BACKGROUND: Adenocarcinoma of the esophagus and cardia is a challenging disease for the surgeon. Delay in diagnosis, nodal involvement, and incompleteness of resection have an adverse effect on long-term prognosis. Efforts are currently oriented to identify patients who may benefit from extensive resection.METHODS: Between November 1992 and May 1998, 218 patients with histologically proven adenocarcinoma of the distal esophagus or cardia were referred to our Department. In 6 patients (10.2%) cancer was discovered during endoscopic surveillance for Barrett's metaplasia. Overall, 147 patients (67%) underwent resection. An Ivor-Lewis approach was used in 121 patients; of these, 51 underwent an extended mediastinal lymph node dissection.RESULTS: Median cumulative survival was 25.9 +/- 3.1 months in patients undergoing resection, and 7 +/- 1.3 months in patients having palliation ( P < 0.01). Survival was significantly higher in patients with negative nodes than in those with lymph node metastases (54 +/- 12.9 versus 17 +/- 2.8 months; P < 0.01). Six of the 51 patients (11.8%) undergoing extended lym-phadenectomy had metastatic upper mediastinal nodes. Additional serial sections and immunohistochemistry were performed in 46 patients. In 6 of 18 patients (33.3%) with negative nodes at conventional hematoxylin-eosin examination, immunohistochemistry demonstrated micrometastases in the lesser curvature, paracardial, peripancreatic, or lower mediastinal nodes. Three of these patients had recurrent disease within the first year of follow-up.CONCLUSIONS: Early diagnosis remains the prerequisite for curative treatment of adenocarcinoma of the esophagus and cardia. Endoscopic surveillance appears to be warranted in patients with Barrett's metaplasia. When a curative resection is attempted, extended lymphadenectomy improves tumor staging and may prevent local recurrences. Serial sections and immunohistochemistry provide additional accuracy in the staging of the disease and may prove useful to select patients for adjuvant therapy.