Clinical Pathological Characteristics And Regularly Surgical Therapy Of Adenocarcinoma Of Gastroesophageal Junction

Gastric cancer is one of the commonest malignant disorders in China,and the prognosis of adenocarcinoma of gastroesophageal junction(GEJ) was poor when compared with similarly staged carcinoma of the middle or lower part of the stomach. Besides differentiation grade,TNM staging and adjuvant chemo-radiotharepy, regularly surgical therapy,such as a curative resection(no macroscopic or microscopic cancer at resection margins and systematic lymph node dissection),is the key of combined modality therapy.Ahead of these,we must fully realize clinical pathological characteristics of GEJ.Firstly,Between January 1999 and April 2008,1575 patients with GEJ were treated in the Department of Thoracic Surgery and the data were retrospectively reviewed.The characteristics included sex,age,histologic type,differentiation grade, esophageal invasion,tumor stage,nodal stage,thoracic nodal metastasis,numbers of lymph node metastasis and dissected,distance metastasis,TNM staging,resection margin,Borrmann's type,and peritoneal metastasis.5.4%(86/1575) proximal section margins of patients with GEJ were tumor involvement.72.7%(1145/1575) had abdominal lymph node metastases,and 16.0%(252/1575) had thoracic lymph node metastases.So GEJ is more similar to gastric cancer.From January 2005 to July 2007,138 of 538 eligible patients with GEJ underwent curative resections and additional dissections of subcrinal lymph nodes. With conventional haematoxylin and eosin(HE),10 patients had metastasis in the subcrinal lymph nodes.Specimens of 128 patients,in whom conventional HE examination did not demonstrate subcrinal lymph node metastasis,were available for serial sections and immunohistochemical analysis using antibodies(AE1/AE3 and CK18) directed against cytokeratins.In 3 patients with negative nodes at conventional HE examination,serial sections or immunohistochemical analysis demonstrated micrometastasis in the subcrinal lymph nodes.M stage was main risk factor of subcrinal lymph nodes involvement. Between January 1999 and November 2003,1069 patients were assigned to the left thoracic approach(LTA.n=783) or the abdominal approach(AA,n=286) in the treatment of GEJ.The 5-year survival were 33%for LTA and 30%for AA(P=0.29. Long-rank test).There was no difference in the postoperative morbidity and hospital mortality between the two arms.Of 15 clinicopathologic characteristics analyzed by the Cox regression model,8 were identified as independent prognostic variables. They were age,differentiation grade,tumor stage,abdominal nodal stage,thoracic nodal metastasis,distance metastasis,vascular invasion and Borrmann's type. Especially,overall lymph node ratio(≥0.2),number of thoracic nodal metastasis and thoracic lymph node ratio(≥0.1) predicated poor prognosis.Differentiation grade, tumor stage,abdominal nodal stage,and distance metastasis were risk factors of thoracic lymph nodes involvement.In order to evaluate the effect of thoracic nodal metastasis on survival in patients with GEJ,we enrolled the patients into two groups: Group1(patients who had abdominal nodal metastasis(N1,N2,N3)without thoracic nodal metastasis;Group2(patients who had thoracic nodal metastasis with abdominal nodal metastasis(N0,N1,N2).Paired compared Group1 with Group2,there was no difference in the survival between the two arms.So the proposal is:overall nodal stage=abdominal nodal stage+thoracic nodal metastasis(0—negative,1—positive). At last,we proved that the number of positive nodes best defines the prognostic influence of metastatic lymph nodes in gastric cancer and survival estimates based on the number of involved nodes are better represented when at least 15 nodes are examined.Based on the presently available data,adenocarcinoma of GEJ in a physically fit patient should preferably be removed via a transthoracic resection.