Esophagectomy or Total Gastrectomy for Siewert 2 Gastroesophageal Junction (GEJ) Adenocarcinoma? A Registry-Based Analysis

Abstract

Backgrounds Due to a lack of randomized and large studies, the optimal surgical approach for Siewert 2 gastroesophageal junctional (GEJ) adenocarcinoma remains unknown. This population-based cohort study aimed to compare survival between esophagectomy and total gastrectomy for the treatment of Siewert 2 GEJ adenocarcinoma. Methods Data from the National Cancer Database (NCDB) from 2010 to 2016 was used to identify patients with non-metastatic Siewert 2 GEJ adenocarcinoma who received either esophagectomy (n = 999) or total gastrectomy (n = 8595). Propensity score-matching (PSM) and multivariable analyses were used to account for treatment selection bias. Results Comparison of the unmatched cohort’s baseline demographics showed that the patients who received esophagectomy were younger, had a lower burden of medical comorbidities, and had fewer clinical positive lymph nodes. The patients in the unmatched cohort who received gastrectomy had a significantly shorter overall survival than those who received esophagectomy (median, 47 vs. 68 months [p < 0.001]; 5-year survival, 45 % vs. 53 %). After matching, gastrectomy was associated with significantly reduced survival compared with esophagectomy (median, 51 vs. 68 months [p < 0.001]; 5-year survival, 47 % vs. 53 %), which remained in the adjusted analyses (hazard ratio [HR], 1.22; 95 % confidence interval [CI], 1.09–1.35; p < 0.001). Conclusions In this large-scale population study with propensity-matching to adjust for confounders, esophagectomy was prognostically superior to gastrectomy for the treatment of Siewert 2 GEJ adenocarcinoma despite comparable lymph node harvest, length of stay, and 90-day mortality. Adequately powered randomized controlled trials with robust surgical quality assurance are the next step in evaluating the prognostic outcomes of these surgical strategies for GEJ cancer.

Expression and Prognostic Value of RAD51 in Adenocarcinoma at the Gastroesophageal Junction

“…ACGEJ is divided into three subtypes (Siewert type I, II, and III) according to the Siewert classification and proximal/distal of the anatomic gastric cardia and the overall survival of the three subtypes were different. The prognosis of ACGEJ is related to several factors, including the extent of nodal involvement (4,5), human epidermal growth factor re-ceptor 2 (HER2) status (6), neoadjuvant chemotherapy, and surgical strategy (7,8). More numbers of resected lymph nodes were associated with better survival in Siewert type II ACGEJ patients (5).…”

“…The prognosis of ACGEJ is related to several factors, including the extent of nodal involvement ( 4 , 5 ), human epidermal growth factor receptor 2 ( HER2 ) status ( 6 ), neoadjuvant chemotherapy, and surgical strategy ( 7 , 8 ). More numbers of resected lymph nodes were associated with better survival in Siewert type II ACGEJ patients ( 5 ).…”

Clinicopathologic and survival differences between adenocarcinoma of the distal oesophagus and gastro‐oesophageal junction

“…21 Recent large-scale studies suggest no difference in post-operative morbidity although oesophagectomy was associated with better overall survival than gastrectomy. 22,23 It remains necessary for these data to be evaluated in a randomized control setting.…”

“…While an extended gastrectomy with a transabdominal approach avoids the pulmonary complications associated with a thoracotomy, 20 it compromises the extent of thoracic lymphadenectomy and is associated with a higher rate of microscopic residual tumour (R1) 21 . Recent large‐scale studies suggest no difference in post‐operative morbidity although oesophagectomy was associated with better overall survival than gastrectomy 22,23 . It remains necessary for these data to be evaluated in a randomized control setting.…”

ASO Author Reflections: Challenges in the Management of Gastroesophageal Junctional Adenocarcinoma

“…The present study 3 included patients with non-metastatic Siewert II GEJ adenocarcinoma receiving either esophagectomy ( n = 999) or total gastrectomy ( n = 8595), from the National Cancer Database (NCDB) from 2010 to 2016. This national population-based cohort study from the US demonstrated that patients receiving esophagectomy had significantly longer survival than total gastrectomy for Siewert II GEJ adenocarcinoma.…”