Lymphadenectomy around the left renal vein in Siewert type II adenocarcinoma of the oesophagogastric junction

Risk factors and clinical significance of lower perigastric lymph node metastases in Siewert type II and III esophagogastric junction adenocarcinoma: a retrospective cohort study

BACKGROUND

No consensus has been concluded with regarding to the scope of lymph node (LN) dissection for Siewert type II and III adenocarcinoma of the esophagogastric junction (AEG). This study aimed to explore risk factors for lower perigastric LN (LPLN) metastases (including no. 4d, 5, 6, and 12a LN stations) and analyze the indications for LPLN dissection.

METHODS

In total, 302 consecutive patients with Siewert type II and III AEG who underwent total gastrectomy (TG) were enrolled. The logistic regression model was used to perform uni- and multivariate analyses of risk factors for LPLN metastases. Kaplan-Meier curves were used for survival analysis, and log-rank tests were used for group comparisons. Basing on the guidelines of Japanese Gastric Cancer Association, the LN metastases (LNM) as well as the efficiency index (EI) of each LN station was further evaluated.

RESULTS

The independent risk factors for LPLN metastases in patients with Siewert type II and III AEG were distance from the esophagogastric junction (EGJ) to the distal end of the tumor (> 4.0 cm), preoperative carcinoembryonic antigen (CEA) ( +), pT4 stage, and HER-2 ( +). LPLN metastases was an independent risk factor for overall survival following TG. The LNM and EI of LPLN were 8.6% and 2.31%, respectively. The LNM of LPLN > 10% under the stratification of the distance from the EGJ to the distal end of the tumor (> 4.0 cm), pT4, preoperative CEA ( +), and HER-2 ( +) exhibited EI values of 3.55%, 2.09%, 2.51%, and 3.64%, respectively.

CONCLUSIONS

LPLN metastases was a malignant factor for the prognosis of patients with Siewert type II and III AEG. For patients with preoperative CEA ( +), pT4 stage, HER-2 ( +), and the distance from the EGJ to the distal end of the tumor (> 4.0 cm), TG with LPLN dissection is prioritized for clinical recommendation.

Efficiency of conversion surgery for esophageal squamous cell carcinoma with solitary abdominal para-aortic lymph node metastasis

PURPOSE

Abdominal para-aortic lymph nodes (PANs) are sites of distant metastasis in esophageal squamous cell cancer (ESCC). The prognosis of patients with Stage IVB ESCC and abdominal PAN metastasis is extremely poor. However, chemotherapy for ESCC has recently been developed, and the effectiveness of combined induction therapy and conversion surgery remains unclear. The primary objective of this study was to evaluate the short- and long-term outcomes of conversion surgery for ESCC and solitary abdominal PAN metastases after induction therapy.

METHODS

Thirteen patients who underwent conversion esophagectomy for cStage IVB ESCC with solitary abdominal PAN metastasis after induction therapy between January 2017 and October 2022 at our institution were enrolled. The short- and long-term outcomes of conversion surgery were retrospectively evaluated.

RESULTS

Three patients (23.1%) had pathological abdominal PAN metastasis, and six patients (46.2%) without pathological abdominal PAN metastasis showed that chemotherapy eliminated the tumors in the abdominal PAN. Three patients (23.1%) had postoperative complications of Clavien-Dindo grade II or higher. The 3-year overall and recurrence-free survival rates were 83.1% and 51.3%, respectively.

CONCLUSIONS

Our findings showed that conversion surgery for ESCC and solitary abdominal PAN metastasis led to a good prognosis when induction therapy was successful.

Significance of Surgery for Resectable M1 Lymph Node Metastases Without Organ Metastasis in Esophageal Carcinoma in the Era of Neoadjuvant Treatment

BACKGROUND

M1 esophageal carcinoma goes beyond localized disease and requires treatment with systemic therapy. M1 status is primarily divided into two categories: M1 lymph node metastasis and distant organ metastasis. Oligometastasis is defined as a state of limited metastatic disease, and surgery for oligometastasis of distant organs is reported to be beneficial in limited conditions. The aim of this study was to investigate resected cases of M1 lymph node metastases as the only metastatic site in stage IVB esophageal carcinoma.

PATIENTS AND METHODS

This study was a single-center retrospective cohort study. Patients with esophageal carcinoma who underwent esophagectomy with curative intent between April 2017 and December 2021 were examined. Neoadjuvant chemotherapy was our standard therapy and administered in almost all cases. We hypothesized that four sites of metastatic M1LN (supraclavicular (no. 104), pretracheal (no. 106pre), posterior thoracic para-aortic (no. 112aoP), and abdominal para-aortic (no. 16a2lat) LNs) were potentially resectable M1LN (rM1LN) metastases with curative intent and compared the prognosis of patients with and without rM1LN metastasis.

RESULTS

Six hundred eight-two patients were included in the study. Among these patients, 80 had rM1LN metastasis and received surgery for curative intent. Short-term safety outcomes were equivalent between patients with and without rM1LN metastases. After propensity score matching, there were no significant differences in overall survival between patients with and without rM1LN metastasis. Multivariate analyses revealed that the only independent prognostic factor was ypN status.

CONCLUSION

The present study suggests the feasibility and favorable OS in the patients with resection of rM1LN metastasis.

Current status of gastrectomy and reconstruction types for patients with proximal gastric cancer in Japan

BACKGROUND

Surgical procedures for proximal gastric cancer remain a highly debated topic. Total gastrectomy (TG) is widely accepted as a standard radical surgery. However, subtotal esophagectomy, proximal gastrectomy (PG) or even subtotal gastrectomy, when a small upper portion of the stomach can technically be preserved, are alternatives in current clinical practice.

METHODS

Using a cohort of the PGSAS NEXT trial, consisting of 1909 patients responding to a questionnaire sent to 70 institutions between July 2018 and December 2019, gastrectomy type, reconstruction method, and furthermore the remnant stomach size and the anti-reflux procedures for PG were evaluated.

RESULTS

TG was the procedure most commonly performed (63.0%), followed by PG (33.4%). Roux-en-Y was preferentially employed following TG irrespective of esophageal tumor invasion, while jejunal pouch was adopted in 8.5% of cases with an abdominal esophageal stump. Esophagogastrostomy was most commonly selected after PG, followed by the double-tract method. The former was preferentially employed for larger remnant stomachs (≧3/4), while being used slightly less often for tumors with as compared to those without esophageal invasion in cases with a remnant stomach 2/3 the size of the original stomach. Application of the double-tract method gradually increased as the remnant stomach size decreased. Anti-reflux procedures following esophagogastrostomy varied markedly.

CONCLUSIONS

TG is the mainstream and PG remains an alternative in current Japanese clinical practice for proximal gastric cancer. Remnant stomach size and esophageal stump location appear to influence the choice of reconstruction method following PG.

Mediastinal Lymph Node Dissection in Gastroesophageal Junction Adenocarcinoma

Currently, the prevalence of gastroesophageal junction adenocarcinoma (GEJAC) is increasing in both Asian and Western countries, although the increasing rate in Asian countries is much slower than in Western countries. With these current trends, concerns regarding the surgical treatment method are also increasing among gastrointestinal surgeons. However, the surgical treatment for GEJAC has been a controversial issue for a long time due to the relative scarcity of this tumor and its characteristics from its borderline location. Recently, a large-scale prospective study of this tumor has been conducted in Japan, and the results are now available. The results of this study will be helpful for understanding this tumor. In this article, the pattern of lymph node metastasis of GEJAC is reviewed, and the extent and method of lymph node dissection for this tumor are discussed and proposed based on the review.

Mapping of lymph node dissection determined by the epicenter location and tumor extension for esophagogastric junction carcinoma

Backgrounds

Previous studies identified the extent of lymph node dissection for esophagogastric junction (EGJ) carcinoma based on the metastatic incidence. The study aimed to determine the optimal extent and priority of lymphadenectomy based on the therapeutic efficacy from each station.

Methods

The studies on the lymph node metastasis (LNM) and therapeutic efficacy index (EI) for EGJ carcinomas were identified until April 2022. The obligatory stations with the LNM rates over 5% and therapeutic EI exceeding 2% should be routinely resected for D2 dissection, whereas the optional stations with EI between 0.5% and 2% should be resected for D3 dissection in selective cases.

Results

The survey yielded 16 eligible articles including 6,350 patients with EGJ carcinoma. The metastatic rates exceeded 5% at no. 1, 2, 3, 7, 9, 11p, and 110 stations and were less than 5% in abdominal no. 4sa~6, 8a, 10, 11d, 12a, and 16a2/b1 and mediastinal no. 105~112 stations. Consequently, obligatory stations with EI over 2% were largely determined by the epicenter location and located at the upper perigastric, lower mediastinal, and suprapancreatic zones, corresponding to those with rates of LNM over 5%. Consistent with the LNM rates less than 5%, the optional stations with EI between 0.5% and 2% were largely dependent on the degree of tumor extension toward the lower perigastric, splenic hilar (grecurvature), para-aortic (less curvature of the cardia), and middle or upper mediastinal zones.

Conclusions

The obligatory stations can be resected as an “envelope-like” wrap by transhiatal proximal gastrectomy with lower esophagectomy, whereas the optional stations for dissection are indicated by the tumor extension. The extended gastrectomy is required for the lower perigastric in the stomach-predominant tumor with gastric involvement exceeding 5.0 cm, para-aortic dissection in the less curvature-predominant tumor and splenic hilar dissection in the grecurvature-predominant tumor whereas transthoracic subtotal esophagectomy is required for complete mediastinal dissection and adequate negative margin in the esophagus-predominant tumor with esophageal invasion exceeding 3.0 cm.

Risk Factors for Para-Aortic Lymph Node Metastasis in Esophagogastric Junction Cancer: Results from a Prospective Nationwide Multicenter Study

BACKGROUND

Several studies have reported a high incidence of metastasis to para-aortic station 16a2lat (no. 16a2lat) among patients with esophagogastric junction (EGJ) cancer. However, the risk factors for no. 16a2lat metastasis are unclear. This study aimed to clarify the risk factors for no. 16a2lat metastasis in patients with EGJ cancer.

METHODS

Among 371 prospectively enrolled patients with EGJ cancer, 344 patients who underwent no. 16a2lat lymph node dissection were analyzed. Background factors were compared between the patients with and those without no. 16a2lat metastasis. The association between the histologic status of 10 regional lymph node stations and that of no. 16a2lat metastasis was evaluated.

RESULTS

Among the background factors, clinical N2-3 was the only independent risk factor for no. 16a2lat metastasis (odds ratio [OR], 5.90; p = 0.003). The metastasis rate of no. 16a2lat was 11.8% (11/93) for the patients with cN2-3 disease and 2.0% (5/251) for those with cN0-1 disease. The multivariate analysis showed that nos. 2 and 7 metastases were independent risk factors for no. 16a2lat metastasis, with respective ORs of 5.53 (p = 0.018) and 4.00 (p = 0.041). The patients with neither station no. 2 nor no. 7 metastasis did not exhibit no. 16a2lat metastasis, whereas the rate of no. 16a2lat metastasis was 23.7% for the patients with metastases of both stations.

CONCLUSIONS

Clinical N2-3 and histologic positivity of station nos. 2 and 7 were independent risk factors for no. 16a2lat metastasis. These findings could potentially assist in determining the indication for no. 16a2lat dissection for patients with EGJ cancer.

Surgical and perioperative treatment strategy for resectable esophagogastric junction cancer

Esophagogastric junction cancer is defined as adenocarcinoma with the epicenter within 5 cm of the esophagogastric junction in the West according to the Siewert classification. In contrast, it is defined as cancer of any histological type with the epicenter located within 2 cm proximal or distal to the esophagogastric junction in Japan according to the Nishi classification. Recently, the incidence of esophagogastric junction cancer has been rapidly rising all over the world, leading to much attention. Esophagogastric junction cancer was previously treated like gastric cancer or esophageal cancer because it is a less frequently occurring tumor. Esophagogastric junction cancer is considered to have worse prognosis than gastric cancer. Therefore, in recent years, esophagogastric junction cancer has been recognized as an independent malignant disease with poor prognosis, and thus development of treatment strategies focused on esophagogastric junction cancer is needed. The mapping of frequent metastasis in the mediastinal and abdominal lymph nodes has revealed the lymphatic flow from esophagogastric junction cancer specifically, establishing the optimal lymph node dissection area and surgical approach. The development of multimodal treatment that includes chemotherapy, radiotherapy and immunotherapy has been applied to improve the survival of esophagogastric junction cancer. In this review, we summarize clinical trials with important evidence on surgical and multimodal perioperative treatments for esophagogastric junction cancer.

Postoperative complications after a transthoracic esophagectomy or a transhiatal gastrectomy in patients with esophagogastric junctional cancers: a prospective nationwide multicenter study

BACKGROUND

Esophagogastric junction (EGJ) cancers are resected thorough esophagectomy or gastrectomy, with the incidence of postoperative complications influenced by the chosen procedure.

METHODS

In this prospective nationwide multicenter study, patients with cT2-T4 EGJ cancers were enrolled before surgery. Based on the protocol, surgeons performed a transthoracic esophagectomy (TTE) or a transhiatal gastrectomy (THG) and dissected all lymph nodes prespecified as the standardized procedure. Postoperative complications were correlated with the clinical factors in each procedure.

RESULTS

A total of 345 patients were eligible for this study. TTE and THG were performed in 120 and 225 patients, respectively. Complications of Clavien-Dindo ≥ Grade II were found in 115/345 (33.3%) patients. Recurrent laryngeal nerve palsy was found only in the TTE group (p < 0.001). The incidence of other complications was not significantly different between the two groups. High body mass index (BMI) in the TTE group, male sex, and longer esophageal invasion in the THG group were significantly correlated with complications ≥ Grade II (p = 0.049, 0.037, and 0.019, respectively). Anastomotic leakage was most frequently observed (12.2%). Tumor size in the THG group (p = 0.02) was significantly associated with leakage. All six patients with ≥ Grade IV leakage underwent THG, whereas, none of the patients in the TTE group had leakage ≥ Grade IV (2.7% vs. 0%, p = 0.096).

CONCLUSIONS

Surgical resection should be performed with utmost care, particularly in patients with a high BMI undergoing TTE, and in patients with larger tumors, longer esophageal invasion, or male patients undergoing THG.

Optimal surgery for esophagogastric junctional cancer

Esophagogastric junctional cancer is classified into three categories according to the Siewert classification, which reflects the epidemiological and biological characteristics. Therapeutic strategies have been evaluated according to the three Siewert types. There is a consensus that types I and III should be treated as esophageal cancer and gastric cancer, respectively. On the other hand, type II is often described as true cardiac cancer, which has different clinicopathological features from the other types. Thus, there is no consensus on the surgical management of type II esophagogastric junctional cancer. The optimal surgical management should focus on the principles of cancer surgery, which take into consideration oncological curability, including an appropriate resection margin, adequate lymphadenectomy, and minimization of postoperative complications. In this review, we evaluate the current relevant literature and evidence, on the surgical treatment of esophagogastric junctional cancer, focusing on type II. Esophagectomy with a thoracic approach has the advantage of ensuring a sufficient proximal resection margin and adequate mediastinal lymphadenectomy. However, the oncological benefit is offset by a high incidence of postoperative complications. Minimally invasive esophagectomy could be a possible solution to reduce complications and improve long-term outcomes. Further development of surgical treatments for Siewert type II is required to improve the outcomes. Furthermore, the surgical team should have expertise in both gastric cancer and esophageal cancer treatment, or patients should be managed with close collaboration between thoracic surgeons and gastric cancer surgeons.

Mapping of Lymph Node Metastasis From Esophagogastric Junction Tumors: A Prospective Nationwide Multicenter Study

OBJECTIVE

The aim of the study was to determine the optimal extent of lymph node dissection for the 2 histological types of esophagogastric junction (EGJ) tumors based on the incidence of metastasis in a prospective nationwide multicenter study.

BACKGROUND

Because most previous studies were retrospective, the optimal surgical procedure for EGJ tumors has not been standardized.

METHODS

Patients with cT2-T4 adenocarcinoma or squamous cell carcinoma located within 2.0 cm of the EGJ were enrolled before surgery. Surgeons dissected all lymph nodes prespecified in the protocol, using either the abdominal transhiatal or right transthoracic approach. The primary endpoint was the metastasis rate of each lymph node. Lymph nodes were classified according to metastasis rate, as follows: category-1 (strongly recommended for dissection), rate more than 10%; category-2 (weakly recommended for dissection), rate from 5% to 10%; and category-3 (not recommended for dissection), rate less than 5%.

RESULTS

Between 2014 and 2017, 1065 patients with EGJ tumor were screened, and 371 were enrolled. Among 358 patients who underwent surgical resection, category-1 nodes included abdominal stations 1, 2, 3, 7, 9, and 11p, whereas category-2 nodes included abdominal stations 8a, 19, and lower mediastinal station 110. If esophageal involvement exceeded 2.0 cm, station 110 was assigned to category-1. Among 98 patients who had either adenocarcinoma with esophageal involvement over 3.0 cm or squamous cell carcinoma, there were no category-1 nodes in the upper/middle mediastinal field, whereas category-2 nodes included upper mediastinal station 106recR and middle mediastinal station 108. When esophageal involvement exceeded 4.0 cm, station 106recR was assigned to category-1.

CONCLUSION

The study accurately identified the distribution of lymph node metastases from EGJ tumors and the optimal extent of subsequent lymph node dissection.

Novel minimally invasive approach to lymph node dissection around the left renal vein in patients with esophagogastric junction cancer

The left renal vein lymph node (LRVLN) may be the extended locoregional node in esophagogastric junction cancer; however, only open-surgical methods of dissection have been reported. We therefore developed a novel minimally invasive laparoscopic method for LRVLN dissection. Following esophagectomy, the stomach was mobilized and LRVLN dissection was started by taping the pancreatic body using two silicone drains. The transverse mesocolon was then retracted through the superior duodenal fossa to expose the horizontal duodenum and permit LRVLN dissection. We carried out the procedure successfully in 17 patients with advanced esophagogastric cancer. The median total and laparoscopic operative times were 415 and 161 min, respectively. Postoperative esophagectomy-related complications occurred in six patients. The median estimated blood loss was 120 ml and hospital stay was 15 days. This minimally invasive laparoscopic LRVLN dissection method was safe and effective, and may support faster recovery and earlier postoperative adjuvant therapy in patients with esophagogastric junction cancer.

Safety and feasibility of total laparoscopic radical resection of Siewert type II gastroesophageal junction adenocarcinoma through the left diaphragm and left thoracic auxiliary hole

BACKGROUND

The incidence of adenocarcinoma of the esophagogastric junction (AEG) is rising every year; however, the mode of operation for Siewert II AEG is still controversial. Accumulating evidence has shown that transabdominal surgery is better than transthoracic surgery for Siewert II AEG with esophageal invasion < 3 cm. In patients with obesity, a large tumor size, and high transection of the esophagus, the transabdominal esophageal hiatus approach for lower mediastinal lymph node dissection and posterior mediastinal anastomosis is difficult. Thus, total laparoscopic radical resection of Siewert II AEG is carried out through the left diaphragm and left chest auxiliary hole for the optimal surgical field of vision and space. In this prospective study, we assessed the feasibility of carrying out the procedure abdominally through the left diaphragm and auxiliary hole.

METHODS

Ten patients with Siewert II AEG were recruited between April and June 2019. Siewert II AEG was treated by total laparoscopy through the left diaphragm and left chest auxiliary hole. Clinicopathological features, surgical data, and adverse events were collected and analyzed in this prospective study.

RESULTS

The average duration of the operation was 348 ± 37.52 min, lower mediastinal dissection took 20.6 min, the OrVil anastomosis time was 29.8 min, the time necessary to suture the seromuscular layer through the left thoracic auxiliary hole was 11 min, the safety margin was 3.2 cm, and the total number of lymph nodes dissected was 40.6. The number of lower mediastinal lymph nodes dissected was 6.2. The rate of lymph node metastasis in the N110 group was 9 ± 12.45%, and the average intraoperative blood loss was 170 ± 57.47 mL. No anastomotic leakage or anastomotic stricture occurred after the operation. The time of intestinal function recovery was 2 days, and the first time of enteral nutrition through a jejunal nutrition tube was 2.4 days. No tumor recurrence was found in 10 patients at 1 year postoperatively.

CONCLUSION

Total laparoscopic radical resection through the left diaphragm and left thoracic auxiliary hole for Siewert II AEG patients is feasible and safe. Thus, it may be a good surgical alternative for patients with esophageal tumors invading less than 3 cm.

TRIAL REGISTRATION

ChiCTR, ChiCTR2000034286. Registered 8 July 2020, http://www.chictr.org.cn/showproj.aspx?proj=55866 .

True esophagogastric junction adenocarcinoma: background of its definition and current surgical trends

The definition of true esophagogastric junction (EGJ) adenocarcinoma and its surgical treatment are debatable. We review the basis for the current definition and the Japanese surgical strategy in managing true EGJ adenocarcinoma. The Siewert classification is a well-known anatomical classification system for EGJ adenocarcinomas: type II tumors in the region 1 cm above and 2 cm below the EGJ are described as "true carcinoma of the cardia". Coincidentally, this range matches gastric cardiac gland distribution. Conversely, Nishi's classification is generally used to describe EGJ carcinomas, defined as tumors with the center located within 2 cm above and 2 cm below the EGJ, regardless of their histological subtype. This range coincides with the extent of the lower esophageal sphincter combined with gastric cardiac gland distribution. The current Japanese surgical strategy focuses on the tumor range from the EGJ to the esophagus and stomach. According to previous studies, the strategy can be roughly classified into three types. The optimal surgical procedure for true EGJ adenocarcinoma is controversial. However, an ongoing Japanese nationwide prospective trial will help confirm the appropriate standard surgery, including the optimal extent of lymph node dissection.

Priority of lymph node dissection for advanced esophagogastric junction adenocarcinoma with the tumor center located below the esophagogastric junction

To clarify the priority of lymph node dissection (LND) in advanced Siewert type II and III AEG, in which the center of the tumor is located below the esophagogastric junction (EGJ).Data in 395 patients with advanced Siewert type II or III AEG was analyzed retrospectively. The index of estimated benefit from LND (IEBLD) was used to evaluate the efficacy of LND for each nodal station.The mean number of dissected LNs did not differ significantly between patients with type II and III AEG, nor did the mean number of retrieved LNs at each station significantly differ between the 2 groups. According to the IEBLD, the dissection of parahiatal LNs (No.19 and 20) and LNs along the distal portion of the stomach (No.5, 6, and 12a) seemed unlikely to be beneficial, whereas the dissection of Nos.1-3, 7, 9 and 11p yielded high therapeutic benefit (IEBLD>3.0) in both groups. The IEBLDs of No.4d, 8a, and 10 were much higher in type III than in type II AEG cases. No.10 LND may improve survival for type III AEG cases (IEBLD = 2.9), especially for subgroups with primary tumors invading the serosa layer, undifferentiated cancers, macroscopic type 3-4 tumors and tumors ≥50 mm in size (all IEBLDs > 4.0).For advanced AEG located below the EGJ, the dissection of paracardial LNs, lesser curvature LNs, and LNs around the celiac axis would promote higher survival benefits regardless of the Siewert subtype. Patients with type III AEG, especially those with serosa-invasive tumors, undifferentiated tumors, macroscopic type 3-4 tumors and tumors ≥50 mm in size may obtain relatively higher survival benefits from No. 10 lymphadenectomy.

Essential updates 2017/2018: Recent topics in the treatment and research of gastric cancer in Japan

Recent developments in diagnostic technology, accumulated clinical effort and established evidence have boosted early detection and drastically improved early and long-term outcomes of gastric cancer. However, gastric cancer continues to be one of the most aggressive and life-threatening malignancies among all cancers and is a global health problem. Between January 2017 and December 2018, various fascinating reports of managements and research were published, including the new 15th Japanese Classification of Gastric Carcinoma reflecting the 8th American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) tumor, node and metastasis (TNM) classification (October 2017) and the new Gastric Cancer Treatment Guidelines version 5 (January 2018). Moreover, pivotal molecular features of gastric cancer were clarified by the worldwide cancer genome project, and various treatment targets and biomarkers such as circulating DNAs and microRNAs were detected. Novel treatment options using programmed cell death protein 1 immune checkpoint inhibitors have been started. In this review, we summarize the recent topics of classification, guidelines, and clinical and basic research in order to bring new insights to gastric cancer treatment.

Aggressive Graphic/Surgical R0 Resection and Jejunal Interposition with Preservation of Mesojejunal Autonomic Nerves in Patients with Stage IV Esophagogastric Junction Adenocarcinoma: A Report of 3 Cases

BACKGROUND Three patients with stage IV esophagogastric junction cancer (EGJC) underwent extended resection to achieve a graphic/surgical R0 status (no visible remnant of viable tumor in imaging/surgical findings) and adjuvant chemotherapy from the early postoperative period. We also introduced use of our digestive reconstruction technique in these patients. CASE REPORT We used jejunal interposition for digestive reconstruction, which involved end-to-end jejunojejunostomy with a biofragmentable anastomosis ring. The mesojejunal autonomic nerves of the lifted jejunum were preserved. The first adenocarcinoma involved the perilesional lymph nodes (LNs). Graphic/surgical R0 resection was completed by para-aortic LN dissection. The diagnosis (Japanese Classification of Gastric Carcinoma) was stage IV [pM1(LYM)]. Adjuvant chemotherapy began on postoperative day (POD) 11. The second adenocarcinoma was accompanied by a solitary lung metastasis. Intraoperative cytology of ascitic fluid was positive, and cisplatin was intraperitoneally administered. Adjuvant chemotherapy began on POD 10. The solitary lung metastasis was then resected, and graphic/surgical R0 resection was achieved. The diagnosis was stage IV [pM1(PUL) and CY1]. The third adenocarcinoma was accompanied by multiple liver metastases and metastatic regional LNs. The diagnosis was stage IV [H1]. Systemic chemotherapy was repeated. Only a solitary liver metastasis remained and was treated by radiofrequency ablation. Conversion surgery was conducted, achieving graphic/surgical R0 resection. Systemic chemotherapy was continued from POD 10. CONCLUSIONS For patients with stage IV EGJC, extended resection to achieve a graphic/surgical R0 status is still controversial, and systemic chemotherapy is important. The results of the present study suggest that our physiological reconstruction technique does not affect the efficacy of other therapies, such as adjuvant chemotherapy.

Surgical Treatment of Gastroesophageal Junction Cancer

Although the incidence of gastroesophageal junction (GEJ) adenocarcinoma has been increasing worldwide, no standardized surgical strategy for its treatment has been established. This study aimed to provide an update on the surgical treatment of GEJ adenocarcinoma by reviewing previous reports and propose recommended surgical approaches. The Siewert classification is widely used for determining which surgical procedure is used, because previous studies have shown that the pattern of lymph node (LN) metastasis depends on tumor location. In terms of surgical approaches for GEJ adenocarcinoma, a consensus was reached based on two randomized controlled trials. Siewert types I and III are treated as esophageal cancer and gastric cancer, respectively. Although no consensus has been reached regarding the treatment of Siewert type II, several retrospective studies suggested that the optimal treatment strategy includes paraaortic LN dissection. Against this background, a Japanese nationwide prospective trial is being conducted to determine the proportion of LN metastasis in GEJ cancers and to identify the optimal extent of LN dissection in each type.

Minimally invasive abdominal and left thoracic approach for Siewert type II adenocarcinoma of the oesophagogastric junction: Novel technique for simultaneous combined use of laparoscopy and thoracoscopy

Background

The optimal approach to resection for Siewert type II adenocarcinoma of the oesophagogastric junction (AEG) is still controversial. Our novel procedures and experience with a minimally invasive abdominal and left thoracic approach (MALTA) for Siewert type II AEG are described.

Patients and Methods

Intra- and post-operative outcomes for MALTA were assessed in seven consecutive patients with a preoperative diagnosis of Siewert type II AEG at Hokkaido University Hospital.

Results

None of the patients were converted to open surgery. The mean surgical duration was 434.0 ± 71.4 min, and mean blood loss was 20.7 ± 16.7 ml. On pathological examination, the median proximal margin was 24.6 ± 12.5 mm. No reoperations were needed, and there were no surgery-related complications.

Conclusions

This novel technique shows considerable advantages, such as ensuring the proximal margin, intrathoracic oesophagojejunostomy and increased operative field exposure of the lower mediastinal area for Siewert type II AEG.

Esophagogastric junction cancer successfully treated by laparoscopic proximal gastrectomy and lower esophagectomy with intrathoracic double-flap technique: A case report

A 66-year-old man was referred to our hospital for treatment of esophagogastric junction cancer. He was diagnosed as cT2N0M0, and the esophageal invasion was found to be 1 cm from the esophagogastric junction. He underwent laparoscopy-assisted proximal gastrectomy and lower esophagectomy with esophagogastrostomy using the intrathoracic double-flap technique through the transhiatal approach. The operative time was 662 min (suturing time was 198 min), and blood loss was 200 mL. The operative time was much longer for this procedure than for esophagogastrostomy with the conventional (intra-abdominal) double-flap technique. The postoperative course was uneventful. No abnormal gastroesophageal reflux, esophageal motility, or lower esophageal sphincter (LES) pressure was demonstrated 3 months after the operation. Laparoscopic proximal gastrectomy and lower esophagectomy with esophagogastrostomy using the double-flap technique through the transhiatal approach is safe and feasible. It may be recommended for patients with esophagogastric junction cancer with esophageal invasion of about 1 cm.

The optimal lymph node dissection in patients with adenocarcinoma of the esophagogastric junction

OBJECTIVE

The aim of this study was to refine the optimal lymph node dissection in Western patients with adenocarcinoma of the esophagogastric junction (AEG).

BACKGROUND

Lymphadenectomy is essential in addition to surgery for AEG. Asian studies continually present superior survival rates using a more extended lymphadenectomy compared with results reproduced in the West. Thus, the optimal extend of the lymphadenectomy remains unclear in Western patients.

METHODS

A retrospective cohort was conducted of patients with AEG from January 1st, 2003 to December 31st, 2011. All patients undergoing curatively intended surgery was included. Two types of resections were constructed; Res1 included patients where only the loco regional lymph nodes were removed (station 1-4, 7 and 9) and Res2 included the additional removal of the more distant stations 8 and/or 11.

RESULTS

We identified 510 patients with AEG. The highest frequency of lymph node metastases was seen in the loco regional stations 1-3, 7 and 9, ranging from 34% to 41.4%. There was no difference in overall survival between the two groups; the median survival rate for Res1 was 30.4 months compared to 24.1 months for Res2 (p = 0.157). Furthermore, the extend of lymph node dissection seemed to have no effect on survival (HR = 1.061, 95%CI 0.84-1.33).

CONCLUSION

No significant difference in survival between the extended and the less extended lymphadenectomy was found. The presence of metastases in distant lymph nodes indicates poor survival and may represent disseminated disease. We do not find evidence that supports an extended lymph node dissection in Western patients.

Recurrence Pattern and Lymph Node Metastasis of Adenocarcinoma at the Esophagogastric Junction

BACKGROUND

The surgical approach for adenocarcinoma of the esophagogastric junction (AEJ) still is controversial despite revised tumor-node-metastasis (TNM) classification. This study aimed to evaluate the oncologic outcome of a routine transhiatal approach for AEJ in terms of recurrence and lymph node (LN) metastasis of AEJ.

METHODS

Recurrence patterns and LN metastasis of a single, primary AEJ (n = 463) treated by a surgical resection using a transhiatal approach without routine complete mediastinal LN dissection or routine splenectomy were analyzed respectively. To validate current treatment for recurrence, a validation index of recurrence (ViR; overall survival/incidence of solitary recurrence factor) was developed.

RESULTS

The overall recurrence rate for AEJ was 20.3%, which did not differ significantly between AEJ II (20.8%; n = 125) and AEJ III (20.1%; n = 338). Mediastinal recurrence did not differ significantly among the subtypes of AEJ, irrespective of gastroesophageal junction involvement. Splenic hilar LN recurrence-free survival did not differ significantly between the gastrectomy-only group, the gastrectomy-plus-splenectomy group, and the gastrectomy plus distal pancreatectomy group. The solitary recurrence rate for the mediastinal LN was 0.7% for AEJ, and the overall median survival with that recurrence was 30.5 months. The ViR for mediastinal LN recurrence (43.6) was higher than for regional LN (20.9) or distant LN (14.6) metastasis.

CONCLUSION

In terms of LN metastasis and recurrence, a transhiatal approach without complete mediastinal LN dissection can be acceptable, and routine splenectomy is not necessary for AEJ II or AEJ III arising within the stomach.

Lymph node dissection for Siewert II esophagogastric junction adenocarcinoma: a retrospective study of 136 cases

BACKGROUND

To compare the lymph node dissection with the right transthoracic Ivor-Lewis (IL) procedure to that with the left transthoracic (LT) approach for Siewert type II adenocarcinoma of the esophagogastric (AEG) junction.

METHODS

In this study, 136 patients with Siewert type II AEG who met the inclusion criteria underwent surgical resection were divided into the IL (47 cases) and LT (89 cases) groups. The number and frequency of the dissected lymph nodes in each station were compared between the two groups.

RESULTS

The IL group had a longer proximal surgical margin (P = 0.000) and more total (P = 0.000), thoracic (P = 0.000), and abdominal lymph nodes (P = 0.000) dissected than the LT group. In general, the IL group had a higher dissection rate in each thoracic lymph node station (P < 0.05) than the LT group. The dissection rates of the hepatic artery, splenic artery and celiac trunk lymph nodes were higher in the IL group than in the LT group (P < 0.05). The lymph node metastasis rate was 78.7% in the IL group, higher than the 61.8% in the LT group (P = 0.045).

CONCLUSIONS

The right transthoracic IL procedure was demonstrated to be a better application than the LT approach for Siewert type II AEG in terms of the number and frequency of lymph node resections.

Optimal treatment for Siewert type II and III adenocarcinoma of the esophagogastric junction: A retrospective cohort study with long-term follow-up

AIM

To determine the optimal treatment strategy for Siewert type II and III adenocarcinoma of the esophagogastric junction.

METHODS

We retrospectively reviewed the medical records of 83 patients with Siewert type II and III adenocarcinoma of the esophagogastric junction and calculated both an index of estimated benefit from lymph node dissection for each lymph node (LN) station and a lymph node ratio (LNR: ratio of number of positive lymph nodes to the total number of dissected lymph nodes). We used Cox proportional hazard models to clarify independent poor prognostic factors. The median duration of observation was 73 mo.

RESULTS

Indices of estimated benefit from LN dissection were as follows, in descending order: lymph nodes (LN) along the lesser curvature, 26.5; right paracardial LN, 22.8; left paracardial LN, 11.6; LN along the left gastric artery, 10.6. The 5-year overall survival (OS) rate was 58%. Cox regression analysis revealed that vigorous venous invasion (v2, v3) (HR = 5.99; 95%CI: 1.71-24.90) and LNR of > 0.16 (HR = 4.29, 95%CI: 1.79-10.89) were independent poor prognostic factors for OS.

CONCLUSION

LN along the lesser curvature, right and left paracardial LN, and LN along the left gastric artery should be dissected in patients with Siewert type II or III adenocarcinoma of the esophagogastric junction. Patients with vigorous venous invasion and LNR of > 0.16 should be treated with aggressive adjuvant chemotherapy to improve survival outcomes.

Different time trend and management of esophagogastric junction adenocarcinoma in three Asian countries

Esophagogastric junction (EGJ) adenocarcinoma has been on the increase in Western countries. However, in Asian countries, data on the incidence of EGJ adenocarcinoma are evidently lacking. In the present review, we focus on the current clinical situation of EGJ adenocarcinoma in three Asian countries: Japan, Hong Kong, and Malaysia. The incidence of EGJ adenocarcinoma has been reported to be gradually increasing in Malaysia and Japan, whereas it has stabilized in Hong Kong. However, the number of cases in these countries is comparatively low compared with Western countries. A reason for the reported difference in the incidence and time trend of EGJ adenocarcinoma among the three countries may be explained by two distinct etiologies: one arising from chronic gastritis similar to distal gastric cancer, and the other related to gastroesophageal reflux disease similar to esophageal adenocarcinoma including Barrett's adenocarcinoma. This review also shows that there are several concerns in clinical practice for EGJ adenocarcinoma. In Hong Kong and Malaysia, many EGJ adenocarcinomas have been detected at a stage not amenable to endoscopic resection. In Japan, histological curability criteria for endoscopic resection cases have not been established. We suggest that an international collaborative study using the same definition of EGJ adenocarcinoma may be helpful not only for clarifying the characteristics of these cancers but also for improving the clinical outcome of these patients.

Western strategy for EGJ carcinoma

In this paper, the epidemiological and clinicobiological behavior of esophagogastric junction (EGJ) adenocarcinoma in the West is compared and contrasted to that in the East, and an overview is provided of current therapeutic strategies employed for this type of tumor in Western countries. It is well known that multimodal treatment is the therapeutic standard in locally advanced EGJ adenocarcinoma, but whether neoadjuvant/perioperative chemotherapy (CT) or neoadjuvant chemoradiotherapy (CRT) is the optimal approach is still debated. Neoadjuvant CRT improves local control in locally advanced Siewert type I and II tumors, so it should be considered the treatment of choice. In the subset of these patients with microscopic systemic disease at diagnosis, more intensive exclusive chemotherapy protocols could be of benefit. Therefore, there is an urgent need to identify these patients before planning the treatment. For Siewert type III tumors, perioperative chemotherapy is the standard. While there is general agreement on the optimal surgical approach for Siewert types I and III (a two-field Ivor Lewis operation and a total gastrectomy with distal esophagectomy, respectively), no standard surgical treatment has been defined for Siewert type II tumors. When data from Western series on proximal and circumferential resection margins and on nodal spread in Siewert type II tumors are taken into account, the optimal surgical approach appears to be Ivor Lewis esophagectomy. Whether the extent of esophageal invasion can correctly predict nodal involvement in middle-upper mediastinal stations as a means to restrict indications for transthoracic esophagectomy requires further investigation in the West.

Results of a nation-wide retrospective study of lymphadenectomy for esophagogastric junction carcinoma

BACKGROUND

Esophagogastric junction (EGJ) carcinoma has attracted considerable attention because of the marked increase in its incidence globally. However, the optimal extent of esophagogastric resection for this tumor entity remains highly controversial.

METHODS

This was a questionnaire-based national retrospective study undertaken in an attempt to define the optimal extent of lymph node dissection for EGJ cancer. Data from patients with EGJ carcinoma, less than 40 mm in diameter, who underwent R0 resection between January 2001 and December 2010 were reviewed.

RESULTS

Clinical records of 2807 patients without preoperative therapy were included in the analysis. There are distinct disparities in terms of the nodal dissection rate according to histology and the predominant tumor location. Nodal metastases frequently involved the abdominal nodes, especially those at the right and left cardia, lesser curvature and along the left gastric artery. Nodes along the distal portion of the stomach were much less often metastatic, and their dissection seemed unlikely to be beneficial. Lower mediastinal node dissection might contribute to improving survival for patients with esophagus-predominant EGJ cancer. However, due to low dissection rates for nodes of the middle and upper mediastinum, no conclusive result was obtained regarding the optimal extent of nodal dissection in this region.

CONCLUSIONS

Complete nodal clearance along the distal portion of the stomach offers marginal survival benefits for patients with EGJ cancers less than 4 cm in diameter. The optimal extent of esophageal resection and the benefits of mediastinal node dissection remain issues to be addressed in managing patients with esophagus-predominant EGJ cancers.

Lymph node dissection for Siewert II esophagogastric junction adenocarcinoma: A retrospective study of 3 surgical procedures

The present study was aimed to investigate the application of right thansthoracic Ivor-Lewis (IL), left transthoracic (LTT), and left thoracoabdominal (LTA) approach in Siewert type II adenocarcinoma of esophagogastric junction (AEG).The data of 196 patients with Siewert type II AEG received surgical resection in our cancer center between January 2014 and April 2016 was retrospectively analyzed. Finally, 136 patients met the inclusion criteria were enrolled in the study and divided into the IL (47 cases), LTT (51 cases), and LTA group (38 cases). Clinical and short-term treatment effects were compared among the 3 groups.The patients with weight loss, diabetes, and heart disease increased in the LTT group (P = 0.054, P = 0.075, and P = 0.063, respectively). Operation time was significantly longest in the IL group (P < 0.001), but the amount of bleeding and tumor size did not significantly differ among the 3 groups (P = 0.176 and P = 0.228, respectively). The IL group had the significantly longest proximal surgical margin (P < 0.001) and most number of total (P < 0.001) and thoracic lymph nodes (P < 0.001) dissected. Both the IL and LTA groups had more abdominal lymph nodes dissected than the LTT group (P < 0.001). In general, the IL and LTT groups had the highest dissection rates of every station of thoracic (P < 0.05) and lower mediastinal lymph nodes (P < 0.05), respectively. The dissection rate of the paracardial, left gastric artery, and gastric lesser curvature lymph nodes did not differ significantly among the 3 groups (P > 0.05), but the dissection rate of the hepatic artery, splenic artery, and celiac trunk lymph nodes was significantly highest in the IL group (P < 0.05). Postoperative hospital stay, perioperative complications, and mortality did not differ significantly among the 3 groups (P > 0.05).Compared with the traditional left transthoracic approach, the Ivor-Lewis approach did not increase the perioperative mortality and complication rates in Siewert type II AEG, but obtained satisfactory length of the proximal surgical margin, and was better than the left transthoracic approach in thoracic and abdominal lymph node dissection. However, the advantages of Ivor-Lewis procedure requires further follow-up and validation through prospective randomized controlled trials.

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.

Theoretical therapeutic impact of lymph node dissection on adenocarcinoma and squamous cell carcinoma of the esophagogastric junction

BACKGROUNDS

The aim of this study was to evaluate the theoretical therapeutic impact of dissecting each lymph node station for adenocarcinoma and squamous cell carcinoma of the esophagogastric junction.

METHODS

This multicenter study included 431 junctional cancer patients (381 adenocarcinomas and 50 squamous cell carcinomas) who fulfilled the following criteria: (1) the center of the tumor was located between 1 cm above and 2 cm below the esophagogastric junction, and (2) the tumor invaded the junction. The theoretical therapeutic impact of dissecting each lymph node station was evaluated based on the therapeutic value index calculated by multiplying the frequency of metastasis to each station and the 5-year survival rate of patients with metastasis to that station.

RESULTS

The 5-year overall survival rates (95% confidence interval) were 60.4% (55.1-65.7) in the adenocarcinoma cases and 52.3% (35.6-69.0) in the squamous cell carcinoma cases. The nodal stations showing the first to fifth highest index were the paracardial and lesser curvature nodes (nos. 1, 2 and 3), nodes at the root of the left gastric artery (no. 7) and lower mediastinal lymph nodes, regardless of the histology.

CONCLUSIONS

Nodal dissection achieved by proximal gastrectomy and lower esophagectomy should be the minimal requirement for junctional cancer regardless of the histology, considering the therapeutic value indices for the relevant lymph node stations.

Laparoscopic lymphadenectomy around the left renal vein (16a2lat) by tunneling under the pancreas for advanced Siewert type II adenocarcinoma

The para-aortic lymph nodes around the left renal vein (16a2lat) are now considered important to target in the treatment of advanced adenocarcinoma of the esophagogastric junction. We describe a laparoscopic approach for resecting these nodes. This new tunneling approach starts from the ligament of Treitz and then enters the retroperitoneal space. The left renal vein and left adrenal vein are dissected to identify the anatomy of the 16a2lat area. After this dissection, the 16a2lat nodes are retrieved through the suprapancreatic area. Six patients with advanced type II junctional cancer underwent laparoscopic 16a2lat lymph node dissection. The median operative time and estimated blood loss were 479 (390-750) min and 250 (130-500) ml, respectively. The median hospital stay was 22 (17-54) days and there were no deaths or serious complications. Although this series was relatively small, our technique proved effective and feasible.

Distribution of involved abdominal lymph nodes is correlated with the distance from the esophagogastric junction to the distal end of the tumor in Siewert type II tumors

BACKGROUND

The optimal surgical approach for Siewert type II adenocarcinoma of the esophagogastric junction (AEG) has not yet been agreed. Here we investigated whether the distance from the esophagogastric junction (EGJ) to the distal end of the tumor was related to the distribution of involved abdominal lymph nodes in Siewert type II tumors.

METHODS

A total of 288 patients with pT2-4 AEG Siewert II, treated by R0 surgical resection at 7 institutions in Japan, were retrospectively investigated. The distribution of involved abdominal nodes was correlated with the distance from the EGJ to the distal end of the tumor.

RESULTS

In patients where the distance from the EGJ to the distal end of the tumor was ≤30 mm, the frequency of nodal involvement along the greater curvature or antrum was low (2.2%). In contrast, in patients where the distance was >50 mm, the incidence of this nodal involvement was 20.0%. In patients where the distance was 30-50 mm incidence was intermediate (8.0%). Multivariate analyses showed that the distance from the EGJ to the distal end of the tumor was significantly related to lymph node involvement along the greater curvature or antrum (odds ratio 3.7, 95% confidence interval 1.3-11, p = 0.006).

CONCLUSIONS

When the distance from the EGJ to the distal end of the tumor is ≤ 30 mm for Siewert II AEG, esophagectomy or proximal gastrectomy is sufficient from the point of view of abdominal lymphadenectomy. However, a total gastrectomy should be considered for abdominal lymphadenectomy when this distance is > 50 mm.

Ten-year follow-up results of a randomized clinical trial comparing left thoracoabdominal and abdominal transhiatal approaches to total gastrectomy for adenocarcinoma of the oesophagogastric junction or gastric cardia

Background

The optimal surgical approach for treatment of oesophagogastric junction (OGJ) cancer is controversial. A randomized clinical trial (JCOG9502) comparing transhiatal (TH) and left thoracoabdominal (LTA) approaches was stopped after the first interim analysis owing to limited efficacy for LTA resections. Complete 10‐year follow‐up data are now available.

Methods

Patients with histologically proven adenocarcinoma of the OGJ or gastric cardia with oesophageal invasion of 3 cm or less were randomized to a TH or LTA approach. Both groups underwent total gastrectomy and splenectomy with D2 nodal dissection plus para‐aortic lymphadenectomy above the left renal vein. For LTA, a thorough mediastinal lymphadenectomy below the left inferior pulmonary vein was also mandatory. The primary endpoint was overall survival.

Results

A total of 167 patients (82 TH, 85 LTA) were enrolled. The 10‐year overall survival rate was 37 (95 per cent c.i. 26 to 47) per cent for the TH approach and 24 (15 to 34) per cent for the LTA technique (P = 0·060). The hazard ratio for death was 1·42 (0·98 to 2·05) for the LTA technique. Subgroup analysis based on the Siewert classification indicated non‐significant survival advantages in favour of the TH approach.

Conclusion

LTA resections should be avoided in the treatment of adenocarcinoma of the OGJ or gastric cardia. Registration number: NCT00149266 (https://www.clinicaltrials.gov).

No survival benefit from a more extensive operation

Mediastinal lymph node metastasis and recurrence in adenocarcinoma of the esophagogastric junction

BACKGROUND

Whether thorough mediastinal dissection is indicated in patients with Siewert type II adenocarcinoma of the esophagogastric junction (EGJ) remains controversial. We conducted a multicenter study to find a preoperative indicator of mediastinal node metastasis.

METHODS

We retrospectively collected data on 315 patients with pT2-T4 Siewert type II tumors who underwent R0 or R1 resection. The rates of metastasis or recurrence were investigated for the upper, middle, and lower mediastinal lymph nodes. Multivariate logistic analysis was used to identify significant indicators of metastasis or recurrence in the mediastinal nodes.

RESULTS

The overall rates of metastasis or recurrence in the upper, middle, and lower mediastinal lymph nodes were 4%, 7%, and 11%, respectively. Rates were significantly higher when the distance from the EGJ to the proximal edge of primary tumor was >3 cm for the upper and middle mediastinal nodes and >2 cm for the lower mediastinal nodes. Multivariate analysis revealed that this distance was the only factor significantly associated with metastasis or recurrence in any mediastinal region. The 5-year overall survival rate in the 12 patients with metastasis in the upper or middle mediastinal lymph nodes was 17%.

CONCLUSION

The distance from the EGJ to the proximal edge of primary tumor may be a significant indicator of metastasis or recurrence in the mediastinal lymph nodes in patients with Siewert type II tumors. Thorough mediastinal lymph node dissection via a transthoracic approach may provide a therapeutic benefit when the distance is >3 cm.

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.

Lymph node metastasis and lymphadenectomy of resectable adenocarcinoma of the esophagogastric junction

Based on Siewert classification, adenocarcinomas of the esophagogastric junction (AEGs) have different behaviors of perigastric-mediastinal nodal metastasis. Siewert type I AEGs have higher incidence of mediastinal nodal metastasis than those of type II or III, especially at middle-upper mediastinum. With regard to the necessity of mediastinal lymphadenectomy, theoretically, transthoracic esophagogastrectomy with complete mediastinal lymphadenectomy is suggested for Siewert type I AEGs, while transhiatal total gastrectomy with lower mediastinal and D2 perigastric lymphadenectomy is a standard surgery for type II-III AEGs. Nevertheless, the mediastinal nodal metastasis is an independent factor of poor prognosis for any type of AEG.

The optimal extent of lymph node dissection for adenocarcinoma of the esophagogastric junction differs between Siewert type II and Siewert type III patients

BACKGROUND

The incidence of adenocarcinoma of the esophagogastric junction (AEG) has been increasing worldwide. We investigated the clinicopathological characteristics of patients with Siewert type II and III AEGs and clarified the optimal intra-abdominal lymph node dissection in these patients.

METHODS

This study included 132 patients with AEG who underwent curative resection at Shizuoka Cancer Center from September 2002 to December 2012. We used the index of estimated benefit from lymph node dissection (IEBLD) to assess the efficacy of lymph node dissection of each station. The clinicopathological characteristics and IEBLDs of each station were compared between patients with Siewert type II and III AEGs.

RESULTS

We analyzed 92 patients with Siewert type II AEG and 40 patients with Siewert type III AEG. The incidence of lymph node metastasis was high in both groups (64.1 % in type II AEG and 75.0 % in type III AEG). The 5-year survival rates were similar for the patients with Siewert type II and III AEGs, at 54.0 and 53.4 %, respectively. The IEBLDs of stations located near the esophagogastric junction were generally high in both groups, while the IEBLDs of lower perigastric lymph nodes were higher in Siewert type III than in Siewert type II AEG cases.

CONCLUSIONS

The IEBLDs were similar between Siewert type II and III AEGs at all stations except for lower perigastric lymph nodes. Total gastrectomy should be selected as a standard treatment for Siewert type III AEG, whereas in Siewert type II AEG, preservation of the distal part of the stomach may be an acceptable procedure.

Esophagogastric tube reconstruction with stapled pseudo-fornix in laparoscopic proximal gastrectomy: a novel technique proposed for Siewert type II tumors

PURPOSE

The incidence of adenocarcinoma of the esophagogastric junction is increasing, but laparoscopic proximal gastrectomy is not widely accepted due to the absence of a standardized technique of reconstruction. This report describes a novel technique of esophagogastric tube reconstruction in laparoscopic proximal gastrectomy for Siewert type II tumors.

METHODS

Laparoscopic proximal gastrectomy, sometimes with transhiatal distal esophagectomy, was performed. After a perigastric, suprapancreatic, and lower thoracic paraesophageal lymphadenectomy, a gastric tube of 35-mm width was prepared. An esophagogastric tube anastomosis with pseudo-fornix was made with a no-knife linear stapler to prevent postoperative reflux esophagitis.

RESULTS

Fifteen patients with Siewert type II tumors underwent this operation. They included six patients with early-stage cancer, six at high risk for transhiatal total gastrectomy due to several comorbidities, and three who needed palliative tumor resection. The mean operation time was 315 min. One postoperative anastomotic leak was treated conservatively, and three anastomotic stenoses were resolved with endoscopic balloon dilatation. Postoperative 1-year follow-up endoscopy revealed four cases of reflux esophagitis that were well controlled by medication.

CONCLUSIONS

This new technique of reconstruction was feasible. With the advantage of a gastric tube, a tension-free anastomosis was possible even for bulky tumors that needed lower esophagectomy. Although long-term follow-up and a larger number of patients are required to evaluate long-term functional outcomes and oncological adequacy, our procedure has the potential of becoming a treatment of choice for early-stage Siewert type II tumors and/or for some selected high-risk patients who need tumor resection.

New therapeutic strategies for squamous cell cancer and adenocarcinoma

This paper presents commentaries on neoadjuvant treatment esophagectomy; the prognostic and predictive effects of single nucleotide polymorphisms (SNP) in the multimodality therapy of esophageal cancer; optimal preoperative treatment prior to surgery for esophageal cancer; a possible role for trastuzumab in treating esophageal adenocarcinoma or any esophageal dysplasia/intra-epithelial neoplasia; surgery after chemoradiation in resectable esophageal cancer; whether para-aortic lymph node dissection should be performed in esophagogastric junction (EGJ) tumors; and transhiatal esophagectomy in treatment of the esophageal cancer.

Lymph node metastasis in gastric cardiac adenocarcinoma in male patients

AIM: To reveal the clinicopathological features and risk factors for lymph node metastases in gastric cardiac adenocarcinoma of male patients.

METHODS: We retrospective reviewed a total of 146 male and female patients with gastric cardiac adenocarcinoma who had undergone curative gastrectomy with lymphadenectomy in the Department of Surgery, Xin Hua Hospital and Rui Jin Hospital of Shanghai Jiaotong University Medical School between November 2001 and May 2012. Both the surgical procedure and extent of lymph node dissection were based on the recommendations of Japanese gastric cancer treatment guidelines. Univariate and multivariate analyses of lymph node metastases and the clinicopathological features were undertaken.

RESULTS: The rate of lymph node metastases in male patients with gastric cardiac adenocarcinoma was 72.1%. Univariate analysis showed an obvious correlation between lymph node metastases and tumor size, gross appearance, differentiation, pathological tumor depth, and lymphatic invasion in male patients. Multivariate logistic regression analysis revealed that tumor differentiation and pathological tumor depth were the independent risk factors for lymph node metastases in male patients. There was an obvious relationship between lymph node metastases and tumor size, gross appearance, differentiation, pathological tumor depth, lymphatic invasion at pN₁ and pN₂, and nerve invasion at pN₃ in male patients. There were no significant differences in clinicopathological features or lymph node metastases between female and male patients.

CONCLUSION: Tumor differentiation and tumor depth were risk factors for lymph node metastases in male patients with gastric cardiac adenocarcinoma and should be considered when choosing surgery.

Priority of lymph node dissection for Siewert type II/III adenocarcinoma of the esophagogastric junction

OBJECTIVE

The purpose of this study was to clarify the priority of nodal dissection in Siewert types II and III adenocarcinoma of the esophagogastric junction (AEG).

METHODS

The priority of nodal dissection was evaluated based on the therapeutic value index calculated by multiplying of the frequency of metastasis to each station and the 5-year survival rate of patients with metastasis to that station.

RESULTS

A total of 176 patients (95 type II and 81 type III) were examined. Among the lymph nodes that had a metastatic incidence exceeding 10 %, the stations showing the first to fourth highest index were the paracardial and lesser curvature nodes (Nos. 1, 2, and 3) and the node at the root of the left gastric artery (No. 7) in the total cohort, as well as in each type. The next station was the lower thoracic paraesophageal lymph node (No. 110), followed by the nodes along the proximal splenic artery (No. 11p) in type II, whereas it was the nodes along the proximal splenic artery (No. 11p) followed by the para-aortic nodes (No. 16a2), the nodes at the celiac artery (No. 9), and the nodes around the splenic hilum (No. 10) in type III.

CONCLUSIONS

These results suggest that the highest priority nodal stations to be dissected were the paracardial and lesser curvature nodes (Nos. 1, 2, and 3) and the nodes at the root of the left gastric artery (No. 7), regardless of the Siewert subtype, but the subsequent priority was different depending on the subtype.

[Treatment of gastric cancer beyond current guideline: state of the art]

The majority of recommendations in the current S3 guideline on the diagnosis and treatment of gastric carcinoma are based on good clinical practice and lack supporting randomized studies. With the development of endoscopic resection and multimodal treatment concepts, pretherapeutic tumor staging has gained in importance. However, the accuracy of present imaging modalities is still limited with a tendency towards overstaging of locally advanced tumors. Extended lymph node dissection cannot be recommended in cases with advanced lymph node involvement. In cardiac cancer retroperitoneal lymphatic spread to the left renal vein is an early event and should thus not be classified as stage IV disease. In cases of intra-abdominal gastrectomy a pouch reconstruction should be considered in cases with a good overall prognosis. Subgroup analyses indicate a differential therapeutic effect of the established perioperative chemotherapy depending on the location of the primary tumor. There is also good evidence for an additional beneficial effect of radiotherapy in combination with chemotherapy.