Epidemiologic trends in esophageal and gastric cancer in the United States

Therapeutic implications of signaling pathways and tumor microenvironment interactions in esophageal cancer

Esophageal cancer (EC) is significantly influenced by the tumor microenvironment (TME) and altered signaling pathways. Downregulating these pathways in EC is essential for suppressing tumor development, preventing metastasis, and enhancing therapeutic outcomes. This approach can increase tumor sensitivity to treatments, enhance patient outcomes, and inhibit cancer cell proliferation and spread. The TME, comprising cellular and non-cellular elements surrounding the tumor, significantly influences EC's development, course, and treatment responsiveness. Understanding the complex relationships within the TME is crucial for developing successful EC treatments. Immunotherapy is a vital TME treatment for EC. However, the heterogeneity within the TME limits the application of anticancer drugs outside clinical settings. Therefore, identifying reliable microenvironmental biomarkers that can detect therapeutic responses before initiating therapy is crucial. Combining approaches focusing on EC signaling pathways with TME can enhance treatment outcomes. This integrated strategy aims to interfere with essential signaling pathways promoting cancer spread while disrupting factors encouraging tumor development. Unraveling aberrant signaling pathways and TME components can lead to more focused and efficient treatment approaches, identifying specific cellular targets for treatments. Targeting the TME and signaling pathways may reduce metastasis risk by interfering with mechanisms facilitating cancer cell invasion and dissemination. In conclusion, this integrative strategy has significant potential for improving patient outcomes and advancing EC research and therapy. This review discusses the altered signaling pathways and TME in EC, focusing on potential future therapeutics.

Immune Checkpoint Inhibitors in Esophageal Carcinoma: Assessment of Efficacy Predictors of Response in Clinical Trials

Esophageal carcinoma (EC) is among the most common causes of cancer-related deaths worldwide. Even with the improvement of multidisciplinary treatment modalities, advanced unresectable EC patients had limited systemic therapeutic options for an extended period. Recently, immune checkpoint inhibitors (ICIs) have been introduced to advanced EC management in both first-line and second-line options, as well as in postoperative settings in resectable EC after preoperative chemoradiation. Herein, the authors present a comprehensive review of clinical trials on administering ICIs in EC patients while discussing reported clinical, molecular, and immune biomarkers and their predictive value for treatment efficacy.

Pathogenesis and potential reversibility of intestinal metaplasia - a milestone in gastric carcinogenesis

BACKGROUND

Non-cardia gastric cancer remains a major cause of cancer-related mortality worldwide, despite declining incidence rates in many industrialized countries. The development of intestinal-type gastric cancer occurs through a multistep process in which normal mucosa is sequentially transformed into hyperproliferative epithelium, followed by metaplastic processes leading to carcinogenesis. Chronic infection with Helicobacter pylori is the primary etiological agent that causes chronic inflammation of the gastric mucosa, induces atrophic gastritis, and can lead to intestinal metaplasia and dysplasia. Both intestinal metaplasia and dysplasia are precancerous lesions, in which gastric cancer is more likely to occur. Atrophic gastritis often improves after eradication of Helicobacter pylori; however, the occurrence of intestinal metaplasia has been traditionally regarded as "the point of no return" in the carcinogenesis sequence. Helicobacter pylori eradication heals non-atrophic chronic gastritis, may lead to regression of atrophic gastritis, and reduces the risk of gastric cancer in patients with these conditions. In this article, we discuss the pathogenesis, epigenomics, and reversibility of intestinal metaplasia and briefly touch upon potential treatment strategy.

CONCLUSIONS

Gastric intestinal metaplasia no longer appears to be an irreversible precancerous lesion. However, there are still many controversies regarding the improvement of intestinal metaplasia after Helicobacter pylori eradication.

Multi-Omics Analysis Reveals the IFI6 Gene as a Prognostic Indicator and Therapeutic Target in Esophageal Cancer

The role of the IFI6 gene has been described in several cancers, but its involvement in esophageal cancer (ESCA) remains unclear. This study aimed to identify novel prognostic indicators for ESCA-targeted therapy by investigating IFI6's expression, epigenetic mechanisms, and signaling activities. We utilized public data from the Gene Expression Omnibus (GEO) and the Cancer Genome Atlas (TCGA) to analyze IFI6's expression, clinical characteristics, gene function, pathways, and correlation with different immune cells in ESCA. The TIMER2.0 database was employed to assess the pan-cancer expression of IFI6, while UALCAN was used to examine its expression across tumor stages and histology subtypes. Additionally, the KEGG database helped identify related pathways. Our findings revealed 95 genes positively correlated and 15 genes negatively correlated with IFI6 in ESCA. IFI6 was over-expressed in ESCA and other cancers, impacting patient survival and showing higher expression in tumor tissues than normal tissues. IFI6 was also correlated with CD4+ T cells and B cell receptors (BCRs), both essential in immune response. GO Biological Process (GO BP) enrichment analysis indicated that IFI6 was primarily associated with the Type I interferon signaling pathway and the defense response to viruses. Intriguingly, KEGG pathway analysis demonstrated that IFI6 and its positively correlated genes in ESCA were mostly linked to the Cytosolic DNA-sensing pathway, which plays a crucial role in innate immunity and viral defense, and the RIG-I-like receptor (RLR) signaling pathway, which detects viral infections and activates immune responses. Pathways related to various viral infections were also identified. It is important to note that our study relied on online databases. Given that ESCA consists of two distinct subgroups (ESCC and EAC), most databases combine them into a single category. Future research should focus on evaluating IFI6 expression and its impact on each subgroup to gain more specific insights. In conclusion, inhibiting IFI6 using targeted therapy could be an effective strategy for treating ESCA considering its potential as a biomarker and correlation with immune cell factors.

Disparities in esophageal cancer incidence and esophageal adenocarcinoma mortality in the United States over the last 25-40 years

BACKGROUND

Esophageal carcinoma presents as 2 types, esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC) with the frequency of both changing in the United States (US).

AIM

To investigate EAC/ESCC incidence time trends among the 3 main US racial groups and investigate trends in US EAC survival by ethnicity.

METHODS

Twenty-five years (1992-2016) of data from SEER 13 program was analyzed to compare incidence trends in EAC and ESCC between non-Hispanic whites (nHW), non-Hispanic Blacks (nHB) and Hispanics (Hisp) using SEERStat^®. In addition, SEER 18 data, from 1975-2015, on EAC in the US was analyzed to evaluate racial disparities in incidence and survival using SEERStat^® and Ederer II method.

RESULTS

In the 3 major US ethnic groups, age-adjusted incidence of ESCC has declined while EAC has continued to rise from 1992-2016. Of note, in Hisp, the EAC incidence rate increased while ESCC decreased from 1992 to 2016, resulting in EAC as the predominant esophageal cancer subtype in this group since 2011, joining nHW. Furthermore, although ESCC remains the predominant tumor in nHB, the difference between ESCC and EAC has narrowed dramatically over 25 years. EAC survival probabilities were worse in all minority groups compared to nHw.

CONCLUSION

Hisp have joined nHW as US ethnic groups more likely to have EAC than ESCC. Of note, EAC incidence in nHB is increasing at the highest rate nationally. Despite lower EAC incidence in all minority groups compared to nHW, these populations have decreased survival compared to nHW.

Cancer Stem Cells of Esophageal Adenocarcinoma are Suppressed by Inhibitors of TRPV2 and SLC12A2

BACKGROUND

The potential of membrane transporters activated in cancer stem cells (CSCs) as new therapeutic targets for cancer is attracting increasing interest. Therefore, the present study examined the expression profiles of ion transport-related molecules in the CSCs of esophageal adenocarcinoma (EAC).

METHODS

Cells that highly expressed aldehyde dehydrogenase 1 family member A1 (ALDH1A1) were separated from OE33 cells, a human Barrett's EAC cell line, by fluorescence-activated cell sorting. CSCs were identified based on the formation of tumorspheres. Gene expression profiles in CSCs were examined by a microarray analysis.

RESULTS

Among OE33 cells, ALDH1A1 messenger RNA levels were higher in CSCs than in non-CSCs. Furthermore, CSCs exhibited resistance to cisplatin and had the capacity to redifferentiate. The results of the microarray analysis of CSCs showed the up-regulated expression of several genes related to ion channels/transporters, such as transient receptor potential vanilloid 2 (TRPV2) and solute carrier family 12 member 2 (SLC12A2). The cytotoxicities of the TRPV2 inhibitor tranilast and the SLC12A2 inhibitor furosemide were higher at lower concentrations in CSCs than in non-CSCs, and both markedly reduced the number of tumorspheres. The cell population among OE33 cells that highly expressed ALDH1A1 also was significantly decreased by these inhibitors.

CONCLUSIONS

Based on the present results, TRPV2 and SLC12A2 are involved in the maintenance of CSCs, and their specific inhibitors, tranilast and furosemide, respectively, have potential as targeted therapeutic agents for EAC.

Endoscope Capsules: The Present Situation and Future Outlooks

This paper presents new perspectives on photonic technologies for capsule endoscopy. It first presents a review of conventional endoscopy (upper endoscopy and colonoscopy), followed by capsule endoscopy (CE), as well as their techniques, advantages, and drawbacks. The technologies for CEs presented in this paper include integration with the existing endoscopic systems that are commercially available. Such technologies include narrow-band imaging (NBI), photodynamic therapy (PDT), confocal laser endomicroscopy (CLE), optical coherence tomography (OCT), and spectroscopy in order to improve the performance of the gastrointestinal (GI) tract examination. In the context of NBI, two optical filters were designed and fabricated for integration into endoscopic capsules, allowing for the visualization of light centered at the 415 nm and 540 nm wavelengths. These optical filters are based on the principle of Fabry-Perot and were made of thin films of titanium dioxide (TiO2) and silicon dioxide (SiO2). Moreover, strategies and solutions for the adaptation of ECs for PDT are also discussed.

Two novel clinical tools to predict the risk of bone metastasis and overall survival in esophageal cancer patients: a large population-based retrospective cohort study

BACKGROUND

The aim of this study was to construct two web-based nomograms to predict the probability of bone metastasis (BM) in esophageal cancer (EC) patients and the prognostic of EC patients with BM (ECBM).

METHODS

We collected the data of EC and ECBM patients in the Surveillance, Epidemiology and End Results (SEER) database from 2010 to 2015. Independent risk variables for the development of BM in EC patients were identified using univariate and multivariate logistic regression analyses. Univariate and multivariate Cox regression analyses were used to assess independent prognostic variables in ECBM patients. And then, constructed two nomograms to predict the risk of bone metastases and overall survival (OS) of ECBM patients. Survival differences were studied by Kaplan-Meier (K-M) survival analysis. The predictive efficacy and clinical applicability of these two nomograms were assessed by using receiver operating characteristic (ROC) curve, the area under curve (AUC), calibration curve and decision curve analysis (DCA).

RESULTS

We selected a total of 6839 patients with EC, of which 326 (4.77%) had BM at the time of initial diagnosis. The results of K-M survival and Cox regression analysis showed significant effects of BM on the OS in EC patients. Age, N stage, tumor size and brain/liver/lung organ metastasis were identified as BM-related risk variables. Chemotherapy and brain/liver organ metastasis were identified as ECBM-related prognostic variables. The ROC, AUC, calibration curves and DCA of two nomograms all showed excellent predictive efficacy and clinical applicability.

CONCLUSIONS

These two nomograms were constructed and validated, which could objectively predict the risk of BM in EC patients and the prognostic in ECBM patients. These tools are expected to make valuable contributions in clinical work, informing surgeons in making decisions about patient care.

The increased risk of colorectal cancer in the women who underwent hysterectomy from the South Korean National Health Insurance Database

BACKGROUND

Several population-based studies and observational studies have shown that oophorectomy is associated with an increased risk of colorectal cancer (CRC), and hormone replacement therapy has been associated with a reduction in the risk of colorectal cancer. This study was carried out to investigate whether hysterectomy, which may affect the levels of female hormones, is associated with a risk of cancer of the specific gastrointestinal tract.

METHODS

This population-based retrospective cohort study was conducted using insurance data provided by the Health Insurance Review and Assessment Service (HIRA) from January 1, 2007, to December 31, 2020. The hysterectomy group included 40- to 59-year-old women who underwent hysterectomy with uterine leiomyoma or uterine endometriosis from January 1, 2011, to December 31, 2014. The control group included women aged 40 to 59 years who visited medical institutions for medical examination from January 1, 2011 to December 31, 2014.

RESULTS

The hysterectomy and non-hysterectomhy groups comprised 66,204 and 89,768 subjects, respectively. The median ages in the non-hysterectomy group and hysterectomy group were 48 (range: 43-53) and 46 (range: 44-49) years, respectively. In the unadjusted results of the analysis, all colorectal cancer (CRC) increased in the hysterectomy alone group (HR 1.222, 95% confidence interval (CI) 1.016-1.47, p = 0.033), sigmoid colon cancer increased in the hysterectomy alone group (HR 1.71, 95% CI 1.073-2.724, p = 0.024), and rectal cancer increased in the hysterectomy with adnexal surgery group (HR 1.924, 95% CI 1.073-2.724, p = 0.002). The adjusted results showed that all CRC increased in the hysterectomy alone group (HR 1.406, 95% CI 1.057-1.871, p = 0.019), colon cancer increased in the hysterectomy alone group (HR 1.523, 95% CI 1.068-2.17, p = 0.02), and rectal cancer increased in the hysterectomy with adnexal surgery group (HR 1.933, 95% CI 1.131-3.302, p = 0.016). The all-cause mortality of GI cancer increased in the hysterectomy alone group (HR 3.495, 95% CI 1.347-9.07, p = 0.001).

CONCLUSIONS

This study showed that the risk of all CRC increased in women who underwent hysterectomy compared with women who did not. In particular, the risk of rectal cancer was significantly higher in the women who underwent hysterectomy with adnexal surgery than in the controls. There was no association between hysterectomy and other GI cancers.

Lifestyle habits and gastric cancer in an East Asian population: a Mendelian randomization study

Background

Epidemiological evidence suggests an association between lifestyle habits (smoking, alcohol consumption, tea, coffee intake, etc.) and gastric cancer (GC). However, the causal relationship remains uncertain. Therefore, the purpose of this study was to ascertain whether there is a causal connection between them.

Methods

Two-sample Mendelian randomization (MR) analysis was performed using the publicly available Genome Wide Association Study summary datasets using six methods: inverse variance weighting (IVW), weighted median, MR using a Robust Adjusted Profile Score (MR.Raps), MR using a Robust Adjusted Profile Score (MR-PRESSO), Radial regression of MR, and Causal Analysis Using Summary Effect Estimates (CAUSE). A sensitivity analysis was conducted to assess the robustness of the results.

Results

In an East Asian population, we found that increased tea intake reduced the risk of GC [odds ratio (OR)= 0.90, 95% confidence interval (CI)= 0.82-0.99, P = 0.037] while there was a positive association between smoking and GC (OR = 1.58, 95% CI = 1.04-2.39, P = 0.032). No causal relationship between alcohol and coffee intake and GC. Sensitivity analyses demonstrated the robustness of these causal associations.

Conclusions

Our study suggests that tea intake may reduce the risk of GC, for which smoking is a potential risk factor. Nevertheless, a larger and more diverse sample size is needed for further validation.

Fruit and vegetable intake in relation to gastric cancer risk: A comprehensive and updated systematic review and dose-response meta-analysis of cohort studies

Background

Since the release of previous meta-analyses, some studies on the associations between fruit and vegetable intake with gastric cancer risk have been published. Therefore, we aimed to update the previous meta-analyses on these associations by including recently published studies as well as considering the main limitations of those meta-analyses.

Methods

A comprehensive search was conducted in online databases including PubMed, Scopus, ISI Web of Science, and Google Scholar to detect relevant prospective cohort studies published up to October 2021. Summary relative risks (RRs) were estimated using a random-effects model.

Results

Overall, 17 articles containing 18 prospective studies with a total sample size of 1,527,995 participants, aged between 18 and 90 years, were included in the current meta-analysis. During the follow-up periods ranging between 4.5 and 21 years, 8,477 cases of gastric cancer were diagnosed. A higher intake of total fruit [RR: 0.87, 95% confidence interval (CI): 0.80 to 0.94, I ² = 0%] and total fruit and vegetable (RR: 0.75, 95% CI: 0.61 to 0.93, I ² = 55.2%) were associated with a lower risk of gastric cancer. For total vegetable intake, a significant inverse association was found among the studies that controlled their analysis for energy intake. Based on the linear dose-response analysis, each 100 g/day increase in total fruit intake (Pooled RR: 0.95, 95% CI: 0.90 to 0.99, I ² = 49%) and 200 g/day increase in total fruit and vegetable intake (RR: 0.94, 95% CI: 0.88 to 0.99, I ² = 37.6%) were associated with a 5 and 6% lower risk of gastric cancer, respectively.

Conclusion

Fruit and vegetable consumption has a protective association with gastric cancer risk.

Influence of adverse effects of neoadjuvant chemoradiotherapy on the prognosis of patients with early-stage esophageal cancer (cT1b-cT2N0M0) based on the SEER database

Objective

To analyze the prognostic impact of neoadjuvant chemoradiotherapy (NCRT) on early-stage (cT1b-cT2N0M0) esophageal cancer (ESCA) and construct a prognostic nomogram for these patients.

Methods

We extracted the clinical data about patients diagnosed with early-stage esophageal cancer from the 2004-2015 period of the Surveillance, Epidemiology, and End Results (SEER) database. We applied the independent risk factors affecting the prognosis of patients with early-stage esophageal cancer obtained after screening by univariate and multifactorial COX regression analyses to establish the nomogram and performed model calibration using bootstrapping resamples. The optimal cut-off point for continuous variables is determined by applying X-tile software. After balancing the confounding factors by propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) method, Kaplan-Meier(K-M) curve, and log-rank test were applied to evaluate the prognostic impact of NCRT on early-stage ESCA patients.

Results

Among patients who met the inclusion criteria, patients in the NCRT plus esophagectomy (ES) group had a poorer prognosis for overall survival (OS) and esophageal cancer-specific survival (ECSS) than patients in the ES alone group (p < 0.05), especially in patients who survived longer than 1 year. After PSM, patients in the NCRT + ES group had poorer ECSS than patients in the ES alone group, especially after 6 months, while OS was not significantly different between the two groups. IPTW analysis showed that, prior to 6 months patients in the NCRT + ES group had a better prognosis than patients in the ES group, regardless of OS or ECSS, whereas after 6 months, patients in the NCRT + ES group had a poorer prognosis. Based on multivariate COX analysis, we established a prognostic nomogram which showed areas under the ROC curve (AUC) for 3-, 5-, and 10-year OS 0.707, 0.712, and 0.706, respectively, with the calibration curves showing that the nomogram was well calibrated.

Conclusions

Patients with early-stage ESCA (cT1b-cT2) did not benefit from NCRT, and we established a prognostic nomogram to provide clinical decision aid for the treatment of patients with early-stage ESCA.

Features of gastric cancer by anatomic subsite in northern China: A multi-center Health Science Report database study

BACKGROUND

The features of gastric cancer based on the anatomic site remain unknown in northern China patients.

AIM

To analyze gastric cancer features and associated trends based on the anatomical site in northern China patients.

METHODS

This cross-sectional study used incident gastric cancer case data from 10 Peking University-affiliated hospitals (2014 to 2018). The clinical and prevailing local features were analyzed.

RESULTS

A total of 10709 patients were enrolled, including antral (42.97%), cardia (34.30%), and stomach body (18.41%) gastric cancer cases. Cancer in the cardia had the highest male:female ratio, proportion of elderly patients, and patients with complications, including hypertension, diabetes, cerebrovascular, and coronary diseases (P < 0.001). gastric cancer involving the antrum showed the lowest proportion of patients from rural areas and accounted for the highest hospitalization rate and cost (each P < 0.001). The proportion of patients with cancer involving the cardia increased with an increase in the number of gastroesophageal reflux disease cases during the same period (P < 0.001). Multivariate analysis revealed that tumor location in the cardia increased the risk of in-hospital mortality (P = 0.046). Anatomical subsite was not linked to postoperative complications.

CONCLUSION

The features of gastric cancer based on the anatomical site differ between northern China and other regions, both globally and within the country. Social factors may account for these differences and should affect policy-making and clinical practice.

Predictive value of nomogram based on Kyoto classification of gastritis to diagnosis of gastric cancer

BACKGROUND AND AIM

It is important to predict the risk of gastric cancer (GC) for endoscopists because early detection of GC determines the selection of the best treatment strategy and the prognosis of patients. The study aimed to evaluate the utility of a predictive nomogram based on the Kyoto classification of gastritis for GC.

METHODS

It was a retrospective study that included 2639 patients who received esophagogastroduodenoscopy and serum pepsinogen (PG) assay from January 2019 to November 2019 at the Endoscopy Center of the Department of Gastroenterology, Wenzhou Central Hospital. Routine biopsy was conducted to determine the benign and malignant lesions pathologically. All cases were randomly divided into the training set (70%) and the validation set (30%) by using the bootstrap method. A nomogram was formulated according to multivariate analysis of the training set. The predictive accuracy and discriminative ability of the nomogram were assessed by concordance index (C-index), area under the curve (AUC) of receiver operating characteristic curve (ROC) as well as calibration curve and were validated by the validation set.

RESULTS

Among all patients enrolled, 102 of 2636 cases showed LGIN, HGIN and gastric cancer pathology results, whereas the rest cases showed benign pathological results. Multivariate analysis indicated that age, sex, PG I/II ratio and Kyoto classification scores were independent predictive variables for GC. The C-index of the nomogram of the training set was 0.79 (95% CI: 0.74 to 0.84) and the AUC of ROC is 0.79. The calibration curve of the nomogram demonstrated an optimal agreement between predicted probability and observed probability of the risk of GC. The C-index was 0.86 (95% CI: 0.79 to 0.94) with a calibration curve of better concurrence in the validation set.

CONCLUSION

The nomogram formulated was proven to be of high predictive value for GC.

Polymorphisms of an oncogenic gene, mesothelin, predict the risk and prognosis of gastric cancer in a Chinese Han population

Mesothelin (MSLN) is a cell surface protein associated with tumor invasion and metastasis. This study aims to explore the biological function of MSLN in gastric cancer and to evaluate the association of MSLN polymorphism (rs3764247, rs3764246, rs12597489, rs1057147, rs3765319) with the risk and prognosis of gastric cancer. Small interfering RNA (siRNA) transfection and MSLN overexpression were performed in human gastric cancer cell lines, respectively. The proliferation of tumor cells was evaluated by Cell counting kit 8(CCK-8) and colony formation assay. Wound healing assay and transwell assay were used to elucidate gastric cancer cell migration and invasion rates. We conducted a case-control study involving 860 patients with gastric cancer and 870 controls. All mutation sites were genotyped by PCR-LDR sequencing. First, our study revealed the cancer-promoting role of MSLN in gastric cancer. Second, we also demonstrated that rs3764247 and rs3764246 were associated with a reduced risk of gastric cancer (OR = 0.83, p = 0.010; OR = 0.84, p = 0.011; respectively). The clinicopathological analysis further showed that rs3764247 was closely related to T stage, vascular infiltration, and HER2 expression. In addition, in the survival analysis of 392 patients with gastric cancer, patients with rs3764247 CC genotype had poorer survival than patients with AA + AC genotype after adjusting for age, sex, TNM stage, and Lauren classification (HR = 2.07, p = 0.029). Our findings indicated that MSLN could be an oncogene whose polymorphisms were closely related to the risk and prognosis of gastric cancer.

Black race is independently associated with underutilization of preoperative chemotherapy in clinical stage T2 or higher gastric adenocarcinoma

BACKGROUND

Consensus guidelines recommend for perioperative chemotherapy and surgery for patients with clinical stage (cT) T2 or greater gastric adenocarcinoma. We compared adherence to guidelines in these patients stratified by race.

METHODS

Non-Hispanic White and Black patients with resected ≥cT2 gastric adenocarcinoma were identified within the National Cancer Database (2008-2017). We compared administration of preoperative chemotherapy by race, adjusting for clinicodemographic variables. We performed marginal standardization of logistic regression to calculate adjusted probabilities of administration of preoperative chemotherapy in patients under the age of 80 years with insurance.

RESULTS

A total of 13,850 patients were identified (White = 12,161; Black = 1,689). Black race was associated with lower likelihood of receiving preoperative chemotherapy than White race (odds ratio = 0.46, 95% confidence interval: 0.39-0.54). Other factors associated with lower likelihood of preoperative chemotherapy included age ≥70 years, female sex, treatment at community facilities, non-private or no health insurance, and cT4 disease. Factors associated with higher likelihood of preoperative chemotherapy included treatment at high-volume facilities, longer distance to facility, higher education and income levels, cT3 disease, and cN+ disease. In patients <80 years with insurance, marginal standardization models demonstrated that Black race was associated with a lower adjusted probability of receiving preoperative chemotherapy regardless of age, insurance payor, facility type/volume, distance to facility, cT stage, cN stage, sex, and education/income levels.

CONCLUSION

Black race was associated with underutilization of preoperative chemotherapy for cT2 or greater gastric cancer, in discordance to published guidelines. The etiology of these disparities is multifactorial, and correcting the root causes represents a critical area for improvement.

Effect of Marital Status on the Survival of Patients With Adenocarcinoma of the Esophagogastric Junction: A Population-Based, Propensity-Matched Study

Background

Marital status has been reported as an independent prognostic factor in various types of malignancies. However, the association between marital status and outcomes of patients with adenocarcinoma of the esophagogastric junction (AEG) has not been fully explored. To this end, we aimed to investigate the effect of marital status on survival of AGE patients.

Methods

The Surveillance Epidemiology and End Results (SEER) database (2010–2015) was used to extract eligible patients with Siewert type II AEG. Meanwhile, propensity score matching was performed to match 1576 unmarried patients with 1576 married patients. Kaplan–Meier method with log-rank test was used to plot survival curves, univariate and multivariate Cox regression analyses were adopted to investigate the association of marital status with overall survival (OS) and cancer-specific survival (CSS) in AEG patients before and after matching.

Results

Multivariate analysis in the unmatched cohort revealed that marital status was an independent prognostic factor in patients with Siewert type II AEG. Unmarried patients had poorer OS (hazard ratio [HR]: 1.22, 95% confidence interval [CI]: 1.12–1.29, P < .001) and poorer CSS (HR: 1.19, 95% CI: 1.10–1.29, P < .001) than married patients before matching. Additionally, widowed patients had the poorest OS (HR: 1.26, 95% CI: 1.11–1.44, P < .001) and CSS (HR: 1.29, 95% CI: 1.12–1.48, P < .001) compared with married patients. Furthermore, unmarried status remained as an independent prognostic for both OS (HR: 1.20, 95% CI: 1.10–1.31, P < .001) and CSS (HR: 1.18, 95% CI: 1.08–1.30, P < .001) in 1:1 propensity score-matched analysis. Subgroup analysis further revealed that OS and CSS rates were significantly higher in married patients than unmarried ones in most subgroups stratified by different variables.

Conclusions

This population-based study identified that marital status was an independent prognostic indicator for AEG patients. Married AEG patients had better prognosis than their unmarried counterparts.

Improving the Diagnosis and Treatment of Early Gastric Cancer in the West

Gastric cancer is the third leading cause of cancer-related death. In Western countries, its lower prevalence and the absence of mass screening programmes contribute to late diagnosis and a slower implementation of minimally invasive treatments. A secondary prevention strategy through endoscopic surveillance of patients at high risk of intestinal-type gastric adenocarcinoma or by screening gastric cancer within colorectal screening programmes is cost-effective in intermediate-risk countries, though the identification of these patients remains challenging. Virtual chromoendoscopy with narrow-band imaging improves the accuracy of endoscopic diagnosis, significantly increasing the sensitivity for intestinal metaplasia while preserving specificity. Endoscopic grading of gastric intestinal metaplasia is feasible, correlates well with histological staging systems and also with gastric neoplasia risk and can be used to stratify risk. Endoscopic submucosal dissection (ESD) in the West achieves efficacy and safety outcomes similar to those reported for Eastern countries, and the long-term disease-specific survival is higher than 95%. A prospective comparative study with gastrectomy confirms its higher safety and its benefits concerning health-related quality of life. However, ESD is associated with a 5% risk of postprocedural bleeding and a 20% risk of non-curative resection. The knowledge of risk factors for adverse events and non-curative resection can improve patient selection. The risk of metachronous lesions after ESD is high (3–5% per year), and endoscopic surveillance is needed. The management of patients with non-curative resection can be optimized using risk scoring systems for lymph node metastasis.

CDKN1A (p21 gene) polymorphisms correlates with age in esophageal cancer

BACKGROUND

CDKN1A gene encoding p21 is an important tumour supressor involved in the pathogenesis of cancers. A few studies have been devoted to the association between CDKN1A single nucleotide polymorphisms (SNPs) and esophageal cancer (EC) in China, India and Iran. The aim of this case-control study was to investigate the association of CDKN1A polymorphisms with EC risk in the Turkey population for the first time.

METHODS

In the present study, CDKN1A SNPs (rs1801270 C > T, rs1059234 C > A and rs3176352 C > G) were genotyped with the use of TaqMan SNP genotyping assays in 102 patients and 119 controls.

RESULTS

The genotypes and alleles of CDKN1A SNPs were not significantly different among patients and controls. However, TT-genotype and T-allele of the rs1059234, the rs1801270 CC-genotype and rs3176352 G-allele were significantly associated with EC risk for ≤ 55 age (p < 0.05). In those over 55 age, CC-genotype and C-allele of the rs1059234 was significantly associated with EC (p < 0.05). The rs1059234 T-carriers had a higher risk of high globulin level (p = 0.017) and low albumin/globulin ratio (p = 0.019) when compared to non-T carriers (CC). The rs3176352 CC-genotype carriers had a higher risk of esophageal adenocarcinoma (EAC) subtype when compared to CG-genotype carriers and CG-genotype carriers had a higher risk of squamous cell carcinoma (ESCC) subtype (OR/95% CI = 4.00/1.06-15.08, p = 0.04). The rs3176352 CC-genotype is also a risk factor for the higher BMI (p = 0.04) and the higher CA-19-9 level (p = 0.009).

CONCLUSION

Our study suggests that the CDKN1A polymorphisms may play an important role in EC risk in relation to age. Future studies are needed to validate our findings.

Functional benefits of the double flap technique after proximal gastrectomy for gastric cancer

BACKGROUND

Proximal gastrectomy is a widely performed procedure that has become more common with an increasing number of proximal gastric cancer cases. Several types of reconstructive procedures after proximal gastrectomy have been developed, and it remains controversial which procedure is the most advantageous with regard to the preservation of postoperative gastric stump function and nutritional status. In the present study, we retrospectively analyzed reconstructive procedures in a consecutive case series for proximal gastrectomy, primarily focusing on postoperative body weight maintenance, nutritional status, and gastric remnant functional preservation.

METHODS

We enrolled 69 patients who had undergone proximal gastrectomy for gastric cancer in our institute between 2005 and 2020. Short-term complications, preservation of gastric remnant functions, nutritional status, and post-operative weight changes were compared.

RESULTS

After proximal gastrectomy, the numbers of patients who underwent direct esophago-gastrostomy, jejunal interposition, double tract reconstruction, and the double flap technique were 9, 10, 14, and 36, respectively. The patients in whom the double flap technique was performed suffered no reflux esophagitis after surgery. Prevalence of gastric residual at 12 months after surgery was lowest in the double flap technique group. Moreover, the double flap technique group had a better tendency regarding post-operative changes of serum albumin ratios. Furthermore, the post-operative body weight change ratio of the double flap technique group was smallest among all groups and was significantly better than that of the double tract group.

CONCLUSIONS

The double flap technique after proximal gastrectomy was considered the most effective technique for reconstruction which leads to better bodyweight maintenance, and results in less reflux esophagitis.

The Influence of Different Treatment Strategies on the Long-Term Prognosis of T1 Stage Esophageal Cancer Patients

Objective

To compare the long-term prognosis effects of non-esophagectomy and esophagectomy on patients with T1 stage esophageal cancer.

Methods

All esophageal cancer patients in the study were included from the National Surveillance Epidemiology and End Results (SEER) database between 2005-2015. These patients were classified into non-esophagectomy group and esophagectomy group according to therapy methods and were compared in terms of esophagus cancer specific survival (ECSS) and overall survival (OS) rates.

Results

A total of 591 patients with T1 stage esophageal cancer were enrolled in this study, including 212 non-esophagectomy patients and 111 esophagectomy patients in the T1a subgroup and 37 non-esophagectomy patients and 140 esophagectomy patients in the T1b subgroup. In all T1 stage esophageal cancer patients, there was no difference in the effect of non-esophagectomy and esophagectomy on postoperative OS, but postoperative ECSS in patients treated with non-esophagectomy was significantly better than those treated with esophagectomy. Cox proportional hazards regression model analysis showed that the risk factors affecting ECSS included race, primary site, tumor size, grade, and AJCC stage but factors affecting OS only include tumor size, grade, and AJCC stage in T1 stage patients. In the subgroup analysis, there was no difference in either ECSS or OS between the non-esophagectomy group and the esophagectomy group in T1a patients. However, in T1b patients, the OS after esophagectomy was considerably better than that of non-esophagectomy.

Conclusions

Non-esophagectomy, including a variety of non-invasive procedures, is a safe and available option for patients with T1a stage esophageal cancer. For some T1b esophageal cancer patients, esophagectomy cannot be replaced at present due to its diagnostic and therapeutic effect on lymph node metastasis.

Expression of Matrix Metalloproteinase-9 in Gastric Cancer

Background Matrix-metalloproteinase-9 (MMP-9) is expressed by a wide range of cells and plays a significant role in the regulation of the tumor microenvironment of various cancers including gastric cancer. This study aims at the correlation of MMP-9 expression in gastric cancer with existing prognostic factors. Methods The MMP-9 expression in gastric cancer was identified by immunohistochemistry using a monoclonal antibody in paraffin-embedded sections, correlated with various clinicopathological parameters, and statistically analyzed. Results MMP-9 expression in gastric cancer was significantly correlated with the grade, depth of invasion, and TNM stage (p-value = 0.003, 0.019, and 0.025, respectively). A significant difference in expression between tumor tissue and adjacent gastric mucosa (p-value = 0.000) was also observed. 100% negative expression was found in well-differentiated tumors and early gastric carcinoma (T1). Conclusion The study results suggest that MMP-9 expression could be a potential biomarker of aggressive gastric cancer and candidates for the possible diagnostic and prognostic tool.

The probability of Lymph node metastasis with a tumor size larger than and smaller than 4 cm is different in stages T1-T3 of Siewert type II adenocarcinoma of esophagogastric junction: A Population-Based Study

Background: In adenocarcinoma of esophagogastric junction (AEG), the relationship between tumor size (TS) and lymph node metastasis (LNM) is unclear. This study aimed to explore the relationship between TS and LNM, and to construct a prediction model for LNM.

Materials and Methods: Data from 4649 Siewert type II AEG patients were retrospectively acquired from the Surveillance, Epidemiology, and End Result (SEER) database. TS data was analyzed as a continuous variable, but also divided into 1-cm-interval categorical groups for further analysis. The logistic regression model and restricted cubic spline (RCS) model was used to explore the relationship between TS and LNM, after adjusting for covariates. Internal validations as well as external validation (Single-Center data) were used to check our LNM prediction model.

Results: TS and LNM showed a significant relationship in the logistic regression analysis, regardless of the TS data being entered as a continuous or a categorical variable, after adjusting for covariates. The logistic regression model and RCS consistently showed that larger TS resulted in larger Odds Ratio (OR) values. When tumors were larger than 4 cm, the OR value remained relatively constant. The receiver operator characteristic curve evaluated the nomogram by the area under the curve (AUC) (AUC=0.737, in internal validation; AUC=0.626, in external validation), and the calibration curve of the nomogram showed an improved prediction system.

Conclusions: In Siewert type II T1-T3 stage AEG patients, we reported that LNM increased with TS up to 4-cm, and our nomogram provided a simple tool to predict LNM.

GIST of the stomach masquerading as recurrent falls in an older adult: a case report and review

BACKGROUND

Gastric tumors become increasingly prevalent with advanced age but can be challenging to diagnose in older adults who may present with non-specific symptoms. Here, we report a rare case of an occult gastric tumor associated with mesenteric panniculitis that presented with recurrent falls precipitated by vertigo.

CASE PRESENTATION

We describe a diagnostically challenging case of cryptogenic gastric tumor associated with mesenteric panniculitis in a 74-year-old female who presented with abdominal bloating and recurrent falls precipitated by vertigo, dehydration, acute kidney injury and electrolyte deficiencies, but had no alarm symptoms. Her symptoms resolved after laparoscopic wedge resection of the gastric tumor.

CONCLUSIONS

Our case highlights that while alarm symptoms such as dysphagia, weight loss, gastrointestinal bleeding and vomiting are considered indications for endoscopy, clinicians should also maintain a high index of suspicion for gastric tumors in older patients who may present with atypical symptoms.

Underutilization of Palliative Care in Metastatic Foregut Cancer Patients Is Associated with Socioeconomic Disparities

BACKGROUND

Metastatic foregut cancers (MFC) are associated with debilitating symptoms that negatively impact patients' quality of life. Palliative care (PC) is effective in mitigating disease-, psychosocial-, and treatment-related effects and may improve survival in select cases. Our study characterizes PC utilization rates in MFC and identifies factors associated with PC receipt.

METHODS

We conducted a retrospective review of 228,027 National Cancer Database patients diagnosed with MFC between 2004 and 2016. Chi-squared tests were used to analyze differences between groups receiving and not receiving PC. Logistic regression was performed to assess the impact of factors on the likelihood of receiving PC.

RESULTS

Overall PC utilization was low (17.8%). A greater proportion of patients not receiving PC were in the lowest median income quartile of < $38,000/year versus those receiving PC (18.1% vs 17.8%, p < 0.0001). Higher education was associated with increased likelihood of receiving PC (OR 1.23 for communities with < 6.3% no high school degree vs ≥ 17.6%, p < 0.0001). Hispanics were significantly less likely to receive PC compared to Whites (OR 0.72, 95% CI 0.68-0.76). Patients treated at academic centers were also more likely to receive PC compared to those treated in the community (OR 1.10, 95% CI 1.05-1.14).

CONCLUSIONS

PC is a key component in improving quality of life among MFC patients. Despite slight increases in PC rates over time, PC remains drastically underutilized. Significant racial and socioeconomic disparities in patterns of PC delivery exist. Further studies are needed to understand these disparities in order to identify key targets for interventions aimed at improving equity.

Feasibility of Endoscopic Screening for Upper Gastrointestinal Malignancy in a Comprehensive Health Checkup

Objective In an effort to reduce mortality from gastric cancer, endoscopic screening was introduced in 2016 as a nationwide screening program in Japan. Recent developments in high-definition endoscopic imaging and diagnostic strategies have enabled the simultaneous detection of other upper gastrointestinal (U-GI) malignancies. Therefore, we conducted a study to evaluate the feasibility of endoscopic screening for U-GI malignancy in a comprehensive health checkup. Methods We retrospectively reviewed the data of 13,120 participants who had received a comprehensive health checkup in a single institution between April 2012 and March 2018. Participants were divided into two groups [gastrointestinal endoscopy (GIE) group (n=9,142) and gastrointestinal X-ray (X-ray) group (n=3,978)] and compared with regards to the screening results, adverse events, and detection rate of U-GI malignancies (gastric cancer or other) using a propensity-score matched analysis. Results The gastric cancer detection rate was significantly higher in the GIE group [34/9,142 (0.48%)] than in the X-ray group [3/3,978 (0.08%)] (p=0.003). Other U-GI malignancies were found only in the GIE group and comprised two hypopharyngeal cancers, five esophageal cancers, two duodenal cancers, and one duodenal gastrointestinal stromal tumor. Adverse events occurred in 6/9,142 (0.07%) participants in the GIE group and 18/3,978 (0.45%) participants in the X-ray group (p<0.0001). A propensity-score matched analysis yielded 1,551 matched pairs, and the detection rate of gastric cancer and other U-GI malignancies remained significantly higher in the GIE group than in the X-ray group. Conclusion This study indicated that not only gastric cancer but also other U-GI malignancies can be detected by endoscopic screening.

Prognostic Nomogram for Postoperative Patients With Gastroesophageal Junction Cancer of No Distant Metastasis

Background

Gastroesophageal junction (GEJ) was one of the most common malignant tumors. However, the value of clinicopathological features in predicting the prognosis of postoperative patients with GEJ cancer and without distant metastasis was still unclear.

Methods

The 3425 GEJ patients diagnosed and underwent surgical resection without distant metastasis in the Surveillance, Epidemiology and End Results (SEER) database from 2010 to 2015 were enrolled,and they were randomly divided into training and validation cohorts with 7:3 ratio. Univariate and multivariate Cox regression analysis were used to determine the predictive factors that constituted the nomogram. The predictive accuracy and discriminability of Nomogram were determined by the area under the curve (AUC), C index, and calibration curve, and the influence of various factors on prognosis was explored.

Results

2,400 patients were designed as training cohort and 1025 patients were designed as validation cohort. The percentages of the distribution of demographic and clinicopathological characteristics in the training and validation cohorts tended to be the same. In the training cohort, multivariate Cox regression analysis revealed that the age, tumor grade, T stage and N stage were independent prognostic risk factors for patients with GEJ cancer without distant metastasis. The C index of nomogram model was 0.667. The AUC of the receiver operating characteristic (ROC) analysis for 3- and 5-year overall survival (OS) were 0.704 and 0.71, respectively. The calibration curve of 3- and 5-year OS after operation showed that there was the best consistency between nomogram prediction and actual observation. In the validation cohort, the C index of nomogram model, the AUC of 3- and 5-year OS, and the calibration curve were similar to the training cohort.

Conclusions

Nomogram could evaluate the prognosis of patients with GEJ cancer who underwent surgical resection without distant metastasis.

Alterations of Gastric Microbiota in Gastric Cancer and Precancerous Stages

Objective

Microbial infections have been shown to contribute to gastric carcinogenesis, the knowledge of gastric microbiota alteration in this process may provide help in early diagnosis of gastric cancer. The aim of this study was to characterize the microbial changes and identify taxonomic biomarkers across stages of gastric carcinogenesis.

Methods

The gastric microbiota was investigated by 16S rRNA gene analysis in gastric mucosal specimens from 47 patients including superficial gastritis (SG), atrophic gastritis (AG), gastric intraepithelial neoplasia (GIN), and gastric cancer (GC). Differences in microbial composition across the disease stages, especially in GIN and GC were assessed using linear discriminant analysis effect size.

Results

There was no gradual changing trend in the richness or diversity of the gastric microbiota across stages of gastric carcinogenesis. The relative abundance of dominant taxa at phylum and genus levels didn’t show a gradual shift pattern, and the only four taxa that continuously enriched from SG to GC were Slackia, Selenomonas, Bergeyella, and Capnocytophaga, all of which were oral bacteria. The most representative taxa which were enriched in GC patients were oral bacteria including Parvimonas, Eikenella and Prevotella-2, and environmental bacteria including Kroppenstedtia, Lentibacillus, and Oceanobacillus. The gastric microbiota in GIN patients were characterized by enrichment of intestinal commensals including Romboutsia, Fusicatenibacter, Prevotellaceae-Ga6A1-group, and Intestinimonas. Gastric cardia cancer and non-cardia cancer patients had significantly different microbiota profiles characterized by a higher abundance of Helicobacter in the cardia cancer patients.

Conclusions

Our results provide insights on potential taxonomic biomarkers for gastric cancer and precancerous stages, and suggest that gastric microbiota might play different roles in the carcinogenesis of cardia cancer and non-cardia cancer.

Histone Deacetylases (HDACs) in Gastric Cancer: An Update of their Emerging Prognostic and Therapeutic Role

Chemotherapy resistance is a rising concern in Gastric Cancer (GC) and has led to the investigation of various cellular compounds. Α functional equilibrium of histone acetylation and deacetylation was discovered in all cells, regulated by Histone Acetyltransferases and Deacetylases (HDACs), controlling chromatin coiling status and changing gene expression appropriately. In accordance with recent research, this equilibrium can be dysregulated in cancer cells aiding in the process of carcinogenesis and tumor progression by altering histone and non-histone proteins affecting gene expression, cell cycle control, differentiation, and apoptosis in various malignancies. In addition, increased HDAC expression in GC cells has been associated with increased stage, tumor invasion, nodal metastases, increased distant metastatic potential, and decreased overall survival. HDAC inhibitors could be used as treatment regimens for GC patients and could develop important synergistic interactions with chemotherapy drugs. The aim of this article is to review the molecular identity and mechanism of action of HDAC inhibitors, as well as highlight their potential utility as anti-cancer agents in GC.

Long non-coding RNA CASC8 polymorphisms are associated with the risk of esophageal cancer in a Chinese population

Background

Esophageal cancer (EC) is an important disease that threatens public health and safety. Although there are numerous treatment options for esophageal cancer including surgery, radiation therapy, and chemotherapy, these treatments have limited effects. Its morbidity and mortality vary widely among countries and regions. Esophageal cancer is classified into squamous cell carcinoma (ESCC) and esopheageal adenocarcinoma (EADC). Here, we examined the genetic susceptibility to ESCC in relation to functional single nucleotide polymorphisms (SNPs) in the long non‐coding RNA (lncRNA) CASC8.

Methods

To detect the susceptibility to ESCC in relation to functional polymorphisms in CASC8, a hypothesis‐driven study was performed to identify CASC8 SNPs in 949 patients with ESCC and 1369 control subjects.

Results

The CASC8 rs1562430 GG genotype was significantly associated with increased ESCC risk in men, patients younger than 63 years, non‐smokers, and nondrinkers.

Conclusions

CASC8 rs1562430 A > G may cause susceptibility to ESCC and CASC8 SNPs may play a vital role in ESCC risk, thereby serving as a potential biomarker for diagnosing ESCC. A larger sample size and multifactor information are needed to confirm these results.

Comparison on the Efficacy of Double Tract Gastric Interposition Reconstruction Versus Jejunal Interposition Reconstruction After Proximal Gastrectomy

Background

This study aimed to compare the efficacy of antrum-preserving double tract gastric interposition reconstruction (ADGR) versus antrum-preserving double tract jejunal interposition reconstruction (ADJR) after proximal gastrectomy (PG).

Material/Methods

In a retrospective study, 62 cases of proximal gastric cancer undergoing proximal gastrectomy were divided into an ADJR group (n=32) and an ADGR group (n=30) according to reconstruction methods. Perioperative outcomes and postoperative complications were compared between the 2 groups, and the changes in hemoglobin (Hb), total protein (TP), body weight, and quality of life (QOL) were observed at 1, 3, 6, and 12 months postoperatively. Endoscopy was given at 12 months postoperatively for assessing reflux esophagitis and residual food.

Results

Differences were indistinct in the 2 groups regarding the operation time, intraoperative blood loss, postoperative length of stay (LOS), first flatus time, and postoperative complications (P>0.05). At 1, 3, 6, and 12 months after operation, no evident differences were shown between the 2 groups regarding weight loss and Visick scores (P>0.05). Compared with the ADJR group, the Hb level at 6 and 12 months after operation and TP level at 12 months after operation were increased markedly in the ADGR group (P<0.05). No apparent difference was detected between the 2 groups in reflux esophagitis (P=0.467). The incidence of residual food in the ADGR group was significantly lower than that in the ADJR group (6.67% versus 31.25%, P=0.014).

Conclusions

ADGR was superior to ADJR in improving nutritional status and preventing residual food of patients with proximal gastric cancer after proximal gastrectomy.

Tumor-associated antigens and their antibodies in the screening, diagnosis, and monitoring of esophageal cancers

Despite the advances in the treatment and management, esophageal cancers continue to carry a dismal prognosis with an overall 5-year survival rate ranging from 15 to 25%. Delayed onset of symptoms and lack of effective screening methods and guidelines for diagnosis of the early disease contribute to the high mortality rate of esophageal cancers. Detection of esophageal cancer at their early stage is really a challenge for physicians including primary care physicians, gastroenterologists and oncologists. Although imaging, endoscopy and biopsy have been proved to be useful diagnostic tools for esophageal cancers, their diagnostic accuracy is unsatisfactory. In addition, expensive costs, invasiveness and special training operator have limited the clinical application of these tools. Recently, tumor-associated antigens (TAAs) and their antibodies have been reported to be potential markers in esophageal cancer screening, diagnosis, monitoring and prognostication. Because TAAs and their antibodies have the advantages of inexpensive cost, noninvasiveness and easy access, they have attracted much attention as an affordable option for early esophageal cancer diagnosis. In this review, we summarized the advances in TAAs and their antibodies in esophageal cancer screening, diagnosis, monitoring and prognostication.

The effect of metformin on esophageal cancer risk in patients with type 2 diabetes mellitus: a systematic review and meta‑analysis

OBJECTIVE

Recently, numerous studies have yielded inconsistent results regarding the effect of metformin on esophageal cancer risk in type 2 diabetes mellitus patients. The purpose of this study is to systematically assess this effect using meta-analysis.

METHODS

We searched clinical studies on metformin and esophageal cancer risk in PubMed, Embase, and the Cochrane Library. After literature screening, a series of meta-analyses were conducted using RevMan 5.3 software. The pooled hazard ratio (HR) and the corresponding 95% confidence interval (CI) were used as the effect size.

RESULTS

Five eligible studies (four cohort studies and one case-control study) were included for our meta-analysis using a random-effect model. The analysis showed that metformin could not reduce esophageal cancer risk in type 2 diabetes mellitus patients (HR 0.88, 95% CI 0.60-1.28, P > 0.05). Subgroup analyses by geographic location showed that metformin significantly reduced esophageal cancer risk in Asian patients with type 2 diabetes mellitus (HR 0.59, 95% CI 0.39-0.91, P = 0.02), without heterogeneity between studies (P = 0.80 and I² = 0%).

CONCLUSIONS

Overall, our systematic review and meta-analysis demonstrate that metformin does not reduce esophageal cancer risk in type 2 diabetes mellitus patients. However, a significant reduction in esophageal cancer risk in Asian populations remains to be clarified.

The Prognostic and Predictive Value of microRNAs in Patients with H. pylori-positive Gastric Cancer

Gastric cancer (GC) has a high mortality rate with a poor 5-year survival. Helicobacter pylori (H. pylori) is present as part of the normal flora of stomach. It is found in the gastric mucosa of more than half of the world population. This bacterium is involved in developing H. pylori-induced GC due to the regulation of different micro ribonucleic acid (miRNA or miR). miRNAs are small noncoding RNAs and are recognized as prognostic biomarkers for GC that may control gene expression. miRNAs may function as tumor suppressors, or oncogenes. In this review, we evaluated studies that investigated the ectopic expression of miRNAs in the prognosis of H. pylori positive and negative GC.

Attention-Based Deep Neural Networks for Detection of Cancerous and Precancerous Esophagus Tissue on Histopathological Slides

Importance

Deep learning-based methods, such as the sliding window approach for cropped-image classification and heuristic aggregation for whole-slide inference, for analyzing histological patterns in high-resolution microscopy images have shown promising results. These approaches, however, require a laborious annotation process and are fragmented.

Objective

To evaluate a novel deep learning method that uses tissue-level annotations for high-resolution histological image analysis for Barrett esophagus (BE) and esophageal adenocarcinoma detection.

Design, Setting, and Participants

This diagnostic study collected deidentified high-resolution histological images (N = 379) for training a new model composed of a convolutional neural network and a grid-based attention network. Histological images of patients who underwent endoscopic esophagus and gastroesophageal junction mucosal biopsy between January 1, 2016, and December 31, 2018, at Dartmouth-Hitchcock Medical Center (Lebanon, New Hampshire) were collected.

Main Outcomes and Measures

The model was evaluated on an independent testing set of 123 histological images with 4 classes: normal, BE-no-dysplasia, BE-with-dysplasia, and adenocarcinoma. Performance of this model was measured and compared with that of the current state-of-the-art sliding window approach using the following standard machine learning metrics: accuracy, recall, precision, and F1 score.

Results

Of the independent testing set of 123 histological images, 30 (24.4%) were in the BE-no-dysplasia class, 14 (11.4%) in the BE-with-dysplasia class, 21 (17.1%) in the adenocarcinoma class, and 58 (47.2%) in the normal class. Classification accuracies of the proposed model were 0.85 (95% CI, 0.81-0.90) for the BE-no-dysplasia class, 0.89 (95% CI, 0.84-0.92) for the BE-with-dysplasia class, and 0.88 (95% CI, 0.84-0.92) for the adenocarcinoma class. The proposed model achieved a mean accuracy of 0.83 (95% CI, 0.80-0.86) and marginally outperformed the sliding window approach on the same testing set. The F1 scores of the attention-based model were at least 8% higher for each class compared with the sliding window approach: 0.68 (95% CI, 0.61-0.75) vs 0.61 (95% CI, 0.53-0.68) for the normal class, 0.72 (95% CI, 0.63-0.80) vs 0.58 (95% CI, 0.45-0.69) for the BE-no-dysplasia class, 0.30 (95% CI, 0.11-0.48) vs 0.22 (95% CI, 0.11-0.33) for the BE-with-dysplasia class, and 0.67 (95% CI, 0.54-0.77) vs 0.58 (95% CI, 0.44-0.70) for the adenocarcinoma class. However, this outperformance was not statistically significant.

Conclusions and Relevance

Results of this study suggest that the proposed attention-based deep neural network framework for BE and esophageal adenocarcinoma detection is important because it is based solely on tissue-level annotations, unlike existing methods that are based on regions of interest. This new model is expected to open avenues for applying deep learning to digital pathology.

Risk evaluation of splenic hilar or splenic artery lymph node metastasis and survival analysis for patients with proximal gastric cancer after curative gastrectomy: a retrospective study

Background

As splenectomy and spleen-preserving lymphadenectomy are performed only in some proximal gastric cancer patients, it is difficult to identify patients who have undergone radical gastrectomy with or without splenic hilar (No.10) or splenic artery (No.11) lymph node metastases. We aimed to determine the risk factors for No.10 and No.11 lymph node metastases and evaluate the survival significance of No.10 and No.11 lymph node dissection in advanced proximal gastric cancer patients.

Methods

A total of 873 advanced proximal gastric cancer patients who underwent curative gastrectomy with or without splenectomy or pancreaticosplenectomy were analyzed retrospectively. The clinicopathological characteristics of 152 patients who underwent splenectomy or pancreaticosplenectomy were analyzed to determine the risk factors for No.10 and No.11 lymph node metastases. The survival difference between patients with No.10 and No.11 lymph node dissections and those who did not undergo these dissections were compared.

Results

Patients with No.10 and No.11 lymph node metastases had very poor prognoses. Tumor invasion of the greater curvature and No.2 and No.4 lymph node metastases were independent risk factors for No.10 and No.11 lymph node metastases. No survival differences were evident between patients with No.10 and No.11 lymph node metastases who underwent No.10 and No.11 lymph node dissections and those who did not undergo these dissections but were at high risks of No.10 and No.11 lymph node metastases.

Conclusions

Splenic hilar or splenic artery lymph node dissection was not associated with increased survival, in proximal gastric cancer patients without direct cancer invasion of the spleen and pancreas, regardless of whether splenectomy, pancreaticosplenectomy, or spleen-preserving lymphadenectomy was performed.

Silencing microRNA-330-5p increases MMP1 expression and promotes an invasive phenotype in oesophageal adenocarcinoma

BACKGROUND

Many patients diagnosed with oesophageal adenocarcinoma (OAC) present with advanced disease and approximately half present with metastatic disease. Patients with localised disease, who are managed with curative intent, frequently undergo neoadjuvant chemoradiotherapy. Unfortunately, ~ 70% of patients have little or no response to chemoradiotherapy. We previously identified miR-330-5p as being the most significantly downregulated microRNA in the pre-treatment OAC tumours of non-responders to treatment, but that loss of miR-330-5p had a limited impact on sensitivity to chemotherapy and radiation in vitro. Here, we further examined the impact of miR-330-5p loss on OAC biology.

METHODS

miR-330-5p was suppressed in OE33 OAC cells following stable transfection of a vector-driven anti-sense RNA. Whole transcriptome digital RNA-Seq was employed to identify miR-330-5p regulated genes, and qPCR was used for validation. Protein expression was assessed by protein array, Western blotting and zymography. Invasive potential was measured using a transwell assay system. Tumour xenograft growth profile studies were performed in immunocompromised CD1 mice.

RESULTS

In OE33 cells, suppression of miR-330-5p significantly altered expression of 42 genes, and several secreted proteases. MMP1 gene expression and protein secretion was significantly enhanced with miR-330-5p suppression. This corresponded to enhanced collagen invasion in vitro. In vivo, OE33-derived tumour xenografts with miR-330-5p suppression grew faster than controls.

CONCLUSIONS

Loss of miR-330-5p expression in OAC tumours may influence tumour cell invasive capacity, tumour growth and therapeutic sensitivity via alterations to the tumour microenvironment.

Screening high-risk populations for esophageal and gastric cancer

Cancers of the esophagus and stomach remain important causes of mortality worldwide, in large part because they are most often diagnosed at advanced stages. Thus, it is imperative that we identify and treat these cancers in earlier stages. Due to significant heterogeneity in incidence and risk factors for these cancers, it has been challenging to develop standardized screening recommendations. This review summarizes the current recommendations for screening populations at high risk of developing esophagogastric cancers.

Clinicopathological Characteristics and Prognosis of Proximal and Distal Gastric Cancer during 1997-2017 in China National Cancer Center

Background

The prognostic relevance of gastric tumor location has been reported and debated. Our study was conducted to examine the differences in clinicopathological features, prognostic factors, and overall survival (OS) between patients with proximal gastric cancer (PGC) and distal gastric cancer (DGC).

Patients and Methods

Patients with PGC or DGC were identified from the China National Cancer Center Gastric Cancer Database (NCCGCDB) during 1997–2017. Survival analysis was performed via Kaplan-Meier estimates and Cox proportional hazards models.

Results

We reviewed 16,119 cases of gastric cancer patients, including 6,479 of PGC and 9,640 of DGC. PGC patients presented as older patients (61.5 versus 56.4 years, P<0.001) and more males (82.9% versus 68.2%, P<0.001). Compared with DGC, PGC was more likely to be in later pT stage (pT3 and pT4, 65.0% versus 52.8%, P<0.001) and lymph node metastasis (54.8% versus 50.9%, P<0.001). In univariate analysis, PGC patients had a worse survival outcome in stage I (Hazard ratio [HR] = 2.04, 95% CI: 1.42-2.94) but a better prognosis in stage IV (HR = 0.85, 95% CI: 0.73-0.98) when compared to DGC patients. However, multivariate analysis demonstrated that PGC was not an independent predictor for poor survival (HR = 1.07, 95% CI: 1.00-1.14). Results from multivariate analysis also revealed that pT4, lymph node metastasis, distant metastasis, no gastrectomy, and Borrmann IV were independent predictors associated with poor survival for both PGC and DGC patients. Additional prognostic factors for PGC patients included underweight (BMI < 18.5) (HR = 1.29, 95% CI: 1.06-1.58), linitis plastica (HR = 2.13, 95% CI: 1.25-3.65), and overweight (23 ≤ BMI <27.5) (HR = 0.80, 95% CI: 0.71-0.90). During the 20-year study period, the 5-year OS increased significantly for both PGC and DGC, with the increase rate of 91.7% and 67.7%, respectively.

Conclusion

In China, PGC significantly differed from DGC in clinicopathological characteristics and prognostic factors. However, there was no significant relationship between survival outcome and gastric tumor location.

Gastric Cancer in Northern Canadian Populations: A Focus on Cardia and Non-Cardia Subsites

In northern Canada where there is a high prevalence of Helicobacter pylori infection, there is a paucity of information on gastric cancer by the topographical subsites cardia (CGC) and non-cardia (NCGC). Here we describe the incidence of CGC and NCGC, separately, among northern Canadian populations. We used data from the Cancer Incidence in Five Continents Volumes X (CI5X) and XI (CI5XI) to obtain CGC and NCGC incidence for Canada and for Yukon (YT), a northern Canadian territory. Using these data with those provided by the Government of the Northwest Territories (NT), we estimated standardized incidence ratios comparing northern populations to Canada as a whole. We also estimated age-standardized incidence rates to permit comparisons across populations globally. NT and YT populations were disproportionately impacted by gastric cancer, particularly NCGC. This was especially true for Indigenous populations: NCGC incidence rates among NT Indigenous men were 2.7 times the rates among all men in Canada, while rates among NT Indigenous women were 3.1 times the rates among all women in Canada. Similarly, age-standardized rates of NCGC among Indigenous NT residents were comparable to global regions where there is a high burden of NCGC. This study has, for the first time, quantified the incidence of CGC and NCGC for the NT and YT, providing new insights into the burden of these cancers among northern Canadian populations.

Managing Squamous Cell Esophageal Cancer

This article reviews the pathophysiology, risk factors, clinical presentation/diagnosis, and management of SCC.

Proposal of a Nomogram for Predicting Survival in Patients with Siewert Type II Adenocarcinoma of the Esophagogastric Junction After Preoperative Radiation

Background

Preoperative radiotherapy tends to be more frequently used for patients with adenocarcinoma of the esophagogastric junction (AEG); however, the prognostic values of postoperative pathologic characteristics in these patients remain unclear. This study aimed to examine the outcomes in Siewert type II AEG patients receiving preoperative radiotherapy to identify the predictive factors for overall survival (OS).

Methods and Results

A total of 1818 AEG patients undergoing preoperative radiotherapy were reviewed. Univariate analyses showed that age, sex, histology, tumor grade, positive lymph node (PLN), lymph node ratio, and log odds of positive lymph nodes (LODDS) were significantly correlated with OS; however, only age, grade, PLN, and LODDS were identified as independent risk factors in a multivariate regression model. Subsequently, patients were randomly grouped into training and validation cohorts (1:1 ratio), and the beta coefficients of these variables in the training set were used to generate the nomogram. The composite nomogram showed improved prognostic accuracy in the training, validation, and entire cohorts compared with that of TNM stage alone.

Conclusions

In conclusion, our proposed nomogram represents a promising tool for estimating OS in Siewert type II AEG patients after preoperative radiotherapy.

Electronic supplementary material

The online version of this article (10.1245/s10434-019-07237-7) contains supplementary material, which is available to authorized users.

Surgical Compliance and Outcomes in Gastric Cancer: a population-based cohort study

Background: Surgical resection is one of curative treatment for gastric cancer (GC), however, a set of patients show poor surgical compliance in the USA. We aimed to identify the risk factors associated with surgical compliance and investigate the difference in survival.

Methods: GC patients diagnosed between 1973 and 2014 were identified from the Surveillance Epidemiology and End Results (SEER) databases. Based on different surgical compliance and treatment regimen, patients were classified into three subgroups: surgical compliance group, surgical noncompliance group, and non-surgical group. Multivariable Logistic regression analysis was adopted to identify the factors related to surgical compliance; Multivariable Cox regression was used to investigate the prognostic factors. Overall survival (OS) and cancer-specific survival (CSS) were analyzed using the Kaplan-Meier estimator method.

Results: Of 79374 GC patients who were recommended for surgical therapy, 15201(19.2%) cases did not perform surgery. Poor compliance of surgery was related to old age, American Indian/Alaska Native race, poor grading/late staging, single/widowed status, lower socioeconomic status and earlier time of diagnosis. As expected, GC patients of surgical compliance group showed significantly more favorable survival than the other two groups (P<0.0001); notably, the outcome of surgical noncompliance group came close to that of non-surgical group.

Conclusion: GC patients of poor surgical compliance demonstrated adverse survival, which was comparable to that of non-surgical patients. The poor surgical compliance was associated with older age, American Indian/Alaska Native race, poor tissue differentiation/advanced stage of tumor, single/widowed status, lower socioeconomic status and earlier time of diagnosis.

Stratification of the dysplasia and neoplasia risk using autofluorescence endoscopic surveillance of Barrett's esophagus

BACKGROUND

This study assessed the efficacy of autofluorescence endoscopy (AFE) using the Onco-LIFE system and numerical color value (NCV) estimation in comparison to white light endoscopy (WLE) in endoscopic surveillance for identification of early dysplasia in Barrett's esophagus (BE) to aid in real-time image elucidation and minimize the overreliance on biopsy and histology.

METHODS

AFE, performed simultaneously during WLE, with biopsy was performed among 24 patients with BE. None of these patients had any obvious mucosal abnormalities in WLE. A total of 376 biopsies were taken, include 325 randomly collected according to Seattle Protocol and 51 additional biopsies, taken from the sites with pathological AF and NCV. All biopsy sites were assessed in vivo using WLE, AFE and NCV and compared to histological examinations, to estimate the efficacy of these methods in dysplasia assessment in BE.

RESULTS

In the case of 248 biopsies taken from sites with NCV below 1.0, two cases of unspecified dysplasia were recognized; in 14 biopsies with NCV above 2.0 in all cases the various grades of dysplasia were documented. Dysplasia was found in 42% of AFE + NCV- guided biopsy specimens, and in 7.1% of WLE-guided biopsy specimens. AFE + NCV detected high-grade dysplasia in 7 patients, 6 more than according to Seattle Protocol in WLE. The expected odds of dysplasia detection in a sample increases almost 1.9 times, if it was selected by the AFE method (p < 0.001), when compared to WLE and with accordance with Seattle Protocol guided biopsy.

CONCLUSION

The above results indicate that AFE + NCV using the Onco-LIFE system leads to improved BE lesion visualization for targeted biopsy with accurate histologic correlation compared to WLE and Seattle Protocol guided biopsy alone, and can serve to minimize additional biopsies.

Mediterranean diet adherence and risk of esophageal and gastric cancer subtypes in the Netherlands Cohort Study

BACKGROUND

Mediterranean diet (MD) adherence has been associated with reduced risks of esophageal and gastric cancer (subtypes) in a limited number of studies. We prospectively investigated associations between MD adherence and risks of esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), gastric cardia adenocarcinoma (GCA), and gastric non-cardia adenocarcinoma (GNCA) in a Dutch cohort.

METHODS

Analyses were conducted using data from the 120852 participants of the Netherlands Cohort Study (NLCS), who were aged between 55 and 69 years at enrollment. Various MD scores, with and without alcohol, were calculated to estimate MD adherence. Using 20.3 years of follow-up, 133 ESCC, 200 EAC, 191 GCA, and 586 GNCA cases could be included in multivariable Cox regression analyses.

RESULTS

Of the investigated scores, the alternate Mediterranean diet score without alcohol (aMEDr) performed best. aMEDr was inversely associated with risks of GCA and GNCA in men and women. However, statistical significance was only reached in men [p_trend: 0.019 (GCA), 0.016 (GNCA)]. Furthermore, higher aMEDr values were significantly associated with a reduced ESCC risk in men [HR_{per two-point increment} (95% CI) = 0.57 (0.41-0.80), p_trend = 0.013], but not in women (p_{heterogeneity} = 0.008). There was no evidence of an association between aMEDr and EAC risk. Educational level was a significant effect modifier for the association between aMEDr and GNCA risk (p_{heterogeneity} = 0.0073).

CONCLUSIONS

Higher MD adherence was associated with reduced risks of ESCC, GCA, and GNCA in the NLCS. However, the decreased ESCC risk might be limited to men.

Epigenetic silencing of ZNF132 mediated by methylation-sensitive Sp1 binding promotes cancer progression in esophageal squamous cell carcinoma

Epigenetic alteration of tumor suppression gene is one of the most significant indicators in human esophageal squamous cell carcinoma (ESCC). In this study, we identified a novel ESCC hypermethylation biomarker ZNF132 by integrative computational analysis to comprehensive genome-wide DNA methylation microarray dataset. We validated the hypermethylation status of ZNF132 in 91 Chinese Han ESCC patients and adjacent normal tissues with methylation target bisulfite sequencing (MTBS) assay. Meanwhile, ZNF132 gene silencing mediated by hypermethylation was confirmed in both solid tissues and cancer cell lines. What is more, we found that in vitro overexpression of ZNF132 in ESCC cells could significantly reduce the abilities of the cell in growth, migration and invasion, and tumorigenicity of cells in a nude mouse model. We validated the Sp1-binding site in the ZNF132 promoter region with chromatin immunoprecipitation assay and demonstrated that the hypermethylation status could reduce the Sp1 transcript factor activity. Our results suggest that ZNF132 plays an important role in the development of ESCC as a tumor suppressor gene and support the underlying mechanism caused by the DNA hypermethylation-mediated Sp1-binding decay and gene silencing.

Epidemiology of gastric cancer and risk factors

Gastric cancer is, still nowadays, an important healthcare problem worldwide. In Italy, it represents the fifth tumour by frequency in both men and women over 70 years old. A crucial point is represented by the percentage of early gastric cancers usually found, which is actually very low, and it carries to a worse morbidity and mortality. The most important focus in this oncological disease, is to perform an effective detection of the most common precancerous lesion linked with this neoplasia, chronic atrophic gastritis, in order to avoid the future outcome of gastric cancer itself. (www.actabiomedica.it)

An observational study on the clinical features of esophageal cancer followed by multiple primary cancers

AIM

To investigate the nature of multiple primary cancers initiated by esophageal cancer-multiple primary cancers (EC-MPC).

PATIENTS & METHODS

SEER data about patients'/tumor characteristics, and survival were analyzed and compared.

RESULTS & CONCLUSION

1727 of 29,733 registered EC patients have EC-MPC. Individuals diagnosed at 60-79 years old, earlier stage and/or moderately differentiated EC were more likely to get EC-MPC. Fewer patients in the EC-MPC group suffered from metastases. Patients in the EC-MPC group showed a longer survival rate and lower EC-specific deaths. Other factors like age, sex, race, tumor differentiation and Tumor, Node, Metastasis stage also affected survival. Radiation can improve survival. EC-MPC patients have some distinct features compared with solitary EC.

Exploring Spatial Trends and Influencing Factors for Gastric Cancer Based on Bayesian Statistics: A Case Study of Shanxi, China

Gastric cancer (GC) is the fourth most common type of cancer and the second leading cause of cancer-related deaths worldwide. To detect the spatial trends of GC risk based on hospital-diagnosed patients, this study presented a selection probability model and integrated it into the Bayesian spatial statistical model. Then, the spatial pattern of GC risk in Shanxi Province in north central China was estimated. In addition, factors influencing GC were investigated mainly using the Bayesian Lasso model. The spatial variability of GC risk in Shanxi has the conspicuous feature of being 'high in the south and low in the north'. The highest GC relative risk was 1.291 (95% highest posterior density: 0.789⁻4.002). The univariable analysis and Bayesian Lasso regression results showed that a diverse dietary structure and increased consumption of beef and cow milk were significantly (p ≤ 0.08) and in high probability (greater than 68%) negatively associated with GC risk. Pork production per capita has a positive correlation with GC risk. Moreover, four geographic factors, namely, temperature, terrain, vegetation cover, and precipitation, showed significant (p < 0.05) associations with GC risk based on univariable analysis, and associated with GC risks in high probability (greater than 60%) inferred from Bayesian Lasso regression model.