| Cancer of the gastroesophageal junction (GEJ) is gaining importance, both in the West and in the East. In Western countries, there has been a dramatic rise in such cancers, coinciding with the epidemic of obesity. In the East, evidences exist that adenocarcinoma around the GEJ is increasing, albeit to a much slower extent. Cancers around the GEJ (5cm proximal and distal are classified by Siewert's classifications into type I to III. The Japanese classification is much more focused, to an area just 2cm proximal and distal to the GEJ, and assigns tumors according to whether they are esophageal or gastric-predominant in their locations. From a surgical standpoint, there isn't much controversy with regards to type I and III cancers. For the former, a transthoracic esophagectomy with mediastinal nodal dissection is generally performed. For type III cancers, they are regarded as primarily gastric in origin, and a total radical gastrectomy is performed. The Dutch trial comparing transhiatal vs. transthoracic resection for type I and II cancers concluded that for type I cancers with limited nodal metastases, a transthoracic approach imparted survival advantage. Type II cancers are most problematic. There are advocates of both total radical gastrectomy with lower mediastinal dissection as well as a two-field Ivor Lewis esophagogastrectomy. In Japan, results from Japanese Oncology Group Trial 9502 suggests that for Siewert type II and III cancers with 3 cm or less of esophageal involvement, a total transabdominal approach with lower mediastinal nodal dissection will give equivalent survival compared with a left thoraco-abdominal approach, but with less postoperative morbidities. Prophylactic lymph node dissection around the distal stomach for GEJ cancers is unlikely to benefit, since the incidence of metastases is low. Total gastrectomy is commonly performed more for the reason of expected impaired quality-of-life with a direct esophago-gastrostomy in the abdomen. Treatment strategies for cancers around the GEJ are further complicated when multimodal therapies are considered. In the West, neoadjuvant chemoradiation is commonly selected for type I and II cancers, while peri-operative chemotherapy is used for type II and III cancers. In the East, surgery is usually performed upfront for resectable cancers, with adjuvant chemotherapy as standard therapy. Knowledge of cancers around the GEJ is still incomplete and much work is required. |
