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Past
For distal gastric cancer, surgical resection can be performed by either distal gastrectomy or total gastrectomy.1 The ability to preserve the proximal stomach is limited by the proximal tumor extent with international guidelines, such as the ESMO guidelines, which recommend a proximal margin distance (PMD) of 3 cm for intestinal-type and 8 cm for diffuse-type cancers, adding an additional safety distance.2 However, the integration of the PMD into guidelines is based on correlations with fewer R1 resections; but meanwhile, with reliable intraoperative frozen section, the PMD may be omitted when feasible.3
Present
In the present analysis, intraoperative frozen section was found to be reliable, with less than 1% of cases having a positive proximal margin regardless.4 While in patients with intestinal-type tumors, oncological outcomes were not impaired when the minimum PMD was not retained, an adequate PMD was associated with improved disease-specific and overall survival in patients with cancers with noncohesive growth patterns (diffuse and mixed type).4 The results were comparable to those of stage II and III gastric cancer in a study by Squires et al., who, however, found a benefit of a 3 cm PMD only in stage I tumors and adjusted for diffuse histology in their multivariable analysis, but did not perform a separate analysis in that subgroup.5
Future
These results may inform intraoperative decision-making in the event that the recommended PMD is not achieved. In patients with intestinal-type tumors, a completion gastrectomy may be omitted without compromising oncological outcomes. Conversely, in patients with diffuse-type cancers, associations of an inadequate PMD with worse oncological outcomes suggest the need for additional margin clearance up to a total gastrectomy. Future research should validate these findings with multi-institutional data from centers with different practices of margin handling.
References
Smyth EC, Nilsson M, Grabsch HI, van Grieken NCT, Lordick F. Gastric cancer. The Lancet. 2020;396(10251):635–48. https://doi.org/10.1016/S0140-6736(20)31288-5.
Smyth EC, Verheij M, Allum W, Cunningham D, Cervantes A, Arnold D. Gastric cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†. Ann Oncol. 2016;27:v38–49. https://doi.org/10.1093/annonc/mdw350.
Bozzetti F, Bonfanti G, Bufalino R, et al. Adequacy of margins of resection in gastrectomy for cancer. Ann Surg. 1982;196(6):685–90. https://doi.org/10.1097/00000658-198212001-00012.
Rompen IF, Schutte I, Crnovrsanin N, et al. Prognostic relevance of the proximal resection margin distance in distal gastrectomy for gastric adenocarcinoma. Ann Surg Oncol. 2024. https://doi.org/10.1245/s10434-024-15721-y.
Squires MH, Kooby DA, Poultsides GA, et al. Is it time to abandon the 5-cm margin rule during resection of distal gastric adenocarcinoma? A multi-institution study of the U.S. Gastric Cancer Collaborative. Ann Surg Oncol. 2015;22(4):1243–51. https://doi.org/10.1245/s10434-014-4138-z.
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G.M.H. reports a consulting or advisory role for Bristol-Myers Squibb; MSD Sharp & Dohme, Lilly, Novartis, Daiichi Sankyo, Servier,Pierre Fabre, Astra Zeneca and Swiss Cancer League, honoraria for lectures or from Servier, MSD Sharp & Dohme, Lilly, Targos, Bristol-Myers Squibb, Astra Zeneca, and MCI Conventions, research funding by DKFZ Heidelberg and MSD Sharp & Dohme, and travel support/accommodations by Bristol-Myers Squibb Lilly Servier, MSD Sharp & Dohme, and Daiichi Sankyo. All other authors report no conflicts of interest.
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This article refers to: Rompen IF, Schutte I, Crnovrsanin N, et al. Prognostic relevance of the proximal resection margin distance in distal gastrectomy for gastric adenocarcinoma. Ann Surg Oncol. (2024). https://doi.org/10.1245/s10434-024-15721-y.
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Rompen, I.F., Schütte, I., Crnovrsanin, N. et al. ASO Author Reflections: The Prognostic Relevance of the Proximal Resection Margin Distance is Dependent upon the Histological Subtype of Gastric Adenocarcinoma. Ann Surg Oncol (2024). https://doi.org/10.1245/s10434-024-15779-8
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DOI: https://doi.org/10.1245/s10434-024-15779-8