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Ca Cardia “Out of the Black Box”

Ca Cardia “Out of the Black Box”. Dr Daniel Ng NDH / AHNH. Case Illustration. M/64 Ex-smoker Painless progressive dysphagia x 2-3 months Weight loss+ Physical examination unremarkable. Case Illustration. Ca Cardia. Before 1987 Adenocarcinoma of cardia Bad surgical result

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Ca Cardia “Out of the Black Box”

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  1. Ca Cardia“Out of the Black Box” Dr Daniel Ng NDH / AHNH

  2. Case Illustration • M/64 Ex-smoker • Painless progressive dysphagia x 2-3 months • Weight loss+ • Physical examination unremarkable

  3. Case Illustration

  4. Ca Cardia Before 1987 • Adenocarcinoma of cardia • Bad surgical result • Difficult discussion No clear definition

  5. Ca Cardia 1987 • J Rudiger Siewert • AEG classification

  6. Anatomical Cardia

  7. AEG Classification Type I Distal esophagus cancer within 5cm from cardia Type II Directly located at endoscopic cardia, 1cm above and below this border Type III Subcardial cancer within 5cm from cardia J Am Coll Surg Vol.205, No.4S, Oct 2007

  8. Epidemiology J Am Coll Surg Vol.205, No.4S, Oct 2007

  9. Epidemiology J Am Coll Surg Vol.205, No.4S, Oct 2007

  10. Type II Tumour • Barrett’s dysplasia vs Ca stomach • Intestinal metaplasia • Globlet cells in 100 specimens • Only 28% • 72% can be understood as gastric cancer J Am Coll Surg Vol.205, No.4S, Oct 2007

  11. Epidemiology • Incidence increasing • AEG I • Western countries • AEG II / III • Asian countries Journal of Surgical Oncology 2005;92:160-168

  12. Lymphatic Metastasis • AEG I • Less frequent lymph vessel invasion • Mediastinal lymph nodes • AEG II and III • Lower mediastinum • Coeliac trunk • Direct retroperitoneal metastasis J Surg Oncol 2005;13:139-146

  13. Prognosis J Am Coll Surg Vol.205, No.4S, Oct 2007

  14. Surgical Strategies • R0 resection • Independent prognostic factor • Complete resection of primary tumour • Complete resection of lymphatic drainage World J Gastroenterol 2006 November 7;12(41):6608-6613

  15. Type I Tumour • Complete removal of the precancerous Barrett’s esophagus • Esophagectomy • Mediastinal lymph node dissection World J Gastroenterol 2006 November 7;12(41):6608-6613

  16. Transhiatal vs Transthoracic N Engl J Med, Vol.347, No.21

  17. Transhiatal vs Transthoracic N Engl J Med, Vol.347, No.21

  18. Type II / III Tumours • Total gastrectomy • Lymph node dissection • Intra-abdominal • Mediastinal World J Gastroenterol 2006 November 7;12(41):6608-6613

  19. Type II / III Tumours

  20. Left Thoracoabdominal vs Transhiatal Lancet Oncol 2006;7:644-51

  21. Left Thoracoabdominal vs Transhiatal Lancet Oncol 2006;7:644-51

  22. Case Illustration • What surgical approach would you adopt?

  23. Future Discussions • Neoadjuvant therapy • Molecular characterization • Sentinel lymph node biopsy • PET hand device

  24. Thank You Question and Answer

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