Top

Published in:

01-03-2018 | Original Article

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

Authors: Susanne Blank, Thomas Schmidt, Patrick Heger, Moritz J. Strowitzki, Leila Sisic, Ulrike Heger, Henrik Nienhueser, Georg Martin Haag, Thomas Bruckner, André L. Mihaljevic, Katja Ott, Markus W. Büchler, Alexis Ulrich

Published in: Gastric Cancer | Issue 2/2018

Abstract

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.

Blot WJ, Devesa SS, Kneller RW, Fraumeni JF Jr. Rising incidence of adenocarcinoma of the esophagus and gastric cardia. JAMA. 1991;265(10):1287–9 (Epub 1991/03/23).CrossRefPubMed

Falk J, Carstens H, Lundell L, Albertsson M. Incidence of carcinoma of the oesophagus and gastric cardia. Changes over time and geographical differences. Acta Oncol. 2007;46(8):1070–4. doi:10.1080/02841860701403046 (Epub 2007/09/14).CrossRefPubMed

Siewert JR, Stein HJ. Classification of adenocarcinoma of the oesophagogastric junction. Br J Surg. 1998;85(11):1457–9. doi:10.1046/j.1365-2168.1998.00940.x (Epub 1998/11/21).CrossRefPubMed

Hasegawa S, Yoshikawa T. Adenocarcinoma of the esophagogastric junction: incidence, characteristics, and treatment strategies. Gastric Cancer. 2010;13(2):63–73.CrossRefPubMed

Derakhshan MH, Malekzadeh R, Watabe H, Yazdanbod A, Fyfe V, Kazemi A, et al. Combination of gastric atrophy, reflux symptoms and histological subtype indicates two distinct aetiologies of gastric cardia cancer. Gut. 2008;57(3):298–305. doi:10.1136/gut.2007.137364 (Epub 2007/10/30).CrossRefPubMed

Hansen S, Vollset SE, Derakhshan MH, Fyfe V, Melby KK, Aase S, et al. Two distinct aetiologies of cardia cancer; evidence from premorbid serological markers of gastric atrophy and Helicobacter pylori status. Gut. 2007;56(7):918–25. doi:10.1136/gut.2006.114504 (Epub 2007/02/24).CrossRefPubMedPubMedCentral

Hosokawa Y, Kinoshita T, Konishi M, Takahashi S, Gotohda N, Kato Y, et al. Clinicopathological features and prognostic factors of adenocarcinoma of the esophagogastric junction according to Siewert classification: experiences at a single institution in Japan. Ann Surg Oncol. 2012;19(2):677–83. doi:10.1245/s10434-011-1983-x (Epub 2011/08/09).CrossRefPubMed

Siewert JR, Feith M, Werner M, Stein HJ. Adenocarcinoma of the esophagogastric junction: results of surgical therapy based on anatomical/topographic classification in 1,002 consecutive patients. Ann Surg. 2000;232(3):353–60.CrossRef

von Rahden BH, Stein HJ, Siewert JR. Surgical management of esophagogastric junction tumors. World J Gastroenterol. 2006;12(41):6608–13 (Epub 2006/11/01).CrossRef

10.

Carboni F, Lorusso R, Santoro R, Lepiane P, Mancini P, Sperduti I, et al. Adenocarcinoma of the esophagogastric junction: the role of abdominal-transhiatal resection. Ann Surg Oncol. 2009;16(2):304–10. doi:10.1245/s10434-008-0247-x.CrossRefPubMed

11.

Fox MP, van Berkel V. Management of gastroesophageal junction tumors. Surg Clin N Am. 2012;92(5):1199–212. doi:10.1016/j.suc.2012.07.011.CrossRefPubMed

12.

Haverkamp L, Ruurda JP, van Leeuwen MS, Siersema PD, van Hillegersberg R. Systematic review of the surgical strategies of adenocarcinomas of the gastroesophageal junction. Surg Oncol (Oxf). 2014;23(4):222–8. doi:10.1016/j.suronc.2014.10.004.CrossRef

13.

Mullen JT, Kwak EL, Hong TS. What’s the best way to treat GE junction tumors? Approach like gastric cancer. Ann Surg Oncol. 2016;23(12):3780–5. doi:10.1245/s10434-016-5426-6.CrossRefPubMed

14.

Rizk N. Gastroesophageal junction tumors. Ann Surg Oncol. 2016;23(12):3798–800. doi:10.1245/s10434-016-5427-5.CrossRefPubMed

15.

Giacopuzzi S, Bencivenga M, Weindelmayer J, Verlato G, de Manzoni G. Western strategy for EGJ carcinoma. Gastric Cancer. 2016;. doi:10.1007/s10120-016-0685-2.

16.

Barbour AP, Lagergren P, Hughes R, Alderson D, Barham CP, Blazeby JM. Health-related quality of life among patients with adenocarcinoma of the gastro-oesophageal junction treated by gastrectomy or oesophagectomy. Br J Surg. 2008;95(1):80–4. doi:10.1002/bjs.5912.CrossRefPubMed

17.

Fuchs H, Holscher AH, Leers J, Bludau M, Brinkmann S, Schroder W, et al. Long-term quality of life after surgery for adenocarcinoma of the esophagogastric junction: extended gastrectomy or transthoracic esophagectomy? Gastric Cancer. 2016;19(1):312–7. doi:10.1007/s10120-015-0466-3.CrossRefPubMed

18.

Cunningham D, Allum W, Stenning S, Thompson J, Van de Velde C, Nicolson M, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006;355(1):11–20. doi:10.1056/NEJMoa055531.CrossRefPubMed

19.

Ychou M, Boige V, Pignon JP, Conroy T, Bouché O, Lebreton G, et al. Perioperative chemotherapy compared with surgery alone for resectable gastroesophageal adenocarcinoma: an FNCLCC and FFCD multicenter phase III trial. J Clin Oncol. 2011;29(13):1715–21. doi:10.1200/JCO.2010.33.0597.CrossRefPubMed

20.

Sjoquist KM, Burmeister BH, Smithers BM, Zalcberg JR, Simes RJ, Barbour A, et al. Survival after neoadjuvant chemotherapy or chemoradiotherapy for resectable oesophageal carcinoma: an updated meta-analysis. Lancet Oncol. 2011;12(7):681–92. doi:10.1016/S1470-2045(11)70142-5.CrossRefPubMed

21.

Stahl M, Walz MK, Stuschke M, Lehmann N, Meyer HJ, Riera-Knorrenschild J, et al. Phase III comparison of preoperative chemotherapy compared with chemoradiotherapy in patients with locally advanced adenocarcinoma of the esophagogastric junction. J Clin Oncol. 2009;27(6):851–6. doi:10.1200/JCO.2008.17.0506.CrossRefPubMed

22.

van Hagen P, Hulshof MC, van Lanschot JJ, Steyerberg EW, van Berge Henegouwen MI, Wijnhoven BP, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med. 2012;366(22):2074–84. doi:10.1056/NEJMoa1112088.CrossRefPubMed

23.

Klevebro F, Alexandersson von Dobeln G, Wang N, Johnsen G, Jacobsen AB, Friesland S, et al. A randomized clinical trial of neoadjuvant chemotherapy versus neoadjuvant chemoradiotherapy for cancer of the oesophagus or gastro-oesophageal junction. Ann Oncol. 2016;27(4):660–7. doi:10.1093/annonc/mdw010 (Epub 2016/01/20).CrossRefPubMed

24.

Ott K, Bader F, Lordick F, Feith M, Bartels H, Siewert J. Surgical factors influence the outcome after Ivor–Lewis esophagectomy with intrathoracic anastomosis for adenocarcinoma of the esophagogastric junction: a consecutive series of 240 patients at an experienced center. Ann Surg Oncol. 2009;16(4):1017–25. doi:10.1245/s10434-009-0336-5.CrossRefPubMed

25.

Kirschner MB. Ein neues Verfahren der Oesophagoplastik. Arch Klin Chir. 1920;114:604–12.

26.

Akiyama H, Hiyama M, Hashimoto C. Resection and reconstruction for carcinoma of the thoracic oesophagus. Br J Surg. 1976;63(3):206–9.CrossRefPubMed

27.

Hartwig W, Strobel O, Schneider L, Hackert T, Hesse C, Buchler MW, et al. Fundus rotation gastroplasty vs. Kirschner–Akiyama gastric tube in esophageal resection: comparison of perioperative and long-term results. World J Surg. 2008;32(8):1695–702. doi:10.1007/s00268-008-9648-z (Epub 2008/06/17).CrossRefPubMed

28.

Buchler MW, Baer HU, Seiler C, Schilling M. A technique for gastroplasty as a substitute for the esophagus: fundus rotation gastroplasty. J Am Coll Surg. 1996;182(3):241–5 (Epub 1996/03/01).PubMed

29.

Moehler M, Baltin CT, Ebert M, Fischbach W, Gockel I, Grenacher L, et al. International comparison of the German evidence-based S3-guidelines on the diagnosis and multimodal treatment of early and locally advanced gastric cancer, including adenocarcinoma of the lower esophagus. Gastric Cancer. 2015;18(3):550–63. doi:10.1007/s10120-014-0403-x (Epub 2014/09/07).CrossRefPubMed

30.

Becker K, Langer R, Reim D, Novotny A, Meyer zum Buschenfelde C, Engel J, et al. Significance of histopathological tumor regression after neoadjuvant chemotherapy in gastric adenocarcinomas: a summary of 480 cases. Ann Surg. 2011;253(5):934–9. doi:10.1097/SLA.0b013e318216f449 (Epub 2011/04/15).CrossRefPubMed

31.

Becker K, Mueller JD, Schulmacher C, Ott K, Fink U, Busch R, et al. Histomorphology and grading of regression in gastric carcinoma treated with neoadjuvant chemotherapy. Cancer (Phila). 2003;98(7):1521–30. doi:10.1002/cncr.11660.CrossRef

32.

Schmidt T, Sicic L, Blank S, Becker K, Weichert W, Bruckner T, et al. Prognostic value of histopathological regression in 850 neoadjuvantly treated oesophagogastric adenocarcinomas. Br J Cancer. 2014;110(7):1712–20. doi:10.1038/bjc.2014.94.CrossRefPubMedPubMedCentral

33.

Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13.CrossRefPubMedPubMedCentral

34.

Schmidt T, Alldinger I, Blank S, Klose J, Springfeld C, Dreikhausen L, et al. Surgery in oesophago-gastric cancer with metastatic disease: treatment, prognosis and preoperative patient selection. Eur J Surg Oncol. 2015;41(10):1340–7. doi:10.1016/j.ejso.2015.05.005.CrossRefPubMed

35.

Barbour AP, Rizk NP, Gonen M, Tang L, Bains MS, Rusch VW, et al. Adenocarcinoma of the gastroesophageal junction: influence of esophageal resection margin and operative approach on outcome. Ann Surg. 2007;246(1):1–8. doi:10.1097/01.sla.0000255563.65157.d2.CrossRefPubMedPubMedCentral

36.

Reeh M, Mina S, Bockhorn M, Kutup A, Nentwich MF, Marx A, et al. Staging and outcome depending on surgical treatment in adenocarcinomas of the oesophagogastric junction. Br J Surg. 2012;99(10):1406–14. doi:10.1002/bjs.8884 (Epub 2012/09/11).CrossRefPubMed

37.

Mariette C, Castel B, Toursel H, Fabre S, Balon JM, Triboulet JP. Surgical management of and long-term survival after adenocarcinoma of the cardia. Br J Surg. 2002;89(9):1156–63. doi:10.1046/j.1365-2168.2002.02185.x (Epub 2002/08/23).CrossRefPubMed

38.

Johansson J, Djerf P, Oberg S, Zilling T, von Holstein CS, Johnsson F, et al. Two different surgical approaches in the treatment of adenocarcinoma at the gastroesophageal junction. World J Surg. 2008;32(6):1013–20. doi:10.1007/s00268-008-9470-7 (Epub 2008/02/27).CrossRefPubMed

39.

Ito H, Clancy TE, Osteen RT, Swanson RS, Bueno R, Sugarbaker DJ, et al. Adenocarcinoma of the gastric cardia: what is the optimal surgical approach? J Am Coll Surg. 2004;199(6):880–6. doi:10.1016/j.jamcollsurg.2004.08.015 (Epub 2004/11/24).CrossRefPubMed

40.

Parry K, Haverkamp L, Bruijnen RC, Siersema PD, Ruurda JP, van Hillegersberg R. Surgical treatment of adenocarcinomas of the gastro-esophageal junction. Ann Surg Oncol. 2015;22(2):597–603. doi:10.1245/s10434-014-4047-1.CrossRefPubMed

41.

Nienhueser H, Kunzmann R, Sisic L, Blank S, Strowitzk MJ, Bruckner T, et al. Surgery of gastric cancer and esophageal cancer: does age matter? J Surg Oncol. 2015;112(4):387–95. doi:10.1002/jso.24004 (Epub 2015/08/26).CrossRefPubMed

42.

Mariette C, Castel B, Balon JM, Van Seuningen I, Triboulet JP. Extent of oesophageal resection for adenocarcinoma of the oesophagogastric junction. Eur J Surg Oncol. 2003;29(7):588–93.CrossRefPubMed

43.

Pedrazzani C, de Manzoni G, Marrelli D, Giacopuzzi S, Corso G, Minicozzi AM, et al. Lymph node involvement in advanced gastroesophageal junction adenocarcinoma. J Thorac Cardiovasc Surg. 2007;134(2):378–85.CrossRefPubMed

44.

Ott K, Blank S, Ruspi L, Bauer M, Sisic L, Schmidt T. Prognostic impact of nodal status and therapeutic implications. Transl Gastroenterol Hepatol. 2017;2:15. doi:10.21037/tgh.2017.01.10.CrossRefPubMedPubMedCentral

45.

Lerut T, Nafteux P, Moons J, Coosemans W, Decker G, De Leyn P, et al. Three-field lymphadenectomy for carcinoma of the esophagus and gastroesophageal junction in 174 R-0 resections: impact on staging, disease-free survival, and outcome: a plea for adaptation of TNM classification in upper-half esophageal carcinoma. Ann Surg. 2004;240(6):962–74. doi:10.1097/01.sla.0000145925.70409.d7.CrossRefPubMedPubMedCentral

46.

Kakeji Y, Yamamoto M, Ito S, Sugiyama M, Egashira A, Saeki H, et al. Lymph node metastasis from cancer of the esophagogastric junction, and determination of the appropriate nodal dissection. Surg Today. 2012;42(4):351–8. doi:10.1007/s00595-011-0114-4.CrossRefPubMed

47.

Monig SP, Baldus SE, Zirbes TK, Collet PH, Schroder W, Schneider PM, et al. Topographical distribution of lymph node metastasis in adenocarcinoma of the gastroesophageal junction. Hepatogastroenterology. 2002;49(44):419–22.PubMed

48.

Sasako M, Sano T, Yamamoto S, Sairenji M, Arai K, Kinoshita T, et al. Left thoracoabdominal approach versus abdominal–transhiatal approach for gastric cancer of the cardia or subcardia: a randomised controlled trial. Lancet Oncol. 2006;7(8):644–51. doi:10.1016/s1470-2045(06)70766-5.CrossRefPubMed

49.

Kurokawa Y, Sasako M, Sano T, Yoshikawa T, Iwasaki Y, Nashimoto A, et al. Ten-year follow-up results of a randomized clinical trial comparing left thoracoabdominal and abdominal transhiatal approaches to total gastrectomy for adenocarcinoma of the oesophagogastric junction or gastric cardia. Br J Surg. 2015;102(4):341–8. doi:10.1002/bjs.9764 (Epub 2015/01/22).CrossRefPubMedPubMedCentral

50.

Wu J, Chen QX, Teng LS, Krasna MJ. Prognostic significance of positive circumferential resection margin in esophageal cancer: a systematic review and meta-analysis. Ann Thorac Surg. 2014;97(2):446–53. doi:10.1016/j.athoracsur.2013.10.043.CrossRefPubMed

51.

Chan DS, Reid TD, Howell I, Lewis WG. Systematic review and meta-analysis of the influence of circumferential resection margin involvement on survival in patients with operable oesophageal cancer. Br J Surg. 2013;100(4):456–64. doi:10.1002/bjs.9015.CrossRefPubMed

52.

Kneuertz PJ, Hofstetter WL, Chiang YJ, Das P, Blum M, Elimova E, et al. Long-term survival in patients with gastroesophageal junction cancer treated with preoperative therapy: do thoracic and abdominal approaches differ? Ann Surg Oncol. 2016;23(2):626–32. doi:10.1245/s10434-015-4898-0.CrossRefPubMed

53.

Tapias LF, Mathisen DJ, Wright CD, Wain JC, Gaissert HA, Muniappan A, et al. Outcomes with open and minimally invasive Ivor–Lewis esophagectomy after neoadjuvant therapy. Ann Thorac Surg. 2016;101(3):1097–103. doi:10.1016/j.athoracsur.2015.09.062.CrossRefPubMed

54.

Palazzo F, Rosato EL, Chaudhary A, Evans NR 3rd, Sendecki JA, Keith S, et al. Minimally invasive esophagectomy provides significant survival advantage compared with open or hybrid esophagectomy for patients with cancers of the esophagus and gastroesophageal junction. J Am Coll Surg. 2015;220(4):672–9. doi:10.1016/j.jamcollsurg.2014.12.023.CrossRefPubMed

Title: Surgical strategies in true adenocarcinoma of the esophagogastric junction (AEG II): thoracoabdominal or abdominal approach?
Authors: Susanne Blank
Thomas Schmidt
Patrick Heger
Moritz J. Strowitzki
Leila Sisic
Ulrike Heger
Henrik Nienhueser
Georg Martin Haag
Thomas Bruckner
André L. Mihaljevic
Katja Ott
Markus W. Büchler
Alexis Ulrich
Publication date: 01-03-2018
Publisher: Springer Japan
Published in: Gastric Cancer / Issue 2/2018
Print ISSN: 1436-3291
Electronic ISSN: 1436-3305
DOI: https://doi.org/10.1007/s10120-017-0746-1

Live Webinar | 27-06-2024 | 18:00 (CEST)

Keynote webinar | Spotlight on medication adherence

Reserve your place

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

WHO estimates that half of all patients worldwide are non-adherent to their prescribed medication. The consequences of poor adherence can be catastrophic, on both the individual and population level.

Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.

Prof. Kevin Dolgin

Prof. Florian Limbourg

Prof. Anoop Chauhan

Developed by: Springer Medicine

Obesity Clinical Trial Summary

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 2/2018

Helicobacter pylori-induced modulation of the promoter methylation of Wnt antagonist genes in gastric carcinogenesis

Histological verification of the usefulness of magnifying endoscopy with narrow-band imaging for horizontal margin diagnosis of differentiated-type early gastric cancers

Controlling Nutritional Status (CONUT) score is a prognostic marker for gastric cancer patients after curative resection

Survival benefit of “D2-plus” gastrectomy in gastric cancer patients with duodenal invasion

Clinical significance of overexpression of NRG1 and its receptors, HER3 and HER4, in gastric cancer patients

The long-term survival of stage IV gastric cancer patients with conversion therapy

Keynote webinar | Spotlight on medication adherence

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

At a glance: The STEP trials