Siewert Type Research Articles

A Case of Siewert Type II Adenocarcinoma of Esophagogastric Junction Treated by Thoracoscopy Assisted Esophagectomy

A 73-year-old woman was admitted to the hospital because of dysphagia. Esophgoscopy showed type 3 tumor at the lower thoracic esophagus and esophagogastric junction. Endoscopic biopsy confirmed Siewert type II adenocarcinoma of esophagogastric junction. Abdominal and chest CT examination revealed no lymph node and distant metastases. Clinical stage was II (T3, N0, M0). The patient underwent a thoracosopic subtotal esophagectomy in the prone position, and a laparoscopy assisted reconstruction of gastric tube in the supine position. Pathological diagnosis was well differentiated adenocarcionma (pT3, pN0, sM0, ly3, v1, fStage II). Postoperative course was uneventful. We attempted thoracosopic esophagectomy in the prone position to treat Siewert type II adenocarcinoma of esophagogastric junction. (日本医科大学医学会雑誌 2013; 9: 160―163)

Adenocarcinoma of the Esophagogastric Junction: Territory of the Esophagus or Stomach, or an Independent Region?

The most recent union for international cancer control (UICC) tumor-node-metastasis (TNM) classification (7th edition) definitively classified adenocarcinoma of the esophagogastric junction (AEG) for the first time. A tumor whose epicenter is within 5 cm of the esophagogastric junction (EGJ) and also extends into the esophagus is classified and staged according to the esophageal cancer scheme. All other gastric tumors with an epicenter greater than 5 cm from EGJ or within 5 cm of EGJ without extension into the esophagus are staged using the gastric cancer scheme. Therefore, most AEGs, including adenocarcinomas of the cardia and subcardia, are now to be staged as esophageal adenocarcinomas rather than gastric cancers by the current edition of TNM classification. AEG has been classified into three subtypes during the last decade, as advocated by Siewert and Stein AEG type I (distal esophageal adenocarcinoma) is a tumor with the epicenter located 1–5 cm above EGJ regardless of invasion to EGJ. AEG type II (true carcinoma of the cardia) is a tumor invading EGJ with the epicenter located between 1 cm above and 2 cm below EGJ. AEG type III (carcinoma of the subcardia) is a tumor invading EGJ with the epicenter located 2–5 cm below EGJ. It is likely that AEG type I tumors may be esophageal adenocarcinomas, which are mainly derived from the Barrett’s esophagus. However, whether AEG type II/III tumors should be also classified as esophageal adenocarcinomas still remains unknown. Recently, Gertler et al. attempted to evaluate whether AEG type II/III tumors are better staged as esophageal or gastric cancer by analysis of a single-center cohort of 1,141 patients who underwent surgery for AEG type II/III tumors in Germany. In their cohort, by esophageal cancer staging and gastric cancer staging as per the 7th edition UICC TNM classification, the authors emphasized that some stage groups were lacking homogeneity (absence of distinct subsets of patients within a stage), monotonicity (continuous decreasing survival with increasing stage group), and distinctiveness (difference in survival between monotonic stage groups). They concluded that neither the esophageal nor the gastric scheme was perfectly suitable for patients with AEG types II/III in terms of prognostic stratification. In contrast, Huang et al. analyzed 142 consecutive resection patients in a single Chinese center and suggested that it may be better to classify carcinomas of the cardia involving the esophagus using gastric cancer staging than esophageal cancer staging of the 7th edition TNM classification. Hasegawa et al. reported the postoperative survival of 163 patients with AEG types II/III when classified by either the esophageal cancer scheme or gastric cancer scheme of the 7th edition TNM classification. When the esophageal cancer scheme was used, patient distribution was substantially deviated to stage IIIC and the survival curves for each stage were not well separated. In contrast, when the gastric cancer schema was used, patient distribution was relatively even and the survival curves were monotonously and distinctively separated. They concluded that gastric cancer staging may be more suitable than esophageal cancer staging for patients with AEG types II/III. These results should be interpreted in context with caution because they represent a single-center retrospective cohort study with a small number of patients. Nevertheless, that study may provide a valuable signpost for the future direction of the AEG staging system. Hulscher et al. reported no significant difference in the postoperative survival between transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) in patients with distal esophageal adenocarcinoma (AEG type I) or gastric adenocarcinoma of the cardia involving the distal Society of Surgical Oncology 2012

Lymphadenectomy around the left renal vein in Siewert type II adenocarcinoma of the oesophagogastric junction

The extent of lymphadenectomy in patients with Siewert type II adenocarcinoma of the oesophagogastric junction is controversial. The aim of this study was to investigate lymph node involvement around the left renal vein. Lymph node involvement and prognosis in patients with Siewert type II cancers treated by R0-1 surgical resection were investigated, with regard to lymphadenectomy around the left renal vein. Based on the incidence of involvement at each node, the node stations were divided into three tiers (first tier, more than 20 per cent involvement; second tier, 10-20 per cent involvement; third tier, less than 10 per cent involvement). Of 150 patients with type II oesophagogastric adenocarcinoma, 94 had left renal vein lymphadenectomy. The first lymph node tier included nodes along the lesser curvature, right cardia, left cardia and left gastric artery, with involvement of 28·0-46·0 per cent and a 5-year survival rate of 42-53 per cent in patients with positive nodes. The nodes around the lower mediastinum, left renal vein, splenic artery and coeliac axis constituted the second tier, with involvement of 12·7-18 per cent and a 5-year survival rate of 11-35 per cent. With regard to the left renal vein, the incidence of involvement was 17 per cent and the 5-year rate survival rate was 19 per cent. Multivariable analysis showed that left renal vein lymphadenectomy was an independent prognostic factor in patients with pathological tumour category pathological T3-4 disease (hazard ratio 0·51, 95 per cent confidence interval 0·26 to 0·99; P = 0·048). Left renal vein nodal involvement is similar to that seen along the splenic artery, in the lower mediastinum and coeliac axis, with similar impact on patient survival.

Value of splenectomy in patients with Siewert type II adenocarcinoma of the esophagogastric junction

The incidence of adenocarcinoma of the esophagogastric junction (AEG) has been increasing recently in both Western and Eastern countries. However, an optimal treatment strategy for Siewert type II AEG is still unclear. The aim of this study was to clarify the value of splenectomy in patients with Siewert type II AEG. From September 2002 to November 2011, 42 patients underwent total gastrectomy with D2 lymph node dissection for Siewert type II AEG and were included in this study. We used the index of estimated benefit from lymph node dissection (IEBLD) to assess the efficacy of lymph node dissection of each station. Surgical complications were graded by the Clavien-Dindo classification. The overall 5-year survival rate of the 42 patients was 57.5 %. The incidence of splenic hilar lymph node metastasis was 4.8 % and the 5-year survival rate of patients with splenic hilar lymph node involvement was zero. Consequently, the IEBLD of splenic hilar lymph nodes was zero. Postoperative morbidities occurred in 25 patients (59.5 %). Pancreas-related complications were the most frequently observed (28.5 %), followed by intraabdominal abscess (14.3 %) and anastomotic leakage (9.5 %). Splenic hilar lymph node dissection may be omitted without decreasing curability in patients with Siewert type II AEG, although a prospective study is necessary for more conclusive results.

Staging and outcome depending on surgical treatment in adenocarcinomas of the oesophagogastric junction

Owing to controversial staging and classification of adenocarcinoma of the oesophago-gastric junction (AOG) before surgery, the choice of appropriate surgical approach remains problematic. In a retrospective study, preoperative staging of AOG and the impact of preoperative misclassification on outcome were analysed. Data from patients with AOG were analysed from a prospectively collected database with regard to surgical treatment, preoperative and postoperative staging, and outcome. One-hundred and thirty patients with Siewert types I and II AOG who did not have neoadjuvant treatment were included in the study: 41 patients with an AOG type I who underwent oesophagectomy, 51 patients with an AOG staged before surgery as type I who underwent oesophagectomy but in whom the final histology showed a type II tumour, and 38 patients whose tumours were staged as AOG type II before and after operation who underwent gastrectomy. Among patients who had an oesophagectomy, lymph node metastases (P = 0.022), tumour relapse (P = 0.009) and recurrent distant metastases (P = 0.028) were significantly more frequent in patients with AOG type II; those with AOG type II had shorter overall survival than those with type I tumours (P = 0.024). Among those with AOG type II, recurrence-free survival was significantly shorter after oesophagectomy compared with extended gastrectomy (P = 0.019). Thoracoabdominal oesophagectomy had a favourable influence on outcome compared with the transhiatal approach. Accurate preoperative staging of AOG and appropriate surgical therapy are crucial for outcome. AOG type II is a more aggressive tumour with higher recurrence rates than AOG type I. These patients therefore benefit from more radical surgical treatment.

Changing Pattern of Adenocarcinoma of the Esophagogastric Junction in Recent 10 Years: Experience at a Large Tertiary Medical Center in China

To investigate the changing pattern of adenocarcinoma of the esophagogastric junction subtypes and its time trend relationship with that of reflux esophagitis over 10 years at a tertiary medical center in China. . The medical records of all patients who underwent gastroscopy from 2000 to 2009 were reviewed. Subtypes of adenocarcinoma of the esophagogastric junction according to Siewert's classification, gastric non-cardiac adenocarcinoma, esophageal squamous cell carcinoma, reflux esophagitis and Helicobacter pylori infection were diagnosed according to the results of gastroscopy and mucosal histopathology. All the patients were divided into three cohorts (cohort A [2000-2003], cohort B [2004-2006]), cohort C [2007-2009]), and the proportion of adenocarcinoma of the esophagogastric junction and its subtypes in all upper gastrointestinal tumors (adenocarcinoma of the esophagogastric junction, gastric non-cardiac adenocarcinoma and esophageal squamous cell carcinoma) in each cohort were compared. The annual percentages of adenocarcinoma of the esophagogastric junction, reflux esophagitis and H pylori in all patients were also compared. 70,073 patients (cohort A, n = 20298, cohort B, n = 20443, cohort C, n = 29332) who underwent gastroscopy were reviewed. Totally there were 279 patients with adenocarcinoma of the esophagogastric junction (0.398%, M:F = 5.6:1), 794 gastric non-cardiac adenocarcinoma patients (1.133%, M:F = 2:1), 366 esophageal squamous cell carcinoma patients (0.522%, M:F = 3.4:1) and 4681 reflux esophagitis patients. Among the three subtypes of adenocarcinoma of the esophagogastric junction, only type I adenocarcinoma of the esophagogastric junction in upper GI tumors exhibited increasing trend over time (1.86%, 3.39% and 4.94% for cohort A, B and C, respectively, P = 0.009). According to the WHO classification of histological types, the tubular types of adenocarcinoma of the esophagogastric junction have decreased (P = 0.008), whereas papillary type (P = 0.001) increased. The annual detection rate of type I adenocarcinoma of the esophagogastric junction appeared to be positively correlated with reflux esophagitis (r = 0.846, P = 0.002) and negatively with H pylori infection (r = -0.785, P = 0.007) in time trend. Over a recent 10-year period, the three subtypes of adenocarcinoma of the esophagogastric junction showed different changing trends, suggesting heterogeneous characteristics of the three Siewert types of adenocarcinoma of the esophagogastric junction.

Pattern of abdominal nodal spread and optimal abdominal lymphadenectomy for advanced Siewert type II adenocarcinoma of the cardia: results of a multicenter study

It remains uncertain whether radical lymphadenectomy combined with total gastrectomy actually contributes to long-term survival for Siewert type II adenocarcinoma of the cardia. We identified the pattern of abdominal nodal spread in advanced type II adenocarcinoma and defined the optimal extent of abdominal lymphadenectomy. Eighty-six patients undergoing R0 total gastrectomy for advanced type II adenocarcinoma were identified from the gastric cancer database of 4,884 patients. Prognostic factors were investigated by multivariate analysis. The therapeutic value of lymph node dissection for each station was estimated by multiplying the incidence of metastasis by the 5-year survival rate of patients with positive nodes in each station. The overall 5-year survival rate was 37.1%. Age less than 65 years [hazard ratio, 0.455 (95% confidence interval (CI), 0.261-0.793)] and nodal involvement with pN3 as referent [hazard ratio for pN0, 0.129 (95% CI, 0.048-0.344); for pN1, 0.209 (95% CI, 0.097-0.448); and for pN2, 0.376 (95% CI, 0.189-0.746)] were identified as significant prognosticators for longer survival. Perigastric nodes of the lower half of the stomach in positions 4d-6 were considered not beneficial to dissect, whereas there were substantial therapeutic benefits to dissecting the perigastric nodes of the upper half of the stomach in positions 1-3 and the second-tier nodes in positions 7 and 11. Limited lymphadenectomy attained by proximal gastrectomy might suffice as an alternative to extended lymphadenectomy with total gastrectomy for obtaining potential therapeutic benefit in abdominal lymphadenectomy for advanced Siewert type II adenocarcinoma.

Laparoscopic Transhiatal Resection for Siewert Type II Adenocarcinoma of the Esophagogastric Junction

Laparoscopic distal gastrectomy has gained wide acceptance, and laparoscopic total gastrectomy (LTG) and laparoscopic proximal gastrectomy (LPG) are now also performed for gastric cancer. We extended these techniques to treat Siewert type II adenocarcinoma of the esophagogastric junction (AEG). Ten patients with clinical T1 AEG type II underwent laparoscopic transhiatal (LTH) resection combined with LTG reconstructed by Roux-en-Y (LTH+LTG: n=2) or LPG reconstructed by jejunal interposition (LTH+LPG: n=8). Intracorporeal esophagojejunostomy was performed using a circular stapler, of which the anvil head was introduced transabdominally or transorally. The median operation time was 243 minutes, and blood loss was 25.5 g. There were no intraoperative complications or conversion to open surgery. No anastomotic leak was observed, but 1 diaphragmatic herniation to the left thoracic cavity occurred postoperatively. The median length of the proximal margin was 14.5 mm. This operation is technically feasible and can be safely performed after adequate experience of LTG or LPG, though esophagojejunostomy in the mediastinum is technically demanding.

Surgical approaches and prognostic analysis of Siewert type I adenocarcinoma of the esophagogastric junction

Objective To investigate rational surgical approaches for Siewert type I adenocarcinoma of the esophagogastric junction （ AEG）, and analyze the prognostic factors. Methods The clinical data of 103 patients with Siewert type I AEG who were admitted to the Renji Hospital from January 2005 to December 2009 were retro- spectively analyzed. All patients were divided into transthoracic approach group （61 patients） and thoracoabdominal approach group （42 patients）. The incidences of numbers of lymph node dissected and postoperative complications of the 2 groups were compared using the chi-square test, Fisher exact probability or the t test. The survival curve was drawn by the Kaplan-Meier method and the survival was analyzed using the Log-rank test. Prognostic factors were analyzed using the one-way analysis of variance and Cox regression model. Results No perioperative death was observed in the 2 groups. There were significant differences in the number of lymph node dissected and number of metastatic lymph node between the 2 groups （t =2. 18, 2.29, P 〈 0.05 ）. There was no significant difference in splenic injury between the 2 groups （ P 〉 0.05 ）. There were no significant differences in postoperative bleed- ing, anastomotic fistula and stricture, esophagogastric reflux, pulmonary infection and osteomyelitis between the 2 groups （X2 =0.07, 0.94, 0.22, 1.41, 0.17, P〉0 up. The mean postoperative survival time was 26 months. 05）. Of the 103 patients, 97 （ 94.2% ） were followed The median survival time was 26 months, and the 3-year survival rate was 35.9%. The 3-year survival rates of transthoracic approach group and thoracoabdominal approach group were 32.8% and 40.2% , with no significant difference between the 2 groups （X2 = 0.37, P 〉 0, 05 ）. The results of univariate analysis showed that radical or palliative resection, TNM stage, lymph node metastasis stage, tumor diameter and metastasis rate, degree of radical resection were independent factors influencing the prognosis of patients with Siewert type I AEG （X2 =21.07, 26.04, 22.42, 6.26, 32.20, 20.80, P 〈0.05）. The results of muhivariate analysis showed that degree of TNM stage, lymph node metastasis rate and radical resection were independent factors influencing the prognosis of patients （ Wald = 12. 01, 8. 75, 10. 03, P 〈 0.05 ）. Conclusions Thoracoabdominal approach is a reasonable selection for patients with Siewert type I AEG. Degree of TNM stage, lymph node metastasis rate and radical resection were independent risk factors influencing the prognosis of patients. Key words: Adenocarcinoma of the esophagogastric junction ; Siewert type I ; Surgical approach ; Prognostic factors

Safety, efficacy, and long-term outcomes for endoscopic submucosal dissection of early esophagogastric junction cancer

Early esophagogastric junction (EGJ) cancer is currently being treated in the same way as early gastric cancer, by endoscopic submucosal dissection (ESD), but long-term outcomes are still unknown. Our aim was to retrospectively evaluate the safety and efficacy of ESD in treating early EGJ cancer and compare risk factors in curative and non-curative resection cases. Forty-four cases of early EGJ cancer, defined as a Siewert's type II tumor, in 44 patients with a mean age of 70.0 years and a male/female ratio of 90.9:9.1 % were treated by ESD between January 2004 and June 2010. There were 30 standard indication cases; the remaining 14 cases were expanded indication cases. Mean resected specimen and tumor sizes were 35 and 17 mm, respectively, and median procedure time was 121 min, with no bleeding or perforation complications. All cases were resected en bloc with an 84.1 % curative resection rate (37/44). The curative resection rates in the standard and expanded indication cases were 90.0 % (27/30) and 71.4 % (10/14), respectively. There were no significant differences in tumor location, tumor morphology, tumor size, histology of biopsy specimens, or standard versus expanded indication cases with regard to risk factors for curative and non-curative resections. However, submucosal invasion, positive tumor margins, lymphovascular invasion, and some components of poorly differentiated adenocarcinomas in just the submucosal layer were significantly more common in the non-curative resection cases. ESD was a safe, effective, and minimally invasive treatment for early EGJ cancer. For tumors without any submucosal invasion findings, therefore, ESD is an acceptable treatment option, in addition to also being suitable for diagnostic purposes in evaluating the need for surgery.

PWE-042 The relevance of the siewert classification in the era of multimodal therapy for adenocarcinoma of the gastro-oesophageal junction

IntroductionSince the early 1980s the Siewert classification has been used to plan treatment for tumours of the gastro-oesophageal junction. However, the relationship between tumour site and survival has not been...

OC-101 Predictive factors for postoperative mortality after resection of junctional and gastric adenocarcinomas

IntroductionPostoperative mortality (POM) within 30 days of oesophago-gastric resection remains significant and should be minimised to provide maximal chance of long-term survival. This study identifies factors predictive of 30-day POM...

Should Adenocarcinoma of the Esophagogastric Junction Be Classified as Esophageal Cancer? A Comparative Analysis According to the Seventh AJCC TNM Classification

The aim of this study was to evaluate the adequacy of esophageal classification for adenocarcinoma of the esophagogastric junction (AEJ) of the seventh American Joint Committee on Cancer (AJCC) TNM classification. The seventh AJCC TNM classification proposed the new classification for AEJ as a part of esophageal cancer depending on the esophagogastric junction (EGJ) involvement. However, there are still many controversies over the classification system for AEJ. A review of pathologic reports and photographic findings at Seoul National University Hospital from 2003 to 2009 identified 4524 patients with single, primary adenocarcinoma of the EGJ (n = 497) and other regions of the stomach (GC, n = 4027) who underwent an operation with curative intent. We analyzed the clinicopathologic features and postoperative prognosis of AEJ using the Siewert classification and the seventh AJCC TNM classification. There was no Siewert type I (AEJ I) in this study. The prognosis of AEJ was similar to that of GC. There was no difference in clinicopathologic features between AEJ II and AEJ III. Even though AEJ extending into the EGJ (AEJe) showed more advanced pathologic features than AEJ not extending into the EGJ (AEJg), the prognosis of AEJe and AEJg was not significantly different when stratified by T stage. Compared with the classification of gastric cancer applied for AEJ, esophageal classification for AEJ from the seventh AJCC TNM classification showed a loss of distinctiveness at each TNM stage. To evaluate the postoperative prognosis of AEJ within the stomach, AEJ II and AEJ III should be considered a part of gastric cancer irrespective of EGJ involvement.

Lower Mediastinal Lymph Node Metastasis is an Independent Survival Factor of Siewert Type II and III Adenocarcinomas in the Gastroesophageal Junction

We examined clinicopathological features and surgical outcomes in patients with adenocarcinoma in the gastroesophageal junction (GEJ), while also analyzing the survival factors that have a prognostic impact. Between 1991 and 2009, 61 patients with tumors in the GEJ (Siewert type II and III) underwent primary surgical resection. Thirty of 61 patients had type II tumors (49.2%) and 31 had type III tumors (50.8%). The tumor size was larger in type III tumors than type II tumors (P = 0.0026). The overall 5-year survival rates in patients with type II tumors and type III tumors were 44.2 per cent and 41.4 per cent, respectively, with no significant differences (P = 0.1888). The independent survival factors were lower mediastinal lymph node metastasis (P = 0.0323) and a noncurative resection (P = 0.0442). The independent survival factors for patients who underwent curative resections were the tumor size (P = 0.0422), M category (P = 0.0489), and lower mediastinal lymph node metastasis (P = 0.0482). This study showed lower mediastinal lymph node metastasis to be an independent survival factor, and also suggested that lower mediastinal lymph node metastasis was associated with distant metastasis in patients with adenocarcinoma in the GEJ (Siewert type II and III). Therefore, the preoperative early detection of such metastasis is important to improve patient survival.

Sa1651 Rate of Lymph Node Metastasis and Outcome of Endoscopic Resection for High Grade Dysplasia and Superficial Adenocarcinoma of the Esophagogastric Junction

Sa1651 Rate of Lymph Node Metastasis and Outcome of Endoscopic Resection for High Grade Dysplasia and Superficial Adenocarcinoma of the Esophagogastric Junction Masayoshi Yamada*, Ichiro Oda, Satoru Nonaka, Haruhisa Suzuki, Shigetaka Yoshinaga, Yutaka Saito, Hirokazu Taniguchi, Shigeki Sekine, Ryoji Kushima Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan; Pathology Division, National Cancer Center Hospital, Tokyo, Japan Background: In the esophagogastoric junction (EGJ), high grade dysplasia (HGD) and intramucosal adenocarcinoma are generally treated by endoscopic resection (ER). There have been a few reports about ER for minute submucosal adenocarcinoma. The aim of this study is to investigate the possibility of ER for minute submucosal adenocarcinoma based on rate of lymph node metastasis (LNM) of surgical cases and outcome after ER at the EGJ. Material and methods: 1. We reviewed 69 consecutive surgically resected cases of HGD and superficial carcinomas (T1) (M/F 56/13, median age 66 years old (33-85), median tumor size 28 mm (7-97), and Barrett’s adenocarcinoma (BA)/non-BA 33/36) and analyzed the rate of LNM.2. We reviewed 78 consecutive endoscopically resected cases (M/F 67/11, median age 68 years old (39-88), median tumor size 19mm (3-63), BA/non-BA 32/46) and analyzed the outcome of ER. We defined HGD and adenocarcinoma of the EGJ when the tumor was classified as Siewert type II. Depth of invasion was divided into HGD/mucosa (M) (excluding muscularis mucosae (MM)), MM, submucosa 1 (SM1) ( 500 m into the submucosa) and SM2 ( 500 m). Histological types were divided into two groups; intestinal or diffuse type, by major histological features. We defined curative resection (CR) as a tumor with HGD/M/MM/SM1, intestinal type, negative for lymphovascular (ly/ v) invasion and negative margins. Results: 1. The rates of LNM were 14.5% (10/ 69) for all cases, 0% (0/5) for M, 14.3% (1/7) for MM, 0% (0/13) for SM1, 20.5% (9/44) for SM2. The rates of LNM were 36.8% (7/19) / 6% (3/50) for positive / negative of the ly/v invasion (p 0.01). The rates of LNM were 12.9% (8/62) / 28.6% (2/7) for intestinal / diffuse type, 13.3% (4/30) / 15.4% (6/39) for 3cm / 3cm in size, 15.2% (5/33) / 13.9% (5/36) for BA / non-BA, respectively. The MM carcinoma with lymph node metastasis had a ly/v invasion.2. En-bloc resection, en-bloc with R0 resection and CR rates were 97.4% (76/78), 82.1% (64/ 78) and 68.0% (53/78), respectively. Median procedure time was 75 minutes (20480). Perforation and stenosis occurred in 1.3% (1/78) and 10.3% (8/78), respectively. All of these cases were treated successfully with endoscopy. None of the patients with CR had recurrence with 3.4 years (0.2-10) of median followup period. The 3-year survival rate of the patients with CR was 100%. However, two patients with non-CR (SM2) died of the disease. One patient had a local recurrence 4 years after additional surgical treatment and another patient, who refused additional surgical treatment, developed lung metastasis 3 years after the ER. Conclusions: ER of superficial adenocarcinoma of EGJ may be indicated for SM1 or less tumor with intestinal type adenocarcinoma. Additional surgical treatment should be subsequently required in cases with ly/v invasion and/or tumor invasion into SM2 after ER.

Survival after chemotherapy and/or radiotherapy versus self-expanding metal stent insertion in the setting of inoperable esophageal cancer: a case-control study

BackgroundOur aim was to compare survival of the various treatment modality groups of chemotherapy and/or radiotherapy in relation to SEMS (self-expanding metal stents) in a retrospective case-control study. We have made the hypothesis that the administration of combined chemoradiotherapy improves survival in inoperable esophageal cancer patients.MethodsAll patients were confirmed histologically as having surgically non- resectable esophageal carcinoma. Included were patients with squamous cell carcinoma, undifferentiated carcinoma as well as Siewert type I--but not type II - esophagogastric junctional adenocarcinoma. The decision to proceed with palliative treatments was taken within the context of a multidisciplinary team meeting and full expert review based on patient's wish, co-morbid disease, clinical metastases, distant metastases, M1 nodal metastases, T4-tumor airway, aorta, main stem bronchi, cardiac invasion, and peritoneal disease. Patients not fit enough to tolerate a radical course of definitive chemo- and/or radiation therapy were referred for self-expanding metal stent insertion. Our approach to deal with potential confounders was to match subjects according to their clinical characteristics (contraindications for surgery) and tumor stage according to diagnostic work-up in four groups: SEMS group (A), Chemotherapy group (B), Radiotherapy group (C), and Chemoradiotherapy group (D).ResultsEsophagectomy was contraindicated in 155 (35.5%) out of 437 patients presenting with esophageal cancer to the Department of General and Abdominal Surgery of the University Hospital of Mainz, Germany, between November 1997 and November 2007. There were 133 males and 22 females with a median age of 64.3 (43-88) years. Out of 155 patients, 123 were assigned to four groups: SEMS group (A) n = 26, Chemotherapy group (B) n = 12, Radiotherapy group (C) n = 23 and Chemoradiotherapy group (D) n = 62. Mean patient survival for the 4 groups was as follows: Group A: 6.92 ± 8.4 months; Group B: 7.75 ± 6.6 months; Group C: 8.56 ± 9.5 months, and Group D: 13.53 ± 14.7 months. Significant differences in overall survival were associated with tumor histology (P = 0.027), tumor localization (P = 0.019), and type of therapy (P = 0.005), respectively, in univariate analysis. Treatment modality (P = 0.043) was the only independent predictor of survival in multivariate analysis. The difference in overall survival between Group A and Group D was highly significant (P < 0.01) and in favor of Group D. As concerns Group D versus Group B and Group D versus Group C there was a trend towards a difference in overall survival in favor of Group D (P = 0.069 and P = 0.059, respectively).ConclusionsThe prognosis of inoperable esophageal cancer seems to be highly dependent on the suitability of the induction of patient-specific therapeutic measures and is significantly better, when chemoradiotherapy is applied.

Factors predicting survival in patients with proximal gastric carcinoma involving the esophagus

To investigate the clinicopathologic features which predict surgical overall survival in patients with proximal gastric carcinoma involving the esophagus (PGCE). Electronic pathology database established in the Department of Pathology of the Nanjing Drum Tower Hospital was searched for consecutive resection cases of proximal gastric carcinoma over the period from May 2004 through July 2009. Each retrieved pathology report was reviewed and the cases with tumors crossing the gastroesophageal junction line were selected as PGCE. Each tumor was re-staged, following the guidelines on esophageal adenocarcinoma, according to the 7th edition of the American Joint Commission on Cancer Staging Manual. All histology slides were studied along with the pathology report for a retrospective analysis of 13 clinicopathologic features, i.e., age, gender, Helicobacter pylori (H. pylori) infection, surgical modality, Siewert type, tumor Bormann's type, size, differentiation, histology type, surgical margin, lymphovascular and perineural invasion, and pathologic stage in relation to survival after surgical resection. Prognostic factors for overall survival were assessed with uni- and multi-variate analyses. Patients' mean age was 65 years (range: 47-90 years). The male: female ratio was 3.3. The 1-, 3- and 5-year overall survival rates were 87%, 61% and 32%, respectively. By univariate analysis, age, male gender, H. pylori, tumor Bormann's type, size, histology type, surgical modality, positive surgical margin, lymphovascular invasion, and pT stage were not predictive for overall survival; in contrast, perineural invasion (P = 0.003), poor differentiation (P = 0.0003), > 15 total lymph nodes retrieved (P = 0.008), positive lymph nodes (P = 0.001), and distant metastasis (P = 0.005) predicted poor post-operative overall survival. Celiac axis nodal metastasis was associated with significantly worse overall survival (P = 0.007). By multivariate analysis, ≥ 16 positive nodes (P = 0.018), lymph node ratio > 0.2 (P = 0.003), and overall pathologic stage (P = 0.002) were independent predictors for poor overall survival after resection. Patients with PGCE showed worse overall survival in elderly, high nodal burden and advanced pathologic stage. This cancer may be more accurately staged as gastric, than esophageal, cancer.

Outcomes of Abdominal Total Gastrectomy for Type II and III Gastroesophageal Junction Tumors: Single Center's Experience in Korea

PurposeThe aim of this study was to evaluate the surgical outcomes of abdominal total gastrectomy, without mediastinal lymph node dissection for type II and III gastroesophageal junction (GEJ) cancers.Materials and MethodsWe retrospectively reviewed surgical outcomes in 67 consecutive patients with type II and III GEJ cancers that were treated by the surgical resection between 2004 and 2008.ResultsThirty (45%) patients had type II and 37 (55%) had type III tumor. Among the 65 (97%) patients with curative surgery, 21 (31%) patients underwent the extended total gastrectomy with trans-hiatal distal esophageal resection, and in 44 (66%) patients, abdominal total gastrectomy alone was done. Palliative gastrectomy was performed in two patients due to the accompanying peritoneal metastasis. The postoperative morbidity and mortality rates were 21.4% and 1.5%, respectively. After a median follow up of 36 months, the overall 3-years was 68%, without any differences between the Siewert types or the operative approaches (transhiatal approach vs. abdominal approach alone). On the univariate analysis, the T stage, N stage and R0 resection were found to be associated with the survival, and multivariate analysis revealed that the N stage was a poor independent prognostic factor for survival.ConclusionsType II and III GEJ cancers may successfully be treated with the abdominal total gastrectomy, without mediastinal lymph node dissection in the Korean population.

Bernstein, Pick, Poisson and related integral expressions for Lambert W

The Lambert W function has a number of integral expressions, including integrals of Bernstein, Thorin, Poisson, Stieltjes, Pick and Burniston–Siewert types. We give explicit integral expressions for W for each of these types. We also give integrals for a number of functions containing W.

Clinicopathological Features and Prognostic Factors of Adenocarcinoma of the Esophagogastric Junction According to Siewert Classification: Experiences at a Single Institution in Japan

Treatment strategy for adenocarcinoma of the esophagogastric junction (AEG) remains controversial. The aims of this study are to evaluate results of surgery for AEG, to clarify clinicopathological differences according to the Siewert classification, and to define prognostic factors. We retrospectively analyzed 179 consecutive patients with Siewert type I, II, and III AEG who underwent curative (R0) resection at the National Cancer Center Hospital East between January 1993 and December 2008. Patients with AEG were divided according to tumor: 10 type I (5.6%), 107 type II (59.8%), and 62 type III (34.6%). Larger, deeper tumors and nodal metastasis were more common in type III than type II tumors. No significant differences were seen in 5-year survival rates among the three types: type I (51.4%), type II (51.8%), and type III (62.6%). Multivariate analysis showed that depth of tumor and mediastinal lymph node metastasis were independent prognostic indicators. The recurrence rate for patients with mediastinal lymph node metastasis was 87.5%. The risk factors for mediastinal lymph node metastasis were length of esophageal invasion and histopathological grade. Mediastinal lymph node metastasis and tumor depth were significant and independent factors for poor prognosis after R0 resection for AEG. Esophageal invasion and histopathological grade were significant and independent factors for mediastinal lymph node metastasis.