Surgical treatment of adenocarcinomas of the gastro-esophageal junction

Comparison between AJCC 8th edition gastric and esophageal ypTNM classification system in Siewert II esophagogastric junction adenocarcinomas: A retrospective study based on Eastern and Western Data

INTRODUCTION

Multimodal therapy has become the standard treatment for curable upper gastrointestinal cancers. However, it remains unclear which 8th edition AJCC post-neoadjuvant therapy pathological classification system, esophageal (ypTNM-EC) or gastric (ypTNM-GC), can predict the overall survival (OS) of patients with Siewert II adenocarcinomas better.

METHODS

Patients diagnosed with Siewert II adenocarcinomas receiving neoadjuvant therapy plus curative resection at the University Medical Center Utrecht (UMC Utrecht) and the Peking University Cancer Hospital (PUCH) between the 2001 and 2022 were included in this study. The patients from two institutions were analyzed separately. Predictive univariable and multivariable Cox models based on ypTNM-EC and ypTNM-GC were constructed. The C-index and calibration curves were used to compare the predictive abilities of ypTNM-EC and ypTNM-GC Cox models.

RESULTS

A total of 125 patients from UMCU and 145 from PUCH were included. There was no significant difference in the C-index between the ypTNM-EC and the ypTNM-GC univariable and multivariable Cox models in the UMC Utrecht (p-value = 0.883; p-value=0.681) and PUCH (p-value = 0.808; p-value=0.548) cohorts, and no significant difference was observed between their calibration curves in the two cohorts.

CONCLUSION

The AJCC 8th edition ypTNM prognostic classification systems for esophageal and gastric cancer demonstrated no difference in predicting OS for patients with Siewert II adenocarcinomas both in the Western and Eastern data. The ypTNM-GC, with fewer stage groups, may offer greater convenience for clinical application.

Contemporary Role of Open Left Thoracoabdominal Approach in Esophageal Malignancy Treatment

INTRODUCTION

Despite the widespread use of minimally invasive techniques, open left thoracoabdominal esophagectomy (LTE) can offer excellent visualization and adaptability. The current study aimed to present and evaluate the outcomes related to an open LTE in esophageal malignancy treatment.

METHODS

A retrospective cohort analysis of data collected from two institutions was performed, including patients with distal esophageal or junctional tumors who underwent open LTE between November 2018 and December 2023.

RESULTS

Twenty-two patients were included (16 males; mean age 62.8 years). Postoperative complications occurred in eight patients (36%), with pulmonary complications being the most prevalent (seven patients; 32%). One patient experienced a clinical anastomotic leak. No reoperations or escalation to a higher level of care were required. In-hospital and 30-day mortality were zero. Tumor cells were found at the surgical margins in six patients (27%). The mean lymph node yield was 27. During the follow-up period, there were nine deaths and 11 cases of disease recurrence. Isolated locoregional recurrence was seen in five patients (23%). The one-year and two-year overall survival rates were 79% and 47%, respectively.

CONCLUSION

In selected cases, open LTE remains a valid and safe operation with acceptable morbidity and oncological efficacy.

Siewert II esophagogastric junction adenocarcinoma: Still searching for the right treatment transabdominal or transthoracic surgical approaches?

INTRODUCTION

To date, the discussion is still ongoing whether the Siewert II adenocarcinoma of the esophagogastric junction (AEG) should be resected either by thoracoabdominal esophagectomy or gastrectomy with resection of the distal esophagus by transhiatal extension. The aim of our study was to compare the oncological and perioperative outcomes of the transthoracic approach (TTA) and the transabdominal approach (TAA).

METHODS

Searches of electronic databases identifying studies from Cochrane, PubMed and Google Scholar were performed. Randomised and non-randomised studies comparing TTA and TAA approaches for surgical treatment of AEG Siewert type II were included. The Newcastle-Ottawa and Jada scales were used to evaluate methodological quality. The risk of bias was assessed using the Rob v2 and Robins-I tools. Meta-analyses were conducted for the outcomes.

RESULTS

We included 17 trials (2 randomised controlled trials and 15 cohorts) involving 15297 patients. Longer three-year overall survival, five-year overall survival and R0 resection rates were observed in the TTA group. However, TTA had greater morbidity and pulmonary complications.

CONCLUSION

Transthoracic approach appears to be preferable for selected Siewert II tumours. This may lead to higher survival rates and better R0 resection rate. Well-designed studies are needed to confirm the results of this systematic review.

Minimally invasive surgery for gastro-oesophageal junction adenocarcinoma: Current evidence and future perspectives

Minimally invasive surgery is increasingly indicated in the management of malignant disease. Although oesophagectomy is a difficult operation, with a long learning curve, there is actually a shift towards the laparoscopic/thoracoscopic/ robotic approach, due to the advantages of visualization, surgeon comfort (robotic surgery) and the possibility of the whole team to see the operation as well as and the operating surgeon. Although currently there are still many controversial topics, about the surgical treatment of patients with gastro-oesophageal junction (GOJ) adenocarcinoma, such as the type of open or minimally invasive surgical approach, the type of oesophago-gastric resection, the type of lymph node dissection and others, the minimally invasive approach has proven to be a way to reduce postoperative complications of resection, especially by decreasing pulmonary complications. The implementation of new technologies allowed the widening of the range of indications for this type of surgical approach. The short-term and long-term results, as well as the benefits for the patient - reduced surgical trauma, quick and easy recovery - offer this type of surgical treatment the premises for future development. This article reviews the updates and perspectives on the minimally invasive approach for GOJ adenocarcinoma.

Surgical Treatment of Siewert II Gastroesophagel Junction Adenocarcinoma: Esophagectomy or Gastrectomy? Review

Introduction. Surgery is the only curative treatment option for patients with gastroesophageal junction (GEJ) adenocarcinoma. These tumors can be resected by gastrectomy or esophagectomy depending on tumor localization. Although, both surgeries are available for Siewert type II GEJ cancer, it remains unknown which one is superior. This review summarizes current evidences on the optimal surgical approach for Siewert type II GEJ adenocarcinoma. Methods. The literature search was performed within the PubMed database and 9 stu­dies comparing gastrectomy and esophagectomy for Siewert type II GEJ adenocarcinoma were included. The outcomes of interest included: length of surgery, numbers of retrieved lymph nodes, resection margins, postoperative morbidity and mortality, hospitalization time, 5-year overall, and disease-free survival rates. Results. Current studies do not favor any type of surgery in terms of length of the surgery, R0 resection rate, or postoperative morbidity. There is some tendency towards higher anastomotic leakage and postoperative surgical site infections rate after gastrectomy, while a higher incidence of pneumonia after esophagectomy. Similar, available studies suggest, that esophagectomy may lead to improved long-term outcomes. Conclusions. There is a lack of high-quality studies comparing gastrectomy and esophagectomy for Siewert type II GEJ adenocarcinoma. Esophagectomy may lead to improved long-term outcomes, but this preliminary data has to be confirmed in large, randomized control trials.

[Surgical treatment of adenocarcinoma of the esophagogastric junction type II : Comparison between transhiatal extended gastrectomy and thoracoabdominal esophagectomy]

BACKGROUND

The incidence of adenocarcinoma of the esophagogastric junction (AEG) has significantly increased. However, the best surgical treatment for AEG type II is still the subject of current research. The goal of this retrospective cohort study is to compare survival and recurrence rates in patients, who underwent either thoracoabdominal esophagectomy (TAE) or transhiatal extended gastrectomy (TEG).

MATERIAL AND METHODS

The study is based on a cohort of 272 patients diagnosed with AEG type II between 2002 and 2020, recorded by a population-based clinical cancer registry. Of the included patients 63 underwent TAE and 209 TEG. In order to compare overall survival, recurrence rates, and recurrence free survival, we applied the Kaplan-Meier method, univariable and multivariable Cox regression.

RESULTS

Our analysis showed no statistically significant difference concerning overall survival (p = 0.333). However a tendency towards higher survival rates after TAE for the period from 2016-2020 (p = 0,058) is possible. In contrast a significant difference concerning higher cumulative recurrence rates after TAE was found after Kaplan-Meier analysis (p = 0.049). This trend was not observed for the time after 2016 (p = 0.993), in which over 50% of TAE were performed. No differences were found regarding recurrence-free survival (p = 0.772).

CONCLUSION

Our findings in a rather small cohort are concordant with most studies showing no differences or a trend towards better survival after TAE. Other studies found no significant difference regarding recurrence-free survival as well. In conclusion, no significant differences were found between TEG and TAE in surgical treatment of AEG type II.

Total laparoscopic versus laparoscopic-assisted transabdominal posterior mediastinal digestive tract reconstruction in the treatment of Siewert II adenocarcinoma of the esophagogastric junction: A retrospective study

Background

The method of operation and the range of resection for Siewert II adenocarcinoma of the esophagogastric junction (AEG) remain controversial. This study aims to evaluate the safety, feasibility, and short-term postoperative effect of total laparoscopic versus laparoscopic-assisted transabdominal posterior mediastinal digestive tract reconstruction in the treatment of Siewert II AEG.

Methods

Total laparoscopic or laparoscopic-assisted gastrointestinal reconstruction through abdominal posterior mediastinum was performed in 108 patients with Siewert II AEG from October 2017 to February 2019. This study evaluated the loss of intraoperative blood, the number of lymph nodes, the marginal of the tumor, short-term postoperative complications (within 30 days), the rate of survival at follow-up, and the economic cost, feasibility, and effect of short-term postoperative recovery for patients who received these two operations.

Result

There were no significant differences in general data between the total laparoscopic group and the laparoscopic-assisted group (P > 0.05). However, the total laparoscopic group cost more time on the surgical procedure and digestive tract reconstruction, lost less intraoperative blood, and had more mediastinal lymph nodes compared with the laparoscopic-assisted group (P < 0.05). The total laparoscopic group was significantly better than the laparoscopic-assisted group compared with the short-term postoperative recovery indexes, such as the first exhaust time, the first defecation time, the first fluid time, the first semi-fluid diet time, the postoperative hospital stay, and other postoperative recovery indexes (P < 0.05). In addition, there were no significant differences in postoperative complications, postoperative pathological indexes, the recurrence rate, and mortality between the total laparoscopic group and laparoscopic-assisted group (P > 0.05).

Conclusions

The safety, feasibility, and short-term effect of total laparoscopic transabdominal posterior mediastinal digestive tract reconstruction in the treatment of Siewert II AEG were better than those for the laparoscopic-assisted group.

Transthoracic esophagectomy compared to transhiatal extended gastrectomy for adenocarcinoma of the esophagogastric junction: a multicenter retrospective cohort study

Optimal surgical treatment for Siewert type II esophagogastric junction adenocarcinoma is debated. The aim of this study was to compare transhiatal extended gastrectomy (TEG) and transthoracic esophagectomy (TTE). Patients with Siewert type II tumors who underwent a resection by TEG or TTE in two centers (Erasmus University Medical Center, Rotterdam, and University of Verona) between 2014 and 2019 were identified. To limit selection bias, patients were matched for baseline characteristics and compared with a multivariable logistic regression model. Some 159 patients treated by TEG (60 patients, 37.7%) or TTE (99 patients, 62.3%) were included. Patients in the TEG group were older, had less tumor invasion of the esophagus, and were more often excluded from neoadjuvant therapy. Post-operative morbidity was comparable (P = 0.88), while 90-day mortality was higher after TEG (90-day mortality 10.0% in TEG group vs. 2.0% in TTE group P = 0.01). R0 resection was achieved in 83.3% of patients after TEG and in 97.9% after TTE (P < 0.01), with the proximal resection margin involved in 16.6% of patients after TEG versus 0 in TTE group (P < 0.01). The 3-year overall survival was comparable (TEG: 36.5%, TTE: 48.4%, P = 0.12). At multivariable analysis, (y)pT category was an independent risk factor for 3-year recurrence. After matching, TEG was still associated with an increased risk of incomplete tumor resection (P = 0.03) and proximal margin involvement (P < 0.01), while there were no differences in post-operative morbidity (P = 0.56) and mortality (P = 0.31). Our data suggest that patients with Siewert type II tumors treated by TEG are exposed to a higher risk of positive proximal resection margin compared to TTE.

The abdominal-transhiatal surgical approach versus the thoracoabdominal surgical approach in Siewert type II adenocarcinoma of the esophagogastric junction: protocol for a multicenter prospective, open, parallel, and randomized controlled trial

Background

To date, Siewert type II adenocarcinoma of the esophagogastric junction (ST-II AEG) can be removed radically utilizing either the abdominal-transhiatal (TH) or the right thoracoabdominal (RTA) approaches. Because of a paucity of high-quality direct evidence, the appropriate surgical approach for ST-II AEG remains debatable. In the present, only several retrospective studies are available, representing ambiguous results. Thus, prospective randomized clinical trials are demanded to compare the survival, oncological outcomes, safety and efficiency and life quality between the TH and RTA approach in patients with resectable AEG of Siewert type II.

Methods

A prospective, multicenter, open, randomized, and parallel controlled study named S2AEG will be conducted. Three hundred and twelve patients who match the inclusion criteria but not the exclusion criteria will be participating in the trial and randomly divided into the TH (156) and RTA (156) cohorts. The primary efficacy endpoint is the 3-year disease-free survival (DFS) following the operation. The rate of R0-resection, the number and site of lymph nodes infiltrated and dissected, postoperative complications, hospital days and life quality are the second endpoints.

Discussion

This study is the first prospectively randomized controlled trial aiming to compare the surgical outcomes between TH and RTA approaches in patients with resectable ST-II AEG. It is hypothesized that patients in the TH cohort would harvest equivalent oncological results and survival while maintaining acceptable life quality when compared to patients in the RTA cohort. Our findings will provide high-level clinical evidence for clinical decision-making on the appropriate surgical approach for patients with ST-II AEG. Embarked in November 2019, this research will be completed 3 years after the final participant’s enrolment date.

Trial registration

Clinical Trial.gov ID: NCT04910789 May 29, 2021. Name: S2AEG.

Evidence-based approach to the treatment of esophagogastric junction tumors

The incidence of esophagogastric junction (EGJ) adenocarcinoma is increasing in developed nations due to the rising prevalence of obesity and gastroesophageal reflux disease. Due to the peculiar location in a histological transition zone between the esophagus and the stomach, the management of EGJ tumors is controversial. Two main surgical approaches exist: total gastrectomy with distal esophagectomy or esophagectomy by either transhiatal or transthoracic approach. These operations differ significantly in the extent of lymphadenectomy. In addition, patients with locally advanced disease can receive either preoperative chemoradiation or perioperative chemotherapy. This evidence-based review analyzes current evidence regarding the management of EGJ tumors in order to help defining the best surgical and systemic treatment of these patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Value of Paratracheal Lymphadenectomy in Esophagectomy for Adenocarcinoma of the Esophagus or Gastroesophageal Junction: A Systematic Review of the Literature

Background

The role of upper mediastinal lymphadenectomy for distal esophageal or gastroesophageal junction (GEJ) adenocarcinomas remains a matter of debate. This systematic review aims to provide a comprehensive overview of evidence on the incidence of nodal metastases in the upper mediastinum following transthoracic esophagectomy for distal esophageal or GEJ adenocarcinoma.

Methods

A literature search was performed using Medline, Embase and Cochrane databases up to November 2020 to include studies on patients who underwent transthoracic esophagectomy with upper mediastinal lymphadenectomy for distal esophageal and/or GEJ adenocarcinoma. The primary endpoint was the incidence of metastatic nodes in the upper mediastinum based on pathological examination. Secondary endpoints were the definition of upper mediastinal lymphadenectomy, recurrent laryngeal nerve (RLN) palsy rate and survival.

Results

A total of 17 studies were included and the sample sizes ranged from 10-634 patients. Overall, the median incidence of upper mediastinal lymph node metastases was 10.0% (IQR 4.7-16.7). The incidences of upper mediastinal lymph node metastases were 8.3% in the 7 studies that included patients undergoing primary resection (IQR 2.0-16.6), 4,4% in the 1 study that provided neoadjuvant therapy to the full cohort, and 10.6% in the 9 studies that included patients undergoing esophagectomy either with or without neoadjuvant therapy (IQR 8.9-15.8%). Data on survival and RLN palsy rates were scarce and inconclusive.

Conclusions

The incidence of upper mediastinal lymph node metastases in distal esophageal adenocarcinoma is up to 10%. Morbidity should be weighed against potential impact on survival.

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.

Esophagectomy or Total Gastrectomy for Siewert 2 Gastroesophageal Junction (GEJ) Adenocarcinoma? A Registry-Based Analysis

Backgrounds

Due to a lack of randomized and large studies, the optimal surgical approach for Siewert 2 gastroesophageal junctional (GEJ) adenocarcinoma remains unknown. This population-based cohort study aimed to compare survival between esophagectomy and total gastrectomy for the treatment of Siewert 2 GEJ adenocarcinoma.

Methods

Data from the National Cancer Database (NCDB) from 2010 to 2016 was used to identify patients with non-metastatic Siewert 2 GEJ adenocarcinoma who received either esophagectomy (n = 999) or total gastrectomy (n = 8595). Propensity score-matching (PSM) and multivariable analyses were used to account for treatment selection bias.

Results

Comparison of the unmatched cohort’s baseline demographics showed that the patients who received esophagectomy were younger, had a lower burden of medical comorbidities, and had fewer clinical positive lymph nodes. The patients in the unmatched cohort who received gastrectomy had a significantly shorter overall survival than those who received esophagectomy (median, 47 vs. 68 months [p < 0.001]; 5-year survival, 45 % vs. 53 %). After matching, gastrectomy was associated with significantly reduced survival compared with esophagectomy (median, 51 vs. 68 months [p < 0.001]; 5-year survival, 47 % vs. 53 %), which remained in the adjusted analyses (hazard ratio [HR], 1.22; 95 % confidence interval [CI], 1.09–1.35; p < 0.001).

Conclusions

In this large-scale population study with propensity-matching to adjust for confounders, esophagectomy was prognostically superior to gastrectomy for the treatment of Siewert 2 GEJ adenocarcinoma despite comparable lymph node harvest, length of stay, and 90-day mortality. Adequately powered randomized controlled trials with robust surgical quality assurance are the next step in evaluating the prognostic outcomes of these surgical strategies for GEJ cancer.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-10346-x.

A Patient-Derived Orthotopic Xenograft Model of Gastroesophageal-Junction Adenocarcinoma Translated to the Clinic by Tumor-Targeting Fluorescent Antibodies to Carcinoembryonic-Antigen-Related Cell-Adhesion Molecules

BACKGROUND/AIM

During surgical resection of gastroesophageal-junction (GEJ) adenocarcinoma, the margin status is often difficult to visualize resulting in high recurrence rates. The aim of the present study was to develop a labelling technique that would allow improved visualization of GEJ tumor margins for surgeons to reduce recurrence rates in a patient-like model.

MATERIALS AND METHODS

A patient GEJ tumor was obtained from an endoscopic biopsy and implanted subcutaneously in a nude mouse. A patient-derived orthotopic xenograft (PDOX) model was established by implanting tumor fragments grown from a subcutaneous model to the cardia of the stomach of nude mice. CC1/3/5-SAB, an antibody to carcinoembryonic-antigen-related cell-adhesion molecules, was conjugated with infrared dye IRDye800 to create SAB-IR800. Forty-eight hours after i.v. injection of SAB-IR800, GEJ-PDOX mice were imaged.

RESULTS

Fluorescence imaging with SAB-IR800 brightly visualized the GEJ adenocarcinoma demonstrating specific targeting. In the PDOX model, injection of SAB-IR800 (50 μg) resulted in a tumor to background ratio of 1.78 at 48 hours and 1.86 at 72 hours.

CONCLUSION

PDOX models of GEJ tumors can be established from patients by endoscopic biopsy without undergoing surgical resection. GEJ PDOX models should be useful for developing novel diagnostics and therapeutics for this recalcitrant disease.

Prognosis of Interval Distant Metastases After Neoadjuvant Chemoradiotherapy for Esophageal Cancer

BACKGROUND

In esophageal cancer patients, distant metastases develop between the start of neoadjuvant chemoradiotherapy and planned surgery, so-called interval metastases. The primary aim of this study was to assess management, overall survival (OS), and prognostic factors for OS in these patients. A secondary aim was to compare OS with synchronous metastatic patients.

METHODS

Esophageal cancer patients with interval distant metastases were identified from the Netherlands Cancer Registry (2010 to 2017). Management was categorized into metastasis-directed therapy (MDT), primary tumor resection, or best supportive care (BSC). The OS was calculated from the diagnosis of the primary tumor. Prognostic factors affecting OS were studied using Cox proportional hazard models. Propensity score-matching (1:3) generated matched cases with synchronous distant metastases.

RESULTS

In all, 208 patients with interval metastases were identified: in 87 patients (42%) MDT was initiated; in 10%, primary tumor resection only; in 7%, primary tumor resection plus MDT; and in 41%, BSC. Median OS was 10 months (interquartile range, 8.6 to 11.1). Compared with BSC, superior OS was independently associated with MDT (hazard ratio [HR] 0.36; 95% confidence interval [CI], 0.26 to 0.49), primary tumor resection (HR 0.55; 95% CI, 0.33 to 0.94), and primary tumor resection plus MDT (HR 0.20; 95% CI, 0.10 to 0.38). Worse OS was independently associated with signet ring cell carcinoma (HR 1.92; 95% CI, 1.12 to 3.28) and poor differentiation grade (HR 1.96; 95% CI, 1.35 to 2.83). The OS was comparable between matched patients with interval and synchronous distant metastases (10.2 versus 9.4 months, P = .760).

CONCLUSIONS

In esophageal cancer patients treated with neoadjuvant chemoradiotherapy with interval distant metastases, the OS was poor and comparable to that of synchronous metastatic patients.

Esophagogastric junction adenocarcinoma shares characteristics with gastric adenocarcinoma: Literature review and retrospective multicenter cohort study

The incidence of esophagogastric junction (EGJ) adenocarcinoma has been gradually increasing in Asia, just like in Western countries a few decades ago. Despite recent advances in next-generation sequencing and multimodal treatments, EGJ adenocarcinoma is still an aggressive malignancy with poor outcomes. Clinically, EGJ adenocarcinoma can be separated into Barrett's adenocarcinoma and cardiac adenocarcinoma, with frequent similarities observed. Barrett's adenocarcinoma is likely to be of gastric origin in terms of its premalignant background, risk factors, and stem cell regulators. Recent comprehensive genomic analyses suggest that immunotherapy may be essential for high-level microsatellite instability (MSI-H)- and Epstein-Barr virus (EBV)-associated subtypes, and against the immunosuppressive phenotype in genomically stable (GS) subtypes, in the treatment of EGJ and gastric adenocarcinoma. Although the chromosomal instability (CIN) subtype dominates EGJ adenocarcinoma, there is still a need to investigate the other molecular subtypes and their targets. Because of the distinctive characteristics of tumor location of EGJ adenocarcinoma, we also described the results of a multicenter cohort study of EGJ adenocarcinoma, comparing Siewert type I (distal esophagus), II (cardia of the stomach), and III (subcardia) tumors. We show that type I tumors were frequently accompanied by Barrett's esophagus (78%, P < .0001), with a significantly unfavorable outcome (multivariate EGJ-cancer-specific mortality hazard ratio = 1.81, 95% CI, 1.06-2.97; P = .031). In addition, over half (56%) of these cases experienced disease recurrence in the lymph nodes. Our findings suggest that Barrett's adenocarcinoma may be an aggressive phenotype of EGJ adenocarcinoma due to the potential risk of tumor spread through the complex lympho-vascular network of the esophagus.

Minimally invasive esophagectomy: clinical evidence and surgical techniques

Background

Surgical esophagectomy plays a crucial role in the curative and palliative treatment of esophageal cancer. Thereby, minimally invasive esophagectomy (MIE) is increasingly applied all over the world. Combining minimal invasiveness with improved possibilities for meticulous dissection, robot-assisted minimal invasive esophagectomy (RAMIE) has been implemented in many centers.

Purpose

This review focuses on the development of MIE as well as RAMIE and their value based on evidence in current literature.

Conclusion

Although MIE and RAMIE are highly complex procedures, they can be performed safely with improved postoperative outcome and equal oncological results compared with open esophagectomy (OE). RAMIE offers additional advantages regarding surgical dissection, lymphadenectomy, and extended indications for advanced tumors.

Minimally Invasive Thoracoabdominal Esophagectomy Is Superior to Minimally Invasive Gastrectomy in Terms of Health-Related Quality of Life

Background and Objectives: There are two operative approaches for adenocarcinomas of the esophagogastric junction: thoracoabdominal esophagectomy or transhiatal extended gastrectomy. Both procedures can be performed minimally invasively. Dependent on the exact localization of the tumor, both approaches are feasible. Aim of this study was to compare the health-related quality of life (HRQOL) of patients after minimally invasive esophagectomy (MIE) with patients who underwent minimally invasive gastrectomy (MIG). Methods: All patients who underwent MIE or gastrectomy for malignoma since 2014 were identified from our clinical database. The identified patients were contacted and asked to fill out a quality of life questionnaire (QLQ) for general and gastrointestinal QOL (European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-OG25). Results: Global HRQOL scores were higher in patients after MIE than after MIG. After MIE, global HRQOL scores were close to the control population. In cancer-specific syndromes, patients after MIE reported lower symptom scores for financial problems, eating, reflux, and eating with others than patients after MIG. Conclusion: In terms of HRQOL, MIE proved superior to MIG in long-term follow-up in this study. Patients after MIE reported a HRQOL close to that of a healthy reference population.

The CARDIA-trial protocol: a multinational, prospective, randomized, clinical trial comparing transthoracic esophagectomy with transhiatal extended gastrectomy in adenocarcinoma of the gastroesophageal junction (GEJ) type II

Background

Adenocarcinoma of the gastroesophageal junction (GEJ) Siewert type II can be resected by transthoracic esophagectomy or transhiatal extended gastrectomy. Both allow for a complete tumor resection, yet there is an ongoing controversy about which surgical approach is superior with regards to quality of life, oncological outcomes and survival. While some studies suggest a better oncological outcome after transthoracic esophagectomy, others favor transhiatal extended gastrectomy for a better postoperative quality of life. To date, only retrospective studies are available, showing ambiguous results.

Methods

This study is a multinational, multicenter, randomized, clinical superiority trial. Patients (n = 262) with a GEJ type II tumor resectable by both transthoracic esophagectomy and transhiatal extended gastrectomy will be enrolled in the trial. Type II tumors are defined as tumors with their midpoint between ≤1 cm proximal and ≤ 2 cm distal of the top of gastric folds on preoperative endoscopy. Patients will be included in one of the participating European sites and are randomized to either transthoracic esophagectomy or transhiatal extended gastrectomy. The trial is powered to show superiority for esophagectomy with regards to the primary efficacy endpoint overall survival. Key secondary endpoints are complete resection (R0), number and localization of tumor infiltrated lymph nodes at dissection, post-operative complications, disease-free survival, quality of life and cost-effectiveness. Postoperative survival and quality of life will be followed-up for 24 months after discharge. Further survival follow-up will be conducted as quarterly phone calls up to 60 months.

Discussion

To date, as level 1 evidence is lacking, there is no consensus on which surgery is superior and both surgeries are used to treat GEJ type II carcinoma worldwide. The CARDIA trial is the first randomized trial to compare transthoracic esophagectomy versus transhiatal extended gastrectomy in patients with GEJ type II tumors. Several quality control measures were implemented in the protocol to ensure data reliability and increase the trial’s significance. It is hypothesized that esophagectomy allows for a higher rate of radical resections and a more complete mediastinal lymph node dissection, resulting in a longer overall survival, while still providing an acceptable quality of life and cost-effectiveness.

Trial registration

The trial was registered on August 2nd 2019 at the German Clinical Trials Register under the trial-ID DRKS00016923.

Current surgical treatment standards for esophageal and esophagogastric junction cancer

A number of different surgical techniques for the treatment of cancer of the esophagus and the esophagogastric junction have been proposed. Guidelines generally recommend a transthoracic approach for esophageal cancer, including Siewert type I tumors. In tumors of the proximal esophageal third, transthoracic esophagectomy may be extended to a three-field approach, including resection of cervical lymph nodes. However, the choice between transthoracic esophagectomy with intrathoracic anastomosis (Ivor Lewis esophagectomy) and the three-incision approach with cervical esophago-gastrostomy (McKeown esophagectomy) remains controversial, with guidelines varying among different countries. Furthermore, it is commonly accepted that Siewert type III tumors should be treated by extended total gastrectomy with transhiatal resection of the lower esophagus, whereas currently no consensus exists regarding the optimal surgical approach for the treatment of Siewert type II adenocarcinoma. Likewise, there is a major controversy regarding palliative and potentially curative treatment modalities in oligometastatic disease. This review deals with current surgical treatment standards for cancer of the esophagus and the eosphagogastric junction, including discussion of ongoing trials.

Current Issues in Minimally Invasive Esophagectomy

Minimally invasive esophagectomy (MIE) was first introduced in the 1990s. Currently, it is a widely accepted surgical approach for the treatment of esophageal cancer, as it is an oncologically sound procedure; its advantages when compared to open procedures, including reduction in postoperative complications, reduction in the length of hospital stay, and improvement in quality of life, are well documented. However, debates are still ongoing about the safety and efficacy of MIE. The present review focuses on some of the current issues related to conventional MIE and robot-assisted MIE based on evidence from the current literature.

Distribution of lymph node metastases in locally advanced adenocarcinomas of the esophagogastric junction (cT2-4): comparison between Siewert type I and selected Siewert type II tumors

INTRODUCTION

The distribution of lymph node metastases in locally advanced Siewert type I and type II AEG (adenocarcinoma of the esophagogastric junction) remains unclear. The diversity of data in the literature reflects the non-uniformity of tumor stages and surgical procedures in previous studies.

MATERIALS AND METHODS

Based on a retrospective analysis from our single-center database, we examined distributions of lymph node metastases in types I and II cT2-4 AEG. The dataset comprised 44 patients; 19 and 25 patients had type I and type II, respectively. All patients underwent subtotal esophagectomy and total mediastinal lymphadenectomy, which included dissection of the upper mediastinal lymph nodes. The histological data of the surgical specimens were analyzed to evaluate metastasis rates in each lymph node station according to the Japanese Esophageal Society (JES) and American Joint Committee on Cancer (AJCC) guidelines.

RESULTS

Lymph node metastases were observed in 75.0% cases (n = 33/44). There was no significant difference in the total lymph node metastasis rate between the two groups (type I 73.7% versus type II 76.0%). On comparing each lymph node region separately, no statistically significant differences were noted between the groups: upper mediastinal (type I 31.6% versus type II 24.0%), middle and lower mediastinal (type I 31.6% versus type II 44.0%), paragastric (type I 61.1% versus type II 76.0%), and celiac lymph nodes (type I 16.7% versus type II 25.0%).

CONCLUSION

In advanced clinical stages, the metastasis rate is high at all mediastinal lymph node regions in both type I and type II AEGs.

Risk Factors and Prognostic Impact of Mediastinal Lymph Node Metastases in Patients with Esophagogastric Junction Cancer

PURPOSE

We retrospectively investigated the risk factors for mediastinal lymph node (MLN) metastasis in esophagogastric junction (EGJ) cancer with an epicenter within 2 cm above and below the anatomical cardia, including both adenocarcinoma (AC) and squamous cell carcinoma (SCC).

METHODS

Fifty patients who underwent initial surgery for EGJ cancer from January 2002 to December 2013 were included in this study. We defined metastatic lymph nodes as pathological metastases in resected specimens and recurrence within 2 years postoperatively.

RESULTS

Thirty-four patients had AC and 16 had SCC; 24 patients underwent transhiatal resection and 26 underwent transthoracic resection. MLN metastasis was observed in 13 patients (26%) regardless of the histological type, 9 of whom had metastasis in the upper and middle mediastinum. Metastasis occurred when the esophageal invasion length (EIL) exceeded 20 mm. In addition, 10/13 patients had stage pN2-3 cancer. Multivariable analysis identified EIL ≥ 20 mm and stage pN2-3 as significant risk factors for MLN metastasis. The 5-year overall survival was 38% and 65% in the MLN-positive and -negative groups, respectively (p = 0.12). Multivariable Cox regression analysis showed that only stage pN2-3, and not the presence of MLN metastasis, was a significantly poor prognostic factor.

CONCLUSION

MLN metastasis in EGJ cancer may have a close association with the EIL of the tumor, but the presence of MLN metastasis itself was not a poor prognostic factor. The significance and indications for MLN dissection should be clarified in prospective clinical trials.

Robotic-assisted minimally invasive esophagectomy: past, present and future

Esophagectomy for cancer of the esophagus is increasingly performed using minimally invasive techniques. After the introduction of minimally invasive esophagectomy (MIE) in the early 1990's, robotic-assisted techniques followed after the turn of the millennium. The advent of robotic platforms has allowed the development of robotic-assisted minimally invasive esophagectomy (RAMIE) over the past 15 years. Although recent trials have shown superior peri-operative morbidity and quality of life compared to open esophagectomy, no randomized trials have compared RAMIE to conventional MIE. This paper summarizes the current literature on RAMIE and provides an overview of expected future developments in robotic surgery.

Comparison of mediastinal lymph node metastases from adenocarcinoma of the esophagogastric junction versus lower esophageal squamous cell carcinoma with involvement of the esophagogastric junction

The distribution of mediastinal lymph node metastasis in patients with adenocarcinoma of the esophagogastric junction (AEG) remains unclear. Additionally, the distribution of nodal mediastinal metastasis from squamous cell carcinoma (SCC) of the lower esophagus with involvement of the esophagogastric junction remains unclear, given the very limited number of these patients. In this retrospective review, we compared the outcomes of radical lymphadenectomy of the mediastinum, including upper mediastinal lymphadenectomy, between patients with AEG and those with SCC. From 2005 to 2017, 69 consecutive patients underwent esophagectomy via right thoracotomy or minimally invasive esophagectomy for a Siewert type I or II tumor with esophageal invasion ≥3 cm. We analyzed the incidences of mediastinal lymph node metastasis in this group relative to those of 73 patients with SCC with involvement of the esophagogastric junction who consecutively underwent esophagectomy during the same period. Mediastinal lymph node metastasis was seen in 26 of 69 patients with AEG (38%), with upper, middle, lower mediastinal nodal metastasis instances of 20%, 17%, and 23%, respectively. Mediastinal lymph node metastasis was seen in 23 of 73 patients with SCC (32%), with upper, middle, lower mediastinal nodal metastasis instances of 12%, 16%, and 19%, respectively. This mediastinal lymph nodal metastasis distribution did not statistically differ between patients with AEG and those with SCC. The relapse-free survival outcomes were poor for patients with clinical (P < 0.01) or pathological (P < 0.01) nodal metastasis of the mediastinum with AEG. In contrast, patients with clinical or pathological mediastinal nodal metastases of SCC did not have extremely poor survival outcomes, compared to patients with AEG. Despite the limited dataset available for analysis, patients with AEG and those with SCC might exhibit similar incidences and distribution of mediastinal lymph node metastasis. However, the clinical or pathological metastasis of AEG to the mediastinum was associated with poor survival outcomes, even if radical mediastinal lymphadenectomy including the upper mediastinal lymphadenectomy was performed.

The Postoperative outcomes of thoracoscopic-laparoscopic Ivor-Lewis surgery plus D2 celiac lymphadenectomy for patients with adenocarcinoma of the esophagogastric junction

OBJECTIVES

Adenocarcinoma of the esophagogastric junction (AEG) is one of the most aggressive and poor prognosis cancers. To date, no standard procedures have been established for the surgical treatment of Siewert type II. In this study, we proposed the approach of thoracoscopic-laparoscopic Ivor-Lewis surgery plus D2 celiac lymphadenectomy (TLILD2) and aimed to investigate the patterns of lymph node metastasis and long-term survival.

METHODS

From June 2015 to June 2018, 72 patients accepted TLILD2 and enrolled in this study. Relevant patient characteristics and postoperative variables were collected and evaluated. The disease-free survival (DFS) and disease-specific survival (DSS) were determined by the Kaplan-Meier method and compared by log-rank tests.

RESULTS

There was no case of postoperative death in this study, and the most common complication was anastomotic mediastinal fistula (5/72, 6.9%). A total of 2811 lymph nodes were retrieved, and the positivity rate was 11.9% (334/2811). The positivity rate of celiac and mediastinal lymph nodes was 14.4% (314/2186) and 3.2% (20/625), respectively. The percentage of patients who had positive celiac and mediastinal lymph nodes reached up to 58.3% (42/72) and 8.3% (6/72), respectively. The DFS and DSS of these 72 patients were 94% and 93.4% at 1 year after surgery and 59.8% and 62% at 3 years after surgery, respectively. The pTNM stage showed a significant difference between DFS and DSS.

CONCLUSIONS

TLILD2 could be a potential way to promote long-term survival of AEG patients. On the basis of the patterns of lymph nodes metastasis, we suggest that lower mediastinal and D2 celiac lymphadenectomy is necessary to improve the oncological outcome.

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

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

For Gastroesophageal Junction Cancers, Does an "Esophageal" or "Gastric" Surgical Approach Offer Better Perioperative and Oncologic Outcomes?

BACKGROUND

The optimal surgical approach to the resection of gastoesophageal junction cancer is unknown. A comprehensive literature search was conducted to further compare the esophageal and gastric approaches to gastroesophageal junction cancer.

METHODS

A systematic review of the literature from January 1990 to May 2018 was performed to determine whether an esophageal or gastric surgical approach offers better perioperative and oncologic outcomes.

RESULTS

A total of 179 abstracts were identified and after excluding publications for non-English language, primary focus on neoadjuvant and/or adjuvant treatment, lack of comparison of surgical approaches or not addressing morbidity, mortality, or survival-related outcomes, a total of 14 nonrandomized, comparative studies were reviewed in detail.

CONCLUSIONS

The proximal and distant extent of the tumor based on Siewert type classification greatly influences choice of operation. Overall survival rates and surgical outcomes are comparable, and surgical approach should be dictated by patient factors.

Current surgical treatment of esophagogastric junction adenocarcinoma

The incidence of esophagogastric junction (EGJ) adenocarcinoma has shown an upward trend over the past several decades worldwide. In this article, we review previous studies and aimed to provide an update on the factors related to the surgical treatment of EGJ adenocarcinoma. The Siewert classification has implications for lymph node spread and is the most commonly used classification. Different types of EGJ cancer have different incidences of mediastinal and abdominal lymph node metastases, and different surgical approaches have unique advantages and disadvantages. Minimally invasive surgeries have been increasingly applied in clinical practice and show comparable oncologic outcomes. Endoscopic resection may be a good therapy for early EGJ cancer. Additionally, there is still a great need for well-designed, large RCTs to forward our knowledge on the surgical treatment of EGJ cancer.

Minimally invasive and robotic surgery in the surgical treatment of esophagogastric junction cancer

Minimally invasive surgery provides for the treatment of esophagogastric junction tumors under safe conditions, reducing respiratory and abdominal wall complications. Recovery is improved, while maintaining the oncological principles of surgery to obtain an optimal long-term outcome. It is important to have a sufficient volume of activity to progress along the learning curve with close expert supervision in order to guarantee R0 resection and adequate lymphadenectomy. Minimal invasiveness ought not become an objective in itself. Should total gastrectomy be performed, the risk of a positive proximal margin makes intraoperative biopsy compulsory, without ruling out a primary open approach. Meanwhile, minimally invasive esophagectomy has been gaining ground. Its main difficulty, the intrathoracic anastomosis, can be safely carried out either with a mechanical side-to-side suture or a robot-assisted manual suture, thanks to the 3-D vision and versatility of the instruments.

Results of the different surgical options for the treatment of cancer of the esophagogastric junction: Review of the evidence

There is significant controversy in the management of cardiac cancer. It seems unanimous that Siewert type I tumors be operated on as cancer of the esophagus and Siewert type III as gastric cancer. However, for "true" cancer of the gastric cardia or Siewert II, the authors do not agree. There is the obvious need for free proximal and distal margins, as well as correct lymphadenectomy. For some, esophagectomy is necessary to perform correct radical oncological surgery, but other authors defend that an abdominal approach is sufficient to perform total gastrectomy and distal esophagectomy. Recent and older papers published do not clarify this issue, and their results are contradictory. Chemotherapy prior to surgery can reduce the size of the tumor and the presence of lymphadenopathies.

Transhiatal distal esophagectomy for Siewert type II cardia cancer can be a treatment option in selected patients

BACKGROUND

While surgical treatment of Siewert I and III (S1,S3) Esophagogastric Junction (EGJ) cancer is codified, the efficay of transhiatal procedure with anastomosis in the lower mediastinum for Siewert II (S2) still remains a dibated topic.

METHODS

This is a large multicenter retrospective study. The results of 598 consecutive patients submitted to resection with curative intent from January 2000 to January 2017 were reported. Clinical and oncological outcomes of different procedures performed in S2 tumor were analyzed to investigate the efficacy of transhiatal approach.

RESULTS

The 5-year overall survival rate (OS) was poor (32%) for all Siewert types. The most performed operations in S2 cancer were proximal gastrectomy + transthoracic esophagectomy (TTE or Ivor-Lewis procedure, 60%), total gastrectomy + transhiatal distal esophagectomy with anastomosis in the chest (THE, 24%) and total gastrectomy + transthoracic esophagectomy (TGTTE, 15%). Cardiovascular and pulmonary complications were higher after TTE. On the contrary, surgical complications were significantly higher after THE. Postoperative mortality was similar. The distribution of TNM stages was different in the 3 types of procedures: patients submitted to THE had an earlier stage disease. With this bias, OS after THE was higher than after TTE but the difference was not significant (49.85% vs 28.42%, p = 0.0587).

CONCLUSIONS

Despite a higher rate of postoperative surgical complications, OS after total gastrectomy and transhiatal distal esophagectomy was at least comparable to that of transthoracic approach in less advanced S2 tumors. Therefore, THE with anastomosis in the chest could be a treatmen option in earlier S2 tumors.

Minimally invasive mesoesophageal resection

Based in the anatomical concept of the mesoesophagus, that at subcarinal level all the vessels come through a by-layer connective tissue plane from the aorta to the esophagus whereas supracarinally these structures will come from both sides, with vagal and recurrent laryngeal nerves, a minimally invasive mesoesophageal (MIME) resection model may be described. Based on this surgical plane concept, dissection of esophagus and mediastinal lymphadenectomy can be performed along these structures establishing clear anatomical modules for an adequate oncological resection.

Extended thoracic lymph node dissection in robotic-assisted minimal invasive esophagectomy (RAMIE) for patients with superior mediastinal lymph node metastasis

Background

Robot-assisted surgery may have a role in improving oncological outcomes in esophagectomy. Especially in the anatomical areas in the chest that are more difficult to reach in open surgery (including the superior mediastinum). The dexterity of the robotic instruments aid in performing a more extensive nodal dissection and the precision and detailed vision of the robotic system potentially improves staging, oncological outcomes and reduces complications (i.e., recurrent nerve palsy). In this article, we describe our experience and clinical outcomes in patients treated by robot assisted minimal invasive esophagectomy (RAMIE) in cN+ esophageal cancer patients with positive nodes localized in the superior mediastinum.

Methods

From May 2007-2018, all patients who had involved nodes by either fluor-18-deoxyglucose positron-emission-tomography-computed tomography (FDG-PET-CT) or endoscopic ultrasound (EUS) + fine needle aspiration (FNA) localized in the superior mediastinum (above level Th4/sternal angle) were identified. Patient characteristics, perioperative data, postoperative clinical outcomes/complications and overall survival were prospectively recorded and retrospectively evaluated.

Results

Forty patients (48% adenocarcinoma) met our inclusion criteria. All patients underwent a three-stage procedure with cervical anastomosis and 90% of the patients underwent neoadjuvant chemoradiotherapy. Mortality occurred in three patients (7.5%), of which two were caused by severe acute respiratory distress syndrome (ARDS). The most frequent complications were pneumonia (25%), chylothorax (20%), anastomotic leakage (17.5%) and vocal cord paralysis (17.5%) which was grade 1 in 72% of the patients. Radicality rate (R0 resection) was 98% and the average lymph node yield was 24 (range, 9-57). Median overall and disease-free survival was 26 and 17 months, respectively.

Conclusions

RAMIE for esophageal cancer patients with node positive disease in the superior mediastinum is associated with increased mortality/morbidity. Oncological outcome showed excellent lymph node yield, R0 rate and survival was equal compared to patients with lower mediastinal node positive disease.

Thoracoabdominal versus transhiatal surgical approaches for adenocarcinoma of the esophagogastric junction-a systematic review and meta-analysis

PURPOSE

The aim of this systematic review and meta-analysis was to compare the oncological and perioperative outcomes of transhiatally extended gastrectomy (TEG) and thoracoabdominal esophagectomy (TAE) for therapy of adenocarcinomas of the esophagogastric junction (AEG) with focus on AEG type II, as the optimal approach for these tumors is still unclear.

METHODS

MEDLINE, EMBASE, and the Cochrane Library (CENTRAL) were searched until July 24, 2018. Studies comparing TAE and TEG for surgical treatment of AEG type tumors have been included. Patient's baseline and perioperative data have been extracted and meta-analyses have been conducted for the outcomes: number of dissected lymph nodes, R0-resection rate, anastomotic leak rate, postoperative morbidity, and 30-day mortality.

RESULTS

Of 6709 articles identified, 8 studies have been included for further analysis. One thousand thirty-four patients underwent TAE, and 1177 patients TEG. No differences were found between the approaches in regard to number of dissected lymph nodes (MD - 0.96; 95% CI - 3.07 to 1.15; p = 0.37), R0-resection rates (OR 0.97; 95% CI 0.57 to 1.63; p = 0.90), anastomotic leak rates (OR 1.13; 95% CI 0.69 to 1.86; p = 0.63), and 30-day mortality (OR 1.53; 95% CI 0.90 to 2.61; p = 0.11). However, a higher rate of postoperative morbidity was found after TAE (OR 1.55; 95% CI 1.12 to 2.14; p = 0.008).

CONCLUSIONS

The optimal approach to surgical therapy of AEG II still remains unclear. This study identified a significantly higher rate of postoperative morbidity after TAE at comparable surgical outcomes. Due to major limitations concerning the quality of included studies, current data strongly mandates a properly designed randomized controlled trial to identify the optimal surgical approach for AEG type II tumors.

Comparison between gastric and esophageal classification system among adenocarcinomas of esophagogastric junction according to AJCC 8th edition: a retrospective observational study from two high-volume institutions in China

BACKGROUND

The new 8th TNM system attributes AEG Siewert type II to esophageal classification system. However, the gastric and esophageal classification system which was more suitable for type II remains in disputation. This study aimed to illuminate the 8th TNM-EC or TNM-GC system which was more rational for type II, especially for patients underwent transhiatal approaches.

METHODS

We collected the database of patients with AEG who underwent radical surgical resection from two high-volume institutions in China: West China Hospital (N = 773) and Xi Jing Hospital of Fourth Military University (N = 637). The cases were randomly matched into 705 training cohort and 705 validation cohort. All the cases were reclassified by the 8th edition of TNM-EC and TNM-GC. The distribution of patients in each stage, the hazard ratio of each stage, and the separation of the survival were compared. Multivariate analysis was performed using the Cox proportional hazard model. Comparisons between the different staging systems for the prognostic prediction were performed with the rcorrp.cens package in Hmisc in R (version 3.4.4. http://www.R-project.org/ ). The validity of these two systems was evaluated by Akaike information criterion (AIC) and concordance index (C-index).

RESULTS

By univariate analysis, the HRs from stage IA/IB to stage IV/IVB were monotonously increased according to TNM-GC scheme in both cohorts (training 2.63, 3.91, 5.02, 8.64, 15.51 and 29.64; validation 1.54, 3.55, 4.91, 7.14, 11.67, 18.71 and 48.32) whereas only a fluctuating increased tendency was found when staged by TNM-EC. After the multivariate analysis, TNM-GC (P < 0.001), TNM-EC (P = 0.001) in training cohort and TNM-GC (P < 0.001) TNM-EC (P < 0.001) in the validation cohort were both independent prognostic factors. The C-index value for the TNM-GC scheme was larger than that of TNM-EC system in both training (0.721 vs. 0.690, P < 0.001) and validation (0.721 vs. 0.696, P < 0.001) cohorts. After stratification analysis for Siewert type II, the C-index for TNM-GC scheme was still larger than that of TNM-EC in both training (0.724 vs. 0.694, P = 0.005) and validation (0.723 vs. 0.699, P < 0.001) cohorts.

CONCLUSIONS

The 8th TNM-GC scheme is superior to TNM-EC in predicting the prognosis of AEG especially for type II among patients underwent transhiatal approaches.

Novel abdominal approach for dissection of advanced type II/III adenocarcinoma of the esophagogastric junction: a new surgical option

OBJECTIVE

The optimal surgical approach for Siewert type II adenocarcinoma of the esophagogastric junction (AEG) is controversial. In this study, we evaluated the outcomes of total gastrectomy for Siewert type II/III AEG via the left thoracic surgical approach that is used at our center.

METHODS

We identified 41 patients with advanced AEG in our retrospective database and analyzed their 3-year survival rate, upper surgical margin, postoperative complications, and index of estimated benefit from lymph node dissection.

RESULTS

The 3-year overall survival rate of the whole group was 63%, but no difference was observed between Siewert type II and III AEGs. Esophageal exposure and lymphadenectomy were sufficient. Eight patients developed postoperative complications, but none of the patients developed anastomotic leakage. Dissection of lymph node station Nos. 19 and 110 may be necessary for patients with Siewert type II AEG. Multivariate analysis revealed that the cT category was the only independent risk factor.

CONCLUSIONS

Total gastrectomy via an approach from the abdominal cavity into the thoracic cavity may be an optimal surgical technique for advanced Siewert type II AEG.

Surgical evaluation of lymph nodes in esophageal adenocarcinoma: Standardized approach or personalized medicine?

The extent of lymphadenectomy for esophageal adenocarcinoma remains controversial. Outstanding issues include the appropriate technical approach such as transthoracic versus transhiatal, or open versus minimally invasive, both of which have implications on overall lymph node harvest numbers and morbidity. Recent data on the relationship of total number of lymph nodes harvested and oncologic survival have been conflicting, due in part to a likely differential impact of lymphadenectomy on survival based on tumor stage and response to neoadjuvant therapy. While standardizing the extent of lymphadenectomy may be desirable, a more useful approach might be to tailor lymphadenectomy considering the multidimensional impact of surgical technique and multimodal treatment strategy.

Surgical strategies in true adenocarcinoma of the esophagogastric junction (AEG II): thoracoabdominal or abdominal approach?

BACKGROUND

The optimal surgical approach for adenocarcinoma directly at the esophagogastric junction (AEG II) is still under debate. This study aims to evaluate the differences between right thoracoabdominal esophagectomy (TAE) (Ivor-Lewis operation) and transhiatal extended gastrectomy (THG) for AEG II.

METHODS

From a prospective database, 242 patients with AEG II (TAE, n = 56; THG, n = 186) were included and analyzed according to characteristics and perioperative morbidity and mortality and overall survival (chi-square, Mann-Whitney U, log-rank, Cox regression).

RESULTS

Groups were comparable at baseline with exception of age. Patients older than 70 years were more frequently resected by THG (p = 0.003). No differences in perioperative morbidity (p = 0.197) and mortality (p = 0.711) were observed, including anastomotic leakages (p = 0.625) and pulmonary complications (p = 0.494). There was no significant difference in R0 resection (p = 0.719) and number of resected lymph nodes (p = 0.202). Overall median survival was 38.4 months. Survival after TAE was significantly longer than after THG (median OS not reached versus 33.6 months, p = 0.02). Multivariate analysis revealed pN-category (p < 0.001) and type of surgery (p = 0.017) as independent prognostic factors. The type of surgery was confirmed as prognostic factor in locally advanced AEG II (cT 3/4 or cN1), but not in cT1/2 and cN0 patients.

CONCLUSIONS

Our single-center experience suggests that patients with (locally advanced) AEG II tumors may benefit from TAE compared to THG. For further evaluation, a randomized trial would be necessary.

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.

[Differentiated surgical approach for adenocarcinoma of the gastroesophageal junction]

For adenocarcinoma of the gastroesophageal junction (GEJ) the classification of Siewert with its three subtypes is well established as a practical approach to surgical treatment. Transthoracic esophagectomy with gastric tube formation is generally accepted as the surgical standard for adenocarcinoma of the distal esophagus (GEJ type I). Intrathoracic esophagogastrostomy has become the most frequently used anastomotic technique (Ivor Lewis esophagectomy). Both the abdominal and thoracic part can be safely performed with a minimally invasive access. For subcardiac gastric cancer (GEJ type III) transhiatal extended gastrectomy is the resection of choice. For true cardiac carcinomas (GEJ type II) it has not yet been decided which of the abovementioned surgical procedures offers the best long-term survival. If technically possible in terms of a complete resection, transhiatal extended gastrectomy should be preferred because of a better postoperative quality of life. For GEJ type II tumors a minimally invasive approach is not recommended if the extent of resection cannot be safely determined preoperatively.

Gastro-esophageal junction cancers: what is the best minimally invasive approach?

The short-term advantages of minimally invasive esophagectomy (MIE) in terms of less morbidity and better quality of life (QoL) in comparison with open esophagectomy (OE) became visible in the last few years. There are two main MIE approaches: a transthoracic esophagectomy (TTE) (either accompanied by an intrathoracic or cervical anastomosis) or a transhiatal esophagectomy (THE) (accompanied by a cervical anastomosis). Additionally, minimally invasive gastrectomy is increasingly gaining popularity over open gastrectomy. Controversy still exists about what approach is the best for esophagogastric junction tumors (EGJ) and the choice of the approach is currently based on the surgeons' discretion. In this study, we describe the definition, staging and classification, indications for each minimally invasive approach for EGJ tumors, the surgical technique, current developments and problems regarding surgical treatment for patients with cancer of the EGJ.

The extent of lymphadenectomy in esophageal resection for cancer should be standardized

The incidence of esophageal cancer increases, with approximately 482,000 patients diagnosed with esophageal cancer each year. Despite the growing incidence of esophageal carcinoma, the extent of the lymphadenectomy is still under discussion. Lymph node status is an important prognostic parameter in esophageal cancer and an independent predictor of survival. Surgical strategy depends on the distribution pattern of nodal metastases but consensus on the extent of lymphadenectomy differs worldwide. For squamous cell cancer, Japanese surgeons have standardized the 2- or 3-field lymphadenectomy according to the location of the tumor. For adenocarcinoma, in the Western World accounting for 85% of all esophageal cancers, the type of lymphadenectomy to perform is not clear. Moreover, the use of neoadjuvant therapy may influence the mediastinal lymph nodes and the significance of the lymphadenectomy for survival. These aspects have challenged the traditional policy concerning lymphadenectomy, at least in the Western World. Furthermore, an extensive lymphadenectomy may improve survival but, on the other hand, may cause significant more morbidity. An overview of the literature on the extent of lymphadenectomy for esophageal cancer with respect to the supposed lymph node distribution patterns for squamous cell carcinoma and adenocarcinoma, the different lymph node classification systems, the commonly used surgical techniques and outcomes, and the proposal of observational cohort study to standardize the type of lymphadenectomy according to the type of tumor, location and use of neoadjuvant therapy will be provided.

New evidence guiding extent of lymphadenectomy for esophagogastric junction tumor: Application of Ber-Ep4 Joint with CD44v6 staining on the detection of lower mediastinal lymph node micrometastasis and survival analysis

For Siewert type II adenocarcinoma of the esophagogastric junction (AEJ), the optimal surgical approach and extent of lymph nodes dissection remain controversial. Immunohistochemistry (IHC) has been reported to be available for identifying lymph node micrometastasis (LNMM) in patients with AEJ. This was a prospective case series of patients who underwent R0 resection and lower mediastinal lymphadenectomy from January 2010 to June 2015 in Fujian Medical University Union Hospital for Siewert type II AEJ. The outcomes were analyzed retrospectively. A total of 1325 lymph nodes were collected from 49 patients, grouped into 3 groups: lower mediastinal, paracardial, and abdominal. The former 2 groups were examined by monoclonal antibodies against Ber-Ep4 and CD44v6. The incidence of LNMM in mediastinal group was 37% (18/49) for Ber-Ep4 and 33% (16/49) for CD44v6. While in routine histological diagnosis, the number of patients with the positive lymph nodes was 7 (14%). When combining IHC with histopathology (HE) staining, the incidence of positive mediastinal lymph nodes was increased to 24%, with a total number of 37 lymph nodes from 28 patients (57%). Micrometastases indicated by Ber-Ep4 and CD44v6 were associated with the depth of tumor invasion (P = 0.020 and 0.037, respectively), histopathological nodal status (P = 0.024 and 0.01, respectively), and Lauren classification (P = 0.038 and, respectively). Expression of CD44v6 and Ber-Ep4 was positively correlated (r = 0.643, P < 0.001). The 3- and 5-year survival rates for all patients were 66% and 50%, respectively. The patients with LNMM had a lower 3-year survival rate of 51%, compared to 80% from no LNMM group; 5-year survival rate was also lower in LNMM group, which is 29% versus 68% (P = 0.006) in the no LNMM group. Patients with positive Ber-Ep4 cells had a lower survival, but not statistically significant (P = 0.058). CD44v6-positive group had a significantly reduced survival (P < 0.001). In patients group with negative lower mediastinal lymph nodes, patients without LNMM obtained a significant survival benefit (P = 0.021). Our study demonstrated that routine test for LNMM is necessary for patients with negative lymph nodes. As a positive prognostic factor, thorough lower mediastinal lymphadenectomy in an invasive approach should be considered when necessary. Ber-Ep4 and CD44v6 were shown to be great markers for detecting LNMM.