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Ann Thorac Surg 2002;73:1040
© 2002 The Society of Thoracic Surgeons

Invited commentary

^a Chirurgische Klinik und Poliklinik, Klinikum Rechts der Isar der Technische Universität Munich, Ismaningerstrasse 22, D-81675 Munich, Germany e-mail: stein@nt1.chir.med.tu-muenchen.de

Because of the borderline location of adenocarcinoma of the esophagogastric junction (AEG tumors) between the esophagus and stomach there are still controversies regarding the optimal surgical approach. For more than 15 years we have classified these tumors purely based on the anatomic/topographic location of the tumor center or the tumor mass into adenocarcinoma originating from the distal esophagus (AEG type I tumors), true adenocarcinoma of the gastric cardia (AEG type II tumors) and subcardial gastric cancer infiltrating the esophagogastric junction from below (AEG type III tumors) [1]. Subsequent evaluation of this classification system has confirmed that it not only provides a good tool to select the surgical approach but also allows discrimination of tumors which etiologically and biologically appear to be markedly different [2]. At a consensus conference of the International Society for Diseases of the Esophagus and the International Gastric Cancer Association most experts therefore agreed that this classification system should become the basis for further studies and comparison of treatment results between various centers [3]. The AEG classification system has subsequently been successfully applied by various groups worldwide.

The report by de Manzoni and associates adds to these studies. The authors selected different surgical approaches for type I and type III tumors. It is therefore not surprising that the classification according to tumor location was not an independent prognostic factor after resection. Rather, these data support the value of the classification system. Similar results can be achieved for rather different tumor entities if the surgical approach is chosen accordingly.

Interestingly, the survival rates after complete resection in the presented study are markedly worse as compared to our experience [2]. A closer look at patient details reveals, that advanced T-categories and N-categories predominated in the study by de Manzoni and associates, while this was is not the case in our series. We prefer to submit such patients to neoadjuvant treatment protocols [2].

While today there are no major controversies in the surgical therapy of patients with type I and type III tumors, the management of patients with type II tumors is still debated. This is also reflected in the data presented by de Manzoni and colleagues. They used three different approaches for type II tumors. Our experience indicates that a R0 resection can be achieved in the vast majority of these tumors by a total gastrectomy with transabdominal resection of the distal esophagus after widely splitting the anterior esophageal hiatus, ie, the same approach as for type III tumors [2]. Nevertheless, the pattern of lymphatic spread, the presence of intestinal metaplasia and several other biologic and molecular parameters indicate that a substantial subgroup of the type II tumors may indeed be more similar to type I tumors than to type III tumors. The relation of type II tumors to distal esophageal or proximal gastric cancer therefore remains controversial. Since the AEG classification system, suggested by our group, provides a clear definition of these tumors, further analysis and comparison of data between various centers offers the chance for an objective discussion of these issues.

References

1. Siewert J.R., Stein H.J. Carcinoma of the gastroesophageal junction: classification, pathology and extent of resection. Dis Esophagus 1986;9:173-182.
2. Siewert J.R., Feith M., Werner M., Stein H.J. Adenocarcinoma of the esophagogastric junction. Results of surgical therapy based on anatomical/topographic classification in 1,002 consecutive patients. Ann Surg 2000;232:353-361.[Medline]
3. Siewert J.R., Stein H.J. Classification of carcinoma of the oesophagogastric junction. Br J Surg 1998;85:1457-1459.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Stein, H. J. Articles by Siewert, J. R. Search for Related Content PubMed Articles by Stein, H. J. Articles by Siewert, J. R. Related Collections Esophagus - cancer Related Article