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Case Reports
. 2024 Jul 19;16(7):e64945.
doi: 10.7759/cureus.64945. eCollection 2024 Jul.

Proximal Margin Involvement Following Total Gastrectomy for Seiwert III Adenocarcinoma: A Management Dilemma

Rajdave S Sadu Singh  1 , Guo H Loo  1 , Guhan Muthkumaran  1 , Sekkapan T Sambanthan  2 , Nik Ritza Kosai  1
Affiliations
Case Reports

Proximal Margin Involvement Following Total Gastrectomy for Seiwert III Adenocarcinoma: A Management Dilemma

Rajdave S Sadu Singh et al. Cureus. .

Abstract

Oesophagogastric junction carcinoma is now being increasingly regarded as a distinct site of neoplasia, separate from its adjacent sites. Recent advances in multimodal treatment approaches, including endoscopic procedures, oesophagectomy with three-field lymph node dissection, and definitive chemoradiotherapy, have significantly improved overall patient survival rates. Despite these advancements, the recurrence rate remains around 50% within one to three years following initial surgery. A major challenge in management arises when the resected surgical margins are involved with cancer. We present a 55-year-old man who experienced progressive dysphagia and, upon further assessment, was noted to have a Siewert III oesophagogastric junction adenocarcinoma. He underwent neoadjuvant chemotherapy before undergoing total gastrectomy with D2 lymphadenectomy with a Roux-en-Y reconstruction. Histopathological examination of the resected specimen revealed a positive proximal margin involvement. After optimization, he then underwent a salvage three-field McKeown oesophagectomy with colonic conduit reconstruction and adjuvant chemotherapy. Salvage surgery can be considered for patients with locoregional recurrence after definitive chemoradiotherapy or surgery. Other options include salvage chemoradiotherapy. Our case outlines the importance of proper patient selection for salvage surgery and highlights the choices of conduit in patients undergoing total esophagectomy post gastrectomy. In conclusion, managing proximal margin involvement of cardioesophageal junction adenocarcinoma remains a complex and multifaceted challenge, necessitating a tailored, multidisciplinary approach. The decision-making process must consider the patient's functional status, previous treatments, and specific anatomical considerations.

Keywords: colonic conduit; junctional cancer; poorly differentiated adenocarcinoma; prehabilitation; salvage surgery.

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Conflict of interest statement

Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. Contrast-enhanced CT of the abdomen axial section (left) and coronal section (right) showing circumferential concentric thickening extending from distal gastroesophageal junction till gastric cardia (white arrow)
Figure 2
Figure 2. Total gastrectomy specimen, with the tumor seen at the esophagogastric junction (white arrow)
Figure 3
Figure 3. Contrast-enhanced CT of the thorax and abdomen in axial (A) and coronal (B) view showing enhancing thickening at esophagojejunostomy anastomotic site suggestive of possible local recurrence
Figure 4
Figure 4. Illustration of esophagoileal-, colojejunal- and coloileal anastomosis performed, with colonic conduit seen within the thorax cavity
See this image and copyright information in PMC

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