Gastroesophageal junction tumours.

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Definition.
Gastroesophageal

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junction tumors are defined as being within 5 cm proximal and distal of the anatomic cardia.

Types.
Type 1 _ arising from distal

esophagus with intenstinal metaplasia and infiltrating cardia from above.

Type 2 _ arising from cardiac

epithelium.(junctional carcinoma)
Type 3 _proximal gastric cancers that

infiltrate GE junction from below.

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Charecteristics.
Dysphagia is most common

presenting symptom.
Weight loss is 2nd most common

symptom
Vague pain due to pliability of gastric

cardia.
Hoarseness of voice and respiratory

symptoms.
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Differential diagnosis.
Achalasia. Stricture. Gastric carcinoma.

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Work up.
History and physical examination. Upper GI endoscopy and biopsy. Chest and abdominal CT with iv and

oral contrast.
Pelvic CT if clinically indicated. EUS with FNAC Laproscopy if no evidence of M1
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disease.

Methods for preoperative staging. Preoperative Endoscopy for

diagnosing and staging disease is the first investigation.
Contrast enhanced CT scan of

chest and abdomen for detecting extent and metastasis.(superior to eus )

Eus _most reliable method for

clinical staging in patients with no distant disease on ct scan. 3/14/12

Endoscopy.

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CT scan.

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EUS.

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TNM staging.
TX T0 TIS T1A T1B T2 T3 T4A
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Primary tumor. PRIMARY TUMOR CAN NOT BE ASSESSED. NO EVIDENCE OF PRIMARY TUMOR. HIGH GRADE DYSPLASIA. INVADES LAMINA PROPRIA,MUSCULARIS MUCOSA. INVADES SUBMUCOSA. INVADES MUSCULARIS PROPRIA INVADES ADVENTITIA. RESECTABLE TUMOR INVADING PLEURA DIAPHRAGM.

REGIONAL LYMPHNODES. NX N0 N1 N2 N3
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CAN NOT BE ASSESSED. NO NODAL INVOLVEMENT. INVOLVING 1-2 REGIONAL NODES INVOLVING 3-6 REGIONAL NODES INVOLVING 7 OR MORE REGIONAL NODES

METASTASIS. MO NO DISTANT METASTASIS.

M1

DISTANT METASTASIS.

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Histologic grade.
GX G1 G2 G3 G4
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GRADE CANNOT BE ASSESSED WELL DIFFERENTIATED MODERATELY DIFFERENTIATED POORLY DIFFERENTIATED UNDIFFERENTIATED

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Stage 0 1A 1B 2A 2B 3A TIS T1 T1 T2 T2 T3 T1-2 T1-2 T3 T4A T3 T4A T4B

T N0 N0 N0 N0 N0 N0 N1 N2 N1 N0 N2 N1-2 ANY

M M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0

GRADE 1,X 1-2,X 3 1-2,X 3 ANY ANY ANY ANY ANY ANY ANY ANY

3B 3C
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Management.
Neo adjuvant chemotherapy. Surgical management. Post op chemoradiation. Palliation. Best supportive care.
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Neo adjuvant chemoradiation.

Reduce the size of the tumor, thereby

improving chances of an R0resection. assessment of the completeness of pathologic response, all of which may influence decisions on postoperative treatment .

Treat micrometastases; and allow accurate

In addition, certain chemotherapeutic agents

may have radiosensitizing properties , and the increased oxygenation of undisturbed tissue in the tumor bed also enhances the effects of preoperative radiation therapy. 3/14/12

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Cisplatin-based combination of

epirubicin and cisplatin along with protracted venous infusion of fluorouracil (ECF) has improved response rates and 2-year survival rates compared with FAMTX

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 Patients with resectable

adenocarcinoma of the stomach, esophagogastric junction, or lower esophagus were randomly assigned to either perioperative ECF (three preoperative cycles and three postoperative cycles) or surgery alone. Compared with the surgery group, the perioperativechemotherapy group had a higher likelihood of overall survival and 3/14/12 progression-free survival, with a 5-

ISDE/IGCA consensus conference

recommended that neoadjuvant therapy be restricted to patients with locally advanced tumors of the esophagogastric junction where an R0resection is questionable.

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Surgical approach.
In patients with no evidence of

distant metastases and who are fit for surgery, surgical resection is the mainstay of therapy for gastroesophageal junction tumors. A complete resection of the tumor and its entire lymphatic drainage offers the best hope for long-term survival
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---- siewert jr (surgical oncology

Both tumor stage (particularly nodal

involvement or N stage) and resection margins (R status) are significant prognostic factors.
Type I tumors are generally treated

by total esophagectomy to obtain adequate proximal margins and remove all mediastinal lymph nodes.
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Type ll and lll tumor.

Abdominothoracic en bloc

esophagogastrectomy .
Subtotal esophagectomy with

resection of the proximal stomach.

Total gastrectomy with transhiatal

resection of the distal esophagus.

Resection of the proximal stomach

and distal esophagus with 3/14/12 esophagogastrostomy.

NCCN.
Tis T1A

EMR EMR + ABLATION ESOPHAGECTOMY. OR

T1B any N T2 any N

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ESOPHAGECTOMY. preop chemoradiation

Unresectable.
EG junction tumours with supraclavicular

lymphnodes.

Distant metastasis. T1-3 with multistation bulky lymphnodes with

poor performance status of patient.

T4b.
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 IVOR LEWIS esophagectomy with

esophagogastric anastomosis in thorax at or above azygous vein with two field lymphadenectomy.

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Advantages of intrathoracic anastomosis. Less anastomotis leak

Lower stricture rate Lower RLN injury

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Disadvantages of thoracic anastomosis.

More severe complications

associated with anastomotic leak.

More bile reflux . Not suitable for extensive disease.
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Lymphadenectomy.
More than two thirds of patients with

esophageal and gastric cancers in Western populations will have lymph node metastases at the time of surgery.
Lymphadenectomy improves the

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accuracy of pathologic staging in both gastric and esophageal cancers and provides locoregional control.

Adjuvant chemoradiation. Palliative care. Best supportive care.

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Thank you!

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