Adenocarcinoma of distal esophagus and gastroesophageal junction: long-term results of surgical treatment in a North Indian Center

Left thoracoabdominal oesophagectomy: contemporary update on technique and outcomes

This contemporary guide to left thoracoabdominal oesophagectomy details the surgical aspects, surgical considerations, and outcomes from the two largest centres in the world that perform this procedure. The left thoracoabdominal approach increases the potential for negative resection margins in distal oesophageal, junctional, and cardial cancers. High-volume oesophageal centres should consider including the left thoracoabdominal approach in their operative options and ensure that their trainees are exposed to this unique approach to oesophagogastric resections.

Clinicopathological Characteristics and Survival Predictions for Adenocarcinoma of the Esophagogastric Junction: A SEER Population-Based Retrospective Study

Objective

Adenocarcinoma of the esophagogastric junction (AEJ) is a relatively rare malignancy in Western countries whose specific clinicopathological characteristics and associated prognosis have not been comprehensively described.

Methods

Data on patients with AEJ between 2005 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) database were extracted, evaluated, and compared with patients with gastric cancer (GC) in general. Overall survival (OS) was evaluated using the Kaplan–Meier method. Univariate and multivariate analyses were performed using the Cox proportional hazards regression model to identify risk factors predictive for OS, and the results were used to construct a nomogram to predict 1-, 3-, and 5-year OS among patients with AEJ.

Results

A total of 8013 patients diagnosed with AEJ were identified from the records of 30,179 patients with GC. The mean age was 65.4 (SD = 12.0) years, 79.5% were men, 87.2% were Caucasian, 91.5% were moderately-to-poorly differentiated, 34.4% had AJCC stage I AEJ, and 28.8% had stage IV. The median OS was 18 months, and the 5-year OS was 25.8% (95% CI: 24.8–26.8%). Fewer patients with AEJ had undergone surgical resection, fewer had T+ and N+ (N2~N3) disease (P < 0.001), and fewer had distant metastases compared to the patients with GC (P < 0.05). In the univariate and multivariate analyses, age, race, summary stage, N stage, M stage, and surgery were identified as independent risk factors. The nomogram had a calibration index of 0.726.

Conclusion

AEJ was found to have distinct clinicopathological characteristics. Age, race, summary stage, N stage, M stage, and surgery were independently associated with OS. The nomogram accurately predicted 1-, 3-, and 5-year OS rates.

Outcome of Surgery for Oesophageal Carcinoma in a Low Volume Centre, with and without Preoperative Chemoradiotherapy

Aims:

To critically assess the outcome of surgery for oesophageal carcinoma, with or without neoadjuvant chemoradiotherapy.

Methods:

Since April 1998 until August 2002 resectable oesophageal cancer patients referred to us have received multimodal treatment, consisting of two courses of fluorouracil, cisplatin and hydroxyurea and 20 Gy of radiotherapy followed by surgery. The outcome of this treatment was compared to the outcome of a historical group of oesophageal cancer patients, treated with surgery alone in the time period 1994 to 1998. The patients represent a consecutive series of 20 resectable oesophageal carcinomas, referred to us since 1994. Four patients (20 %) were treated for squamocellular carcinoma, 16 (80 %) patients for adenocarcinoma.

Results:

Treatment related toxicity was low and there was no death attributable to the chemoradiotherapy. Postoperative hospital mortality (< 30 days) and morbidity rates were 10 % and 50 %, respectively. A complete pathological response (T0) occurred in two of the nine patients in the multimodal group (22 %). Overall median survival was 11 months. Median survival among patients in the multimodal group was 14 months, as compared with 7 months in the group treated with surgery alone (P = 0.041).

Conclusions:

Despite low volume, outcome of surgery for oesophageal carcinoma was acceptable.

Suboptimal intake of nutrients after esophagectomy with gastric tube reconstruction

Esophagectomy with gastric tube reconstruction results in a variety of postoperative nutrition-related complaints that can impair nutritional intake and nutritional status. The aim of this study was to determine to what extent patients reached the recommended intake of various nutrients at 6 and 12 months after esophagectomy. It was also analyzed whether a suboptimal intake could be explained by the most clinically significant nutrition-related complaints after esophagectomy. In a prospective cohort study (2002 to 2006), the nutrient intake of 96 patients, recorded in preprinted nutritional diaries, was compared with the recommended energy intake in The Netherlands and Recommended Dietary Allowance of protein and micronutrients. Energy and protein intake remained below recommendations in 24% and 7% of the patients, respectively. Less than 10% of the patients had a sufficient intake of all micronutrients. Folic acid, vitamin D, copper, calcium, and vitamin B-1 were the micronutrients most often reported to have a suboptimal intake. Multivariate logistic regression, corrected for preoperative epigastric pain and energy intake, showed that the number of nutrition-related complaints was not an independent risk factor for the presence of a suboptimal intake of nutrients (adjusted odds ratio=1.11; 95% CI: 0.94 to 1.31; P = 0.22). This study shows that the intake of micronutrients remains below recommendations in the majority of patients 12 months after esophagectomy. This problem requires special attention and care by registered dietitians.

Presence and persistence of nutrition-related symptoms during the first year following esophagectomy with gastric tube reconstruction in clinically disease-free patients

BACKGROUND

Esophagectomy with gastric tube reconstruction results in a variety of postoperative nutrition-related symptoms that may influence the patient's nutritional status.

METHODS

We developed a 15-item questionnaire, focusing on the nutrition-related complaints the first year after an esophagectomy. The questionnaire was filled out the first week after discharge and 3, 6, and 12 months after surgery. The use of enteral nutrition, meal size and frequency, social aspects related to eating, defecation pattern, and body weight were recorded at the same time points. We analyzed the relationship between the baseline characteristics and the number of nutrition-related symptoms, as well as the relationship between those symptoms and body weight with linear mixed models.

RESULTS

We found no significant within-patient change for the total number of nutrition-related symptoms (P = 0.67). None of the baseline factors were identified as predictors of the complaint scores. The most frequently experienced complaints were early satiety, postprandial dumping syndrome, inhibited passage due to high viscosity, reflux, and absence of hunger. One year after surgery, meal sizes were still smaller, the social aspects of eating were influenced negatively, and patients experienced an altered stool frequency. Directly after the surgical procedure 78% of the patients lost weight, and the entire postoperative year the mean body weight remained lower (P = 0.47). We observed no association between the complaint scores and body weight (P = 0.15).

CONCLUSIONS

After an esophagectomy, most patients struggle with nutrition-related symptoms, are confronted with nutrition-related adjustments and a reduced body weight.

Adenocarcinoma of the esophago-gastric junction

BACKGROUND

The border between the esophagus and stomach gives rise to many discrepancies in the current literature regarding the etiology, classification and surgical treatment of adenocarcinoma arising at the esophago-gastric junction. We have consequently used the AEG-criteria (adenocarcinoma of the esophago-gastric junction) for classification and have based the selection of the surgical approach on the anatomic topographic subclassification.

METHODS

In the following we report an analysis of a large and homogeneously classified population of 1602 consecutive patients with adenocarcinoma of the esophago-gastric junction, with an emphasis on the surgical approach, the pattern of lymphatic spread, the outcome after surgical treatment and the prognostic factors. Demographic data, morphologic and histopathologic tumor characteristics, and long-term survival rates were compared among the three tumor subclassifiations.

RESULTS

The study confirms the marked differences in sex distribution, associated specialized intestinal metaplasia in the esophagus, tumor grading, tumor growth pattern, lymphatic spread, and stage between the three tumor entities. The degree of resection and lymph node status were the dominating independent prognostic factors by multivariate analysis. The data show no significant differences of long-term survival after abdomino-thoracic esophagectomy and extended total gastrectomy in these patients.

CONCLUSION

The classification of adenocarcinomas of the esophago-gastric junction in three types, AEG type I, type II and type III shows marked differences between the tumor entities and is recommended for selection of a proper surgical approach. Complete tumor resection and adequate lymphadenectomy are associated with good long-term prognosis. Better surgical management and standardized procedures will improve the outcome also of patients who need to undergo more radical surgery, i.e. abdomino-thoracic esophagectomy.

Adenocarcinoma of the esophagogastric junction: surgical therapy based on 1602 consecutive resected patients

Because of the borderline location between the esophagus and stomach, many discrepancies exist in the current literature regarding the etiology, classification, and surgical treatment of adenocarcinoma arising at the esophagogastric junction. The classification of adenocarcinomas into three types, AGE type I, type II, and type III, shows marked differences between the tumor entities and is recommended for selection of a proper surgical approach. Complete tumor resection and adequate lymphadenectomy are recommended for a good, long-term prognosis. With better surgical management and standardized procedures, even the results in patients with more radical surgical approaches, the abdomino-thoracic esophagectomy improved.

Left thoracoabdominal esophagogastrectomy: still a valid operation for carcinoma of the distal esophagus and esophagogastric junction

The left thoraco-abdominal (LTA) esophago-gastrectomy is rarely performed and yet provides excellent exposure of the esophageal hiatus. The aim of this study was to review the outcome of LTA esophago-gastrectomy within a single unit. Patients were selected for an LTA esophago-gastrectomy (January 2000 - June 2003) based upon the presence of locally advanced tumors of the distal esophagus and cardia. These patients were identified from a prospective consultant database. LTA esophagogastrectomy was technically possible in all 38 patients (34 males; median age = 63 years). In-hospital mortality was 2.6% (1 patient). Four patients (10.5%) were admitted to the intensive care unit and three (7.9%) returned to theatre. Two patients developed clinically apparent anastomotic leaks (5.3%). A potentially curative resection was performed in 34 patients (89%) but 22 (57.8%) of these patients were subsequently found to have tumor cells at or within 2 mm from the circumferential resection margin. The 1-year and 2-year overall survival rates were 70% and 52%, respectively. Long-term complications included benign anastomotic stricture (24%), delayed gastric emptying (26%) and a persistent thoracic wound sinus (15%). LTA esophagogastrectomy remains a viable approach with an acceptably low incidence of short and long-term complications.

Prognostic factors in adenocarcinoma of the esophagus or gastroesophageal junction

The incidence of adenocarcinoma of the esophagus is rising rapidly in Western Europe and North America. It is an aggressive disease with early lymphatic and hematogenous dissemination. TNM cancer staging systems predict survival on the basis of the anatomic extent of the tumor. However, the adequacy of the current TNM staging system for adenocarcinoma of the esophagus or gastroesophageal junction (GEJ) is questioned repeatedly. Numerous prognostic factors have been described, but are not included in the TNM system. This review describes clinical parameters, aspects of operative technique, response to preoperative chemoradiotherapy therapy, complications and established pathologic determinants found in the resection specimen that have a prognostic impact. Furthermore, their potential application in the clinical setting in patients with adenocarcinoma of the esophagus or GEJ is discussed. Future directions to improve staging systems are given.

Systematic review of the staging performance of 18F-fluorodeoxyglucose positron emission tomography in esophageal cancer

PURPOSE

Despite the increasing number of publications concerning (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) for staging of esophageal cancer and the increasing availability of this novel diagnostic modality, its exact role in preoperative staging of these tumors is still unknown. The aim of this study was to systematically review the literature regarding the diagnostic performance of FDG-PET in preoperative staging of patients with esophageal cancer, and to calculate summary estimates of its sensitivity and specificity.

METHODS

The databases of PubMed, Embase, and Cochrane were searched for relevant studies. Two reviewers independently assessed the methodological quality of each study. A meta-analysis of the reported sensitivity and specificity of each study was performed.

RESULTS

Twelve studies met the inclusion criteria. The studies had several design deficiencies. Pooled sensitivity and specificity for the detection of locoregional metastases were 0.51 (95% CI, 0.34 to 0.69) and 0.84 (95% CI, 0.76 to 0.91), respectively. For distant metastases, pooled sensitivity and specificity were 0.67 (95% CI, 0.58 to 0.76) and 0.97 (95% CI, 0.90 to 1.0), respectively.

CONCLUSION

FDG-PET showed moderate sensitivity and specificity for the detection of locoregional metastases, and reasonable sensitivity and specificity in detection of distant lymphatic and hematogenous metastases.

Surgical management of and long-term survival after adenocarcinoma of the cardia

BACKGROUND

The choice of surgical strategy for patients with adenocarcinoma of the oesophagogastric junction is controversial. This study was performed to analyse the surgical results of a 20-year experience with these lesions.

METHODS

From January 1981 to January 2001, 126 patients with adenocarcinoma of the cardia underwent resection in the authors' institution. The treatment of choice was oesophagectomy for type I tumours, and extended gastrectomy for type II and III lesions. Morbidity, mortality and survival were determined retrospectively.

RESULTS

Fifty-six patients (44.4 per cent) had type I tumours, 44 (34.9 per cent) type II and 26 (20.6 per cent) type III. Primary resection was performed in 113 patients (89.7 per cent). Oesophagectomy with resection of the proximal stomach was carried out in 65 patients (51.6 per cent) and extended total gastrectomy with transhiatal resection of the distal oesophagus in 61 (48.4 per cent). In-hospital mortality and morbidity rates were 4.8 and 34.1 per cent respectively. The overall 3- and 5-year survival rates were 40.9 and 25.1 per cent respectively, and were not affected by the surgical approach. Survival was significantly associated with R0 resection, pathological node-positive category, postoperative complications and tumour differentiation.

CONCLUSION

Postoperative mortality, morbidity and long-term survival did not appear to be affected by surgical approach. Further prospective studies are needed to confirm the equivalence between transthoracic and transabdominal approaches.

Validation of a modified GTNM classification in peri-junctional oesophago-gastric carcinoma and its use as a prognostic indicator

AIM

A modified GTNM classification (with additional T and N subdivisions) has been used for many years. The aim of this paper was to validate this classification in a group of patients with oesophago-gastric carcinoma and to see if the more detailed information may be useful.

METHOD

The 3-year survival of 139 consecutive patients who survived resection has been related to the individual values of the modified and international classifications.

RESULTS

A step-wise reduction in the survival was found with increasing values of G, T, N and M. The international T3 value yielded a 17.7% survival rate, when subdivided, rates of 37.5%, 17.3% and 3.2% were found. The international N1 value yielded a rate of 12.9% which subdivided into rates of 25.0%, 18.7% and 7.5%.

CONCLUSION

If these results are repeated in a larger and more detailed study, this modified classification may provide added information when discussing prognosis and management.

Adenocarcinoma of the esophagogastric junction: results of surgical therapy based on anatomical/topographic classification in 1,002 consecutive patients

OBJECTIVE

To assess the outcome of surgical therapy based on a topographic/anatomical classification of adenocarcinoma of the esophagogastric junction.

SUMMARY BACKGROUND DATA

Because of its borderline location between the stomach and esophagus, the choice of surgical strategy for patients with adenocarcinoma of the esophagogastric junction is controversial.

METHODS

In a large single-center series of 1,002 consecutive patients with adenocarcinoma of the esophagogastric junction, the choice of surgical approach was based on the location of the tumor center or tumor mass. Treatment of choice was esophagectomy for type I tumors (adenocarcinoma of the distal esophagus) and extended gastrectomy for type II tumors (true carcinoma of the cardia) and type III tumors (subcardial gastric cancer infiltrating the distal esophagus). Demographic data, morphologic and histopathologic tumor characteristics, and long-term survival rates were compared among the three tumor types, focusing on the pattern of lymphatic spread, the outcome of surgery, and prognostic factors in patients with type II tumors.

RESULTS

There were marked differences in sex distribution, associated intestinal metaplasia in the esophagus, tumor grading, tumor growth pattern, and stage distribution between the three tumor types. The postoperative death rate was higher after esophagectomy than extended total gastrectomy. On multivariate analysis, a complete tumor resection (R0 resection) and the lymph node status (pN0) were the dominating independent prognostic factors for the entire patient population and in the three tumor types, irrespective of the surgical approach. In patients with type II tumors, the pattern of lymphatic spread was primarily directed toward the paracardial, lesser curvature, and left gastric artery nodes; esophagectomy offered no survival benefit over extended gastrectomy in these patients.

CONCLUSION

The classification of adenocarcinomas of the esophagogastric junction into type I, II, and III tumors shows marked differences between the tumor types and provides a useful tool for selecting the surgical approach. For patients with type II tumors, esophagectomy offers no advantage over extended gastrectomy if a complete tumor resection can be achieved.

Clinicopathologic findings and results of surgical treatment in cardiac adenocarcinoma

BACKGROUND AND OBJECTIVES

There is a great deal of controversy regarding the definition, classification, and staging of cardiac adenocarcinoma (CA). Recently, a shift from distal to proximal lesions has been documented in gastric cancer. We have stratified our cases of gastric cancer as CA, distal gastric cancer (DGC), and stump cancer (SC).

METHODS

Between 1986 and 1998, 450 patients with gastric cancer were operated on at our institute. The resectability rate was 81.6%. Of 367 patients, 48 were CA, 298 DGC, and 21 SC. These 3 groups were compared in terms of clinicopathologic factors and survival rates.

RESULTS

CA was significantly higher in male patients and showed a prevalence of the Lauren intestinal type. Regarding staging parameters, CA showed a higher rate of T3 tumors and of resection line involvement. Five-year survival rates were 23. 2% for CA, 45.0% for DGC, and 17.4% for SC.

CONCLUSIONS

A possible cause of the poor outcome of CA is presentation at a more advanced stage. CA was similar to SC as far as epidemiology, pathologic factors, and survival rates.