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INTRODUCTION

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Diagnosis and therapy of cancers of the esophagogastric junction (EGJ) tend to be accompanied by some unique and specific challenges. Some of these result from the historic lack of specific definitions of the anatomic location and extent of the EGJ. Others stem from the findings or limitations of endoscopic diagnosis, where the appearance of a locally advanced, near-obstructing proximal gastric cancer with EGJ involvement may be that of a distal esophageal cancer or that of a true EGJ lesion may be best visualized upon intragastric retroflection giving the impression of only a proximal gastric cancer without more proximal EGJ involvement. Additional challenges may be a function of the specialization pattern within medical disciplines, that is, a clinical therapeutic spectrum of thoracic versus abdominal disorders, without sufficient overlap. Despite significant institutional variations on surgical specialties involved in the care of EGJ cancer, a separation between thoracic (with a focus on “esophageal cancer”) and general/abdominal surgeons (treating “gastric cancer”) remains commonplace. Such difference in perspective or background may even be evident through distinctive terminologic use of “esophagogastric junction” compared to “gastroesophageal junction” (GEJ) cancer. This problem is worsened in settings of specialty-directed postgraduate training pathways, at least in Northern America, through which the trainee may get exposed to either esophageal cancer or to gastric cancer, but rarely to both. This is disturbing, as operative components and multidisciplinary aspects of care for EGJ cancers would clearly benefit from specialty expertise in both areas. In fact, for both esophageal and gastric resections, specialty high-volume settings have been associated with superior outcomes in terms of postoperative mortality or long-term survival after either procedure.1,2 In addition, significant contributions in the management of EGJ cancer have traditionally originated in programs in which the same providers deliver treatment of esophageal and gastric cancer in parallel.3-9 Finally, EGJ cancer treatment is challenged by significant shifts in incidence and demographic factors. There is an ongoing trend within the United States of an increased incidence of lower esophageal adenocarcinomas (Siewert Type I) and to a lesser extent of cardia cancers (Siewert Type II), almost entirely reflecting a steep incidence rise in Caucasian and to a lesser extent African-American men.10-12 At the same time, traditional (distal) gastric adenocarcinoma and esophageal squamous cell cancer are declining. The worse prognostic survival of proximal gastric cancer compared to distal gastric cancer has been recognized earlier and suggests different disease courses based on primary locations even within the stomach itself.13 In other countries, EGJ cancer represents a quite different disease spectrum, as for instance in Japan, lower esophageal adenocarcinomas (Siewert Type I) are rather rare, and most EGJ cancers there can be assigned Siewert Type II or III (proximal gastric cancer) status; as a result, the treatment pattern of EGJ cancer in Japan thus follows mainly that of gastric adenocarcinoma.14-16 Classifying all cancers involving the esophagogastric junction as “esophageal cancer,” as suggested through the seventh ...

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