Left thoracoabdominal approach for adenocarcinoma of the esophagogastric junction.

BACKGROUND/AIMS: To evaluate usefulness of esophagogastrectomy via left thoracoabdominal (LT) approach for adenocarcinoma of the esophagogastric junction (AEG), the results of surgery stratified by Siewert's classification, were analyzed retrospectively. METHODOLOGY: The tumor diameter, distance of the proximal tumor border from the esophagogastric junction, and length of the esophagus in the resected specimens of consecutive 171 AEG patients were measured. The surgical approach was classified as total esophagectomy (TE), esophagogastrectomy via LT, or transhiatal/abdominal (HA) approach. RESULTS: Sixteen patients underwent TE, 71 had LT, and 84 had HA. Overall survival of the TE and LT groups was significantly lower than that of the HA group. The difference was seen between LT and HA for type II T3 tumors, but the tumor diameter in LT was significantly larger than that in HA. The approach could not be determined by Siewert's classification, but by distance of proximal tumor border from the junction. The tumors with distance over 5cm might be indicated for the TE approach; 5-3cm, the LT; within 3cm, the HA. The percentage of patients in whom the LT approach is indicated might be only 19%. CONCLUSION: Left thoracoabdominal esophagogastrectomy may be valid for some AEG.

HER2-positive gastric cancer with paraaortic nodal metastasis successfully resected after chemotherapy with trastuzumab: a case report.

We report on a case of human epidermal growth factor receptor-2 (HER2)-positive gastric cancer with paraaortic lymph node metastasis. The patient (a 49-year-old female) received chemotherapy (capecitabine and cisplatin) plus molecular-targeted therapy (trastuzumab), followed by curative resection. Interestingly, the resected residual cancer was HER2-negative. Intra-tumor heterogeneity hinders molecular-targeted therapy for gastric cancer. In our case, continued trastuzumab administration presented few benefits since the residual cancer cells were HER2-negative. No consensus exists regarding the appropriate therapy for unresectable gastric cancers whose non-curative factors disappear following trastuzumab chemotherapy. The principal options are treatment with surgery or continued chemotherapy with trastuzumab. In our case, resection treated the HER2-negative residual cancer effectively, resulting in curative therapy. This is the first case of positive-to-negative change in the HER2 expression of residual tumor cells following trastuzumab therapy. It suggests that, due to intra-tumor heterogeneity, the risks presented by remnant HER2-negative cancer cells persist despite trastuzumab therapy.

Detection of bone marrow micrometastasis in gastric cancer patients by immunomagnetic separation.

BACKGROUND: Micrometastasis to the bone marrow can predict widespread disease and a poor prognosis of cancer patients after surgery. The purpose of this study was to evaluate the clinical significance of detecting micrometastasis in the bone marrow of gastric cancer patients. METHODS: Bone marrow and peripheral blood samples were obtained from 53 gastric cancer patients at the time of surgery. These samples were enriched by immunomagnetic separation and immunostained with an anti-cytokeratin antibody. Expression of vascular endothelial growth factor and erbB-2/HER2 was examined in the primary tumors. RESULTS: Cytokeratin-positive cancer cells were observed in the bone marrow of 16 (30%) of 53 patients. Among them, two patients also had cancer cells in the peripheral blood. The presence of bone marrow micrometastasis was correlated with the depth of invasion and lymph node metastasis but was not associated with peritoneal dissemination. Detection of bone marrow micrometastasis was not correlated with vascular endothelial growth factor or HER2 expression in the primary tumors. Four patients with micrometastasis had recurrence in the liver or lungs, but this did not occur in patients without micrometastasis. CONCLUSIONS: Detection of cancer cells in the bone marrow might be an indicator of postoperative hematogenous metastasis in gastric cancer patients.