International cancer seminars: a focus on esophageal squamous cell carcinoma

SPP1 promotes radiation resistance through JAK2/STAT3 pathway in esophageal carcinoma

BACKGROUND

Therapeutic resistance to radiotherapy is one of the major obstacles in clinical practice that significantly affect the therapeutic efficiency and prognosis of human esophageal carcinoma (ESCA). Thus, it is critical to understand the molecular mechanisms of radiation resistance in ESCA. Secreted phosphoprotein 1 (SPP1) plays an essential role in various human cancers, but its role in radiation resistance remains unclear.

METHOD

Cell culture and transfection; Cell Counting Kit-8 (CCK-8) assays; EdU incorporation assays; Patient sample collection and medical records review; Transwell assays; Colony formation assays; Wound healing assays; Western blot; Immunofluorescence; Immunohistochemistry; Irradiation; Flow cytometry; Animal studies; Human Apoptosis Array Kit; Bioinformatics.

RESULT

In the current study, we reported the novel phenomenon that radiation-treated human ESCA cells upregulated SPP1 expression, which in turn contributed to the ESCA resistance to radiotherapy. We also reported the tumor-promoting effect of SPP1 in ESCA systematically and comprehensively. Furthermore, subsequent studies by knocking down or overexpressing SPP1 in human ESCA cells showed that SPP1 could facilitate the repair of DNA damage and the survival of tumor cells post-radiation in ESCA, which might contribute to the development of radiation resistance during the radiotherapy process. More detailed investigations on the downstream molecular pathway suggested that radiation could increase the phosphorylation level of JAK2 and STAT3 by increasing SPP1 expression. Further in vivo validation using a mouse ESCA xenograft model showed that SPP1 overexpression significantly increased tumor volume while either SPP1 knockdown or pharmacological inhibition of the JAK2-STAT3 pathway reduced tumor volume in a synergistic manner with radiotherapy.

CONCLUSION

Collectively, these findings suggested that the SPP1/JAK2/STAT3 axis is a critical player in ESCA progression and radiation resistance, which is a potential therapeutic target for combined therapy with the standard radiotherapy regimen to improve curative effect and increase patients' survival with ESCA.

Cellulose Sponge, the Detector of Esophageal Cancer: Innovation for Early Detection of Esophageal Cancer without Biopsy?: A Mini Review

Patients with esophageal cancer each year can reach 400,000 people. Inefficient screening methods and worsening symptoms, patients often come late. Squamous cell carcinoma, which is the cause of esophageal cancer, has percentage of 84% of all cancer incidences. So far, the current screening strategy is endoscopy with biopsy. This screening has the main side effect of bleeding in metaplastic area. Cellulose Sponge, the Detector of Esophageal Cancer (CaSPER), can be used for screening without a biopsy using a cellulose sponge. The method used in this mini review is an evidence-based method that focuses on evaluating pre-existing journals. The result is that CaSPER is able to provide strong cellular results of 98%, specificity of 100%, and sensitivity of 97%. Capsules made of glucose and cytosponge of cellulose will bring the metaplastic cells to the sponge. This screening is feasible, safe, comfortable, and without side effects. Using trefoil factor 3 as biomarker is able to distinguish between goblet and pseudogoblet cells. CaSPER is minimally invasive, cheaper, and easily accepted, so that in the future it is hoped that it can be mass produced, especially for areas with high esophageal cancer.

A Circ-0007022/miR-338-3p/Neuropilin-1 Axis Reduces the Radiosensitivity of Esophageal Squamous Cell Carcinoma by Activating Epithelial-To-Mesenchymal Transition and PI3K/AKT Pathway

Radiotherapy resistance is an important cause of treatment failure in esophageal squamous cell carcinoma (ESCC). Circular RNAs have attracted a lot of attention in cancer research, but their role in ESCC radiosensitivity has not been elucidated yet. Here, we aimed to evaluated the functional impacts of circ-0007022 on ESCC radiosensitivity. In this study, a stable radiotherapy-resistant cell line was established and verified by a series of functional experiments. Subsequently, high-throughput sequencing revealed that circ-0007022 was significantly overexpressed in the radiotherapy-resistant cell line and this conclusion was verified in ESCC patients’ tumor tissues by real-time quantitative PCR. Moreover, loss-of-function and overexpression experiments in vitro and in vivo revealed that, after irradiation, the abilities of proliferation and migration in circ-0007022-overexpressing stable transgenic strain were significantly higher than that in circ-0007022-knockdown stable transgenic strain. Additionally, RNA Immunoprecipitation, RNA pull-down, luciferase reporter assays, and fluorescence in situ hybridization experiments demonstrated the mechanism of how circ-0007022 could sponge miR-338-3p and upregulate downstream target of miR-338-3p, neuropilin-1 (NRP1). Moreover, NRP1 led to poor prognosis for ESCC patients receiving radiotherapy, and NRP1 knock-down enhanced radiosensitivity of ESCC cells. Furthermore, circ-0007022 overexpression activated Epithelial-to-mesenchymal transition and PI3K/Akt pathway, and NRP1 knock-down could reversed this phenomenon. Finally, Akt Inhibitor reversed circ-0007022s role in radiotherapy in ESCC cells. Taken together, the circ-0007022/miR-338-3p/NRP1 axis enhances the radiation resistance of ESCC cells via regulating EMT and PI3K/Akt pathway. The new circRNA circ-0007022 is thus expected to be a therapeutic target for ESCC patients.

Extracellular vesicle IL-32 promotes the M2 macrophage polarization and metastasis of esophageal squamous cell carcinoma via FAK/STAT3 pathway

Background

Metastasis is the leading cause of mortality in human cancers, including esophageal squamous cell carcinoma (ESCC). As a pro-inflammatory cytokine, IL-32 was reported to be a poor prognostic factor in many cancers. However, the role of IL-32 in ESCC metastasis remains unknown.

Methods

ESCC cells with ectopic expression or knockdown of IL-32 were established and their effects on cell motility were detected. Ultracentrifugation, Transmission electron microscopy and Western blot were used to verify the existence of extracellular vesicle IL-32 (EV-IL-32). Coculture assay, immunofluorescence, flow cytometry, and in vivo lung metastasis model were performed to identify how EV-IL-32 regulated the crosstalk between ESCC cells and macrophages.

Results

Here, we found that IL-32 was overexpressed and positively correlated to lymph node metastasis of ESCC. IL-32 was significantly higher in the tumor nest compared with the non-cancerous tissue. We found that IL-32β was the main isoform and loaded in EV derived from ESCC cells. The shuttling of EV-IL-32 derived from ESCC cells into macrophages could promote the polarization of M2 macrophages via FAK-STAT3 pathway. IL-32 overexpression facilitated lung metastasis and was positively correlated with the proportion of M2 macrophages in tumor microenvironment.

Conclusions

Taken together, our results indicated that EV-IL-32 derived from ESCC cell line could be internalized by macrophages and lead to M2 macrophage polarization via FAK-STAT3 pathway, thus promoting the metastasis of ESCC. These findings indicated that IL-32 could serve as a potential therapeutic target in patients with ESCC.

Supplementary information

The online version contains supplementary material available at 10.1186/s13046-022-02348-8.

Pembrolizumab for the treatment of advanced esophageal cancer

The prognosis of patients with advanced esophageal cancer (EC) remains poor and there are limited effective therapeutic agents for EC. Pembrolizumab monotherapy exerts clinically meaningful benefits for advanced esophageal squamous cell carcinoma patients with a combined positive score of ≥10. Additionally, pembrolizumab plus doublet chemotherapy results in a significant survival benefit for patients with advanced EC as first-line treatment compared with chemotherapy alone. We provide an overview of immune checkpoint inhibitors and present important clinical data related to treatment for EC patients. In our opinion, pembrolizumab plus chemotherapy should be the standard first-line treatment for patients with advanced EC, regardless of histology and combined positive score. Biomarker studies to identify patient populations in which immune checkpoint inhibitors are expected to show efficacy are needed.

Hafnium-Based Metal-Organic Framework Nanoparticles as a Radiosensitizer to Improve Radiotherapy Efficacy in Esophageal Cancer

Radiotherapy is one of the most widely used clinical treatments for tumors, but it faces limitations, such as poor X-ray retention at the tumor site. The use of radiosensitizers containing high Z elements is an effective way to enhance X-ray absorption. Here, we demonstrate a simple one-step method for the synthesis of UiO-66-NH₂(Hf) metal-organic framework nanoparticles for use as radiosensitizers in radiotherapy. The UiO-66-NH₂(Hf) nanoparticles had a diameter of less than 100 nm and were stable in the physiological environment. UiO-66-NH₂(Hf) induced apoptosis by enhancing X-ray absorption, as confirmed by in vitro and in vivo experiments. These characteristics make UiO-66-NH₂(Hf) a promising radiosensitizer for esophageal cancer radiotherapy.

Effect of prior cancer history on survival of patients with esophageal carcinoma: a propensity score matching, population-based study

BACKGROUND

When conducting esophageal cancer clinical trials, prior cancer history is frequently considered an exclusion criterion due to the assumption that prior malignancy may exert significant interference with the prognosis in patients with esophageal carcinoma. This study aimed to evaluate the impact of prior cancer on survival of patients with esophageal cancer and provide valuable assistance for trial design.

METHODS

Data regarding patients diagnosed with esophageal cancer between 2011 and 2016 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database and divided into two groups depending on the presence or absence of prior cancer history. Propensity score matching (PSM) was performed to minimize the confounding bias caused by covariates. Subsequently, Kaplan-Meier analysis and multivariate Cox proportional hazards models were used to compare all-cause and esophageal cancer-specific survival between patients with and without prior cancer.

RESULTS

Among 17,123 patients with esophageal carcinoma included in this study, 2,224 (13%) patients had prior cancer history. Before PSM, Kaplan-Meier curves between the two groups classified by prior cancer history showed no significant differences in all-cause (HR =1.047, 95% CI: 0.995-1.102, P=0.077) and esophageal cancer-specific survival (HR =0.986, 95% CI: 0.928-1.048, P=0.65). Similar results were obtained after PSM. In multivariate Cox analysis, prior malignancy was not significantly associated with all-cause (HR =1.002, 95% CI: 0.936-1.072, P=0.965) and esophageal cancer-specific survival (HR =0.964, 95% CI: 0.890-1.045, P=0.374). Subgroup analysis stratified by timing of prior cancer demonstrated that prior cancer had no significant effect on prognosis in the recent latency period subgroups (P>0.05). Furthermore, patients with a prior cancer of lung and bronchus (P=0.013) or head and neck (P=0.012) displayed significantly worse survival than patients without prior cancer, while other types of prior cancer showed no significant effect.

CONCLUSIONS

The findings suggest that prior cancer is likely not a definite factor that has an impact on all-cause and esophageal cancer-specific survival. Therefore, exclusion criteria of prior cancer history in esophageal cancer clinical trials should be seriously reconsidered.

Identifying Novel Causes of Cancers to Enhance Cancer Prevention: New Strategies Are Needed

The burden of cancer from a clinical, societal, and economic viewpoint continues to increase in all parts of the world, along with much debate regarding how to confront this. Projected increases in cancer indicate a 50% increase in the number of cases over the next 2 decades, with the greatest proportional increase in low- and medium-income settings. In contrast to the historic high cancer burden due to viral and bacterial infections in these regions, future increases are expected to be due to cancers linked to westernization including breast, colorectum, lung, and prostate cancer. Identifying the reasons underlying these increases will be paramount to informing prevention efforts. Evidence from epidemiological and laboratory studies conducted in high-income countries over the last 70 years has led to the conclusion that approximately 40% of the cancer burden is explained by known risk factors-the 2 most important being tobacco and obesity in that order-raising the question of what is driving the rest of the cancer burden. International cancer statistics continue to show that approximately 80% of the cancer burden in high-income countries could be preventable in principle, implying that there are important environmental or lifestyle risk factors for cancer that have not yet been discovered. Emerging genomic evidence from population and experimental studies points to an important role for nonmutagenic promoters in driving cancer incidence rates. New research strategies and infrastructures that combine population-based and laboratory research at a global level are required to break this deadlock.

Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis

BACKGROUND

A transthoracic esophagectomy is associated with high rates of morbidity. Minimally invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE).

METHODS

A systematic literature search was performed to identify original articles analyzing patients who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia, arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome.

RESULTS

A total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients was 63.5 (55-67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39% (95% CI, 33%-45%) and 20% (95% CI, 13%-28%), respectively. Postoperative pneumonia and arrhythmia rates were 10% (95% CI, 8%-13%) and 12% (95% CI, 8%-17%), respectively. Anastomotic leak rate across studies was 8% (95% CI, 6%-10%). Chyle leak rate was 3% (95% CI, 2%-5%). Mortality rate was 2% (95% CI, 2%-2%). Median ICU stay and length of hospital stay were 2 (1-4) and 11.2 (7-20) days, respectively.

CONCLUSIONS

Totally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed.

Comparative genomic analysis of esophageal squamous cell carcinoma and adenocarcinoma: New opportunities towards molecularly targeted therapy

Esophageal cancer is one of the most lethal cancers worldwide because of its rapid progression and poor prognosis. Esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC) are two major subtypes of esophageal cancer. ESCC predominantly affects African and Asian populations, which is closely related to chronic smoking and alcohol consumption. EAC typically arises in Barrett's esophagus with a predilection for Western countries. While surgical operation and chemoradiotherapy have been applied to combat this deadly cancer, molecularly targeted therapy is still at the early stages. With the development of large-scale next-generation sequencing, various genomic alterations in ESCC and EAC have been revealed and their potential roles in the initiation and progression of esophageal cancer have been studied. Potential therapeutic targets have been identified and novel approaches have been developed to combat esophageal cancer. In this review, we comprehensively analyze the genomic alterations in EAC and ESCC and summarize the potential role of the genetic alterations in the development of esophageal cancer. Progresses in the therapeutics based on the different tissue types and molecular signatures have also been reviewed and discussed.

Characterization of Desmoglein 3 (DSG3) as a Sensitive and Specific Marker for Esophageal Squamous Cell Carcinoma

Although P40 and P63 are both sensitive and specific for routine esophageal squamous cell carcinoma (SCC) diagnosis, we recently showed that P40 and P63 immunoreactivities were significantly lower in well-differentiated SCC than those in higher grade tumors. Therefore, a novel esophageal SCC marker, ideally performing better in well-differentiated SCC, is still needed. We characterized desmoglein 3 (DSG3) immunohistochemistry in esophageal SCC, esophageal adenocarcinoma, small-cell lung carcinoma, and large B-cell lymphoma, alongside P40 and CK5/6. The World Health Organization classification was used to grade tumors as well-differentiated (WD), moderately differentiated (MD), or poorly differentiated (PD). There were 20 WD, 26 MD, and 17 PD components among 39 esophageal SCC cases. All esophageal SCC components showed significant DSG3 immunoreactivity (mean, 80%; range, 30%–100%), and the proportions of DSG3 immunoreactive cells were higher in the WD and MD components than in the PD components. No esophageal adenocarcinoma cases showed more than 10% DSG3 immunoreactivity with only weak cytoplasmic staining. With a 5% immunoreactivity cutoff, DSG3 positivity was 100% in all 63 SCC components, 18% in adenocarcinoma cases, and 0% in small-cell lung carcinoma or large B-cell lymphoma cases. The overall DSG3 specificity was 94%. To the best of our knowledge, this is the first study to characterize DSG3 as a sensitive and specific marker for esophageal SCC.

A reliable nomogram model for predicting esophageal stricture after endoscopic submucosal dissection

Currently, endoscopic submucosal dissection (ESD) has gradually become the diagnosis and treatment of choice for initial esophageal cancer. However, the formation of esophageal stricture after ESD is one of its important complications. In this paper, we intend to identify the risk factors of esophageal stricture to develop a nomogram model to predict the risk of esophageal stricture and validate this model.A total, 159 patients were included in this study, including 21 patients with esophageal stenosis. Multivariate analysis showed that age greater than 60 years, high neutrophil-to-lymphocyte ratio, the extent of esophageal mucosal defect greater than 1/2, and postoperative pathological type of early esophageal squamous cell carcinoma were independent risk factors for predicting esophageal stricture. We constructed a nomogram model to predict esophageal stenosis by these 4 independent predictors.The prediction performance of the model was verified by the area under the receiver operating characteristic curve, the area under the receiver operating characteristic curve of the model was 0.889, and the sensitivity and specificity were 80.00% and 91.28%, respectively, indicating that the prediction performance of the model was good; The calibration curve constructed by internal cross-validation suggested that the predicted results of the nomogram agreed well with the actual observed values.The nomogram model has a high accuracy for predicting esophageal stricture after esophageal ESD and is extremely important to reduce or avoid the occurrence of esophageal stricture. But it needs more external and prospective validation.

GATA3 positivity is associated with poor prognosis in patients with oesophageal squamous cell carcinoma

AIMS

GATA-binding protein 3 (GATA3) is a zinc finger transcription factor with diverse biological functions and is an excellent diagnostic marker for breast and urothelial carcinoma. We aimed to study GATA3 expression in oesophageal squamous cell carcinoma (SCC) and its significance with respect to histological features, clinical parameters and overall survival.

METHODS

We characterised GATA3 immunohistochemistry in 40 patients with oesophageal SCC. Electronic medical records were reviewed for clinical and follow-up information, as well as patient survival.

RESULTS

Eleven (28%) oesophageal SCC were positive for GATA3. The predominant stain patterns were patchy, with either mild or moderate intensities. Patients with GATA3-positive tumours showed significantly shorter overall survival than those with GATA3-negative tumours (p=0.023, Kaplan-Meier survival analysis with log-rank test). In the multivariate Cox proportional hazards regression model, GATA3 positivity was an independent adverse prognostic factor for overall survival (p=0.019, HR 5.671). Surgery, definitive chemotherapy and/or radiotherapy, and initial clinical stage were confirmed as independent prognostic factors.

CONCLUSION

To the best of our knowledge, this is the first study to investigate the incidence of GATA3 positivity in oesophageal SCC and showed GATA3 positivity is associated with poor prognosis in oesophageal SCC.

Correlation Analysis of circRNA Circ_0071662 in Diagnosis and Prognosis of Esophageal Squamous Cell Carcinoma

Background

The role of circRNA circ_0071662 has been studied in bladder cancer. The present study aimed to analyze its involvement in esophageal squamous cell carcinoma (ESCC).

Methods

Patients with ESCC (n = 66), esophageal ulcer (EU, n = 66), or gastroesophageal reflux disease (GERD, n = 66) and healthy controls (n = 66) were enrolled in this study. Plasma samples were collected from all patients and controls. ESCC and paired non-tumor tissue samples were collected from ESCC patients. Circ_0071662 levels in these samples were determined by RT-qPCRs. Diagnostic and prognostic values of circ_0071662 for ESCC were analyzed with ROC curve and survival curve analyses.

Results

Circ_0071662 level was decreased in ESCC, but not in GERN and EU compared to the controls and in ESCC tissues compared to the non-tumor tissues. Plasma circ_0071662 was closely correlated with patients’ tumor size but not with other clinical features. Decreased plasma circ_0071662 levels separated ESCC patients from GERN patients, EU patients, and healthy controls. Low plasma circ_0071662 levels were closely correlated with worse survival outcomes of ESCC patients.

Conclusion

Circ_0071662 is lowly expressed in ESCC and may serve as a potential diagnostic and prognostic biomarker for ESCC.

Esophageal squamous cell cancer in Plummer-Vinson syndrome: Is lichen planus a missing link?

This retrospective study analyzed the occurrence of esophageal squamous cell cancer (ESCC) in a cohort of patients with Plummer-Vinson syndrome (PVS) and mucosal lichen planus (LP). ESCC occurred in 6.2% cases of PVS, more than half of whom had associated oral LP. Mucosal LP and PVS together may increase the predisposition to ESCC.

A concise review towards defining the exposome of oesophageal cancer in sub-Saharan Africa

CONTEXT

Oesophageal cancer (EC) is among the common causes of illness and death among all cancers worldwide. Advanced EC has a poor prognosis, with worse outcomes observed in low-income settings. Oesophageal squamous cell carcinoma (ESCC) is the most common EC histology reported globally, with the highest ESCC incidence rates in the 'Asian Belt' and the African EC corridor. While the aetiology of ESCC is well-documented in the 'Asian belt', data for the African EC corridor and the entirety of sub-Saharan Africa (SSA) are fewer.

OBJECTIVE

To help address gaps in ESCC aetiology in SSA, we critically evaluated evidence of lifestyle, environmental, and epigenetic factors associated with ESCC risk and discussed prospects of defining ESCC exposome.

DATA INCLUSION

Unlimited English and non-English articles search were made on PubMed Central and Web of Science databases from January 1970 to August 2021. In total, we retrieved 999 articles and considered meta-analyses, case-control, and cohort studies. The quality of individual studies was assessed using the Newcastle-Ottawa scale.

DATA EXTRACTION

Details extracted include the year of publication, country of origin, sample size, comparators, outcomes, study subjects, and designs.

DATA ANALYSIS

Together, we assessed 13 case-control studies and two meta-analyses for the effect of lifestyle or environmental exposures on ESCC risk. Again, we evaluated seven case-control studies and one meta-analysis regarding the role of epigenetics in ESCC tumorigenesis.

RESULTS

In general, evidence of ESCC aetiology points to essential contributions of alcohol, tobacco, hot beverages, biomass fuel, and poor oral health/hygiene, although more precise risk characterisation remains necessary.

CONCLUSION

We conclude that ESCC in SSA is a multifactorial disease initiated by several external exposures that may induce aberrant epigenetic changes. The expanding aetiological research in this domain will be enhanced by evidence synthesis from classical and molecular epidemiological studies spanning the external and internal exposome.

The relationship between esophageal cancer mortality‐to‐incidence ratios of countries and ranking of world's health system

The mortality‐to‐incidence ratio (MIR) is a marker that reflects the clinical outcome of cancer treatment. The MIR as a prognostic marker is more reliable and accessible when compared with the long‐term follow‐up survival survey. Theoretically, countries with good health care systems should have favorable cancer outcomes. However, no report has evidenced an association between MIR and countries' placement on the World Health Organization's (WHO) ranking of the world's health systems for esophageal cancer (EC). Therefore, we analyzed the correlation of MIRs with the WHO's rankings and total expenditures on health/gross domestic product (e/GDP) via linear regression analyses. In total, 35 countries were selected according to the data quality. The results showed similar crude rates of incidence/mortality but much lower age‐standardized rates (ASR) of incidence/mortality in more developed regions. Among the continents, Asia had both the highest crude rates and ASR of incidence/mortality. Regarding the MIR, Latin America and the Caribbean had the lowest MIR (0.80), while North America had the highest MIR (0.94). Furthermore, the MIRs of EC failed to correlate with a good WHO ranking and a high e/GDP (P = 0.475 and P = 0.591, respectively). Hence, not all cancer MIRs are associated with a country's health system ranking and their expenditure on health. The results suggest that more effective screening policies are needed to manage EC issues.

Identification of Immune-Cell-Related Prognostic Biomarkers of Esophageal Squamous Cell Carcinoma Based on Tumor Microenvironment

Background

Esophageal squamous cell carcinoma (ESCC) is one of the most fatal cancers in the world. The 5-year survival rate of ESCC is <30%. However, few biomarkers can accurately predict the prognosis of patients with ESCC. We aimed to identify potential survival-associated biomarkers for ESCC to improve its poor prognosis.

Methods

ImmuneAI analysis was first used to access the immune cell abundance of ESCC. Then, ESTIMATE analysis was performed to explore the tumor microenvironment (TME), and differential analysis was used for the selection of immune-related differentially expressed genes (DEGs). Weighted gene coexpression network analysis (WGCNA) was used for selecting the candidate DEGs. Least absolute shrinkage and selection operator (LASSO) Cox regression was used to build the immune-cell-associated prognostic model (ICPM). Kaplan–Meier curve of survival analysis was performed to evaluate the efficacy of the ICPM.

Results

Based on the ESTIMATE and ImmuneAI analysis, we obtained 24 immune cells’ abundance. Next, we identified six coexpression module that was associated with the abundance. Then, LASSO regression models were constructed by selecting the genes in the module that is most relevant to immune cells. Two test dataset was used to testify the model, and we finally, obtained a seven-genes survival model that performed an excellent prognostic efficacy.

Conclusion

In the current study, we filtered seven key genes that may be potential prognostic biomarkers of ESCC, and they may be used as new factors to improve the prognosis of cancer.

Long noncoding RNA SNHG6 promotes oesophageal squamous cell carcinoma by downregulating the miR-101-3p/EZH2 pathway

Long noncoding RNAs (LncRNAs) have been reported to play a vital role in the development of oesophageal squamous cell carcinoma (OSCC). Our previous study revealed that the significant upregulation of the LncRNA small nucleolar RNA host gene 6 (SNHG6) in OSCC promotes OSCC tumourigenesis. However, the mechanisms underlying the dynamics of SNHG6 expression in OSCC have rarely been studied. In this study, we verified the tumour-promoting effect of SNHG6 through sponging miR-101-3p, and their levels were negatively correlated in human samples of OSCC. In addition, miR-101-3p overexpression reversed the effect of SNHG6. Moreover, we confirmed that SNHG6/miR-101-3p affects OSCC by regulating the expression of the enhancer of zeste 2 (EZH2). The effect of EZH2 silencing resembled closely that of SNHG6 knockdown. EZH2 silencing inhibited the expression of protein cyclin D1 and β-catenin, but in contrast, it enhanced the expression of E-cadherin. These findings demonstrated the oncogenic role of SNHG6, which promotes OSCC progression by regulating the expression of EZH2 through its interaction with miR-101-3p. These findings may help in improving the diagnosis and treatment methods of OSCC.

Mutational signatures in esophageal squamous cell carcinoma from eight countries with varying incidence

Esophageal squamous cell carcinoma (ESCC) shows remarkable variation in incidence that is not fully explained by known lifestyle and environmental risk factors. It has been speculated that an unknown exogenous exposure(s) could be responsible. Here we combine the fields of mutational signature analysis with cancer epidemiology to study 552 ESCC genomes from eight countries with varying incidence rates. Mutational profiles were similar across all countries studied. Associations between specific mutational signatures and ESCC risk factors were identified for tobacco, alcohol, opium and germline variants, with modest impacts on mutation burden. We find no evidence of a mutational signature indicative of an exogenous exposure capable of explaining differences in ESCC incidence. Apolipoprotein B mRNA-editing enzyme, catalytic polypeptide-like (APOBEC)-associated mutational signatures single-base substitution (SBS)2 and SBS13 were present in 88% and 91% of cases, respectively, and accounted for 25% of the mutation burden on average, indicating that APOBEC activation is a crucial step in ESCC tumor development.

Cancer Etiology and Prevention Principle: "1 + X"

Cancer was previously thought to be an inevitable aspect of human health with no effective treatments. However, the results of in-depth cancer research suggest that most types of cancer may be preventable. Therefore, a comprehensive understanding of the disparities in cancer burden caused by different risk factors is essential to inform and improve cancer prevention and control. Here, we propose the cancer etiology and prevention principle "1 + X," where 1 denotes the primary risk factor for a cancer and X represents the secondary contributing risk factors for the cancer. We elaborate upon the "1 + X" principle with respect to risk factors for several different cancer types. The "1 + X" principle can be used for precise prevention of cancer by eliminating the main cause of a cancer and minimizing the contributing factors at the same time.

Systematic Review and Meta-analysis of the Most Common Genetic Mutations in Esophageal Squamous Cell Carcinoma

PURPOSE

Esophageal cancer is the second most common cancer among men and women. There is a need to systematically assess the current evidence to map out the contribution of genetic factors in the development of esophageal squamous cell carcinoma (ESCC).

METHODS

A literature search was carried out on published and unpublished studies up to August 2021 in Medline (PubMed), Embase (Ovid), Scopus, Proquest, Web of Science, and Google scholar. Studies that have reported the frequency of genetic mutations in ESCC were included in this study.

RESULTS

A total of 1238 titles were retrieved through searches, and finally, 56 articles, including 8114 samples, met our predefined inclusion criteria. Of the included studies, 31 were conducted in China, 12 in Japan, and the remaining were conducted in various nations, including Brazil, Korea, and Iran. Most of our included studies evaluated the TP53 (n = 37 studies) and PIK3CA (n = 30 studies) gene mutations. TP53 (68.6%; 95% CI: 61.6-74.9), CCND1 (39.3%; 95% CI: 26.2-54.1), MDM2 (24.9%; 95% CI: 9.5-51.0), NOTCH1/2/3 (17.9%; 95% CI: 15.0-21.2), KMT2D (17.4%; 95% CI: 12.4-23.8), CDKN2A (15.0%; 95% CI: 8.1-26.1), PIK3CA (13.8%; 95% CI: 10.3-18.1), FAT1 (13.3%; 95% CI: 11.7-15.0), and EGFR (9.9%; 95% CI: 5.6-17.0) were the most common involved genetic factors in developing ESCC.

CONCLUSION

This systematic review and meta-analysis revealed that more than 10% of ESCC patients had changes in TP53, CCND1, MDM2, NOTCH1/2/3, KMT2D, CDKN2A, PIK3CA, and FAT1 genes, which can highlight their role in developing ESCC. TP53, CCND1, and MDM2 are the most prevalent, demonstrating 68.6%, 39.3%, and 24.9% of the mutations in ESCC patients.

Variations of P40 and P63 Immunostains in Different Grades of Esophageal Squamous Cell Carcinoma: A Potential Diagnostic Pitfall

The distinction of esophageal squamous cell carcinoma (SCC) from adenocarcinoma (adenoCA) using targeted therapies has become critical for small biopsies. In the United States, esophageal SCC is relatively uncommon compared with AdenoCA, with only few detailed immunohistochemical (IHC) studies on esophageal SCC. We characterized p40 and p63 IHC across various grades of squamous differentiation in esophageal SCC and compared their sensitivities between esophageal SCC and adenoCA. Twenty-eight esophageal SCC and 26 esophageal adenoCA (control group) samples were stained for p40, p63, and CK5/6. All hematoxylin-and-eosin-stained SCC slides were reviewed. Tumors were graded according to the World Health Organization classification: well, moderately, or poorly differentiated (WD, MD, and PD, respectively). Considering morphological heterogeneity, individual differentiation components within the same tumor were scored separately (0% to 100%) according to the proportion of immunoreactive cells and marked as positive (≥5%) or negative (<5%). Among 28 esophageal SCC, 15 had mixed intratumoral differentiation. There were 16 WD, 19 MD, and 14 PD components. P40 immunoreactivity was significantly lower in WD than in MD or PD components (P<0.001), P63 immunoreactivity patterns were similar (P<0.001), while CK5/6 showed no differences (P>0.05). The sensitivities for SCC components were 98% (P40), 100% (P63), and 100% (CK5/6), while those for esophageal AdenoCA were significantly lower: 4% (P40), 4% (P63), and 8% (CK5/6). P40 and P63 were sensitive and specific for routine esophageal SCC diagnosis. However, their immunostaining was significantly lower in WD SCC than in higher grade tumors. IHC results for small biopsy specimens should be interpreted carefully, particularly in WD components.

The upregulated expression of RFC4 and GMPS mediated by DNA copy number alteration is associated with the early diagnosis and immune escape of ESCC based on a bioinformatic analysis

Esophageal squamous cell carcinoma (ESCC) is a malignant tumor that commonly occurs worldwide. Usually, Asia, especially China, has a high incidence of esophageal cancer. ESCC often has a poor outcome because of a late diagnosis and lack of effective treatments.

To build foundations for the early diagnosis and treatment of ESCC, we used the gene expression datasets GSE20347 and GSE17351 from the GEO database and a private dataset to uncover differentially expressed genes (DEGs) and key genes in ESCC. Notably, we found that replication factor C subunit 4 (RFC4) and guanine monophosphate synthase (GMPS) were upregulated but have been rarely studied in ESCC. In particular, to the best of our knowledge, our study is the first to explore GMPS and ESCC. Furthermore, we found that high levels of RFC4 and GMPS expression may result from an increase in DNA copy number alterations. Furthermore, RFC4 and GMPS were both upregulated in the early stage and early nodal metastases of esophageal carcinoma. The expression of RFC4 was strongly correlated with GMPS. In addition, we explored the relationship between RFC4 and GMPS expression and tumor-infiltrating immune cells (TILs) in esophageal carcinoma. The results showed that the levels of RFC4 and GMPS increased with a decrease in some tumor-infiltrating cells. Upregulated RFC4 and GMPS with high TILs indicate a worse prognosis.

In summary, our study shows that RFC4 and GMPS have potential as biomarkers for the early diagnosis of ESCC and may played a crucial role in the process of tumor immunity in ESCC.

[Prevention of gastrointestinal cancer]

Throughout the past decades, considerable progress has been made in the (early) diagnosis and treatment of gastrointestinal cancers. However, the prognosis for advanced stages of gastrointestinal tumors remains limited for many patients and approximately one third of all tumor patients die as a result of gastrointestinal tumors. The prevention and early detection of gastrointestinal tumors is therefore of great importance.For this reason, we summarize the current state of knowledge and recommendations for the primary, secondary and tertiary prevention of esophageal, stomach, pancreas, liver and colorectal cancer in the following.

Identification of Key Modules and Hub Genes Involved in Esophageal Squamous Cell Carcinoma Tumorigenesis Using WCGNA

Introduction:

The mechanistic basis for the development of esophageal squamous cell carcinoma (ESCC) remains poorly understood. The goal of the present study was thus to characterize mRNA and long noncoding RNA (lncRNA) expression profiles associated with ESCC in order to identify key hub genes associated with the pathogenesis of this cancer.

Materials and Methods:

The GSE26866 and GSE45670 datasets from the Gene Expression Omnibus (GEO) database were used to conduct a weighted gene co-expression network analysis (WGCNA), after which Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were conducted. Cytoscape was additionally used to construct lncRNA-mRNA networks, after which hub genes were identified and validated through the assessment of TCGA datasets and clinical samples.

Results:

Two gene modules were found to be closely linked to ESCC tumorigenesis. These genes were enriched in cell cycle, MAPK signaling, JAK-STAT signaling, pyrimidine metabolism, arachidonic acid metabolism, and P53 signaling pathway activity, all of which are directly linked with the development of cancer. In total, we identified and validated 9 hub genes associated with ESCC (DDX18, DNMT1, NCAPG, WDHD1, PRR11, VOPP1, ZKSCAN5, LC35C2, and PHACTR2).

Conclusion:

In summary, we identified key gene modules and hub genes associated with ESCC development, and we constructed a lncRNA-mRNA network pertaining to this cancer type. These results provide a foundation for future research regarding the mechanistic basis of ESCC.

Microbiome and Cancers of the Esophagus: A Review

Esophageal cancer (EC) is an aggressive malignant disease ranking amongst the leading causes of cancer deaths in the world. The two main histologic subtypes, esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC), have distinct geographic and temporal patterns and risk factor profiles. Despite decades of research, the factors underlying these geo-temporal patterns are still not fully understood. The human microbiome has recently been implicated in various health conditions and disease, and it is possible that the microbiome may play an important role in the etiology of EC. Although studies of the microbiome and EC are still in their early stages, we review our current understanding of the potential links between ESCC, EAC, and bacterial communities in the oral cavity and esophagus. We also provide a summary of the epidemiology of EC and highlight some key challenges and future directions.

Esophageal Cancer-Derived Extracellular Vesicle miR-21-5p Contributes to EMT of ESCC Cells by Disorganizing Macrophage Polarization

The disorganized polarization of tumor-associated macrophages (TAMs) exerts a critical effect on tumor progression. MicroRNAs (miRNAs) in extracellular vesicles (EVs) secreted from cancer cells may contribute to this process. However, the relationship between TAMs and EVs-miRNAs-mediated regulation in esophageal squamous cell carcinoma (ESCC) remains unclear. In the present study, immunoaffinity magnetic beads combined with antiepithelial cell adhesion molecules (EpCAM) were used to isolate and identify EVs-miR-21-5p from the plasma of ESCC patients. An in vitro coculture system was designed to evaluate the effect of esophageal cancer cells with miR-21-5p overexpression on macrophage polarization. We found that phorbol myristate acetate-induced THP-1 macrophages took up EVs-miR-21-5p from EC109 or EC9706 cells and were transformed into M2 macrophages. This, in turn, contributed to the excessive migration and invasion of esophageal cancer cells. The mechanism underlying these changes may involve activation of M2 macrophages by upregulated ESCC-derived EVs-miR-21-5p through the PTEN/AKT/STAT6 pathway. This may result in esophageal cancer cell epithelial-mesenchymal transition (EMT) via TGF-β/Smad2 signaling. Our results indicate positive feedback between M2 macrophage polarization and EMT of esophageal cancer cells in the tumor microenvironment via shuttling of miR-21-5p in tumor-derived EVs.

Risk factors for esophageal cancer in a high-incidence area of Malawi

PURPOSE

To explore associations of nutritional, infectious, and lifestyle factors with esophageal cancer (EC) occurrence in a high-risk area of Malawi.

METHODS

This case-control study was performed with 227 patients undergoing endoscopy for dysphagia or other upper gastrointestinal complaints. Data on clinicopathological characteristics and risk factors were collected using a questionnaire developed for this study specifically. Ninety-eight blood samples were collected and the prevalence of antibodies against human immunodeficiency virus, herpes simplex virus, cytomegalovirus, Epstein-Barr virus, varicella-zoster virus, and Helicobacter pylori were determined serologically.

RESULTS

The tumor and control groups comprised 157 (69.2%) and 70 (31.8%) patients, respectively. Patients with tumors were significantly older than controls (55.5 vs. 43.5 years, p < 0.001). The male/female ratio did not differ between groups (59% and 54% male, respectively; p = 0.469). EC was associated with smoking (p < 0.001), and alcohol consumption (p = 0.020), but 43% of patients with tumors did not smoke or drink. EC was associated with the consumption of hot food and tea (p = 0.003) and smoked fish (p = 0.011). EC was not associated with any serologically investigated infectious agents. In an age adjusted binary logistic regression analysis of all nutritive factors, only locally made alcohol was significant [odds ratio (OR), 9.252; 95% confidence interval (CI), 1.455-58.822; p = 0.018].

CONCLUSIONS

Apart from alcohol consumption and smoking, the consumption of hot food or tea and smoked fish are associated with EC. Locally distilled alcohol consumption increases the EC risk in Malawi.

Emerging data on nivolumab for esophageal squamous cell carcinoma

INTRODUCTION

Esophageal cancer (EC) is the seventh most common malignancy in the world. The standard treatment for advanced EC patients is systemic chemotherapy, but few effective cytotoxic agents are available. Recently, nivolumab, a human monoclonal immunoglobulin G4 antibody that inhibits programmed cell death protein 1, has been tested for the treatment of advanced squamous cell carcinoma (ESCC) patients. The ATTRACTION-1 trial showed a promising efficacy of nivolumab monotherapy for advanced ESCC patients after prior chemotherapy. The ATTRACTION-3 phase III trial showed the superiority of nivolumab monotherapy over taxane monotherapy for advanced ESCC patients as a second-line treatment. The CheckMate-577 trial also showed survival benefits of postoperative nivolumab monotherapy in patients with resectable EC.

AREAS COVERED

This review mainly outlines emerging data on nivolumab for patients with advanced ESCC after prior chemotherapy. Additionally, this review includes data from the CheckMate-577 trial for patients with resectable EC.

EXPERT OPINION

Nivolumab has been approved by the US Food and Drug Administration for treatment after prior chemotherapy in patients with advanced ESCC. Several trials evaluating nivolumab-containing treatments are ongoing in patients with not only advanced EC, but also locally advanced EC, and these investigational treatments might improve the clinical outcomes of EC patients.

Exome sequencing identifies novel somatic variants in African American esophageal squamous cell carcinoma

Esophageal cancer has a strikingly low survival rate mainly due to the lack of diagnostic markers for early detection and effective therapies. In the U.S., 75% of individuals diagnosed with esophageal squamous cell carcinoma (ESCC) are of African descent. African American ESCC (AA ESCC) is particularly aggressive, and its biological underpinnings remain poorly understood. We sought to identify the genomic abnormalities by conducting whole exome sequencing of 10 pairs of matched AA esophageal squamous cell tumor and control tissues. Genomic analysis revealed diverse somatic mutations, copy number alterations (SCNAs), and potential cancer driver genes. Exome variants created two subgroups carrying either a high or low tumor mutation burden. Somatic mutational analysis based on the Catalog of Somatic Mutations in Cancer (COSMIC) detected SBS16 as the prominent signature in the high mutation rate group suggesting increased DNA damage. SBS26 was also detected, suggesting possible defects in mismatch repair and microsatellite instability. We found SCNAs in multiple chromosome segments, encoding MYC on 8q24.21, PIK3CA and SOX2 on 3q26, CCND1, SHANK2, CTTN on 11q13.3, and KRAS on 12p12. Amplifications of EGFRvIII and EGFRvIVa mutants were observed in two patients, representing a novel finding in ESCC that has potential clinical relevance. This present exome sequencing, which to our knowledge, represents the first comprehensive exome analysis exclusively in AA ESCC, and highlights novel mutated loci that might explain the aggressive nature of AA ESCC and lead to the development of diagnostic and prognostic markers as well as therapeutic targets.

Demographic Trends in Carcinoma Esophagus from India along with a Brief Comparative Review of the Global Trends

Background Esophageal cancers (ECs) are more prevalent in the East Asian countries of the world, wherein squamous cell carcinomas (SCCs) are the predominant histological subtype. In contrast, the patterns in the West are a bit heterogeneous, with esophageal adenocarcinoma (AC) being the more frequent histological subtype. There is very sparse published Indian data pertaining to the demographic trends of ECs.

Materials and Methods Our study was a retrospective analysis of the demographic trends of 917 patients afflicted with ECs who were managed at our center over a 10-year period.

Results and Discussion EC accounted for nearly 4.1% of the total cancer burden managed at our center from January 2002 to December 2011. The mean age of our patient cohort was 54.2 years. The male:female ratio was nearly 1.7:1. Tobacco chewing was noted in 25.4%, smoking in 37%, while alcohol consumption was noted in approximately 20% of the patients. SCC was the most common histological subtype (78.3%), while ACs constituted only 9.9%. Eighty-nine percent of our patients presented with locally advanced staged tumors. Definitive chemoradiation was the most common modality of definitive management then; however, over the years, our preferred choice of the management of ECs has shifted to neoadjuvant chemoradiation, followed by surgery in the carefully selected patients of locally advanced resectable ECs.

Conclusion Our study clearly shows SCC to be the most common histological subtype among ECs, a trend that has been observed in the vast majority of the East Asian nations. The epidemic rise in the incidence of esophageal ACs as seen in the West is not seen in our study. Periodic monitoring of the demographic trends of ECs is of great importance both for clinicians and policymakers. We hope that our study will enlighten both policy holders and clinicians to better channelize the efforts toward prevention and more effective management of this deadly cancer.

Indoor wood combustion, carcinogenic exposure and esophageal cancer in southwest Kenya

BACKGROUND

Exposure to polycyclic aromatic hydrocarbons (PAHs) is a risk factor for esophageal squamous cell carcinoma (ESCC) in high-incidence areas of China, Iran and Brazil, but PAH assessments have not been conducted in East Africa, another ESCC hot spot.

OBJECTIVE

To evaluate demographic or lifestyle factors associated with the PAH biomarker concentrations in the study population, and whether PAH metabolite concentrations showed any associations with esophageal precancerous lesions.

METHODS

We recruited a community-based sample of 289 asymptomatic adults from a rural area of Kenya and performed Lugol's chromoendoscopy to detect esophageal squamous dysplasia (ESD); participants completed a questionnaire and provided a spot urine specimen. We analyzed urine for seven hydroxylated metabolites of naphthalene, fluorene, phenanthrene, and pyrene at the U.S. National Center for Environmental Health, and compared creatinine-corrected PAH metabolite concentrations with questionnaire data and the presence of ESD.

RESULTS

PAH metabolite concentrations among never tobacco users in these rural Kenya residents were 2.4-28.1 times higher than those reported from never tobacco users in Iran, Brazil and the USA. Female sex, cooking indoors, having no post-primary education, and age <50, but not tobacco use, were positively and significantly associated with PAH metabolite concentrations. Almost all participants used wood as cooking fuel. Nine participants had advanced ESD. Adjusted logistic regression showed a significant association between 2-hydroxynaphthalene (OR = 4.19, 95%CI: 1.01-17.47) and advanced ESD. All other PAH metabolites had positive but non-significant associations with advanced ESD.

CONCLUSIONS

Urinary PAH metabolite concentrations among never tobacco users are markedly higher in this group from Kenya than in other populations and are associated with indoor cooking with wood on open, unvented stoves. These metabolite concentrations were also associated with the presence of advanced esophageal dysplasia. Our findings underline the importance of assessing alternative cooking conditions to reduce PAH exposure in this population.

Effect of perioperative flurbiprofen axetil on long-term survival of patients with esophageal carcinoma who underwent thoracoscopic esophagectomy: A retrospective study

Background and Objectives

Nonsteroidal anti‐inflammatory drugs (NSAIDs) have an anti‐inflammatory response, but it remains unclear whether the perioperative use of flurbiprofen axetil can influence postoperative tumor recurrence and survival in esophageal carcinoma. We aimed to explore the effect of perioperative intravenous flurbiprofen axetil on recurrence‐free survival (RFS) and overall survival (OS) in patients with esophageal carcinoma who underwent thoracoscopic esophagectomy.

Methods

This retrospective study included patients who underwent surgery for esophageal carcinoma between December 2009 and May 2015 at the Department of Thoracic Surgery, Anhui Provincial Hospital. Patients were categorized into a non‐NSAIDs group (did not receive flurbiprofen axetil), single‐dose NSAIDs group (received a single dose of flurbiprofen axetil intravenously), and multiple‐dose NSAIDs group (received multiple doses of flurbiprofen).

Results

A total of 847 eligible patients were enrolled. Univariable and multivariable analyses revealed that the intraoperative use of flurbiprofen was associated with long‐term RFS (hazard ratio [HR]: 0.56, 95% confidence interval [CI]: 0.42–0.76, p = .001) and prolonged OS (HR: 0.49, 95% CI: 0.38–0.63, p = .001).

Conclusions

Perioperative flurbiprofen axetil therapy may be associated with prolonged RFS and OS in patients with esophageal carcinoma undergoing thoracoscopic esophagectomy.

Associations of circulating mediators of inflammation, cell regulation and immune response with esophageal squamous cell carcinoma

BACKGROUND

Esophageal squamous cell carcinoma (ESCC) is the most common histologic subtype of esophageal cancer globally. The development of squamous cell carcinoma has important inflammatory influences and effects. We, therefore, examined circulating levels of inflammation- and immune-related proteins for associations with ESCC.

METHODS

We used pre-treatment EDTA plasma from 80 ESCC patients (44% clinical stages I and II) and 80 cancer-free control individuals within the Hospital-based Epidemiologic Research Program at Aichi Cancer Center. Levels of 184 biomarkers were measured by high-throughput multiplexed proximity extension assays using Olink's Proseek Cell Regulation and Immuno-Oncology Panels. ESCC odds ratios (OR) per quantile (based on two to four categories) of each biomarker were calculated by unconditional logistic regression models, adjusted for age, sex, cigarette smoking and alcohol consumption. Correlations among continuous biomarker levels were assessed by Spearman's rank correlation. All statistical tests were two-sided with p values < 0.05 considered as significant. Given the exploratory nature of the study, we did not adjust for multiple comparisons.

RESULTS

Seven proteins were undetectable in nearly all samples. Of the remaining 177 evaluable biomarkers, levels of cluster of differentiation 40 (CD40, per quartile OR 1.64; p trend = 0.018), syntaxin 16 (STX16, per quartile OR 1.63; p trend = 0.008), heme oxygenase 1 (per quartile OR 1.59; p trend = 0.014), and γ-secretase activating protein (GSAP, per quartile OR 1.47; p trend = 0.036) were significantly associated with ESCC. Amongst these significant markers, levels of CD40, STX16, and GSPA were moderately correlated (Rho coefficients 0.46-0.55; p < 0.05).

CONCLUSION

Our case-control study expands the range of inflammation and immune molecules associated with ESCC. These novel findings warrant replication and functional characterization.

The 3-deoxysappanchalcone induces ROS-mediated apoptosis and cell cycle arrest via JNK/p38 MAPKs signaling pathway in human esophageal cancer cells

BACKGROUND

The 3-deoxysappanchalcone (3-DSC), a chemical separated from Caesalpinia sappan L, has been substantiated to display anti-inflammatory, anti-influenza, and anti-allergy activities according to previous studies. However, the underlying mechanisms of action on esophageal cancer remain unknown.

PURPOSE

The present research aims to survey the action mechanisms of 3-DSC in esophageal squamous cell carcinoma (ESCC) cells in vitro.

METHODS

Evaluation of cytotoxicity was determined by MTT tetrazolium salt assay and soft agar assay. Cell cycle distribution, apoptosis induction, reactive oxygen species (ROS) generation, mitochondrial membrane potential (MMP), and multi-caspases activity were appreciated by Muse™ Cell Analyzer. The expressions of cell cycle- and apoptosis-related proteins were presented using Western blotting.

RESULTS

3-DSC blocked cell growth and colony formation ability in a concentration-dependent manner and invoked apoptosis, G2/M cell cycle arrest, ROS production, MMP depolarization, and multi-caspase activity. Furthermore, Western blotting results demonstrated that 3-DSC upregulated the expression of phospho (p)-c-jun NH2-terminal kinases (JNK), p-p38, cell cycle regulators, pro-apoptotic proteins, and endoplasmic reticulum (ER) stress-related proteins whereas downregulated the levels of anti-apoptotic proteins and cell cycle promoters. The effects of 3-DSC on ROS induction were counteracted by pretreatment with N-acetyl-L-cysteine (NAC). Also, our results indicated that p38 (SB203580) and JNK (SP600125) inhibitor slightly inhibited 3-DSC-induced apoptosis. These results showed that 3-DSC-related G2/M phase cell cycle arrest and apoptosis by JNK/p38 MAPK signaling pathway in ESCC cells were mediated by ROS.

CONCLUSION

ROS generation by 3-DSC in cancer cells could be an attractive strategy for apoptosis of cancer cells by inducing cell cycle arrest, ER stress, MMP loss, multi-caspase activity, and JNK/p38 MAPK pathway. Our findings suggest that 3-DSC is a promising novel therapeutic candidate for both prevention and treatment of esophageal cancer.

CircRNA_2646 functions as a ceRNA to promote progression of esophageal squamous cell carcinoma via inhibiting miR-124/PLP2 signaling pathway

MicroRNA-124 (miR-124) has been predicted as a tumor suppressor in esophageal squamous cell carcinoma (ESCC). However, factors contributing to miR-124 reduction remain unclear. Circular RNAs (circRNAs) are a new family of non-coding RNAs with gene regulatory potential via interacting with miRNAs. We predicted three circRNAs, including CircRNA_14359, CircRNA_2646, and CircRNA_129, that could interact with miR-124 by bioinformatics analysis and determined their expressions in ESCC tissues and adjacent normal tissues. We found that CircRNA_2646 was up-regulated in ESCC, negatively correlated with the expression of miR-124 and positively associated with TNM stage and lymph node metastasis of ESCC. Luciferase reporter assay showed that CircRNA_2646 interacted with miR-124 in ESCC Eca109 and TE-1 cells. Moreover, ectopical overexpression of CircRNA_2646 accelerated cell proliferation, migration, invasion, and epithelial-to-mesenchymal transition (EMT), but restoration of miR-124 abrogated these functions and promoted Bcl-2-dependent cell apoptosis. Furthermore, it was found that the oncogene Proteolipid Protein 2 (PLP2) was the target gene of miR-124. In Eca109 and TE-1 cells, restoration of miR-124 decreased the level of PLP2 and inhibited PLP2-induced cell proliferation, migration, invasion, and EMT, but enhanced cell apoptosis. The in vivo study confirmed that CircRNA_2646 promoted ESCC development by repressing miR-124 and activating PLP2. Taken together, we identified that CircRNA_2646 functioned as an inhibitor in miR-124 signaling pathway in ESCC for carcinogenesis and could be a promising target for ESCC therapy.

High expression of spermatogenesis associated serine rich 2 promotes tumorigenicity in esophageal squamous cell carcinoma cells and is associated with poor patient prognosis

Spermatogenesis associated serine rich 2 (SPATS2), recognized as a cytoplasmic RNA-binding protein, is implicated in the tumorgenicity of several cancers. However, the potential role of SPATS2 in esophageal squamous cell carcinoma (ESCC) is yet to be elucidated. The present study aimed to explore the functional implication of SPATS2 in ESCC. The ESCC cell lines Eca109 and KYSE-150 were used to conduct loss-of-function experiments. The expression patterns of SPATS2 in patients with ESCC were obtained from Oncomine, The Cancer Genome Atlas and Genotype-Tissue Expression databases. Reverse transcription-quantitative PCR and western blot analysis were applied to determine the expression levels of SPATS2 in ESCC cells. The proliferation of ESCC cells was measured via cell proliferation and colony-formation assays. Subsequently, the migration and invasion capacities of ESCC cells were observed using Transwell assays. Finally, the expression levels of P53, cyclin E, matrix metalloproteinase (MMP)-9 and neuronal-cadherin were determined via western blot analysis. SPATS2 was expressed at higher levels in ESCC tissues compared with the controls, and high expression of SPATS2 was associated with poor prognosis. ESCC cell line proliferation, migration and invasion abilities were suppressed after silencing SPATS2. Moreover, following knockdown of SPATS2, the proteins cyclin E, MMP-9 and N-cadherin were expressed at markedly decreased levels, while P53 expression was increased. In summary, the results of the present study suggest that SPATS2 promotes ESCC development and progression, providing potential insights into future ESCC targeted treatment.

Evaluation of the Cancer Transition Theory in the US, Select European Nations, and Japan by Investigating Mortality of Infectious- and Noninfectious-Related Cancers, 1950-2018

IMPORTANCE

Despite cancer being a leading cause of death worldwide, scant research has been carried out on the validity of the cancer transition theory, the idea that as nations develop, they move from a situation where infectious-related cancers are prominent to one where noninfectious-related cancers dominate.

OBJECTIVE

To examine whether cancer transitions exist in the US, select European countries, and Japan.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, annual cause-of-death data from the 1950s to 2018 for the US, England and Wales, France, Sweden, Norway, and Japan were extracted from the Human Mortality Database and the World Health Organization (WHO). Statistical analysis was performed from April 2020 to February 2021.

MAIN OUTCOMES AND MEASURES

Age-standardized death rates for all ages and both sexes combined were estimated for cancers of the stomach, cervix, liver, lung, pancreas, esophagus, colorectum, breast, and prostate.

RESULTS

The results of the analysis show that for all countries in this study except for Japan, mortality from infectious-related cancers has declined steadily throughout the period, so that by the end of the period, for Norway, England and Wales, Sweden, and the US, rates were approximately 20 deaths per 100 000 population. Regarding noninfectious-related cancers, at the beginning of the period, all countries exhibited an increasing trend in rates, with England and Wales having the greatest peak of 215.1 deaths per 100 000 population (95% CI 213.7-216.6 deaths per 100 000 population) in 1985 followed by a decline, with most of the other countries reaching a peak around 1990 and declining thereafter. Furthermore, there is a visible crossover in the trends for infectious-related and noninfectious-related cancers in Japan and Norway. This crossover occurred in 1988 in Japan, when the rates for both types of cancers stood at 116 per 100 000 population (95% CI, 115.0-116.5 per 100 000 population), and in 1955 in Norway, when they passed each other at 100 per 100 000 population (95% CI, 96.4-105.3 per 100 000 population).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, the findings suggest that cancer mortality patterns parallel the epidemiological transition, which states that as nations develop, they move from a stage where infectious diseases are prominent to one where noninfectious diseases dominate. An implication is that the epidemiological transition theory as originally formulated continues to be relevant, despite some researchers arguing that there should be additional stages beyond the original 3.

Gastrointestinal cancers in China, the USA, and Europe

Gastrointestinal (GI) cancers, including colorectal cancer, gastric cancer, and esophageal cancer, are a major medical and economic burden worldwide and have the largest number of new cancer cases and cancer deaths each year. Esophageal and gastric cancers are most common in developing countries, while colorectal cancer forms the major GI malignancy in Western countries. However, a great shift in the predominant GI-cancer type is happening in countries under economically transitioning and, at the same time, esophageal and gastric cancers are reigniting in Western countries due to the higher exposure to certain risk factors. The development of all GI cancers is highly associated with lifestyle habits and all can be detected by identified precancerous diseases. Thus, they are all suitable for cancer screening. Here, we review the epidemiological status of GI cancers in China, the USA, and Europe; the major risk factors and their distribution in these regions; and the current screening strategies.

A nomogram for screening esophageal squamous cell carcinoma based on environmental risk factors in a high-incidence area of China: a population-based case-control study

Background

Selection of high-risk subjects for endoscopic screening of esophageal squamous cell carcinoma (ESCC) lacks individual predictive tools based on environmental risk factors.

Methods

We performed a large population-based case-control study of 1418 ESCC cases and 1992 controls in a high-risk area of China. Information on potential risk factors was collected via face-to-face interview using an electronic structured questionnaire. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using unconditional logistic regression models, and predictive nomograms were established accordingly. A weighted analysis was further conducted to introduce age into predictive nomograms due to frequency matching study design.

Results

Most cases were usually exposed to 4 to 6 risk factors, but most controls were usually exposed to 3 to 5 risk factors. The AUCs of male and female predictive nomograms were 0.75 (95%CI: 0.72, 0.77) and 0.76 (95%CI: 0.73, 0.79), respectively. The weighted analysis adding age in the predictive model improved the AUC in both men and women (0.81 (95%CI: 0.79, 0.84) and 0.88 (95%CI: 0.85, 0.90), respectively).

Conclusions

An easy-to-use preclinical predictive tool is provided to select candidate population with high ESCC risk for endoscopic screening. Its usefulness needs to be further evaluated in future screening practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08053-7.

Trichostatin A augments esophageal squamous cell carcinoma cells migration by inducing acetylation of RelA at K310 leading epithelia-mesenchymal transition

Protein acetylation modification controlled by acetyltransferases (HATs) and histone deacetylases (HDACs) regulates multiple biologic processes including cell proliferation and migration. HDAC inhibitors (HDACi) are currently used as a promising epigenetic-based therapy for cancer treatment. Of the anticancer activity, accumulating evidence has shown that HDACi can enhance cell migration in subset of cancer cells. Thus, there is a critical need to identify such counter anticancer activity to HDACi in different cancer cell types and elucidate the rational in order to develop appropriate combination therapies in cancer treatment. In seeking to address the effect of HDACi on esophageal squamous cell carcinoma (ESCC) cells migration, trichostatin A (TSA), a canonical HDACi targeting class I and class II HDACs, was used. Here, we report the discovery that TSA augmented ESCC cells migration by increasing the acetylation of nuclear factor-κB/RelA at lysine 310 (K310). To elucidate the mechanism by which TSA promotes the migration of ESCC cells, plasmid of RelA K310R, a mutant precluding acetylation at K310, was transfected into ESCC cells. Blocking acetylation of RelA at K310 significantly arrogated TSA-induced cell migration. Mechanistic investigations revealed that TSA increased the level of acetylated RelA at K310 (RelA K310ac), thereby increasing the level of epithelia-mesenchymal transition (EMT) transcription factor slug mRNA, which in turn induced EMT. Overall, this study indicates that TSA promotes ESCC cells migration by RelA K310ac-slug-EMT pathway. Our findings provide a strategy to eradicate HDACi-induced ESCC cells migration by targeting RelA as a combination therapy with nonspecific HDACi in ESCC treatment.

Polygalacin D suppresses esophageal squamous cell carcinoma growth and metastasis through regulating miR-142-5p/Nrf2 axis

Esophageal squamous cell carcinoma (ESCC) is a common malignancy worldwide with poor survival. High expression of nuclear factor erythroid 2-related factor 2 (Nrf2) is an antioxidant transcript factor that protects malignant cells from death. Polygalacin D (PGD), a bioactive compound isolated from Platycodongrandiflorum (Jacq.), has recently been reported to be an anti-tumor agent. This study aimed to investigate the anti-cancer effects of PGD and its underlying molecular mechanisms in human ESCC. Here, we confirmed that Nrf2 was over-expressed in clinical ESCC tissues and cell lines. PGD treatments markedly reduced Nrf2 expression in a dose- and time-dependent manner in ESCC cell lines. Importantly, we found that PGD significantly reduced proliferation, and induced G2/M cell cycle arrest and apoptosis in ESCC cells. Also, PGD dramatically triggered autophagy in ESCC cells, and autophagy inhibitor bafilomycinA1 (BafA1) greatly abrogated the inhibitory role of PGD in cell viability and apoptosis. In addition, PGD evidently provoked reactive oxygen species (ROS) accumulation in ESCC cells, and pre-treatment of ROS scavenger N-acetyl-l-cysteine (NAC) markedly abolished PGD-triggered cell death. PGD also dramatically repressed migration and invasion in ESCC cells. Mechanistic investigation revealed that Nrf2 gene was directly targeted by miR-142-5p. MiR-142-5p negatively regulated Nrf2 expression in ESCC cells. We notably found that PGD-inhibited proliferation, migration and invasion in ESCC were considerably rescued by miR-142-5p knockdown; however, ROS production, apoptosis and autophagy induced by PGD were almost eliminated when miR-142-5p was silenced. On the contrast, over-expressing miR-142-5p could remarkably promote the anti-ESCC effects of PGD. Experiments in vivo by the tumor xenograft model confirmed that miR-142-5p effectively improved the activity of PGD to repress tumor growth and lung metastasis. Both in vitro and in vivo studies showed that PGD had few side effects on normal cells and major organs. Collectively, our findings provided the first evidence that PGD could be an effective therapeutic strategy for ESCC treatment by regulating miR-142-5p/Nrf2 axis with few adverse effects.

International trends in oesophageal cancer survival by histological subtype between 1995 and 2014

INTRODUCTION

Survival from oesophageal cancer remains poor, even across high-income countries. Ongoing changes in the epidemiology of the disease highlight the need for survival assessments by its two main histological subtypes, adenocarcinoma (AC) and squamous cell carcinoma (SCC).

METHODS

The ICBP SURVMARK-2 project, a platform for international comparisons of cancer survival, collected cases of oesophageal cancer diagnosed 1995 to 2014, followed until 31st December 2015, from cancer registries covering seven participating countries with similar access to healthcare (Australia, Canada, Denmark, Ireland, New Zealand, Norway and the UK). 1-year and 3-year age-standardised net survival alongside incidence rates were calculated by country, subtype, sex, age group and period of diagnosis.

RESULTS

111 894 cases of AC and 73 408 cases of SCC were included in the analysis. Marked improvements in survival were observed over the 20-year period in each country, particularly for AC, younger age groups and 1 year after diagnosis. Survival was consistently higher for both subtypes in Australia and Ireland followed by Norway, Denmark, New Zealand, the UK and Canada. During 2010 to 2014, survival was higher for AC compared with SCC, with 1-year survival ranging from 46.9% (Canada) to 54.4% (Ireland) for AC and 39.6% (Denmark) to 53.1% (Australia) for SCC.

CONCLUSION

Marked improvements in both oesophageal AC and SCC survival suggest advances in treatment. Less marked improvements 3 years after diagnosis, among older age groups and patients with SCC, highlight the need for further advances in early detection and treatment of oesophageal cancer alongside primary prevention to reduce the overall burden from the disease.

Upregulation of deubiquitinase USP7 by transcription factor FOXO6 promotes EC progression via targeting the JMJD3/CLU axis

Esophageal carcinoma (EC) is recognized as one of the most frequently occurring malignancies worldwide, and its high morbidity rate motivates efforts to identify potential therapeutic targets. Notably, forkhead box (FOX) family genes are highlighted as possible biomarkers for diagnostics, prognostics, and therapeutics of various malignancies, including EC. Our present study was performed to investigate the underlying mechanism of FOXO6 on the development of EC. We observed a significant upregulation of FOXO6 in EC tissues, contributing to the migration and proliferation in EC cells through gain- and loss-of-function assays. FOXO6 directly interacted with the ubiquitin-specific processing protease 7 (USP7) gene promoter and enhanced its transcriptional activity, which resulted in suppressed cancer cell apoptosis as revealed by chromatin immunoprecipitation (ChIP)-qPCR. USP7 enhanced the ubiquitination of Jumonji domain-containing protein D3 (JMJD3), elevated JMJD3-promoted growth of EC cells, and transcriptionally activated clusterin (CLU) expression at the promoter region via histone H3 lysine 27 tri-methyl (H3K27me3) demethylation, according to immunoprecipitation and ubiquitination assays. Finally, we verified that FOXO6 mediated effects on the USP7/JMJD3/CLU axis to exert an oncogenic role in vivo, which was blocked by USP7 and JMJD3 inhibitor. Our findings demonstrate an important role of the FOXO6/USP7/JMJD3/CLU pathway in EC progression and thus provide attractive potential therapeutic targets for EC patients.

Initial results from a multi-center population-based cluster randomized trial of esophageal and gastric cancer screening in China

Background

We initiated the first multi-center cluster randomized trial of endoscopic screening for esophageal cancer and gastric cancer in China. The objective of the study was to report the baseline screening findings in this trial.

Methods

We recruited a total of 345 eligible clusters from seven screening centers. In the intervention group, participants from high-risk areas were screened by endoscopy; in non-high-risk areas, high-risk individuals were identified using a questionnaire and advised for endoscopy. Lugol’s iodine staining in esophagus and indigo carmine dye in stomach were performed to aid in the diagnosis of suspicious lesions. The primary outcomes of this study were the detection rate (proportion of positive cases among individuals who underwent endoscopic screening) and early detection rate (the proportion of positive cases with stage 0/I among all positive cases).

Results

A total of 149,956 eligible subjects were included. The detection rate was 0.7% in esophagus and 0.8% in stomach, respectively. Compared with non-high-risk areas, the detection rates in high-risk areas were higher, both in esophagus (0.9% vs. 0.1%) and in stomach (0.9% vs. 0.3%). The same difference was found for early-detection rate (esophagus: 92.9% vs. 53.3%; stomach: 81.5% vs. 33.3%).

Conclusions

The diagnostic yield of both esophagus and stomach were higher in high-risk areas than in non-high-risk areas, even though in non-high-risk areas, only high-risk individuals were screened. Our study may provide important clues for evaluating and improving the effectiveness of upper-endoscopic screening in China.

Trial registration: Protocol Registration System in Chinese Clinical Trial Registry, ChiCTR-EOR-16008577. Registered 01 June 2016-Retrospectively registered, http://www.chictr.org.cn/showprojen.aspx?proj=14372

High expression of CIN85 promotes proliferation and invasion of human esophageal squamous cell carcinoma

SH3 domain-containing kinase-binding protein 1 (CIN85), an 85 kDa protein known to be a member of the signal adaptor family, is abnormally expressed in several human malignancies and has been found to be involved in the growth, migration and invasion of these tumors. The objective of the present study was to clarify the clinical significance of CIN85 in human esophageal squamous cell carcinoma (ESCC), as well as its in vitro functions. CIN85 expression was evaluated in 129 cases of ESCC and its adjacent normal tissues using immunohistochemistry to explore its clinical relevance and prognostic value. The functions of CIN85 in the ESCC TE1 cell line were analyzed in vitro using the interfering short hairpin RNA silencing technique. MTS, wound healing, clone formation and Transwell assays were used to detect the proliferation, migration and invasion of ESCC cells. CIN85 expression was identified mainly in ESCCs and their adjacent normal tissues, and the high expression of CIN85 was significantly associated with advanced Tumor Node Metastasis stage and lymph node metastasis. CIN85 gene silencing significantly inhibited TE1 cell proliferation, migration and invasion. These results demonstrated that CIN85 was highly expressed in advanced stage ESCC and lymph node metastasis, and played a critical role in tumor proliferation and progression. Therefore, CIN85 may be a promising therapeutic target for human ESCC.

P2Y2 receptor activation promotes esophageal cancer cells proliferation via ERK1/2 pathway

Esophageal cancer is a prominent worldwide illness that is divided into two main subtypes: esophageal squamous cell carcinoma and esophageal adenocarcinoma. Mortality rates are alarming, and the understanding of the mechanisms involved in esophageal cancer development, becomes essential. Purinergic signaling is related to many diseases and among these various types of tumors. Here we studied the effects of the P2Y₂ receptor activation in different types of esophageal cancer. Esophageal tissue samples of healthy controls were used for P2Y₂R expression quantification. Two human esophageal cancer cell lines Kyse-450 (squamous cell carcinoma) and OE-33 (adenocarcinoma) were used to perform in vitro analysis of cell proliferation, migration, adhesion, and the signaling pathways involved in P2Y₂R activation. Data showed that P2Y₂R was expressed in biopsies of patients with ESCC and adenocarcinoma, as well as in the two human esophageal cancer cell lines studied. The RT-qPCR analysis demonstrated that OE-33 cells have higher P2RY2 expression than Kyse-450 squamous cell line. Results showed that P2Y₂R activation, induced by ATP or UTP, promoted esophageal cancer cells proliferation and colony formation. P2Y₂R blockage with the selective antagonist, AR-C 118925XX, led to decreased proliferation, colony formation and adhesion. Treatments with ATP or UTP activated ERK 1/2 pathway in ESCC and ECA cells. The P2Y₂R antagonism did not alter the migration of esophageal cancer cells. Interestingly, the esophageal cancer cell lines presented a distinct profile of nucleotide hydrolysis activity. The modulation of P2Y₂ receptors may be a promising target for esophageal cancer treatment.

The Synthetic Flavonoid Derivative GL-V9 Induces Apoptosis and Autophagy in Cutaneous Squamous Cell Carcinoma via Suppressing AKT-Regulated HK2 and mTOR Signals

Cutaneous squamous-cell carcinoma (cSCC) is one of most common type of non-black skin cancer. The malignancy degree and the death risk of cSCC patients are significantly higher than basal cell carcinoma patients. GL-V9 is a synthesized flavonoid derived from natural active ingredient wogonin and shows potent growth inhibitory effects in liver and breast cancer cells. In this study, we investigated the anti-cSCC effect and the underlying mechanism of GL-V9. The results showed that GL-V9 induced both apoptosis and autophagy in human cSCC cell line A431 cells, and prevented the growth progression of chemical induced primary skin cancer in mice. Metabolomics assay showed that GL-V9 potentially affected mitochondrial function, inhibiting glucose metabolism and Warburg effect. Further mechanism studies demonstrated that AKT played important roles in the anti-cSCC effect of GL-V9. On one hand, GL-V9 suppressed AKT-modulated mitochondrial localization of HK2 and promoted the protein degradation of HK2, resulting in cell apoptosis and glycolytic inhibition. On the other hand, GL-V9 induced autophagy via inhibiting Akt/mTOR pathway. Interestingly, though the autophagy induced by GL-V9 potentially antagonized its effect of apoptosis induction, the anti-cSCC effect of GL-V9 was not diluted. All above, our studies suggest that GL-V9 is a potent candidate for cSCC treatment.

Health-related quality of life and treatment modality among esophageal squamous cell carcinoma survivors: A prospective study using time to deterioration model analysis

BACKGROUND AND OBJECTIVES

This study aimed to analyze the association between health-related quality of life and treatment modality among esophageal squamous cell carcinoma (ESCC) survivors.

METHODS

Patients completed the EORTC QLQ-C30 and EORTC QLQ-OES18 at baseline and follow-up. A time to deterioration model analysis was performed to compare longitudinal EORTC QLQ-C30/QLQ-OES18 data between surgery alone and surgery with adjuvant chemotherapy.

RESULTS

For EORTC QLQ-C30 scale, compared with surgery alone, significant delays in time to deterioration in role functioning (16.05 months vs. 15.00 months; p = .045), cognitive functioning (20.80 months vs. 16.26 months; p = .017), social functioning (19.09 months vs. 12.35 months; p = .001), and dyspnea (18.53 months vs. 14.62 months; p = .011) were observed for surgery with adjuvant chemotherapy. For QLQ-OES18 scale, compared with surgery alone, significant delays in time to deterioration in dysphagia (13.75 months vs. 8.16 months; p = .005), choking when swallowing (20.67 months vs. 15.08 months; p = .001), and dry mouth (21.78 months vs. 17.28 months; p = .039) were observed for surgery with adjuvant chemotherapy.

CONCLUSIONS

Patients who received postoperative chemotherapy had significant delay in time to deterioration in multiple ESCC-related symptoms, functions of EORTC QLQ-C30 and EORTC QLQ-OES18.