Surgical therapy for adenocarcinoma of the cardia: modalities of recurrence and extension of resection

In order to define the optimal extent of resection for cancer of the cardia , we considered 116 patients operated upon with five different surgical tec hniques. The procedures were: transabdominal total gastrectomy associated w ith distal esophagectomy in 38 patients; transabdominal total gastrectomy a nd left thoracotomic esophageal resection at the inferior pulmonary vein le vel in 26 patients; transabdominal total gastrectomy and right thoracotomic esophageal resection at the azygos vein level in 27 patients; transabdomin al total gastrectomy and transhiatal lower third esophagectomy in 18 patien ts; transhiatal total esophagectomy and upper third gastrectomy with cervic al esophago-gastroplasty in seven patients. Grading, staging, neoplastic ly mphangitis, satellite intramural metastases, infiltration of the resection margin, site of recurrence, and survival were analyzed. N+ was the single i ndependent prognostic factor for survival. A poorly differentiated grading was related to T (P = 0.0009), N (P = 0.001), satellite growth (P = 0.05), and infiltration of the resection margin (P = 0.0001). Recurrence was local in 26% and distant in 74% of patients. The modalities of recurrence were n ot related to the aggressiveness parameters and the surgical technique. Inf iltration of the esophageal resection margin was related to the type of ope ration (P = 0.005) and survival (P = 0.02), but it was not related to the s ite of recurrence. Transabdominal total gastrectomy and the right thoracoto mic esophageal resection procedure achieved free margins and control of the lymph nodal metastatic spread. Transabdominal total gastrectomy and right thoracotomic esophageal resection at the azygos vein level provides a radic al oncologic resection, particularly in poorly differentiated tumors. Howev er, surgery alone cannot cure the majority of adenocarcinomas of the cardia .