R1-Resektion beim Magenkarzinom

Risk factor analysis for duodenal margin positivity following gastrectomy for resectable gastric cancer

BACKGROUND

Duodenal margin positivity is a poor prognostic factor following gastrectomy for resectable gastric cancer. Intraoperative frozen section (IFS) analysis allows radical resection to be achieved in a single operation but is time- and resource-consuming. Hence resection is usually performed based on surgeon's judgment and palpation.

AIM OF STUDY

To determine risk factors for duodenal resection margin (RM) positivity following gastrectomy for resectable gastric cancer.

MATERIALS AND METHODS

We retrospectively analyzed prospectively maintained data of 376 patients admitted with diagnosis of gastric cancer from August 2011 to January 2020 in JIPMER, a tertiary center in Puducherry, India. Of these, 146 patients underwent gastric resection with curative intent and were the subject of this study. RM status was assessed by definitive histopathology examination. The potential risk factors were compared between patients with positive margin on definitive histopathology examination and a control cohort of similar patients with negative margins.

RESULTS

Of the 146 patients, 16 patients (10.9%), 11 men and 5 women, had positive duodenal margin. The mean age of study group was 59 years. None of the patient characteristics like age, sex, comorbidities, or addictions were statistically significant with regard to duodenal margin positivity. Among tumor characteristics, locally advanced tumors and pyloroantral tumors were found more frequently in the margin-positive group. High-risk features for duodenal margin positivity were extensive nodal disease, oligometastatic disease, lymphovascular invasion, and perineural invasion. Neoadjuvant chemotherapy and types of surgical access did not have significant impact on RM. Interestingly, both proximal and circumferential resection margin positivity had a linear association with distal margin positivity suggesting that tumor biology may have a significant role in margin positivity. However, none of these factors were statistically significant on multivariate analysis using logistic regression model. Among oligometastatic patients, survival was dependent on R0 resection and was not different from patients without metastases though our study was not powered for survival analysis (mean survival of 11.040 months) and expectedly, duodenal margin positive patients had lower overall survival compared to margin negative patients (mean survival of 5.188 vs. 11.763 months, p = 0.12).

CONCLUSIONS

Locally advanced tumors and pyloroantral tumors are associated with an increased risk of duodenal margin positivity after gastrectomy for carcinoma stomach and may benefit from intraoperative frozen section analysis as survival is negatively affected by positive RM. Patients with high-risk features like extensive nodal and oligometastatic disease have a greater propensity for positive duodenal margin. A prospective study with a large sample size is needed to further validate these results.

Inflammatory Ratios as Predictors for Tumor Invasiveness, Metastasis, Resectability and Early Postoperative Evolution in Gastric Cancer

Our study aimed to evaluate the baseline neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and systemic immune-inflammation index (SII) in relation to invasion, metastasis, and resectability for patients with gastric cancer, respectively, as predictors of death during hospitalization or surgical complications. A retrospective cohort study was conducted on 657 gastric cancer subjects. Inflammatory biomarkers were computed. The associations with tumor stage, metastasis, optimal procedure, in-hospital mortality, and surgical complications were evaluated. Subjects who underwent curative-intent surgery presented lower median NLRs (2.9 vs. 3.79), PLRs (166.15 vs. 196.76), and SIIs (783.61 vs. 1122.25), and higher LMRs (3.34 vs. 2.9) than those who underwent palliative surgery. Significantly higher NLRs (3.3 vs. 2.64), PLRs (179.68 vs. 141.83), and SIIs (920.01 vs. 612.93) were observed for those with T3- and T4-stage cancer, in comparison with those with T1- and T2-stage cancer. Values were significantly higher in the case of metastasis for the NLR (3.96 vs. 2.93), PLR (205.22 vs. 167.17), and SII (1179 vs. 788.37) and significantly lower for the LMR (2.74 vs. 3.35). After the intervention, the NLR, PLR, and SII values were higher (p < 0.01) for patients with surgical complications, and the NLR and SII values were higher for those who died during hospitalization. Higher NLRs, PLRs, SIIs, and lower LMRs were associated with a more aggressive tumor; during early follow-up, these were related to post-operative complications and death during hospitalization.

Impact of perioperative chemotherapy on postoperative morbidity after gastrectomy for gastric cancer

INTRODUCTION

The use of perioperative chemotherapy (CT) in patients with advanced gastric carcinoma increases their overall survival. This therapy may also increase the number of patients with R0 resection. Potential drawbacks of this therapy, besides its toxicity, include increased surgical morbidity.

METHODS

We retrospectively evaluated the records of patients undergoing gastrectomy with curative intent, for carcinoma, at our institution between January 2009 and August 2018. They were divided into two groups: direct surgery (SURG) and perioperative CT (CHEMO). Patients with other neoadjuvant therapies and cardia Siewert I and II carcinomas were excluded. The primary objective was to evaluate the impact of perioperative CT on surgical morbidity. As secondary objectives, resection radicality and total lymph node count were compared between the two groups.

RESULTS

A total of 307 patients (97 direct surgery and 210 perioperative CT) were evaluated. Median age was 67 years old. The overall major surgical morbidity (Clavien-Dindo 3-5) was 10.6% in the CHEMO group and 12.4 in the SURG group (p=0.643). There was no statistically significant difference between the surgical radicality (R0 98% in the SURG group vs 97.5% CHEMO group (p=0.865). There was an increase in the total number of lymph nodes retrieved in the specimen in the CHEMO group (25 vs 22, p=0.001), a difference that was not maintained in the subgroup analysis as a function of the surgery performed.

CONCLUSIONS

Perioperative CT in gastric carcinoma does not increase surgical morbidity, surgical radicality and total lymph node count.

Impact of perioperative chemotherapy on postoperative morbidity after gastrectomy for gastric cancer

INTRODUCTION

The use of perioperative chemotherapy (CT) in patients with advanced gastric carcinoma increases their overall survival. This therapy may also increase the number of patients with R0 resection. Potential drawbacks of this therapy, besides its toxicity, include increased surgical morbidity.

METHODS

We retrospectively evaluated the records of patients undergoing gastrectomy with curative intent, for carcinoma, at our institution between January 2009 and August 2018. They were divided into two groups: direct surgery (SURG) and perioperative CT (CHEMO). Patients with other neoadjuvant therapies and cardia Siewert I and II carcinomas were excluded. The primary objective was to evaluate the impact of perioperative CT on surgical morbidity. As secondary objectives, resection radicality and total lymph node count were compared between the two groups.

RESULTS

A total of 307 patients (97 direct surgery and 210 perioperative CT) were evaluated. Median age was 67 years old. The overall major surgical morbidity (Clavien-Dindo 3-5) was 10.6% in the CHEMO group and 12.4 in the SURG group (p=0.643). There was no statistically significant difference between the surgical radicality (R0 98% in the SURG group vs 97.5% CHEMO group (p=0.865). There was an increase in the total number of lymph nodes retrieved in the specimen in the CHEMO group (25 vs 22, p=0.001), a difference that was not maintained in the subgroup analysis as a function of the surgery performed.

CONCLUSIONS

Perioperative CT in gastric carcinoma does not increase surgical morbidity, surgical radicality and total lymph node count.

Population-Based Study on Risk Factors for Tumor-Positive Resection Margins in Patients with Gastric Cancer

Background

Radical gastrectomy is the cornerstone of the treatment of locally advanced gastric cancer. This study was designed to evaluate factors associated with a tumor-positive resection margin after gastrectomy and to evaluate the influence of hospital volume.

Methods

In this Dutch cohort study, patients with junctional or gastric cancer who underwent curative gastrectomy between 2011 and 2017 were included. The primary outcome was incomplete tumor removal after the operation defined as the microscopic presence of tumor cells at the resection margin. The association of patient and disease characteristics with incomplete tumor removal was tested with multivariable regression analysis. The association of annual hospital volume with incomplete tumor removal was tested and adjusted for the patient- and disease characteristics.

Results

In total, 2799 patients were included. Incomplete tumor removal was seen in 265 (9.5%) patients. Factors associated with incomplete tumor removal were: tumor located in the entire stomach (odds ratio (OR) [95% confidence interval (CI): 3.38 [1.91–5.96] reference: gastroesophageal junction), cT3, cT4, cTx (1.75 [1.20–2.56], 2.63 [1.47–4.70], 1.60 [1.03–2.48], reference: cT0-2), pN+ (2.73 [1.96–3.80], reference: pN−), and diffuse and unknown histological subtype (3.15 [2.14–4.46] and 2.05 [1.34–3.13], reference: intestinal). Unknown differentiation grade was associated with complete tumor removal (0.50 [0.30–0.83], reference: poor/undifferentiated). Compared with a hospital volume of < 20 resections/year, 20–39, and > 39 resections were associated with lower probability for incomplete tumor removal (OR 0.56 [0.42–0.76] and 0.34 [0.18–0.64]).

Conclusions

Tumor location, cT, pN, histological subtype, and tumor differentiation are associated with incomplete tumor removal. The association of incomplete tumor removal with an annual hospital volume of < 20 resections may underline the need for further centralization of gastric cancer care in the Netherlands.

Electronic supplementary material

The online version of this article (10.1245/s10434-019-07381-0) contains supplementary material, which is available to authorized users.