Therapy for locally advanced adenocarcinoma of the gastroesophageal junction: optimizing outcome

Adenocarcinoma of the distal esophagus and gastroesophageal junction has been rapidly increasing in incidence in Western nations over the past several decades. Although in the past, a similar management strategy has been used for adenocarcinoma and squamous cell carcinoma, without distinguishing by location or pathology, there is now greater motivation to optimize therapeutic strategies for adenocarcinoma in general and by specific location within the esophagus, with the goal of improving outcome. Siewert recognized the need to classify tumors based on anatomic location and proposed a classification scheme for distal esophageal and gastroesophageal junction neoplasms to guide therapy and allow more meaningful study. Although the available randomized data relevant to adenocarcinoma patients often include a mix of the 2 histologies and the various anatomical locations bundled together, these data suggest that a variety of surgical approaches are appropriate and that neoadjuvant therapy improves survival for patients with locally advanced disease. Although definitive evidence is lacking, neoadjuvant chemoradiation appears superior to neoadjuvant chemotherapy alone for improving resectability, maintaining locoregional control, and maximizing survival. There is a need to identify more effective approaches to identifying optimal systemic regimens for individual patients that may be combined with local therapy to further improve outcome.