Utility of the Proximal Margin Frozen Section for Resection of Gastric Adenocarcinoma: A 7-Institution Study of the US Gastric Cancer Collaborative

Malcolm H. Squires; David A. Kooby; Timothy M. Pawlik; Sharon M. Weber; George Poultsides; Carl Schmidt; Konstantinos Votanopoulos; Ryan C. Fields; Aslam Ejaz; Alexandra W. Acher; David J. Worhunsky; Neil Saunders; Linda X. Jin; Edward Levine; Clifford S. Cho; Mark Bloomston; Emily Winslow; Kenneth Cardona; Charles A. Staley; Shishir K. Maithel

doi:10.1245/s10434-014-3834-z

Utility of the Proximal Margin Frozen Section for Resection of Gastric Adenocarcinoma: A 7-Institution Study of the US Gastric Cancer Collaborative

Malcolm H. Squires, David A. Kooby, Timothy M. Pawlik, Sharon M. Weber, George Poultsides, Carl Schmidt, Konstantinos Votanopoulos, Ryan C. Fields, Aslam Ejaz, Alexandra W. Acher, David J. Worhunsky, Neil Saunders, Linda X. Jin, Edward Levine, Clifford S. Cho, Mark Bloomston, Emily Winslow, Kenneth Cardona, Charles A. Staley, Shishir K. Maithel

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Abstract

Background: The proximal gastric margin dictates the extent of resection for gastric adenocarcinoma (GAC). The value of achieving negative margins via additional gastric resection after a positive proximal margin frozen section (FS) is unknown.

Methods: The US Gastric Cancer Collaborative includes all patients who underwent resection of GAC at seven institutions from 2000–2012. Intraoperative proximal margin FS data and final permanent section (PS) data were classified as R0 or R1, respectively; positive distal margins were excluded. The primary aim was to evaluate the impact on local recurrence of converting a positive proximal FS-R1 margin to a PS-R0 final margin by additional resection. Secondary endpoints were recurrence-free survival (RFS) and overall survival (OS).

Conclusion: Conversion of a positive intraoperative proximal margin frozen section during gastric cancer resection may decrease local recurrence, but it is not associated with improved RFS or OS. This may guide decisions regarding the extent of resection.

Results: Of 860 patients, 520 had a proximal margin FS and 67 were positive. Of these, 48 were converted to R0 on PS by additional resection. R0 proximal margin was achieved in 447 patients (86 %), PS-R1 in 25 (5 %), and converted FS-R1-to-PS-R0 in 48 (9 %). The median follow-up was 44 months. Local recurrence was significantly decreased in the converted FS-R1-to-PS-R0 group compared to the PS-R1 group (10 vs. 32 %; p = 0.01). Median RFS was similar between the FS-R1-to-PS-R0 and PS-R1 cohorts (25 vs. 20 months; p = 0.49), compared to 37 months for the PS-R0 group. Median OS was similar between the FS-R1-to-PS-R0 conversion and PS-R1 groups (36 vs. 26 months; p = 0.14) compared to 50 months for the PS-R0 group. On multivariate analysis, increasing T-stage and N-stage were associated with worse OS; the FS-R1-to-PS-R0 proximal margin conversion was not significantly associated with improved RFS (p = 0.68) or OS (p = 0.44).

Original language	English
Pages (from-to)	4202-4210
Number of pages	9
Journal	Annals of Surgical Oncology
Volume	21
Issue number	13
DOIs	https://doi.org/10.1245/s10434-014-3834-z
State	Published - Oct 31 2014

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Squires, M. H., Kooby, D. A., Pawlik, T. M., Weber, S. M., Poultsides, G., Schmidt, C., Votanopoulos, K., Fields, R. C., Ejaz, A., Acher, A. W., Worhunsky, D. J., Saunders, N., Jin, L. X., Levine, E., Cho, C. S., Bloomston, M., Winslow, E., Cardona, K., Staley, C. A., & Maithel, S. K. (2014). Utility of the Proximal Margin Frozen Section for Resection of Gastric Adenocarcinoma: A 7-Institution Study of the US Gastric Cancer Collaborative. Annals of Surgical Oncology, 21(13), 4202-4210. https://doi.org/10.1245/s10434-014-3834-z

@article{a002b12f00734769b8b6c6f8521e8f5f,

title = "Utility of the Proximal Margin Frozen Section for Resection of Gastric Adenocarcinoma: A 7-Institution Study of the US Gastric Cancer Collaborative",

abstract = "Background: The proximal gastric margin dictates the extent of resection for gastric adenocarcinoma (GAC). The value of achieving negative margins via additional gastric resection after a positive proximal margin frozen section (FS) is unknown.Methods: The US Gastric Cancer Collaborative includes all patients who underwent resection of GAC at seven institutions from 2000–2012. Intraoperative proximal margin FS data and final permanent section (PS) data were classified as R0 or R1, respectively; positive distal margins were excluded. The primary aim was to evaluate the impact on local recurrence of converting a positive proximal FS-R1 margin to a PS-R0 final margin by additional resection. Secondary endpoints were recurrence-free survival (RFS) and overall survival (OS).Conclusion: Conversion of a positive intraoperative proximal margin frozen section during gastric cancer resection may decrease local recurrence, but it is not associated with improved RFS or OS. This may guide decisions regarding the extent of resection.Results: Of 860 patients, 520 had a proximal margin FS and 67 were positive. Of these, 48 were converted to R0 on PS by additional resection. R0 proximal margin was achieved in 447 patients (86 %), PS-R1 in 25 (5 %), and converted FS-R1-to-PS-R0 in 48 (9 %). The median follow-up was 44 months. Local recurrence was significantly decreased in the converted FS-R1-to-PS-R0 group compared to the PS-R1 group (10 vs. 32 %; p = 0.01). Median RFS was similar between the FS-R1-to-PS-R0 and PS-R1 cohorts (25 vs. 20 months; p = 0.49), compared to 37 months for the PS-R0 group. Median OS was similar between the FS-R1-to-PS-R0 conversion and PS-R1 groups (36 vs. 26 months; p = 0.14) compared to 50 months for the PS-R0 group. On multivariate analysis, increasing T-stage and N-stage were associated with worse OS; the FS-R1-to-PS-R0 proximal margin conversion was not significantly associated with improved RFS (p = 0.68) or OS (p = 0.44).",

author = "Squires, {Malcolm H.} and Kooby, {David A.} and Pawlik, {Timothy M.} and Weber, {Sharon M.} and George Poultsides and Carl Schmidt and Konstantinos Votanopoulos and Fields, {Ryan C.} and Aslam Ejaz and Acher, {Alexandra W.} and Worhunsky, {David J.} and Neil Saunders and Jin, {Linda X.} and Edward Levine and Cho, {Clifford S.} and Mark Bloomston and Emily Winslow and Kenneth Cardona and Staley, {Charles A.} and Maithel, {Shishir K.}",

note = "Funding Information: ACKNOWLEDGMENT This study is supported in part by the Katz Foundation. Publisher Copyright: {\textcopyright} 2014, Society of Surgical Oncology.",

year = "2014",

month = oct,

day = "31",

doi = "10.1245/s10434-014-3834-z",

language = "English",

volume = "21",

pages = "4202--4210",

journal = "Annals of Surgical Oncology",

issn = "1068-9265",

number = "13",

}

Squires, MH, Kooby, DA, Pawlik, TM, Weber, SM, Poultsides, G, Schmidt, C, Votanopoulos, K, Fields, RC, Ejaz, A, Acher, AW, Worhunsky, DJ, Saunders, N, Jin, LX, Levine, E, Cho, CS, Bloomston, M, Winslow, E, Cardona, K, Staley, CA & Maithel, SK 2014, 'Utility of the Proximal Margin Frozen Section for Resection of Gastric Adenocarcinoma: A 7-Institution Study of the US Gastric Cancer Collaborative', Annals of Surgical Oncology, vol. 21, no. 13, pp. 4202-4210. https://doi.org/10.1245/s10434-014-3834-z

TY - JOUR

T1 - Utility of the Proximal Margin Frozen Section for Resection of Gastric Adenocarcinoma

T2 - A 7-Institution Study of the US Gastric Cancer Collaborative

AU - Squires, Malcolm H.

AU - Kooby, David A.

AU - Pawlik, Timothy M.

AU - Weber, Sharon M.

AU - Poultsides, George

AU - Schmidt, Carl

AU - Votanopoulos, Konstantinos

AU - Fields, Ryan C.

AU - Ejaz, Aslam

AU - Acher, Alexandra W.

AU - Worhunsky, David J.

AU - Saunders, Neil

AU - Jin, Linda X.

AU - Levine, Edward

AU - Cho, Clifford S.

AU - Bloomston, Mark

AU - Winslow, Emily

AU - Cardona, Kenneth

AU - Staley, Charles A.

AU - Maithel, Shishir K.

PY - 2014/10/31

Y1 - 2014/10/31

N2 - Background: The proximal gastric margin dictates the extent of resection for gastric adenocarcinoma (GAC). The value of achieving negative margins via additional gastric resection after a positive proximal margin frozen section (FS) is unknown.Methods: The US Gastric Cancer Collaborative includes all patients who underwent resection of GAC at seven institutions from 2000–2012. Intraoperative proximal margin FS data and final permanent section (PS) data were classified as R0 or R1, respectively; positive distal margins were excluded. The primary aim was to evaluate the impact on local recurrence of converting a positive proximal FS-R1 margin to a PS-R0 final margin by additional resection. Secondary endpoints were recurrence-free survival (RFS) and overall survival (OS).Conclusion: Conversion of a positive intraoperative proximal margin frozen section during gastric cancer resection may decrease local recurrence, but it is not associated with improved RFS or OS. This may guide decisions regarding the extent of resection.Results: Of 860 patients, 520 had a proximal margin FS and 67 were positive. Of these, 48 were converted to R0 on PS by additional resection. R0 proximal margin was achieved in 447 patients (86 %), PS-R1 in 25 (5 %), and converted FS-R1-to-PS-R0 in 48 (9 %). The median follow-up was 44 months. Local recurrence was significantly decreased in the converted FS-R1-to-PS-R0 group compared to the PS-R1 group (10 vs. 32 %; p = 0.01). Median RFS was similar between the FS-R1-to-PS-R0 and PS-R1 cohorts (25 vs. 20 months; p = 0.49), compared to 37 months for the PS-R0 group. Median OS was similar between the FS-R1-to-PS-R0 conversion and PS-R1 groups (36 vs. 26 months; p = 0.14) compared to 50 months for the PS-R0 group. On multivariate analysis, increasing T-stage and N-stage were associated with worse OS; the FS-R1-to-PS-R0 proximal margin conversion was not significantly associated with improved RFS (p = 0.68) or OS (p = 0.44).

AB - Background: The proximal gastric margin dictates the extent of resection for gastric adenocarcinoma (GAC). The value of achieving negative margins via additional gastric resection after a positive proximal margin frozen section (FS) is unknown.Methods: The US Gastric Cancer Collaborative includes all patients who underwent resection of GAC at seven institutions from 2000–2012. Intraoperative proximal margin FS data and final permanent section (PS) data were classified as R0 or R1, respectively; positive distal margins were excluded. The primary aim was to evaluate the impact on local recurrence of converting a positive proximal FS-R1 margin to a PS-R0 final margin by additional resection. Secondary endpoints were recurrence-free survival (RFS) and overall survival (OS).Conclusion: Conversion of a positive intraoperative proximal margin frozen section during gastric cancer resection may decrease local recurrence, but it is not associated with improved RFS or OS. This may guide decisions regarding the extent of resection.Results: Of 860 patients, 520 had a proximal margin FS and 67 were positive. Of these, 48 were converted to R0 on PS by additional resection. R0 proximal margin was achieved in 447 patients (86 %), PS-R1 in 25 (5 %), and converted FS-R1-to-PS-R0 in 48 (9 %). The median follow-up was 44 months. Local recurrence was significantly decreased in the converted FS-R1-to-PS-R0 group compared to the PS-R1 group (10 vs. 32 %; p = 0.01). Median RFS was similar between the FS-R1-to-PS-R0 and PS-R1 cohorts (25 vs. 20 months; p = 0.49), compared to 37 months for the PS-R0 group. Median OS was similar between the FS-R1-to-PS-R0 conversion and PS-R1 groups (36 vs. 26 months; p = 0.14) compared to 50 months for the PS-R0 group. On multivariate analysis, increasing T-stage and N-stage were associated with worse OS; the FS-R1-to-PS-R0 proximal margin conversion was not significantly associated with improved RFS (p = 0.68) or OS (p = 0.44).

UR - http://www.scopus.com/inward/record.url?scp=84911956274&partnerID=8YFLogxK

U2 - 10.1245/s10434-014-3834-z

DO - 10.1245/s10434-014-3834-z

M3 - Article

C2 - 25047464

AN - SCOPUS:84911956274

SN - 1068-9265

VL - 21

SP - 4202

EP - 4210

JO - Annals of Surgical Oncology

JF - Annals of Surgical Oncology

IS - 13

ER -

Utility of the Proximal Margin Frozen Section for Resection of Gastric Adenocarcinoma: A 7-Institution Study of the US Gastric Cancer Collaborative

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