Primary Motility  Disorders of the  Esophagus
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 Barrett's
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OESO©2015
 
Volume: Barrett's Esophagus
Chapter: Adenocarcinomas
 

What is the compared value of tumor stage and lymph node invasion in cancers of the cardia?

H. Udagawa, Y. Kinoshita, M. Ueno, K. Tsutsumi, T. Nakamura, T. Iidsuka, H. Akiyama (Tokyo)

Cancer of the gastric cardia poses many problems for surgeons because of its unique location. In Western countries, cancer of the cardia is attracting attention because its incidence is thought to be rapidly increasing. In this study, we retrospectively reviewed our data on this disease to clarify the significance of the T and N categories of the TNM system with respect to prognosis and preoperative decision-making.

Material and methods

The subjects were 68 consecutive patients with adenocarcinoma of the cardia (Siewert type II [1]) who underwent surgical resection at Toranomon Hospital from 1990 to 1999 without preoperative adjuvant treatment. The relationship between the pT, pN, or pM categories and survival was investigated. The actual locations of lymph node metastasis were investigated in a special group of patients and the pattern of recurrence was also investigated.

Results

The relationship between the pT and pN (including pM1-lym, pM1 due to extra-regional lymph node involvement) categories is shown in Table I, and the metastasis rates to various lymph node groups are listed in Table II. Disease-specific survival curves stratified by pT and pN status are shown in Figures 1 and 2, respectively, Also, disease-specific survival curves stratified by the number of metastatic lymph nodes (regional and extraregional) are shown in Figure 3. The clinical features of three pM1-lym patients who survived more than 2 years are described in Table III. Recurrence was experienced by 11 patients. Among these 11 patients, hematogenous metastasis was found in 9 patients, lymph node metastasis in 3,

Table I. Relationship between pT and pN.

Table II. Rate of metastasis to different lymph node groups.

Figure 1. Disease-specific survival curves stratified by pT.

Figure 2. Disease-specific survival curves stratified by pN (Refer to comment 1. of Table I).

Figure 3. Disease-specific survival curves stratified by the number of metastatic lymph nodes regardless of regional or extraregional development.

Table III. Clinical features of patients who survived for more than 2 years with TNM extraregional lymph node metastasis.

and peritoneal dissemination in 2. Among the 3 patients with lymph node recurrence, 2 developed cervical lymph node metastasis and 2 had abdominal paraaortic node recurrence.

Discussion

As shown in Table I, pT1a tumors, which are limited to the mucosa (epithelium, lamina propria mucosae, and muscularis mucosae), were not associated with lymph node metastasis in our series. Although the number of cases is too small to conclude that T1a tumors are never associated with lymph node metastases (a large-scale study has given different results), limited procedures such as endoscopic mucosal resection (EMR) or laparoscopic local resection have a good chance of achieving a cure. T1b tumors, which invade the submucosa, have about a 15% risk of lymph node involvement, but it is limited to the regional lymph nodes of the TNM system and the number of metastatic nodes is relatively small. This means that a good prognosis can be expected after complete removal of the primary tumor and thorough dissection of the regional nodes. Once a tumor invades the proper muscle layer (T2), the number of metastatic nodes increases and the extraregional lymph node involvement may also occur. At the same time, no metastasis was seen to the infra-pyloric nodes or the right gastroepiploic nodes (Table II), implying that even when extraregional node involvement occurs, proximal gastrectomy is still possible for Siewert type II tumors.

As shown in Figures 1 and 2, pT and pN are both meaningful prognostic factors. When pM1-lym is categorized as pN4 and considered together with pN0~pN3 (Figure 2), an interesting inversion of the survival curves between pN2 and pN4 occurs. When survival curves are drawn according to a simpler grading of the number of metastatic nodes, this shows a better correlation with the prognosis (Figure 3). This tells us that even when a patient has a few extraregional lymph node metastases, a fair prognosis can still be achieved if such nodes are completely cleared (Table III). Accordingly, the total number of metastatic lymph nodes is a better prognostic indicator than a crude regional versus extraregional classification.

Although pT and pN are correlated with each other, as shown in Table I, they essentially express different aspects of tumor spread. It should be noted that pT1a has an absolutely good prognosis, while pN0 does not. Also, complete cure is very difficult in pN2-3 patients with 7 or more lymph nodes involved, while pT4 patients have a much higher chance of cure. The lesson from this is that efforts to remove the primary tumor (pT) and lymph node metastases (pN) are equally important, and a good result is only possible when both are achieved. In this sense, preoperative staging is extremely important to determine the proper approach and the extent of lymph node dissection. However, preoperative diagnosis of lymph node metastasis is not completely accurate. Therefore, we decide the approach and the extent of lymph node dissection according to the cT category and the tumor location [2].

As a general rule for cT1b or deeper tumors, we perform upper median laparotomy and abdominal lymphadenectomy when the tumor is limited to the stomach, and adopt a left thoracoabdominal approach for the clearance of lower mediastinal nodes when the tumor invades the abdominal esophagus. When the upper margin of the tumor is located in the thoracic esophagus, we perform right thoracotomy to allow complete mediastinal lymph node clearance. We think that the low rate of lymph node recurrence supports the validity of our criteria for selection of the surgical approach.

References

1. Siewert JR, Stein HJ. Carcinoma of the cardia: carcinoma of the gastroesophageal junction; classification, pathology, and extent of resection. Dis Esophagus 1996;9:173-182.

2. Udagawa H, Tsutsumi K, Kinoshita Y, Nakamura T, Ueno M, Kajiyama Y, Tsurumaru M. Therapeutic strategy for adenocarcinoma in Barrett's esophagus: a study based on a comparison with squamous cell carcinoma. J Japan Surg Soc 1999;100(3):261-264

3. Japanese Gastric Cancer Association. Japanese Classification of Gastric Carcinoma,13th ed. Tokyo: Kanehara, 1999:7-9.


Publication date: August 2003 OESO©2015