Beyond margin length: Integrating tumour biology into the extent of gastrectomy

Recent surgical studies have renewed interest in the oncological relevance of proximal resection margin length in gastric and oesophagogastric junction cancer. While some data suggest that the absolute length of a negative proximal margin does not independently influence survival, other observations indicate that unexpected microscopic proximal tumour extension may predict adverse outcomes despite margin negativity. These findings challenge a purely distance-based surgical doctrine and suggest that horizontal intramural spread may reflect tumour biology rather than technical inadequacy. Alterations in adhesion molecules such as E-cadherin and CD44v6 have been associated with infiltrative growth and nodal dissemination and may partly explain unpredictable microscopic extension. In parallel, evolving perioperative strategies and increasing response rates further question a strictly anatomy-driven approach to resection planning. Integrating biological and response-based considerations into surgical decision-making may represent a logical next step in refining the extent of gastrectomy.