Histologically positive esophageal margin in the surgical treatment of gastric cancer.

Histologically positive esophageal margins caused by transection of the esophagus in an area involved by disease were encountered in 20 percent of 350 patients undergoing total or proximal subtotal gastrectomy for gastric cancer. There was a significant increase in the incidence of positive margins in patients with neoplasms of the cardia and in those who were managed without frozen-section examination of the resected esophagus. Positive margins were avoided only with resection of 12 cm or more of macroscopically tumor-free esophagus above the primary. Despite the presence of tumor at the margin, anastomotic recurrences appeared in only 23 percent of the patients at risk. Recurrences affected mainly those who had TNM stage I and II lesions. Patients with more advanced disease usually died from metastasis without developing anastomotic recurrence. Positive margins were associated with a poor prognosis that was not influenced by adjuvant postoperative treatment. The avoidance of positive margins by wide esophagectomy is important in patients with TNM stage I and II disease, particularly if the primary lesion is located in the cardia. Patients with positive margins should be watched closely rather than subjected to further treatment.