Clinical Characteristics, Biological Behaviour, and Survival after Esophagectomy are similar for Adenocarcinoma of the Gastroesophageal Junction and the Distal Esophagus
Jessica M. Leers, Steven R. DeMeester, Nadia Chan, Shahin Ayazi, Arzu Oezcelik, Emmanuele Abate, Farazaneh Bank, John Lipham, Jeffrey A. Hagen, Tom R. DeMeester; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
Comment on this Abstract
Objective: The Siewert classification system differentiates between adenocarcinoma of the gastroesophageal junction and the distal esophagus. The purpose of this study was to confirm that there is a significant difference between these cancers.
Methods: Records of 608 consecutive patients who underwent esophagectomy for adenocarcinoma were retrospectively reviewed. In 296 patients the tumors were categorized as Type I (tumor in the distal third of the esophagus) and in 194 patients as Type II (tumor located at the gastroesophageal junction). It was not possible to definitively categorize the tumor location in 118 patients and they were excluded. The pattern of lymph node spread was analysed in a subgroup of patients that underwent an en bloc esophagectomy with extended lymphadenectomy. Clinical and pathologic features and long term outcome were compared.
Results: There were no significant differences in age, gender, or BMI. Patients with Type I tumors were more likely to have reflux symptoms (75% vs 55%, p=0.0001) and peritumoral intestinal metaplasia (72% vs 54%, p=0.0003) compared to Type II tumors. There were no significant differences in the type of resection or the use of neoadjuvant therapy between groups.
Tumor length and the prevalence of nodal metastases were similar (Type I: median length 3.1 cm, N1 51%; Type II: median length 3.5 cm, N1 58%; p=0.2407 and p=0.1387 respectively). The depth of invasion was also similar although the prevalence of a transmural tumor was higher in Type II tumors (T3 & T4: Type I = 43%, Type II = 57%, p=0.0042). Subcarinal node metastases were more common in Type I tumors compared to Type II (16% vs 5%, p=0.02). The prevalence of at least one positive lymph node in the mediastinum was not significantly different (Type I = 49%, Type II = 41%; p=0.5746). Long term survival was similar (log rank, p=0.1406). [Figure 1].
Conclusion: In contrast to the reported differences between adenocarcinomas located in the distal esophagus versus the gastroesophageal junction, we found the patient and tumor characteristics were similar, and there was no difference in overall survival. Further, over 40% of patients with these tumors have at least one positive mediastinal lymph node. These tumors should be treated in a similar fashion, and efforts to distinguish the precise location of the tumor are not necessary.
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