Differences in prognosis of Siewert II and III oesophagogastric junction cancers are determined by the baseline tumour staging but not its anatomical location

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Abstract

Background

The anatomical Siewert classification for adenocarcinoma of the oesophagogastric junction (OGJ) was dictated by the potential differences in tumour epidemiology and pathology. However, there are some uncertainties whether the distinction of true carcinoma of the cardia (type II) and subcardial gastric cancer (type III) is of clinical value.

Methods

Using a multicentre data set, we studied 243 patients with OGJ adenocarcinomas who underwent gastric resections between 1998 and 2008. Postoperative complications and long-term survival were compared to evaluate the potential differences in clinically relevant outcomes.

Results

A group of 109 patients with Siewert type II and 134 with Siewert type III OGJ adenocarcinoma was identified. Both groups showed similar baseline characteristics, including clinical symptoms and duration of diagnostic delay. However, the prevalence of node-negative cancers and superficial (T1–T2) lesions was significantly higher among type II tumours, i.e. 42% vs 21% (P = 0.003) and 43% vs 20% (P = 0.045), respectively. Morbidity and mortality rates were 25% and 3.7%, respectively, but types and incidence of postoperative complications were not affected by the anatomical location of the tumour. The overall median survival was significantly longer for Siewert type II tumours (42 vs 16 months; P < 0.001). However, only patients' age >70 years, depth of tumour infiltration, lymph node metastases, distant metastases, and radical resection were identified as independent prognostic factors using the Cox proportional hazards model.

Conclusion

The topographic-anatomic sub-classification of OGJ adenocarcinomas does not correspond to relevant differences in clinical parameters of safety and efficacy of surgical treatment.

Introduction

The incidence of adenocarcinoma of the oesophagogastric junction (OGJ) has increased over the past decades in most Western countries, probably causally associated with the prevalence of smoking, obesity and reflux disease.1, 2 While the tendency regarding proximal migration of gastric cancers seems to be stabilizing in some European territories, the incidence of OGJ adenocarcinoma continues to rise in the USA.3, 4 Therefore, this type of malignancy remains a significant clinical challenge in most geographic areas.5, 6

OGJ cancers are biologically aggressive tumours with the overall 5-year survival rates of about 18–38% following curative surgery.7, 8 Traditionally, anatomical location of the tumour defined by the Siewert classification is considered as one of the principal factors determining selection of surgical treatment.9, 10 However, the anatomical complexity of these tumours also implies many challenges for both diagnosis and treatment. Consequently there are some uncertainties whether the Siewert classification in the era of modern combined modality treatments is still of clinical value.11 This is particularly relevant for type II and III tumours that share some common clinical and pathological features, and could potentially follow the same therapeutic algorithms. However, application of different classification systems hamper the generalizability of results obtained from various geographic locations to daily surgical practice.

Considering the existing discrepancies in previous reports, the aim of this study was to compare short- and long-term outcomes of treatment for type II and III OGJ adenocarcinomas, using a well defined multi-institutional data set of Western patients classified according to the most recent guidelines of the TNM system.12

Section snippets

Methods

An electronic database of all patients with resectable gastric cancer treated between 1998 and 2008 at seven university surgical centres cooperating in the Polish Gastric Cancer Study Group (PGCSG) was reviewed to identify tumours of the oesophagogastric junction. Type II tumours were defined as adenocarcinoma within 1 cm above and 2 cm below the junction, while type III cancers included cases of adenocarcinoma within 2–5 cm below the junction.9 All relevant data, including demographics,

Clinicopathological characteristics

A total of 2398 patients with resectable gastric cancer were identified in the PGCSG database between 1998 and 2008, including 109 patients with Siewert type II and 134 with Siewert type III adenocarcinoma of the oesophagogastric junction that constituted the final population of this study (Table 1). There were 172 males and 71 females with a median age of 63 years (IQR 53–70). Both groups showed similar characteristics with respect to clinical factors, such as age, gender, comorbidities, ASA

Discussion

Potential differences in biological behaviour of Siewert type II and III adenocarcinomas of the oesophagogastric junction may have important clinical implications. However, in a well-defined population of Western patients undergoing gastric resections for OGJ cancers we have demonstrated that the anatomical location of the tumour was associated with some differences in the locoregional extent of the disease, but did not influence the short- and long-term outcomes.

The Siewert classification for

Conflict of interest statements

The authors declare that they have no conflicts of interest.

Ethics committee approval

This study was approved by the Bioethics Committees at each institution.

Role of funding source

This study was financially supported by the Polish State Committee for Scientific Research, Grants no. N N403 069 31/3255 and N N403 038839.

The funding source did not participate in study design, collection, analysis, or interpretation of the data, or writing of the report.

Acknowledgements

Other Members of the Polish Gastric Cancer Study Group:

R. Bandurski, A. Dabrowski, J. Dadan, M. Drews, H. Jaroszewicz-Heigelmann, A. Jeziorski, M. Fraczek, M. Krawczyk, T. Starzynska, B. Stawny, A.M. Szczepanik, G. Wallner, K. Wronski.

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