Adenocarcinoma of the Esophagogastric Junction: Classification, Staging, and Surgical Approach.

Abstract

Diagnostic delay, nodal involvement, and incompleteness of resection carry an adverse effect on long-term prognosis of adenocarcinoma of the esophagogastric junction. Since three different tumor entities arise in this area, classification is important to compare surgical approaches and to investigate new therapeutic modalities in order to improve survival. The role of mediastinal nodal dissection and the impact of neo-adjuvant regimens are still controversial.Patients and Methods-Between November 1992 and December 1998, 248 patients with histologically proven adenocarcinoma of the esophagogastric junction were referred to our Department. In 7 patients (9.4%) cancer was discovered during endoscopic surveillance for Barrett's metaplasia. Overall, 169 patients (68.1%) underwent resection. A Ivor-Lewis approach was used in 140 patients ; of these, 57 underwent an extended mediastinal lymph node dissection.Results-The median cumulative survival was 22±3 months in patients undergoing resection, and 7±0.8 months in patients having palliation (p <0.01). Survival was significantly better in patients with negative nodes than in those with lymph node metastases (44.7±3.7 versus 22.3±2 months, p <0.01). Six of the 57 patients (10.5%) undergoing extended lymphadenectomy had metastases in the upper mediastinal nodes. Additional serial sections and immunohistochemistry were performed in 46 patients. In 6 of 18 patients (33.3%) with negative nodes at conventional hematoxylin-eosin examination, immunohistochemistry demonstrated micrometastases in the lesser curvature, paracardial, peripancreatic, or lower mediastinal nodes. Three of these patients had recurrent disease within the first year of follow-up.Conclusions-Endoscopic surveillance is mandatory in patients with Barrett's metaplasia. When a curative resection is attempted in patients with adenocarcinoma of the esophagogastric junction, extended lymphadenectomy improves tumor staging and may prevent local recurrences. Serial sections and immunohistochemistry provide additional accuracy in the staging of the disease and may prove useful to select patients for adjuvant therapy.