Surgical treatment for cancer of the oesophagus and gastric cardia in Hebei, China

Ten-Year Survivals of Right Thoracic vs Left Thoracic Approach for Esophageal Cancer

BACKGROUND

Esophagectomy can be performed using various surgical techniques. The aim of this study was to understand the impact of surgery on long-term survival for esophageal cancer.

METHODS

Between May 2010 and July 2012, 300 patients with esophageal cancer were randomly assigned to undergo esophagectomy with either a left or right thoracic approach. Disease-free survival (DFS) and overall survival (OS) were compared based on the per-protocol principle among 286 patients with esophageal squamous cell carcinoma determined by postoperative pathologic results (146 in the right and 140 in the left thoracic arms).

RESULTS

The median DFS was 92 months in the right thoracic arm and 41 months in the left thoracic arm (hazard ratio, 0.73; 95% CI, 0.54-0.99; P = .045), with a cumulative 10-year DFS of 47.6% and 37.5%, respectively. The median OS was 136 months in the right thoracic arm and 99 months in the left thoracic arm (hazard ratio, 0.75; 95% CI, 0.54-1.04; P = .081), with cumulative 10-year OS of 52.4% and 43.7%, respectively. DFS and OS were comparable between the 2 arms for patients without lymph node metastasis. Conversely, for patients with lymph node metastasis, 10-year DFS was 32.7% and 21.4%, respectively (P = .018), and 10-year OS of the right and left thoracic arms was 37.9% and 25.9%, respectively (P = .012).

CONCLUSIONS

Compared with the left thoracic approach, patients who underwent esophagectomy through the right thoracic approach had better 10-year survival rates, and the survival benefit was significant for those with lymph node metastasis.

Effect of taking aspirin before diagnosis on the prognosis of esophageal squamous cell carcinoma and analysis of prognostic factors

Objective

The 5-year survival rate of patients with esophageal squamous cell cancer (ESCC) is very low. However, long-term aspirin use has been suggested to have an adjuvant therapeutic effect. We therefore investigated the effect of long-term aspirin use before ESCC diagnosis on postoperative patient survival.

Methods

We carried out a retrospective cohort study of patients who underwent esophageal cancer resection in our hospital from 2008 to 2018. Patients were divided into an aspirin group (n = 79) and control group (n = 79), and were followed up until December 2019. We analyzed the clinicopathological and follow-up data of the patients during hospitalization, and the cyclooxygenase-2 (COX-2) protein expression levels by immunohistochemistry, and related these to postoperative survival.

Results

Patients who took aspirin had significantly lower survival rates than those who did not. COX-2-negative patients had better survival than patients with either low or high COX-2 expression levels. T stage was the only independent predictor of survival in patients who took aspirin.

Conclusions

Long-term regular use of aspirin before diagnosis had an adverse effect on postoperative survival in patients with ESCC. Different COX-2 protein expression levels were associated with significantly different postoperative survival rates, with COX-2-positive patients having the poorest survival.

Patterns of metastasis and prognosis of elderly esophageal squamous cell carcinoma patients in stage IVB: a population-based study

Background

Esophageal squamous cell carcinoma (ESCC) has been listed among the most common esophageal cancers (ECs). Patients are generally relatively old in terms of their age at diagnosis of ESCC. A retrospective, population-based study appraising 537 elderly ESCC patients who suffered distant metastasis (DM) in stage IVB from 2010 to 2016 was performed. To this end, data pertaining to Surveillance, Epidemiology, and End Results (SEER) were adopted.

Methods

A total of 537 elderly patients with IVB-stage ESCC suffering DM treated from 2010 to 2016 were taken as subjects. Prognosis was determined by using Kaplan-Meier analysis, as well as univariate and multivariate Cox regression. In accordance with sites of metastasis, these patients were classified into five groups: bone-, lung-, brain-, liver-only, and multiple-site (metastases to two or more organs) groups. In order to assess the prognosis, the cancer-specific survival (CSS), median survival time (MST), overall survival (OS), and survival rate (SR) were examined.

Results

The lung was found to be the organ most vulnerable to metastasis in the population with single-organ metastasis, and liver, bone and brain followed in descending rank order. Relative to the group only having bone metastasis, the multiple-site group had the lowest CSS (HR: 1.067; 95% CI: 0.767–1.485; P=0.700) and OS (HR: 1.051; 95% CI: 0.759–1.454; P=0.766). The MST (MST: both 2 months in CSS and OS) and SR (6-month SR: 28.2% in CSS, 27.7% in OS; 1-year SR: 7.5% in CSS, 6.7% in OS; 3-year SR: 2.5% in CSS, 1.5% in OS) were also found to be the lowest for the multiple-site group among the total population. These patients benefited from treatment with chemotherapy (C), radiotherapy (R), and surgery (S), as evinced by the prognosis (CSS and OS: P<0.001), in comparisons with untreated patients (N) in the total population. The S or/and R + C resulted in no statistically significant differences to C alone (CSS: P=0.593; OS: P=0.510) in terms of the prognostic results, which indicated that C alone can have almost the same prognostic effect as multimodal therapy.

Conclusions

Population-based research was used to determine patterns of metastasis and survival outcomes of elderly patients with IVB-stage ESCC suffering DM. The worst CSS and OS were found in patients with multiple-site metastasis across all groups. The treatment is an independent prognostic factor affecting prognosis. Chemotherapy plays a vital role in prognosis. Active therapies are beneficial to elderly patients with IVB-stage ESCC suffering DM, particularly chemotherapy.

Recent advances in regenerative medicine strategies for cancer treatment

Cancer stands as one of the most leading causes of death worldwide, while one of the most significant challenges in treating it is revealing novel alternatives to predict, diagnose, and eradicate tumor cell growth. Although various methods, such as surgery, chemotherapy, and radiation therapy, are used today to treat cancer, its mortality rate is still high due to the numerous shortcomings of each approach. Regenerative medicine field, including tissue engineering, cell therapy, gene therapy, participate in cancer treatment and development of cancer models to improve the understanding of cancer biology. The final intention is to convey fundamental and laboratory research to effective clinical treatments, from the bench to the bedside. Proper interpretation of research attempts helps to lessen the burden of treatment and illness for patients. The purpose of this review is to investigate the role of regenerative medicine in accelerating and improving cancer treatment. This study examines the capabilities of regenerative medicine in providing novel cancer treatments and the effectiveness of these treatments to clarify this path as much as possible and promote advanced future research in this field.

Site-Specific Variation in Familial Cancer as Suggested by Family History, Multiple Primary Cancer, Age at Onset, and Sex Ratio Associated With Upper, Middle, and Lower Third Esophageal and Gastric Cardia Carcinoma

Background

In China, esophageal squamous cell carcinoma (ESCC) and gastric cardia adenocarcinoma (GCA) differ in terms of multiple primary cancer (MPC) and male-to-female sex ratio (MFSR).

Methods

We studied site-specific variation in familial cancer by comparing family history (FH), MPC, age at onset (AO), and MFSR among 8768 patients with ESCC/GCA.

Results

ESCC/GCA patients with a positive FH are associated with a significantly higher rate of MPC and a younger AO than those without (sex-specifically: MPC 1.6% vs. 0.7%, P<0.01 and 3.2% vs. 0.8%, P<0.01; AO 53.1 ± 8.1 vs. 54.5 ± 8.2, P=0.000 and 52.9 ± 7.4 vs. 54.0 ± 8.0, P=0.005). Among patients with a positive FH, MPC decreases significantly from upper-, middle-, and lower-third ESCC to GCA (sex-specifically: 53.6%, 1.8%, 1.6%, 0.8%, P=0.000; and 71.4%, 1.5%, 2.2%, 1.6%, P=0.000). From MPC, upper-, middle-, and lower-third ESCC to GCA, AO increased sex-specifically: 51.9 ± 7.2, 52.8 ± 7.9, 52.1 ± 8.3, 54.3 ± 8.4, 55.6 ± 7.6 (P=0.000) and 49.3 ± 6.5, 51.8 ± 9.8, 52.6 ± 7.8, 54.4 ± 8.0, 55.7 ± 7.2 (P=0.000), and FH decreased: 43.8%, 35.1%, 28.2%, 29.5%, 24.4% (P=0.000) and 55.2%, 26.7%, 25.0%, 24.3%, 22.3% (P=0.000). The preponderance of males, smoking, alcohol consumption, and patients ≥50 years old increased from 2.2:1, 1.7:1, 1.0:1, 2.0:1 in ESCC to 6.1:1, 2.8:1, 2.5:1, 4.0:1 in GCA, yet more MPCs were associated with non-preponderant than preponderant counterparts; particularly in GCA, the difference was statistically significant.

Conclusion

The proportion of familial cancer may decrease from upper-, middle-, and lower-third ESCC to GCA. This entails molecular investigation, and appreciating this may help us devise a better screening strategy or individualize cancer treatment.

Prognostic factors affecting long-term outcomes in patients with brain metastasis from esophageal carcinoma

Objective

The incidence of brain metastasis from esophageal cancer (BMEC) has increased in recent years. Thus, it is necessary to identify factors that affect long-term outcomes for such patients.

Methods

From January 1997 to July 2018, consecutive patients (10,043 patients, 31 with brain metastasis) with esophageal cancer (EC) treated at Zhejiang Cancer Hospital were recruited for retrospective analysis. Demographic, clinical, and pathological variables and the survival data were retrieved.

Results

The median time from diagnosis of EC to diagnosis of brain metastases was 7.67 (range, 0.43−55.20) months. The median survival time of BMEC patients from diagnosis of primary esophageal tumor was 16.7 (range, 2.33−163.30) months and the median survival time from the point of diagnosis of brain metastasis was 6.47 (range, 0.43−148.13) months. Univariate and multivariate analyses showed that the pathology type, EC without chemotherapy, and bone metastasis history were significantly associated with a shorter time interval between the first treatment of EC and brain metastasis. Chemotherapy history after brain metastasis, whole brain radiation therapy (WBRT) history, and surgery were significant predictors for better long-term survival outcomes.

Conclusions

Our findings indicate that the use of surgery, WBRT, and chemotherapy can achieve the best therapeutic effects for BMEC patients.

Downregulation of microRNA‑449a‑5p promotes esophageal squamous cell carcinoma cell proliferation via cyclin D1 regulation

Aberrant microRNA-449a (miR-449a-5p) expression has been demonstrated to be associated with the development of various cancer types. However, the effect of miR-449a-5p on esophageal squamous cell carcinoma (ESCC) cell proliferation remains unknown. The present study aimed to determine whether miR-449a-5p may regulate ESCC cell proliferation via negative regulation of cyclin D1. Reverse transcription quantitative-polymerase chain reaction was used to measure the expression of miR-449a-5p in ESCC tissues and cells. Western blot was performed to analyze the protein level of cyclin D1. The proliferation of ESCC cells was determined by MTT and clone formation assay. Paired ESCC and adjacent normal esophageal squamous tissues were collected from patients with ESCC. It was demonstrated that miR-449a-5p expression was reduced, whereas cyclin D1 expression was increased in ESCC tissues compared with adjacent normal tissues. Proliferation was investigated in vivo using the ESCC cell line Eca-190. miR-449a-5p inhibitor transfection facilitated the proliferation of Eca-109 cells. By contrast, transfection with miR-449a-5p mimics inhibited Eca-109 cell proliferation. Furthermore, it was confirmed that miR-449a-5p directly bound to the 3′-untranslated region of cyclin D1. Transfection with cyclin D1 small interfering RNA reversed the effects of the miR-449a-5p inhibitor on Eca-109 cell proliferation. In conclusion, miR-449a-5p may control ESCC proliferation through the negative regulation of cyclin D1 expression.

Alcohol and survival in ESCC: prediagnosis alcohol consumption and postoperative survival in lymph node-negative esophageal carcinoma patients

BACKGROUND

The association between esophageal cancer and prediagnosis alcohol consumption is well established. However, evidence that prediagnosis alcohol consumption affects postoperative survival in patients with lymph node-negative esophageal squamous cell carcinoma (ESCC) is lacking. We conducted a retrospective study on the effect of prediagnosis alcohol consumption on the postoperative survival of patients with lymph node-negative ESCC in China.

METHODS

We enrolled 643 ESCC patients with negative lymphatic metastasis who had undergone esophagectomy between 1990 and 2005 at the Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China, and reviewed their demographic, pathologic, preoperative, and cancer outcome data obtained from medical records. These data were analyzed using life table and Kaplan-Meier analyses and multivariate Cox regression.

RESULTS

There was a significant reduction in 3- and 5-year survival in drinkers with lymph node-negative ESCC. For drinkers, 3- and 5-year survival rates were 43% and 36% respectively, whereas, for nondrinkers, the corresponding values were 63% and 58%, respectively (p < 0.05). Multivariate Cox regression showed that drinking (p = 0.001, relative risk =1.583) was an independent factor for survival in patients with lymph node-negative ESCC. Striated analysis revealed that drinking was an independent factor for survival in patients with stage II A (p = 0.008, relative risk =1.679), stage IB (p = 0.044, relative risk=1.517), and well (p=0.011, relative risk =1.783) and moderately (p = 0.002, relative risk = 1.915) differentiated ESCC.

CONCLUSIONS

Prediagnosis alcohol consumption is an independent prognostic factor for postoperative survival in patients with lymph node-negative ESCC.

Prognostic factors influencing the survival of patients with carcinoma of the gastric cardia receiving preoperative interventional embolization chemotherapy

The purpose of this study was to analyze the characteristics of patients with gastric cardia cancer (GCC) to identify the main factors the influence the survival rate after interventional embolization chemotherapy (IEC). One hundred and fifty-six patients with advanced GCC were treated with IEC via the left gastric artery. Survival time was defined as from the date of diagnosis until death or the end of this study in June 2015. The median survival time was 15 months (range 3 to 29 months). The Cox proportional hazard model found that patients’ age (p < 0.001), sex (p = 0.039), weight loss more than 10% in the prior 3 months (p = 0.014), body mass index (BMI) (p = 0.047), and hematocrit value less than 37% (p < 0.001) were correlated with mortality after removal of cases of poorly differentiated carcinoma and undifferentiated carcinoma from the analysis. Kaplan-Meier curves of survival according to patients’ age showed significant differences by the log-rank test (p = 0.0015). The median survival time was 17 months among patients of aged < 50 years. In conclusion, BMI, weight loss > 10% in the prior 3 months, albumin, and hematocrit were prognostic indicators for patients with advanced GCC, and patients younger than 50 years have a higher survival rate after IEC.

Prognostic significance of the location of metastatic lymph nodes in patients with adenocarcinoma of the oesophagogastric junction

BACKGROUND

Adenocarcinoma of the oesophagogastric junction (AEG) potentially metastasizes to lymph nodes (LNs) in the abdomen and thorax. The aim of this study was to analyse the impact of metastatic LN location on prognosis in patients with AEG.

METHODS

From May 2000 to March 2002, 645 patients with AEG underwent resection in our hospital. There were 525 males and 120 females, aged from 31 to 78 years (median = 60 years). Follow-up was carried out by correspondence every 6 months. N-classification according to the number (0, 1-2, 3-6, >6; N0-3), station (0, 1, 2, 3; S0-3) or field (0, 1 (abdominal or mediastinal), 2 (abdominal and mediastinal); F0-2) of LN metastasis and other prognostic factors were evaluated by univariate and multivariate survival analyses.

RESULTS

Of the 645 patients, 307 (47.6%) had LN metastasis. The 5-year survival rate for patients with LN metastases was 16.0% compared to 36.8% for those without LN metastases (P = 0.000). The length of tumour, and the number, station and field of the LN metastasis were independent prognostic factors by multivariate analysis. However, when patients without LN metastasis were excluded from the survival analysis by log-rank test, there were significant differences only in patients with F1 versus F2 LN metastasis, with 5-year survival rates of 14.4% and 8.0%, respectively (P = 0.022).

CONCLUSION

The presence of LN metastases concurrently in both the abdomen and mediastinum is a significant adverse prognostic factor for patients with AEG, and should be included in the future TNM staging system.

Perioperative versus Preoperative Chemotherapy with Surgery in Patients with Resectable Squamous Cell Carcinoma of Esophagus: A Phase III Randomized Trial

BACKGROUND

Perioperative chemotherapy for resectable squamous cell carcinoma of esophagus remains elusive. Thus, we assessed whether a perioperative regimen of paclitaxel, cisplatin, and 5- fluorouracil (PCF) improved outcomes among patients with curable squamous cell carcinoma of esophagus comparing with preoperative chemotherapy alone.

METHODS

Overall, 346 patients with resectable squamous cell carcinoma of esophagus were randomly assigned to receive surgery plus perioperative chemotherapy (175, arm A) or preoperative chemotherapy (171, arm B). Both arms received two preoperative cycles of PCF: intravenous paclitaxel (100 mg per square meter of body surface area) and cisplatin (60 mg per square meter of body surface area) on day 1, and a continuous intravenous infusion of 5- fluorouracil (700 mg per square meter of body surface area per day) for 5 days. Arm A received two added postoperative cycles of PCF. The primary end point was relapse-free survival, and the secondary end point was overall survival.

RESULTS

Compared with preoperative chemotherapy group, perioperative chemotherapy group had a greater likelihood of 5-year relapse-free survival (hazard ratio for relapse, 0.62; 95% confidence interval, 0.49-0.73; 31% versus 17%, p < 0.001) and of 5-year overall survival (hazard ratio for death, 0.79; 95% confidence interval, 0.59-0.95; 38% versus 22%, p < 0.001). A pathologic complete response rate was achieved in 77 of 320 patients (24.1%) who underwent resection after chemotherapy. The increased PCF-related toxic events were not detected with the addition of two postoperative cycles of PCF.

CONCLUSION

In patients with operable esophageal squamous cell carcinoma, perioperative regimen of PCF can significantly improve 5-year relapse-free and overall survival comparing with preoperative chemotherapy alone. (The trial has been registered at ClinicalTrials.gov, number NCT01225523.).

Inflammation-based prognostic system predicts postoperative survival of esophageal carcinoma patients with normal preoperative serum carcinoembryonic antigen and squamous cell carcinoma antigen levels

BACKGROUND

The Glasgow Prognostic Score (GPS) is an established inflammation-based system that is used to predict the prognosis for several types of malignancies. In this retrospective study, we assessed the postoperative survival of 725 patients with non-metastatic esophageal squamous cell carcinoma who had normal preoperative serum tumor marker levels according to the GPS.

METHODS

Among 1394 patients who underwent esophagectomy between August 2006 and December 2010, 725 with normal preoperative serum levels of carcinoembryonic antigen (CEA) and squamous cell carcinoma antigen (SCC-Ag) were enrolled. All demographic, pathologic, and survival data were analyzed retrospectively. Uni- and multivariate analyses were performed to evaluate the relationship with overall survival. The Kaplan-Meier analysis and log-rank tests were used to compare the survival curves between patients with GPS 0 (group A) and 1 or 2 (group B).

RESULTS

Patients in group A exhibited significantly better 3- and 5-year cancer-specific survival (CSS) rates (0.780 and 0.759, respectively) than those in group B (0.624 and 0.605, respectively). Multivariate Cox regression analysis revealed that age, tumor length, pathological tumor-node-metastasis (pTNM) stage, venous invasion, lymph node metastasis, serum albumin and C-reactive protein levels, and GPS were associated with postoperative survival of these patients. Further multivariate analysis confirmed that GPS was an independent prognostic factor. The Kaplan-Meier analysis and log-rank tests demonstrated a significant difference in CSS between groups A and B (P = 0.001).

CONCLUSIONS

GPS may be a valuable prognostic indicator for esophageal cancer patients with normal preoperative CEA and SCC-Ag serum levels.

The tumor-suppressive function of miR-1 by targeting LASP1 and TAGLN2 in esophageal squamous cell carcinoma

OBJECTIVE

This study determined the expression of microRNA-1 in esophageal squamous cell carcinoma (ESCC) tissue and cell lines to evaluate its effects on clinicopathological parameters and its target genes LASP1 and TAGLN2.

METHODS

The expression of miR-1, lasp1, and tagln2 was detected in 55 ESCC tissues and adjacent normal tissues by reverse transcription-polymerase chain reaction (RT-PCR). The association between miR-1, lasp1, and tagln2 expression and clinicopathological characteristics was observed. MicroRNA-1 (mimics-miR-1) and its inhibitor (Inhibitor-miR-1) were transfected into esophageal cancer cells KYSE 510 and Eca 109; cell proliferation, migration, and invasion assays were carried out. Plasmid construction and dual-luciferase reporter assay were also carried out to indicate whether LASP1 and TAGLN2 were miR-1 target genes. The expression of LASP1 and TAGLN2 was detected with Western blot methods in cell lines, by immunohistochemistry in ESCC tissue.

RESULTS

The gene expression level of microRNA-1 in cancer tissues was significantly lower than that in adjacent normal tissues (P < 0.01). The expression of miR-1 in ESCC was correlated with involvement of lymph nodes (P = 0.002), histologic classification (P = 0.000), and vessel invasion (P = 0.022). The expression of lasp1 and tagln2 increased in cancer tissues compared with in adjacent normal tissues (P < 0.05). MiR-1 suppresses the cell growth, migration, and invasion in vitro. The expression of LASP1 and TAGLN2 decreased in mimics-miR-1 transfected cells, and increased in inhibitor-miR-1 transfected cells. Luciferase reporter assay confirmed that LASP1 and TAGLN2 mRNA actually had the target sites of miR-1.

CONCLUSIONS

miR-1 suppresses cell proliferation, invasiveness, metastasis, and progression of ESCC by binding its targeted genes LASP1 and TAGLN2.

Nimesulide inhibits the growth of human esophageal carcinoma cells by inactivating the JAK2/STAT3 pathway

Although selective COX-2 inhibitors have cancer-preventive effects and induce apoptosis, the mechanisms underlying these effects are not fully understood. This study investigated the effects of nimesulide, a selective COX-2 inhibitor, on apoptosis and on the JAK/STAT signaling pathway in Eca-109 human esophageal squamous carcinoma cells. The effects and mechanisms of nimesulide on Eca-109 cell growth were studied in culture and in nude mice with Eca-109 xenografts. Cells were cultured with or without nimesulide and/or the JAK2 inhibitor AG490. Cell proliferation was evaluated using the MTT assay, and apoptosis was investigated. COX-2 mRNA expression was measured using reverse transcription polymerase chain reaction, and protein expression was detected by Western blot analysis, immunohistochemistry, and flow cytometry. Nimesulide significantly inhibited Eca-109 cell viability in vitro in a dose- and time-dependent manner (P<0.05). Nimesulide also induced apoptosis, which was accompanied by a significant decrease in the expression of COX-2 and survivin and an increase in caspase-3 expression. Nimesulide downregulated the phosphorylation levels of JAK2 and STAT3, and JAK2 inhibition by AG490 significantly augmented both nimesulide-induced apoptosis and the downregulation of COX-2 and survivin (P<0.05). In vivo, nimesulide inhibited the growth of Eca-109 tumors and the expression of p-JAK2 and p-STAT3. Thus, nimesulide downregulates COX-2 and survivin expression and upregulates caspase-3 expression in Eca-109 cells, by inactivating the JAK2/STAT3 pathway. These effects may mediate nimesulide-induced apoptosis and growth inhibition in Eca-109 cells in vitro and in vivo.

Endoscopic submucosal dissection for superficial Barrett's esophageal cancer in the Japanese state and perspective

The incidence of Barrett's esophageal cancer is one of the most rapidly increasing among all cancers in the West, and it is also expected to increase in Japan. The optimal treatment for early Barrett's esophageal cancer remains controversial. En bloc esophagectomy with regional lymph node dissection has been considered the standard therapy. Endoscopic therapies are currently being evaluated as alternatives to esophagectomy because they can provide the least postoperative morbidity and the best quality of life. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) allow for removal of visible lesions and histopathologic review of resected tissue, which help in diagnostic staging of the disease. EMR is limited with respect to resection size, and large lesions must be resected in several fragments. Piecemeal resection of lesions is associated with high local recurrence rates, probably because of minor remnants of neoplastic tissue being left in situ. ESD provides larger specimens than does EMR in patients with early Barrett's neoplasia. This in turn allows for more precise histological analysis and higher en bloc and curative resection rates, potentially reducing the incidence of recurrence. Detailed endoscopic examination to determine the invasion depth and spread of Barrett's esophageal cancer is essential before ESD. The initial inspection is usually conducted with white-light imaging followed by narrow-band imaging. The ESD procedure is similar to that for lesions in other parts of the gastrointestinal tract. However, the narrow space of the esophagogastric junction and contraction of the lower esophageal sphincter sometimes disturb the visual field and endoscopic control. Skilled endoscope handling, sometimes including retroflexion, is required during ESD for Barrett's esophageal cancer. Previous reports have shown that ESD achieves en bloc resection in >80% of lesions. Although promising short-term results are reported, a long-term, large-scale study is required for better understanding of ESD for Barrett's esophageal cancer.

Factors affecting long-term survival in elderly patients undergoing radiotherapy for esophageal carcinoma

This study was conducted with the aim to analyze the factors affecting the 1-, 3- and 5-year survival rate of elderly patients with esophageal carcinoma. Between 2004 and 2008, a total of 371 patients aged ≥70 years treated with radiotherapy alone were enrolled in this study. The clinical characteristics and radiotherapy dose were evaluated by survival rate and the 1-, 3- and 5-year overall survival (OS) rates were found to be 42, 13.2 and 9.16%, respectively. The univariate analysis revealed significant differences in T, N, M and clinical stage and radiotherapy dose (all P-values <0.05) and no significant differences in gender (all P-values >0.05). There was a difference in tumor location when only comparing the 3- and 5-year OS rates (P=0.031 and P=0.025, respectively). The multivariate analysis identified clinical stage as an independent factor for the 1-year OS rate (P=0.003), whereas radiotherapy dose and clinical stage were found to be independent factors for the 3- and 5-year OS rates (all P-values 0.05). In the analysis of radiotherapy dose, we observed no significant difference in the 1-year OS rate between the radiation dose (DT) >60 Gy and the 50 Gy≤DT<60 Gy groups (P=0.363); however, there were statistically significant differences in the 3-year OS rate between the 50 Gy≤DT<60 Gy and the other groups (P=0.039 and P=0.032); there were no significant differences in the 5-year OS rate among the dose groups (all P-values >0.05). In conclusion, according to the findings of this retrospective study, radiotherapy alone for elderly patients with esophageal cancer does not appear to be acceptable and there is a need for a more effective treatment. T, N, M and clinical stage and radiotherapy dose were identified as factors significantly affecting the 1-, 3- and 5-year OS in elderly patients with esophageal carcinoma, although a higher radiotherapy dose with normal fractionation did not appear to improve the OS rate.

Transmembrane protein 166 expression in esophageal squamous cell carcinoma in Xinjiang, China

OBJECTIVE

Transmembrane protein 166 (TMEM166) expression in esophageal squamous cell carcinoma (ESCC) and remote normal esophageal tissues was examined to assess any role in tumour biology.

METHODS

TMEM166 mRNA expression in 36 cases with ESCC (36 tumour samples, 36 remote normal esophageal tissue samples) was detected by RT-PCR. TMEM166 protein expression was analysed in paraffin-embedded tissue samples from the same cases by immunohistochemistry.

RESULTS

Semi-quantitative analysis showed TMEM166 mRNA expression in ESCCs to be significantly lower than in remote normal esophageal tissues (0.759 ± 0.713 vs. 2.622 ± 1.690, P=0.014). TMEM166 protein expression was also significantly reduced (69.4% vs. 94.4%, P<0.01).

CONCLUSION

TMEM166 mRNA and protein expression demonstrated significant reduction in ESCCs compared with remote esophageal tissues, albeit with no correlation with tumour size, differentiation, stage, and lymph node metastasis, suggesting a role in regulating autophagic and apoptotic processes in the ESCC.

Estimation of hazard function and its associated factors in gastric cancer patients using wavelet and kernel smoothing methods

BACKGROUND AND OBJECTIVES

Increase of mortality rates of gastric cancer in Iran and the world in recent years reveal necessity of studies on this disease. Here, hazard function for gastric cancer patients was estimated using Wavelet and Kernel methods and some related factors were assessed.

MATERIALS AND METHODS

Ninety- five gastric cancer patients in Fayazbakhsh Hospital between 1996 and 2003 were studied. The effects of age of patients, gender, stage of disease and treatment method on patient's lifetime were assessed. For data analyses, survival analyses using Wavelet method and Log-rank test in R software were used.

RESULTS

Nearly 25.3% of patients were female. Fourteen percent had surgery treatment and the rest had treatment without surgery. Three fourths died and the rest were censored. Almost 9.5% of patients were in early stages of the disease, 53.7% in locally advance stage and 36.8% in metastatic stage. Hazard function estimation with the wavelet method showed significant difference for stages of disease (P<0.001) and did not reveal any significant difference for age, gender and treatment method.

CONCLUSION

Only stage of disease had effects on hazard and most patients were diagnosed in late stages of disease, which is possibly one of the most reasons for high hazard rate and low survival. Therefore, it seems to be necessary a public education about symptoms of disease by media and regular tests and screening for early diagnosis.

Surveillance and follow-up strategies in patients with high-grade dysplasia in Barrett's esophagus: a Dutch population-based study

OBJECTIVES

In patients with high-grade dysplasia (HGD) in Barrett's esophagus (BE), it is incompletely known which factors are associated with developing esophageal adenocarcinoma (EAC). We analyzed prior biopsy and follow-up strategies in a large nationwide population-based cohort of patients with HGD in BE, and identified predictors of EAC progression.

METHODS

Prior biopsy records and follow-up evaluations were studied in patients with HGD in BE diagnosed between 1999 and 2008, using PALGA, a nationwide network and registry of histopathology and cytopathology in the Netherlands. Multivariate Cox proportional hazards regression analysis was performed to identify predictors for prevalent (≤ 6 months) and incident (> 6 months) EAC.

RESULTS

In total, 827 patients with HGD in BE were included. Follow-up data after HGD diagnosis were available in 699 (85%) patients. In 249 (36%) of these patients, an EAC was detected (14.1 EACs per 100 person-years). The risk of prevalent EAC (n=177) was lower with previous surveillance (hazards ratio 0.7; 95% confidence interval 0.5-0.9), unifocal HGD (0.3;0.2-0.6), diagnosis in a university hospital (0.5;0.3-0.9), endoscopic resection (0.5;0.3-0.7), or ablation (0.0;0.0-0.3); and higher when patients were 65-75 years (1.5;1.04-2.04). After exclusion of prevalent EACs, the progression rate was 4.2 EACs per 100 person-years. The risk of progression to incident EAC (n = 72) was lower with previous surveillance (0.6;0.3-0.9) and ablation (0.2;0.0-0.8), and higher when > 75 years (3.8;2.0-7.2) or with an interval > 6 months between HGD diagnosis and first follow-up (e.g., 7-12 months 2.9;1.3-6.3).

CONCLUSIONS

In this cohort of patients with HGD in BE, the EAC detection rate was 14.1 per 100 person-years and 4.2 per 100 person-years after excluding prevalent cases. The risk of both prevalent and incident EAC was reduced with previous surveillance and endoscopic treatment, while it was increased with older age.

Variant allele of CHEK2 is associated with a decreased risk of esophageal cancer lymph node metastasis in a Chinese population

Growing evidence suggests that the checkpoint kinase 2 (CHEK2) signaling pathway occupies a central position in the signaling networks of DNA-damage signaling. Many functional and molecular epidemiological studies have evaluated the association between genetic variants of CHEK2 and various cancers. To evaluate the relationship between CHEK2 functional genetic variants and esophageal cancer risk and the risk of lymph node metastasis among a Chinese population. We genotyped CHEK2 rs738722, rs2236141 and rs2236142 single nucleotide polymorphisms (SNPs) using the matrix assisted laser desorption/ionization time-of-flight mass spectrometry assay in a case-controlled study, including 380 esophageal cancer cases and 380 healthy controls in a Chinese population. We found that none of the three polymorphisms achieved significant difference in their distributions between esophageal cancer cases and controls. Multiple logistic regression analyses revealed that esophageal cancer risk was not associated significantly with the variant genotypes of the three CHEK2 polymorphisms as compared with their wild-type genotypes. However, we found that functional variant rs738722 and rs2236142 in CHEK2 might contribute to susceptibility to lymph node metastasis. Our data did not support a significant association between CHEK2 SNPs and the risk of esophageal cancer. Functional variant CHEK2 rs738722 and rs2236142 might contribute to lymph node metastasis susceptibility. The CT allele of SNP rs738722 and the GC allele of SNP rs2236142 might be a protective factor of the risk for lymph node metastasis of esophageal cancer.

Long-term survival after esophagectomy for early esophageal squamous cell carcinoma in Linxian, China

BACKGROUND AND OBJECTIVES

Linxian in Henan Province, China, has among the highest rates of esophageal cancer worldwide. Little is known about long-term survival after esophagectomy for early neoplastic lesions found during early detection screening. A long-term survival analysis was performed for 315 patients from Linxian who received esophagectomy for early esophageal squamous cell carcinoma (ESCC).

METHODS

Cases that received esophagectomy for early ESCC were age- and gender-matched with two healthy controls, and Kaplan-Meier survival analyses were performed for both groups.

RESULTS

Ten-year survival was 77% for cases and 64% for controls, and this difference was not statistically significant (P = 0.33). There were no significant differences in survival based on age or gender (P > 0.05). Cases with ESCC in situ had significantly better survival than cases with invasive ESCC (P = 0.035).

CONCLUSIONS

Survival of cases who received esophagectomy for early ESCC was not significantly different from survival of age- and gender-matched controls. Early intervention probably improved survival rates for these patients who otherwise would most likely have developed advanced esophageal carcinoma. Early screening and intervention are highly relevant in areas with a high risk of esophageal cancer such as Linxian, China.

Endotherapy for Barrett's esophagus: Which, how, when, and who?

Recent developments in endoscopic therapeutic options for Barrett's esophagus (BE) early neoplasia have resulted in a dramatic paradigm shift in its clinical management. With multiple endoscopic choices available, it is important to discern subtle differences between these approaches based on the available current data and known limitations of each modality. The goals of endoscopic therapy of Barrett's neoplasia are to preserve the esophagus while ablating or removing the entire BE segment. This article reviews the currently available BE endoscopic treatments with emphasis on appropriate selection of patients, indications and timing of use, and clinical management considerations.

Endoscopic treatment of Barrett’s esophagus: From metaplasia to intramucosal carcinoma

The annual incidence of adenocarcinoma arising from Barrett’s esophagus (BE) is approximately 0.5%. Through a process of gradual transformation from low-grade dysplasia to high-grade dysplasia (HGD), adenocarcinoma can develop in the setting of BE. The clinical importance of appropriate identification and treatment of BE in its various stages, from intestinal metaplasia to intramucosal carcinoma (IMC) hinges on the dramatically different prognostic status between early neoplasia and more advanced stages. Once a patient has symptoms of adenocarcinoma, there is usually locally advanced disease with an approximate 5-year survival rate of about 20%. Esophagectomy has been the gold standard treatment for BE with HGD, due to the suspected risk of harboring occult invasive carcinoma, which was traditionally estimated to be as high as 40%. In recent years, the paradigm of BE early neoplasia management has recently evolved, and endoscopic therapies (endoscopic mucosal resection, radiofrequency ablation, and cryotherapy) have entered the clinical forefront as acceptable non-surgical alternatives for HGD and IMC. The goal of endoscopic therapy for HGD or IMC is to ablate all BE epithelium (both dysplastic and non-dysplastic) due to risk of synchronous/metachronous lesion development in the remaining BE segment.

Low-grade dysplasia in Barrett's esophagus: overdiagnosed and underestimated

OBJECTIVES

Published data on the natural history of low-grade dysplasia (LGD) in Barrett's esophagus (BE) are inconsistent and difficult to interpret. We investigated the natural history of LGD in a large community-based cohort of BE patients after reviewing the original histological diagnosis by an expert panel of pathologists.

METHODS

Histopathology reports of all patients diagnosed with LGD between 2000 and 2006 in six non-university hospitals were reviewed by two expert pathologists. This panel diagnosis was subsequently compared with the histological outcome during prospective endoscopic follow-up.

RESULTS

A diagnosis of LGD was made in 147 patients. After pathology review, 85% of the patients were downstaged to non-dysplastic BE (NDBE) or to indefinite for dysplasia. In only 15% of the patients was the initial diagnosis LGD. Endoscopic follow-up was carried out in 83.6% of patients, with a mean follow-up of 51.1 months. For patients with a consensus diagnosis of LGD, the cumulative risk of progressing to high-grade dysplasia or carcinoma (HGD or Ca) was 85.0% in 109.1 months compared with 4.6% in 107.4 months for patients downstaged to NDBE (P<0.0001). The incidence rate of HGD or Ca was 13.4% per patient per year for patients in whom the diagnosis of LGD was confirmed. For patients downstaged to NDBE, the corresponding incidence rate was 0.49%.

CONCLUSIONS

LGD in BE is an overdiagnosed and yet underestimated entity in general practice. Patients diagnosed with LGD should undergo an expert pathology review to purify this group. In case the diagnosis of LGD is confirmed, patients should undergo strict endoscopic follow-up or should be considered for endoscopic ablation therapy.

Association between epidermal growth factor polymorphism and esophageal squamous cell carcinoma susceptibility

Genetic factors are known to be important in the development of esophageal squamous cell carcinoma (ESCC). Epidermal growth factor (EGF) can activate several signaling pathways leading to proliferation, differentiation, and tumorigenesis of epithelial tissues by binding with its receptor. Interindividual variations in EGF production were genetically contributed to EGF +61 G/A polymorphism. The purpose of this study is to investigate the potential association between EGF gene polymorphism and ESCC in a Chinese population. In this study, we analyzed single nucleotide polymorphism of EGF +61 G/A in 158 patients with ESCC and 212 age- and sex-matched controls in a Chinese population using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) strategy and DNA sequencing. The variant genotypes of GA/AA were associated with a significantly decreased risk of ESCC compared with the wild-type homozygote GG (OR = 0.657, 95% CI: 0.434-0.996). However, no significant difference was observed between the EGF +61 G/A polymorphism and the risk of ESCC when the analyses were stratified in terms of age, gender, smoking status, different clinical stage, and lymph node status. The EGF +61 G/A polymorphism is associated with ESCC in a Chinese population. Our data suggests that the EGF gene may play a role in the development of ESCC.

Endoscopic therapy using radiofrequency ablation for esophageal dysplasia and carcinoma in Barrett's esophagus

Radiofrequency ablation (RFA) is a novel and promising treatment modality for treatment of Barrett's esophagus (BE) with high-grade dysplasia or early carcinoma. RFA can be used as a single-modality therapy for flat-type mucosa or as a supplementary therapy after endoscopic resection of visible abnormalities. The treatment protocol consists of initial circumferential ablation using a balloon-based electrode, followed by focal ablation of residual Barrett's epithelium. RFA is less frequently associated with stenosis and buried glandular mucosa as are other ablation techniques and has shown to be safe and effective in the treatment of patients with BE and early neoplasia. In this article, the technical background, current clinical experience, and future prospects of RFA are evaluated.

Adjuvant chemotherapy in oesophageal cancer: a meta-analysis and experience from the Shanghai Cancer Hospital

Whether adjuvant chemotherapy increases survival of oesophageal cancer patients has been widely debated. The present study used meta-analysis software to combine data from six studies up to July 2007 that were found and selected as suitable, comprising a total of 1001 oesophageal cancer patients. The results indicated that adjuvant chemotherapy did not significantly improve outcome in oesophageal cancer patients. A trend towards improved outcome from adjuvant chemotherapy was found in lymph node-positive patients, but did not reach significance. In our own study including 270 oesophageal cancer patients, adjuvant chemotherapy did not improve overall patient survival, but did improve survival for patients with metastases in cervical and/or celiac lymph nodes (stage IVa). Although our study had the largest patient sample, more prospective clinical trials with large numbers of patients are necessary to confirm the value of adjuvant chemotherapy in stage IVa patients.

Mutation analysis of DNA polymerase β gene promoter in human esophageal cancer

AIM: To investigate the mutations of DNA polymerase β (polβ) gene promoter in esophageal cancer tissue, the corresponding cancer-adjacent tissue and distal normal mucosal tissue.

METHODS: We examined the promoter sequence of polβ gene in tumor tissues, the corresponding cancer-adjacent tissues and normal mucosal tissues from 25 patients with esophageal cancer using polymerase chain reaction (PCR) and DNA sequence analysis. DNASIS and OMIGA softwares were used to analyze the DNA sequencing results.

RESULTS: The mutation of polβ gene promoter was found in 8 esophageal cancer tissues, 6 corresponding cancer-adjacent tissues and 5 normal mucosa tissues, respectively. No significant change was found among three groups. There were 18, 9 and 8 mutation points in three groups (35 mutation points in total), respectively. Of the 35 mutation points, 25 located the core region of polβ gene promoter. In all the specimens, mutation forms of C→A at -37 nt, G→T at-65 nt, and T→C at 29 nt were found 8, 7 and 2 times, respectively. Also, the mutation form of C deletion and insertion at -19 nt was found one time, respectively.

CONCLUSION: The mutation of DNA polβ gene promoter may be related to the carcinogenesis and development of esophageal cancer.

Expression and prognostic roles of Eag1 in resected esophageal squamous cell carcinomas

Expression of Eag1 was detected in resected esophageal squamous cell carcinomas tissues and matched tissues by immunohistochemistry and RT-PCR. Positive expression of Eag1 protein was 75% (51/68), and mRNA was 73% (8/11) in primary cancer tissues. Eag1 protein positively stained in all 10 metastatic lymph nodes. Eag1 protein and mRNA were negatively expressed in all non-cancerous matched tissues. Eag1 protein was associated with depth of penetration (P = 0.023), but not associated with other clinicopathological factors. Eag1 protein positive group had a significantly shorter survival time than the negative group (P = 0.005). Survival rates at each time-point for the positive group were lower than that for the negative group (P = 0.006), and Eag1 was identified as an independent prognostic factor of long-term survival (P = 0.016). In conclusion, Eag1 was aberrantly expressed in ESCC and correlated with poor prognosis after surgery.

Complications after esophagectomy for cancer: 53-year experience with 20,796 patients

The incidence of esophageal cancer in Hebei Province in China is the highest in the world. Our experience in the Department of Thoracic Surgery, Fourth Hospital, Hebei Medical University with the management of postoperative complications following esophagectomy was determined. From September 1952 to December 2005, a total of 20,796 patients underwent an intended esophagectomy for cancer in our department. Data for the outcome of these procedures was sourced from reported articles in the Chinese-language literature. The data were collated to determine the incidence and outcomes of postoperative complications. The incidence of major complications declined over the period of study. The likelihood of anastomotic leakage decreased from 5.0% to 2.3%, and pulmonary complications declined from 3.2% to 1.6%. The surgical mortality rate decreased from 17.1% to 0.6%. The incidence of postoperative complications and deaths following esophagectomy for cancer in our unit has fallen steadily over the past five decades. Improvements in preoperative preparation and postoperative management have contributed to this decrease.

Prospective, controlled tandem endoscopy study of narrow band imaging for dysplasia detection in Barrett's Esophagus

BACKGROUND & AIMS

High-resolution endoscopy with narrow band imaging (NBI) enhances the visualization of mucosal glandular and vascular structures. This study assessed whether narrow band targeted biopsies could detect advanced dysplasia using fewer biopsy samples compared with standard resolution endoscopy.

METHODS

We conducted a prospective, blinded, tandem endoscopy study in a tertiary care center with 65 patients with Barrett's esophagus undergoing evaluation for previously detected dysplasia. Standard resolution endoscopy was used first to detect visible lesions. Narrow band endoscopy was then used by another gastroenterologist to detect and biopsy areas suspicious for dysplasia. The lesions initially detected by standard resolution endoscopy were then disclosed and biopsied, after biopsy of the lesions targeted with NBI. Finally, random 4-quadrant biopsies were taken throughout the segment of Barrett's mucosa.

RESULTS

Higher grades of dysplasia were found by NBI in 12 patients (18%), compared with no cases (0%) in whom standard resolution white light endoscopy with random biopsy detected a higher grade of histology (P < .001). Correspondingly, narrow band directed biopsies detected dysplasia in more patients (n = 37; 57%) compared with biopsies taken using standard resolution endoscopy (n = 28; 43%). In addition, more biopsies were taken using standard resolution endoscopy with random biopsy compared with narrow band targeted biopsies (mean 8.5 versus 4.7; P < .001).

CONCLUSIONS

In patients evaluated for Barrett's esophagus with dysplasia, NBI detected significantly more patients with dysplasia and higher grades of dysplasia with fewer biopsy samples compared with standard resolution endoscopy.

Adjuvant chemotherapy of cisplatin, 5-fluorouracil and leucovorin for complete resectable esophageal cancer: a case-matched cohort study in east China

It is still controversial whether adjuvant chemotherapy of cisplatin, 5-fluorouracil and leucovorin can increase the overall survival of esophageal cancer patients, and which subgroup of patients get most benefits from it. Between 1998 and 2004, 66 esophageal cancer patients with adjuvant chemotherapy and 160 well-matched patients without chemotherapy were included in this study. Nine markers were measured in the protein level to analyze prognostic significance. In the whole group, adjuvant chemotherapy did not improve the survival of esophageal cancer patients. There was also no significant difference for survival in stage I (P=0.59 and P=0.59), stage II (P=0.28 and P=0.28) and stage III patients (P=0.144 and P=0.06) between the observation and the chemotherapy group. Chemotherapy was most effective for the patients who had metastases in cervical and/or celiac lymph nodes (IV subgroup). One and 3-year disease-free survival and overall survival were significantly better than for those who did not receive the chemotherapy(P=0.038, and 0.016, respectively). Bcl-2 expression was a bad prognostic factor, and was more predictive in the adjuvant chemotherapy group than in the no-chemotherapy group. Adjuvant chemotherapy significantly improved the treatment result of stage IV patients compared with the observation group. Bcl-2 could be used to analyze prognosis and guide the adjuvant treatment.

Surveillance history of endoscopically treated patients with early Barrett's neoplasia: nonadherence to the Seattle biopsy protocol leads to sampling error

The study's aim was to retrospectively evaluate the surveillance history of Barrett's esophagus (BE) patients with endoscopically treated early neoplasia. All BE patients endoscopically treated for early cancer (EC) or high-grade intraepithelial neoplasia (HGIN) in a lesion or mass between 1998 and 2005 were included. Endoscopy and histology records were reviewed. Ninety-four patients (78 males, mean age 67 years, 24 HGIN, 70 EC) were included. In 36 (38%) patients, HGIN/EC was diagnosed at (or within 6 months after) initial endoscopy. The remaining 58 (62%) patients had a surveillance history (median duration 7 years, mean 6.7 endoscopies). Seventy-nine percent of these had low-grade intraepithelial neoplasia (LGIN) diagnosed at least once during their surveillance period with a median of seven endoscopies and a median number of biopsies that was 50% of what should have been taken according to the Seattle protocol. Patients without any dysplasia during earlier surveillance (n = 12, 21%) had undergone significantly less endoscopies (median four endoscopies, P = 0.02) and had a median biopsy percentage that was 23% of the Seattle protocol (P < 0.001 versus 50% in LGIN). In this selected cohort of patients with early Barrett's neoplasia, 38% of patients were diagnosed at initial endoscopy. Of the patients with a surveillance history, 79% had shown LGIN prior to HGIN/EC diagnosis. Only 21% of patients had a surveillance history without any dysplasia, which in general encompassed endoscopies with an insufficient number of biopsies, suggesting sampling error. This underlines the importance of obtaining an adequate number of biopsies during surveillance endoscopies.

Overexpression of hERG1 in resected esophageal squamous cell carcinomas: a marker for poor prognosis

BACKGROUND AND OBJECTIVES

The aim of this study was to evaluate the expression and prognostic roles of human ether à go-go related gene (hERG1) potassium channels in resected esophageal squamous cell carcinoma.

METHODS

Expression of hERG1 protein and mRNA was detected by immunohistochemistry and reverse transcription PCR in resected esophageal squamous cell carcinomas (ESCCs) and non-cancerous matched tissues, and the correlation was examined between expression of hERG1 protein and clinicopathological factors and prognosis of ESCC patients.

RESULTS

Frequency of positive expression of hERG1 protein was 77.9% (53/68), mRNA was 81.8% (9/11). hERG1 protein and mRNA were negatively expressed in all non-cancerous matched tissues. There was no significant correlation between hERG1 protein expression and lymph node metastases, depth of penetration, stage, and other clinicopathological factors. Completeness was 92.5% for hERG1-positive group and 92.0% for hERG1-negative group. ESCC patients with positive expression of hERG1 protein had a significantly shorter postoperative survival time than those with negative expression (median, 30 vs. 56 months). Survival rates at each time-point for hERG1-positive group were lower than that for hERG1-negative group, and hERG1 was identified as an independent prognostic factor of long-term survival by multivariate analysis.

CONCLUSION

In ESCC, hERG1 was aberrantly expressed and correlated with poor prognosis after surgery.

Hospital volume does not influence long-term survival of patients undergoing surgery for oesophageal or gastric cancer

BACKGROUND

Guidelines suggest that surgery for oesophageal and gastric cancer should be conducted in large cancer centres. This national study examined the relationship between hospital volume and outcome in Scotland.

METHODS

This was a prospective, population-based study of 3293 consecutive patients with oesophageal or gastric cancer diagnosed between 1997 and 1999. Some 1302 patients underwent surgery and were followed for 5 years after operation.

RESULTS

The 5-year adjusted overall survival rate for the 3293 patients was 18.7 (95 per cent confidence interval (c.i.) 17.2 to 20.2) per cent and that after surgical resection was 39.6 (95 per cent c.i. 36.3 to 43.0) per cent. Death within 1 year after surgical resection was associated with a postoperative complication (odds ratio (OR) 2.5 (95 per cent c.i. 1.6 to 3.8); P < 0.001) or resection margin involvement by tumour (OR 7.2 (95 per cent c.i. 1.1 to 47.5); P = 0.042) after adjustment for age, sex and tumour location. There was no relationship between hospital volume and postoperative morbidity or mortality, nor between survival and volume of patients either for hospital of diagnosis or hospital of surgery.

CONCLUSION

This population-based study of oesophageal and gastric cancer suggests that the link between hospital volume and long-term survival for patients undergoing surgery requires re-evaluation.

Spleen preservation in radical surgery for gastric cardia cancer

BACKGROUND

In gastric cardia cancer (GCC), the spleen is usually removed when the tumor is resected. This allows thorough lymph node dissection in the splenic hilus. However, the long-term effect of splenectomy on patient survival is controversial. The purpose of this study was to investigate the effect of spleen preservation on survival following radical resection for gastric cardia cancer.

METHODS

We reviewed the records of 116 GCC patients (Siewert types II and III) who underwent radical resection with D2 or D3 lymphadenectomy between July 1994 and December 2003. Survival status was ascertained in December 2004 and data from 108 patients were analysed. Of these 108 patients, 38 underwent splenectomy and 70 had splenic preservation. Clinicopathological features and prognostic data of the splenectomy(+) and splenectomy(-) groups were compared.

RESULTS

Seventy-four patients (68.5%) had lymph node involvement; 18 (16.7%) had involvement of nodes in the splenic hilus. Postoperative morbidity in the two groups was similar. Overall 5-year survival was higher in the splenectomy(-) group than the splenectomy(+) group (38.7% versus 16.9%, P =.008). Multivariate regression indicated that tumor invasion (P =.009) and lymph node metastasis (P = .001) were independent prognostic factors--they predicted decreased survival--with or without splenectomy. Although splenectomy was be associated with lower survival, it was not an independent prognostic factor (P =.085).

CONCLUSIONS

Splenectomy does not improve survival of patients who undergo curative resection for gastric cardia cancer. Thus, the spleen should be preserved in patients without direct cancer invasion of the spleen.

Cyclooxygenase-2 expression in squamous cell carcinoma of the esophagus

Increased cyclooxygenase-2 expression has been reported to be a poor prognostic indicator in a number of cancers. In this study we investigated the relationship between COX-2 expression in squamous cell carcinoma of the esophagus and tumor characteristics and patient survival. The study group consisted of 90 men and 48 women who underwent esophagectomy for squamous cell carcinoma of the esophagus between October 1984 and May 1985. COX-2 expression was measured by immunohistochemistry in 138 primary cancers, 23 metastatic lymph nodes and 21 normal esophageal stumps. The relationship between the extent of staining for COX-2 and clinicopathological features and survival was determined. The extent of staining for COX-2 in both primary and metastatic cancers was higher than in normal squamous epithelia (P = 0.002 and P < 0.0001 respectively), and the grade of staining in the primary tumor correlated positively with the finding of lymph node metastases (P = 0.03). The 5-year survival rate in patients with less than 10% COX-2 positive cells was 47.5% compared to 23.2% in patients with more than 10% COX-2 positive cells (P = 0.0036). The relationship between survival and COX-2 staining was not due to COX-2 being a surrogate marker for TNM stage. Our results show that the expression of COX-2 is elevated in squamous cell carcinoma of the esophagus compared to normal epithelium and correlates with lymph node metastases. Survival was longer in those patients whose tumors expressed lower levels of COX-2.

Aspirin induces apoptosis in oesophageal cancer cells by inhibiting the pathway of NF-kappaB downstream regulation of cyclooxygenase-2

BACKGROUND

Aspirin has potential in the prevention or treatment of oesophageal cancer, the seventh most common cancer in the world, but its mechanism of action is still not certain.

METHODS

The oesophageal squamous cell carcinoma cell line TE-13 was cultured with aspirin at different concentrations or for different times. Proliferation and apoptosis were measured by MTT reduction and flow cytometry. Expression of COX-2 mRNA was measured by RT-PCR and COX-2 protein levels with Western blot analysis. Nuclear NF-kappaB and cytoplasmic IkappaB protein levels were determined by electrophoretic mobility shift assay and Western blot, respectively.

RESULTS

Aspirin significantly inhibited cell proliferation and induced apoptosis at concentrations of 1, 4, 8 mmol/L. Aspirin dose-dependently decreased the levels of COX-2 mRNA, COX-2 protein and nuclear NF-kappaB protein and increased the cytoplasmic IkappaB protein.

CONCLUSION

We conclude that aspirin inhibits the proliferation of, and induced apoptosis in, the cultured TE-13 SCC cell line. These changes correlate with a reduction in COX-2 mRNA and protein expression, prostaglandin synthesis, an inhibition of NF-kappaB nuclear translocation, and an increase in cytoplasmic IkappaB. These results support the further investigation of the cyclooxygenase pathway in investigating the potential of aspirin and similar drugs in cancer prevention and therapy.

Endoscopic treatment of high-grade intraepithelial neoplasia and early cancer in Barrett oesophagus

In the last 5 years, endoscopic therapy for high-grade intraepithelial neoplasia (HGIN) and early cancer (EC) in Barrett oesophagus has emerged as an effective and safe alternative to surgery. Adequate work-up of patients includes histopathological review of the initial biopsies, a high-resolution endoscopy with four-quadrant random biopsies every 1cm of Barrett mucosa and staging with endoscopic ultrasonography. Endoscopic resection (ER) forms the mainstay of the endoscopic treatment since it provides large tissue specimens for optimal histopathological evaluation. The ER-cap technique with submucosal injection and the 'suck-band-and cut' method are the resection methods most widely used in Barrett oesophagus patients. ER monotherapy for HGIN or EC in Barrett oesophagus is associated with recurrent lesions in up to 30% of treated patients. ER may be combined with ablative techniques such as photodynamic therapy (PDT) to treat all of the mucosa at risk for neoplastic progression. Unlike ER, PDT lacks histopathological correlation and residual Barrett mucosa may remain after treatment or may be hidden underneath the neosquamous epithelium. Management of Barrett oesophagus patients with HGIN or EC should be performed in centres with multi-disciplinary experience in this field and future studies should focus on development of ER techniques that allow radical resection of the whole Barrett segment.

Long-term effects of proglumide on resection of cardiac adenocarcinoma

AIM: Patients with advanced stage cardiac adenocarcinoma have a very poor prognosis. Surgery is the first choice of treat-ment for this kind of patients. Peptide hormone gastrin is a recognized growth factor for gastric cancer, and gastrin receptor antagonist proglumide can block the effects of gastrin. The aim of this study was to investigate the actions of proglumide as an adjuvant treatment to improve the postoperative long-term survival rate of patients with cardiac adenocarcinoma.

METHODS: We performed a randomized, controlled study of gastrin receptor antagonist proglumide in 301 patients with cardiac adenocarcinoma after proximal subtotal gastrectomy. The oral dose of 0.4 g proglumide thrice daily preprandially was maintained for more than 5 years in 153 cases (proglumide treatment group). In the control group, 148 patients underwent operation only. In clinicopathologic features, there was no significant difference between the two groups (P>0.05). All patients were followed up during their lifetime, and the survival rates were analyzed combined with clinicopathologic factors by SPSS 11.5 statistical software.

RESULTS: The 1, 3, 5 and 10-year survival rate of the patients was 88.4%, 48.8%, 22.6% and 13.4%, respectively. The 1, 3, 5 and 10-year survival rate of the proglumide treatment group was 90.2%, 49.7%, 26.8% and 17.6% compared to 86.5%, 48.0%, 18.2% and 8.9% of the control group. There was a significant difference between the two groups (P = 0.0460). The patients in proglumide treatment group had no obvious side effects after administration of the drug, and no definite hepatic and renal function damage was found. According to single factor log-rank analysis, the long-term survival rate was correlated with the primary tumor position (P = 0.0205), length of the tumor (P = 0.0000), property of the operation (P = 0.0000), histopathologic grading (P = 0.0003), infiltrating degree of the tumor (P = 0.0000), influence of lymph node metastasis (P = 0.0000), clinicopathologic staging (P = 0.0000) and administration of proglumide (P = 0.0460). Cox regression analysis demonstrated the infiltrating degree of tumor (P = 0.000), influence of lymph node metastasis (P = 0.039) and the clinicopathologic staging (P = 0.003) were independent prognostic factors. Administration of proglumide (P = 0.081), length of the tumor (P = 0.304), radical status of the resection (P = 0.224) and histopathologic types (P = 0.072) were not the independent prognostic factors.

CONCLUSION: Proglumide is convenient to use with no obvious toxic side effects, and prolonged postoperative administration of proglumide as a postoperative adjuvant treatment can increase the survival rate of patients after resection of cardiac adenocarcinoma. Proglumide may provide a new effective approach of endocrinotherapy for patients with gastric cardiac cancer.

Endoscopic treatment of high-grade dysplasia and early stage cancer in Barrett's esophagus

BACKGROUND

The aim of this study was to prospectively evaluate endoscopic resection (ER) combined with photodynamic therapy (PDT) for the treatment of selected patients with early neoplasia in Barrett's esophagus.

METHODS

Patients with Barrett's esophagus and neoplastic lesions <2 cm in diameter and no sign of submucosal infiltration, positive lymph nodes, or distant metastasis underwent diagnostic ER (cap technique). Patients with a T1sm tumor in the resection specimen were referred for surgery; those with a T1m or a less invasive tumor underwent additional endoscopic therapy (ER, PDT, and/or argon plasma coagulation [APC]), or they were followed. PDT was performed with 5-aminolevulinic acid and a light dose of 100 J/cm 2 at lambda = 632 nm.

RESULTS

Thirty-three patients underwent diagnostic ER. Endoscopic treatment was not performed in 5 patients, who underwent surgery (4 T1sm; 1, patient preference). Five patients were immediately entered into a follow-up protocol, and 23 received additional endoscopic treatment (13 additional ER, 19 PDT, 3 APC). Endoscopic treatment was successful in 26/28 patients; no severe complication was observed. During follow-up (median 19 months, range 13-24 months), 5/26 patients had a recurrence of high-grade dysplasia: all were successfully re-treated with ER. At the end of follow-up, 26/33 originally enrolled patients (79%) and 26/28 endoscopically treated patients (93%) were in local remission.

CONCLUSIONS

Endoscopic therapy is safe and effective for selected patients with early stage neoplasia in Barrett's esophagus.

Effect of Fuzheng Yiliu decoction combined with chemotherapy on patients with intermediate and late stage gastrointestinal cancer

AIM: To investigate the therapeutic effects of Fuzheng Yiliu (strengthening the body resistance to inhibit tumor) decoction combined with chemotherapy on the patients with intermediate and late stage gastrointestinal cancer.

METHODS: Sixty patients were randomly divided into treatment group (chemotherapy combined with Fuzheng Yiliu decoction) and control group (chemotherapy alone). Four indexes, including the tumor recent remission rate (RR), the change of main symptoms, the toxic and side effects caused by chemotherapy and the change of performance status, were observed in the patients. Peripheral blood contents of CD3⁺, CD4⁺, CD8⁺ cells, CD4⁺/CD8⁺ and soluble interleukin-2 receptor (sIL-2R) were tested before and after treatment and the values were compared with those of healthy peoples.

RESULTS: The improving rate of main symptoms (69.6%) and performance status (56.7%) were significantly higher in the treatment group than in the control group (34.8%, 26.7%, P<0.05). The occurrence rates of grade II toxic and side-effects on both bone marrow (13.3%) and digestive tract (30%) were lower in the treatment group compared to the control group (36.7%, 63.3%, P<0.05). Before treatment, the proportion of CD3⁺, CD4⁺ and CD4⁺/CD8⁺ decreased and the proportion of CD8⁺ and sIL-2R raised markedly both in the control group and treatment group as compared to the healthy people. After treatment, that increased of CD3⁺, CD4⁺, CD4⁺/CD8⁺ increased (62.25±10.01% vs 68.31±9.72%, 36.83±10.44% vs 42.6±9.62%, 1.24±0.65 vs 1.66±0.85, P<0.05) and the values of CD8⁺ and sIL-2R decreased obviously (33.06±7.69% vs 29.24±6.25%, 588.23±216.86 U/mL vs 475.87±211.36 U/mL, P<0.05) in the treatment group, whereas these values were opposite in the control group (64.22±6.91% vs 60.63±5.75%, 35.62±7.49% vs 31.53±5.53%, 32.95±8.28% vs 37.14±7.48%, 1.17±0.43 vs 0.94±0.43, 573.63±214.32 U/mL vs 692.17±221.33 U/mL, P<0.05).

CONCLUSION: Fuzheng Yiliu decoction can enhance therapeutic effects of chemotherapy on malignant gastrointestinal tumor, and also reduce the toxic and side effects on bone marrow and digestive tract, thereby improving the quality of life and cellular immunity in patients with malignant gastrointestinal tumor.