Extension of resection after positive intraoperative pathology during surgery for gastric and gastroesophageal junction adenocarcinoma - a retrospective cohort study.

Abstract

Residual tumor at the resection margins after surgery for gastric and gastroesophageal junction (GEJ) adenocarcinoma is a known prognostic factor. In this single-center, retrospective cohort study in a tertiary referral center, we aimed to evaluate the relevance of intraoperative pathology consultation (IOC) and consecutive extension of surgery on patient survival. Of 737 consecutive patients undergoing (sub)total gastrectomy for gastric or GEJ adenocarcinoma, 679 cases with curative intent surgery between 05/1996 and 03/2019 were included. Patients were categorized into: i) R0 without further resection (direct R0), ii) R0 after positive IOC and extension of resection (converted R0) and iii) R1. IOC was performed in 242 (35.6%) patients, in 216 (89.3%) at the proximal resection margin. Direct R0 status was achieved in 598 (88.1%), converted R0 in 26 (3.8%) of 38 (5.6%) patients with positive IOC and R1 in 55 (8.1%) patients. Median follow-up was 29 months for surviving patients. 3-year survival rate (3-YSR) was significantly higher for direct R0 compared to converted R0 with 62.3% compared to 21.8% (hazard ratio (HR)=0.298; 95%CI=0.186-0.477, P<0.001). 3-YSR was similar between converted R0 and R1 (21.8% vs. 13.3%; HR=0.928; 95%CI=0.526-1.636, P=0.792). In multivariate analysis, advanced T (P<0.001), N (P<0.001), R (P=0.003) and M1 status (P<0.001) were associated with worse overall survival (OS). IOC and consecutive extended resection for positive resection margins in gastrectomy for proximal gastric and gastroesophageal junction does not achieve long-term survival benefits in advanced tumor stages.