Trends in esophageal adenocarcinoma incidence and mortality

Loss of ARID1A expression is associated with DNA mismatch repair protein deficiency and favorable prognosis in advanced stage surgically resected esophageal adenocarcinoma

Esophageal adenocarcinoma often presents at an advanced stage and has a dismal prognosis. Current prognostic markers have limited utility. ARID1A is implicated as a tumor suppressor gene in esophageal adenocarcinoma. Loss of ARID1A expression correlates with DNA mismatch repair (MMR) protein deficiency in other tumors. We hypothesized that ARID1A loss is associated with prognosis and DNA MMR protein deficiency in esophageal adenocarcinoma. Tissue microarrays representing 316 surgically resected esophageal adenocarcinomas without neoadjuvant treatment were evaluated for ARID1A and MMR proteins by immunohistochemistry. Loss of ARID1A expression (ARID1A-loss) was detected in 41 of 316 (13%) adenocarcinomas. MMR deficiency was identified in 5% (17/316) but was detected more frequently in ARID1A-loss adenocarcinomas (13/41, 32%) than in ARID1A-retained adenocarcinomas (4/275, 1%; P < .001). Morphologically, ARID1A-loss adenocarcinomas frequently demonstrated peritumoral lymphoid aggregates (90%) and tumor infiltrating lymphocytes (51%). In patients with locally advanced or metastatic disease (stages III or IV, N = 169), patients with ARID1A-loss adenocarcinomas (N = 22) had longer overall survival than patients with ARID1A-retained adenocarcinomas (median [month]: 26 vs. 16, P = .010). In these patients, ARID1A-loss correlated with a 56% reduction in mortality independent of other prognostic factors (P = .007). In summary, loss of ARID1A expression is associated with DNA MMR protein deficiency in esophageal adenocarcinoma. Furthermore, ARID1A loss is independently associated with a more favorable prognosis for patients with locally advanced or metastatic esophageal adenocarcinomas.

Treatment of early stage (T1) esophageal adenocarcinoma: Personalizing the best therapy choice

Esophagectomy is considered the primary form of management for esophageal adenocarcinoma (EAC); however, the surgery is associated with high rates of morbidity and mortality. For patients with early-stage EAC, endoscopic resection (ER) presents a potential curative treatment option that is less invasive and carries fewer risks procedure related risks, but it is associated with higher rates of cancer recurrence following the procedure. For some patients, age and comorbidities may prevent them from having esophagectomy as a treatment option, while other patients may be operative candidates but do not wish to undergo esophagectomy for a variety of reasons related to their values and preferences. Furthermore, while anxiety of cancer recurrence following ER may significantly diminish a patient’s quality of life (QOL), so might the morbidity surrounding esophagectomy. In addition to considering health status, patient preferences, and impacts on QOL, physicians and patients must also consider what treatments would be both beneficial and available to the patient, considering esophagectomy methods-minimally invasive vs open-or the use of chemoradiotherapy in addition to ER. Our article reviews and summarizes available treatment options for patients with early EAC and their potential effects on the health and wellbeing of patients based on the current data. We conclude with a request for more research of available options for early EAC patients, the conditions that determine when each option should be employed, and their effects not only on patient health but also QOL.

Targeting the COX1/2-Driven thromboxane A2 pathway suppresses Barrett's esophagus and esophageal adenocarcinoma development

Background

Barrett's esophagus (BE), a complication of gastroesophageal reflux disease (GERD), predisposes patients to esophageal adenocarcinoma (EAC). Reliable biomarkers for early detection and discovery of potential drug targets are urgently needed for improved BE and EAC patient outcomes.

Methods

Patient biopsy samples were evaluated for COX1/2, and thromboxane A2 synthase (TBXAS) expression. Circulating prostaglandins biosynthesis was determined using enzyme immunoassay kits. Anchorage-independent cell growth assay, crystal violet staining assay, and xenograft experiments were conducted to assess BE and EAC cell growth. A surgical mouse model of reflux (i.e., esophagoduodenostomy) was established and samples were analyzed using an enzyme immunoassay kit, immunohistochemistry, immunoblotting, or RT-PCR. Esophageal biopsy samples (pre- and post-intervention) were obtained from a randomized clinical trial in which participants were administered esomeprazole (40 mg) twice daily in combination with an acetylsalicylic acid (ASA) placebo or 81 or 325 mg ASA for 28 days. Esophageal biopsy specimens before and after the intervention period were analyzed.

Findings

COX2 and TBXAS are highly expressed in BE and EAC patients accompanied by a pronounced elevation of circulating TXA2 levels. ASA suppressed BE and EAC growth by targeting the TXA2 pathway. Additionally, biopsies from 49 patients (with similar baseline characteristics) showed that ASA substantially decreased serum TXA2 levels, resulting in reduced inflammation.

Interpretation

This study establishes the importance of the COX1/2-driven TXA2 pathway in BE and EAC pathophysiology and lays the groundwork for introducing a TXA2-targeting strategy for EAC prevention and early detection.

Funding

Hormel Foundation, Exact Sciences, Pentax Medical, Intromedic and National Cancer.

Insights into Effects/Risks of Chronic Hypergastrinemia and Lifelong PPI Treatment in Man Based on Studies of Patients with Zollinger-Ellison Syndrome

The use of proton pump inhibitors (PPIs) over the last 30 years has rapidly increased both in the United States and worldwide. PPIs are not only very widely used both for approved indications (peptic ulcer disease, gastroesophageal reflux disease (GERD), Helicobacter pylori eradication regimens, stress ulcer prevention), but are also one of the most frequently off-label used drugs (25-70% of total). An increasing number of patients with moderate to advanced gastroesophageal reflux disease are remaining on PPI indefinitely. Whereas numerous studies show PPIs remain effective and safe, most of these studies are <5 years of duration and little data exist for >10 years of treatment. Recently, based primarily on observational/epidemiological studies, there have been an increasing number of reports raising issues about safety and side-effects with very long-term chronic treatment. Some of these safety issues are related to the possible long-term effects of chronic hypergastrinemia, which occurs in all patients taking chronic PPIs, others are related to the hypo-/achlorhydria that frequently occurs with chronic PPI treatment, and in others the mechanisms are unclear. These issues have raised considerable controversy in large part because of lack of long-term PPI treatment data (>10-20 years). Zollinger-Ellison syndrome (ZES) is caused by ectopic secretion of gastrin from a neuroendocrine tumor resulting in severe acid hypersecretion requiring life-long antisecretory treatment with PPIs, which are the drugs of choice. Because in <30% of patients with ZES, a long-term cure is not possible, these patients have life-long hypergastrinemia and require life-long treatment with PPIs. Therefore, ZES patients have been proposed as a good model of the long-term effects of hypergastrinemia in man as well as the effects/side-effects of very long-term PPI treatment. In this article, the insights from studies on ZES into these controversial issues with pertinence to chronic PPI use in non-ZES patients is reviewed, primarily concentrating on data from the prospective long-term studies of ZES patients at NIH.

Bile acid-induced "Minority MOMP" promotes esophageal carcinogenesis while maintaining apoptotic resistance via Mcl-1

Barrett's esophagus (BE) is associated with reflux and is implicated the development of esophageal adenocarcinoma (EAC). Apoptosis induces cell death through mitochondrial outer membrane permeabilization (MOMP), which is considered an irreversible step in apoptosis. Activation of MOMP to levels that fail to reach the apoptotic threshold may paradoxically promote cancer-a phenomenon called "Minority MOMP." We asked whether reflux-induced esophageal carcinogenesis occurred via minority MOMP and whether compensatory resistance mechanisms prevented cell death during this process. We exposed preneoplastic, hTERT-immortalized Barrett's cell, CP-C and CP-A, to the oncogenic bile acid, deoxycholic acid (DCA), for 1 year. Induction of minority MOMP was tested via comet assay, CyQuant, annexin V, JC-1, cytochrome C subcellular localization, caspase 3 activation, and immunoblots. We used bcl-2 homology domain-3 (BH3) profiling to test the mitochondrial apoptotic threshold. One-year exposure of Barrett's cells to DCA induced a malignant phenotype noted by clone and tumor formation. DCA promoted minority MOMP noted by minimal release of cytochrome C and limited caspase 3 activation, which resulted in DNA damage without apoptosis. Upregulation of the antiapoptotic protein, Mcl-1, ROS generation, and NF-κB activation occurred in conjunction with minority MOMP. Inhibition of ROS blocked minority MOMP and Mcl-1 upregulation. Knockdown of Mcl-1 shifted minority MOMP to complete MOMP as noted by dynamic BH3 profiling and increased apoptosis. Minority MOMP contributes to DCA induced carcinogenesis in preneoplastic BE. Mcl-1 provided a balance within the mitochondria that induced resistance complete MOMP and cell death. Targeting Mcl-1 may be a therapeutic strategy in EAC.

Role of Mitochondrial Markers in Improved Detection and Risk-Stratification in Barrett's Esophagus Patients

Barrett's esophagus (BE) is the only known precursor of esophageal adenocarcinoma (EAC) and is amenable to treatment. However, more than 90 percent of EAC patients are never diagnosed with antecedent BE. Identification of molecular markers for BE is needed to improve detection of BE through efficient non-endoscopic methods that are cost-effective, sensitive and can be used to cater to a larger group of the population at risk. Alterations in mitochondria and mitochondrial DNA have been shown to be associated with various cancers, including esophageal cancer. Mitochondrial response to oxidative stress, alterations in mitochondrial metabolism, changes in mitochondrial membrane potential and mitochondrial genetic mutations have been found to be associated with BE pathogenesis. This mini-review focuses on the role of mitochondria in the pathogenesis of BE and EAC and the prospects of using that knowledge to develop effective strategies for the improved detection and risk-stratification in BE patients.

Role of photodynamic therapy in the treatment of esophageal cancer

Photodynamic therapy (PDT), a treatment of choice for cancer, induces a photochemical reaction, thereby eradicating tumor cells. This is achieved through the administration of a photosensitizer drug, which is activated with a laser after localization to the tumor mass, and is an approved curative endoscopic ablative treatment for superficial esophageal squamous cell carcinoma (ESCC) in Japan. PDT has been approved for dysplastic Barrett's esophagus and as a palliative treatment for patients with symptomatic obstructive esophageal cancer in US. However, its adverse events and complicated procedure and the development of alternative endoscopic procedures such as endoscopic submucosal dissection, radiofrequency ablation and cryotherapy, have largely limited the practice of PDT in esophageal cancer worldwide. Recently, owing to the invention of second-generation PDT using talaporfin sodium and diode laser, PDT can be performed with less phototoxicity and therefore has regained popularity in the treatment of ESCC. As a salvage treatment for patients with local failure after chemoradiotherapy (CRT), PDT has shown promising complete response with less phototoxicity and shorter sun shade period. In addition, the efficacy and safety of PDT in patients with local failure of ESCC after CRT were shown in several clinical trials. The direction of the study interest of the next-generation PDT is the safety and potential expansion of the indications for its application in the future. This review covers the PDT for the treatment of ESCC and dysplastic Barrett's esophagus, with special focus on the role of PDT in practice for esophageal cancer.

Barrett Esophagus

Barrett esophagus is a metaplastic change in the lining of the distal esophageal epithelium, characterized by replacement of the normal squamous epithelium by specialized intestinal metaplasia. The presence of Barrett esophagus increases the risk of esophageal adenocarcinoma several-fold. Esophageal adenocarcinoma is a malignancy with rapidly rising incidence and persistently poor outcomes when diagnosed after the onset of symptoms. Risk factors for Barrett esophagus include chronic gastroesophageal reflux, central obesity, white race, male gender, older age, smoking, and a family history of Barrett esophagus or esophageal adenocarcinoma. Screening for Barrett esophagus in those with several risk factors followed by endoscopic surveillance to detect dysplasia or adenocarcinoma is currently recommended by society guidelines. Minimally invasive nonendoscopic tools for the early detection of Barrett esophagus are currently being developed. Multimodality endoscopic therapy-using a combination of endoscopic resection and ablation techniques-for the treatment of dysplasia and early adenocarcinoma is successful in eliminating intestinal metaplasia and preventing progression to adenocarcinoma, with outcomes comparable to those after esophagectomy. Risk stratification of those diagnosed with Barrett esophagus is a challenge at present, with active research focused on identifying clinical and biomarker panels to identify those with low and high risk of progression. This narrative review highlights some of the challenges and recent progress in this field.

What Quality Metrics Should We Apply in Barrett's Esophagus?

A GI Quality improvement consortium registry study published in this issue of The American Journal of Gastroenterology confirms the lack of adherence to surveillance intervals and guidelines in patients with Barrett's esophagus (BE). Given the widespread use of upper endoscopy for evaluation of patients with gastroesophageal reflux disease and surveillance of BE, the lack of well-defined standard criteria for performing a high quality upper endoscopy calls for the establishment of valid quality indicators in BE endoscopy. These quality metrics should be able to help define and rate endoscopist performance for screening, surveillance, and management of patients with BE. Neoplasia detection rate and Barrett's inspection time could serve as key benchmarks. The issue of nonadherence and overutilization of endoscopy can be addressed by continuing education, feedback, and incorporation of better healthcare models.

Shorter time to achieve endoscopic eradication is not associated with improved long-term outcomes in Barrett's esophagus

Quality indicators have been proposed for endoscopic eradication therapy of Barrett's esophagus (BE). One such measure suggests that complete eradication of intestinal metaplasia (CE-IM) should be achieved within 18 months of starting treatment. The aim of this study was to assess whether achievement of CE-IM within 18 months is associated with improved long-term clinical outcomes. This was a retrospective cohort study of BE patients who underwent endoscopic eradication. Time to CE-IM was recorded and categorized as ≤ or > 18 months. The main outcome measures were recurrence of IM and of dysplasia after CE-IM, defined as a single endoscopy without endoscopic evidence of BE or histologic evidence of intestinal metaplasia. Recurrence was analyzed using the Kaplan-Meier method and multivariable Cox proportional hazards modeling. A total of 290 patients were included in the analyses. The baseline histology was high-grade dysplasia or intramucosal carcinoma in 74.2% of patients. CE-IM was achieved in 85.5% of patients, and 54.1% of the cohort achieved CE-IM within 18 months. Achieving CE-IM within 18 months was not associated with reduced risk of recurrence of IM or dysplasia in both unadjusted and adjusted analyses. In this cohort, older age and increased BE length were associated with IM recurrence, and increased hiatal hernia size was associated with dysplasia recurrence. Compared to longer times, achieving CE-IM within 18 months was not associated with a reduced risk of recurrence of IM or dysplasia. Alternative evidence-based quality metrics for endoscopic eradication therapy should be identified.

Esophageal cancer treatment costs by phase of care and treatment modality, 2000-2013

BACKGROUND

Detailed cost estimates are not widely available for esophageal cancer. Our study estimates phase-specific costs for esophageal cancer by age, year, histology, stage, and treatment for older patients in the United States and compares these costs within stage and treatment modalities.

METHODS

We identified 8061 esophageal cancer patients in the Surveillance, Epidemiology, and End Results-Medicare database for years 1998-2013. Total, cancer-attributable, and patient-liability costs were calculated based on separate phases of care-staging (or surgery), initial, continuing, and terminal. We estimated costs by treatment modality within stage and phase for esophageal adenocarcinoma and squamous cell carcinoma separately. We fit linear regression models using log transformation to determine cost by age and calendar year. All costs are reported in 2018 US dollars.

RESULTS

Overall, mean (95% CI) monthly total cost estimates were high during the staging ($8953 [$8385-$9485]) and initial phases ($7731 [$7492-$7970]), decreased over the continuing phase ($2984 [$2814-$3154]), and increased substantially during the 6-month terminal phase ($18 150 [$17 211-$19 089]). This pattern of high staging and initial phase costs, decreasing continuing phase costs, and increasing terminal phase costs was seen in all stages. The highest staging costs were in stages III ($9249, $8025-$10 474) and II ($9171, $7642-$10 699). The highest initial phase cost was in stage IV, $9263 ($8758-49 768), the lowest continuing phase cost was in stage I, $2338 ($2160-$2517), and the highest terminal phase costs were in stages II ($20 533, $17 772-$23 293) and III ($20 599, $18 268-$22 929). The linear regression models showed that cancer-attributable costs remained stable over the study period and were unaffected by age for most histology, stage, and treatment modality subgroups.

CONCLUSIONS

Our estimates demonstrate that esophageal cancer costs can vary widely by histology, stage, and treatment. These cost estimates can be used to guide future resource allocation for esophageal cancer care and research.

Glyco-conjugated bile acids drive the initial metaplastic gland formation from multi-layered glands through crypt-fission in a murine model

Bile acid reflux is known to be associated with the development of Barrett’s esophagus and esophageal adenocarcinoma (EAC), yet the role of specific bile acids and the mechanism behind the metaplastic changes is unclear. Here, we demonstrate that multi-layered glandular structures at the squamo-columnar junction in mice contain multiple cell lineages, which resemble the human esophageal submucosal gland ducts. Exposing mice to patient’s refluxates induced expansion of multi-layered glandular structures and development of columnar metaplasia at the squamo-columnar junction. The glycine conjugated bile acids induced an intestinal type of metaplasia more typical for Barrett’s esophagus. Through lineage tracing, we excluded the involvement of K5⁺, DCLK1⁺, and LGR5⁺ progenitor cells as the primary source in the development of the glandular metaplastic epithelium. We show that the mechanism behind development of metaplasia involves crypt fission and may be independent of stem cell proliferation. Our findings support the hypothesis that in humans, BE arises from non-squamous cells residing in submucosal gland ducts and that induction of intestinal type of metaplasia is most effectively induced by glycine-conjugated bile acids. These novel insights may lead to more effective strategies to prevent development of Barrett’s esophagus and esophageal adenocarcinoma.

Novel Screening Tests for Barrett's Esophagus

PURPOSE OF REVIEW

There has been an exponential increase in the incidence of esophageal adenocarcinoma (EAC) over the last half century. Barrett's esophagus (BE) is the only known precursor lesion of EAC. Screening for BE in high-risk populations has been advocated with the aim of identifying BE, followed by endoscopic surveillance to detect dysplasia and early stage cancer, with the intent that treatment can improve outcomes. We aimed to review BE screening methodologies currently recommended and in development.

RECENT FINDINGS

Unsedated transnasal endoscopy allows for visualization of the distal esophagus, with potential for biopsy acquisition, and can be done in the office setting. Non-endoscopic screening methods being developed couple the use of swallowable esophageal cell sampling devices with BE specific biomarkers, as well as trefoil factor 3, methylated DNA markers, and microRNAs. This approach has promising accuracy. Circulating and exhaled volatile organic compounds and the foregut microbiome are also being explored as means of detecting EAC and BE in a non-invasive manner. Non-invasive diagnostic techniques have shown promise in the detection of BE and may be effective methods of screening high-risk patients.

Endoscopic therapy and surveillance versus esophagectomy for early esophageal adenocarcinoma: A review of early outcomes and cost analysis

BACKGROUND

Endoscopic therapy is considered to be comparable to esophagectomy with respect to oncologic outcomes in early (cT1) esophageal adenocarcinoma (EC). The current study aims to compare early outcomes and financial costs, associated with endoscopic versus surgical therapy for early esophageal adenocarcinoma.

METHODS

Retrospective review of patients undergoing either endoscopic or surgical therapy for cT1 EC between 2010 and 2015.

RESULTS

Age, BMI, and Charlson Comorbidity Scores were similar in patients undergoing endoscopic therapy (N = 20) and esophagectomy (N = 23). For patients undergoing endoscopic therapy a median of 6 endoscopic interventions, were performed per patient (range 2-18). Esophagectomy was associated with a median hospital stay of 9 (8-13) days and greater procedure specific morbidity compared to endoscopic therapy. Costs related to endoscopic therapy were significantly lower compared to esophagectomy ($22,640 vs. $53,849, P < 0.001).

CONCLUSIONS

Endoscopic treatment is associated with decreased morbidity and financial costs when compared to esophagectomy.

Surgical principles for optimal treatment of esophagogastric junction adenocarcinoma

The incidence of esophagogastric junction (EGJ) adenocarcinoma is increasing worldwide. Management of these tumors remains controversial given their unique location between the esophagus and the stomach. Debate surrounding the optimal therapy for EGJ adenocarcinoma has often centered around the tumor origin as defined by the Siewert classification system. However, the optimal surgical management should focus on adhering to important surgical principles that will allow for the best outcomes and prognosis regardless of tumor location including resection with appropriate and negative histological margins, adequate lymphadenectomy, minimization of morbidity and mortality, and preservation of quality-of-life. In this article, we provide a discussion of the controversy surrounding EGJ adenocarcinoma within the framework of these concepts.

Feasibility of a simplified narrow-band imaging classification system for Barrett's esophagus for novice endoscopists

BACKGROUND

Narrow-band imaging (NBI) classifications for Barrett's esophagus have been proposed for the detection of early esophageal adenocarcinoma. We developed a simplified classification system with demonstrated high diagnostic accuracy and reproducibility among experienced endoscopists, but the feasibility of this system among novice endoscopists was unclear.

METHODS

In the present study, eight novice endoscopists with no experience of magnification endoscopy were asked to review 248 images of Barrett's esophagus (72 dysplastic, 176 non-dysplastic) obtained using high-definition magnification endoscopy with NBI 6 weeks before (1st test), immediately after (2nd test), and 6 weeks after (3rd test) being taught the simplified classification system. The primary outcomes were differences in diagnostic accuracy for dysplasia among the three tests.

RESULTS

The specificity and overall accuracy improved significantly in the 2nd vs. 1st test [97% vs. 80% (p < 0.001) and 94% vs. 82% (p < 0.001), respectively], but sensitivity was comparable (87% in both tests; p = 0.42). In the 3rd test, the sensitivity and overall accuracy decreased significantly compared with the 2nd test [82% vs. 87% (p < 0.001) and 93% vs. 94% (p < 0.05), respectively], but there was no significant difference in specificity (97% in both tests; p = 0.16). The kappa values for interobserver agreement for the mucosal pattern, vascular pattern, and predicted histology were substantial, and improved significantly in the 2nd vs. 1st test (0.78 vs. 0.59, 0.70 vs. 0.53, and 0.79 vs. 0.66, respectively; p < 0.001 for all).

CONCLUSIONS

The simplified NBI classification system may be appropriate for novice endoscopists to use in providing high accuracy and reproducibility.

Efficacy and Toxicity of Weekly Carboplatin and Paclitaxel as Induction or Palliative Treatment in Advanced Esophageal Cancer Patients

Many patients have advanced esophageal cancer at diagnosis. However, the most optimal treatment has not been identified. Therefore, we evaluated a weekly regimen of carboplatin (area under the curve (AUC)) of 4 and paclitaxel at 100 mg/m² as an induction or palliative treatment. All patients with advanced (gastro)esophageal cancer treated with this regimen between 2002-2018 were included. Exclusion criteria were previous radiotherapy or treatment elsewhere. Data on toxicity, response, and survival were collected. Analyses were performed in two groups: induction (iCT) or palliative chemotherapy (pCT). Median progression free survival (PFS) and overall survival (OS) were estimated with the Kaplan-Meier method. A total of 291 patients was included (iCT: 122; pCT: 169). Most patients had T3 carcinoma (iCT: 54%; pCT: 66%) and stage IV disease (iCT: 42%; pCT: 91%). A toxicity grade ≥3 occurred mainly as hematological toxicity (iCT: 71%; pCT: 73%) and gastrointestinal toxicity (iCT: 3%; pCT: 5%). Response rates were 48% (iCT) and 44% (pCT). Esophagectomy or definitive chemoradiotherapy followed in 42% of iCT, resulting in a PFS of 22.1 months (interquartile range (IQR): 12.4-114.2) and OS of 26.8 months (IQR: 15.4-91.7). For pCT, PFS was 8.2 months (IQR: 5.1-14.5) and OS 10.9 months (IQR: 6.5-18.3). This retrospective cohort study demonstrated that weekly carboplatin (AUC4) and paclitaxel (100 mg/m²) is a well-tolerated and effective induction or palliative treatment regimen for patients with locally advanced or metastatic disease. Future research should directly compare this treatment regimen with other first-line treatment options to determine its true value for clinical practice.

Alteration of the esophageal microbiota in Barrett's esophagus and esophageal adenocarcinoma

The incidence of esophageal adenocarcinoma (EAC) has increased in recent decades, and its 5-year survival rate is less than 20%. As a well-established precursor, patients with Barrett's esophagus (BE) have a persistent risk of progression to EAC. Many researchers have already identified some factors that may contribute to the development of BE and EAC, and the identified risks include gastroesophageal reflux (GER), male sex, older age, central obesity, tobacco smoking, Helicobacter pylori (H. pylori) eradication, and the administration of proton pump inhibitors (PPIs) and antibiotics. The human gut harbors trillions of microorganisms, the majority of which are bacteria. These microorganisms benefit the human host in many ways, such as helping in digestion, assisting in the synthesis of certain vitamins, promoting the development of the gastrointestinal immune system, regulating metabolism and preventing invasion by specific pathogens. In contrast, microbial dysbiosis may play important roles in various diseases, such as inflammation and cancers. The composition of the microbiota located in the normal esophagus is relatively conserved without distinct microbial preferences in the upper, middle and lower esophagus. Six major phyla constitute the esophageal microbiota, including Firmicutes, Bacteroides, Actinobacteria, Proteobacteria, Fusobacteria and TM7, similar to the oral microbiota. Streptococcus dominates the esophageal microbiota. However, the microbiota varies in different esophageal diseases compared to that in the healthy esophagus. The type I microbiota, which is primarily composed of gram-positive bacteria, is closely associated with the normal esophagus, while type II microbiota has enriched gram-negative bacteria and is mainly associated with the abnormal esophagus. These increased gram-negative anaerobes/microaerophiles include Veillonella, Prevotella, Haemophilus, Neisseria, Granulicatella and Fusobacterium, many of which are associated with BE. The microbial diversity in the esophagus is decreased in EAC patients, and Lactobacillus fermentum is enriched compared to that in controls and BE patients. Furthermore, the microbiota may be associated with BE and EAC by interacting with their risk factors, including central obesity, GER, H. pylori, administration of PPIs and antibiotics. Therefore, a large gap in research must be bridged to elucidate the associations among these factors. Some studies have already proposed several potential mechanisms by which the microbiota participates in human carcinogenesis by complicated interactions with the human host immune system and signaling pathways. The activation of the LPS-TLR4-NF-κB pathway may contribute to inflammation and malignant transformation. This exciting field of gastrointestinal microbiota allows us to unravel the mystery of carcinogenesis from another perspective. Further studies are needed to explore whether the microbiota changes before or after disease onset, to improve our understanding of the pathogenesis, and to find novel targets for prevention, diagnosis and therapy, which could offer more cost-effective and relatively safe choices.

Systems Biology Analyses Show Hyperactivation of Transforming Growth Factor-β and JNK Signaling Pathways in Esophageal Cancer

BACKGROUND & AIMS

Esophageal adenocarcinoma (EAC) is resistant to standard chemoradiation treatments, and few targeted therapies are available. We used large-scale tissue profiling and pharmacogenetic analyses to identify deregulated signaling pathways in EAC tissues that might be targeted to slow tumor growth or progression.

METHODS

We collected 397 biopsy specimens from patients with EAC and nonmalignant Barrett's esophagus (BE), with or without dysplasia. We performed RNA-sequencing analyses and used systems biology approaches to identify pathways that are differentially activated in EAC vs nonmalignant dysplastic tissues; pathway activities were confirmed with immunohistochemistry and quantitative real-time polymerase chain reaction analyses of signaling components in patient tissue samples. Human EAC (FLO-1 and EsoAd1), dysplastic BE (CP-B, CP-C, CP-D), and nondysplastic BE (CP-A) cells were incubated with pharmacologic inhibitors or transfected with small interfering RNAs. We measured effects on proliferation, colony formation, migration, and/or growth of xenograft tumors in nude mice.

RESULTS

Comparisons of EAC vs nondysplastic BE tissues showed hyperactivation of transforming growth factor-β (TGFB) and/or Jun N-terminal kinase (JNK) signaling pathways in more than 80% of EAC samples. Immunohistochemical analyses showed increased nuclear localization of phosphorylated JUN and SMAD proteins in EAC tumor tissues compared with nonmalignant tissues. Genes regulated by the TGFB and JNK pathway were overexpressed specifically in EAC and dysplastic BE. Pharmacologic inhibition or knockdown of TGFB or JNK signaling components in EAC cells (FLO-1 or EsoAd1) significantly reduced cell proliferation, colony formation, cell migration, and/or growth of xenograft tumors in mice in a SMAD4-independent manner. Inhibition of the TGFB pathway in BE cell lines reduced the proliferation of dysplastic, but not nondysplastic, cells.

CONCLUSIONS

In a transcriptome analysis of EAC and nondysplastic BE tissues, we found the TGFB and JNK signaling pathways to be hyperactivated in EACs and the genes regulated by these pathways to be overexpressed in EAC and dysplastic BE. Inhibiting these pathways in EAC cells reduces their proliferation, migration, and formation of xenograft tumors. Strategies to block the TGFB and JNK signaling pathways might be developed for treatment of EAC.

Screening for Barrett's Esophagus: Balancing Clinical Value and Cost-effectiveness

In predisposed individuals with long standing gastroesophageal reflux disease (GERD), esophageal squamous mucosa can transform into columnar mucosa with intestinal metaplasia, commonly called Barrett’s esophagus (BE). Barrett’s mucosa can develop dysplasia, which can be a precursor for esophageal adenocarcinoma (EAC). However, most EAC cases are identified when esophageal symptoms develop, without prior BE or GERD diagnoses. While several gastrointestinal societies have published BE screening guidelines, these vary, and many recommendations are not based on high quality evidence. These guidelines are concordant in recommending targeted screening of predisposed individuals (eg, long standing GERD symptoms with age > 50 years, male sex, Caucasian race, obesity, and family history of BE or EAC), and against population based screening, or screening of GERD patients without risk factors. Targeted endoscopic screening programs provide earlier diagnosis of high grade dysplasia and EAC, and offer potential for endoscopic therapy, which can improve prognosis and outcome. On the other hand, endoscopic screening of the general population, unselected GERD patients, patients with significant comorbidities or patients with limited life expectancy is not cost-effective. New screening modalities, some of which do not require endoscopy, have the potential to reduce costs and expand access to screening for BE.

Stricture Prevention after Extensive Endoscopic Submucosal Dissection of Neoplastic Barrett's Esophagus: Individualized Oral Steroid Prophylaxis

Introduction

Endoscopic resection (ER) exceeding ≥75% of the esophageal circumference is accompanied with a high stricture risk regardless of the resection method. The ideal strategy for stricture prevention is not well defined today. Different approaches have been reported but data are limited to the resection of squamous cell neoplasia. The aim of this study was to assess the efficacy of an individualized oral steroid regimen to prevent strictures after extensive ER in neoplastic Barrett's esophagus (NBE).

Materials and Methods

Over a 50-month period, endoscopic submucosal dissection (ESD) was performed in 193 patients with NBE. 23 patients with resections exceeding 75% of the circumference were included. 19 resection ulcers were noncircumferential (NCR) while 4 were circumferential (CR). Stricture prevention was performed using oral prednisolone starting with a daily dose of 50 mg and standard tapering over 8 weeks (50/40/30/25/20/15/10/5 mg). Tapering was individualized according to the ulcer healing process (assessed endoscopically in the first tapering period and before stopping the steroids). Data were analyzed retrospectively.

Results

Stricture rates were 5.3% (1/19) for NCR and 100% (4/4) for CR (p < 0.001). The only stricture in the NCR group was seen in a patient who had stopped steroids without any reason after few days. 12/19 patients received standard tapering over 8 weeks (63.1%). According to the individual ulcer healing, treatment was prolonged to 9-10 weeks in 4/19 (21.1%) and shortened to 7 weeks in another 2/19 (10.5%). After CR, all patients needed endoscopic balloon dilatation (median 6.5 sessions; range 3-14 sessions for 8-40 weeks). Side effects of the steroid therapy were not noted.

Conclusion

Oral prednisolone therapy with an endoscopy-based individualized tapering regimen is effective in avoiding strictures after NCR of Barrett's neoplasia. After CR, the stricture risk is not sufficiently decreased. CR should be restricted to circumferential neoplasia which is a very rare scenario in neoplastic BE.

IL-10 in vitro could enhance IFNγ expression and suppress PD-1 expression in CD8 T cells from esophageal cancer patients

IL-10 is commonly regarded as an immunoregulatory cytokine, but accumulating evidence suggests that IL-10 may promote CD8 T cell expansion and proliferation. In this study, tumor infiltrating (TI) and peripheral blood (PB) CD8 T cells were collected from esophageal cancer patients. Interestingly, IL-10 concentration in the tumor microenvironment increased with advancing tumor stage, while TI CD8 T cell-mediated IL-10 production decreased with advancing tumor stage. By flow cytometry, three distinctive subsets, including IL-10⁺IFNγ^-, IL-10⁺IFNγ⁺, and IL-10^-IFNγ⁺, could be observed in TI CD8 T cells. The former two subsets were present at much higher frequency in stage I and stage II patients than in stage III patients. IL-10⁺IFNγ⁺ TI CD8 T cells presented significantly higher IFNγ and lower PD-1 expression than the IL-10^-IFNγ⁺ TI CD8 T cells. PB CD8 T cells, on the other hand, produced little IL-10 but potent IFNγ upon stimulation. Interestingly, intermediate level of exogenous IL-10 could significantly elevate the expression of IFNγ by PB CD8 T cells, while high level of exogenous IL-10 resulted in reduced expression of IFNγ by PB CD8 T cells. Exogenous IL-10 could not significantly reduce the frequencies of PD-1⁺ PB CD8 T cells, but significantly reduced the MFI of PD-1 in the PB CD8 T cells, especially in stage III patients. Together, this investigation demonstrated that IL-10 enhanced IFNγ expression and suppressed PD-1 expression in PB and TI CD8 T cells; however, the frequency of IL-10-expressing TI CD8 T cells decreased with increasing severity in esophageal cancer.

Low Prevalence of Suspected Barrett's Esophagus in Patients With Gastroesophageal Reflux Disease Without Alarm Symptoms

BACKGROUND & AIMS

Esophagogastroduodenoscopy (EGD) is frequently used to evaluate gastroesophageal reflux disease (GERD) without alarm symptoms, although the benefits are not clear. We aimed to determine the prevalence of uncomplicated GERD as an indication for EGD, the demographic characteristics of these patients, and the endoscopic outcomes of these procedures.

METHODS

We collected endoscopy data from a large national database of 543,103 EGDs performed at 82 sites from 2003 through 2014. We identified patients with GERD without alarm symptoms (dysphagia, bleeding, vomiting, or weight loss). Endpoints included the prevalence of endoscopically suspected Barrett's esophagus (sBE) and suspected long-segment BE (sLSBE), defined as ≥3 cm.

RESULTS

We found that 73,535 EGDs (13.5%) were performed for a primary indication of GERD without alarm symptoms: only 4122 patients (5.6%) had sBE, and of these, 24.2% had sLSBE. Significant risk factors for sBE and sLSBE included male sex, age, and white race. Other findings included peptic ulcers in 1337 patients (1.8%) and suspected tumors (47 esophageal, 42 gastric, 13 duodenal tumors, 2 others) in 101 patients.

CONCLUSIONS

In an analysis of a large cohort of patients undergoing EGD, uncomplicated GERD accounted for almost 14% of EGDs; within this population, only 23.6% were white men older than 50 years, who have an increased risk of BE and esophageal adenocarcinoma. The prevalence of sBE is lower than in prior time periods-this raises questions about the utility of EGD to detect BE in patients with uncomplicated GERD. Guidelines for management of uncomplicated GERD should account for these observations.

Staging of T1 esophageal adenocarcinoma with volumetric laser endomicroscopy: a feasibility study

Background and study aims  Precise staging in T1 esophageal adenocarcinoma (EAC) is critical in determining candidacy for curative endoscopic resection. High-frequency endoscopic ultrasound (EUS) has demonstrated suboptimal accuracy in T1 EAC staging due to insufficient spatial resolution. Volumetric laser endomicroscopy (VLE) allows for high-resolution wide-field visualization of the esophageal microstructure. We aimed to investigate the role of VLE in staging T1 EAC. Patients and methods  Patients undergoing endoscopic mucosal resection (EMR) were prospectively enrolled and only T1 EAC cases were included. EMR specimens were imaged using second-generation VLE immediately after resection. VLE images were analyzed for signal intensity by depth and signal attenuation (dB/mm) in both cross-sectional and en-face orientation. A decision tree model was constructed to combine measured VLE parameters and delineate diagnostic thresholds. Results  Thirty EMR scans were obtained - 15 T1a specimens from 9 patients and 15 T1b specimens from 11 patients. T1b specimen VLE scans exhibited higher signal intensity ( P  < 0.0001) and higher signal attenuation compared to T1a specimens ( P  = 0.03). A combination of signal attenuation and signal intensity at 150 µm depth yielded optimal diagnostic thresholds and an area under the curve (AUC) of 0.77. VLE signal attenuation was significantly associated with grade of differentiation, irrespective of EAC stage. Conclusions  VLE signal intensity and signal attenuation are quantitatively distinct in T1a and T1b EAC and associated with grade of differentiation. This is the first study examining the role of VLE for staging of T1 EAC and demonstrates promising diagnostic performance. With further in vivo validation, VLE may serve a role in staging superficial EAC.

Substantial Interobserver Agreement in the Diagnosis of Dysplasia in Barrett Esophagus Upon Review of a Patient's Entire Set of Biopsies

The pathologic diagnosis of dysplasia in Barrett esophagus (BE) suffers from interobserver disagreement. Many of the studies demonstrating disagreement in the diagnosis of dysplasia have pathologists review individual biopsy slides in isolation. To more closely mimic daily practice, 3 pathologists reviewed hematoxylin and eosin slides made from 549 individual biopsy jars obtained from 129 unique patients with a diagnosis of BE. Each pathologist reviewed the entirety of a given patient's biopsy material. The grade of dysplasia present in each biopsy jar was given as well as an overall highest grade of dysplasia from the patient's entire set of biopsies. The interobserver agreement in the diagnosis of dysplasia per biopsy jar and per patient's set of biopsies was measured by Fleiss κ statistic for multiple raters. The κ values for each diagnosis was higher in the per patient analysis compared with the per biopsy jar analysis indicating that pathologists are more likely to agree on the overall grade of dysplasia compared with the grade in an individual biopsy jar. In the per patient analysis, the interobserver agreement in the diagnosis of nondysplastic BE and high-grade dysplasia were substantial (κ=0.66; 95% confidence interval [CI], 0.56-0.76 and κ=0.76; 95% CI, 0.66-0.86, respectively). The interobserver agreement in the diagnosis of low-grade dysplasia (LGD) was fair (κ=0.31; 95% CI, 0.21-0.42). When LGD and high-grade dysplasia were collapsed into 1 category of positive for dysplasia, the interobserver agreement in the per patient analysis remained substantial (κ=0.70; 95% CI, 0.60-0.80), suggesting that much of the disagreement in LGD is not due to lack of recognition of dysplastic Barrett's mucosa, but rather the degree of dysplasia. These results indicate that pathologists can reliably distinguish between nondysplastic BE and dysplastic BE when a patient's entire set of biopsies is reviewed as a group. When second opinions are obtained, all available slides from that endoscopic procedure should be sent for review.

Subtypes of Barrett's oesophagus and oesophageal adenocarcinoma based on genome-wide methylation analysis

OBJECTIVE

To identify and characterise DNA methylation subtypes in oesophageal adenocarcinoma (EAC) and its precursor Barrett's oesophagus (BE).

DESIGN

We performed genome-wide DNA methylation profiling on samples of non-dysplastic BE from cancer-free patients (n=59), EAC (n=23), normal squamous oesophagus (n=33) and normal fundus (n=9), and identified methylation subtypes using a recursively partitioned mixture model. We assessed genomic alterations for 9 BE and 22 EAC samples with massively parallel sequencing of 243 EAC-associated genes, and we conducted integrative analyses with transcriptome data to identify epigenetically repressed genes. We also carried out in vitro experiments treating EAC cell lines with 5-Aza-2'-Deoxycytidine (5-Aza-dC), short hairpin RNA knockdown and anticancer therapies.

RESULTS

We identified and validated four methylation subtypes of EAC and BE. The high methylator subtype (HM) of EAC had the greatest number of activating events in ERBB2 (p<0.05, Student's t-test) and the highest global mutation load (p<0.05, Fisher's exact test). PTPN13 was silenced by aberrant methylation in the HM subtype preferentially and in 57% of EACs overall. In EAC cell lines, 5-Aza-dC treatment restored PTPN13 expression and significantly decreased its promoter methylation in HM cell lines (p<0.05, Welch's t-test). Inhibition of PTPN13 expression in the SK-GT-4 EAC cell line promoted proliferation, colony formation and migration, and increased phosphorylation in ERBB2/EGFR/Src kinase pathways. Finally, EAC cell lines showed subtype-specific responses to topotecan, SN-38 and palbociclib treatment.

CONCLUSIONS

We identified and characterised methylator subtypes in BE and EAC. We further demonstrated the biological and clinical relevance of EAC methylator subtypes, which may ultimately help guide clinical management of patients with EAC.

Combined hepatocellular-cholangiocarcinoma: a population level analysis of incidence and mortality trends

Background

The purpose of this study was to explore trends in incidence, incidence-based (IB) mortality, and survival for combined hepatocellular-cholangiocarcinoma (cHCC-CC) utilizing a population-based database to attract people’s attention to this disease.

Methods

The Surveillance, Epidemiology, and End Results (SEER) database was utilized to investigate the incidence and IB mortality for cHCC-CC from 2000 to 2014. Trends in age-adjusted incidence and IB mortality were characterized by the Joinpoint Regression program. The Kaplan-Meier method and log-rank test were utilized to implement survival analyses. Cox regression was utilized to estimate independent predictors of mortality.

Results

The incidence of cHCC-CC was 0.26 per 1,000,000 individuals in 2000 and 0.59 per 1,000,000 individuals in 2014, with an annual percent change (APC) (i.e., the extent of increase in incidence) of 3.84% (95% confidence interval [CI] 1.7–6.1; P < 0.05). The IB mortality also displayed a sustained increase (APC was 4.59%, 95% CI 1.9–7.4; P < 0.05). Compared to patients not undergoing surgery, patients undergoing surgical treatment experienced a significant increase in median survival (3 vs. 28 months; P < 0.001). However, the median survival decreased in patients with tumor size > 5 cm (20 vs. 9 months; P < 0.001). Based on univariate Cox regression analysis, African-American race, distant stage, regionalized stage, tumor size ≥ 5 cm, and no surgery were risk factors for death.

Conclusions

We identified an overall steady increase in the incidence of cHCC-CC, which indicates that primary prevention strategies for cHCC-CC have not improved much in recent years and that cHCC-CC needs to be taken seriously.

Lorenz Curves and Gini Coefficient Analyses Indicate Inefficiencies in Esophageal Adenocarcinoma Screening

Rates of esophageal adenocarcinoma (EAC) have increased rapidly in the United States and much of western Europe, and 5-year survival continues to be poor.¹ Prevention and early detection efforts for EAC have focused on identifying persons with EAC precursor state, Barrett's esophagus, but the survival benefit has been disappointingly low.

Influence of Patients' Age in the Utilization of Esophagectomy for Esophageal Adenocarcinoma

BACKGROUND

The indication of surgical resection in esophageal cancer is often conditioned by patient's age. We aimed to assess the trends in utilization of surgical treatment for esophageal adenocarcinoma (EAC) in the United States, stratified by age groups.

METHODS

We performed a retrospective analysis of the National Cancer Institute's Surveillance, Epidemiology, and End Results program registry for the period 2004-2014. Adult patients (aged ≥18 years) diagnosed with EAC were eligible for inclusion. The yearly incidence of esophagectomy, stratified by age groups (18-49, 50-70, and >70 years old), was calculated using Poisson regression. Weighted log-binomial regression was used to compare the proportion of patients undergoing esophagectomy, within each age group. Inverse probability of treatment weights were used to account for potential confounders.

RESULTS

A total of 21,301 patients were included. During the study period, the rate of esophagectomy decreased from 34.1% to 28.2% (P = .40) in patients between 18 and 49 years old, from 38.6% to 33.3% (P = .06) in patients between 50 and 70 years old, and from 21.4% to 16.9% (P = .04) in patients older than 70 years. After accounting for patient and cancer characteristics, patients older than 70 years were 50% less likely to undergo esophagectomy compared with both patients between 18 and 49 years old (risk ratio [RR] 0.51, 95% confidence interval [CI] 0.45-0.57, P < .0001) and patients between 50 and 70 years old (RR 0.53, 95% CI 0.50-0.56, P < .0001).

CONCLUSION

Surgical resection is scarcely used in patients older than 70 years in the United States. Further investigation of surgical outcomes in elderly patients is warranted to determine if surgical treatment is underutilized in a large proportion of EAC patients.

[Chemoradiation for oesophageal cancer: A critical review of the literature]

Locally advanced oesophageal cancer treatment requires a multidisciplinary approach with the combination of chemotherapy and radiotherapy for preoperative and definitive strategy. Preoperative chemoradiation improves the locoregional control and overall survival after surgery for locally advanced oesophageal cancer. Definitive chemoradiation can also be proposed for non-resectable tumours or medically inoperable patients. Besides, definitive chemoradiation is considered as an alternative option to surgery for locally advanced squamous cell carcinomas. Chemotherapy regimen associated to radiotherapy consists of a combination of platinum derived drugs (cisplatinum or oxaliplatin) and 5-fluorouracil or a weekly scheme combination of carboplatin and paclitaxel according to CROSS protocol in a neoadjuvant strategy. Radiation doses vary from 41.4Gy to 45Gy for a preoperative strategy or 50 to 50.4Gy for a definitive treatment. The high risk of lymphatic spread due to anatomical features could justify the use of an elective nodal irradiation when the estimated risk of microscopic involvement is higher than 15% to 20%. An appropriate delineation of the gross tumour volume requires an exhaustive and up-to-date evaluation of the disease. Intensity-modulated radiation therapy represents a promising approach to spare organs-at-risk. This critical review of the literature underlines the roles of radiotherapy for locally advanced oesophageal cancers and describes doses, volumes of treatment, technical aspects and dose constraints to organs-at-risk.

Biomarker identification and trans-regulatory network analyses in esophageal adenocarcinoma and Barrett's esophagus

BACKGROUND

Esophageal adenocarcinoma (EAC) is an aggressive disease with high mortality and an overall 5-year survival rate of less than 20%. Barrett's esophagus (BE) is the only known precursor of EAC, and patients with BE have a persistent and excessive risk of EAC over time. Individuals with BE are up to 30-125 times more likely to develop EAC than the general population. Thus, early detection of EAC and BE could significantly improve the 5-year survival rate of EAC. Due to the limitations of endoscopic surveillance and the lack of clinical risk stratification strategies, molecular biomarkers should be considered and thoroughly investigated.

AIM

To explore the transcriptome changes in the progression from normal esophagus (NE) to BE and EAC.

METHODS

Two datasets from the Gene Expression Omnibus (GEO) in NCBI Database (https://www.ncbi.nlm.nih.gov/geo/) were retrieved and used as a training and a test dataset separately, since NE, BE, and EAC samples were included and the sample sizes were adequate. This study identified differentially expressed genes (DEGs) using the R/Bioconductor project and constructed trans-regulatory networks based on the Transcriptional Regulatory Element Database and Cytoscape software. Enrichment of Kyoto Encyclopedia of Genes and Genomes (KEGG) and Gene Ontology (GO) terms was identified using the Database for Annotation, Visualization, and Integrated Discovery (DAVID) Bioinformatics Resources. The diagnostic potential of certain DEGs was assessed in both datasets.

RESULTS

In the GSE1420 dataset, the number of up-regulated DEGs was larger than that of down-regulated DEGs when comparing EAC vs NE and BE vs NE. Among these DEGs, five differentially expressed transcription factors (DETFs) displayed the same trend in expression across all the comparison groups. Of these five DETFs, E2F3, FOXA2, and HOXB7 were up-regulated, while PAX9 and TFAP2C were down-regulated. Additionally, the majority of the DEGs in trans-regulatory networks were up-regulated. The intersection of these potential DEGs displayed the same direction of changes in expression when comparing the DEGs in the GSE26886 dataset to the DEGs in trans-regulatory networks above. The receiver operating characteristic curve analysis was performed for both datasets and found that TIMP1 and COL1A1 could discriminate EAC from NE tissue, while REG1A, MMP1, and CA2 could distinguish BE from NE tissue. DAVID annotation indicated that COL1A1 and MMP1 could be potent biomarkers for EAC and BE, respectively, since they participate in the majority of the enriched KEGG and GO terms that are important for inflammation and cancer.

CONCLUSION

After the construction and analyses of the trans-regulatory networks in EAC and BE, the results indicate that COL1A1 and MMP1 could be potential biomarkers for EAC and BE, respectively.

Activation of EGFR-DNA-PKcs pathway by IGFBP2 protects esophageal adenocarcinoma cells from acidic bile salts-induced DNA damage

Background

The incidence of esophageal adenocarcinoma (EAC) is rising rapidly in the US and Western countries. The development of Barrett’s esophagus (BE) and its progression to EAC have been linked to chronic gastroesophageal reflux disease (GERD). Exposure of BE and EAC cells to acidic bile salts (ABS) in GERD conditions induces high levels of oxidative stress and DNA damage. In this study, we investigated the role of insulin-like growth factor binding protein 2 (IGFBP2) in regulating ABS-induced DNA double-strand breaks.

Methods

Real-time RT-PCR, western blot, immunohistochemistry, immunofluorescence, co-immunoprecipitation, flow cytometry, and cycloheximide (CHX) chase assays were used in this study. To mimic GERD conditions, a cocktail of acidic bile salts (pH 4) was used in 2D and 3D organotypic culture models. Overexpression and knockdown of IGFBP2 in EAC cells were established to examine the functional and mechanistic roles of IGFBP2 in ABS-induced DNA damage.

Results

Our results demonstrated high levels of IGFBP2 mRNA and protein in EAC cell lines as compared to precancerous Barrett’s cell lines, and IGFBP2 is frequently overexpressed in EACs (31/57). Treatment of EAC cells with ABS, to mimic GERD conditions, induced high levels of IGFBP2 expression. Knocking down endogenous IGFBP2 in FLO1 cells (with constitutive high levels of IGFBP2) led to a significant increase in DNA double-strand breaks and apoptosis, following transient exposure to ABS. On the other hand, overexpression of exogenous IGFBP2 in OE33 cells (with low endogenous levels of IGFBP2) had a protective effect against ABS-induced double-strand breaks and apoptosis. We found that IGFBP2 is required for ABS-induced nuclear accumulation and phosphorylation of EGFR and DNA-PKcs, which are necessary for DNA damage repair activity. Using co-immunoprecipitation assay, we detected co-localization of IGFBP2 with EGFR and DNA-PKcs, following acidic bile salts treatment. We further demonstrated, using cycloheximide chase assay, that IGFBP2 promotes EGFR protein stability in response to ABS exposure.

Conclusions

IGFBP2 protects EAC cells against ABS-induced DNA damage and apoptosis through stabilization and activation of EGFR - DNA-PKcs signaling axis.

Electronic supplementary material

The online version of this article (10.1186/s13046-018-1021-y) contains supplementary material, which is available to authorized users.

2017 David Sun Lecture: Screening and Surveillance of Barrett's Esophagus: Where Are We Now and What Does the Future Hold?

Barrett's esophagus and esophageal adenocarcinoma continue to present considerable management challenges in the Western world. Despite our best efforts to date, the prognosis of advanced esophageal adenocarcinoma remains poor and far too many individuals with esophageal adenocarcinoma have not had a prior endoscopy to detect Barrett's esophagus. As such, current strategies of screening for Barrett's esophagus and subsequent surveillance need to be further optimized. Screening today is limited to high definition white light endoscopy in high-risk patient populations and as such has multiple limitations. However, a variety of exciting new techniques including risk prediction tools, tethered capsule endomicroscopy, a cytology sponge, breath testing for exhaled volatile organic compounds, and assessment of the oral microbiome are now under study in an effort to develop less expensive population-based screening methods. Similarly, endoscopic surveillance, as currently practiced has a variety of limitations. Inexpensive readily available adjuncts are already available to optimize surveillance including increased inspection time in an effort to detect mucosal or vascular abnormalities, special attention to the right hemisphere of the esophagus, and utilization of narrow band imaging or other electronic chromoendoscopy techniques. To improve endoscopic surveillance, a variety of new paradigms are under study including wide area trans-epithelial sampling, advanced endoscopic imaging, molecular imaging, clinical risk stratification and utilization of biomarkers of increased risk. However, progress will be challenging due to the complexity of esophageal cancer biology and the rarity of progression to cancer among patients with nondysplastic Barrett's epithelium.

Trends in incidence and survival of esophageal cancer in Korea: Analysis of the Korea Central Cancer Registry Database

BACKGROUND AND AIM

The diagnostic and therapeutic modalities of esophageal cancer have recently improved in Asia, and its prognosis is expected to change. This study provides a population-based report on the epidemiology of esophageal cancer in Korea.

METHODS

Cancer incidence data from 1999 to 2013 were obtained from the Korea Central Cancer Registry, covering the entire population. Age-standardized incidence rates and annual percent changes were calculated according to subsites and histological types. Five-year relative survival rates were estimated for cases diagnosed between 1993 and 2013. Relative excess rates were compared between patients diagnosed from 2009 to 2013 and 2006 to 2008.

RESULTS

The age-standardized incidence rates decreased from 8.8 per 100 000 populations in 1999 to 5.9 in 2013 with an annual percent change of -2.6% in men and -2.2% in women. The most common histological type was squamous cell carcinoma, accounting for 90.2% of all esophageal cancers in 2013, followed by adenocarcinomas (3.1%), and their incidences decreased. The proportion of localized and regional cancer tended to increase compared with that of distant cancer. Five-year relative survival of squamous cell carcinoma improved from 12.1% (1993-1995) to 34.6% (2009-2013). Relative excess rate was 0.72 (95% confidence interval 0.65-0.80) in localized stage and 0.88 (95% confidence interval, 0.82-0.95) in regional stage comparing patients diagnosed from 2009 to 2013 and 2006 to 2008.

CONCLUSIONS

The incidence of esophageal cancer has decreased in Korea for the past 15 years, and 5-year survival rates have improved significantly. These increases may be attributable to more effective detection of early-stage disease.

Evaluation of Serum Glycoprotein Biomarker Candidates for Detection of Esophageal Adenocarcinoma and Surveillance of Barrett's Esophagus

Esophageal adenocarcinoma (EAC) is thought to develop from asymptomatic Barrett's esophagus (BE) with a low annual rate of conversion. Current endoscopy surveillance of BE patients is probably not cost-effective. Previously, we discovered serum glycoprotein biomarker candidates which could discriminate BE patients from EAC. Here, we aimed to validate candidate serum glycoprotein biomarkers in independent cohorts, and to develop a biomarker candidate panel for BE surveillance. Serum glycoprotein biomarker candidates were measured in 301 serum samples collected from Australia (4 states) and the United States (1 clinic) using previously established lectin magnetic bead array (LeMBA) coupled multiple reaction monitoring mass spectrometry (MRM-MS) tier 3 assay. The area under receiver operating characteristic curve (AUROC) was calculated as a measure of discrimination, and multivariate recursive partitioning was used to formulate a multi-marker panel for BE surveillance. Complement C9 (C9), gelsolin (GSN), serum paraoxonase/arylesterase 1 (PON1) and serum paraoxonase/lactonase 3 (PON3) were validated as diagnostic glycoprotein biomarkers in lectin pull-down samples for EAC across both cohorts. A panel of 10 serum glycoprotein biomarker candidates discriminated BE patients not requiring intervention (BE± low grade dysplasia) from those requiring intervention (BE with high grade dysplasia (BE-HGD) or EAC) with an AUROC value of 0.93. Tissue expression of C9 was found to be induced in BE, dysplastic BE and EAC. In longitudinal samples from subjects that have progressed toward EAC, levels of serum C9 were significantly (p < 0.05) increased with disease progression in EPHA (erythroagglutinin from Phaseolus vulgaris) and NPL (Narcissus pseudonarcissus lectin) pull-down samples. The results confirm alteration of complement pathway glycoproteins during BE-EAC pathogenesis. Further prospective clinical validation of the confirmed biomarker candidates in a large cohort is warranted, prior to development of a first-line BE surveillance blood test.

SERUM CYTOKINE OF IL-2, IL-10 AND IL-12 LEVELS IN PATIENTS WITH STOMACH ADENOCARCINOMA

ABSTRACT BACKGROUND: Gastric adenocarcinoma is the fourth most common cause of cancer-associated death worldwide. OBJECTIVE: We evaluated the immunological status of patients with gastric cancer before surgery and circulating cytokines as potential diagnostic biomarkers for gastric cancer. METHODS: We included 90 healthy controls and 95 patients with distal Gastric adenocarcinoma in Mazandaran, Sari, Iran. We measured serum IL-2, IL-10 and IL-12 Levels by a sandwich enzyme-linked immunosorbent assay using the IBL international GMBH kit. RESULTS: The serum IL-10 levels in the patients with Gastric adenocarcinoma were significantly higher than those of the healthy controls (P=0.02). There were no significant differences in serum IL-2 and IL-12 levels between patients with gastric cancer and healthy controls. CONCLUSION: Increased levels of IL-10 might be useful as diagnostic biomarkers for Gastric adenocarcinoma; however, this needs to be confirmed with larger number of patients and with control groups other than blood donors, properly age paired. These results suggest that positive expression of IL-10 may be useful as a molecular marker to distinguish stage of gastric cancers which can be more readily controlled.

Risk stratifying the screening of Barrett's esophagus: An Asian perspective

Background and Aim

Barrett's esophagus (BE) is a premalignant condition for esophageal adenocarcinoma. Although risk factors exist for screening patients in the West, we aimed to determine the factors in terms of demographics and symptoms for patients in an Asian setting.

Methods

We recruited 1378 patients over a 7‐year period as part of an ongoing gastric cancer screening program. An appropriately designed questionnaire was utilized to determine the necessary risk factors and symptoms with endoscopic analysis and subsequent histological confirmation as the gold standard. We utilized the existence of intestinal metaplasia of the distal esophagus as the primary diagnostic pathology.

Results

We demonstrated that no symptoms were indicative of BE in an Asian setting. Age (odds ratio 1.081, 95% confidence interval 1.022–1.143) and male gender (odds ratio 4.808, 95% confidence interval 1.727–13.33) proved significant demographic factors for the presence of intestinal metaplasia (P 0.007, 0.003, respectively).

Conclusions

We advocate the utilization of increasing age and male gender as the primary risk factors for patients at risk of BE. We also recommend astute examination of the distal esophagus whilst patients undergo simultaneous gastric cancer screening.

Esophageal adenocarcinoma in a first-degree relative increases risk for esophageal adenocarcinoma in patients with Barrett's esophagus

Background

The significance of a family history of esophageal adenocarcinoma in the progression to esophageal adenocarcinoma in patients with Barrett's esophagus has not been thoroughly evaluated. The purpose of this study is to evaluate the presence of esophageal adenocarcinoma in a first-degree relative in patients with Barrett's esophagus.

Methods

A retrospective cohort study was conducted of patients with Barrett's esophagus at a tertiary care center undergoing radiofrequency ablation. Family history, demographics, and pathology and endoscopy reports were assessed in all patients.

Findings

Three hundred and one patients with Barrett's esophagus were assessed. Nineteen patients who had a diagnosis of esophageal adenocarcinoma on index endoscopy were excluded. Nineteen (6.7%) patients had a first-degree relative with esophageal adenocarcinoma. Four (21.1%) of these patients progressed to esophageal adenocarcinoma. Of patients without first-degree relative with esophageal adenocarcinoma 22/263 (8.7%) progressed to esophageal adenocarcinoma. In a logistic regression model adjusted for sex and the number of radiofrequency ablation treatments, we found that family history of esophageal adenocarcinoma was a significant independent predictor of progression to esophageal adenocarcinoma (odds ratio = 5.55, 95% confidence interval: 1.47-20.0).

Conclusion

Our study indicates that Barrett's esophagus patients with a first-degree family member with esophageal adenocarcinoma are at 5.5-fold higher risk for disease progression to esophageal adenocarcinoma. Family history of esophageal adenocarcinoma in Barrett's esophagus patients should be considered in patient surveillance and radiofrequency ablation treatment, beyond recommended guidelines.

FOXM1c promotes oesophageal cancer metastasis by transcriptionally regulating IRF1 expression

Objectives

We aimed to elucidate the role and molecular mechanisms of FOXM1 in regulating metastasis in oesophageal squamous cell carcinoma (ESCC) as well as its clinical implications.

Materials and methods

The expression levels of four isoforms of FOXM1 were analysed by real‐time PCR. Next, genetically modification using overexpression and RNAi systems and transwell were employed to examine FOXM1c function in invasion and migration. Dual luciferase and ChIP assays were performed to decipher the underlying mechanism for transcriptional regulation. The expression levels of FOXM1 and IRF1 were determined by immunohistochemistry staining in ESCC specimens.

Results

The FOXM1c was predominantly overexpressed in ESCC cell lines compared to the other FOXM1 isoforms. Ectopic expression of FOXM1c promoted invasion and migration of ESCC cells lines, whereas downregulation of FOXM1c inhibited these processes. Moreover, FOXM1c expression was positively correlated with IRF1 expression in ESCC cell lines and tumour specimens. IRF1 is, at least in part, responsible for FOXM1c‐mediated invasion and migration. Mechanistically, we identified IRF1 as a transcriptional target of FOXM1c and found a FOXM1c‐binding site in the IRF1 promoter region. Furthermore, high expression levels of both FOXM1c and IRF1 were positively associated with low survival rate and predicted a poor prognosis of oesophageal cancer patients.

Conclusion

FOXM1c promotes the metastasis by transcriptionally targeting IRF1 and may serve as a potential prognostic predictor for oesophageal cancer.

Temporal Changes in Esophageal Cancer Mortality by Geographic Region: A Population-based Analysis

Purpose

To analyze differences in esophageal cancer survival by geographic region of the U.S. from the 1970s to the 2000s, and attribute the causes of these discrepancies.

Methods

Raw data were obtained from the Surveillance Epidemiology and End Results (SEER) program of the National Cancer Institute. Patients were stratified by decade of diagnosis and by geographic region (East, Hawaii/Alaska, Midwest, Southwest, and West), containing SEER registries. The Kaplan-Meier method with the log-rank test was used to compare the overall survival (OS) among these geographic groups. A multivariate Cox Proportional Hazard analysis was conducted to evaluate the impact of the following factors on differences in survival: patient age, gender, race, tumor stage, site, histology, treatment method, and metropolitan size.

Results

A total of 87,834 patients were identified. OS has increased significantly since 1973, with five-year OS improving from 4.9% (the 1970s) to 15.3% (2000s) (P<0.001). Residence in the East was prognostic for higher OS compared to all the other regions, with a median OS of six months in the 1970s and 12 months in the 2000s (P<0.001). The multivariate analysis revealed increased age, African American race, distant disease, non-distal tumor location, squamous cell histology, and no radiation therapy were associated with worse OS. The West and East had the highest amount of cancer centers (12 and seven, respectively). And the East had the highest number of cancer centers per person (5.7E-07) while the South had the lowest (1.6E-07).

Conclusions

There are disparities in esophageal cancer survival and quality of care through different geographic regions of the U.S., which may be attributed to a combination of the unbalanced distribution of medical resources, the regional differences in cancer biology, and other lifestyle and socioeconomic factors. More research should be conducted to further characterize regional differences and guide the implementation of improvements in survival.