Gundavda Kaival, Rajavelu Narayanan, Chopde Amit, Rane Pallavi, Ostwal Vikas, Ramaswamy Anant, Gudi Shivakumar, Kaushal Rajiv Kumar, Deodhar Kedar, Chaudhari Vikram, Shrikhande Shailesh V, Bhandare Manish S
Department of Gastrointestinal and Hepatopancreatobiliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
Department of Biostatistics, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
J Gastrointest Surg. 2025 Sep;29(9):102123. doi: 10.1016/j.gassur.2025.102123. Epub 2025 Jun 20.
Positive proximal resection margins after resection for gastroesophageal junction (GEJ) and proximal third of the stomach portend poor survival. Although associated with unfavorable tumor biology rather than technical insufficiency, the benefit of re-resecting intraoperatively encountered positive proximal margin, especially in locally advanced gastric cancers (GCs), is uncertain.
A total of 388 consecutive patients with proximal third gastric and Siewert type II and III GEJ adenocarcinomas who underwent radical resection between 2010 and 2022 were analyzed for R1 resection rates and the effect of margin conversion from R1 to R0 on long-term survival.
Of note, 91 patients (23%) had an initial positive proximal resection margin, of which 69 patients (75%) were converted to R0 after frozen section analysis. Moreover, 22 patients (5.6%) had persistent R1 margins on final pathology. The R0 resection group had a 3-year overall survival (OS) of 70%, which fared best, whereas the R1-to-R0 resection group had a 3-year OS of 55%. However, patients with R1 resection fared poorly, with a 3-year OS of 36%. The median disease-free survival estimates for the R0, R1-to-R0, and R1 groups were 42, 28, and 18 months, respectively. Among the node-positive patients, we found a significant OS benefit for margin revision in N1 disease (P =.036) but not in N2 or N3 disease (P =.51).
A positive resection margin is an independent poor prognostic factor, regardless of the tumor stage. Conversion of an intraoperatively encountered R1 margin to an R0 resection status is associated with improved survival and should be performed even in locally advanced GCs, especially in N0 and N1 diseases.
胃食管交界部（GEJ）及胃近端三分之一切除术后近端切缘阳性预示着生存率较低。尽管这与不良的肿瘤生物学特性相关而非技术不足，但术中遇到近端切缘阳性时再次切除的益处，尤其是在局部进展期胃癌（GC）中，尚不确定。
对2010年至2022年间连续接受根治性切除的388例胃近端三分之一及Siewert II型和III型GEJ腺癌患者进行分析，以评估R1切除率以及切缘从R1转换为R0对长期生存的影响。
值得注意的是，91例患者（23%）初始近端切缘阳性，其中69例患者（75%）在冰冻切片分析后转换为R0。此外，22例患者（5.6%）最终病理切缘仍为R1。R0切除组3年总生存率（OS）为70%，情况最佳，而R1转换为R0切除组3年OS为55%。然而，R1切除的患者预后较差，3年OS为36%。R0、R1转换为R0及R1组的无病生存期中位数分别为42、28和18个月。在淋巴结阳性患者中，我们发现N1期疾病切缘修正有显著的OS获益（P = 0.036），但N2或N3期疾病无此获益（P = 0.51）。
切缘阳性是一个独立的不良预后因素，与肿瘤分期无关。术中遇到的R1切缘转换为R0切除状态与生存率提高相关，即使在局部进展期GC中也应进行，尤其是在N0和N1期疾病中。
