Impact of Surgical Margins on Overall Survival after Gastrectomy for Gastric Cancer: A Validation of Japanese Gastric Cancer Association Guidelines on a Western Series

Abstract

Purpose No consensus exists on the resection extent needed to ensure oncological safety in gastrectomy for gastric adenocarcinoma (GAC). This study aims to assess the impact of margin adequacy according to Japanese Gastric Cancer Association (JGCA) guidelines on overall survival (OS). Patients and Methods Patients who underwent surgery for stage I–III GAC at our institution between 2010 and 2017 were included. Margin adequacy according to JGCA, National Comprehensive Cancer Network (NCCN), and European Society for Medical Oncology (ESMO) guidelines was assessed, and their predictive value on OS was evaluated with Harrell’s C-index. Patients were analyzed according to their margins’ adherence to JGCA guidelines, and a propensity score matching (PSM) was run. Indication to either total gastrectomy (TG) or distal gastrectomy (DG) according to each guideline was also assessed. Results A total of 279 patients were included, of whom 220 (79%) underwent DG. Adequate margins according to JGCA were obtained in 209 patients (75%). On multivariate analysis, JGCA margin adequacy was independently associated with OS, together with American Society of Anesthesiologist class, neoadjuvant chemotherapy, lymphadenectomy extent, R0 resection, and postoperative N stage. After PSM, patients with JGCA adequate margins showed better OS, recurrence-free survival (RFS), and local RFS than patients with JGCA inadequate margins. For 220 DG, JGCA guidelines would have recommended TG in 25 patients (11%), NCCN in 30 (14%), and ESMO in 90 (41%) (p < 0.001). Conclusion Adequacy of surgical resection margins to JGCA guidelines leads to improved survival outcomes and allows for a more organ-preserving approach than Western guidelines.

Gastric cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up

“…Subtotal gastrectomy can be selected when a satisfactory proximal resection margin can be obtained. [58][59][60] The extent of nodal dissection accompanying radical gastrectomy has been extensively debated. D1 resection implies removal of the perigastric lymph nodes plus those along the left gastric artery.…”

Surgery Matters: Progress in Surgical Management of Gastric Cancer

“…In the current version of the guidelines, the recommendation was adapted to the recommendations of the Asian guidelines by requiring proximal margins of at least 3 cm for tumours with an expansive growth pattern and at least 5 cm for tumours with an infiltrative growth pattern [ 10 ]. The changes made to European recommendations are the result of an Italian study that validated the minimal resection margins required by the Japanese guidelines on a Western patient population [ 65 •]. In this study, compliance with the Japanese recommendations for resection margins was independently associated with overall survival.…”

The Role of Surgery in the Management of Gastric Cancer: State of the Art

“…Despite the aforementioned guidelines, several authors highlighted the absence of any significant influence of proximal margin length on GC overall survival [ 36 , 37 , 38 , 39 ], unlike others which advocated for a patient-tailored proximal margin length as an independent prognostic factor [ 40 ]. Recently, Maspero et al assessed the impact of JGCA-recommended resection margins on long-term outcomes of 279 consecutive Western patients [ 41 ]. Analyzing 220 distal gastrectomies, the authors found that application of JGCA guidelines resulted in improved overall survival and a more organ-preserving surgical strategy, owing to a significant lower number of total gastrectomies compared with NCCN and ESMO guidelines (30% vs. 31% vs. 47%, respectively) without compromising oncological outcomes [ 41 ].…”

“…Recently, Maspero et al assessed the impact of JGCA-recommended resection margins on long-term outcomes of 279 consecutive Western patients [ 41 ]. Analyzing 220 distal gastrectomies, the authors found that application of JGCA guidelines resulted in improved overall survival and a more organ-preserving surgical strategy, owing to a significant lower number of total gastrectomies compared with NCCN and ESMO guidelines (30% vs. 31% vs. 47%, respectively) without compromising oncological outcomes [ 41 ].…”