Ten-year follow-up results of a randomized clinical trial comparing left thoracoabdominal and abdominal transhiatal approaches to total gastrectomy for adenocarcinoma of the oesophagogastric junction or gastric cardia

Abstract

Background: The optimal surgical approach for treatment of oesophagogastric junction (OGJ) cancer is controversial. A randomized clinical trial (JCOG9502) comparing transhiatal (TH) and left thoracoabdominal (LTA) approaches was stopped after the first interim analysis owing to limited efficacy for LTA resections. Complete 10-year follow-up data are now available.

Methods: Patients with histologically proven adenocarcinoma of the OGJ or gastric cardia with oesophageal invasion of 3 cm or less were randomized to a TH or LTA approach. Both groups underwent total gastrectomy and splenectomy with D2 nodal dissection plus para-aortic lymphadenectomy above the left renal vein. For LTA, a thorough mediastinal lymphadenectomy below the left inferior pulmonary vein was also mandatory. The primary endpoint was overall survival.

Results: A total of 167 patients (82 TH, 85 LTA) were enrolled. The 10-year overall survival rate was 37 (95 per cent c.i. 26 to 47) per cent for the TH approach and 24 (15 to 34) per cent for the LTA technique (P = 0·060). The hazard ratio for death was 1·42 (0·98 to 2·05) for the LTA technique. Subgroup analysis based on the Siewert classification indicated non-significant survival advantages in favour of the TH approach.

Conclusion: LTA resections should be avoided in the treatment of adenocarcinoma of the OGJ or gastric cardia.

Registration number: NCT00149266 (https://www.clinicaltrials.gov).

Figure 1

CONSORT diagram for the JCOG9502 trial. TH, transhiatal; LTA, left thoracoabdominal

Figure 2

Kaplan–Meier curves of a overall and b disease‐free survival in all randomized patients by treatment group. TH, transhiatal approach; LTA, left thoracoabdominal approach. a Hazard ratio (HR) 1·42 (95 per cent c.i. 0·98 to 2·05; P = 0·970 and P = 0·060, 1‐ and 2‐sided log rank test respectively); b HR 1·28 (0·87 to 1·89; P = 0·892 and P = 0·215, 1‐ and 2‐sided log rank test respectively)

Figure 3

Forest plot for overall survival in the subgroup analysis. *Data not available for two patients in the left thoracoabdominal (LTA) group who did not undergo surgical resection owing to M1 disease. Hazard ratios are shown with 95 per cent c.i. OGJ, oesophagogastric junction; TH, transhiatal. †Japanese Classification of Gastric Carcinoma, 12th edition16; ‡International Union Against Cancer (UICC) TNM classification, 6th edition17

Figure 4

Kaplan–Meier curves of overall survival in patients with a Siewert type II and b Siewert type III tumours by treatment group. TH, transhiatal approach; LTA, left thoracoabdominal approach. a Hazard ratio (HR) 1·19 (95 per cent c.i. 0·72 to 1·95; P = 0·496, 2‐sided log rank test); b HR 1·67 (0·90 to 3·11; P = 0·102, 2‐sided log rank test)