Analysis of Esophagectomy Margin Practice and Survival Implications.

Abstract Background The objective of this study was to determine how thoracic surgeons manage intraoperative esophagectomy positive margins and how these decisions may relate to overall (OS) and progression-free survival (PFS) in esophageal cancer. Methods A survey was sent to thoracic surgeons to understand the management of intraoperative positive esophagectomy margins. Primary data at two high volume esophageal cancer institutions from 1994-2017 were retrospectively reviewed to identify patients who had intraoperative positive frozen section margins during esophagectomy. Patient characteristics and survival were collected and analyzed. OS and PFS were assessed using a Cox model. Results 85% of thoracic surgeons responding to a survey reported the utilization of frozen pathologic evaluation during esophagectomy with attempts at re-resection to achieve negative margin. Our esophagectomy database identified 94 patients with intraoperative positive margins. Of those re-resected (n=67, 63%), 44 patients (46.8%) were converted to R0 resections. OS was improved for patients in the R0 (13 months) versus R+ groups (3.4 months, p=0.04). PFS was also improved between R0 (8.6 months) versus R+ groups (2.2 months, p=0.03). In a multivariable analysis for PFS, margin status was an independent predictor of survival (HR 3.13, p=0.03). Conclusions From a thoracic surgery survey, 85% of surgeons use intraoperative frozen section margin analysis to guide surgical decision-making during an esophagectomy. Analyzing patients with a positive margin discovered during esophagectomy suggests that esophageal cancer patients who can be re-resected to a negative margin have increased PFS. Final margin appears to be related to PFS.