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Proximal Margin Involvement Following Total Gastrectomy for Siewert III Adenocarcinoma; a Management Dilemma.

Authors
Rajdave S1, GH Loo1, M. Guhan1, Kosai NR1

Affiliations

  1. UGI and Metabolic Surgery Unit, Department of Surgery, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia

Introduction
Esophageal cancer ranks as the 6th most common cancer globally. Recent advances in multimodal treatment approaches, including endoscopic procedures, esophagectomy with three-field lymph node dissection, and definitive chemoradiotherapy (CRT), have significantly improved overall patient survival rates. Despite these advancements, the recurrence rate remains around 50% within 1-3 years following initial surgery. A major challenge in management arises when the resected surgical margins are involved with cancer.

Case Report
We present a 55-year-old man who experienced progressive dysphagia for six months and lost 20 kg. Further investigation revealed a Siewert III cardioesophageal tumor, which was moderate to poorly differentiated adenocarcinoma. He underwent four cycles of neoadjuvant treatment before undergoing total gastrectomy with D2 lymphadenectomy and transhiatal esophagectomy. Postoperative histopathological examination reveal proximal margin involved. After optimization, he then underwent salvage surgery ( 3 field Mckeown with colonic conduit ) and adjuvant chemotherapy.

Discussion
Salvage surgery can be considered for patients with locoregional recurrence after definitive chemoradiotherapy (CRT) or surgery. Other options include salvage chemoradiotherapy. Our case outlines the importance of proper patient selection for salvage surgery and highlights the Conduit choices in patients undergoing total esophagectomy post gastrectomy.

Conclusion
In conclusion, managing proximal margin involvement of cardio esophageal junction tumors remains a complex and multifaceted challenge, necessitating a tailored, multidisciplinary approach. The decision-making process must consider the patient's overall health, previous treatments, and specific anatomical considerations.

Keywords Esophageal cancer, colonic conduit, COJ tumor, Salvage surgery