Audit of Gastroesophageal Junction Tumors

Field: Medicine (Health Sciences)

INTRODUCTION:
Gastroesophageal junction tumors are considered to be those tumors whose epicenter lies within the 5 cm range (totally-10cm) on either side of anatomic gastro-esophageal junction. A cancer in the stomach with its epicenter 5cm beyond the gastroesophageal junction aborally, and also those within 5 cm but not encroaching the gastroesophageal junction, are considered as proximal gastric cancer. Endoscopically the gastro esophageal junction is defined as the place where distal end of esophageal longitudinal vessels meet the proximal ends of gastric mucosal folds. Histological confirmation of the esophagus is needed by identifying the distal end of esophageal squamous mucosa, its multilayered epithelium and the deep esophageal sub mucosal glands or ducts. Identification of the proximal end of gastric oxyntic mucosa is also useful. In hiatus hernia the squamocolumnar junction is not a reliable marker of gastro esophageal junction. The most common tumors to arise in this area is the adenocarcinoma and the squamous cell carcinoma. This is a heterogeneous group comprising both, esophageal and gastric carcinoma and the true junctional type tumors.
AIM OF THE STUDY:
To study the epidemiology, clinical presentation, age group affected, sex ratio, resectability, type of surgical procedure, margin status, pathological type of tumors, complications occurring post surgery including death in the patients presenting to our department (Surgical Gastroenterology and proctology) during the study period from August 2010 to February 2013.
MATERIALS AND METHODS
All the patients presenting to our department (surgical gastroenterology) at Rajiv Gandhi Government General hospital from august 2010 to February2013 with gastroesophageal junction tumors or those presenting with dysphagia and regurgitation and on evaluation by upper gastrointestinal endoscopy and imaging studies, found to have gastroesophageal junction tumors and distant metastasis ruled out by a CECT were studied.
Age, gender, chief complaints, co-morbid illness, nature of diet, personal habits like smoking and alcohol consumption were noted.
Complete physical examination findings of the patients like presence or absence of jaundice, pallor, pedal edema and bilateral supraclavicular lymphadenopathy if any were noted. Abdominal examination was done to look for any palpable mass, hepatomegaly and free fluid. Rectal examination was done in all patients to rule out pelvic deposits. Lab investigations including a complete hemogram, liver function tests and renal function tests were done.
Inclusion criteria:
All patients with gastroesophageal junction tumors who have resectable disease by imaging and in whom surgery is planned.
Exclusion criteria:
Patients with carcinoma lower third of esophagus not encroaching the anatomic gastro esophageal junction, Carcinoma esophagus with epicenter beyond 5cm on the oral side of the anatomic gastroesophageal junction. Carcinoma arising in the cardia of stomach but not involving gastroesophageal junction and those with epicenter 5cm beyond GEJ aborally. Carcinoma of GEJ with distant metastasis identified preoperatively.
RESULTS:
Of all the patients with gastroesophageal junction tumors, those patients who were found to have distant metastasis or locally advanced disease by imaging were referred to palliative chemotherapy, chemoradiotherapy or palliative supportive care and were excluded from the study. Also patients with proximal gastric cancer within 5cm of gastroesophageal junction but not involving the gastroesophageal junction and those with esophageal carcinoma 5cm proximal to gastroesophageal junction and those not involving the gastroesophageal junction were excluded from the study. 81 patients who had resectable disease on imaging in whom surgery was planned were studied.
CONCLUSION:
GE junction cancers represent an emerging health problem. The incidence of adenocarcinoma in this part of the world is on the rise similar to the west probably due to changing life styles and adaptation of western culture. The AJCC 7th edition staging manual for esophageal carcinoma includes the gastroesophageal junction and harmonizes the esophageal and gastric cancer staging system. Surgical resection for cure remains the mainstay of treatment at present. Tailoring the surgical approach in accordance with the histological type, and siewert type gives the optimal outcome to the patient.