title: Adenocarcinoma of the gastric cardia: what is the optimal surgical approach?
abstract: BACKGROUND
  The incidence of adenocarcinoma of the gastric cardia is rising in Western countries. This study evaluates prognostic factors associated with surgical management of this cancer.
  
  
  METHODS
  Medical records of consecutive patients with gastric cardial cancer treated by surgical resection from 1991 through 2001 were reviewed. Survival was analyzed using the Kaplan-Meier method. Prognostic factors were evaluated using log-rank test and Cox regression. Mean followup period was 34 months.
  
  
  RESULTS
  Eighty-two patients met study inclusion criteria. Median patient age was 65 years (range 86 to 22). Fifty-nine (72%) patients had type II tumors and 23 (28%) patients had type III tumors, according to the Siewert classification for gastroesophageal junction tumors. Twenty-seven (33%) patients underwent total esophagectomy, 24 (29%) patients underwent extended gastrectomy with thoracotomy, and 31 (38%) patients underwent extended gastrectomy without thoracotomy. Overall postoperative 5-year survival rate was 30%. On multivariate analysis, patient age 65 years and older, absence of lymph node metastasis, and R0 resection emerged as factors independently associated with improved postoperative survival. Frequency with which proximal resection margin was infiltrated with cancer was a function of gross margin length and T stage. Proximal gross margin length of at least 6 cm was required to achieve a microscopically negative proximal margin for T3 and T4 cancers.
  
  
  CONCLUSIONS
  Achieving R0 resection should be the goal of surgical therapy for the gastric cardial cancer. The surgical approach should be tailored to individual patients to achieve this goal.
authors.affiliation: Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
authors.forename: Hiromichi
authors.initials: H
authors.lastname: Ito
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Clancy
authors.forename: Robert T
authors.initials: RT
authors.lastname: Osteen
authors.forename: Richard S
authors.initials: RS
authors.lastname: Swanson
authors.forename: Raphael
authors.initials: R
authors.lastname: Bueno
authors.forename: David J
authors.initials: DJ
authors.lastname: Sugarbaker
authors.forename: Stanley W
authors.initials: SW
authors.lastname: Ashley
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Zinner
authors.forename: Edward E
authors.initials: EE
authors.lastname: Whang
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000601:surgery*; D000368:Aged; D002299:Cardia; D016629:Esophagectomy; D005260:Female; D005743:Gastrectomy; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D011379:Prognosis; D013274:Stomach Neoplasms / Q000401:mortality / Q000601:surgery*; D016019:Survival Analysis