How to decide surgical procedure for esophagogastric junction cancer?

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Abstract


Standard surgical procedure for esophagogastric junction cancer, especially adenocarcinoma, has still remained controversial. Various procedures has been allowed and applied for Siewert type II tumors. Negative long resection margin had been regarded as essential in decision on the procedure. Recent papers have, however, shown the priority of invasion length to each side (esophagus and stomach), because it relates the frequency and sites of lymph node metastasis to be dissected. And, the size of remnant stomach is, also, important when a proximal gastrectomy is considered.


Introduction

Standard surgical procedure of esophagogastric junction (EGJ) cancer, especially adenocarcinoma, has not been established though it is increasing worldwide, in Asia 1)–4) as well as western countries 5)–7). The debate focused on the issue has still remained 8). Squamous cell carcinoma developed in EGJ region is usually treated as esophageal cancer. Siewert classification has been widely applied for EGJ adenocarcinoma: type I (adenocarcinoma of the distal esophagus); tumors with an epicenter located more than 1 cm above EGJ, type II (true cardia cancer); tumors with an epicenter located within 1 cm proximal and 2 cm distal from EGJ, type III (subcardial cancer); tumors with an epicenter located below 2 cm from EGJ 9) 10). Siewert type I and III tumors are mostly treated as esophageal and gastric cancers, respectively. There have been various surgical approaches for Siewert type II adenocarcinoma; Ivor-Lewis (right thoracic and abdominal), left thoracoabdominal, transhiatal, and abdominal approaches. Among them, Ivor-Lewis and transhiatal approaches have been mainly applied 11) and accepted 12). In the former, esophagectomy through right thoracotomy with reconstruction by gastric conduit and intrathoracic anastomosis is usually performed like esophageal cancer, while in the latter, extended total gastrectomy is done like gastric cancer. Why are those two quite different procedures allowed to Siewert type II tumor ? Recent paper desribed that the choice of approach has been still based on surgeon’s discretion 13).

The decision of the procedure according to the classification, e.g., Siewert classification, is rational or not?  The classification of EGJ cancer, including TNM classification, is based on the location of tumor’s epicenter. However, the correct diagnosis of an epicenter’s site is often difficult, especially on a large tumor. Therefore, discussions, how to decide the surgical procedure, have been done, but unsolved, to date.

Resection margin

There have been many papers describing the appropriate length of the resection margin for EGJ cancer surgery. Among them, 8 cm 14), 6 cm 15), 5 cm 16), 4 cm 17), 3 cm 18), and 2 cm 19) were recommended as the proximal gross margin. And, at least 5cm was reported for the distal margin20). Finally, for attaining a perfect negative margin, some papers recommended the combination of total esophagectomy and total gastrectomy with colonic interposition for EGJ cancer 21) 22). This procedure, however, seems to be over-surgery and may result in a poor QOL. In our department, the functional maintenance has a great priority as similar as oncological aspects when the surgical procedure is considered. We showed that the lymphadenectomy around the lower stomach is unnecessary for EGJ cancer if the tumor size is less than 4 cm 23). Total gastrectomy should be avoided to the utmost for postoperative QOL. Typical case in our series is presented here. Figure 1 and 2 show the photographs of the endoscopic examination and resected specimen of a proximal gastrectomy case. The tumor was a poorly diff. adenocarcinoma and the depth of the invasion was T3. The size of the diameter was 30mm and four metastatic nodes (4/65) were histologically observed. The proximal and distal margins were 13mm and 65mm, respectively. During surgery, the frozen section analysis showed the negative proximal margin. This patient has been alive more than 6 years without any recurrence, even the proximal margin was relatively short as compared to the previous reports’ recommendations. We think that 2 cm gross margin is sufficient, but the frozen section analysis is essential in that case.

 

Figure 1  Endoscopic view; left: from esophagus  right: from stomach

 

Figure 2  Resected specimen right: magnified

 

Invasion length, Tumor extension

Recently, many papers have shown the relationship of invasion length (tumor extension) in each side (esophagus and stomach) and lymphnode metastasis 24) 25)). Koyanagi, et al. reported that Siewert type II cancers with an esophageal invasion length of more than 25mm had a higher incidence of the upper and middle mediastinal metastatic nodes 26). Kurokawa, et al, showed that 30mm of esophageal invasion length was the border of presence or absence of metastatic nodes in the upper and middle mediastinum region 27). Yonemura, et al. reported the similar results previously 28). Therefore, when the invasion length to esophagus is more than 30mm, the upper and middle mediastinum lymph nodes should be dissected, and that case should be operated as an esophageal cancer. As for the gastric invasion, Mine, et al. reported that the frequency of nodal involvement around the lower stomach was rare when the distance from EGJ to the distal end of the tumor less than 30 mm 29). And, Sato, et al. demonstrated that a gastric invasion length of more than 40mm was a significant risk factor for the no. 3b (the lesser curvature along the right gastric artery) node metastasis 30). Therefore, when the invasion length to stomach is less than 40mm, the proximal gastrectomy can be applied and the distal stomach can be preserved.

Size of remnant stomach

When the proximal gastrectomy is considered, the size of remnant stomach is quite important. A large remnant stomach, e.g., more than three-quarters, was observed to have better QOL in Japanese QOL study31). In our department, when more than 12 cm along the lesser curvature and 25 cm along the greater curvature can be preserved, the proximal gastrectomy is applied (Fig. 3 ).

Figure 3 Shema of the indication of proximal gastrectomy

Yasuyuki Seto

The University of Tokyo Hospital

Author for correspondence.
Email: seto-tky@umin.ac.jp

Japan, 7-3-1 Hongo Bunkyo-ku, Tokyo 113-8655

PhD, Professor, Department of Gastrointestinal Surgery

Hiroharu Yamashita

The University of Tokyo Hospital

Email: eto-tky@umin.ac.jp

Japan, 7-3-1 Hongo Bunkyo-ku, Tokyo 113-8655

MD, PhD, Department of Gastrointestinal Surgery

 

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