From the Guidelines
The optimal safety margin for subtotal oesophagectomy in cases of lower oesophageal carcinoma is generally considered to be at least 5 cm proximal to the macroscopic tumor edge and 3 cm distal. This recommendation aims to ensure complete removal of microscopic disease while preserving as much normal esophageal tissue as possible. In practice, surgeons should obtain frozen section analysis during the procedure to confirm negative margins. For distal (lower) oesophageal carcinomas, a total gastrectomy with distal oesophagectomy may be required to achieve adequate margins, particularly when the tumor involves the gastroesophageal junction. The 5 cm margin is based on the tendency of oesophageal carcinoma to spread submucosally, which can extend beyond visible tumor boundaries. In cases where achieving a 5 cm margin is anatomically challenging due to proximity to the cricopharyngeus muscle or other vital structures, a minimum of 2-3 cm may be acceptable if confirmed negative by frozen section. However, closer margins are associated with higher local recurrence rates. Post-operative adjuvant therapy should be considered in cases where optimal margins cannot be achieved to reduce recurrence risk 1.
Some key points to consider:
- The choice of surgical approach depends on the location and stage of the tumor, as well as the patient's overall health and preferences 1.
- Minimally invasive oesophagectomy (MIO) techniques, including robotics, have become increasingly implemented into clinical practice in recent years, with reported lower post-operative morbidity, quicker functional recovery, and better quality of life up to 1 year after surgery compared to open oesophagectomy 1.
- Preoperative chemoradiation can be recommended as a standard of care for squamous cell carcinoma (SCC) of the oesophagus, with improved survival compared to surgery alone 1.
Overall, the goal of subtotal oesophagectomy is to remove the tumor with adequate margins while preserving as much normal esophageal tissue as possible, and the choice of surgical approach and margin size should be individualized based on the patient's specific circumstances.
From the Research
Optimal Safety Margin for Subtotal Oesophagectomy
The optimal safety margin for subtotal oesophagectomy in cases of lower oesophageal carcinoma is a crucial factor in determining the success of the surgery.
- The recommended proximal resection margin is 5cm, however one study recommends a proximal resection margin of 12 cm for complete resection of esophageal cancer 2.
- The recommended distal resection margin is at least 5 cm of macroscopically normal foregut below the distal margin of the primary tumor to achieve consistently negative distal resection margins 2.
- Other options such as 5cm upper and 2cm down or 5cm proximal and 3cm distal are not supported by the provided evidence.
- The choice of safety margin may depend on various factors, including the type and location of the tumor, as well as the overall health of the patient.
Key Findings
- A study published in The Annals of thoracic surgery found that a distal resection margin of at least 5 cm is recommended to achieve consistently negative distal resection margins 2.
- The same study found that positive distal resection margins were seen in 12% of primary esophageal adenocarcinomas and 28% of cardia adenocarcinomas, highlighting the importance of achieving negative margins 2.
- Other studies have discussed the techniques and outcomes of subtotal oesophagectomy, but do not provide specific guidance on the optimal safety margin 3, 4, 5, 6.