Chapter 93: Surgical and Multimodality Treatments of Cancers at the Esophagogastric Junction: The Eastern Perspective

INTRODUCTION

The incidence of gastric adenocarcinoma in the East is much higher than in the West; the main etiology is Helicobacter pylori (H. pylori) infection. However, in Japan esophageal adenocarcinoma accounts for only 4.3% of all cases of esophageal cancer, which is a rather low proportion compared to the West.¹ Although the high prevalence of H. pylori infection has contributed to a decrease in the risk of esophageal adenocarcinoma in the East, decreased prevalence of H. pylori infection and increased incidence of obesity have gradually increased the incidence of esophagogastric junction (EGJ) cancer in recent years.² Treatment for EGJ cancer requires special attention to surgical technique, in particular to lymph node dissection. Although surgery is the most effective curative treatment for EGJ cancer, the proportion of R1 or R2 resections is comparatively high. Even after R0 resection, the recurrence rate is high. To improve the R0 resection rate and long-term outcomes, perioperative treatment has been attempted. In this section, we outline the Eastern perspective on the surgical approach and perioperative therapy for EGJ cancer.

SURGICAL APPROACHES

The surgical approach for EGJ cancer is mainly based on tumor histology and location. Adenocarcinomas located around the EGJ are usually classified into three categories according to the Siewert system based on their epicenter.³ Mediastinal dissection via a right thoracotomy is usually used to treat Siewert type I adenocarcinomas based on the results of a Dutch randomized controlled trial (RCT).⁴ Lymph node dissection including the upper mediastinum is often performed in Japan because Siewert type I adenocarcinomas can sometimes metastasize to the upper mediastinal lymph nodes.^5,6

A Japanese RCT compared the left transthoracic and transhiatal approaches for mainly Siewert type II and III adenocarcinomas.^7,8 This study demonstrated that there was no survival benefit and higher morbidity associated with the transthoracic approach. The transthoracic approach was also associated with more weight loss, postoperative symptoms, and respiratory dysfunction compared to the transhiatal approach.⁹ Subgroup analysis showed no survival benefit for Siewert type II patients who underwent the transthoracic approach. The transhiatal approach was associated with better survival than the transthoracic approach for Siewert type III patients. Based on the results of this trial, transhiatal resection of the distal esophagus with lymph node dissection of the lower mediastinum is recommended for Siewert type II or III adenocarcinoma. However, we should keep in mind that this trial excluded patients with esophageal invasion over 3 cm because it is difficult to obtain sufficient margins using the transhiatal approach if the tumor has invaded the distal esophagus 3 cm beyond the EGJ.

A Japanese multicenter retrospective study of 315 patients with pT2–T4 Siewert type II adenocarcinoma reported that the overall rate of metastasis or recurrence in the upper and middle mediastinal lymph nodes was 3.8% and 7.0%, respectively.¹⁰ The 5-year overall survival rate in ...