Gastric cardia cancer and precursor lesions- current dilemmas

Authors Jovanovic I., Mouzas I..


Over the last two decades a marked increase in the incidence
of adenocarcinoma of the gastroesophageal junction
has been observed. This carcinoma can develop, either from
short segment Barretts esophagus or metaplastic gastric
epithelium in the cardia. Much confusion exists regarding
the malignant potential of such short segments of intestinal
metaplasia, at or above the esophagogastric junction.
Furthermore, it is currently unclear whether intestinal
metaplasia at the esophagogastric junction and in the distal
esophagus, represent a continuum of the same underlying
disease process, i.e., gastroesophageal reflux, or constitute
different entities with a different pathogenesis. Such
a difference may not be crucial since all patients with cancer
would undergo surgical procedure, but the identification
of precursor lesions is merited since different therapeutic
and surveillance protocol can be established. Biopsies
below the Z line might show specialized epithelium in
some patients and the question is whether this is another
form of short segment Barretts esophagus or whether it is
related to a generalized atrophic process of the stomach.
Epidemiological data and classic parameters for the diagnosis
of gastroesophageal reflux disease do not currently
support a causal role of gastroesophageal reflux in the
pathogenesis of specialized intestinal metaplasia of the
gastric cardia. Results from recent studies still leave us
with a dilemma concerning the role of reflux disease and
Helicobacter pylori infection in the development of carditis
and consecutive intestinal metaplasia. It appears that such discrepancies often originate from different biopsy
sampling protocols. At present, there are no accepted criteria
concerning the position of gastric cardia. Anatomic
and histological landmarks do not always coincide. A promising
tool for future investigation may be the different expression
of cytokeratins in metaplastic epithelium arising
from the esophageal, as opposed to the gastric mucosa. This
article reviews the results of the recent studies and presents
dilemmas relating to the burning issue of gastric cardia cancer.