The effectiveness of plasma miR-33a-5p as a predictive biomarker for the efficacy of colorectal cancer chemotherapy

Several chemotherapeutic options are available for patients with metastatic colorectal cancer (mCRC), making it important to individualize treatment regimens. Individualization requires the clinical application of biomarkers for regimen selection, which is presently insufficient. miRNAs serve an important role in the control of biological processes in several types of cancer, acting as plasma biomarkers. The current study aimed to evaluate novel plasma microRNAs for predicting chemo-resistance in chemotherapy for patients with colorectal cancer (CRC) by employing a Toray 3D-Gene microRNA array-based approach, which compared plasma content before and during treatment. Specific miRNAs that acted as biomarkers of the fluoropyrimidine (FP) + oxaliplatin (OX) + bevacizumab (BEV) regime, a common first-line treatment for mCRC, were searched. The plasma samples of 110 patients with mCRC who had received the FP+OX+BEV regimen were subjected to microarray analyses using the 3D-Gene miRNA microarray platform, after which miRNAs levels were quantified via reverse transcription- quantitative PCR. Patients exhibiting complete response, partial response (PR) and reduced stable disease (SD) were defined as responders. Patients with extended SD and progression disease (PD) were defined as non-responders. Following microarray analysis, miR-33a-5p was selected as the candidate miRNA as it was upregulated in non-responder plasma samples. The expression of miR-33a-5p was upregulated in the non-responders (n=15) compared with the responders (n=95) (P=0.032). The high expression group demonstrated significantly poor progression-free survival (P<0.01). To evaluate whether miR-33a-5p can serve as a marker of chemo-resistance, miR-33a-5p expression levels were assessed at the following three time-points: Pre-point (before chemotherapy); PR-point (3-months after chemotherapy began); and PD-point (the time at which recurrence or progression was recorded). The results revealed that expression levels were significantly increased at the PD-point when compared with that at the pre-point (P=0.024). The current study determined that the miR-33a-5p expression level in the plasma may serve as a predictive marker of efficacy and as a biomarker of chemo-resistance.

Evaluation of synchronous multiple primary superficial laryngo-pharyngeal cancers that were treated by endoscopic laryngo-pharyngeal surgery

OBJECTIVE

ndoscopic laryngopharyngeal surgery (ELPS) is a useful surgery for superficial cancers of the head and neck region, but it has not yet been well evaluated for synchronous multiple primary cancers (multiple primaries). The purpose of this study was to clarify the safety and usefulness of ELPS for patients with multiple superficial primary cancers in the head and neck region.

METHODS

rom December 2009 to December 2016, 145patients with superficial head and neck cancers underwent ELPS. The patients were divided into two groups; a group consisting of patients with a single primary cancer (single primary) and another group consisting of patients with synchronous multiple primaries, and the incidences of postoperative complications and lymph node metastasis were retrospectively compared between the two groups.

RESULTS

f the 145 patients, 107 had a single primary cancer and 38 had multiple primaries. There was no significant difference in the age, sex, or rate of intraepithelial cancer between the two groups. Postoperative complications included dysphagia in 6 (5.6%) patients with a single primary and 2 (5.3%) patients with multiple primaries. One patient with multiple primaries required gastrostomy because of aspiration pneumonia. In addition, the following complications were also observed. Laryngeal paralysis occurred in 2 (1.9%) patients with a single primary, and 1 (2.6%) patient with multiple primaries; tracheostomy because of postoperative bleeding in 1 (0.9%) patient with a single primary; infection occurred in 2 (5.3%) patients with multiple primaries. Postoperative lymph node metastasis was found in 7 (6.5%) patients with a single primary and 6 (15.8%) patients with multiple primaries. Lymphatic invasion of the primary cancer was noted in 3 (2.8%) patients with a single primary and 5 (13.2%) patients with multiple primaries, being significantly higher in the latter group.

CONCLUSION

ELPS is also a safe surgery for patients with multiple primaries. However, the incidence of lymphatic invasion of the primary cancer was significantly higher in patients with multiple primaries.

Linked Color Imaging Focused on Neoplasm Detection in the Upper Gastrointestinal Tract : A Randomized Trial

BACKGROUND

Linked color imaging (LCI) is a new image-enhanced endoscopy technique that allows users to recognize slight differences in mucosal color.

OBJECTIVE

To compare the performance of LCI with white light imaging (WLI) in detecting neoplastic lesions in the upper gastrointestinal tract.

DESIGN

A controlled, multicenter trial with randomization using minimization. (University Hospital Medical Information Network Clinical Trials Registry: UMIN000023863).

SETTING

16 university hospitals and 3 tertiary care hospitals in Japan.

PATIENTS

1502 patients with known previous or current cancer of the gastrointestinal tract and undergoing surveillance for gastrointestinal cancer.

INTERVENTION

WLI followed by LCI examination (WLI group) or LCI followed by WLI examination (LCI group).

MEASUREMENTS

Diagnosis of 1 or more neoplastic lesions in the pharynx, esophagus, or stomach in the first examination (primary outcome) and 1 or more neoplastic lesions overlooked in the first examination (secondary outcome).

RESULTS

752 patients were assigned to the WLI group and 750 to the LCI group. The percentage of patients with 1 or more neoplastic lesions diagnosed in the first examination was higher with LCI than with WLI (60 of 750 patients or 8.0% [95% CI, 6.2% to 10.2%] vs. 36 of 752 patients or 4.8% [CI, 3.4% to 6.6%]; risk ratio, 1.67 [CI, 1.12 to 2.50; P = 0.011]). The proportion with overlooked neoplasms was lower in the LCI group than in the WLI group (5 of 750 patients or 0.67% [CI, 0.2% to 1.6%] vs. 26 of 752 patients or 3.5% [CI, 2.3% to 5.0%]; risk ratio, 0.19 [CI, 0.07 to 0.50]).

LIMITATION

Endoscopists were not blinded.

CONCLUSION

LCI is more effective than WLI for detecting neoplastic lesions in the pharynx, esophagus, and stomach.

PRIMARY FUNDING SOURCE

Fujifilm Corporation.

Prediction of surgical difficulty in minimally invasive surgery for rectal cancer by use of MRI pelvimetry

Background

Technical difficulties in rectal surgery are often related to dissection in a limited surgical field. This study investigated the clinical value of MRI pelvimetry in the prediction of surgical difficulty associated with minimally invasive rectal surgery.

Methods

Patients with rectal cancer who underwent laparoscopic or robotic total mesorectal excision between 2005 and 2017 were reviewed retrospectively and categorized according to surgical difficulty on the basis of duration of surgery, conversion to an open procedure, use of the transanal approach, postoperative hospital stay, blood loss and postoperative complications. Preoperative clinical and MRI‐related parameters were examined to develop a prediction model to estimate the extent of surgical difficulty, and to compare anastomotic leakage rates in the low‐ and high‐grade surgical difficulty groups. Prognosis was investigated by calculating overall and relapse‐free survival, and cumulative local and distant recurrence rates.

Results

Of 121 patients analysed, 104 (86·0 per cent) were categorized into the low‐grade group and 17 (14·0 per cent) into the high‐grade group. Multivariable analysis indicated that high‐grade surgical difficulty was associated with a BMI above 25 kg/m² (odds ratio (OR) 4·45, P = 0·033), tumour size 45 mm or more (OR 5·42, P = 0·042), anorectal angle 123° or more (OR 5·98, P = 0·028) and pelvic outlet less than 82·7 mm (OR 6·62, P = 0·048). All of these features were used to devise a four‐variable scoring model to predict surgical difficulty. In patients categorized as high grade for surgical difficulty, the anastomotic leakage rate was 53 per cent (9 of 17 patients), compared with 9·6 per cent (10 of 104) in the low‐grade group (P < 0·001). The high‐grade group had a significantly higher local recurrence rate than the low‐grade group (P = 0·002).

Conclusion

This study highlights the impact of clinical variables and MRI pelvimetry in the prediction of surgical difficulty in minimally invasive rectal surgery.

The evaluation of the hemodynamics of a gastric tube in esophagectomy using a new noninvasive blood flow evaluation device utilizing near-infrared spectroscopy

OBJECTIVE

We herein evaluated the hemodynamics of a gastric tube in esophagectomy using a new noninvasive blood flow evaluation device utilizing near-infrared spectroscopy.

METHODS

Thirty-two cases of subtotal esophagectomy and gastric tube reconstruction for esophageal cancer were studied. The new device measures the regional tissue saturation of oxygen (rSO₂: 0-99%) and total hemoglobin index (T-HbI: 0-1.0) with a small sensor. We measured these values at the antrum (point A), final branch of the right gastroepiploic artery (point B) and planned anastomotic point (point C) before and after gastric tube formation. The values at the three points were compared, and the gradients at the three points from before to after gastric tube formation were compared.

RESULTS

The mean values of rSO₂ at point A, B, and C before gastric tube formation were 57.2%, 57.8% and 56.0%, and those after formation were 54.6%, 58.0% and 55.8%, respectively. There was no significant difference in the comparison of the rSO₂ gradient before and after formation (p = 0.167). The mean values of T-HbI at point A, B, and C before formation were 0.126, 0.178 and 0.211, and those after formation were 0.167, 0.247 and 0.292, respectively. There was no significant difference in the gradient of the increase before and after formation (p = 0.461).

CONCLUSION

A new device has shown that the gastric tube used in our facility is one that maintains tissue saturation of oxygen and does not cause excessive congestion at anastomosis.

Flexible Gastric Tube: A Novel Gastric Tube Formation Method to Prevent Anastomotic Leakage

Gastric tube reconstruction is now the method most frequently used for digestive tract reconstruction after the resection of esophageal carcinoma. In our institute, a ^"flexible^" gastric tube designed to supply a sufficient amount of blood to the tip of the gastric tube (the same as a subtotal gastric tube) and simultaneously provide sufficient length for tension-free anastomosis in the cervical surgical field (the same as a narrow gastric tube) was introduced. This gastric tube formation method has contributed to reducing the rate of anastomotic leakage.

Mid- and long-term outcomes of endoscopic resection for submucosal esophageal cancer types pT1b-SM1 and pT1b-SM2

Background and study aims  Endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) are promising therapeutic options for early esophageal cancer (EC). The factors that can affect mid- and long-term survival in patients with submucosal EC (SM1 and SM2) have not been described in the literature. We aim to describe clinicopathological outcomes and factors that can affect the mid- and long-term survival in patients with resected submucosal tumors. Patients and methods  We performed a retrospective analysis of patients who underwent endoscopic resection (ER) for submucosal tumors over a 20-year period. The final study population included 119 cases with 137 lesions. Information was collected according to the Japanese Classification of Esophageal Cancer 11-edition and factors affecting survival for 2 and 5 years after ER were analyzed. Results  EMR was performed in 99 cases (72.3 %), ESD in 38 cases (27.7 %). There were no significant complications. Two- and 5-year survival rates were 91 % and 82 %, respectively. Mean age was 67.22 years (± 9.49 years), mortality caused by EC occurred in 13 cases (11 %). Factors that had a significant impact on long-term survival were age > 65 years ( P  = 0.0026), number of resected specimens ( P  = 0.0031), presence of another progressive disease (not EC) ( P  ≤ 0.001), recurrence ( P  = 0.0002), and relation between histopathological positive vertical margin and recurrence ( P  = 0.0112). Conclusions  ER is viable treatment for esophageal submucosal cancer, selection between ESD/EMR can depend on tumor size and patient condition, and en bloc ER is the recommended technique for submucosal tumors. Long-term survival factors were identified.

Histological study of the thin membranous structure made of dense connective tissue around the esophagus in the upper mediastinum

BACKGROUND

The structure of the fascia in upper mediastinum has already been reported from gross anatomical viewpoints by Sarrazin. But it is necessary to understand meticulous anatomy for thoracoscopic or mediastinoscopic surgery. So herein, we investigate histologically the thin membranous structure made of dense connective tissues.

METHODS

Semi-sequential transverse sections of the mediastinum were obtained from three cadavers. Hematoxylin and eosin staining, Elastica van Gieson staining, and Masson trichrome staining were performed to identify the presence and location of the thin membranous structure made of dense connective tissues.

RESULTS

The "visceral sheath" and "vascular sheath," as previously described by Sarrazin, were observed histologically. These two thin membranous structures do not surround the esophagus and trachea cylindrically. In addition, the "visceral sheath" on the right side of the upper mediastinum was unclear in comparison to the left side. The "visceral sheath" (on the left side) gradually became unclear, and seemed to almost disappear; the esophagus was found to be very close to the thoracic duct on the caudal side of the bifurcation of the trachea. Although the left recurrent nerve was located inside the "visceral sheath" in all cadavers, the left recurrent nerve lymph nodes were located inside the "visceral sheath" in cadaver 1 and between the "visceral sheath" and "vascular sheath" in cadaver 3.

CONCLUSION

The "visceral sheath" around the esophagus in the upper mediastinum was histologically demonstrated; however, the findings were not constant.

Detection of Second Primary Malignancies of the Esophagus and Hypophraynx in Oral Squamous Cell Carcinoma Patients

Objective

To assess the usefulness of modified esophagogastroduodenoscopy (EGD) for the detection of second primary malignancies of the esophagus or hypopharynx in patients with oral squamous cell carcinoma and determine the association between the oral lesion subsite and esophageal or hypopharyngeal lesion occurrence.

Study Design

Retrospective review.

Methods

In total, 166 patients with oral squamous cell carcinoma without any established symptoms of esophageal or hypopharyngeal squamous cell carcinoma underwent modified EGD based on the Valsalva maneuver and U-turn method, image-enhanced endoscopy, and chromoendoscopy using Lugol's iodine for diagnosis. All suspected lesions were biopsied to determine the clinical stages and duplication rates. Odds ratios for the occurrence of duplicate lesions according to the oral lesion subsite were determined.

Results

In total, 37 esophageal and 16 hypopharyngeal lesions were detected. According to the Union for International Cancer Control/American Joint Committee on Cancer classification (2009), 75.7% and 5.4% esophageal lesions were classified as stage IA and IB, respectively, and 50% and 18.8% hypopharyngeal lesions as stage II and stage I, respectively. Approximately 59.1% and 50% esophageal and hypopharyngeal lesions, respectively, were successfully treated by endoscopic resection. Oral lesions involving the floor of the mouth were more frequently accompanied by second primary malignancies of the esophagus or hypopharynx.

Conclusions

Modified EGD is an effective noninvasive technique for early diagnosis and treatment of second primary malignancies of the esophagus and hypopharynx in patients with oral squamous cell carcinoma. In particular, patients with floor of the mouth lesions need close monitoring for hypopharyngeal and esophageal lesions.

Level of Evidence

3b.

Comparative Study of Predictive Mortality Scores in Esophagectomy with Three-Field Lymph Node Dissection in Patients with Esophageal Cancer

BACKGROUND/AIM

Esophagectomy is still the best therapeutic option for curing resectable esophageal cancer (EC). Radical surgical resection with three-field lymphadenectomy (3FLD) is a potentially curative treatment option. We compared the predictive accuracy of 5 different scores in patients with EC who underwent 3FLD.

METHODS

Five years' worth of medical records in a single institution were analyzed (January 2010 to January 2015) from 311 patients who underwent esophagectomy for EC. We selected 191 in whom 3FLD was performed. Mortality was calculated based on 5 predictive scores. Outcomes measures were intraoperative mortality, 30-day mortality, and 1- and 2-year mortality after surgery.

RESULTS

Intraoperative mortality and 30-day mortality after surgery was 0%; 1 and 2-year mortality were 19.8 and 31.4%, respectively. The area under the curve showed poor discriminatory power for all 5 scores (<0.7). In one-way analysis of variance, for 1 year mortality, Portsmouth-Physiological and Operative Severity Score for mortality (P-Possum) was significant (p = 0.0424); in a multivariable analysis for 2-year mortality, P-Possum (p < 0.0001) remained significant.

CONCLUSION

There is no accurate prognosis score for esophagectomy in patients who undergo high-risk procedures like 3FLD. New scores are needed to predict the mortality after 3FLD with good discriminatory power. Independent factors affect survival and may function as the baseline for obtaining a new accurate mortality score.

Comparative analysis of avascular areas in superficial esophageal squamous cell carcinomas using in vivo and ex vivo magnifying endoscopy

BACKGROUND AND STUDY AIMS

 An avascular area (AVA), one of the microvasculature changes in superficial esophageal cancers, appears when a tumor demonstrates a bulky growth pattern. We aimed to compare endoscopic and histopathological findings by observing formalin-fixed AVA specimens using magnifying endoscopy.

PATIENTS AND METHODS

 A prospective analysis was conducted on 16 patients with superficial esophageal cancer, including AVA, who underwent endoscopic submucosal dissection (ESD). Magnifying endoscopy and blue laser imaging were used to identify AVAs. After the ESD, the AVA width was measured on formalin-fixed specimens using magnifying endoscopy, and AVA thickness and depth were determined after hematoxylin and eosin staining using microscopy.

RESULTS

 Mean AVA widths of M1, M2, and M3/SM-lesions were 0.434, 0.578, and 0.835 mm, respectively (M1 vs. M2, P = 0.16; M2 vs. M3/SM-, P  = 0.07). Mean AVA thicknesses of M1, M2, and M3/SM-lesions were significantly different (0.176, 0.518, and 0.800 mm; M1 vs. M2, P < 0.01; M2 vs. M3/SM-, P  < 0.05). There was a significant correlation between AVA width and thickness.

CONCLUSIONS

 AVA size can be measured accurately on formalin-fixed specimens with magnifying endoscopy. AVA thickness can be useful for determining tumor depth.

Risk of metastasis in adenocarcinoma of the esophagus: a multicenter retrospective study in a Japanese population

BACKGROUND

Little is known about the specific risks of metastasis in esophageal adenocarcinoma in relation to invasion depth or other pathologic factors.

METHODS

We conducted a multicenter retrospective study in 13 high-volume centers in Japan from January 2000 to October 2014 to elucidate the risk of metastasis of esophageal adenocarcinoma. A total of 458 patients (217 surgically resected and 241 endoscopically resected) with esophageal adenocarcinoma or esophagogastric adenocarcinoma involving the esophagus were included. Metastasis was considered positive if there was histologically confirmed metastasis in the surgical specimen or clinically confirmed metastasis during follow-up. Metastasis was considered negative if no metastasis was identified in resected specimens and during follow-up in patients treated surgically or no metastasis during follow-up for >5 years in patients treated by endoscopic resection.

RESULTS

Metastasis was identified in 72 patients. Multivariate analysis confirmed lymphovascular involvement [odds ratio (OR) 6.20; 95 % confidence interval (CI) 3.12-12.32; p < 0.001], a poorly differentiated component (OR 3.69; 95 % CI 1.92-7.10; p < 0.001), and lesion size >30 mm (OR 3.12; 95 % CI 1.63-5.97; p = 0.001) as independent risk factors for metastasis. No metastasis was detected in patients with mucosal cancer without lymphovascular involvement and a poorly differentiated component (0/186 lesions) or in patients with cancer invading the submucosa (1-500 µm) without lymphovascular involvement, a poorly differentiated component, and ≤30 mm (0/32 lesions).

CONCLUSIONS

Mucosal and submucosal cancers (1-500 µm invasion) without risk factors have a low incidence of metastasis and may thus be good candidates for endoscopic resection.

A prospective study of nutritional supplementation for preventing oral mucositis in cancer patients receiving chemotherapy

BACKGROUND AND OBJECTIVES

Patients undergoing chemotherapy often develop distressing adverse effects such as oral mucositis and diarrhea. Nutritional support with elemental diet is effective against various gastrointestinal complications and may exert protective effects against adverse effects induced by chemotherapy. To evaluate the influence of elemental diet on chemotherapy-induced oral mucositis and diarrhea, we conducted a randomized control trial in patients with esophageal cancer undergoing chemotherapy.

METHODS AND STUDY DESIGN

Twenty esophageal cancer patients receiving chemotherapy with 5-fluorouracil plus cisplatin were assigned randomly to one of the following two groups: (1) receiving elemental diet with Elental (one pack per day) for 14 days and (2) not receiving Elental during chemotherapy. The severity of oral mucositis and diarrhea was graded using clinical examination by doctors and a standard questionnaireon days 1-14.

RESULTS

Based on the analysis of the standard questionnaire, the distribution of the maximum severity of oral mucositis showed a statistically significant reduction in the Elental group (p=0.020), while clinical examination showed insignificant reduction but shift toward lower grade. In the Elental group, the incidence of oral mucositis (grade >=2) reduced consistently and the median grade was lower at all-time points. Regarding diarrhea, no difference was observed between the two groups based on the analysis of the standard questionnaire and clinical examination results.

CONCLUSIONS

This study illustrates the effectiveness of oral elemental diet in preventing oral mucositis during chemotherapy. This is a preliminary report and further study with larger patients groups should be devoted to optimization of efficacy.

A Pilot Trial of S-1 and Paclitaxel in Unresectable or Postoperative Recurrent Esophageal Squamous Cell Carcinoma Pretreated by Fluorouracil, Cisplatin, and Docetaxel Chemotherapy

BACKGROUND/AIMS

This study documents the clinical efficacy and toxicity of S-1 and paclitaxel (S1/PTX) in patients with unresectable or postoperative recurrent esophageal squamous cell carcinoma (ESCC) who had been previously treated with fluorouracil (5FU), cisplatin, and docetaxel.

METHODS

Twenty-eight ESCC patients treated using S1/PTX at our institute since 2010 were enrolled in this study. S1 was administered orally at a dose of 80 mg/m2/day from days 1 to 14, and PTX was administered intravenously on days 1 and 8 at a dose of 80-100 mg/m2.

RESULTS

A total of 106 cycles (median 2.5 cycles, range 1-12 cycles) were administered. The response rate was 14.8%, including 3 complete responses. The median progression-free survival time was 137 days, and the median overall survival time was 306 days. Severe neutropenia occurred in 13 patients, and 3 showed febrile neutropenia. All non-hematological toxicities were mild, and peripheral nerve paralysis was observed in 2 patients.

CONCLUSION

S1/PTX was found to have tolerable clinical efficacy in terms of the response rate, survival and toxicity in patients with unresectable or postoperative recurrent ESCC who had previously been treated with 5FU, cisplatin, and docetaxel.