Multidisciplinary management of esophageal cancer

Interferon Alpha-Expressing Oncolytic Adenovirus for Treatment of Esophageal Adenocarcinoma

INTRODUCTION

Esophageal adenocarcinoma (EAC) has increased in incidence in Western countries, and its poor prognosis necessitates the development of novel therapeutics. We previously reported the potential of conditionally replicative adenoviruses (CRAd) as a novel therapeutic treatment for this disease. To further augment the therapeutic effectiveness of our cyclooxygenase-2 (Cox2) controlled CRAd in EAC, we inserted an interferon alpha (IFN) transgene into the viral genome that is expressed upon viral replication. In this manuscript, we analyze the cytotoxic and oncolytic effects of an IFN-expressing oncolytic adenovirus in EAC and the role of the Cox2 promoter in providing for selective replication in human tissues.

METHODS

An infectivity-enhanced IFN-expressing CRAd (5/3 Cox2 CRAd ΔE3 ADP IFN) and other control viruses were first tested in vitro with cell lines. For the in vivo study, EAC xenografts in nude mice were treated with a single intratumoral dose of virus. An ex vivo analysis with live tissue slices was conducted using surgically resected EAC patient specimens.

RESULTS

Expression of IFN significantly enhanced the cytotoxic and oncolytic effect of a Cox2-promoter controlled CRAd. This virus showed significant tumor growth suppression in a xenograft model. Furthermore, in human EAC samples, the promoter-controlled virus demonstrated selective replication in cancerous tissues, leaving normal esophageal tissue unaffected.

CONCLUSION

An IFN-expressing CRAd driven by the Cox2 promoter has strong oncolytic effects as well as cancer-specific replication. Our novel vector possesses critical characteristics that make it a potential candidate for clinical translation to treat EAC.

Role of a multidisciplinary team in administering radiotherapy for esophageal cancer

BACKGROUND

Radiotherapy (RT) is the major part of the treatment strategy set by a multidisciplinary team (MDT) for patients diagnosed with esophageal cancer (EC). The effect of an MDT collaboration on patients with EC who underwent RT is unclear.

METHODS

We retrospectively collected all patients diagnosed with EC in the radiation oncology department at our institution from January 2015 to May 2017. The patients were divided into groups based on if they had their cases presented or not presented at the MDT meeting (with MDT and non-MDT, respectively). Propensity score matching (PSM) was applied at a ratio of 1:1 and the nearest neighbor matching method to compare the two groups.

RESULTS

A total of 212 consecutive patients were analyzed, including 157 with MDT and 55 non-MDT. In the unmatched population, the patients with MDT were more likely to received chemotherapy than the non-MDT patients (84.7% vs. 69.1%; × 2 = 6.373; P = 0.012).MDT-patients had significantly improved overall survival compared with non-MDT patients (p = 0.025). In the multivariate analysis, MDT was an independent prognostic factor for OS in patients with EC who underwent RT (P = 0.019, HR 0.59, 95% CI 0.38-0.92). After PSM for baseline characteristics, the benefit of MDT for OS became more obvious. Additionally, we also found that MDT was an independent predictor of receiving chemotherapy by using logistic regression analysis.

CONCLUSION

In patients who underwent radiotherapy for esophageal cancer, MDT was an independent factor for overall survival, which probably due to the selection of multimodality treatment when compared to non-MDT setting.

Investigation of Mg-Zn-Y-Nd alloy for potential application of biodegradable esophageal stent material

In recent years, due to unhealthy dietary habits and other reasons, advanced esophageal cancer patients are on the rise, threatening human health and life safety at all times. Stents implantation as an important complementary or alternative method for chemotherapy has been widely applied in clinics. However, the adhesion and proliferation of pathological cells, such as tumor cells, fibroblasts and epithelial cells, may interfere the efficacy of stents. Further multiple implantation due to restenosis may also bring pain to patients. In this contribution, we preferred a biodegradable material Mg-Zn-Y-Nd alloy for potential application of esophageal stent. The hardness testing showed that Mg-Zn-Y-Nd alloy owned less mechanical properties compared with the commercial esophageal stents material, 317L stainless steel (317L SS), while Mg-Zn-Y-Nd displayed significantly better biodegradation than 317L SS. Cell apoptosis assay indicated Mg-Zn-Y-Nd inhibited adhesion and proliferation of tumor cells, fibroblasts and epithelial cells. Our research suggested potential application of Mg-Zn-Y-Nd alloy as a novel material for biodegradable esophageal stent.

Efficacy comparison of transcervical video-assisted mediastinoscopic lymphadenectomy combined with left transthoracic esophagectomy versus right transthoracic esophagectomy for esophageal cancer treatment

Background

This study aimed to propose a new surgical strategy, i.e., the transcervical video-assisted mediastinoscopic lymphadenectomy (VAMLA) with esophagectomy via the left transthoracic approach for patients with esophageal cancer (EC), and to compare the outcomes with those of esophagectomy via the right thoracic approach.

Methods

From December 2014 to March 2016, 49 cases were enrolled in this non-randomized concurrent control study. Twenty-eight patients with EC who underwent transcervical VAMLA with esophagectomy via the left transthoracic approach were assigned into the study group, while 21 EC patients undergoing esophagectomy via the right transthoracic approach during the same period were enrolled into the control group. Operative outcomes including operative time, the numbers of removed lymph nodes, intraoperative blood loss, the length of hospital stay, and postoperative complications in both groups were evaluated and compared.

Results

There were no significant differences in the baseline profiles between the two groups, and all patients in the two groups successfully underwent the surgery. There was a significant difference between transcervical VAMLA with esophagectomy via the left thoracic approach and esophagectomy via the right thoracic approach with regard to the number of all dissected lymph nodes [(29.0 ± 8.7) vs. (17.8 ± 8.1), p < 0.05], dissected superior mediastinal lymph nodes [(11.2 ± 5.0) vs. (3.7 ± 2.9), p < 0.05], and dissected in the recurrent laryngeal nerve lymph nodes [(5.6 ± 3.5) vs. (2.3 ± 2.1), p < 0.05]. No significant differences were observed in the operative time, intraoperative blood loss, length of postoperative hospital stay, number of dissected abdominal lymph nodes, postoperative pulmonary complications (pneumonia and atelectasis), anastomotic fistula, chylothorax, and vocal cord paralysis (p > 0.05).

Conclusion

Transcervical VAMLA combined with esophagectomy via the left thoracic approach appears technically feasible and safe and shows advantages in the number of dissected superior mediastinal lymph nodes, suggesting that it may serve as a new treatment option for patients with esophageal carcinoma.

Surface modification of esophageal stent materials by a polyethylenimine layer aiming at anti-cancer function

Esophageal cancer is difficult to cure globally and possesses high mortality rate, and it is generally accepted that palliative care such as stent implantation is the main therapy method for esophageal cancer in later period. However, the restenosis caused by tumor cells and inflammatory cells seriously interferes the stent clinical application and limits its long-term services. To solve this problem, series of drug delivery stents were developed and proven rather effective in the early stage of implantation, but more serious restenosis occurred after the drug delivery was over, which endangered the patients' life. Therefore, endowing the esophageal stent continuous anti-cancer function become an ideal strategy for inhibiting the restenosis. In this contribution, the functional layer composed of polydopamine (PDA) and Poly-ethylenimine (PEI) with series of molecular weights (MW, 1.8 × 10³, 1 × 10⁴, 2.5 × 10⁴ and 7 × 10⁴ Da) were fabricated onto the esophageal stent material 317L stainless steel (317L SS) surface. The surface characterization including amine quantitative, atomic force microscopy (AFM) and water contact angle measurement indicated successful preparation of the PDA/PEI layer. The Eca109 cells culture results proved that the PDA/PEI layers significantly improve Eca109 cells apoptosis and necrosis, suggesting excellent anti-cancer function. In addition, we also found that the anti-cancer function of the PDA/PEI layers was positively correlated to the immobilized PEIs' MW. All the results demonstrated the potential application of the PDA/PEI layers on the surface modification of esophageal stent for continuous anti-cancer function. It is generally accepted that the restenosis caused by tumor cells seriously interferes the esophageal stent clinical application. Thus, endowing the esophageal stent continuous anti-cancer function is the ideal strategy for inhibiting the restenosis. In this work, we fabricated functional layers composed of polydopamine (PDA) and Poly-ethylenimine (PEI) with series of molecular weights (MW, 1.8 × 10³, 1 × 10⁴, 2.5 × 10⁴ and 7 × 10⁴ Da) onto the esophageal stent material 317L stainless steel (317L SS) surface to inhibit the tumor cells growth, and this function was related to the PEIs' molecular weights. The functional PDA/PEI layers were expected potentially applied for surface modification of esophageal stent materials.

Changes in treatment and outcome of oesophageal cancer in Denmark between 2004 and 2013

Background

Since 2003, care for patients with oesophageal cancer has been centralized in a few dedicated centres in Denmark. The aim of this study was to assess changes in the treatment and outcome of patients registered in a nationwide database.

Methods

All patients diagnosed with oesophageal cancer or cancer of the gastro-oesophageal junction who underwent oesophagectomy in Denmark between 2004 and 2013, and who were registered in the Danish clinical database of carcinomas in the oesophagus, gastro-oesophageal junction and stomach (DECV database) were included. Quality-of-care indicators, including number of lymph nodes removed, anastomotic leak rate, 30- and 90-day mortality, and 2- and 5-year overall survival, were assessed. To compare quality-of-care indicators over time, the relative risk (RR) was calculated using a multivariable log binomial regression model.

Results

Some 6178 patients were included, of whom 1728 underwent oesophagectomy. The overall number of patients with 15 or more lymph nodes in the resection specimen increased from 38·1 per cent in 2004 to 88·7 per cent in 2013. The anastomotic leak rate decreased from 14·8 to 7·6 per cent (RR 0·66, 95 per cent c.i. 0·43 to 1·01). The 30-day mortality rate decreased from 4·5 to 1·7 per cent (RR 0·51, 0·22 to 1·15) and the 90-day mortality rate from 11·0 to 2·9 per cent (RR 0·46, 0·26 to 0·82). There were no statistically significant changes in 2- or 5-year survival rates over time.

Conclusion

Indicators of quality of care have improved since the centralization of oesophageal cancer treatment in Denmark.

Clinical study on postoperative recurrence in patients with pN0 esophageal squamous cell carcinoma

BACKGROUND

Despite increasingly radical surgery for esophageal carcinoma, many patients still develop tumor recurrence after operation. This study was designed to analyze the clinical and pathologic influencing factors of early recurrence in patients with histological node-negative (pN0 stage) esophageal squamous cell carcinoma (ESCC) after radical esophagectomy.

METHODS

A retrospective study on 112 consecutive pN0 stage ESCC patients who underwent esophagectomy with lymphadenectomy by the same surgical team from January 2004 to December 2010. There were 92 male and 20 female patients, aging from 36 to 80 years with a mean age of 60.3 years. The Cox proportional hazards model was used to determine the independent risk factors for recurrence within 3 years after the operation.

RESULTS

Recurrence was recognized in 45 patients (40.2%) within 3 years after operation. The median time to tumor recurrence was 17.4 months. Locoregional recurrence was found in 38 patients (33.9%) and hematogenous metastasis in 7 patients (6.3%). However, locoregional recurrence accounted for 84.4% of all relapse patients. Recurrence closely correlated with tumor location, grade of differentiation, primary tumor stage (pT) and pathologic stage (χ2 = 6.380 to 18.837, p < 0.05). The Cox multivariate analysis showed that upper/middle thoracic location (OR = 1.092, p = 0.049) and pT3-4a stage (OR = 3.296, p = 0.017) were independent risk factors for postoperative locoregional recurrence.

CONCLUSION

Locoregional recurrence was the most common recurrence pattern of patients with pN0 ESCC within 3 years after operation. Upper/middle thoracic location and pT3-4a stage were independent risk factors for locoregional recurrence of pN0 ESCC after radical esophagectomy.

Prognosis-related microRNAs in esophageal cancer

INTRODUCTION

Despite improvements in detection, surgical resection and adjuvant therapy, the prognosis of esophageal cancer (EC) patients is dismal. A number of microRNAs (miRNAs) are related with the prognosis of EC.

AREAS COVERED

This review summarises the recent advances in prognosis-related miRNAs in EC and also analyses the molecular functions that they provide. This study further envisages future developments in the potential clinical applications of these miRNAs.

EXPERT OPINION

Altered miRNA expression of cancer tissues is useful for predicting the prognosis of EC patients. Individual circulating miRNAs have the potential to be used as novel biomarkers. Continued basic studies are warranted to gain more mechanistic insights into the functional effect of prognosis-related miRNAs on EC. More clinical trials should be performed to promote the clinical use of prognosis-related miRNAs.