Genomic Landscape of Adenocarcinomas Across the Gastroesophageal Junction Moving on From the Siewert Classification

Objective: To investigate how the Siewert classification of gastroesophageal junction adenocarcinomas correlates with genomic profiles. Background: Current staging and treatment guidelines recommend that tumors with an epicenter <2 cm into the gastric cardia be treated as esophageal cancers, whereas tumors with an epicenter >2 cm into the cardia be staged and treated as gastric cancers. To date, however, few studies have compared the genomic profiles of the 3 Siewert classification groups to validate this distinction. Methods: Using targeted tumor sequencing data on patients with adenocarcinoma of the gastroesophageal junction previously treated with surgery at our institution, we compared genomic features across Siewert classification groups. Results: A total of 350 patients were included: 121 had Siewert type I, 170 type II, and 59 type III. Comparisons by Siewert location revealed that Siewert types I and II were primarily characterized as the chromosomal instability molecular subtype and displayed Barrett metaplasia and p53 and cell cycle pathway dysregulation. Siewert type III tumors, by contrast, were more heterogeneous, including higher proportions of microsatellite instability and genomically stable tumors, and more frequently displayed ARID1A and somatic CDH1 alterations, signet ring cell features, and poor differentiation. Overall, Siewert type I and II tumors demonstrated greater genomic overlap with lower esophageal tumors, whereas Siewert type III tumors shared genomic features with gastric tumors. Conclusions: Overall, our results support recent updates in treatment and staging guidelines. Ultimately, however, molecular rather than anatomic classification may prove more valuable in determining staging, treatment, and prognosis.