Carcinoma of the Cardia: Is there progress in the management of non-Barrett

1
Carcinoma of the Cardia Is there progress in
the management of non-Barretts cancer
XXIV Congress
Spanish Association of Surgeons Madrid 11
November 2002
The University of Hong Kong
2
Adenocarcinoma of Esophagogastric Junction

• Reflux esophagitis is rare in Asia
• Barretts esophagus and cancer are clinical
  curiosities
• One Chinese patient out of 1,200 resections had
  Barretts cancer
• Adenocarcinoma of cardia and proximal stomach is
  a continuum

3
Adenocarcinoma of Esophagogastric Junction

• Presentation is late, with anaemia followed by
  dysphagia
• Resection is mostly palliative
• CT or CTRT is undergoing trials
• Survival has not increased significantly over the
  last two decades

4
Olmsted County 1974-1989
Cases / 100,000 / yr
Squamous
Adeno (GEJ)
Adeno (ESO)
Pera et al, Gastroenterology, 1993
5
Surgical Resection
East West
SCC middle third Adenocarcinoma lower third and cardia
Thoracotomy more appropriate Three-field lymphadenectomy Transhiatal resection Infracarinal and upper abdominal lymphadenectomy
6
Fein et al, Surgery, 1998
7
Fein et al, Surgery, 1998
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Controversy

• Does type II behave as
• type I (esophageal) or type III (gastric) ?

9
Adenocarcinoma of Esophagogastric Junction

• Adenocarcinoma of the distal esophagus and
  gastric cardia are one clinical entity

Wijnhoven et al, BJS, 1999
10
No. at risk Total 252 175 100 62 42 25
Oesophagus 111 76 43 25 18 12 Gastric
cardia 141 99 57 37 24 13
Wijnhoven et al, BJS, 1999
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Adenocarcinoma of Esophagogastric Junction

• Tumors spreads to thoracic and abdominal lymph
  nodes
• Staging as esophageal or gastric cancers makes no
  different in survival
• Suggested that these tumors behaves like
  esophageal cancer

Steup et al, J Thorac Cardiovasc Surg, 1996
12
Adenocarcinoma of the Esophagogastric Junction

• Type II cancers can be treated by abdominal
  gastrectomy

Siewert et al, Ann Surg, 2000
13
Adenocarcinoma of Esophagogastric Junction
Limited Resection for Carcinoma of Cardia

• 1970 1988 149 patients

Stage III and IV 75
Hospital mortality 3/149
Palliation of dysphagia 80
5 yr survival 22.4
Ellis et al, Ann Surg, 1988
14
Adenocarcinoma of Esophagogastric Junction

• Proximal gastrectomy should be performed for
  upper third gastric cancer when invasion is
  confined to muscularis propria

Kitamura et al, Surg Today, 1997
15
Adenocarcinoma of Esophagogastric Junction

• Total gastrectomy is not necessary for proximal
  gastric cancer

Harrison et al, Surgery, 1998
16
Adenocarcinoma of Esophagogastric Junction

• After resection of proximal gastric cancer, use
  of gastric tube is the best reconstruction

Shiraishi et al, WJS, 2002
17
Adenocarcinoma of Esophagogastric Junction

• An operation based on epi-centre of tumor is
  appropriate and can be performed safely and with
  acceptable survival

Fein et al, Surgery, 1998
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Esophageal Cancer
1982 2001 1850 patients
Adenocarcinoma 318 patients
Male / Female 4.5 / 1
Age (yrs)
median 68
range 23-92
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Adenocarcinoma of Esophagogastric Junction
Group 1 Group 2 Group 3
Period 1982-1988 1989-1994 1995-2001

Patients 105 85 128
Stage III/IV () 77 85 70
Curative intent () 44 35 45
20
Adenocarcinoma of Esophagogastric Junction
Main Treatment ()
Group 1 Group 2 Group 3
Thoracotomy 23 35 44
Transhiatal 3 0 0
Abdominal 42 41 23
Exploration 12 5 1
21
Adenocarcinoma of Esophagogastric Junction
Main Treatment ()
Group 1 Group 2 Group 3
CT/RT 1 1 17
Intubation 1 2 3
No treatment 14 9 9
Others 4 7 3
22
Adenocarcinoma of Esophagogastric Junction

• Overall Resection 70
• CT / RT 8
• Intubation 2
• No treatment 11

23
Adenocarcinoma of Esophagogastric Junction
Site of Anastomosis ()
Group 1 Group 2 Group 3 Overall
Neck 14 3 0 5
Chest 24 42 66 46
Abdomen 62 55 34 49
24
Adenocarcinoma of Esophagogastric Junction
Resection Margin and Anastomotic Site
CMS Chest (patients) Abdomen (patients)
0-1 1 39
1-2 11 33
2-3 21 15
3-4 23 2
4 43 0
25
Adenocarcinoma of Esophagogastric Junction
Resection Margin and Recurrence
CMS (patients) Rate ()
0-1 (37) 16
1-2 (41) 10
2-4 (55) 5
4-6 (26) 4
6 (23) 0
26
Adenocarcinoma of Esophagogastric Junction
Complications ()
Group 1 Group 2 Group 3 Overall
Major pulmonary 14 6 7 9
Anastomotic leakage 7 4 2 4
Re-exploration 10 4 5 6
27
Survival After Resection
ADC N223
28
Survival After Resection
SCC N855
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Adenocarcinoma of Esophagogastric Junction
Mortality ()
Group 1 Group 2 Group 3 Overall
30 days 5.6 3.0 0 2.7
Hospital 9.9 9.1 1.2 6.3
30
Adenocarcinoma of Esophagogastric Junction
Mortality and Morbidity ()
Chest Abdomen Overall
30 days 1.0 4.6 2.8
Hospital 3.9 8.3 6.2
Curative intent 62 38
Anastomotic recurrence 4.1 13.0 8.6

Major complications No differences
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Survival after Resection
ADC (N 223)
p 0.4838
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Adenocarcinoma of Esophagogastric Junction
Survival ADC 223 Resections
30 M HM Median mths 5 yrs
1982-1988 5.6 9.9 11 17
1989-1994 3 9.1 11 20
1995-2001 0 1.2 14 16
Overall 2.7 6.3 11 18
33
Survival after Resection
ADC (N 223)
p lt 0.01
34
Survival after Resection
ADC (N 223)
p 0.2850
35
Evolution of Treatment Outcome

• 1970-2001
• Patients 1097
• Curative resection 994
• Survivors 879
• 1970-1985 246 (Group 1)
• 1986-1996 465 (Group 2)
• 1997-2001 283 (Group 3)
• 1997-2001 230 (HKU)

Hofstetter et al, Ann Surg, 2002
36
Evolution of Treatment Outcome

• Group 1 Group 2 Group 3 HKU
• M / F 2/1 4/1 8/1 5/1
• ADC / SCC () 29/71 66/32 83/17
  27/73
• M1/3 / L1/3 () 34/44 19/74 13/86
  44/19

Hofstetter et al, Ann Surg, 2002
37
Evolution of Treatment Outcome

• Group 1 Group 2 Group 3 HKU
• Transhiatal () 7 29 33 0.4
• Gastric conduit () 64 97 99
  94
• Neoadjuvant
• CT () 2 33 5 5
• RT () 51 3 1 0
  CTRT () 2 10 59
  27

Hofstetter et al, Ann Surg, 2002
38
Evolution of Treatment Outcome

• Group 1 Group 2 Group 3 HKU
• Hospital mortality () 12 5 6 0
• Leakage () 10 10 6 4
• R0 resection () 78 87 94
  72
• Recurrence () 43 49 33
  57
• Survival
• Median (m) 13 21 32
  20
• 3 yr () 27 34 46 33

Hofstetter et al, Ann Surg, 2002
39
Survival after Resection
University of Hong Kong n1094
University of Texas n1097
p lt 0.01
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Conclusions

• Carcinoma of cardia presents late
• Complications of operations are less than SCC
• Mortality can be reduced to zero
• Thoracotomy does not add risks
• Prognosis same in SCC ADC
• Systemic CT or CTRT may have benefit
• Regional CT may be superior
• Prediction of response important to determine