What is the approach and management for a gastric lesion near the gastroesophageal (GE) junction suspected to be gastric cancer, specifically regarding surgery?

Management of Gastric Lesions Near the Gastroesophageal Junction

For gastric lesions near the gastroesophageal (GE) junction suspected to be gastric cancer, a multidisciplinary team approach with appropriate staging followed by surgical resection is the recommended management strategy, with the specific surgical approach determined by the Siewert classification and extent of disease.

Diagnostic Approach

• Initial evaluation must include:

  • Upper GI endoscopy with biopsy for histological confirmation 1
  • Chest and abdominal CT scan with oral and IV contrast 1
  • Endoscopic ultrasound (EUS) for T and N staging 1
  • PET-CT to identify otherwise undetected metastases 1

• Additional staging procedures:

  • Laparoscopy with peritoneal washings for locally advanced (T3/T4) tumors to rule out peritoneal metastases 1
  • Biopsy confirmation of any suspected metastatic disease 1

Classification and Staging

• Siewert Classification is essential for determining surgical approach 1, 2:

  • Type I: Distal esophageal adenocarcinoma
  • Type II: True cardia/GE junction adenocarcinoma
  • Type III: Proximal stomach/subcardial adenocarcinoma

• Clinical staging should follow the TNM system with AJCC stage grouping 1

Surgical Management

1. For early-stage disease (Tis, T1a):

   • Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) may be considered for superficial lesions 1, 2
   • Curative endoscopic resection criteria: intramucosal carcinoma or submucosal invasion <500 μm; tumor <3 cm; negative margins; no lymphovascular invasion 1

2. For resectable locally advanced disease:

   • Siewert Type I tumors: Transthoracic esophagectomy with two-field lymphadenectomy 1
   • Siewert Type II tumors: Esophagogastrectomy with adequate lymphadenectomy 1
   • Siewert Type III tumors: Total gastrectomy with D2 lymphadenectomy 1

3. Extent of lymphadenectomy:

   • Lower mediastinal and suprapancreatic lymph node stations should be dissected for tumors with 2-4 cm esophageal invasion 1, 2
   • At least 15 lymph nodes should be removed for adequate nodal staging 1
   • D2 lymphadenectomy recommended for gastric component 1

4. Surgical approach:

   • Minimally invasive techniques (thoracoscopic/robotic esophagectomy) are recommended when a transthoracic approach is indicated 1, 2
   • Adequate longitudinal and radial resection margins must be achieved 1

Multimodal Treatment

1. For locally advanced resectable disease:

   • Perioperative chemotherapy: FLOT regimen (docetaxel, oxaliplatin, leucovorin, fluorouracil) is preferred for smaller tumors 2
   • Preoperative chemoradiotherapy: Recommended for larger tumors with proximal extension (CROSS regimen: weekly carboplatin and paclitaxel with 50.4 Gy radiation) 2

2. For unresectable locally advanced disease:

   • Definitive chemoradiotherapy with 5-FU/cisplatin and 50.4 Gy radiation 2

3. For metastatic disease:

   • Palliative chemotherapy based on performance status 1
   • HER2 testing should be performed to guide targeted therapy options 1, 2
   • Consider surgical resection after chemotherapy in carefully selected patients with oligo-metastases 1

Pitfalls and Caveats

• Avoid routine or prophylactic splenectomy unless directly involved by tumor 1
• Distal pancreas should only be removed when there is direct invasion 1
• Palliative gastric resection should not be performed unless the patient is symptomatic 1
• Higher radiation doses (>50.4 Gy) should be avoided as they increase toxicity without improving outcomes 2
• Preoperative chemoradiotherapy may increase postoperative mortality and should be carefully considered 1

Follow-up

• Regular surveillance with history and physical examination every 3-6 months for 1-2 years, then every 6-12 months for 3-5 years 1
• Imaging and upper GI endoscopy as clinically indicated 1
• Nutritional counseling and support 1, 2

By following this structured approach to the management of gastric lesions near the GE junction, optimal oncological outcomes can be achieved while minimizing treatment-related morbidity.