title: Tumor Biology: Is It Time to Redefine Unresectability? An Extraordinary Case of Gastroesophageal Junctional Adenocarcinoma.
abstract: BACKGROUND
  Disease assessment based on measurements of size and anatomic involvement have historically been central to surgical strategy. We propose this to be an outdated concept, which should be replaced by a deeper understanding of tumor biology and careful treatment planning. Report of case: A 34-year-old male was diagnosed with a Siewert Type 3 locally advanced cancer of the gastroesophageal junction, involving the coeliac axis and the superior mesenteric artery (SMA). He was treated with neoadjuvant chemotherapy, followed by chemoradiation, and then proceeded to surgery, at which time the tumor was judged unresectable. After extensive planning, a further surgery was attempted - an extended gastrectomy with distal esophagectomy, left hepatectomy, and splenectomy were performed. Additionally, the coeliac axis and the SMA were excised, followed by reconstruction of the hepatic artery and the SMA with grafts. Adjuvant chemotherapy was administered, and the patient is recurrence-free after five years follow-up.
  
  
  CONCLUSIONS
  This case highlights the importance of the distinction between resectability and operability, and that patient treatment should be tailored and individualised based on the response to treatment, comorbidities, and underlying tumor biology.
authors.affiliation: London Oncology Clinic, Guy's and St. Thomas' NHS Foundation Trust.
authors.forename: Andy
authors.initials: A
authors.lastname: Gaya
authors.affiliation: Department of HPB Surgery, Royal London Hospital.
authors.forename: Alex
authors.initials: A
authors.lastname: Giakoustidis
authors.affiliation: Department of Surgery, Royal Free Hospital.
authors.forename: Mark
authors.initials: M
authors.lastname: Winslet
authors.affiliation: Department of Academic Surgery, The Royal Marsden Hospital.
authors.forename: Satvinder
authors.initials: S
authors.lastname: Mudan
keywords: appleby procedure; chemotherapy; esophageal cancer; gastric cancer; immunotherapy; radiotherapy; surgical resection; surgical technique
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