Surgery for Cardioesophageal Junction Cancer (Garlock Type)

This surgery was performed almost 3 years ago. Patient with T4aN2M0 is still disease free. Surgical treatment of cardioesophageal cancer is not very simple. This tumor is not too much sensitive to chemotherapy and results of treatment are not satisfied in our days despite of good quality of surgery. This patient was operated by our team in early spring 2013 on the background of dysphagia and bleeding . We received T4aN2Mo pathological stage. Patient has the conglomerate of metastatic lymphnodes following celiac trunk (N2 area by Japaneese classification). Despite of biologically palliative situation for this case, we performed Proximal gastrectomy with lower part of oesphagus resection with D2 lymphadenectomy + lower mediastinal lymphnodes dissection and received clear resection margins. 6 courses of FOLFOX were performed in adjuvant mode. It seems that our treatment form was not too modern as MAGIC trial recommends (neoajuvant chemo+surgery+adjuvant chemo). BUT WE HAVE ALMOST 3-YEAR CANCER-FREE (!!!) PATIENT It is the case when if we do not perform D2 it would not be cancer free exactly because N2 area nodes were in progress. Also it was not simple technically because metastatic nodes were encircling arterial vessel and adhesion with celiac trunk. Also 3 other nodes were metastatic. I know that for Siewert II type tumor some authors prefer total esophagogastrectomy. I suppose that proximal resection (or gastrectomy) with partial esophageal resection not esophagectomy) is not bad choice for them. I did not have local recurrence according to my memory. Radical boundaries can be really achieved if the patient is well evaluated preoperatively. This short report shows that biologically all cases seems to be very individual and unfortunately we can not know the individual prognosis. If gastric cancer is locally advanced (T4a-b) but it is N0 5-year survival is very real to be achieved. Despite of my only 10 year experience in gastric surgery I can not remember 3- year disease free patient with such extensive tumor with N2 ! Its very rare I think. But it happens! I want you to understand my position very clearly. I perform such quality of lymphadenectomy to all of my patients. But it does not work as I wish it to work. Best trials show 10-15% improvement in treatment results. So, its not a panacea. But if this procedure can be performed safely it must be performed. I emphasize again, that lymphadenectomy and clean resection margins were not the crucial key for his 3 year disease free result! . Definitely , this very good result is determinated by individual qualities of his tumor. And a little bit by good surgeons ! If the tumor gives us the opportunity to treat it we must do it using all the possibilities even very aggressive surgery. But nowadays we do not always know how to define these patients. Video by dr Ilya Gotsadze.