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CLASSIFICATION
Classification
Siewert classification (EGJ adenocarcinoma)
Splits adenocarcinoma whose center lies within 5 cm of the EGJ into Type I / II / III. Japanese rules and guidelines use the Nishi definition (center within 2 cm of the EGJ, any histology). That zone roughly matches Siewert Type II.
Classification overview
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Landmark
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EGJ · Zero point
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Siewert
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Type I · Distal esophageal adenocarcinoma
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Type II · True cardia carcinoma
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Type III · Subcardial carcinoma
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Nishi
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Nishi EGJ carcinoma · Center within ±2 cm
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E · Esophagus only
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EG · Center on the esophageal side
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E=G · Equal occupation
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GE · Center on the gastric side
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G · Stomach only
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Japanese guidelines
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JGCA / JES guideline · Nishi zone; invasion length
Landmark
EGJ
Zero point
Siewert
The anatomical cardia is identified endoscopically as the proximal end of the longitudinal gastric mucosal folds.
JCE 11th
Endoscopic findings take priority. The EGJ is the lower margin of the palisading small vessels. If those vessels are unclear, the oral margin of the longitudinal folds of the greater curvature is used.
SCJ
The squamocolumnar junction (Z-line) does not always coincide with the EGJ.
Note: Siewert / Prague use the top of the gastric folds. Japanese rules prefer the lower end of the palisade vessels. In Barrett esophagus or hiatal hernia, use the fold tops as the EGJ.
Siewert
Type I
Distal esophageal adenocarcinoma
Center
1–5 cm above the anatomical cardia (EGJ)
Entity
Adenocarcinoma of the distal esophagus, usually arising from specialized intestinal metaplasia (Barrett’s esophagus)
Note: Usually outside the Nishi EGJ zone (±2 cm). In Japan this is treated as esophageal (Barrett) adenocarcinoma. Siewert applies to adenocarcinoma only.
Type II
True cardia carcinoma
Center
Within 1 cm above and 2 cm below the anatomical cardia
Entity
True carcinoma of the cardia arising from cardiac epithelium or short-segment intestinal metaplasia at the EGJ
Note: Roughly the same as Nishi EGJ carcinoma. This is what Japanese guidelines mean by EGJ cancer.
Type III
Subcardial carcinoma
Center
2–5 cm below the anatomical cardia, infiltrating the EGJ and distal esophagus from below
Entity
Subcardial gastric carcinoma
Note: If the center is 2–5 cm on the gastric side but the esophagus is not involved, it is gastric cancer, not Type III. It lies outside the Nishi ±2 cm zone.
Nishi
Nishi EGJ carcinoma
Center within ±2 cm
Definition
A tumor whose center is located between 2 cm proximal to and 2 cm distal from the EGJ, irrespective of histological type.
Scope
Includes adenocarcinoma and squamous cell carcinoma. Corresponds to Siewert Type II (true cardia cancer), not to the whole Siewert ±5 cm field.
Source
Nishi M et al. Geka Shinryo 1973;15:1328-1338. Adopted by the Japanese Classification of Esophageal Cancer (11th) and the Japanese Classification of Gastric Carcinoma.
Note: Current rules have no size limit (older editions required diameter ≤4 cm). This is not the same as Siewert’s AEG field (adenocarcinoma within ±5 cm).
E
Esophagus only
Occupation
The tumor lies entirely on the esophageal side of the EGJ (within the Nishi zone).
EG
Center on the esophageal side
Occupation
The tumor crosses the EGJ; the center is on the esophageal side. The oral portion is written first (E then G).
E=G
Equal occupation
Occupation
The esophagus and stomach are involved equally; the center is at the EGJ.
GE
Center on the gastric side
Occupation
The tumor crosses the EGJ; the center is on the gastric side.
G
Stomach only
Occupation
The tumor lies entirely on the gastric side of the EGJ (within the Nishi zone).
Japanese guidelines
JGCA / JES guideline
Nishi zone; invasion length
Definition
EGJ cancer: adenocarcinoma or squamous cell carcinoma whose center lies within 2 cm above or below the EGJ (Nishi).
Surgery
The JGCA 6th edition algorithm is based on esophageal invasion length, not on Siewert type. Invasion ≤2 cm: lower mediastinal dissection is usually limited. Invasion >2 cm: add lower mediastinal nodes. Invasion >4 cm: add upper and middle mediastinal nodes.
UICC 8th
A tumor that involves the EGJ with its epicenter ≤2 cm into the stomach is staged as esophageal cancer. If the epicenter is >2 cm into the stomach, it is staged as gastric cancer.
Note: The JGCA 6th edition and the esophageal-society EGJ algorithm are shared. Approach is chosen by esophageal invasion length, not by Siewert type. Newer analyses measure invasion on the resected specimen rather than by endoscopy alone.
JCE 2017, Fig. 2-6, Not original, CC BY
JCE 2017, Fig. 2-5, Not original, CC BY
JCE 2017, Fig. 2-7, Not original, CC BY
Siewert 1998, Original
Reference
Original article
Siewert JR, Stein HJ. Br J Surg 1998;85:1457-1459
Japanese reference
JGCA gastric cancer guideline, 6th ed. (EGJ cancer)
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Decision support only. Follow current guidelines and local protocols. Classification definitions and terminology follow the original publication language.