Optimal approach for esophageal cancer surgery varies

By Sarah Guy, medwireNews Reporter

Accurate preoperative staging of junctional adenocarcinoma of the esophagus (AEG) can impact the surgical approach used, and postoperative outcomes vary according to the patients' stage of disease, report German researchers.

Their findings show that recurrent lymph node (LN) and distant metastases were significantly more frequent in patients with AEG type II (using the Siewert classification system) treated with esophagectomy compared with those with AEG type I, and that those with type II also had shorter overall survival than those with type I tumors.

In addition, for individuals with AEG type II, esophagectomy resulted in a significantly shorter recurrence-free survival than extended gastrectomy, the researchers note in the British Journal of Surgery.

"It is therefore reasonable to suggest that patients with AEG type II should as a minimum undergo extended gastrectomy with formal DII lymphadenectomy, including the perigastric LNs," they write.

Furthermore, they found that more than half of AEG patients initially staged as Siewert type I were reclassified as type II after surgery.

"Owing to a lack of uniform definition of the cardia, the correct classification of AEG remains difficult even in experienced cancer centers," remark M Reeh and colleagues from the University Hospital Hamburg-Eppendorf.

Their study included 137 AEG patients who underwent esophagectomy or extended gastrectomy between 1992 and 2009, of whom seven died during surgery, 41 were classed as type I before surgery and remained so postoperatively (group 1), 51 were type I before surgery but were upgraded to type II after esophagectomy (group 2), and 38 were type II both before and after surgery (group 3).

LN metastasis was more common in group 2 than group 1, at 78% versus 56%, and patients with AEG type II (groups 2 and 3) were significantly more likely to experience tumor relapse, distant metastatic recurrence, and cancer-related death compared with group 1.

Local tumor recurrence was significantly more common in patients who underwent transhiatal esophagectomy compared with those who underwent thoracoabdominal esophagectomy, at 24 versus six patients, report Reeh et al.

Commenting on the study, editorialist Abe Fingerhut (University of Athens Medical School, Greece) remarked that the results highlight that preoperative interpretation of cancer localization "is still highly subjective," and that methods of assessment "do not seem to be effective at the present time."

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