Ridwelski K, Fahlke J, Huß M, Otto R, Wolff S
AN-Institut für Qualitätssicherung in der operativen Medizin an der Otto-von-Guericke-Universität Magdeburg gGmbH, Leipziger Str. 44, 39120, Magdeburg, Deutschland.
Klinik für Allgemein- und Viszeralchirurgie, Klinikum Magdeburg, Magdeburg, Deutschland.
Chirurg. 2017 Sep;88(9):756-763. doi: 10.1007/s00104-017-0460-x.
The results reported in the literature in the context of an R1 situation for a resected gastric carcinoma are not uniform. An R1 situation worsens the prognosis for the long-term survival of patients. This is significant especially for low T stages and lymph node metastasis with 0-≤3 lymph node metastases. In higher tumor stages with extensive lymph node metastases, the survival difference between R0 and R1 resections is lower and frequently no longer significant. The frequency of R1 resection is approximately 5% (range 1.8-9%) and for adenocarcinoma of the esophagogastric junction (AEG tumors)> 10%. The data are mainly related to the oral and aboral resection line but there are only a few specifications on the circumferential margin. The risk of an infiltrated resection line increases with the size of the tumor (>5 cm), T3+4 and pN2/pN3 stages. Poorly differentiated signet ring cell or mucinous adenocarcinomas and carcinomas of the Bormann type 3+4 also lead to an increased R1 rate. In order to achieve an R0 resection, an intraoperative frozen section is the standard approach. Immediate reoperation should be performed in the case of tumor infiltration. If an R1 resection is detected only in the definitive histology, surgical re-excision to achieve an R0 resection is the standard approach in publications. Nevertheless, a reoperation is rare. Only 1 study showed 122 patients with 100% re-operations, which were successfully performed in 50 patients (41% R0). For the R0 group, median survival was extended from 18 months to 23 months. There are only sporadic literature data and no evidence for postoperative additive treatment (chemotherapy, radiotherapy and radiochemotherapy).
文献报道的关于胃癌切除术后处于R1情况的结果并不一致。R1情况会使患者长期生存的预后变差。这对于低T分期以及伴有0至≤3个淋巴结转移的淋巴结转移情况尤为显著。在伴有广泛淋巴结转移的较高肿瘤分期中，R0和R1切除之间的生存差异较小且通常不再显著。R1切除的频率约为5%（范围1.8 - 9%），而对于食管胃交界腺癌（AEG肿瘤）>10%。数据主要与口侧和肛侧切除线相关，但关于切缘的规定较少。肿瘤浸润切除线的风险随着肿瘤大小（>5厘米）、T3 + 4和pN2/pN3分期而增加。低分化印戒细胞癌或黏液腺癌以及Borrmann 3 + 4型癌也会导致R1切除率增加。为了实现R0切除，术中冰冻切片是标准方法。如果发现肿瘤浸润，应立即再次手术。如果仅在最终组织学检查中发现R1切除，手术再次切除以实现R0切除是出版物中的标准方法。然而，再次手术很少见。只有1项研究显示122例患者进行了100%的再次手术，其中50例（41%为R0）成功进行。对于R0组，中位生存期从18个月延长至23个月。仅有零星的文献数据，且没有证据支持术后辅助治疗（化疗、放疗和放化疗）。
