Comparison of the surgical treatment strategies for Siewert type II squamous cell carcinoma in the same area as esophagogastric junction carcinoma: data from a single Japanese high-volume cancer center

Therapeutic value of lymph node dissection for Siewert type II and III adenocarcinoma: meta-analysis

BACKGROUND

Adenocarcinoma of the oesophagogastric junction presents an increasing incidence. Surgical resection with lymphadenectomy is the only curative treatment modality at the present time, but the optimal extent of lymphadenectomy is debatable. The aim of the present meta-analysis was to estimate the therapeutic value of each nodal station.

METHODS

Studies reporting the therapeutic value index of each nodal station in Siewert types II/III oesophagogastric junction (EGJ) were searched in PubMed, Web of Science and Embase up to October 2022. This index was calculated by multiplication of metastatic incidence and 5-year overall survival rate at each nodal station. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies. Pooled metastatic incidence and therapeutic value index were calculated using RevMan 5.4.

RESULTS

Twelve studies involving 3513 patients were included. Nodes No. 3, 1, 7 and 2 were routinely dissected and achieved a high (≥10) or moderate (5-10) therapeutic value index in decreasing order, due to their high metastatic incidence and favourable survival rate. The index was relatively low (2-5) in suprapancreatic nodes No. 9, 11p and 8a. The index for nodes No. 4d and 10 was relatively low in Siewert type Ⅲ EGJ but very low (<2) in type Ⅱ. The index was very low for nodes No. 5, 6, 11d and 12a, due to their low metastatic incidence and poor survival if positive. Para-aortic, parahiatal and mediastinal nodes were dissected only in highly selected cases. Dissection of the lower mediastinal nodes, especially No. 110, could improve survival rates in type Ⅱ EGJ.

CONCLUSION

These data could help assess the optimal extent of lymphadenectomy for EGJ. Nodes No. 1, 2, 3, 7, 8a, 9 and 11p need routine dissection in both Siewert types Ⅱ/Ⅲ EGJ; nodes around the lower oesophagus (especially No. 110) in Siewert type Ⅱ EGJ and nodes No. 4d and 10 in Siewert type Ⅲ EGJ might be considered for dissection.

Comparison of lymph node metastasis pattern from esophagogastric junction adenocarcinoma versus very low thoracic esophageal squamous cancer: a propensity-matched analysis

Background

The anatomical locations of esophagogastric junction adenocarcinoma (AEG) and very low thoracic esophageal squamous cell carcinoma (ESCC) are similar. This study aimed to evaluate the difference in lymph node metastasis (LNM) distribution between AEG and very low thoracic ESCC.

Methods

Data from 156 Siewert I-II AEG patients and 120 ESCC patients with proximal edges located within 5 cm of the esophagogastric junction (EGJ) and underwent curative surgery from 2010 to 2015 were retrospectively analyzed using propensity score matching (PSM). Five or six baseline variables were included in PSM separately. All patients underwent curative transthoracic surgery and systematic lymphadenectomy. After PSM, LNM rates of major stations were compared using the chi-squared test or Fisher's exact test.

Results

After PSM was performed with covariates (age, sex, T stage, grade, tumor length), 60 pairs of patients were included. The lower mediastinal and total thoracic LNM rates of ESCC were significantly higher than those of AEG (18.3% vs. 3.3%, P=0.019; 25% vs. 3.3%, P=0.002). After further addition of the N stage as a variant to the previous PSM model, we found that the paracardial LNM distribution was significantly different between ESCC and AEG patients (36.1% vs. 19.7%, P=0.043). Among all tumor characteristics, only the T stage was positively correlated with paracardial LNM in ESCC (P=0.010), but not in AEG. In AEG, the median survival was poor for patients with thoracic LNM.

Conclusions

Patients with very low thoracic ESCC exhibit stronger metastatic ability in the lower mediastinal and paracardial nodes than Siewert I-II AEG. However, the pathological metastasis of AEG in thoracic nodes was associated with poor survival outcomes.

Mapping of lymph node dissection determined by the epicenter location and tumor extension for esophagogastric junction carcinoma

BACKGROUNDS

Previous studies identified the extent of lymph node dissection for esophagogastric junction (EGJ) carcinoma based on the metastatic incidence. The study aimed to determine the optimal extent and priority of lymphadenectomy based on the therapeutic efficacy from each station.

METHODS

The studies on the lymph node metastasis (LNM) and therapeutic efficacy index (EI) for EGJ carcinomas were identified until April 2022. The obligatory stations with the LNM rates over 5% and therapeutic EI exceeding 2% should be routinely resected for D2 dissection, whereas the optional stations with EI between 0.5% and 2% should be resected for D3 dissection in selective cases.

RESULTS

The survey yielded 16 eligible articles including 6,350 patients with EGJ carcinoma. The metastatic rates exceeded 5% at no. 1, 2, 3, 7, 9, 11p, and 110 stations and were less than 5% in abdominal no. 4sa~6, 8a, 10, 11d, 12a, and 16a2/b1 and mediastinal no. 105~112 stations. Consequently, obligatory stations with EI over 2% were largely determined by the epicenter location and located at the upper perigastric, lower mediastinal, and suprapancreatic zones, corresponding to those with rates of LNM over 5%. Consistent with the LNM rates less than 5%, the optional stations with EI between 0.5% and 2% were largely dependent on the degree of tumor extension toward the lower perigastric, splenic hilar (grecurvature), para-aortic (less curvature of the cardia), and middle or upper mediastinal zones.

CONCLUSIONS

The obligatory stations can be resected as an "envelope-like" wrap by transhiatal proximal gastrectomy with lower esophagectomy, whereas the optional stations for dissection are indicated by the tumor extension. The extended gastrectomy is required for the lower perigastric in the stomach-predominant tumor with gastric involvement exceeding 5.0 cm, para-aortic dissection in the less curvature-predominant tumor and splenic hilar dissection in the grecurvature-predominant tumor whereas transthoracic subtotal esophagectomy is required for complete mediastinal dissection and adequate negative margin in the esophagus-predominant tumor with esophageal invasion exceeding 3.0 cm.

Feasibility of Preserving No. 5 and No. 6 Lymph Nodes in Gastrectomy of Proximal Gastric Adenocarcinoma: A Retrospective Analysis of 395 Patients

Objective

The extent of regional lymphadenectomy for proximal gastric cancer (PGC) has remained a controversy and a matter of considerable debate for a long time. We retrospectively analyzed the clinicopathological features to investigate the predictive factors for No. 5 and/or No. 6 lymph node metastases (LNMs) and evaluate the feasibility of performing proximal gastrectomy (PG) with preservation of No. 5 and/or No. 6 lymph nodes for these patients.

Method

Patients who had undergone total gastrectomy plus D2 lymphadenectomy in the Department of Gastrointestinal Surgery, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, from January 2008 to December 2017 were retrospectively collected and analyzed.

Results

Among the 395 eligible patients in our study, 34 patients (8.61%) had No. 5 and No. 6 LNM. The degree of differentiation, Borrmann classification, vascular or perineural invasion, tumor diameter, depth of invasion, and other perigastric LNM were associated with No. 5 and/or No. 6 LNM. Multivariate analyses showed that tumor diameter ≥4 cm, No. 4 LNM positive, and No. 7, No. 8, No. 9 LNM positive were independent risk factors of No. 5 and/or No. 6 LNM. No. 5 and/or No. 6 LNM was not observed in the 105 patients who were staged from T1 to T3 and were found to be without independent risk factors.

Conclusion

The metastatic rate of No. 5 and/or No. 6 lymph node of the proximal gastric adenocarcinoma was closely associated with the diameter of the tumor and other perigastric LNMs. It is feasible to preserve No. 5 and No. 6 lymph nodes with PG for the T1-T3 patients with lower risk of No. 5 and/or No. 6 LNM.

Transhiatal versus transthoracic surgical approach for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction: a meta-analysis

BACKGROUND

With the increasing prevalence of Siewert type Ⅱ adenocarcinoma of the esophagogastric junction (EGJ), the optimal surgical treatment is not universally agreed. This meta-analysis compares the safety and efficacy between the transhiahtal (TH) approach and the transthoracic (TT) approach.

METHODS

A systematic and electronic search of several databases was performed up to June 2020. The Newcastle-Ottawa scale was used to evaluate article quality and funnel plots were created to identify potential publication bias. The random-effects model was used when significant heterogeneity was identified.

RESULTS

In total, nine retrospective studies and two randomized controlled trials (RCTs) involving 2331 patients were included. Decreased intraoperative blood loss, shorter hospital stay, lower incidence of pulmonary complications, and longer 3-year overall survival were observed in the TH group. There were no significant differences concerning duration of surgery, R0 resection rate, number of dissected lymph nodes, perioperative mortality and morbidity rate, abdominal complication rate, or anastomotic leak rate. With regard to 5-year overall survival, a potential benefit may be achieved with the TH approach, which requires further confirmation.

CONCLUSION

In terms of surgery-related and long-term outcomes, the TH approach may be more appropriate for Siewert type Ⅱ adenocarcinoma of EGJ, especially for esophagus invasion ≤4 cm.

Factors associated with colon cancer early, intermediate and late recurrence after surgery for stage I-III: A 5-year prospective study

OBJECTIVE

To identify factors associated with early, intermediate or late recurrence colon cancer recurrence.

METHODS

A total of 1,732 consecutive patients with colon cancer were recruited and followed for a period of 5 years. Recurrence at 1 year (early), from 1 to 2 (early), from 2 to 3 (intermediate) and from 3 to 5 years (late) was the main outcome measures.

RESULTS

Predictors of early recurrence (AUC (95% CI):0.74 (0.70-0.78) were as follows: TNM stage II and III, more than one type of invasion, haemoglobin <10 g/dl, residual tumour (R1), ASA IV, log odds of positive lymph nodes ratio ≥-0.53, perforation, neoadjuvant chemotherapy, infectious complications within 1 year and CEA pre- and post-intervention. These factors remained significant for predicting intermediate (AUC [95% CI]: 0.72 [0.67-0.77]) and late (AUC [95% CI]: 0.68 [0.63-0.74]) recurrence, except for ASA class, log lymph node ratio, perforation and neoadjuvant chemotherapy. Additionally, laterality (left) and medical complications up to 2 years were significant.

CONCLUSIONS

These risk factors show good predictive ability of early, intermediate and late recurrence, confirming factors established by guidelines and adding some others. They could serve to provide more appropriate and accurate treatment and follow-up tailored to patient characteristics.

Patterns of recurrence in adenocarcinoma of the esophagogastric junction: a retrospective study

Background

The prognosis of adenocarcinoma of the esophagogastric junction (AEG) is poor. Understanding the postoperative recurrence pattern of AEG is helpful to verify the effectiveness of treatment and optimize subsequent treatment, so as to improve prognosis.

Methods

This single-center retrospective study included patients with stage III AEG who underwent surgical treatment between January 2009 and December 2016. According to the different postoperative treatment arm, patients were divided into surgery and surgery plus chemotherapy groups. Recurrence-free survival was used as the outcome to compare the recurrence site and pattern between the groups.

Results

In total, were 306 patients enrolled, 123 in the surgery group and 183 in the surgery plus chemotherapy group. During follow-up (median 17.1 months) of 24 months after surgery, 62.0% of patients had tumor recurrence. The overall recurrence rates in the surgery and surgery plus chemotherapy groups were 86.9% and 77.0%, respectively. The recurrence patterns of both groups were mainly distant metastasis. Postoperative chemotherapy reduced the incidence of hematogenous dissemination from 51.2 to 42.0%. Multivariate Cox analysis showed that the pN stage increased the risk of recurrence, while surgery plus chemotherapy reduced the risk.

Conclusions

Patients with AEG have a risk of hematogenous dissemination after surgery. Postoperative treatment arm and pN stage were independent risk factors in patients with AEG. Surgery plus chemotherapy can improve recurrence-free survival and reduce distant metastasis, but they do not have a beneficial role in controlling local recurrence.

The Postoperative outcomes of thoracoscopic-laparoscopic Ivor-Lewis surgery plus D2 celiac lymphadenectomy for patients with adenocarcinoma of the esophagogastric junction

OBJECTIVES

Adenocarcinoma of the esophagogastric junction (AEG) is one of the most aggressive and poor prognosis cancers. To date, no standard procedures have been established for the surgical treatment of Siewert type II. In this study, we proposed the approach of thoracoscopic-laparoscopic Ivor-Lewis surgery plus D2 celiac lymphadenectomy (TLILD2) and aimed to investigate the patterns of lymph node metastasis and long-term survival.

METHODS

From June 2015 to June 2018, 72 patients accepted TLILD2 and enrolled in this study. Relevant patient characteristics and postoperative variables were collected and evaluated. The disease-free survival (DFS) and disease-specific survival (DSS) were determined by the Kaplan-Meier method and compared by log-rank tests.

RESULTS

There was no case of postoperative death in this study, and the most common complication was anastomotic mediastinal fistula (5/72, 6.9%). A total of 2811 lymph nodes were retrieved, and the positivity rate was 11.9% (334/2811). The positivity rate of celiac and mediastinal lymph nodes was 14.4% (314/2186) and 3.2% (20/625), respectively. The percentage of patients who had positive celiac and mediastinal lymph nodes reached up to 58.3% (42/72) and 8.3% (6/72), respectively. The DFS and DSS of these 72 patients were 94% and 93.4% at 1 year after surgery and 59.8% and 62% at 3 years after surgery, respectively. The pTNM stage showed a significant difference between DFS and DSS.

CONCLUSIONS

TLILD2 could be a potential way to promote long-term survival of AEG patients. On the basis of the patterns of lymph nodes metastasis, we suggest that lower mediastinal and D2 celiac lymphadenectomy is necessary to improve the oncological outcome.

Essential updates 2017/2018: Recent topics in the treatment and research of gastric cancer in Japan

Recent developments in diagnostic technology, accumulated clinical effort and established evidence have boosted early detection and drastically improved early and long-term outcomes of gastric cancer. However, gastric cancer continues to be one of the most aggressive and life-threatening malignancies among all cancers and is a global health problem. Between January 2017 and December 2018, various fascinating reports of managements and research were published, including the new 15th Japanese Classification of Gastric Carcinoma reflecting the 8th American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) tumor, node and metastasis (TNM) classification (October 2017) and the new Gastric Cancer Treatment Guidelines version 5 (January 2018). Moreover, pivotal molecular features of gastric cancer were clarified by the worldwide cancer genome project, and various treatment targets and biomarkers such as circulating DNAs and microRNAs were detected. Novel treatment options using programmed cell death protein 1 immune checkpoint inhibitors have been started. In this review, we summarize the recent topics of classification, guidelines, and clinical and basic research in order to bring new insights to gastric cancer treatment.

Surgical Treatment of Gastroesophageal Junction Cancer

Although the incidence of gastroesophageal junction (GEJ) adenocarcinoma has been increasing worldwide, no standardized surgical strategy for its treatment has been established. This study aimed to provide an update on the surgical treatment of GEJ adenocarcinoma by reviewing previous reports and propose recommended surgical approaches. The Siewert classification is widely used for determining which surgical procedure is used, because previous studies have shown that the pattern of lymph node (LN) metastasis depends on tumor location. In terms of surgical approaches for GEJ adenocarcinoma, a consensus was reached based on two randomized controlled trials. Siewert types I and III are treated as esophageal cancer and gastric cancer, respectively. Although no consensus has been reached regarding the treatment of Siewert type II, several retrospective studies suggested that the optimal treatment strategy includes paraaortic LN dissection. Against this background, a Japanese nationwide prospective trial is being conducted to determine the proportion of LN metastasis in GEJ cancers and to identify the optimal extent of LN dissection in each type.

Appropriate extent of lymphadenectomy for squamous cell carcinoma of the esophagogastric junction

AIM

To investigate the appropriate extent of lymphadenectomy for squamous cell carcinoma (SCC) of the esophagogastric junction (ECJ).

METHODS

We retrospectively reviewed the cases of 52 patients with SCC of the ECJ who underwent extended mediastinal lymphadenectomy. We assessed potential risk factors for lymph node metastasis (LNM) in the upper/middle mediastinum by conducting univariate and multivariate analyses, and a receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive value. Survival rates were calculated using the Kaplan-Meier method, and the therapeutic value index of each nodal basin dissection was calculated by multiplying the frequency of metastasis at the basin and the 5-year overall survival rate of patients with metastasis at that basin.

RESULTS

Twenty patients (38%) had mediastinal LNM; 13 (25%) had metastasis in the upper/middle mediastinum, and 13 (25%) had metastasis in the lower mediastinum. Tumor length (P = 0.03) and pathological nodal status (P = 0.01) were independent risk factors for upper/middle mediastinal LNM. The optimal ROC cutoff value of tumor length was 54 mm. The 5-year overall survival rate of the patients with LNM in the upper/middle mediastinum was 46%. The therapeutic value index of upper/middle mediastinal lymphadenectomy was 11.6, which was inferior to that of perigastric lymphadenectomy at 17.3, but superior to that of lower mediastinal lymphadenectomy at 5.8.

CONCLUSION

An upper/middle mediastinal lymphadenectomy may be required for patients with tumors that are ≥54 mm long, and in those with suspected LNM.

Results of a nation-wide retrospective study of lymphadenectomy for esophagogastric junction carcinoma

BACKGROUND

Esophagogastric junction (EGJ) carcinoma has attracted considerable attention because of the marked increase in its incidence globally. However, the optimal extent of esophagogastric resection for this tumor entity remains highly controversial.

METHODS

This was a questionnaire-based national retrospective study undertaken in an attempt to define the optimal extent of lymph node dissection for EGJ cancer. Data from patients with EGJ carcinoma, less than 40 mm in diameter, who underwent R0 resection between January 2001 and December 2010 were reviewed.

RESULTS

Clinical records of 2807 patients without preoperative therapy were included in the analysis. There are distinct disparities in terms of the nodal dissection rate according to histology and the predominant tumor location. Nodal metastases frequently involved the abdominal nodes, especially those at the right and left cardia, lesser curvature and along the left gastric artery. Nodes along the distal portion of the stomach were much less often metastatic, and their dissection seemed unlikely to be beneficial. Lower mediastinal node dissection might contribute to improving survival for patients with esophagus-predominant EGJ cancer. However, due to low dissection rates for nodes of the middle and upper mediastinum, no conclusive result was obtained regarding the optimal extent of nodal dissection in this region.

CONCLUSIONS

Complete nodal clearance along the distal portion of the stomach offers marginal survival benefits for patients with EGJ cancers less than 4 cm in diameter. The optimal extent of esophageal resection and the benefits of mediastinal node dissection remain issues to be addressed in managing patients with esophagus-predominant EGJ cancers.

Theoretical therapeutic impact of lymph node dissection on adenocarcinoma and squamous cell carcinoma of the esophagogastric junction

BACKGROUNDS

The aim of this study was to evaluate the theoretical therapeutic impact of dissecting each lymph node station for adenocarcinoma and squamous cell carcinoma of the esophagogastric junction.

METHODS

This multicenter study included 431 junctional cancer patients (381 adenocarcinomas and 50 squamous cell carcinomas) who fulfilled the following criteria: (1) the center of the tumor was located between 1 cm above and 2 cm below the esophagogastric junction, and (2) the tumor invaded the junction. The theoretical therapeutic impact of dissecting each lymph node station was evaluated based on the therapeutic value index calculated by multiplying the frequency of metastasis to each station and the 5-year survival rate of patients with metastasis to that station.

RESULTS

The 5-year overall survival rates (95% confidence interval) were 60.4% (55.1-65.7) in the adenocarcinoma cases and 52.3% (35.6-69.0) in the squamous cell carcinoma cases. The nodal stations showing the first to fifth highest index were the paracardial and lesser curvature nodes (nos. 1, 2 and 3), nodes at the root of the left gastric artery (no. 7) and lower mediastinal lymph nodes, regardless of the histology.

CONCLUSIONS

Nodal dissection achieved by proximal gastrectomy and lower esophagectomy should be the minimal requirement for junctional cancer regardless of the histology, considering the therapeutic value indices for the relevant lymph node stations.

Pattern of Lymphatic Spread of Esophageal Cancer at the Cervicothoracic Junction Based on the Tumor Location : Surgical Treatment of Esophageal Squamous Cell Carcinoma of the Cervicothoracic Junction

BACKGROUND

There is no consensus about the extent of lymphadenectomy for patients with esophageal squamous cell carcinoma at the cervicothoracic junction (CT-ESCC). The purpose of this study was to examine the pattern of lymph node spread in patients with CT-ESCC and the extent of lymphadenectomy that is necessary.

METHODS

We included 64 consecutive patients with CT-ESCC who underwent surgery. All patients were divided into two groups based on the location of the epicenter or anal edge of the primary tumor. Using the height of the epicenter, 27 and 37 patients were classified as having cervical-centered and thoracic-centered tumors, respectively; while, using the height of the anal edge, 38 and 26 patients had tumors that were cervical-localized and thoracic-invading, respectively.

RESULTS

In the patients with cervical-centered tumors, the incidences of metastasis and/or recurrences in the cervical paraesophageal, supraclavicular, and upper mediastinal nodes were 21.4-28.5 %. No patient had metastasis or recurrence in the middle and lower mediastinal and perigastric nodes. In patients with thoracic-centered tumors, the lymph node metastasis and/or recurrence spread to the cervical paraesophageal (41.7 %), supraclavicular (25 %), and upper mediastinal (55.6 %) nodes, as well as the middle (22.2 %) and lower mediastinal (8.3 %) and perigastric (19.4 %) nodes. There was no difference in the distribution and incidence of lymphatic spread between patients with the cervical-localized and thoracic-invading classifications.

CONCLUSIONS

Our results indicate a cervical and upper mediastinal lymphadenectomy is better indicated for patients with cervical-centered CT-ESCC, whereas patients with thoracic-centered CT-ESCC should be treated with a three-field lymphadenectomy.

Distribution of lymph node metastasis and clinical validity of gastric tube reconstruction in lower thoracic esophageal squamous cell carcinoma with gastric invasion

BACKGROUND

The distribution of lymph node (LN) metastases of esophageal squamous cell carcinoma (SCC) with gastric invasion remains unclear. The purpose of this study was to clarify the relationship between gastric invasion and abdominal LN metastasis in patients with esophageal SCC. Furthermore, the clinical validity of gastric tube reconstruction for those with gastric invasion was investigated.

METHODS

Patients who underwent subtotal esophagectomy at our institution were reviewed. Gastric invasion was evaluated with pretreatment upper gastrointestinal endoscopy and classified into 3 groups: no invasion, Gr 0; slight invasion (0-19 mm), Gr 1; and massive invasion (20 mm or longer), Gr 2. The correlations between gastric invasion, the number of abdominal LN metastases, and postoperative recurrence were investigated.

RESULTS

Of 79 patients, the distribution of pretreatment gastric invasion was Gr 0, 1, and 2 in 57, 15, and 7 patients, respectively. All patients underwent subtotal esophagectomy with gastric tube reconstruction. There was no significant difference in the number of abdominal LN metastases among groups. In survival analysis, the location of the distal end of the tumor was not a predictive factor for postoperative recurrence. Regarding patterns of recurrence, in patients with gastric invasion, there was no remarkable increase in the frequency of recurrence in the abdominal LNs or the regional LNs around the gastric tube.

CONCLUSIONS

Pretreatment gastric invasion did not significantly influence abdominal LN metastasis and postoperative recurrence. In patients with esophageal SCC at the lower thoracic esophagus with gastric invasion, subtotal esophagectomy with gastric tube reconstruction might be a valid surgical procedure.