Adenocarcinoma of the Esophagogastric Junction: Staging and Surgical Treatment.

Parry, K. (Kevin) (2014) Adenocarcinoma of the Esophagogastric Junction: Staging and Surgical Treatment. thesis, Medicine.

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Abstract

Introduction The aim of this study was to evaluate the outcome of surgical therapy and the accuracy of preoperative endoscopy, endoscopic ultrasonography (EUS) and CT-scanning on staging and tumor localization. Furthermore, the different surgical approaches were evaluated with regard to postoperative outcomes and survival. Method A prospective single center database of 266 patients was used of all patients with surgically resectable esophageal and gastric carcinomas from 2003 until present. All upper gastro-intestinal endoscopy, endoscopic ultrasound and histopathological reports were reviewed and patients were classified according the Siewert classification (I-III). Treatment was based on pre-operative imaging as well as intra-operative tumor localization. Either an esophagus-cardia resection or an extended total gastrectomy was performed. Histopathological analysis, considered as gold standard, was compared with the preoperative findings. Results The overall accuracy for endoscopy/EUS and CT scan in determining the tumor localization according to the Siewert classification was 73% and 61% respectively. The main reason for this low accuracy was due to the high amount of patients that were preoperatively classified as a type I tumor, whereas the pathology report showed a type II tumor. The overall accuracy for determining a positive nodal station was 77% for EUS and 71% for CT. The accuracy was high, 80 – 92%, for the upper thoracic lymph nodes and decreased to 50 – 80% for the peritumoral and abdominal lymph nodes. Overall 5-year survival improved with esophagectomy on univariable analysis in patients with a type II tumor (p = 0.026). However, the overall morbidity was significantly higher in the esophagectomy group (p = 0.028), due to a higher amount of pneumonia (47% versus 25%; p = 0.015). In patients with a Siewert type II tumor, high thoracic nodal involvement was present in 10% of the cases. In patients who received a transthoracic or transhiatal esophagectomy, lymph node metastases in the para-esophageal nodes was found in respectively 32% and 36% of the cases, whereas in patients who received a gastrectomy, in only 5% of the patients the para-esophageal nodes contained metastases. Conclusion The application of endoscopy/EUS and CT in determining the tumor localization according to the classification described by Siewert is of limited value. EUS seems to be superior than CT in determining the nodal status. It can accurately predict nodal involvement of the high thoracic lymph nodes, however it tends to understage with peritumoral and abdominal nodal stations. Our data suggest to perform an esophagectomy in patients with a type II tumor. Further research, preferably a prospectively randomized controlled trail, needs to be conducted to confirm these findings.

Item Type:	Thesis (Thesis)
Supervisor name:	Keyzer-Dekker, Dr. C.M.G.
Supervisor name:	Ruurda, Dr. J.P. and Universitair Medisch Centrum Utrecht
Faculty:	Medical Sciences
Date Deposited:	25 Jun 2020 11:02
Last Modified:	25 Jun 2020 11:02
URI:	https://umcg.studenttheses.ub.rug.nl/id/eprint/2192

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