Positive Proximal Resection Margin Research Articles

480. OUTCOMES OF ADJUVANT LOCAL TREATMENT AFTER ESOPHAGEAL SURGERY WITH POSITIVE RESECTION MARGIN IN INTRATHORACIC ANASTOMOSIS

Abstract Esophageal cancer is aggressive diseases requiring surgery as an essential part of treatment. To achieve increased overall survival, complete resection (R0) is preferred. In some case, however, we encounter positive resection margin (R1). Further resection will be required, but sometimes it is difficult to do additional procedure because of various reasons, especially the highest location of anastomosis. Hypothesis of study is that R1 resection with adjuvant local therapy shows comparable result with R0 resection in intrathoracic anastomosis From 2000 to 2017, total 2723 patients received the esophagectomy and mediastinal lymph node dissection for esophageal cancer. R0 resection was 1701, and R1 resection was 76 patients. Patients who received distal esophagectomy (n=56) and lack of information about adjuvant therapy (n=24) were excluded Because of differences in some variables, we conducted 2:1 propensity score matching to reduce differences between groups. Comparison of R1 resection group with adjuvant local therapy to R0 resection group is conducted Overall survival (OS) and recurrence free survival (RFS) were estimated with Kaplan-Meier method. 76 patients were identified with R1 resection. Of those patients, 30 patients showed positive proximal resection margin from frozen section during surgery. When compared to R0 resection group (including patients with adjuvant treatment), OS and RFS were statistically lower in R1 resection group (p=0.03 and 0.023, respectively) When comparing R1 with adjuvant local treatment group to R0 resection group, there were no statistical differences in both OS and RFS.(p=0.13 and 0.22, respectively) In R1 resection group, adjuvant local treatment group show favorable result compared to non-local treatment group, but there were no statistical differences in OS and RFS.(p=0.26 and 0.17, respectively) R1 resection with proper adjuvant local treatment enable us to achieve comparable result with R0 resection group in intrathoracic anastomosis When anastomosis is made at the highest level of thorax (i.e. thoracic inlet level), it is not easy to perform additional intrathoracic resection. If it is difficult to do further resection when resection margin is positive, adjuvant local treatment after surgery can be one reasonable option to improve patient’s survival or minimize disease recurrence

473. SAFETY AND USEFULNESS OF LARYNX- PRESERVING HIGH-LEVEL CERVICAL ANASTOMOSIS FOR CERVICAL ESOPHAGEAL CANCER

Abstract In cases of cervical esophageal cancer, total Pharyngo-Laryngo-Esophagectomy is often performed when the oral edge of the primary tumor is less than 2 cm from the esophageal entrance. In our hospital, we provide neo-adjuvant chemotherapy for cervical esophageal cancer and perform larynx-preserving esophagectomy whenever possible. The aim of this study was to evaluate the safety and efficacy of larynx- preserving high-level cervical anastomosis for cervical esophageal cancer. 41 patients underwent larynx- preserving esophagectomy for cervicothoracic esophageal cancer between January 2009 and September 2021 at our hospital were included. The distance from the oral edge of the primary tumor to the esophageal entrance was measured by esophagography and endoscopy. Patients with the distance of 2 cm or less were classified as the high cervical anastomosis group (H group: n=23), and patients with the distance of 2.1 cm or more were classified as the low cervical anastomosis group (L group: n=18). We compared the short-term and long-term results between the H and L groups. There were no differences between H and L groups in terms of patient characteristics, such as clinical depth of tumor invasion, grading of lymph node metastasis, frequency neo-adjuvant chemotherapy. The incidence of postoperative complications was similar in the two groups such as pneumonia, anastomotic leakage, anastomotic stenosis, recurrent nerve palsy. In histopathological examination, the rate of positive proximal resection margin was significantly higher in H group. (34.8 vs 5.6%(P=0.028). 3-year recurrence-free survival rate and 3-year survival rate were similar in the two groups. The anastomotic recurrence rates did not differ between the two groups. (5.0 vs 5.9% (P=0.715)) In the H group, the rate of positive proximal resection margin was significantly higher. However, there was no difference in the anastomotic recurrence rate and the 3-year survival rate between the two groups. Therefore, we believe that larynx- preserving high-level cervical anastomosis is useful to maintain QOL in cervical esophageal cancer patients with the oral edge of the primary tumor is less than 2 cm from the esophageal entrance.

Transthoracic esophagectomy compared to transhiatal extended gastrectomy for adenocarcinoma of the esophagogastric junction: a multicenter retrospective cohort study.

Optimal surgical treatment for Siewert type II esophagogastric junction adenocarcinoma is debated. The aim of this study was to compare transhiatal extended gastrectomy (TEG) and transthoracic esophagectomy (TTE). Patients with Siewert type II tumors who underwent a resection by TEG or TTE in two centers (Erasmus University Medical Center, Rotterdam, and University of Verona) between 2014 and 2019 were identified. To limit selection bias, patients were matched for baseline characteristics and compared with a multivariable logistic regression model. Some 159 patients treated by TEG (60 patients, 37.7%) or TTE (99 patients, 62.3%) were included. Patients in the TEG group were older, had less tumor invasion of the esophagus, and were more often excluded from neoadjuvant therapy. Post-operative morbidity was comparable (P = 0.88), while 90-day mortality was higher after TEG (90-day mortality 10.0% in TEG group vs. 2.0% in TTE group P = 0.01). R0 resection was achieved in 83.3% of patients after TEG and in 97.9% after TTE (P < 0.01), with the proximal resection margin involved in 16.6% of patients after TEG versus 0 in TTE group (P < 0.01). The 3-year overall survival was comparable (TEG: 36.5%, TTE: 48.4%, P = 0.12). At multivariable analysis, (y)pT category was an independent risk factor for 3-year recurrence. After matching, TEG was still associated with an increased risk of incomplete tumor resection (P = 0.03) and proximal margin involvement (P < 0.01), while there were no differences in post-operative morbidity (P = 0.56) and mortality (P = 0.31). Our data suggest that patients with Siewert type II tumors treated by TEG are exposed to a higher risk of positive proximal resection margin compared to TTE.

Impact of proximal resection margin involvement on survival outcome in patients with proximal gastric cancer

AimThe aim of this study was to evaluate the risk factors for proximal resection margin involvement and its impact on survival outcome in patients with proximal gastric cancer.MethodsA total of...

A positive proximal resection margin is associated with anastomotic complications following primary ileocaecal resection for Crohn's disease.

Bowel resection in patients with Crohn's disease (CD) has a high reported rate of postoperative complications and surgical recurrence. A macroscopically normal resection margin is recommended in CD surgery as wider margins do not translate in reduced recurrence rates. The aim of this study was to evaluate the association between resection margin status and anastomotic complications following ileocaecal resection for primary CD. All patients treated with ileocaecal resection for primary CD from 2010 to 2018 were included in this retrospective observational study. Emergency operations and recurrent CD were excluded. Patients in whom an anastomosis was not fashioned at the time of the surgery were also excluded. Histopathology data collected included macroscopic description, presence of macroscopic and microscopic involvement of the proximal and distal resection margins. The primary outcome was the rate of positive resection margin in patients who developed anastomotic complications(anastomotic leaks and intra-abdominal collections), and the secondary outcomes were overall complications rate, length of hospital stay, reoperations and rehospitalisation within 30days. A total of 104 patients were included. The proximal resection margin was microscopically involved in 19 patients (18.2%). Ten patients (9.6%) developed intra-abdominal anastomotic related complications, with 5 patients out of 10 (50%) in the group of postoperative anastomotic complications having a positive microscopic proximal margin at histology, compared to 14 patients (14.9%) in the group that did not develop anastomotic complications (p < 0.0001). Microscopic involvement of the proximal resection margin is more frequent in patients who develop postoperative anastomotic complications following elective ileocaecal resection for primary CD.

Do dysplastic proximal resection margins predict the risk of anastomotic recurrence and overall survival in patients with esophageal squamous cell carcinoma?

Positive proximal resection margins are strongly associated with anastomotic recurrence in esophageal cancer. However, the prognostic significance of dysplastic proximal resection margins remains unclear. The aim of this study is to investigate whether the dysplastic proximal resection margin can predict anastomotic recurrence and overall survival in patients with esophageal squamous cell carcinoma. Between 2000 and 2014, patients with esophageal squamous cell carcinoma who received a nonpalliative resection and survived the perioperative period were included. Two expert pathologists independently reviewed the proximal resection margin status, which was classified as negative, dysplastic, or positive. The kappa statistic was used to test interobserver reliability. Anastomotic recurrence and overall survival served as the main outcome measures. The study cohort consisted of 469 patients (445 males and 27 females). There was an excellent interobserver agreement for negative (kappa=0.88), dysplastic (kappa=0.88), and positive (kappa=1) proximal resection margins-which were identified in 418 (89.1%), 37 (7.9%), and 14 (3.0%) patients, respectively. After a median follow-up of 21.6 months, 30 (6.4%) patients developed an anastomotic recurrence. Compared with patients with negative proximal resection margins (24/418, 5.7%), the occurrence of anastomotic recurrence was more commonly observed in those with positive proximal resection margins (3/14, 21.4%, P=0.017) but not in those with dysplastic proximal resection margins (3/37, 8.1%, P=0.56). Multivariable Cox regression analysis identified positive proximal resection margins (hazard ratio: 5.93, P=0.010) and advanced clinical stage (hazard ratio: 12.04, P=0.023) as independent risk factors for anastomotic recurrence. Dysplastic proximal resection margins were not retained in the model as an independent predictor (hazard ratio: 1.38, P=0.602). The 5-year overall survival rates of patients with negative (38.2%) and dysplastic margins (27.0%) were similar (P=0.814), and significantly higher than that observed in those with positive proximal resection margins (9.5%, P=0.015). In conclusion, dysplastic proximal resection margins can be identified in at least 7.9% of patients with esophageal squamous cell carcinoma, but neither they are associated with an increased risk of anastomotic recurrence nor they portend a poor overall survival.

Proximal Resection Margins: More Prognostic than Distal Resection Margins in Patients Undergoing Hilar Cholangiocarcinoma Resection.

PurposeEven though the therapeutic gold standard of hilar cholangiocarcinoma (HCCA) resection is cancer-free resection margin (RM), surgical treatment still remains challenging. This study evaluated the prognostic significance of RM status in resected HCCA patients and identified survival prognostic factors.Materials and MethodsWe reviewed records of 96 HCCA patients who underwent surgery from 2001 to 2012 and analyzed the RM status and prognostic factors that affecting survival.ResultsNegative RM (n=31, 33%) was significantly associated with better survival vs. positive RM (n=65, 67%) (mean survival time [MST], 33 months vs. 21 months; p=0.011). Margins with histological findings of non-dysplastic epithelium, low-grade dysplasia, and carcinoma in situ were not associated with survival differences (MST, 33 months vs. 33 months vs. 30 months; p=0.452), whereas positive margins were associated with poorer survival relative to carcinoma in situ (MST, 30 months vs. 21 months; p=0.050). Among patients with R0 resection, narrow (≤ 5 mm) and wide (> 5 mm) margins were not associated with survival differences (MST, 33 months vs. 30 months; p=0.234). Although positive proximal RM was associated with poorer survival compared to negative RM (MST, 19 vs. 33; p=0.002), no survival difference was observed between positive and negative distal RMs (MST, 30 vs. 33; p=0.628). Proximal RM positivity (hazard ratio [HR], 2.688; p=0.007) and nodal involvement (HR, 3.293; p < 0.001) were independent survival prognostic factors.ConclusionA clear RM, especially proximal RM status, was significant prognosticator, and proximal bile duct resection to the greatest technically feasible extent may be necessary, with careful consideration of the potential morbidity and oncologic outcomes after resection. However, an aggressive approach to obtain a negative distal RM might be controversial and should be considered carefully, depending on the patient's status.

Unexpected Microscopically Positive Proximal Resection Margins in Esophageal Squamous Cell Carcinoma After Chemoradiotherapy: Predictors and Prognostic Significance.

Esophageal cancer has the propensity to spread in a longitudinal manner (either proximally or distally), potentially resulting in the unexpected presence of microscopic disease at grossly tumor-free margins. The clinical significance of this phenomenon in patients treated with chemoradiotherapy (CRT) remains unclear. The purpose of this study was to investigate the prevalence, predictors, and prognostic impact of microscopically positive proximal resection margins (PPRMs) in patients with esophageal squamous cell carcinoma (ESCC) who received CRT. Between 2000 and 2014, we identified 332 ESCC patients who underwent complete gross resection (R0/R1) following CRT. Patients were divided into two groups according to the status of the proximal resection margins on microscopic examination [negative proximal resection margins (NPRMs) vs PPRMs]. The occurrence of anastomotic leakage (AL) and anastomotic recurrence (AR) served as outcome measures. Sixteen (4.8%) patients had PPRM. The presence of PPRM was not associated with AL but was a strong predictor of AR (PPRM vs NPRM, 23.1 vs 7%, respectively, P=0.033). Multivariate analysis identified a resection margin length <3.5cm [odds ratio (OR) 4.473, P=0.022] and salvage resection (OR 3.171, P=0.045) as independent predictors of PPRM. The estimated PPRM rates were 16.7, 6.3, and 1.3% for patients with 2, 1, and 0 predictors, respectively. PPRM occurred in 4.8% of ESCC patients following CRT and was associated with AR. An intraoperative frozen section margin analysis should be performed in patients carrying risk factors to avoid unexpected PPRM.

A case of distal extrahepatic cholangiocarcinoma with two positive resection margins

Cholangiocarcinoma is an uncommon primary malignancy of the biliary tract that is challenging to diagnose and treat effectively due to its relatively silent and late clinical presentation. The present study reports a case of a 60-year-old male with distal extrahepatic cholangiocarcinoma with a 3-week history of painless obstructive jaundice symptoms and subjective weight loss. Imaging revealed an obstructing lesion in the common bile duct, just distal to the entrance of the cystic duct. Pathology revealed moderately differentiated cholangiocarcinoma with two positive proximal resection margins. The two positive resection margins presented a challenge during surgery and points to an urgent need for further studies to better illuminate diagnostic and therapeutic options for patients with similar clinicopathological presentation.

Optic nerve gliomas: role of Ki-67 staining of tumour and margins in predicting long-term outcome

BackgroundAlthough optic nerve gliomas (ONGs) are generally slow-growing with a good prognosis, factors for identifying cases that may pursue a more aggressive course are not well established. The authors investigated...

Extent of oesophageal resection for adenocarcinoma of the oesophagogastric junction

Aims: The optimal extent of oesophageal resection and surgical approach in patients treated for adenocarcinomas of the oesophagogastric junction (OGJ) are still uncertain. We report the correlations between resection margin involvement and outcome. Methods: Patients with positive proximal resection margin (PPRM) and those with negative proximal resection margin (NPRM) were compared. Results: Of 94 patients with macroscopically complete resection, eight were PPRM. There was no difference between the two groups in postoperative mortality or morbidity rates, in anastomotic leakage or in recurrence rates. The median survival in the PPRM group was 11.1 months compared with 36.3 months in the NPRM group ( P=0.02). No infiltration was observed in patients whose proximal margin exceeded 7 cm. The extended transthoracic approach was the only prognostic factor for tumours type II ( P=0.03, RR=1.4, 95% CI: 1.1–1.8). Conclusion: Histologic infiltration of oesophageal resection margin influences 5-year survival rate. In adenocarcinomas of the OGJ that can be treated curatively, a transection with a 8 cm oesophagectomy above the tumour in fresh specimen should be performed, and by thoracoabdominal approach for tumours type I and II.

Prognostic Value of Esophageal Resection-line Involvement in a Total Gastrectomy for Gastric Cancer

Purpose: A positive esophageal margin is encountered in a total gastrectomy not infrequently. The aim of this retrospective review was to evaluate whether a positive esophageal margin predisposes a patient to loco-regional recurrence and whether it has an independent impact on long-term survival. Materials and Methods: A retrospective review of 224 total gastrectomies for adenocarcinomas was undertaken. The Chisquare test was used to determine the statistical significance of differences, and the Kaplan-Meier method was used to calculate survival rates. Significant differences in the survival rates were assessed using the log-rank test, and independent prognostic significance was evaluated using the Cox regression method. Results: The prevalence of esophageal margin involvement was (8/224). Univariate analysis showed that advanced stage (stage III/IV), tumor size (5 cm), tumor site (whole or upper one-third of the stomach), macroscopic type (Borrmann type 4), esophageal invasion, esophageal margin involvement, lymphatic invasion, and venous invasion affected survival. Multivariate analysis demonstrated that TNM stage, venous invasion, and esophageal margin involvement were the only significant factors influencing the prognosis. All patients with a positive esophageal margin died with metastasis before local recurrence became a problem. A macroscopic proximal distance of more than 6 cm of esophagus was needed to be free of tumors, excluding one exceptional case which involved 15 cm of esophagus. Conclusion: All of the patients with a positive proximal resection margin after a total gastrectomy had advanced disease with a poor prognosis, but they were not predisposed to anastomotic recurrence. Early detection and extended, but reasonable, surgical resection of curable lesions are mandatory to improve the prognosis.

Positive proximal resection margins after resection for carcinoma of the oesophagus and stomach: effect on survival and symptom recurrence.

Our aim was to determine the frequency, survival and symptomatic local recurrence rate of patients with a positive proximal resection margin in a series of patients having a resection for carcinoma of the oesophagus or stomach. A retrospective study of pathology reports and case notes. Survival and data on local recurrence were obtained from the patient or general practitioner. Ten (11.5%) of 87 patients having a gastric or oesophageal resection for carcinoma had a positive proximal resection margin. All 10 patients underwent a palliative resection for late-stage disease. Nine were dead at an average 8.3 months (range 2-20 months) post-resection and one patient remains alive at 9 months. Only one of these 10 patients had evidence of a local recurrence with recurrent dysphagia prior to death at 11 months. A high incidence of a positive proximal resection margin was found. This occurred in patients who underwent a palliative resection for late-stage disease, most of whom died before local recurrence became a problem. For patients recognized as having late-stage disease, surgery for symptom palliation need not be aggressive (such as to include a thoracotomy) because achieving microscopic clearance is unlikely to affect the long-term outcome.