The incidence of adenocarcinoma of the gastroesophageal junction (AGEJ) is rapidly increasing in the western world. Early diagnosis is usually difficult, curative chances are very low with advanced stages, and radical treatments are required to obtain a better survival. Several conditions including Barrett's disease, type of surgery, and oncological treatment have been suggested as prognostic factors in the 5-year survival. We analyze here our surgical experience with emphasis on the impact of these factors on the long-term follow up.
Methods: 153 patients (median age 59 years, interquartile range: 46-72 years) were operated between 1991 and 2006. Long-term follow up (27 months, range 1-175 months) was available in 145 patients (94%). According to Siewert's classification for AGEJ, 40 patients were type I, 88 were type II, and 25 were type III. Transabdominal esophagectomy with proximal gastrectomy and extended lymphadenectomy (“over D1”) was the procedure of choice for patients with AGEJ type I and II. In patients with AGEJ type III, total gastrectomy with distal esophagectomy and D2 modified lymphadenectomy was performed. 26 patients underwent adyuvant chemotherapy with 5-FU, Leucovorine and radiotherapy with 4500 cGy (protocol 0116). Overall survival was correlated with tumor location, underlying Barrett's mucosa, lymph node metastasis, radical resection (R0), adyuvant therapy and age. Kaplan-Meier survival test and Cox regression were used to identify independent prognostic factors.
Results: Overall 5-year survival was 33%. R0 resection was achieved in 58% of cases and these patients had a better survival (50%) than those where R0 could not be obtained (<10%, p<0,001). Lymphatic spreading and stage were independent prognostic factors in multivariate analysis (p<0,001). Underlying Barrett's mucosa and age under 60 were also associated with better prognosis (p=0,01 and 0,06 respectively). Finally, those patients that underwent adyuvant therapy had a better outcome than those who did not (p<0,01). Overall mortality was 6% and the main complication was anastomotic leakage (20%).
Discussion: Surgical treatment of AGEJ is the current therapy of choice with curative intent. The extent of resection and type of surgery are relevant factors that affect the long-term survival. Early diagnosis is essential since lymphatic metastases are strongly associated with a poorer survival. Association of surgical therapy and adyuvant oncological treatment seems to be beneficial but stronger evidence is needed. The association of Barrett's mucosa with a better outcome suggests the relevance of the surveillance programs when intestinal metaplasia is diagnosed.