Conduta terapêutica atual no adenocarcinoma da cárdia e da junção esofagogástrica

Correia, Mauro Monteiro; Brennan, Murray Frederic

doi:10.1590/S0100-69911998000100012

Resumo

Adenocarcinomas of the cardia and gastroesophageal junction are peculiar entities with three different origins, which differ somewhat from other adenocarcinomas of the stomach in their clinical presentation and pathogenesis, and have a poorer prognosis. In this article the authors reviewed definitions, incidence and epidemiology, etiologic factors, genetic implications, clinical presentation, diagnosis, staging and treatment, with emphasis on the surgical approach, discussing the current management of these cancers. The prognostic factors related specifically to the cardia cancers are: esophageal invasion greater than 3cm, microscopic residual tumor and wall penetration (>T2). Preoperative workup should include computed tomography, and endoscopic ultrasonography and laparoscopy when available. Preoperative recognition of T3/ T4/N2 lesions should indicate inclusion in neo-adjuvant protocols whenever possible. The authors present the results of 46 resected cases of adenocarcinomas of the cardia and GE junction of the Instituto Nacional do Câncer- Brazil (1981-1995). Cure was intended in 29 and palliation in 17 patients. The most common type of resection was total gastrectomy with abdominal esophagectomy (28 cases). Morbidity (major and minor) occurred in 50% of the patients. The main causes were of respiratory origin and fistulas (19.6% each). Death occurred in 44% of the patients with fistula. Postoperative death until the 30th day occurred in 17.24% of the curative cases and in 23.52% of the palliative ones. The median survival time was 68.5 months for stage I, 25 months for stage II, 31 months for stage III and 12.5 months for stage IV diseases. The median survival time was 8 months for palliation and 28.5 months for cure. No long-term survival was obtained with the palliative group, whereas 25% survived five years of more in the curative group. The authors conclude that the surgical approach should be the one the surgeon feels more comfortable with. Complete removal of the disease proved by frozen section, splenectomy and D2 lymphadenectomy should be the standard therapy with curative intent.

Adenocarcinoma; Cardia; Gastroesophageal junction; Neoplasia

ARTIGO DE REVISÃO

Conduta terapêutica atual no adenocarcinoma da cárdia e da junção esofagogástrica

Current management of the adenocarcinoma of the cardia and gastroesophageal junction

Mauro Monteiro Correia, ACBC-RJ^I; Murray Frederic Brennan, HeCBC^II

^IMédico da Seção de Cirurgia Abdômino-Pélvica do Hospital do Câncer. Mestre e Doutor em Cirurgia Abdominal pela Faculdade de Medicina da UFRJ. Estagiário no MSKCC através do Programa do Brazilian Children's Fund (95/96)

^IIChairman of the Gastric and Mixed Tumors Department Memorial Sloan Kettering Cancer Center - NY-NY-USA

^{Endereço para correspondência} Endereço para correspondência: Dr. Mauro Monteiro Correia Instituto Nacional de Câncer Praça Cruz Vermelha, 23 Seção de Abdome - 5° andar 20230-130 - Rio de Janeiro - RJ

ABSTRACT

Adenocarcinomas of the cardia and gastroesophageal junction are peculiar entities with three different origins, which differ somewhat from other adenocarcinomas of the stomach in their clinical presentation and pathogenesis, and have a poorer prognosis. In this article the authors reviewed definitions, incidence and epidemiology, etiologic factors, genetic implications, clinical presentation, diagnosis, staging and treatment, with emphasis on the surgical approach, discussing the current management of these cancers. The prognostic factors related specifically to the cardia cancers are: esophageal invasion greater than 3cm, microscopic residual tumor and wall penetration (>T2). Preoperative workup should include computed tomography, and endoscopic ultrasonography and laparoscopy when available. Preoperative recognition of T3/ T4/N2 lesions should indicate inclusion in neo-adjuvant protocols whenever possible. The authors present the results of 46 resected cases of adenocarcinomas of the cardia and GE junction of the Instituto Nacional do Câncer- Brazil (1981-1995). Cure was intended in 29 and palliation in 17 patients. The most common type of resection was total gastrectomy with abdominal esophagectomy (28 cases). Morbidity (major and minor) occurred in 50% of the patients. The main causes were of respiratory origin and fistulas (19.6% each). Death occurred in 44% of the patients with fistula. Postoperative death until the 30th day occurred in 17.24% of the curative cases and in 23.52% of the palliative ones. The median survival time was 68.5 months for stage I, 25 months for stage II, 31 months for stage III and 12.5 months for stage IV diseases. The median survival time was 8 months for palliation and 28.5 months for cure. No long-term survival was obtained with the palliative group, whereas 25% survived five years of more in the curative group. The authors conclude that the surgical approach should be the one the surgeon feels more comfortable with. Complete removal of the disease proved by frozen section, splenectomy and D2 lymphadenectomy should be the standard therapy with curative intent.

Key words: Adenocarcinoma; Cardia; Gastroesophageal junction; Neoplasia.

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Full text available only in PDF format.

REFERÊNCIAS

1. Jakl RJ, Ifiholic J, Koller R, et al. Prognostic factors in adenocarcinoma of the cardia. Am J Surg 1995;169:3-19.

2. Seitz JF. Alternatives au traitement chirurgical des adenocarcinomes de l'oesophage et du cardia. Gastroenterol Clin Biol 1994;18:D 67- D70.

3. Johnson P, Belluco C, Masood S, et al. Preoperative factors of prognostic significance in gastric cancer. J Nat Med Assoc 1991; 87(6): 423-426.

4. Nanus DM, Kelsen DP, Niedzwiecki D, et al. Flow cytometry as a predictive indicator in patients with erable gastric cancer. J Clin Oncol 1989;7(8):I.105-1.112.

5. Paraf F. Le cancer du cardia est-il un cancer de l'oesophage ou un cancer de l'estomac? Ann Pathol 1994;14(5):303 -306.

6. UICC- União Internacional Contra o Câncer. TNM Classificação dos Tumores Malignos. Ministério da Saúde - Brasília - 4a ed. 1989.

7. Smith JW, Brennan NW. Surgical treatment of gastric cancer. Proximal, mid and distal stomach. Surg Clin North Am 1992; 72 (2): 381-399.

8. Longmire WP. A current view of gastric cancer in the US. Editorial. Ann Surg 1993;218(5) :579-582.

9. Shiu ME, Moore E, Sanders M, et al. Influence of the extent of resection on survival after curative treatment of gastric carcinoma. A retrospective Multivariate Analysis. Arch Surg 1987; 122:1.347-1.351.

10. Staley CA. "Gastric Carcinoma". In The M.D. Anderson Surgica/ Onc%gy Handbook ed by Berger DH, Feig BW and Fuhnnan GM. Little Brown and Co, Boston - 1st ed 1995, ppI20-141.

11. Inoue M, Tajima K, Hirose K, et al. Life-style and subsite of gastric cancer- Joint effect of smoking and drinking habits. /nt 1 Cancer 1994;56:494-499.

12. Fein R, Kelsen DP, Geller N, et al. Adenocarcinoma ofthe esophagus and gastroesophageal junction- Prognostic factors and results of therapy. Cancer 1985;56:2.512-2.518.

13. Chow W, Finkle F, McLaughlin JK, et al. The relation of gastro- esophageal reflux disease and Its treatment to adenocarcinornas ofthe esoPhagus and gastric cardia. lAMA 1995;274(6):474-477.

14. Wang LD, Shi ST, Zhou Q, et al. Changes in p 53 and cyclin DI protejo levels and cell proliferation in different stages of human esophageal and gastric-cardia carcinogenesis. Int J Cancer 1994; 59:514-519.

15. Noguchi Y, Imada T, Matsumoto A. Radical surgery for gastric cancer. A review fo the japanese experience. Cancer 1989;64: 2.053-2.062.

16. Yonemura Y, Tsugawa K, Fonseca L, et al. Lymph node metastasis and surgical management of gastric cancer invading the esophagus. Hepatogastroenteroly 1995;42:37-42.

17. Botet JF, Lightdale CJ, Zauber AG,et al. Preoperative staging of esophageal cancer: comparison of endoscopic US and dynamic CT. Radiology 1991;181(2):419-25.

18. Molloy RG, McCourtney JS, Anderson JR. Laparoscopy in the management of patients with cancer of the gastric cardia and oesophagus. Br J Surg 1995;82:353- 354.

19. Sauvanet A, Berthoux L, Gayet B, et al. Adenocarcinome du cardia: l'etendue de l'exerese gastrique et du curage ganglionnaire Influence-t-elle Ia survie? Ga.ftroentero/ C/in Bio/1995; 19: 244-251.

20. Cherveniakov A, Cherveniakov P. Colon substitution for radical treatment of cardia and lower third esophageal cancer. Eur J Cardiothorac Surg 1993;7:601605.

21. Jougon J, Velly JF, Clerc F, et al. La thoracophrenotornie gauche dans l'exerese des cancers du cardia et du tiers inferieur de l'oesophage. A propos d'une serie de 210 caso Chirurgie 1994-1995;120 (4): 211-215.

22. Sadanaga N, Kuwano H, Watanabe M, et al. Laparoscopy- assisted surgery: a new technique for transhiatal esophageal dissection. Am 1 Surg 1994;168(4):355-7.

23. Papachristou DN, Shiu Nffi. Management by en bloc multiple organ resection of carcinoma of the stornach invading adjacent organs and gastric carcinomas. Patho/ Res Pract 1994;190:1.141-1.148.

24. Gonzalez EM. " Cancer of the cardia: the value of total extended esophago-gastrectomy ". In: P. Sugarbaker (ed): Management (1/ Gastric Cancel: Kluwer-Academic Publishers. Boston 1991, pp 205-246.

25. Tanigawa N, Shimomtsuya T, Horiuchi T, et al. En bloc resection for cancer of the gastric cardia without thoracotomy. J Surg Oncol 1993;54:23-28.

26. Collard JM, Tinton N, Malaise J, et al. Esophageal replacement: gastric tube of whole stornach? Ann Thor Surg 1995;60(2): 261-7.

27. Rahamim J, Chaw CW. Oesophagogastrectomy for carcinoma of the oesophagus and cardia. Br J Surg 1993;80(10):1.305-9.

28. Liedman BL, Bennegard K, Olbe LC, et al. Predictors of postoperative morbidity and mortality after surgery for gastro-oesophageal carcinomas. Eur J Surg 1995;161(3):173-80.

29. Matory YL, Burt M. Esophagogastrectomy: reoperation for complications. J Surg Oncol 1993;54:29-33.

30. Bardini R, Bonavina L, Asolati M, et al. E. single-layered cervical esophageal anastomoses: a prospective study of two suturing techniques. Ann Thorac Surg 1994;58:1.087-90.

31. Posner MC, Pappo I. Neoadjuvant therapy for upper GI tumors. Contemp Oncol 1993;October: 16-24 and 30.

32. Hermans J, Bonenkamp JJ, Boon MC, et al. Adjuvant therapy after curative resection for gastric cancer: meta-analysis of randomized trials. J Clin Oncol 1993;II,(8): 1.441-1.447.

33. Estape J, Grau JJ, Alcobendas F, et al. Mitomycin C as adjuvant treatment to resected gastric cancer. A 10 year follow-up. Ann Surg 1991;3:219-221.

34. Brennan M. Benefit of aggressive multimodality treatment for gastric cancer. Editorial. Ann Surg Oncol 1995;2(4):286-87.

35. Fugimoto S, Kasanuki J, Yoshida S, et al. "New trends in therapy for gastric malignancy". In P. Sugarbaker (ed): Management of gastric Cancer. Kluwer- Academic Publishers. Boston 1991, pp 307-324.

36. Atiq OT, Kelsen DP, Shiu MIH, et al. Phase II trial of postoperative adjuvant intraperitoneal cisplatin and fluorouracil and systemic fluorouracil chemotherapy in patients with resected gastric cancer. J Clin Oncol 1993;1 1(3):425-433.

37. Botet JF, Lightdale CJ, Zauber AG, et al. Preoperative staging of gastric cancer: comparison of endoscopic US and dynamic CT. Radiology 1991;18 I (2):426-32.

38. Peracchia A, Segalin A, Bonavina L. Indicazioni e risultati del trattamento palliativo nei pazienti con carcinoma dell'esofago e del cardias. Ann Ital Chir 1993;LXIV, 6:651-656.

39. Hoffmann W. Lasertherapie und tubusimplantation zur paliativen behandlung des inoperablen osophagus und kardiakarzinoms. Bildgebung 1993;60:157-160.

40. Moreira LS, Coelho RCL, Sadala RU, et al. The use of ethanol infection under endoscopic control to palliate dysphagia caused by esophagogastric cancer. Endoscopy 1994;26:311-314.

Recebido em 26/3/97

Aceito para publicação em 9/10/97

Trabalho realizado no Memorial Sloan Kettering Cancer Center ao ténnino do intercâmbio patrocinado pelo Brazilian Children's Fund- MSKCC e no Hospital de Câncer do Instituto Nacional de Câncer - Rio de Janeiro.

1. Jakl RJ, Ifiholic J, Koller R, et al. Prognostic factors in adenocarcinoma of the cardia. Am J Surg 1995;169:3-19.
2. Seitz JF. Alternatives au traitement chirurgical des adenocarcinomes de l'oesophage et du cardia. Gastroenterol Clin Biol 1994;18:D 67- D70.
3. Johnson P, Belluco C, Masood S, et al. Preoperative factors of prognostic significance in gastric cancer. J Nat Med Assoc 1991; 87(6): 423-426.
⁴
Nanus DM, Kelsen DP, Niedzwiecki D, et al. Flow cytometry as a predictive indicator in patients with erable gastric cancer. J Clin Oncol 1989;7(8):I.105-1.112.
5. Paraf F. Le cancer du cardia est-il un cancer de l'oesophage ou un cancer de l'estomac? Ann Pathol 1994;14(5):303 -306.
⁶
UICC- União Internacional Contra o Câncer. TNM Classificação dos Tumores Malignos. Ministério da Saúde - Brasília - 4a ed. 1989.
7. Smith JW, Brennan NW. Surgical treatment of gastric cancer. Proximal, mid and distal stomach. Surg Clin North Am 1992; 72 (2): 381-399.
8. Longmire WP. A current view of gastric cancer in the US. Editorial. Ann Surg 1993;218(5) :579-582.
9. Shiu ME, Moore E, Sanders M, et al. Influence of the extent of resection on survival after curative treatment of gastric carcinoma. A retrospective Multivariate Analysis. Arch Surg 1987; 122:1.347-1.351.
¹⁰
Staley CA. "Gastric Carcinoma". In The M.D. Anderson Surgica/ Onc%gy Handbook ed by Berger DH, Feig BW and Fuhnnan GM. Little Brown and Co, Boston - 1st ed 1995, ppI20-141.
11. Inoue M, Tajima K, Hirose K, et al. Life-style and subsite of gastric cancer- Joint effect of smoking and drinking habits. /nt 1 Cancer 1994;56:494-499.
12. Fein R, Kelsen DP, Geller N, et al. Adenocarcinoma ofthe esophagus and gastroesophageal junction- Prognostic factors and results of therapy. Cancer 1985;56:2.512-2.518.
13. Chow W, Finkle F, McLaughlin JK, et al. The relation of gastro- esophageal reflux disease and Its treatment to adenocarcinornas ofthe esoPhagus and gastric cardia. lAMA 1995;274(6):474-477.
14. Wang LD, Shi ST, Zhou Q, et al. Changes in p 53 and cyclin DI protejo levels and cell proliferation in different stages of human esophageal and gastric-cardia carcinogenesis. Int J Cancer 1994; 59:514-519.
15. Noguchi Y, Imada T, Matsumoto A. Radical surgery for gastric cancer. A review fo the japanese experience. Cancer 1989;64: 2.053-2.062.
16. Yonemura Y, Tsugawa K, Fonseca L, et al. Lymph node metastasis and surgical management of gastric cancer invading the esophagus. Hepatogastroenteroly 1995;42:37-42.
17. Botet JF, Lightdale CJ, Zauber AG,et al. Preoperative staging of esophageal cancer: comparison of endoscopic US and dynamic CT. Radiology 1991;181(2):419-25.
18. Molloy RG, McCourtney JS, Anderson JR. Laparoscopy in the management of patients with cancer of the gastric cardia and oesophagus. Br J Surg 1995;82:353- 354.
19. Sauvanet A, Berthoux L, Gayet B, et al. Adenocarcinome du cardia: l'etendue de l'exerese gastrique et du curage ganglionnaire Influence-t-elle Ia survie? Ga.ftroentero/ C/in Bio/1995; 19: 244-251.
20. Cherveniakov A, Cherveniakov P. Colon substitution for radical treatment of cardia and lower third esophageal cancer. Eur J Cardiothorac Surg 1993;7:601605.
21. Jougon J, Velly JF, Clerc F, et al. La thoracophrenotornie gauche dans l'exerese des cancers du cardia et du tiers inferieur de l'oesophage. A propos d'une serie de 210 caso Chirurgie 1994-1995;120 (4): 211-215.
22. Sadanaga N, Kuwano H, Watanabe M, et al. Laparoscopy- assisted surgery: a new technique for transhiatal esophageal dissection. Am 1 Surg 1994;168(4):355-7.
23. Papachristou DN, Shiu Nffi. Management by en bloc multiple organ resection of carcinoma of the stornach invading adjacent organs and gastric carcinomas. Patho/ Res Pract 1994;190:1.141-1.148.
²⁴
Gonzalez EM. " Cancer of the cardia: the value of total extended esophago-gastrectomy ". In: P. Sugarbaker (ed): Management (1/ Gastric Cancel: Kluwer-Academic Publishers. Boston 1991, pp 205-246.
25. Tanigawa N, Shimomtsuya T, Horiuchi T, et al. En bloc resection for cancer of the gastric cardia without thoracotomy. J Surg Oncol 1993;54:23-28.
26. Collard JM, Tinton N, Malaise J, et al. Esophageal replacement: gastric tube of whole stornach? Ann Thor Surg 1995;60(2): 261-7.
27. Rahamim J, Chaw CW. Oesophagogastrectomy for carcinoma of the oesophagus and cardia. Br J Surg 1993;80(10):1.305-9.
28. Liedman BL, Bennegard K, Olbe LC, et al. Predictors of postoperative morbidity and mortality after surgery for gastro-oesophageal carcinomas. Eur J Surg 1995;161(3):173-80.
29. Matory YL, Burt M. Esophagogastrectomy: reoperation for complications. J Surg Oncol 1993;54:29-33.
30. Bardini R, Bonavina L, Asolati M, et al. E. single-layered cervical esophageal anastomoses: a prospective study of two suturing techniques. Ann Thorac Surg 1994;58:1.087-90.
31. Posner MC, Pappo I. Neoadjuvant therapy for upper GI tumors. Contemp Oncol 1993;October: 16-24 and 30.
32. Hermans J, Bonenkamp JJ, Boon MC, et al. Adjuvant therapy after curative resection for gastric cancer: meta-analysis of randomized trials. J Clin Oncol 1993;II,(8): 1.441-1.447.
33. Estape J, Grau JJ, Alcobendas F, et al. Mitomycin C as adjuvant treatment to resected gastric cancer. A 10 year follow-up. Ann Surg 1991;3:219-221.
34. Brennan M. Benefit of aggressive multimodality treatment for gastric cancer. Editorial. Ann Surg Oncol 1995;2(4):286-87.
³⁵
Fugimoto S, Kasanuki J, Yoshida S, et al. "New trends in therapy for gastric malignancy". In P. Sugarbaker (ed): Management of gastric Cancer. Kluwer- Academic Publishers. Boston 1991, pp 307-324.
36. Atiq OT, Kelsen DP, Shiu MIH, et al. Phase II trial of postoperative adjuvant intraperitoneal cisplatin and fluorouracil and systemic fluorouracil chemotherapy in patients with resected gastric cancer. J Clin Oncol 1993;1 1(3):425-433.
37. Botet JF, Lightdale CJ, Zauber AG, et al. Preoperative staging of gastric cancer: comparison of endoscopic US and dynamic CT. Radiology 1991;18 I (2):426-32.
38. Peracchia A, Segalin A, Bonavina L. Indicazioni e risultati del trattamento palliativo nei pazienti con carcinoma dell'esofago e del cardias. Ann Ital Chir 1993;LXIV, 6:651-656.
39. Hoffmann W. Lasertherapie und tubusimplantation zur paliativen behandlung des inoperablen osophagus und kardiakarzinoms. Bildgebung 1993;60:157-160.
40. Moreira LS, Coelho RCL, Sadala RU, et al. The use of ethanol infection under endoscopic control to palliate dysphagia caused by esophagogastric cancer. Endoscopy 1994;26:311-314.

Endereço para correspondência:

Dr. Mauro Monteiro Correia

Instituto Nacional de Câncer

Praça Cruz Vermelha, 23

Seção de Abdome - 5° andar

20230-130 - Rio de Janeiro - RJ

Datas de Publicação

Publicação nesta coleção
26 Jul 2010
Data do Fascículo
Fev 1998

Histórico

Aceito
09 Out 1997
Recebido
26 Mar 1997

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Jakl RJ, Ifiholic J, Koller R, et al. Prognostic factors in adenocarcinoma of the cardia. Am J Surg 1995;169:3-19.

[2] 2. Seitz JF. Alternatives au traitement chirurgical des adenocarcinomes de l'oesophage et du cardia. Gastroenterol Clin Biol 1994;18:D 67- D70.

[3] 3. Johnson P, Belluco C, Masood S, et al. Preoperative factors of prognostic significance in gastric cancer. J Nat Med Assoc 1991; 87(6): 423-426.

[4] ⁴
Nanus DM, Kelsen DP, Niedzwiecki D, et al. Flow cytometry as a predictive indicator in patients with erable gastric cancer. J Clin Oncol 1989;7(8):I.105-1.112.

[5] 5. Paraf F. Le cancer du cardia est-il un cancer de l'oesophage ou un cancer de l'estomac? Ann Pathol 1994;14(5):303 -306.

[6] ⁶
UICC- União Internacional Contra o Câncer. TNM Classificação dos Tumores Malignos. Ministério da Saúde - Brasília - 4a ed. 1989.

[7] 7. Smith JW, Brennan NW. Surgical treatment of gastric cancer. Proximal, mid and distal stomach. Surg Clin North Am 1992; 72 (2): 381-399.

[8] 8. Longmire WP. A current view of gastric cancer in the US. Editorial. Ann Surg 1993;218(5) :579-582.

[9] 9. Shiu ME, Moore E, Sanders M, et al. Influence of the extent of resection on survival after curative treatment of gastric carcinoma. A retrospective Multivariate Analysis. Arch Surg 1987; 122:1.347-1.351.

[10] ¹⁰
Staley CA. "Gastric Carcinoma". In The M.D. Anderson Surgica/ Onc%gy Handbook ed by Berger DH, Feig BW and Fuhnnan GM. Little Brown and Co, Boston - 1st ed 1995, ppI20-141.

[11] 11. Inoue M, Tajima K, Hirose K, et al. Life-style and subsite of gastric cancer- Joint effect of smoking and drinking habits. /nt 1 Cancer 1994;56:494-499.

[12] 12. Fein R, Kelsen DP, Geller N, et al. Adenocarcinoma ofthe esophagus and gastroesophageal junction- Prognostic factors and results of therapy. Cancer 1985;56:2.512-2.518.

[13] 13. Chow W, Finkle F, McLaughlin JK, et al. The relation of gastro- esophageal reflux disease and Its treatment to adenocarcinornas ofthe esoPhagus and gastric cardia. lAMA 1995;274(6):474-477.

[14] 14. Wang LD, Shi ST, Zhou Q, et al. Changes in p 53 and cyclin DI protejo levels and cell proliferation in different stages of human esophageal and gastric-cardia carcinogenesis. Int J Cancer 1994; 59:514-519.

[15] 15. Noguchi Y, Imada T, Matsumoto A. Radical surgery for gastric cancer. A review fo the japanese experience. Cancer 1989;64: 2.053-2.062.

[16] 16. Yonemura Y, Tsugawa K, Fonseca L, et al. Lymph node metastasis and surgical management of gastric cancer invading the esophagus. Hepatogastroenteroly 1995;42:37-42.

[17] 17. Botet JF, Lightdale CJ, Zauber AG,et al. Preoperative staging of esophageal cancer: comparison of endoscopic US and dynamic CT. Radiology 1991;181(2):419-25.

[18] 18. Molloy RG, McCourtney JS, Anderson JR. Laparoscopy in the management of patients with cancer of the gastric cardia and oesophagus. Br J Surg 1995;82:353- 354.

[19] 19. Sauvanet A, Berthoux L, Gayet B, et al. Adenocarcinome du cardia: l'etendue de l'exerese gastrique et du curage ganglionnaire Influence-t-elle Ia survie? Ga.ftroentero/ C/in Bio/1995; 19: 244-251.

[20] 20. Cherveniakov A, Cherveniakov P. Colon substitution for radical treatment of cardia and lower third esophageal cancer. Eur J Cardiothorac Surg 1993;7:601605.

[21] 21. Jougon J, Velly JF, Clerc F, et al. La thoracophrenotornie gauche dans l'exerese des cancers du cardia et du tiers inferieur de l'oesophage. A propos d'une serie de 210 caso Chirurgie 1994-1995;120 (4): 211-215.

[22] 22. Sadanaga N, Kuwano H, Watanabe M, et al. Laparoscopy- assisted surgery: a new technique for transhiatal esophageal dissection. Am 1 Surg 1994;168(4):355-7.

[23] 23. Papachristou DN, Shiu Nffi. Management by en bloc multiple organ resection of carcinoma of the stornach invading adjacent organs and gastric carcinomas. Patho/ Res Pract 1994;190:1.141-1.148.

[24] ²⁴
Gonzalez EM. " Cancer of the cardia: the value of total extended esophago-gastrectomy ". In: P. Sugarbaker (ed): Management (1/ Gastric Cancel: Kluwer-Academic Publishers. Boston 1991, pp 205-246.

[25] 25. Tanigawa N, Shimomtsuya T, Horiuchi T, et al. En bloc resection for cancer of the gastric cardia without thoracotomy. J Surg Oncol 1993;54:23-28.

[26] 26. Collard JM, Tinton N, Malaise J, et al. Esophageal replacement: gastric tube of whole stornach? Ann Thor Surg 1995;60(2): 261-7.

[27] 27. Rahamim J, Chaw CW. Oesophagogastrectomy for carcinoma of the oesophagus and cardia. Br J Surg 1993;80(10):1.305-9.

[28] 28. Liedman BL, Bennegard K, Olbe LC, et al. Predictors of postoperative morbidity and mortality after surgery for gastro-oesophageal carcinomas. Eur J Surg 1995;161(3):173-80.

[29] 29. Matory YL, Burt M. Esophagogastrectomy: reoperation for complications. J Surg Oncol 1993;54:29-33.

[30] 30. Bardini R, Bonavina L, Asolati M, et al. E. single-layered cervical esophageal anastomoses: a prospective study of two suturing techniques. Ann Thorac Surg 1994;58:1.087-90.

[31] 31. Posner MC, Pappo I. Neoadjuvant therapy for upper GI tumors. Contemp Oncol 1993;October: 16-24 and 30.

[32] 32. Hermans J, Bonenkamp JJ, Boon MC, et al. Adjuvant therapy after curative resection for gastric cancer: meta-analysis of randomized trials. J Clin Oncol 1993;II,(8): 1.441-1.447.

[33] 33. Estape J, Grau JJ, Alcobendas F, et al. Mitomycin C as adjuvant treatment to resected gastric cancer. A 10 year follow-up. Ann Surg 1991;3:219-221.

[34] 34. Brennan M. Benefit of aggressive multimodality treatment for gastric cancer. Editorial. Ann Surg Oncol 1995;2(4):286-87.

[35] ³⁵
Fugimoto S, Kasanuki J, Yoshida S, et al. "New trends in therapy for gastric malignancy". In P. Sugarbaker (ed): Management of gastric Cancer. Kluwer- Academic Publishers. Boston 1991, pp 307-324.

[36] 36. Atiq OT, Kelsen DP, Shiu MIH, et al. Phase II trial of postoperative adjuvant intraperitoneal cisplatin and fluorouracil and systemic fluorouracil chemotherapy in patients with resected gastric cancer. J Clin Oncol 1993;1 1(3):425-433.

[37] 37. Botet JF, Lightdale CJ, Zauber AG, et al. Preoperative staging of gastric cancer: comparison of endoscopic US and dynamic CT. Radiology 1991;18 I (2):426-32.

[38] 38. Peracchia A, Segalin A, Bonavina L. Indicazioni e risultati del trattamento palliativo nei pazienti con carcinoma dell'esofago e del cardias. Ann Ital Chir 1993;LXIV, 6:651-656.

[39] 39. Hoffmann W. Lasertherapie und tubusimplantation zur paliativen behandlung des inoperablen osophagus und kardiakarzinoms. Bildgebung 1993;60:157-160.

[40] 40. Moreira LS, Coelho RCL, Sadala RU, et al. The use of ethanol infection under endoscopic control to palliate dysphagia caused by esophagogastric cancer. Endoscopy 1994;26:311-314.

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