Surgical strategies for adenocarcinoma of the esophagogastric junction

Short-term postoperative complications and prognostic factors in patients with adenocarcinoma of the esophagogastric junction

Background

The study was conducted to investigate the short‐term complications and prognostic factors in patients with esophagogastric junction adenocarcinoma (EGJA).

Methods

This retrospective study included 110 EGJA patients who underwent surgery from January 2010 to November 2012 at The First Affiliated Hospital of BengBu Medical College. The overall survival and short‐term complications were analyzed according to the patients’ clinical characteristics.

Results

The incidence of postoperative cardiopulmonary complications was significantly higher in patients with preoperative cardiopulmonary disease or elderly patients (P < 0.05). Four cases of upper margin cancer residue were detected using the abdominal approach and three using the thoracic approach, which indicated that the cancer residue margin was related to surgical approach. The overall five‐year survival rate was 34.3% and statistically differed according to pathological stage and en block resection (P_all < 0.05). Cox regression analysis showed that lymph node metastasis (P < 0.05) and the extent of tumor invasion (P < 0.05) were independent prognostic factors.

Conclusion

Elderly patients with preoperative cardiopulmonary disease had an increased risk of developing postoperative cardiopulmonary complications. Lymph node status and depth of tumor invasion were independent factors related to patient prognosis.

18FDG-PET-CT identifies histopathological non-responders after neoadjuvant chemotherapy in locally advanced gastric and cardia cancer: cohort study

Background

Pathologic response to neoadjuvant chemotherapy (neoCTX) is a prognostic factor in many cancer types, and early prediction would help to modify treatment. In patients with gastric and esophagogastric junction (AEG) cancer, the accuracy of FDG PET-CT to predict early pathologic response after neoadjuvant chemotherapy (neoCTX) is currently not known.

Methods

From a consecutive cohort of 72 patients, 44 patients with resectable, locally-advanced gastric cancer or AEG Siewert type II and III received neoCTX after primary staging with endoscopic ultrasound, PET-CT and laparoscopy. Overall, 14 patients did not show FDG uptake, and the remaining 30 were restaged by PET-CT 14 days after the first cycle of neoCTX. Metabolic response was defined as decrease of tumor standardized uptake value (SUV) by ≥35%. Major pathologic regression was defined as less than 10% residual tumor cells.

Results

Metabolic response after neoCTX was detected in 20/30 (66.7%), and non-response in 10/30 (33.3%) patients. Among metabolic responders, n = 10 (50%) showed major and n = 10 (50%) minor pathologic regression. In non-responders, n = 9 (90%) had minor and 1 (10%) a major pathologic regression. This resulted in a sensitivity of 90.9%, specificity 47.3%, positive predictive value 50%, negative predictive value 90% and accuracy of 63.3%.

Conclusion

Response PET-CT after the first cycle of neoCTX does not accurately predict overall pathologic response. However, PET-CT reliably detects non-responders, and identifies patients who should either immediately proceed to resection or receive a modified multimodality therapy.

Trial registration

The trial was registered and approved by local ethics committee PB_2016–00769.

Detection of circulating tumor cells in patients with esophagogastric or pancreatic adenocarcinoma using the CellSearch® system: An observational feasibility study

Circulating tumor cells (CTCs) in the blood of cancer patients have been demonstrated to be of prognostic value regarding metastasis and survival. The CellSearch^® system has been certified for the detection of CTCs and as a prognostic tool in patients with metastatic breast, colon and prostate cancer. Few studies have evaluated the detection of CTCs originating from esophagogastric or pancreatic cancer with the CellSearch^® system. In the present small pilot study, a total of 16 patients with either esophagogastric (n=8) or pancreatic (n=8) adenocarcinomas at various disease stages were randomly screened and included. A total of 7.5 ml of blood was drawn from each patient and analyzed for CTCs using the CellSearch^® device. CTCs could be detected in 1 out of 8 patients (12.5%) with esophagogastric and in 7 out of 8 patients (87.5%) with pancreatic cancer. The preliminary data obtained from this observational feasibility study suggested that the CellSearch^® system may become a valuable tool for the detection of CTCs in patients with pancreatic adenocarcinoma, whereas the usefulness in patients with early-stage esophagogastric adenocarcinoma may be limited. This study clearly points towards a requirement for larger studies focusing on patients with pancreatic adenocarcinoma at various disease stages and assessing CTCs, whereas patients with esophagogastric adenocarcinomas should be part of further pilot studies.

Total esophagogastrectomy in the neoplasms of the esophagus and esofagogastric junction: when must be indicated?

OBJECTIVE

to analyse the indications and results of the total esophagogastrectomy in cancers of the distal esophagus and esophagogastric junction.

METHODS

twenty patients with adenocarcinomas were operated with a mean age of 55 ± 9.9 years (31-70 years), and 14 cases were male (60%). Indications were 18 tumors of the distal esophagus and esophagogastric junction (90%) and two with invasion of gastric fundus (10%) in patients with previous gastrectomy. Preoperative colonoscopy to exclude colonic diseases was performed in ten cases.

RESULTS

the surgical technique consisted of median laparotomy and left cervicotomy, followed by transhiatal esophagectomy associated with D2 lymphadenectomy. The reconstructions were performed with eight esophagocoloduodenoplasty and the others were Roux-en-Y esophagocolojejunoplasty to prevent the alkaline reflux. Three cases were stage I / II, while 15 cases (85%) were stages III / IV, reflecting late diagnosis of these tumors. The operative mortality was 5 patients (25%): a mediastinitis secondary to necrosis of the transposed colon, abdominal cellulitis secondary to wound infection, severe pneumonia, an irreversible shock and sepsis associated with colojejunal fistula. Four patients died in the first year after surgery: 3 (15%) were due to tumor recurrence and 1 (5%) secondary to bronchopneumonia. The 5-year survival was 15%.

CONCLUSION

the total esophagogastrectomy associated with esophagocoloplasty has high morbidity and mortality, requiring precise indication, and properly selected patients benefit from the surgery, with the risk-benefit acceptable, contributing to increased survival and improved quality of life.

Clinical comparison of antrum-preserving double tract reconstruction vs roux-en-Y reconstruction after gastrectomy for Siewert types II and III adenocarcinoma of the esophagogastric junction

AIM: To explore a reasonable method of digestive tract reconstruction, namely, antrum-preserving double-tract reconstruction (ADTR), for patients with adenocarcinoma of the esophagogastric junction (AEG) and to assess its efficacy and safety in terms of long-term survival, complications, morbidity and mortality.

METHODS: A total of 55 cases were retrospectively collected, including 18 cases undergoing ADTR and 37 cases of Roux-en-Y reconstruction (RY) for AEG (Siewert types II and III) at North Sichuan Medical College. The cases were divided into two groups. The clinicopathological characteristics, perioperative outcomes, postoperative complications, morbidity and overall survival (OS) were compared for the two different reconstruction methods.

RESULTS: Basic characteristics including sex, age, body mass index (BMI), Siewert type, pT status, pN stage, and lymph node metastasis were similar in the two groups. No significant differences were found between the two groups in terms of perioperative outcomes (including the length of postoperative hospital stay, operating time, and intraoperative blood loss) and postoperative complications (consisting of anastomosis-related complications, wound infection, respiratory infection, pleural effusion, lymphorrhagia, and cholelithiasis). For the ADTR group, perioperative recovery indexes such as time to first flatus (P = 0.002) and time to resuming a liquid diet (P = 0.001) were faster than those for the RY group. Moreover, the incidence of reflux esophagitis was significantly decreased compared with the RY group (P = 0.048). The postoperative morbidity and mortality rates for overall postoperative complications and the rates of tumor recurrence and metastasis were not significantly different between the two groups. Survival curves plotted using the Kaplan-Meier method and compared by log-rank test demonstrated similar outcomes for the ADTR and RY groups. Multivariate analysis of significantly different factors that presented as covariates on Cox regression analysis to assess the survival and recurrence among AEG patients showed that age, gender, BMI, pleural effusion, time to resuming a liquid diet, lymphorrhagia and tumor-node-metastasis stage were important prognostic factors for OS of AEG patients, whereas the selection of surgical method between ADTR and RY was shown to be a similar prognostic factor for OS of AEG patients.

CONCLUSION: ADTR by jejunal interposition presents similar rates of tumor recurrence, metastasis and long-term survival compared with classical reconstruction with RY esophagojejunostomy; however, it offers considerably improved near-term quality of life, especially in terms of early recovery and decreased reflux esophagitis. Thus, ADTR is recommended as a worthwhile digestive tract reconstruction method for Siewert types II and III AEG.

Distribution of involved abdominal lymph nodes is correlated with the distance from the esophagogastric junction to the distal end of the tumor in Siewert type II tumors

BACKGROUND

The optimal surgical approach for Siewert type II adenocarcinoma of the esophagogastric junction (AEG) has not yet been agreed. Here we investigated whether the distance from the esophagogastric junction (EGJ) to the distal end of the tumor was related to the distribution of involved abdominal lymph nodes in Siewert type II tumors.

METHODS

A total of 288 patients with pT2-4 AEG Siewert II, treated by R0 surgical resection at 7 institutions in Japan, were retrospectively investigated. The distribution of involved abdominal nodes was correlated with the distance from the EGJ to the distal end of the tumor.

RESULTS

In patients where the distance from the EGJ to the distal end of the tumor was ≤30 mm, the frequency of nodal involvement along the greater curvature or antrum was low (2.2%). In contrast, in patients where the distance was >50 mm, the incidence of this nodal involvement was 20.0%. In patients where the distance was 30-50 mm incidence was intermediate (8.0%). Multivariate analyses showed that the distance from the EGJ to the distal end of the tumor was significantly related to lymph node involvement along the greater curvature or antrum (odds ratio 3.7, 95% confidence interval 1.3-11, p = 0.006).

CONCLUSIONS

When the distance from the EGJ to the distal end of the tumor is ≤ 30 mm for Siewert II AEG, esophagectomy or proximal gastrectomy is sufficient from the point of view of abdominal lymphadenectomy. However, a total gastrectomy should be considered for abdominal lymphadenectomy when this distance is > 50 mm.

Transthoracic vs transhiatal surgery for cancer of the esophagogastric junction: A meta-analysis

AIM: To compare the efficacy and safety of the transthoracic and transhiatal approaches for cancer of the esophagogastric junction.

METHODS: An electronic and manual search of the literature was conducted in PubMed, EmBase and the Cochrane Library for articles published between March 1998 and January 2013. The pooled data included the following parameters: duration of surgical time, blood loss, dissected lymph nodes, hospital stay time, anastomotic leakage, pulmonary complications, cardiovascular complications, 30-d hospital mortality, and long-term survival. Sensitivity analysis was performed by excluding single studies.

RESULTS: Eight studies including 1155 patients with cancer of the esophagogastric junction, with 639 patients in the transthoracic group and 516 in the transhiatal group, were pooled for this study. There were no significant differences between two groups concerning surgical time, blood loss, anastomotic leakage, or cardiovascular complications. Dissected lymph nodes also showed no significant differences between two groups in randomized controlled trials (RCTs) and non-RCTs. However, we did observe a shorter hospital stay (WMD = 1.92, 95%CI: 1.63-2.22, P < 0.00001), lower 30-d hospital mortality (OR = 3.21, 95%CI: 1.13-9.12, P = 0.03), and decreased pulmonary complications (OR = 2.95, 95%CI: 1.95-4.45, P < 0.00001) in the transhiatal group. For overall survival, a potential survival benefit was achieved for type III tumors with the transhiatal approach.

CONCLUSION: The transhiatal approach for cancers of the esophagogastric junction, especially types III, should be recommended, and its long-term outcome benefits should be further evaluated.

Status and prognosis of lymph node metastasis in patients with cardia cancer - a systematic review

BACKGROUND

Adenocarcinoma of the gastroesophageal junction (GEJ) has a poor prognosis and survival rates significantly decreases if lymph node metastasis is present. An extensive lymphadenectomy may increase chances of cure, but may also lead to further postoperative morbidity and mortality. Therefore, the optimal treatment of cardia cancer remains controversial. A systematic review of English publications dealing with adenocarcinoma of the cardia was conducted to elucidate patterns of nodal spread and prognostic implications.

METHODS

A systematic literature search based on PRISMA guidelines identifying relevant studies describing lymph node metastasis and the associated prognosis. Lymph node stations were classified according to the Japanese Gastric Cancer Association guidelines.

RESULTS

The highest incidence of metastasis is seen in the nearest regional lymph nodes, station no. 1-3 and additionally in no. 7, 9 and 11. Correspondingly the best survival is seen when metastasis remain in the most locoregional nodes and survival equally tends to decrease as the metastasis become more distant. Furthermore, the presence of lymph node metastasis significantly correlates to the TNM-stage. Incidences of metastasis in mediastinal lymph nodes are associated with poor survival.

CONCLUSION

The best survival rates is seen when lymph node metastasis remains locoregional and survival rates decreases when distant lymph node metastasis is present. The dissection of locoregional lymph nodes offers significantly therapeutic benefit, but larger and prospective studies are needed to evaluate the effect of dissecting distant and mediastinal lymph nodes.

Thoracic lymph node involvement in adenocarcinoma of the esophagogastric junction and lower esophageal squamous cell carcinoma relative to the location of the proximal end of the tumor

BACKGROUND

It is difficult to determine preoperatively whether upper/middle thoracic lymphadenectomy is necessary in patients with adenocarcinoma of the esophagogastric junction (AEG) or lower esophageal squamous cell carcinoma (ESCC). Here, we investigated whether stratification based on the location of the proximal end of the tumor, as assessed using preoperative computed tomography (CT) images, would be useful for predicting upper/middle thoracic lymph node involvement for AEG and lower ESCC.

METHODS

A total of 142 patients with AEG and lower ESCC treated by R0-1 surgical resection via a thoracotomy was retrospectively investigated. The location of the proximal end of the tumor in comparison with the vena cava foramen (VCF) was decided by inspecting preoperative CT images and then correlated with upper/middle thoracic lymph node involvement.

RESULTS

The incidence of upper/middle thoracic lymph node involvement was low in AEG and ESCC tumors having proximal ends below the VCF (0 %, 0 of 13, and 5.9 %, 1 of 17, for AEG and ESCC, respectively). In contrast, when the tumors' proximal ends were above the VCF, patients had higher frequencies of upper/middle thoracic lymph node involvement (36.4 %, 8 of 22, and 37.8 %, 34 of 90, for AEG and ESCC, respectively). Multivariate analysis showed that the location of the proximal end of the tumor is an independent risk factor related to upper/middle thoracic lymph node involvement (odds ratio 14.3, 95 % confidence interval 1.76-111, p = 0.013), whereas other clinical factors (cT, cN, tumor length, and histologic types) are not.

CONCLUSIONS

This manner of stratification using preoperative CT images could be useful in deciding the extent of thoracic lymphadenectomy in both AEG and ESCC.

New therapeutic strategies for squamous cell cancer and adenocarcinoma

This paper presents commentaries on neoadjuvant treatment esophagectomy; the prognostic and predictive effects of single nucleotide polymorphisms (SNP) in the multimodality therapy of esophageal cancer; optimal preoperative treatment prior to surgery for esophageal cancer; a possible role for trastuzumab in treating esophageal adenocarcinoma or any esophageal dysplasia/intra-epithelial neoplasia; surgery after chemoradiation in resectable esophageal cancer; whether para-aortic lymph node dissection should be performed in esophagogastric junction (EGJ) tumors; and transhiatal esophagectomy in treatment of the esophageal cancer.

Comparison of Clinicopathological Characteristics in the Patients with Cardiac Cancer with or without Esophagogastric Junctional Invasion: A Single-Center Retrospective Cohort Study

Background. This study addresses clinicopathological differences between patients with gastric cardia and subcardial cancer with and without esophagogastric junctional invasion. Methods. We performed a single-center, retrospective cohort study. We studied patients who underwent curative surgery for gastric cardia and subcardial cancers. Tumors centered in the proximal 5 cm of the stomach were classed into two types, according to whether they did (Ge) or did not (G) invade the esophagogastric junction. Results. A total of 80 patients were studied; 19 (73.1%) of 26 Ge tumors and 16 (29.6%) of 54 G tumors had lymph nodes metastases. Incidence of nodal metastasis in pT1 tumors was significantly higher in the Ge tumor group. No nodal metastasis in cervical lymph nodes was recognized. Only two patients with Ge tumors had mediastinal lymph node metastases. Incidence of perigastric lymph node metastasis was significantly higher in those with Ge tumors. Ge tumors tended to be staged as progressive disease using the esophageal cancer staging manual rather than the gastric cancer staging manual. Conclusion. Because there are some differences in clinicopathological characteristics, it is thought to be adequate to distinguish type Ge from type G tumor.

Clinicopathological characteristics and optimal management for esophagogastric junctional cancer; a single center retrospective cohort study

BACKGROUND

Esophagogastric junctional (EGJ) cancer occurs in the mucosa near the esophagogastric junction, and has characteristics of both esophageal and gastric malignancies; its optimal treatment strategy is controversial.

METHODS

We conducted a single-center retrospective cohort study of the patients who underwent curative surgery with lymphadenectomy for EGJ cancer. Tumor specimens were categorized by histology and location into four types-centered in the esophagus < 5 cm from EGJ (type E), which were subtyped as (i) squamous-cell carcinoma (SQ) or (ii) adenocarcinoma (AD); (iii) any histological tumor centered in the stomach < 5 cm from EGJ, with EGJ invasion (type Ge); (iv) any histological tumor centered in the stomach < 5 cm from EGJ, without EGJ invasion (type G)-and classified by TNM system; these were compared to patients' clinicopathological characteristics and survival outcomes.

RESULTS

A total of 92 EGJ cancer patients were studied. Median follow-up of surviving patients was 35.5 months. Tumors were categorized as 12 type E (SQ), 6 type E (AD), 27 type Ge and 47 type G; of these 7 (58.3%), 3 (50%), 19 (70.4%) and 14 (29.8%) and 23 patients, respectively, had lymph node metastases. No patients with type E (AD) and Ge tumors had cervical lymph node metastasis; those with type G tumors had no nodal metastasis at cervical and mediastinal lymph nodes. Multivariate analysis showed that type E (AD) tumor was an independent prognostic factor.

CONCLUSIONS

We should distinguish type Ge tumor from type E (AD) tumor because of the clinicopathological and prognostic differentiation. Extended gastrectomy with or without lower esophagectomy according to tumor location and lower mediastinal and abdominal lymphadenectomy are recommended for EGJ cancer.

TRIAL REGISTRATION

University Hospital Medical Information Network in Japan, UMIN000008596.

Lymphadenectomy around the left renal vein in Siewert type II adenocarcinoma of the oesophagogastric junction

BACKGROUND

The extent of lymphadenectomy in patients with Siewert type II adenocarcinoma of the oesophagogastric junction is controversial. The aim of this study was to investigate lymph node involvement around the left renal vein.

METHODS

Lymph node involvement and prognosis in patients with Siewert type II cancers treated by R0-1 surgical resection were investigated, with regard to lymphadenectomy around the left renal vein. Based on the incidence of involvement at each node, the node stations were divided into three tiers (first tier, more than 20 per cent involvement; second tier, 10-20 per cent involvement; third tier, less than 10 per cent involvement).

RESULTS

Of 150 patients with type II oesophagogastric adenocarcinoma, 94 had left renal vein lymphadenectomy. The first lymph node tier included nodes along the lesser curvature, right cardia, left cardia and left gastric artery, with involvement of 28·0-46·0 per cent and a 5-year survival rate of 42-53 per cent in patients with positive nodes. The nodes around the lower mediastinum, left renal vein, splenic artery and coeliac axis constituted the second tier, with involvement of 12·7-18 per cent and a 5-year survival rate of 11-35 per cent. With regard to the left renal vein, the incidence of involvement was 17 per cent and the 5-year rate survival rate was 19 per cent. Multivariable analysis showed that left renal vein lymphadenectomy was an independent prognostic factor in patients with pathological tumour category pathological T3-4 disease (hazard ratio 0·51, 95 per cent confidence interval 0·26 to 0·99; P = 0·048).

CONCLUSION

Left renal vein nodal involvement is similar to that seen along the splenic artery, in the lower mediastinum and coeliac axis, with similar impact on patient survival.