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J Thorac Cardiovasc Surg 2009;138:601-602
© 2009 The American Association for Thoracic Surgery

Invited Commentary

Discussion

Dr Thomas W. Rice (Cleveland, Ohio). Confusion and controversy surrounds the esophagogastric junction. I would like to thank Dr Leers and her colleagues for presenting this most important analysis of their experience with the surgical treatment of cancers of the esophagogastric junction. It is reports such as this that will shed light on this contentious transition area of the upper gastrointestinal tract, help end therapeutic disputes, and guide us in the treatment of cancers arising in this borderland.

This 10-cm/4-inch segment of the DE and proximal stomach has been classified into 3 areas by Dr Siewert and his colleagues. Importantly, their classification is based on pathologic assessment of the epicenter of the tumor, an easy thing to do in the quiet of the pathology laboratory. However, if this information is to be clinically important, it must be available before treatment in the living, swallowing world of the esophagoscopy suite. Dr Leers and her colleagues rightly determined Siewert type at initial endoscopy. They point out the difficulty of defining the esophagogastric junction endoscopically but have rigorously attempted to type these cancers in 613 patients. Not surprisingly, every sixth patient defied classification. At first, I wondered how these missing data should have been handled in the analysis, but it became evident that these 96 unclassifiable patients represented an interesting quasi–control group for your analysis. Although it might require propensity scoring, because these are typically larger tumors, it would strengthen your argument if patients with unclassifiable tumors had a survival similar to that of patients from either classifiable group.

My first question is this: Have you or will you add this group to your analysis?

Dr DeMeester. Thanks, Tom. Yes, we actually did that. The same thought struck us, so we plotted the Kaplan–Meier survival for those patients, and it is identical. . . . [Full Text of this Article]