Department of Abdominal and Paediatric Surgery, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway.
Department of Pathology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway.
Br J Surg. 2019 Mar;106(4):419-426. doi: 10.1002/bjs.11027. Epub 2018 Dec 3.
According to guidelines, adjuvant treatment or re-excision should be considered after R1 resection of gastrointestinal stromal tumours (GISTs). However, the prognostic significance of R1 resection is uncertain and tumour rupture confounds its assessment. Here, the impact of positive margins was examined and related to rupture in a population-based cohort.
Patients undergoing surgery for non-metastatic GIST since 2000 were identified in the sarcoma database of Oslo University Hospital. Margins were coded according to the residual tumour (R) classification and tumour rupture defined according to the Oslo criteria.
Among 410 patients, there were 47 who underwent R1 resection and 52 had tumour rupture. The relative risk of R1 resection with rupture was 3·55 (95 per cent c.i. 2·09 to 6·03; P < 0·001). In patients without rupture, there was no difference in estimated 5-year recurrence-free survival after R0 versus R1 resection (87·6 versus 93 per cent; hazard ratio (HR) 0·71, 95 per cent c.i. 0·17 to 2·98; P = 0·638); nor was there any difference among patients with rupture (37 versus 31 per cent; HR 1·31, 0·68 to 2·54; P = 0·420). In multivariable analysis, tumour rupture but not R1 resection was independently associated with recurrence. Twenty-four patients at very low, low or intermediate risk did not receive adjuvant imatinib after R1 resection and remained recurrence-free.
Positive resection margins are strongly associated with tumour rupture. R1 resection does not independently influence prognosis. Adjuvant imatinib may not be justified after R1 resection in the absence of tumour rupture or other high-risk features.
根据指南，胃肠道间质瘤（GIST）R1 切除后应考虑辅助治疗或再次切除。然而，R1 切除的预后意义尚不确定，且肿瘤破裂会影响其评估。在此，我们在一个基于人群的队列中检查了阳性切缘的影响，并将其与肿瘤破裂相关联。
在奥斯陆大学医院肉瘤数据库中，确定了自 2000 年以来接受非转移性 GIST 手术的患者。根据残留肿瘤（R）分类对切缘进行编码，并根据奥斯陆标准定义肿瘤破裂。
在 410 例患者中，有 47 例接受了 R1 切除，52 例有肿瘤破裂。破裂患者中 R1 切除的相对风险为 3.55（95%可信区间 2.09 至 6.03；P＜0.001）。在没有破裂的患者中，R0 与 R1 切除后 5 年无复发生存率无差异（87.6%与 93%；风险比（HR）0.71，95%可信区间 0.17 至 2.98；P=0.638）；破裂患者之间也无差异（37%与 31%；HR 1.31，0.68 至 2.54；P=0.420）。多变量分析显示，肿瘤破裂而非 R1 切除与复发独立相关。24 例极低、低或中危患者在 R1 切除后未接受辅助伊马替尼治疗，且无复发。
阳性切缘与肿瘤破裂密切相关。R1 切除并不独立影响预后。在没有肿瘤破裂或其他高危特征的情况下，R1 切除后可能不需要伊马替尼辅助治疗。
