Treatment results of adenocarcinoma of the gastroesophageal junction.

BACKGROUND/AIMS: In the treatment of cardiac cancer, the selection of surgical procedures is controversial.

METHODOLOGY

In this study 297 resectable adenocarcinomas arising around the GE junction, that had their center within 5cm oral and aboral of the anatomical GE junction, were analyzed. They were subdivided into those with the tumor center located more than 1cm above the GE junction (Type 1, N = 7), those with the tumor center located within 1cm oral and 2cm aboral of the GE junction (Type 2) and those with the tumor center 2cm below the junction (Type 3). Type 2 and 3 are subdivided into four groups as Type 2A (N = 47), 2B (N = 18), 3A (N = 37) and 3B (N = 188). Type 2A and 3A have esophageal invasion and Type 2B and 3B have no esophageal invasion. Thoraco-abdominal approach and transhiatal resection were done in 65 and 35 patients. Left and right thoracotomies were performed in 60 and 5 patients, respectively.

RESULTS

Esophageal invasion distance of 83 among 84 Type 2A and 3A tumors limited within 5cm from the GE junction. The maximum esophageal length by transhiatal approach was 6cm. Postoperative mortality rates after transhiatal approach and thoracotomy were 0% and 5.8%, respectively. One patient of Type 2A with No110 involvement survived longer than 5 years. No patients with Type 2A and 3A had recurrence in the upper mediastinal nodes after transhiatal approach and left thoracotomy. Mediastinal node involvement was found in 3 of 7 Type 1 tumors. Cox regression analyses revealed that the esophageal invasion distance (< 3cm vs. > 3cm), lymph node status (N0 vs. N2) and extent of lymph node dissection (D1 vs. D2) are the independent prognostic factors.

CONCLUSION

Dissection of the lower thoracic paraesophageal nodes is recommended if the esophageal invasion longer than 1cm. Almost all Type 2A and 3A tumors can be treated by transhiatal approach without positive esophageal margin under a routine use of intraoperative frozen section. Right thoracotomy and the dissection of the upper mediastinal nodes are recommended for Type 1 tumor. Cardiac resection with D2 dissection is indicated for Type 1 and T1 tumors of Type 2. Total gastrectomy +D2 dissection is recommended for T2-3 tumors of Type 2 and T1-4 tumors of Type 3. Treatment should be selected according to the proposed classification.