Lymphadenectomy for adenocarcinoma of the gastroesophageal junction (GEJ): Impact of adequate staging on outcome

Introduction: Adequate staging of gastric cancer requires examination of at least 15 lymph nodes. Most resected patients are inadequately staged potentially confounding the interpretation of clinical data. The aim of this study was to determine whether adequate staging revealed different prognostic factors or improved survival compared with patients with < 15 nodes examined after R0 resection for GEJ cancer. Methods: A prospectively maintained database identified 366 patients with Siewert types II and III adenocarcinoma of the GEJ who underwent R0 resection without neoadjuvant therapy at a single institution. Patients were grouped into adequately (>= 15 nodes examined) or inadequately staged (< 15 nodes examined). Median follow up was 51 months. Results: From 1985 through 2003, 250/366 (68%) patients were adequately staged and 116/366 (32%) were inadequately staged. There was no difference in operative mortality between adequately staged (5.2%) and inadequately staged patients (4.3%, P = NS). Adequately staged patients had more positive lymph nodes (median 2) compared with inadequately staged patients (median 1, P < 0.01). Multivariable analysis of adequately staged patients found the number of positive lymph nodes, T stage, and lymphovascular invasion to be independent prognostic factors for overall survival (OS). For inadequately staged patients only the number of positive lymph nodes and T stage were independent prognostic factors. Adequate staging was an independent prognostic factor for patients with advanced (T >= 2 Nany) tumors. For T1 tumors adequate staging was not associated with improved survival. Conclusions: Patients with GEJ cancer should undergo adequate lymphadenectomy to permit examination of >= 15 lymph nodes allowing the accurate identification of prognostic variables. Removal of >= 15 lymph nodes is associated with more accurate survival estimates for patients with advanced disease.