Elsevier

Seminars in Oncology

Volume 31, Issue 4, August 2004, Pages 513-529
Seminars in Oncology

Staging and preoperative evaluation of upper gastrointestinal malignancies

https://doi.org/10.1053/j.seminoncol.2004.04.014Get rights and content

Abstract

Esophageal and gastric cancers are distinct carcinomas of the upper gastrointestinal tract, although the distinction between them becomes less clear at the gastroesophageal junction (GEJ). Increasingly accurate staging is possible based on newer radiographic and surgical techniques such as positron emission tomography (PET), laparoscopy and thoracoscopy, laparoscopic ultrasound, and endoscopic ultrasound (EUS). For both cancer types, tumor classification is determined by depth of penetration of the primary tumor into the gastric or esophageal wall. For esophageal cancer, primary tumor anatomic position-upper, mid, and lower esophagus-is used to define the local nodal basin. Metastases in nodes outside the local basin are considered to be distant (M) rather than regional (N). In gastric cancer, the region of nodal metastasis has been abandoned in favor of the number of lymph nodes containing metastasis, which predicts outcome more accurately—patients with more than 15 positive lymph nodes have an outcome comparable to those with M disease. Increasing consideration is being given to the subclassification of tumors near the GEJ into types based on anatomical position, although this staging scheme (“Adenocarcinoma of the EsophagoGastric junction” or AEG type) has not yet been universally adopted. We review the current pathologic staging systems for esophageal and gastric cancers, the clinical staging approaches for these diseases, and the controversy surrounding classification of tumors of the GEJ.

Section snippets

Pathologic staging

The current (sixth edition) American Joint Committee on Cancer (AJCC) TNM staging system for esophageal cancer is outlined in Table 1. 3 This system accounts for different patterns of lymphatic spread of esophageal cancer based on the anatomic position of the tumor within the esophagus, which reflects treatment differences for each described anatomic region. For these purposes, the AJCC describes four anatomic regions of the esophagus as follows.

The cervical esophagus begins anatomically at the

Conclusion

Staging esophageal and gastric cancer accurately is essential to guide therapy and to minimize the morbidity associated with poorly selected treatment. Optimal pretreatment radiological staging for esophageal cancer includes spiral chest and abdominal CT and EUS. For patients with T2 or greater lesions on EUS, and tumors located at or above the carina, bronchoscopy is indicated to evaluate for invasion of the tracheobronchial tree; if the tumor is at the GEJ, laparoscopy should be considered to

Acknowledgements

The authors thank Melissa Burkett for editorial assistance, and Storm Weaver and Vivian Garcia for their secretarial assistance in preparation of the manuscript.

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