GE jucntion tumors

1. Gastroesophageal junction
tumors
Uttam Laudari
MCh Resident, Second year

2. OG junction- No mans land
• Partly intrathoracic and partly
intraabdominal
• Mix up AC and SCC
• Confusions regarding margins
• Extent of nodal dissection
• Surgical approach which is best
• Multimodality of treatment

3. SCC Adenoca

4. Confusion according to AJCC

5. GERD and Barrett’s Metaplasia
• Siewert type I tumours
• have a strong association with Barrett’s metaplasi
• Chronic GERD and Barrett’s metaplasia have been found in 70–97% of patients)
• Type II tumours
• low prevalence of Barrett’s that is slightly more than type 3 tumours
• Type III tumors similar in pathology to gastric carcinoma
• do not have an etiologic background of Barrett’s metaplasia

6. Obesity
• 16% for every 1 kg/m2 increase in BMI
• high risk of esophageal adenocarcinoma chronic GERD and metaplasia,
• Hiatus hernia also has a similar close association with GERD and esophageal
adenocarcinoma
Thrift AP, et al. J Natl Cancer Inst. 2014;106:dju252

7. Helicobacter pylori
• H. pylori infection (especially CagA strain) adenocarcinoma of the distal stomach
• Siewert type III adenocarcinoma association with H. pylori.
• Type I an infection with H. pylori seems to have a protective effect for esophageal
Nie S et al Dis Esophagus. 2014;27:645–53

9. Tobacco Smoking
• well-established and moderately strong risk factor
• doubled risk of adenocarcinoma compared with never smoking (OR, 1.96)
• twofold increased progression risk from Barrett’s esophagus to adenocarcinoma associated with tobacco
smoking
• A similar association was reported with cardia cancer (type 2) as well
Cook MB, et al. J Natl Cancer Inst. 2010;102:1344–53

10. Alcohol
• A large study confirmed no association between alcohol intake and increased
risk of esophageal adenocarcinoma
Freedman ND, et al. Gut. 2011;60:1029–37.

11. Dietary Factors
good evidence for linking any conventional dietary factors with
esophageal adenocarcinoma, except that vegetable intake had limited
suggestive evidence for a reduced risk of adenocarcinoma
Diet, nutrition, physical activity and oesophageal cancer, vol. 2018; 2018

12. Siewert Type I adenocarcinoma
• Distal esophageal adenocarcinoma
infiltrating the EGJ and mostly
associated with intestinal metaplasia
i.e. Barrett’s esophagus
• epicentre located more between 1
and 5 cm above the EGJ

13. Siewert Type II tumors
• True carcinoma of the cardia arising
from the epithelium of the gastro-
esophageal junction and often
referred to as ‘junctional carcinoma’
• (epicentre located between 1 cm
above to 2 cm below the EGJ).

14. Siewert Type III tumors
Subcardiac gastric carcinoma located below the
EGJ and infiltrating the gastro-esophageal
junction and distal esophagus
(epicentre located between 2 and 5 cm below
the EGJ)
an almost equal proportion of intestinal and diffuse
histological types
an insignificant association with reflux

15. Nishi’s Classification
• Both Siewert’s and Nishi’s classification
clearly settled the epicenter location
within 2 cm above and below the EGJ,
irrespective of tumor size in the former
And
• histological type in the latter as well as
tumor extension in both. EGJ
esophagogastric junction.

16. AJCC 8 th Staging
• Siewert type I and II  staged in the esophageal carcinoma staging
schema
• Siewert type III tumors (2–5 cm below the EGJ) are to be staged as
gastric carcinoma
AJCC Cancer Staging Manual. New York: Springer; 2017. p. 185–202

17. Cavallin F. Ann Surg. 2018
AJCC8 the Edition

20. Staging

21. Staging

22. Siewert JR et al. Adenocarcinoma of the esophago-gastric junction. Scand J Surg. 2006;95:260–9.
Rudiger Siewert et al. Results of surgical therapy based on anatomical/topographic classification in 1,002 consecutive
patients. Ann Surg. 2000

23. Clinical Presentation
• Asymptomatic
• The majority of patients at presentation already have advanced disease
• Symptomatic
• Dysphagia (75% lumen obstructed) and odynophagia (i.e. painful swallow)
• Complications
• Hoarseness or Horner’s syndrome occur with the invasion of the recurrent laryngeal nerve or
cervical ganglia ( usually inoperable)
• Occult or overt GI bleeding can occur especially with ulcerated tumours

24. Clinical Presentation
• Cervical or supraclavicular lymphadenopathy.
• symptoms that indicate advanced disease  chest pain, back pain, excessive
weight loss (more than 10%) , long duration of dysphagia (more than 6 months)
• Submucosal infiltrating carcinoma at the EGJ may mimic achalasia, and as such is
termed pseudoachalasia

25. Investigations endoscopy
• Barrett’s mucosa extension of the
salmon-pink velvety gastric mucosa
proximal to the squamocolumnar
junction
• Any visible lesion in the mucosa
should be biopsied
• In addition four-quadrant biopsies
should be taken at every 2 cm along
the Barrett’s mucosa

26. • At least six biopsies from non-necrotic areas
of the tumour increase the yield to nearly
100%.
• Endoscopic views while crossing the EGJ and
then the retroflexed views after entering the
stomach are a good way of preoperatively
subgrouping the tumors as per the Siewert
classification.

27. EUS
• enables the endosonographer to evaluate the wall-layer pattern of the esophagus and to detect
the presence of regional and celiac lymph nodes.
• EUS guided FNA permits directed tissue sampling of adjacent nodes
• the role of EUS in EGJ carcinoma found a 48% concordance between EUS uT-stage and pathologic
pT-stage (under-staged 23%, over-staged 29%)
Dhupar R, et al.. Ann Thorac Surg. 2015;100:1812–6

28. EUS
• Frequencies of 7.5 and 12 MHz
Staging: Locoregional
• High frequency (20 MHz)
• 9 layers in the esophageal wall
• Evaluating superficial lesions
Boonstra JJ. Surg Oncol. 2009

29. • Selected patients with high-grade dysplasia and early (T1a) tumors for nonsurgical treatment—For accurate
T and N staging
• Locally advanced esophageal carcinoma—Staging of T4 tumors to determine resectability
• Locally advanced esophageal carcinoma—Staging for remote nodal disease and selecting out
patients who may not undergo a R0 resection, e.g. upper mediastinal nodes in EGJ carcinoma
• Locally advanced esophageal carcinoma—To select patients for neoadjuvant therapy.
• Stage 2 and 3 patients are usually selected to undergo neoadjuvant treatment prior to surgery
Thosani N, et al.. Gastrointest Endosc. 2012;75:242–53.
EUS is recommended to be performed in all patients with only loco-regional disease, and it
may be helpful in the following clinical scenarios:

30. CT Scan
• CT scan of the neck, thorax, abdomen and pelvis with
intravenous and oral contrast is the standard of care
investigation for staging of esophageal carcinoma
• The fissure of the ligamentum venosum is seen on the CT
separating the caudate lobe from the lateral segment of the left
lobe of liver; it points directly at the EGJ

31. CECT…
• The key findings on CT scan include:
• Wall thickening greater than 5 mm (circumferential or part of the wall).
• Dilated esophagus proximal to an obstructing lesion
• Tumors infiltrating outside the wall may appear as soft tissue and fat stranding around the esophagus
• Locally advanced tumors may cause displacement of the tracheobronchial tree.
• Unfortunately loss of fat plane between the airway and the esophageal tumor cannot be used as an
indication of invasion, as no fat plane is normally evident even in patients without a tumor.

32. Aortic invasion in CECT
• The Picus angle is the angle of contact (loss of fat plane) between the
esophageal mass and aorta.
• Angle of contact more than 90° is highly suggestive of invasion of aorta
• angle less than 45° is associated with no invasion, and angle in between 45°
and 90° is indeterminate
• Accuracy of these findings is about 80%

33. CECT…
• Node metastasis- mediastinal node with short axis diameter > 1cm is
abnormal
• Sensitivity for nodal mets is low
• Distance metastasis

34. PET- CT
• Poor uptake of FDG (i.e. FDG non-avid tumours) is usually associated
• diffuse Lauren type tumours
• small tumour size
• mucinous content
• good differentiation
• Up to one-third of gastric tumours can be PET non-avid

35. PET- CT
• Prognostic value
• a good correlation between higher maximum SUV (SUVmax) and poor overall and disease-
free survival
• Staging
• is less accurate than EUS for determining the T-stage
• not much better than EUS or CT scan for nodal staging
• Uptake in the primary lesion may obscure the involved loco-regional nodes
• best investigation for diagnosis of unsuspected distant metastasis and extra-regional involved nodes
In a meta-analysis van Vliet et al. showed that the sensitivity and specificity for detecting distant metastases by 18F-
FDG PET were 71% and 93%, respectively, and by CT scan it was 52% and 91%, respectively

36. PET- CT
• Response assessment during neoadjuvant therapy—
• Early PET-CT during neoadjuvant therapy allows early recognition of non-responders and
institution of salvage therapy for them.
• Response assessment after neoadjuvant therapy
• posttreatment 18F-FDG PET has good predictive value for long-term outcomes
• Follow-up
• PET can detect recurrent/metastatic disease in 8–17% of patients, sometimes even
before disease can be diagnosed on standard imaging

37. Staging laparoscopy
• National Cancer Care Network (NCCN) recommends
• laparoscopic staging with peritoneal washings (lavage cytology) for
• patients with Siewert type 2 and type 3 advanced tumours
• clinical stage T3 or more or clinical node-positive tumours
• Changes treatment if 59.6%
• Avoid laparotomy- 43.8 %
• Bulky tumor, bulky nodal tumors, GE junction

38. SCC- ADC conceptual difference
Field cancerization and lymphatic spread
All etiology caused impact in whole
esophagus, so entire esophagus has to be
treated as SCC
Lymphatic spread- proximal and distal

39. Management of SCC esophagus
Irrespective of location
• Total esophagectomy
• Stomach tubes- for recon
• neck anastomosis
• Mckeown
• Thoracic, abdominal and cervical
• Transhiatal

40. Adenocarcinoma concept
• Need not treat entire esophagus
• Adequate margins only
• Proximal and distal margins- 3-5cm
• Beware of signet ring
• Use frozen section
• Adequate nodal clearance

42. Early Adenocarcinoma
high-grade intraepithelial neoplasia or high-grade dysplasia and mucosal (T1a) and
submucosal (T1b) carcinoma
In a large study, the incidence of nodal metastasis was
0% T1a
13%- T1b-sm1
19% -T1b-sm2
56% - T1b-sm3

43. T1m1 and T1m2 (?T1m3)-- EMR
If well differentiated
If not depressed
If less than 2cm
If final HPR- T1m3 o more- completion surgery
5 year survivial 87-90%

44. Management of Type III ADC
Total Gastrectomy with D2 Dissection and lower esophageal LN

45. Type I lesion
• Higher lesion
• Clear subcarinal LN
• Ivor Lewis
• Intrathoracic anastomosis
• Mckeown
• Neck anastomosis ( often not needed in AdenoCa of OG junction)

46. Type II

47. Hulshcer Trial - Type I and Type II ADC

48. Hulshcer Trial - Type I and Type II ADC

49. • Transthoracic operation
• Risk of complications
• for a possible oncologic advantage is indicated for the fit and/or younger patients
• Transhiatal surgery
• reserved for older patients with multiple comorbid conditions
• the early tumors wherein radical clearance in the mediastinum is considered unnecessary

50. • an extended total gastrectomy including wide splitting of the diaphragmatic hiatus,
transhiatal resection of the distal esophagus
• enbloc lymphadenectomy of the lower posterior mediastinum
• formal abdominal D2 lymphadenectomy
Surg Oncol Clin N Am 15 (2006) 751–764

51. Dutch group, Annals of Surgery , December 2007
Transthoracic radical esophagectomy did not yield any survival benefit over a transhiatal esophagectomy

52. Lancet Oncol 2006
10 yr OS almost same

53. • Left Thoracabdominal approach does not improve survival thas TH
• LTA leads to increased morbidity in patients with cancer of the cardia or subcardia
• LTA cannot be justified to treat these tumors if the length of oesophageal invasion
is 3 cm or less
Lancet Oncol 2006

55. Therefore, a transhiatal abdominal approach can be recommended for cases where
the length of esophageal invasion is 4 cm or less, if safe excision and reconstruction
are technically possible.

56. Summary of surgical management

57. Extended Lymphadenectomy Versus Standard
Lymphadenectomy
• The extent of lymphadenectomy abdominal, thoracic and cervical fields
• German guidelines, 16 nodes; UK guidelines, 15 nodes and NCCN (USA)
guidelines, 15 nodes
most acceptable operation in a young fit patient of EGJ adenocarcinoma is a standard two-field
lymphadenectomy best done as a part of en bloc esophagectomy

59. Neoadjuvant and adjuvant in Adenoca
Neoadjuvant protocols
Perioperative
chemotherapy
Chemoradiation
MAGIC protocol FLOT Protocol CROSS protocol

60. MAGIC – Stage II and III
CA stomach
3 ECF
SURGERY
SURGERY 3 ECF
Plus
• First adequately powered
RCT
• Good design and conduct
• National and International
Guidelines
Minus
• Only 40% completed all chemo
• 26% OG jxn cases
• No updates
• 70% node positive ( no adju)
13 % improvement in overall survival

61. FLOT Trial
2018/2019
55 % patient – OG junction tumors

62. 5Fu/Leucoverin/Oxaliplatin/Taxane
MAGIC FLOT
Med OS 35% 50%
5 yr OS 36% 45%
Toxicity 27% 27%
Hospitalization 26% 26%

63. Consensus
Locally advanced ADC OG jn
(T3/t4/N+)
4 FLOT
SURGERY
4 FLOT
3 EOX
SURGERY
3 EOX
TOXICITY
MAGIC
REGIMEN

64. PROXIMAL STOMACH- CROSS TIRAL NEOADJUVANT
RADIATION
LOCALLY ADVANCED OG JN
TUMORS
CTRT
SURGERY
SURGERY
75 % ADENOCARCINOMA- strong evidence
CARBOPLATIN + PACLITAXEL+XRT (41.4 /Gy)--Surgery

65. PROXIMAL STOMACH- MAGIC VS CROSS VS FLOT
Medial OS 5 yr Survival
MAGIC 35 MONTHS 36%
CROSS 49 MONTH 45%
FLOT 50 MONTHS 47 %
Decision between FLOT and CROSS still no conclusion
Decision by MDT

66. Awaited results of
TOP Gear/ CRITICS II/ ESOPEC trials
Regarding comparing CTRT VS FLOT

67. CROSS protocol- concerns
Radiation field irradiates proximal
stomach also – concern of
vascularity or viability, as it is
used in anastomosis in neck
Lung toxicity
Desmoplasia in irradiated
patients

68. • Thank you

69. References
1. Shackelford's text book of Alimentary tract
2. NCCN Guidelines/ Japanese Guideline of Esophagus and Esophagogastric
junction cancer
3. Japanese Gastric cancer guideline 2021
4. AJCC 8th Edition Manual
5. MAGIC/FLOT/CROSS Trials
6. Mastery of Surgery
7. GI Surgery Annual Volume 25 Indian Association of Surgical
Gastroenterology
8. Maingots Abdominal operation

70. Superior polar Gastrectomy
• Early Type III OG adeno tumors

71. • Thank you

72. Siewert Type 2
• extent of esophageal involvement (less or more than 3 cm)
• presence of mediastinal nodes
• the bulk of the tumour
• patient fitness to withstand a transthoracic procedure
• the experience of the surgical team to carry out adequate mediastinal
clearance through the transhiatal route

73. • Siewert type 2 tumours is a
• transhiatally extended total gastrectomy with radical resection of
lower mediastinal nodes and a D2 lymphadenectomy in the abdomen
• alternative (e.g. transthoracic) surgical approaches may have to be
chosen based on the above described factors

74. Siewert III
• total gastrectomy with D2 lymphadenectomy.

75. staging
• as based entirely on patients treated by esophagectomy alone
(without preoperative or postoperative chemotherapy and/or
chemoradiotherapy), the dataset used to develop the eighth edition
TNM stage groupings included patients who had received
preoperative induction therapy (neoadjuvant) and/or postoperative
adjuvant therapy. The availability of these data led to the ability to
explicitly define cTNM and ypTNM cohorts and stages

78. Tumours involving the
esophagogastric junction with
epicentre no more than 2 cm into the
proximal stomach (originally Siewert
type 1 and 2) are now to be staged as
esophageal cancers
tumours with epicentre located
greater than 2 cm into the proximal
stomach (originally Siewert type 3)
are to be staged as stomach cancers
even if EGJ is involved

79. • A matched control study of two specialized esophageal centres
comparing esophagectomy and endoscopic resection for pT1a
tumours demonstrated excellent longterm survival rates (median
follow-up: 4 years) in both groups
• but morbidity (32 vs. 0%) and mortality rates (2.6 vs. 0%) were much
higher after esophagectomy [80].

80. • In patients with adenocarcinoma, the depth of invasion determines
the curative potential of endoscopic therapy. In case of T1a
adenocarcinoma with favourable histology (absence of
lymphovascular invasion or well differentiated G1 and G2 tumour), if
the margins of EMR resection are involved, then further endoscopic
resection by EMR can be done multiple times till the entire lesion is
resected.
• In general, if the post EMR T-stage is T1b or there are high-risk factors
like lymphovascular invasion or poor differentiation, then surgical
treatment is indicat

81. • achieve this eradication of remainder of Barrett’s mucosa include
complete endoscopic resection, radio-frequency ablation (RFA),
cryotherapy and argon plasma coagulation (APC)

82. Surgery for Early Carcinoma
• multicentric disease or multiple islands of preneoplastic epithelium
could be present throughout the Barrett’s mucosa in about half of the
patients with early Barrett’s cancer
• Removal of the entire Barrett’s intestinal metaplasia in the distal
esophagus therefore should be considered desirable in order to avoid
recurrences. In addition adenocarcinoma invading the submucosa
(T1b) has a high likelihood of local node involvement, though these
are limited to lower mediastinum or lower.

83. • r, endoscopic treatment has high metachronous/recurrent cancers
within the Barrett’s mucosa in up to one-third of patients, thus
needing lifelong surveillance and treatment [97]. The other problems
of endoscopic treatment are persistent sub-epithelial islands of
intestinal metaplasia and stricture rate that can approach 30%

84. The surgical options for early
adenocarcinoma are as follows:
• Radical (transthoracic) esophagectomy
• (b) Transhiatal esophagectomy (most widely practiced option)
• (c) Minimally invasive esophagectomy
• (d) Vagus preserving esophagectomy
• (e) Merendino procedure
• (f) Sentinel node navigation surgery

85. Treatment of Locally Advanced Tumours
• Good quality surgical resection for EGJ carcinoma should aim to
provide oncologic clearance with regard to the longitudinal resection
margins (proximal and distal), circumferential resection margin and
removal of all lymph node stations at risk of metastasis

86. Longitudinal Resection Margins
• it is reasonable to aim for 5 cm in vivo longitudinal resection margins
(proximal and distal) and to confirm a tumour-free status with an
intraoperative frozen section examination of the resection margins.

87. Circumferential Resection Margin (CRM)

88. Type II lesion
• Transhiatally extended total gastrectomy with
radical resection of lower mediastinal nodes
and a D2 lymphadenectomy in the abdomen
• alternative (e.g. transthoracic) surgical
approaches may have to be chosen based on
the above described factors
• Ivor Lewis/or Mckewons

89. Trans hiatal Esophagectomy (Orringer)
Abdominal and neck incison
Blunt dissection
Oncological not safe

90. Mc kewon Trincisional surgery
• Three stage
• Thoracic approach- mobilize thoracic esophagus (open/MIS)
• Supine position – abdominal sugery
• Neck surgey
• Anastomosis in neck

91. Ivor Lewis
• Two stage
• Abdominal part- mobilize
• Lateral position- thoracoscopic part
• Thoracoscopic anastomosis