Carcinoma of the gastroesophageal junction - classification, pathology and extent of resection

From the epidemiologic and therapeutic point of view, tumours of the gastroesophageal junction should be classified either as adenocarcinoma of the distal esophagus (Type I), true carcinoma of the cardia (Type II) or subcardial carcinoma (Type III). This classification can be performed easily by summarizing the information available from contrast radiography, endoscopy, and intraoperative findings and allows comparison of data between various centers and facilitates the choice of surgical therapy. Complete removal of the primary tumor and its lymphatic drainage has to be the primary goal of any surgical approach to adenocarcinoma of the gastroesophageal junction. In patients with tumors located in the distal esophagus (Type I) this can be achieved by a radical two-field transmediastinal esophagectomy and proximal gastric resection with en bloc removal of the lymphatic drainage in the lower posterior mediastinum and along the celiac axis. This approach is associated with lower morbidity and provides longterm survival comparable with the more radical transthoracic en bloc resection. In contrast, patients with true adenocarcinoma of the cardia (Type II) or subcardial tumors (Type III) should be treated as having gastric cancer. Total gastrectomy with transhiatal resection of the distal esophagus and lymphadenectomy in the lower posterior mediastinum, along the celiac axis and at the splenic hilum and left renal vein should be adopted as standard procedure for these patients. The morbidity associated with left pancreatic resection can be avoided by a pancreas preserving splenectomy without compromising the extent of lymphadenectomy.