Sadu Singh Rajdave S, Loo Guo H, Muthkumaran Guhan, Sambanthan Sekkapan T, Ritza Kosai Nik
Upper Gastrointestinal and Metabolic Surgery, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Kuala Lumpur, MYS.
Surgery, Sultanah Aminah Hospital, Ministry of Health Malaysia, Johor Bharu, MYS.
Cureus. 2024 Jul 19;16(7):e64945. doi: 10.7759/cureus.64945. eCollection 2024 Jul.
Oesophagogastric junction carcinoma is now being increasingly regarded as a distinct site of neoplasia, separate from its adjacent sites. Recent advances in multimodal treatment approaches, including endoscopic procedures, oesophagectomy with three-field lymph node dissection, and definitive chemoradiotherapy, have significantly improved overall patient survival rates. Despite these advancements, the recurrence rate remains around 50% within one to three years following initial surgery. A major challenge in management arises when the resected surgical margins are involved with cancer. We present a 55-year-old man who experienced progressive dysphagia and, upon further assessment, was noted to have a Siewert III oesophagogastric junction adenocarcinoma. He underwent neoadjuvant chemotherapy before undergoing total gastrectomy with D2 lymphadenectomy with a Roux-en-Y reconstruction. Histopathological examination of the resected specimen revealed a positive proximal margin involvement. After optimization, he then underwent a salvage three-field McKeown oesophagectomy with colonic conduit reconstruction and adjuvant chemotherapy. Salvage surgery can be considered for patients with locoregional recurrence after definitive chemoradiotherapy or surgery. Other options include salvage chemoradiotherapy. Our case outlines the importance of proper patient selection for salvage surgery and highlights the choices of conduit in patients undergoing total esophagectomy post gastrectomy. In conclusion, managing proximal margin involvement of cardioesophageal junction adenocarcinoma remains a complex and multifaceted challenge, necessitating a tailored, multidisciplinary approach. The decision-making process must consider the patient's functional status, previous treatments, and specific anatomical considerations.
食管胃交界部癌现在越来越被视为一个独立的肿瘤发生部位，与其相邻部位不同。多模式治疗方法的最新进展，包括内镜手术、三野淋巴结清扫的食管切除术和根治性放化疗，显著提高了患者的总体生存率。尽管有这些进展，但初次手术后一至三年内的复发率仍约为50%。当切除的手术切缘累及癌症时，管理中就会出现一个重大挑战。我们报告一名55岁男性，他出现进行性吞咽困难，进一步评估后发现患有Siewert III型食管胃交界部腺癌。他在接受全胃切除术加D2淋巴结清扫和Roux-en-Y重建之前接受了新辅助化疗。对切除标本的组织病理学检查显示近端切缘受累阳性。优化后，他随后接受了挽救性三野McKeown食管切除术加结肠代食管重建和辅助化疗。对于根治性放化疗或手术后局部区域复发的患者，可以考虑挽救性手术。其他选择包括挽救性放化疗。我们的病例概述了挽救性手术中正确选择患者的重要性，并强调了胃切除术后全食管切除患者的管道选择。总之，处理食管胃交界部腺癌近端切缘受累仍然是一个复杂且多方面的挑战，需要一种量身定制的多学科方法。决策过程必须考虑患者的功能状态、既往治疗以及具体的解剖学因素。
