Adenocarcinoma of the gastroesophageal junction - Influence of esophageal resection margin and operative approach on outcome

Objective: To determine whether the length of esophageal resection or the operative approach influences outcome for patients with adenocarcinoma of the gastroesophageal junction (GEJ). Summary Background Data: While R0 resection remains the mainstay of curative treatment of patients with GEJ cancer, the optimal length of esophageal resection remains controversial. Methods: Patients with Siewert I, II, or III adenocarcinoma who underwent complete gross resection without neoadjuvant therapy were identified from a prospectively maintained database. Proximal margin lengths were recorded ex vivo as the distance from the gross tumor edge to the esophageal transection line. Operative approaches were grouped into gastrectomy (limited esophagectomy) or esophagectomy (extended esophagectomy). Results: From 1985 through 2003, 505 patients underwent R0/R1 gastrectomy (n = 153) or esophagectomy (n = 352) without neoadjuvant treatment. There were no differences in R I resection rate, number of nodes examined or operative mortality between gastrectomy and esophagectomy. Univariate analysis found > 3.8 cm to be the ex vivo proximal margin length (approximately 5 ern in situ) most predictive of improved survival. Multivariable analysis in patients who underwent R0 resection with >= 15 lymph nodes examined (n = 275) found the number of positive lymph nodes, T stage, tumor grade, and ex vivo proximal margin length >3.8 cm to be independent prognostic factors. Subset analysis found that the benefit associated with > 3.8 cm margin was limited to patients with T2 or greater tumors and <= 6 positive lymph nodes. Conclusions: In patients not receiving neoadjuvant therapy, the goal for patients with adenocarcinoma of the GEJ should be R0 resection including at least 15 lymph nodes, preferably with 5 cm of grossly normal in situ proximal esophagus for those with <= 6 positive lymph nodes. The operative approach may be individualized to achieve these goals.