Subclassification of superficial cardia cancer in relation to the endoscopic esophagogastric junction

Kyoto international consensus report on anatomy, pathophysiology and clinical significance of the gastro-oesophageal junction

OBJECTIVE

An international meeting was organised to develop consensus on (1) the landmarks to define the gastro-oesophageal junction (GOJ), (2) the occurrence and pathophysiological significance of the cardiac gland, (3) the definition of the gastro-oesophageal junctional zone (GOJZ) and (4) the causes of inflammation, metaplasia and neoplasia occurring in the GOJZ.

DESIGN

Clinical questions relevant to the afore-mentioned major issues were drafted for which expert panels formulated relevant statements and textural explanations.A Delphi method using an anonymous system was employed to develop the consensus, the level of which was predefined as ≥80% of agreement. Two rounds of voting and amendments were completed before the meeting at which clinical questions and consensus were finalised.

RESULTS

Twenty eight clinical questions and statements were finalised after extensive amendments. Critical consensus was achieved: (1) definition for the GOJ, (2) definition of the GOJZ spanning 1 cm proximal and distal to the GOJ as defined by the end of palisade vessels was accepted based on the anatomical distribution of cardiac type gland, (3) chemical and bacterial (Helicobacter pylori) factors as the primary causes of inflammation, metaplasia and neoplasia occurring in the GOJZ, (4) a new definition of Barrett's oesophagus (BO).

CONCLUSIONS

This international consensus on the new definitions of BO, GOJ and the GOJZ will be instrumental in future studies aiming to resolve many issues on this important anatomic area and hopefully will lead to better classification and management of the diseases surrounding the GOJ.

Different roles for p16(INK) (4a) -Rb pathway and INK4a/ARF methylation between adenocarcinomas of gastric cardia and distal stomach

BACKGROUND AND AIM

The incidence of distal gastric adenocarcinoma has significantly decreased, but gastric cardia adenocarcinoma has been on the rise. Cardia adenocarcinoma might be a specific entity distinct from the carcinoma of the rest stomach. The aim was to explore putative differences in p16(INK) (4a) -retinoblastoma (Rb) pathway and INK4a/ARF methylation between gastric cardia and distal adenocarcinomas.

METHODS

Ninety-six cardia adenocarcinomas and 79 distal samples were analyzed for comparing p16(INK) (4a) -Rb expressions, INK4a/ARF deletion, and methylation using immunohistochemistry, polymerase chain reaction, and methylation-specific polymerase chain reaction.

RESULTS

The expression of p16(INK) (4a) in cardia adenocarcinoma (43.2%) was significantly lower than in distal cases (75.0%, P < 0.05). As well, cardia adenocarcinoma showed lower expression of p14(ARF) compared with distal cases (34.1% vs 57.5%, P < 0.05). The incidence of p16(INK) (4a) deletion was 20.5% and 15.0%, while p14(ARF) deletion was 18.2% and 10.0% in cardia and distal adenocarcinomas, respectively, showing no significant differences between two entities. However, the incidences of p14(ARF) and p16(INK) (4a) methylation in cardia adenocarcinoma were significantly higher than in distal samples (p14(ARF) : 61.5% vs 43.6%; p16(INK) (4a) : 73.1% vs 51.3%, P < 0.05). INK4a/ARF methylations were more prevalent in poorly differentiated cardia carcinoma compared with poorly differentiated distal cases.

CONCLUSIONS

There were differences in p16(INK) (4a) -Rb immunotypes and INK4a/ARF methylation between two entities, indicating that cardia adenocarcinoma may be different in cell proliferation, differentiation, and gene biomarkers compared with distal gastric adenocarcinoma.

Definition of the esophagogastric junction: a critical mini review

CONTEXT

Accurate diagnosis of diseases involving the esophagogastric junction (EGJ) is challenging because of difficulty in defining the EGJ endoscopically and histologically. Recent research results have redefined the EGJ, and the endoscopic and histologic diagnostic criteria of the mucosal EGJ have become available.

OBJECTIVE

To review the recent literature on endoscopy, histology, and pathology of the EGJ with critical analysis.

DATA SOURCES

Recently published research articles and guidelines in the peer-reviewed core journals and personal research results in this field.

CONCLUSIONS

At present, the mucosal EGJ can be defined endoscopically as the distal ends of esophageal longitudinal vessels that meet the proximal ends of gastric longitudinal mucosal folds. However, histologic validation of this criterion is needed. The histologic criteria of the EGJ include the distal ends of esophageal squamous mucosa, deep esophageal glands or ducts, or multilayered epithelium. The squamocolumnar junction is not a reliable landmark of the EGJ in patients with diseases involving the EGJ, such as hiatal hernias.

Tumors of the gastroesophageal junction have intermediate prognosis compared to tumors of the esophagus and stomach, but share the same clinical determinants

The issue of whether carcinoma of the gastroesophageal junction (GEJ) should be considered a distal esophageal, a proximal gastric or an independent tumor, at least with regards to clinical evaluation and management remains controversial. This study included 613 retrospective consecutive patients with carcinoma of the upper digestive tract, 64 of the esophagus, 58 of the GEJ and 491 of the stomach. The prognostic impact of the main clinical and histological parameters was analyzed in relation to relative survival as an estimate of the excess mortality. Relative survival and standardized mortality ratio (SMR) were calculated from the observed survival and the expected survival of the general population with identical age, gender and calendar years of observation. Multivariate analyses were applied to the proportional hazards model of the relative survival. The excess mortality, expressed by the relative survival and SMR of the patients with GEJ carcinoma are intermediate compared to those of patients with esophageal and gastric tumors. However, prognosis is not determined by tumor location, histology or administration of adjuvant chemotherapy, but mainly by stage and radical surgical resection. Gender has a minor but significant prognostic effect and age showed a slight inverse correlation with excess mortality. In conclusion, the excess mortality related to the tumors of the upper digestive tract is determined by stage, radical resection, gender and age. The intermediate prognosis of GEJ tumors mainly depends on a particular combination of such elementary determinants.