How to decide surgical procedure for esophagogastric junction cancer?

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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.


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.

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

PhD, Professor, Department of Gastrointestinal Surgery

Hiroharu Yamashita

The University of Tokyo Hospital


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

MD, PhD, Department of Gastrointestinal Surgery


  1. Wang K, Yang CQ, Duan LP, et al. Changing pattern of adenocarcinoma of the esophagogastric junction in recent 10 years: experience at a large tertiary medical center in China. Tumori. 2012;98(5):568–574. doi: 10.1700/1190.13196.
  2. Liu K, Yang K, Zhang W, et al. Changes of esophagogastric junctional adenocarcinoma and gastroesophageal reflux disease among surgical patients during 1988-2012: a single-institution, high-volume experience in China. Ann Surg. 2016;263(1):88–95. doi: 10.1097/SLA.0000000000001148.
  3. Hatta W, Tong D, Lee YY, et al. Different time trend and management of esophagogastric junction adenocarcinoma in three Asian countries. Dig Endosc. 2017;29 Suppl 2:18–25. doi: 10.1111/den.12808.
  4. Koizumi S, Motoyama S, Iijima K. Is the incidence of esophageal adenocarcinoma increasing in Japan? Trends from the data of a hospital-based registration system in Akita Prefecture, Japan. J Gastroenterol. 2018;53(7):827–833. doi: 10.1007/s00535-017-1412-4.
  5. Brown LM, Devesa SS, Chow WH. Incidence of adenocarcinoma of the esophagus among white Americans by sex, stage, and age. J Natl Cancer Inst. 2008;100(16):1184–1187. doi: 10.1093/jnci/djn211.
  6. Pohl H, Sirovich B, Welch HG. Esophageal adenocarcinoma incidence: are we reaching the peak? Cancer Epidemiol Biomarkers Prev. 2010;19(6):1468–1470. doi: 10.1158/1055-9965.EPI-10-0012.
  7. Buas MF, Vaughan TL. Epidemiology and risk factors for gastroesophageal junction tumors: understanding the rising incidence of this disease. Semin Radiat Oncol. 2013;23(1):3–9. doi: 10.1016/j.semradonc.2012.09.008.
  8. Van Laethem JL, Carneiro F, Ducreux M, et al. The multidisciplinary management of gastro-oesophageal junction tumours: European Society of Digestive Oncology (ESDO): expert discussion and report from the 16th ESMO World Congress on Gastrointestinal Cancer, Barcelona. Dig Liver Dis. 2016;48(11):1283–1289. doi: 10.1016/j.dld.2016.08.112.
  9. Siewert JR, Hölscher AH, Becker K, Gössner W. [Cardia cancer: attempt at a therapeutically relevant classification (In German)]. Chirurg. 1987;58(1):25–32.
  10. Stein HJ, von Rahden BH, Höfler H, Siewert JR. [Carcinoma of the oesophagogastric junction and Barrett’s esophagus: an almost clear oncologic model? (In German)]. Chirurg. 2003;74(8):703–708.
  11. Mariette C, Piessen G, Briez N, et al. Oesophagogastric junction adenocarcinoma: which therapeutic approach? Lancet Oncol. 2011;12(3):296–305. doi: 10.1016/s1470-2045(10)70125-x.
  12. Zheng Z, Cai J, Yin J, et al. Transthoracic versus abdominal-transhiatal resection for treating Siewert type II/III adenocarcinoma of the esophagogastric junction: a meta-analysis. Int J Clin Exp Med. 2015;8(10):17167–17182.
  13. Jezerskyte E, van Berge Henegouwen MI, Cuesta MA, Gisbertz SS. Gastro-esophageal junction cancers: what is the best minimally invasive approach? J Thorac Dis. 2017;9(Suppl 8):S751–S760. doi: 10.21037/jtd.2017.06.56.
  14. Mariette C, Castel B, Balon JM, et al. Extent of oesophageal resection for adenocarcinoma of the oesophagogastric junction. Eur J Surg Oncol. 2003;29(7):588–593. doi: 10.1016/s0748-7983(03)00109-4.
  15. Ito H, Clancy TE, Osteen RT, et al. Adenocarcinoma of the gastric cardia: what is the optimal surgical approach? J Am Coll Surg. 2004;199(6):880–886. doi: 10.1016/j.jamcollsurg.2004.08.015
  16. Barbour AP, Rizk NP, Gonen M, 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.
  17. Tsujitani S, Okuyama T, Orita H, et al. Margins of resection of the esophagus for gastric cancer with esophageal invasion. Hepatogastroenterology. 1995;42(6):873–877.
  18. Bissolati M, Desio M, Rosa F, et al. Risk factor analysis for involvement of resection margins in gastric and esophagogastric junction cancer: an Italian multicenter study. Gastric Cancer. 2017;20(1):70–82. doi: 10.1007/s10120-015-0589-6.
  19. Mine S, Sano T, Hiki N, et al. Proximal margin length with transhiatal gastrectomy for Siewert type II and III adenocarcinomas of the oesophagogastric junction. Br J Surg. 2013;100(8):1050–1054. doi: 10.1002/bjs.9170.
  20. Casson AG, Darnton SJ, Subramanian S, Hiller L. What is the optimal distal resection margin for esophageal carcinoma? Ann Thorac Surg. 2000;69(1):205–209. doi: 10.1016/s0003-4975(99)01262-x.
  21. Avella D, Garcia L, Hartman B, et al. Esophageal extension encountered during transhiatal resection of gastric or gastroesophageal tumors: attaining a negative margin. J Gastrointest Surg. 2009;13(2):368–373. doi: 10.1007/s11605-008-0579-7.
  22. Butte JM, Waugh E, Parada H, De La Fuente H. Combined total gastrectomy, total esophagectomy, and D2 lymph node dissection with transverse colonic interposition for adenocarcinoma of the gastroesophageal junction. Surg Today. 2011;41(9):1319–1323. doi: 10.1007/s00595-010-4412-z.
  23. Yamashita H, Seto Y, Sano T, et al.; Japanese Gastric Cancer Association and the Japan Esophageal Society. Results of a nation-wide retrospective study of lymphadenectomy for esopha–gogastric junction carcinoma. Gastric Cancer. 2017;20(Suppl 1):69–83. doi: 10.1007/s10120-016-0663-8.
  24. Shiozaki A, Itoi H, Ueda Y, et al. The extending range of the tumor is a more suitable predictive risk factor for lymph node metastases than the location of the deepest tumor invasion in distal thoracic esophageal and cardiac cancer. Oncol Rep. 2005;14(1):195–199.
  25. Ueda Y, Shiozaki A, Itoi H, et al. The range of tumor extension should have precedence over the location of the deepest tumor center in determining the regional lymph node grouping for widely extending esophageal carcinomas. Jpn J Clin Oncol. 2006;36(12):775–782. doi: 10.1093/jjco/hyl105.
  26. Koyanagi K, Kato F, Kanamori J, et al. Clinical significance of esophageal invasion length for the prediction of mediastinal lymph node metastasis in Siewert type II adenocarcinoma: a retrospective single-institution study. Ann Gastroenterol Surg. 2018;2(3):187–196. doi: 10.1002/ags3.12069.
  27. Kurokawa Y, Hiki N, Yoshikawa T, et al. Mediastinal lymph node metastasis and recurrence in adenocarcinoma of the esophagogastric junction. Surgery. 2015;157(3):551–555. doi: 10.1016/j.surg.2014.08.099.
  28. Yonemura Y, Kojima N, Kawamura T, et al. Treatment results of adenocarcinoma of the gastroesophageal junction. Hepatogastroenterology. 2008;55(82–83):475–481.
  29. Mine S, Kurokawa Y, Takeuchi H, et al. Distribution of involved abdominal lymph nodes is correlated with the distance from the esophagogastric junction to the distal end of the tumor in Siewert type II tumors. Eur J Surg Oncol. 2015;41(10):1348–1353. doi: 10.1016/j.ejso.2015.05.004.
  30. Sato Y, Katai H, Ito M, et al. Can proximal gastrectomy be justified for advanced adenocarcinoma of the esophagogastric junction? J Gastric Cancer. 2018;18(4):339–347. doi: 10.5230/jgc.2018.18.e33.
  31. Inada T, Yoshida M, Ikeda M, et al. Evaluation of QOL after proximal gastrectomy using a newly developed assessment scale (PGSAS-45). World J Surg. 2014;38(12):3152–3162. doi: 10.1007/s00268-014-2712-y.


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