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Gastroesophogeal Adenocarcinoma: A Distinct Clinical Entity

Gastroesophogeal Adenocarcinoma: A Distinct Clinical Entity. Shaun McKenzie, MD Assistant Professor of Surgery University of Kentucky. Objectives. Outline the complexities associated with GEJ Adenocarcinomas Establish the unique behavior of this disease based on its biology

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Gastroesophogeal Adenocarcinoma: A Distinct Clinical Entity

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  1. Gastroesophogeal Adenocarcinoma:A Distinct Clinical Entity Shaun McKenzie, MD Assistant Professor of Surgery University of Kentucky

  2. Objectives • Outline the complexities associated with GEJ Adenocarcinomas • Establish the unique behavior of this disease based on its biology • Review the controversies in clinical decision making associated with the multidisciplinary management of these cancers

  3. Shifting Epidemiology

  4. What is the GE Junction

  5. The Sliding Z Line

  6. Siewert Classification • Type 1: Esophageal adenocarcinoma; tumors with epicenter between 1-5cm proximal to the anatomic cardia • Type 2: Cardia adenocarcinoma: tumors with epicenter from 1 cm proximal to the anatomic cardia to 2cm distal • Type 3: Subcardial adenocarcinoma: tumors with epicenter between 2-5 cm distal to the anatomic cardia with or without esophageal extension

  7. Not truly Esophageal Association with Barrett’s esophagus in only 40% Association with obesity and GERD is not as strong Nodal spread pattern appears different Phenotypic expression differs from EAC Response to therapy is different? Not truly gastric Not associated with h. pylori or chronic gastritis Incidence is divergent between both Prognosis more closely matches EAC Is it Esophagus or Stomach

  8. Siewert Series

  9. Clinical and Pathologic Characteristics of Early EAC, GEJCA, and Distal GAC

  10. Cytokeratin Expression

  11. Cytokeratin Expression

  12. Patterns of Nodal Spread

  13. Validation of Nodal Spread

  14. Neoadjuvant Therapy Response

  15. Controversies for Treatment • What kind of Adjuvant Therapy • Appropriate Surgical Approach • Extent of Node Dissection • Biologic Tailoring of Therapy

  16. Approximately 50 % Type II or III • Perioperative mortality 3.8% vs. 10% (NS) • pCR 2% vs 15.6% (p=0.03) • ypN0: 36.7% vs 64.4% (p-0.01) • MS 21.1 mos vs 33.1 mos (p=0.07) • Closed early due to poor accrual

  17. Biologic Guided Therapy

  18. Surgery Tailored to the Tumor

  19. Esophagogastrectomy vs Total Gastrectomy: Why argue? JACS:

  20. Proximal Gastrectomy: A Surgical Legacy Procedure • Proponents quote equivalent survival • Majority of studies report increased complication rate • Symptomatic GE reflux assured • Complication rate for the above study PG: 48.8% vs TG: 14.4% (p<0.001)

  21. No western trial has shown a benefit of extended node dissection to date • Need >15 nodes to adequately stage the patient • Extended node dissection survival studies have been hampered due to excessive mortality in the D2 group • Potential benefit in N2 disease

  22. Conclusions • GEJ Adenocarcinomas have both similarities and differences with both gastric and esophageal adenocarcinomas and exhibit their own distinct biologic therapy • Neoadjuvant chemoradiation may likely be the best current adjuvant approach • Surgical technique and timing can be tailored to the location, preoperative stage and response of the tumor • Adequate nodal sampling is an important part of the surgical therapy

  23. Surgical Oncology Public Service Announcement

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