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Esophagectomy vs Gastrectomy for Early Stage Adenocarcinoma of the Gastroesophageal Junction: What is the Optimal Oncologic Surgical Treatment?

      Guidelines for the management of gastroesophageal junction (GEJ) adenocarcinoma recommend esophagectomy as the preferred surgical treatment. Gastrectomy has been proposed as an equivalent procedure. This study aims to compare the oncologic outcomes of these operations. The National Cancer Database was queried for patients with clinical T1N0M0 (all sizes) and T2N0M0 (≤2cm) GEJ adenocarcinoma from 2004-2017. Patients treated with surgery-only were included and were stratified by surgical treatment. Propensity-score matching (PSM) was used to create a balanced cohort. Multivariable logistic regression was performed to evaluate for factors predictive of treatment. Kaplan-Meier (KM) and Cox proportional hazards models were used to compare overall survival (OS). 2,446 patients were identified. 75.1% received esophagectomy, while 24.9% were treated with gastrectomy. Patients at high volume facilities were more likely to undergo esophagectomy (OR 1.750, P < 0.001). Factors associated with lower likelihood of undergoing esophagectomy included age ≥75 years (OR 0.588, P = 0.001), female sex (OR 0.706, P = 0.003), and non-White race (OR 0.430, P < 0.001), compared to age ≤50 years, male, and White race, respectively. In the unmatched cohort, gastrectomy was associated with a higher rate of positive margins (4.1% vs 2.3%, P = 0.022). PSM yielded 591 pairs. In the matched cohort, patients treated with esophagectomy had improved 5-year OS compared to gastrectomy (70.6% vs 66.5%, P = 0.030). Multivariable analysis showed improved OS in patients treated with esophagectomy compared to gastrectomy (HR 0.767, P = 0.010). Esophagectomy is associatedwith improved survival and a lower incidence of positive margins in patients with early-stage GEJ adenocarcinoma when compared to gastrectomy.

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      References

        • Zhang Y
        Epidemiology of esophageal cancer.
        World J Gastroenterol. 2013; 19: 5598-5606
        • Siewert JR
        • Stein HJ
        Classification of adenocarcinoma of the oesophagogastric junction.
        Br J Surg. 1998; 85: 1457-1459
        • National Comprehensive Cancer Network
        Esophageal and Esophagogastric Junction Cancers (Version 1.2022).
        2022
        • Haverkamp L
        • Seesing MF
        • Ruurda JP
        • et al.
        Worldwide trends in surgical techniques in the treatment of esophageal and gastroesophageal junction cancer.
        Dis Esophagus. 2017; 30: 1-7
        • Johansson J
        • Djerf P
        • Oberg S
        • et al.
        Two different surgical approaches in the treatment of adenocarcinoma at the gastroesophageal junction.
        World J Surg. 2008; 32: 1013-1020
        • Reeh M
        • Mina S
        • Bockhorn M
        • et al.
        Staging and outcome depending on surgical treatment in adenocarcinomas of the oesophagogastric junction.
        British Journal of Surgery. 2012; 99: 1406-1414
        • Siewert JR
        • Feith M
        • Werner M
        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
        • Fuchs H
        • Hölscher AH
        • Leers J
        • et al.
        Long-term quality of life after surgery for adenocarcinoma of the esophagogastric junction: extended gastrectomy or transthoracic esophagectomy?.
        Gastric Cancer. 2016; 19: 312-317
        • Jezerskyte E
        • Saadeh LM
        • Hagens ERC
        • et al.
        Long-term quality of life after total gastrectomy versus ivor lewis esophagectomy.
        World J Surg. 2020; 44: 838-848
        • Mariette C
        • Castel B
        • Toursel H
        Surgical management of and long-term survival after adenocarcinoma of the cardia.
        Br J Surg. 2002; 89: 1156-1163
        • Bilimoria KY
        • Stewart AK
        • Winchester DP
        • et al.
        The National Cancer Data Base: A powerful initiative to improve cancer care in the United States.
        Ann Surg Oncol. 2008; 15: 683-690
        • Zhou Y
        • Tian M
        • Güngör C
        Neoadjuvant radiotherapy for locoregional Siewert type II gastroesophageal junction adenocarcinoma: A propensity scores matching analysis.
        PLoS One. 2021; 16e0251555
        • Zhu K
        • Xu Y
        • Fu J
        • et al.
        Proximal gastrectomy versus total gastrectomy for siewert Type II adenocarcinoma of the esophagogastric junction: A comprehensive analysis of data from the seer registry.
        Dis Markers. 2019; 9637972
        • Deyo RA
        • Cherkin DC
        • Ciol MA
        Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.
        J Clin Epidemiol. 1992; 45: 613-619
        • Austin PC
        Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples.
        Stat Med. 2009; 28: 3083-3107
        • McMurry TL
        • Hu Y
        • Blackstone EH
        Propensity scores: Methods, considerations, and applications in the journal of thoracic and cardiovascular surgery.
        J Thorac Cardiovasc Surg. 2015; 150: 14-19
        • Haverkamp L
        • Ruurda JP
        • van Leeuwen MS
        Systematic review of the surgical strategies of adenocarcinomas of the gastroesophageal junction.
        Surg Oncol. 2014; 23: 222-228
        • Jezerskyte E
        • Mertens AC
        • van Dieren S
        • et al.
        Gastrectomy versus esophagectomy for gastroesophageal junction tumors: Short- and long-term outcomes from the Dutch Upper GI Cancer Audit.
        Ann Surg. 2020;
        • Leers JM
        • Knepper L
        • van der Veen A
        • et al.
        The CARDIA-trial protocol: A multinational, prospective, randomized, clinical trial comparing transthoracic esophagectomy with transhiatal extended gastrectomy in adenocarcinoma of the gastroesophageal junction (GEJ) type II.
        BMC Cancer. 2020; 20: 781
        • Hagens ERC
        • van Berge Henegouwen MI
        • van Sandick JW
        • et al.
        Distribution of lymph node metastases in esophageal carcinoma [TIGER study]: Study protocol of a multinational observational study.
        BMC Cancer. 2019; 19: 662
        • Ito H
        • Clancy TE
        • Osteen RT
        • et al.
        Adenocarcinoma of the gastric cardia: What is the optimal surgical approach?.
        J Am Coll Surg. 2004; 199: 880-886
        • Javidfar J
        • Speicher PJ
        • Hartwig MG
        Impact of positive margins on survival in patients undergoing esophagogastrectomy for esophageal cancer.
        Ann Thorac Surg. 2016; 101: 1060-1067
        • Adhia AH
        • Feinglass JM
        • Schlick CJR
        Hospital volume predicts guideline-concordant care in Stage III esophageal cancer.
        Ann Thorac Surg. 2021;
        • Pickens A
        Racial disparities in esophageal cancer.
        Thorac Surg Clin. 2022; 32: 57-65
        • Asan U
        • Agency BCC
        • et al.
        • Cancer Genome Atlas Research N, Analysis Working Group
        Integrated genomic characterization of oesophageal carcinoma.
        Nature. 2017; 541: 169-175
        • Hayakawa Y
        • Sethi N
        • Sepulveda AR
        • et al.
        Oesophageal adenocarcinoma and gastric cancer: should we mind the gap?.
        Nature Reviews Cancer. 2016; 16: 305-318

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