Total esophagectomy versus proximal esophagectomy for esophageal cancer at the cervicothoracic junction

To investigate the adequate extent of esophagectomy and lymphadenectomy for an esophageal cancer localized at the cervicothoracic junction, the mortality and morbidity rates, survival rates, and patterns of recurrence were retrospectively analyzed in two groups-14 patients who underwent total esophagectomy with or without laryngectomy and 15 patients who underwent proximal esophagectomy with or without laryngectomy-at Kurume University Hospital from 1981 to 1996. Proximal esophagectomy with or without laryngectomy resulted in a lower hospital mortality rate and better overall survival for patients who underwent curative esophagectomy compared with total esophagectomy with or without laryngectomy. Multivariate analysis indicated that the extent of esophagectomy (total esophagectomy versus proximal esophagectomy) was not a prognostic factor. The incidence of recurrence was not different between the two groups. Lymph node metastasis or recurrence from such esophageal cancers was localized to the neck and upper mediastinum. For an esophageal cancer localized at the cervicothoracic junction, therefore, proximal esophagectomy with or without laryngectomy and with cervical and upper mediastinal lymphadenectomy could be better indicated for preselected patients.

Effect of combination therapy with a methionine-mitomycin C conjugate and a methionine-deficient diet on tumor growth

BACKGROUND

We investigated effects of a combination therapy of a methionine-mitomycin C conjugate (M-M conj) and methionine-free nutrition both in vitro and in vivo, compared to mitomycin C (MMC) administration alone.

MATERIALS AND METHODS

The human esophageal cancer cell line, KE-3, incubated in either standard or methionine-free media, was treated with phosphate buffered saline (PBS), M-M conj in PBS, or MMC in PBS. The rate of cell survival was determined. The tumor bearing mice were maintained on either a standard or methionine-free diet (MFD) and treated with PBS, MMC, or M-M conj.

RESULTS

The lowest tumor cell survival rate was found with the M-M conj plus methionine-free media at every dose tested (p < 0.05). Tumor weight was significantly lower with the M-M conj plus MFD than in any other group (p < 0.003).

CONCLUSION

Methionine targets MMC to tumor during administration of MFD.

Effects of glutamine supplements and radiochemotherapy on systemic immune and gut barrier function in patients with advanced esophageal cancer

OBJECTIVE

The objective of this study was to determine whether oral glutamine supplements can protect lymphocyte and gut barrier function in patients with advanced esophageal cancer undergoing radiochemotherapy.

SUMMARY BACKGROUND DATA

Glutamine supplements improved protein metabolism in tumor bearing rats who underwent chemotherapy and reduced the toxicity of chemotherapy through an enhancement of glutathione production in rats.

METHODS

Thirteen patients with esophageal cancer were randomly placed in either a control or a glutamine group. Glutamine was administered orally (30 g/day) at the start of radiochemotherapy and for the subsequent 28 days. All patients underwent mediastinal irradiation and chemotherapy consisting of 5-fluorouracil and cisplatin. The lymphocyte count was determined, and blast formation was assessed after stimulation with phytohemagglutinin and concanavalin A. Gut barrier function was assessed by measuring the total amount of phenolsulfonphthalein excreted in the urine after the oral administration of phenolsulfonphthalein.

RESULTS

Glutamine supplements prevented a reduction in the lymphocyte count (control: 567 +/- 96/mm3 vs. glutamine: 1007 +/- 151, p < 0.05), and blast formation of lymphocyte (phytohemagglutinin, control: 19478 +/- 2121 dpm vs. glutamine: 33860 +/- 1433, p < 0.01, concanavalin A, control: 19177 +/- 1897 dpm vs. glutamine: 29473 +/- 2302, p < 0.01), and amount of phenolsulfonphthalein excretion in the urine was greater with control than with glutamine group (control: 15.4 +/- 2.4% vs. glutamine: 7.4 +/- 1.2, p < 0.05) 7 days after the initiation of radiochemotherapy.

CONCLUSIONS

Oral glutamine supplementation protects lymphocytes and attenuates gut permeability in patients with esophageal cancer during radiochemotherapy.

A gene encoding antigenic peptides of human squamous cell carcinoma recognized by cytotoxic T lymphocytes

Except for melanomas, tumor antigens recognized by cytotoxic T lymphocytes (CTLs) are yet unidentified. We have identified a gene encoding antigenic peptides of human squamous cell carcinomas (SCCs) recognized by human histocompatibility leukocyte antigens (HLA)- A2601-restricted CTLs. This gene showed no similarity to known sequences, and encoded two (125- and 43-kilodalton [kD]) proteins. The 125-kD protein with the leucine zipper motif was expressed in the nucleus of the majority of proliferating cells tested, including normal and malignant cells. The 43-kD protein was expressed in the cytosol of most SCCs from various organs and half of lung adenocarcinomas, but was not expressed in other cancers nor in a panel of normal tissues. The three nonapeptides shared by the two proteins were recognized by the KE4 CTLs, and one of the peptides induced in vitro from peripheral blood mononuclear cells (PBMCs) the CTLs restricted to the autologous tumor cells. The 43-kD protein and this nonapeptide (KGSGKMKTE) may be useful for the specific immunotherapy of HLA-A2601(+) epithelial cancer patients.

Clinicopathologic study of multiple primary superficial carcinoma of the esophagus

Endoscopic examination with iodine staining has led to the easy detection of multiple superficial esophageal carcinoma (MSEC). The purpose of this study was to better understand the characteristics of MSEC. Of 49 patients with multiple esophageal carcinomas, 19 had superficial carcinoma. Multiple esophageal carcinomas were more often found in superficial carcinomas (31.1%) than in advanced carcinomas (14.4%). Comparing the depth of invasion of multiple esophageal carcinomas, the secondary lesions represented relatively early stages. Ki-67-positive cells were seen significantly more frequently in the main lesion of MSEC than in the secondary lesions, but proliferating cell nuclear antigen positivity and p53 expression did not differ significantly. Since multiple carcinoma occurs more frequently, care should be taken to look for small secondary lesions when treating superficial esophageal carcinoma. Ki-67 immunohistochemistry suggested that tumor cells proliferate more slowly in secondary lesions than in main lesions of MSEC.

The effect of radioimmunotherapy using murine monoclonal antibody KIS1 on esophageal squamous cell carcinoma-bearing nude mice

The monoclonal antibody (MoAb) KIS1 has been shown to react specifically with an antigen of human squamous cell carcinoma (SCC); however, a major problem in its clinical application is that the intact murine antibody induces a human anti-mouse antibody (HAMA). To overcome this problem, we produced the KIS1 F(ab')2 fragment, then radioiodinated the intact KIS1 antibody and its F(ab')2 fragment. Nude mice bearing human esophageal SCC implants were injected with 100 microCi of 131I-intact KIS1 or 131I-KIS1 F(ab')2, and images were obtained using a gamma camera. Radioimmunotherapy (RIT) was performed by injecting the tumor-bearing nude mice with 131I-intact KIS1 or 131I-KIS1 F(ab')2 at a dosage of 300 microCi, following which 7 or 3 days were required to produce high quality tumor images by scintigraphy. The tumor-bearing mice treated with 131I-KIS1 F(ab')2 showed significant tumor growth inhibition, about 5.4 times greater than that of the control group and 1.8 times greater than that of the 131I-intact KIS1 group 21 days after the injection. These results indicate that the KIS1 F(ab')2 fragment is superior to intact KIS1, and that it may be clinically useful for radioimmunodetection followed by tumor targeting therapy for patients with SCC of the esophagus.

Impact on outcome of additional microvascular anastomosis--supercharge--on colon interposition for esophageal replacement: comparative and multivariate analysis

The impact on the outcome of an additional microvascular anastomosis--supercharge--on colon interposition for esophageal replacement was retrospectively evaluated by comparing it with colon interposition without supercharge. A series of 53 patients had undergone colon interposition for esophageal replacement at Kurume University Hospital from 1981 to 1996. The postoperative courses and the morbidity and mortality rates were compared between the 24 patients who underwent colon interposition without supercharge from 1981 to 1988 and the other 29 patients who underwent colon interposition with supercharge from 1989 to 1996. Risk factors for leakage of the esophagocolostomy and for hospital mortality after colon interposition were evaluated by multivariate analysis. Colon interposition with supercharge required a longer operation time but resulted in a lower incidence of necrosis in the colon graft and leakage in the esophagocolostomy (Odds ratio = 34), a shorter duration until peroral intake, and a shorter hospital stay compared to colonic interposition without supercharge. The addition of supercharge to colon interposition for esophageal replacement has been an effective option that has prevented serious complications caused by graft ischemia.

Effect of methionine-free total parenteral nutrition and insulin-like growth factor I on tumor growth in rats

The objectives of this study were to evaluate the effect of insulin-like growth factor I (IGF-I) on the fractional synthesis rate (FSR) of muscle and whole body protein breakdown rate (WPBR) during methionine-free total parenteral nutrition (MTPN). We also determined whether the inhibition of endogenous methionine availability reduced tumor protein synthesis. AH109A hepatoma cells were inoculated onto the backs of Donryu rats on day 0. On day 10, the rats were catheterized for TPN and assigned to one of four groups: 1) standard TPN (STPN), 2) STPN + IGF-I, 3) MTPN, or 4) MTPN + IGF-I. The addition of IGF-I to MTPN reduced the loss of body weight by both increasing muscle FSR and reducing WPBR. The tumor FSR did not differ between MTPN + IGF-I and MTPN. The methionine extraction ratio from the liver was negative with MTPN + IGF-I but positive in the other groups. We concluded that IGF-I blockage of endogenous methionine release from peripheral protein sites was associated with a shift to liver-derived methionine, with no change in tumor growth in MTPN-treated rats.

HLA class I-restricted and tumor-specific cytotoxic T lymphocytes from metastatic lymph nodes of esophageal cancers

This paper investigates the presence of HLA class I-restricted and tumor-specific cytotoxic T lymphocytes (CTL) in tumor sites of esophageal cancers. Five CTL lines were established from the metastatic lymph nodes or pleural effusion by incubation with interleukin-2 of tumor-infiltrating lymphocytes: cases 1 and 5, HLA-A26- and HLA-A33-restricted and squamous cell carcinoma (SCC)-specific CTL; case 2, HLA-Cw0102-restricted and esophageal SCC-specific CTL; case 3, HLA-A24- and HLA-A26-restricted CTL recognizing histologically different tumor cells; and case 4, HLA-A26-restricted and esophageal SCC-specific CTL. These results suggest the existence of HLA class I-restricted and tumor-specific CTL in metastatic esophageal SCC.

Pattern of recurrence after extended radical esophagectomy with three-field lymph node dissection for squamous cell carcinoma in the thoracic esophagus

Factors responsible for recurrence of esophageal cancer were investigated in 90 patients who underwent extended radical esophagectomy with three-field dissection for a squamous cell carcinoma in the thoracic esophagus. The initial tumor recurrence was grouped as either locoregional (site of the primary tumor, anastomotic site, or lymph nodes) or as distant (distant organs, pleura, or peritoneum). Nineteen patients (21%) developed a locoregional recurrence, and 19 (21%) developed a distant recurrence. One (1%) developed both recurrences simultaneously and was classified as a distant recurrence. The locoregional recurrence was correlated with the stage factors, particularly the number of metastasis-positive nodes. For the distant recurrence, vascular invasion was found to have been the most important prognostic factor. Our findings suggested that locoregional recurrence was due to tumor progress related to the extent of lymph node metastasis, whereas distant recurrence was due to the oncologic behavior of the tumor. Locoregional recurrence in patients with limited disease may be reduced by extended radical esophagectomy with three-field dissection. Distant recurrence cannot be controlled by surgery. Adopted postoperative adjuvant therapies showed no effect on recurrence.

[An experimental study on antitumor effect of MMC-fibrin glue mixture]

In spite of postoperative chemo- and/or radiation therapy, the prognosis of advanced cancer patients undergoing palliative operation is still poor. Therefore, in order to improve the effect of chemotherapy, we made a mixture of MMC and fibrin glue (MMC-FIB) as a local chemotherapy. Using FIB with MMC, we expected to enhance the efficiency of MMC by sustained release of MMC. We examined cytotoxic effects and anti-tumor effects of the MMC-FIB using a gastric cancer cell line (MKN-28) and an esophageal cancer cell line (KE-3). Effects of the MMC-FIB were twice as strong as those of MMC on in vitro and in vivo studies. MMC-FIB is easy to make and apply to residual tumor. These results suggest that MMC-FIB is an effective treatment as a local chemotherapy for postoperative residual cancer.

Comparative analysis of imaging modalities in the preoperative assessment of nodal metastasis in esophageal cancer

Preoperative radiological findings of nodal status in 74 patients, using endoscopic ultrasonography (EUS), computed tomography (CT), ultrasonography (US), and magnetic resonance imaging (MRI), were compared to histopathology reports following transthoracic total esophagectomy with radical lymphadenectomy (TTE), involving complete dissection of the mediastinal and abdominal nodes and lower cervical lymph nodes. Accuracy, sensitivity, and specificity of each radiological investigation were calculated for each anatomic group of nodes. Statistical analysis revealed that EUS is more accurate and significantly more sensitive (P<0.01) for lymph nodes along the right recurrent laryngeal nerve and those in the upper and mid-periesophageal, infracarinal locations. Paratracheal and lower paraesophageal nodes are assessed better using CT whereas MRI is better for mid-paraesophageal and infra-aortic nodes. US is most accurate and sensitive for evaluation of cervical and abdominal nodes (P<0.01).

Endosonography for preoperative staging of specific nodal groups associated with esophageal cancer

The results of endoscopic ultrasonography (EUS), used preoperatively in 74 endoscopically evaluable patients, were compared with the histopathology after subsequent total esophagectomy with radical lymphadenectomy involving a three-field dissection of the lower cervical, mediastinal, and abdominal nodes. Patients with obstruction to endoscopy were excluded from this study. Overall accuracy, specificity, and sensitivity were 87%, 90%, and 37%, respectively. EUS has an accuracy of more than 80% for detecting metastatic nodes in the cervical paraesophageal, supraclavicular, right recurrent laryngeal, left paratracheal, upper and lower paraesophageal, infraaortic, infracarinal, and lower posterior mediastinal regions. Its sensitivity is highest for cervical and upper thoracic paraesophageal, infracarinal, left paratracheal, and recurrent laryngeal nodes. Accuracy is maximum for periesophageal nodes and varies inversely with the axial distance of the nodes from the esophageal axis. We recommend that EUS be used routinely for preoperative assessment of the cervical and mediastinal nodal status.

A monoclonal antibody KIS-1 recognizing a new membrane antigen on human squamous-cell carcinoma

A KIS-1 monoclonal antibody (MAb) (IgG1, kappa) recognizing a membrane antigen on human squamous-cell carcinomas (SCC) was developed to understand their antigenicity using an esophageal SCC as an immunogen. The KIS-1 MAb recognized a membrane antigen on a majority of esophageal, lung, and oral- cavity SCC by immunofluorescent and by immunohistochemical analyses. In contrast, it showed little reactivity to adenocarcinomas from different organs, and none to keratinocyte cell lines. This MAb showed reactivity to the cells in the basal layer of normal esophageal epithelium adjacent to the esophageal SCC, but none of the other normal tissues, including esophageal epithelium far from the SCC and that from patients with non-malignant disease. The KIS-1 MAb immunoprecipitated a 46-kDa membrane protein of the esophageal SCC in non-reducing and in reducing conditions. It recognized the 46- and the 40-kDa proteins of the esophageal SCC by immunoblot analysis. These results suggest that the KIS-1 MAb recognizes a new membrane antigen preferentially expressed on SCC, and that this antigenicity is shared only by the cells in the basal layer of the esophageal epithelium adjacent to SCC. The KIS-1 MAb may be a new tool for understanding the antigenicity of SCC.

Comparative analysis of imaging modalities in the preoperative assessment of nodal metastasis in esophageal cancer

Preoperative radiological findings of nodal status in 74 patients, using endoscopic ultrasonography (EUS), computed tomography (CT), ultrasonography (US), and magnetic resonance imaging (MRI), were compared to histopathology reports following transthoracic total esophagectomy with radical lymphadenectomy (TTE), involving complete dissection of the mediastinal and abdominal nodes and lower cervical lymph nodes. Accuracy, sensitivity, and specificity of each radiological investigation were calculated for each anatomic group of nodes. Statistical analysis revealed that EUS is more accurate and significantly more sensitive (P<0.01) for lymph nodes along the right recurrent laryngeal nerve and those in the upper and mid-periesophageal, infracarinal locations. Paratracheal and lower paraesophageal nodes are assessed better using CT whereas MRI is better for mid-paraesophageal and infra-aortic nodes. US is most accurate and sensitive for evaluation of cervical and abdominal nodes (P<0.01).

Pulmonary capacity in lung cancer patients prior to lung resection--comparison of the unilateral pulmonary artery occlusion test with expired gas analysis during exercise testing

We attempted to determine if expired gas analysis during exercise testing has equal value to the unilateral pulmonary artery occlusion test (UPAO). Sixty-four lung cancer patients were evaluated. We performed UPAO and measured mean pulmonary artery pressure (PPA) and cardiac output (C.O.) 15 min later, and calculated total pulmonary vascular resistance (TPVR). Expired gas analysis during exercise testing was performed, and the maximum oxygen consumption per unit body surface area (VO2max/m2) and the anaerobic threshold (AT/m2) were calculated. The patients were divided into two groups according to the PPA as follows: Group PPA(L) and Group PPA(H), and the TPVR as follows: Group TPVR(L) and Group TPVR(H). Comparative studies of the mean values of VO2max/m2 and AT/m2 were performed between the two groups. VO2max/m2 was significantly higher in Group PPA(L) than in Group PPA(H). VO2max/m2 was significantly higher in Group TPVR(L) than in Group TPVR(H). TPVR and VO2max/m2 showed no significant correlation, but a weak negative quadratic correlation with the equation y = 2276-246.6 logx was found. This result led a minimal acceptable levels for lung resection of Vo2max/m2 of 650 ml/min/m2 corresponding to the TPVR levels of 700 dyne.sec.cm5/m2.

Immunohistochemical localization of vascular endothelial growth factor in esophageal cancer

We have studied the expression of vascular endothelial growth factor (VEGF) in esophageal cancer using immunohistochemistry. A total of 101 specimens of esophageal cancer tissue were fixed by formalin, embeded in paraffin wax, and examined in 3 microns sections by avidin-biotin peroxidase complex method. VEGF was noted in the cytoplasm of normal esophageal glandular cells, monocyte-macrophages, squamous carcinoma cells and of the vascular endothelial cells themselves. VEGF expression by monocyte-macrophages was observed in all cases, in contrast the incidence of VEGF expression in the tumor cells was relatively low at 26.7% of all specimens. However, in the cases where the tumor cells were positive for VEGF, it was discovered that the main source of the VEGF production was the tumor cells themselves. In the cases with proper mucosal invasion the incidence of VEGF expression by the tumor cells was quite low at 7.6%. However, when the tumor invaded the submucosal layer the expression increased to 33.3%. There was also a significant correlation in those with the submucosal invasion between the expression of VEGF in the tumor cells and that VEGF may play an important role in tumor progression and in the angiogenesis via auto-crine and para-crine mechanisms in esophageal cancer.

[Tumor-rejection antigens expressed on human squamous cell carcinoma]

Squamous cell carcinoma (SCC) is one of the most common cancers in human. SCC, particularly, esophageal and lung SCC are relatively resistant to currently available regimens of chemotherapy or radiation therapy. Therefore, development of a specific immunotherapy using tumor specific cytotoxic T lymphocytes (CTL) would be important to offer other treatment modalities. However, generation of HLA class I-restricted CTL recognizing SCC has been rarely reported. We established the HLA A2601-restricted CTL cell line recognizing a peptide antigen expressed on SCC. This CD4- CD8+ cytotoxic T lymphocyte (KE-4 CTL) cell line was established in a patient with esophageal cancer. The KE-4 CTL recognized a peptide antigen on esohageal and lung SCC in an HLA A2601-restricted manner as evaluated by cytotoxity against a panel of tumor cells, transfection experiments with HLA A2601 cDNA, and reconstitution with eleted peptides. None of normal cells tested was lysed by this CTL. These results suggest the exstence of HLA A2601-restricted CTL precursors recognizing a peptide antigen on SCC in a patient with esophageal cancer.