Fast track — ArticlesLeft thoracoabdominal approach versus abdominal-transhiatal approach for gastric cancer of the cardia or subcardia: a randomised controlled trial
Introduction
By contrast with the notable decrease in the incidence of distal gastric cancer, frequency of adenocarcinoma in the oesophagogastric junction has increased, especially in developed countries.1, 2, 3 The Siewert classification for these tumours is now widely accepted.4 Studies of adjuvant treatment for gastric cancer with chemotherapy or chemoradiotherapy have included tumours in the oesophagogastric junction.5, 6 However, no evidence suggests that oesophagogastric-junction tumours can be treated in the same way as gastric cancers; if thoracotomy is mandatory for oesophagogastric-junction tumours, they should not be included in studies on the treatment of gastric cancers. So far, only one prospective randomised controlled trial7 has been undertaken to compare the effects of surgical treatments in Siewert type 1 and 2 tumours in the oesophagogastric junction. Although the trial was slightly underpowered, it suggested that extended transthoracic resection resulted in better survival than a restricted transhiatal resection. However, a systematic review8 comparing surgical treatments for lower oesophageal carcinoma showed a higher morbidity for transthoracic resection than for transhiatal resection, but with similar survival.
In eastern Asian countries, including Japan, most tumours in the oesophagogastric junction are of Siewert type 2 and 3.9 The occurrence of lower mediastinal lymph-node metastasis from type 2 and 3 tumours is reported to be 10–40%.10, 11, 12, 13, 14, 15, 16 Some researchers10, 11 claim that a thoracotomy is needed to thoroughly dissect the mediastinal nodes and to obtain a safe surgical margin, although mediastinal lymph-node metastasis is an indicator of poor prognosis. Other studies12, 13 recommend the use of a transhiatal resection, because patients with mediastinal-lymph-node metastasis have poor prognosis even if a more extensive procedure was done. Advances in circular stapling devices have enabled surgeons to make safe intrathoracic or mediastinal anastomosis without thoracotomy.
In 1995, the Gastric Cancer Surgical Study Group of the Japan Clinical Oncology Group (GCSSG/JCOG) initiated a multicentre, randomised controlled trial with the aim to compare the effects of the left thoracoabdominal approach (LTA) with the abdominal-transhiatal approach (TH) on patients with cancer of the cardia or subcardia (JCOG 9502).
Section snippets
Patients
Our study was designed as a multicentre, prospective, randomised phase III trial. The study protocol was approved by the clinical trial review committee of JCOG and the institutional review boards of all 27 participating Japanese hospitals before the initiation of the study, and all patients provided written informed consent. Eligibility criteria included: histologically proven adenocarcinoma of the gastric body or cardia with oesophageal invasion of 3 cm or less, tumour status T2–4, age 75
Results
Between July, 1995, and December, 2003, 82 patients were randomly assigned to TH and 85 to LTA (figure 1). One patient was ineligible because of a second lesion in the distal stomach. Ten cases of protocol violation were reported. Two patients underwent adjuvant chemotherapy after surgery because of positive peritoneal lavage cytology. Nine patients did not complete the lymph-node dissection required in the protocol, one of whom underwent adjuvant chemotherapy.
The first interim analysis was
Discussion
This study shows that LTA does not provide a survival advantage compared with TH in the treatment of curable gastric cancers with an oesophageal invasion of 3 cm or less, which corresponds mainly to tumours classified as Siewert type 2 or 3. The study was stopped after the interim analysis, because patients assigned LTA were unlikely to have an improved overall survival compared with those assigned TH for Siewert type 2 or 3 tumours.
Some controversy exists about whether type 2 tumours should be
References (30)
- et al.
Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis
Ann Thorac Surg
(2001) - et al.
Adenocarcinoma of the gastroesophageal junction in Japan: relevance of Siewert's classification applied to 177 cases resected at a single institution
J Am Coll Surg
(1999) - et al.
The pattern of metastatic lymph node dissemination from adenocarcinoma of the esophagogastric junction
Surgery
(2001) - et al.
Randomised controlled trial comparing transfusion of leucocyte-depleted or buffy-coat-depleted blood in surgery for colorectal cancer
Lancet
(1994) - et al.
Rising incidence of adenocarcinoma of the esophagus and gastric cardia
JAMA
(1991) - et al.
Esophageal and gastric carcinoma in Norway 1958–1992: incidence time trend variability according to morphological subtypes and organ subtypes
Int J Cancer
(1997) Cancer at the gastro-oesophageal junction (epidemiology)
- et al.
Carcinoma of the gastroesophageal junction—classification, pathology and extent of resection
Dis Esoph
(1996) - et al.
Paclitaxel-based chemoradiotherapy in localized gastric carcinoma: degree of pathologic response and not clinical parameters dictated patient outcome
J Clin Oncol
(2005) - et al.
Perioperative chemotherapy in operable gastric cancer and lower esophageal cancer: final results of a randomised controlled trial (the MAGIC trial, ISRCTN 93793971)
J Clin Oncol
(2005)
Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus
N Engl J Med
Total gastrectomy with left oblique abdominothoracic approach for gastric cancer involving the esophagus
Arch Surg
Lymph node metastasis and lymphadenectomy for carcinoma in the gastric cardia: clinical experience
Int Surg
Surgical treatment for gastric cancer: the Japanese approach
Semin Oncol
Lymph node metastasis and surgical management of gastric cancer invading the esophagus
Hepatogastroenterology
Cited by (397)
Minimally invasive surgery for esophagogastric junction cancer with Leriche’s syndrome-induced ischemic enteritis in the rectum: A case report
2024, Clinical Journal of Gastroenterology