Reproductive factors and risk of esophageal squamous cell carcinoma in northern Iran: a case-control study in a high-risk area and literature review. Eur J Cancer Prev. 2013;22:461-466. [PMID: 23238586 DOI: 10.1097/CEJ.0b013e32835c7f87]

A case report of metastatic esophageal squamous cell carcinoma during pregnancy

Esophageal cancer is extremely rare in pregnant women, accounting for only 0.07%-0.1% of all malignant neoplasms in pregnancy. It is rapidly progressive in nature and requires timely intervention. Our literature search yielded six case reports of esophageal cancers in pregnancy thus far. We herein report the case of a 30-year-old female, presenting at 32 weeks of gestation with complaints of hoarseness, dysphagia, and weight loss. The biopsy taken from within the esophagus, using an endoscope during an upper endoscopy procedure confirmed the diagnosis of squamous cell carcinoma of esophagus and Positron emission tomography-computed tomography revealed metastasis to parathyroid region. She was confirmed with metastatic squamous cell cancer positive for cytokeratin 5/6 and cytokeratin P40 immunohistochemistry. The Positron emission tomography-computed tomography of the chest showed a large hypermetabolic soft tissue mass in the mid-esophagus with significant proximal dilation. The head-and-neck computed tomography scan represented a necrotic nodal mass in the neck and circumferential mural thickening involving the mid-esophagus resulting in the proximal dilation confirming the primary tumor site. Two weeks after the delivery, the patient started a chemotherapy regimen consisting of nine cycles of Carboplatin and Paclitaxel. Postchemotherapeutic computed tomography showed remonstration of lesion in the thyroid gland and middle part of the esophagus. Thus, in pregnant patients with new onset hoarseness, dysphagia, or substantial weight loss, clinicians should keep esophageal cancer as part of their differentials. A thorough history, detailed physical examination, and imaging should be performed to determine esophageal cancer, as it can advance swiftly and has a poor prognosis if left untreated.

Use of anti-androgenic 5α-reductase inhibitors and risk of oesophageal and gastric cancer by histological type and anatomical sub-site

Background

To investigate if anti-androgenic medications 5α-reductase inhibitors (5-ARIs) decrease the risk of developing oesophageal and gastric tumours, analysed by histological type and anatomical sub-site.

Methods

A Swedish population-based cohort study between 2005 and 2018 where men using 5-ARIs were considered exposed. For each exposed participant, ten male age-matched non-users of 5-ARIs (non-exposed) were included. Multivariable Cox regression provided hazard ratios (HR) with 95% confidence intervals (CI) adjusted for age, calendar year, smoking, non-steroidal anti-inflammatory drugs/aspirin use, and statins use. Further adjustments were made depending on the tumour analysed.

Results

The cohort included 191,156 users of 5-ARIs and 1,911,560 non-users. Overall, the use of 5-ARIs was not associated with any statistically significantly reduced risk of oesophageal or cardia adenocarcinoma (adjusted HR 0.92, 95% CI 0.82–1.02) or gastric non-cardia adenocarcinoma (adjusted HR 0.90, 95% CI 0.80–1.02). However, the use of 5-ARIs indicated a decreased risk of oesophageal or cardia adenocarcinoma among obese or diabetic participants (adjusted HR 0.55, 95% CI 0.39–0.80) and a reduced risk of oesophageal squamous cell carcinoma (adjusted HR 0.49, 95% CI 0.37–0.65).

Conclusion

Users of 5-ARIs may have a decreased risk of developing oesophageal or cardia adenocarcinoma among those obese or diabetic, and a decreased risk of oesophageal squamous cell carcinoma.

Increased prognostic value of clinical–reproductive model in Chinese female patients with esophageal squamous cell carcinoma

BACKGROUND

In China, it has been well recognized that some female patients with esophageal squamous cell carcinoma (ESCC) have different overall survival (OS) time, even with the same tumor-node-metastasis (TNM) stage, challenging the prognostic value of the TNM system alone. An effective predictive model is needed to accurately evaluate the prognosis of female ESCC patients.

AIM

To construct a novel prognostic model with clinical and reproductive data for Chinese female patients with ESCC, and to assess the incremental prognostic value of the full model compared with the clinical model and TNM stage.

METHODS

A new prognostic nomogram incorporating clinical and reproductive features was constructed based on univariatie and Cox proportional hazards survival analysis from a training cohort (n = 175). The results were recognized using the internal (n = 111) and independent external (n = 85) validation cohorts. The capability of the clinical–reproductive model was evaluated by Harrell’s concordance index (C-index), Kaplan–Meier curve, time-dependent receiver operating characteristic (ROC), calibration curve and decision curve analysis. The correlations between estrogen response and immune-related pathways and some gene markers of immune cells were analyzed using the TIMER 2.0 database.

RESULTS

A clinical–reproductive model including incidence area, age, tumor differentiation, lymph node metastasis (N) stage, estrogen receptor alpha (ESR1) and beta (ESR2) expression, menopausal age, and pregnancy number was constructed to predict OS in female ESCC patients. Compared to the clinical model and TNM stage, the time-dependent ROC and C-index of the clinical–reproductive model showed a good discriminative ability for predicting 1-, 3-, and 5-years OS in the primary training, internal and external validation sets. Based on the optimal cut-off value of total prognostic scores, patients were classified into high- and low-risk groups with significantly different OS. The estrogen response was significantly associated with p53 and apoptosis pathways in esophageal cancer.

CONCLUSION

The clinical–reproductive prognostic nomogram has an incremental prognostic value compared with the clinical model and TNM stage in predicting OS in Chinese female ESCC patients.

Incidence of Esophageal Cancer in Iran, a Population-Based Study: 2001-2015

PURPOSE

Even though Kurdistan, the western province of Iran, has a cancer surveillance system, a detailed analysis of incidence rate has not been yet performed. We describe Age Standardized Incidence Rates (ASRs) for esophageal cancer (EC) in Kurdistan Province of Iran in 2001-2015.

METHODS

Incidence cases of EC were obtained from a population-based cancer registry. We obtained ASRs and 95% confidence intervals (CI) per 100,000 populations for each calendar year group.

RESULTS

Between 2001 and 2015, 1362 incidence cases with EC were reported to the cancer registry. Annual ASRs in 2006-2010 were more than the other years in both men and women, respectively. Most ASRs were reported among women in Divandarreh (18.95, 95% CI 14.76, 23.92), Saqez (12.75, 95% CI 10.73, 15.01), Sanandaj (8.84, 95% CI 7.64, 10.17), and Qorveh (8.19, 95% CI 6.54, 10.12), and among men in Divandarreh (19.38, 95% CI 15.38, 24.06), Saqez (13.64, 95% CI 11.49, 16.05), Sanandaj (8.70, 95% CI 7.56, 9.96), and Marivan (7.93, 95% CI 6.26, 9.88).

CONCLUSIONS

It was concluded that EC in Divandarreh, Saqez, and Sanandaj has the highest ASRs, and these areas are considered as high-risk areas for this disease in the Iranian province of Kurdistan. Therefore, to understand the reasons of these problems, a considerable work is needed.

Interaction of Estradiol and Endoplasmic Reticulum Stress in the Development of Esophageal Carcinoma

Gender differences in esophageal cancer patients indicate that estradiol may have antitumor effects on esophageal cancer. The initiation of endoplasmic reticulum stress (ERS) can induce apoptosis in esophageal cancer cells. However, it is still unknown whether estradiol inhibits the development of esophageal cancer by activating ERS pathway. In this study, the gender difference in the development of esophageal cancer was observed by analyzing clinical data and the experimental tumor xenografts in mice. Meanwhile, we investigated the mechanism of ERS in estradiol-mediated inhibition of esophageal cancer using esophageal squamous cell carcinoma cell line EC109. The proportion of male patients with esophageal cancer was significantly higher than female patients. Meanwhile, male patients were prone to have adventitial invasion. The weight of transplanted tumors in female mice was significantly smaller than that in male mice. In vitro experiments showed estradiol inhibits the viability and migration of EC109 cells by increasing the expression of ERS-related proteins, whereas ERS inhibitor 4-PBA abolished the effects of estradiol. In conclusion, our data demonstrate that sex difference exists in the occurrence of esophageal cancer. Estradiol can inhibit the viability and migration of esophageal cancer cells through the activation of ERS, providing a novel insight for esophageal cancer development, treatment, and prevention.

Incidence Trends of Esophageal and Gastric Cancer Subtypes by Race, Ethnicity, and Age in the United States, 1997-2014

BACKGROUND & AIMS

There is limited information on contemporary incidence rates and trends, by race, ethnicity, and age, for major subtypes of esophageal and gastric cancer in the United States. We examined the most recent nationwide incidence data for esophageal squamous cell carcinoma, esophageal adenocarcinoma (EAC), gastric cardia adenocarcinoma (GCA), and gastric non-cardia adenocarcinoma (GNCA) by race, ethnicity, and age in the United States.

METHODS

Average contemporary incidence rates (2010-2014) and annual percent changes in rates (from 1997 through 2014) by race, ethnicity, and age were calculated for each cancer subtype using nationwide data compiled by the North American Association of Central Cancer Registries.

RESULTS

From 1997 through 2014, overall esophageal squamous cell carcinoma incidence rates continuously decreased in both sexes and all racial and ethnic groups, although rates remained stable among younger non-Hispanic white women. Overall, EAC incidence rates decreased or stabilized during the most recent time period (2006-2007 through 2014) in men and women, after increasing from 1997 through 2006 and 2007. However, EAC incidence rates continued to increase from 1997 through 2014 in several subpopulations, including non-Hispanic white men younger than 50 years, non-Hispanic white women younger than 70 years, and Asian/Pacific Islander men (all ages combined). Overall GCA incidence rates increased among non-Hispanic whites, but decreased among Hispanics (men only) and Asian/Pacific Islanders. Although overall GNCA rates decreased in both sexes and all racial and ethnic groups, rates increased in younger age groups among men (all races and ethnicities combined) and non-Hispanic white, non-Hispanic black, and Hispanic women.

CONCLUSIONS

Using high-quality nationwide population-based data, we found increasing incidence trends for EAC, GCA, and GNCA in several subpopulations in the United States.

Systematic review: the etiology of esophageal squamous cell carcinoma in low-income settings

Esophageal carcinoma causes over 380 000 deaths per year, ranking sixth worldwide in mortality amongst all malignancies. Globally, the squamous cell subtype is most common and accounts for 80% of esophageal cancers. Nonetheless, esophageal squamous cell carcinoma is much more poorly understood than esophageal adenocarcinoma, including what is driving such high prevalences, why it often presents in young patients, and shows such marked geographical delineations Areas covered: The current literature was searched for articles focusing on aetiopathogenesis of squamous cell esophageal carcinoma via a systematic review, particularly in low-resource settings. This was supplemented by papers of interest known to the authors. Expert commentary: Current putative mechanisms include polycyclic aromatic hydrocarbons, nitrosamines, acetaldehyde, cyclo-oxygenase-2 pathways, androgen and their receptor levels, as well as smoking & alcohol, micronutrient deficiencies and diet, mycotoxins, thermal damage, oral hygiene and microbiotal factors, inhaled smoke, viral infections such as HPV, and chronic irritative states. Etiology is likely multifactorial and varies geographically. Though smoking and alcohol play a predominant role in high-income settings, there is strong evidence that mycotoxins, diet and temperature effects may play an under-recognized role in low and middle-income settings.

Worldwide incidence, mortality and time trends for cancer of the oesophagus

The incidence and mortality trends of oesophageal cancer are changing significantly across the world with considerable heterogeneity between sex, histological types, ethnic patterns and geographical distribution. Recent oesophageal cancer incidence and mortality trends have been analysed using data available from the WHO mortality database, the GLOBOCAN 2012 database and the Cancer Incidence in Five Continents database managed by the International Agency for Research on Cancer. Huge geographical variation is an epidemiological characteristic of oesophageal cancer, with the highest incidence rates observed in Eastern Asia and in Eastern and Southern Africa and the lowest rates observed in Western Africa. The variation is to the order of more than 21 times between the lowest-incidence and the highest-incidence countries. Although the incidence of squamous cell carcinoma is increasing globally, its incidence rates are decreasing in the USA and a few European countries. However, the decrease in the incidence of squamous cell carcinomas in these countries has been accompanied by a marked increase in adenocarcinoma incidence rates. There is a significant sex variation as well, with men being affected three to four times more commonly than women worldwide. The observed trends reflect significant global variations in the incidence and mortality of oesophageal cancers on the basis of sex, geographical distribution, ethnicity and histology. These epidemiological factors related to oesophageal cancers point out a possibly significant role of molecular epidemiological factors (genetic susceptibility and response to treatment) with major differences likely between the characteristics of Asian and Western populations.

Characterization of serum estradiol level and tissue estrogen receptor immunostaining with clinical response and reproductive factor changes in Chinese female patients with esophageal squamous cell carcinoma

Pre-menopausal female patients have a prolonged survival than post-menopausal patients, indicating that estrogen and/or estrogen receptor (ER) may have some biological effects on prognosis. ER expression in cancer tissue has been reported to be a significant prognostic marker in multiple human cancers. However, the prognostic value of estrogen and/or ER on female patients with esophageal squamous cell carcinoma (ESCC) is rarely reported. The present study was undertaken to elucidate the associations of serum estradiol level, tissue estrogen receptor alpha (ERα) and estrogen receptor beta (ERβ) expression with clinical response and reproductive factor changes in 387 female ESCC patients. Radioimmunoassay revealed that serum estradiol level was higher in pre-menopausal than those in peri-menopausal and post-menopausal patients. Furthermore, patients with higher serum estradiol level appeared to have a better survival. Immunostaining results suggested that ERα positive (+) expression was mainly located in cytoplasm of tumor cells with a positive rate of 69.9% and ERβ (+) was mainly located in nucleus of tumor cells with a positive rate of 64.9%. We did not find the relations of ER expression with tumor invasion (P>0.05), lymph node metastasis (P>0.05), TNM staging (P>0.05) and treatment method (P>0.05). Surprisingly, ERα (+) expression was higher in post-menopausal patients than those in pre-menopausal patients (P<0.05). Patients with number of pregnancy≥4 have a higher ERβ (+) expression than those patients with≤3 (P<0.05). Univariate and multivariate survival analysis showed that ERβ (+) expression in addition to ERα (-) expression are favorable prognostic markers in female ESCC patients (P<0.05). Further related study is needed to in-depth explore the potential mechanisms of ERα and ERβ in survival of female patients with ESCC.

Expression of 4-hydroxynonenal in esophageal squamous cell carcinoma

Esophageal squamous cell carcinoma (ESCC) is one of the most common types of cancer in Asia, particular in China. However, the pathogenesis of ESCC has not previously been well demonstrated. A major product of lipid peroxidation, 4-hydroxynonenal (4-HNE), is considered to be an oxidative stress inducer, as it is involved in the pathogenesis of a number of degenerative diseases, including Alzheimer's disease, atherosclerosis, cataracts and cancer. In order to investigate the association between oxidative stress and the pathogenic process of ESCC, the present study determined the expression levels of 4-HNE in 23 non-malignant esophageal epithelial tissues, 11 esophageal carcinoma in situ tissues and 57 ESCC tissues from patients in the Chaoshan area, a high-risk region for esophageal cancer in China. A significantly higher expression level of 4-HNE was identified in ESCC tissues compared with that in non-malignant esophageal epithelial tissues (P<0.05). Furthermore, immunohistochemical analysis demonstrated that expression levels of 4-HNE were significantly associated with the clinical stage. The patients with positive staining of 4-HNE revealed a poorer clinical outcome compared with that of patients with negative staining. 4-HNE was significantly associated with the severity of inflammation and increased with the progression of precancerous lesions (P<0.05). These results provide pathological evidence that oxidative stress is a driving force of ESCC carcinogenesis.

Hormonal and reproductive factors and risk of esophageal cancer in women: a meta-analysis

Currently published studies on the relationship between hormonal and reproductive factors and esophageal cancer (EC) risk in women have yielded contradictory findings. For a better understanding of this relationship, we first performed this meta-analysis by pooling all available publications. Sixteen independent studies were retrieved after a comprehensive search in PubMed and Embase databases. The pooled relative risks (RRs) with 95% confidence intervals (95% CIs) were calculated. The pooled RRs implicated that hormone replacement therapy was negatively associated with the risk of EC (RR = 0.72, 95% CI 0.60-0.86, P < 0.001) and esophageal squamous cell carcinoma (RR = 0.68, 95% CI 0.48-0.97, P = 0.031). Menopausal women were at an increased risk of EC (RR = 1.47, 95% CI 1.07-2.03, P = 0.018), particularly esophageal squamous cell carcinoma (RR = 1.66, 95% CI 1.12-2.48, P = 0.012). Additionally, decreased risk of EC (RR = 0.79, 95% CI 0.68-0.92, P = 0.003) and esophageal adenocarcinoma (RR = 0.66, 95% CI 0.53-0.82, P < 0.001) was demonstrated among women with breast-feeding history. Moreover, such associations were more significant among Caucasians, but not Asians. Our study suggests that menopause is an independent risk factor for EC, while hormone replacement therapy and breast-feeding history play a protective role against EC, particularly among Caucasians. All results are consistent with the hypothesis that effects of estrogen may lower the risk of EC in women.

The Male Predominance in Esophageal Adenocarcinoma

The incidence of esophageal adenocarcinoma (EAC) has increased rapidly during the past 4 decades in many Western populations, including North America and Europe. The established etiological factors for EAC include gastroesophageal reflux and obesity, Helicobacter pylori infection, tobacco smoking, and consumption of fruit and vegetables. There is a marked male predominance of EAC with a male-to-female ratio in incidence of up to 9:1. This review evaluates the available literature on the reasons for the male predominance, particularly an update on epidemiologic evidence from human studies during the past decade. The striking sex difference does not seem to be explained by established risk factors, given that the prevalence of the etiological factors and the strengths of associations between these factors and EAC risk are similar between the sexes. Sex hormonal factors may play a role in the development of EAC; estrogenic exposures may prevent such development, whereas androgens might increase the risk of EAC. However, continuing research efforts are still needed to fully understand the reasons for the male predominance of EAC.

Prevention strategies for esophageal cancer: Perspectives of the East vs. West

Esophageal cancer is the eighth most common cancer worldwide. Esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC) are the two major phenotypes in Western and Eastern countries, respectively. Because of different pathways in carcinogenesis, the risk factors and effective steps for prevention of esophageal cancer are different between EAC and ESCC. The carcinogenesis of EAC is initiated by the acid exposure of the esophageal mucosa from stomach while that of the ESCC are related to the chronic irritation of carcinogens mainly by the alcohol, cigarette, betel quid, and hot beverage. To eliminate the burden of esophageal cancer on the global health, the effective strategy should be composed of the primary, secondary, and tertiary prevention. In this article, we perform a systematic review of the preventive strategies for esophageal cancer with special emphasis on the differences from the perspectives of Western and Eastern countries.

Effects of reproductive and menstrual factors on survival of women with esophageal squamous cell carcinoma

AIM: To determine the effects of reproductive and menstrual factors on the survival of women with esophageal squamous cell carcinoma (ESCC).

METHODS: A total of 12041 Chinese women with ESCC were enrolled in this study, and their median age was 61 years. All patients' information was retrieved from the esophageal cancer database of Henan Key Laboratory for Esophageal Cancer Research based on the records of reproduction and menstrual history. The menopausal status was categorized as pre-, peri- and post-menopausal. Questionnaire, home interview and/or telephone were performed for survival follow-up. Cox proportional hazards regression models were used for analysis of relative risks (RRs) and 95% confidence intervals (95%CIs) to determine the effects of reproductive and menstrual factors on ESCC survival.

RESULTS: Survival analysis demonstrated that patients with increased number of pregnancy had a longer survival (RR = 1.49, 95%CI: 1.16-1.92); the prolonged survival remained in patients from the high incidence area (RR = 1.41, 95%CI: 1.03-1.86) and in patients with a negative family history (RR = 1.21, 95%CI: 1.04-1.41). Pre-menopausal patients had a longer survival than peri- and postmenopausal patients (P = 0.00); this remained in patients from the high incidence area (RR for post- vs pre-menopausal, 0.73, 95%CI: 0.62-0.86) and in patients with a negative family history (RR = 0.70, 95%CI: 0.58-0.85).

CONCLUSION: Increasing number of pregnancy and premenopausal status may be favorable factors for ESCC survival in Chinese women with ESCC.

Reproductive Factors but Not Hormonal Factors Associated with Thyroid Cancer Risk: A Systematic Review and Meta-Analysis

Many studies have investigated the association between hormonal and reproductive factors and thyroid cancer risk but provided contradictory and inconclusive findings. This review was aimed at precisely estimating this association by pooling all available epidemiological studies. 25 independent studies were retrieved after a comprehensive literature search in databases of PubMed and Embase. Overall, common hormonal factors including oral contraceptive and hormone replacement therapy did not alter the risk of thyroid cancer. Older age at menopause was associated with weakly increased risk of thyroid cancer in overall analysis (RR = 1.24, 95% CI 1.00–1.53, P = 0.049); however, longer duration of breast feeding was related to moderately reduced risk of thyroid cancer, suggested by pooled analysis in all cohort studies (RR = 0.7, 95% CI 0.51–0.95, P = 0.021). The pooled RR in hospital-based case-control studies implicated that parous women were more susceptible to thyroid cancer than nulliparous women (RR = 2.30, 95% CI 1.31–4.04, P = 0.004). The present meta-analysis suggests that older age at menopause and parity are risk factors for thyroid cancer, while longer duration of breast feeding plays a protective role against this cancer. Nevertheless, more relevant epidemiological studies are warranted to investigate roles of hormonal and reproductive factors in thyroid carcinogenesis.

Rheological Characterization and Cluster Classification of Iranian Commercial Foods, Drinks and Desserts to Recommend for Esophageal Dysphagia Diets

BACKGROUND

In the absence of dysphagia-oriented food products, rheological characterization of available food items is of importance for safe swallowing and adequate nutrient intake of dysphagic patients. In this way, introducing alternative items (with similar ease of swallow) is helpful to improve quality of life and nutritional intake of esophageal cancer dysphagia patients. The present study aimed at rheological characterization and cluster classification of potentially suitable foodstuffs marketed in Iran for their possible use in dysphagia diets.

METHODS

In this descriptive study, rheological data were obtained during January and February 2012 in Rheology Lab of National Nutrition and Food Technology Research Institute Tehran, Iran. Steady state and oscillatory shear parameters of 39 commercial samples were obtained using a Physica MCR 301 rheometer (Anton-Paar, GmbH, Graz, Austria). Matlab Fuzzy Logic Toolbox (R2012 a) was utilized for cluster classification of the samples.

RESULTS

Using an extended list of rheological parameters and fuzzy logic methods, 39 commercial samples (drinks, main courses and desserts) were divided to 5 clusters and degree of membership to each cluster was stated by a number between 0 and 0.99.

CONCLUSION

Considering apparent viscosity of foodstuffs as a single criterion for classification of dysphagia-oriented food products is shortcoming of current guidelines in dysphagia diets. Authors proposed to some revisions in classification of dysphagia-oriented food products and including more rheological parameters (especially, viscoelastic parameters) in the classification.