Cancer of the Cardia/GE Junction: Surgical Options

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1 Cancer of the Cardia/GE Junction: Surgical Options Michael A Smith, MD Associate Chief Thoracic Surgery Center for Thoracic Disease St Joseph s Hospital and Medical Center Phoenix, AZ

2 Michael Smith, MD I have no financial relationship with any manufacturer of any commercial product and/or provider of commercial services discussed in the CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product or device in my presentation. The planning committee for this event has no relevant financial relationships with commercial interest to disclose.

3 Rate per 1,000,000 Histology and Esophageal Cancer Incidence ( ) Adenocarcinoma Squamous cell carcinoma Not otherwise specified Pohl H and Welch HG. J Natl Cancer Inst 2005;95:

4 Relative Change in Incidence of Esophageal Adenocarcinoma and Other Malignancies Rate ratio relative to Esophageal adenocarcinoma Melanoma Prostate Cancer Breast Cancer Lung Cancer Colorectal Cancer Pohl H and Welch HG. J Natl Cancer Inst 2005;95:

5 Esophageal Cancer Staging 7 th Edition EGJ and proximal 5 cm of stomach that extend to EGJ included (Siewert III) Tis is redefined (carcinoma in-situ no longer used) T4 is subclassified based on resectability Regional lymph nodes redefined N subclassified based on number of nodes not location M is redefined (No M1a/M1b Celiac nodes considered regional) Separate groupings for adenoca and SCCA Number of nodes given preference over location of nodes in terms of stage and survival Grade classification used

6 Cardia Cancer now staged with Esophageal Cancer But should they be managed the same?

7 No! One size doesn t fit all!

8 Cancer of the Cardia can be 2 types of cancers? Siewert Classification Siewert I, in esophagus, growing down to GE junction Siewert II, at GE junction Siewert III, in Cardia of stomach, growing up into esophagus III II I Siewert III may act more like gastric cancer and signet cells sometimes seen Siewert I most often associated with Barrett s esophagus

9 Cardia Cancers: two different etiologies?? Key to differentiating type II is histology of the stomach wall clear of the cancer atrophy/h-pylori gastric healthy stomach, no H-pylori, reflux Sx - esophagus Gut March 2010 Vol 59 No 3

10 Why is this important? Esophageal Cancer address the esophagus Note Barrett s cancers are more common Gastric Cancer address the stomach Don t want a new gastric cancer (or recurrence) in the gastric tube (up to 15%)

11 Tailor Surgical Therapy Based on Tumor Location and Histology Type I and esophageal Type II Esophagectomy with gastric pull up Tansthoracic Transhiatal MIE Type III and gastric Type II Total gastrectomy with R-Y reconstruction Proximal subtotal gastrectomy

12 Tailor Surgical Therapy Barrett's esophagus LGD HGD Intramucosal Carcinoma Based on Possibility of Nodal involvement?? Submucosal Carcinoma Higher T Stages

13 Esophageal Cancer Seiwert type I and esophageal type II Management Options Endoscopic therapy Lesion limited to mucosa EMR, RFA, cryotherapy, brachytherapy Limited resection Merendino procedure Vagal sparing esophagectomy Radical resection Transhiatal esophagectomy Transthoracic esophagectomy Minimally invasive esophagectomy

14 Endoscopic Mucosal Resection

15 Endoscopic Management Endoscopic resection/rfa/cryo/brachy Nodes Muscularis Mucosa Tis: HGD T1a (intramucosal carcinoma) T1b (submucosal carcinoma) 0 % <5% >25%

16 EMR: endoscopic mucosal resection (ER, since submucosa involved) Allows accurate T staging If submucosa involved then resection recommended Soetikno, R. et al. J Clin Oncol 2005; 23:

17 Limited Resection: Early Cancer Merendino operation Potential benefits: 1) Retain peristalsis 2) Preserve gastric reservoir 3) Preserve vagal function 4) smaller operation 5) No Roux complications 6) Ability to remove local nodes Potential problems 1) Reflux if too short 2) Learning curve

18 Limited Resection: Early Cancer Vagal Sparing Esophagectomy Potential benefits: 1) Remove long segment Barrett s and HGD 2) Preserve Vagal function 3) Possible to save gastric reservoir Potential problems 1) No nodal dissection, so limited to T1a 2) Learning curve 3) Big operation

19 More Extensive Resection Esophagectomy Transhiatal, Transthoracic Resections and MIE Potential benefits: 1) Remove all possible extent of Ca 2) Ability to remove nodes Potential problems 1) Eating habits 2) Dumping 3) REFLUX 4) Bigger operation

20 Long-term outcomes Quality of life Post gastric interposition greatest problem is REFLUX Cause of esophageal cancer in the first place REFLUX If early cancer, younger person propensity to get Barrett s again and then another cancer???

21 Long-term outcomes Genetic predisposition to develop a) Barrett s and b) Cancer If continued post-op reflux..? More Barrett s and more Cancer Lord R et al: Surgery Volume 138, Issue 5, 2005, Burnat G et al: J Physiol Pharmacol 61(2): (2010) Huo and Zang: GASTROENTEROLOGY 2010;139:

22 How to overcome long term reflux? 1. Antireflux procedure at time of esophagectomy GERD from 70% - 40% An Antireflux Anastomosis Following Esophagectomy: A Randomized Controlled Trial: Glyn G. Jamieson J Gastrointest Surgery 2010, 14;470

23 How to overcome long term reflux? 1. Antireflux procedure at time of esophagectomy 70% - 40% 2. Don t use a gastric conduit 1. Colon - bigger operation, redundancy etc 2. Small intestine limited length (Merendino) But Roux-en-Y ultimate antireflux operation. An Antireflux Anastomosis Following Esophagectomy: A Randomized Controlled Trial: Glyn G. Jamieson J Gastrointest Surgery 2010, 14;470

24 THE vs TTE: Role of lymph node dissection Omloo and Hulcher: Netherlands 220 patients randomized to: THE or TTE Full Lymph node dissection as Approach allowed.. No overall survival difference Ann Surg, 246(6) Dec 2007, 992

25 TTE vs THE (Role of Lymphadenectomy) No Nodes 1-8 nodes > 8 nodes Patients with a limited number of positive lymph nodes in the resection specimen seem to benefit from an extended transthoracic esophagectomy Ann Surg, 246(6) Dec 2007, 992

26 Cardia Cancer Seiwert III and gastric Type II Management Options Endoscopic therapy EMR Surgical resection Total gastrectomy R-Y reconstruction Proximal subtotal gastrectomy

27 Cardia Cancer: Total Gastrectomy Roux-en-Y reconstruction Potential benefits: 1) Remove cancerous stomach 2) Remove acid reflux 3) Better nodal resection 4) Weight loss Potential problems: 1) Eating habits 2) Dumping/Roux syndromes 3) Nutrition

28 Cardia Cancer: Proximal Subtotal Gastrectomy Potential benefits: 1) Remove proximal cancerous stomach 2) Retain gastric reservoir 3) No weight loss Potential problems: 1) Limited nodal dissection 2) How much stomach to remove? 3) Reflux

29 Node Dissection is Important Optimal Extent is Controversial D1 vs D2 More nodes with D2 but greater morbidity Minimize stage migration Number of nodes more important than location Pathological examination of at least 16 nodes

30 Decision Tree Cancer of GE Junction History, EGD, Bx lesion, stomach/eso, EUS Siewert I Siewert II Siewert III T1a ER, RFA T1b T2 Intraop LN + - Merendino/Roux TTE,THE submucosa Partial gastrect?merendino Roux Total Gastrectomy

31 Summary All EGJ and cardia cancers should not be managed the same We should do our best to understand tissue of origin. Do not want to pull up a carcinogenic stomach Tailor management approach to tissue of origin and likelihood of nodal disease Early esophageal or cardia cancer: T1a local resection with EMR is feasible Muscularis involved more extensive operations needed in part because of likelihood of nodal involvement

32 Summary Early esophageal cancer: T1b (submucosa -?LN) Limited resection preserve esophageal function, preserve gastric reservoir, evaluate lymph nodes Cardia cancer- gastric resection to avoid recurrence in a gastric pull up For node dissections: If some is good, more is better.