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De Pasqual CA, van der Sluis PC, Weindelmayer J, Lagarde SM, Giacopuzzi S, De Manzoni G, Wijnhoven BPL. Transthoracic esophagectomy compared to transhiatal extended gastrectomy for adenocarcinoma of the esophagogastric junction: a multicenter retrospective cohort study. Dis Esophagus 2022; 35:6490090. [PMID: 34969080 DOI: 10.1093/dote/doab090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/27/2021] [Indexed: 12/11/2022]
Abstract
Optimal surgical treatment for Siewert type II esophagogastric junction adenocarcinoma is debated. The aim of this study was to compare transhiatal extended gastrectomy (TEG) and transthoracic esophagectomy (TTE). Patients with Siewert type II tumors who underwent a resection by TEG or TTE in two centers (Erasmus University Medical Center, Rotterdam, and University of Verona) between 2014 and 2019 were identified. To limit selection bias, patients were matched for baseline characteristics and compared with a multivariable logistic regression model. Some 159 patients treated by TEG (60 patients, 37.7%) or TTE (99 patients, 62.3%) were included. Patients in the TEG group were older, had less tumor invasion of the esophagus, and were more often excluded from neoadjuvant therapy. Post-operative morbidity was comparable (P = 0.88), while 90-day mortality was higher after TEG (90-day mortality 10.0% in TEG group vs. 2.0% in TTE group P = 0.01). R0 resection was achieved in 83.3% of patients after TEG and in 97.9% after TTE (P < 0.01), with the proximal resection margin involved in 16.6% of patients after TEG versus 0 in TTE group (P < 0.01). The 3-year overall survival was comparable (TEG: 36.5%, TTE: 48.4%, P = 0.12). At multivariable analysis, (y)pT category was an independent risk factor for 3-year recurrence. After matching, TEG was still associated with an increased risk of incomplete tumor resection (P = 0.03) and proximal margin involvement (P < 0.01), while there were no differences in post-operative morbidity (P = 0.56) and mortality (P = 0.31). Our data suggest that patients with Siewert type II tumors treated by TEG are exposed to a higher risk of positive proximal resection margin compared to TTE.
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Affiliation(s)
| | - Pieter C van der Sluis
- Department of Surgery, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Jacopo Weindelmayer
- Department of General and Upper G.I. Surgery, University of Verona, Verona, Italy
| | - Sjoerd M Lagarde
- Department of Surgery, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Simone Giacopuzzi
- Department of General and Upper G.I. Surgery, University of Verona, Verona, Italy
| | - Giovanni De Manzoni
- Department of General and Upper G.I. Surgery, University of Verona, Verona, Italy
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Di Leo A, Zanoni A. Siewert III adenocarcinoma: treatment update. Updates Surg 2017; 69:319-325. [PMID: 28303519 DOI: 10.1007/s13304-017-0429-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 03/08/2017] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Alberto Di Leo
- Unit of General Surgery, Rovereto Hospital, APSS of Trento, Corso Verona 4, 38068, Rovereto, TN, Italy.
| | - Andrea Zanoni
- Unit of General Surgery, Rovereto Hospital, APSS of Trento, Corso Verona 4, 38068, Rovereto, TN, Italy
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Giacopuzzi S, Bencivenga M, Weindelmayer J, Verlato G, de Manzoni G. Western strategy for EGJ carcinoma. Gastric Cancer 2017; 20:60-68. [PMID: 28039533 DOI: 10.1007/s10120-016-0685-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 12/15/2016] [Indexed: 02/06/2023]
Abstract
In this paper, the epidemiological and clinicobiological behavior of esophagogastric junction (EGJ) adenocarcinoma in the West is compared and contrasted to that in the East, and an overview is provided of current therapeutic strategies employed for this type of tumor in Western countries. It is well known that multimodal treatment is the therapeutic standard in locally advanced EGJ adenocarcinoma, but whether neoadjuvant/perioperative chemotherapy (CT) or neoadjuvant chemoradiotherapy (CRT) is the optimal approach is still debated. Neoadjuvant CRT improves local control in locally advanced Siewert type I and II tumors, so it should be considered the treatment of choice. In the subset of these patients with microscopic systemic disease at diagnosis, more intensive exclusive chemotherapy protocols could be of benefit. Therefore, there is an urgent need to identify these patients before planning the treatment. For Siewert type III tumors, perioperative chemotherapy is the standard. While there is general agreement on the optimal surgical approach for Siewert types I and III (a two-field Ivor Lewis operation and a total gastrectomy with distal esophagectomy, respectively), no standard surgical treatment has been defined for Siewert type II tumors. When data from Western series on proximal and circumferential resection margins and on nodal spread in Siewert type II tumors are taken into account, the optimal surgical approach appears to be Ivor Lewis esophagectomy. Whether the extent of esophageal invasion can correctly predict nodal involvement in middle-upper mediastinal stations as a means to restrict indications for transthoracic esophagectomy requires further investigation in the West.
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Affiliation(s)
- Simone Giacopuzzi
- General and Upper G.I. Surgery Division, Department of Surgery, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
| | - Maria Bencivenga
- General and Upper G.I. Surgery Division, Department of Surgery, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
| | - Jacopo Weindelmayer
- General and Upper G.I. Surgery Division, Department of Surgery, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
| | - Giuseppe Verlato
- Unit of Epidemiology and Medical Statistics, Department of Public Health and Community Medicine, University of Verona, Verona, Italy
| | - Giovanni de Manzoni
- General and Upper G.I. Surgery Division, Department of Surgery, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy.
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Morgagni P, Tringali D, La Barba G, Vittimberga G, Ercolani G. Historical assumptions of lymphadenectomy. Transl Gastroenterol Hepatol 2016; 1:90. [PMID: 28138655 DOI: 10.21037/tgh.2016.11.06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 11/24/2016] [Indexed: 12/17/2022] Open
Abstract
The role of lymphadenectomy for the treatment of gastric cancer is still very much open to debate. Consequently, Japanese, European and American surgeons perform different typologies of lymphadenectomy because of the absence of randomized clinical trials confirming the superiority of extended lymphadenectomy over less invasive surgery. In Japan, D2 lymphadenectomy has been considered as the gold standard for advanced gastric carcinoma for many years. Although numerous European studies have been conducted in an attempt to find differences between D1 and D2 lymphadenectomy, none has succeeded to date. The decision to wait for results attesting to the fact that D2 guarantees a better outcome than D1 resulted in a long delay in the implementation of D2 as the gold standard treatment in Europe. In the U.S., the study by Macdonald et al. established D1 lymphadenectomy followed by chemoradiotherapy as the treatment of choice for advanced cancer, whereas D2 is officially indicated as the gold standard in the most recent European guidelines [the Italian Research Group for Gastric Cancer (GIRGC), German, British, ESSO]. Interestingly, European guidelines for lymphadenectomy are not based on evidence-based medicine but rather on the experience of the most important centers involved in the treatment of gastric cancer.
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Affiliation(s)
- Paolo Morgagni
- Department of General Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Domenico Tringali
- Department of General Surgery and Esophagus and Stomach, Borgo Trento Hospital, Verona, Italy
| | - Giuliano La Barba
- Department of General Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy
| | | | - Giorgio Ercolani
- Department of General Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy
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Song W, He Y, Wang S, He W, Xu J. Significance of the lymph nodes in the 7th station in rational dissection for metastasis of distal gastric cancer with different T categories. Chin J Cancer Res 2014; 26:423-30. [PMID: 25232215 DOI: 10.3978/j.issn.1000-9604.2014.08.19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 07/22/2014] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To determine the clinicopathological characteristics, and evaluate the appropriate extent of lymph node dissection in distal gastric cancer patients with comparable T category. METHODS A retrospective study was conducted on 570 distal gastric cancer patients, who underwent gastric resection with D2 nodal dissection, which was performed by the same surgical team from January 1997 to January 2011. We compared the differences in lymph node metastasis rates and metastatic lymph node ratios between different T categories. Additionally, we investigated the impact of lymph node metastasis in the 7(th) station on survival rate of distal gastric cancer patients with the same TNM staging. RESULTS Among the 570 patients, the overall lymph node metastasis rate of advanced distal gastric cancer was 78.1%, and the metastatic lymph node ratio was 27%. The lymph node metastasis rate in the 7(th) station was similar to that of perigastric lymph nodes. There was no statistical significance in patients with the same TNM stage (stage II and III), irrespective of the metastatic status in the 7(th) station. CONCLUSIONS Our results suggest that to a certain extent, it is reasonable to include lymph nodes in the 7(th) station in the D1 lymph node dissection.
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Affiliation(s)
- Wu Song
- Department of Gastrointestinal Pancreatic Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510275, China
| | - Yulong He
- Department of Gastrointestinal Pancreatic Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510275, China
| | - Shaochuan Wang
- Department of Gastrointestinal Pancreatic Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510275, China
| | - Weiling He
- Department of Gastrointestinal Pancreatic Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510275, China
| | - Jianbo Xu
- Department of Gastrointestinal Pancreatic Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510275, China
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Dorth JA, Pura JA, Palta M, Willett CG, Uronis HE, D'Amico TA, Czito BG. Patterns of recurrence after trimodality therapy for esophageal cancer. Cancer 2014; 120:2099-105. [PMID: 24711267 DOI: 10.1002/cncr.28703] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Revised: 02/25/2014] [Accepted: 03/10/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patterns of failure after neoadjuvant chemoradiotherapy and surgery for esophageal cancer are poorly defined. METHODS All patients in the current study were treated with trimodality therapy for nonmetastatic esophageal cancer from 1995 to 2009. Locoregional failure included lymph node failure (NF), anastomotic failure, or both. Abdominal paraaortic failure (PAF) was defined as disease recurrence at or below the superior mesenteric artery. RESULTS Among 155 patients, the primary tumor location was the upper/middle esophagus in 18%, the lower esophagus in 32%, and the gastroesophageal junction in 50% (adenocarcinoma in 79% and squamous cell carcinoma in 21%) of patients. Staging methods included endoscopic ultrasound (73%), computed tomography (46%), and positron emission tomography/computed tomography (54%). Approximately 40% of patients had American Joint Committee on Cancer stage II disease and 60% had stage III disease. The median follow-up was 1.3 years. The 2-year locoregional control, event-free survival, and overall survival rates were 86%, 36%, and 48%, respectively. The 2-year NF rate was 14%, the isolated NF rate was 3%, and the anastomotic failure rate was 6%. The 2-year PAF rate was 9% and the isolated PAF rate was 5%. PAF was found to be increased among patients with gastroesophageal junction tumors (12% vs 6%), especially for the subset with ≥ 2 clinically involved lymph nodes at the time of diagnosis (19% vs 4%). CONCLUSIONS Few patients experience isolated NF or PAF as their first disease recurrence. Therefore, it is unlikely that targeting additional regional lymph node basins with radiotherapy would significantly improve clinical outcomes.
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Affiliation(s)
- Jennifer A Dorth
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
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Pattern of abdominal nodal spread and optimal abdominal lymphadenectomy for advanced Siewert type II adenocarcinoma of the cardia: results of a multicenter study. Gastric Cancer 2013; 16:301-8. [PMID: 22895616 DOI: 10.1007/s10120-012-0183-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 07/15/2012] [Indexed: 02/07/2023]
Abstract
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.
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Prognostic value of the 7th AJCC/UICC TNM classification of noncardia gastric cancer: analysis of a large series from specialized Western centers. Ann Surg 2012; 255:486-91. [PMID: 22167003 DOI: 10.1097/sla.0b013e3182389b1a] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To conduct a retrospective evaluation of the 7th-TNM classification of gastric cancer (GC) on a prospectively collected database. BACKGROUND The recent TNM introduced relevant changes to GC classification. METHODS Data regarding 2090 consecutive patients with noncardia GC operated upon between 1991 and 2005 at 5 specialized centers were considered. The application of the new TNM was simulated, and its prognostic value was estimated. RESULTS Relevant changes in stage distribution between 6th and 7th TNM were observed, mainly regarding the shift of a large proportion of cases from stages IB to IIA and from IIIA and IV to stages IIIB and IIIC. Cancer-related 10-year survival probability was 53% ± 1%. Different survival rates between new T (T2 vs. T3, P < 0.001) and N categories (N1 vs. N2, P < 0.001) were observed. Survival rate of N3a subgroup (7-15 involved lymph nodes) was significantly better than N3b (>15 involved lymph nodes; P < 0.001). Stages IB and IIA of the 7th TNM showed similar prognosis, whereas significant differences were observed among all other subgroups. The analysis of TNM categories within 7th TNM stages revealed nonhomogeneous survival rates in stages IIB, IIIB, and IV. CONCLUSIONS The 7th AJCC/UICC TNM classification of noncardia GC identifies subgroups of patients with different prognosis. Stage distribution and stage-related survival changed notably from the 6th edition. Some improvements may be suggested from our data, with special reference to a higher prognostic weight of N status and the separation of N3a and N3b categories for stage grouping.
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Matzinger O, Gerber E, Bernstein Z, Maingon P, Haustermans K, Bosset JF, Gulyban A, Poortmans P, Collette L, Kuten A. EORTC-ROG expert opinion: radiotherapy volume and treatment guidelines for neoadjuvant radiation of adenocarcinomas of the gastroesophageal junction and the stomach. Radiother Oncol 2009; 92:164-75. [PMID: 19375186 DOI: 10.1016/j.radonc.2009.03.018] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Accepted: 03/05/2009] [Indexed: 01/20/2023]
Abstract
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.
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Huang CM, Lin BJ, Lu HS, Zhang XF, Li P, Xie JW. Prognostic impact of metastatic lymph node ratio in advanced gastric cancer from cardia and fundus. World J Gastroenterol 2008; 14:4383-8. [PMID: 18666330 PMCID: PMC2731193 DOI: 10.3748/wjg.14.4383] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the prognostic impact of the metastatic lymph node ratio (MLR) in advanced gastric cancer from the cardia and fundus.
METHODS: Two hundred and thirty-six patients with gastric cancer from the cardia and fundus who underwent D2 curative resection were analyzed retrospectively. The correlations between MLR and the total lymph nodes, positive nodes and the total lymph nodes were analyzed respectively. The influence of MLR on the survival time of patients was determined with univariate Kaplan-Meier survival analysis and multivariate Cox proportional hazard model analysis. And the multiple linear regression was used to identify the relation between MLR and the 5-year survival rate of the patients.
RESULTS: The MLR did not correlate with the total lymph nodes resected (r = -0.093, P = 0.057). The 5-year overall survival rate of the whole cohort was 37.5%. Kaplan-Meier survival analysis identified that the following eight factors influenced the survival time of the patients postoperatively: gender (χ2 = 4.26, P = 0.0389), tumor size (χ2 = 18.48, P < 0.001), Borrmann type (χ2 = 7.41, P = 0.0065), histological grade (χ2 = 5.07, P = 0.0243), pT category (χ2 = 49.42, P < 0.001), pN category (χ2 = 87.7, P < 0.001), total number of retrieved lymph nodes (χ2 = 8.22, P = 0.0042) and MLR (χ2 = 34.3, P < 0.001). Cox proportional hazard model showed that tumor size (χ2 = 7.985, P = 0.018), pT category (χ2 = 30.82, P < 0.001) and MLR (χ2 = 69.39, P < 0.001) independently influenced the prognosis. A linear correlation between MLR and the 5-year survival was statistically significant based on the multiple linear regression (β = -0.63, P < 0.001). Hypothetically, the 5-year survival would surpass 50% when MLR was lower than 10%.
CONCLUSION: The MLR is an independent prognostic factor for patients with advanced gastric cancer from the cardia and fundus. The decrease of MLR due to adequate number of total resected lymph nodes can improve the survival.
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Huang CM, Lin BJ, Lu HS, Zhang XF, Li P, Xie JW. Effect of lymphadenectomy extent on advanced gastric cancer located in the cardia and fundus. World J Gastroenterol 2008; 14:4216-21. [PMID: 18636669 PMCID: PMC2725385 DOI: 10.3748/wjg.14.4216] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the prognostic impact of lymphade-nectomy extent in advanced gastric cancer located in the cardia and fundus.
METHODS: Two hundred and thirty-six patients with advanced gastric cancer located in the cardia and fundus who underwent D2 curative resection were analyzed retrospectively. Relationships between the numbers of lymph nodes (LNs) dissected and survival was analyzed among different clinical stage subgroups.
RESULTS: The 5-year overall survival rate of the entire cohort was 37.5%. Multivariate prognostic variables were total LNs dissected (P < 0.0001; or number of negative LNs examined, P < 0.0001), number of positive LNs (P < 0.0001), T category (P < 0.0001) and tumor size (P = 0.015). The greatest survival differences were observed at cutoff values of 20 LNs resected for stage II (P = 0.0136), 25 for stage III(P < 0.0001), 30 for stage IV (P = 0.0002), and 15 for all patients (P = 0.0024). Based on the statistically assumed linearity as best fit, linear regression showed a significant survival enhancement based on increasing negative LNs for patients of stages III (P = 0.013) and IV (P = 0.035).
CONCLUSION: To improve the long-term survival of patients with advanced gastric cancer located in the cardia and fundus, removing at least 20 LNs for stage II, 25 LNs for stage III, and 30 LNs for stage IVpatients during D2 radical dissection is recommended.
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Meier I, Merkel S, Papadopoulos T, Sauer R, Hohenberger W, Brunner TB. Adenocarcinoma of the esophagogastric junction: the pattern of metastatic lymph node dissemination as a rationale for elective lymphatic target volume definition. Int J Radiat Oncol Biol Phys 2008; 70:1408-17. [PMID: 18374226 DOI: 10.1016/j.ijrobp.2007.08.053] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Revised: 08/21/2007] [Accepted: 08/21/2007] [Indexed: 01/28/2023]
Abstract
PURPOSE Regional nodal metastasis after neoadjuvant chemoradiation of adenocarcinoma of the esophagogastric junction (AEG) predicts survival. We aimed to clarify the lymph node (LN) distribution of AEG according to location of the tumor mass and invasion of neighboring areas for the selection of radiotherapy planning target volume (PTV) margins. METHODS AND MATERIALS Patterns of regional spread were analyzed in pathology reports of 326 patients patients with AEG who had undergone primary resection, with > or = 15 lymph nodes examined. Tumors were classified into AEG types based on endoscopy and pathology reports. Fisher's exact test was used to compare nodal disease and tumor characteristics. Pulmonary dose-volume histograms were tested in 8 patients. RESULTS Nodes were positive in 81% of T2 to T4 tumors. Type of AEG, tumor size, lymphovascular invasion, and grading significantly influenced nodal distribution. We found that marked esophageal invasion of AEG II/III significantly correlated with paraesophageal nodal disease, and T3 to T4 AEG II/III had a significant rate of splenic hilum/artery nodes. Middle and lower paraesophageal nodes should be treated in T2 to T4 AEG I and AEG II with > or = 15 mm involvement above the Z-line, and T3 to T4 AEG II. The splenic hilum and artery nodes can be spared in T2 AEG tumors, especially Type I tumors. The influence of paraesophageal nodal treatment on the risk of postoperative pulmonary complications can be estimated from dose-volume histograms. CONCLUSIONS Accurate pretherapeutic staging predicts the risk of subclinical nodal disease and should be used to select the appropriate radiotherapeutic PTV. Careful selection of the PTV can be used to maximize the therapeutic window in multimodal therapy for AEG.
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Affiliation(s)
- Iris Meier
- Department of Radiation Oncology, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
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Pedrazzani C, de Manzoni G, Marrelli D, Giacopuzzi S, Corso G, Minicozzi AM, Rampone B, Roviello F. Lymph node involvement in advanced gastroesophageal junction adenocarcinoma. J Thorac Cardiovasc Surg 2007; 134:378-85. [PMID: 17662776 DOI: 10.1016/j.jtcvs.2007.03.034] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2006] [Revised: 01/24/2007] [Accepted: 03/08/2007] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Corrado Pedrazzani
- Department of Human Pathology and Oncology, Unit of Surgical Oncology, University of Siena, Siena, Italy
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Di Leo A, Marrelli D, Roviello F, Bernini M, Minicozzi A, Giacopuzzi S, Pedrazzani C, Baiocchi LG, de Manzoni G. Lymph node involvement in gastric cancer for different tumor sites and T stage: Italian Research Group for Gastric Cancer (IRGGC) experience. J Gastrointest Surg 2007; 11:1146-53. [PMID: 17576611 DOI: 10.1007/s11605-006-0062-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of lymphadenectomy is to clear all the metastatic nodes achieving a complete removal of the tumor; nevertheless, its role in gastric cancer has been very much debated. MATERIALS AND METHODS The frequency of node metastasis in each lymphatic station according to the International Gastric Cancer Association, was studied in 545 patients who underwent D2 or D3 lymphadenectomy from June 1988 to December 2002. RESULTS Upper third early cancers have shown an involvement of N2 celiac nodes in 25%. In advanced cancers, there was a high frequency of metastasis in the right gastroepiploic (from 10% in T2 to 50% in T4) and in the paraaortic nodes (26% in T2, 32% in T3, 38 % in T4). N3 left paracardial nodes involvement was observed in an important share of middle third tumors (17% in T3, 36% in T4). Splenic hilum nodes metastasis were common in T3 and T4 cancers located in the upper (39%) and middle (17%) stomach. N2 nodal involvement was frequent in lower third advanced cancers. Metastasis in M left paracardial and short gastric nodes were observed in a small percentage of cases. CONCLUSION Given the nodal diffusion in our gastric cancer patients, extended lymphadenectomy is still a rationale to obtain radical resection.
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Affiliation(s)
- Alberto Di Leo
- First Division of General Surgery, University of Verona, Verona, Italy.
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15
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Abstract
Surgical resection with lymphadenectomy is the mainstay of treatment for all resectable esophagogastric junction tumors, prior to systemic generalization of the disease. This makes accurate pre-treatment staging and classification of the tumors most demanding. A well-established and internationally accepted classification for adenocarcinomas of the esophagogastric junction (AEG) helps to choose the appropriate surgical approach and to make results from different institutions comparable. Distal esophageal adenocarcinomas (AEGI) are distinguished from true cardia carcinomas (AEG II) and subcardiac gastric cancers (AEG III). Substantial advancements in this surgical field during the preceding decades have clearly revealed that individualization of the surgical strategy is the key to successfully approaching these entities. In this review we discuss the surgical management of esophagogastric junction tumors with a tailored surgical strategy.
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Affiliation(s)
- Burkhard H A von Rahden
- Department of Surgery, Technische Universitat Munchen, Ismaningerstr 22, Munchen D-81675, Germany.
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Current Controversy in the Treatment of Proximal Gastric Cancer. World J Surg 2006. [DOI: 10.1007/s00268-006-0340-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Bosset JF, Lorchel F, Mantion G, Buffet J, Créhange G, Bosset M, Chaigneau L, Servagi S. Radiation and chemoradiation therapy for esophageal adenocarcinoma. J Surg Oncol 2005; 92:239-45. [PMID: 16299784 DOI: 10.1002/jso.20365] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The aims of preoperative chemoradiation therapy (preop-CRT) for esophageal adenocarcinoma are to reduce incomplete local resection (R1,R2), local and systemic recurrences that are reported in up to 30% of patients who undergo surgery alone. Phase II studies of preop-CRT, with radiation doses in the 40-50 Gy range, and concurrent chemotherapy with 5-fluorouracil (5-FU)-cisplatin +/- paclitaxel, or cisplatin-paclitaxel, have reported subsequent RO resection rates of 80%-100%, with tumor sterilization achieved in 8%-49% of cases, and consequently improved local control. New chemotherapy regimens omitting 5-FU have reduced the incidence of severe esophagitis, unplanned hospitalization, with comparable efficacy. Among three randomised trials that compared preop-CRT to surgery alone, one shown a debatable survival advantage. Reducing local recurrence rates lead to a switch to more distant failures, and increasing the radiation dose beyond 45 Gy appears to be of little value. However, it should be remembered that preop-CRT has associated toxicity, and may increase postoperative mortality. Novel strategies, which include induction with chemotherapy followed by preop-CRT, and for radiation therapy, three dimensional conformation techniques, image fusioning, and improved definition of treatment volumes, are still considered experimental and should be tested in specialized centers.
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Affiliation(s)
- Jean-François Bosset
- Department of Radiation-Oncology, Besançon University Hospital, Boulevard Fleming, F-25030 Besançon Cedex, France.
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de Manzoni G, Pedrazzani C, Pasini F, Di Leo A, Durante E, Castaldini G, Cordiano C. Results of surgical treatment of adenocarcinoma of the gastric cardia. Ann Thorac Surg 2002; 73:1035-40. [PMID: 11996237 DOI: 10.1016/s0003-4975(01)03571-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Comparison among different studies regarding adenocarcinoma of the cardia has been difficult since the Siewert classification was introduced. This study analyzed the experience of a single institution in the treatment of gastric cardia cancer with the aim of assessing principal prognostic factors and long-term outcome. METHODS The results of 96 patients who underwent resection with curative intent for gastric cardia cancer at the First Division of General Surgery, University of Verona, from January 1988 to February 2000, were analyzed statistically with special reference to Siewert type. RESULTS Despite a high number of curative resections (85.4%), the 5-year survival rate was poor (24%) for all Siewert types (p = 0.8), and for early tumors (51%) also. Chance of cure was limited to pN0 and pN1 patients. Multivariate analysis showed that microscopic or macroscopic residual tumor and pN-positive categories had a significantly higher risk of death (risk ratio, 2.18 and 2.68, respectively) and the pN2 and pN3 category had the most negative prognostic factor (risk ratio, 7.6). CONCLUSIONS The long-term prognosis for gastric cardia cancer remains poor and is independent of Siewert type, with cure limited to pN0 and pN1 patients.
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Bozzetti F, Bignami P, Bertario L, Fissi S, Eboli M. Surgical treatment of gastric cancer invading the oesophagus. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2000; 26:810-4. [PMID: 11087650 DOI: 10.1053/ejso.2000.1009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION There is controversy regarding which type of surgical treatment is most appropriate for upper gastric cancer invading the oesophagus. METHODS A review of the pertinent literature was carried out regarding oesophageal involvement in gastric cancer. RESULTS Invasion of the oesophagus occurred in 26-63% of Western surgical series. It was more frequent in Borrmann IV type, linitis plastica, pT3-pT4, diffuse type by Lauren, N+ or tumours exceeding 5 cm in diameter. Lymphatic tumour spread was caudad (coeliac nodes, hepatoduodenal nodes, paraortic nodes) but mediastinal nodes were also involved if tumour growth in the oesophagus exceeded 3 cm or if there was transmural oesophageal infiltration. In Western countries there was less than 30% 5-year survival and no long-term survivors when hepatoduodenal or mediastinal nodes were metastatic. Mediastinal dissection through thoracotomy did not provide any benefit. CONCLUSIONS A rational approach involves total gastrectomy plus partial oesophagectomy. Abdominal transhiatal resection may be performed in the case of a localized, non-infiltrating tumour and oesophageal involvement <2 cm. However, infiltrating, poorly differentiated or Borrmann III-IV tumours require a right thoracotomy to achieve a longer margin of clearance. When oesophageal involvement is >3 cm, or hepatoduodenal or mediastinal nodes are positive, no surgical procedure is curative and the literature demonstrates that extended aggressive surgery has no benefits.
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Affiliation(s)
- F Bozzetti
- Unit of Surgical Oncology of the Digestive Tract, National Cancer Institute, Via Venezian, Milan, 1,20133, Italy.
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22
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Abstract
In the Western world, there has been an alarming rise in the incidence and prevalence of adenocarcinoma arising at the esophagogastric junction during recent decades. Epidemiological, clinical and pathological data support a sub-classification of adenocarcinomas arising in the vicinity of the esophagogastric junction (AEG) into adenocarcinoma of the distal esophagus (Type I), true carcinoma of the cardia (Type II) and subcardial carcinoma (Type III). While most, if not all, adenocarcinomas of the distal esophagus arise from areas with specialized intestinal metaplasia, which develop as a consequence of chronic gastroesophageal reflux, the etiology and pathogenesis of true carcinoma of the gastric cardia and subcardial gastric cancer is not clear at present. Although a subgroup of true carcinomas of the gastric cardia may also develop within short segments of intestinal metaplasia at the esophagogastric junction, a causal relation between these tumors and gastroesophageal reflux has been difficult to establish. Irrespective of the etiology, a complete removal of the primary tumor and its lymphatic drainage has to be the primary goal of any surgical approach to adenocarcinoma of the esophagogastric junction. Our experience in the management of more than 1000 such patients during the past 18 years suggests that an individualized therapeutic strategy oriented by tumor type and stage results in survival rates superior to those reported with a more indiscriminate approach. This individualized strategy prescribes a transmediastinal esophagectomy with lymphadenectomy in the lower posterior mediastinum and along the celiac axis for Type I tumors, extended total gastrectomy with transhiatal resection of the distal esophagus and D2 lymphadenectomy for Type II and Type III tumors, a limited resection of the esophagogastric junction and distal esophagus with interposition of a pedicled jejunal segment for uT1N0 tumors, and neoadjuvant chemotherapy followed by resection for uT3/T4 tumors. Extensive preoperative staging is essential to allow correct selection of the appropriate therapeutic strategy using this tailored approach.
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Affiliation(s)
- H J Stein
- Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany.
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Stein HJ, Sendler A, Fink U, Siewert JR. Multidisciplinary approach to esophageal and gastric cancer. Surg Clin North Am 2000; 80:659-82; discussions 683-6. [PMID: 10836011 DOI: 10.1016/s0039-6109(05)70205-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Despite marked advances in surgical therapy for patients with esophageal, esophagogastric, and gastric cancers, the overall prognosis of these patients has not markedly improved during the past decades. Multidisciplinary approaches using adjuvant postoperative and neoadjuvant preoperative therapeutic principles have received increasing attention with regard to the management of these patients. A series of randomized, prospective trials has demonstrated that adjuvant postoperative radiation or chemotherapy does not result in a convincing survival advantage after complete tumor resection in esophageal, esophagogastric junction, or gastric cancer. The available data on the role of neoadjuvant preoperative therapy are not yet conclusive. Although neoadjuvant therapy may reduce the tumor mass in many patients, several randomized, controlled trials have shown that, compared with primary resection, a multimodal approach does not result in a survival benefit in patients with locoregional, that is, potentially resectable, tumors. In contrast, in patients with locally advanced tumors, that is, patients in whom complete tumor removal with primary surgery seems unlikely, neoadjuvant therapy increases the likelihood of complete tumor resection on subsequent surgery, but only patients with objective histopathologic response to preoperative therapy seem to benefit from this approach. Consequently, in the future, improvements in the overall survival of patients with esophageal, esophagogastric junction, or gastric cancer most likely will be achieved only by tailored therapeutic strategies that are based on the individual tumor location, tumor stage, and consideration of established prognostic factors. A clear classification of the underlying tumor entity, a profound knowledge of the prognostic factors applicable, a thorough preoperative staging, and identification of parameters that allow for the prediction of response to preoperative therapy will become essential for the selection of the optimal therapeutic modality for individual patients.
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Affiliation(s)
- H J Stein
- Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar of the Technische Universität München, Germany.
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Kodera Y, Yamamura Y, Shimizu Y, Torii A, Hirai T, Yasui K, Morimoto T, Kato T. Adenocarcinoma of the gastroesophageal junction in Japan: relevance of Siewert's classification applied to 177 cases resected at a single institution. J Am Coll Surg 1999; 189:594-601. [PMID: 10589596 DOI: 10.1016/s1072-7515(99)00201-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND There had been a lack of international consensus about the definition of cancer of the gastric cardia until Siewert's classification was approved at a consensus conference during the second International Gastric Cancer Congress held in 1997. STUDY DESIGN A review of the prospective gastric cancer database at Aichi Cancer Center from 1983 to 1992 identified 1,913 gastric carcinoma patients who underwent gastrectomy. These patients were classified retrospectively according to the Siewert classification, and 177 patients who fell into one of the three types form the basis of this study. Survival analyses were performed after stratifying patients by clinicopathologic variables. RESULTS There were 33 patients with type II and 144 with type III, although none had type I, a type frequently observed in the west. No evidence of a change in the frequency of types II or III cancers (approximately 9.3% overall) among gastric carcinoma patients was observed over the 10-year period. Clinical staging of gastric carcinoma by the TNM classification was found to reflect accurately the prognosis of these patients. There were no longterm survivors among the few patients with metastasis to the perigastric nodes of the distal stomach. CONCLUSIONS A striking difference in the distribution of types of adenocarcinoma of the gastroesophageal junction was observed in Japan compared with previously reported western data. A subgroup of carcinoma of the proximal stomach identified as types II and III may not require proximal gastrectomy from the viewpoint of sufficient lymphadenectomy.
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Affiliation(s)
- Y Kodera
- Department of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan
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25
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Abstract
From the pathogenic and therapeutic point of view, adenocarcinomas of the esophagogastric junction (AEG) should be classified into adenocarcinoma of the distal esophagus (Type I), true carcinoma of the cardia (Type II), and subcardial carcinoma (Type III). This classification can be easily performed by summarizing the information available from contrast radiography, endoscopy, and intra-operative findings; it allows comparison of data between various centers and facilitates the choice of surgical therapy. A complete removal of the primary tumor and its lymphatic drainage has to be the primary goal of any surgical approach to adenocarcinoma of the esophagogastric junction. In patients with potentially resectable, true carcinoma of the cardia (AEG Type II), this can be achieved by a total gastrectomy with transhiatal resection of the distal esophagus and en bloc removal of the lymphatic drainage in the lower posterior mediastinum and along the celiac axis and superior border of the pancreas. This approach is associated with lower morbidity and provides equal long-term survival as compared to the more radical transmediastinal or abdominothoracic esophagogastrectomy. Whether a routine splenectomy for lymphadenectomy in the splenic hilus offers a survival benefit in these patients is questionable. In patients with early tumors staged as uT1 on pre-operative endosonography, a limited resection of the proximal stomach, cardia, and distal esophagus with interposition of a pedicled isoperistaltic jejunal segment appears justified since this procedure allows a complete tumor removal with adequate lymphadenctomy and offers excellent functional results. Multimodal therapy with pre-operative polychemotherapy or combined radio-chemotherapy appears to offer a significant survival benefit in patients with locally advanced tumors. With this tailored approach, extensive pre-operative staging becomes mandatory for an adequate selection of the appropriate therapeutic concept.
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Affiliation(s)
- J R Siewert
- Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
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