We searched Medline, Cancerlit, Embase, and references of relevant articles with the search terms “randomised trials”, “junction adenocarcinoma”, “treatment”, “surgery”, “chemotherapy”, “radiotherapy”, and “chemoradiotherapy” for papers published in English between January, 2000, and May, 2010. Data related to oesophageal or gastric cancers were included only if a substantial portion was concerned with treatment of oesophagogastric junction adenocarcinoma. Prospective or retrospective
ReviewOesophagogastric junction adenocarcinoma: which therapeutic approach?
Introduction
Although the prevalence of gastric cancer is decreasing, there is an alarming rise in the incidence and prevalence of oesophagogastric junction adenocarcinoma (OGJA) in developed countries.1, 2 Many discrepancies exist in the published work about the causes, classification, and surgical and perioperative oncological treatments of these tumours. First, the borderline location of these tumours between the oesophagus and stomach leads to confusion. Second, clinical trials investigating such tumours have been divided between those aimed at treating gastric cancer and those aimed at treating oesophageal cancer; very few randomised studies have treated OGJA as a separate entity. Third, a clear range of tumours arise in the oesophagus, the oesophagogastric junction, and the stomach in terms of epidemiology, genetics, patterns of spread, and prognosis. Fourth, OGJAs might not all be the same disease, which has led to specific classification.3 Therefore, a review and summary of the guidelines about endoscopic, surgical, and perioperative treatments, such as neoadjuvant or adjuvant (radio)chemotherapy, is important for the treatment of patients with OGJA.
There is no standardised definition or classification of OGJA. The terms cardia adenocarcinoma, junctional adenocarcinoma, and lower-oesophageal adenocarcinoma encompass tumour types that can differ, and that are, at best, grouped together under the term OGJA. The anatomical and surgical classification of the three types of OGJA, adapted from Siewert and colleagues,3 has allowed resection to be codified and a comparison to be made between surgical series (figure 1). Type I tumours are lower-oesophageal adenocarcinomas, and usually develop on Barrett's mucosa, type II tumours are true cardia adenocarcinomas, and type III tumours are subcardial adenocarcinomas of the stomach. Such a classification system has been established with data from preoperative morphological assessments and perioperative findings. The main strength of this system is the clarification of various tumour locations, which allows the treatment strategy to be adapted correspondingly. Such clarification is especially useful for the surgical approach, because type I is treated as an oesophageal cancer and type III as a gastric cancer. Some controversy exists for treatment of type II disease. The disadvantages of this classification system are that it is based on preoperative and perioperative data, so the outcomes cannot be reliably anticipated; it is difficult or impossible to establish if there is a hiatal hernia or an advanced tumour, which are common situations; and the advantage of its prognostic ability has been questioned.4, 5, 6, 7 Overall, efforts to classify OGJA has produced two anatomo-clinical entities—tumours that have either oesophageal or gastric locations.
Section snippets
Endoscopic treatment
Recent improvements in endoscopic technique have led to increased interest in its application to OGJA. Node-negative T1 tumours are associated with a 5-year overall survival of more than 90% after surgery.8 Endoscopic therapy should be accepted as the treatment of choice in most patients with high-grade intraepithelial neoplasia and mucosal OGJA, because it has the potential to achieve the same curative effect as surgery—that is, it can result in no residual disease and the eradication of the
Surgery
The choice of surgical techniques is controversial, with particular uncertainty about the appropriate extent of resection in the oesophagus and the stomach, the extent and the sites of lymphadenectomy, and the optimum surgical approach.
Combination of surgery and neoadjuvant or adjuvant treatments
Chemotherapy and radiotherapy could improve the control of the disease by downstaging cancer, and thereby increasing resectability via the eradication of micrometastastic disease, the decrease in cancer-cell dissemination during intervention, and by complementing another treatment modality without affecting postoperative mortality and morbidity.
New horizons in treatment of resectable OGJA
To optimise the treatment of resectable locally advanced OGJA, the following points need to be resolved: the preferred endoscopic treatment for tumoural and Barrett's ablation; the optimum surgical approach for Siewert type II tumours; the appropriate extent of lymphadenectomy; whether extension of surgical resection can be modified after neoadjuvant treatment; how to decrease morbidity and mortality with a minimally invasive approach; identification of an effective chemotherapy regimen;
Conclusion
On the basis of the data collected and discussed in this Review, we propose the following guidelines for the treatment of OGJA. For superficial tumours, endoscopic mucosal resection could be proposed for T1m1 to sm1 OGJA if the tumour is well-differentiated, not depressed, and smaller than 2 cm. In the case of invasive lesions on the resected specimen (sm2 or sm3), because of the high risk of lymph-node involvement, curative surgery is needed in operable patients and exclusive chemoradiotherapy
Search strategy and selection criteria
References (65)
- et al.
Endoscopic resection of early oesophageal and gastric neoplasia
Best Pract Res Clin Gastroenterol
(2008) - et al.
Adenocarcinoma of the esophagogastric junction: surgical therapy based on 1602 consecutive resected patients
Surg Oncol Clin N Am
(2006) - et al.
Therapeutic strategies in oesophageal carcinoma: role of surgery and other modalities
Lancet Oncol
(2007) - et al.
Left thoracoabdominal approach versus abdominal-transhiatal approach for gastric cancer of the cardia or subcardia: a randomised controlled trial
Lancet Oncol
(2006) - et al.
The role of surgery in the management of oesophageal cancer
Lancet Oncol
(2003) - et al.
Mortality and morbidity after resection for adenocarcinoma of the gastroesophageal junction: predictive factors
J Am Coll Surg
(2005) Future strategies and adjuvant treatment of gastric cancer
Ann Oncol
(2003)- et al.
Adjuvant chemotherapy with epirubicin, leucovorin, 5-fluorouracil and etoposide regimen in resected gastric cancer patients: a randomized phase III trial by the Gruppo Oncologico Italia Meridionale (GOIM 9602 Study)
Ann Oncol
(2007) - et al.
Neo-adjuvant chemotherapy for operable gastric cancer: long term results of the Dutch randomised FAMTX trial
Eur J Surg Oncol
(2004) - et al.
Chemotherapy for operable gastric cancer: results of the Dutch randomised FAMTX trial. The Dutch Gastric Cancer Group (DGCG)
Eur J Cancer
(1999)
Survival benefits from neoadjuvant chemoradiotherapy or chemotherapy in oesophageal carcinoma: a meta-analysis
Lancet Oncol
PET to assess early metabolic response and to guide treatment of adenocarcinoma of the oesophagogastric junction: the MUNICON phase II trial
Lancet Oncol
Surgery alone versus chemoradiotherapy followed by surgery for resectable cancer of the oesophagus: a randomised controlled phase III trial
Lancet Oncol
Individual patient data-based meta-analysis assessing the effect of preoperative chemo-radiotherapy in resectable oesophageal carcinoma
Int J Radiat Oncol Biol Phys
The second British Stomach Cancer Group trial of adjuvant radiotherapy or chemotherapy in resectable gastric cancer: five-year follow-up
Lancet
Postoperative chemoradiotherapy for gastric cancer
Ann Oncol
Randomized phase III study comparing irinotecan combined with 5-fluorouracil and folinic acid to cisplatin combined with 5-fluorouracil in chemotherapy naive patients with advanced adenocarcinoma of the stomach or esophagogastric junction
Ann Oncol
Changing patterns in the incidence of esophageal and gastric carcinoma in the United States
Cancer
Demographic variations in the rising incidence of esophageal adenocarcinoma in white males
Cancer
Adenocarcinoma of the esophagogastric junction: results of surgical therapy based on anatomical/topographic classification in 1002 consecutive patients
Ann Surg
Outcome of surgical treatment
Surgical management of and long-term survival after adenocarcinoma of the cardia
Br J Surg
Application of the new classification for cancer of the cardia
Surgery
Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett's oesophagus
Gut
Endoscopic resection of early oesophageal cancer
Gut
Adenocarcinoma of the esophagus and cardia: a review of the disease and its treatment
Ann Surg Oncol
Radiofrequency ablation in Barrett's esophagus with dysplasia
N Engl J Med
Early Barrett's carcinoma with “low-risk” submucosal invasion: long-term results of endoscopic resection with a curative intent
Am J Gastroenterol
Early gastric cancer: lymph node metastasis starts with deep mucosal infiltration
Ann Surg
Long-term results of RTOG trial 8911 (USA Intergroup 113): a random assignment trial comparison of chemotherapy followed by surgery compared with surgery alone for esophageal cancer
J Clin Oncol
Surgical resection with or without preoperative chemotherapy in oesophageal cancer: a randomised controlled trial
Lancet
Cited by (174)
Should the splenic hilar lymph node be dissected for the management of adenocarcinoma of the esophagogastric junction?
2023, European Journal of Surgical OncologyCitation Excerpt :AEG is categorized into three types according to the Siewert classification [2]. Surgically, type I tumors are treated as esophageal cancer, type III tumors are treated as gastric cancer, and type II tumors are treated as esophageal or gastric cancers depending on the direction of longitudinal invasion [3]. Type II and III tumors easily spread, at least in part, to the greater curvature of the upper stomach.
The correlation between the margin of resection and prognosis in esophagogastric junction adenocarcinoma
2023, World Journal of Surgical Oncology