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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

Gastroesophogeal Adenocarcinoma:A Distinct Clinical Entity

Shaun McKenzie, MD

Assistant Professor of Surgery

University of Kentucky

objectives
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
siewert classification
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
is it esophagus or stomach
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
controversies for treatment
Controversies for Treatment
  • What kind of Adjuvant Therapy
  • Appropriate Surgical Approach
  • Extent of Node Dissection
  • Biologic Tailoring of Therapy
slide17
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
proximal gastrectomy a surgical legacy procedure
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)
slide22
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
conclusions
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