Results of surgical treatment of adenocarcinoma of the gastric cardia

Transhiatal versus transthoracic esophagectomy for esophageal SCC: outcomes and complications

Background

Transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) are both accepted procedures for esophageal cancer but still the most effective surgical approach continues to be controversial. This study aimed to determine post-operative complications and outcomes of TTE compared with THE.

Methods

A retrospective analysis was performed on data of 243 adult patients with resectable esophageal cancer who underwent THE or TTE between December 2016 and October 2018. Demographic data, consisting of preoperative co-morbidities, disease stage, and perioperative morbidity and mortality were collected.

Results

Among the patients, 99 individuals (40.7%) had a transhiatal resection and 144 (59.3%) had a transthoracic resection. Most patients (83.1%) were above 50 years old with no significant difference between groups (p = 0.297). The frequency distribution of comorbidities was similar in both groups. The most common site of the tumor in TTE group was middle esophagus and in THE group was lower esophagus. The most common complication was recurrence of dysphagia which was more common in THE group without significant difference. The other complications including pulmonary and cardiac events, tracheal and recurrent laryngeal nerve injury, chylothorax and anastomosis stricture did not differ between the groups. The operative mortality within 30 days after the operation was 2.8% with significant difference favored the THE group (THE 0%, TTE 5.2%, p = 0.033).

Conclusion

Because of the controversies, the decision on the type of surgical technique in esophageal cancer treatment hinges on patient’s co-morbidities, cancer stage, tumor location and surgeon’s experience.

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.

Adenocarcinoma of the esophagogastric junction and its background mucosal pathology: A comparative analysis according to Siewert classification in a Japanese cohort

Adenocarcinoma of the esophagogastric junction (AEG) has heterogeneous carcinogenic process due to its location straddling the esophagogastric junction. We assessed background mucosal pathology and its correlation with clinicopathological features of each Siewert type of AEG. Clinicopathological and immunohistochemical analyses of 103 AEGs and 58 gastric cancers (GCs) were conducted. Background mucosal features were evaluated according to the updated Sydney System. Siewert classification divided 103 AEGs into three type I, 75 type II, and 25 type III tumors, respectively. Two type I, 9 type II AEGs, and none of type III AEGs were Barrett-related and were excluded from further analysis. Background mucosa of type III AEGs more frequently showed moderate to marked degree of atrophy and intestinal metaplasia than those of type II AEGs and was very similar to those of GCs. Among type II AEGs, tumors with atrophic background were significantly associated with higher patient age and intestinal-type histology. Type II AEGs with nonatrophic background, but not those with atrophic background, showed more frequent mismatch repair deficiency, TP53 overexpression, and less frequent intestinal phenotypic markers expression than type III AEG or GC. Type II AEGs with atrophic background involved suprapancreatic nodes more frequently than those without. We demonstrated that chronic atrophic gastritis was a major precancerous condition of AEG in the Japanese population, especially Siewert type III which had background mucosal pathology similar to that of GC. Type II AEGs with and without atrophic background showed some clinicopathological differences, and these observations might represent heterogeneous carcinogenic process within type II AEGs.

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

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

Siewert III adenocarcinoma: treatment update

Siewert III cancer, although representing around 40% of EGJ cancers and being the EGJ cancer with worst prognosis, does not have a homogenous treatment, has few dedicated studies, and is often not considered in study protocols. Although staged as an esophageal cancer by the TNM 7th ed., it is considered a gastric cancer by new TNM 8th ed. Our aim was to consolidate the current literature on the indications and treatment options for Siewert III adenocarcinoma. A review of the literature was performed to better delineate treatment indications (according to stage, surgical margins, type of lymphatic spread and lymphadenectomy) and treatment strategy. The treatment approach is strictly dependent on cancer site and nodal diffusion. T1m cancers have insignificant risk of nodal metastases and can be safely treated with endoscopic resections. The risk of nodal metastases increases markedly starting from T1sm cancers and requires surgery with lymphadenectomy. The site of this type of cancer and the nodal diffusion require a total gastrectomy and distal esophagectomy, with 5 cm of clear proximal and distal margins and a D2 abdominal and inferior mediastinal lymphadenectomy. Multimodal treatments are indicated in all locally advanced and node positive cancers. Siewert III cancers are gastric cancers with some peculiarities and require dedicated studies and deserve more consideration in the current literature, especially because their treatment is particularly challenging.

Mediastinal lymph node dissection and distal esophagectomy is not essential in early esophagogastric junction adenocarcinoma

BACKGROUND

Optimal extent of surgery remains controversial in types 2 and 3 adenocarcinoma of esophagogastric junction (AEG). We aimed to determine whether the extended procedure including mediastinal lymphadenectomy is essential in all patients with AEG by comparing prognosis and recurrence of proximal gastric adenocarcinoma based on total gastrectomy with intra-abdominal lymphadenectomy.

METHODS

The clinicopathologic characteristics of 672 patients (type 2: 90, type 3: 211, upper third of the stomach: 371 cases) who underwent curative total gastrectomy with lymphadenectomy between 2003 and 2009 were reviewed.

RESULTS

Recurrence was observed in 36.7, 16.1, and 16.1% of cases of type 2 AEG, type 3 AEG, and cancer of the upper third of the stomach, respectively. The 5-year disease-free survival rates were 62.6, 82.5, and 84.6%, respectively. Subgroup analysis revealed that in early cancers, there was no difference in survival between the groups (93.2 vs. 96.7 vs. 98.7%) but in advanced cancers, there was a difference (47.9 vs. 75.4 vs. 71.8%, P < 0.001). There was no survival difference in stage 1 (97.5 vs. 98.7 vs. 98.3%), but, in stage 2, type 2 AEG had a worse prognosis (41.9 vs. 92.1 vs. 83.0%). Types 2 and 3 advanced AEG had higher rates of locoregional recurrence, especially in the vicinity of the esophagojejunostomy and mediastinal lymph nodes compared to proximal gastric cancer.

CONCLUSIONS

Total gastrectomy without mediastinal lymphadenectomy might produce favorable outcomes in early AEG and acquisition of a greater length of proximal margin, and removal of mediastinal lymph nodes might be helpful in advanced cancers.

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.

Changes of Esophagogastric Junctional Adenocarcinoma and Gastroesophageal Reflux Disease Among Surgical Patients During 1988-2012: A Single-institution, High-volume Experience in China

To evaluate the changes of esophagogastric junctional adenocarcinoma (EGJA) and gastroesophageal reflux disease (GERD) among surgical patients from 1988 to 2012 in a Chinese high-volume hospital.

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.

Esophagus or stomach? The seventh TNM classification for Siewert type II/III junctional adenocarcinoma

BACKGROUND

The aim of this study is to clarify whether TNM-EC or TNM-GC is better for classifying patients with AEG types II/III.

METHODS

The patients who had AEG types II/III and received D1 or more radical lymphadenectomy were selected. The patients were staged both by seventh edition of TNM-EC and TNM-GC. The distribution of the patients, the hazard ratio (HR) of each stage, and the separation of the survival were compared.

RESULTS

A total of 163 patients were enrolled in this study. TNM-EC and TNM-GC classified 25 (20 and 5) and 32 (20 and 12) patients to stage I (IA and IB), 15 (4 and 11), and 33 (11 and 22) to stage II (IIA and IIB), 88 (24, 3, and 61) and 63 (14, 26, and 23) to stage III (IIIA, IIIB, and IIIC), and 35 and 35 to stage IV, respectively. The distribution of the patients was substantially deviated to stage IIIC in TNM-EC but was almost even in TNM-GC. A stepwise increase of HR was observed in TNM-GC, but not in TNM-EC. The survival curves between stages II and III were significantly separated in TNM-GC (P = 0.019), but not in TNM-EC (P = 0.204). The 5-year survival rates of stages IIIA, IIIB, and IIIC were 69.0, 100, and 38.9% in TNM-EC and were 52.0, 43.4, and 33.9% in TNM-GC, respectively.

CONCLUSIONS

TNM-GC is better for classifying patients with AEG types II/III than TNM-EC is. These results could impact the next TNM revision for AEG.

Staging and outcome depending on surgical treatment in adenocarcinomas of the oesophagogastric junction

BACKGROUND

Owing to controversial staging and classification of adenocarcinoma of the oesophago-gastric junction (AOG) before surgery, the choice of appropriate surgical approach remains problematic. In a retrospective study, preoperative staging of AOG and the impact of preoperative misclassification on outcome were analysed.

METHODS

Data from patients with AOG were analysed from a prospectively collected database with regard to surgical treatment, preoperative and postoperative staging, and outcome.

RESULTS

One-hundred and thirty patients with Siewert types I and II AOG who did not have neoadjuvant treatment were included in the study: 41 patients with an AOG type I who underwent oesophagectomy, 51 patients with an AOG staged before surgery as type I who underwent oesophagectomy but in whom the final histology showed a type II tumour, and 38 patients whose tumours were staged as AOG type II before and after operation who underwent gastrectomy. Among patients who had an oesophagectomy, lymph node metastases (P = 0.022), tumour relapse (P = 0.009) and recurrent distant metastases (P = 0.028) were significantly more frequent in patients with AOG type II; those with AOG type II had shorter overall survival than those with type I tumours (P = 0.024). Among those with AOG type II, recurrence-free survival was significantly shorter after oesophagectomy compared with extended gastrectomy (P = 0.019). Thoracoabdominal oesophagectomy had a favourable influence on outcome compared with the transhiatal approach.

CONCLUSION

Accurate preoperative staging of AOG and appropriate surgical therapy are crucial for outcome. AOG type II is a more aggressive tumour with higher recurrence rates than AOG type I. These patients therefore benefit from more radical surgical treatment.

Factors predicting survival in patients with proximal gastric carcinoma involving the esophagus

AIM: To investigate the clinicopathologic features which predict surgical overall survival in patients with proximal gastric carcinoma involving the esophagus (PGCE).

METHODS: Electronic pathology database established in the Department of Pathology of the Nanjing Drum Tower Hospital was searched for consecutive resection cases of proximal gastric carcinoma over the period from May 2004 through July 2009. Each retrieved pathology report was reviewed and the cases with tumors crossing the gastroesophageal junction line were selected as PGCE. Each tumor was re-staged, following the guidelines on esophageal adenocarcinoma, according to the 7th edition of the American Joint Commission on Cancer Staging Manual. All histology slides were studied along with the pathology report for a retrospective analysis of 13 clinicopathologic features, i.e., age, gender, Helicobacter pylori (H. pylori) infection, surgical modality, Siewert type, tumor Bormann’s type, size, differentiation, histology type, surgical margin, lymphovascular and perineural invasion, and pathologic stage in relation to survival after surgical resection. Prognostic factors for overall survival were assessed with uni- and multi-variate analyses.

RESULTS: Patients’ mean age was 65 years (range: 47-90 years). The male: female ratio was 3.3. The 1-, 3- and 5-year overall survival rates were 87%, 61% and 32%, respectively. By univariate analysis, age, male gender, H. pylori, tumor Bormann’s type, size, histology type, surgical modality, positive surgical margin, lymphovascular invasion, and pT stage were not predictive for overall survival; in contrast, perineural invasion (P = 0.003), poor differentiation (P = 0.0003), > 15 total lymph nodes retrieved (P = 0.008), positive lymph nodes (P = 0.001), and distant metastasis (P = 0.005) predicted poor post-operative overall survival. Celiac axis nodal metastasis was associated with significantly worse overall survival (P = 0.007). By multivariate analysis, ≥ 16 positive nodes (P = 0.018), lymph node ratio > 0.2 (P = 0.003), and overall pathologic stage (P = 0.002) were independent predictors for poor overall survival after resection.

CONCLUSION: Patients with PGCE showed worse overall survival in elderly, high nodal burden and advanced pathologic stage. This cancer may be more accurately staged as gastric, than esophageal, cancer.

Outcomes of Abdominal Total Gastrectomy for Type II and III Gastroesophageal Junction Tumors: Single Center's Experience in Korea

Purpose

The aim of this study was to evaluate the surgical outcomes of abdominal total gastrectomy, without mediastinal lymph node dissection for type II and III gastroesophageal junction (GEJ) cancers.

Materials and Methods

We retrospectively reviewed surgical outcomes in 67 consecutive patients with type II and III GEJ cancers that were treated by the surgical resection between 2004 and 2008.

Results

Thirty (45%) patients had type II and 37 (55%) had type III tumor. Among the 65 (97%) patients with curative surgery, 21 (31%) patients underwent the extended total gastrectomy with trans-hiatal distal esophageal resection, and in 44 (66%) patients, abdominal total gastrectomy alone was done. Palliative gastrectomy was performed in two patients due to the accompanying peritoneal metastasis. The postoperative morbidity and mortality rates were 21.4% and 1.5%, respectively. After a median follow up of 36 months, the overall 3-years was 68%, without any differences between the Siewert types or the operative approaches (transhiatal approach vs. abdominal approach alone). On the univariate analysis, the T stage, N stage and R0 resection were found to be associated with the survival, and multivariate analysis revealed that the N stage was a poor independent prognostic factor for survival.

Conclusions

Type II and III GEJ cancers may successfully be treated with the abdominal total gastrectomy, without mediastinal lymph node dissection in the Korean population.

Gastric cardiac carcinomas involving the esophagus are more adequately staged as gastric cancers by the 7th edition of the American Joint Commission on Cancer Staging System

The aim of this study was to compare the 7th with the 6th edition of the American Joint Commission on Cancer Staging System for prognostic stratification of gastric cardiac carcinomas involving the esophagus. We retrospectively compared differences in pathological stages with patient survival between the 7th and the 6th staging systems in 142 consecutive resection cases of this cancer. Patient median age was 65 years. The male-female ratio was 3.3. The epicenter of all tumors was within 5 cm below the gastroesophageal junction. The median tumor size was 5.0 cm. Most tumors (79%) were typical adenocarcinomas and the rest showed uncommon histology types. Using the guidelines for gastric cancer, this group of cancer was better stratified by the 7th than the 6th edition of the staging system, especially for pathological nodal (pN) and overall stage pIIIC. Patients with celiac axis nodal disease had the 5-year survival rate worse than those staged at pN3A and pIIIA. Patients staged at pT3 and pN3B had the 5-year survival rate worse than those at pM1 and pIV. We showed that the overall stage of gastric cardiac carcinomas was better stratified by gastric than by esophageal cancer grouping. We conclude that these tumors are better stratified with the 7th than the 6th edition of the gastric staging system, especially for pIII cancers, and better staged by the new gastric than esophageal cancer staging system. We propose that the staging of these tumors be reverted to gastric grouping and combine pT3 and pN3B into the overall stage pIV.

Adenocarcinoma of the esophagogastric junction: incidence, characteristics, and treatment strategies

The incidence of adenocarcinoma of the esophagogastric junction (AEG) is dramatically increasing in Western countries, while it is not increasing in Eastern countries. Siewert type I tumors are observed less frequently in Eastern countries in comparison to Western countries. On the other hand, other clinicopathological features of AEG, including age, male-to-female ratio, pathological grade, tumor progression, and prognosis, are similar in Western and Eastern countries. Two surgical phase III trials have indicated that AEG type I should be treated surgically as esophageal cancer, while types II and III should be regarded as true gastric cancer. No phase III trials have demonstrated a significant interaction comparing hazard ratios for death between AEG and true gastric cancer in the subset analyses with regard to chemotherapy.

Is adenocarcinoma of the esophagogastric junction different between Japan and western countries? The incidence and clinicopathological features at a Japanese high-volume cancer center

BACKGROUND

We clarified the incidence of adenocarcinoma of the esophagogastric junction (AEG) at a Japanese high-volume cancer center and its clinicopathological features between the Siewert subtypes.

METHODS

Patients with AEG were selected from a prospective database of gastric and esophageal tumors established by Kanagawa Cancer Center. The Siewert subtypes were determined retrospectively by examining pathological pictures of the resected specimens and by evaluating the pathology and endoscopy findings.

RESULTS

From January 1986 to December 2005, 147 (4.0%) patients were determined to have AEG; 2,794 (75.8%) were diagnosed to be true gastric cancer, whereas 745 (20.2%) were true esophageal cancer. Of these 147 patients with AEG, 5 (3.4%) were classified as type I, 82 (55.8%) as type II, and 60 (40.8%) as type III tumors. The depth of tumor invasion was deeper and the nodal metastases were more frequent in type III compared with type II. The risk factors for nodal metastases included the depth and size of the tumor, but not the Siewert subtypes itself. Mediastinal nodal metastases were strongly influenced by a thoracotomy and the extent of the dissection. The pathological grade was higher in type III than in type II. Although the 5-year survival rate was significantly higher in type II than in type III tumors, the survival difference disappeared when the patients were restricted to an R0 resection, even though type III patients demonstrated a more advanced stage.

CONCLUSIONS

The proportions of AEG were strikingly different between Japan and western countries. Although each Siewert subtype had some different characteristics, nodal metastases were determined by both the tumor progression and the extent of the nodal dissection. An R0 resection was a key for the survival in AEG.

Clinical characteristics, biologic behavior, and survival after esophagectomy are similar for adenocarcinoma of the gastroesophageal junction and the distal esophagus

OBJECTIVE

The Siewert classification system differentiates between adenocarcinoma of the gastroesophageal junction and that of the distal esophagus. The purpose of this study was to evaluate whether there were differences in the location and prevalence of lymph node metastases, type of recurrence, and survival with these tumors that warrant distinguishing between them in clinical practice.

METHODS

Records of all patients who underwent resection for adenocarcinoma of the distal esophagus or gastroesophageal junction from 1987 to 2007 were retrospectively reviewed. Based on the endoscopic location of the epicenter of the tumor in relation to the gastroesophageal junction, tumors were categorized in 301 patients as being of the distal esophagus and in 208 as being of the gastroesophageal junction.

RESULTS

There were no significant differences in age, sex, or body mass index between patients with adenocarcinoma of the distal esophagus or gastroesophageal junction. Patients with adenocarcinoma of the distal esophagus were more likely to have reflux symptoms (75% vs 53%, P < .0001) and peritumoral intestinal metaplasia (73% vs 51%, P < .0001) and be in a surveillance program (54% vs 9%, P = .0005) compared with patients with adenocarcinoma of the gastroesophageal junction. However, the prevalence and location of nodal metastases was similar, and in node-positive patients mediastinal node involvement was present in more than 40% of the patients in each group (distal esophageal adenocarcinoma, 47%; gastroesophageal junction adenocarcinoma, 41%). Survival was similar (5 years: distal esophageal adenocarcinoma, 45%; gastroesophageal junction adenocarcinoma, 38%; P = .14), as was the prevalence and type of recurrence.

CONCLUSION

The prevalence and distribution of lymph node metastases in patients with adenocarcinoma of the distal esophagus and gastroesophageal junction were similar, and after esophagectomy, there was no difference in overall survival or recurrence. Efforts to differentiate between these tumors are unnecessary, and both are effectively treated with esophagectomy.

Adenocarcinoma of the esophagogastric junction: the role of abdominal-transhiatal resection

The surgical strategy for adenocarcinoma of the esophagogastric junction is still controversial. The aim of this study was to evaluate surgical results of the abdominal-transhiatal approach for 100 consecutively operated type II and III cardia adenocarcinoma, to clarify clinicopathological differences between these tumors, and to define prognostic factors. A prospectively maintained database identified 100 consecutively operated patients with Siewert type II and III cardia adenocarcinoma. Survival was analyzed by the Kaplan-Meier method. Differences between subgroups and prognostic factors were evaluated by the log rank test and Cox regression. Concerning clinicopathological characteristics, only the incidence of T1-2 stage was significantly higher in Siewert II type (P = .006). A complete (R0) resection was obtained in 74 patients (74%). Overall postoperative mortality and morbidity rates were 6% and 28%, respectively. Overall actuarial 5-year survival rate in resected patients was 27.4% (median 27 months), with 20.6% for type II and 34 for type III cancers (P = .07). Considering R0 resections, overall actuarial 5-year survival rate was 33.9% (median 33 months), with 26.7% for type II and 40.5 for type III cancer (P = .06). Pathologic T and N stage and R status were independent prognostic factors by multivariate analysis, and Siewert type showed a trend toward significance. The abdominal-transhiatal approach is a safe surgical approach, allowing complete tumor resection and adequate lymphadenectomy in these patients. True carcinoma of the cardia may be a distinct clinical entity with a more aggressive natural history than subcardial gastric carcinoma.

Minimally invasive esophagectomy: a comparative study of transhiatal laparoscopic approach versus laparoscopic right transthoracic esophagectomy

BACKGROUND

The development of minimally invasive surgery gave birth to an interest in a mini-invasive approach to esophageal cancer; however, it is still considered to be one of the most complex gastrointestinal surgical operations, and many questions still remain unanswered, regarding the oncologic results of a mini-invasive approach in long-term follow-ups. Here, the authors report on the short-term and long-term results of a series of laparoscopic esophagectomies.

PATIENTS AND METHODS

From January 2002 to March 2006, 22 nonrandomized patients were recruited to undergo an esophagectomy for neoplastic disease. The esophagectomy and esophagogastroplasty were carried out using the laparoscopic transhiatal technique in 9 patients; whereas, a combined laparoscopic and right-transthoracic incision was performed in the other 13 patients.

RESULTS

The mean follow-up was 21+/-3.23 months (mean+/-SD); range, 2 to 46 months. The overall survival rate resulted 84.0% at 12 months, 61.3% at 24 months, and 51.0% at 36 months. The proportions of cumulative survival showed significant differences when the following variables were considered: site of neoplasm (lower esophagus), American Society of Anesthesiologists 2, chronic obstructive pulmonary disease, type of surgical procedure, and inclusion in neoadjuvant protocol and staging. Recurrence rates were 3 (25%) in the radio-chemotherapy-treated group, and 5 (50%) in the primary surgery group (P=n.s.).

CONCLUSIONS

The two-year survival rates (61.3%) recorded in our series are comparable with those reported in other series of both laparoscopic and open surgeries. The logical conclusion was that a less invasive procedure did not imply a less curative one.

Expression of multidrug-resistance-related proteins P-glycoprotein, glutathione-S-transferases, topoisomerase-II and lung resistance protein in primary gastric cardiac adenocarcinoma

AIM

Multidrug resistance (MDR) is closely correlated to an unfavorable prognosis in various human cancers. However, the clinical significance of the expression of MDR-related proteins p-glycoprotein (PGP), glutathione-s-transferases (GST-pi), topoisomerase-II (Topo-II) and lung resistance protein (LRP) in primary gastric cardiac adenocarcinoma (PGCA) remains unclear. In this present study, the total of the four kinds of MDR-related proteins mentioned above were detected by using immunohistochemistry, and their clinical significance in chemoresistance were also investigated.

METHODS

This retrospective study included 69 resected specimens from patients with PGCA. The expression of PGP, GST-pi, Topo-II and LRP in formalin-fixed paraffin-embedded tissue sections was determined by a labelled streptavidin-biotin immunohistochemical technique, and the results were analyzed in correlation with clinicopathological data. None of these patients received chemotherapy prior to surgery.

RESULTS

The positive rates of expression of PGP, GST-pi, Topo-II and LRP in malignant tissues (49.2%, 75.4%, 68.1% and 58%, respectively) were all higher than that of the normal tissues(0, 30%, 20% and 0, respectively, P < 0.01). PGP expression in tumors that had metastasized was significantly more frequent than in tumors that had not metastasized (67.5% vs 24.1%, P < 0.01). The expression of PGP was closely related with clinicopathologic staging (staging 1/2 vs 3/4, 28.6% vs 58.3%, P < 0.05). No significant correlation was shown between PGP and increasing differentiated degree (40%, 42.4% and 61.5%, P > 0.05). GST-pi expression status progressively increased with increasing differentiated degree (40%, 75.8% and 88.5%, P < 0.05) and clinicopathologic stage (staging 1/2 vs 3/4, 57.1% vs 83.3%, P < 0.05). In addition, a significant positive correlation was also observed between GST-pi and lymphatic metastasis (with vs. without metastasis, 87.5% vs 58.6%, P < 0.05). The expression of Topo-II was associated with increasing differentiated degree (33.3%, 69.7 and 80.7%, P < 0.01). No significant differences with Topo-II expression were found in relation to the clinicopathologic stage (staging 1/2 vs 3/4, 57.1% vs 72.9%, P > 0.05) and lymphatic metastasis (with vs. without metastasis, 65.0% vs 72.4%, P > 0.05). Moreover, a significant difference with the expression of LRP was found in relation to the clinicopathologic stage (staging 1/2 vs 3/4, 38% vs 66.6%, P < 0.05), and lymphatic metastasis (with vs without metastasis, 70.0% vs 41.4%, P < 0.05). Comparing the well, moderately and poorly differentiated cohort, a non-statistical increasing trend towards LRP expression status was noted (50.0%, 54.5% and 65.3%, respectively, P > 0.05). Besides, the co-expression of all four tested MDR-related proteins also existed. The positive rates of co-expression of PGP and GST-pi, PGP and Topo-II, PGP and LRP, GST-pi and Topo-II, LRP and GST-pi, LRP and Topo-II, PGP, GST-pi, Topo-II and LRP in malignant cells were 23.2%, 15.9%, 11.6%, 13.0, 26.1, 7.24, 5.8, respectively.

CONCLUSIONS

MDR-related proteins PGP, GST-pi, Topo-II alpha and LRP are involved in multiple mechanisms of drug resistance in PGCA. Combined determination of PGP, GST-pi, Topo-II and LRP may be prospectively valuable for optimizing the chemotherapy regimes, developing high quality anti-cancer drugs, and further predicting the outcomes of those patients with PGCA.

Lymph node involvement in advanced gastroesophageal junction adenocarcinoma

OBJECTIVE

The prognosis of gastroesophageal junction adenocarcinoma is unquestionably related to the extent of nodal involvement; nonetheless, few studies deal with the pattern of lymph node spread and specifically analyze the prognostic value of the site of metastasis. The present study was aimed at evaluating these key aspects in advanced gastroesophageal junction adenocarcinoma.

METHODS

Of 219 patients consecutively operated on for gastroesophageal junction adenocarcinoma at the Department of General Surgery and Surgical Oncology, University of Siena, and at the Department of General Surgery, University of Verona, 143 pT2-4 tumors not submitted to prior chemoradiation were analyzed according to the Japanese Gastric Cancer Association pN staging system.

RESULTS

The majority of patients were given diagnoses of nodal metastases (77.6%). The mean number (P = .076) and the percentage of patients with pN+ disease (P = .022) progressively increased from Siewert type I to type III tumors. Abdominal nodes were involved in all but 1 of the patients with pN+ disease; conversely, nodal metastases into the chest were 46.2% for type I, 29.5% for type II, and 9.3% for type III tumors. Survival analysis showed virtually no chance of recovery for patients with more than 6 metastatic nodes or lymph nodes located beyond the first tier.

CONCLUSIONS

In advanced gastroesophageal junction adenocarcinoma, the high frequency of nodal metastases and the related unfavorable long-term outcome achieved by means of surgical intervention alone are indicative of the need for aggressive multimodal treatment along with surgical intervention to improve long-term results.

Management of gastroesophageal tumors

The incidence of adenocarcinomas of the gastroesophageal junction has increased in recent years. These tumors possess distinct pathophysiologic characteristics. Although the consensus is that an R0 resection (complete microscopic and macroscopic resection) is the goal when operating for curative intent, much controversy remains regarding other aspects of patient management. There is lack of consensus regarding the type of surgery to perform, the role and extent of lymphadenectomy, and the role of neoadjuvant therapy. Utilizing an evidence-based approach, this review article provides an overview of the management of gastroesophageal junction carcinomas with particular emphasis on current areas of controversy.

Nodal Staging in Adenocarcinoma of the Gastro-Esophageal Junction. Proposal of a Specific Staging System

PURPOSE

This study was aimed at developing a proper nodal staging system for GEJ adenocarcinoma.

METHODS

The study analyzed 113 patients with GEJ adenocarcinoma consecutively resected at the Department of General Surgery and Surgical Oncology of the University of Siena and at the Department of General Surgery of the University of Verona. Both the number (TNM) and site (JGCA) of lymph node metastasis was evaluated in considering nodal staging.

RESULTS

The TNM and JGCA staging systems coincided only in 56.3% of cases. Nodal involvement resulted to be the most important prognostic factor considering both the staging systems (P < 0.001). An extremely poor prognosis and a prominent risk of death were observed for patients with more than six metastatic nodes (TNM pN2-3) as well as for patients with involvement of second and third tier nodes (JGCA pN2-3) (P < 0.001). The combined prognostic significance of the two classifications showed a similar risk of death for patients with less than seven metastatic nodes (TNM pN1) located beyond the first tier (JGCA pN2-3) and for patients with more than six involved nodes (TNM pN2-3) independently from the interested level (JGCA pN1-3). Accordingly, these classes were pooled together and four classes considered: pN0, TNM-JGCA pN1, TNM pN2-3 or JGCA pN2-3, M1a (P < 0.001).

CONCLUSIONS

The combination of the TNM and JGCA staging systems herein proposed is extremely practical from a clinical point of view and leads to the stratification of pN+ patients in two classes only with very different risk of death.

Surgical management of esophagogastric junction tumors

Surgical resection with lymphadenectomy is the mainstay of treatment for all resectable esophagogastric junction tumors, prior to systemic generalization of the disease. This makes accurate pre-treatment staging and classification of the tumors most demanding. A well-established and internationally accepted classification for adenocarcinomas of the esophagogastric junction (AEG) helps to choose the appropriate surgical approach and to make results from different institutions comparable. Distal esophageal adenocarcinomas (AEGI) are distinguished from true cardia carcinomas (AEG II) and subcardiac gastric cancers (AEG III). Substantial advancements in this surgical field during the preceding decades have clearly revealed that individualization of the surgical strategy is the key to successfully approaching these entities. In this review we discuss the surgical management of esophagogastric junction tumors with a tailored surgical strategy.

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.

Metabolic imaging predicts response, survival, and recurrence in adenocarcinomas of the esophagogastric junction

PURPOSE

A previous study suggested that measurement of therapy-induced changes in tumor glucose metabolism by positron emission tomography (PET) with the glucose analog [18F]fluorodeoxyglucose (FDG) allows to select patients most likely to benefit from preoperative chemotherapy in adenocarcinomas of the esophagogastric junction (AEG). The aim of this study was to prospectively validate these findings by using an a priori definition of metabolic response.

PATIENTS AND METHODS

Sixty-five patients with locally advanced AEGs were included. Tumor glucose utilization was quantitatively assessed by FDG-PET before chemotherapy and 14 days after initiation of therapy. Patients were classified as metabolic responders when the metabolic activity of the primary tumor had decreased by more than 35% at the time of the second PET.

RESULTS

Metabolic responders showed a high histopathologic response rate (44%) with a 3-year survival rate of 70%. In contrast, prognosis was poor for metabolic nonresponders with a histopathologic response rate of 5% (P = .001) and a 3-year survival rate of 35% (P = .01). A multivariate analysis (covariates: ypT-, ypN-category, histopathologic response) demonstrated that metabolic response was the only factor predicting recurrence (P = .018) in the subgroup of completely resected (R0) patients.

CONCLUSION

This study prospectively demonstrates that changes in tumor metabolic activity during chemotherapy predict response, prognosis, and recurrence. These data provide the basis for clinical trials in which preoperative treatment is changed for patients without a metabolic response early in the course of therapy. PET-guided induction therapy may even be applicable to earlier tumor stages because surgery is only minimally delayed in nonresponding patients.

Surgical treatment of tumors of the proximal stomach with involvement of the distal esophagus: a 26-year experience with Siewert type III tumors

OBJECTIVE

A paucity of outcome data exists regarding patients with proximal stomach cancer involving the distal esophagus (Siewert type III tumors). This is especially true with regard to long-term survival rates after surgical intervention.

METHODS

Medical records were reviewed of all patients who underwent total gastrectomy and distal esophagectomy with Roux-en-Y esophagojejunostomy for Siewert type III tumors from January 1975 through December 2000.

RESULTS

There were 116 patients (93 men and 23 women). The median age was 66 years (range, 22-87 years). Pathologic stage was 0 (carcinoma in situ) in 1 patient, IB in 13 patients, II in 17 patients, IIIA in 34 patients, IIIB in 10 patients, and IV in 41 patients. Complete resection was achieved in 69 (59.5%) patients. Eleven (9.5%) patients were treated with neoadjuvant therapy, 49 (42.2%) received adjuvant therapy, and 6 (5.2%) received intraoperative radiation. Follow-up was complete in 114 (98.3%) patients, ranging from 1 to 281 months (median, 14 months). Operative mortality was 5.2%. Complications occurred in 51 (43.9%) patients. Clinically significant anastomotic leaks occurred in 15 (12.9%) patients. Median hospitalization was 13 days (range, 8-70 days). Median follow-up was 14 months (range, 1-281 months). Overall median survival was 434 days, with 1-, 5-, and 10-year survivals of 56.2%, 19.0%, and 13.5%, respectively. The only factor associated with increased hospital mortality was anastomotic leakage (P = .002). Incomplete resection, increased tumor stage and grade, and splenic involvement significantly worsened long-term survival.

CONCLUSIONS

Total gastrectomy and distal esophagectomy for Siewert type III tumors is associated with reasonable mortality and significant morbidity. Although often palliative, surgical intervention can provide long-term survival, especially in patients with completely resected, early-stage, low-grade tumors.

Evaluation of Siewert classification in gastro-esophageal junction adenocarcinoma: What is the role of endoscopic ultrasonography?

BACKGROUND

Preoperative assessment of gastro-esophageal junction (GEJ) adenocarcinoma stage and its location according to Siewert are essential for planning the therapeutic approach. The present study was aimed at analyzing the utility of endoscopic ultrasonography (EUS) in evaluating GEJ adenocarcinoma stage and whether this modality added to EGD improves assessment of Siewert type.

METHODS

The results of 51 patients studied by EGD plus EUS (EGD/EUS group) were compared with the results of 54 patients studied by EGD only (EGD group).

RESULTS

A differentiation of pT1 tumors was attempted by measurement of the tumor length using 4 cm as a criterion. This goal was not achieved because of a high rate of advanced tumors less than 4 cm (sensitivity and specificity were 81.3% and 34.2%, respectively). Conversely EUS ability in pT1 assessment was very reliable (92%). The accuracy in defining the Siewert type was 72.5% and 64.8% for EGD/EUS and EGD groups, respectively (P = 0.394). Some difficulties in distinguishing between type II and III tumors were observed in both groups with an extremely low specificity (44%) in classifying type II tumors by EGD group.

CONCLUSIONS

EUS seems to be essential in differentiating pT1 from advanced tumors. It shows an accuracy in defining the Siewert type of 72.5%, with some difficulties in distinguishing from type II and III tumors.

Biologic and clinical variations of adenocarcinoma at the esophago-gastric junction: relevance of a topographic-anatomic subclassification

A topographic-anatomic subclassification of adenocarcinomas of the esophago-gastric junction (AEG) in distal esophageal adenocarcinoma (AEG Type I), true carcinoma of the cardia (AEG Type II), and subcardial gastric cancer (AEG Type III) was introduced in 1987 and is now increasingly accepted and used worldwide. Our experience with now more than 1,300 resected AEG tumors indicates that the subtypes differ markedly in terms of surgical epidemiology, histogenesis and histomorphologic tumor characteristics. While underlying specialized intestinal metaplasia can be found in basically all patients with AEG Type I tumors, this is uncommon in Type II tumors and virtually absent in Type III tumors. Stage distribution and overall long-term survival after surgical resection also shows marked differences between the AEG subtypes. Surgical treatment strategies based on tumor type allow a differentiated approach and result in survival rates superior to those reported with other approaches. The subclassification of AEG tumors thus provides a useful tool for the selection of the surgical procedure and allows a better comparison of treatment results.

High pathological response rate in locally advanced esophageal cancer after neoadjuvant combined modality therapy: dose finding of a weekly chemotherapy schedule with protracted venous infusion of 5-fluorouracil and dose escalation of cisplatin, docetaxel and concurrent radiotherapy

BACKGROUND

This phase I study was aimed at defining the toxicity profile and pathological response rate of a neoadjuvant schedule including weekly docetaxel and cisplatin, protracted venous infusion (PVI) of 5-FU and concomitant radiotherapy (RT) in locally advanced esophageal cancer.

PATIENTS AND METHODS

The schedule consisted of a first phase of chemotherapy alone and a second phase of concurrent chemoradiation. Initial doses were: docetaxel and cisplatin 20 mg/m2 on days 1, 8, 15, 29, 36 and 43 plus 5-FU 150 mg/m2 PVI on days 1-21 and 29-49; RT (40 Gy) started on day 29. In the following steps the doses were escalated up to docetaxel 35 mg/m2 and cisplatin 25 mg/m2 on days 1, 8, 15, 29, 36, 43, 50 and 57 plus 5-FU 180 mg/m2 PVI on days 1-21 and 150 mg/m2 PVI on days 29-63 concurrently with RT 50 Gy.

RESULTS

Forty-seven patients were enrolled and 46 completed the planned treatment. During the concomitant phase, grade 3-4 hematological toxicities occurred in three patients (6.5%) (or 3/174 cycles) and non-hematological toxicities in six patients (13%) (or 7/179 cycles). A pathological downstaging was obtained in 59.6% of the cases (28/47): complete remission (pCR) in 14 patients, near pCR (residual microfoci on the primary pN0) in eight patients, pT2 pN0 in three patients and partial response on the primary with positive lymph nodes in three patients. Six (13%) and 13 (28%) patients were considered stable and non-responders, respectively. In the last dose level, eight pCR and four near-pCR were obtained out of 15 patients. The maximum tolerable dose was not formally defined because dose escalation was stopped at the last dose level.

CONCLUSION

This schedule represents a feasible treatment and the high pathological response rate is extremely encouraging; the doses found in the last dose-level are the basis for an ongoing phase II study at our institution.

Long-term effects of proglumide on resection of cardiac adenocarcinoma

AIM: Patients with advanced stage cardiac adenocarcinoma have a very poor prognosis. Surgery is the first choice of treat-ment for this kind of patients. Peptide hormone gastrin is a recognized growth factor for gastric cancer, and gastrin receptor antagonist proglumide can block the effects of gastrin. The aim of this study was to investigate the actions of proglumide as an adjuvant treatment to improve the postoperative long-term survival rate of patients with cardiac adenocarcinoma.

METHODS: We performed a randomized, controlled study of gastrin receptor antagonist proglumide in 301 patients with cardiac adenocarcinoma after proximal subtotal gastrectomy. The oral dose of 0.4 g proglumide thrice daily preprandially was maintained for more than 5 years in 153 cases (proglumide treatment group). In the control group, 148 patients underwent operation only. In clinicopathologic features, there was no significant difference between the two groups (P>0.05). All patients were followed up during their lifetime, and the survival rates were analyzed combined with clinicopathologic factors by SPSS 11.5 statistical software.

RESULTS: The 1, 3, 5 and 10-year survival rate of the patients was 88.4%, 48.8%, 22.6% and 13.4%, respectively. The 1, 3, 5 and 10-year survival rate of the proglumide treatment group was 90.2%, 49.7%, 26.8% and 17.6% compared to 86.5%, 48.0%, 18.2% and 8.9% of the control group. There was a significant difference between the two groups (P = 0.0460). The patients in proglumide treatment group had no obvious side effects after administration of the drug, and no definite hepatic and renal function damage was found. According to single factor log-rank analysis, the long-term survival rate was correlated with the primary tumor position (P = 0.0205), length of the tumor (P = 0.0000), property of the operation (P = 0.0000), histopathologic grading (P = 0.0003), infiltrating degree of the tumor (P = 0.0000), influence of lymph node metastasis (P = 0.0000), clinicopathologic staging (P = 0.0000) and administration of proglumide (P = 0.0460). Cox regression analysis demonstrated the infiltrating degree of tumor (P = 0.000), influence of lymph node metastasis (P = 0.039) and the clinicopathologic staging (P = 0.003) were independent prognostic factors. Administration of proglumide (P = 0.081), length of the tumor (P = 0.304), radical status of the resection (P = 0.224) and histopathologic types (P = 0.072) were not the independent prognostic factors.

CONCLUSION: Proglumide is convenient to use with no obvious toxic side effects, and prolonged postoperative administration of proglumide as a postoperative adjuvant treatment can increase the survival rate of patients after resection of cardiac adenocarcinoma. Proglumide may provide a new effective approach of endocrinotherapy for patients with gastric cardiac cancer.

Endoscopic ablation of Barrett’s esophagus using high power setting argon plasma coagulation: A prospective study

AIM: This prospective study evaluated the effectiveness of 90 W argon plasma coagulation (APC) for the ablation of Barrett’s esophagus (BE) that is considered to be the main risk factor for the development of esophageal adenocarcinoma.

METHODS: The results from 25 patients, observed at the First Department of General Surgery, University of Verona, Italy, from October 2000 to October 2003, who underwent APC for histologically proven BE were prospectively analyzed.

RESULTS: The ablation treatment was completed in all the patients but one (96%). The mean number of APC sessions needed to complete ablation was 1.6 (total number: 40). The eradication was obtained in the majority of cases by one session only (60%), two sessions were required in 24% of the cases and three or more in 16%. About 43% of the sessions were complicated. Retrosternal pain (22.5%) and fever (17.5%) were the most frequent symptoms. Only one major complication occurred, it was an hemorrhage due to ulcer formation on the treated esophagus that required urgent endoscopic sclerosis and admission. The follow-up was accomplished in all the patients with a mean period of 26.3 mo and 20 patients (84%) with a follow-up period longer than 24 mo. Only one patient showed a relapse of metaplastic mucosa 12 mo after the completion of ablation. The patient was hence re-treated and now is free from recurrence 33 mo later.

CONCLUSION: High power setting (90 W) APC showed to be safe and effective. The effects persist at a mean follow-up period of two years with a comparable cost in term of complications with respect to standard power settings. Further studies with greater number of patients are required to confirm these results and to assess if ablation reduces the incidence of malignant progression.

Carcinoma of the cardia: classification as esophageal or gastric cancer?

INTRODUCTION

The cardia is the anatomical borderland between the esophagus and stomach. Carcinomas of the cardia are regarded to share features of both, esophageal and gastric cancers. Controversy exists concerning their appropriate classification and whether these tumors comprise--in respect to tumor biology, pathophysiology as well as clinical features--an entirely separate entity.

CLASSIFICATION

In order to distinguish cardia carcinomas from other adenocarcinomas arising within the vicinity of the esophagogastric junction, a classification system has been introduced from a surgical viewpoint, and is now well established and increasingly used worldwide. According to the topography of the main tumor mass, cardia carcinomas (AEG II) are distinguished from adenocarcinomas of the distal esophagus (AEG I) and subcardiac gastric cancers (AEG III). The tumor-node-metastasis (TNM) staging system by the International Union Against Cancer (UICC) does not provide a separate classification for tumors of the esophagogastric junction. The use of the classification for esophageal or for gastric cancers is recommended, irrespective of the elementary differences in the classification of lymphatic spread implemented herein.

DISCUSSION

New aspects concerning this controversial debate are discussed based on current insights into the pathogenesis and the cellular origin of these entities. The controversies concerning the classification of cardia carcinomas and the failure of the current esophageal and gastric cancer staging systems to reflect the peculiarities of this entity accurately, present a strong argument in favor of a new classification system.

[Adenocarcinoma of the esophagogastric junction: prognostic factors and results of primary surgery]

INTRODUCTION

The incidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing worldwide, and classification systems and resection procedures are being controversially discussed.

METHODS AND PATIENTS

We report on 225 AEG patients undergoing primary resection in our unit (1986-2000) with a special focus on perioperative morbidity, mortality, and long-term prognosis under consideration of the AEG type (Siewert classification) and operative procedure performed (subtotal esophagectomy with proximal gastric resection in AEG I, total gastrectomy with distal esophageal resection in AEG II and AEG III).

RESULTS

Types I, II, and III carcinomas were found in 32%, 42%, and 26% of the patients, respectively, with R(0) resections in 65%, 69%, and 51% ( P=0.039). The overall 5-year survival rates were 29%, 31%, and 14% ( P=0.068), respectively; in R(0)-resected patients, they were 40%, 41%, and 27% ( P=0.771). In univariate analysis, the TNM classification ( P<0.001), R classification ( P<0.001), and tumor stage ( P<0.001) were relevant prognostic factors. In multivariate analysis, only the R classification ( P=0.003), LN ratio ( P=0.012), and N stage ( P=0.027) were independent prognostic factors. In 35 of 177 patients resected with curative intent, R(0) resections could not be achieved, mainly because of residual tumor in the circumferential plane (22/35=63%). Only in 37% of cases (13/35) was the R(1) situation due to exclusive positive oral or aboral resection margins. Therefore, in only 7% of all patients resected with curative intent (13/177) did the question arise of whether the R(1) resection could have been avoided by a different surgical approach. Surgical, pulmonary, and cardiac complications were found in 33%, 26%, and 10%, respectively. The mortality within 30 days was 4%.

CONCLUSIONS

Failure of R(0) resection in patients treated with curative intent is mostly caused by residual tumor in the circumferential plane. Therefore, different surgical approaches with varying oral and aboral resection margins are of minor importance for reducing the frequency of R(1) resections. Downstaging of tumors by neoadjuvant treatment may increase the R(0) resection rate.

Adenocarcinoma of the gastric cardia: what is the optimal surgical approach?

BACKGROUND

The incidence of adenocarcinoma of the gastric cardia is rising in Western countries. This study evaluates prognostic factors associated with surgical management of this cancer.

STUDY DESIGN

Medical records of consecutive patients with gastric cardial cancer treated by surgical resection from 1991 through 2001 were reviewed. Survival was analyzed using the Kaplan-Meier method. Prognostic factors were evaluated using log-rank test and Cox regression. Mean followup period was 34 months.

RESULTS

Eighty-two patients met study inclusion criteria. Median patient age was 65 years (range 86 to 22). Fifty-nine (72%) patients had type II tumors and 23 (28%) patients had type III tumors, according to the Siewert classification for gastroesophageal junction tumors. Twenty-seven (33%) patients underwent total esophagectomy, 24 (29%) patients underwent extended gastrectomy with thoracotomy, and 31 (38%) patients underwent extended gastrectomy without thoracotomy. Overall postoperative 5-year survival rate was 30%. On multivariate analysis, patient age 65 years and older, absence of lymph node metastasis, and R0 resection emerged as factors independently associated with improved postoperative survival. Frequency with which proximal resection margin was infiltrated with cancer was a function of gross margin length and T stage. Proximal gross margin length of at least 6 cm was required to achieve a microscopically negative proximal margin for T3 and T4 cancers.

CONCLUSIONS

Achieving R0 resection should be the goal of surgical therapy for the gastric cardial cancer. The surgical approach should be tailored to individual patients to achieve this goal.

Comparison of old and new TNM systems for nodal staging in adenocarcinoma of the gastro-oesophageal junction

Background

Adenocarcinoma of the gastro-oesophageal junction is considered a distinct clinical entity, although the current pathological tumour node metastasis (pTNM) classification does not consider this tumour specifically. A prospective study was undertaken to determine the prognostic importance of lymph node involvement in adenocarcinoma of the gastro-oesophageal junction, analysing both a number- and site-based classification, in order to develop a clinically useful nodal staging system.

Methods

Two classification systems were analysed in 116 patients who underwent resection for adenocarcinoma of the gastro-oesophageal junction from January 1988 to August 2001. The Cox regression model was used to evaluate the prognostic significance of the site and number of positive nodes.

Results

The number- and site-based staging systems coincided only in 42 (56 per cent) of 75 patients; in particular, the old pN1 classification was upstaged in 13 of 41 patients and the old pN2 was downstaged in 13 of 34 patients. Lymph node involvement was the most important prognostic factor in both classifications (P &lt; 0·001). The risk of death was significantly influenced by the site of nodal metastasis among patients with a similar number of involved nodes (relative risk with respect to pN0: 2·18 for pN1 with one to six nodes; 6·53 for pN2 with one to six nodes; 7·53 for pN1 with more than six nodes; 39·13 for pN2 with more than six nodes).

Conclusion

Adenocarcinoma of the gastro-oesophageal junction requires a specific lymph node classification which should take into account both the number and site of nodal metastases.

Identical cytokeratin expression pattern CK7+/CK20- in esophageal and cardiac cancer: etiopathological and clinical implications

Surgical treatment and prognosis is different in esophageal, cardiac and distal gastric adenocarcinomas. Determination of the origin, in particular of adenocarcinomas situated at the gastroesophageal junction, may be difficult. It has been suggested that esophageal adenocarcinomas are characterized by a specific cytokeratin pattern, namely the CK7+/CK20- pattern. According to the same authors, this cytokeratin pattern is absent in gastric adenocarcinomas. The aim of our study is to evaluate if this cytokeratin pattern CK7+/CK20- is absent in cardiac and distal gastric adenocarcinomas. Therefore, we evaluated the combined immunohistochemical expression of CK7 and CK20 on paraffin-embedded material of 214 resection specimens for adenocarcinoma, comprising 66 esophageal, 73 cardiac and 75 distal gastric adenocarcinomas (UICC-classification). The adenocarcinomas were subtyped into intestinal- and diffuse-type according to the Lauren classification. The immunohistochemical staining was considered as positive if 50% or more of the tumor cells were stained. Statistical analysis has been performed applying the chi2-test. The tumors situated at the gastroesophageal junction, esophageal as well as cardiac adenocarcinomas, showed predominantly a CK7+/CK20- expression pattern (67 vs 68%), whereas this cytokeratin pattern is rather uncommon in distal gastric adenocarcinomas (31%, P<4 x 10(-5)). Independent of their localization, intestinal- as well as diffuse-type adenocarcinomas have a similar cytokeratin pattern. Our data show that the combined expression of CK7 and CK20 is different for the adenocarcinomas situated on both sides of the gastroesophageal junction compared to the distal gastric adenocarcinomas. However, in contrast to data in the literature, the combined expression of CK7 and CK20 has a low specificity in the distinction between esophageal and cardiac adenocarcinomas. This may suggest a similar origin (cell lineage) and thus may have an impact on therapeutic strategies.

Pattern of recurrence after surgery in adenocarcinoma of the gastro-oesophageal junction

AIMS

This study reports mode, timing and predictive factors of recurrence after curative surgery for cardia cancer.

METHODS

A prospective study in a series of 92 curatively (R0) resected patients from 1988 to 2002.

RESULTS

The 5-year recurrence rate was 71%. Lymph node involvement was the only predictor of recurrence. No patients with more than 6 metastatic nodes were free from relapse 2 years after surgery. Locoregional, peritoneal and haematogenous relapses showed a similar median recurrence time (12, 10 and 12 months, respectively), 80% occurred within 24 months.

CONCLUSIONS

Few patients can be cured by surgery, lymph nodal involvement is the only predictor of recurrence.

Gastric cancer

The past decade has seen many advances in knowledge about gastric cancer. Notably, tumour biology and lymphatic spread are now better understood, and treatment by surgical and medical oncologists has become more standardised. Since refrigerators have replaced other methods of food conservation, Helicobacter pylori has become a factor in the cause of gastric cancer. Cancers that arise at the oesophagogastric junction might be further examples of wealth-associated disease. To tailor treatment better, the western hemisphere needs to borrow from the East by establishing screening programmes for early diagnosis, through careful surgical resection, and through detailed analysis of tumour spread. In Europe and the USA, most patients reach treatment with cancers already at an advanced stage. For these patients, three important randomised trials are underway that evaluate combined therapy. Cytostatic drugs, especially angiogenesis inhibitors have proved disappointing; however, basic research efforts to detect familial gastric cancers and to assess minimally residual disease look more hopeful.