Oesophageal and gastric cardia adenocarcinomas: analysis of regional variation using the Cancer Incidence in Five Continents database

Prognostic and clinicopathological value of Ki-67 in patients with oesophageal squamous cell carcinoma: a systematic review and meta-analysis

OBJECTIVES

The relationship between Ki-67 expression and the prognosis of patients with oesophageal squamous cell carcinoma (ESCC) has been extensively studied. However, their findings were inconsistent. Consequently, the present meta-analysis was performed to identify the precise value of Ki-67 in predicting the prognosis of ESCC.

DESIGN

The current meta-analysis was carried out in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

DATA SOURCES

Electronic databases of PubMed, Embase, Web of Science and Cochrane Library were systematically searched until 26 September 2023.

STATISTICAL METHODS

Pooled HRs and corresponding 95% CIs were calculated to estimate the role of Ki-67 in predicting overall survival (OS) and disease-free survival (DFS) in ESCC. Between-study heterogeneity was evaluated using Cochrane's Q test and I2 statistics. Specifically, significant heterogeneities were identified based on p<0.10 on the Q statistic test or I2>50% so the random-effects model should be used; otherwise, the fixed-effects model should be used. The relationship between Ki-67 and clinicopathological characteristics of ESCC was evaluated by combining ORs with their corresponding 95% CIs.

RESULTS

11 articles with 1124 patients were included in the present meta-analysis. Based on our analysis, increased Ki-67 expression was markedly associated with poor OS (HR 1.62, 95% CI 1.15 to 2.28, p=0.006) and DFS (HR 1.72, 95% CI 1.22 to 2.43, p=0.002) in ESCC. Moreover, subgroup analysis revealed that Ki-67 upregulation significantly predicted OS and DFS when a Ki-67 threshold of >30% was used. Nonetheless, Ki-67 was not significantly associated with sex, T stage, N stage, TNM stage, tumour differentiation or tumour location.

CONCLUSIONS

In the present meta-analysis, high Ki-67 expression significantly predicted OS and DFS in patients with ESCC, especially when Ki-67>30% was used as the threshold. These results suggest that Ki-67 could serve as an effective and reliable prognostic indicator for ESCC.

The development and validation of automated machine learning models for predicting lymph node metastasis in Siewert type II T1 adenocarcinoma of the esophagogastric junction

Background

Lymph node metastasis (LNM) is considered an essential prognosis factor for adenocarcinoma of the esophagogastric junction (AEG), which also affects the treatment strategies of AEG. We aimed to evaluate automated machine learning (AutoML) algorithms for predicting LNM in Siewert type II T1 AEG.

Methods

A total of 878 patients with Siewert type II T1 AEG were selected from the Surveillance, Epidemiology, and End Results (SEER) database to develop the LNM predictive models. The patients from two hospitals in Suzhou were collected as the test set. We applied five machine learning algorithms to develop the LNM prediction models. The performance of predictive models was assessed using various metrics including accuracy, sensitivity, specificity, the area under the curve (AUC), and receiver operating characteristic (ROC) curve.

Results

Patients with LNM exhibited a higher proportion of male individuals, a poor degree of differentiation, and submucosal infiltration, with statistical differences. The deep learning (DL) model demonstrated relatively good accuracy (0.713) and sensitivity (0.868) among the five models. Moreover, the DL model achieved the highest AUC (0.781) and sensitivity (1.000) in the test set.

Conclusion

The DL model showed good predictive performance among five AutoML models, indicating the advantage of AutoML in modeling LNM prediction in patients with Siewert type II T1 AEG.

Clinicopathological profile and survival analysis of esophageal carcinoma: A retrospective study in a tertiary care hospital in Northeast India

BACKGROUND

Esophageal cancer (EC) is an extremely aggressive tumor with one of the highest geographic, ethnic, and gender variations. Various factors including tobacco consumption, unhealthy diet, and socioeconomic status have been implicated in the etiology of EC. Despite the advent of modern treatments, the prognosis of EC is dismal. This study has been undertaken to review the clinical and pathologic profiles, treatment approach, and survival pattern in patients with EC in a tertiary care hospital in northeast India.

MATERIALS AND METHODS

A retrospective descriptive study was done with 179 EC patients presented to our department between January 2013 and December 2020. Statistical analysis was done by using IBM Statistical Package for the Social Sciences version 21. P- value <0.05 was considered significant.

RESULTS

The majority of the patients presented in the sixth decade of life from rural areas with male to female ratio of 3.7:1. Dysphagia was the most common presenting feature. High incidence of tobacco and alcohol use was found. Mid-esophagus is the most common site and squamous cell carcinoma is the most common type. Fifty-two (29.1%) and 71 (39.6%) patients presented in stages III and IV, respectively. Twenty-four (13.4%) patients presented with metastatic disease, the lung being the most common site. Patients were treated with surgery, chemotherapy, radiotherapy, or combination of any of these. Overall median survival for the EC patients was 6 months. Patients treated with concurrent chemoradiation had better survival.

CONCLUSION

EC is a serious malignancy with a dismal prognosis due to the advanced stage at presentation. Larger clinical trials using new therapeutic strategies are the need of the hour.

Comparative analysis of immune checkpoint inhibitors in first-line treatment of esophageal squamous cell carcinoma: a network meta-analysis

Aim: To evaluate the efficacy and safety of first-line immunochemotherapy in the treatment of advanced esophageal squamous cell carcinoma (CRD42021287033). Methods: PubMed, Embase, Cochrane Library and Web of Science were systematically searched to obtain randomized controlled trials, and the outcome indicators of the reports were compared and analyzed. Results: A total of 3163 patients from five reported randomized controlled trials were included in the meta-analysis. The results showed the comprehensive benefits of toripalimab combined with chemotherapy, in terms of overall survival (hazard ratio: 0.59; 95% CI: 0.43-0.81) and progression-free survival (hazard ratio: 0.58; 95% CI: 0.46-0.73). Conclusion: Toripalimab combined with chemotherapy may be a better choice for first-line immunochemotherapy, although this needs to be verified by clinical studies.

Update on Management of Squamous Cell Esophageal Cancer

PURPOSE OF THE REVIEW

Esophageal cancer is the sixth most common cause of cancer death globally. Squamous cell carcinoma of the esophagus (ESCC) is the predominant histologic type in the world. Treatment strategies have evolved in the last decade and new paradigms are replacing traditional approaches at all stages of cancer. This review will summarize the epidemiology, diagnosis, staging, and treatment of esophageal squamous cell carcinoma.

RECENT FINDINGS

Novel approaches to screening may be cost-effective in regions with a high incidence of ESCC. Multi-disciplinary evaluation and treatment has become the standard of care. Endoscopic resection may be an option for early stage ESCC. Minimally invasive esophagectomy can be performed safely as a primary therapy or after-induction chemoradiation. Several recent studies have found a survival benefit to immunotherapy for patients with metastatic or persistent disease. Multi-disciplinary evaluation and multi-modal therapy including cytotoxic chemotherapy, radiation, surgery, and immunotherapy have improved survival compared to surgery alone.

Predictors of Lymph Node Metastasis in Siewert Type II T1 Adenocarcinoma of the Esophagogastric Junction: A Population-Based Study

Background:

Endoscopic resection has been introduced as an alternative treatment for superficial adenocarcinoma of the esophagogastric junction (AEG), but is limited by positive nodal status. We aimed to investigate the predictors of lymph node metastasis (LNM) in patients with Siewert type II T1 AEG.

Methods:

The Surveillance, Epidemiology, and End Results (SEER) database was used to identify eligible patients with Siewert type II T1 AEG. The prevalence of LNM was assessed. Logistic regression analysis with multivariable adjustment was used to determine predictors of LNM. We also performed Cox regression analysis to examine the prognostic value of LNM, which was further confirmed by competing risk analysis and cumulative incidence function (CIF).

Results:

In total, 2651 patients with T1 AEG were included, with a median age of 69 years and a median follow-up of 28 months. The overall prevalence of LNM was 17.2% in T1 AEG. When stratified by tumor invasion depth, the prevalence of LNM was 8.5% for intramucosal tumors and 22.6% for submucosal tumors. Adjusted logistic regression analysis showed that age, sex, tumor grade, tumor size and tumor infiltration depth were independent predictors of LNM in T1 AEG. Multivariate Cox regression analysis revealed that positive nodal status was significantly associated with worse overall survival and cancer-specific survival (CSS). Subgroup analysis consistently demonstrated that patients with LNM had significantly poorer CSS than those without LNM in most subgroups. Finally, the CIF was calculated, showing that patients with LNM had a significantly higher cancer-specific death rate than those without LNM.

Conclusions:

This population-based study identified age, sex, tumor grade, tumor infiltration depth and tumor size as independent predictors of LNM in T1 AEG. Considering the high prevalence of LNM in T1 AEG, endoscopic resection for curative aims may only be introduced in patients without high risks of LNM.

TRANSHIATAL ESOPHAGECTOMY IN SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS: WHAT ARE THE BEST INDICATIONS?

BACKGROUND

Overall survival in patients who underwent transhiatal esophagectomy submitted or not to neoadjuvant therapy. Southern Brazil has one of the highest incidences of esophageal squamous cell carcinoma in the world. Transthoracic esophagectomy allows more complete abdominal and thoracic lymphadenectomy than transhiatal. However, this one is associated with less morbidity.

AIM

To analyze the outcomes and prognostic factors of squamous esophageal cancer treated with transhiatal procedure.

METHODS

All patients selected for transhiatal approach were included as a potentially curative treatment and overall survival, operative time, lymph node analysis and use of neoadjuvant therapy were analyzed.

RESULTS

A total of 96 patients were evaluated. The overall 5-year survival was 41.2%. Multivariate analysis showed that operative time and presence of positive lymph nodes were both associated with a worse outcome, while neoadjuvant therapy was associated with better outcome. The negative lymph-node group had a 5-year survival rate of 50.2%.

CONCLUSION

Transhiatal esophagectomy can be safely used in patients with malnutrition degree that allows the procedure, in those with associated respiratory disorders and in the elderly. It provides considerable long-term survival, especially in the absence of metastases to local lymph nodes. The wider use of neoadjuvant therapy has the potential to further increase long-term survival.

The complexity of cancer origins at the gastro-oesophageal junction

Chronic acid-biliary reflux and Helicobacter pylori infection are instrumental environmental drivers of cancer initiation and progression in the upper gastrointestinal tract. Remarkably, although these environmental carcinogens are quite dissimilar, the tumour progression cascade these carcinogens engender is highly comparable. For this reason, studies of malignant progression occurring at the anatomic borderland between the oesophagus and the stomach have traditionally lumped junctional adenocarcinomas with either oesophageal adenocarcinoma or gastric adenocarcinoma. Whilst studies have revealed remarkable epidemiological and genetic similarities of these cancers and their associated premalignant conditions, these works have also revealed some key differences. This highlights that further scientific effort demands a dedicated focus on the understanding of the cell-cell interaction between the epithelium and the local microenvironment in this anatomic region. We here review available evidence with regards to tumour progression occurring at the gastro-oesophageal junction and contrast it with available data on cancer evolution in the metaplastic oesophagus and distal stomach.

Low GSTM3 expression is associated with poor disease-free survival in resected esophageal squamous cell carcinoma

Background

Glutathione S-transferase mu 3 (GSTM3) plays a crucial role in tumor progression in various cancers. However, the relationship between GSTM3 expression and the clinical prognosis of esophageal squamous cell carcinoma (ESCC) has not been studied to date. We aimed to characterize the role of GSTM3 in predicting postoperative prognosis of ESCC patients.

Methods

In the retrospective study, GSTM3 mRNA levels in 184 ESCC tissues and matched 43 adjacent nontumorous tissues were measured by quantitative real-time PCR. GSTM3 protein levels in 247 ESCC tissues were measured by immunohistochemistry.

Results

Downregulation of GSTM3 occurred in 62.8 % of primary ESCC tissues compared with their nontumor counterparts. Patients with low GSTM3 expression tended to exhibit an increased rate of poor differentiation in both the mRNA cohort (p = 0.024) and protein cohort (p = 0.004). In the mRNA cohort, low GSTM3 expression was associated with unfavorable 3-year disease-free survival (DFS) (39.2 % vs. 57.4 %) and 5-year DFS (26.8 % vs. 45.1 %) (p = 0.023). The result was confirmed in the protein cohort. Patients with low GSTM3 expression had unfavorable 3-year disease-free survival (DFS) (18.7 % vs. 33.5 %) and 5-year DFS (5.3 % vs. 30.5 %) (p = 0.006). Cox multivariate analysis revealed that GSTM3 expression was an independent prognostic factor.

Conclusions

The findings of the present study provide evidence that GSTM3 may function as a tumor suppressor in ESCC and represents a potential novel prognostic biomarker for disease-free survival for resected ESCC patients.

Comparison of spectral computed tomography imaging parameters between squamous cell carcinoma and adenocarcinoma at the gastroesophageal junction

OBJECTIVE

To compare the spectral computed tomography (CT) imaging parameters between squamous cell carcinoma (SCC) and adenocarcinoma (AC) at the gastroesophageal junction (GEJ).

METHODS

A total of 80 patients were enrolled in this retrospective study. Among them, 35 were diagnosed with SCC (SCC group) and 45 were diagnosed with AC (AC group). All patients underwent an enhanced scan with spectral CT. The following CT imaging parameters were evaluated: iodine concentration (IC), water content (WC), effective atomic number (Eff-Z) and slope of the spectral HU curve (λHU) of lesions. Receiver operating characteristic (ROC) curve was used to analyze the predictive value of spectral CT imaging parameters for diagnosis of SCC and AC.

RESULTS

Patients with SCC had lower IC, Eff-Z, and λHU in arterial phase and venous phase compared with AC (p< 0.05). There were no significant differences in WC between the two groups. ROC curve analyses revealed that IC, Eff-Z, and λHU in arterial phase and venous phase were predictors for diagnosis of SCC and AC (AUC > 0.5). Moreover, the IC, Eff-Z and λHU in venous phase had better differential diagnostic performances than that in arterial phase.

CONCLUSIONS

Spectral CT could be useful in the differential diagnosis of SCC and AC at the GEJ. Therefore, a routine spectral CT scan is recommended for patients with carcinoma of the GEJ.

Prognostic Value of Serum Soluble Programmed Death-Ligand 1 and Dynamics During Chemotherapy in Advanced Gastric Cancer Patients

Purpose

The soluble form programmed death-ligand 1 (sPDL1) has immunosuppressive properties and is being studied as a candidate biomarker for immuno-oncology drug development. We measured the serum sPDL1 at pre-and post-chemotherapy and evaluated its prognostic implication and dynamics during chemotherapy in advanced gastric cancer (GC).

Materials and Methods

We prospectively enrolled 68 GC patients who were candidates for palliative standard first-line chemotherapy, and serially collected blood at baseline and after one cycle of chemotherapy, at the best response and after disease progression. sPDL1 was measured using an enzyme-linked immunosorbent assay. Response to chemotherapy, overall survival (OS), progression-free survival (PFS) and other prognostic factors including neutrophil-lymphocyte ratio (NLR) were obtained. The cut-off value of sPDL1 levels for survival analysis was found using C-statistics.

Results

The median baseline sPDL1 was 0.8 ng/mL (range, 0.06 to 6.06 ng/mL). The median OS and PFS were 14.9 months and 8.0 months, respectively. sPDL1 and NLR showed a weak positive correlation (Spearman’s rho=0.301, p=0.013). Patients with low levels of sPDL1 at diagnosis (< 1.92 ng/mL) showed a better OS and PFS than patients with a high sPDL1. The baseline sPDL1 before treatment was higher in the progressive disease group than in the stable disease and partial response groups. Patients whose sPDL1 increased after the first cycle of chemotherapy showed worse PFS and OS. Following disease progression, sPDL1 increased compared with the baseline.

Conclusion

sPDL1 at prechemotherapy confers a prognostic value for PFS and OS in GC patients under palliative first-line chemotherapy. Dynamics of sPDL1 during chemotherapy correlates with disease progression.

Cumulative evidence for the relationship between body mass index and the risk of esophageal cancer: An updated meta-analysis with evidence from 25 observational studies

BACKGROUND AND AIM

A large number of papers reporting the relationships between body mass index (BMI) and esophageal cancer (EC) risk have been published in the past few decades; however, these results are inconsistent. Therefore, we carried out meta-analyses to explore the relationships between BMI and the risk of EC (including esophageal squamous cell carcinoma [ESCC] and esophageal adenocarcinoma [EADC]).

METHODS

We used the Web of Science, PubMed, and Embase to identify all published/online articles before December 30, 2018, which yielded 25 articles eligible for data extraction (including 16,561 cases and 11,954,161 controls), and then pooled the relative risks (RRs) and corresponding 95% confidence intervals (CIs) using random-effects model.

RESULTS

Our study presented that underweight had statistically significant association with the risk of EC (RR = 1.78, 95% CI = 1.48, 2.14, P < 0.001) and ESCC (RR = 1.57, 95% CI = 1.20, 2.06, P = 0.001) when compared with normal weight. Interestingly, both overweight and obesity could increase the risk of EADC (RR = 1.56, 95% CI = 1.42, 1.71, P < 0.001; RR = 2.34, 95% CI = 2.02, 2.70, P < 0.001) while decrease the risk of ESCC (RR = 0.71, 95% CI = 0.60, 0.84, P < 0.001; RR = 0.63, 95% CI = 0.60, 0.84, P = 0.002). Additionally, obesity could increase the risk of EC (RR = 1.51, 95% CI = 1.21, 1.89, P < 0.001).

CONCLUSION

These meta-analyses provide a comprehensive and updated epidemiological evidence to confirm the associations between BMI and EC risk. These findings have public health implications with respect to better control bodyweight and then reduce the occurrence of EC (including ESCC and EADC).

Helicobacter pylori Is Associated With Precancerous and Cancerous Lesions of the Gastric Cardia Mucosa: Results of a Large Population-Based Study in China

Background: Helicobacter pylori (H. pylori) is widely accepted to be the most important cause of gastric non-cardia adenocarcinoma (GNCA), while its role in the development of gastric cardia adenocarcinoma (GCA) is not well-defined. We aimed to investigate current H. pylori infection in relation to the severity of both precancerous and cancerous lesions of the gastric cardia in an Asian population at high risk of GCA. Methods: A population-based cross-sectional study was conducted in Linzhou County, Henan Province, China. Two thousand three (2,003) randomly selected participants with data on current H. pylori infection, assayed by 13C-urea breath test (13C-UBT), and a sequence of histological diagnoses of the gastric cardia mucosa were analyzed. Results: Of 2,003 subjects, 828 (41.33%) were currently infected with H. pylori. The prevalence of current H. pylori infection increased with increasing severity of histological lesions, from 34.12% in subjects with normal gastric cardia mucosa to 52.17% in subjects with gastric cardia high-grade intraepithelial neoplasia (CHIN)/ gastric cardia adenocarcinoma (GCA) (P for trend <0.001). With H. pylori-negative subjects as the reference category, H. pylori-positive subjects had statistically significant elevated adjusted prevalence odds ratios (PORs) for each of the histological lesions. The PORs (95% CI) were 2.15 (1.74-2.64), 3.46 (2.08-5.75), 2.78 (1.90-4.07), and 3.05 (1.30-7.17) for subjects with carditis, cardia intestinal metaplasia (CIM), cardia low-grade intraepithelial neoplasia (CLIN), and CHIN/GCA), respectively. The associations remained when subjects with abnormal stomach non-cardia mucosa were excluded. Conclusions: This large epidemiologic study demonstrates a positive association between current H. pylori infection and the severity of both precancerous and cancerous lesions of the gastric cardia in an Asian population at high risk of GCA. These findings suggest that H. pylori infection may play a role throughout both early- and late-stage development of GCA.

Nomogram-Integrated C-Reactive Protein/Albumin Ratio Predicts Efficacy And Prognosis In Patients With Thoracic Esophageal Squamous Cell Carcinoma Receiving Chemoradiotherapy

Objective

To investigate the therapeutic effect and survival outcome using nomogram by incorporating significant inflammatory markers in patients with thoracic esophageal squamous cell carcinoma (ESCC) who received chemoradiotherapy (CRT) or single radiotherapy (RT).

Method

A total of 266 patients diagnosed with thoracic ESCC receiving standard curative RT only or concurrent CRT were retrospectively analysed. The patients were grouped for statistical analysis depending on the median values of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and C-reactive protein/albumin (CRP/Alb) ratio. The therapeutic effect was analysed by univariate and multivariate logistic analyses. The survival prognosis was estimated by univariate and multivariate Cox analyses. At last, the nomogram was developed by incorporating the significant inflammatory markers and clinicopathological parameters, and the predictive value was verified by calibration curve, concordance index (C-index) and decision curve.

Results

The treatment responses were highly associated with clinical stage, tumor location, NLR, PLR and CRP/Alb ratio (all P<0.05) by univariate logistic analysis. However, in the multivariate logistic analysis, the results showed that only CRP/Alb ratio (P=0.000) and TNM stage (P=0.008) were independent risk parameters for tumour response. In addition, NLR, PLR, CRP/Alb ratio, age and TNM stage were significantly associated with OS by the univariate Cox analysis (all P<0.05). Furthermore, the multivariate Cox analysis showed that only CRP/Alb ratio (P=0.000), TNM stage (P=0.000) and age (P=0.001) were considered independent prognostic factors for OS. Finally, the calibration curves of nomogram were highly consistent with actual observation for the therapeutic effect and prognosis, and the decision curve analysis showed more potential of clinical benefit of the nomogram compared with TNM staging system.

Conclusion

This research found that nomogram-integrated CRP/Alb ratio was promising as a predictive model for the therapeutic effect and survival outcome in patients with thoracic ESCC receiving CRT or single RT.

The role of pretreatment prognostic nutritional index in esophageal cancer: A meta-analysis

Clinicopathological characteristics and prognosis of esophageal cancer (EC) patients with decreased prognostic nutritional index (PNI) have not been well investigated. So, we conducted this meta‐analysis. We performed comprehensive research in PubMed, Embase, and Cochrane databases. The effect size was hazard ratio (HR) with 95% confidence interval (CI) for overall survival (OS) and cancer‐specific survival (CSS). The pooled odds ratio (OR) with 95% CI were used to assess the association between PNI and clinicopathological features. A total of 3,425 EC patients were included in the present meta‐analysis. Male patients, advanced age, higher tumor stage, and lymph node metastases were associated with reduced PNI level (OR = 1.40, 95% CI: 1.10‐1.79; OR = 1.35, 95% CI: 1.10‐1.66; OR = 2.37, 95% CI: 1.91‐2.94; OR = 1.63, 95% CI: 1.04‐2.56). And, the EC patients with decreased PNI held a worse OS and CSS compared with those who carried a higher PNI (HR = 1.29, 95% CI: 1.10‐1.50; HR = 2.53, 95% CI: 1.15‐5.57). This meta‐analysis demonstrated PNI level was associated with tumor stage and lymph nodes metastases and was an independent prognostic factor in EC.

Surgical Treatment of Gastroesophageal Junction Cancer

Although the incidence of gastroesophageal junction (GEJ) adenocarcinoma has been increasing worldwide, no standardized surgical strategy for its treatment has been established. This study aimed to provide an update on the surgical treatment of GEJ adenocarcinoma by reviewing previous reports and propose recommended surgical approaches. The Siewert classification is widely used for determining which surgical procedure is used, because previous studies have shown that the pattern of lymph node (LN) metastasis depends on tumor location. In terms of surgical approaches for GEJ adenocarcinoma, a consensus was reached based on two randomized controlled trials. Siewert types I and III are treated as esophageal cancer and gastric cancer, respectively. Although no consensus has been reached regarding the treatment of Siewert type II, several retrospective studies suggested that the optimal treatment strategy includes paraaortic LN dissection. Against this background, a Japanese nationwide prospective trial is being conducted to determine the proportion of LN metastasis in GEJ cancers and to identify the optimal extent of LN dissection in each type.

Proposed modifications of supraclavicular lymph node metastasis in the esophageal squamous cell carcinoma staging system for improved survival stratification

The present study aims to investigate the clinical implication of supraclavicular lymph nodes (SCLNs) in thoracic esophageal squamous cell carcinoma (ESCC). A total of 1156 ESCC patients who underwent three-field lymphadenectomy with node metastasis were analyzed retrospectively. SCLNs were defined as regional nodes in the current system or as distant nodes in the modified system. Survival was analyzed using the Kaplan-Meier method, and values were compared using the log-rank test. Multivariate analysis was performed using the Cox proportional hazard model. The Akaike information criterion (AIC) and the concordance index (c-index) were applied to compare the two prognostic systems. Among 1156 patients, 183 (15.8%) patients were diagnosed with SCLN metastasis. Higher rate of SCLN metastasis was associated with upper tumor location, metastasis involving seven or more nodes, and positive recurrent laryngeal nerve node status. The current staging system was unable to stratify overall survival well in patients with N2, N3, and M1 status using a univariate analysis. In both the current staging system and the modified version, age, gender, pathological T status, and nodal status were independent prognostic factors in a multivariate analysis. The AIC value for the modified version was smaller than that for the current staging system; the c-index value for the modified version was larger than that for the current staging system. Based on the data from our single center, SCLNs should be reclassified as regional lymph nodes in thoracic ESCC for better stratification of overall survival.

Genetic variants in miRNA machinery genes associated with clinicopathological characteristics and outcomes of gastric cancer patients

Background:

Polymorphisms in miRNA machinery genes have been proved to be related to risk or survival of several kinds of cancers, but the results are controversial and the role of these polymorphisms in gastric cancer remains uncertain. In our study, we investigated the association between five genetic variants in miRNA machinery genes ( DICER, RAN, XPO5 [name of the gene]) and clinical outcomes in Chinese gastric cancer patients.

Methods:

A total of 96 patients with stage IB-III gastric cancer treated with radical gastrectomy and adjuvant chemotherapy of oxaliplatin and fluorouracils were analyzed. The MassARRAY MALDI-TOF system was used to determine the genotypes.

Results:

DICER rs3742330 AG+GG genotype was associated with more advanced T stage compared to AA genotype ( P=0.009). More patients with XPO5 rs2257082 CC genotype had poorly differentiated tumors compared with CT+TT genotype carriers. After adjustment by age, sex, differentiation, T stage, and lymph node status, XPO5 rs2257082 CC genotype carriers were found to have worse disease-free survival than CT+TT genotype carriers (adjusted HR 3.099; 95% CI 1.270, 7.564; P=0.013), carriers of RAN rs14035 CC genotype had higher three-year OS rate than carriers of CT+TT genotype (adjusted HR 3.174; 95% CI 1.010, 9.973; P=0.048).

Conclusions:

These results indicated that genetic variants in miRNA machinery genes might be associated with the clinicopathological features and prognosis of completely resected gastric cancer patients.

Coffee consumption and risk of esophageal cancer incidence: A meta-analysis of epidemiologic studies

BACKGROUND

In epidemiologic studies, association between coffee consumption and esophageal cancer risk is inconsistent.

OBJECTIVE

The aim of tjis study was to evaluate the effect of coffee on esophageal cancer by combining several similar studies.

METHODS

We conducted a meta-analysis for association of coffee intake and esophageal cancer incidence. Eleven studies, including 457,010 participants and 2628 incident cases, were identified. A relative risk (RR, for cohort study) or odds ratio (OR, for case-control study) of heavy coffee drinkers was calculated, compared with light coffee drinkers or non-drinkers. The analysis was also stratified by cancer types (esophageal squamous cell carcinoma and esophageal adenocarcinoma), sex, and geographic region.

RESULTS

The summarized OR of having esophageal cancer in heavy coffee drinkers was 0.93 (95% confidence interval [CI]: 0.73-1.12), compared with light coffee drinkers. When stratified by sex, pathologic type of esophageal cancer, and type of epidemiologic study, we did not find any association of coffee consumption and esophageal cancer incidence. However, an inverse association between coffee consumption and incidence of esophageal cancer was found in East Asia participants with OR of 0.64 (95% CI: 0.44-0.83), but not in Euro-America participants (OR = 1.05; 95% CI: 0.81-1.29).

CONCLUSION

There is a protective role of coffee consumption against esophageal cancer in East Asians, but not in Euro-Americans.

Modifiable factors and esophageal cancer: a systematic review of published meta-analyses

There are marked differences in the etiology of the major histological types of esophageal cancer (EC)-squamous cell carcinomas (ESCC) and adenocarcinomas (EAC). This study aimed to summarize the current scientific knowledge on modifiable risk factors for EC, by histological type, through a systematic review of meta-analyses referenced in PubMed and ISI Web of Knowledge. We identified 100 meta-analyses on risk factors for ESCC (n = 54), EAC (n = 43), or EC (n = 51). ESCC risk significantly increased with alcohol and maté drinking, smoking, red and processed meat consumption and human papillomavirus infection, while it was negatively associated with body mass index and consumption of fruit, vegetables, white meat, folate, and some carotenoids. Cessation of drinking and smoking significantly reduced ESCC risk. For EAC, an increased risk was reported for smoking, body mass index, and red and processed meat consumption, while risk decreased with Helicobacter pylori infection, low/moderate alcohol drinking, physical activity, and consumption of fruit, vegetables, folate, fiber, beta-carotene, and vitamin C. Differences in results between meta-analyses and mechanisms underlying some of the associations found are discussed. This work reinforces the importance of a separate assessment of EC subtypes to allow for a proper evaluation of incidence trends and planning of prevention/control interventions.

Gastrointestinal tract carcinoma in pediatric and adolescent age: The Italian TREP project experience

BACKGROUND

Gastrointestinal (GI) carcinomas are very rare in the pediatric and adolescent age range. We report the clinical features, treatment, and outcome of a series of children and adolescents with GI carcinoma prospectively registered in the Italian Tumori Rari in Età Pediatrica (TREP) project.

METHODS

The TREP project developed diagnostic and therapeutic guidelines based on recommendations currently in use for adults. Clinical data were centrally registered and reviewed.

RESULTS

Fifteen patients were registered over the years 2000-2016. Most of the tumors were colorectal carcinomas (12 cases). All but one patient had advanced-stage disease (American Joint Committee on Cancer stages III-IV), and the majority of patients had aggressive histological subtypes, i.e. poorly differentiated (G3) (five patients), mucinous (four patients), and signet ring (two patients) adenocarcinomas. Surgery was performed in 13 of 15 patients, and was radical in nine of 13 patients. Only one patient received postoperative radiotherapy. All patients received chemotherapy, with the addition of bevacizumab in two cases. Nine patients were still alive at the time of the present report, but two of them had only just completed their treatment program and one patient is still on treatment. Six patients died due to disease progression.

CONCLUSIONS

This prospective report on pediatric GI tract carcinomas confirms the rarity and biological aggressiveness of these diseases in pediatric and adolescent age. Further prospective studies are needed to explore the distinct biology of tumor in this age group in order to find new therapeutic targeted agents.

Joint Effects of Low Body Mass Index and Alcohol Consumption on Developing Esophageal Squamous Cell Cancer: a Korean Nationwide Population-Based Cohort Study

Objective:

In Korea, 95% of esophageal cancer (EC) was the squamous cell-type. We sought to determine the combined risk of alcohol consumption on developing esophageal squamous cell carcinoma (ESCC) in pre-diagnostic underweight subjects using Korean national data.

Methods:

We analyzed the clinical data from a total of 264,084 individuals aged 40 years or older, who received healthcare checkups arranged by the national insurance program, between 2003 and 2008 in Korea. Cox proportional hazards regression was used after adjusting confounding factors.

Result:

Newly diagnosed 278 EC was identified using the claims data during a median follow-up duration of 7.9 years. It was determined that underweight and obesity-compared with normal weight-were significantly associated with 73% increased risk and 30% decreased risk of EC, respectively. Weight gain reduced the risk of EC. Alcohol consumption increased risk for EC in a dose-dependent manner. Heavy alcohol consumption in individuals with underweight increased the risk of developing EC dramatically.

Conclusion:

Underweight was a risk factor for ESCC and alcohol consumption raised the risk synergistically with low BMI. Achieving normal range of BMI could reduce the risk of ESCC.

Hiatus hernia in healthy volunteers is associated with intrasphincteric reflux and cardiac mucosal lengthening without traditional reflux

BACKGROUND AND AIMS

Hiatus hernia (HH) is a key mediator of gastro-oesophageal reflux disease but little is known about its significance in the general population. We studied the structure and function of the gastro-oesophageal junction in healthy volunteers with and without HH.

METHODS

We compared 15 volunteers with HH, detected by endoscopy or MRI scan, but without gastro-oesophageal reflux disease with 15 controls matched for age, gender and body weight. Jumbo biopsies were taken across the squamocolumnar junction (SCJ). High-resolution pH metry (12 sensors) and manometry (36 sensors) were performed upright and supine, before and after a meal. The SCJ was marked with an endoscopically placed clip and visualised fluoroscopically.

RESULTS

Cardiac mucosa was longer in volunteers with HH (3.5 vs 2.5 mm, p=0.01). There was no excessive acid reflux 5 cm above the upper border of the lower oesophageal sphincter (LOS) in either group but those with HH had short segment reflux 11 mm above the pH transition point after the meal when supine (pH<4 for 5.5% vs 0.3% of time, p=0.01). The SCJ and pH transition point were proximally displaced within the gastro-oesophageal junction in those with HH versus controls (p<0.05). The pH transition point was proximal to the peak LOS pressure point in HH subjects but distal to it in controls after the meal (p<0.05). When supine, the postprandial pH transition point crossed the SCJ in those with HH (p=0.03).

CONCLUSIONS

Healthy volunteers with HH have increased intrasphincteric reflux and lengthening of cardiac mucosa in the absence of traditional transsphincteric reflux.

The increasing incidence of esophageal squamous cell carcinoma in women in Turkey

BACKGROUND/AIM

This study assessed the trend changes in the histological types of esophageal cancer in a 25-year period in eastern Turkey.

MATERIALS AND METHODS

We searched all cases of esophageal cancer from 1990 to 2015 according to their histological diagnosis and sex, grouping the patients in 5-year time periods to evaluate time trends.

RESULTS

We identified 1462 cases of esophageal cancer. In terms of patient make-up, 742 were male and 720 were female. In general, 75.86% of the patients had squamous cell carcinoma (SCC), 19.56% of the patients had adenocarcinoma (ADC), and the remaining 4.58% patients were found to have other histopathologic disorders. While the SCC to ADC ratio was 1.76 between 1990 and 1994, this rate increased to 8.73 between 2010 and 2014; during these periods, the male to female ratio decreased from 1.43 to 0.86. Between these two periods, statistically significant changes were observed of SCC and the number of female patients (P < 0.001, P = 0.008, respectively).

CONCLUSION

While the incidence of esophagus ADC and the number of male patients increased recently in Western countries, the number of female patients and SCC cases increased in our region in the last 25 years.

Human papillomavirus and gastrointestinal cancer: A review

Human papillomavirus (HPV) is one of the most common sexually transmitted infections worldwide. Exposure to HPV is very common, and an estimated 65%-100% of sexually active adults are exposed to HPV in their lifetime. The majority of HPV infections are asymptomatic, but there is a 10% chance that individuals will develop a persistent infection and have an increased risk of developing a carcinoma. The International Agency for Research on Cancer has found that the following cancer sites have a strong causal relationship with HPV: cervix uteri, penis, vulva, vagina, anus and oropharynx, including the base of the tongue and the tonsils. However, studies of the aetiological role of HPV in colorectal and esophageal malignancies have conflicting results. The aim of this review was to organize recent evidence and issues about the association between HPV infection and gastrointestinal tumours with a focus on esophageal, colorectal and anal cancers. The ultimate goal was to highlight possible implications for prognosis and prevention.

Theoretical therapeutic impact of lymph node dissection on adenocarcinoma and squamous cell carcinoma of the esophagogastric junction

BACKGROUNDS

The aim of this study was to evaluate the theoretical therapeutic impact of dissecting each lymph node station for adenocarcinoma and squamous cell carcinoma of the esophagogastric junction.

METHODS

This multicenter study included 431 junctional cancer patients (381 adenocarcinomas and 50 squamous cell carcinomas) who fulfilled the following criteria: (1) the center of the tumor was located between 1 cm above and 2 cm below the esophagogastric junction, and (2) the tumor invaded the junction. The theoretical therapeutic impact of dissecting each lymph node station was evaluated based on the therapeutic value index calculated by multiplying the frequency of metastasis to each station and the 5-year survival rate of patients with metastasis to that station.

RESULTS

The 5-year overall survival rates (95% confidence interval) were 60.4% (55.1-65.7) in the adenocarcinoma cases and 52.3% (35.6-69.0) in the squamous cell carcinoma cases. The nodal stations showing the first to fifth highest index were the paracardial and lesser curvature nodes (nos. 1, 2 and 3), nodes at the root of the left gastric artery (no. 7) and lower mediastinal lymph nodes, regardless of the histology.

CONCLUSIONS

Nodal dissection achieved by proximal gastrectomy and lower esophagectomy should be the minimal requirement for junctional cancer regardless of the histology, considering the therapeutic value indices for the relevant lymph node stations.

Influence of Metastatic Status and Number of Removed Lymph Nodes on Survival of Patients With Squamous Esophageal Carcinoma

The aim of this study was to determine the impact of lymph node (LN) metastasis conditions on the prognosis of patients with esophageal squamous carcinoma and the minimum number of LNs that should be removed to maximize overall postoperative survival among patients with this specific pathologic subtype. In this study, 312 patients with thoracic squamous esophageal carcinoma who received in-patient thoracic surgery by the same surgeon in our hospital from August 1, 2003 to December 31, 2009 were recruited. Subsequently, Kaplan-Meier methods were used to determine associations between LN metastasis conditions and mortality and between the numbers of LNs removed during esophagectomy and mortality. Cox regression models were used to adjust for potential confounding covariates. According to Kaplan-Meier analyses, the number of metastatic LNs was a good predictor for the prognosis of patients with esophageal squamous carcinoma and the dissection of ≥ 29 LNs during thoracic surgery significantly improved patient survival (P = 0.011).Lymph node metastasis rates may be a significant predictor for the prognosis of patients with esophageal squamous carcinoma. The number of LNs removed during esophagectomy is an independent predictor for the survival of patients with esophageal squamous carcinoma with maximal postoperative survival after the removal of ≥ 29 LNs.

In healthy volunteers, immunohistochemistry supports squamous to columnar metaplasia as mechanism of expansion of cardia, aggravated by central obesity

INTRODUCTION

Recently, we showed that the length of cardiac mucosa in healthy volunteers correlated with age and obesity. We have now examined the immunohistological characteristics of this expanded cardia to determine whether it may be due to columnar metaplasia of the distal oesophagus.

METHODS

We used the squamocolumnar junction (SCJ), antral and body biopsies from the 52 Helicobacter pylori-negative healthy volunteers who had participated in our earlier physiological study and did not have hiatus hernia, transsphincteric acid reflux, Barrett's oesophagus or intestinal metaplasia (IM) at cardia. The densities of inflammatory cells and reactive atypia were scored at squamous, cardiac and oxyntocardiac mucosa of SCJ, antrum and body. Slides were stained for caudal type homeobox 2 (CDX-2), villin, trefoil factor family 3 (TFF-3) and liver-intestine (LI)-cadherin, mucin MUC1, Muc-2 and Muc-5ac. In addition, biopsies from 15 Barrett's patients with/without IM were stained and scored as comparison. Immunohistological characteristics were correlated with parameters of obesity and high-resolution pH metry recording.

RESULTS

Cardiac mucosa had a similar intensity of inflammatory infiltrate to non-IM Barrett's and greater than any of the other upper GI mucosae. The immunostaining pattern of cardiac mucosa most closely resembled non-IM Barrett's showing only slightly weaker CDX-2 immunostaining. In distal oesophageal squamous mucosa, expression of markers of columnar differentiation (TFF-3 and LI-cadherin) was apparent and these correlated with central obesity (correlation coefficient (CC)=0.604, p=0.001 and CC=0.462, p=0.002, respectively). In addition, expression of TFF-3 in distal oesophageal squamous mucosa correlated with proximal extension of gastric acidity within the region of the lower oesophageal sphincter (CC=-0.538, p=0.001).

CONCLUSIONS

These findings are consistent with expansion of cardia in healthy volunteers occurring by squamo columnar metaplasia of distal oesophagus and aggravated by central obesity. This metaplastic origin of expanded cardia may be relevant to the substantial proportion of cardia adenocarcinomas unattributable to H. pylori or transsphincteric acid reflux.

Polymorphism in miR-146a associated with clinical characteristics and outcomes in gastric cancer patients treated with adjuvant oxaliplatin and fluoropyrimidines

Purpose

Polymorphism in miR-146a (rs2910164) has been reported to be associated with gastric cancer risk in the Chinese population. We aimed at evaluating the relationship between rs2910164 and the clinical characteristics and outcomes in stage IB–III gastric cancer patients treated with adjuvant chemotherapy after surgery.

Materials and methods

Ninety-eight patients with stage IB–III gastric cancer treated with surgical resection followed by adjuvant chemotherapy of oxaliplatin and fluoropyrimidines were included in the analysis. Genomic DNA was extracted from peripheral blood sample of all patients. Polymerase chain reaction-based restriction fragment length polymorphism assay was used to determine the genotypes.

Results

The 2-year disease-free survival rate was 63%, and the 3-year overall survival (OS) rate was 73.4%. In dominant model, we found that rs2910164 GC + CC (G: guanine, C: cytosine) genotype carriers were less likely to develop lymph node metastasis (P=0.059). The 3-year OS was significantly different for patients with or without lymph node metastasis (89.3% vs 63.7%, P=0.015) and for patients with stage I–III disease (100.0%, 88.6%, and 56.9%; P=0.018). The 3-year OS for GC + CC carriers was significantly higher than for GG carriers (75.1% vs 66.7%, P=0.041). After the multivariant Cox regression analysis, histological grade (P=0.033, relative risk: 5.116, 95% confidence interval: 1.145–22.865) and lymph node status (P=0.031, relative risk: 6.648, 95% confidence interval: 1.191–37.118) were found to be independent prognostic factors for these patients.

Conclusion

rs2910164 could be associated with the lymph node metastasis and prognosis of Chinese gastric cancer patients treated with oxaliplatin and fluoropyrimidines after surgical resection.

Differences in intestinal metaplasia in Barrett's esophagus patients in an ethnically diverse south London population

Barrett's esophagus (BE) is the replacement of any portion of the normal distal squamous epithelial mucosa by metaplastic columnar epithelium and is the only known precursor for esophageal adenocarcinoma. We undertook a study to identify ethnic differences for the presence of intestinal metaplasia (IM) in BE in patients in an ethnically diverse south London population. Retrospective analysis was done using the endoscopy database of St George's Hospital NHS Trust, which serves a large ethnically diverse London population. Gastroscopy records between 2009 and 2012 were retrieved, and patients with an endoscopic diagnosis of BE were identified. Patients of Indian subcontinent Asian origin (ISCA) were further identified. The presence of IM was retrieved from hospital pathology databases and was the primary outcome measured. Multivariate logistic regression analysis was performed to determine the odds of having IM by ethnic origin. ISCAs were 70% less likely to have IM compared to non-ISCAs (OR 0.32, 95% CI: 0.16-0.61, p = 0.001). This is the first study to identify differences in histological findings in ISCAs with BE living in the UK. Our findings may be useful for the future risk stratification of BE patients. Identification of environmental factors responsible for this difference would be of great therapeutic value.

Application of Bayesian Multilevel Space-Time Models to Study Relative Risk of Esophageal Cancer in Iran 2005-2007 at a County Level

BACKGROUND

Reported age standardized incidence rates for esophageal cancer in Iran are 0.88 and 6.15 for females and males, at fifth and the eighth ranks, respectively, of cancers overall. The present study aimed to map relative risk using more realistic and less problematic methods than common estimators.

MATERIALS AND METHODS

In this ecological investigation, the studied population consisted of all esophageal cancer patients in Iran from 2005 to 2007. The Bayesian multilevel space-time model with three levels of county, province, and time was used to measure the relative risk of esophageal cancer. Analyses were conducted using R package INLA.

RESULTS

The total number of registered patients was 7,160. According to the results, the three-level model with adjustment for risk factors of physical activity and smoking had the best fit among all models .The overall temporal trend was significantly increasing. At county level, Ahar, Marand, Salmas, Bojnoord, Saghez, Sarakhs, Shahroud and Torbatejam had the highest relative risks. Physical activity was found to have significant direct association with risk of developing esophageal cancer.

CONCLUSIONS

Given to great variation across geographical areas, many different factors affect the incidence of esophageal cancer. Conducting further studies at the individual level in areas with high incidence could provide more detailed information on risk factors of esophageal cancer.

Impact of body mass index on survival of esophageal squamous carcinoma patients in southern China

BACKGROUND

Although high body mass index (BMI) increases risk for developing esophageal adenocarcinoma (EAC), the prognostic influence of BMI is unknown in esophageal squamous carcinoma.

METHODS

BMI was calculated using measured height and weight at the first diagnosis and categorized as overweight (25 to 29.9 kg/m(2)), normal (18.5 to 24.9 kg/m(2)) or underweight (<18.5 kg/m(2)). Survival was compared by using the log-rank test on the Kaplan-Meier life table. Multivariate Cox regression analysis was used to evaluate whether BMI was an independent prognostic factor for disease-specific survival (DSS).

RESULTS

Among 1,176 esophageal squamous carcinoma patients, 146 (12.4%) were categorized as overweight, and 277 (23.6%) underweight. More patients in the underweight group had anemia (P=0.001), weight loss (P=0.035) and R1 resection (P<0.001). Less patients in the underweight group received adjuvant chemotherapy (P=0.01). Patients in the overweight group had a higher incidence rate of high blood pressure (P<0.001), diabetes (P<0.001) and coronary artery diseases (P<0.001). Moreover, more patients in the overweight group had a lower TNM stage (P=0.003). In the univariated analysis, high BMI was significantly associated with better DSS (P=0.013).

CONCLUSIONS

After adjusting for covariates enrolled for study, high BMI was an independent prognostic factor in weight loss esophageal squamous carcinoma patients.

Viruses, Other Pathogenic Microorganisms and Esophageal Cancer

BACKGROUND

Esophageal cancer (EC) is the eighth most prevalent malignant tumor and the sixth leading cause of cancer mortality throughout the world. Despite the technical developments in diagnosis and treatment, the 5-year survival rate is still low. The etiology of EC remains poorly understood; multiple risk factors may be involved and account for the great variation in EC incidence in different geographic regions.

SUMMARY

Infection with carcinogenetic pathogens has been proposed as a risk factor for EC. This review explores the recent studies on the association of human papillomavirus (HPV), Epstein-Barr virus (EBV), Helicobacter pylori and esophageal bacterial biota with EC.

KEY MESSAGE

Among the above-mentioned pathogens, HPV most likely contributes to esophageal squamous cell carcinoma (ESCC) in high-risk populations. New techniques are being applied to studies on the role of infection in EC, which will inevitably bring novel ideas to the field in the near future.

PRACTICAL IMPLICATIONS

Multiple meta-analyses support the finding of a higher HPV detection rate in regions associated with high risk for ESCC compared to low-risk areas. A potential role of HPV in the rise of esophageal adenocarcinoma (EAC) was proposed recently. However, further studies are required before a firm conclusion can be drawn. Less work has been done in studying the association between EBV and ESCC, and the results are quite controversial. H. pylori infection is found to be inversely related to EC, which is probably due to the reduced incidence of gastroesophageal reflux disease. Analysis of the esophageal bacterial biota revealed distinct clusters of bacteria in normal and diseased esophagi. A type II microbiome rich in Gram-negative bacteria potentially contributes to EAC by inducing chronic inflammation. Novel findings from such studies as these may benefit public health by justifying anti-infection measures to prevent EC.

Interleukin 12B rs3212227 T > G polymorphism was associated with an increased risk of gastric cardiac adenocarcinoma in a Chinese population

Gastric cardiac adenocarcinoma (GCA) is one of common malignant tumors in the world. Multiple genes that play critical roles in inflammatory pathways probably are associated with GCA risk. We conducted a hospital-based case-control study to evaluate the genetic effects of functional single nucleotide polymorphisms (SNPs): interleukin 9 (IL9) rs31563 C > T, IL9 rs31564 G > T, IL10 rs1800872 T > G, IL12A rs2243115 T > G, IL12B rs3212227 T > G, and IL13 rs1800925 C > T on the development of GCA. Two hundred and forty-three GCA cases and 476 controls were recruited. Their genotypes were determined using a custom-by-design 48-Plex SNPscan kit. IL12B rs3212227 T > G polymorphism was associated with the increased risk of GCA. However, there was no significant association between the other five SNPs and GCA risk. Stratified analyses indicated that the risk of GCA associated with the IL12B rs3212227 T > G polymorphism was evident among female patients and patients who never smoked or consumed alcoholic drinks. These findings indicated that functional polymorphism IL12B rs3212227 T > G might correlate with GCA risk. However, our results were obtained with a limited sample size; the power of our analysis was low. Larger studies are required to confirm the current findings.

Prognostic significance of the recurrence pattern and risk factors for recurrence in patients with proximal gastric cancer who underwent curative gastrectomy

Proximal gastric cancer has a high propensity of early recurrence after curative resection due to high incidence of lymph node involvement. In the present study, we aimed to investigate the pattern and time of recurrence and to evaluate the risk factors for recurrence of patients with proximal gastric cancer. Between 2005 and 2013, 99 patients with recurrent proximal gastric cancer who underwent radical gastrectomy were retrospectively analyzed. The prognostic significance of the pattern and the time of recurrence and the relationship between the pattern of recurrence and the other clinicopathological factors were evaluated. The median time to recurrence was 24 months; 45.5 % of patients relapsed within 2 years. Forty-three (43.4 %) patients indicated hematogenous recurrence and 41 (41.4 %) patients revealed peritoneal recurrence with the most predominant patterns. The median progression-free survival (PFS) time for patients with locoregional recurrence was significantly better than that of patients with peritoneal recurrences, hematogenous recurrences, and distant lymph nodes (32.2 vs. 18.9 vs. 18.2 vs. 9.7 months, p = 0.005, respectively). Moreover, the median overall survival (OS) interval for patients with distant lymph nodes recurrence was significantly worse than that of patients with locoregional, peritoneal, and hematogenous recurrences (13.5 vs. 48.5 vs. 31.4 vs. 29.9 months, p = 0.006, respectively). The presence of lymph node metastasis (p = 0.004) and surgery type (p = 0.04) for PFS and the time of recurrence (p = 0.033), lymph node metastasis (p = 0.03), and surgery type (p = 0.04) for OS were found to be independent prognostic factors by multivariate analysis. Logistic regression analysis indicated that the presence of lymph node metastasis and surgery type were independent risk factors for predicting the occurrence of early recurrence (p = 0.001, OR 0.48 and p = 0.028, OR 0.41, respectively). The median OS time of early recurrence patients was significantly shorter than that of patients with late recurrence (16.6 vs. 55.2 months, p < 0.001). Furthermore, proximal gastrectomy, poorly differentiated histology, advanced pT stage, and lymph node metastasis were significantly associated with early recurrence. Our results showed that lymph node metastasis and surgery type were independent risk factors for prediction of early recurrence in proximal gastric cancer. Thus, total gastrectomy with regional lymph node dissection may be a suitable treatment option for proximal gastric cancer patients with tumors that have high risk features for recurrence.

Dietary Risk Reduction Factors for the Barrett's Esophagus-Esophageal Adenocarcinoma Continuum: A Review of the Recent Literature

Esophageal adenocarcinoma (EA) incidence is among the most rapidly increasing of any cancer type in the U.S., and prognosis is poor. Prevalence of the potential precursor lesion, Barrett's esophagus (BE), is also increasing. Candidates for safe and effective risk reduction strategies are needed, potentially including dietary components. In this qualitative review, we summarize recently published epidemiologic studies, in context of earlier work, on dietary intake and BE-EA outcomes. Potential cohort study/intervention trial candidates which could be increased to reduce BE-EA development include intake of: (1) fruits and vegetables; vegetables; fruit (EA only); (2) β-carotene and vitamins C and E; (3) folate (EA only); and (4) total fiber (EA only). Also, (5) red and processed meat intake could be targeted for dietary reduction/omission to reduce EA development. Few dietary constituents have been evaluated among EA patients to examine associations with mortality, thus interventions conducted among EA patients are premature.

Association Between Smoking and p53 Mutation in Oesophageal Squamous Cell Carcinoma: A Meta-analysis

AIMS

Several studies have evaluated the association between smoking and p53 mutation in oesophageal squamous cell carcinoma (ESCC), but the conclusions are inconsistent. The aim of the present study was to carry out a meta-analysis evaluating the relationship between smoking and p53 mutation in patients with ESCC.

MATERIALS AND METHODS

Eligible studies were identified through searches in PubMed and EMBASE. The odds ratio with 95% confidence interval was used to assess the association. In total, 20 studies were identified that met the selection criteria; these studies were analysed using STATA 12.0 software.

RESULTS

The 20 studies identified comprised 1524 ESCC patients, of whom 72.97% were smokers and 27.03% were non-smokers. The pooled odds ratio of p53 mutation in ESCC for any cigarette smoking versus no smoking was 1.28 (95% confidence interval=0.88-1.88). The estimated odds ratios were 1.06 (95% confidence interval=0.56-2.00, based on five studies, 129 light smokers and 70 non-smokers) for light smoking and 2.01 (95% confidence interval=1.12-3.60, based on five studies, 223 heavy smokers and 73 non-smokers) for heavy smoking.

CONCLUSION

The results of our meta-analysis indicate an overall positive relationship between heavy smoking and p53 mutation in ESCC. Heavy smokers with ESCC have a higher risk for p53 mutation than non-smokers. Large-scale clinical studies are still needed to draw a more precise conclusion.

Is hormone replacement therapy in post-menopausal women associated with a reduced risk of oesophageal cancer?

PURPOSE

The rise in oesophageal adenocarcinoma incidence in women with age is delayed compared with men until the post-menopausal period. A matched cohort study was therefore undertaken of post-menopausal women on hormone replacement therapy (HRT) to examine the association between HRT, oesophageal cancer and the potentially associated conditions, reflux oesophagitis and Barrett's oesophagus.

METHODS

Women aged over 50 years within the UK General Practice Research Database with a history of HRT exposure were matched by age and general practice with controls without HRT exposure (1:1). Matched Cox-regression analysis was performed to estimate adjusted hazard ratios.

RESULTS

51,851 HRT users and controls were studied. Prolonged HRT use for 5-10 years (hazard ratio 0.25 (95% CI 0.07-0.95)) and time-dependent covariates for increasing duration of HRT use (0.06 (0.01-0.43)) were associated with a reduced oesophageal cancer risk. HRT use was associated with reflux oesophagitis (1.27 (1.12-1.43)), but when analysis was confined to women with codes for both reflux oesophagitis and endoscopy there was no association (1.1 (0.81-1.44)), suggesting increased reporting of reflux symptoms among HRT users rather than an association with endoscopic reflux oesophagitis.

CONCLUSION

Long-term post-menopausal HRT may be associated with a reduced risk of oesophageal cancer.

The combination of platelet count and neutrophil lymphocyte ratio is a predictive factor in patients with esophageal squamous cell carcinoma

OBJECTIVE: The prognostic value of inflammation indexes in esophageal cancer was not established. In this study, therefore, both prognostic values of Glasgow prognostic score (GPS) and combination of platelet count and neutrophil lymphocyte ratio (COP-NLR) in patients with esophageal squamous cell carcinoma (ESCC) were investigated and compared. METHODS: This retrospective study included 375 patients who underwent esophagectomy for ESCC. The cancer-specific survival (CSS) was calculated by the Kaplan-Meier method, and the difference was assessed by the log-rank test. The GPS was calculated as follows: patients with elevated C-reactive protein (> 10 mg/l) and hypoalbuminemia (< 35 g/l) were assigned to GPS2. Patients with one or no abnormal value were assigned to GPS1 or GPS0, respectively. The COP-NLR was calculated as follows: patients with elevated platelet count (> 300 × 10⁹/l) and neutrophil lymphocyte ratio (> 3) were assigned to COP-NLR2. Patients with one or no abnormal value were assigned to COP-NLR1 or COP-NLR0, respectively. RESULTS: The 5-year CSS in patients with GPS0, 1, and 2 was 50.0%, 27.0%, and 12.5%, respectively (P < .001). The 5-year CSS in patients with COP-NLR0, 1, and 2 was 51.8%, 27.0%, and 11.6%, respectively (P < .001). Multivariate analysis showed that both GPS (P = .003) and COP-NLR (P = .003) were significant predictors in such patients. In addition, our study demonstrated a similar hazard ratio (HR) between COP-NLR and GPS (HR = 1.394 vs HR = 1.367). CONCLUSIONS: COP-NLR is an independent predictive factor in patients with ESCC. We conclude that COP-NLR predicts survival in ESCC similar to GPS.

The changing pattern of upper gastrointestinal disorders by endoscopy: data of the last 40 years

Objectives. We have investigated the changes in the incidence of various diagnoses that have been made in the endoscopy unit throughout the last 40 years. Methods. In this study, changes in the incidence of endoscopic diagnosis in upper gastrointestinal system between 1970 and 2010 were evaluated. Their diagnosis, age, and gender data were entered into the Excel software. Results. Of the 52816 cases who underwent esophagogastroduodenoscopy in the 40-year time period, the mean age was 48.17 ± 16.27 (mean ± SD). Although overall more than half of the patients were male (54.3%), in 1995 and after a marked increase was seen in the proportion of female gender (51–55%). The presence of hiatal hernia, reflux esophagitis, and the number of Barrett's esophaguses significantly increased. Erosive gastritis showed gradual increase, while the number of gastric ulcers decreased significantly. The presence of gastric and esophageal cancer significantly decreased. The number of duodenal ulcers significantly decreased. Conclusion. We detected that the incidences of esophagitis, Barrett's esophagus, and erosive gastritis significantly increased while the incidences of gastric/duodenal ulcer and gastric/esophageal cancer decreased throughout the last 40 years.

SIRT1 expression is associated with lymphangiogenesis, lymphovascular invasion and prognosis in pN0 esophageal squamous cell carcinoma

Background

Sirtuin1 (SIRT1) is an NAD⁺-dependent type III histone deacetylase (HDAC). This research investigated the prevalence of SIRT1 protein expression and its prognostic influence with the aim of validating its potential role in lymphangiogenesis and lymphovascular invasion (LVI) in pN0 esophageal squamous cell carcinoma (ESCC).

Methods

A total of 206 patients were enrolled in this retrospective study. SIRT1 and VEGF-C protein expression was detected by immunohistochemical staining. Peritumoral lymphatic microvessel density (LVD) and LVI were evaluated by immunostaining for D2-40. Statistical analysis was then preformed to investigate the relevance of SIRT1 expression and various clinicopathologic features and to examine the effect of SIRT1 on tumor-induced lymphangiogenesis, LVI and prognosis.

Results

SIRT1 positive expression was identified in 95 cases in the nucleus and was significantly correlated with T status (P < 0.001), disease stage (P = 0.001), VEGF-C positive expression (P = 0.015), high LVD (P = 0.013) and positive LVI (P = 0.015). Patients with SIRT1 positive expression, high LVD and positive LVI had a significantly unfavorable 5-year disease free survival (P < 0.001, P = 0.030, and P < 0.001, respectively) and overall survival (P < 0.001, P = 0.017, and P < 0.001, respectively). However, based on multivariate Cox regression analysis, only SIRT1 positive expression and positive LVI were significant independent prognosticators of poor disease-free survival (P = 0.029 and 0.018, respectively) and overall survival (P = 0.045 and 0.031, respectively).

Conclusions

SIRT1 positive expression was significantly associated with tumor progression, lymphangiogenesis, LVI and poor survival in pN0 ESCC patients. Our research shows a utilization of SIRT1 in prognosing poor survival and providing possible target for ESCC patients through inhibiting its lymphangiogenesis activity.

Changing trends in the proportions of small (≤ 2 cm) proximal and non-proximal gastric carcinomas treated at a high-volume tertiary medical center in China

OBJECTIVE

Guided by the recently established histological criteria of the gastroesophageal junction (GEJ), we aimed to investigate and compare trends in the proportions of small (≤ 2 cm) proximal gastric carcinoma (PGC) vs non-PGC (NPGC) in Chinese patients over an 8-year period.

METHODS

The study was conducted with consecutive surgical resected specimens of small PGC that was located within 3 cm below the GEJ and NPGC (located at all other gastric regions) treated at a single medical center in China. Differences in proportions between the two groups were compared.

RESULTS

Among all 313 cases, 111 (35.5%) were classified as PGC and the remaining 202 (64.5%) as NPGC. Patients with PGC were significantly elder than those with NPGC, and none aged younger than 40 years. The proportions of PGC significantly and progressively increased from 16% in 2004 to 45% in 2011, in contrast to a steady decreasing trend for NPGC from 84% to 55% over the same period. The difference in trends between the two groups approached, but was not at a statistically significant level (P = 0.08). Proportions of small cancers in the gastric corpus and in female patients remained low and stable, in contrast to a significantly higher proportion in male patients (P < 0.05).

CONCLUSIONS

Our data showed a significantly upward-shifting trend in the proportions of small PGC, primarily in elderly male patients, in contrast to a downward shifting trend in NPGC over the most recent 8-year period in Chinese patients.

Preoperative platelet lymphocyte ratio (PLR) is superior to neutrophil lymphocyte ratio (NLR) as a predictive factor in patients with esophageal squamous cell carcinoma

Background

Recent studies have shown that the presence of systemic inflammation correlates with poor survival in various cancers. The aim of this study was to determinate the prognostic value of the neutrophil lymphocyte ratio (NLR) and the platelet lymphocyte ratio (PLR) in patients with esophageal squamous cell carcinoma (ESCC).

Methods

Preoperative NLR and PLR were evaluated in 483 patients undergoing esophagectomy for ESCC from January 2005 to December 2008. The prognostic significance of both markers was then determined by both uni- and multivariate analytical methods. Receiver operating characteristic (ROC) curves were also plotted to verify the accuracy of NLR and PLR for survival prediction.

Results

High preoperative NLR (≥3.5 versus < 3.5, P = 0.039) and PLR (≥150 versus < 150, P < 0.001) were significantly associated with poor overall survival in multivariate analysis. However, our study demonstrated a better discrimination for the PLR in terms of hazard ratio(HR) than the NLR (HR = 1.840 versus HR = 1.339). Patients with NLR ≥3.5 had significantly poorer overall survival compared to NLR <3.5 (35.4% versus 57.7%, P < 0.001). Patients with PLR ≥150 also had significantly poorer overall survival compared to patients with PLR <150 (32.7% versus 63.5%, P < 0.001). The area under the curve (AUC) was 0.658 (95% confidence interval (CI): 0.610 to 0.706, P < 0.001) for NLR and 0.708 (95% CI: 0.662 to 0.754, P < 0.001) for PLR, indicating that PLR was superior to NLR as a predictive factor in ESCC.

Conclusions

Preoperative NLR and PLR were significant predictors of overall survival in patients with ESCC. However, PLR is superior to NLR as a predictive factor in patients with ESCC.

Prevalence of human papillomavirus among oesophageal squamous cell carcinoma cases: systematic review and meta-analysis

Background:

Oncogenic human papillomavirus (HPV) has been hypothesised as a risk factor for oesophageal squamous cell carcinoma (OSCC), but aetiological research has been limited by the varying methodology used for establishing HPV prevalence. The aims of this systematic review and meta-analysis were to estimate the prevalence of HPV DNA detected in OSCC tumours and the influence of study characteristics.

Methods:

Study-level estimates of overall and type-specific HPV prevalence were meta-analysed to obtain random-effects summary estimates.

Results:

This analysis included 124 studies with a total of 13 832 OSCC cases. The average HPV prevalence (95% confidence interval) among OSCC cases was 0.277 (0.234, 0.320) by polymerase chain reaction; 0.243 (0.159, 0.326) by in situ hybridisation; 0.304 (0.185, 0.423) by immunohistochemistry; 0.322 (0.154, 0.490) by L1 serology; and 0.176 (0.061, 0.292) by Southern/slot/dot blot. The highest HPV prevalence was found in Africa and Asia, notably among Chinese studies from provinces with high OSCC incidence rates.

Conclusions:

Future research should focus on quantifying HPV in OSCC cases using strict quality control measures, as well as determining the association between HPV and OSCC incidence by conducting large, population-based case–control studies. Such studies will provide a richer understanding of the role of HPV in OSCC aetiology.

Systematic review of laparoscopy-assisted versus open gastrectomy for advanced gastric cancer

OBJECTIVE

The study compared laparoscopy-assisted gastrectomy (LAG) with open gastrectomy (OG) in the management of advanced gastric cancer (AGC).

METHODS

Literature search was performed in the Medline, Embase, and Cochrane Library databases to identify control studies that compared LAG and OG for AGC. A meta-analysis was conducted to examine the surgical safety and oncologic adequacy, using the random-effect model.

RESULTS

Seven eligible studies including 815 patients were analyzed. LAG was associated with less blood loss, less use of analgesics, shorter time of flatus and periods of hospital stay, but longer time of operation. The incidence of most complications was similar between the two groups. However, LAG was associated with a lower rate of pulmonary infection (odds ratio (OR) 0.19; 95% confidence interval (CI) 0.05 to 0.68; P<0.05). No significant differences were noted in terms of the number of harvested lymph nodes (weighted mean difference (WMD) 1.165; 95% CI -2.000 to 4.311; P>0.05), overall mortality (OR 0.65; 95% CI 0.39 to 1.10; P>0.05), cancer-related mortality (OR 0.64; 95% CI 0.32 to 1.25; P>0.05), or recurrence (OR 0.62; 95% CI 0.33 to 1.16; P>0.05).

CONCLUSIONS

LAG could be performed safely for AGC with adequate lymphadenectomy and has several short-term advantages compared with conventional OG. No differences were found in long-term outcomes. However, these results should be validated in large randomized controlled studies (RCTs) with sufficient follow-up.