gastric cancer. Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association. 1999;2(2):129-35.
Iranian Journal of Colorectal Research
Volume 11, Issue 3
September 2023
Pages 104-109

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