[Analysis of the prognosis of 111 patients with gastric cancer or adenocarcinoma of the esophagogastric junction combined with pleural or abdominal effusion]

OBJECTIVE

To explore the prognostic factors in patients with gastric cancer (GC) or adenocarcinoma of the esophagogastric junction (AEG) combined with malignant pleural and/or abdominal effusion.

METHODS

Clinicopathological data of 111 GC or AEG patients with malignant pleural and/or abdominal effusion treated in our hospital from January 2001 to December 2010 were retrospectively analyzed.

RESULTS

The median survival time for the whole group of 111 patients was 6 months. Effusion disappeared in 12 patients, was reduced in 36 cases, with no changes in 15 cases, and increased in 48 patients. The effusion control rate was 56.8%. Effusion was better controlled in female patients, with simple abdominal ascites, Karnovsky performance scores ≥ 80, with no liver metastases, effusion at initial diagnosis, and effective response to systemic chemotherapy.Univariate analysis showed that patients of female sex, Karnovsky performance scores ≥ 80, effusion present at initial diagnosis, simple abdominal ascites, minimal volume of effusion, absence of liver metastasis, control of effusion, initial treatment with effusions and effective response to systemic chemotherapy, normal hemoglobin, albumin, direct and indirect bilirubin levels showed better prognosis (all P < 0.05). Multivariate analysis showed that liver metastases, control of effusions were independent prognostic factors in patients with gastric cancer and adenocarcinoma of the esophagogastric junction (all P < 0.05).

CONCLUSIONS

Female patients, simple abdominal ascites, KPS scores ≥ 80, ascites at initial diagnosis, no liver metastases and effective systemic chemotherapy seem to have a better control of the malignant effusion. Patients with no liver metastases and effective control of effusion have a longer survival time.

[Prognostic value of metastatic lymph node ratio in adenocarcinoma of the gastroesophageal junction]

OBJECTIVE

To compare the prognostic value of AJCC/UICC pN stage with metastatic lymph node ratio (MLR) and the prognostic difference between the tumor-node-metastasis (TNM) stage and tumor-ratio-metastasis (TRM) stage in patients with adenocarcinoma of the gastroesophageal junction.

METHODS

Clinical data of 414 patients with adenocarcinoma of the gastroesophageal junction undergoing curative resection at the Tianjin Medical University Cancer Institute and Hospital from January 2000 to June 2007 were retrospectively reviewed. Spearman correlation analysis was performed to examine the correlations between pN, MLR and retrieved nodes. Univariate Kaplan-Meier survival analysis and multivariate Cox proportional hazard model analysis were performed to analyze the effects of pN, MLR, TNM and TRM stage on the prognosis of these patients. The area under the ROC curve (AUC) was plotted to compare the value of these stages and to predict the 5-year survival rate.

RESULTS

The median number of retrieved nodes was 17 (4-71) per patient, and the median number of positive nodes was 4 (0-67) per patient. The number of metastatic lymph node was positively correlated with that of retrieved nodes (P<0.01), but MLR was not correlated with the number of retrieved nodes (P>0.05). Univariate and multivariate survival analysis showed that either pN or MLR could be used as an independent risk factor for survival (P<0.01) and the hazard ratio of MLR stage was larger than that of pN stage (1.573 vs 1.382). While pN and MLR were entered into the Cox hazard ratio model as covariates at the same time, MLR remained as the independent prognostic factor (P<0.01), but pN lost significance (P>0.05). The AUC of MLR and pN staging was 0.726 and 0.714, and of TRM and TNM staging was 0.747 and 0.736, respectively, however the differences were not statistically significant (all P>0.05).

CONCLUSIONS

MLR is an independent prognostic factor for patients with adenocarcinoma of the gastroesophageal junction. The value of MLR and TRM staging systems may be superior to pN and TNM staging systems in evaluating the prognosis of these patients.

[Application of transorally inserted anvil (OrVil(TM)) in laparoscopic-assisted radical resection for Siewert type II adenocarcinoma of the esophagogastric junction]

OBJECTIVE

To study the safety and feasibility of transorally inserted anvil (OrVil(TM)) in laparoscopic-assisted radical resection for Siewert type II adenocarcinoma of the esophagogastric junction (AEG).

METHODS

Clinical data (operative time, rate of thoracotomy, residual cancer in the proximal margin, and postoperative recovery) of 72 patients suffered from Siewert type II AEG were analyzed retrospectively, including 46 cases of applying OrVil(TM) in digestive tract reconstruction for laparoscopic-assisted radical resection and 26 cases of applying pouch clamp embedding anvil, between May 2009 and August 2012 in Department of Minimally Invasive Gastrointestinal Surgery at the Peking University Cancer Hospital and Institute.

RESULTS

The length between proximal margin and superior border of tumor was (2.5±1.5) cm in OrVil(TM) group, significantly longer than that in the traditional group [(1.6±1.1) cm, P<0.01]. Moreover, the intraoperative frozen pathological positive incidence of cancer remnant was 2.2% (1/46), and rate of thoracotomy was 0, both of which were significantly lower as compared to the traditional group [23.1% (6/26) and 15.4% (4/26) respectively, both P<0.01]. However, intraoperative blood loss and postoperative complications did not differ between the two groups (both P>0.05).

CONCLUSIONS

As for laparoscopic-assisted Siewert type II AEG radical resection, application of OrVil(TM) in digestive tract reconstruction is a safe surgical procedure, and can effectively reduce the rate of intra-operative thoracotomy, which is beneficial to postoperative recovery.

Modified EOX (Epirubicin, Oxaliplatin and Capecitabine) as palliative first-line chemotherapy for gastroesophageal adenocarcinoma

BACKGROUND

The efficacy of triple-drug combination regimens such as epirubicin, oxaliplatin and capecitabine (EOX) is superior to standard cisplatin/5-fluorouracil, but considerable toxicity needs to be taken into account in patients with upper gastrointestinal adenocarcinoma. Therefore, we aimed to establish a modified version of the EOX regimen with improved tolerability for these patients.

PATIENTS AND METHODS

Patients received palliative first-line chemotherapy with a modified EOX regimen repeated every three weeks (epirubicin 50 mg/m(2) i.v., day 1; oxaliplatin 130 mg/m(2) i.v., day 1; capecitabine at a twice-daily dose of 1000 mg/m(2) p.o. for two weeks).

RESULTS

Out of 51 patients, partial remission was observed in five (10.2%) and stable disease in 31 (60.8%). Progression-free survival was four months, and overall survival twelve months.

CONCLUSION

Modified EOX was generally well-tolerated and, therefore, further investigation within prospective clinical trials is warranted.

Brain metastases of gastro-oesophageal cancer: evaluation of molecules with relevance for targeted therapies

BACKGROUND

Brain metastases (BM) of gastro-oesophageal cancer are exceedingly rare and only limited data exist on their pathobiology.

MATERIALS AND METHODS

We identified tissue samples of BM of gastro-oesophageal cancer and analyzed the expression of human epidermal growth factor receptor-2 (HER2), phosphorylated signal transducer and activator of transcription-3 (pSTAT3), epithelial growth factor receptor (EGFR), V600E point mutation of the v-raf murine sarcoma viral oncogene homolog-B1 (BRAF V600E), cluster of differentiation molecule-34 (CD34), hypoxia inducible factor-1α (HIF 1-α) and Ki-67 by immunohistochemical methods.

RESULTS

Our series comprised of twenty adenocarcinomas and one oesophageal squamous cell carcinoma. Three (14%), 7 (33%), 9 (43%), 18 (86%) and 0 BM specimens were scored positively for HER2, EGFR, pSTAT3, HIF1-α and BRAF V600E expression. The median Ki-67 index was 59%. The microvascular density was moderate-to-high and active intratumoral microvascular sprouting was evident in 20/21 (95%) of BMs. The HER2 and EGFR expression status were consistent between primary tumors and BM in all three assessable cases. HIF1-α and pSTAT3 expression were significantly higher in HER2-positive cases.

CONCLUSION

Therapeutic use of agents targeting HER2, pSTAT3, EGFR and angiogenesis may be feasible for selected BM of gastro-esophageal cancer. HER2 positivity does not seem to predispose to brain colonization in gastro-esophageal cancer.

Assessment of diffusion-weighted MRI and 18F-fluoro-deoxyglucose PET/CT in monitoring early response to neoadjuvant chemotherapy in adenocarcinoma of the esophagogastric junction

BACKGROUND & AIMS

To prospectively assess whether changes in apparent diffusion coefficient (ADC) values or standardized uptake value (SUV) changes in 18F-fluorodeoxyglucose (FDG) PET correlate with treatment response under neoadjuvant chemotherapy in patients with locally advanced adenocarcinoma of the esophagogastric junction (AEG).

METHODS

Fifteen patients (median age, 64 years) with histologically proven AEG type I and II received 1.5 Tesla MRI including "diffusion-weighted imaging" and FDG PET/CT before and 14 days after neoadjuvant EOX chemotherapy. The FDG uptake of the tumor was quantified by calculating the SUV in static PET scans. ADC values within the tumor tissue were quantitatively assessed using a region-of-interest analysis excluding necrotic areas. Early metabolic response was defined as a decrease in the SUV(mean) >/= 35% in FDG PET two weeks following the start of neoadjuvant chemotherapy, which had been reported to be predictive of histopathological response and survival. Concordance between ADC and SUV changes, differences at first examination and overall survival were assessed.

RESULTS

The ADC within the AEG tumors was significantly lower than in normal esophagus and increased following neoadjuvant chemotherapy by 16.0 +/- 1.1% (p=0.007). Tumor glucose SUV decreased by 29.1 +/- 23.2% (p=0.002). Initial ADC and SUV were comparable in both groups (p=0.65, p=0.82). ADC increase and metabolic PET-response were concordant in 73.3% of all patients. The median overall survival was 757 days for PET-responders and 623 days for PET-non-responders (p=0.138).

CONCLUSION

The ADC increase in AEG tumors following chemotherapy is concordant in the majority of cases to PET-response, but not correlated to prognosis in this study.

Epidemiology and risk factors for gastroesophageal junction tumors: understanding the rising incidence of this disease

Gastroesophageal (GE) junction carcinoma is a rare but often lethal condition with increasing importance as a public health problem in recent decades. Whereas diagnosis of this disease has been complicated historically by the lack of uniform classification standards, available data from the Surveillance, Epidemiology, and End Results cancer registry program in the United States show an approximate 2.5-fold increase in the incidence of GE junction adenocarcinoma from 1973 to 1992, with rates stabilizing in the past 2 decades. Similar proportional trends are observed among subgroups defined by race and gender, but rates are significantly higher in males relative to females, and in white males relative to black males. Smoking, obesity, and GE reflux disease are significant risk factors for GE junction adenocarcinoma, and may account for a substantial fraction of total disease burden. Infection with Helicobacter pylori has been associated with reduced incidence, and high dietary fiber intake has also been linked to lower disease risk. Ongoing studies continue to explore a potential role for nonsteroidal anti-inflammatory drugs in chemoprevention.

Body mass index in relation to oesophageal and oesophagogastric junction adenocarcinomas: a pooled analysis from the International BEACON Consortium

BACKGROUND

Previous studies suggest an association between obesity and oesophageal (OA) and oesophagogastric junction adenocarcinomas (OGJA). However, these studies have been limited in their ability to assess whether the effects of obesity vary by gender or by the presence of gastro-oesophageal reflux (GERD) symptoms.

METHODS

Individual participant data from 12 epidemiological studies (8 North American, 3 European and 1 Australian) comprising 1997 OA cases, 1900 OGJA cases and 11 159 control subjects were pooled. Logistic regression was used to estimate study-specific odds ratios (ORs) and 95% confidence intervals (CIs) for the association between body mass index (BMI, kg/m(2)) and the risk of OA and OGJA. Random-effects meta-analysis was used to combine these ORs. We also investigated effect modification and synergistic interaction of BMI with GERD symptoms and gender.

RESULTS

The association of OA and OGJA increased directly with increasing BMI (P for trend <0.001). Compared with individuals with a BMI <25, BMI ≥40 was associated with both OA (OR 4.76, 95% CI 2.96-7.66) and OGJA (OR 3.07, 95% CI 1.89-4.99). These associations were similar when stratified by gender and GERD symptoms. There was evidence for synergistic interaction between BMI and GERD symptoms in relation to OA/OGJA risk.

CONCLUSIONS

These data indicate that BMI is directly associated with OA and OGJA risk in both men and women and in those with and without GERD symptoms. Disentangling the relationship between BMI and GERD will be important for understanding preventive efforts for OA and OGJA.

Perioperative chemotherapy with docetaxel, cisplatin and capecitabine (DCX) in gastro-oesophageal adenocarcinoma: a phase II study of the Arbeitsgemeinschaft Internistische Onkologie (AIO){dagger}

BACKGROUND

This prospective multicentre phase II trial assessed the feasibility and efficacy of perioperative chemotherapy with docetaxel, cisplatin and capecitabine (DCX) in patients with gastro-oesophageal adenocarcinoma.

METHODS

Patients with curatively resectable adenocarcinoma of the stomach, the gastro-oesophageal junction or the lower third of the oesophagus were enrolled. Patients received docetaxel 75 mg/m(2) plus cisplatin 60 mg/m(2) (day 1), followed by oral capecitabine 1875 mg/m(2) divided into two doses (days 1-14) every 3 weeks. There were three cycles preoperatively and three cycles postoperatively. The primary end point was the R0 resection rate.

RESULTS

Fifty-one patients were recruited and assessed for feasibility and efficacy. 94.1% of patients received all three planned cycles preoperatively, and 52.9% received three cycles postoperatively. The R0 resection rate was 90.2%. 13.7% of patients showed complete pathological remission (pCR). Toxicity was acceptably tolerable. Without prophylactic granulocyte colony-stimulating factor administration, neutropenic fever developed in 21.5% of patients preoperatively (grade 3 or 4) and in 11.1% of patients postoperatively.

CONCLUSIONS

DCX is a safe and feasible perioperative regimen in the treatment of gastro-oesophageal adenocarcinoma with a high percentage of cycles delivered pre- and postoperatively, compared with standard practice. The high efficacy in terms of R0 resection rate and pCR is very promising.

FDG-PET/CT based response-adapted treatment

It has been shown that [(18)F]fluorodeoxyglucose (FDG)-positron emission tomography (PET) provides robust and reproducible data for early metabolic response assessment in various malignancies. This led to the initiation of several prospective multicenter trials in malignant lymphoma and adenocarcinoma of the esophagogastric junction, in order to investigate whether the use of PET-guided treatment individualization results in a survival benefit. In Hodgkin lymphoma and aggressive non-Hodgkin lymphoma, several trials are ongoing. Some studies aim to investigate the use of PET in early identification of metabolic non-responders in order to intensify treatment to improve survival. Other studies aim at reducing toxicity without adversely affecting cure rates by safely de-escalating therapy in metabolic responders. In solid tumors the first PET response-adjusted treatment trials have been realized in adenocarcinoma of the esophagogastric junction. These trials showed that patients with an early metabolic response to neoadjuvant chemotherapy benefit from this treatment, whereas metabolic non-responders should switch early to surgery, thus reducing the risk of tumor progression during chemotherapy and the risk of toxic death. The trials provide a model for designing response-guided treatment algorithms in other malignancies. PET-guided treatment algorithms are the promise of the near future; the choice of therapy, its intensity, and its duration will become better adjusted to the biology of the individual patient. Today's major challenge is to investigate the impact on patient outcome of personalized response-adapted treatment concepts.

[Surgical treatment of Siewert II adenocarcinoma of the esophagogastric junction]

OBJECTIVE

To explore the outcomes after surgical treatment of esophagogastric junction carcinoma (EGJC).

METHODS

One hundred and eighty-five patients with EGJC undergoing surgery from October 2000 to September 2006 at the Cancer Hospital of Shantou University were reviewed retrospectively. The clinical outcomes were compared between transthoracic and transabdominal approach.

RESULTS

Of the 185 patients, 133 underwent operation via transthoracic approach and 52 via transabdominal approach. The postoperative complication rates were 10.5%(14/133) and 11.5%(6/52) and the 1-, 3-, 5-year overall survival rates were 83.9%, 44.5%, 32.9% and 86.0%, 38.0%, 30.0% in transthoracic and transabdominal groups respectively, and the difference were not statistically significant (both P>0.05).

CONCLUSION

Surgical approach should be individualized for EGCJ.

[Multimodality therapy for adenocarcinoma of the esophagogastric junction]

The definition of esophagogastric junction (EGJ) adenocarcinoma and progress in multidisciplinary treatment for the tumor were revised in this review. Siewert classification is especially useful for the surgical approach of EGJ adenocarcinoma. Siewert I should be treated as esophageal cancer, and Ivor-Lewis esophagogastrectomy (right thoracotomy and laparotomy) is recommended as an extended two-field lymphadenectomy. For Siewert II or III tumors, left thoracophreno-laparotomy is preferred, especially in case of positive thoracic lymph nodes or positive resection margin. If there is any contraindication against thoracotomy, or a high operating risk, a transhiatal esophagectomy with lower mediastinal lymphadenectomy is an alternative. Preoperative chemoradiotherapy or perioperative chemotherapy improves overall survival and the rate of complete resection for patients with large tumor or lymph node metastasis. Neoadjuvant chemoradiotherapy is associated with high but acceptable postoperative complications. Adjuvant chemoradiotherapy remains a rational standard therapy for curatively resected EGJ cancer with T3 or greater lesion or positive nodes.

[Transabdominal and transhiatal esophagogastrostomy or esophagojejunostomy using novel double stapling technique]

OBJECTIVE

To explore the techniques of esophagogastrostomy or esophagojejunostomy in the mediastinum through the abdomen and hiatus after extended proximal gastrectomy or total gastrectomy.

METHODS

From May 2010 to January 2012, 15 patients with esophagogastric junction carcinoma underwent open transhiatal extended gastrostomy or total gastrectomy. After full mobilization, the anvil was reversely introduced into the esophagus and the esophagus was transected with curved stapler. The rod of the anvil was then pulled out with a stitch to complete esophagogastrostomy after proximal gastrectomy(n=9) or esophagojejunostomy after total gastrectomy(n=6).

RESULTS

The anastomosis was successfully performed in all the patients. The mean operation time was(185.5±13.1) min. The mean operation time for anastomosis was(42.0±8.6) min. The mean estimated blood loss was (106.7±34.9) ml. The proximal resection margin was(4.4±1.2) cm. All the margins were negative for residual cancer. There was no postoperative death or fistula. During the follow up, there was one case of anastomotic stenosis which was successfully managed by endoscopic balloon dilatation.

CONCLUSIONS

Esophagogastrostomy or esophagojejunostomy can be safely performed with double stapling technique including reverse anvil introduction and curved stapling transection of the esophagus. It is an ideal technique for anastomosis after extended gastrectomy for esophagogastric junction carcinoma.

Low morbidity after palliation of obstructing gastro-oesophageal adenocarcinoma to restore swallowing function

INTRODUCTION

This study describes the procedure-related complications and survival after deployment of self-expanding metal stents (SEMS) or use of argon plasma coagulation (APC) in patients with obstructing gastro-oesophageal junction (GEJ) adenocarcinoma.

MATERIAL AND METHODS

During an 8-year period, 312 patients with non-resectable, obstructing adenocarcinoma at the GEJ were treated with SEMS and/or APC and thereafter followed with endoscopies.

RESULTS

A total of 707 procedures (246 SEMS procedures and 461 ablations) were performed. No patients died in relation to the procedures. Minor bleeding during APC was seen in 20 patients. Early complications to SEMS were migration and misplacement. A single perforation with the guide-wire was seen. Late complications were tumour overgrowth and food impaction. A single treatment with SEMS or APC was performed in 115 (37%) and 49(16%) patients, respectively. SEMS replacement was necessary in 17 (5%) patients. Repeated APC treatments were necessary in 57 (18%) patients. The median time of survival in patients treated with SEMS, APC or both procedures was 134 days, 114 days and 215 days (p = 0.004), respectively. The survival in patients palliated with SEMS and/or APC alone was significantly lower compared to those who were palliated with SEMS and/or APC in combination with chemoradiotherapy. The median time of survival was 120 days in SEMS and 203 days in APC patients (p = 0.05).

CONCLUSION

SEMS and APC are safe treatment options for restoration of the swallowing function in patients with obstructing GEJ adenocarcinoma. SEMS or APC are equivalent treatment modalities in terms of survival.

Acceptable results after self-expanding metallic stent treatment for dysphagia in non-resectable oesophageal cancer

INTRODUCTION

Dysphagia is the most common symptom of malignant obstruction in the oesophagus and at the gastro-oesophageal junction (GEJ) region, and the relief of dysphagia plays a major role in palliative treatment of this condition. The aim of the present study was to evaluate the need for and nature of re-intervention after self-expanding metallic stents (SEMS) insertion in patients who were palliated for cancer of the oesophagus or GEJ.

MATERIAL AND METHODS

At a third-level referral centre in Denmark, all SEMS procedures were prospectively registered for SEMS characteristics and procedural events and data regarding re-interventions and survival were retrieved retrospectively in a six-year inclusion period.

RESULTS

A total of 108 stents were inserted into 87 patients (63 males and 23 females) with a median age of 71 years (range: 41-94 years). The primary SEMS used was Ultraflex in 77, Cook or Choo in seven and Wallstent in three cases. All but one SEMS were successfully placed, and no perforations occurred. Fifty patients had their dysphagia scores recorded. The average score before and after stent insertion was 2.4 and 0.8, respectively, (p < 0.01). Two-thirds of the patients needed late re-interventions. The most common problem was tissue/tumour ingrowth (n = 40). Seven patients (8%) experienced stent migration. The average re-intervention rate was 2.8 per patient. The median survival after SEMS was 116 days (range 2-866 days). The median time to first re-intervention was 44 days.

CONCLUSION

SEMS treatment was a safe and effective palliation of malignant obstruction in the oesophagus and GEJ region, but the procedure was associated with a frequent need for re-interventions.

Preoperative chemoradiotherapy for esophageal or junctional cancer

BACKGROUND

The role of neoadjuvant chemoradiotherapy in the treatment of patients with esophageal or esophagogastric-junction cancer is not well established. We compared chemoradiotherapy followed by surgery with surgery alone in this patient population.

METHODS

We randomly assigned patients with resectable tumors to receive surgery alone or weekly administration of carboplatin (doses titrated to achieve an area under the curve of 2 mg per milliliter per minute) and paclitaxel (50 mg per square meter of body-surface area) for 5 weeks and concurrent radiotherapy (41.4 Gy in 23 fractions, 5 days per week), followed by surgery.

RESULTS

From March 2004 through December 2008, we enrolled 368 patients, 366 of whom were included in the analysis: 275 (75%) had adenocarcinoma, 84 (23%) had squamous-cell carcinoma, and 7 (2%) had large-cell undifferentiated carcinoma. Of the 366 patients, 178 were randomly assigned to chemoradiotherapy followed by surgery, and 188 to surgery alone. The most common major hematologic toxic effects in the chemoradiotherapy-surgery group were leukopenia (6%) and neutropenia (2%); the most common major nonhematologic toxic effects were anorexia (5%) and fatigue (3%). Complete resection with no tumor within 1 mm of the resection margins (R0) was achieved in 92% of patients in the chemoradiotherapy-surgery group versus 69% in the surgery group (P<0.001). A pathological complete response was achieved in 47 of 161 patients (29%) who underwent resection after chemoradiotherapy. Postoperative complications were similar in the two treatment groups, and in-hospital mortality was 4% in both. Median overall survival was 49.4 months in the chemoradiotherapy-surgery group versus 24.0 months in the surgery group. Overall survival was significantly better in the chemoradiotherapy-surgery group (hazard ratio, 0.657; 95% confidence interval, 0.495 to 0.871; P=0.003).

CONCLUSIONS

Preoperative chemoradiotherapy improved survival among patients with potentially curable esophageal or esophagogastric-junction cancer. The regimen was associated with acceptable adverse-event rates. (Funded by the Dutch Cancer Foundation [KWF Kankerbestrijding]; Netherlands Trial Register number, NTR487.).

Treatment of esophago-gastric junction adenocarcinoma

AIM

The incidence of Adenocarcinoma of the esophagogastric junction (EGJ) is increasing and its treatment is still debated, primarily because of the non-uniform definition of EGJ.

MATERIALS AND METHODS

The most used classification of EGJ cancer was proposed by Siewert and it divides the EGJ in three regions: from 5 to 1 cm above the Z line (Siewert type I or esophageal Adenocarcinoma), from 1 over to 2 below the Z line (Siewert type II or real Cardia cancer) and from 2 below to 5 below the Z line (Siewert type III or proximal Gastric cancer diffused to Cardia). The neoplasia is defined type I, II or III depending on where is the center of the cancer.

DISCUSSION

This classification did not show to be related to differences in prognosis and survival, but it has been used to guide the surgical strategy based on the site of the tumor. Criticism about this classification focuses mainly on the non-uniform treatment, in the current literature, of Siewert Type II cancer.

CONCLUSION

From January 2010, a new definition of EGJ carcinoma has been introduced by TNM. This new definition considers esophageal cancers all the ones whose centers falls inside a line drawn 5 cm below the Z line with invasion of the esophagus. This means that Siewert type I and II are now considered esophageal cancers, while type III can be esophageal or proximal gastric cancer depending if the esophagus is infiltrated or not. Criticism about this new definition rises on the border-line definition of former Siewert type III cancers.

Lower mediastinal lymph node metastasis is an independent survival factor of Siewert type II and III adenocarcinomas in the gastroesophageal junction

We examined clinicopathological features and surgical outcomes in patients with adenocarcinoma in the gastroesophageal junction (GEJ), while also analyzing the survival factors that have a prognostic impact. Between 1991 and 2009, 61 patients with tumors in the GEJ (Siewert type II and III) underwent primary surgical resection. Thirty of 61 patients had type II tumors (49.2%) and 31 had type III tumors (50.8%). The tumor size was larger in type III tumors than type II tumors (P = 0.0026). The overall 5-year survival rates in patients with type II tumors and type III tumors were 44.2 per cent and 41.4 per cent, respectively, with no significant differences (P = 0.1888). The independent survival factors were lower mediastinal lymph node metastasis (P = 0.0323) and a noncurative resection (P = 0.0442). The independent survival factors for patients who underwent curative resections were the tumor size (P = 0.0422), M category (P = 0.0489), and lower mediastinal lymph node metastasis (P = 0.0482). This study showed lower mediastinal lymph node metastasis to be an independent survival factor, and also suggested that lower mediastinal lymph node metastasis was associated with distant metastasis in patients with adenocarcinoma in the GEJ (Siewert type II and III). Therefore, the preoperative early detection of such metastasis is important to improve patient survival.

Case report

Adenosquamous carcinoma is a rare tumor with coexisting elements of infiltrating squamous cell carcinoma and adenocarcinoma. This tumor is reported to arise in different organs but rarely in the oesophagus. In most cases, it shows highly aggressive biological behaviour with high propensity to regional lymph-node metastasis and poor prognosis. We describe the management of a patient with an aggressive adenosquamous carcinoma of the esophagogastric junction.

[Therapeutic value of endoscopic submucosal dissection for gastrointestinal stromal tumor in the esophagogastric junction]

OBJECTIVE

To evaluate the safety and efficacy of endoscopic submucosal dissection (ESD) for gastrointestinal stromal tumor(GIST) in the esophagogastric junction(EGJ).

METHODS

Twenty patients with pathologically confirmed GIST in the EGJ were screened from all the patients undergoing ESD between November 2007 and June 2011. The clinicopathological and postoperative follow up data were analyzed.

RESULTS

There were 11 males and 9 females with the age ranging from 29 to 67 years(mean, 54.1 years). The maximum diameter of the lesions ranged from 8 to 20 mm(mean,14.8 mm). Fifteen patients underwent endoscopic submucosal excavation, 4 patients underwent endoscopic full-thickness resection, and 1 patient underwent submucosal tunneling endoscopic resection. The operative time ranged from 15 to 90 min(mean, 47.8 minutes). The estimated blood loss was 5 to 200 ml. The en bloc resection rate was 100%. Perforations occurred in 4 patients, pneumoperitoneum in 3 patients, cardia mucosal tear in 1 patient. All the complications were successfully managed with endoscopic intervention and conservative therapy. The post-operative follow up ranged from 3 to 36 months(mean, 13.2 months). No local recurrence or distant metastasis occurred.

CONCLUSION

ESD is a safe and effective procedure for GIST in the EGJ.

Analysis of HER2 expression and gene amplification in adenocarcinoma of the stomach and the gastro-oesophageal junction: rationale for the Belgian way of working

The Human Epidermal growth factor Receptor 2 (HER2) has been established as a key player in the development of certain human tumors. ToGA trial has demonstrated that the addition of the monoclonal antibody blocking HER2 receptor, trastuzumab (Herceptin®), to chemotherapy significantly improves overall survival of patients with HER2-positive advanced or metastatic adenocarcinoma of the stomach or gastro-oesophageal junction. Therefore, it is essential that pathologists guarantee an accurate testing of HER2 status in these tumours. Following the international recommendations and the Belgian criteria for reimbursement of trastuzumab, a consortium of expert pathologists (Belgian Working Group Molecular Pathology) proposes an adaptation of the international guidelines in order to develop strategies for optimal performance, interpretation and reporting assays.

Fundic rotation technique: a useful procedure for laparoscopic exogastric resection of gastric submucosal tumors located on the posterior wall near the esophagogastric junction

OBJECTIVE

To develope a new procedure for laparoscopic exogastric resection using a so-called "fundic rotation technique (FRT)" for gastric submucosal tumors (SMTs) on the posterior wall near the esophagogastric junction (EGJ).

METHODS

Between April 2006 and February 2010, we performed laparoscopic resection for SMTs located near the EGJ (within 3.0 cm from the EGJ) in ten consecutive patients. Out of seven exogastric resections, an FRT was used in five patients with posterior tumors near the EGJ.

RESULTS

The patients comprised three men and two women, with an average age of 65 years. The maximum tumor diameter averaged 3.8 cm (range, 2.0-8.0 cm), and the average distance from the EGJ was 1.5 cm (range, 0-2.5 cm). The pathological diagnosis was GIST in all cases. One case was converted to an open surgery due to its large size (8.0 cm) and the difficult access. All the patients quickly returned to their normal activities. No patient complained any symptoms of regurgitation, and endoscopic examination revealed no remarkable reflux esophagitis. No tumor recurrences occurred during a median follow-up period of 30 months.

CONCLUSION

The indications for laparoscopic resection of SMTs located near the EGJ may be extended using an FRT.

Population attributable fractions of adenocarcinoma of the esophagus and gastroesophageal junction

Obesity, gastroesophageal reflux, and smoking have repeatedly been shown to be important and independent risk factors for adenocarcinoma of the esophagus (EAC) and of the gastroesophageal junction (GEJAC). There have been few attempts, however, to quantify the proportion of disease associated with these potentially modifiable factors. The authors have estimated the population attributable fraction of EAC and GEJAC attributable to obesity, symptoms of gastroesophageal reflux, and smoking using data from a population-based case-control study conducted in Australia between 2002 and 2005. Cases were patients with EAC (n = 364) or GEJAC (n = 425). Controls (n = 1,580) were randomly sampled from a population register. Combinations of smoking, body mass index (weight in kilograms divided by height in meters squared), and gastroesophageal reflux together accounted for 76% (95% confidence interval: 66, 84) of EAC cases and 69% (95% confidence interval: 58, 78) of GEJAC cases. Individually, high body mass index (≥30) and frequent acid reflux (≥1 time/week) accounted for the greatest proportions of EAC (23% and 36%, respectively), and smoking and frequent symptoms of acid reflux accounted for the greatest proportions of GEJAC (43% and 28%, respectively). The present study suggests that these cancers may be largely prevented by maintaining healthy body mass index, avoiding smoking, and controlling symptomatic gastroesophageal reflux.

[Dual-color silver-enhanced in-situ hybridization and fluorescence in-situ hybridization for determination of HER2 gene status in gastric carcinoma]

OBJECTIVE

To investigate the advantages and disadvantages of dual-color silver-enhanced in-situ hybridization (DSISH) and fluorescence in-situ hybridization (FISH) for determination of HER2 gene status in gastric carcinoma and to evaluate the feasibility of DSISH.

METHODS

Eighty cases of primary gastric or gastroesophageal junction adenocarcinomas diagnosed and treated surgically from January to March, 2009 at the West China Hospital were enrolled in the study. Automated immunohistochemistry (IHC) staining, FISH and automated DSISH were carried out to detect the HER2 status, respectively, and the concordance of the three techniques was then evaluated.

RESULTS

DSISH and FISH failed initially, but repeated detection was successful in 5 cases. Gene amplification was detected in 12/13 IHC 3+ cases in DSISH and in 11/13 IHC 3+ cases in FISH. In 6 IHC 2+ cases, the amplification rate was both 1/6; in 18 IHC 1+ cases, the amplification rate was both 2/18. No amplification was observed in 43 IHC 0 cases. Only one of the 80 cases showed discrepancy, and therefore the overall concordance between FISH and DSISH was 98.8% (κ = 0.958, P < 0.01).

CONCLUSIONS

DSISH represents a novel approach for the determination of HER2 status in gastric carcinoma, and the overall concordance between DSISH and FISH is excellent. Despite their advantages and disadvantages, DSISH is more feasible and practical for routine application in surgical pathology.

Prognostic significance of baseline positron emission tomography and importance of clinical complete response in patients with esophageal or gastroesophageal junction cancer treated with definitive chemoradiotherapy

BACKGROUND

Metabolic imaging is of interest in esophageal cancer; however, the usefulness of initial standardized uptake value (SUV) in positron emission tomography (PET) is unknown in patients with esophageal or gastroesophageal carcinoma treated with definitive chemoradiotherapy. The authors hypothesized that initial SUV would correlate with patient outcome.

METHODS

The authors retrospectively analyzed esophageal or gastroesophageal carcinoma patients who had baseline PET and endoscopic ultrasonography in addition to other routine staging. All patients received definitive chemoradiotherapy. Multiple statistical methods were used.

RESULTS

The authors analyzed 209 consecutive esophageal or gastroesophageal carcinoma patients treated with definitive chemoradiation for outcome; of these, 180 had baseline PET for additional analyses. The median overall survival (OS) for all patients was 20.7 months (95% confidence interval, 18.8-26.3). Patients with clinical complete response (CR) lived longer than those with less than clinical CR (P < .0001). The median initial SUV was 12.7 (range, 0-51). Higher initial SUV was associated with longer tumors (P = .0001), higher T-stage status (P < .0001), positive N-stage status (P = .0001), higher overall stage (P < .0001), lack of clinical CR (P = .0002), and squamous cell histology (P < .0001). In the univariate analysis, initial SUV was associated with OS (Cox model, P = .016; log-rank test, P = .002). In the multivariate analysis, initial SUV dichotomized by the median value (P = .024) and tumor grade (P = .016) proved to be independent OS prognosticators. Median initial SUV for clinical CR patients was 10.2, compared with 15.3 for less than clinical CR patients (P = .0058).

CONCLUSIONS

The data indicate that a higher initial SUV is associated with poorer OS in patients with esophageal or gastroesophageal carcinoma receiving definitive chemoradiation. Upon validation, baseline PET may become a useful stratification factor in randomized trials and for individualizing therapy.

Stomach cancer

INTRODUCTION

Stomach cancer is usually an adenocarcinoma arising in the stomach, and includes tumours arising at or just below the gastro-oesophageal junction (type II and III junctional tumours). The annual incidence varies among countries and by sex, with about 80/100,000 cases per year in Japanese men, 30/100,000 in Japanese women, 18/100,000 in British men, and 10/100,000 in British women.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of radical versus conservative surgical resection? What are the effects of adjuvant chemotherapy? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 19 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review, we present information relating to the effectiveness and safety of the following interventions: adjuvant chemoradiotherapy, adjuvant chemotherapy, lymphadenectomy (radical, conservative), removal of adjacent organs, and subtotal gastrectomy for resectable distal tumours.

Gastroesophageal junction adenocarcinoma of young patients who underwent curative surgery: a comparative analysis with older group

PURPOSE

Adenocarcinoma of the stomach at a young age has a poor prognosis, but there are few reports describing gastroesophageal junction adenocarcinoma. This study aimed to compare the clinicopathological characteristics between the young and old patients who underwent curative surgery.

METHODS

One thousand three hundred and sixty-one patients with gastric adenocarcinoma underwent a curative gastrectomy between January 1, 1992 and December 31, 2006. Of these, 141 (10.4%) cases were gastroesophageal junction adenocarcinoma according to the Siewert's classification, and the data were collected prospectively for the analysis of the young age group (under 44 years old), in comparison to the older age group, with factors such as pathological characteristics, recurrence, and survival.

RESULTS

The sex ratio was near 1:1 in the younger group while it was predominantly male in the older group. There were no significant differences in the clinicopathological characteristics, such as the recurrence and survival rate, between the two groups.

CONCLUSIONS

The factor of young age does not critically affect the clinical course of gastroesophageal junction adenocarcinoma. This may be attributed to curative surgery and multimodality therapy.

Efficacy of irinotecan in combination with 5-fluorouracil (FOLFIRI) for metastatic gastric or gastroesophageal junction adenocarcinomas (MGA) treatment

OBJECTIVES

The most commonly used schedules are 5-FU in combination with CDDP with or without epirubicin (ECF) or docetaxel (TCF) in treatment of MGA patients (pts), independently of HER status. We evaluated the efficacy of FOLFIRI regimen in a large retrospective series of MGA pts.

METHODS

Two hundred and twelve pts from 13 French centers were treated with at least one cycle of FOLFIRI (irinotecan 180 mg/m2 intravenous (i.v.) over 90 minutes on day 1 with folinic acid (FA) 400mg/m2 i.v. over two hours followed by 5-FU 400mg/m2 i.v. bolus then 5- FU 2400 mg/m2 continuous infusion over 46 hours on day 1, repeated every 14 days). Primary tumour sites were 120 (58%) stomach and 92 (42%) gastroesophageal junction. FOLFIRI was administered as first-line in 137 (65%) pts and as later-line in 75 (35%) pts for MGA.

RESULTS

There was no difference between chemonaive and not chemonaive pts treated as firstline in terms of response rate 37% (95% CI: 25-50) vs 44% (95% CI: 21-69), median PFS, 6.7 (95% CI: 5.5-9.9) vs 5.3 months (95% CI: 3.6-6.9) (P = 0.25), and OS, 13.1 (95% CI: 11.7-18.7) vs 8.8 months (95% CI: 7.3—15.6) (P = 0.19), respectively. There was no difference between pts treated as second or later-line in terms of response rate 20% (95% CI: 8-39) vs 22% (95% CI: 6-48), median PFS, four months (95% CI: 2.8-5.4) vs 3.5 months (95% CI: 2.3-4.5) (P = 0.56), and OS, 10.4 months (95% CI: 5.4-14.4) vs 5.3 months (95% CI: 3.5-11.3) (P = 0.58), respectively. The global grade 3-4 toxicities were: diarrhea 11%, vomiting 9%, neutropenia 18%, febril neutropenia 4% (one toxic death).

CONCLUSIONS

This retrospective study confirms the activity and good tolerance of FOLFIRI regimen in MGA as first-line as well as later-line.

[Five cases of advanced gastroesophageal junction adenocarcinoma successfully treated with chemoradiotherapy followed by curative resection]

We reviewed five patients with advanced gastroesophageal cancer who were successfully treated with chemoradiotherapy followed by a curative resection. Patients with histologically-documented adenocarcinoma of the gastroesophageal junction were eligible. Direct tumor extension into the stomach (cT3 or cT4), and involvement of lymph nodes were observed. The patients stopped receiving orally administered carcinostatic drugs due to digestive stenosis or tumor bleeding. They received 25 mg/m2 of cisplatin and 60 mg/m2 of paclitaxel once a week on days 1, 8, 15 and 22. Radiation was administered concurrently at a total dose of 45 Gy in 1.8 Gy fractions for over 25 treatments. Effectiveness of the therapy was evaluated 4 weeks after the chemoradiotherapy. All patients with clinical partial responses underwent gastrectomy (n=4) or esophagogastrectomy (n=1). Curative resection was performed in 5 patients (resection A/B 4/1), and no patient suffered from major postoperative complications. Four patients were downstaged according to the pathological findings. The histologically effective responses of all patients were Grade 2. The obvious chemotherapeutic efficacy of the present regimen suggested that it may be a good treatment option for advanced gastroesophageal cancers. Further studies including randomized controlled trials are needed to evaluate the significance of preoperative chemoradiotherapy.

Phase I study of docetaxel, oxaliplatin and capecitabine (TEX) as first line therapy to patients with advanced gastro-oesophageal cancer

BACKGROUND

ECF (epirubicin, cisplatin, 5-FU) has been a standard first-line regimen in patients with advanced gastro-esophageal cancer (GEC). If cisplatin is substituted by oxaliplatin (Eloxatin®) - E) and 5-FU by capecitabine (X - Xeloda®) this regimen is easily administered with at least comparable efficacy and lower toxicity. Recent studies indicate that efficacy can be improved by adding docetaxel (Taxotere® - T) to CF. We initiated a phase I trial of T, short-time infusion of E and continuously X (TEX) as first-line therapy in GEC to establish the recommended dose (RD) for further therapy.

MATERIALS AND METHODS

Patients were enrolled in cohorts of three at five dose levels. Patients had histologically confirmed GEC adenocarcinoma. Therapy was administered day 1 with escalating doses of docetaxel (60 mg/m² to 75 mg/m² iv as a 60 minutes infusion), oxaliplatin (85 to 130 mg/m² iv as a 30 minutes infusion) and oral capecitabine (1 000 to 1 250 mg/m²/day). TEX was repeated every third week for a maximum of eight cycles. Toxicity was evaluated according to CTCAE v3.0 and dose limiting toxicity (DLT) was evaluated after the first course of TEX.

RESULTS

From June 2007 to April 2009, 23 consecutive patients received TEX. At dose level V, two of four patients experienced DLT and therefore we included additional seven patients at dose level IV. Only one of seven experienced DLT but dose-intensity was reduced to 75% in four of seven patients after three courses of TEX. Therefore we defined dose level III as RD. Efficacy was promising with response rate 38%, PFS 9.4 months and OS 12.5 months.

CONCLUSION

The recommended dose of TEX (docetaxel 60 mg/m² iv day 1, oxaliplatin 115 mg/m² iv day 1 and oral capecitabine 1250 mg/m²/day continuously) every three weeks is easily administered in an out-patient setting. Efficacy is promising and will be evaluated in a phase II study.

[Surgical treatment results and prognostic analysis of 514 cases with gastroesophageal junction carcinoma]

OBJECTIVE

To clarify the important clinicopathological and therapeutical factors affecting the prognosis of patients with gastroesophageal junction carcinoma.

METHODS

Data of 514 cases with gastroesophageal junction carcinoma who underwent surgical treatment from September 1995 to January 2007 was retrospectively analyzed. Relevant prognostic factors were studied with univariate and multivariate analysis.

RESULTS

For all 514 cases (424 men and 90 women), the median age was 63 years. The 1-, 3- and 5-year survival rates of this group were 74.8%, 42.1% and 29.1%, respectively. Gross type, TNM classification, histological type, vascular invasion and extent of surgical resection affected patients' survival remarkably. There was no significant difference in survival between operative approaches (via laparotomy or left thoracotomy) (P > 0.05). Long-term survival was similar between proximal subtotal gastrectomy and total gastrectomy in advanced cases (P > 0.05). For stage II and III tumors, patients with neoadjuvant chemotherapy had better prognosis than those without (P < 0.05). Cox multivariate regression analysis revealed TNM classification and vascular invasion were independent prognostic factors.

CONCLUSIONS

TNM classification and vascular invasion are independent prognostic factors for gastroesophageal junction carcinoma. Neoadjuvant chemotherapy may improve prognosis of the patients with stage II and III tumors. Radical resection should be achieved with rational surgical procedures tailored by tumor position, size, staging and so on.

Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial

BACKGROUND

Trastuzumab, a monoclonal antibody against human epidermal growth factor receptor 2 (HER2; also known as ERBB2), was investigated in combination with chemotherapy for first-line treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer.

METHODS

ToGA (Trastuzumab for Gastric Cancer) was an open-label, international, phase 3, randomised controlled trial undertaken in 122 centres in 24 countries. Patients with gastric or gastro-oesophageal junction cancer were eligible for inclusion if their tumours showed overexpression of HER2 protein by immunohistochemistry or gene amplification by fluorescence in-situ hybridisation. Participants were randomly assigned in a 1:1 ratio to receive a chemotherapy regimen consisting of capecitabine plus cisplatin or fluorouracil plus cisplatin given every 3 weeks for six cycles or chemotherapy in combination with intravenous trastuzumab. Allocation was by block randomisation stratified by Eastern Cooperative Oncology Group performance status, chemotherapy regimen, extent of disease, primary cancer site, and measurability of disease, implemented with a central interactive voice recognition system. The primary endpoint was overall survival in all randomised patients who received study medication at least once. This trial is registered with ClinicalTrials.gov, number NCT01041404.

FINDINGS

594 patients were randomly assigned to study treatment (trastuzumab plus chemotherapy, n=298; chemotherapy alone, n=296), of whom 584 were included in the primary analysis (n=294; n=290). Median follow-up was 18.6 months (IQR 11-25) in the trastuzumab plus chemotherapy group and 17.1 months (9-25) in the chemotherapy alone group. Median overall survival was 13.8 months (95% CI 12-16) in those assigned to trastuzumab plus chemotherapy compared with 11.1 months (10-13) in those assigned to chemotherapy alone (hazard ratio 0.74; 95% CI 0.60-0.91; p=0.0046). The most common adverse events in both groups were nausea (trastuzumab plus chemotherapy, 197 [67%] vs chemotherapy alone, 184 [63%]), vomiting (147 [50%] vs 134 [46%]), and neutropenia (157 [53%] vs 165 [57%]). Rates of overall grade 3 or 4 adverse events (201 [68%] vs 198 [68%]) and cardiac adverse events (17 [6%] vs 18 [6%]) did not differ between groups.

INTERPRETATION

Trastuzumab in combination with chemotherapy can be considered as a new standard option for patients with HER2-positive advanced gastric or gastro-oesophageal junction cancer.

FUNDING

F Hoffmann-La Roche.

Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial

BACKGROUND

Trastuzumab, a monoclonal antibody against human epidermal growth factor receptor 2 (HER2; also known as ERBB2), was investigated in combination with chemotherapy for first-line treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer.

METHODS

ToGA (Trastuzumab for Gastric Cancer) was an open-label, international, phase 3, randomised controlled trial undertaken in 122 centres in 24 countries. Patients with gastric or gastro-oesophageal junction cancer were eligible for inclusion if their tumours showed overexpression of HER2 protein by immunohistochemistry or gene amplification by fluorescence in-situ hybridisation. Participants were randomly assigned in a 1:1 ratio to receive a chemotherapy regimen consisting of capecitabine plus cisplatin or fluorouracil plus cisplatin given every 3 weeks for six cycles or chemotherapy in combination with intravenous trastuzumab. Allocation was by block randomisation stratified by Eastern Cooperative Oncology Group performance status, chemotherapy regimen, extent of disease, primary cancer site, and measurability of disease, implemented with a central interactive voice recognition system. The primary endpoint was overall survival in all randomised patients who received study medication at least once. This trial is registered with ClinicalTrials.gov, number NCT01041404.

FINDINGS

594 patients were randomly assigned to study treatment (trastuzumab plus chemotherapy, n=298; chemotherapy alone, n=296), of whom 584 were included in the primary analysis (n=294; n=290). Median follow-up was 18.6 months (IQR 11-25) in the trastuzumab plus chemotherapy group and 17.1 months (9-25) in the chemotherapy alone group. Median overall survival was 13.8 months (95% CI 12-16) in those assigned to trastuzumab plus chemotherapy compared with 11.1 months (10-13) in those assigned to chemotherapy alone (hazard ratio 0.74; 95% CI 0.60-0.91; p=0.0046). The most common adverse events in both groups were nausea (trastuzumab plus chemotherapy, 197 [67%] vs chemotherapy alone, 184 [63%]), vomiting (147 [50%] vs 134 [46%]), and neutropenia (157 [53%] vs 165 [57%]). Rates of overall grade 3 or 4 adverse events (201 [68%] vs 198 [68%]) and cardiac adverse events (17 [6%] vs 18 [6%]) did not differ between groups.

INTERPRETATION

Trastuzumab in combination with chemotherapy can be considered as a new standard option for patients with HER2-positive advanced gastric or gastro-oesophageal junction cancer.

FUNDING

F Hoffmann-La Roche.

Nasogastric placement of sump tube through the leak for the treatment of esophagogastric anastomotic leak after esophagectomy for esophageal carcinoma

OBJECTIVE

We seek to retrospectively analyze the nasogastric placement of sump tube through the leak for the treatment of intra-thoracic esophagastric anastomotic leak after esophagectomy for esophageal carcinoma.

MATERIALS AND METHODS

Esophagectomy with intrathoracic esophagogastric anastomotic procedures were performed in 2954 patients who suffered from esophageal carcinoma in our hospital between May 2004 and July 2008. Anastomotic leak had developed in 38 patients, of whom four patients were treated by reoperations. Stent insertion, the traditional "three-tube method" and the nasogastric placement of sump tube through the leak were applied in two, seven, and 25 patients, respectively.

RESULTS

The presence of anastomotic leak was proven by radiographic contrast examinations in 38 patients (1.3%). Among them, four received reoperations and recovered. Two patients were treated with the placement of self-expanding metallic coated stents and both died 10 and 13 d after placement due to uncontrollable hematemesis. Seven and 25 patients were managed by the traditional "three-tube method" and the nasogastric placement of sump tube through the leak, respectively. The mean time interval of the leak treatment was 42 d in the traditional "three-tube method" group and 31.2 d in the nasogastric placement of sump tube through the leak group, and the relatively average hospital mortality rates were 14.3% and 12%, respectively.

CONCLUSION

The nasogastric placement of sump tube through the leak appears to be an effective, technically feasible, and minimally invasive option for the treatment of intrathoracic esophagogastric anastomotic leak.

Genetic profiles of gastroesophageal cancer: combined analysis using expression array and tiling array--comparative genomic hybridization

We aimed to characterize the genomic profiles of adenocarcinomas in the gastroesophageal junction in relation to cancers in the esophagus and the stomach. Profiles of gains/losses as well as gene expression profiles were obtained from 27 gastroesophageal adenocarcinomas by means of 32k high-resolution array-based comparative genomic hybridization and 27k oligo gene expression arrays, and putative target genes were validated in an extended series. Adenocarcinomas in the distal esophagus and the gastroesophageal junction showed strong similarities with the most common gains at 20q13, 8q24, 1q21-23, 5p15, 13q34, and 12q13, whereas different profiles with gains at 5p15, 7p22, 2q35, and 13q34 characterized gastric cancers. CDK6 and EGFR were identified as putative target genes in cancers of the esophagus and the gastroesophageal junction, with upregulation in one quarter of the tumors. Gains/losses and gene expression profiles show strong similarity between cancers in the distal esophagus and the gastroesophageal junction with frequent upregulation of CDK6 and EGFR, whereas gastric cancer displays distinct genetic changes. These data suggest that molecular diagnostics and targeted therapies can be applied to adenocarcinomas of the distal esophagus and gastroesophageal junction alike.

[Therapy in gastric cancer. From an oncological perspective]

In two randomized trials it was demonstrated that preoperative and postoperative chemotherapy shows a statistically significant and clinically relevant improvement in progression-free and overall survival for adenocarcinoma of the esophagogastric junction and stomach when compared with the surgical control arm. The absolute benefit in overall survival was 13% and 14% after 5 years. This benefit is clearly shown for patients with locally advanced tumors but remains debatable in early disease stages. Postoperative mortality and the complication rate were not increased. Based on published study results perioperative chemotherapy has to be regarded as the new standard of care at least for patients staged as uT3/uT4 tumors as defined by endoscopic ultrasound. To date there are no indications for adjuvant chemotherapy or chemoradiation after R0 resection and adequate surgery.

WITHDRAWN: Chemotherapy for metastatic carcinoma of the esophagus and gastro-esophageal junction

BACKGROUND

More than 50% of patients with esophageal cancer have metastatic disease at presentation. The use of chemotherapy for this patient group is increasing with the intention of local and distant tumor control, improving quality of life and prolongation of survival.

OBJECTIVES

To assess the effectiveness of a) chemotherapy versus best supportive care or b) different chemotherapy regimes against each other, in metastatic esophageal carcinoma.

SEARCH STRATEGY

Trials were identified by searching MEDLINE 1950- November week 3 2008, Central (Cochrane Library 4th Quarter 2008), Embase 1980 - 2008 week 50. We did not confine our search to English language publications. Searches in all databases were updated in February 2005, February 2006 and December 2008.The Cochrane Highly Sensitive Search Strategy for identifying randomized trials in MEDLINE, Sensitivity maximising version; Ovid format was combined with the following search terms to identify RCTs in MEDLINE. The MEDLINE search strategy was adapted for use in the other databases searched. Members of the Cochrane UGPD Group, and experts in the field were contacted and asked to provide details of outstanding clinical trials and any relevant unpublished materials.

SELECTION CRITERIA

Randomized controlled trials comparing chemotherapy versus best supportive care, or different chemotherapy regimes against each other in patients with metastatic carcinoma of the esophagus or gastro-esophageal junction.

DATA COLLECTION AND ANALYSIS

Two authors (MYVH/EJK) extracted data and assessed trial quality. Study authors were contacted to obtain subgroup results of patients with metastatic esophageal carcinoma.

MAIN RESULTS

Only two RCTs with a total of 42 participants compared chemotherapy with best supportive care for metastatic esophageal cancer. No survival benefit was shown for chemotherapy treatment in these RCTs. Five RCTs with a total of 1242 participants compared different chemotherapy regimes. Due to variation in patient population and chemotherapy regimes, it was not possible to perform a formal pooled analysis. There was no consistent benefit of any specific chemotherapy regimen.

AUTHORS' CONCLUSIONS

There is a need for well designed, adequately powered, phase III trials comparing chemotherapy versus best supportive care for patients with metastatic esophageal cancer. Chemotherapy agents with promising response rates and tolerable toxicity are cisplatin, 5-fluorouracil (5-FU), paclitaxel and antracyclins. Future trials comparing palliative treatment modalities should assess quality of life with validated quality of life measures.