What treatment do you recommend for patients with Siewert III gastroesophageal junction cancer with periesophageal or mediastinal lymph node involvement beyond what is considered regional for gastric cancer?

Patients with non-regional lymph node metastaseshave stage IV disease by definition and should be treated with palliative chemotherapy. There is no defined role for chemoradiation in this setting. However, in rare instances (e.g. young patient with excellent functional status and minimal non-regional adenopathy who has a significant, durable response after an extendedcourse of chemotherapy), it may be reasonable to consider chemoradiation as part of an aggressive approach (including surgery)to leave the patient with no evidence of disease. I want to emphasize that this is not at allastandard approach and should only be considered in patients with very favorable disease biology after extensive multidisciplinary discussion.