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PubMed1987

Lymph drainage originating from the lower esophagus and gastric cardia as measured by radioisotope uptake in the regional lymph nodes following lymphoscintigraphy.

Lymph drainage originating from the lower esophagus and gastric cardia was determined using uptake of radioisotope (RI) in the regional lymph nodes in 19 patients with primary cancer at these sites. On the day prior to operation, 99m Tc colloid solution was injected submucosally in the distal esophagus or gastric cardia during endoscopy. The regional lymph nodes were removed at operation and RI uptake of individual nodes was measured in a well-type scintillation counter. Uptake was expressed as the amount per nodal weight. After radioactive colloid was injected into the lower esophagus, high RI uptake was common in both the mid-mediastinal and abdominal nodes, suggesting that lymph originating from the lower esophagus drains in both a superior and inferior direction. On the other hand, after radioactive colloid was injected into the gastric cardia, high RI uptake was never demonstrated in mediastinal lymph nodes suggesting that direct mediastinal lymph flow from the gastric cardia is rare. These results support clinical observations on the distribution of lymph nodal metastases in patients with lower esophageal and gastric cardia malignancies. As a diagnostic tool for lymph nodal metastases, however, lymphoscintigraphy is unreliable.

Abdomen↗
PubMed1998

Distal chromosome 17q loss in Barrett's esophageal and gastric cardia adenocarcinomas: implications for tumorigenesis.

The molecular genetic mechanisms underlying esophageal cancer are poorly understood. However, a novel gene that may be involved in esophageal carcinogenesis was recently localized by others to distal 17q by linkage analysis of kindreds with palmoplantar keratoderma and squamous cell carcinoma of the esophagus. To help determine whether a distal 17q gene may also be involved in the pathogenesis of primary Barrett's esophageal and gastric cardia adenocarcinomas, we performed loss of heterozygosity (LOH) analysis of 21 Barrett's and 18 gastric cardia adenocarcinomas at loci spanning 17q: cen-BRCA1-SSTR2-D17S2058-D17S929-D17S722-+ ++D17S937-D17S802-tel. Over 50% of the Barrett's and cardia adenocarcinomas demonstrated loss of an allele at one or more informative distal 17q markers. One common overlapping region of loss involved loci mapped to distal 17q24-proximal 17q25, which tentatively defines a potential chromosomal region distal to BRCA1 involved in the pathogenesis or progression of both types of adenocarcinomas. LOH analysis of DNA from matched microdissected sections of Barrett's metaplasia suggested that loss of D17S2058 in this region may be an early event in the malignant transformation of Barrett's metaplasia. No statistically significant correlations between 17q LOH and tumor stage or patient survival were noted. In summary, LOH mapping of 17q in Barrett's and cardia adenocarcinomas suggests the existence of at least one putative distal 17q tumor suppressor gene involved in the pathogenesis of these tumors.

Adenocarcinoma↗
PubMed1987

Early carcinoma of the gastric cardia. A clinicopathologic study of 21 cases.

A clinicopathologic study was done on 21 cases of early carcinoma of the gastric cardia. The disease was preponderant in men, with a male-female ratio of 17:4. Five patients had no symptoms, while the other 16 had epigastric pain, epigastric discomfort, or other symptoms. Melena or hematemesis occurred in five patients. The first detection was made by barium study in 16 and by endoscopy in five. Detailed examinations using double-contrast radiography in both the prone right anterior oblique and supine left lateral projections were useful to detect the early carcinoma of the gastric cardia. All depressed-type carcinomas were incidentally detected during endoscopic examinations of benign peptic ulcers, therefore, whenever endoscopic examinations are being done for other entities, all the stomach including the cardia should be examined, carefully and continuously. Compared with early carcinomas of the other areas of the stomach, grossly elevated and histologically well-differentiated early carcinomas were more common in the gastric cardia. In the mucosa adjacent to the carcinoma, chronic gastritis was apparent in almost all cases, although intestinal metaplasia was found less frequently than in other areas of the stomach.

Adult↗
PubMed1989

Time-related changes in characteristics of prognostic significance in carcinomas of the oesophagus and cardia.

During 25 years (1960-84) 657 patients were operated on for squamous cell carcinomas (n = 230), adenocarcinomas (n = 399) or anaplastic carcinomas (n = 28) of the thoracic oesophagus or cardia. The male:female ratio was 2.8:1 and the mean age was 66 years (range 22-91 years). Oesophagogastrectomy (n = 514) was performed whenever technically possible. From the first (1960-64) to the last (1980-84) 5-year period the proportion of adenocarcinomas increased from 56 to 78 per cent (P less than 0.001), poorly differentiated cancers increased from 34 to 65 per cent (P less than 0.0001), and stage III-IV tumours increased from 72 to 88 per cent (P less than 0.05). Five-year cumulative rates(s.e.) were 11(3) per cent for operations during 1960-69 (n = 262), 8(2) per cent during 1970-79 (n = 256) and 3(2) per cent during 1980-84 (n = 139; P less than 0.05). Hospital mortality rates (less than or equal to 30 days) and 5-year cumulative survival rates(s.e.) were 6.5 per cent and 36(7) per cent (n = 46) for stage I, 14.0 per cent and 21(4) per cent (n = 114) for stage II, 17.8 per cent and 5(1) per cent (n = 258) for stage III and 23.8 per cent and 3(1) per cent (n = 239) for stage IV tumours (P less than 0.05 and P less than 0.001). Well differentiated (n = 70) cancers, those of medium differentiation (n = 239) and poorly differentiated cancers (n = 348) had 5-year survival rates(s.e.) of 24(5), 10(2) and 5(1) per cent, respectively (P = 0.0007). Squamous cell carcinomas had a better prognosis than adenocarcinomas, even after stratification according to location of primary tumour. The 657 patients who underwent surgery constituted 50 per cent of a total of 1316 cases with cancer of the oesophagus and cardia reported from our catchment area during the study period. Frequency of surgery decreased with age. The annual incidence (number per 100,000 inhabitants aged 20 years or more) of adenocarcinomas of the lower oesophagus and cardia doubled to 5.9 in 1980-84, while that of squamous cell carcinomas tended to decrease (to 2.9). A successive worsening of long-term survival after surgery was explained by significant changes in cancer characteristics having pronounced prognostic significance. Over the 25 years the carcinomas changed towards the present pattern where poorly differentiated adenocarcinomas of the lower third of the oesophagus and cardia in stages III-IV have become predominant.

Adenocarcinoma↗
PubMed1995

Yield pressure, anatomy of the cardia and gastro-oesophageal reflux.

The yield pressure at which the cardia opens in response to gastric distension was measured in 155 subjects with and without gastro-oesophageal reflux (GOR) and after Nissen fundoplication. Yield pressure was measured by endoscopy or during oesophageal manometry. The median pressure was significantly lower in subjects with GOR than in those without (P < 0.0001). After successful Nissen fundoplication this pressure increased to supranormal values (P < 0.0001). There was a close relationship between yield pressure and the presence and size of hiatus hernia and also between yield pressure and the valvular appearance of the cardia at endoscopy. There was a significant correlation between yield pressure and oesophageal acid exposure. However, no relationship was observed between yield pressure and lower oesophageal sphincter pressure or intra-abdominal length. These results suggest that yield pressure is useful for assessment of the competence of the cardia, particularly after antireflux surgery. The competence of the cardia is greatly influenced by its anatomical structure.

Adolescent↗
PubMed2003

Barrett's adenocarcinomas resemble adenocarcinomas of the gastric cardia in terms of chromosomal copy number changes, but relate to squamous cell carcinomas of the distal oesophagus with respect to the presence of high-level amplifications.

Three different cancers predominantly occur at the gastro-oesophageal junction: squamous cell carcinomas of the distal oesophagus, adenocarcinomas of the distal oesophagus (Barrett's carcinomas), and adenocarcinomas of the gastric cardia. The aim of the present study was to investigate how, and to what extent, Barrett's carcinoma differs from adenocarcinoma of the gastric cardia on the one hand and squamous cell carcinoma of the distal oesophagus on the other, with respect to chromosomal aberrations and related gene expression. The present study analysed 14 squamous cell carcinomas, 24 Barrett's carcinomas, and 16 carcinomas of the gastric cardia. Comparative genomic hybridization revealed chromosomal abnormalities in all cases. Typical chromosomal aberrations for the squamous cell carcinoma type were gains at 3q and 11q13, and losses at 3p, 4q, 9p, 11q, and 13q. In contrast, typical copy number changes for both cardiac and Barrett's adenocarcinomas were gains at 2q, 7p, and 13q, and losses at 17p. High-level amplification occurred in all three groups, but its frequency in the cardiac carcinomas was lower than in the other two groups. In conclusion, squamous cell carcinomas are characterized by chromosomal aberrations which are distinct from those seen in carcinomas of the gastric cardia and in Barrett's adenocarcinomas. With respect to Barrett's cancer, the chromosomal aberrations more closely reflect the adenocarcinoma phenotype than the squamous origin of the epithelium.

Adenocarcinoma↗
PubMed1989

Endoscopic sclerosis of the cardia affects gastroesophageal reflux.

Gastroesophageal reflux disease remains a disorder of unknown etiology associated with abnormal function of the lower esophageal sphincter (LES) and other physiological co-factors of the pathologic reflux. Effective operations for reflux are designed to reinforce the anti-reflux barrier and alter the tendency towards abnormal reflux. We have postulated that the most important component of these procedures is the prevention of distraction of the lowermost components of the LES at the onset of a potential reflux episode. Distraction of the LES causes shortening of the effective sphincter mechanism and can initiate experimental reflux events. In this study we used endoscopic sclerosis of the submucosal space at the cardia as a means of reducing distraction of the cardia in the hope that this would reduce abnormal reflux events. Canine gastroesophageal reflux was induced by intravenous atropine and monitored by continuous esophageal pH monitoring. Sclerosis of the cardia prevented gastroesophageal reflux, without measurable effect on the LES pressure or length. Endoscopic sclerosis of the cardia may be a useful technique in the control of human gastroesophageal reflux.

Animals↗
PubMed1989

Definition of carcinoma of the gastric cardia.

This study concerns the definition of carcinoma of the gastric cardia. The topography of the esophagogastric mucosal junction (mucosal EGJ) was investigated with an endoscope in 182 patients who were free of hiatal hernias, ulcers, and neoplasms in the esophagus and stomach. The relationship between the EGJ and the cardiac gland area was then examined histologically in 56 resected specimens containing intact EGJs and cardia gland areas. Furthermore the cancerous center was determined; the shortest distance between the cancerous center and the EGJ and the amount of esophageal invasion were measured in 102 resected carcinomas located close to the junction; the carcinomas contained the EGJ and were good enough for pathohistological examination. The EGJ was located 0.5 - 1.0 cm proximal to the His angle (the gastric cardia) in radiological and endoscopic examinations. Histologically the cardiac gland area was found to straddle the EGJ at a range of about 1 cm proximal and 2 cm distal to the junction. Among the upper stomach carcinomas, most of the tumors (87.5%) whose center was located within 2 cm from the EGJ invaded the esophagus. In conclusion, carcinoma of the gastric cardia is defined as a lesion with its center located within 1 cm proximal and 2 cm distal to the EGJ.

Adolescent↗
PubMed1989

Difference in main lymphatic pathways from the lower esophagus and gastric cardia.

Lymphatic pathways draining the lower esophago-cardiac region were studied in 17 patients with carcinoma of the lower esophagus or gastric cardia, by measuring radioisotope uptakes in the regional lymph nodes. The uptakes were most remarkable in lower mediastinal and upper gastric lymph nodes, when the radioactive colloid was injected at the lower esophagus. A lesser degree of uptakes were observed both in other mediastinal and abdominal lymph nodes. On the contrary, a high degree of uptakes were detected only in abdominal lymph nodes, when the colloid was injected at the gastric cardia. The results indicated that main lymphatic pathways originating from the lower esophagus advance both upward and downward, and that those from the gastric cardia make their way downward to upper gastric, para-celiac and para-aortic lymph nodes. The actual incidences of lymph node metastases were also studied in 108 patients with carcinoma of the lower esophagus and 93 patients with carcinoma of the gastric cardia. In the former group, very high incidences were observed in lower esophageal and upper gastric lymph nodes. In the latter group, the incidence was most remarkable in upper gastric lymph nodes and far less significant in lower mediastinal lymph nodes. The results confirmed those of the radioisotope study. The importance of dissection of para-aortic lymph nodes near the left renal vein was also stressed.

Adult↗
PubMed2001

Endoscopic augmentation of the cardia with a biocompatible injectable polymer (Enteryx) in a porcine model.

BACKGROUND: Endoscopic approaches to restore the gastroesophageal barrier in patients with gastroesophageal reflux disease (GERD) are presently undergoing clinical trial. The aim of the study was to demonstrate the feasibility, durability, safety, and antireflux efficacy following augmentation of the cardia with a biocompatible injectable polymer (Enteryx). METHODS: Augmentation was performed in 12 Yucatan mini-pigs. The cardia was injected circumferentially with 1-1.5 ml of Enteryx at three or four sites. Four groups of three animals each were killed at 2, 6, 12, and 24 weeks following augmentation. Gastrointestinal endoscopy and esophageal manometry were performed preoperatively and postoperatively. Competency was determined as the intragastric pressure (yield pressure) and volume (yield volume) needed during gastric distension with air and water to result in equalization of gastric and esophageal pressure. Comparisons were made with a group of noninjected animals (n = 6). RESULTS: All animals had a normal eating pattern; none showed any evidence of vomiting or regurgitation. The median injection volume was 4 ml (range, 1-8). At autopsy, implants were found in 83% of the animals. Intramuscular placement of the implant was durable, whereas sloughing occurred if the implant was placed submucosally. The mechanical properties of sphincter length and pressure were unaffected by the injection. The median yield pressure of the animals that survived for >6 weeks (21.4 mmHg) was significantly greater (p = 0.049) than the animals that survived for <6 weeks (4.5 mmHg) and greater (p = 0.054) than the control animals (9.1 mmHg), suggesting that the healing process was associated with reduced distensibility of the cardia. CONCLUSIONS: Augmentation of the cardia with an injectable polymer (Enteryx) is simple, safe, and durable. Early studies suggest that alteration in the distensibility and geometry of the gastroesophageal junction may provide antireflux protection.

Animals↗
PubMed1998

Esophageal intramural metastasis from an adenocarcinoma of the gastric cardia: report of a case.

We report herein the rare case of a 65-year-old man found to have esophageal intramural metastasis from cancer of the gastric cardia. Endoscopic examination initially revealed an infiltrating ulcerative tumor of the gastric cardia involving the esophagogastric junction, as well as a submucosal tumor of the lower esophagus. A total thoracic esophagogastrectomy with lower mediastinal lymphadenectomy was performed, and the resected specimen demonstrated that both the cardia and esophageal tumors were adenocarcinomas with the same cellular differentiation. As lymphatic invasion and metastases to the paracardial and mediastinal lymph nodes were observed, the esophageal submucosal tumor was considered to be an intramural metastasis from the carcinoma of the gastric cardia resulting from extensive lymphatic spread. The patient died of recurrent disease 9 months after the resection. This case report serves to demonstrate that intramural metastasis may be a local indicator of the systemic spread of disease in patients with gastric carcinoma, as it is in esophageal carcinoma.

Adenocarcinoma↗
PubMed2005

[Public screening for early carcinoma of gastric cardia: rule of carcinogenetic development observed by endoscopy].

OBJECTIVE: To study the rule of development of early cancer of gastric cardia in vivo in public screening. METHODS: A prospective cohort study on gastric cardiac cancer was held in the high incidence area of cancer of esophagus and stomach in China. 106 subjects had been examined regularly by endoscopy to observe the change of mucosa in high incidence area of gastric cardiac carcinoma developing at the root of gastric cardiac ridge by taking serial biopsy specimens. All specimens were diagnosed through the normal pathological processes to study the prognosis of pre-cancerous lesion of gastric cardia. RESULTS: The result of 106 subjects who had been observed for four years were: 1. Of 8 normal persons, 3 stayed normal, 4 turned to chronic gastritis, 1 developed early gastric cardiac cancer. 2. Of 61 persons chronic gastritis, 11 was observed to have glandular atrophy, 4 with mild atypical hyperplasia, and 2 with highly atypical hyperplasia. 3. Of 9 subjects showing atrophic chronic gastritis, 5 revealed no change, and 4 became chronic gastritis. 4. Of 22 subjects who revealed mild atypical hyperplasia, 17 resolved, 4 showed no change, and 1 advanced to highly atypical hyperplasia. 5. One person with highly atypical hyperplasia reverted to mild atypical hyperplasia. 6. Of 5 subjects with early gastric cardiac cancer without any treatment, 1 became advanced cancer, 1 still stayed in early stage, and 3 turned to atypical hyperplasia. CONCLUSION: 1. The development of early cancer of gastric cardia would proceed through the stages of chronic gastritis, glandular atrophy, and atypical hyperplasia. 2. The early cancer and pre-cancerous lesion of gastric cardia is reversible, though possessing malignant possibility.

Adult↗
PubMed2004

Polymorphisms of XRCC1 and risk of esophageal and gastric cardia cancer.

BACKGROUND: Linxian, a rural county in North Central China, has among the highest rates of esophageal squamous cell carcinoma and gastric cardia adenocarcinoma in the world. In a nested case-cohort study that originated from two cancer prevention trials in Linxian, we examined the relationship between these cancers and two polymorphisms in the DNA repair gene XRCC1. METHODS: We conducted a case-cohort study among individuals in the cohort who were alive and cancer free in 1991, and had blood samples for DNA extraction. Real time Taqman analyses were conducted to genotype incident cancer cases (n = 221, 131 esophageal and 90 gastric cardia cancer cases) that developed through May 1996, and on an age- and sex-matched reference cohort (n = 454). We used Cox proportional hazard models to estimate relative risks (RR) and 95% confidence intervals (95% CI). RESULTS: We observed no association between the variant genotype in XRCC1 Arg194Trp (codon 194 arganine to tryptophan substitution) and esophageal or gastric cardia cancer. However, carrying at least one copy of the variant allele in XRCC1 Arg399Gln (codon 399 arganine to glutamine substitution) was associated with reduced risk of gastric cardia cancer (RR: 0.60, 95% CI: 0.37-0.97) and the combined category esophageal/gastric cancer (RR: 0.67, 95% CI: 0.48-0.95). In combined polymorphisms analyses, we observed a significant reduction in risk of combined esophageal/gastric cancer among individuals that had both the XRCC1 Arg194Trp and Arg399Gln variant genotyopes (RR: 0.47, 95% CI: 0.26-0.84). CONCLUSIONS: Our results suggest that the XRCC1 Arg399Gln variant genotype is associated with reduced risk of upper GI cancer and that individuals with both XRCC1 variant genotypes are also at significantly reduced risk of upper GI cancer in this high-risk Chinese population.

Asian People↗
PubMed2001

Molecular cytogenetic evaluation of gastric cardia adenocarcinoma and precursor lesions.

Analyses of cancer incidence data in the United States and Western Europe revealed steadily rising rates over the past decades of adenocarcinomas of the esophagus and gastric cardia. Genetic information on gastric cardia adenocarcinoma and its preneoplasias is sparse. We have used comparative genomic hybridization to obtain a genome-wide overview of 20 archival gastric cardia adenocarcinomas and 10 adjacent preneoplastic lesions (4 metaplasias, 1 low-grade dysplasia, 5 high-grade dysplasias). Multiple genetic alterations were discriminated in all adenocarcinomas. Frequent loss (> or =25% of all tumors) was detected, in decreasing order of frequency, on 5q, 18q, 4q, 3p, 9p, 2q, 11q, 14q, 21q, 4p, 9q, 16q, 1p, and 8p. Frequent gain (> or =25% of all tumors) was disclosed, in decreasing order of frequency, on 20q, 7p, 8q, 1q, 7q, 20p, 17q, 13q, Xp, 6q, 8p, 19q, 5p, 6p, and Xq. Loss of the Y chromosome was found in 60% of male cases. High level amplification was frequently (>10% of all tumors) detected on 7q21, 8p22, 12p11.2, 17q12-q21, and 19q13.1-q13.2. The precursor lesions showed multiple aberrations in all high-grade dysplasias, whereas few genetic changes were discerned in LGD and metaplasias. High level amplifications were also found in high-grade dysplasias, ie, on 7q21, 8p22, and 17q12-q21. Moreover, the percentage of aberrations was not significantly different for invasive carcinomas or high-grade dysplasias. Approximately 70% of the precursor aberrations were also present in the adjacent carcinoma. Minimal overlapping regions in the preneoplasias included loss on 18q12-q21 and gains on 8q23 and 17q12-q21, suggesting involvement of genes residing in these regions. In conclusion, we have (i) created a map of genetic alterations in gastric cardia adenocarcinomas and (ii) provided evidence for the presence of a metaplasia-dysplasia-carcinoma sequence in this poorly understood type of cancer.

Adenocarcinoma↗
PubMed1998

Surgical management of adenocarcinoma of the cardia.

BACKGROUND: The incidence of adenocarcinoma of the cardia is increasing. The surgical management remains controversial. The present study reviews our experience with surgically resected adenocarcinoma of the cardia. METHODS: A retrospective review of 153 cases of surgically resected adenocarcinoma of the cardia was performed. Preoperative radiotherapy was used in 31 patients. The surgical approach, morbidity, mortality, impact of preoperative radiotherapy, and survival were determined. RESULTS: The type of resection performed was a transhiatal esophagogastrectomy in 78%, a transthoracic esophagogastrectomy in 21%, and a transabdominal esophagogastrectomy in 1%. The in-hospital mortality rate was 4%. The frequency of complications was not associated with the use of preoperative radiotherapy or surgical approach. The 1-year (61%), 2-year (38%), 3-year (23%), and 5-year (16%) survival were not affected by the use of preoperative radiotherapy or surgical approach. Survival was significantly associated with stage and the presence of lymph node metastasis. CONCLUSIONS: Adenocarcinoma of the cardia is associated with a poor long-term prognosis. The long-term survival does not appear to be affected by the use of preoperative radiotherapy or by surgical approach.

Adenocarcinoma↗
PubMed2002

Results of surgical treatment of adenocarcinoma of the gastric cardia.

BACKGROUND: Comparison among different studies regarding adenocarcinoma of the cardia has been difficult since the Siewert classification was introduced. This study analyzed the experience of a single institution in the treatment of gastric cardia cancer with the aim of assessing principal prognostic factors and long-term outcome. METHODS: The results of 96 patients who underwent resection with curative intent for gastric cardia cancer at the First Division of General Surgery, University of Verona, from January 1988 to February 2000, were analyzed statistically with special reference to Siewert type. RESULTS: Despite a high number of curative resections (85.4%), the 5-year survival rate was poor (24%) for all Siewert types (p = 0.8), and for early tumors (51%) also. Chance of cure was limited to pN0 and pN1 patients. Multivariate analysis showed that microscopic or macroscopic residual tumor and pN-positive categories had a significantly higher risk of death (risk ratio, 2.18 and 2.68, respectively) and the pN2 and pN3 category had the most negative prognostic factor (risk ratio, 7.6). CONCLUSIONS: The long-term prognosis for gastric cardia cancer remains poor and is independent of Siewert type, with cure limited to pN0 and pN1 patients.

Adenocarcinoma↗
PubMed2004

Accuracy of linear-array EUS for preoperative staging of gastric cardia cancer.

BACKGROUND: The feasibility of a less invasive operation for early stage cancer of the gastric cardia with a low frequency of lymph node involvement has been previously demonstrated by us. Precise discrimination among mucosal, submucosal, and advanced cancers, as well as accurate evaluation of the proximal tumor margin are prerequisites for such stage-specific treatment. EUS is considered the most reliable staging modality. However, there is no EUS study specifically of cardia cancer. METHODS: Forty-five patients with gastric cardia cancer who underwent gastrectomy with at least first-tier lymphadenectomy were retrospectively analyzed. The results of preoperative linear-array echoendoscopy (7.5 MHz) with respect to cancer depth, lymph node involvement, and esophageal invasion were compared with postoperative histopathologic findings. RESULTS: Overall diagnostic accuracy for depth of invasion was 71%. Sensitivity for T1, T2, and T3 lesions was 100%, 31% and 75%, respectively. Overstaging of T2 cancers was the main diagnostic error. Mucosal (pT1-m) and submucosal (pT1-sm) cancers were correctly discriminated in 81% of patients. Diagnostic accuracy for lymph node involvement was 80%. EUS had positive and negative predictive values of 90% and 80%, respectively, for esophageal invasion. CONCLUSIONS: For gastric cardia cancer, the linear-array echoendoscope yielded satisfactory results with respect to depth of invasion, lymph node involvement, and esophageal invasion evaluation. The information obtained is useful to the performance of stage-specific treatment.

Adult↗
PubMed1997

Esophagogastrectomy for carcinoma of the esophagus and cardia: a comparison of findings and results after standard resection in three consecutive eight-year intervals with improved staging criteria.

OBJECTIVE: A review of findings and results after standard resection for carcinoma of the esophagus and cardia without neoadjuvant therapy was done to provide a basis for comparison with current reports of radical resection and neoadjuvant therapy. METHODS: A 24-year experience on one surgical service with 454 operations for carcinoma of the esophagus and cardia was reviewed. A comparison of findings and results in three consecutive 8-year intervals was analyzed, and new staging criteria were developed and compared with those currently favored by the American Joint Committee on Cancer. RESULTS: From January 1, 1970, to January 1, 1994, 454 patients with carcinoma of the esophagus or cardia underwent operation, of whom 408 (90%) had esophagogastrectomy with a 30-day mortality rate of 2.5% and an additional hospital mortality rate of 1.2%. Of the 121 complications (30.7%), 71 (18%) were major and 50 (12.7%) were minor. Cardiovascular complications predominated. The overall 5-year survival was 24.7%, with a 33.7% survival after complete resections in the most recent interval under study. Palliation of dysphagia was achieved in nearly 80% of patients who survived the operation. During the three intervals under review, resectability, mortality, and complication rates remained constant. The percentages of left thoracotomies and transhiatal resections increased, and there was a decrease in thoracoabdominal incisions. The percentages of patients with Barrett's esophagus and stage 0 and I tumors increased. The percentage of complete resections (R0) increased, whereas that for resections with residual microscopic tumor (R1) decreased, and there was no change in the percentage of patients with residual gross tumor after resection (R2). Modified WNM staging criteria are proposed that provide better prognostic stratification of the disease than those currently favored by The American Joint Committee on Cancer. CONCLUSIONS: Standard esophagogastrectomy is applicable in 90% of patients with operable carcinoma of the esophagus or cardia, with consistently low mortality and morbidity rates and satisfactory palliation of dysphagia. The 5-year survival (24.7% overall) remains suboptimal, but the current figure for complete resections (33.7%) is encouraging. There is a need for revision of the current American Joint Committee on Cancer staging criteria.

Adenocarcinoma↗