Alcohol Consumption and Multiple Dysplastic Lesions Increase Risk of Squamous Cell Carcinoma in the Esophagus, Head, and Neck

Artificial intelligence-based detection of pharyngeal cancer using convolutional neural networks

OBJECTIVES

The prognosis for pharyngeal cancer is relatively poor. It is usually diagnosed in an advanced stage. Although the recent development of narrow-band imaging (NBI) and increased awareness among endoscopists have enabled detection of superficial pharyngeal cancer, these techniques are still not prevalent worldwide. Nevertheless, artificial intelligence (AI)-based deep learning has led to significant advancements in various medical fields. Here, we demonstrate the diagnostic ability of AI-based detection of pharyngeal cancer from endoscopic images in esophagogastroduodenoscopy.

METHODS

We retrospectively collected 5403 training images of pharyngeal cancer from 202 superficial cancers and 45 advanced cancers from the Cancer Institute Hospital, Tokyo, Japan. Using these images, we developed an AI-based diagnostic system with convolutional neural networks. We prepared 1912 validation images from 35 patients with 40 pharyngeal cancers and 40 patients without pharyngeal cancer to evaluate our system.

RESULTS

Our AI-based diagnostic system correctly detected all pharyngeal cancer lesions (40/40) in the patients with cancer, including three small lesions smaller than 10 mm. For each image, the AI-based system correctly detected pharyngeal cancers in images obtained via NBI with a sensitivity of 85.6%, much higher sensitivity than that for images obtained via white light imaging (70.1%). The novel diagnostic system took only 28 s to analyze 1912 validation images.

CONCLUSIONS

The novel AI-based diagnostic system detected pharyngeal cancer with high sensitivity. It could facilitate early detection, thereby leading to better prognosis and quality of life for patients with pharyngeal cancers in the near future.

Long-term outcome of endoscopic resection for intramucosal esophageal squamous cell cancer: a secondary analysis of the Japan Esophageal Cohort study

BACKGROUND

Prospectively collected long-term data of patients undergoing endoscopic resection for superficial esophageal squamous cell carcinoma (ESCC) are limited. The aim of this study was to determine the prospectively collected long-term outcomes of endoscopic resection for ESCC as a secondary analysis of the Japan Esophageal Cohort (JEC) study.

METHODS

Patients who underwent endoscopic resection of intramucosal ESCC at 16 institutions between September 2005 and May 2010 were enrolled in the JEC study. All patients underwent endoscopic examination with iodine staining at 3 and 6 months after resection, and every 6 months thereafter. We investigated clinical courses after endoscopic resection, survival rates, and cumulative incidence of metachronous ESCC.

RESULTS

330 patients (mean age 67.0 years) with 396 lesions (mean size 20.4 mm) were included in the analysis. Lesions were diagnosed as high-grade intraepithelial neoplasia in 17.4 % and as squamous cell carcinoma in 82.6 % (limited to epithelium in 28.4 %, to lamina propria in 55.4 %, and to muscularis mucosa in 16.2 %). En bloc resection was achieved in 291 (73.5 %). The median follow-up period was 49.4 months. Local recurrences occurred in 13 patients (3.9 %) and were treated by endoscopic procedures. Lymph node metastasis occurred in two patients (0.6 %) after endoscopic resection. The 5-year overall, disease-specific, and metastasis-free survival rates were 95.1 %, 99.1 %, and 94.6 %, respectively. The 5-year cumulative incidence rate of metachronous ESCC was 25.7 %.

CONCLUSIONS

Our study demonstrated that endoscopic resection is an effective treatment for intramucosal ESCC, with favorable long-term outcomes.

Evaluation of the usefulness of upper gastrointestinal endoscopy and the ValsamouthⓇ by an otolaryngologist in patients with Hypopharyngeal cancer

OBJECTIVE

The aim of this retrospective study is to evaluate the usefulness of upper gastrointestinal endoscopy and the Valsamouth^Ⓡ by an otolaryngologist in patients with hypopharyngeal cancer to assess the risk.

METHODS

The study group comprised 41 patients with untreated hypopharyngeal cancer that was precisely diagnosed by an otolaryngologist using upper gastrointestinal endoscopy and the Valsamouth^Ⓡ at our hospital from January 2016 to December 2017. With upper gastrointestinal endoscopy and the Valsamouth^Ⓡ, the oral cavity, oropharynx, larynx, hypopharynx, and esophagus were observed in this order. Narrow-band imaging, and subsequently, white-light observation were performed. At the hypopharynx, vocalization, and subsequently, the Valsalva maneuver were performed. After observing the esophagus, Lugol chromoendoscopy of the esophagus was performed.

RESULTS

The mean age of the 38 men and 3 women included in the study was 69.7 ± 10.0 years (range, 51-94 years). As for the T category of hypopharyngeal cancer, T1 cancer was observed in 9 patients, T2 cancer in 14, T3 cancer in 11, and T4 cancer in 7. With vocalization, the grade of visualization in the hypopharynx was 1 in 30 patients (73.2%), 2 in 11 patients (26.8%), and 3 or more in 0 patients (0.0%). With the Valsalva maneuver, the grade of visualization in the hypopharynx was 1 in 1 patient (2.4%), 2 in 15 patients (36.6%), 3 in 8 patients (19.5%), 4 in 11 patients (26.8%), and 5 in 6 patients (14.6%). The grade of visualization in the hypopharynx on average was 1.27 after vocalization and 3.15 after the Valsalva maneuver (p < 0.001). With vocalization, the percentage of patients in whom the entire image of hypopharyngeal cancer could be observed was 0.0% for grade 1 and 18.2% for grade 2. With the Valsalva maneuver, the percentage of patients in whom the entire image of hypopharyngeal cancer could be observed was 0.0% for grade 1, 40.0% for grade 2, 50.0% for grade 3, 86.1% for grade 4, and 100% for grade 5. Synchronous esophageal cancers were detected in 17.1% (7/41) of the patients. The grade of Lugol-voiding lesions was A in 5.6%, B in 52.8%, and C in 41.7%.

CONCLUSION

The examination with upper gastrointestinal endoscopy and the Valsamouth^Ⓡ by an otolaryngologist is feasible in patients with hypopharyngeal cancer. This procedure can detect synchronous esophageal cancer, allowing the risk of metachronous cancer in the head and neck or the esophagus to be recognized after the treatment.

Association between the findings of metachronous secondary primary malignancies and the number of Lugol-voiding lesions

This study was designed to evaluate the relation between dysplastic squamous epithelium in the esophageal mucosa and the development of metachronous secondary primary malignancies (mSPM) other than esophagus after endoscopic resection (ER) in patients with early esophageal squamous cell carcinoma (SCC). We studied 330 patients with early esophageal SCC who underwent ER as a post hoc analysis of a prospective multicenter cohort study (UMIN Clinical Trials Registry ID UMIN000001676). Lugol-voiding lesions (LVL) were graded into 3 categories (A = no lesion; B = 1 to 9 lesions; C ≥ 10 lesions). The following variables were studied: (i) the incidences of mSPM other than esophagus; (ii) the standardized incidence ratios (SIRs) of mSPM; (iii) the cumulative incidence and total number of mSPM other than esophagus; and (iv) predictors of mSPM other than esophagus on analysis with a multivariate Cox proportional-hazards model. After a median follow-up of 46.6 months, mSPM other than esophagus was diagnosed in a total of 73 patients (90 lesions). Among the 106 patients in group C, 37 patients had mSPM (51 lesions), including head and neck cancer in 14 patients (24 lesions) and gastric cancer in 12 patients (16 lesions). The SIR of mSPM was 3.61 in this study subjects. An increase in the LVL grade (A to B to C) was associated with a progressive increase in the cumulative incidence rate of mSPM other than esophagus (P = 0.017 for A vs. C, P = 0.023 for B vs. C). An increase in the LVL grade (A to B to C) was also associated with a progressive increase in the total number of mSPM other than esophagus per 100 person-years (primary events, relative risk [RR] = 1.66 and 3.24 for grades B and C, respectively, vs. A, P = 0.002 for trend; all events, RR = 1.81 and 4.66 for grades B and C, respectively, vs. A, P < 0.0001 for trend). LVL grade C was a strong predictor of mSPM other than esophagus (RR = 3.41 for A vs. C). LVL grade may be a useful predictor of the risk of mSPM other than esophagus after ER in patients with early esophageal SCC.

The Alcohol Use Disorders Identification Test and the risk of metachronous cancer after endoscopic resection of esophageal cancer

Follow-up studies of Japanese patients who had undergone endoscopic resection (ER) for early esophageal squamous cell carcinoma (ESCC) have reported a high prevalence of metachronous SCC in the upper aerodigestive tract (UAT). This prospective multicenter cohort study followed up 330 Japanese patients after ER of ESCC for a median of 49.4 months. The Alcohol Use Disorders Identification Test (AUDIT) for the 12-month period prior to study registration revealed high frequencies of high-risk drinking behaviors: 84 (25.4%) subjects had AUDIT scores of ≥15 points (suspected alcohol dependence) and 121 (36.7%) subjects had AUDIT scores of 8-14 points (hazardous drinking). Seventy-four subjects were metachronously diagnosed with ESCC, and 20 subjects with head and neck SCC (HNSCC). AUDIT scores ≥15 were associated with increases in the total number of HNSCCs per 100 person-years (0.4 for 0-7, 1.2 for 8-14 and 7.1 for ≥15; P < 0.0001). AUDIT scores were progressively associated with the grade of esophageal Lugol-voiding lesions (LVLs), a predictor of field cancerization in the UAT. Both an AUDIT score of ≥15 points and the presence of multiple LVLs were independent predictors of metachronous HNSCC [multivariate hazard ratio (95% confidence interval) = 6.98 (1.31-37.09) and 3.19 (1.19-8.54), respectively]. However, a high AUDIT score was not a predictor of metachronous ESCC. In conclusion, high AUDIT scores were markedly frequent in this population and increased the risk of metachronous HNSCC. The assessment of drinking behavior using the AUDIT and the completion of interventions for alcohol problems should be incorporated into the treatment strategy of ESCC. The name of the clinical trial register and the clinical trial registration number: Japan Esophageal Cohort Study, UMIN000001676.

Newly developed primary malignancies in long-term survivors who underwent curative esophagectomy for squamous cell carcinoma of the esophagus

PURPOSE

We evaluated the efficacy of the long-term follow-up of patients who underwent radical esophagectomy for esophageal squamous cell carcinoma (ESCC) to screen for recurrence and new primary malignancies.

METHODS

We retrospectively collected 448 ESCC patients who underwent radical esophagectomy. Esophagogastroduodenoscopy, computed tomography, a stool test and the assessment of the serum concentration of squamous cell carcinoma antigen and carcinoembryonic antigen were performed annually, even over 5 years after esophagectomy. The incidence of ESCC recurrence and new primary malignancies was investigated.

RESULTS

We enrolled 222 patients who survived at least 5 years after esophagectomy. A total of 104 new primary malignancies occurred in 82 patients (36.9%) after esophagectomy. Twenty-one malignancies were in the head and neck region, 14 in the residual esophagus, 13 in the prostate and 11 in the gastric tube and lung. Patients who developed new primary malignancies after esophagectomy had a significantly higher Brinkman index than those without new malignancies. An endoscopic approach successfully treated 92.9% of carcinomas in the residual esophagus, 90.9% of cancers in the gastric tube and 42.9% of carcinomas in the head and neck region.

CONCLUSION

The incidence of new primary malignancies was higher than the age-standardized incidence. Long-term follow-up and systemic screening may increase the probability of an early diagnosis and subsequent low-invasive treatment.

Essential gene expression pattern of head and neck squamous cell carcinoma revealed by tumor-specific expression rule based on single-cell RNA sequencing

Head and neck squamous cell carcinoma (HNSCC) has been widely reported and considered as one of the most threatening diseases to human health. Derived from complicated tissue subtypes, HNSCC has diverse symptoms and pathogenesis. They make the identification of the core carcinogenic factors of such diseases at the multi-cell level difficult. With the development of single-cell sequencing technologies, the effects of non-malignant cells on traditional bulk sequencing data can be eliminated directly. On the basis of fresh single-cell RNA-seq data, we set up a computational filtering strategy for tumor cell identification in an expression rule manner. This strategy can reveal the accurate expression distinction between tumor cells and adjacent tumor microenvironment, which are all supported by literature reports. Validated by several independent datasets, these rule genes can further group HNSCC patients with significant difference on survival risks. Thus, the establishment of our computational approach may not only provide an efficient tool to identify malignant cells in the tumor ecosystem but also deepen our understanding of tumor heterogeneity and tumorigenesis.

Esophageal Histological Precursor Lesions and Subsequent 8.5-Year Cancer Risk in a Population-Based Prospective Study in China

INTRODUCTION

Data on the associations between esophageal histological lesions and risk of esophageal squamous cell carcinoma (ESCC) in general populations are limited. We aimed to investigate these associations in a large Chinese general population to inform future Chinese ESCC screening guidelines.

METHODS

We performed endoscopic screening of 21,111 participants aged 40-69 years from 3 high-risk areas of China in 2005-2009, and followed the cohort through 2016. Cumulative incidence and mortality rates of ESCC were calculated by baseline histological diagnosis, and hazard ratios of ESCC, overall and by age and sex, were assessed using the Cox proportional hazards models.

RESULTS

We identified 143 new ESCC cases (0.68%) and 62 ESCC deaths (0.29%) during a median follow-up of 8.5 years. Increasing grades of squamous dysplasia were associated with the increasing risk of ESCC incidence and mortality. The cumulative ESCC incidence rates for severe dysplasia/carcinoma in situ, moderate dysplasia (MD), and mild dysplasia were 15.5%, 4.5%, and 1.4%, respectively. Older individuals (50-69 years) had 3.1 times higher ESCC incidence than younger individuals (40-49 years), and men had 2.4 times higher ESCC incidence than women.

DISCUSSION

This study confirmed that increasing grades of squamous dysplasia are associated with increasing risk of ESCC and that severe dysplasia and carcinoma in situ require clinical treatment. This study suggests that in high-risk areas of China, patients with endoscopically worrisome MD should also receive therapy, the first screening can be postponed to 50 years, and endoscopic surveillance intervals for unremarkable MD and mild dysplasia can be lengthened to 3 and 5 years, respectively.

Utility of Valsalva maneuver in the endoscopic pharyngeal observation

BACKGROUND

Metachronous cancer rate in the pharynx is high before and after the treatment of esophageal cancer. Endoscopic observation is difficult in the pharynx especially in the postcricoid area. Pharyngeal cancer in the postcricoid area has been often found in advanced stage. Valsalva maneuver has been reported to improve the visibility.

METHODS

From May 2017 we introduced a dedicated mouthpiece to conduct Valsalva maneuver. One hundred consecutive patients who had been observed throughout the pharynx by one endoscopist were enrolled. A total of 200 image files before and after introduction were made and reviewed by three endoscopists. We retrospectively evaluated the utility and safety of Valsalva maneuver.

RESULTS

The visibility before introduction was Good in three cases, Moderate in 12 cases and Poor in 85 cases. Meanwhile, the visibility after introduction was Good in 58 cases, Moderate in 23 cases, and Poor in 19 cases (P < 0.05). Nine lesions including hypopharyngeal cancer were found and adverse events were not observed in this study.

CONCLUSION

The Valsalva maneuver was considered to be a safe and effective method in endoscopic observation of the pharynx.

Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer

The Japan Gastroenterological Endoscopy Society has developed endoscopic submucosal dissection/endoscopic mucosal resection guidelines. These guidelines present recommendations in response to 18 clinical questions concerning the preoperative diagnosis, indications, resection methods, curability assessment, and surveillance of patients undergoing endoscopic resection for esophageal cancers based on a systematic review of the scientific literature.

Clinical characteristic of esophageal cancer without lugol-voiding lesions in the background esophagus

Lugol chromoendoscopy is useful for the detection of early esophageal squamous cell cancer (ESCC). Multiple lugol-voiding lesions (LVLs) on lugol chromoendoscopy are associated with a very high risk of multiple cancers arising in the esophagus. Due to the widespread use of narrow band image technology in many institutions, esophageal cancer without LVLs in the background esophagus is sometimes detected. This retrospective study aims to clarify the clinical characteristic of esophageal cancer without LVLs in the background esophagus. A total of 191 consecutive patients with 204 ESCCs had undergone endoscopic submucosal dissection (ESD) from 2011 and 2014. Amongst these lesions, the number of LVLs in the background esophagus per endoscopic view was counted excluding main lesion, and the grading was divided into no LVLs ESCC (nL-ESCC) group and LVLs ESCC (L-ESCC) group. This study evaluated the clinical characteristics and the cumulative incidence of metachronous ESCC after ESD in both groups. Thirty-six patients with 36 lesions and 155 patients with 168 lesions were separated into the nL-ESCC group and L-ESCC group, respectively. On multivariate analysis, the nL-ESCC group was found to be more common in females, who were non-drinkers, or with erosive esophagitis. During follow-up periods, the cumulative incidence of metachronous ESCC at 3-years was 14.4% and 0.00% in the L-ESCC and nL-ESCC groups, respectively (P < 0.01). Our study showed that esophageal cancer without LVLs in the background esophagus was mostly occurred in females, who were non-drinkers, or with erosive esophagitis, which are uncommon features of ESCC.

Association between macrocytosis and metachronous squamous cell carcinoma of the esophagus after endoscopic resection in men with early esophageal squamous cell carcinoma

BACKGROUND

Macrocytosis is associated with an increased risk of squamous cell carcinoma (SCC) arising in the esophagus in men. The aim of this study was to evaluate the association between macrocytosis and metachronous SCC of the esophagus after endoscopic resection (ER) of early esophageal SCC in men.

METHODS

The study group comprised 278 men with early esophageal SCC after ER. The main study variables were as follows: (1) cumulative incidence and total number of metachronous SCC of the esophagus according to the presence or absence of macrocytosis (mean corpuscular volume ≥ 106 fl) and (2) predictors of metachronous SCC of the esophagus as assessed with a multivariate Cox proportional-hazards model.

RESULTS

The median follow-up was 50.3 months. Macrocytosis was associated with a higher 2-year cumulative incidence of metachronous SCC of the esophagus (without macrocytosis vs. with macrocytosis: 11.4% vs. 38.1%, p = 0.002). Macrocytosis was also associated with a higher total number of metachronous SCC of the esophagus per 100 person-years (without macrocytosis vs. with macrocytosis: 7.7 vs. 31.5 per 100 person-years, p < 0.0001). In addition, macrocytosis was a significant predictor of metachronous SCC of the esophagus on multivariate Cox proportional-hazards analysis (relative risk 2.23).

CONCLUSION

Macrocytosis is a useful predictor of the risk of metachronous SCC of the esophagus after ER of early esophageal SCC in men.

High incidence of head and neck cancers after endoscopic resection for esophageal cancer in younger patients

BACKGROUND

Second cancers in patients with esophageal cancer (EC) are common and have a poor prognosis. We evaluated the incidence of second cancers at different sites by patients' ages when their index ECs were diagnosed.

METHODS

This study included patients who underwent endoscopic resection for superficial EC at our hospital between September 1994 and September 2011. Patients' data, including sex, age at diagnosis, sequence of cancer incidence, cancer histology, and cancer site, were extracted from the cancer registry.

RESULTS

Of 544 patients, 255 developed second cancers. Simultaneous head and neck cancers (HNCs) and other organ cancers (OCs) were, respectively, present in 15% (80/544) and 9.6% (52/544) of patients; and 30% (162/544) developed metachronous second cancers over a median follow-up period of 79.5 months (range 2-120), including 44 metachronous HNCs and 70 OCs. The cumulative incidence of metachronous HNCs was significantly higher in younger patients (< 60 years) than in older patients (≥ 60 years; P = 0.001), whereas the cumulative incidence of OCs was significantly higher in older patients than in younger patients (P = 0.03).

CONCLUSIONS

The incidence of second HNC after index EC was higher in younger-onset patients than in older-onset patients. We suggest that younger patients with EC should be carefully monitored for early detection of second HNC.

Usefulness of a dedicated mouthpiece for the Valsalva maneuver to visualize the hypopharynx during transoral endoscopy

Background and study aims  Patients with esophageal squamous cell carcinoma (SCC) are at high risk of developing second primary SCCs in the hypopharynx. However, such second primary tumors are difficult to observe because of lumen closure. The Valsalva maneuver using a dedicated mouthpiece is a promising technique to visualize the hypopharynx during transoral endoscopy. In the current study, we investigated the utility of this method. Patients and methods  The current study was a randomized, controlled, crossover trial. Patients with esophageal SCC were randomly assigned first to undergo pharyngeal observation using the dedicated mouthpiece followed by observation using a conventional mouthpiece, or vice versa. The primary endpoint was complete visualization of the hypopharynx, which was assessed blindly by three external evaluators. Results  A total of 68 pharyngeal examinations were analyzed - 34 with the dedicated mouthpiece and 34 with a conventional mouthpiece. Complete visualization was achieved in 68 % of the examinations (23/34) using the dedicated mouthpiece, whereas none of the examinations using the conventional mouthpiece achieved complete visualization of the hypopharynx. Observation scores of the oropharynx were not significantly different between both types of examination ( P  = 0.50). No serious adverse events (AEs) occurred. Conclusions  Endoscopic view of the hypopharynx was markedly improved by the Valsalva maneuver using the dedicated mouthpiece, with no serious AEs. This procedure should be included in the endoscopic examinations for the patients with esophageal SCCs.

Association between BTLA polymorphisms and susceptibility to esophageal squamous cell carcinoma in the Chinese population

Background

Growing evidence suggested that B‐ and T‐lymphocyte attenuator (BTLA) polymorphisms raised the susceptibility to a wide range of cancers. This study aimed to evaluate whether BTLA variants were related to the risk of esophageal squamous cell carcinoma (ESCC).

Methods

A total of 721 ESCC patients and 1208 matched non‐cancer controls were included in this research, and four tagging BTLA polymorphisms (rs2171513 G > A, rs3112270 A > G, rs1982809 G > A, and rs16859629 T > C) were selected and genotyped using SNPscan™ Assays.

Results

In the present study, no significant relationship between BTLA polymorphisms and ESCC was observed. However, stratified analyses suggested that the variant of BTLA rs3112270 A > G reduced the risk of ESCC in the male subgroup (AG vs AA: adjusted OR = 0.78, 95% CI = 0.61‐0.99, P = .042), BMI < 24 kg/m² subgroup (AG vs AA: adjusted OR = 0.72, 95% CI = 0.55‐0.93, P = .012; AG/GG vs AA: adjusted OR = 0.77, 95% CI = 0.60‐0.98, P = .032), and ever drinking subgroup (AG vs AA: adjusted OR = 0.61, 95% CI = 0.38‐0.97, P = .037). But when stratified by BMI ≥ 24 kg/m², the rs3112270 A > G polymorphism increased the susceptibility to ESCC (GG vs AA: adjusted OR = 1.91, 95% CI = 1.02‐3.59, P = .045). Besides, we demonstrated that BTLA rs2171513 G > A polymorphism was protective of ESCC in the ever drinking subgroup (GA/AA vs GG: adjusted OR = 0.62, 95% CI = 0.39‐0.97, P = .037).

Conclusion

Taken together, our initial investigation postulated that the rs3112270 A > G and rs2171513 G > A variants in the BTLA gene are candidates for the risk of ESCC, which might be helpful for the early diagnosis and treatment of ESCC.

Macroscopic Assessment and Sampling of Endoscopic Resection Specimens for Squamous Epithelial Malignancies with Superficial Involvement of Esophagus

Endoscopic resection is commonly used for superficial squamous cell carcinoma or high-grade dysplasia of esophageal squamous cell carcinoma. The depth of invasion, clearance from resection margins, and other pathological parameters are important parameters to be examined. The depth of invasion by carcinoma is associated with the risk of lymph node metastases. In endoscopic resection of superficial squamous malignancies of the esophagus, proper pathological examination of the resected specimen could guide the management of the patients in terms of the need for additional treatment, including lymph node dissection, chemotherapy, and radiation therapies.

Treatment outcomes for one-stage concurrent surgical resection and reconstruction of synchronous esophageal and head and neck squamous cell carcinoma

PURPOSE

It is not uncommon to see the synchronous presentation of esophageal squamous carcinoma (ESCC) and head and neck cancer (HNC), and most patients were treated with staged interventions. This study retrospectively reported the outcomes of patients with synchronous ESCC and HNC treated with one-stage concurrent surgical resection and reconstruction.

METHODS

We identified 17 consecutive patients with synchronous ESCC and HNC undergoing primary concurrent surgical resections between 2011 and 2017 at our hospital. All patients had received esophageal screenings prior to treatment.

RESULTS

The HNC patients in this study had the following subsite involvements: oral cavity (n = 5), oropharynx (n = 4), larynx (n = 1), hypopharynx (n = 9), and thyroid gland (n = 1). Eighty percent of the HNC subsites (16/20) were treated in advanced stages, while most ESCCs were treated at early stages. The mean follow-up time was 3.2 ± 1.6 years. Surgery-associated morbidity and mortality were 94.1% and 0%, respectively, and the most common complication was anastomotic leakage. The two-year overall survival, 2-year loco-regional recurrence-free survival, and 2-year distant metastasis-free survival were 86.7%, 85.6%, and 78.7%, respectively. No significant difference was found between overall survival and HNC subsite or anastomotic leakage. Four patients (23.5%) developed secondary primary malignancies (SPMs) within a mean follow-up period of 2.9 years (standard deviation 1.6 years).

CONCLUSION

Although one-stage concurrent surgical resection and reconstruction of synchronous ESCC and HNC were highly invasive and complicated, survival was promising. Isolated distant metastasis remained the most common failure pattern. Vigilant follow-up strategy is mandatory to detect secondary primary malignancies (SPMs), especially within the first 3 years following initial treatment.

Genomic characterization of early-stage esophageal squamous cell carcinoma in a Japanese population

Major risk factors for esophageal squamous cell carcinoma (ESCC) are smoking, alcohol consumption, and single nucleotide polymorphisms in ADH1B and ALDH2. Several groups have reported large-scale genomic analyses of ESCCs. However, the specific genetic changes that promote the development of ESCC have not been characterized. We performed exome sequencing of 16 fresh esophageal squamous cell neoplasms and targeted sequencing of 128 genes in 52 archival specimens, of which 26 were cancerous, and 26 were adjacent normal tissue, from Japanese ESCC patients. We found significantly more somatic mutations in TP53 and NOTCH1, CDKN2A deletions, and CCND1 amplifications in cancerous areas than in non-cancerous areas, consistent with previous studies that have characterized them as tumor suppressors and oncogenes. These data suggest that mutations, deletions, and amplifications, which alter the function of TP53, NOTCH1, CDKN2A, and CCND1, are the key changes that promote the transformation of esophageal mucosa to ESCC.

Current status of esophageal endoscopy including the evaluation of smoking and alcohol consumption in Japan: an analysis based on the Japan endoscopy database

PURPOSE

The aim was to investigate the current status of esophageal endoscopy, including the evaluation of smoking and alcohol consumption, in Japan.

METHODS

A total of 47,441 patients who underwent 69,748 sessions of esophageal endoscopy were registered in the Japan Endoscopy Database between January 2015 and March 2017. The study variables were as follows: (1) methods for monitoring the esophagus and the time required for monitoring and (2) the status of smoking and alcohol consumption in patients with esophageal cancer and head and neck cancer.

RESULTS

Image-enhanced endoscopy was performed in 10.6%, Lugol chromoendoscopy in 4.1%, and magnifying endoscopy in 3.2%. The mean time required for gastrointestinal endoscopy was 10 min 58 s. The mean examination times in patients with or without monitoring of the head and neck were 10 min 51 s and 11 min 13 s, respectively. In 57.0% of the patients with esophageal cancer, the head and neck were monitored at the time of gastrointestinal endoscopy. The proportion of current smokers (esophageal cancer: 16.8-4.7%; head and neck cancer: 24.3-9.3%) and addicted drinkers (esophageal cancer: 52.3-40.8%; head and neck cancer: 50.2-47.3%) were lower at the second or subsequent endoscopy than at the initial endoscopy.

CONCLUSIONS

The new strategy for esophageal endoscopy has led to an evolutionary change in Japan. The patients with esophageal cancer and head and neck cancer who underwent a second or subsequent endoscopy had lower incidences of smoking and alcohol consumption, although the incidences remained high.

Clinical feasibility of endoscopic submucosal dissection with minimum lateral margin of superficial esophageal squamous cell carcinoma

Background  Esophageal stricture following endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell cancer (SESCC) has been associated with wide mucosal defects greater than three-quarters of the luminal circumference. Some patients developed dysphagia and required repeated endoscopic balloon dilation even after steroid therapy. As iodine staining clearly visualized the margin of SESCC, we made a longitudinal mucosal incision close to the margin of the lesion to avoid a mucosal defect involving over three-quarters of the luminal circumference for large lesions. This retrospective study aimed to clarify the clinical feasibility of ESD with minimum lateral margin of SESCC. Patients and methods  Between 2005 and 2013, 94 patients with 94 initial SESCCs had lesions greater than half of the luminal circumference. Of those, 70 patients with 70 SESCCs had achieved endoscopic clearance for the initial SESCC. In this study, endoscopic clearance was defined as en bloc resection of SESCC histologically confined to the mucosa without lymphovascular invasion and with a free deep margin regardless of the lateral margin. This study evaluated the short- and long-term outcomes in patients undergoing endoscopic clearance. Results  In total, 61.4 % (43/70) of the patients had mucosal defects involving over three-quarters of the luminal circumference and 38.5 % (27/70) had a positive or indeterminate lateral margin. However, there was no local or nodal recurrence during the median follow-up period of 3.8 years; the 3-year overall survival rate was 98.5 % and the 3-year disease-free survival rate was 100 %. Conclusion  Using our institutions' strategy, ESD for SESCCs with minimum lateral margins was oncologically acceptable; this approach could reduce the known risk factor of post-ESD stricture.

Risk Factors Linking Esophageal Squamous Cell Carcinoma With Head and Neck Cancer or Gastric Cancer

GOALS

To investigate retrospectively the risk factors for synchronous and metachronous cancers in the upper gastrointestinal tract in patients with superficial esophageal squamous cell carcinoma (ESCC).

BACKGROUND

In patients who have received endoscopic resection (ER) for ESCC, synchronous and metachronous cancers are frequently detected not only in the esophagus but also in the head and neck area and the stomach.

STUDY

A total of 285 patients who received ER for superficial ESCC were enrolled in this analysis. These patients were periodically followed-up endoscopically. Cumulative occurrence rates of the metachronous second primary cancers were determined by Kaplan-Meier method. Risk factors for synchronous and metachronous cancers in the head and neck area and the stomach were determined by logistic regression analyses.

RESULTS

During a mean follow-up period of 76 months, the 5-year cumulative occurrence of metachronous esophageal, head and neck, and stomach cancer was 14.0%, 2.8%, and 4.1%, respectively. Although the presence of multiple lugol-voiding lesions in the esophagus was a significant risk factor for synchronous and metachronous head and neck cancers (odds ratio, 3.8; 95% confidence interval, 1.7-9.0), older age (>65 y) was a significant risk factor for synchronous and metachronous gastric cancer (odds ratio, 3.1; 95% confidence interval, 1.2-9.3).

CONCLUSIONS

The risk factors for the cooccurrence of head and neck cancer and that of gastric cancer in patients with ESCC differ. This information will likely be useful for managing patients who have been treated with ER for ESCC and who possess carcinogenic potential throughout the upper gastrointestinal tract.

Endoscopic findings corresponding to multiple Lugol-voiding lesions in the esophageal background mucosa

BACKGROUND AND AIM

Multiple Lugol-voiding lesions (LVLs) on Lugol chromoendoscopy can predict the development of metachronous multiple cancers in the esophagus and the head and neck regions. However, Lugol chromoendoscopy sometimes causes adverse events such as chest pain and discomfort. We therefore investigated the endoscopic findings on narrow band imaging (NBI) or blue laser imaging (BLI) that correspond to the presence of multiple LVLs in patients with esophageal squamous cell carcinoma.

METHODS

First, we investigated the NBI/BLI findings corresponding to individual small LVLs (one-to-one correspondence). Second, we investigated the association between the grade of multiple LVLs and the five endoscopic findings, including multiple foci of dilated vessels (MDV), multiple small brownish areas without microvascular irregularity, and a nonuniform color tone.

RESULTS

One-to-one correspondence of endoscopic findings was analyzed in 106 small LVLs. The main findings matched with small LVLs were a focus of dilated vessels (44 lesions), a small brownish area (17 lesions), and a small brownish area with a focus of dilated vessels (19 lesions). The relationship between multiple LVLs and each finding assessed by NBI/BLI was assessed in 155 patients. Multivariate logistic regression indicated that the presence of MDV was the only finding independently associated with multiple LVLs (P < 0.01).

CONCLUSIONS

The presence of MDV in the noncancerous background esophageal mucosa was significantly associated with multiple LVLs. This pilot study demonstrates that MDV has the potential to be a new risk factor for the development of metachronous multiple esophageal squamous cell carcinoma.

An Asian consensus on standards of diagnostic upper endoscopy for neoplasia

BACKGROUND

This is a consensus developed by a group of expert endoscopists aiming to standardise the preparation, process and endoscopic procedural steps for diagnosis of early upper gastrointestinal (GI) cancers.

METHOD

The Delphi method was used to develop consensus statements through identification of clinical questions on diagnostic endoscopy. Three consensus meetings were conducted to consolidate the statements and voting. We conducted a systematic literature search on evidence for each statement. The statements were presented in the second consensus meeting and revised according to comments. The final voting was conducted at the third consensus meeting on the level of evidence and agreement.

RESULTS

Risk stratification should be conducted before endoscopy and high risk endoscopic findings should raise an index of suspicion. The presence of premalignant mucosal changes should be documented and use of sedation is recommended to enhance detection of superficial upper GI neoplasms. The use of antispasmodics and mucolytics enhanced visualisation of the upper GI tract, and systematic endoscopic mapping should be conducted to improve detection. Sufficient examination time and structured training on diagnosis improves detection. Image enhanced endoscopy in addition to white light imaging improves detection of superficial upper GI cancer. Magnifying endoscopy with narrow-band imaging is recommended for characterisation of upper GI superficial neoplasms. Endoscopic characterisation can avoid unnecessary biopsy.

CONCLUSION

This consensus provides guidance for the performance of endoscopic diagnosis and characterisation for early gastric and oesophageal neoplasia based on the evidence. This will enhance the quality of endoscopic diagnosis and improve detection of early upper GI cancers.

Clinical and Prognostic Features of Patients With Esophageal Cancer and Multiple Primary Cancers: A Retrospective Single-institution Study

OBJECTIVE

To investigate the clinical and prognostic characteristics of patients with esophageal cancer and multiple primary cancers.

SUMMARY BACKGROUND DATA

Patients with esophageal cancer frequently have multiple primary cancers, the presence of which may complicate physicians' decision-making because the clinical and prognostic features of such patients remain unknown.

METHODS

This retrospective single-institution study included 538 consecutive patients who had undergone resection of esophageal cancer. The Cox proportional hazard model was used to compute the hazard ratio (HR) for mortality.

RESULTS

At the time of surgery, 163 patients (30%) had multiple primary cancers (77, metachronous; 86, synchronous). Multiple primary cancers were significantly associated with alcohol use and tobacco smoking (Brinkman index). Patients with synchronous cancers had significantly shorter overall survival than those without multiple primary cancers (log-rank P = 0.032; univariate HR = 1.53, 95% confidence interval 1.02-2.17, P = 0.040; multivariate HR: 1.61; 95% confidence interval: 1.08-2.36; P = 0.020). Patients with metachronous cancers had similar prognoses to those without multiple primary cancers. The prognostic effect of synchronous cancers on overall survival was particularly prominent in patients with Stage I esophageal cancer (log-rank P = 0.0002).

CONCLUSIONS

Multiple primary cancers are associated with a history of tobacco and alcohol use, supporting the concept of field cancerization. Synchronous multiple primary cancers may be an independent predictor of poorer long-term survival in patients undergoing resection of esophageal cancers.

Endoscopic screening using esophageal iodine staining and genotypes of ADH1B and ALDH2 in Japanese alcohol-dependent women

BACKGROUND

The presence of large or multiple esophageal distinct iodine-unstained lesions (DIULs) is a strong predictor of field cancerization in the upper aerodigestive tract. Several risk factors for DIULs, including genetic polymorphisms of alcohol and aldehyde dehydrogenases (ADH1B, rs1229984; ALDH2, rs671), have been demonstrated in Japanese alcohol-dependent men. However, few evaluations of alcohol-dependent women have been conducted in this field.

METHODS

Using multiple logistic regression models, we investigated the results of screening using esophageal iodine staining and the identification of determinants for esophageal DIULs in 472 Japanese alcohol-dependent women.

RESULTS

DIULs ≥5 mm, multiple DILUs, and both characteristics were observed in 35 (7.4%), 31 (6.6%), and 16 (3.4%) patients, respectively. DIULs ≥5 mm were histologically diagnosed as low-grade intraepithelial neoplasia in 26 patients and superficial squamous cell carcinoma in 9 patients. Although the inactive heterozygous ALDH2*1/*2 genotype was more common (33.3% vs. 11.4%, p = 0.002) in the group with DIULs ≥5 mm than in the group without DIULs ≥5 mm, no significant differences in the results of a questionnaire asking about current and past facial flushing after a glass of beer were seen between the groups with and without DIULs ≥5 mm. When individuals with current or former flushing were assumed to have inactive ALDH2, the sensitivity and specificity of current or former flushing to identify the presence of inactive ALDH2 were 50.0% and 93.5%, respectively; these values were previously reported to be 88% and 92%, respectively, in a Japanese general female population. The low sensitivity in the present study suggests that a lack of alcohol flushing may play a crucial role in the development of alcohol dependence in women with inactive ALDH2. No significant differences in age, usual alcohol consumption, or smoking habits were observed according to ADH1B and ALDH2 genotypes. Multiple logistic regression analyses showed that the slow-metabolizing ADH1B*1/*1 genotype (odds ratio [95% confidence interval], 12.5 [4.82-32.4] and 9.89 [3.50-27.9]), the inactive heterozygous ALDH2*1/*2 genotype (2.94 [1.18-7.38] and 3.79 [1.40-10.3]), a lower body mass index per -1 kg/m2 (1.17 [1.02-1.35] and 1.38 [1.14-1.67]), and a mean corpuscular volume ≥106 fl (3.70 [1.56-8.81] and 3.27 [1.24-8.64]) increased the risk of DIULs ≥5 mm and multiple DIULs, respectively. The combination of ADH1B*1/*1 and ALDH2*1/*2 markedly increased the risk of esophageal DIULs ≥5 mm (39.3 [10.6-146]).

CONCLUSIONS

Japanese alcohol-dependent women shared several common risk factors for esophageal squamous cell neoplasia with alcohol-dependent men, but with considerably different magnitudes.

Systematic review: the etiology of esophageal squamous cell carcinoma in low-income settings

Esophageal carcinoma causes over 380 000 deaths per year, ranking sixth worldwide in mortality amongst all malignancies. Globally, the squamous cell subtype is most common and accounts for 80% of esophageal cancers. Nonetheless, esophageal squamous cell carcinoma is much more poorly understood than esophageal adenocarcinoma, including what is driving such high prevalences, why it often presents in young patients, and shows such marked geographical delineations Areas covered: The current literature was searched for articles focusing on aetiopathogenesis of squamous cell esophageal carcinoma via a systematic review, particularly in low-resource settings. This was supplemented by papers of interest known to the authors. Expert commentary: Current putative mechanisms include polycyclic aromatic hydrocarbons, nitrosamines, acetaldehyde, cyclo-oxygenase-2 pathways, androgen and their receptor levels, as well as smoking & alcohol, micronutrient deficiencies and diet, mycotoxins, thermal damage, oral hygiene and microbiotal factors, inhaled smoke, viral infections such as HPV, and chronic irritative states. Etiology is likely multifactorial and varies geographically. Though smoking and alcohol play a predominant role in high-income settings, there is strong evidence that mycotoxins, diet and temperature effects may play an under-recognized role in low and middle-income settings.

Aldehyde-Induced DNA and Protein Adducts as Biomarker Tools for Alcohol Use Disorder

Alcohol use disorder (AUD) screening frequently involves questionnaires complemented by laboratory work to monitor alcohol use and/or evaluate AUD-associated complications. Here we suggest that measuring aldehyde-induced DNA and protein adducts produced during alcohol metabolism may lead to earlier detection of AUD and AUD-associated complications compared with existing biomarkers. Use of aldehyde-induced adducts to monitor AUD may also be important when considering that approximately 540 million people bear a genetic variant of aldehyde dehydrogenase 2 (ALDH2) predisposing this population to aldehyde-induced toxicity with alcohol use. We posit that measuring aldehyde-induced adducts may provide a means to improve precision medicine approaches, taking into account lifestyle choices and genetics to evaluate AUD and AUD-associated complications.

Risk assessment of metachronous squamous cell carcinoma after endoscopic resection for esophageal carcinoma based on the genetic polymorphisms of alcoholdehydrogense-1B aldehyde dehydrogenase-2: temperance reduces the risk

BACKGROUND

Metachronous multiple squamous cell carcinoma (SCC) of the esophagus and the head and neck is commonly observed in patients who have previously undergone endoscopic resection (ER) for SCC of the esophagus (ESCC). We evaluated the risk for developing metachronous SCC following ER for ESCC based on the genetic polymorphisms for alcohol dehydrogenase-1B (ADH1B) and aldehyde dehydrogenase-2 (ALDH2) as well as the alcohol consumption and smoking habits.

METHODS

We studied 158 patients who underwent ER for ESCC (median follow-up 80 months). Genotyping of ADH1B/ALDH2 was performed using saliva sampling. The alcohol consumption and smoking histories of the patients before and after the ER were documented.

RESULTS

Multivariate analyses revealed that inactive heterozygous ALDH2 [hazard ratio (HR) 2.25] and alcohol consumption after ER (HR 1.94) were independently associated with the risk of developing secondary SCC. Moreover, inactive heterozygous ALDH2 (HR 4.39) and alcohol consumption after the ER (HR 2.82) were independently associated with the risk of a third SCC. We analyzed 110 patients who had a history of moderate or heavy alcohol consumption before the ER. The 3-year cumulative incidence rates of secondary SCC in the temperance (n = 65) and non-temperance groups (n = 45) were 14.0 and 42.1% (p = 0.0002). Further, the 5-year cumulative incidence rates of a third SCC in the temperance and non-temperance groups were 0 and 15.6% (p = 0.0011), respectively. In addition, the 7-year cumulative incidence rates of a fourth SCC in the temperance and non-temperance groups were 0 and 15.3% (p = 0.0015), respectively.

CONCLUSIONS

Continued alcohol consumption is an important risk factor for the onset of metachronous SCC and is a risk factor for the third and subsequent SCCs. Strict advice in favor of temperance is crucial.

Achalasia and esophageal cancer: risks and links

Esophageal cancer affects more than 4,50,000 persons worldwide, and its incidence has increased in recent years. It is the eighth most common cancer across the globe. The main histologic types are esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EA), and their associated risk factors are well known. Achalasia, an idiopathic esophageal disorder that conditions aperistalsis and the absence of lower esophageal sphincter relaxation, stands out among them. The prevalence of ESCC in subjects with esophageal achalasia is 26 in every 1,000 cases, whereas the prevalence of EA is 4 in every 1,000. Patients with achalasia have a 50 times higher risk of presenting with ESCC than the general population, and the disease manifests 20-25 years after achalasia symptom onset. Multiple mechanisms are related to the development of ESCC in achalasia, and they include bacterial overgrowth, food stasis, genetic alterations, and chronic inflammation. Regarding the risk of EA in achalasia patients, most cases are associated with Barrett's esophagus, due to uncontrolled chronic acid reflux. Given that achalasia is a well-established factor for ESCC/EA, clinicians must be aware of said associations to enable the development of programs for the prevention and opportune detection of these cancers in patients with achalasia.

Transoral endoscopic examination of head and neck region

Transoral endoscopy with narrow band imaging (NBI) is useful for early detection of head and neck (HN) cancer. However, the lateral and anterior walls of the oropharynx, postcricoid area, and posterior wall of the hypopharynx are difficult to observe using transoral endoscopy. Advanced cancers in these regions may be missed even when NBI is used. This report highlights a method of transoral endoscopic examination of the HN region. For observation of the oral cavity and oropharynx, it is important to observe these regions without using a mouthpiece. Wide opening of the mouth facilitates observation of the oral cavity and oropharynx. Moreover, visibility of the oropharynx, including the anterior wall, is dramatically improved, when the patient positions the tongue forward and says 'aaah.' This technique also facilitates observation of the dorsum of the tongue, which is difficult to observe from a tangential view when using a mouthpiece. To observe the hypopharynx, the Valsalva maneuver is very useful. Patient cooperation is important when observing the HN region thoroughly to gain clear endoscopic views. Narcotic drugs, such as pethidine hydrochloride, are ideal for conscious sedation and reduce the gag reflex while still allowing patient cooperation. From the oral cavity to the hypopharynx, including the lateral and anterior walls of the oropharynx, postcricoid area, and posterior wall of the hypopharynx, most of the HN region can be observed during routine examination using transoral endoscopy without any special devices.

Role of the NFκB-signaling pathway in cancer

Cancer is a group of cells that malignantly grow and proliferate uncontrollably. At present, treatment modes for cancer mainly comprise surgery, chemotherapy, radiotherapy, molecularly targeted therapy, gene therapy, and immunotherapy. However, the curative effects of these treatments have been limited thus far by specific characteristics of tumors. Abnormal activation of signaling pathways is involved in tumor pathogenesis and plays critical roles in growth, progression, and relapse of cancers. Targeted therapies against effectors in oncogenic signaling have improved the outcomes of cancer patients. NFκB is an important signaling pathway involved in pathogenesis and treatment of cancers. Excessive activation of the NFκB-signaling pathway has been documented in various tumor tissues, and studies on this signaling pathway for targeted cancer therapy have become a hot topic. In this review, we update current understanding of the NFκB-signaling pathway in cancer.

Pharyngeal fistulas after total laryngectomy with and without tracheostoma plasty according to Herrmann

PURPOSE

Pharyngeal fistula (PF) is one of the most common complications after total laryngectomy (TL). The tracheostoma plasty technique according to Herrmann (TPH) represents an alternative surgical technique to shape the tracheostoma. The aim of this study was to determine whether the performance of a TPH affects the incidence of PF after TL. A secondary aim was to identify potential risk factors for the development of PF with regard to TPH.

METHODS

Retrospective evaluation of records of 151 consecutive patients at two tertiary care centers with regard to the occurrence and risk factors of PF after TL with and without TPH.

RESULTS

60 patients with TPH and 91 patients without TPH contributed to the results. The overall incidence of PF was 21.2% (32 out of 151). 23.3% (14 out of 60) of patients with TPH and 19.8% (18 of 91) of patients without TPH developed a PF (p = 0.91). Binary logistic regression analysis revealed significant influence of salvage surgery on the risk to develop PF (odds ratio = 2.9; 95% CI 1.16-7.23; p = 0.026). The occurrence of PF was not significantly influenced by any other investigated factors including performance of TPH.

CONCLUSIONS

Performance of TPH after TL does not increase the incidence of PF. Thus, TPH can be considered as a safe alternative surgical technique for the shaping of the tracheostoma following TL.

Type of second primary malignancy after achieving complete response by definitive chemoradiation therapy in patients with esophageal squamous cell carcinoma

BACKGROUND

While the standard treatment for stage II-III (non-T4) esophageal squamous cell carcinoma (ESCC) is neoadjuvant therapy followed by esophagectomy, definitive chemoradiation therapy (dCRT) is an option to treat ESCC patients who reject or may not tolerate surgical treatment. Second primary malignancy (SPM) is a problem for long-term survivors after achieving complete response (CR) by dCRT.

METHODS

The source of the subjects in this study was the patients with stage II/III (excluding T4 disease) ESCC (UICC6th) who underwent dCRT from 2000 to 2011 at the National Cancer Center Hospital, Japan. SPM, defined as malignancy newly detected at different site from the initial disease, was checked in patients who achieved CR by the initial dCRT.

RESULTS

Among the 285 patients with stage II/III (excluding T4 disease) ESCC who underwent dCRT, 185 patients achieved CR. SPM was detected in 49 patients (median time to developing SPM, 41.5 months), accounting for 19.3% (95% CI 0.137-0.257) as the 5-year cumulative risk of SPM. SPMs were head and neck cancer (n = 12), gastric cancer (n = 12), esophageal cancer (n = 7), lung cancer (n = 5), colon cancer (n = 4), diffuse large B-cell lymphoma (n = 3), bladder cancer (n = 2), small intestinal cancer (n = 1), cholangiocarcinoma (n = 1), malignant melanoma (n = 1), and breast cancer (n = 1). There were no significant differences in baseline characteristics between the patients who developed SPM (n = 49) and others (n = 136).

CONCLUSIONS

Because second primary malignancy developed often after achieving CR by dCRT for ESCC, it should be followed carefully.

Impact of alcohol dehydrogenase-aldehyde dehydrogenase polymorphism on clinical outcome in patients with hypopharyngeal cancer

BACKGROUND

The purpose of this research was to investigate the association between alcohol dehydrogenase 1B (ADH1B) and aldehyde dehydrogenase 2 (ALDH2) polymorphisms and hypopharyngeal squamous cell carcinoma (SCC) survival.

METHODS

We genotyped ADH1B (rs1229984) and ALDH2 (rs671) single nucleotide polymorphisms (SNPs) in 85 Japanese male patients with hypopharyngeal SCC. The independent prognostic values of ADH1B-ALDH2 genotypes were analyzed by univariate and multivariate proportional hazard Cox regression, taking well-known clinical risk factors into account.

RESULTS

Heavy drinkers with ALDH2*2 allele resulted in significantly worse overall survival (OS; P = .028) and disease-free survival (DFS; P = .029) compared with other patients. Heavy drinkers with ALDH2*2 allele remained statistically significant in multivariate analysis for OS and DFS, indicating independent poor prognostic factor (hazard ratio [HR] 2.251; 95% confidence interval [CI] 1.018-4.975 and HR 2.261; 95% CI 1.021-5.006, respectively).

CONCLUSION

We conclude that heavy drinkers with the ALDH2*2 allele are associated with poor outcome in hypopharyngeal SCC.

Endoscopic diagnosis and treatment of early esophageal squamous neoplasia

Esophageal cancer is one of the leading causes of cancer-related death and is associated with high morbidity and mortality. It carries a poor prognosis as more than half of patients present with advanced and unresectable disease. One contributing factor is the increased risk of lymph node metastases at early stages of disease. As such, it is essential to detect squamous cell neoplasia (SCN) at an early stage. In order to risk stratify lesions, endoscopists must be able to perform image enhanced endoscopy including magnification and Lugol’s chromoendoscopy. The assessment of both the horizontal extent and depth of any lesion is also of utmost importance prior to treatment. Endoscopic mucosal resection and submucosal dissection remain the standard of care with literature supportive their respective use. Radiofrequency ablation and other endoscopic treatments are currently available although should not be considered first line at this time. Our objective is to review the current options for the endoscopic diagnosis and treatment of esophageal SCN.

Molecular Mechanisms of Acetaldehyde-Mediated Carcinogenesis in Squamous Epithelium

Acetaldehyde is a highly reactive compound that causes various forms of damage to DNA, including DNA adducts, single- and/or double-strand breaks (DSBs), point mutations, sister chromatid exchanges (SCEs), and DNA-DNA cross-links. Among these, DNA adducts such as N²-ethylidene-2'-deoxyguanosine, N²-ethyl-2'-deoxyguanosine, N²-propano-2'-deoxyguanosine, and N²-etheno-2'-deoxyguanosine are central to acetaldehyde-mediated DNA damage because they are associated with the induction of DNA mutations, DNA-DNA cross-links, DSBs, and SCEs. Acetaldehyde is produced endogenously by alcohol metabolism and is catalyzed by aldehyde dehydrogenase 2 (ALDH2). Alcohol consumption increases blood and salivary acetaldehyde levels, especially in individuals with ALDH2 polymorphisms, which are highly associated with the risk of squamous cell carcinomas in the upper aerodigestive tract. Based on extensive epidemiological evidence, the International Agency for Research on Cancer defined acetaldehyde associated with the consumption of alcoholic beverages as a "group 1 carcinogen" (definite carcinogen) for the esophagus and/or head and neck. In this article, we review recent advances from studies of acetaldehyde-mediated carcinogenesis in the squamous epithelium, focusing especially on acetaldehyde-mediated DNA adducts. We also give attention to research on acetaldehyde-mediated DNA repair pathways such as the Fanconi anemia pathway and refer to our studies on the prevention of acetaldehyde-mediated DNA damage.

Alcohol abstinence and risk assessment for second esophageal cancer in Japanese men after mucosectomy for early esophageal cancer

BACKGROUND

Alcohol consumption combined with inactive aldehyde dehydrogenase-2 (ALDH2) and the presence of multiple esophageal Lugol-voiding lesions (LVLs; dysplasia) are strong predictors for multiple development of esophageal squamous cell carcinoma (ESCC) in East Asians. We invented a health risk appraisal (HRA) model for predicting the risk of ESCC based on drinking, smoking, dietary habits, and alcohol flushing, i.e., past or present facial flushing after drinking a glass of beer, a surrogate marker for inactive ALDH2.

METHODS

Prospective follow-up examinations (median follow-up time, 50.3 months) were performed in 278 Japanese men after endoscopic mucosectomy for early ESCC (UMIN Clinical Trials Registry ID: UMIN000001676).

RESULTS

Sixty-four subjects developed metachronous ESCC. A receiver operating characteristic curve showed that HRA scores ≥12 best predicted the development of metachronous ESCC. The ESCC detection rate per 100 person-years was 9.8 in the high-HRA-score group (n = 104) and 4.5 in the low-HRA-score group (n = 174), and the risk of development of metachronous ESCC was higher in the high-HRA-score group than in the low-HRA-score group (adjusted hazard ratio: 2.00 [95% CI: 1.12-3.30]). Multiple LVLs was a very strong predictor of the development of metachronous SCC, but high HRA scores predicted it independently. The cumulative incidences of metachronous ESCC decreased after drinking cessation in the high-HRA-score drinker group (adjusted hazard ratio: 0.37 [0.14-0.97]).

CONCLUSIONS

Both the HRA model that included alcohol flushing and the multiple LVL grade predicted the development of metachronous ESCC in Japanese men after endoscopic mucosectomy for ESCC. Drinking cessation in the high-HRA-score drinker group reduced the rate of metachronous ESCC.

The use of rapid and cost-effective blood-based biomarkers in combination with tumour TNM stage for individual head and neck cancer patient treatment selection

Head and neck (H&N) cancer is an aggressive disease and the incidence has increased in younger population worldwide. Tumour TNM staging is the main basis for treatment decision despite significant variation in clinical outcome. Survival time of these patients has marginally improved during the last 30 years. Various biomarkers with cumbersome analysis, high cost, time consumption and requirement of special laboratory facilities have been investigated. However, none of these biomarkers have been shown to be suitable to use for individual H&N cancer patient treatment selection in the clinic. For practical use in clinical settings, the given biomarkers must be simple to analyse, rapid, cost effective and available in routine laboratories. With this intension, we suggested the combination of standard TNM staging and biomarkers associated with inflammation such as neutrophils, neutrophil to lymphocyte ratio, plasma C-reactive protein or plasma tumour necrosis factor alpha (TNFa) and single-nucleotide polymorphism in TNFa rs1800629 using blood-based analysis. The optimal treatment outcome of H&N cancer by using combination of TNM stage and these blood-based biomarkers for individual patient selection need further investigation.

Surveillance of patients at high-risk of squamous cell esophageal cancer

Currently curative treatment for esophageal squamous cell cancer (ESCC) is possible only in patients with early-stage, usually asymptomatic disease. In Western countries, where the incidence of ESCC is relatively low, a screening of asymptomatic, average-risk population is untenable. In order to detect early-stage ESCC or its precursor lesions it is important to identify high-risk patients and consider endoscopic surveillance in these groups. These high-risk groups include patients after curative treatment for head and neck cancer, previous endoscopic resection of ESCC, caustic injury, and patients with tylosis or achalasia. This paper discuss the evidence and proposed method of endoscopy surveillance of these high-risk patients.