Clinicopathological characteristics and optimal management for esophagogastric junctional cancer; a single center retrospective cohort study

Abstract

Background: Esophagogastric junctional (EGJ) cancer occurs in the mucosa near the esophagogastric junction, and has characteristics of both esophageal and gastric malignancies; its optimal treatment strategy is controversial.

Methods: We conducted a single-center retrospective cohort study of the patients who underwent curative surgery with lymphadenectomy for EGJ cancer. Tumor specimens were categorized by histology and location into four types-centered in the esophagus < 5 cm from EGJ (type E), which were subtyped as (i) squamous-cell carcinoma (SQ) or (ii) adenocarcinoma (AD); (iii) any histological tumor centered in the stomach < 5 cm from EGJ, with EGJ invasion (type Ge); (iv) any histological tumor centered in the stomach < 5 cm from EGJ, without EGJ invasion (type G)-and classified by TNM system; these were compared to patients' clinicopathological characteristics and survival outcomes.

Results: A total of 92 EGJ cancer patients were studied. Median follow-up of surviving patients was 35.5 months. Tumors were categorized as 12 type E (SQ), 6 type E (AD), 27 type Ge and 47 type G; of these 7 (58.3%), 3 (50%), 19 (70.4%) and 14 (29.8%) and 23 patients, respectively, had lymph node metastases. No patients with type E (AD) and Ge tumors had cervical lymph node metastasis; those with type G tumors had no nodal metastasis at cervical and mediastinal lymph nodes. Multivariate analysis showed that type E (AD) tumor was an independent prognostic factor.

Conclusions: We should distinguish type Ge tumor from type E (AD) tumor because of the clinicopathological and prognostic differentiation. Extended gastrectomy with or without lower esophagectomy according to tumor location and lower mediastinal and abdominal lymphadenectomy are recommended for EGJ cancer.

Trial registration: University Hospital Medical Information Network in Japan, UMIN000008596.

Figure 1

Tumor classification. We categorized tumors near the EGJ into four types according to its location and main histological type. Categorization criteria were: (i) squamous-cell carcinoma with epicenter in the esophagus within 5 cm from EGJ (type E (SQ)); (ii) adenocarcinoma with epicenter in the esophagus within 5 cm from EGJ (type E (AD)); (iii) any histological tumor with epicenter in the stomach within 5 cm from EGJ, with EGJ invasion (type Ge); (iv) any histological tumor with epicenter in the stomach within 5 cm from EGJ, without EGJ invasion (type G). Type E (SQ), E (AD) and Ge tumors were categorized as esophageal cancer; type G tumor was categorized as gastric cancer by the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) Cancer Staging Manual. Siewert type I and III tumors were categorized as type E (AD) and Ge tumors, and Siewert type II tumor was categorized as type E (AD) or Ge tumor in this study.

Figure 2

Flow diagram of the patients in this study. Total 92 patients who underwent curative surgical resection for esophagogastric junctional cancer at the Digestive Disease Center, Showa University Northern Yokohama Hospital between October 2001 and December 2010 were retrospectively studied.

Figure 3

Overall survival of patients. (A) Patients with pT1–4 tumors (n = 92). Type G tumor group demonstrated higher overall survival rate compared with type E adenocarcinoma (AD) (P = 0.013) tumor group. Although not significantly, the type G tumor group had a higher survival rate than the type E squamous-cell carcinoma (SQ) (P = 0.366) and Ge (P = 0.850) tumor group. (B) Patients with pT2–4 Tumors (n = 59). The type E (AD) tumor group demonstrated significantly lower overall survival rate compared with the type Ge (P = 0.001) and type G (P = 0.003) tumor group. The type E (AD) tumor group had a lower survival rate than the type E (SQ) tumor group (P = 0.076) although not significantly.