Outcome of microscopically non-radical oesophagectomy for oesophageal and oesophagogastric junctional cancer: nationwide cohort study.

P Hollertz,M Lindblad,I Halldestam,D Edholm,P Sandström

doi:10.1093/bjsopen/zrab038

Abstract

BackgroundMicroscopically non-radical (R1) oesophageal cancer resection has been associated with worse survival. The aim of this study was to identify risk factors for R1 resection and to investigate how this affects long-term survival.MethodsThe Swedish National Register for Oesophageal and Gastric Cancer was used to identify all patients who underwent oesophageal cancer resection with curative intent between 2006 and 2017. Risk factors for R1 resection were assessed by multivariable logistic regression analysis, and factors predicting 5-year survival identified by multivariable Cox regression.ResultsThe study included 1460 patients. Surgical margins were involved microscopically in 142 patients (9.7 per cent). The circumferential resection margin was involved in 114 (7.8 per cent), the proximal margin in 53 (3.6 per cent), and the distal margin in 29 (2.0 per cent). In 30 specimens (2.1 per cent), two or all three margins were involved. Independent risk factors for R1 resection were male sex, low BMI, absence of neoadjuvant treatments, and clinical T4 disease. The 5-year survival rate for the entire cohort was 42.2 per cent, but only 18.0 per cent for those who had an R1 resection. Independent risk factors for death within 5 years of resection were male sex, age above 60 years, normal BMI, ASA fitness grade III, intermediate-level education, R1 resection (hazard ratio 1.80, 95 per cent c.i. 1.40 to 2.32), clinical T3 disease, and clinical lymph node metastasis.ConclusionR1 resection is common and predicts poor 5-year survival. Absence of neoadjuvant treatment is a risk factor for R1 resection.

Highlights

The incidence of cancer of the oesophagus and oesophagogastric junction is increasing in many populations1
Patients were identified in the Swedish National Register for Oesophageal and Gastric Cancers (NREV), which has previously been shown to correctly identify 96 per cent of resections performed in Sweden13
1460 patients who underwent resection of an oesophageal or oesophagogastric junctional cancer were included in the final analysis (Fig. 1)

Summary

Introduction

The incidence of cancer of the oesophagus and oesophagogastric junction is increasing in many populations. Microscopic non-radical resection (R1), where cancer cells are identified at the resection margin, is an adverse prognostic factor compared with tumour-free margins (R0) It is unclear whether this worse prognosis is due to the inadequate surgical margin or whether R1 is a marker of more aggressive tumour biology. Some studies have identified positive margin as an independent negative prognostic factor for survival after resection for cancer of the oesophagus and oesophagogastric junction, whereas others have not. Independent risk factors for death within 5 years of resection were male sex, age above 60 years, normal BMI, ASA fitness grade III, intermediate-level education, R1 resection (hazard ratio 1.80, 95 per cent c.i. 1.40 to 2.32), clinical T3 disease, and clinical lymph node metastasis. Absence of neoadjuvant treatment is a risk factor for R1 resection

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