Should gastric cardia cancers be treated with esophagectomy or total gastrectomy? A comprehensive analysis of 4,996 NSQIP/SEER patients

Background Category 1 guidelines emphasize multimodality therapy (MMT) for patients with gastric cardia cancer (GCC). These patients are often referred to thoracic surgeons for "esophagogastric junction" cancers rather than to abdominal surgeons for "proximal gastric" cancers. This study sought to determine the ideal surgical approach using national datasets evaluating morbidity/mortality (M/M) and overall survival (OS). Study Design Patients with resected GCC were identified from the 2005 to 2012 ACS-NSQIP dataset and the 1998 to 2010 SEER dataset. Multivariate 30-day M/M analyses were performed using NSQIP. Survival analyses were derived from SEER and stratified by surgical approach. Results There were 1,181 NSQIP patients with GCC included; 81.8% had esophagectomies and 18.1% had gastrectomies. Major postoperative M/M occurred in 33.2%/3.7% patients after gastrectomy vs 35.0%/2.4% after esophagectomy (p = 0.260). Although a major postoperative complication (odds ratio 12.8, p < 0.001) was an independent predictor of mortality on multivariate analysis, surgical approach was not. Of the 3,815 SEER patients included, 71.1% had esophagectomies and 28.9% had gastrectomies. Radiation use (surrogate for MMT) was administered more often with esophagectomy vs gastrectomy (42.9% vs 29.6%, p < 0.001). Unadjusted median overall survival (OS) favored esophagectomy (26.0 vs 21.0 months, p = 0.025). However, multivariate analysis confirmed age (hazard ratio [HR] 1.01), T/N stages (HR 1.12/1.91), and radiation use (HR 0.83, all p ≤ 0.018), but not surgical approach (HR 0.95, p = 0.259), as independent predictors of OS. Conclusions Tumor biology and MMT, rather than surgical approach, dictate oncologic outcomes for GCC. Therefore, the decision of esophagectomy vs gastrectomy for GCC should be based on proximal and distal tumor extent and the multidisciplinary strategy with the lower rate of complications and the higher rate of MMT completion.