Gastroesophageal Junction Cancer

Abstract

Cancers of the gastroesophageal junction (GEJ) remain challenging malignancies to treat effectively. The GEJ represents the transition between esophagus and stomach, and approaching GEJ cancers as “esophageal” or as “gastric” cancers, a priori will run risk for excluding some more appropriate therapeutic options based on actual location. Gastroesophageal junction cancers are increasing in incidence, in particular at the distal esophageal and gastric cardia locations. They may be discovered in an early stage on upper GI endoscopy, but when presenting with dysphagia symptoms they are often of more advanced stage. Endoscopic resection options are limited to non-ulcerated T1 lesions, and surgical resection as only therapy is accepted for nodal-negative T1 or T2 disease. All other mid-stage GEJ cancers should be considered for multimodality therapy and should undergo a formal and complete multidisciplinary evaluation process before any therapy is started. While the proper approach remains debated, most often trimodality therapy with preoperative chemoradiation followed by resection is being offered, as it offers the greatest likelihood for complete pathologic response and survival benefit but requires a shorter preoperative treatment duration. Perioperative chemotherapy remains acceptable as well, based on the patient’s tolerance for related toxicity. The Siewert classification with 3 subtypes of GEJ cancers, based on the relationship of the tumor’s epicenter to the gastric cardia, remains useful for planning resection approach and extent as well as reconstruction technique. Type I (proximal GEJ) tumors require esophageal resection with mediastinal and retrogastric lymphadenectomy; reconstruction most often involves a gastric tube pull-up. Type III (distal GEJ) lesions are gastric cancers that require total or proximal gastrectomy with D2 dissection; reconstruction often utilizes Roux-Y esophagojejunostomy, but may include small bowel interposition for proximal gastrectomy too. Best approaches to type II lesions (of the cardia) remain debated; complete resection through esophagectomy (as type I) or transhiatal esophagogastrectomy (as in type III with appropriate proximal extension) remain acceptable, as long as complete resection and proper extent lymphadenectomy are performed. Minimally invasive approaches (versus open), patient comorbidity, individual tumor extent and surgeon’s experience should determine the best individual choice for operative approach. Surgeons engaging in GEJ cancer care should be familiar with all aspects of multidisciplinary and operative treatment planning, and should be able to offer the most appropriate resection choice for the patient’s best benefit. This review contains 2 figures, 3 tables, and 100 references. Key words: adenocarcinoma, gastrectomy, gastroesophageal junction, laproscopy, lymphadenectomy, metastasis, minimally invasive esophagectomy