Updates in Surgery

, Volume 70, Issue 2, pp 241–249 | Cite as

Siewert III esophagogastric junction adenocarcinoma: does TNM 8th save us?

  • Andrea ZanoniEmail author
  • Giuseppe Verlato
  • Gian Luca Baiocchi
  • Francesco Casella
  • Andrea Cossu
  • Alessia d’Ignazio
  • Stefano De Pascale
  • Simone Giacopuzzi
Original Article
Part of the following topical collections:
  1. Gastric Cancer Surgery


Siewert III cancers were classified as esophageal cancers by the TNM 7th edition (TNM7), while being defined as gastric cancers by the new TNM 8th edition (TNM8). Aim of this study was to compare previous and present TNM classifications of Siewert III. From 2000 to 2015, 309 patients with Siewert III adenocarcinoma were treated at ten high-volume centers, belonging to the GIRCG (Italian Research Group for Gastric Cancer). We retrospectively analyzed overall survival according to TNM classifications: gastric TNM8 was compared with either gastric TNM7 or esophageal TNM7. Median number of lymph nodes harvested was 31 (interquartile range 22–44). Agreement between gastric TNM7 and TNM8 was very good (weighted kappa 92.3%, IC 95% 90.3–94.1%). Accordingly, stage migration was observed in 54 of 309 patients (17.5%), with 12 patients upstaged (3.9%) and 42 downstaged (13.6%). Cox models including either gastric TNM7 or TNM8 achieved similar goodness-of-fit and c-index. Differences were much larger, when shifting from esophageal TNM7 to gastric TNM8: the agreement was much lower (weighted kappa 69.1%, 65.2–73.2%), with 196 of 309 patients (63.4%) downstaging. The corresponding Cox model presented the lowest goodness-of-fit and discrimination ability. Gastric TNM7 and TNM8 were largely superimposable, so that stage migration was minor and prognostic significance was similar. At variance, stage migration was substantial when shifting from esophageal TNM7 to TNM8. Moreover, survival models with esophageal TNM7 presented the worst goodness-of-fit and the lowest discrimination ability. This further supports placing Siewert III among gastric cancers, as done in TNM8.


Siewert III EGJ Esophageal TNM7 Gastric TNM7 Gastric TNM8 



We thank Giovanni Vittimberga (General Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy), Fausto Rosa (Division of Digestive Surgery, Department of Surgical Sciences, Catholic University, Rome, Italy), Giovanni Sgroi (Department of General Surgery, Treviglio Hospital, ASST of Bergamo, Bergamo, Italy) and Francesco Ricci (Unit of General Surgery, Rovereto Hospital (APSS of Trento), Italy) for their precious participation in this study.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Human participants and/or animals statement

The research does not involve human participants and/or animals.

Informed consent

There was no need to get informed consent.


  1. 1.
    Rice TW, Blackstone EH, Rusch VW (2010) 7th edition of the AJCC cancer staging manual: esophagus and esophagogastric junction. Ann Surg Oncol 17(7):1721–1724. CrossRefPubMedGoogle Scholar
  2. 2.
    Lutz MP, Zalcberg JR, Ducreux M et al (2012) Highlights of the EORTC st. Gallen international expert consensus on the primary therapy of gastric, gastroesophageal and oesophageal cancer—differential treatment strategies for subtypes of early gastroesophageal cancer. Eur J Cancer 48(16):2941–2953. CrossRefPubMedGoogle Scholar
  3. 3.
    Ajani JA, D’Amico TA, Almhanna K, et al (2015) Esophageal and esophagogastric junction cancers, version 1.2015. J Natl Compr Cancer Netw 13(2):195–227Google Scholar
  4. 4.
    Siewert JR, Stein HJ (1998) Classification of adenocarcinoma of the oesophagogastric junction. Br J Surg 85(11):1457–1459. CrossRefPubMedGoogle Scholar
  5. 5.
    Brierley JD, Gospodarowicz MKWC (2017) TNM classification of malignant tumours, 8th edn. Wiley-Blackwell, OxfrodGoogle Scholar
  6. 6.
    In H, Solsky I, Palis B, Langdon-Embry M, Ajani J, Sano T (2009) Validation of the 8th edition of the AJCC TNM staging system for gastric cancer using the National Cancer Database. Ann Surg Oncol. CrossRefGoogle Scholar
  7. 7.
    Kim SG, Seo HS, Lee HH, Song KY, Park CH (2017) Comparison of the differences in survival rates between the 7th and 8th editions of the AJCC TNM staging system for gastric adenocarcinoma: a single-institution study of 5,507 patients in korea. J Gastric Cancer 17(3):212–219. CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Lu J, Zheng C, Cao L et al (2017) The effectiveness of the 8th American Joint Committee on Cancer TNM classification in the prognosis evaluation of gastric cancer patients: A comparative study between the 7th and 8th editions. Eur J Surg Oncol. CrossRefPubMedGoogle Scholar
  9. 9.
    Di Leo A, Zanoni A (2017) Siewert III adenocarcinoma: treatment update. Updates Surg 69(3):319–325. CrossRefPubMedGoogle Scholar
  10. 10.
    Rice TW, Rusch VW, Apperson-Hansen C et al (2009) Worldwide esophageal cancer collaboration. Dis Esophagus 22(1):1–8. CrossRefPubMedGoogle Scholar
  11. 11.
    Sano T, Coit DG, Kim HH et al (2017) Proposal of a new stage grouping of gastric cancer for TNM classification: international Gastric Cancer Association staging project. Gastric Cancer 20(2):217–225. CrossRefPubMedGoogle Scholar
  12. 12.
    Marrelli D, Morgagni P, de Manzoni G et al (2012) Prognostic value of the 7th AJCC/UICC TNM classification of noncardia gastric cancer. Ann Surg 255(3):486–491. CrossRefPubMedGoogle Scholar
  13. 13.
    McGhan LJ, Pockaj BA, Gray RJ, Bagaria SP, Wasif N (2012) Validation of the updated 7th edition AJCC TNM staging criteria for gastric adenocarcinoma. J Gastrointest Surg 16(1):53–61. CrossRefPubMedGoogle Scholar
  14. 14.
    Barbour AP, Rizk NP, Gonen M et al (2007) Lymphadenectomy for adenocarcinoma of the gastroesophageal junction (GEJ): impact of adequate staging on outcome. Ann Surg Oncol 14(2):306–316. CrossRefPubMedGoogle Scholar
  15. 15.
    Zhang X, Watson DIJG (2007) Lymph node metastases of adenocarcinoma of the esophagus and esophagogastric junction. Chin Med J 120(24):2268–2270PubMedGoogle Scholar
  16. 16.
    Rizk NP, Ishwaran H, Rice TW et al (2010) Optimum lymphadenectomy for esophageal cancer. Ann Surg 251(1):46–50. CrossRefPubMedGoogle Scholar
  17. 17.
    Altorki NK, Zhou XK, Stiles B et al (2008) Total number of resected lymph nodes predicts survival in esophageal cancer. Ann Surg 248(2):221–226. CrossRefPubMedGoogle Scholar
  18. 18.
    Peyre CG, Hagen JA, DeMeester SR et al (2008) The number of lymph nodes removed predicts survival in esophageal cancer: an international study on the impact of extent of surgical resection. Ann Surg 248(4):549–556. PubMedCrossRefGoogle Scholar
  19. 19.
    Shen Z, Ye Y, Xie Q, Liang B, Jiang K, Wang S (2015) Effect of the number of lymph nodes harvested on the long-term survival of gastric cancer patients according to tumor stage and location: a 12-year study of 1,637 cases. Am J Surg 210(3):431–440. CrossRefPubMedGoogle Scholar
  20. 20.
    Lu J, Wang W, Zheng C et al (2017) Influence of total lymph node count on staging and survival after gastrectomy for gastric cancer: an analysis from a two-institution database in China. Ann Surg Oncol 24(2):486–493. CrossRefPubMedGoogle Scholar
  21. 21.
    Ji X, Bu Z-D, Li Z-Y et al (2017) Prognostic significance of the total number of harvested lymph nodes for lymph node-negative gastric cancer patients. BMC Cancer. 17(1):558. CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    He H, Shen Z, Wang X, Qin J, Sun Y, Qin X (2016) Survival benefit of greater number of lymph nodes dissection for advanced node-negative gastric cancer patients following radical gastrectomy. Jpn J Clin Oncol 46(1):63–70. CrossRefPubMedGoogle Scholar
  23. 23.
    Baiocchi GL, Tiberio GA, Minicozzi AM et al (2010) A multicentric Western analysis of prognostic factors in advanced, node-negative gastric cancer patients. Ann Surg 252(1):70–73. CrossRefPubMedGoogle Scholar

Copyright information

© Italian Society of Surgery (SIC) 2018

Authors and Affiliations

  1. 1.Unit of General SurgeryRovereto Hospital (APSS of Trento)RoveretoItaly
  2. 2.General and Upper G.I. Surgery DivisionUniversity of VeronaVeronaItaly
  3. 3.Unit of Epidemiology and Medical StatisticsUniversity of VeronaVeronaItaly
  4. 4.Department of Clinical and Experimental SciencesBrescia UniversityBresciaItaly
  5. 5.Division of General SurgeryVannini HospitalRomeItaly
  6. 6.Department of SurgeryVita-Salute San Raffaele UniversityMilanItaly
  7. 7.Department of General Surgery and OncologyUniversity of SienaSienaItaly
  8. 8.Division of General and Minimally Invasive SurgeryHumanitas Clinical and Research CenterRozzanoItaly

Personalised recommendations