Phenytoin mouthwash to treat cancer therapy-induced oral mucositis: A pilot studyPrimary neuroendocrine carcinoma of breast: A rare tumor

BACKGROUND

Oral mucositis is one of the most common side effects of cancer therapy with no definite treatment. Phenytoin has positive effects on healing of mucosal and dermal wounds. In this study efficacy of 1% phenytoin mouthwash on severity of mucositis (on the basis of WHO scale), pain relief (based on Visual Analogue Scale), and improvement of patients' quality of life (on the basis of EORTC-QLQ-H and N35 questionnaire) was evaluated.

MATERIALS AND METHODS

In a pilot -double-blind randomized clinical trial, eight patients in study group were given 1% phenytoin mouthwash while eight patients in control group used normal saline. Data analysis was performed by Mann-Whitney and Repeated Measured ANOVA tests.

RESULTS

Reduction of mucositis severity was observed, but the difference was not significant. On the other hand, patients on phenytoin therapy had better pain relief (VAS# 6.75 ± 1.58 at the beginning of the study reached to # 3.75 ± 1.16 after 3 weeks in phenytoin group) and improvement in quality of life (score of QOL was 70.63 ± 5.5 that reached to 63.61 ± 6.39 in phenytoin group) than normal saline group significantly (P < 0.05).

CONCLUSION

One percent phenytoin mouthwash caused pain relief and improvement of life quality significantly in patients with mucositis due to cancer therapy, but it did not reduce the severity of mucositis in a statistically significant scale.

The incidence and risk factors for surgical site infection after clean spinal operations: A prospective cohort study and review of the literature

Background:

Postoperative infection is one of the most common complications after spine surgeries. In our study, surgical site infection (SSI) is described as; superficial (i.e., skin and subcutaneous tissues) and deep (i.e., fascia and muscles) infections occurring in the short term (i.e., 1-month) after spine surgeries (Centers for Disease Control and Prevention definition 81.00–81.08). To detect the risk factors for the occurrence of such a complication, studies require a large number of patients, a high quality of data and adequate analysis. In this study, we prospectively enrolled 987 patients undergoing spinal surgery over a 3 years period.

Methods:

From November 2010 to November 2013, 987 patients had a variety of spinal operations that included; disc herniation, spinal stenosis, spondylolisthesis, fracture-dislocations, spine and spinal cord tumors, and syringomyelia. Patients under the age of 10, those with a recent history of infection and antibiotherapy, and patients with immunodeficiency disorders were excluded.

Results:

Of the 987 spine procedures performed, 27 (2.73%) developed postoperative infections. Multi-variant data analysis indicated that multiple factors correlated with an increased risk of SSI in descending order; trauma, a past history of diabetes, smoking, being confined to bed, in the perioperative period, mean blood sugar levels above 120 mg/dl, longer lengths of incisions, and longer hospital stay.

Conclusion:

Considering the preventable nature of most of the factors contributing to SSI, it should be possible to reduce these complications.

Effect of magnesium on functional outcome and paraclinical parameters of patients undergoing supratentorial craniotomy for brain tumors: a randomized controlled trial

BACKGROUND

Several studies have demonstrated that magnesium (Mg) plays an important role in the prevention and treatment of central nervous system (CNS) insults. In this study, we tested the effect of intravenous magnesium sulfate (MgSO4) on the outcome of patients with brain tumors who underwent craniotomy. The outcome was defined clinically as the Barthel index score and paraclinically as blood levels of NSE (neuron-specific enloase) and S100Β protein.

METHODS

Sixty patients were randomly divided into two groups of 30 patients: the treatment and control groups. In the treatment group, 5 g of MgSO4 in normal saline was infused in 6 h 2 days before surgery, and the same dosage was repeated the day before and during surgery. The control group received placebo. Serum S100Β and NSE concentrations were measured at baseline before administration of magnesium, before surgery, and on the 2nd postoperative day. The Barthel index score was evaluated and registered before surgery, 3, and 6 months after the operation.

RESULTS

The study results showed a significant change in S100Β protein levels before and after surgery (p < 0.05), but we could not find similar results for NSE protein and the Barthel index score. There was a correlation between NSE protein and the Barthel index.

CONCLUSIONS

The results of this study revealed that administration of intravenous MgSO4 before and during surgery is safe and effective in reducing S100B protein levels in patients undergoing supratentorial craniotomy for brain tumors. Further studies to elucidate the pathophysiology of brain injuries and role of magnesium are warranted.

Identical twins with lumbosacral lipomyelomeningocele

Lipomyelomeningocele, a congenital spine defect, is presented as skin-covered lipomatous tissue that attaches to the cord in different ways according to its subtypes. Unlike other types of neural tube defects, the exact cause of this birth defect has not been confirmed yet, but it is proposed to be a multifactorial disease with involvement of both genetic and environmental factors. The authors describe identical twins with lipomyelomeningocele of the same subtype and location without any familial history of similar abnormality. Therefore, the same genetic and/or environmental risk factors could have played a part in their condition.

Re-evaluation of the first phenytoin paste healing effects on oral biopsy ulcers

BACKGROUND

Until now, several formulations of topical phenytoin have been used to promote wound healing.

AIM

This study was aimed at re-evaluating the effects of a newly formulated phenytoin mucoadhesive paste on wound healing after oral biopsy.

SUBJECTS AND METHODS

In a double-blind clinical trial, 35 consecutive patients with oral lichenoid or lichen planus lesions were randomized into two groups. After incisional biopsy, patients applied simple, or 1% phenytoin paste at least three times a day (after each meal), for 4 days. They were evaluated every other day for size of wound closure, severity of pain, and diameter of the inflammatory halo. This study was approved by Medical Ethics committee of Shahid Beheshti University of Medical Sciences, Tehran, Iran. Statistical analysis was performed using Mann-Whitney U test and Ordinal Logistic Regression.

RESULTS

Of 35 patients, 17 (10 [10/17, 59%]) men, 7 (7/17, 41%) women, mean age: 40 (4.11) were in phenytoin group, and 18 (9 [9/9, 50%]) men, 9 (9/9, 50%) women, mean age: 43.1 (5.15) were in placebo group. There were no significant differences between both study groups in terms of age and sex (male/female ratio) (P = 0.76, P = 0.88). As all biopsies were done by means of punch number 8, the incisions were of 10 mm length. After second and third appointments, it was observed that patients in the treatment group showed quicker wound closure and less pain compared to control group significantly (P < 0.05). Although not significant, patients treated with phenytoin paste had smaller inflammatory halo than controls.

CONCLUSION

Applying 1% phenytoin mucoadhesive paste on oral biopsy incisions resulted in accelerated wound healing and decrease in pain.

Impact of milk components on recovery of viral RNA from MS2 bacteriophage

Noroviruses are responsible for approximately 44 % of outbreaks involving dairy products for which causative agents are reported. Recovery of viruses from milk and dairy products is a difficult task. The role of different components of milk in the recovery of viral RNA was evaluated in this study. Four model milk formulations (A-D) were prepared by mixing different combinations of lactose, whey protein, casein, and fat in water. Each model formulation was spiked with five concentrations of bacteriophage MS2. The phenol-guanidine thiocyanate-chloroform protocol was used for extracting viral RNA from the model milk formulations and then extracted RNA was measured by a nanodrop spectrophotometer in ng/μl. The results showed that casein and whey protein had the highest negative impact on RNA yield, especially when the number of MS2 was less than 1.3 pfu/ml. The highest RNA recovery was obtained from the model milk formulation containing all four components; lactose, whey protein, casein, and fat. The amount of extracted RNA was closely correlated with the dry matter content of each formulation and the spiked concentration of coliphage using response surface modeling (R²:0.93). It was determined that milk fat is the most effective component in facilitating RNA extraction and the highest RNA yield can be achieved via elimination of whey protein and casein from milk by centrifugation at 40,000×g for 60 min. To achieve the highest viral RNA recovery efficiency by the proposed method, milk fat must be recombined with the supernatant of the centrifuged sample and then homogenized before performing the extraction protocol.

Exophytic glioma of the medulla: presentation, management and outcome

OBJECTIVE

Exophytic gliomas of the medulla are rare childhood tumors that mostly are pilocytic astrocytomas. Here we report our experience in 11 -children with this rare tumor.

METHODS

A retrospective study was performed using the records of children with exophytic gliomas of the medulla at Children's Hospital Medical Center in Tehran, Iran, from 2002 through 2013. The general, clinical, and radiological data and follow-up of all patients were reviewed.

RESULTS

The patients mostly were male aged from 11 months to 7 years. Swallowing problems, failure to thrive and nausea and vomiting were the most common symptoms. The time span between the onset of symptoms and the diagnosis was 2-24 months. Gross total resection of tumor was possible in 8 patients. Most tumors were pilocytic astrocytomas. Patients were followed for 2 months to 11 years (mean = 3.6 years). There was no intraoperative mortality. Recurrence occurred in 1 child with fibrillary astrocytoma.

CONCLUSION

Gross total resection of symptomatic dorsal exophytic medullary glioma is recommended. Most tumors are pilocytic astrocytomas. The attachment of these tumors to important brainstem structures usually inhibits total resection. Electrophysiological monitoring of sensorimotor pathways and cranial nerves can be helpful to preserve surrounding neural tissue during tumor resection and to minimize complications. Regular follow-up of patients with clinical examination and brain MRI is mandatory. Repeated surgery, radiation therapy and chemotherapy are suggested in cases with tumor recurrence or progression.

Single-center experience of percutaneous abdominal aortic aneurysm repair with local anesthesia and conscious sedation: technique and results

AIM

Totally percutaneous endovascular abdominal aortic aneurysm repair (PEVAR) by using the "Preclose" technique has been previously described. We retrospectively analyzed data, collected prospectively at our institution, regarding PEVAR via femoral artery access with local anesthesia and conscious sedation.

METHODS

Between January 2001 and May 2009, 1150 patients underwent PEVAR in the endovascular suite of the cardiac catheterization laboratory at our institution. Of those procedures, 915 (79%) were performed with local anesthesia and conscious sedation.

RESULTS

The majority of patients were male (87%). Their mean age was 72±10 years, and 98% had a risk status of American Society of Anesthesiologists class III or IV. The PEVAR involved bilateral percutaneous femoral access with 12F to 24F sheaths (depending on the stent-graft system). The mean total procedure time was 149 minutes. Percutaneous closure of the arterial access sites with the Prostar XL was successful in 1727 (94.3%) of the 1830 femoral arteries in which PEVAR was attempted, whereas 103 femoral arteries (5.6%) required surgical repair because adequate hemostasis was not attained at the access site. There were no procedural deaths, but 6 patients (0.6%) died within 30 days of the procedure: 3 died of intestinal ischemia, 1 of stroke, 1 of refractory ventricular arrhythmia, and 1 of worsening renal failure. Mean length of hospital stay was 1.3±2 days.

CONCLUSION

PEVAR with local anesthesia and intravenous sedation is safe and feasible and should be considered for patients for whom general anesthesia poses a high risk.

P5-02-04: Disruption of Endothelial Cells Barrier Integrity by Invasive Breast Cancer Cells

Despite its critical role in cancer metastasis the molecular mechanisms regulating breast cancer cells transendothelial migration are poorly understood, but clearly depend on the invasive capacity of tumor cells and their ability to breach the endothelial cell barrier. Vascular endothelial-cadherin (VE-cadherin) is found specifically in the endothelial cell adherens junction and has been implicated in playing a fundamental role in controlling the transport across the endothelial barrier. Tyrosine phosphorylation of VE-cadherin has been implicated in the disruption of endothelial cells adherens junctions and diapedesis of metastatic cancer cells. We tested this hypothesis that interaction of breast cancer cells with endothelial cells initiates the signal transductions that disrupt the endothelium barrier integrity. Our studies demonstrated that the attachment of MDA-MB-231 human breast cancer cells to Human Umbilical Vein Endothelial Cells (HUVECs) leads to tyrosine phosphorylation of VE-cadherin and the formation of gaps between endothelial cells. These were accompanied by activation of two tyrosine kinases, Src and proline rich tyrosine kinase (Pyk-2). In addition, immunoprecipitation studies indicated that the endothelial cells adherens junction structure was disrupted through MDA-MB-231-induced dissociation of VE-cadherin and β-catenin complex. Activation of RhoA and HRas by over expression of constitutively active forms of the genes leads to tyrosine phosphorylation of VE-cadherin and Pyk-2 in HUVECs. Over expression of dominant negative forms of RhoA, HRas, Raf and ERK2 but not Rac1 and Cdc42 attenuated breast cancer cell-induced tyrosine phosphorylation of VE-cadherin and Pyk-2 in HUVECs. Indicating that breast cancer cell-induced VE-cadherin tyrosine phosphorylation and disruption of adherens junction in endothelial cells is mediated by RhoA and HRas\Raf\MEK\ERK signaling cascade. Understanding the precise molecular mechanisms that facilitate breast cancer cells transendothelial migration could develop novel therapeutic strategies targeting cancer cell metastasis by improving the protective role of endothelial cells.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-02-04.

Antitumor effects of AR-42, a novel histone deacetylase inhibitor, in embryonal carcinoma

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Background: Histone deacetylase inhibitors (HDACIs) modulate gene expression and induce cellular differentiation, growth inhibition and apoptotic cell death by chromatin hyperacetylation. Developmental arrest of germ cell differentiation earlier in the life is responsible for the pathogenesis of germ cell tumors (GCT). With current treatment nearly 95% of patients with GCT can be cured. Yet, effective agents with less toxicity are desired. In addition, those with relapsed/refractory disease have a dismal prognosis, indicating a clear need for new, more effective agents. Here we assess the antitumor effects of AR-42, a novel HDACI in in vitro and in vivo models of embryonal carcinoma.

Methods: In vitro effects of AR-42 and suberoylanilide hydroxamic acid (SAHA) were evaluated in NTERA-2, an embryonal carcinoma (EC) cell line derived from a human testicular cancer. Cell viability (MTS assay), apoptosis (caspase 3/7 activity and PARP cleavage), cell cycle analysis (flow cytometry) and HDAC inhibition (immunoblotting) were assessed. The in vivo efficacy of AR-42 was assessed in a NTERA-2 xenograft tumor model in male athymic nude mice. Mice were fed control diet and diet containing AR-42 at an average dose of 25 mg/kg/day. Tumor volumes and weights were used as in vivo endpoints.

Results: Treatment of NTERA-2 cells with both agents at 0.1-10 μM concentrations showed a time- and dose-dependent reduction in cell viability. Both agents significantly induced apoptosis, cell cycle inhibition and hyperacetylation of histones H-3 and H-4 in a dose-dependent manner. In vitro studies showed that AR-42 was more potent than SAHA. In our rodent model, AR-42-containing diet resulted in a significant reduction in tumor volumes and weights (50% and 56%, respectively). The results for intratumoral changes of proliferation and apoptosis are pending. There were no significant toxicities associated with AR-42, except for testicular atrophy, known to be reversible.

Conclusions: AR-42 appears to be a potent inhibitor of EC through different mechanisms, orally bioavailable and well tolerated in our rodent model. Our data indicates that AR- 42 may have clinical value in the treatment of GCT and requires further investigation in clinical trials.

No significant financial relationships to disclose.

A phase II trial of gemcitabine (G), carboplatin (C), and sorafenib (S) in patients (pts) with transitional cell carcinoma (TCC): Preliminary safety and outcome

278

Background: Sorafenib is an oral tyrosine kinase inhibitor with anti-angiogenic properties that may enhance the antitumor activity of GC and when administered as maintenance therapy after GC may delay disease recurrence. This study investigated the safety and clinical outcome of adding S to GC for pts with advanced TCC and the role of S maintenance after GC.

Methods: Metastatic/unresectable chemotherapy naive TCC pts ECOG PS 0-1 received G 1,000 mg/m2 d1, 8 and C AUC = 5 d1 with S 400 mg bid d2-19 q21 d for 6 cycles. Pts with stable disease or PR/CR continued on 400 mg bid of S. The primary endpoint was proportion of pts free of progression at 5 months with secondary endpoint of proportion of pts with PR/CR. A Simon two-stage design would enroll 30 pts; if 8 of the initial 17 followed for 5 months or more post treatment showed disease progression, the trial would terminate.

Results: 17 pts enrolled, 14 male, 3 female; median age 64 (47-86); ECOG 0 (7)/1 (10). The median number of cycles of GC + S given was 4.4 with multiple dose reductions in 71%. 7 pts (47%) experienced grade (gr) 3/4 neutropenia and 4 (24%) gr 3/4 anemia during GC + S; no neutropenic fever was seen. Gr 3/4 thrombocytopenia occurred in 59% with 2 events of hematuria, 1 epistaxis, and 1 bleeding colitis. Gr 3 nonhematologic toxicities: hypophosphotemia (29%), diarrhea (6%), fatigue (24%), anorexia (6%), dehydration (6%), hand foot syndrome (6%), rash (12%), hypertension (6%). Responses: 1 CR (6%), 4 PR (24 %), 8 SD (47%); 3 pts with evaluable disease showed tumor shrinkage, including 1 with resolution of bone metastases. 9 (53 %) were progression free at 5 months; 7 (41%) came off trial due to > 3 dose reductions (1 prior to first restaging) and 1 withdrew consent. 7 (41%) that achieved CR, PR or SD after a minimum of 4 cycles GC + S received maintenance S for a median of 8 cycles.

Conclusions: GC + S showed clinical activity in advanced TCC similar to GC alone but prolonged progression-free intervals were observed in patients treated with S maintenance. GC + S was associated with increased hematologic toxicity although S maintenance was well tolerated. Further studies exploring the role of S maintenance after chemotherapy are warranted.

[Table: see text]

Phase I study of high-dose interleukin (HD-IL2) and sorafenib in patients with metastatic clear cell renal cell carcinoma (RCC) and melanoma

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Background: HD-IL2 has demonstrated activity for immune therapy of RCC and melanoma. Sorafenib is a multitargeted kinase inhibitor with antiangiogenic activity and may also modulate antitumor immunity. This ongoing phase I study assesses the safety, tolerability, dose-limiting toxicity (DLT), and maximum tolerated dose of the combination of HD-IL2 and sorafenib in patients with unresectable or metastatic clear cell RCC and melanoma.

Methods: Eligible patients with ECOG PS 0-1, adequate organ function, and favorable or intermediate Motzer status (RCC patients) received up to two series of therapy. Each 82-day series consisted of two cycles of bolus HD-IL2 and 8 weeks of sorafenib. HD-IL2 (600,000 IU/kg IV q8h x 8-12 doses) was given on days 1-5 (cycle 1) and 15-20 (cycle 2). Sorafenib was given on days 29-82 and discontinued 48-72 hours prior to the next series. Dosing levels for sorafenib were (1) 200mg daily, (2) 200mg BID, (3) 200mg qAM and 400mg qPM, and (4) 400mg BID. Patients who achieved stable disease (SD), partial response (PR), or complete response (CR) after Series 1 proceeded to Series 2.

Results: Fourteen patients (8 RCC, 6 melanoma) have been treated. Nine patients completed Series 1 (5 patients came off study due to poor tolerance of HD-IL2, prior to receiving sorafenib). Six patients had SD or better (3 PR, 3 SD) after Series 1. Of these, five have completed Series 2 and one patient progressed during sorafenib treatment in the second series. No DLTs were observed at the first 3 dose levels. All observed grade 3 and 4 AEs were transient and attributable to the known toxicities of HD-IL2 or sorafenib, and were not considered DLT. Adverse events occurring more frequently in Series 2 (HD-IL2 after sorafenib) included proteinuria and dry skin. One death occurred in a patient with melanoma who received only the first cycle of HD- IL2 (never received sorafenib) and one week later experienced sudden death at home, an event reported as possibly related to the HD-IL2.

Conclusions: No DLT was seen in this study of HD-IL2 and sorafenib and the toxicity was predictable and manageable. Both RCC and melanoma patients experienced PR and SD, but not CR. Enrollment to cohort 4 is ongoing.

[Table: see text]

Early outcomes with neoadjuvant high-dose intensity methotrexate, vinblastine, doxorubicin, and cisplatin (HD-MVAC) or gemcitabine and cisplatin (GC) in muscle-invasive urothelial carcinoma of the bladder: A single-institution experience

280

Background: Compared to MVAC, HD-MVAC achieves significantly higher complete response rates in patients (pts) with metastatic bladder cancer. Based on current literature, 7%-38% of pts with muscle-invasive bladder cancer achieve pathological down-staging (pT0) with neoadjuvant chemotherapy (NC), which correlates with improved disease-free and overall survival. The role of HD-MVAC has not been evaluated in the neoadjuvant setting. In this retrospective study, we present our data in pts who received NC with HD-MVAC or GC followed by radical cystectomy (RC).

Methods: From July 2008 to August 2010, 38 (pts) received 4 cycles of NC with either HD-MVAC or GC for at least T2 bladder cancer followed by RC. The endpoints of interest of this study were the complete pathologic response (pT0) or down-staging to < pT2 (pT0, pTis, and pT1) at RC; and median interval to RC from the time of diagnosis of muscle-invasive bladder cancer and start of NC.

Results: Median age at the time of diagnosis was 66 years (35-80 years). Fifteen pts received neoadjuvant HD-MVAC, and 23 received neoadjuvant GC. Clinical T stage at the time of diagnosis was T2 in 29 (76%), T3 in 3 (8%), and T4 in 6 (16%) pts. Down-staging to < pT2 was achieved in 8 (53%) of HD-MVAC pts and 10 (43%) of GC pts. pT0 was achieved in 5 (33%) of HD-MVAC pts and 9 (39%) of GC pts. The median interval from time of diagnosis to RC was 129 days (range 84-154) for the HD-MVAC pts, and 145 days (range 108-252) for the GC pts. The median interval from initiation of NC to RC was 85 days (range 53-122) for the HD-MVAC pts and 107 days (range 60-126) for the GC pts. Overall, NC was well tolerated with 80% of HD-MVAC pts and 78% of GC pts completing the planned chemotherapy. To this date, none of the pT0 pts had recurrence.

Conclusions: Both neoadjuvant HD-MVAC and GC appear to be well tolerated, with very promising rate of pathological down-staging. Longer follow-up is needed for the survival outcomes of these patients. A shorter interval from diagnosis and initiation of NC to RC might be responsible for our better outcomes comparing to some historical data.

No significant financial relationships to disclose.

Sildenafil efficacy in erectile dysfunction secondary to spinal cord injury depends on the level of cord injuries

To evaluate the efficacy of sildenafil in the treatment of neurogenic erectile dysfunction (ED) secondary to upper motor neuron (UMN) and lower motor neuron (LMN) spinal cord injury (SCI). After taking consents 105 patients suffering from ED were enrolled in this prospective study. Seventy-two patients had signs and symptoms of UMN and 33 patients had signs and symptoms of LMN or mixed (UMN and LMN) spinal cord injuries. The patients took 50-100 mg sildenafil or placebo tablet at least 45 min before sexual intercourse. Based on a IIEF questionnaire, success in achieving erection adequate for sexual intercourse was compared between sildenafil and placebo groups in UMN and non-UMN spinal cord injuries. In patients with UMN disease, sildenafil was effective in 82% of patients and its efficacy was statistically higher than placebo (82 vs. 25%, p < 0.05). Twenty-eight per cent of patients with non-UMN disease had a favourable response to sildenafil that was not statistically different from placebo. Sildenafil seems more effective in the treatment of neurogenic ED secondary to UMN spinal cord injury compared with that secondary to LMN injury. Actually, its efficacy on LMN injuries does not seem different from placebo and administration of this treatment may not be effective in spinal cord injury which has caused LMN symptoms.

Premature ejaculation and serum leptin level: a diagnostic case-control study

INTRODUCTION

Premature ejaculation (PE) is regarded as the most common male sexual disorder. To date, there is no accurate and objective diagnostic test for PE.

AIM

To determine the diagnostic value of serum leptin level for PE.

METHODS

In a case-control design, the serum leptin level of 46 PE patients referred to our outpatient clinic were determined and compared with 44 control patients referred to the same clinic with the complaint of nephrolithiasis. PE was defined based on the Diagnostic and Statistical Manual of Mental Disorders IV criteria and an intravaginal ejaculatory latency time of less than a minute.

MAIN OUTCOME MEASURES

Serum leptin level and presence of PE.

RESULTS

The PE patients had significantly higher serum leptin levels (8.3+/-3 ng/mL) than the controls (3.3+/-1 ng/mL) (P<0.001). Sensitivity and specificity for the test as a predictive diagnostic tool for PE were 80.4% and 97.7%, respectively, at the cutoff value of 6.3 ng/mL.

CONCLUSIONS

According to our results, leptin level in patients with PE was significantly higher than in the control subjects. More studies are necessary to determine the value of serum leptin as a diagnostic tool for PE.

Should preoperative, post-chemoradiotherapy endoscopy be routine for esophageal cancer patients?

Chemoradiation therapy is used widely for locoregional esophageal cancer. Patients with persistent disease may benefit from surgery. Preoperative esophagoscopy can identify persistent tumor but its accuracy is uncertain. The primary objective of this study is to assess the extent of agreement between esophagoscopy and surgical pathology in patients treated with neoadjuvant chemoradiation. A retrospective chart review of patients who underwent chemoradiation, preoperative endoscopy and surgery from January 1996 to December 2002 was performed. Cohen's kappa statistic was used to measure the degree of agreement between findings at endoscopic biopsy and surgical pathology. Thirty cases were identified. All patients received chemoradiation followed by surgical resection. There was insufficient agreement between tumor size (kappa 0.25, standard error 0.17, P = 0.07) and appearance (kappa 0.19, standard error 0.18, P = 0.14). Preoperative endoscopy revealed atypia/inflammation in 15 cases and dysplasia in eight. Of these 23 cases, 11 were adenocarcinomas at surgery. Only nine patients had concurrence between surgical pathology and endoscopy. The positive and negative predictive values of esophagoscopy for identifying residual tumor were 100% and 11%, respectively. Our data suggests that after chemoradiation, esophagoscopy is unreliable for excluding residual disease. The roles of other modalities need to be explored.