Esophageal cancer in Iran; a population-based study regarding adequacy of cancer surgery and overall survival

Fashioning esophagogastric anastomosis in robotic Ivor-Lewis esophagectomy: a multicenter experience

BACKGROUND

The aim of the present study is to compare outcomes of the robotic hand-sewn, linear- and circular-stapled techniques performed to create an intrathoracic esophagogastric anastomosis in patients who underwent Ivor-Lewis esophagectomy.

METHODS

Patients who underwent a planned Ivor-Lewis esophagectomy were retrospectively analysed from prospectively maintained databases. Only patients who underwent a robotic thoracic approach with the creation of an intrathoracic esophagogastric anastomosis were included in the study. Patients were divided into three groups: hand-sewn-, circular stapled-, and linear-stapled anastomosis group. Demographic information and surgery-related data were extracted. The primary outcome was the rate of anastomotic leakages (AL) in the three groups. Moreover, the rate of grade A, B and C anastomotic leakage were evaluated. In addition, patients of each group were divided in subgroups according to the characteristics of anastomotic fashioning technique.

RESULTS

Two hundred and thirty patients were enrolled in the study. No significant differences were found between the three groups about AL rate (p = 0.137). Considering the management of the AL for each of the three groups, no significant differences were found. Evaluating the correlation between AL rate and the characteristics of anastomotic fashioning technique, no significant differences were found.

CONCLUSIONS

No standardized anastomotic fashioning technique has yet been generally accepted. This study could be considered a call to perform ad hoc high-quality studies involving high-volume centers for upper gastrointestinal surgery to evaluate what is the most advantageous anastomotic technique.

Clinicopathological relevance of stem cell marker growth and differentiation factor 3 in esophageal squamous cell carcinoma

Esophageal squamous cell carcinoma (ESCC) is the second leading cause of cancer-related deaths in Iran, often diagnosed in advanced stages with a poor prognosis. Growth and differentiation factor 3 (GDF3) is a member of the transforming growth factor-beta (TGF-β) superfamily. It acts as an inhibitor of bone morphogenetic proteins (BMPs) signaling pathway associated with pluripotent embryonic and cancer stem cells (CSCs) characteristics. Since its expression in ESCC has not yet been evaluated, the clinicopathological relevance of GDF3 expression was elucidated in ESCC patients. Expression of GDF3 in tumor tissues from 40 ESCC patients was compared to the related margin normal tissues by relatively comparative real-time polymerase chain reaction (PCR). Glyceraldehydes 3-phosphate dehydrogenase (GAPDH) was used as the endogenous control. Likewise, the function of GDF3 in the differentiation and development of embryonic stem cells (ESCs) was also reviewed. GDF3 was significantly overexpressed in 17.5% of tumors and a significant correlation between GDF3 expression and the depth of tumor invasion was observed (P = 0.032). The results suggest that GDF3 expression is likely to have substantial roles in the progression and invasiveness behavior of ESCC. Having considered the importance of CSC markers identification and their exploitation in targeted cancer therapy, GDF3 may be introduced as a promising therapeutic target to inhibit the invasion of tumor cells in ESCC.

Nuplazid suppresses esophageal squamous cell carcinoma growth in vitro and in vivo by targeting PAK4

Background

Due to the high recurrence and low 5-year survival rates of esophageal squamous cell carcinoma (ESCC) after treatment, the discovery of novel drugs for recurrence chemoprevention is of particular importance.

Methods

We screened the FDA-approved drug library and found that Nuplazid, an atypical antipsychotic that acts as an effective 5-HT 2 A receptor inverse agonist, could potentially exert anticancer effects in vitro and in vivo on ESCC.

Results

Pull-down results indicated that Nuplazid binds with p21-activated kinase 4 (PAK4), and a kinase assay showed that Nuplazid strongly suppressed PAK4 kinase activity. Moreover, Nuplazid exhibited inhibitory effects on ESCC in vivo.

Conclusions

Our findings indicate that Nuplazid can suppress ESCC progression through targeting PAK4.

Comparison of end-to-side hand-sewn and side-to-side stapled cervical esophagogastric anastomosis in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy: an Iranian retrospective cohort study

Background

Controversies in terms of efficacy and postoperative advantages surround stapled esophagogastric anastomosis compared with the hand-sewn technique as a treatment for patients with esophageal cancer. The purpose of this study was to compare the clinical outcomes of hand-sewn end-to-side esophago-gastrostomy and side-to-side stapled cervical esophagogastric anastomosis after esophagectomy for the aforementioned patients.

Methods

This retrospective cohort study involved examining the medical records of 433 patients who underwent transhiatal esophagectomy for esophageal cancer from March 2010 to March 2016. All the patients were operated using end-to-side hand-sewn esophago-gastrostomy and side-to-side stapled cervical esophagogastric anastomosis. 409 of the patients received a year’s worth of follow-up evaluations. All the cases were revisited in 2 weeks as well as in four, eight, and 12 months after surgery. The patients were assessed in terms of postoperative outcomes, including reflux symptoms, anastomotic leakage and stricture, and the need for anastomotic dilatation.

Results

Hand-sewn anastomosis was carried out in 271 (62.5%) patients, whereas stapled anastomosis was performed in 162 (37.4%) patients. The mean operative times were 214.46 ± 84.33 min and 250.55 ± 43.31 min for the stapled and hand-sewn anastomosis groups, respectively (P = 0.028). The two groups showed no significant differences with respect to stays in intensive care units and hospitals. Postoperatively, 38 (14.67%) cases of anastomotic leakage were detected in the hand-sewn anastomosis group, with incidence being significantly higher than that in the stapled anastomosis group (8 cases or 5.33%; P = 0.002). Anastomotic stricture occurred less frequently in the patients who underwent stapled anastomosis (P = 0.004). Within the one-year follow-up period, the patients treated via hand-sewn anastomosis more frequently required anastomotic dilatation (P = 0.02).

Conclusion

Side-to-side stapled cervical esophagogastric anastomosis may reduce operation times and decrease the rates of anastomotic leakage, anastomotic stricture, and anastomotic dilatation in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy.

Burden of esophageal cancer in Iran during 1995-2015: Review of findings from the Global Burden of Disease studies

Background: Iran is located in Asian esophageal cancer belt, with age-standardized incidence rate (ASR) of approximately 7 per 100,000 for both men and women. To provide potential solution recommendations for achieving accurate estimations regarding the burden of the disease in Iran, we designed a study to assess the burden of esophageal cancer in Iran during 1995-2015 by collecting data from the Global Burden of Disease studies.

Methods: Data were extracted from the Global Burden of Disease (GBD) during 1995-2015, which were published by the Institute for Health Metrics and Evaluation. For this purpose, disability adjusted life years (DALYs), incidence, and prevalence rate were applied to report burden of esophageal cancer based on gender and age group in Iran during 1995-2015. The Cochran-Armitage and t test were used to assess statistical significance. Stata Version 13 and Excel 2016 were used for data analysis.

Results: During 1995-2015, in total, 304 102 DALYs (179 562 for males vs. 124 540 for females) were attributed to esophageal cancer in Iran. In both genders and all ages, the number of DALYs increased significantly from 45 018 in 1995 to 74 399 in 2015.

Conclusion: Esophageal cancer is still a public health issue in Iran. Most of DALYs were due to years of life lost (YLL), suggesting the need for prevention, early detection, and screening programs. P-value was statistically significant just between male and female groups (p<0.05).

Ectopic expression of TWIST1 upregulates the stemness marker OCT4 in the esophageal squamous cell carcinoma cell line KYSE30

Background

The transcription factor TWIST1 plays an important role in the epithelial–mesenchymal transition (EMT) process and in the migration, invasion and metastasis of cancer cells. OCT4, which is a homeobox transcription factor, has an important role in the self-renewal potential of cancer cells. Our aim here is to elucidate impact of ectopic expression of TWIST1 on OCT4 gene expression in esophageal squamous cell carcinoma (ESCC).

Methods

The ESCC line was KYSE30. GP293T cells were transfected with purf-IRES-GFP and pGP plasmids to produce recombinant viral particles. A semi-confluent KYSE30 culture was transduced with the prepared retroviral particles. mRNA extraction and cDNA synthesis were performed from normal KYSE30 cells and those ectopically expressing TWIST1. Expressional analysis of TWIST1 and OCT4 were performed with relative comparative real-time PCR.

Results

Ectopic expression of TWIST1 in KYSE30 cells was related to its significant overexpression: nearly nine-fold higher in GFP-hTWIST1 KYSE-30 cells than in control GFP cells. This induced expression of TWIST1 caused significant upregulation of OCT4 in GFP-hTWIST1 KYSE-30 cells: nearly eight-fold higher. In silico analysis predicted the correlation of TWIST1 and OCT4 through ETS2.

Conclusions

Overexpressed TWIST1 can be correlated with upregulation of the cancer stem cell marker OCT4 and the protein may play critical regulatory role in OCT4 gene expression. Since OCT4 is involved in the self-renewal process, the results may suggest a new linkage between TWIST1 and OCT4 in the cell biology of ESCC, highlighting the probable role of TWIST1 in inducing self-renewal.

Comparison of the 7th and proposed 8th editions of the AJCC/UICC TNM staging system for esophageal squamous cell carcinoma underwent radical surgery

BACKGROUND

Recently, the 8th edition of the TNM classification of esophageal cancer has come up. The present study aims to compare the 7th and the proposed 8th edition of the AJCC/UICC TNM staging system for esophageal squamous cell carcinoma (ESCC).

METHODS

A total of 1872 ESCC patients who underwent radical surgery with curative intent were analyzed retrospectively. Survival was analyzed using the Kaplan-Meier method, and values were compared using the log-rank test. Multivariate analysis was performed using the Cox proportional hazard model. The Akaike information criterion (AIC) and the concordance index (c-index) were applied to compare the two prognostic systems.

RESULTS

On univariate analysis, the 7th staging system, the proposed 8th staging system, gender, age as well as adjuvant treatment were found to have significant association with overall survival (OS). In both the current staging system and the modified version, age and gender were independent prognostic factors in a multivariate analysis. The AIC value for the proposed 8th version was smaller than that for the 7th staging system; the c-index value for the proposed 8th version was larger than that for the 7th staging system. Subgroup analysis in patients with/without nodal metastasis obtained consistent results.

CONCLUSION

Based on the data from our single center, the proposed 8th AJCC staging system seems to be superior to the 7th AJCC staging system in terms of OS for patients with thoracic ESCC who underwent radical surgery.

Predictors of survival in oesophageal cancer patients in a high-risk area in Northern Iran: the role of health services utilisation

We aimed to determine predictors of survival in oesophageal cancer (EC) patients in a high-risk area. This study was conducted on EC patients diagnosed in 2007-2008 in Golestan province, Iran. Diagnostic (DU) and Therapeutic (TU) services utilisation indices were determined. DU and TU indices of 1 were considered as good utilisation. EC-specific survival rates were calculated. Multivariate Cox-regression model was used to calculate adjusted hazard ratios (AHRs). Two hundred and twenty-three EC subjects were enrolled. The median survival time was 10.47 months and the 5-year survival rate was 11%. Cox-regression analysis suggested that stage of tumour (AHR_regional  = 3.75, 95% confidence interval [CI]: 2.34-6.00; AHR_metastasis  = 12.21, 95% CI: 7.42-20.08) and TU (AHR = 1.78, 95% CI: 1.25-2.52) were the strongest variables related to EC survival. The median survival time in patients with good and poor TU were 14.37 and 8.53 months respectively (p < .01). There was no significant relationship between DU and EC survival. We found relatively low survival rates in our EC patients when compared with developed countries. Our results also suggested an increasing trend for EC survival rate during recent years. Good TU could predict higher survival rates. Patients' access to therapeutic services may be considered as an important indicator in decision-making for controlling EC.

The surgical treatment of esophageal cancer in Sudan: A 100 consecutive cases

OBJECTIVE

Esophageal cancer is the most common gastrointestinal (GI) cancer in The Sudan. This study aimed to evaluate the outcome of the surgical management.

METHODS

A 100 consecutive patients who underwent esophagectomy in Shaab Hospital in Khartoum during the period June 2003-Aug 2007 were studied.

RESULTS

The mean age was 55 ± 14 years with an equal sex ratio. Fifty five per cent of patients presented with stage III&IV locally advanced and or metastatic disease. Sixty seven percent of the patients underwent a 2-stage resection, Lewis Tanner type while 27% underwent a 3-stage resection, McKeon operation and 6% had total gastrectomy with distal esophagectomy and roux-en-y reconstruction. The 30 days postoperative mortality was 10%. In 75 patients who could be traced, the overall 5 years survival was 21% (n = 16) and the 10 years survival was 8% (n = 6).

CONCLUSION

There was great improvement in the early postoperative mortality from 27% in 1986 to 10% in this series. The surgical treatment offered a rapid symptoms relief which suited most patients coming from distant locations and couldn't afford to stay for long in the Capital as will be required if chemo-radiotherapy was used as sole or as a neo-adjuvant treatment.

Cancer notification at a referral hospital of Kermanshah, Western Iran (2006-2009)

BACKGROUND

Cancer is a major public health problem and the leading cause of mortality in both males and females in developed and developing countries. The incidence of cancer is gender dependent. Among Iranians, it is the third cause of death.

MATERIALS AND METHODS

The information recorded in the files of all patients (7,695 individuals) pathologically diagnosed with cancer in Imam Reza referral hospital of Kermanshah University of Medical Sciences during the four year period of 2006-2009 were reviewed and analyzed using SPSS statistical software package version 16.0.

RESULTS

Around 61.6% of reported cancer cases were males and 38.4% were females. The most prevalent reported malignant tumors occurred at the age group of 70-79 years in males and in females these tumors were presented in the ages of 60-69 years. The most prevalent cancers among studied patients were gastrointestinal (GI) cancers with a frequency of 22.9% [gastric 10.7%, colorectal 6.9%, and esophageal 6%]. The second, third and forth prevalent cancers were blood at 16.4%, lung 13.5% and bladder 12.8%, respectively. In males the cancers of GI (25.6%) were the most prevalent followed in order of frequency by bladder (18%), blood (17.6%), lung (17.4%) and prostate (6.8%) . In females the most frequent recorded cancer was breast (24.1%) followed in order of frequency by GI (20.5%), blood (14.4%), lung (7.3%), uterus (6.2%) and ovary (5.1%) . Breast cancer was the most prevalent cancer (27%) in the age group of 40-49 years.

CONCLUSIONS

The present study provides frequency data for various types of cancers in both males and females from a referral hospital of Kermanshah that are comparable with some reports from other areas of the country.