Clinical Tumor Staging of Adenocarcinoma of the Esophagus and Esophagogastric Junction

Abstract

We congratulate Davies et al 1 on the retrospective analysis of 400 patients treated with neoadjuvant chemotherapy followed by surgery at two high-volume London centers over the course of a decade. Rather than examining the prognostic effect of tumor regression, the authors focused on the downstaging effect of neoadjuvant chemotherapy as a predictor of recurrence-free and overall survival. Following adjustment for known clinicopathologic variables, tumor downstaging was associated with a reduction in the risk of recurrence and death, suggesting that major clinical decisions should be based on postchemotherapy staging.As mentioned by the authors, advanced diagnostic staging procedures, such as positron emission tomography-computed tomography (PET-CT), are important for detecting nodal disease and distant metastases. To classify a tumor as downstaged, it is essential to not only accurately define the pathologic stage following surgical resection but also to define the clinical stage before chemotherapy. Although much work has been carried out to standardize the reporting of pathologic stage, the use of clinical staging methodologies has varied over time and between centers. 2,3 Staging that uses PET-CT can detect occult metastatic disease in up to 13% of patients, and in one study, it led to a change in treatment intent in 38% of the patients. 4,5 Considering that the patient cohort in this study was compiled between 2000 and 2010, earlier patients were most likely staged with CT and possibly endoscopic ultrasound, and the authors comment that PET-CT was introduced only "latterly." The authors did not provide a clear breakdown of the proportion of patients staged with PET-CT,asrecommendedbycurrentguidelines. [6][7][8] Whateffectcouldthis have had on the study results? Without clinical staging that incorporates PET-CT,itislikelythatupto13%ofpatientshadoccultmetastaticdisease and so were incurable by surgical resection at presentation. The T3/T4 node-positive patients were used as the reference group in the Kaplan-Meier graphs, and their 3-year survival was unexpectedly low, at approximately 20%, suggesting understaging. In a comparable group of patients with poor prognosis who were clinically staged by using PET-CT and who showed no evidence of a metabolic response to therapy on a repeat PET-CT scan carried out 14 days later, the 3-year survival rate was 35%. 9 The T3/T4 node-positive patients who were not downstaged represented 35% of the patients in the study and the majority of the 56% of patients in the reference group who were used in the multivariable analysis and who were not downstaged. This would lead to an overestimate of the benefit of tumor downstaging because the reference group could contain a subset of patients with resistant metastatic disease. In addition, the R1 resection rate for all patients receiving chemotherapy was 44.8%, markedly above the rate of 31.1% reported in the recent United Kingdom's National Oesophago-GastricCancerAudit,whichemphasizestheimprovementin surgical outcomes over the last...

Patients unfit for neoadjuvant therapy may still undergo resection of locally advanced esophageal or esophagogastric junctional cancer with acceptable oncological results

“…A third of patients going straight to surgery in our study were also incorrectly T-staged. This highlights the limited accuracy of current clinical staging methods and caution should be advised before conclusions of downstaging are drawn from comparison of clinical and pathologic stages 35 .…”

Predictors of Lymph Node Metastasis in Siewert Type II T1 Adenocarcinoma of the Esophagogastric Junction: A Population-Based Study

“…5 AEG is commonly considered as a separate tumor entirety of digestive tract cancer. 6,7 Due to its special anatomical location, the classification of AEG has been historically complicated. Siewert classified AEG into 3 subgroups based on the anatomical location of the tumor epicenter relative to the esophagogastric junction (EGJ): Siewert type I (5 to 1 cm above the EGJ), type II (1 cm above to 2 cm below the EGJ), and type III (2 to 5 cm below the EGJ).…”

Explored Risk Factors for Lymph Node Metastasis with Siewert II/III Adenocarcinoma of the Gastroesophageal Junction

“…The incidence of adenocarcinoma of the esophagogastric junction (AEG) has rapidly increased in Western and Eastern countries over the past decades (1). Meanwhile, AEG is commonly regarded as a separate tumor entirety of digestive tract cancer (2,3). AGE is a malignant tumor with early hematogenous and lymphatic dissemination.…”