1. Ca Cardia “Out of the Black Box” Dr Daniel Ng NDH / AHNH Dr Daniel Ng NDH / AHNH

2. Case Illustration M/64 Ex-smoker Painless progressive dysphagia x 2-3 months Weight loss+ Physical examination unremarkable M/64 Ex-smoker Painless progressive dysphagia x 2-3 months Weight loss+ Physical examination unremarkable

3. Case Illustration

4. Ca Cardia Before 1987 Adenocarcinoma of cardia Bad surgical result Difficult discussion No clear definition Before 1987 Adenocarcinoma of cardia Bad surgical result Difficult discussion No clear definition

6. Ca Cardia 1987 J Rudiger Siewert AEG classification 1987 J Rudiger Siewert AEG classification

7. Anatomical Cardia

8. AEG Classification Type I Distal esophagus cancer within 5cm from cardia Type II Directly located at endoscopic cardia, 1cm above and below this border Type III Subcardial cancer within 5cm from cardia J Am Coll Surg Vol.205, No.4S, Oct 2007

9. Epidemiology Type IType III Age at presentation 60.1  10.564  12.1 Male:Female10.7:12.2:1 Barrett’s Esophagus97.4%0.8% Undifferentiated tumours54.4%73.4% Intestinal growth pattern80.9%38.5% J Am Coll Surg Vol.205, No.4S, Oct 2007

10. Epidemiology Type IType IIType III Age at presentation 60.1  10.561.7  11.464  12.1 Male:Female10.7:14.9:12.2:1 Barrett’s Esophagus97.4%5.6%0.8% Undifferentiated tumours54.4%60.2%73.4% Intestinal growth pattern80.9%55.4%38.5% J Am Coll Surg Vol.205, No.4S, Oct 2007

11. Type II Tumour Barrett’s dysplasia vs Ca stomach Intestinal metaplasia Globlet cells in 100 specimens Only 28% 72% can be understood as gastric cancer Barrett’s dysplasia vs Ca stomach Intestinal metaplasia Globlet cells in 100 specimens Only 28% 72% can be understood as gastric cancer J Am Coll Surg Vol.205, No.4S, Oct 2007

12. Epidemiology Incidence increasing AEG I Western countries AEG II / III Asian countries Incidence increasing AEG I Western countries AEG II / III Asian countries Journal of Surgical Oncology 2005;92:160-168

13. Lymphatic Metastasis AEG I Less frequent lymph vessel invasion Mediastinal lymph nodes AEG II and III Lower mediastinum Coeliac trunk Direct retroperitoneal metastasis AEG I Less frequent lymph vessel invasion Mediastinal lymph nodes AEG II and III Lower mediastinum Coeliac trunk Direct retroperitoneal metastasis J Surg Oncol 2005;13:139-146

14. Prognosis J Am Coll Surg Vol.205, No.4S, Oct 2007

15. Surgical Strategies R0 resection Independent prognostic factor Complete resection of primary tumour Complete resection of lymphatic drainage R0 resection Independent prognostic factor Complete resection of primary tumour Complete resection of lymphatic drainage World J Gastroenterol 2006 November 7;12(41):6608-6613

16. Type I Tumour Complete removal of the precancerous Barrett’s esophagus Esophagectomy Mediastinal lymph node dissection Complete removal of the precancerous Barrett’s esophagus Esophagectomy Mediastinal lymph node dissection World J Gastroenterol 2006 November 7;12(41):6608-6613

17. Transhiatal vs Transthoracic N Engl J Med, Vol.347, No.21

18. Transhiatal vs Transthoracic N Engl J Med, Vol.347, No.21

19. Type II / III Tumours Total gastrectomy Lymph node dissection Intra-abdominal Mediastinal Total gastrectomy Lymph node dissection Intra-abdominal Mediastinal World J Gastroenterol 2006 November 7;12(41):6608-6613

20. Type II / III Tumours

21. Left Thoracoabdominal vs Transhiatal Lancet Oncol 2006;7:644-51

22. Left Thoracoabdominal vs Transhiatal Lancet Oncol 2006;7:644-51

23. Case Illustration What surgical approach would you adopt?

24. Future Discussions Neoadjuvant therapy Molecular characterization Sentinel lymph node biopsy PET hand device Neoadjuvant therapy Molecular characterization Sentinel lymph node biopsy PET hand device

25. Thank You Question and Answer