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Karstens KF, Ghadban T, Effenberger K, Sauter G, Pantel K, Izbicki JR, Vashist Y, König A, Reeh M. Lymph Node and Bone Marrow Micrometastases Define the Prognosis of Patients with pN0 Esophageal Cancer. Cancers (Basel) 2020; 12:cancers12030588. [PMID: 32143307 PMCID: PMC7139797 DOI: 10.3390/cancers12030588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/27/2020] [Accepted: 03/02/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Pathological routine lymph node staging is postulated to be the main oncological prognosticator in esophageal cancer (EC). However, micrometastases in lymph nodes (LNMM) and bone marrow (BNMM) are discussed as the key events in tumor recurrence. We assessed the prognostic significance of the LNMM/BNMM status in initially pN0 staged patients with curative esophagectomy. METHODS From 110 patients bone marrow aspirates and lymph node tissues were analyzed. For LNMM detection immunohistochemistry was performed using the anticytokeratin antibody AE1/AE3. To detect micrometastases in the bone marrow a staining with the pan-keratin antibody A45-B/B3 was done. Results were correlated with clinicopathologic parameters as well as recurrence and death during follow-up time. RESULTS Thirty-eight (34.5%) patients showed LNMM, whereas in 54 (49.1%) patients BNMM could be detected. LNMM and BNMM positive patients showed a correlation to an increased pT category (p = 0.017). Univariate and multivariate analyses revealed that the LNMM/BNMM status and especially LNMM skipping the anatomical lymph node chain were significant independent predictors of overall survival and recurrence-free survival. CONCLUSIONS This study indicates that routine pathological staging of EC is insufficient. Micrometastases in lymph nodes and the bone marrow seem to be the main reason for tumor recurrence and they are a strong prognosticator following curative treatment of pN0 EC.
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Affiliation(s)
- Karl-F. Karstens
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; (K.-F.K.); (T.G.); (K.E.); (J.R.I.); (Y.V.); (A.K.)
| | - Tarik Ghadban
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; (K.-F.K.); (T.G.); (K.E.); (J.R.I.); (Y.V.); (A.K.)
| | - Katharina Effenberger
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; (K.-F.K.); (T.G.); (K.E.); (J.R.I.); (Y.V.); (A.K.)
| | - Guido Sauter
- Department of Pathology, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany;
| | - Klaus Pantel
- Department of Tumor Biology, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany;
| | - Jakob R. Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; (K.-F.K.); (T.G.); (K.E.); (J.R.I.); (Y.V.); (A.K.)
| | - Yogesh Vashist
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; (K.-F.K.); (T.G.); (K.E.); (J.R.I.); (Y.V.); (A.K.)
| | - Alexandra König
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; (K.-F.K.); (T.G.); (K.E.); (J.R.I.); (Y.V.); (A.K.)
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; (K.-F.K.); (T.G.); (K.E.); (J.R.I.); (Y.V.); (A.K.)
- Correspondence:
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Wu L, Ge L, Qin Y, Huang M, Chen J, Yang Y, Zhong J. Postoperative morbidity and mortality after neoadjuvant chemotherapy versus upfront surgery for locally advanced gastric cancer: a propensity score matching analysis. Cancer Manag Res 2019; 11:6011-6018. [PMID: 31308742 PMCID: PMC6614824 DOI: 10.2147/cmar.s203880] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/31/2019] [Indexed: 01/02/2023] Open
Abstract
Background Cohort studies have shown that neoadjuvant chemotherapy (NAC) is not associated with increased risk of postoperative complications and mortality as compared to upfront surgery (SURG). Objective The aim of this study was to compare postoperative morbidity and mortality after NAC with SURG. Patients and methods Patients who underwent gastrectomy with D2 lymphadenectomy for advanced gastric cancer (GC) between 2010 and 2017 were selected. The impact of neoadjuvant chemotherapy on surgical safety was investigated by using propensity score matching. Results Three hundred and seventy-seven patients were included. After propensity score matching, 86 patients in each group were matched. The percentage of patients with one or more complications was 10.5% in NAC group and 15.1% in SURG group (P=0.361), there was no mortality developed in either group. The total blood loss was significantly more in the NAC group than that in the SURG group (320.79 vs 243.37 ml, P<0.04). In univariate and multivariate of the matched cohort, sex, age (<70), BMI (<24), ASA grade, surgical procedure (open vs laparoscopy), gastrectomy extent, cTNM and Charlson index comorbidity were not associated with postoperative complications (all P>0.05). Conclusion This study showed that postoperative morbidity and mortality were similar for NAC group and SURG group.
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Affiliation(s)
- Liucheng Wu
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi Autonomous Region 530021, People's Republic of China
| | - Lianying Ge
- Department of Endoscopy, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi Autonomous Region 530021, People's Republic of China
| | - Yuzhou Qin
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi Autonomous Region 530021, People's Republic of China
| | - Mingwei Huang
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi Autonomous Region 530021, People's Republic of China
| | - Jiansi Chen
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi Autonomous Region 530021, People's Republic of China
| | - Yang Yang
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi Autonomous Region 530021, People's Republic of China
| | - Jianhong Zhong
- Department of Hepatobilliary Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi Autonomous Region 530021, People's Republic of China
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Davies AR, Myoteri D, Zylstra J, Baker CR, Wulaningsih W, Van Hemelrijck M, Maisey N, Allum WH, Smyth E, Gossage JA, Lagergren J, Cunningham D, Green M. Lymph node regression and survival following neoadjuvant chemotherapy in oesophageal adenocarcinoma. Br J Surg 2018; 105:1639-1649. [PMID: 30047556 DOI: 10.1002/bjs.10900] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/12/2018] [Accepted: 05/03/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aim was to define the pathological response in lymph nodes following neoadjuvant chemotherapy for oesophageal adenocarcinoma and to quantify any associated survival benefit. METHODS Lymph nodes retrieved at oesophagectomy were examined retrospectively by two pathologists for evidence of a response to chemotherapy. Patients were classified as lymph node-negative (either negative nodes with no evidence of previous tumour involvement or negative with evidence of complete regression) or positive (allocated a lymph node regression score based on the proportion of fibrosis to residual tumour). Lymph node responders (score 1, complete response; 2, less than 10 per cent remaining tumour; 3, 10-50 per cent remaining tumour) and non-responders (score 4, more than 50 per cent viable tumour; 5, no response) were compared in survival analyses using Kaplan-Meier and Cox regression analysis. RESULTS Among 377 patients, 256 had neoadjuvant chemotherapy. Overall, 68 of 256 patients (26·6 per cent) had a lymph node response and 115 (44·9 per cent) did not. The remaining 73 patients (28·5 per cent) had negative lymph nodes with no evidence of regression. Some patients had a lymph node response in the absence of a response in the primary tumour (27 of 99, 27 per cent). Lymph node responders had a significant survival benefit (P < 0·001), even when stratified by patients with or without a response in the primary tumour. On multivariable analysis, lymph node responders had decreased overall (hazard ratio 0·53, 95 per cent c.i. 0·36 to 0·78) and disease-specific (HR 0·42, 0·27 to 0·66) mortality, and experienced reduced local and systemic recurrence. CONCLUSION Lymph node regression is a strong prognostic factor and may be more important than response in the primary tumour.
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Affiliation(s)
- A R Davies
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, King's College London, London, UK
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - D Myoteri
- Department of Cellular Pathology, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | - J Zylstra
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, King's College London, London, UK
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - C R Baker
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, King's College London, London, UK
| | - W Wulaningsih
- Translational Oncology and Urology Research, School of Cancer Sciences, King's College London, London, UK
| | - M Van Hemelrijck
- Translational Oncology and Urology Research, School of Cancer Sciences, King's College London, London, UK
| | - N Maisey
- Department of Oncology, Guy's Cancer Centre, Guy's Hospital, London, UK
| | - W H Allum
- Department of Oncology, Royal Marsden Hospital, London, UK
| | - E Smyth
- Department of Oncology, Royal Marsden Hospital, London, UK
| | - J A Gossage
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, King's College London, London, UK
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - J Lagergren
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, King's College London, London, UK
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - D Cunningham
- Department of Oncology, Royal Marsden Hospital, London, UK
- Institute of Cancer Research, London, UK
| | - M Green
- Department of Cellular Pathology, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
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Javadinia SA, Gholami A, Joudi Mashhad M, Ferns GA, Shahidsales S, Avan A, Kermani AT. Anti-tumoral effects of low molecular weight heparins: A focus on the treatment of esophageal cancer. J Cell Physiol 2018; 233:6523-6529. [PMID: 29741755 DOI: 10.1002/jcp.26613] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 03/22/2018] [Indexed: 12/19/2022]
Abstract
Esophageal cancer is one of the most prevalent types of cancer globally. With current treatment options, the survival is poor, and there are ongoing efforts to find new and more efficient therapeutic approaches. There are several reports on the anti-tumoral effects of low-molecular-weight heparins (LMWH). We have assessed the possible survival benefits and underlying mechanisms of LMWHs in malignancies with a focus on esophageal cancer. We conclude that the effects of LMWHs on survival of cancer patients is probably due to a combination of direct anti-tumoral, anti-angiogenic, and immunomodulatory effects and indirect effects on the coagulation system.
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Affiliation(s)
| | - Arezoo Gholami
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mona Joudi Mashhad
- Cancer Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Gordon A Ferns
- Division of Medical Education, Department of Medical Education, Brighton and Sussex Medical School Brighton & Sussex Medical School, Falmer, Brighton, Sussex, UK
| | | | - Amir Avan
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Taghizadeh Kermani
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Davies AR, Zylstra J, Baker CR, Gossage JA, Dellaportas D, Lagergren J, Findlay JM, Puccetti F, El Lakis M, Drummond RJ, Dutta S, Mera A, Van Hemelrijck M, Forshaw MJ, Maynard ND, Allum WH, Low D, Mason RC. A comparison of the left thoracoabdominal and Ivor-Lewis esophagectomy. Dis Esophagus 2018; 31:4566196. [PMID: 29087474 DOI: 10.1093/dote/dox129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/05/2017] [Indexed: 12/11/2022]
Abstract
The purpose of this study was to assess the oncological outcomes of a large multicenter series of left thoracoabdominal esophagectomies, and compare these to the more widely utilized Ivor-Lewis esophagectomy. With ethics approval and an established study protocol, anonymized data from five centers were merged into a structured database. The study exposure was operative approach (ILE or LTE). The primary outcome measure was time to death. Secondary outcome measures included time to tumor recurrence, positive surgical resection margins, lymph node yield, postoperative death, and hospital length of stay. Cox proportional hazards models provided hazard ratios (HR) with 95% confidence intervals (CI) adjusting for age, pathological tumor stage, tumor grade, lymphovascular invasion, and neoadjuvant treatment. Among 1228 patients (598 ILE; 630 LTE), most (86%) had adenocarcinoma (AC) and were male (81%). Comparing ILE and LTE for AC patients, no difference was seen in terms of time to death (HR 0.904 95%CI 0.749-1.1090) or time to recurrence (HR 0.973 95%CI 0.768-1.232). The risk of a positive resection margin was also similar (OR 1.022 95%CI 0.731-1.429). Median lymph node yield did not differ between approaches (LTE 21; ILE 21; P = 0.426). In-hospital mortality was 2.4%, significantly lower in the LTE group (LTE 1.3%; ILE 3.6%; P = 0.004). Median hospital stay was 11 days in the LTE group and 14 days in the ILE group (P < 0.0001). In conclusion, this is the largest series of left thoracoabdominal esophagectomies to be submitted for publication and the only one to compare two different transthoracic esophagectomy strategies. It demonstrates oncological equivalence between operative approaches but possible short- term advantages to the left thoracoabdominal esophagectomy.
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Affiliation(s)
- A R Davies
- Department of Surgery, Guy's & St Thomas' Esophago-Gastric Centre.,Division of Cancer Studies, King's College London.,Upper GI Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - J Zylstra
- Department of Surgery, Guy's & St Thomas' Esophago-Gastric Centre.,Division of Cancer Studies, King's College London.,Upper GI Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - C R Baker
- Department of Surgery, Guy's & St Thomas' Esophago-Gastric Centre.,Division of Cancer Studies, King's College London.,Upper GI Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - J A Gossage
- Department of Surgery, Guy's & St Thomas' Esophago-Gastric Centre.,Division of Cancer Studies, King's College London.,Upper GI Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - D Dellaportas
- Department of Surgery, Guy's & St Thomas' Esophago-Gastric Centre
| | - J Lagergren
- Department of Surgery, Guy's & St Thomas' Esophago-Gastric Centre.,Division of Cancer Studies, King's College London.,Upper GI Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - J M Findlay
- Department of Upper Gastrointestinal Surgery, Oxford Esophago-Gastric Centre, Oxford University Hospitals.,NIHR Oxford Biomedical Research Centre, Churchill Hospital, Oxford
| | - F Puccetti
- Department of Surgery, Royal Marsden Hospital, London
| | - M El Lakis
- Department of Thoracic Surgery, Virginia Mason Medical Centre, Seattle, Washington, USA
| | - R J Drummond
- Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - S Dutta
- Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - A Mera
- Cancer Epidemiology Group, Division of Cancer Studies, King's College London
| | - M Van Hemelrijck
- Cancer Epidemiology Group, Division of Cancer Studies, King's College London
| | - M J Forshaw
- Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - N D Maynard
- Department of Upper Gastrointestinal Surgery, Oxford Esophago-Gastric Centre, Oxford University Hospitals
| | - W H Allum
- Department of Surgery, Royal Marsden Hospital, London
| | - D Low
- Department of Thoracic Surgery, Virginia Mason Medical Centre, Seattle, Washington, USA
| | - R C Mason
- Department of Surgery, Guy's & St Thomas' Esophago-Gastric Centre.,Division of Cancer Studies, King's College London.,Upper GI Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Minimal Residual Disease in Head and Neck Cancer and Esophageal Cancer. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1100:55-82. [DOI: 10.1007/978-3-319-97746-1_4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Disseminated tumour cells with highly aberrant genomes are linked to poor prognosis in operable oesophageal adenocarcinoma. Br J Cancer 2017; 117:725-733. [PMID: 28728164 PMCID: PMC5572184 DOI: 10.1038/bjc.2017.233] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 06/13/2017] [Accepted: 06/23/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Chromosomal instability (CIN) has repeatedly been identified as a prognostic marker. Here we evaluated the percentage of aberrant genome per cell (PAG) as a measure of CIN in single disseminated tumour cells (DTC) isolated from patients with operable oesophageal adenocarcinoma (EAC), to assess the impact of CINhigh DTCs on prognosis. METHODS We isolated CK18positive DTCs from bone marrow (BM) or lymph node (LN) preparations of operable EAC patients. After whole-genome amplification, single DTCs were analysed for chromosomal gains and losses using metaphase-based comparative genomic hybridisation (mCGH). We calculated the PAG for each DTC and determined the critical threshold value that identifies high-risk patients by STEPP (Subpopulation Treatment Effect Pattern Plot) analysis in two independent EAC patient cohorts (cohort #1, n=44; cohort #2; n=29). RESULTS The most common chromosomal alterations observed among the DTCs were typical for EAC, but the DTCs showed a varying PAG between individual patients. Generally, LNDTCs displayed a significantly higher PAG than BMDTCs. STEPP analysis revealed an increasing PAG of DTCs to be correlated with an increased risk for short survival in two independent EAC cohorts as well as in the corresponding pooled analysis. In all three data sets (cohort #1, cohort #2 and pooled cohort), PAGhigh DTCs conferred an independent risk for a significantly decreased survival. CONCLUSIONS The analysis of PAG/CIN in solitary marker-positive DTCs identifies operable EAC patients with poor prognosis, indicating a more aggressive minimal residual disease.
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Ronellenfitsch U, Schwarzbach M, Hofheinz R, Kienle P, Nowak K, Kieser M, Slanger TE, Burmeister B, Kelsen D, Niedzwiecki D, Schuhmacher C, Urba S, van de Velde C, Walsh TN, Ychou M, Jensen K. Predictors of overall and recurrence-free survival after neoadjuvant chemotherapy for gastroesophageal adenocarcinoma: Pooled analysis of individual patient data (IPD) from randomized controlled trials (RCTs). Eur J Surg Oncol 2017; 43:1550-1558. [PMID: 28551325 DOI: 10.1016/j.ejso.2017.05.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 05/02/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Neoadjuvant chemotherapy improves prognosis of patients with locally advanced gastroesophageal adenocarcinoma. The aim of this study was to identify predictors for postoperative survival following neoadjuvant therapy. These could be useful in deciding about postoperative continuation of chemotherapy. METHODS This meta-analysis used IPD from RCTs comparing neoadjuvant chemotherapy with surgery alone for gastroesophageal adenocarcinoma. Trials providing IPD on age, sex, performance status, pT/N stage, resection status, overall and recurrence-free survival were included. Survival was calculated in the entire study population and subgroups stratified by supposed predictors and compared using the log-rank test. Multivariable Cox models were used to identify independent survival predictors. RESULTS Four RCTs providing IPD from 553 patients fulfilled the inclusion criteria. (y)pT and (y)pN stage and resection status strongly predicted postoperative survival both after neoadjuvant therapy and surgery alone. Patients with R1 resection after neoadjuvant therapy survived longer than those with R1 resection after surgery alone. Patients with stage pN0 after surgery alone had better prognosis than those with ypN0 after neoadjuvant therapy. Patients with stage ypT3/4 after neoadjuvant therapy survived longer than those with stage pT3/4 after surgery alone. Multivariable regression identified resection status and (y)pN stage as predictors of survival in both groups. (y)pT stage predicted survival only after surgery alone. CONCLUSION After neoadjuvant therapy for gastroesophageal adenocarcinoma, survival is determined by the same factors as after surgery alone. However, ypT stage is not an independent predictor. These results can facilitate the decision about postoperative continuation of chemotherapy in pretreated patients.
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Affiliation(s)
- U Ronellenfitsch
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - M Schwarzbach
- Department of General, Visceral, Vascular, and Thoracic Surgery, Klinikum Frankfurt Höchst, Gotenstraße 6-8, 65929 Frankfurt am Main, Germany.
| | - R Hofheinz
- Day Treatment Center (TTZ), Interdisciplinary Tumor Center Mannheim (ITM) & 3rd Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - P Kienle
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - K Nowak
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - M Kieser
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130, 69120 Heidelberg, Germany.
| | - T E Slanger
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - B Burmeister
- University of Queensland, Princess Alexandra Hospital, Brisbane, QLD 4102, Australia.
| | - D Kelsen
- Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, NY 10021, USA.
| | - D Niedzwiecki
- The Alliance for Clinical Trials in Oncology (Alliance) Statistics and Data Center, Duke University Medical Center, Hock Plaza, 2424 Erwin Rd, Room 8040, Durham, NC 27705, USA.
| | - C Schuhmacher
- Department of Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany.
| | - S Urba
- Division of Hematology/Oncology, University of Michigan Medical Center, 1500 E Medical Center Drive, C347, SPC 5848, Ann Arbor, MI 48109, USA.
| | - C van de Velde
- Department of Surgery, Leiden University Medical Center, K6-R, P.O. Box 9600, 2300 RC Leiden, The Netherlands.
| | - T N Walsh
- Department of Surgery, Connolly Hospital, Blanchardstown, Dublin 15, Ireland.
| | - M Ychou
- Centre Régional de Lutte Contre le Cancer, Val d'Aurelle, Montpellier Cedex 05, France.
| | - K Jensen
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130, 69120 Heidelberg, Germany.
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Giacopuzzi S, Bencivenga M, Weindelmayer J, Verlato G, de Manzoni G. Western strategy for EGJ carcinoma. Gastric Cancer 2017; 20:60-68. [PMID: 28039533 DOI: 10.1007/s10120-016-0685-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 12/15/2016] [Indexed: 02/06/2023]
Abstract
In this paper, the epidemiological and clinicobiological behavior of esophagogastric junction (EGJ) adenocarcinoma in the West is compared and contrasted to that in the East, and an overview is provided of current therapeutic strategies employed for this type of tumor in Western countries. It is well known that multimodal treatment is the therapeutic standard in locally advanced EGJ adenocarcinoma, but whether neoadjuvant/perioperative chemotherapy (CT) or neoadjuvant chemoradiotherapy (CRT) is the optimal approach is still debated. Neoadjuvant CRT improves local control in locally advanced Siewert type I and II tumors, so it should be considered the treatment of choice. In the subset of these patients with microscopic systemic disease at diagnosis, more intensive exclusive chemotherapy protocols could be of benefit. Therefore, there is an urgent need to identify these patients before planning the treatment. For Siewert type III tumors, perioperative chemotherapy is the standard. While there is general agreement on the optimal surgical approach for Siewert types I and III (a two-field Ivor Lewis operation and a total gastrectomy with distal esophagectomy, respectively), no standard surgical treatment has been defined for Siewert type II tumors. When data from Western series on proximal and circumferential resection margins and on nodal spread in Siewert type II tumors are taken into account, the optimal surgical approach appears to be Ivor Lewis esophagectomy. Whether the extent of esophageal invasion can correctly predict nodal involvement in middle-upper mediastinal stations as a means to restrict indications for transthoracic esophagectomy requires further investigation in the West.
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Affiliation(s)
- Simone Giacopuzzi
- General and Upper G.I. Surgery Division, Department of Surgery, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
| | - Maria Bencivenga
- General and Upper G.I. Surgery Division, Department of Surgery, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
| | - Jacopo Weindelmayer
- General and Upper G.I. Surgery Division, Department of Surgery, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
| | - Giuseppe Verlato
- Unit of Epidemiology and Medical Statistics, Department of Public Health and Community Medicine, University of Verona, Verona, Italy
| | - Giovanni de Manzoni
- General and Upper G.I. Surgery Division, Department of Surgery, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy.
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10
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Garg PK, Sharma J, Jakhetiya A, Goel A, Gaur MK. Preoperative therapy in locally advanced esophageal cancer. World J Gastroenterol 2016; 22:8750-8759. [PMID: 27818590 PMCID: PMC5075549 DOI: 10.3748/wjg.v22.i39.8750] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 08/23/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
Esophageal cancer is an aggressive malignancy associated with dismal treatment outcomes. Presence of two distinct histopathological types distinguishes it from other gastrointestinal tract malignancies. Surgery is the cornerstone of treatment in locally advanced esophageal cancer (T2 or greater or node positive); however, a high rate of disease recurrence (systemic and loco-regional) and poor survival justifies a continued search for optimal therapy. Various combinations of multimodality treatment (preoperative/perioperative, or postoperative; radiotherapy, chemotherapy, or chemoradiotherapy) are being explored to lower disease recurrence and improve survival. Preoperative therapy followed by surgery is presently considered the standard of care in resectable locally advanced esophageal cancer as postoperative treatment may not be feasible for all the patients due to the morbidity of esophagectomy and prolonged recovery time limiting the tolerance of patient. There are wide variations in the preoperative therapy practiced across the centres depending upon the institutional practices, availability of facilities and personal experiences. There is paucity of literature to standardize the preoperative therapy. Broadly, chemoradiotherapy is the preferred neo-adjuvant modality in western countries whereas chemotherapy alone is considered optimal in the far East. The present review highlights the significant studies to assist in opting for the best evidence based preoperative therapy (radiotherapy, chemotherapy or chemoradiotherapy) for locally advanced esophageal cancer.
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Ryan P, Furlong H, Murphy CG, O'Sullivan F, Walsh TN, Shanahan F, O'Sullivan GC. Prognostic significance of prospectively detected bone marrow micrometastases in esophagogastric cancer: 10-year follow-up confirms prognostic significance. Cancer Med 2015; 4:1281-8. [PMID: 25914238 PMCID: PMC4559039 DOI: 10.1002/cam4.470] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 03/07/2015] [Accepted: 03/27/2015] [Indexed: 01/20/2023] Open
Abstract
We have previously reported that most patients with esophagogastric cancer (EGC) undergoing potentially curative resections have bone marrow micrometastases (BMM). We present 10-year outcome data of patients with EGC whose rib marrow was examined for micrometastases and correlate the findings with treatment and conventional pathologic tumor staging. A total of 88 patients with localized esophagogastric tumors had radical en-bloc esophagectomy, with 47 patients receiving neoadjuvant (5-fluorouracil/cisplatin based) chemoradiotherapy (CRT) and the remainder being treated with surgery alone. Rib marrow was examined for cytokeratin-18-positive cells. Standard demographic and pathologic features were recorded and patients were followed for a mean 10.04 years. Disease recurrences and all deaths in the follow-up period were recorded. No patients were lost to follow-up. 46 EGC-related and 10 non-EGC-related deaths occurred. Multivariate Cox analysis of interaction of neoadjuvant chemotherapy, nodal status, and BMM positivity showed that the contribution of BMM to disease-specific and overall survival is significant (P = 0.014). There is significant interaction with neoadjvant CRT (P < 0.005), and lymph node positivity (P < 0.001) but BMM positivity contributes to increase in risk of cancer-related death in patients treated with either CRT or surgery alone. Bone marrow micrometastases detected at the time of surgery for EGC is a long-term prognostic marker. Detection is a readily available, technically noncomplex test which offers a window on the metastatic process and a refinement of pathologic staging and is worthy of routine consideration.
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Affiliation(s)
- Paul Ryan
- Department of Pathology, Bon Secours Hospital, Cork, Ireland.,Cork Cancer Research Centre, University College Cork, Cork, Ireland
| | - Heidi Furlong
- Royal College of Surgeons of Ireland Department of Surgery, Connolly Hospital, Blanchardstown, Dublin, Ireland
| | | | - Finbarr O'Sullivan
- School of Mathematical Sciences/Statistics, University College Cork, Cork, Ireland
| | - Thomas N Walsh
- Royal College of Surgeons of Ireland Department of Surgery, Connolly Hospital, Blanchardstown, Dublin, Ireland
| | - Fergus Shanahan
- Department of Medicine, University College Cork, Cork, Ireland
| | - Gerald C O'Sullivan
- Cork Cancer Research Centre, University College Cork, Cork, Ireland.,Department of Surgery, University College Cork, Cork, Ireland
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12
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Davies AR, Gossage JA, Zylstra JL, Mattsson F, Lagergren J, Maisey N, Smyth EC, Cunningham D, Allum WH, Mason RC. Reply to R.C. Turkington et al. J Clin Oncol 2015; 33:1089-90. [PMID: 25646188 DOI: 10.1200/jco.2014.59.9506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Davies AR, Gossage JA, Zylstra J, Mattsson F, Lagergren J, Maisey N, Smyth EC, Cunningham D, Allum WH, Mason RC. Tumor stage after neoadjuvant chemotherapy determines survival after surgery for adenocarcinoma of the esophagus and esophagogastric junction. J Clin Oncol 2015; 32:2983-90. [PMID: 25071104 DOI: 10.1200/jco.2014.55.9070] [Citation(s) in RCA: 180] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Neoadjuvant chemotherapy is established in the management of most resectable esophageal and esophagogastric junction adenocarcinomas. However, assessing the downstaging effects of chemotherapy and predicting response to treatment remain challenging, and the relative importance of tumor stage before and after chemotherapy is debatable. METHODS We analyzed consecutive resections for esophageal or esophagogastric junction adenocarcinomas performed at two high-volume cancer centers in London between 2000 and 2010. After standard investigations and multidisciplinary team consensus, all patients were allocated a clinical tumor stage before treatment, which was compared with pathologic stage after surgical resection. Survival analysis was conducted using Kaplan-Meier analysis and Cox regression analysis. RESULTS Among 584 included patients, 400 patients (68%) received neoadjuvant chemotherapy. Patients with downstaged tumors after neoadjuvant chemotherapy experienced improved survival compared with patients without response (P < .001), and such downstaging (hazard ratio, 0.43; 95% CI, 0.31 to 0.59) was the strongest independent predictor of survival after adjusting for patient age, tumor grade, clinical tumor stage, lymphovascular invasion, resection margin status, and surgical resection type. Patients downstaged by chemotherapy, compared with patients with no response, experienced lower rates of local recurrence (6% v. 13%, respectively; P = .030) and systemic recurrence (19% v. 29%, respectively; P = .027) and improved Mandard tumor regression scores (P = .001). Survival was strongly dictated by stage after neoadjuvant chemotherapy, rather than clinical stage at presentation. CONCLUSION The stage of esophageal or esophagogastric junction adenocarcinoma after neoadjuvant chemotherapy determines prognosis rather than the clinical stage before neoadjuvant chemotherapy, indicating the importance of focusing on postchemotherapy staging to more accurately predict outcome and eligibility for surgery. Patients who are downstaged by neoadjuvant chemotherapy benefit from reduced rates of local and systemic recurrence.
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Targeting therapy for esophageal cancer in patients aged 70 and over. J Geriatr Oncol 2013; 4:107-13. [PMID: 24071535 DOI: 10.1016/j.jgo.2012.12.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 10/22/2012] [Accepted: 12/20/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND While cancer is a disease of the elderly, these patients are under-represented in randomized trials. Esophageal cancer-management in the elderly is challenging because of the morbidity and mortality associated with surgery. OBJECTIVES We examined a strategy of neo-adjuvant chemo-radiotherapy (naCRT), followed by surgery or surveillance, in selected patients with cancer aged 70 and older. METHODS A prospectively-accrued database identified 56 consecutive patients over a 90-month period, who were aged 70years and over, presented with esophageal carcinoma and were treated with neo-adjuvant CRT (naCRT)±surgery. RESULTS Of 129 eligible patients, 66 (51%) received palliative measures, while 63 (49%) had curative intervention, namely 7 had surgery and 56 had naCRT±surgery. Of these 56 patients, 33 (59%) had adenocarcinoma (AC) and 23 (41%) had squamous cell carcinoma (SCC). Twenty-five (45%) had a complete clinical response (cCR), of which 6 had immediate resection; 4 (67%) had a complete pathological response (pCR); 19 patients with a cCR declined or were unfit for surgery and underwent surveillance; of these, 3 had interval esophagectomy; 16 were not offered or declined resection. Eight (50%) have survived ≥3years. Mean overall survival was 28months for the entire cohort; 47months for cCRs; 61months for patients undergoing primary resection, 46months for cCRs who did not undergo resection and 29months for those undergoing interval resection for recurrent disease. In cCRs, surgery did not provide a survival advantage (p=0.861). CONCLUSION cCR yields an overall 3-year survival of 50% without operation. As 45% of patients have a cCR to naCRT, obligatory resection in high-risk cCR patients makes little sense. With the option for salvage esophagectomy in re-emergent disease, this selective strategy is an attractive alternative for elderly patients with cancer.
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Nosotti M, Palleschi A, Rosso L, Tosi D, Santambrogio L, Mendogni P, Marzorati A, Righi I, Bosari S. Lymph node micrometastases detected by carcinoembryonic antigen mRNA affect long-term survival and disease-free interval in early-stage lung cancer patients. Oncol Lett 2012; 4:1140-1144. [PMID: 23162668 DOI: 10.3892/ol.2012.880] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Accepted: 08/16/2012] [Indexed: 11/05/2022] Open
Abstract
The majority of stage I lung cancer patients undergo a complete resection of their tumor; however, they still harbor a considerable risk of mortality due to recurrences. A correlation between the presence of lymph node micrometastases and poor prognosis has been observed. The aim of this study was to correlate the lymph node molecular staging with the 5-year survival and disease-free interval following pulmonary lobectomy for non-small cell lung cancer (NSCLC). A quantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR) for carcinoembryonic antigen (CEA) mRNA was performed on primary lung tumors and regional lymph nodes from 55 surgically resected NSCLC patients classified as clinical stage I. CEA mRNA was found to be present in all the primary tumors. RT-PCR revealed the presence of cancer cells in the lymph nodes of 20 patients (36.3%) and routine staining detected lymph node metastases in 11 patients. Significant differences in survival and disease-free intervals were observed in patients with lymph node micrometastases versus patients with negative lymph nodes (P=0.0026 and P=0.0044, respectively). Multivariate analyses confirmed that micrometastases were an independent predictor for worse prognosis (P=0.0098) and a short disease-free interval (P=0.0137). This study demonstrated strong correlations between the molecular detection of lymph node micrometastases and 5-year survival rates and disease-free interval in patients who underwent pulmonary lobectomy for early-stage lung cancer.
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Griniatsos J, Michail O, Dimitriou N, Karavokyros I. Lymph node, peritoneal and bone marrow micrometastases in gastric cancer: Their clinical significance. World J Gastrointest Oncol 2012; 4:16-21. [PMID: 22403737 PMCID: PMC3296804 DOI: 10.4251/wjgo.v4.i2.16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 10/03/2011] [Accepted: 10/12/2011] [Indexed: 02/05/2023] Open
Abstract
The 7th TNM classification clearly states that micrometastases detected by morphological techniques (HE stain and immunohistochemistry) should always be reported and calculated in the staging of the disease (pN1mi or M1), while patients in whom micrometastases are detected by non-morphological techniques (e.g., flow cytometry, reverse-transcriptase polymerase chain reaction) should still be classified as N0 or M0. In gastric cancer patients, micrometastases have been detected in lymph nodes, the peritoneal cavity and bone marrow. However, the clinical implications and/or their prognostic significance are still a matter of debate. Current literature suggests that lymph node micrometastases should be encountered for the loco-regional staging of the disease, while skip lymph node micrometastases should also be encountered in the total number of infiltrated lymph nodes. Peritoneal fluid cytology examination should be obligatorily performed in pT3 or pT4 tumors. A positive cytology classifies gastric cancer patients as stage IV. Although a curative resection is not precluded, these patients face an overall dismal prognosis. Whether patients with a positive cytology should be treated similarly to patients with macroscopic peritoneal recurrence should be evaluated further. Gastric cancer cells are detected with high incidence in the bone marrow. However, the published results make comparison of data between groups almost impossible due to severe methodological problems. If these methodological problems are overcome in the future, specific target therapies may be designed for specific groups of patients.
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Affiliation(s)
- John Griniatsos
- John Griniatsos, Othon Michail, Nikoletta Dimitriou, Ioannis Karavokyros, 1st Department of Surgery, University of Athens, Medical School, GR 115-27, Athens, Greece
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Disseminated and circulating tumor cells in gastrointestinal oncology. Crit Rev Oncol Hematol 2011; 82:103-15. [PMID: 21680197 DOI: 10.1016/j.critrevonc.2011.05.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 05/06/2011] [Accepted: 05/20/2011] [Indexed: 12/19/2022] Open
Abstract
Circulating (CTCs) and disseminated tumor cells (DTCs) are two different steps in the metastatic process. Several recent techniques have allowed detection of these cells in patients, and have generated many results using different isolation techniques in small cohorts. Herein, we review the detection results and their clinical consequence in esophageal, gastric, pancreatic, colorectal, and liver carcinomas, and discuss their possible applications as new biomarkers.
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18
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Zhang X, Chen SB, Chen JX, Wen J, Yang H, Xie MR, Zhang Y, Hu YZ, Lin P. CK19 mRNA expression in the bone marrow of patients with esophageal squamous cell carcinoma and its clinical significance. Dis Esophagus 2010; 23:437-43. [PMID: 20095997 DOI: 10.1111/j.1442-2050.2009.01033.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The 5-year survival rate in resectable patients with esophageal cancer is only 20% to 36%. Regional relapse and distant metastasis are responsible for the failure of treatment and the majority of cancer-related deaths. Earlier detection of metastases, especially micrometastases, has the potential for more accurate risk stratification in subsequent therapy decisions. No effective techniques have yet been found to detect metastases in erroneously thought to have early stage disease. This study was designed to investigate the clinical significance of bone marrow micrometastases detected by reverse transcriptase-polymerase chain reaction (RT-PCR) in patients with esophageal cancer. Expression of CK19 mRNA in the bone marrow of 61 patients with esophageal squamous cell carcinoma (ESCC) and 15 benign pulmonary and esophageal disease patients was assessed via RT-PCR. Correlation of CK19 mRNA expression to the clinicopathologic features and prognosis of the 61 patients was analyzed: 21.3% (13/61) were positive for expression of CK19 mRNA in patients with ESCC. No CK19 mRNA was detected of the 15 benign pulmonary and esophageal disease patients. CK19 mRNA expression did not correlate with the clinicopathologic features of the patients with ESCC, but patients with CK19 mRNA-positive bone marrow had earlier recurrence and shorter survival after surgery. In multivariate analysis, CK19 mRNA was found to be an independent predictor of a poor outcome. CK19 mRNA may be used as a molecular maker to detect bone marrow micrometastases in patients with ESCC and may help to select the proper therapy and predict the prognosis.
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Affiliation(s)
- X Zhang
- State Key Laboratory of Oncology in Southern China, Sun Yat-Sen University, Guangzhou, China
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Abstract
OBJECTIVE To address the role of lymphadenectomy in the treatment of esophageal cancer. BACKGROUND The role of lymphadenectomy in esophageal cancer surgery is controversial, and there is a lack of uniformity as to what the term means. METHODS The published data was reviewed to evaluate the evidence base for, and the terminology associated with, lymphadenectomy for esophageal cancer. RESULTS Recommendations are given for a standardization of terminology for radical and nonradical lymphadenectomy procedures. Although there is no doubt that the presence of lymph node metastases worsens prognosis for a patient, there is a lack of high-level evidence to support lymphadenectomy. Logically, the best procedure, from a staging and perhaps theoretical oncologic point of view, is a 3-field lymphadenectomy but it is not clear which patients, if any, are most likely to benefit. CONCLUSIONS Well-designed randomized controlled trials are required to test, in a scientific manner, which of these procedures we should be offering our patients.
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Klein CA, Stoecklein NH. Lessons from an aggressive cancer: evolutionary dynamics in esophageal carcinoma. Cancer Res 2009; 69:5285-8. [PMID: 19549904 DOI: 10.1158/0008-5472.can-08-4586] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rapid progression to metastatic disease and an intrinsic resistance to any type of systemic therapy are hallmarks of aggressive solid cancers. The molecular basis for this phenotype is not clear. A detailed study of the somatic progression from local to early systemic esophageal cancer revealed rapid diversification of cancer cells isolated from various sites, but also evidence for early clonal expansion. These findings have implications for diagnostic pathology and therapeutic decision making.
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Affiliation(s)
- Christoph A Klein
- Department of Pathology, Division of Oncogenomics, University of Regensburg, Regensburg, Germany.
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21
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Jamieson GG, Thompson SK. Detection of lymph node metastases in oesophageal cancer. Br J Surg 2008; 96:21-5. [DOI: 10.1002/bjs.6411] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
The importance of lymph node status in oesophageal cancer cannot be disputed. It is therefore surprising that no standardization exists in either terminology or methodology in lymph node analysis.
Methods
All online databases were searched to identify articles published from 1970 onwards. This was supplemented by hand searching references of retrieved articles.
Results and conclusion
Without accurate identification of lymph node metastases, patients cannot be staged properly, nor can best practice for the treatment of oesophageal cancer be determined. This review outlines the problem and proposes recommendations for standardization in terminology and methodology for the detection of lymph node metastases in oesophageal cancer.
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Affiliation(s)
- G G Jamieson
- Department of Surgery, University of Adelaide, Adelaide, South Australia, Australia
| | - S K Thompson
- Department of Surgery, University of Adelaide, Adelaide, South Australia, Australia
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Bollschweiler E, Metzger R, Drebber U, Baldus S, Vallböhmer D, Kocher M, Hölscher AH. Histological type of esophageal cancer might affect response to neo-adjuvant radiochemotherapy and subsequent prognosis. Ann Oncol 2008; 20:231-8. [PMID: 18836090 DOI: 10.1093/annonc/mdn622] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND This study investigates response and prognosis after neo-adjuvant chemoradiation (CTx/RTx) in patients with advanced esophageal carcinoma, according to histological type. PATIENTS AND METHODS Patients with uT3 carcinoma of the esophagus treated with curative-intention esophagectomy from 1997 until 2006 were included in this retrospective analysis. Patients receiving preoperative CTx/RTx (5-fluorouracil, cisplatin, 36 Gy) were compared with those with primary surgery for pT3 tumors. Therapy response after CTx/RTx was evaluated using 'Cologne Regression Grade' (minor response: >or=10% vital residual tumor cells (VRTCs), major response: <10% VRTC or pathologic complete response). Prognosis was evaluated for adenocarcinoma (AC) and squamous cell carcinoma (SCC). RESULTS Of 297 patients, 52% were SCC and 48% AC. In all, 192 patients underwent CTx/RTx, 100 (65%) SCC and 92 (64%) AC (nonsignificant). In SCC group 51% and in AC group 29% achieved major response (P < 0.01). Patients with major response had a 2-year survival rate (2y-SR) of 78% versus those with minor response or without CTx/RTx, with a 2y-SR of 45% (P = 0.001). Examining patients with major response exclusively, the prognosis of AC (2y-SR 85%) is better than that of SCC (2y-SR 54%) (P < 0.01). CONCLUSION This retrospective study concludes that in esophageal tumors, response to and prognosis after neo-adjuvant CTx/RTx vary according to histology.
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Affiliation(s)
- E Bollschweiler
- Department of General-, Visceral- and Cancer Surgery, University of Cologne, Germany.
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Nosotti M, Tosi D, Palleschi A, Rosso L, Mendogni P, Santambrogio L. Immunocytochemical Detection of Occult Tumor Cells in the Bone Marrow: Prognostic Impact on Early Stages of Lung Cancer. Eur Surg Res 2008; 41:267-71. [DOI: 10.1159/000141961] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Accepted: 02/05/2008] [Indexed: 11/19/2022]
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Kolodziejczyk P, Pituch-Noworolska A, Drabik G, Kulig J, Szczepanik A, Sierzega M, Gurda A, Popiela T, Zembala M. The effects of preoperative chemotherapy on isolated tumour cells in the blood and bone marrow of gastric cancer patients. Br J Cancer 2007; 97:589-92. [PMID: 17700573 PMCID: PMC2360365 DOI: 10.1038/sj.bjc.6603904] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Recent studies in breast cancer suggest that monitoring the isolated tumour cells (ITC) may be used as a surrogate marker to evaluate the efficacy of systemic chemotherapy. In the present study, we have investigated the effects of preoperative chemotherapy on ITC in the blood and bone marrow of patients with potentially resectable gastric cancer. After sorting out the CD45-positive cells, the presence of ITC defined as cytokeratin-positive cells was examined before and after preoperative chemotherapy. The patients received two courses of preoperative chemotherapy with cisplatin (100 mg m−2, day 1) and 5-fluorouracil (1000 mg m−2, days 1–5), administered every 28 days. Fourteen of 32 (44%) patients initially diagnosed with ITC in blood and/or bone marrow were found to be negative (responders) after preoperative chemotherapy (P<0.01). The incidence of ITC in bone marrow was also significantly (P<0.01) reduced from 97 (31 of 32) to 53% (17 of 32). The difference between patients positive for ITC in the blood before (n=7, 22%) and after (n=5, 16%) chemotherapy was statistically insignificant. The overall 3-year survival rates were 32 and 49% in the responders and non-responders, respectively (P=0.683). These data indicate that preoperative chemotherapy can reduce the incidence of ITC in patients with gastric cancer.
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Affiliation(s)
- P Kolodziejczyk
- 1st Department of Surgery, Jagiellonian University Medical College, 40 Kopernika Street, Krakow 31-501, Poland
| | - A Pituch-Noworolska
- Department of Clinical Immunology, Jagiellonian University Medical College, Krakow 31-501, Poland
| | - G Drabik
- Department of Clinical Immunology, Jagiellonian University Medical College, Krakow 31-501, Poland
| | - J Kulig
- 1st Department of Surgery, Jagiellonian University Medical College, 40 Kopernika Street, Krakow 31-501, Poland
- E-mail:
| | - A Szczepanik
- 1st Department of Surgery, Jagiellonian University Medical College, 40 Kopernika Street, Krakow 31-501, Poland
| | - M Sierzega
- 1st Department of Surgery, Jagiellonian University Medical College, 40 Kopernika Street, Krakow 31-501, Poland
| | - A Gurda
- 1st Department of Surgery, Jagiellonian University Medical College, 40 Kopernika Street, Krakow 31-501, Poland
| | - T Popiela
- 1st Department of Surgery, Jagiellonian University Medical College, 40 Kopernika Street, Krakow 31-501, Poland
| | - M Zembala
- Department of Clinical Immunology, Jagiellonian University Medical College, Krakow 31-501, Poland
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Cady B. Regional lymph node metastases; a singular manifestation of the process of clinical metastases in cancer: contemporary animal research and clinical reports suggest unifying concepts. Ann Surg Oncol 2007; 14:1790-800. [PMID: 17342568 DOI: 10.1245/s10434-006-9234-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2006] [Revised: 08/28/2006] [Accepted: 08/31/2006] [Indexed: 02/06/2023]
Abstract
Research results from laboratory animals and human clinical reports provide insight into cancer cell disseminations and elaborate the complex metastatic cascade of cells into both regional lymph nodes and other distant organs. Critical appraisal of clinical trials indicates that lymph node metastases are themselves non-lethal, but indicate prognosis, confirming laboratory conclusions. Distant vital organ metastases can be resected with long term survival in highly selective situations, demonstrating metastatic specificity in oligometastatic disease. Appreciating lymphatic system embryology, anatomy, and physiology is necessary for understanding lymph node metastases. The primary lymphatic system function was to return interstitial fluid to the circulation. Later evolutionary insertion of lymphocyte collections in lymph nodes interrupting lymph flow completed a system of analyzing external antigens to enable adaptive immunologic responses. Human cancers seldom elicit major immunological responses; they are not generally "foreign" enough. Therefore, lymphatic metastases have little meaning in evolutionary terms. Organ specificity of both lymphatic and distant metastases occurs as metastatic cells lie dormant, but grow selectively only in liver, lung, bone, or lymph nodes. These organ specific metastatic cells have little ability to produce different organ site clinical metastases. Thus, laboratory findings and clinical correlations emphasize that surgical lymph node removal should be de-emphasized or omitted. More physiological approaches to the highly manipulable multi-step processes of clinical metastases arising from host microenvironments will eventually prevail.
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Affiliation(s)
- Blake Cady
- Brown Medical School Interim Director, Comprehensive Breast Center, Rhode Island Hospital 593 Eddy Street, APC 4 Providence, RI 02903, USA.
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Matsuyama J, Doki Y, Yasuda T, Miyata H, Fujiwara Y, Takiguchi S, Yamasaki M, Makari Y, Matsuura N, Mano M, Monden M. The effect of neoadjuvant chemotherapy on lymph node micrometastases in squamous cell carcinomas of the thoracic esophagus. Surgery 2007; 141:570-80. [PMID: 17462456 DOI: 10.1016/j.surg.2006.11.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2006] [Revised: 11/16/2006] [Accepted: 11/20/2006] [Indexed: 01/10/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NACT) has been postulated but not yet proven to eradicate micrometastases and improve the prognosis of patients with advanced esophageal squamous cell carcinomas (ESCC). Cytokeratin immunohistochemistry of the lymph nodes of ESCC revealed immunohistochemical micrometastases (IHM) and cytokeratin deposits (CD), which are hyalinized denucleated particles considered to be cadavers of carcinoma cells. Successful chemotherapy should convert cancer cells from IHM to CD and improve the status of ESCC patients from systemic disease to regional disease. METHODS Cytokeratin immunostaining of surgically removed lymph nodes was performed for 107 patients with node-positive ESCC, including 32 patients without preoperative treatment (Surgery group) and 75 patients undergoing NACT using CDDP, doxorubicin hydrochroride, and 5-fluorouracil (NACT group). Cytokeratin-positive staining was done for serial hematoxylin-eosin-stained sections and classified as pathologic metastasis, IHM, or CD. RESULTS CD was observed less frequently in the Surgery group than in the NACT group (6% vs 43%, P < .0001), whereas IHM was more frequent in the former (47% vs 24%, P = .019). IHM was a poor prognostic factor in both groups, whereas CD was a favorable one in the NACT group. The effect of chemotherapy on IHM was classified as eradicated, IHM(-)/CD(+); persistent, IHM(+)/CD(+); no effect, IHM(+)/CD(-); or not informative, IHM(-)/CD(-). This classification correlated well with the clinical response of the primary neoplasm, number of pathologic metastases, and postoperative survival (3-year survival rates: 78%, 18%, 0%, and 38%). IHM/CD was found to be an independent prognostic factor together with the number of pathologic metastases in the multivariate analysis. CONCLUSIONS Disappearance of IHM and the emergence of CD suggest the eradication of micrometastases by NACT. The clinical benefit of NACT was apparent for IHM(-)/CD(+) patients with node-positive ESCC.
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Affiliation(s)
- Jin Matsuyama
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
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Cady B. Regional lymph node metastases, a singular manifestation of the process of clinical metastases in cancer: contemporary animal research and clinical reports suggest unifying concepts. Cancer Treat Res 2007; 135:185-201. [PMID: 17953417 DOI: 10.1007/978-0-387-69219-7_14] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The multistep complex metastatic cascade in cancer has been extensively studied in recent years. In addition, the concept of metastatic organ specificity has been elaborated. Histological studies in clinical situations have become far more sophisticated, enabling the frequent discovery of minor collections of cells in bone marrow and lymph nodes. Pertinent clinical evidence of the selective nodal metastatic pattern exists in differentiated thyroid cancer in younger, low-risk patients, yet none of the published risk group definitions indicate that lymph node metastases have a relationship to thyroid cancer survival. This unique clinical situation with very frequent nodal metastases but excellent survival is replicated in carcinoid cancers of the gastrointestinal tract. The lymph node metastatic frequency without distant organ metastases in these two human cancers help cement the understanding gained from laboratory and animal research regarding metastatic specificity and hopefully will help place the role of lymph node metastases generally and their surgical removal on a more scientifically and logically based understanding. More broadly, the elaboration of the frequency of metastatic cell dissemination to distant organs as well as lymph nodes, and comprehension of the metastatic cascade with metastatic specificity may reorient our understanding of the evolution from metastatic cells to clinical metastatic disease. Additionally, these concepts reemphasize that lymph node metastases are indicators, not governors, of distant metastases and survival, and add the assumption that metastatic tumor cells and tumor cell clusters, and perhaps even micrometastases in other organs, are themselves only indicators and not governors of distant metastases and survival in human cancers since they represent dormant metastases prior to their host microenvironmental changes that, on rare occasions, lead to angiogenesis and clinical metastases. Thus, the future may allow us to abandon some aspects of our surgical or systemic attack on clinical cancer metastases, such as lymph node removal or use of toxic chemotherapy, but open the door to more physiological and hopefully less traumatic approaches to the highly manipulable multistep genetic and physiological process of metastatic development. The future biological models of clinical cancer behavior will have to incorporate aspects of understanding the intricate metastatic cascade, and particularly the host microenvironmental factors that permit or prevent progressive growth of dormant cells or cell clusters to clinical metastases.
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Affiliation(s)
- Blake Cady
- Department of Surgery, Brown Medical School, Providence, Rhode Island, USA
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Gretschel S, Bembenek A, Schulze T, Kemmner W, Schlag PM. [Minimal residual tumor in gastrointestinal carcinoma. Relevance to prognosis and oncologic surgical consequences]. Chirurg 2006; 77:1104-17. [PMID: 17119886 DOI: 10.1007/s00104-006-1263-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Isolated tumor cells as a consequence of minimal residual disease are often not detectable by routine diagnostic procedures. However, before or after surgery, isolated tumor cells in lymph nodes, the peritoneal cavity, blood, or bone marrow can frequently be identified by immunohistochemical or molecular methods. Failure to reveal the presence of such cells results in under-staging of tumor patients and may constitute the source of unexpected tumor recurrence after radical surgery. These facts emphasize the importance of isolated tumor cells at least as a surrogate marker. The frequency of appearance of isolated tumor cells in different organ systems also depends on the type of primary tumor. Developments in modern detection methods have led to increasing sensitivity but at the expense of specificity. Isolated tumor cells demonstrate remarkable heterogeneity with respect to proliferative potential and tumorigenicity. This characteristic is also reflected by a striking variability in the expression of various genes conditioning the aforementioned biological behavior. Unfortunately there is also remarkable heterogeneity in methods used for sampling and processing patient material as well as for the enrichment and detection of isolated tumor cells. Despite the ongoing controversies concerning detection methods and biological significance of isolated tumor cells, several clinical trials providing data supporting the prognostic relevance of minimal residual disease should also be considered for gastrointestinal carcinoma. In future this finding should be integrated in the planning of trials in surgical oncology, and "minimal residual disease" should receive stronger attention as a stratification criterion in such clinical studies.
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Affiliation(s)
- S Gretschel
- Klinik für Chirurgie und Chirurgische Onkologie, Robert-Rössle-Klinik am Helios Klinikum Berlin, Universitätsmedizin Berlin, Charite Campus Buch, Lindenberger Weg 80, 13125 Berlin
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Gretschel S, Schick C, Schneider U, Estevez-Schwarz L, Bembenek A, Schlag PM. Prognostic Value of Cytokeratin-Positive Bone Marrow Cells of Gastric Cancer Patients. Ann Surg Oncol 2006; 14:373-80. [PMID: 17080240 DOI: 10.1245/s10434-006-9039-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Epithelial cells in the bone marrow of patients with gastric cancer suggest tumor dissemination; however, their prognostic implications are controversial. We prospectively evaluated the correlation of bone marrow findings, recurrence rate, and disease-free survival after long-term follow-up. METHODS Bone marrow were aspirated from both iliac crests and stained with monoclonal cytokeratin (CK)-18 antibody in 209 patients before their initial operation. Patients were followed up for a median of 56 months. RESULTS Overall, 39 (19%) of 209 patients and 15 (14%) of 109 R0-resected patients had CK-positive cells. CK-positive patients had more local, regional, and distant recurrence than CK-negative patients (P < .05). We found a significantly shorter disease-free survival (P < .05) in the patients with >2 CK-positive cells per 2 x 10(6) bone marrow cells (mean, 35 months) than in patients with <or=2 CK-positive cells per 2 x 10(6 )bone marrow cells (mean, 70 months) or in patients with no CK-positive cells (mean, 86 months). Multivariate analysis confirmed that >2 CK-positive cells per 2 x 10(6) bone marrow cells was an independent prognostic factor for tumor-related death (P < .05). CONCLUSIONS Not only the mere presence of CK-positive epithelial cells in bone marrow, but also the cell number, correlates with prognosis. Our findings suggest that classifying CK-positive bone marrow cells in these patients will facilitate future studies.
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Affiliation(s)
- Stephan Gretschel
- Department of Surgery and Surgical Oncology, Charité-Universitätsmedizin Berlin, Campus Buch, Robert-Rössle-Klinik at the Helios Klinikum Berlin, Lindenberger Weg 80, 13125, Berlin, Germany
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Lagarde SM, ten Kate FJW, Reitsma JB, Busch ORC, van Lanschot JJB. Prognostic factors in adenocarcinoma of the esophagus or gastroesophageal junction. J Clin Oncol 2006; 24:4347-55. [PMID: 16963732 DOI: 10.1200/jco.2005.04.9445] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The incidence of adenocarcinoma of the esophagus is rising rapidly in Western Europe and North America. It is an aggressive disease with early lymphatic and hematogenous dissemination. TNM cancer staging systems predict survival on the basis of the anatomic extent of the tumor. However, the adequacy of the current TNM staging system for adenocarcinoma of the esophagus or gastroesophageal junction (GEJ) is questioned repeatedly. Numerous prognostic factors have been described, but are not included in the TNM system. This review describes clinical parameters, aspects of operative technique, response to preoperative chemoradiotherapy therapy, complications and established pathologic determinants found in the resection specimen that have a prognostic impact. Furthermore, their potential application in the clinical setting in patients with adenocarcinoma of the esophagus or GEJ is discussed. Future directions to improve staging systems are given.
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Affiliation(s)
- Sjoerd M Lagarde
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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Thorban S, Rosenberg R, Maak M, Friederichs J, Gertler R, Siewert JR. Impact of disseminated tumor cells in gastrointestinal cancer. Expert Rev Mol Diagn 2006; 6:333-43. [PMID: 16706737 DOI: 10.1586/14737159.6.3.333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The detection of epithelial cells by sensitive immunological and molecular methods in blood, lymph nodes or bone marrow of gastrointestinal cancer patients may open a new approach to clinical metastasis research. The phenotypic and genomic characterization of these cells is of great value in the prediction of the further course of the disease and the monitoring of response to treatment. In addition, the role of ultrastaging in blood, lymph nodes and bone marrow of cancer patients for the indication of multimodal therapy is discussed in this review. The impact of prognostic or predictive factors for new treatment protocols in patients with gastrointestinal cancer was evaluated as well as the correlation with clinical factors.
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Affiliation(s)
- Stefan Thorban
- Technische University Munich, Chirurgische Klinik & Poliklinik, Klinikum Rechts der Isar, Ismaningerstr 22, 81675 Munich, Germany.
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DeMeester SR. Adenocarcinoma of the esophagus and cardia: a review of the disease and its treatment. Ann Surg Oncol 2006; 13:12-30. [PMID: 16378161 DOI: 10.1245/aso.2005.12.025] [Citation(s) in RCA: 167] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2004] [Accepted: 07/20/2005] [Indexed: 02/06/2023]
Abstract
BACKGROUND Over the past 50 years there has been a remarkable change in the epidemiology of esophageal cancer. Previously rare, adenocarcinoma of the esophagus and gastroesophageal junction is now the most common esophageal cancer, and in the United States the incidence is increasing faster than that of any other malignancy. Surveillance in patients with Barrett's esophagus is identifying adenocarcinoma at an earlier, more curable stage in many patients, and at the same time new endoscopic and surgical options are available for the therapy of these localized tumors. METHODS This article is a review of the epidemiology, diagnosis, staging, and treatment options for esophageal and gastroesophageal junction adenocarcinoma. RESULTS The epidemiology, prognosis, patterns of lymphatic metastasis, and survival for esophageal and gastroesophageal junction adenocarcinoma suggest that these tumors are similar. New options for therapy, as well as the results of surgical resection with and without chemoradiotherapy, are reviewed. CONCLUSIONS Surveillance programs for Barrett's are identifying patients with early, curable adenocarcinoma of the esophagus or gastroesophageal junction. Therapy for more advanced tumors hinges on local control of the disease and the eradication of systemic metastases.
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Affiliation(s)
- Steven R DeMeester
- Department of Cardiothoracic Surgery, The University of Southern California, Keck School of Medicine, 1510 San Pablo Street, Suite 514, Los Angeles, California, 90033, USA.
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Natarajan S, Taneja C, Cady B. Evolution of Lymphadenectomy in Surgical Oncology. Surg Oncol Clin N Am 2005; 14:447-59, v. [PMID: 15978423 DOI: 10.1016/j.soc.2005.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Subramanian Natarajan
- Department of Surgery, Roger Williams Medical Center, 825 Chalkstone Avenue, Providence, RI 02908, USA
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Patel M, Ferry K, Franceschi D, Kaklamanos I, Livingstone A, Ardalan B. Esophageal Carcinoma: Current Controversial Topics. Cancer Invest 2004; 22:897-912. [PMID: 15641488 DOI: 10.1081/cnv-200039672] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Worldwide, esophageal carcinoma is a common gastrointestinal cancer with a high mortality. The incidence of adenocarcinoma of the esophagus is increasing in the western world, but squamous cell carcinoma remains dominant in the underdeveloped parts of the world. Both types of esophageal carcinoma remain equally virulent. Currently, there are no optimal preventative screening programs available and most patients present with advanced or metastatic disease. Although many options are available for improving diagnostic accuracy, a single method has not displayed significant advantages over the others. In addition, selecting a superior treatment regimen has not surfaced. Preferred resection techniques exist, but one method has not illustrated improvements in survival over the others. A lack of improved survival rates with single modality therapies has led to a multi modality approach. However, developments in neoadjuvant and adjuvant therapies have led to mixed conclusions. Collectively, past studies have not shown an optimal neoadjuvant or adjuvant regimen in terms of survival benefit. This review highlights existing staging modalities and treatment regimens for esophageal carcinoma, in an effort to illustrate the controversial nature surrounding its management.
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Affiliation(s)
- M Patel
- Department of Hematology/Oncology, Sylvester Cancer Institute, University of Miami School of Medicine, Miami, Florida 33136, USA
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36
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Kaganoi J, Shimada Y, Kano M, Okumura T, Watanabe G, Imamura M. Detection of circulating oesophageal squamous cancer cells in peripheral blood and its impact on prognosis. Br J Surg 2004; 91:1055-60. [PMID: 15286970 DOI: 10.1002/bjs.4593] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Many studies have attempted to detect cancer cells using the reverse transcription-polymerase chain reaction (RT-PCR) for specific mRNAs. None has examined the correlation between the presence of circulating oesophageal cancer cells in peripheral blood and long-term outcome. METHODS Blood samples were obtained on admission, and before, during and after operation from 70 patients with squamous oesophageal cancer who had complete clinicopathological records and who underwent curative oesophagectomy between June 1997 and June 2000. RT-PCR for mRNA encoding squamous cell carcinoma antigen (SCCA mRNA) was used to detect oesophageal cancer cells in peripheral blood. RESULTS Twenty-three patients (33 per cent) were positive for SCCA mRNA on admission and 17 of these patients developed recurrent disease. SCCA mRNA on admission correlated with the depth of tumour invasion (P < 0.001) and with venous invasion (P < 0.001). Eleven of 24 patients with a positive intraoperative result were positive for SCCA mRNA only during operation, of whom seven also developed recurrence. CONCLUSION RT-PCR for SCCA mRNA can detect oesophageal cancer cells in peripheral blood. The presence of such cells in blood samples obtained on admission or during operation is a useful predictor of outcome in patients with oesophageal squamous cell carcinoma.
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Affiliation(s)
- J Kaganoi
- Department of Surgery and Surgical Basic Science, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawara-cho, Sakyo-ku, Kyoto 606-8507, Japan
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Ryan P, McCarthy S, Kelly J, Collins JK, Dunne C, Grogan L, Breathnach O, Shanahan F, Carey PD, Walsh TN, O'Sullivan GC. Prevalence of bone marrow micrometastases in esophagogastric cancer patients with and without neoadjuvant chemoradiotherapy. J Surg Res 2004; 117:121-6. [PMID: 15013722 DOI: 10.1016/j.jss.2003.12.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2003] [Indexed: 02/07/2023]
Abstract
BACKGROUND Bone marrow micrometastases are present in a high proportion of patients undergoing curative resection for esophagogastric cancer. The incorporation of preoperative systemic therapies into these patients' treatment is widely practiced. This study investigates the effect of neoadjuvant chemoradiotherapy (CRT) on the incidence of micrometastases and the viability of detected tumor cells. MATERIALS AND METHODS Rib bone marrow was obtained from patients (n = 106) in three centers, who were selected for potentially curative resection. Patients received neoadjuvant CRT plus surgery (n = 55), or surgery alone (n = 51). To detect micrometastases, mononuclear cells were isolated from fresh marrow and immediately stained immunohistochemically with an anti-cytokeratin-18 antibody using the APAAP technique. Tumor cell viability was assessed by immunohistochemical staining of marrow cell cultures for cytokeratin-positive cells. RESULTS Micrometastases were detected in fresh marrow in 42% (23/55) of patients who received neoadjuvant CRT plus surgery, and in 67% (34/51) of patients treated with surgery alone. Viable tumor cells were demonstrated in 10 of 18 marrow cultures from CRT plus surgery cases. In this patient subset, combination of results of staining fresh and cultured marrow significantly increased micromet detection to 78%. CONCLUSIONS A significant proportion of patients with esophagogastric cancer have disseminated viable tumor cells at time of surgery, irrespective of pre-operative treatment. The use of marrow culture in parallel with fresh marrow staining may increase the detection of micrometastases. The persistence of tumor cells resistant to systemic therapy may explain why these regimens fail in a majority of patients.
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Affiliation(s)
- Paul Ryan
- Cork Cancer Research Centre, National University of Ireland, Cork, Dublin, Ireland.
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Abstract
In curatively resected gastric cancer, the incidence of distant relapse is as high as 30%. Although the most important factor contributing to the local control of the tumor is the microscopic tumor-free margin of the surgical resection, the occurrence of distant metastases is in many cases due to preoperative or perioperative tumor cell dissemination. In addition to the established TNM staging system, disseminated tumor cells may serve as independent prognostic factors influencing patient outcome after curative surgery. Basically, in gastric cancer three compartments have been identified in which single tumor cells may be shed: lymph nodes, peritoneal cavity, and bone marrow. Assessment of resected regional lymph nodes with monoclonal antibodies directed against cytokeratin antigens leads to an upstaging in comparison with conventional histology. Nodal micrometastases detected by immunohistochemistry result in an upstaging of up to 36% of patients. However, their prognostic significance remains controversial. Local dissemination of tumor cells in the peritoneal cavity determines the outcome in advanced gastric cancer and diffuse-type carcinoma. Patients with negative peritoneal washings seem to have a more favorable prognosis. Moreover, with the use of these diagnostic tools, patient subpopulations may be identified which profit from intraperitoneal therapy regimens. Diffuse hematogenous tumor cell dissemination into the bone marrow has been shown to be a prognostic factor in several studies. In our own population of 180 gastric cancer patients, bone marrow cells were screened immunohistochemically with a monoclonal antibody directed against cytokeratin 18 (CK18). In 95 patients (53%), CK2-posititve cells were detected. In a multivariate analysis, the independence of the presence of three or more disseminated tumor cells per 10(6) mononuclear cells was proven to be a prognostic factor in patients with intestinal-type tumors, pT1/2 status, and pN0 status. In conclusion, the TNM status only partially reflects the actual extent of systemic disease in patients with resected gastric cancer. The assessment of minimal residual disease is valuable in estimating the prognosis in many patients. In the future, staging systems will have to not only include TNM data but also provide specific information on biological properties of residual cancer cells in order to establish more exact prognostic estimates and provide patients with an individually tailored multimodal treatment.
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Affiliation(s)
- Hendrik Seeliger
- Klinik und Poliklinik für Chirurgie, Klinikum der Universität Regensburg, 93042 Regensburg, Germany
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Macadam R, Sarela A, Wilson J, MacLennan K, Guillou P. Bone marrow micrometastases predict early post-operative recurrence following surgical resection of oesophageal and gastric carcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2003; 29:450-4. [PMID: 12798750 DOI: 10.1016/s0748-7983(03)00029-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM Tumour cells in the bone marrow of patients with gastrointestinal cancer may detect patients at higher risk of disease recurrence and death following potentially curative surgery. METHODS Immunocytochemistry using the monoclonal antibody Ber-EP4, which detects tumour cells from squamous and adenocarcinomas was used. In preliminary spiking experiments to define sensitivity, tumour cells were detected in blood at 10(3)/ml. Bone marrow samples from 74 patients with oesophago-gastric cancer and from 14 control patients was examined. RESULTS 27 (36.5%) patients with cancer and one control patient had stained cells present in their bone marrow at the time of resection. During the follow up period (mean 14 months), relapse and disease-specific death were commoner in patients whose marrow contained tumour cells. Multivariate analysis confirmed bone marrow micrometastasis as an independent prognostic variable for both recurrence and survival. CONCLUSIONS Bone marrow immunocytochemistry using Ber-EP4 may identify those patients at highest risk of early relapse following RO resection of oesophageal or gastric cancer.
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Affiliation(s)
- Robert Macadam
- Department of Surgery, St James' University Hospital, Leeds, UK.
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Matsunami K, Nakamura T, Oguma H, Kitamura Y, Takasaki K. Detection of bone marrow micrometastasis in gastric cancer patients by immunomagnetic separation. Ann Surg Oncol 2003; 10:171-5. [PMID: 12620913 DOI: 10.1245/aso.2003.06.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Micrometastasis to the bone marrow can predict widespread disease and a poor prognosis of cancer patients after surgery. The purpose of this study was to evaluate the clinical significance of detecting micrometastasis in the bone marrow of gastric cancer patients. METHODS Bone marrow and peripheral blood samples were obtained from 53 gastric cancer patients at the time of surgery. These samples were enriched by immunomagnetic separation and immunostained with an anti-cytokeratin antibody. Expression of vascular endothelial growth factor and erbB-2/HER2 was examined in the primary tumors. RESULTS Cytokeratin-positive cancer cells were observed in the bone marrow of 16 (30%) of 53 patients. Among them, two patients also had cancer cells in the peripheral blood. The presence of bone marrow micrometastasis was correlated with the depth of invasion and lymph node metastasis but was not associated with peritoneal dissemination. Detection of bone marrow micrometastasis was not correlated with vascular endothelial growth factor or HER2 expression in the primary tumors. Four patients with micrometastasis had recurrence in the liver or lungs, but this did not occur in patients without micrometastasis. CONCLUSIONS Detection of cancer cells in the bone marrow might be an indicator of postoperative hematogenous metastasis in gastric cancer patients.
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Affiliation(s)
- Katsuhiro Matsunami
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
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41
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Affiliation(s)
- John Wong
- Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong
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42
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Doki Y, Ishikawa O, Mano M, Hiratsuka M, Sasaki Y, Kameyama M, Ohigashi H, Murata K, Yamada T, Miyashiro I, Yokoyama S, Ishiguro S, Imaoka S. Cytokeratin deposits in lymph nodes show distinct clinical significance from lymph node micrometastasis in human esophageal cancers. J Surg Res 2002; 107:75-81. [PMID: 12384067 DOI: 10.1006/jsre.2002.6506] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cytokeratin immunostaining is the most common method used to identify micrometastatic cancer cells from the lymph nodes. However, contamination with hyalinized cytokeratin particles, frequently observed in the lymph nodes of esophageal cancer patients, can lead to misinterpretation of cytokeratin immunostaining. MATERIALS AND METHODS Cytokeratin immunostaining (AE1/AE3) of surgically removed lymph nodes was performed for 41 cases of node-negative, but locally advanced (T3, T4), esophageal cancer patients. Cytokeratin immunoreactivity (CK) was classified as micrometastasis (MM) or cytokeratin deposit (CD) by the presence or absence of tumor nuclei in serial sections given hematoxylin-eosin staining. RESULTS CK (+) was observed in 18 patients (44%), including 11 with MM (+) (27%) and 10 with CD (+) (24%). There was no correlation between MM and CD, and neither was associated with clinicopathological factors, except for a high incidence of preoperative chemotherapy in CD (+) patients. The presence of CK did not affect postoperative survival of esophageal cancer patients at this limited stage, showing a 5-year survival rate of 57% for CK (+) and 64% for CK (-) (P = 0.6064). Interestingly, patients with MM (+) showed poorer prognosis than MM (-) (5-year survival: 28% vs 79%, P = 0.0188), while CD (+) patients tended to display better prognosis than CD (-) ones (5-year survival: 78% vs 56%, P = 0.1860). CONCLUSIONS Evaluation by cytokeratin immunostaining of lymph nodes requires careful discrimination of CD from MM, in order to allow MM to be used as a prognostic factor for esophageal cancer patients.
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Affiliation(s)
- Yuichiro Doki
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan
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de Manzoni G, Pelosi G, Pavanel F, Di Leo A, Pedrazzani C, Durante E, Cordiano C, Pasini F. The presence of bone marrow cytokeratin-immunoreactive cells does not predict outcome in gastric cancer patients. Br J Cancer 2002; 86:1047-51. [PMID: 11953846 PMCID: PMC2364170 DOI: 10.1038/sj.bjc.6600211] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2001] [Revised: 12/10/2001] [Accepted: 12/28/2001] [Indexed: 02/07/2023] Open
Abstract
The independent prognostic significance of isolated tumour cells in bone marrow is still a matter of debate. This study evaluated the possible association of bone marrow micrometastases with tumour progression and prognosis in patients affected by gastric cancer. Bone marrow aspirates from both iliac crests were obtained from 114 consecutive patients operated on for gastric cancer. The specimens were stained with monoclonal antibody CAM 5.2 which reacts predominantly with cytokeratin filaments 8 and 19. Among 114 cases analysed, 33 cases (29%) had cytokeratine-positive cells in the bone marrow. There was no significant relationship between the presence of bone marrow micrometastases and site, depth of tumour invasion, lymph node metastases, presence of metastases. Patients with cytokeratine-positive cells had a trend towards a diffuse type histology (P=0.06). Among the 88 curatively resected patients, median survivals were 40 months and 36 months for cytokeratine-negative and cytokeratine-positive subsets respectively (P=0.9). Recurrence of the disease was observed in 39 cases (44.3%); 11 of 24 (45.8%) in the cytokeratine-positive subset and 28 of 64 (43.7%) in the cytokeratine-negative subset. In conclusion in our experience the presence of cytokeratine-positive cells in the bone marrow of curatively resected gastric cancer patients did not affect outcome and its independent prognostic significance remains to be proven before its official acceptance in the TNM classification.
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Affiliation(s)
- G de Manzoni
- Istituto di Semeiotica Chirurgica, Università di Verona, Verona, Italy
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Chilton AP, Jankowski J. Squamous carcinoma of the oesophagus: continuing to challenge. Dig Liver Dis 2001; 33:528-30. [PMID: 11816538 DOI: 10.1016/s1590-8658(01)80101-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- A P Chilton
- Epithelial Laboratory, Division of Medical Sciences, University of Birmingham, UK
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45
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Kienle P, Koch M. Minimal residual disease in gastrointestinal cancer. SEMINARS IN SURGICAL ONCOLOGY 2001; 20:282-93. [PMID: 11747270 DOI: 10.1002/ssu.1046] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Tumor progression after curative resection of gastrointestinal carcinomas is probably caused by pre- or intraoperative tumor cell dissemination. Disseminated tumor cells are generally detected by immunohistochemistry- or PCR-based molecular-biology methods. A consensus on which is the most adequate detection method has not yet been found, which makes the comparison of data difficult. The prognostic relevance of disseminated cells has been shown, at least in part, for esophageal, gastric, pancreatic, and colonic cancer. The data regarding hepatocellular cancer is conflicting. This article gives a critical review of tumor cell detection in gastrointestinal cancer.
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Affiliation(s)
- P Kienle
- Department of Surgery, University of Heidelberg, Heidelberg, Germany.
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