Clinicopathologic comparison of Siewert type II and III adenocarcinomas of the gastroesophageal junction

Contemporary outcomes for resected type 1-3 gastroesophageal junction adenocarcinoma: a single-center experience

BACKGROUND

Surgical resection remains the mainstay of treatment for tumors of the gastroesophageal junction (GEJ). However, contemporary analyses of the Western experience for GEJ adenocarcinoma are sparsely reported.

METHODS

Patients with GEJ adenocarcinoma undergoing resection between 2012 and 2022 at a single institution were grouped based on Siewert subtype and analyzed. Pathologic and treatment related variables were assessed with relation to outcomes.

RESULTS

A total of 302 patients underwent resection: 161 (53.3%) with type I, 116 (38.4%) with type II, and 25 (8.3%) with type III tumors. Most patients received neoadjuvant therapy (86.4%); 86% of cases were performed in a minimally invasive fashion. Anastomotic leak occurred in 6.0% and 30-day mortality in only 0.7%. The rate of grade 3+ morbidity was lower for the last 5 years of the study than for the first 5 years (27.5% vs 49.3%, P < .001), as was median length of stay (7 vs 8 days, P < .001). There was a significantly greater number of signet ring type tumors among type III tumors (44.0%) than type I/II tumors (11.2/12.9%, P < .001). Otherwise, there was no difference in the distribution of pathologic features among Siewert subtypes. Notably, there was a significant difference in 3-year overall survival based on Siewert classification: type I 60.0%, type II 77.2%, and type III 86.3% (P = .011). Siewert type I remained independently associated with worse survival on multivariable analysis (hazard ratio, 4.5; P = .023).

CONCLUSIONS

In this large, single-institutional series, operative outcomes for patients with resected GEJ adenocarcinoma improved over time. On multivariable analysis, type I tumors were an independent predictor of poor survival.

Survival outcomes of neoadjuvant and adjuvant chemoradiotherapy for locally advanced adenocarcinoma of the oesophagogastric junction: a retrospective cohort study using the SEER database

BACKGROUND

Both neoadjuvant chemoradiotherapy (nCRT) and adjuvant chemoradiotherapy (aCRT) have survival advantages over surgery alone in patients with adenocarcinoma of the oesophagogastric junction (AEG). However, whether there is a difference in the survival benefit between these two treatments and who can benefit from them remains controversial, and there are currently no randomised controlled trials to address these issues. This study compared the survival outcomes of patients with locally advanced AEG receiving nCRT and aCRT.

METHODS

The data of patients with locally advanced AEG were collected from the Surveillance, Epidemiology, and End Results (SEER) database (2004-2015). Patients in the nCRT and aCRT groups were propensity-score matched 1:1, and the Kaplan-Meier method and log-rank test were used for survival analysis between the two groups. Univariable and multivariable Cox regression models were performed to identify the prognostic factors.

RESULTS

Of the 1,436 cases diagnosed as locally advanced AEG, we included 442 in the final analysis. The median overall survival (OS) of the nCRT and aCRT cohorts were 30.0 and 25.0 months, respectively (P=0.042), and the median tumour specific survival times were 37.0 and 31.0 months, respectively (P=0.249). Multivariable Cox regression analysis showed that OS was independently related to age [<60 years vs. ≥70 years, hazard ratio (HR) =0.619, 95% CI: 0.510-0.751, P<0.001; 60-69 years vs. ≥70 years, HR =0.661, 95% CI: 0.536-0.814, P<0.001] and N stage (N2 vs. N1, HR =1.213, 95% CI: 1.002-1.468, P=0.048; N3 vs. N1, HR =1.606, 95% CI: 1.190-2.167, P=0.002). Through stratifying patients by TNM stage, stage IIIB, and N1 stage, we observed that patients receiving nCRT had a better prognosis.

CONCLUSIONS

Patients receiving nCRT had significantly better survival than those receiving aCRT. nCRT may offer some therapeutic benefits in patients with IIIB stage AEG.

Systematic review with meta-analysis: prevalence of prior and concurrent Barrett's oesophagus in oesophageal adenocarcinoma patients

BACKGROUND

The proportions of patients with oesophageal adenocarcinoma (OAC) diagnosed by Barrett's oesophagus surveillance or with pre-existing Barrett's oesophagus are unclear.

AIM

To estimate the prevalence of prior and concurrent Barrett's oesophagus diagnosis among patients with OAC or oesophagogastric junction adenocarcinomas (OGJAC).

METHODS

We searched PubMed and Embase to identify studies published 1966-1/8/2020 that examined the prevalence of prior (≥6 months) or concurrent Barrett's diagnosis (at cancer diagnosis) among OAC and OGJAC patients. Random effects models estimated overall and stratified pooled prevalence rates.

RESULTS

A total of 69 studies, including 33 002 OAC patients (53 studies) and 2712 patients with OGJAC (28 studies) were included. The pooled prevalence of prior Barrett's oesophagus diagnosis in OAC was 11.8% (95% confidence interval [CI] 8.4%-15.6%). The prevalence of prior Barrett's oesophagus diagnosis was higher in single-centre resection studies (16.0%, 95% CI 8.7%-24.9%) than population-based cancer registry studies (8.4%, 95% CI 5.5%-11.9%). The prevalence of concurrent Barrett's oesophagus in OAC was 56.6% (95% CI 48.5%-64.6%). Studies with 100% early stage OAC had higher prevalence of concurrent Barrett's oesophagus (91.3%, 95% CI 82.4%-97.6%) than studies with <50% early OAC (39.7%, 95% CI 33.7%-45.9%). In OGJAC, the prevalence of prior and concurrent Barrett's oesophagus was 23.2% (95% CI 7.5%-44.0%) and 26.3% (95% CI 17.8%-35.7%), respectively.

CONCLUSIONS

Most patients with OAC have Barrett's oesophagus. Our meta-analysis found ~12% of OAC patients had prior Barrett's diagnosis, but concurrent Barrett's oesophagus was found in ~57% at the time of OAC diagnosis. This represents a considerable missed opportunity for Barrett's oesophagus screening.

Optimal Extent of Transhiatal Gastrectomy and Lymphadenectomy for the Stomach-Predominant Adenocarcinoma of Esophagogastric Junction: Retrospective Single-Institution Study in China

Background: The optimal extent of gastrectomy and lymphadenectomy for esophagogastric junction (EGJ) cancer is controversial. Our study aimed to compare the long-term survival of transhiatal proximal gastrectomy with extended periproximal lymphadenectomy (THPG with EPL) and transhiatal total gastrectomy with complete perigastric lymphadenectomy (THTG with CPL) for patients with the stomach-predominant EGJ cancer. Methods: Between January 2004, and August 2015, 306 patients with Siewert II tumors were divided into the THTG group (n = 148) and the THPG group (n = 158). Their long-term survival was compared according to Nishi's classification. The Kaplan-Meier method and Cox proportional hazards models were used for survival analysis. Results: There were no significant differences between the two groups in the distribution of age, gender, tumor size or Nishi's type (P > 0.05). However, a significant difference was observed in terms of pathological tumor stage (P < 0.05). The 5-year overall survival rates were 62.0% in the THPG group and 59.5% in the THTG group. The hazard ratio for death was 0.455 (95% CI, 0.337 to 0.613; log-rank P < 0.001). Type GE/E = G showed a worse prognosis compared with Type G (P < 0.05). Subgroup analysis stratified by Nishi's classification, Stage IA-IIB and IIIA, and tumor size ≤ 30 mm indicated significant survival advantages for the THPG group (P < 0.05). However, this analysis failed to show a survival benefit in Stage IIIB (P > 0.05). Conclusions: Nishi's classification is an effective method to clarify the subdivision of Siewert II tumors with a diameter ≤ 40 mm above or below the EGJ. THPG with EPL is an optimal procedure for the patients with the stomach-predominant EGJ tumors ≤30 mm in diameter and in Stage IA-IIIA. For more advanced and larger EGJ tumors, further studies are required to confirm the necessity of THTG with CPL.

Prognostic value of resected lymph nodes numbers for Siewert II gastroesophageal junction cancer

We aim to evaluate whether resected lymph nodes (RLNs) numbers have prognostic value in patients with gastroesophageal junction cancers (GEJ, Siewert type II). Patients with gastroesophageal junction cancers were identified from the Surveillance Epidemiology and End Results (SEER) registry between 1988 to 2013. Multivariate Cox regression analyses and Kaplan–Meier method were performed to analyze risk factors for overall survival (OS) and cause-specific survival(CSS). A total of 8396 patients who underwent surgeries and had reginal lymph nodes examined were identified. Kaplan–Meier analysis indicated that more numbers of resected lymph nodes (RLNs) were associated with better survival. The five-year OS rates for 1–20 and 21–90 RLNs were 26.8% and 32.4%, with a median survival time of 62 and 72 months, respectively (P < 0.001). The five-year CSS rates were 32.2% and 37.2% in each group, with median survival time of 90 and 101 months, respectively (P < 0.001). Cox regression multivariate analysis showed that year of diagnosis, age, sex, marital status, grade, seer histology, tumor histology, lymph node ratio (LNR) and RLNs as a categorical variable were all significant prognostic factors for both OS and CSS. RLN count is an independent prognostic factor for Siewert type II GEJ cancer patients and patients can achieve better overall and cancer-specific survival with more than 20 RLNs dissected.

Siewert III adenocarcinoma: treatment update

Siewert III cancer, although representing around 40% of EGJ cancers and being the EGJ cancer with worst prognosis, does not have a homogenous treatment, has few dedicated studies, and is often not considered in study protocols. Although staged as an esophageal cancer by the TNM 7th ed., it is considered a gastric cancer by new TNM 8th ed. Our aim was to consolidate the current literature on the indications and treatment options for Siewert III adenocarcinoma. A review of the literature was performed to better delineate treatment indications (according to stage, surgical margins, type of lymphatic spread and lymphadenectomy) and treatment strategy. The treatment approach is strictly dependent on cancer site and nodal diffusion. T1m cancers have insignificant risk of nodal metastases and can be safely treated with endoscopic resections. The risk of nodal metastases increases markedly starting from T1sm cancers and requires surgery with lymphadenectomy. The site of this type of cancer and the nodal diffusion require a total gastrectomy and distal esophagectomy, with 5 cm of clear proximal and distal margins and a D2 abdominal and inferior mediastinal lymphadenectomy. Multimodal treatments are indicated in all locally advanced and node positive cancers. Siewert III cancers are gastric cancers with some peculiarities and require dedicated studies and deserve more consideration in the current literature, especially because their treatment is particularly challenging.

Combination of concept and clinical practice - putting a high premium on neoadjuvant therapy for adenocarcinoma of the esophagogastric junction

The incidence of adenocarcinoma of the esophagogastric junction (AEG) is rising rapidly in recent years. The opinion that AEG is an independent disease different from squamous cell carcinoma of the esophagus and gastric adenocarcinoma has been accepted by more and more scholars. R0 resection with D2 lymph node dissection is the cornerstone of treatment, but surgical techniques remain controversial with particular uncertainty about the operation ways, appropriate resection extent about the esophagus and stomach, and lymphadenectomy sites. Neoadjuvant therapy has attracted increasing attention due to a high rate of relapse after resection and poor survival rate for most patients with advanced disease at diagnosis. Although clinical literature and meta-analyses show that neoadjuvant chemotherapy results in a significant survival benefit at 5 years for resectable locally advanced AEG, and preoperative chemoradiotherapy also should be as a standard treatment for AEG versus surgery alone, the optimal regimens of neoadjuvant therapy and comparisons between preoperative chemotherapy and chemoradiotherapy still need to be studied further.

Clinicopathological characterisation of small (2 cm or less) proximal and distal gastric carcinomas in a Chinese population

SummaryClinicopathological characteristics of small gastric carcinoma have not been well defined in Chinese patients. The aim of this study was to investigate and compare small proximal (PGC, n = 111) with distal (DGC, n = 202) gastric carcinoma in 313 consecutive surgically resected small (≤2 cm) gastric carcinomas diagnosed with the WHO criteria. PGC patients were significantly older (average age 63 years versus 59 in DGCs) with a male/female ratio of 3:1. Most tumours were clustered along the lesser curvature (74% in PGCs and 65% in DGCs). Compared to DGCs, PGCs showed a protruded gross pattern significantly more frequently and were significantly better differentiated with a significantly wider histomorphological spectrum. Surprisingly, PGCs were composed of significantly fewer signet-ring cell carcinomas (1% versus 16% in DGCs) but were significantly more deeply invasive, compared to DGCs. Lymph node metastasis was detected in 23% overall, but was significantly less frequent in PGCs (16%) than in DGCs (26%) (p < 0.05). However, the difference in survival between the two groups was not statistically significant. Our results demonstrate that in Chinese patients, PGCs display distinct clinicopathological characteristics, compared to DGCs.

Recent advances in proximal gastric carcinoma

The American Joint Committee on Cancer (AJCC) staging scheme requires staging proximal gastric carcinoma (PGC) as esophageal adenocarcinoma (EAC), which has been shown to be controversial by recent research results. To update the current research findings on PGC, we systematically reviewed and analyzed the scientific evidence on key arguments related to PGC. The data of high-quality research articles showed that PGC arised in the cardiac mucosa in the proximal stomach within 3 cm below the gastroesophageal junction. Its incidence is rising in East Asian countries, but decreasing in the West, and plateaued at a low level in the United States. PGC is a slowly progressive cancer with unknown independent risk factors and the mechanisms of pathogenesis. This carcinoma exhibits a wide histopathological spectrum and heterogeneous post-resection patient survival characteristics, and cannot be adequately staged for prognotic stratification by the current AJCC staging classification. The results on PGC genomics reveal unique genetic profiles, especially in East Asian populations. In conclusion, mounting evidence defies a simple placement of PGC in a single category of EAC for disease classification; further investigations on the mechanisms of PGC pathogenesis are urgently needed.

Differences in prognosis of Siewert II and III oesophagogastric junction cancers are determined by the baseline tumour staging but not its anatomical location

BACKGROUND

The anatomical Siewert classification for adenocarcinoma of the oesophagogastric junction (OGJ) was dictated by the potential differences in tumour epidemiology and pathology. However, there are some uncertainties whether the distinction of true carcinoma of the cardia (type II) and subcardial gastric cancer (type III) is of clinical value.

METHODS

Using a multicentre data set, we studied 243 patients with OGJ adenocarcinomas who underwent gastric resections between 1998 and 2008. Postoperative complications and long-term survival were compared to evaluate the potential differences in clinically relevant outcomes.

RESULTS

A group of 109 patients with Siewert type II and 134 with Siewert type III OGJ adenocarcinoma was identified. Both groups showed similar baseline characteristics, including clinical symptoms and duration of diagnostic delay. However, the prevalence of node-negative cancers and superficial (T1-T2) lesions was significantly higher among type II tumours, i.e. 42% vs 21% (P = 0.003) and 43% vs 20% (P = 0.045), respectively. Morbidity and mortality rates were 25% and 3.7%, respectively, but types and incidence of postoperative complications were not affected by the anatomical location of the tumour. The overall median survival was significantly longer for Siewert type II tumours (42 vs 16 months; P < 0.001). However, only patients' age >70 years, depth of tumour infiltration, lymph node metastases, distant metastases, and radical resection were identified as independent prognostic factors using the Cox proportional hazards model.

CONCLUSION

The topographic-anatomic sub-classification of OGJ adenocarcinomas does not correspond to relevant differences in clinical parameters of safety and efficacy of surgical treatment.

Undervalued criteria in the evaluation of multimodal trials for upper GI cancers

Global economies and their health systems face a huge challenge from cancer: 1 in 3 women and 1 in 2 men will develop cancer in their lifetime. In the less developed countries, the volume of cancer patients will overwhelm the existing healthcare systems. Even in developed regions, patients with upper gastrointestinal (GI) cancer usually present with locally advanced tumors that their prognosis is poor. A detailed knowledge of anatomy, embryology, epidemiology, tumor classifications and tumor growth is key understanding and evaluating the relevant research. We review undervalued criteria necessary to evaluate the response to multimodal therapy for upper GI cancers.

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.

Pattern of abdominal nodal spread and optimal abdominal lymphadenectomy for advanced Siewert type II adenocarcinoma of the cardia: results of a multicenter study

BACKGROUND

It remains uncertain whether radical lymphadenectomy combined with total gastrectomy actually contributes to long-term survival for Siewert type II adenocarcinoma of the cardia. We identified the pattern of abdominal nodal spread in advanced type II adenocarcinoma and defined the optimal extent of abdominal lymphadenectomy.

METHODS

Eighty-six patients undergoing R0 total gastrectomy for advanced type II adenocarcinoma were identified from the gastric cancer database of 4,884 patients. Prognostic factors were investigated by multivariate analysis. The therapeutic value of lymph node dissection for each station was estimated by multiplying the incidence of metastasis by the 5-year survival rate of patients with positive nodes in each station.

RESULTS

The overall 5-year survival rate was 37.1%. Age less than 65 years [hazard ratio, 0.455 (95% confidence interval (CI), 0.261-0.793)] and nodal involvement with pN3 as referent [hazard ratio for pN0, 0.129 (95% CI, 0.048-0.344); for pN1, 0.209 (95% CI, 0.097-0.448); and for pN2, 0.376 (95% CI, 0.189-0.746)] were identified as significant prognosticators for longer survival. Perigastric nodes of the lower half of the stomach in positions 4d-6 were considered not beneficial to dissect, whereas there were substantial therapeutic benefits to dissecting the perigastric nodes of the upper half of the stomach in positions 1-3 and the second-tier nodes in positions 7 and 11.

CONCLUSIONS

Limited lymphadenectomy attained by proximal gastrectomy might suffice as an alternative to extended lymphadenectomy with total gastrectomy for obtaining potential therapeutic benefit in abdominal lymphadenectomy for advanced Siewert type II adenocarcinoma.

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.

Surgical Outcomes for Cancer at the Gastroesophageal Junction

The aim of this study was to evaluate the clinicopathological characteristics and prognostic factors of cancer at the gastroesophageal junction (GEJ) whose center is situated at a site within 2 cm above and below the junction. This retrospective study included 90 patients with cancer at the GEJ, including 58 with adenocarcinoma (ADC) and 32 with squamous cell carcinoma (SCC). ADC tumors were larger in size than SCC tumors. ADC and SCC at the GEJ showed a similar distribution of the pattern of lymphatic spread. The rate of lower mediastinal lymph node metastasis was approximately 20 per cent, which is similar to the nodes along the celiac artery and the nodes along the common hepatic artery. The overall survival rates were similar between the groups. The presence of five or more lymph node metastases was an independent prognostic factor according to a multivariate analysis. When two or more lymph nodes larger than 10 mm were detected preoperatively, five or more lymph node metastases were proven by histology in most cases. The most frequent sites of recurrence of ADC and SCC were the peritoneum and lymph nodes, respectively. Aggressive additional treatment may be needed if two or more lymph nodes are seen on preoperative imaging.

Gastric tube reconstruction reduces postoperative gastroesophageal reflux in adenocarcinoma of esophagogastric junction

BACKGROUND

The anastomosis of gastric remnant to esophagus after proximal gastrectomy is the traditional surgical treatment procedure for patients with types II and III adenocarcinoma of esophagogastric junction. However, the postoperative complications such as gastroesophageal reflux are frequent.

AIMS

To assess the outcome of the intraperitoneal anastomosis of the reconstructed gastric tube to esophagus after proximal gastrectomy for types II and III adenocarcinoma of esophagogastric junction.

METHODS

Seventy-six consecutive patients with preoperative diagnosis of type II or type III adenocarcinoma of esophagogastric junction were recruited. Forty-one patients had the traditional anastomosis of gastric remnant to esophagus and 35 patients underwent an anastomosis of esophagus to a gastric tube that was constructed from the gastric remnant after proximal gastrectomy.

RESULTS

Twenty-three (56.1%) versus 12 (28.6%) patients (p = 0.016) complained various discomforts and/or were diagnosed with complications in the traditional group and gastric tube group, respectively, although there were no significant differences between the two groups in demographic data and pathological characteristics. Fourteen (34.1%) versus five (14.3%) patients (p = 0.046) complained of heartburn or acid regurgitation and nine (22.0%) versus two (5.7%) patients (p = 0.045) were confirmed reflux esophagitis in the traditional group and the gastric tube group, respectively.

CONCLUSIONS

The intraperitoneal anastomosis of the reconstructed gastric tube to esophagus demonstrates less complaints of gastroesophageal reflux and reflux esophagitis than the traditional anastomosis of gastric remnant to esophagus in the surgical treatment of types II and III adenocarcinoma of esophagogastric junction in 1-year follow-up.

Comparison of gastro-oesophageal junction carcinomas in Chinese versus American patients

AIMS

To compare the clinical and pathological features of gastro-oesophageal junction (GEJ) carcinomas in Chinese and American patients.

METHODS AND RESULTS

Eighty consecutive patients with a GEJ carcinoma (43 from mainland China, and 37 from the USA) were evaluated for association with Barrett oesophagus (BO), chronic Helicobacter pylori gastritis, intestinal metaplasia, and outcome. GEJ carcinomas were defined as tumours that were located within 20 mm of, and crossed, the GEJ. Overall, GEJ carcinomas from Chinese patients revealed significantly more frequent location in the proximal stomach, higher pathological stage, larger size, younger patient age, and association with chronic H. pylori gastritis. In contrast, GEJ cancers from American patients showed a strong association with distal oesophageal location, BO, and associated intestinal metaplasia and dysplasia. Pathologically, GEJ carcinomas from American patients were predominantly adenocarcinomas, whereas Chinese patients showed a higher proportion of mucinous, adenosquamous, acinar or neuroendocrine tumours. Overall, 3- and 5-year survival rates were statistically similar between both patient groups, but upon multivariate analysis, Chinese patients showed statistically better survival rates for stage III tumours.

CONCLUSIONS

Most GEJ carcinomas in patients from China represent proximal gastric cancers associated with chronic H. pylori gastritis, and BO-associated carcinomas are rare among this patient population.

Clinicopathological features and prognostic factors of adenocarcinoma of the esophagogastric junction according to Siewert classification: experiences at a single institution in Japan

BACKGROUND

Treatment strategy for adenocarcinoma of the esophagogastric junction (AEG) remains controversial. The aims of this study are to evaluate results of surgery for AEG, to clarify clinicopathological differences according to the Siewert classification, and to define prognostic factors.

METHODS

We retrospectively analyzed 179 consecutive patients with Siewert type I, II, and III AEG who underwent curative (R0) resection at the National Cancer Center Hospital East between January 1993 and December 2008.

RESULTS

Patients with AEG were divided according to tumor: 10 type I (5.6%), 107 type II (59.8%), and 62 type III (34.6%). Larger, deeper tumors and nodal metastasis were more common in type III than type II tumors. No significant differences were seen in 5-year survival rates among the three types: type I (51.4%), type II (51.8%), and type III (62.6%). Multivariate analysis showed that depth of tumor and mediastinal lymph node metastasis were independent prognostic indicators. The recurrence rate for patients with mediastinal lymph node metastasis was 87.5%. The risk factors for mediastinal lymph node metastasis were length of esophageal invasion and histopathological grade.

CONCLUSIONS

Mediastinal lymph node metastasis and tumor depth were significant and independent factors for poor prognosis after R0 resection for AEG. Esophageal invasion and histopathological grade were significant and independent factors for mediastinal lymph node metastasis.

Surgical strategies for adenocarcinoma of the esophagogastric junction

This chapter summarizes the surgical strategies for adenocarcinomas of the distal esophagus, gastric cardia, and subcardial gastric cancer invading the cardia+/-distal esophagus known as adenocarcinomas of the esophagogastric junction (AEG). The different surgical approaches according to the tumor origin, localization, and tumor stage are addressed with particular attention to the extent and type of resection and appropriate lymphadenectomy (LAD). The classification of AEG according to Siewert is helpful for the selection of the surgical strategy. While type I tumors benefit from a transthoracic en bloc esophagectomy including a two-field LAD, type II and III tumors can be treated by an extended total gastrectomy with a transhiatal resection of the distal esophagus and LAD of the lower mediastinum and the abdominal D2 compartment. Limited resections appear to be -possible for early tumor stages in selected cases of type I-III tumors.

Is adenocarcinoma of the esophagogastric junction different between Japan and western countries? The incidence and clinicopathological features at a Japanese high-volume cancer center

BACKGROUND

We clarified the incidence of adenocarcinoma of the esophagogastric junction (AEG) at a Japanese high-volume cancer center and its clinicopathological features between the Siewert subtypes.

METHODS

Patients with AEG were selected from a prospective database of gastric and esophageal tumors established by Kanagawa Cancer Center. The Siewert subtypes were determined retrospectively by examining pathological pictures of the resected specimens and by evaluating the pathology and endoscopy findings.

RESULTS

From January 1986 to December 2005, 147 (4.0%) patients were determined to have AEG; 2,794 (75.8%) were diagnosed to be true gastric cancer, whereas 745 (20.2%) were true esophageal cancer. Of these 147 patients with AEG, 5 (3.4%) were classified as type I, 82 (55.8%) as type II, and 60 (40.8%) as type III tumors. The depth of tumor invasion was deeper and the nodal metastases were more frequent in type III compared with type II. The risk factors for nodal metastases included the depth and size of the tumor, but not the Siewert subtypes itself. Mediastinal nodal metastases were strongly influenced by a thoracotomy and the extent of the dissection. The pathological grade was higher in type III than in type II. Although the 5-year survival rate was significantly higher in type II than in type III tumors, the survival difference disappeared when the patients were restricted to an R0 resection, even though type III patients demonstrated a more advanced stage.

CONCLUSIONS

The proportions of AEG were strikingly different between Japan and western countries. Although each Siewert subtype had some different characteristics, nodal metastases were determined by both the tumor progression and the extent of the nodal dissection. An R0 resection was a key for the survival in AEG.

EORTC-ROG expert opinion: radiotherapy volume and treatment guidelines for neoadjuvant radiation of adenocarcinomas of the gastroesophageal junction and the stomach

PURPOSE

The Gastro-Intestinal Working Party of the EORTC Radiation Oncology Group (GIWP-ROG) developed guidelines for target volume definition in neoadjuvant radiation of adenocarcinomas of the gastroesophageal junction (GEJ) and the stomach.

METHODS AND MATERIALS

Guidelines about the definition of the clinical target volume (CTV) are based on a systematic literature review of the location and frequency of local recurrences and lymph node involvement in adenocarcinomas of the GEJ and the stomach. Therefore, MEDLINE was searched up to August 2008. Guidelines concerning prescription, planning and treatment delivery are based on a consensus between the members of the GIWP-ROG.

RESULTS

In order to support a curative resection of GEJ and gastric cancer, an individualized preoperative treatment volume based on tumour location has to include the primary tumour and the draining regional lymph nodes area. Therefore we recommend to use the 2nd English Edition of the Japanese Classification of Gastric Carcinoma of the Japanese Gastric Cancer Association which developed the concept of assigning tumours of the GEJ and the stomach to anatomically defined sub-sites corresponding respectively to a distinct lymphatic spread pattern.

CONCLUSION

The GIWP-ROG defined guidelines for preoperative irradiation of adenocarcinomas of the GEJ and the stomach to reduce variability in the framework of future clinical trials.

Adenocarcinoma of the esophagogastric junction: the role of abdominal-transhiatal resection

The surgical strategy for adenocarcinoma of the esophagogastric junction is still controversial. The aim of this study was to evaluate surgical results of the abdominal-transhiatal approach for 100 consecutively operated type II and III cardia adenocarcinoma, to clarify clinicopathological differences between these tumors, and to define prognostic factors. A prospectively maintained database identified 100 consecutively operated patients with Siewert type II and III cardia adenocarcinoma. Survival was analyzed by the Kaplan-Meier method. Differences between subgroups and prognostic factors were evaluated by the log rank test and Cox regression. Concerning clinicopathological characteristics, only the incidence of T1-2 stage was significantly higher in Siewert II type (P = .006). A complete (R0) resection was obtained in 74 patients (74%). Overall postoperative mortality and morbidity rates were 6% and 28%, respectively. Overall actuarial 5-year survival rate in resected patients was 27.4% (median 27 months), with 20.6% for type II and 34 for type III cancers (P = .07). Considering R0 resections, overall actuarial 5-year survival rate was 33.9% (median 33 months), with 26.7% for type II and 40.5 for type III cancer (P = .06). Pathologic T and N stage and R status were independent prognostic factors by multivariate analysis, and Siewert type showed a trend toward significance. The abdominal-transhiatal approach is a safe surgical approach, allowing complete tumor resection and adequate lymphadenectomy in these patients. True carcinoma of the cardia may be a distinct clinical entity with a more aggressive natural history than subcardial gastric carcinoma.

Lymph node involvement in advanced gastroesophageal junction adenocarcinoma

OBJECTIVE

The prognosis of gastroesophageal junction adenocarcinoma is unquestionably related to the extent of nodal involvement; nonetheless, few studies deal with the pattern of lymph node spread and specifically analyze the prognostic value of the site of metastasis. The present study was aimed at evaluating these key aspects in advanced gastroesophageal junction adenocarcinoma.

METHODS

Of 219 patients consecutively operated on for gastroesophageal junction adenocarcinoma at the Department of General Surgery and Surgical Oncology, University of Siena, and at the Department of General Surgery, University of Verona, 143 pT2-4 tumors not submitted to prior chemoradiation were analyzed according to the Japanese Gastric Cancer Association pN staging system.

RESULTS

The majority of patients were given diagnoses of nodal metastases (77.6%). The mean number (P = .076) and the percentage of patients with pN+ disease (P = .022) progressively increased from Siewert type I to type III tumors. Abdominal nodes were involved in all but 1 of the patients with pN+ disease; conversely, nodal metastases into the chest were 46.2% for type I, 29.5% for type II, and 9.3% for type III tumors. Survival analysis showed virtually no chance of recovery for patients with more than 6 metastatic nodes or lymph nodes located beyond the first tier.

CONCLUSIONS

In advanced gastroesophageal junction adenocarcinoma, the high frequency of nodal metastases and the related unfavorable long-term outcome achieved by means of surgical intervention alone are indicative of the need for aggressive multimodal treatment along with surgical intervention to improve long-term results.