Elsevier

The Lancet Oncology

Volume 12, Issue 3, March 2011, Pages 296-305
The Lancet Oncology

Review
Oesophagogastric junction adenocarcinoma: which therapeutic approach?

https://doi.org/10.1016/S1470-2045(10)70125-XGet rights and content

Summary

Gastric and oesophageal cancers are among the leading causes of cancer-related death worldwide. By contrast with the decreasing prevalence of gastric cancer, incidence and prevalence of oesophagogastric junction adenocarcinoma (OGJA) are rising rapidly in developed countries. We provide an update about treatment strategies for resectable OGJA. Here we review findings from the latest randomised trials and meta-analyses, and propose guidelines regarding endoscopic, surgical, and perioperative treatments. Through a team approach, members from all diagnostic and therapeutic disciplines, such as gastroenterologists, surgeons, oncologists, radiologists, and radiotherapists, can effectively administer a range of treatment modalities.

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

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

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