Treatment of esophagogastric junction carcinoma: An unsolved debate

Gross tumor volume of adenocarcinoma of esophagogastric junction corresponding to cT and cN stages measured with computed tomography to quantitatively determine resectabiliy: A case control study

PURPOSE

To determine whether gross tumor volume (GTV) of adenocarcinoma of esophagogastric junction (AEG) corresponding to cT and cN stages measured on CT could help quantitatively determine resectability.

MATERIALS AND METHODS

343 consecutive patients with AEG, including 279 and 64 randomly enrolled in training cohort (TC) and validation cohort (VC), respectively, underwent preoperative contrast-enhanced CT. Univariate and multivariate analyses for TC were performed to determine factors associated with resectability. Receiver operating characteristic (ROC) analyses were to determine if GTV corresponding to cT and cN stages could help determine resectability. For VC, Cohen's Kappa tests were to assess performances of the ROC models.

RESULTS

cT stage, cN stage and GTV were independently associated with resectability of AEG with odds ratios of 4.715, 4.534 and 1.107, respectively. For differentiating resectable and unresectable AEG, ROC analyses showed that cutoff GTV of 32.77 cm3 in stage cT1-4N0-3 with an area under the ROC curve (AUC) of 0.901. Particularly, cutoffs of 27.67 and 32.77 cm3 in stages cT3 and cT4 obtained AUC values of 0.860 and 0.890, respectively; and cutoffs of 27.09, 33.32 and 37.39 cm3 in stages cN1, cN2 and cN3 obtained AUC values of 0.852, 0.821 and 0.902, respectively. In VC, Cohen's Kappa tests verified that the ROC models had good performance in distinguishing between resectable and unresectable AEG (all Cohen's K values > 0.72).

CONCLUSIONS

GTV, cT and cN stages could be independent determinants of resectability of AEG. And GTV corresponding to cT and cN stages can help quantitatively determine resectability.

Gastroesophageal junction cancer with hepatic metastasis: Effective Treatment using microsphere embolization combined with transarterial infusion chemotherapy

PURPOSE

To determine the safety and efficacy of microsphere embolization plus transarterial infusion chemotherapy for the treatment of gastroesophageal junction cancer with hepatic metastasis.

METHODS

Sixty patients with gastroesophageal junction cancer and hepatic metastasis were randomly divided into two groups: group A (treatment group), which was treated with transarterial infusion chemotherapy plus microsphere embolization for gastroesophageal cancer, and with transarterial chemoembolization for hepatic metastasis; and group B (control group), which was treated with transarterial infusion chemotherapy for gastroesophageal cancer, and with transarterial chemoembolization for hepatic metastasis. The chemotherapy regimen used consisted of oxaliplatin plus FUDR. The embolization agent used for gastroesophageal cancer and the hepatic metastasis were Embosphere and ultra-liquefied lipiodol, respectively.

RESULTS

The median survival time of patients in group A was 19 months, with survival rates at 12, 18, and 24 months of 93.3%, 60.0%, and 23.3%, respectively. The median survival time of patients in group B was 13 months, with survival rates at 12, 18, and 24 months of 60.0%, 30.0%, and 3.3%, respectively. There was a significant difference in survival between the two groups (P = 0.00). One month after treatment, the severity of dysphagia was significantly less in group A, as compared to that in group B (p < 0.001).

CONCLUSION

Treatment of gastroesophageal junction cancer with hepatic metastasis by transarterial infusion chemotherapy plus microsphere embolization can rapidly reduce tumor size near the gastroesophageal junction. This treatment is an effective therapeutic option for these patients as it can relieve dysphagia and improve long-term survival rate.

Dorsal Track Control (DTC): A Modified Surgical Technique for Atraumatic Handling of the Distal Esophagus in Esophagojejunostomy

Surgical therapy for adenocarcinoma of the esophagogastric junction II requires distal esophagectomy, in which a transhiatal management of the lower esophagus is critical. The ‘dorsal track control’ (DTC) maneuver presented here facilitates the atraumatic handling of the distal esophagus, in preparation for a circular-stapled esophagojejunostomy. It is based on a ventral semicircular incision in the distal esophagus, with an intact dorsal wall for traction control of the esophagus. The maneuver facilitates the proper placement of the purse-string suture, up to its tying (around the anvil), thus minimizing the manipulation of the remaining esophagus. Furthermore, the dorsally-exposed inner wall surface of the ventrally-opened esophagus serves as a guiding chute that eases anvil insertion into the esophageal lumen. We performed this novel technique in 21 cases, enabling a safe anastomosis up to 10 cm proximal to the Z-line. No anastomotic insufficiency was observed. The DTC technique improves high transhiatal esophagojejunostomy.

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.