Surgical therapy for adenocarcinoma of the cardia: modalities of recurrence and extension of resection

Transthoracic single-port-assisted laparoscopic gastrectomy versus laparoscopic transhiatal approach for Siewert type II adenocarcinoma of the esophagogastric junction: a single-center retrospective study

BACKGROUND

The surgical approach for patients with Siewert type II AEG remains controversial. Several studies have described a new laparoscopic radical resection approach of Siewert type II AEG through the left diaphragm. However, the technical safety and feasibility of the new surgical approach compared with the transhiatal approach have not yet been tested.

STUDY DESIGN

We retrospectively reviewed patients with AEG who underwent TSLG and LTH operations in the Guangdong Provincial Hospital of Chinese Medicine between January 2017 and April 2021. Histologically confirmed AEG and D2 lymphadenectomy with curative R0 patients were included, and patients with Siewert I/III AEG or distant metastasis were excluded. Blood loss, the amount of harvested lymph node, and complications related to surgery were evaluated.

RESULTS

A total of 99 patients with Siewert type II AEG were analyzed, 44 in the TSLG group and 55 in the LTH group. There was no difference in clinicopathological features between the two groups. The more harvested lymph node (23.33 ± 11.41 vs. 32.18 ± 12.85, p < 0.01), lower mediastinal lymph node (1.07 ± 2.08 vs. 3.25 ± 3.31, p < 0.01), and longer proximal margin length (3.08 ± 1.19 vs. 4.47 ± 0.95 cm, p < 0.01) were observed in the TSLG group. The rate of cure (R0 gastrectomy) in the TSLG group was higher than that in the LTH group (100% vs. 89.09%, p = 0.03).

CONCLUSION

The TSLG approach is associated with improved surgical views, simplified lymphatic dissection in the inferior mediastinum, and more reliable margins. TSLG surgery may be an effective addition to LTH surgery, particularly when lower mediastinal lymph node metastases are suspected.

Short- and Long-Term Outcomes of the Minimal Proximal Resection Margin in Total Gastrectomy for Siewert II Adenocarcinoma of the Esophagogastric Junction

OBJECTIVE

This study aimed to investigate the feasibility of the minimal proximal resection margin (PRM) in total gastrectomy (TG) for Siewert II adenocarcinoma of the esophagogastric junction (AEG).

METHODS

This study finally included 178 Siewert II advanced AEG patients who underwent TG from January 2017 to September 2020. According to the PRM length, patients were divided into 20-25 mm group and 30-35 mm group. Intraoperative, short-, and long-term postoperative outcomes were compared between two groups.

RESULTS

The PRM of the 20-25 mm group had significantly less operation time compared with the PRM of the 30-35 mm group (P < .001), but the amount of blood loss, management of the diaphragmatic crura, and the incidence of positive resection margin were not significantly different between two groups (P > .05). In short-term postoperative outcomes, first gas-passing time, gastric-tube removal time, start time of diet, hospitalization, postoperative complications, and body weight loss were similar between two groups (P > .05). During the follow-up, the 3-year overall survival rates and the recurrence rates were not significantly different between the PRM of 20-25 mm and 30-35 mm groups (81.2% vs 83.5%, P = .695; 18.8% vs 15.5%, P = .812, respectively).

CONCLUSION

With less operation time and more preserved esophagus, the minimal PRM length of 20-25 mm could be an appropriate option in TG for patients with Siewert II advanced AEG.

The correlation between the margin of resection and prognosis in esophagogastric junction adenocarcinoma

Adenocarcinoma of the gastroesophageal junction (AEG) has become increasingly common in Western and Asian populations. Surgical resection is the mainstay of treatment for AEG; however, determining the distance from the upper edge of the tumor to the esophageal margin (PM) is essential for accurate prognosis. Despite the relevance of these studies, most have been retrospective and vary widely in their conclusions. The PM is now widely accepted to have an impact on patient outcomes but can be masked by TNM at later stages. Extended PM is associated with improved outcomes, but the optimal PM is uncertain. Academics continue to debate the surgical route, extent of lymphadenectomy, preoperative tumor size assessment, intraoperative cryosection, neoadjuvant therapy, and other aspects to further ensure a negative margin in patients with gastroesophageal adenocarcinoma. This review summarizes and evaluates the findings from these studies and suggests that the choice of approach for patients with adenocarcinoma of the esophagogastric junction should take into account the extent of esophagectomy and lymphadenectomy. Although several guidelines and reviews recommend the routine use of intraoperative cryosections to evaluate surgical margins, its generalizability is limited. Furthermore, neoadjuvant chemotherapy and radiotherapy are more likely to increase the R0 resection rate. In particular, intraoperative cryosections and neoadjuvant chemoradiotherapy were found to be more effective for achieving negative resection margins in signet ring cell carcinoma.

The Prognostic Impact of Histology in Esophageal and Esophago-Gastric Junction Adenocarcinoma

Stage significantly affects survival of esophageal and esophago-gastric junction adenocarcinomas (EA/EGJAs), however, limited evidence for the prognostic role of histologic subtypes is available. The aim of the study was to describe a morphologic approach to EA/EGJAs and assess its discriminating prognostic power. Histologic slides from 299 neoadjuvant treatment-naïve EA/EGJAs, resected in five European Centers, were retrospectively reviewed. Morphologic features were re-assessed and correlated with survival. In glandular adenocarcinomas (240/299 cases-80%), WHO grade and tumors with a poorly differentiated component ≥6% were the most discriminant factors for survival (both p < 0.0001), distinguishing glandular well-differentiated from poorly differentiated adenocarcinomas. Two prognostically different histologic groups were identified: the lower risk group, comprising glandular well-differentiated (34.4%) and rare variants, such as mucinous muconodular carcinoma (2.7%) and diffuse desmoplastic carcinoma (1.7%), versus the higher risk group, comprising the glandular poorly differentiated subtype (45.8%), including invasive mucinous carcinoma (5.7%), diffuse anaplastic carcinoma (3%), mixed carcinoma (6.7%) (CSS p < 0.0001, DFS p = 0.001). Stage (p < 0.0001), histologic groups (p = 0.001), age >72 years (p = 0.008), and vascular invasion (p = 0.015) were prognostically significant in the multivariate analysis. The combined evaluation of stage/histologic group identified 5-year cancer-specific survival ranging from 87.6% (stage II, lower risk) to 14% (stage IVA, higher risk). Detailed characterization of histologic subtypes contributes to EA/EGJA prognostic prediction.

Adenocarcinoma of the oesophagogastric junction Siewert II: An oesophageal cancer better cured with total gastrectomy

INTRODUCTION

Type II AEG is now considered as oesophageal cancer in the seventh and eighth edition of TNM classification but optimal surgical approach for these tumors remains debated. The objective of the study is to assess and compare surgical and oncological outcomes of two surgical approaches: superior polar oesogastrectomy (SPO) or total gastrectomy (TG) in patients with type II adenocarcinoma of the oesophagogastric junction (AEG).

MATERIAL AND METHODS

183 patients with type II AEG treated from 1997 to 2010 in 21 French centers by SPO or TG were included in a multicenter retrospective study. The surgical and oncological outcomes were compared between these two surgical approaches.

RESULTS

A TG was performed in 64 (35%) patients whereas 119 (65%) patients were treated by SPO with transthoracic approach in 100 of them (83.2%) and transhiatal approach with cervicotomy in 19 (16.8%). Surgical outcomes were comparable between the two approaches with a postoperative mortality rate of 4.9% and a severe operative morbidity rate within 30 days of 15.3%. Median survival in patients operated on by TG was of 46 months compared to 27 months in patients treated by SPO (p = 0.118). At multivariate analysis, TG appears to be an independent good prognostic factor compared to SPO (HR = 1.847; p = 0.008). However, TG was also associated with a higher rate of incomplete resection, (12.5% vs 5.9%; p = 0.120).

CONCLUSION

When TG allows obtaining tumor-free resection margins, this approach should be preferred to SPO.

Surgical principles for optimal treatment of esophagogastric junction adenocarcinoma

The incidence of esophagogastric junction (EGJ) adenocarcinoma is increasing worldwide. Management of these tumors remains controversial given their unique location between the esophagus and the stomach. Debate surrounding the optimal therapy for EGJ adenocarcinoma has often centered around the tumor origin as defined by the Siewert classification system. However, the optimal surgical management should focus on adhering to important surgical principles that will allow for the best outcomes and prognosis regardless of tumor location including resection with appropriate and negative histological margins, adequate lymphadenectomy, minimization of morbidity and mortality, and preservation of quality-of-life. In this article, we provide a discussion of the controversy surrounding EGJ adenocarcinoma within the framework of these concepts.

Safety and feasibility of preoperative exercise training during neoadjuvant treatment before surgery for adenocarcinoma of the gastro-oesophageal junction

Background

Neoadjuvant chemotherapy or chemoradiotherapy is used widely before tumour resection in cancer of the gastro‐oesophageal junction (GOJ). Strategies to improve treatment tolerability are warranted. This study examined the safety and feasibility of preoperative exercise training during neoadjuvant treatment in these patients.

Methods

Patients were allocated to a standard‐care control group or an exercise group, who were prescribed standard care plus twice‐weekly high‐intensity aerobic exercise and resistance training sessions. The primary endpoint was the incidence of serious adverse events (SAEs) that prevented surgery, including death, disease progression or physical deterioration. Preoperative hospital admission, postoperative complications, changes in patient‐reported quality of life and pathological treatment response were also recorded. In the exercise group, adherence to exercise and changes in aerobic fitness, muscle strength and body composition were measured.

Results

The incidence of SAEs was not increased in the exercise group. The risk of failure to reach surgery was 5 versus 21 per cent in the control group (risk ratio (RR) 0·23, 95 per cent c.i. 0·04 to 1·29), the risk of preoperative hospital admission was 15 versus 38 per cent respectively (RR 0·39, 0·12 to 1·23) and the risk of postoperative complications was 58 versus 57 per cent (RR 1·06, 0·61 to 1·73). The exercise group attended a mean of 17·5 sessions, and improved fitness, muscle strength and Functional Assessment of Cancer Therapy — Esophageal (FACT‐E) total score compared with the baseline level.

Conclusion

Preoperative exercise training during neoadjuvant treatment in patients with GOJ cancer is safe and feasible, with improvements in fitness, strength and quality of life. Preoperative exercise training may be associated with a lower risk of critical SAEs that preclude surgery or result in hospitalization.

Oncologic Quality Indicators in Thoracic Surgery

This article outlines a structure for assessing thoracic surgical quality and provides an overview of evidence-based quality metrics for surgical care in both lung cancer and esophageal cancer, with a focus on process and outcome measures in the preoperative, intraoperative, and postoperative setting.

Recurrence after surgery in esophago-gastric junction adenocarcinoma: Current management and future perspectives

Recurrent esophago-gastric junction adenocarcinoma is not a rare event and its correct management is still debated. Many approaches for the treatment of these patients exist, but only few studies compare the different techniques. Most of the studies are retrospectives series and describe the experiences of single institutions in the treatment of recurrent esophageal and esophago-gastric junction cancers. Nowadays surgery is still the main and only curative treatment. Other alternative palliative therapies could be endoscopic stent placement and balloon dilation, photodynamic therapy, thermal tumor ablation (laser photoablation and Argon plasma coagulation), radiation therapy and brachytherapy, and chemotherapy. The aim of this review is to investigate the different rates, patterns and timings of recurrence of this tumor, and to explain the various approaches used for the treatment of recurrent esophago-gastric junction cancer.

Esophageal and Gastric Cancer Pearl: a nationwide clinical biobanking project in the Netherlands

Esophageal and gastric cancer is associated with a poor prognosis since many patients develop recurrent disease. Treatment requires specific expertise and a structured multidisciplinary approach. In the Netherlands, this type of expertise is mainly found at the University Medical Centers (UMCs) and a few specialized nonacademic centers. Aim of this study is to implement a national infrastructure for research to gain more insight in the etiology and prognosis of esophageal and gastric cancer and to evaluate and improve the response on (neoadjuvant) treatment. Clinical data are collected in a prospective database, which is linked to the patients' biomaterial. The collection and storage of biomaterial is performed according to standard operating procedures in all participating UMCs as established within the Parelsnoer Institute. The collected biomaterial consists of tumor biopsies, blood samples, samples of malignant and healthy tissue of the resected specimen and biopsies of recurrence. The collected material is stored in the local biobanks and is encoded to respect the privacy of the donors. After approval of the study was obtained from the Institutional Review Board, the first patient was included in October 2014. The target aim is to include 300 patients annually. In conclusion, the eight UMCs of the Netherlands collaborated to establish a nationwide database of clinical information and biomaterial of patients with esophageal and gastric cancer. Due to the national coverage, a high number of patients are expected to be included. This will provide opportunity for future studies to gain more insight in the etiology, treatment and prognosis of esophageal and gastric cancer.

The importance of the proximal resection margin distance for proximal gastric adenocarcinoma: A multi-institutional study of the US Gastric Cancer Collaborative

BACKGROUND

A 5 cm margin is advocated for distal gastric adenocarcinoma (GAC). The optimal proximal resection margin (PM) length for proximal GAC is not established.

METHODS

Patients who underwent curative-intent resection for proximal GAC from 2000 to 2012 at 7 centers in the US Gastric Cancer Collaborative were included. PM length was sequentially dichotomized and analyzed at 0.5 cm increments (0.5-6.5 cm). Outcomes after negative margin (R0) and positive microscopic margin (R1) resections were compared. Primary endpoints were local recurrence (LR) and overall survival (OS).

RESULTS

All patients (n = 162) had R0 distal margins. 151 (93.2%) had an R0-PM with mean length of 2.6 cm (median:1.7 cm; range:0.1-15 cm). A greater PM distance was not associated with LR or OS. An R1-PM was associated with higher N-stage (N3:73% vs. 26%; P = 0.007) and increased LR (HR6.1; P = 0.009) but not associated with decreased OS. On multivariate analysis, an R1-PM was also not independently associated with LR.

CONCLUSIONS

For resection of proximal gastric adenocarcinoma, proximal margin length is not associated with local recurrence or overall survival. An R1 margin is associated with advanced N-stage but is not independently associated with recurrence or survival. When performing resection of proximal gastric adenocarcinoma, efforts to achieve a specific margin distance, especially if it necessitates an esophagectomy, should be abandoned.

Systematic review of the surgical strategies of adenocarcinomas of the gastroesophageal junction

INTRODUCTION

The optimal surgical treatment of patients with adenocarcinoma of the gastroesophageal junction has not been established yet.

OBJECTIVE

To evaluate the surgical strategies to treat adenocarcinoma of the gastroesophageal junction.

METHODS

Databases Pubmed, Cochrane, and Embase were searched for "adenocarcinoma of the gastroesophageal junction" AND ("surgery" OR "esophagectomy" OR "gastrectomy") or its synonyms or abbreviations. Only comparative studies that evaluated gastrectomy versus esophagectomy were included.

RESULTS

In total 10 cohort studies comparing esophagectomy versus gastrectomy fulfilled the quality criteria. The R0 resection rates varied between 72-93% for esophagectomy and 62%-93% for gastrectomy. Morbidity was 33-39% after esophagectomy versus 11-54% after gastrectomy. The 30-day mortality ranged between 1.0-2.3 after esophagectomy and 1.8-2.7% after gastrectomy. At 6 months after surgery, health-related quality of life was higher after total gastrectomy than after esophagectomy. The 5-year survival rates varied between 30-42% for esophagectomy and 18-38% for gastrectomy, but were not significantly different.

CONCLUSION

No clear oncologic benefit of either esophagectomy or gastrectomy in patients with adenomacarcinoma of gastroesophageal junction could be observed. However, gastrectomy seems to be accompanied with better quality of life. Future research should preferably consist of a multicenter RCT comparing esophagectomy and gastrectomy for adenocarcinomas of the gastroesophageal junction.

Surgical treatment of adenocarcinomas of the gastro-esophageal junction

BACKGROUND

Patients with adenocarcinoma of the gastro-esophageal junction (GEJ) may undergo either esophagectomy or gastrectomy. The aim of this study was to evaluate the outcome of surgical therapy with regard to postoperative outcome and survival in patients with Siewert type II tumors.

METHODS

A prospective database of 266 consecutive patients with surgically resectable GEJ adenocarcinomas from 2003 to 2013 was analyzed. The surgical approach was based on preoperative imaging and intraoperative findings.

RESULTS

According to the histopathological analysis, 67 patients (25 %) had type I tumor, 176 patients (66 %) had type II tumor, and 16 patients (6 %) had type III tumor. In total, 86 % were treated with esophagectomy and 14 % with gastrectomy. Overall 5-year survival was 38 %. In type II patients, the type of operation did not significantly influence overall survival on multivariate analysis (p = 0.606). A positive circumferential resection margin (CRM) at the site of the esophagus was more common with gastrectomy (29 vs. 11 %; p = 0.025). No significant differences in mortality, morbidity, or disease recurrence were found. In patients with type II tumors, upper mediastinal nodal involvement (subcarinal, paratracheal, and aortapulmonary window) was found in 11 % of the patients. In 34 % of patients treated with esophagectomy, paraesophageal lymph nodes metastases were harvested compared with 5 % of patients treated with gastrectomy.

CONCLUSIONS

In patients with a type II GEJ adenocarcinoma, a positive CRM was more common with gastrectomy. Esophagectomy provides for a more complete para-esophageal lymphadenectomy. Furthermore, the high prevalence of mediastinal nodal involvement indicates that a full lymphadenectomy of these stations should be considered.

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.

Diagnostic accuracy and utility of intraoperative microscopic margin analysis of gastric and esophageal adenocarcinoma

BACKGROUND

Positive resection margins are amongst the strongest predictors of cancer-related mortality for adenocarcinoma of the stomach and esophagus. Although intraoperative pathology consultation with frozen section of margins can predict final permanent section pathology, the accuracy of this approach is not known. We sought to determine the diagnostic accuracy of frozen section margin analysis in esophagogastric adenocarcinoma and the impact that it had on surgical therapy.

METHODS

Patients with resection of esophagogastric adenocarcinoma at a single centre from 1998 to 2008 were identified. Clinicopathologic data were collected. Frozen section results were compared to permanent section assessment, and sensitivity, specificity, positive, and negative predictive values were calculated. Patients with positive margins by frozen section were reviewed to assess the impact on surgical decision-making.

RESULTS

Of 220 patients who underwent surgery for adenocarcinoma of the esophagus and stomach (esophagus: 34/220, EGJ: 106/220, stomach 80/220), 56 % had an intraoperative consultation. Of these 122 patients, 66 % underwent frozen section. All errors on frozen section occurred on the interpretation of the proximal margin. The diagnostic accuracy of frozen section at the proximal margin was 93 % with sensitivity = 67 %, specificity = 100 %, positive predictive value = 100 %, and negative predictive value = 91 %. Signet ring cells were present in 83 % of false-negative readings. Surgical management was altered in 10 of the 13 of patients who had a true positive frozen section and 9 of these patients were converted to R0 resections.

CONCLUSIONS

Although very specific, negative results on frozen section require greater caution when signet ring cells are present. For esophagogastric adenocarcinoma, frozen section alters management and may increase the rate of complete resection.

Surgery for esophageal cancer: goals of resection and optimizing outcomes

Determining what defines an adequate esophageal resection to optimize long-term outcomes in esophageal cancer is an elusive goal. The primary reason for this ambiguousness is the almost total lack of good quality prospective randomized surgical trials that examine this question adequately. Most available data are derived from small retrospective series typically representing single institution series and their treatment biases. The intent of this article is to identify the goals of an appropriate esophagectomy for cancer, essentially defining the targets that should be achieved from an operation.

Outcomes of Abdominal Total Gastrectomy for Type II and III Gastroesophageal Junction Tumors: Single Center's Experience in Korea

Purpose

The aim of this study was to evaluate the surgical outcomes of abdominal total gastrectomy, without mediastinal lymph node dissection for type II and III gastroesophageal junction (GEJ) cancers.

Materials and Methods

We retrospectively reviewed surgical outcomes in 67 consecutive patients with type II and III GEJ cancers that were treated by the surgical resection between 2004 and 2008.

Results

Thirty (45%) patients had type II and 37 (55%) had type III tumor. Among the 65 (97%) patients with curative surgery, 21 (31%) patients underwent the extended total gastrectomy with trans-hiatal distal esophageal resection, and in 44 (66%) patients, abdominal total gastrectomy alone was done. Palliative gastrectomy was performed in two patients due to the accompanying peritoneal metastasis. The postoperative morbidity and mortality rates were 21.4% and 1.5%, respectively. After a median follow up of 36 months, the overall 3-years was 68%, without any differences between the Siewert types or the operative approaches (transhiatal approach vs. abdominal approach alone). On the univariate analysis, the T stage, N stage and R0 resection were found to be associated with the survival, and multivariate analysis revealed that the N stage was a poor independent prognostic factor for survival.

Conclusions

Type II and III GEJ cancers may successfully be treated with the abdominal total gastrectomy, without mediastinal lymph node dissection in the Korean population.

Thoracoscopic-assisted esophagectomy for esophageal cancer: analysis of patterns and prognostic factors for recurrence

OBJECTIVE

The authors report the recurrence pattern of esophageal cancer after thoracoscopic-assisted esophagectomy (TAE), comparing it to the recurrence pattern after open surgery and identify prognostic factors for recurrence.

SUMMARY OF BACKGROUND DATA

To improve long-term survival for esophageal cancer radical surgery has been proposed increasingly, however, recurrent disease remains a problem. Opinion is divided as to the adequacy of resection possible using minimally invasive techniques with concerns that there may be an increased incidence in locoregional recurrence.

METHODS

A total of 221 patients who underwent esophagectomy at the Princess Alexandra Hospital without any neoadjuvant or adjuvant therapy were identified from a prospective database. Patients were followed up for the detection of symptomatic recurrence for a median of 59 months.

RESULTS

Within this group 165 patients underwent TAE and 56 an open transthoracic esophagectomy (TTE). The 5-year overall recurrence rate was 133/221 (60%). The 5-year rates of symptomatic first recurrence following TAE was 4%, 9%, and 47% for local, regional, and distant recurrence, respectively. The 5-year rates of symptomatic first recurrence following TTE was 5%, 18%, and 55% for local, regional, and distant recurrence, respectively. Operative approach was not a prognostic factor for any type of recurrence. Independent prognostic factors associated with locoregional recurrence were positive margins and number of positive nodes. Distant recurrence was associated with T stage, differentiation, tumor length >6 cm, and number of positive nodes.

CONCLUSION

Distant recurrence remains a significant problem in esophageal cancer. TAE achieved adequate locoregional control and compared favorably with open TTE.

The impact of operative approach on outcome of surgery for gastro-oesophageal tumours

BACKGROUND

The choice of operation for tumours at or around the gastro-oesophageal junction remains controversial with little evidence to support one technique over another. This study examines the prevalence of margin involvement and nodal disease and their impact on outcome following three surgical approaches (Ivor Lewis, transhiatal and left thoraco-laparotomy) for these tumours.

METHODS

A retrospective analysis was conducted of patients undergoing surgery for distal oesophageal and gastro-oesophageal junction tumours by a single surgeon over ten years. Comparisons were undertaken in terms of tumour clearance, nodal yield, postoperative morbidity, mortality, and median survival. All patients were followed up until death or the end of the data collection (mean follow up 33.2 months).

RESULTS

A total of 104 patients were operated on of which 102 underwent resection (98%). Median age was 64.1 yrs (range 32.1-79.4) with 77 males and 25 females. Procedures included 29 Ivor Lewis, 31 transhiatal and 42 left-thoraco-laparotomies. Postoperative mortality was 2.9% and median survival 23 months. Margin involvement was 24.1% (two distal, one proximal and 17 circumferential margins). Operative approach had no significant effect on nodal clearance, margin involvement, postoperative mortality or morbidity and survival. Lymph node positive disease had a significantly worse median survival of 15.8 months compared to 39.7 months for node negative (p = 0.007), irrespective of approach.

CONCLUSION

Surgical approach had no effect on postoperative mortality, circumferential tumour, nodal clearance or survival. This suggests that the choice of operative approach for tumours at the gastro-oesophageal junction may be based on the individual patient and tumour location rather than surgical dogma.

Adenocarcinoma of the gastroesophageal junction: influence of esophageal resection margin and operative approach on outcome

OBJECTIVE

To determine whether the length of esophageal resection or the operative approach influences outcome for patients with adenocarcinoma of the gastroesophageal junction (GEJ).

SUMMARY BACKGROUND DATA

While R0 resection remains the mainstay of curative treatment of patients with GEJ cancer, the optimal length of esophageal resection remains controversial.

METHODS

Patients with Siewert I, II, or III adenocarcinoma who underwent complete gross resection without neoadjuvant therapy were identified from a prospectively maintained database. Proximal margin lengths were recorded ex vivo as the distance from the gross tumor edge to the esophageal transection line. Operative approaches were grouped into gastrectomy (limited esophagectomy) or esophagectomy (extended esophagectomy).

RESULTS

From 1985 through 2003, 505 patients underwent R0/R1 gastrectomy (n = 153) or esophagectomy (n = 352) without neoadjuvant treatment. There were no differences in R1 resection rate, number of nodes examined or operative mortality between gastrectomy and esophagectomy. Univariate analysis found >3.8 cm to be the ex vivo proximal margin length (approximately 5 cm in situ) most predictive of improved survival. Multivariable analysis in patients who underwent R0 resection with >or=15 lymph nodes examined (n = 275) found the number of positive lymph nodes, T stage, tumor grade, and ex vivo proximal margin length >3.8 cm to be independent prognostic factors. Subset analysis found that the benefit associated with >3.8 cm margin was limited to patients with T2 or greater tumors and <or=6 positive lymph nodes.

CONCLUSIONS

In patients not receiving neoadjuvant therapy, the goal for patients with adenocarcinoma of the GEJ should be R0 resection including at least 15 lymph nodes, preferably with 5 cm of grossly normal in situ proximal esophagus for those with <or=6 positive lymph nodes. The operative approach may be individualized to achieve these goals.

Immunopathological Patterns of the Stomach in Adenocarcinoma of the Esophagus, Cardia, and Gastric Antrum: Gastric Profiles in Siewert Type I and II Tumors

BACKGROUND

The morphologic and immunohistochemical profiles of gastric mucosa and of the tumor were assessed in Siewert type I, type II, and gastric antrum adenocarcinomas.

METHODS

Sixty-two patients, prospectively operated upon, were included in the study: 37 type II, 15 type I, and 10 antrum adenocarcinoma. Samples of the tumor, the surrounding area, and the gastric corpus and antrum were analyzed histologically, and immunostained for cytokeratins (CK)7/20 (staining positive for cells labeled > or = 50%).

RESULTS

Among the 37 type II adenocarcinomas were the following: (1) 13 of 37 (35%) had intestinal metaplasia (IM) in the stomach; (2) 24 of 37 (65%) did not show IM at any level; (3) 34 of 37 (92%) had Helicobacter pylori (HP) infection; (4) 13 of 37(35%) had CK7/20 expression of "Barrett's type" (CK7+/20-); 24 of 37 (65%) had a "no Barrett's type" profile (10 of 37 with CK7-/CK20+ and 14 of 37 with CK7+/CK20+); (5) 100% showed the same CK immunoprofile, both in IM and adenocarcinoma (measure of agreement k = 1, p = 0.000). Type I adenocarcinomas showed the following: (1) 87.5% CK Barrett's type, both in the tumor, and in the surrounding IM; (2) 100% gastric samples devoid of both IM and HP infection. Comparison between CK immunoprofiles in type I and type II tumors showed a difference within the two groups (p = 0.002). One hundred percent of antrum adenocarcinomas showed a no Barrett's type CK profile, both in the tumor and in the IM of the entire stomach.

CONCLUSIONS

Data suggest that type II adenocarcinoma cannot be always considered a gastroesophageal reflux disease-related tumor; other pathogenetic pathways should be taken into consideration.

Management of gastroesophageal tumors

The incidence of adenocarcinomas of the gastroesophageal junction has increased in recent years. These tumors possess distinct pathophysiologic characteristics. Although the consensus is that an R0 resection (complete microscopic and macroscopic resection) is the goal when operating for curative intent, much controversy remains regarding other aspects of patient management. There is lack of consensus regarding the type of surgery to perform, the role and extent of lymphadenectomy, and the role of neoadjuvant therapy. Utilizing an evidence-based approach, this review article provides an overview of the management of gastroesophageal junction carcinomas with particular emphasis on current areas of controversy.

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

BACKGROUND

Since Misumi et al. and Siewert proposed a new classification for carcinoma of the gastroesophageal junction (GEJ), few surgical studies using these criteria have been reported from Eastern countries. Siewert type II adenocarcinomas are managed using general rules for either gastric or esophageal cancer. We set out to determine whether type II adenocarcinoma is a distinct clinical entity requiring a more specific treatment plan.

METHODS

Among 125 Japanese patients who underwent resection of adenocarcinoma of the GEJ (type I, 2; type II, 44; type III, 79), 101 who underwent R0 resections (type II, 40; type III, 61) were analyzed to evaluate surgical results and compare clinicopathologic factors.

RESULTS

Barrett's epithelium was recognized in two patients with type II adenocarcinoma. Type II differed significantly from type III in higher prevalence of Borrmann macroscopic type 2, more frequent lymph node metastasis (58% vs. 34%), higher metastatic rate to lower mediastinal lymph nodes (13%), increased risk of hepatic recurrence, and lower 5-year survival after R0 resection (67.4% vs. 87.1%).

CONCLUSIONS

Clinicopathologic differences were evident between type II and III adenocarcinomas. Siewert type II adenocarcinoma differs sufficiently to be considered a clinical entity distinct and independent from type III.

Adenocarcinoma of the gastric cardia: what is the optimal surgical approach?

BACKGROUND

The incidence of adenocarcinoma of the gastric cardia is rising in Western countries. This study evaluates prognostic factors associated with surgical management of this cancer.

STUDY DESIGN

Medical records of consecutive patients with gastric cardial cancer treated by surgical resection from 1991 through 2001 were reviewed. Survival was analyzed using the Kaplan-Meier method. Prognostic factors were evaluated using log-rank test and Cox regression. Mean followup period was 34 months.

RESULTS

Eighty-two patients met study inclusion criteria. Median patient age was 65 years (range 86 to 22). Fifty-nine (72%) patients had type II tumors and 23 (28%) patients had type III tumors, according to the Siewert classification for gastroesophageal junction tumors. Twenty-seven (33%) patients underwent total esophagectomy, 24 (29%) patients underwent extended gastrectomy with thoracotomy, and 31 (38%) patients underwent extended gastrectomy without thoracotomy. Overall postoperative 5-year survival rate was 30%. On multivariate analysis, patient age 65 years and older, absence of lymph node metastasis, and R0 resection emerged as factors independently associated with improved postoperative survival. Frequency with which proximal resection margin was infiltrated with cancer was a function of gross margin length and T stage. Proximal gross margin length of at least 6 cm was required to achieve a microscopically negative proximal margin for T3 and T4 cancers.

CONCLUSIONS

Achieving R0 resection should be the goal of surgical therapy for the gastric cardial cancer. The surgical approach should be tailored to individual patients to achieve this goal.

E-cadherin expression as predictive marker of proximal resection line involvement for advanced carcinoma of the gastric cardia

AIMS

Total gastrectomy for gastric cardia tumours harbours a high risk of proximal resection line (PRL) involvement. The adhesion markers CD44v6 and E-cadherin were evaluated as predictive factors for PRL involvement independent of tumour stage.

METHODS

Forty-nine gastrectomy specimens for gastric cardia carcinoma (type II) were evaluated for stage, resection margins, and CD44v6 and E-cadherin immunohistochemistry.

RESULTS

PRL involvement was microscopically recognized in 49% of specimens. CD44v6 expression was found in 84% of intestinal tumours, and in 56% of diffuse/mixed tumours (p=0.045). In the group of resections performed with curative intent, the proximal extension of the resection (margin) was significantly shorter in E-cadherin negative tumours than in E-cadherin positive tumours (p=0.029). Histological type and stage of the tumour, lymph node metastases, and absence of E-cadherin expression, but not the presence of CD44v6 correlated with PRL involvement. Only the absence of E-cadherin expression appeared to be a significant predictor of PRL involvement, independent of tumour stage. Survival for patients with PRL involvement was shorter than that for patients after R0 resection (p=0.07). Stage was the only independent prognostic factor emerging from multivariate survival analysis (p=0.002).

CONCLUSIONS

When curative resection is intended in type II cardiac cancer patients, an oesophageal resection and gastric tube reconstruction should be considered, especially for a tumour without E-cadherin expression.

Pattern of recurrence after surgery in adenocarcinoma of the gastro-oesophageal junction

AIMS

This study reports mode, timing and predictive factors of recurrence after curative surgery for cardia cancer.

METHODS

A prospective study in a series of 92 curatively (R0) resected patients from 1988 to 2002.

RESULTS

The 5-year recurrence rate was 71%. Lymph node involvement was the only predictor of recurrence. No patients with more than 6 metastatic nodes were free from relapse 2 years after surgery. Locoregional, peritoneal and haematogenous relapses showed a similar median recurrence time (12, 10 and 12 months, respectively), 80% occurred within 24 months.

CONCLUSIONS

Few patients can be cured by surgery, lymph nodal involvement is the only predictor of recurrence.