Esophageal Margin Research Articles

Application of intraoperative endoscopic in laparoscopic gastric cancer surgery

The application of intraoperative endoscopic in laparoscopic gastric cancer surgery can compensate for the limitations of a single laparoscopic mode that only relies only on serous vision, and work as the Chinese saying "four ounces can move a thousand pounds". Intraoperative endoscopy not only effectively helps to accurately locate the tumor boundary in real-time and achieve precise resection, but also enables real time and interactive inspection of the quality of esophagojejunal anastomosis, reduces postoperative complications such as anastomotic leakage and bleeding, and accelerates postoperative recovery. However, most centers in China do not emphasize the application of intraoperative endoscopy in laparoscopic gastric cancer surgery due to the lack of a good cooperation mechanism between the gastrointestinal surgery team and the digestive endoscopy team. Therefore, based on clinical practice experience, the author briefly discusses the application of intraoperative endoscopic in routine laparoscopic gastric cancer surgery, including pre-examination preparation operator position, endoscopic techniques, postoperative management, etc., covering application scenarios such as early tumor localization, confirmation of upper esophageal margin confirmation, anastomotic examination, biopsy of primary lesion specimens in neoadjuvant/conversion treatment cases. We hope that it will help gastroenterologists to better apply intraoperative endoscopy in laparoscopic gastric cancer surgery, and assist in precise resection and safe anastomosis of the operation.

Skip metastasis at the esophageal resection margin in radical gastrectomy: clinical characteristics of 30 cases

Objective: To summarize the clinical characteristics of patients with skip metastasis at esophageal resection margin during radical gastrectomy. Methods: This is a descriptive study of case series. Relevant data from 2006 to 2022 were collected from two major gastric cancer consultation and treatment centers: Nanjing Drum Tower Hospital and Jinling Hospital.Characteristics, surgical approach, number of dissected lymph nodes, immunohistochemical staining, and pathological staging were summarized and analyzed. The distribution of residual tumor cells at the esophageal margins was further analyzed at the cellular and tissue levels. Skip metastasis at the esophageal resection margin was defined as a negative esophageal margin with a positive margin in the cephalad donut. Results: Thirty (0.33%, 30/8972) eligible patients, 24 (80.0%) of whom were male, were identified in the two centers. The mean age was 63.9±11.0 years. Seventeen (56.7%) of these patients had papillary or tubular adenocarcinomas, including 13 (43.3%) poorly- and four (13.3%) moderately-differentiated tumors; four (13.3%) had signet-ring cell carcinomas; four (13.3%) mucinous adenocarcinomas; three (10.0%) mixed adenocarcinomas, including two with poorly-differentiated tubular adenocarcinomas mixed with signet-ring cell carcinoma and mucinous adenocarcinoma; and one had a poorly differentiated tubular adenocarcinoma mixed with signet-ring cell carcinoma. Two patients (6.7%) had other types of cancer, namely adenosquamous carcinoma in one patient and undifferentiated carcinoma in the other one. The predominant tumor sites were the lesser curvature (n=26, 86.7%) and the cardia (n=24, 80.0%). The mean tumor diameter was 6.6 cm, mean distance between tumor and esophageal resection margin was 1.5 cm, and proportions of tumor invasion into the dentate line, nerves, and vessels were 80.0% (24/30), 86.7%(26/30), and 93.3% (28/30), respectively. The mean number of lymph nodes resected was 20.4±8.9. The pathological stage was mainly T4 (n=18, 60.0%) and N3 (n=21, 70.0%), the median Ki67 was 52.7%, and the rates of positivity for HER2, EGFR, VEGFR, E-cadherin and PD-L1 were 40.0% (12/30), 46.7% (14/30), 80.0% (24/30), 86.7% (26/30) and 16.7% (5/30), respectively. At the cellular level, cancer cells were mainly distributed in small focal areas, as cell masses, or as tumor thrombi; large numbers of widely distributed atypic cells were seldom observed. At the tissue level, cancer cells were located in the mucosal layer in seven patients (23.3%), in the submucosal layer in 18 (60.0%), and in the muscular layer in five (16.7%); no cancer cells were identified in the outer membrane. Five of the seven tumors were located in the lamina propria, two in the muscularis mucosae, and none in the mucosal epithelium. Conclusion: Patients with skip metastasis at the esophageal resection margin at radical gastrectomy have unfavorable tumor biology and a high proliferation index, are at a late pathological stage, and the residual cancer is mostly located in the submucosa.

Measuring distance from the incisors to the esophageal cancer by FDG PET/CT: endoscopy as the reference

BackgroundUsing endoscopy as the reference, this study evaluated the accuracy of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) in measuring distance from the incisors to the PET detectable esophageal cancer. If there is high concordance between endoscopic and PET measurements, our results may provide a basis to use FDG PET/CT in cooperation with endoscopic measurement to localize those PET/CT and CT undetectable esophageal tumors for radiotherapy planning.MaterialsEsophageal cancer patients with pretreatment endoscopy and FDG PET/CT detectable esophageal tumors were recruited retrospectively. The distances from the incisors to the proximal esophageal tumor margins were determined by endoscopy and by the sagittal images of FDG PET/CT. The endoscopic measurement was used as the comparative reference. A nuclear medicine doctor and a radiation oncologist each performed the FDG PET/CT measurement twice for every patient. We analyzed the differences in these measurements, and assessed agreement and reproducibility of the results by the intraclass correlation coefficient (ICC).ResultsThirty-four patients, with 35 esophageal tumors, were included. By endoscopy and FDG PET/CT, the mean distances from the incisors to the proximal esophageal tumor margin were 27.3 ± 6.4 cm (range 17.1–40.0 cm) and 26.8 ± 6.3 cm (range 15.7–41.3 cm), respectively. The mean absolute differences between the endoscopic and four FDG PET/CT measurements ranged from 1.129 to 1.289 cm (SD: 0.98–1.19). The measurement agreement between FDG PET/CT and endoscopy by ICC was between 0.962 and 0.971. The intra- and interobserver reproducibilities of the two readers were excellent (intraobserver ICC: 0.985, 0.996; interobserver ICC: 0.976–0.984).ConclusionsFDG PET/CT was in high agreement with endoscopy in measuring the distance from the incisors to the proximal esophageal tumor margin. For FDG PET/CT and CT undetectable esophageal cancer, incorporation of the endoscopic measurement with PET/CT might be a way for making radiotherapy plan.

Evaluation of HOTAIR and HOXC13 Genes in Tumor And Normal Tissues Adjacent to Tumor in Patients with Esophageal Cancer

Background and Objectives One of the molecules that associated with cancer progression are Long non coding RNA (LncRNAs). HOX transcript antisense RNA (HOTAIR) is a member of the lncRNA family. Homeobox C13 (HOXC13) gene is one of the several HOX genes that is located near the HOTAIR. This study was to evaluate the expression of HOTAIR and HOXC13 genes in tumor and normal tissues adjacent to tumor in patients with esophageal cancer. Methods This is an experimental study. 30 pairs of esophageal tumor tissue and tumor margin tissue were purchased. RNA of these tissues was extracted and Real-time PCR with Beta-actin gene was used for their relative expression. Statistical analysis of data, t-test and Analysis of variance (ANOVA) were performed in GraphPad Prism 8 software. Results Comparison of target gene expression in esophageal tumor samples relative to tumor margins showed that the relative expression of the HOTAIR genes was 1.95 time (P=0.0219) and the HOXC13 14.4 time (P=0.014) significantly increased expression. Also, the HOXC13 gene expression shows a significant relationship with metastasis to distant regions, type and degree of tumor. The correlation coefficient between the relative expression of the HOTAIR and the HOXC13 genes was 0.152. It was positive but not significant between the two genes (P=0.2). Conclusion According to the association of the HOTAIR and the HOXC13 genes with cancer, our study may partially express the role of these two genes in the tumorigenesis process in the development of esophageal cancer.

Guiding significance of intraoperative frozen section for range of judging incisal edge of Esophageal Carcinoma

Objective:To explore guiding significance of intraoperative frozen section for judging incisal edge range of esophageal carcinoma.Methods:A retrospective descriptive research design was used to collect the clinical and pathological data of 205 patients with esophageal cancer who were treated in Huaihe Hospital of Henan University from March 2012 to July 2015. Among them, 46 patients’ esophageal margins were made into intraoperative frozen sections.Results:In the 205 cases, nine cases were diagnoses with upper incisal edge cancerization, accounting for 4.39%, and five cases were diagnosed with lower incisal edge cancerization, accounting for 2.4%. There were 14 cases in total, accounting for 6.83%. four cases showed positive residual end of intraoperative frozen section.Conclusion:The cancerous focus residue of incisal edge in esophageal carcinoma is not uncommon. Intraoperative frozen section is helpful to judge the proper excision length of esophageal carcinoma.

Treatment Alternatives for Recurrent Esophagogastric Junction Adenocarcinoma: Case Report of an Ileocolonic Reconstruction and Literature Review

Esophagogastric junction tumors are a challenging pathology for surgeons and the best treatment depends on an adequate initial localization and stadification. Approximately half of patients relapse after curative surgery during the first two years. Surgical resection could increase the survival of these patients, but the esophageal reconstruction is a surgical challenge for which there are multiple reconstruction techniques described with different organs.In this report, we present the case of a patient with an esophagogastric junction tumor treated initially with total gastrectomy and esophageal margin. The patient presented an anastomotic recurrence that was taken to surgical resection, but a second recurrence required a residual esophagectomy with ileocolonic reconstruction, to achieve adequate oncologic treatment.

Current status of surgical treatment for adenocarcinoma of esophagogastric junction

Adenocarcinoma of esophagogastric junction (AEG) refers to the tumor invading the esophagogastric junction and Siewert type is the most practical classification at present. There are many surgical controversies about AEG, mainly focusing on Siewert Ⅱ type. In this paper, definition and classification of AEG, epidemiological characteristics, pathological TNM staging, rules of lymph node metastasis and dissection, esophageal resection margin, gastric resection scope, surgical approach and other issues are investigated combined with recent high-quality evidence. Key words: Adenocarcinoma of esophagogastric junction; Siewert type; Surgical treatment; Lymph node dissection; Surgical approach

Prevalence of False-Negative Results of Intraoperative Consultation on Surgical Margins During Resection of Gastric and Gastroesophageal Adenocarcinoma

Intraoperative consultation (IOC) on surgical margins during curative intent resection of gastric and gastroesophageal adenocarcinoma presents sampling and interpretive challenges. A false-negative (FN) IOC result can affect clinical care. Many factors may be associated with higher risk for an FN result of IOC on surgical margins. To assess the prevalence and clinical implications of FN results of IOC on surgical margins during resection of gastric and gastroesophageal adenocarcinoma. This retrospective study assessed the results of IOC on surgical margins to determine the prevalence of FN results and the accuracy and clinical implications of the results for patients undergoing curative intent resection for gastric or gastroesophageal adenocarcinoma. The study examined patients with gastric or gastroesophageal adenocarcinoma who underwent resection with curative intent at a single-institution referral center from January 1, 1992, to December 31, 2015. Curative intent gastric and/or esophageal resection. False-negative results of IOC on surgical margins, accuracy of the results, factors associated with decreased accuracy of the results, and clinical implications of FN results. This study included 2002 patients (median age, 65 years; 1343 [67.1%] male; 1638 [81.8%] white) who received 3171 IOCs on surgical margins. Of the 3171 IOCs, the prevalence of FN results was 1.7%, with an accuracy of 98.1%. The prevalence of an FN IOC result was 1.2% for esophageal margins, 2.0% for gastric margins, and 2.5% for duodenal margins (P = .04). The prevalence of an FN IOC result was higher for patients with diffuse or signet ring disease compared with those without (2.6% vs 1.2%, P = .002) and for those not receiving neoadjuvant radiotherapy compared with those receiving neoadjuvant radiotherapy (1.4% vs 0.7%, P < .001). The prevalence of FN results of IOCs performed by nongastrointestinal pathologists was similar to that of IOCs performed by gastrointestinal pathologists (2.3% vs 1.9%, P = .60). The disease-specific survival was 34 months (95% CI, 20.7-47.2 months) for those with an FN result and 26.9 months (95% CI, 18.3-35.4; P = .72) for those with a true-positive result. Half of the patients with FN IOC results received further margin-directed therapy, including subsequent resection or radiotherapy. This study found that IOC on surgical margins was accurate at a specialty center. Signet ring or diffuse disease, duodenal margins, and not receiving neoadjuvant radiotherapy were challenging scenarios for IOC on surgical margins. The use of IOC on surgical margins may be optimal when it will affect intraoperative decision making framed by the stage of disease, tumor location, and surgical fitness of the patient.

A rapid, computational approach for assessing interfraction esophageal motion for use in stereotactic body radiation therapy planning

PurposeWe present a rapid computational method for quantifying interfraction motion of the esophagus in patients undergoing stereotactic body radiation therapy on a magnetic resonance (MR) guided radiation therapy system. Methods and materialsPatients who underwent stereotactic body radiation therapy had simulation computed tomography (CT) and on-treatment MR scans performed. The esophagus was contoured on each scan. CT contours were transferred to MR volumes via rigid registration. Digital Imaging and Communications in Medicine files containing contour points were exported to MATLAB. In-plane CT and MR contour points were spline interpolated, yielding boundaries with centroid positions, CCT and CMR. MR contour points lying outside of the CT contour were extracted. For each such point, BMR(j), a segment from CCT intersecting BMR(j), was produced; its intersection with the CT contour, BCT(i), was calculated. The length of the segment Sij, between BCT(i) and BMR(j), was found. The orientation θ was calculated from Sij vector components:θ = arctan[(Sij)y / (Sij)x]A set of segments {Sij} was produced for each slice and binned by quadrant with 0° < θ ≤ 90°, 90° < θ ≤ 180°, 180° < θ ≤ 270°, and 270° < θ ≤ 360° for the left anterior, right anterior, right posterior, and left posterior quadrants, respectively. Slices were binned into upper, middle, and lower esophageal (LE) segments. ResultsSeven patients, each having 3 MR scans, were evaluated, yielding 1629 axial slices and 84,716 measurements. The LE segment exhibited the greatest magnitude of motion. The mean LE measurements in the left anterior, left posterior, right anterior, and right posterior were 5.2 ± 0.07 mm, 6.0 ± 0.09 mm, 4.8 ± 0.08 mm, and 5.1 ± 0.08 mm, respectively. There was considerable interpatient variability. ConclusionsThe LE segment exhibited the greatest magnitude of mobility compared with the middle and upper esophageal segments. A novel computational method enables personalized, nonuniform esophageal margins to be tailored to individual patients.

Study on the safety margin of esphagus in the radical gastrectomy of adenocarcionma of esophagogastric junction

Objective To discuss decision of the safety margin of esophagus in the radical gastrectomy of adenocarcionma of esophagogastric junction. Methods The length of esophageal resection margin of intraoperative, postoperative and pathological large slice under the microscope of 50 cases adenocarcionma of esophagogastric junction underwent radical gastrectomy were measured, and the proximal invasive length of esophagus in large pathological slice were also measured, and the relationship between it and pathological factors was analyzed.Determined the minimum safety cut edge distance. Results In 46 of 50 patients, proximal intramural spread of the tumor was observed.The invasive length of tumor from 0.1 cm to 3.5 cm.The invasive length of tumor was <1.0 cm with 11 patients, 1.0-1.5 cm with 19 patients, 1.5-3.0 cm with 15 patients, in only 1 patient was the distance of spread 3.5 cm.Invasive length of adenocarcionma of esophagogastric junction had a significant difference between the groups in different pathological factors(P<0.001). Conclusion The length of 3.5 cm is the safety margin of esophagus in the radical gastrectomy of adenocarcionma of esophagogastric junction(SiewertⅡ, Ⅲ type) by abdominal incision. Key words: Adenocarcionma of esophagogastric junction; Operation; Invasive length

Positive esophageal proximal resection margin: an important prognostic factor for esophageal cancer that warrants adjuvant therapy.

Positive esophageal proximal resection margin (ERM+) following esophagectomy was considered as incomplete or R1 resection. The clinicopathological data and long-term prognosis of esophageal cancer (EC) patients with ERM+ after esophagectomy were still unknown. Therefore, the aim of this study was to assess the clinical significance of ERM+ and its therapeutic option. From November 2008 to December 2014, 3,594 patients with histologically confirmed EC underwent radical resection in our department. Among them there were 37 patients (1.03%) who had ERM+. ERM+ was defined as carcinoma or atypical hyperplasia (severe or moderate) at the residual esophageal margin in our study. For comparison, another 74 patients with negative esophageal proximal resection margin (ERM-) were propensity-matched at a ratio of 1:2 as control group according to sex, age, tumor location and TNM staging. The relevant prognostic factors were investigated by univariate and multivariate regression analysis. In this large cohort of patients, the rate of ERM+ was 1.03%. The median survival time was 35.000 months in patients with ERM+, significantly worse than 68.000 months in those with ERM- (Chi-square =4.064, P=0.044). Survival in patients with esophageal residual atypical hyperplasia (severe or moderate) was similar to those with esophageal residual carcinoma. Survival rate in stage I-II was higher than that in stage III-IV (Chi-square =27.598, P=0.000) in ERM-; But there was no difference between the two subgroups of patients in ERM+. Furthermore, in those patients with ERM+, survival was better in those who having adjuvant therapy, compared to those without adjuvant therapy (Chi-square =5.480, P=0.019). And the average survival time which was improved to a well situation for ERM+ patients who have adjuvant therapy was 68.556 months which is comparable to average survival time (65.815 months) of ERM- for those patients who are at earlier stages. ERM+ after esophagectomy nowadays is of low incidence but still an important prognostic factor for patients with EC. Survival of ERM+ patients who have adjuvant therapy was improved to a well situation which is comparable to overall survival (OS) rate of ERM- for those patients who are at earlier stages.

TU‐AB‐BRA‐08: Slice by Slice Approach to Quantifying Inter‐Fractional Organ Motion

Purpose:To demonstrate the feasibility of a rapid computational algorithm for generating esophageal margin expansions.Methods:Inter‐fraction MRI allows visualization of relative variations of the esophagus and other critical structures when compared to planning CT. We have developed a rapid computational method for quantifying this motion. CT simulation and on‐treatment MR data sets of seven patients were obtained using a 0.3 T MR‐guided RT system. Rigid registration guided by bony anatomy from the cricoid to the gastro‐esophageal junction was used for transferring CT contours to MR volumes. CT‐ and MR‐based contours were re‐sampled to form boundaries – BCT and BMR respectively – that densely sample the image grid. Centroids CCT and CMR were calculated slice‐by‐slice from BCT and BMR respectively. For each CT boundary point BCT(i) within an area enclosed by the MR boundary points, the intersection BMR(j) was calculated between the MR boundary and a line defined by BCT(i) and CCT. The length of the vector defined by BCT(i) and BMR(j) provides a margin expansion within a given slice for that vector orientation. This procedure is repeated for every slice to characterize margin expansions along the esophagus.Results:Expansions were determined for in‐plane quadrants along the length of the esophagus. With the analysis relying on simple geometry, the non‐negligible time constraint in the procedure is manual contouring. Given the soft tissue contrast on MR volumes, systematic margin uncertainties are ultimately determined by in‐plane spatial resolution (1.5×1.5 mm2 in most cases).Conclusion:We demonstrate a rapid method for assessing inter‐fractional variation for the sake of suggesting thorough treatment margins (applied to the esophagus). Ongoing work aims to assess intra‐fractional esophageal motion.

Proximal margin length with transhiatal gastrectomy for Siewert type II and III adenocarcinomas of the oesophagogastric junction

A gross proximal oesophageal margin greater than 5 cm is considered to be necessary for curative surgery of adenocarcinoma of the oesophagogastric junction. This study investigated whether a shorter proximal margin might suffice in the context of total gastrectomy for Siewert type II and III tumours. The gross proximal margin was measured on stretched specimens just after resection. Relationships between gross proximal margin lengths and clinicopathological features were investigated in patients with Siewert type II and III adenocarcinoma of the oesophagogastric junction treated by R0-1 surgical resection. For survival analyses, only patients who had undergone R0 resection for pathological (p) T2-4N0-3M0 tumour via a transhiatal approach were evaluated. Of the 140 patients, 120 had a total gastrectomy. Two patients (1·4 per cent) had histologically positive proximal margins and another two (1·4 per cent) developed anastomotic recurrence. Of 100 patients with pT2-4N0-3M0 tumours who underwent gastrectomy via a transhiatal approach, those with gross proximal margins larger than 20 mm appeared to have better survival than those with shorter margins (P = 0·027). Multivariable analysis demonstrated that a gross proximal margin of 20 mm or less was an independent prognostic factor (hazard ratio (HR) 3·56, 95 per cent confidence interval 1·39 to 9·14; P = 0·008), as was pathological node status (HR 1·76, 1·08 to 2·86; P = 0·024). Gross proximal margin lengths of more than 20 mm in resected specimens seem satisfactory for patients with type II and III adenocarcinoma of the oesophagogastric junction treated by transhiatal gastrectomy.

63. Gastric cancer surgery: The unexpected positive oesophageal margin/direct invasion into colon or pancreas

UGI surgeons must be aware before the operation of those gastric cancer patients with a greater risk of having positive oesophageal margins after total gastrectomy. It has been shown that patients with larger tumour size, deeper wall penetration, more extensive gastric involvement, greater nodal involvement, higher stage and diffuse histology belong to this group at risk. In those cases, and once the pathologist confirms intraoperatively the oesophageal margin involvement, the surgeon should balance the potential benefit of achieving a negative margin against the risks of performing a more extensive resection.

The application value of diffusion-weighted magnetic resonance imaging in gross tumor volume delineation of esophageal squamous cell carcinoma

Objective To analyze the application value of diffusion-weighted magnetic resonance imaging (DWMRI) in gross tumor volume (GTV) delineation of esophageal squamous cell carcinoma (SCC).Methods Twenty-nine patients with esophageal SCC treated with radical surgery were analyzed.Routine CT scan,MRI T2-weighted and DWMRI were employed before surgery;diffusion-sensitive gradient b-values were taken 400,600 and 800 s/mm2.GTVs were delineated using CT,MRI T2-weighted images and DWMRI under different b-value images.The length of GTVs measured under different images was compared with the pathological length and confirm the most accurate imaging condition.Use radiotherapy planning system to fuse DWMRI images and CT images to investigate the possibility of delineate GTVs on fused images.Results The difference of GTV length value between CT,T2 WI images and specimen was 3.36 mm and 2.84 mm.When b =400,600 and 800 s/mm2,the difference between GTV length value on the DWMRI images and on specimen was 0.47 mm,-0.47 mm and - 1.53 mm;the correlation coefficient of the measuring esophageal lengths on DWMRI images and the pathological lengths was 0.928,0.927 and 0.938.DWMRI images and CT images could fuse accurately on radiotherapy planning system.GTV margin could.show clearly on fused images.Conclusions DWMRI images can display the esophageal carcinoma lengths and margin accurately.When DWMRI images fused with CT images,GTV margin could show clearly,it can be used to delineate GTV accurately. Key words: Esophageal neoplasms; Diffusion-weighted magnetic resonance imaging; Target delineation

Recurrence of intramucosal esophageal adenocarcinoma arising in a former esophagostomy site: a unique case report

A 75-year-old male with a long history of gastroesophageal reflux symptoms developed adenocarcinoma proximally within a long segment of Barrett's esophagus. He was taken for esophagectomy and gastric pull-up, but intraoperatively, he was found to have a marginal blood supply in the gastric tube. A temporary left-sided esophagostomy was created with the gastric tube sutured to the left sternocleidomastoid muscle in the neck. Pathology showed an intramucosal adenocarcinoma, limited to the muscularis mucosa with surrounding high-grade dysplasia and intestinal metaplasia. The proximal esophageal margin showed no tumor cells, but there was low-grade dysplasia within Barrett's esophagus. He was reconstructed after several months, and 2 years after reconstruction, the patient noticed a nodule at the former esophagostomy site. Biopsy revealed an implant metastasis of esophageal adenocarcinoma. Here, we review the literature and discuss the possible etiology.

Four-Dimensional Computed Tomography (4D-CT)-Based Analysis of Intra-Fractional Esophageal Motion

Lung Cancer Patients usually experience esophagitis during radiation, often worsened by combined therapy. To minimize this toxicity lower esophagus (ESO) doses are required, demanding a more accurate determination of relevant margins. These are affected by respiration-induced organ motion. This study evaluates the intra-fractional esophageal motion induced by respiration and determines the population-based approach for esophageal margins.

Anastomotic recurrence in the oesophagus complicating gastrectomy for adenocarcinoma of the stomach.

Gastric adenocarcinomas often spread to the distal oesophagus. Failure to control the disease in this area during total and proximal subtotal gastrectomy results in recurrence at the oesophageal anastomosis. The incidence of recurrence in a series of 351 such patients was 10 per cent and was influenced by the location of the main lesion, the stage of the disease, the presence of tumour at the margin of resection and the length of clearance of the oesophageal margin. Recurrence were prevented only with in vivo margins greater than 12 cm. Dysphagia combined with radiological signs of oesophageal obstruction was diagnostic of anastomotic recurrence regardless of the results obtained by oesophagoscopy and biopsy. Treatment was seldom effective in patients developing recurrence. Complete excision of the entire recurrent process offered the only hope for a long survival in these patients. Prevention by obtaining adequate oesophageal clearance at the time of gastrectomy is the only reasonable approach to this problem. The adequacy of resection cannot be judged accurately by intraoperative palpation of the oesophagus or by frozen section examination of the surgical margins.

Cardia carcinoma considered as a distinct clinical entity.

From 1 January 1969 until 31 December 1985, gastric resections were performed in 937 patients with carcinoma of the stomach and 422 patients with carcinoma of the cardia. During this period, the general frequency of cardia carcinoma increased continuously from 6.6 per cent (1969-71) to 37.5 per cent (1984-85) and a corresponding decrease of carcinomas in other sites was observed. Early carcinomas (pT1) of the oesophageal margin (n = 10, 2.4 per cent) were diagnosed less often than early carcinomas in other sites (n = 177, 18.9 per cent). Whereas 51.4 per cent of all resected carcinomas of the stomach showed no lymph node metastases (pN0), only 14.1 per cent of cardia carcinomas belonged to this category. With respect to operative treatment, Laurén's classification which defines the required margin of clearance according to diffuse type (frequency in cardia carcinoma 43 per cent, in other stomach sites 51 per cent), is of great significance. We believe that extensive oesophageal resection is necessary for patients with such difficult tumours. The pattern of metastasis in cardia carcinoma is similar to that of cancer in other stomach sites, the preferred area is the regional lymph nodes on the lesser curve (83 per cent). Histological classification and metastasis pattern show that cardia carcinoma is a type of carcinoma of the stomach which must be treated according to the criteria of stomach cancer surgery.

Analysis of Recurrence and Survival after Hypopharyngeal Ablative Surgery with Radial Forearm Free Flap Reconstruction

To address the controversial acceptable distal resection margin for the surgical management of patients with hypopharyngeal cancer. Retrospective review of the records of 28 consecutive patients who underwent pharyngoesophagectomy and reconstruction with radial forearm free flaps between 1996 to 2001. The Kaplan-Meier method was used to estimate survival and recurrence-free time. The minimum follow-up time was 2 years, and there were 14 (50%) patients who had recurrences. Analysis revealed that only one (3%) patient experienced a recurrence at the inferior resection margin, the junction of the free flap reconstruction, and the cervical esophagus. Estimated 4 year survival was 48.5%. Total laryngopharyngectomy and partial esophagectomy with radial forearm free flap reconstructions in appropriately selected patients with hypopharyngeal cancer does not compromise local recurrence rates at the distal esophageal margin.