Preoperative in vitro chemosensitivity test of esophageal cancer with endoscopic specimens

Outcome of histologically node-negative esophageal squamous cell carcinoma

The outcome of node-negative esophageal carcinoma and the prognostic significance of lymph node micrometastasis remain unknown. The aim of this retrospective study was to clarify these two points. A series of 98 patients who underwent curative operation for histologically node-negative (pN0 in TNM classification) esophageal carcinoma were enrolled in the study. We reviewed the cause of death of these patients. The survival curves were calculated and compared after stratifications according to clinicopathologic parameters. Lymph node micrometastasis in the patients with recurrences was examined using immunohistochemical staining of cytokeratin. Their ages ranged from 45 to 83 years (mean 64.3 years). There were 83 men and 15 women. Altogether, 54 patients were still alive, and 44 had died. A total of 9 patients died from recurrence of their esophageal carcinoma, 33 died from other causes (pneumonia 11, extraesophageal carcinoma 7, and so on), and 2 died from unknown causes. Eight patients had locoregional recurrences, and two patients had distant recurrences. The overall survival rate for the 98 patients was 58.2%. The survival for patients with pT2 or pT3 tumors was significantly worse than for those with pTis or pT1 tumors (p = 0.02, log-rank test). Other clinicopathologic factors did not affect the prognosis. Immunohistochemical study found no lymph node micrometastasis in 365 lymph nodes resected from the patients with recurrences. Only the depth of tumor invasion affected the outcome of patients with node-negative esophageal carcinoma. Altogether, 75% of patients died of other causes without recurrence, with the two main causes of death being pulmonary complications and extraesophageal carcinoma in these patients. Lymph node micrometastasis was not associated with recurrence in this series.

The prognostic significance of cell cycle markers in esophageal cancer after neoadjuvant chemotherapy

Proliferating cell nuclear antigen (PCNA), p27 and cyclin A were analyzed by immunohistochemistry in 89 patients (untreated control n = 40, neoadjuvant chemotherapy n = 49) with esophageal cancer invading the submucosal lesion. The mitotic index (MI) was calculated as the percentage of mitotic cells. In control subjects, the mean PCNA, p27, cyclin A and MI were, respectively, 60.4%, 18.0%, 19.9% and 1.7%; in the chemotherapy group, these values were 46.8%, 15.1%, 18.0% and 1.2% respectively. Neoadjuvant chemotherapy decreased PCNA and the MI significantly. As prognostic indicators, PCNA and the MI were significant in control subjects and p27 and cyclin A were significant in the chemotherapy group. Using multivariate analysis, p27 was a prognostic factor in both groups and cyclin A was prognostic only in the chemotherapy group. Although PCNA and the MI were useful growth and prognostic markers in untreated control subjects, their significance was lost after neoadjuvant chemotherapy. p27 and cyclin A were determined to be significant markers in the neoadjuvant chemotherapy group, especially p27, which was independent in both groups.

Does neoadjuvant chemotherapy for carcinoma in the thoracic esophagus increase postoperative morbidity?

OBJECTIVES

The aims of this study were to examine whether neoadjuvant chemotherapy for a carcinoma in the thoracic esophagus increased the incidence of postoperative complications, and which clinicopathological factors may affect postoperative complications after esophagectomy.

SUBJECTS AND METHODS

One hundred and forty-four patients who underwent neoadjuvant chemotherapy followed by esophagectomy for a carcinoma in the thoracic esophagus were reviewed in a retrospective study. Ninety-six patients received neoadjuvant chemotherapy and 48 did not. The postoperative complications were grouped either general complications (Complications A) or surgery-related complications (Complications B). Complications A consisted of pulmonary, cardiac, hepatic, renal, and neurological complications, and catheter sepsis. Complications B consisted of a gastrointestinal tract leak, gastrointestinal tract necrosis, an intrathoracic or intraabdominal abscess, hemorrhage, ileus, and vocal cord palsy. In these two categories of complications, 17 factors obtained from subjects were compared between patients with complications and those without by univariate and multivariate analyses.

RESULTS

The patient characteristics did not differ between patients who received neoadjuvant chemotherapy and those without. The preoperative serum albumin level was higher in patients without complication than in those with complication in both two categories of complications (Complications A: p = 0.001, Complications B: p = 0.05). The proportion of patients who received neoadjuvant chemotherapy did not differ between patients with complication and those without complication in either category of complications. Multivariate analysis showed that preoperative Onodera's Prognostic Nutritional Index was the only factor reducing the incidence of complications A (p = 0.02, Odds ratio: 0.63).

CONCLUSION

Neoadjuvant chemotherapy was well tolerated and was not associated with any increased morbidity or mortality after esophagectomy for a carcinoma in the thoracic esophagus.

Understanding the biology of cancer: has this any impact on treatment?

Rapid advances in laboratory techniques in the last two decades and, what is more important, in the last 5-7 years have significantly increased our knowledge and understanding on many fronts. We have learned much about (a) the basic biological processes of growth control and its aberrations, (b) the possible mechanisms involved in genetic initiation, progression and suppression, (c) the complexity of the multistep carcinogenesis induced by viruses, chemicals, hormones and other iatrogenic factors, (d) the secrets of immunological defence mechanisms and a host of other fundamental processes, (e) the application of molecular biology techniques to clinical problems, etc. The list is unending and often leads the uninitiated clinician to believe that the resolution of the mystery of the cancer cell and its successful control and cure are almost at hand. He or she often comes to believe that conventional principles in cancer treatment have radically changed from the 1960 and 1970 and that a new era in cancer treatment, based on our recent biological understanding, has already arrived. There is little doubt that the treatment scenario has changed significantly and that there is more hope for a cancer patient today than ever before-especially in certain types of paediatric and lymphoproliferative disorders; however, the unfortunate fact is that this cautiously optimistic therapeutic scenario has come about not because of any great understanding of the biological processes, which continue to confound us, but because of the intense interaction of various therapeutic disciplines and sophisticated technology now available for early diagnosis and more efficient therapeutic procedures in radiotherapy, chemotherapy and surgery. The author presents evidence and data here to show that, while treatment results have improved, we have a long way to go in understanding the biological processes before our knowledge can have a significant impact on the overall treatment methods in current use. The principles of cancer treatment, though modified have not changed. In fact, in the light of our current knowledge, they have been re-emphasized.