Ma Lucy X, Espin-Garcia Osvaldo, Lim Charles H, Jiang Di M, Sim Hao-Wen, Natori Akina, Chan Bryan A, Suzuki Chihiro, Chen Eric X, Liu Geoffrey, Brar Savtaj S, Swallow Carol J, Yeung Jonathan C, Darling Gail E, Wong Rebecca K, Kalimuthu Sangeetha N, Conner James, Elimova Elena, Jang Raymond W
Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada.
Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada.
J Gastrointest Oncol. 2020 Apr;11(2):356-365. doi: 10.21037/jgo.2020.03.03.
A microscopically positive (R1) resection margin following resection for gastric and esophageal cancers has been documented to be a poor prognostic factor. The optimal strategy and impact of different modalities of adjuvant treatment for an R1 resection margin remain unclear.
A retrospective analysis was performed for patients with gastric and esophageal adenocarcinoma treated at the Princess Margaret Cancer Centre (PMCC) from 2006-2016. Electronic medical records of all patients with an R1 resection margin were reviewed. Kaplan-Meier and Cox proportional hazards methods were used to analyze recurrence free survival (RFS) and overall survival (OS) with stage and neoadjuvant treatment as covariates in the multivariate analysis.
We identified 69 gastric and esophageal adenocarcinoma patients with a R1 resection. Neoadjuvant chemoradiation was used in 13% of patients, neoadjuvant chemotherapy in 12%, surgery alone in 75%. Margins involved included proximal in 30%, distal in 14%, radial in 52% and multiple margins in 3% of patients. Pathological staging showed 3% with stage I disease, 20% stage II and 74% stage III. Adjuvant therapy was given in 52% of R1 pts (28% CRT, 20% chemotherapy alone, 3% radiation alone, 1% reoperation). Median RFS was 14.1 months [95% confidence interval (CI), 11.1-17.2]. The site of first recurrence was 72% distant, 12% mixed, 16% locoregional alone. Median OS was 34.5 months (95% CI, 23.3-57.9) for all patients. There was no significant difference in RFS (adjusted P=0.26) or OS (adjusted P=0.83) comparing modality of adjuvant therapy.
Most patients with positive margins after resection for gastric and esophageal cancer had advanced pathologic stage and prognosis was poor. Our study did not find improved RFS or OS with adjuvant treatment and only one patient had reresection. The main failure pattern was distant recurrence, suggesting that patients being considered for adjuvant radiotherapy (RT) should be carefully selected. Further studies are required to determine factors to select patients with good prognosis despite a positive margin, or those who may benefit from adjuvant treatment.
已有文献记载，胃癌和食管癌切除术后显微镜下切缘阳性（R1）是一个不良预后因素。对于R1切缘，不同辅助治疗方式的最佳策略及其影响仍不明确。
对2006年至2016年在玛格丽特公主癌症中心（PMCC）接受治疗的胃癌和食管腺癌患者进行回顾性分析。查阅了所有切缘为R1的患者的电子病历。在多变量分析中，采用Kaplan-Meier法和Cox比例风险法，以分期和新辅助治疗作为协变量来分析无复发生存期（RFS）和总生存期（OS）。
我们确定了69例切缘为R1的胃癌和食管腺癌患者。13%的患者采用了新辅助放化疗，12%采用了新辅助化疗，75%仅接受了手术治疗。切缘受累情况包括：30%为近端切缘，14%为远端切缘，52%为径向切缘，3%为多切缘。病理分期显示，3%为I期疾病，20%为II期，74%为III期。52%的R1患者接受了辅助治疗（28%为放化疗，20%仅为化疗，3%仅为放疗，1%再次手术）。中位RFS为14.1个月[95%置信区间（CI），11.1 - 17.2]。首次复发部位为远处复发的占72%，混合复发的占12%，仅局部区域复发的占16%。所有患者的中位OS为34.5个月（95% CI，23.3 - 57.9）。比较辅助治疗方式，RFS（校正P = 0.26）或OS（校正P = 0.83）无显著差异。
大多数胃癌和食管癌切除术后切缘阳性的患者病理分期较晚，预后较差。我们的研究未发现辅助治疗能改善RFS或OS，且仅有1例患者再次手术。主要失败模式为远处复发，这表明在考虑辅助放疗（RT）的患者时应谨慎选择。需要进一步研究以确定尽管切缘阳性但预后良好的患者的选择因素，或那些可能从辅助治疗中获益的患者。
