1. Carcinoma of the Cardia: Is there progress in the management of non-Barrett’s cancer Spanish Association of Surgeons Madrid 11 November 2002 The University of Hong Kong XXIV Congress

2.  Reflux esophagitis is rare in Asia  Barrett ’ s esophagus and cancer are clinical curiosities  One Chinese patient out of 1,200 resections had Barrett ’ s cancer  Adenocarcinoma of cardia and proximal stomach is a continuum Adenocarcinoma of Esophagogastric Junction

3.  Presentation is late, with anaemia followed by dysphagia  Resection is mostly palliative  CT or CTRT is undergoing trials  Survival has not increased significantly over the last two decades Adenocarcinoma of Esophagogastric Junction

4. Olmsted County 1974-1989 Cases / 100,000 / yr Squamous Adeno (GEJ) Adeno (ESO) Pera et al, Gastroenterology, 1993

5. Surgical Resection EastWest SCC middle third Adenocarcinoma lower third and cardia Thoracotomy more appropriate Three-field lymphadenectomy Transhiatal resection Infracarinal and upper abdominal lymphadenectomy

6. Fein et al, Surgery, 1998

8. Does type II behave as type I (esophageal) or type III (gastric) ? Controversy

9. Adenocarcinoma of the distal esophagus and gastric cardia are one clinical entity Wijnhoven et al, BJS, 1999 Adenocarcinoma of Esophagogastric Junction

10. Wijnhoven et al, BJS, 1999 No. at risk Total252175100624225 Oesophagus111 76 43251812 Gastric cardia141 99 57372413

11. Tumors spreads to thoracic and abdominal lymph nodes Staging as esophageal or gastric cancers makes no different in survival Suggested that these tumors behaves like esophageal cancer Adenocarcinoma of Esophagogastric Junction Steup et al, J Thorac Cardiovasc Surg, 1996

12. Type II cancers can be treated by abdominal gastrectomy Adenocarcinoma of the Esophagogastric Junction Siewert et al, Ann Surg, 2000

13. 1970 – 1988; 149 patients Ellis et al, Ann Surg, 1988 Stage III and IV75% Hospital mortality3/149 Palliation of dysphagia80% 5 yr survival22.4% Adenocarcinoma of Esophagogastric Junction Limited Resection for Carcinoma of Cardia

14. Proximal gastrectomy should be performed for upper third gastric cancer when invasion is confined to muscularis propria Kitamura et al, Surg Today, 1997 Adenocarcinoma of Esophagogastric Junction

15. Total gastrectomy is not necessary for proximal gastric cancer Harrison et al, Surgery, 1998 Adenocarcinoma of Esophagogastric Junction

16. After resection of proximal gastric cancer, use of gastric tube is the best reconstruction Shiraishi et al, WJS, 2002 Adenocarcinoma of Esophagogastric Junction

17. An operation based on “epi-centre” of tumor is appropriate and can be performed safely and with acceptable survival Fein et al, Surgery, 1998 Adenocarcinoma of Esophagogastric Junction

18. Esophageal Cancer 1982 – 20011850 patients Adenocarcinoma318 patients Male / Female4.5 / 1 Age (yrs) median68 range23-92

19. Adenocarcinoma of Esophagogastric Junction Group 1Group 2Group 3 Period1982-19881989-19941995-2001 Patients10585128 Stage III/IV (%)778570 Curative intent (%)443545

20. Adenocarcinoma of Esophagogastric Junction Group 1Group 2Group 3 Thoracotomy233544 Transhiatal300 Abdominal424123 Exploration1251 Main Treatment (%)

21. Adenocarcinoma of Esophagogastric Junction Group 1Group 2Group 3 CT/RT1117 Intubation123 No treatment1499 Others473 Main Treatment (%)

22. Overall Resection70% CT / RT 8% Intubation 2% No treatment11% Adenocarcinoma of Esophagogastric Junction

23. Site of Anastomosis (%) Group 1Group 2Group 3Overall Neck14305 Chest24426646 Abdomen62553449

24. Adenocarcinoma of Esophagogastric Junction Resection Margin and Anastomotic Site CMSChest (patients) Abdomen (patients) 0-1139 1-21133 2-32115 3-4232 4+430

25. Adenocarcinoma of Esophagogastric Junction Resection Margin and Recurrence CMS (patients)Rate (%) 0-1 (37)16 1-2 (41)10 2-4 (55)5 4-6 (26)4 6+ (23)0

26. Adenocarcinoma of Esophagogastric Junction Complications (%) Group 1Group 2Group 3Overall Major pulmonary14679 Anastomotic leakage7424 Re-exploration10456

27. Survival After Resection ADC N=223

28. SCC N=855 Survival After Resection

29. Adenocarcinoma of Esophagogastric Junction Mortality (%) Group 1Group 2Group 3Overall 30 days5.63.002.7 Hospital9.99.11.26.3

30. Adenocarcinoma of Esophagogastric Junction Mortality and Morbidity (%) ChestAbdomenOverall 30 days1.04.62.8 Hospital3.98.36.2 Curative intent6238 Anastomotic recurrence4.113.08.6 Major complications No differences

31. p = 0.4838 ADC (N = 223) Survival after Resection

32. Adenocarcinoma of Esophagogastric Junction Survival – ADC 223 Resections 30 M % HMMedian mths 5 yrs % 1982-19885.69.91117 1989-199439.11120 1995-200101.21416 Overall2.76.31118

33. p < 0.01 ADC (N = 223) Survival after Resection

34. p = 0.2850 ADC (N = 223) Survival after Resection

35. Evolution of Treatment & Outcome 1970-2001 Patients1097 Curative resection 994 Survivors 879 1970-1985246(Group 1) 1986-1996465(Group 2) 1997-2001283(Group 3) 1997-2001230(HKU) Hofstetter et al, Ann Surg, 2002

36. Evolution of Treatment & Outcome Group 1 Group 2 Group 3 HKU M / F 2/1 4/18/1 5/1 ADC / SCC (%) 29/7166/32 83/17 27/73 M1/3 / L1/3(%) 34/4419/74 13/86 44/19 Hofstetter et al, Ann Surg, 2002

37. Evolution of Treatment & Outcome Group 1 Group 2 Group 3 HKU Transhiatal (%)7 29 33 0.4 Gastric conduit (%) 64 97 99 94 Neoadjuvant CT (%)2 33 5 5 RT (%) 51 3 1 0 CTRT (%) 2 10 59 27 Hofstetter et al, Ann Surg, 2002

38. Evolution of Treatment & Outcome Group 1 Group 2 Group 3 HKU Hospital mortality (%)12 5 6 0 Leakage (%)10 10 6 4 R 0 resection (%)78 87 94 72 Recurrence (%)43 49 33 57 Survival Median (m)13 21 32 20 3 yr (%)27 34 46 33 Hofstetter et al, Ann Surg, 2002

39. Survival after Resection p < 0.01 University of Hong Kong n=1094 University of Texas n=1097

40.  Carcinoma of cardia presents late  Complications of operations are less than SCC  Mortality can be reduced to zero  Thoracotomy does not add risks  Prognosis same in SCC & ADC  Systemic CT or CTRT may have benefit  Regional CT may be superior  Prediction of response important to determine Conclusions