Androgens and esophageal cancer: What do we know?

Significant disparities exist between genders for the development and progression of several gastro-intestinal (GI) diseases including cancer. Differences in incidence between men vs women for colon, gastric and hepatocellular cancers suggest a role for steroid sex hormones in regulation of GI carcinogenesis. Involvement of intrinsic gender-linked mechanisms is also possible for esophageal adenocarcinoma as its incidence is disproportionally high among men. However, the cause of the observed gender differences and the potential role of androgens in esophageal carcinogenesis remains unclear, even though the cancer-promoting role of androgen receptors (AR) shown in other cancers such as prostate and bladder suggests this aspect warrants exploration. Several studies have demonstrated expression of ARs in esophageal cancer. However, only one study has suggested a potential link between AR signaling and outcome - poorer prognosis. Two groups have analyzed data from cohorts with prostate cancer and one of these found a decreased incidence of esophageal squamous and adenocarcinoma after androgen deprivation therapy. However, very limited information is available about the effects of androgen and AR-initiated signaling on esophageal cancer cell growth in vitro and in vivo. Possible mechanisms for androgens/AR involvement in the regulation of esophageal cancer growth are considered, and the potential use of AR as a prognostic factor and clinical target is highlighted, although insufficient evidence is available to support clinical trials of novel therapies. As esophageal adenocarcinoma is a gender linked cancer with a large male predominance further studies are warranted to clarify the role of androgens and ARs in shaping intracellular signaling and genomic responses in esophageal cancer.

Estrogen, male dominance and esophageal adenocarcinoma: is there a link?

Esophageal adenocarcinoma is a cancer with poor prognosis, and its incidence has risen sharply over recent decades. Obesity is a major risk factor for developing this cancer and there is a clear male gender bias in the incidence that cannot be fully explained by known risk factors. It is possible that a difference in the expression of estrogen, or its signaling axes, may contribute to this gender bias. We undertook a comprehensive literature search and analyzed the available data regarding estrogen and estrogen receptor expression, and the possible sex-specific links with esophageal adenocarcinoma development. Potentially relevant associations between visceral vs subcutaneous fat deposition and estrogen expression, and the effect of crosstalk between estrogen and leptin signaling were identified. We also found limited studies suggesting a role for estrogen receptor β expression in esophageal adenocarcinoma development. The current literature supports speculation on an etiological role for estrogen in the male gender bias in esophageal adenocarcinoma, but further studies are required.

MicroRNAs, development of Barrett's esophagus, and progression to esophageal adenocarcinoma

Barrett's esophagus is a premalignant condition caused by gastroesophageal reflux. Once developed, it can progress through varying grades of dysplasia to esophageal adenocarcinoma. Whilst it is well accepted that Barrett's esophagus is caused by gastroesophageal reflux, the molecular mechanisms of its pathogenesis and progression to cancer remain unclear. MicroRNAs (miRNAs) are short segments of RNA that have been shown to control the expression of many human genes. They have been implicated in most cellular processes, and the role of miRNAs in disease development is becoming increasingly evident. Understanding altered miRNA expression is likely to help unravel the molecular mechanisms that underpin the development of Barrett's esophagus and its progression to cancer.

From blood to breath: New horizons for esophageal cancer biomarkers

Esophageal cancer is a lethal cancer encompassing adenocarcinoma and squamous cell carcinoma sub-types. The global incidence of esophageal cancer is increasing world-wide, associated with the increased prevalence of associated risk factors. The asymptomatic nature of disease often leads to late diagnosis and five-year survival rates of less than 15%. Current diagnostic tools are restricted to invasive and costly endoscopy and biopsy for histopathology. Minimally and non-invasive biomarkers of esophageal cancer are needed to facilitate earlier detection and better clinical management of patients. This paper summarises recent insights into the development and clinical validation of esophageal cancer biomarkers, focussing on circulating markers in the blood, and the emerging area of breath and odorant biomarkers.

Safety and Early Clinical Outcomes Following Repair of Very Large Hiatus Hernia in Octogenarians

BACKGROUND

Very large hiatus hernias are often symptomatic, impact quality of life, and are increasingly encountered in aging populations. Laparoscopic repair offers excellent clinical outcomes. However, surgeons can be reluctant to offer surgery to the elderly due to concerns about morbidity and mortality. To determine safety, we evaluated outcomes following repair of very large hiatus hernias in patients aged 80 years and older and compared them to younger patients.

METHODS

Data were extracted from a prospective database. Patients who underwent operative repair of a very large hiatus hernia (> 50% intrathoracic stomach) between 2000 and 2023 were included and categorized into groups based on age: young (< 70 years), older (70-79 years), and octogenarian (≥ 80 years). Perioperative and early postoperative clinical outcomes were determined and compared.

RESULTS

1353 patients underwent surgery (< 70 years: 733 [54.2%], 70-79 years: 451 [33.3%], and ≥ 80 years: 169 [12.5%]). Rates of total intrathoracic stomach were commonest in octogenarians (11.6% vs. 20.4% vs. 32.5% and p < 0.001). Young and older patients were more likely to undergo elective surgery for heartburn (56.6% vs. 44.4% vs. 29.0% and p < 0.001), whereas octogenarians more likely underwent emergency surgery for gastric volvulus (5.4% vs. 6.6% vs. 14.5% and p = 0.019). Conversion to open surgery (1.1% vs. 1.1% vs. 5.0% and p = 0.002) and length of stay (2.69 vs. 3.19 vs. 4.62 days and p < 0.001) were greater in the octogenarian group. Major complications (4.2% vs. 5.1% vs. 8.1% and p = 0.120) and return to theater rates (2.6% vs. 2.9% vs. 2.7% and p = 0.925) were similar. Thirty-day mortality rates were low for all groups but highest in octogenarians (0.3% vs. 0.4% vs. 1.8% and p = 0.048). Adverse outcomes were more likely with emergency presentations, which were more common in octogenarians.

CONCLUSION

Despite a higher rate of emergency surgery in octogenarians-major complications and overall mortality rates are still acceptably low. Repair of very large symptomatic hiatus hernia should not be withheld from patients aged over 80 who are otherwise fit.