GE junction carcinoma staging

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torero

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Anyone know if there is a consensus on the TNM classification of GE junction adenocarcinomas? Particularly the ones unassociated with Barretts and located right at the junction. Let’s say it’s involving the adventitia/subserosa, and there are 8 positive nodes. Do you say T3 N1 (esophageal primary), or do you say T2N2 (gastric primary). Also, will this result in a different treatment? Thanks in advance.

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Anyone know if there is a consensus on the TNM classification of GE junction adenocarcinomas? Particularly the ones unassociated with Barretts and located right at the junction. Let's say it's involving the adventitia/subserosa, and there are 8 positive nodes. Do you say T3 N1 (esophageal primary), or do you say T2N2 (gastric primary). Also, will this result in a different treatment? Thanks in advance.
I'm having a trouble following the thrust of the question because the adventitia of the esophagus and the subserosa of the stomach are not analogous.
The adventitia and serosa are the outermost layers of the esophagus and stomach, respectively. If the tumor invades either one, it's a T3 tumor. If the tumor falls short of reaching this outermost layer, then the tumor only is classified as invading the muscularis propria (in the case of the esophageal primary) or as invading the muscularis propria or subserosa (in the case of the gastric primary); hence, T2. In either case, T4 signifies invasion into adjacent structures...doesn't apply here.

In any case, I would consider your situation to represent an esophageal rather than a gastric primary. But yeah, it's tricky since I assume you're talking about the anatomic GE junction rather than the squamocolumnar junction (oh wait, you said not associated with Barrett's...nevermind). But let's go through the following mental exercise:

The actual stage (based on how the T, N, and M classifications) determines treatment. So a T3 N1 M0 esophageal primary is a Stage III cancer. A T2 N2 M0 gastric primary is a Stage III cancer as well. The prognosis in either case is not good. Treatment probably doesn't differ by all that much. Patient probably gets chemo and radiation therapy.
 
To my knowledge Barrett's cancers are treated like esophageal cancers and staged thusly. Clinicians are going to stage it and treat it however they want to though. Like Bierstiefel said, both stage III.
 
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I'm having a trouble following the thrust of the question because the adventitia of the esophagus and the subserosa of the stomach are not analogous.
The adventitia and serosa are the outermost layers of the esophagus and stomach, respectively. If the tumor invades either one, it's a T3 tumor. If the tumor falls short of reaching this outermost layer, then the tumor only is classified as invading the muscularis propria (in the case of the esophageal primary) or as invading the muscularis propria or subserosa (in the case of the gastric primary); hence, T2. In either case, T4 signifies invasion into adjacent structures...doesn't apply here.

In any case, I would consider your situation to represent an esophageal rather than a gastric primary. But yeah, it's tricky since I assume you're talking about the anatomic GE junction rather than the squamocolumnar junction (oh wait, you said not associated with Barrett's...nevermind). But let's go through the following mental exercise:

The actual stage (based on how the T, N, and M classifications) determines treatment. So a T3 N1 M0 esophageal primary is a Stage III cancer. A T2 N2 M0 gastric primary is a Stage III cancer as well. The prognosis in either case is not good. Treatment probably doesn't differ by all that much. Patient probably gets chemo and radiation therapy.

I see your point, and conceptually it makes sense. However, in practice it’s difficult to apply. Many of the GE junction adenocarcinomas I see invade through the muscularis propria and into the connective tissue adjacent to it. That connective tissue, in the esophagus, corresponds to the adventitia (pT3). The same connective tissue would be the subserosa in the stomach (pT2). The actual serosa is, of course, only the mesothelial lining. In order to classify a gastric adenoca as T3 you would need actual penetration of the serosa, or at least some sort of mesothelial inflammatory reaction or hyperplasia with tumor close to it. That same scenario in the colon would be a T4.

I just think that the guys who sit on the AJCC would make my life easier if they do a separate classification for GE junction carcinomas, just like they separate the anal from colorectal carcinomas.

But in the end, I agree with you and Yaah, in that both are Stage III, and the treatment will probably depend more on performance status and other clinical stuff.
 
According to the 2000 GI WHO blue book (which is quoting the TNM): "carcinomas that are mainly on the gastric side should be classified according to the TNM for gastric tumors, while those predominantly on the oesophageal side should be staged according to the TNM for oesophageal carcinomas" (p. 34).

The problem arises because they don't define "mainly" or "predominantly". Other authors have quoted 50% above or below the GEJ as the cutoff for esophageal or gastric staging respectively. Alternatively, you can use whatever will upstage the patient (to be on the safe side?).

At MSKCC, they submit sections separately from esophageal and gastric sides so that if the tumor is in the esophageal adventitia it is a T3, but if it stays within gastric subserosa (not on the gastric serosal surface) it is only a T2. The problem being that in the esophagus there is no distinction between the different layers of adventitia (as in the stomach where the serosal lining is an additional "barrier" in the subeserosal extension of tumor).

I guess the comment about both being stage III makes sense, but we, as pathologists, should try to adhere to histologic staging classifications if we want to be able to use and compare data across the board for prognostic purposes.
 
Radiate that mofo! (I'm on rad onc right now).
 
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