背景:十二指肠切缘阳性是可切除胃癌胃切除术后的不良预后因素。术中冰冻切片(IFS)分析允许在单次手术中实现根治性切除,但耗时耗力。因此,通常根据外科医生的判断和触诊进行切除。
目的:确定可切除胃癌胃切除术后十二指肠切缘(RM)阳性的危险因素。
方法:我们回顾性分析了2011年8月至2020年1月在JIPMER住院的376例诊断为胃癌的患者的前瞻性数据,普杜切利的一个三级中心,印度。其中,146例患者接受了治愈性胃切除术,是本研究的主题。通过明确的组织病理学检查评估RM状态。在确定的组织病理学检查中具有阳性切缘的患者与具有阴性切缘的相似患者的对照队列之间比较了潜在的危险因素。
结果:在146名患者中,16例(10.9%),11男5女,十二指肠边缘呈阳性。研究组的平均年龄为59岁。没有像年龄这样的病人特征,性别,合并症,或成瘾在十二指肠边缘阳性方面具有统计学意义。在肿瘤特征中,在边缘阳性组中发现局部晚期肿瘤和幽门窦肿瘤更为常见.十二指肠边缘阳性的高风险特征是广泛的淋巴结疾病,寡转移疾病,淋巴管浸润,和神经周侵犯。新辅助化疗和手术入路类型对RM没有显著影响。有趣的是,近端和周向切除切缘阳性与远端切缘阳性呈线性关系,提示肿瘤生物学可能在切缘阳性中起重要作用.然而,在使用逻辑回归模型的多变量分析中,这些因素均无统计学意义。在寡转移患者中,生存率取决于R0切除,与没有转移的患者没有差异,尽管我们的研究没有足够的生存率分析(平均生存期为11.040个月),十二指肠切缘阳性患者的总生存率低于切缘阴性患者(平均生存率为5.188vs.11.763个月,p=0.12)。
结论:局部晚期肿瘤和幽门窦肿瘤与胃癌胃切除术后十二指肠切缘阳性的风险增加相关,并且可能从术中冰冻切片分析中受益,因为阳性RM对生存率有负面影响。具有广泛淋巴结和寡转移疾病等高风险特征的患者十二指肠边缘阳性的倾向更大。需要大样本量的前瞻性研究来进一步验证这些结果。
BACKGROUND: Duodenal margin positivity is a poor prognostic factor following gastrectomy for resectable gastric cancer. Intraoperative frozen section (IFS) analysis allows radical resection to be achieved in a single operation but is time- and resource-consuming. Hence resection is usually performed based on surgeon\'s judgment and palpation.
OBJECTIVE: To determine risk factors for duodenal resection margin (RM) positivity following gastrectomy for resectable gastric cancer.
METHODS: We retrospectively analyzed prospectively maintained data of 376 patients admitted with diagnosis of gastric cancer from August 2011 to January 2020 in JIPMER, a tertiary center in Puducherry, India. Of these, 146 patients underwent gastric resection with curative intent and were the subject of this study. RM status was assessed by definitive histopathology examination. The potential risk factors were compared between patients with positive margin on definitive histopathology examination and a control cohort of similar patients with negative margins.
RESULTS: Of the 146 patients, 16 patients (10.9%), 11 men and 5 women, had positive duodenal margin. The mean age of study group was 59 years. None of the patient characteristics like age, sex, comorbidities, or addictions were statistically significant with regard to duodenal margin positivity. Among tumor characteristics, locally advanced tumors and pyloroantral tumors were found more frequently in the margin-positive group. High-risk features for duodenal margin positivity were extensive nodal disease, oligometastatic disease, lymphovascular invasion, and perineural invasion. Neoadjuvant chemotherapy and types of surgical access did not have significant impact on RM. Interestingly, both proximal and circumferential resection margin positivity had a linear association with distal margin positivity suggesting that tumor biology may have a significant role in margin positivity. However, none of these factors were statistically significant on multivariate analysis using logistic regression model. Among oligometastatic patients, survival was dependent on R0 resection and was not different from patients without metastases though our study was not powered for survival analysis (mean survival of 11.040 months) and expectedly, duodenal margin positive patients had lower overall survival compared to margin negative patients (mean survival of 5.188 vs. 11.763 months, p = 0.12).
CONCLUSIONS: Locally advanced tumors and pyloroantral tumors are associated with an increased risk of duodenal margin positivity after gastrectomy for carcinoma stomach and may benefit from intraoperative frozen section analysis as survival is negatively affected by positive RM. Patients with high-risk features like extensive nodal and oligometastatic disease have a greater propensity for positive duodenal margin. A prospective study with a large sample size is needed to further validate these results.