Adenocarcinoma at the gastroesophageal junction

Outcomes of the Surgical Treatment for Adenocarcinoma of the Cardia - Single Institution Experience

Background

Adenocarcinomas at the cardia are biologically aggressive tumors with poor long-term survival following curative resection. For resectable adenocarcinoma of the cardia, mostly esophagus extended total gastrectomy or esophagus extended proximal gastric resection is performed; however, the surgical approach, transhiatal or transthoracic, is still under discussion. Postoperative morbidity, mortality and long-term survival were analyzed to evaluate the potential differences in clinically relevant outcomes.

Patients and methods

Of altogether 844 gastrectomies performed between January 2000 and December 2016, 166 were done for the adenocarcinoma of the gastric cardia, which we analyzed with using the Cox proportional hazards model.

Results

136 were esophagus extended total gastrectomy and 125 esophagus extended proximal gastric resection. A D2 lymphadenectomy was performed in 88.2%, splenectomy in 47.2%, and multivisceral resections in 12.4% of patients. R0 resection rate was 95.7%. The mean proximal resection margin on the esophagus was 42.45 mm. It was less than 21 mm in 9 patients. Overall morbidity regarding Clavien-Dindo classification (> 1) was altogether 28.6%. 15.5% were noted as surgical and 21.1% as medical complications. The 30-day mortality was 2.2%. The 5-year survival for R0 resections was 33.4%. Multivisceral resection, depth of tumor infiltration, nodal stage, and curability of the resection were identified as independent prognostic factors.

Conclusions

Transhiatal approach for resection of adenocarcinoma of the cardia is a safe procedure for patients with Siewert II and III regarding the postoperative morbidity and mortality; moreover, long-term survival is comparable to transthoracic approach. The complications associated with thoracoabdominal approach can therefore be avoided with no impact on the rate of local recurrence.

Gastrectomy compared to oesophagectomy for Siewert II and III gastro-oesophageal junctional cancer in relation to resection margins, lymphadenectomy and survival

It is unclear whether gastrectomy or oesophagectomy offer better outcomes for gastro-oesophageal junction (GOJ) cancer. A total of 240 patients undergoing total gastrectomy (n = 85) or oesophagectomy (n = 155) for Siewert II-III GOJ adenocarcinoma were identified from a Swedish prospective population-based nationwide cohort. The surgical approaches were compared in relation to non-radical resection margins (main outcome) using multivariable logistic regression, providing odds ratios (ORs) and 95% confidence intervals (CIs), mean number of removed lymph nodes with standard deviation (SD) using ANCOVA, assessing mean differences and 95% CIs, and 5-year mortality using Cox regression estimating hazard ratios (HRs) and 95% CIs. The models were adjusted for age, sex, comorbidity, tumour stage, and surgeon volume. The non-radical resection rate was 15% for gastrectomy and 14% for oesophagectomy, and the adjusted OR was 1.61 (95% CI 0.68-3.83). The mean number of lymph nodes removed was 14.2 (SD ± 9.6) for gastrectomy and 14.2 (SD ± 10.4) for oesophagectomy, with adjusted mean difference of 2.4 (95% CI-0.2-5.0). The 5-year mortality was 76% following gastrectomy and 75% following oesophagectomy, with adjusted HR = 1.07 (95% CI 0.78-1.47). Gastrectomy and oesophagectomy for Siewert II or III GOJ cancer seem comparable regarding tumour-free resection margins, lymph nodes removal, and 5-year survival.

The surgical management of esophago-gastric junctional cancer

The best available surgical strategy in the treatment of resectable esophago-gastric junctional (EGJ) cancer is a controversial topic. In this review we evaluate the current literature and scientific evidence examining the surgical treatment of locally advanced EGJ cancer by comparing esophagectomy with gastrectomy, transhiatal with transthoracic esophagectomy, minimally invasive with open esophagectomy, and less extensive with more extensive lymphadenectomy. We also assess endoscopic procedures increasingly used for early EGJ cancer. The current evidence does not favor any of the techniques over the others in terms of oncological outcomes. Health-related quality of life may be better following gastrectomy compared to esophagectomy. Minimally invasive procedures might be less prone to surgical complications. Endoscopic techniques are safe and effective alternatives for early-stage EGJ cancer in the short term, but surgical treatment is the mainstay in fit patients due to the risk of lymph node metastasis. Any benefit of lymphadenectomy extending beyond local or regional nodes is uncertain. This review demonstrates the great need for well-designed clinical studies to improve the knowledge in how to optimize and standardize the surgical treatment of EGJ cancer.