The changing incidence of oesophageal and gastric adenocarcinoma by anatomic sub-site

Epidemiological Review of Gastroesophageal Junction Adenocarcinoma in Asian Countries

BACKGROUND

Similar trends in the prevalence of gastroesophageal reflux disease (GERD), obesity, and Helicobacter pylori infection have been observed in Asian and Western countries despite their time differences. However, it is unclear whether the prevalence of gastroesophageal junction adenocarcinomas in Asian countries is increasing. In this review, we discuss the epidemiological trends of gastroesophageal junction adenocarcinoma in Asian countries.

SUMMARY

The prevalence of GERD is increasing in Asian countries, but most cases are considered mild. Obesity is a serious problem worldwide, but it is considered less serious in Asia than in Western countries. In Asian countries where gastric cancer is common, both cardiac and noncardiac cancers are associated with high rates of H. pylori infection, which is considered a carcinogenic risk factor for both sites of cancer. The widespread use of H. pylori eradication therapy for chronic gastritis in several Asian countries has not directly led to an increased prevalence of esophageal adenocarcinoma. One of the originating sites of junctional adenocarcinoma in most Asian countries is Barrett's esophagus, with short-segment Barrett's esophagus having much lower carcinogenicity than long-segment Barrett's esophagus. Key Messages: Considering the future trends of several risk factors for gastroesophageal junction adenocarcinoma in Asian countries, it is likely that the incidence of gastroesophageal junction adenocarcinoma will gradually increase, but not at a rate that exceeds that of squamous cell carcinoma, as in Western countries.

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.

Study on the correlation between Helicobacter Pylori and biological characteristics of early Gastric Cancer

Objective: Retrospective analysis was used to determine the population diagnosed with EGC, and HP infection was used as the cut-off point to further evaluate the correlation between helicobacter pylori (HP) infection and tumor biological characteristics of early gastric cancer (EGC). Methods: All cases were collected from patients diagnosed with EGC through endoscopic surgery or surgical procedures from January 2009 to October 2018. General information, tumor site, tumor pathology, HER2 immunohistochemical results, and degree of HP infection were collected for retrospective analysis. Results: A total of 111 cases were collected in this study. Among the HP negative group, there were statistically significant differences in tumor sites between the uninfected group and the previously infected group (P<0.05).There were significant differences in monocyte infiltration and neutrophil infiltration between the positive and negative groups (P<0.05).The differentiated adenocarcinoma in the positive group was significantly lower than that in the negative group. The incidence rate of Mixed type cancer was significantly higher than that in the positive group (P<0.01). In the positive group of HP, there was a statistically significant difference in HER2 between the unsterilized group and the previously sterilized group (P<0.05).There was a statistically significant difference in HER2 between the HP positive group and the HP negative group (P<0.01). HP infection was significantly correlated with HER2 index and presented a positive correlation (P=0.014). Conclusion: HP infection is related to the tumor site and mucosal inflammatory infiltration of EGC. The malignant degree of EGC complicated with HP infection is higher, and most of them are mixed type. The degree of HP infection was positively correlated with the degree of invasion and malignancy of ECG. Furthermore, the tumor indicator HER2 is closely related to HP infection, and the detection of HP combined with HER2 is of great significance in the discovery of EGC and the evaluation of its malignancy.

HER2 Heterogeneity in Personalized Therapy of Gastro-Oesophageal Malignancies: An Overview by Different Methodologies

Human epidermal growth factor receptor-2 (HER2)-expression gastro-oesophageal adenocarcinomas (GEA) gained interest as an important target for therapy with trastuzumab. In the current review, we focused the current knowledge on HER2 status in dysplastic and neoplastic gastric conditions, analyzing the methodological procedures to identify HER2 expression/amplification, as well as the proposed scoring recommendations. One of the most relevant questions to evaluate the useful impact of HER2 status on therapeutic choice in GEAs is represented by the significant heterogeneity of HER2 protein and gene expression that may affect the targeted treatment selection. Future development of biotechnology will continue to evolve in order to offer more powerful detection systems for the assessment of HER2 status. Finally, liquid biopsy as well as mutation/amplification of several additional genes may furnish an early detection of secondary HER2 resistance mechanisms in GEAs with a better monitoring of the treatment response.

Evaluation of MT Family Isoforms as Potential Biomarker for Predicting Progression and Prognosis in Gastric Cancer

Background

Metallothioneins (MTs) family comprises many isoforms, most of which are frequently dysregulated in a wide range of cancers. However, the expression pattern and exact role of each distinct MT family isoform which contributes to tumorigenesis, progression, and drug resistance of gastric cancer (GC) are still unclear.

Methods

Publicly available databases including Oncomine, Gene Expression Profiling Interactive Analysis (GEPIA), Kaplan-Meier plotter, SurvExpress, MethHC, cBioportal, and GeneMANIA were accessed to perform an integrated bioinformatic analysis and try to detect fundamental relationships between each MT family member and GC.

Results

Bioinformatic data indicated that the mRNA expression of all MT family members was almost lowly expressed in GC compared with normal gastric tissue (P<0.05), and patients with reduced mRNA expression of each individual MT member had inconsistent prognostic value (OS, FP, PPS), which depended on the individual isoform of MT. A negative correlation between the methylation in promoter region of majority of MT members and their mRNA expression was detected from MethHC database (p<0.001). Data downloaded from TCGA revealed that MTs were rarely mutated in GC patients and MT2A was frequently regulated by other three genes (FOS, JUN, SP1) in GC patients.

Conclusion

MTs were nearly downregulated, and distinct type of MT harbored different prognostic role in GC patients. Methylation in gene promoter region of MTs partially contributed to their reduced expression in GC. Our comprehensive analyses from multiple independent databases may further lead researches to explore MT-targeting reagents or potential diagnostic and prognostic markers for GC patients.

Clinicopathologic characteristics of early gastric cancer according to specific intragastric location

Background

Although the incidence of early gastric cancer (EGC) continues to rise, there have been few studies on the intra-gastric distribution and locational characteristics of EGCs. In addition, there has been no attempt to visualize the intra-gastric distribution of EGCs using a merged tumor map.

Methods

We investigated the anatomic distribution of 644 cases of EGCs and analyzed the correlation between clinicopathologic findings and location by dividing areas of the stomach vertically and transversely. Merged tumor maps were generated using 310 surgically resected cases.

Results

Early gastric cancer was most commonly located in the antrum (57.5%) along the lesser curvature (37.8%). The intra-gastric distributions were similar in the merged tumor maps. Vertically, cancers of the middle third were associated with younger patient age, larger tumor size, and more frequent poorly differentiated (PD) or signet ring cell histology than cancers in other sites. Submucosal invasion was most frequently observed in the upper third. When divided transversely, tumors in the anterior or posterior wall showed more frequent PD or signet ring cell histology than those along the lesser or greater curvatures.

Conclusions

EGC is the most prevalent in the antrum along the lesser curvature and has characteristic locational features, including histologic type, invasion depth, patient age, and tumor size. These results will improve the endoscopic detection rate of EGC and help to determine endoscopic resectability.

Electronic supplementary material

The online version of this article (10.1186/s12876-019-0949-5) contains supplementary material, which is available to authorized users.

Clinicopathological Features and Increased Expression of Toll-Like Receptor 4 of Gastric Cardia Cancer in a High-Risk Chinese Population

The incidence of gastric cardia cancer (GCC) is high in China. However, the clinicopathological characteristics and the carcinogenesis of GCC are unclear. Toll-like receptor 4 (TLR4) is an important innate immunity receptor and has a role in non-GCC (NGCC). We compared the clinicopathological characteristics of GCC patients from a high-risk area in China to esophageal cancer (EC) patients. Immunohistochemistry for TLR4 was performed in 201 histological samples of normal gastric cardia mucosa (n = 11), gastric cardia inflammation (n = 87), and GCC (n = 103). We included 84 patients with EC and 99 with GCC. GCC tissue was more poorly differentiated than EC tissue and more invasive, with more histomorphologic variation. Lymph node metastasis was more frequent in GCC than in EC. The Helicobacter pylori infection rate was higher but not significantly with GCC than EC. Survival was shorter with lymph node metastasis. We found a statistically significant trend for progressive increase of TLR4 expression from normal mucosa to inflammation in GCC. GCC in this high-risk area displays clinicopathologic characteristics different from those of EC and different from those of gastroesophageal junction carcinomas in other countries, although this was not analyzed statistically. Increased TLR4 expression in gastric cardia lesions may be associated with GCC tumorigenesis.

Clinicopathological characterisation of small (2 cm or less) proximal and distal gastric carcinomas in a Chinese population

SummaryClinicopathological characteristics of small gastric carcinoma have not been well defined in Chinese patients. The aim of this study was to investigate and compare small proximal (PGC, n = 111) with distal (DGC, n = 202) gastric carcinoma in 313 consecutive surgically resected small (≤2 cm) gastric carcinomas diagnosed with the WHO criteria. PGC patients were significantly older (average age 63 years versus 59 in DGCs) with a male/female ratio of 3:1. Most tumours were clustered along the lesser curvature (74% in PGCs and 65% in DGCs). Compared to DGCs, PGCs showed a protruded gross pattern significantly more frequently and were significantly better differentiated with a significantly wider histomorphological spectrum. Surprisingly, PGCs were composed of significantly fewer signet-ring cell carcinomas (1% versus 16% in DGCs) but were significantly more deeply invasive, compared to DGCs. Lymph node metastasis was detected in 23% overall, but was significantly less frequent in PGCs (16%) than in DGCs (26%) (p < 0.05). However, the difference in survival between the two groups was not statistically significant. Our results demonstrate that in Chinese patients, PGCs display distinct clinicopathological characteristics, compared to DGCs.

Expression of stem cell markers nanog and PSCA in gastric cancer and its significance

The present study aimed to determine the expression of stem cell markers Nanog compared with PSCA in gastric cancer tissues and adjacent normal tissues, and to investigate the association between tumor stem cells and initiation, progression, metastasis, and prognosis of gastric cancer. One hundred chemotherapy- and radiotherapy-naive patients with pathologically confirmed gastric cancer were enrolled from the General Surgery Department and Surgical Oncology Department of the Affiliated Hospital of Inner Mongolia Medical University (Hohhot, P.R. China), between October 2011 and June 2013. Surgically resected specimens of cancer tissues and adjacent normal tissues (>5 cm from the boundary of cancerous component) were collected. The mRNA expression levels of Nanog and PSCA in those tissues was determined by reverse transcription-quantitative polymerase chain reaction (RT-qPCR). The correlation between the expression of stem cell markers Nanog and PSCA in gastric cancer tissues and clinicopathological factors was analyzed. The qPCR results demonstrated that the relative expression of Nanog was increased in gastric cancer tissues compared with in the adjacent tissues (P<0.05); and relative expression of PSCA was reduced in gastric cancer tissues compared with adjacent tissues (P<0.05). The expression of Nanog and PSCA in gastric cancer tissues was associated with tumor differentiation. The expression of Nanog was increased in poorly-differentiated and undifferentiated tumors compared with moderately- and well-differentiated tumors (P<0.05). The expression of PSCA was reduced in poorly differentiated and undifferentiated tumors compared with moderately- and well-differentiated tumors (P<0.05). However, the expression of Nanog and PSCA was not associated with age, gender, tumor size, TNM stage, depth of invasion, or lymph node metastasis. Therefore, Nanog and PSCA may have potential as molecular markers to reflect the differentiation status of gastric cancer.

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.

A pooled analysis of the ERCC2 Asp312Asn polymorphism and esophageal cancer susceptibility

Published data regarding the association between the excision repair cross-complimentary group 2 (ERCC2) Asp312Asn polymorphisms and esophageal cancer susceptibility remained controversial. This meta-analysis of literatures was performed to assess the strength of association between the ERCC2 and esophageal cancer susceptibility using random effects model. We systematically searched PubMed, Embase and Web of Science with a time limit of September 15, 2013. Summary odds ratios (ORs) with 95 % confidence intervals (CIs) were used to assess the strength of association between the ERCC2 Asp312Asn polymorphism and esophageal cancer susceptibility using random effects model. A total of seven case-control studies including 1,831 cases and 2,728 controls were included for analysis. Overall, a significant association was found between ERCC2 Asp312Asn polymorphism and esophageal cancer susceptibility for GA vs. GG (OR = 1.20, 95 % CI = 1.03-1.40) and for the dominant model GA/AA vs. GG (OR = 1.18, 95 % CI = 1.03-1.35). However, the ERCC2 Asp312Asn polymorphism was a protective factor for AA vs. GA/GG (OR = 0.63, 95 % CI = 1.15-2.65) in esophageal squamous cell carcinoma. Our meta-analysis suggested that the ERCC2 Asp312Asn polymorphism might be associated with increased risk of esophageal adenocarcinoma and a protective factor for esophageal squamous cell carcinoma.

Cancer of the esophagus: histopathological sub-types in northern Uganda

BACKGROUND

Esophageal cancer is the eighth most common cause of cancer death worldwide with squamous cell carcinoma and adenocarcinoma carcinoma as the main histopathological subtypes. Esophageal cancer is known for its marked variation by geographic region, ethnicity, and gender. Hitherto, the histopathological subtype of this cancer in Northern Uganda were not known. Therefore the aim of the study was to describe the characteristics of esophageal cancer with respect to the histopathologic subtypes, different sites of occurrence, age and gender in this region since its distribution varies with location.

METHODS

The study was carried out at Lacor Hospital, in northern part of Uganda. The record of 71 patients who had endoscopic and histopathological diagnosis of cancer of esophagus over a period of 3 years between January 2009 and December 2011 were retrospectively analyzed.

RESULTS

A total of 140 patients had endoscopic diagnosis of cancer of the esophagus and of these, 71 patients had both endoscopic and histopathological diagnosis of cancer of esophagus during the three-year period covered in the study between January 2009 to December 2011. The female to male ratio was 1:3 with mean age of 55.5 years ± SD 11.8. The common histopathological pattern of cancer of esophagus was squamous cell carcinoma of esophageal consisting of 66 patients (93.o%). The ratio of squamous cell carcinoma to adenocarcinoma was 13:1.The majority of the esophageal cancers were found in the middle third with 38 patients (53.52%), followed by lower third with 27 patients (38.0%) and the upper third which was only 6 patients (8.5%).

CONCLUSSIONS

Squamous cell carcinoma is the most common histopathological subtype in this geographical location with overall cancer of the esophagus mainly affecting the lower 2/3 of the esophagus with the majority in the middle third.

Dietary fiber and the risk of precancerous lesions and cancer of the esophagus: a systematic review and meta-analysis

Dietary fiber has several anticarcinogenic effects and is thought to be protective against esophageal cancer. The aim of this systematic review was to quantify the association between dietary fiber and the risk of esophageal cancer by investigating histological subtypes of esophageal cancer and the stage at which fiber may influence the carcinogenic pathway. Systematic search strategies were used to identify relevant studies, and adjusted odds ratios (ORs) were combined using random-effects meta-analyses to assess the risk of cancer when comparing extreme categories of fiber intake. Ten relevant case-control studies were identified within the timeframe searched. Pooled estimates from eight studies of esophageal adenocarcinoma revealed a significant inverse association with the highest fiber intakes (OR 0.66; 95% confidence interval [CI] 0.44-0.98). Two studies also identified protective effects of dietary fiber against Barrett's esophagus. Similar, though nonsignificant, associations were observed when results from five studies of fiber intake and risk of squamous cell carcinoma were combined (OR 0.61; 95%CI 0.31-1.20). Dietary fiber is associated with protective effects against esophageal carcinogenesis, most notably esophageal adenocarcinoma. Potential methods of action include modification of gastroesophageal reflux and/or weight control.

Three decades of clinical-pathological trends in gastric cancer: prospective data from a Portuguese hospital

INTRODUCTION

Gastric cancer is a heterogeneous disease, whose pathological and clinical patterns have changed in the last decades. In most western countries, decreases in incidence and mortality and a proximal migration have been reported. The clinical and pathological trends in an European country with high prevalence of gastric cancer were reviewed, based on the patients treated at a University Hospital.

METHODS

Analysis of a prospective database with 1618 patients who underwent surgery for gastric cancer in the last 3 decades. The patients were divided in 3 groups according to decades and the cohorts were analyzed according to demographic, surgical and pathological factors.

RESULTS

The mean age increased from 59.8 to 65.6 years. Antral tumors and intestinal cancer were the most frequent. The rate of complete resection increased as well as the percentage of total gastrectomies and D2-type lymphadenectomies. There was an increase both in early stage carcinomas and in surgically treated Stage-IV carcinomas. The median overall crude survival almost doubled from 14 to 22 months (p = 0.003), but once stratified for stage, only in stage II patients could we observe a significant increase in survival time. (29-47 months; p = 0.047).

CONCLUSION

The proximal migration described for Western Europe was not observed and the intestinal-type carcinoma is still the most frequent. We are treating older patients, often with more advanced disease. In spite of an increasing surgical aggressiveness, the prognosis has only been significantly improved in Stage-II cancers. The prognosis for advanced cancer is still dismal, hence the need for effective adjuvant treatments.

Carcinoma of the gastroesophageal junction in Chinese patients

Carcinoma of the gastroesophageal junction (GEJ) is defined as carcinoma that crosses the GEJ line, irrespective of where the tumor epicenter is located. This group of cancer is rare but controversial. Based on study results from the majority of epidemiologic and clinicopathologic investigations carried out in Western countries, this cancer is believed to arise from Barrett’s esophagus (BE) and includes both distal esophageal and proximal gastric carcinomas because of similar characteristics in epidemiology, clinicopathology, and molecular pathobiology in relation to BE. As such, the most recent American Joint Committee on Cancer staging manual requires staging all GEJ carcinomas with the rule for esophageal adenocarcinoma (EA). This mandate has been challenged recently by the data from several studies carried out mainly in Chinese patients. The emerging evidence derived from those studies suggests: (1) both BE and EA are uncommon in the Chinese population; (2) almost all GEJ cancers in Chinese arise in the proximal stomach and show the features of proximal gastric cancer, not those of EA; (3) application of the new cancer staging rule to GEJ cancer of Chinese patients cannot stratify patients’ prognosis effectively; and (4) prognostic factors of GEJ cancer in Chinese are similar, but not identical, to those of EA. In conclusion, the recent evidence suggests that GEJ cancer in Chinese shows distinct clinicopathologic characteristics that are different from EA. Further investigations in molecular pathology may help illustrate the underlying pathogenesis mechanisms of this cancer in Chinese patients and better manage patients with this fatal disease.

Putative role of the mTOR/4E-BP1 signaling pathway in the carcinogenesis and progression of gastric cardiac adenocarcinoma

The mammalian target of rapamycin/eukaryotic translation inititiation factor 4E binding protein 1 (mTOR/4E-BP1) transduction pathway is activated in a range of malignant cancers, but its role in human gastric cardiac adenocarcinoma (GCA) has not been well defined. The present study used western blotting and reverse transcription polymerase chain reaction (RT-PCR) to assess the expression of mTOR, 4E-BP1 and eukaryotic translation initiation factor 4E (eIF4E) at the protein and mRNA levels in 33 cases of GCA and paired adjacent normal gastric mucosal tissues. The expression of mTOR at the protein level in GCA was significantly lower than that in the corresponding normal gastric mucosa (0.296 ± 0.27 vs. 1.348 ± 0.80, P<0.05), but the ratio of p-mTOR to mTOR was significantly increased in tumor tissues (1.425 ± 1.07 vs. 0.450 ± 0.24, P<0.05). The expression of 4E-BP1 was significantly decreased in GCA compared with normal tissues (p<0.05), while the levels of phosphorylated 4E-BP1 (p-4E-BP1) were markedly increased in tumor tissues (p<0.05). The levels of phosphorylated eIF4E (p‑eIF4E) were significantly higher in the tumors in comparison to the corresponding normal tissues (1.822 ± 0.63 vs. 0.997 ± 0.38, P<0.05), and the levels of p-eIF4E were closely correlated with lymph node metastasis (p<0.05). The mTOR/4E-BP1 signaling pathway is activated in GCA, with mTOR activated mainly through increased mTOR phosphorylation rather than protein overexpression.

Gastric carcinomas localized to the cardia

Objectives. Gastric adenocarcinomas localized to the cardia are increasing. Enterochromaffin-like (ECL) cells play a role in gastric carcinogenesis in hypergastrinemia, and the use of proton pump inhibitors (PPI) leading to hypergastrinemia has increased considerably during the last decades. We have examined cardia cancers for neuroendocrine and ECL cell differentiation. Methods. Thirty-two cardia cancers were examined by immunohistochemical labelling of chromogranin A (CgA), synaptophysin, serotonin, and histidine decarboxylase (HDC). Information about PPI use was collected from the patient records. Results. In 15 of 32 tumours, there were positive signs for one or several neuroendocrine markers. Five cases were CgA and serotonin positive; three of these carcinomas were also positive for HDC. Three patients were long-term users of PPI, and two of these were immunoreactive for neuroendocrine markers. Conclusions. A high proportion of cardia cancers expressed neuroendocrine markers, but only few patients with cardia cancers were using PPI.

Comparison of gastro-oesophageal junction carcinomas in Chinese versus American patients

AIMS

To compare the clinical and pathological features of gastro-oesophageal junction (GEJ) carcinomas in Chinese and American patients.

METHODS AND RESULTS

Eighty consecutive patients with a GEJ carcinoma (43 from mainland China, and 37 from the USA) were evaluated for association with Barrett oesophagus (BO), chronic Helicobacter pylori gastritis, intestinal metaplasia, and outcome. GEJ carcinomas were defined as tumours that were located within 20 mm of, and crossed, the GEJ. Overall, GEJ carcinomas from Chinese patients revealed significantly more frequent location in the proximal stomach, higher pathological stage, larger size, younger patient age, and association with chronic H. pylori gastritis. In contrast, GEJ cancers from American patients showed a strong association with distal oesophageal location, BO, and associated intestinal metaplasia and dysplasia. Pathologically, GEJ carcinomas from American patients were predominantly adenocarcinomas, whereas Chinese patients showed a higher proportion of mucinous, adenosquamous, acinar or neuroendocrine tumours. Overall, 3- and 5-year survival rates were statistically similar between both patient groups, but upon multivariate analysis, Chinese patients showed statistically better survival rates for stage III tumours.

CONCLUSIONS

Most GEJ carcinomas in patients from China represent proximal gastric cancers associated with chronic H. pylori gastritis, and BO-associated carcinomas are rare among this patient population.

Barrett's esophagus-related diseases remain uncommon in China

Barrett's esophagus (BE)-related esophageal adenocarcinoma (EAC) has shown the fastest rise in incidence in Western countries; however, research data on BE-related diseases from China are inconclusive. We aimed to review and analyze the published results on these diseases in China. We searched PubMed and Chinese medical literature for key words: BE, EAC, Chinese and China. Relevant research papers along with the study results from our own groups were reviewed and analyzed. Using standardized criteria, columnar-lined esophagus (CLE) was found in as many as 29% of resection specimens in Chinese patients with proximal gastric cancer. However, BE with intestinal metaplasia was rare, ranging from 0.06% in the general population to <2% in referral patients. Risk factors included advancing age, hiatal hernia and probably gastroesophageal reflux disease and tobacco or alcohol abuse, but not male gender or obesity. At endoscopy, most CLE/BE were <2 cm in length, and appeared tongue-like and island-like. The long-segment BE was rare, especially in women. Population-based studies conducted in Taiwan and Hong Kong SAR, China showed that EAC was not only rare but also stable or had decreased in incidence over the past decade. By histopathology, EAC accounted for only 1% of all distal esophageal cancers and almost all gastroesophageal junction (GEJ) cancers were centered in the proximal stomach. BE-related diseases, except for CLE, are rare in China. The clinical significance and malignant potential of CLE in the Chinese population remain elusive. Further investigation on these diseases is in progress.

Epidemiology and natural history of intestinal metaplasia of the gastroesophageal junction and Barrett's esophagus: a population-based study

OBJECTIVES

Population-based data on the epidemiology and outcomes of subjects with intestinal metaplasia of the gastroesophageal junction (IMGEJ) and Barrett's esophagus (BE) are limited. The objectives of this study were to (i) estimate the incidence of IMGEJ and BE diagnosed from clinically indicated endoscopy in Olmsted County, MN, over three decades (1976-2006) and prevalence as of 1 January 2007, (ii) compare baseline characteristics of subjects with IMGEJ and BE, and (iii) study the natural history and survival of both cohorts.

METHODS

This was a population-based cohort study. The study setting was Olmsted County, MN. Patients with BE (columnar segment >1 cm with intestinal metaplasia) and IMGEJ (intestinal metaplasia in biopsies from the gastroesophageal junction) from 1976 to 2006 in Olmsted County, MN, were identified using Rochester Epidemiology Project resources. Demographic and clinical data were abstracted from medical records and pathology confirmed by gastrointestinal pathologists. The association of baseline characteristics with overall and progression-free survival was assessed using proportional hazards regression models. Outcome measures were baseline characteristics and overall survival of subjects with IMGEJ compared to those with BE.

RESULTS

In all, 487 patients (401 with BE and 86 with IMGEJ) were identified and followed for a median interval of 7 (BE subjects) to 8 (IMGEJ subjects) years. Subjects with BE were older, heavier, reported reflux symptoms more often, and had higher prevalence of advanced neoplasia than those with IMGEJ. No patient with IMGEJ progressed to esophageal adenocarcinoma (EAC) in contrast to BE subjects who had a cumulative risk of progression of 7% at 10 years and increased risk of death from EAC (standardized mortality ratio 9.62). The overall survival of subjects with BE and IMGEJ did not differ from that expected in similar age- and sex-distributed white Minnesota populations.

CONCLUSIONS

Subjects with IMGEJ appear to have distinct clinical characteristics and substantially lower cancer progression risk compared to those with BE.

Survival trends in gastric cancer patients of Northeast China

AIM: To describe survival trends in patients in Northeast China diagnosed as gastric cancer.

METHODS: A review of all inpatient and outpatient records of gastric cancer patients was conducted in the First Affiliated Hospital of China Medical University. All the gastric cancer patients who satisfied the inclusion criteria from January 1, 1980 through December 31, 2003 were included in the study. The main outcomes were based on median survival and 3-year and 5-year survival rates, by decade of diagnosis.

RESULTS: From 1980 through 2003, the median survival for patients with gastric cancer (n = 1604) increased from 33 mo to 49 mo. The decade of diagnosis was not significantly associated with patient survival for gastric cancer (P = 0.084 for overall survival, and P = 0.150 for 5-year survival); however, the survival rate of the 2000s was remarkably higher than that of the 1980s (P = 0.019 for overall survival, and P = 0.027 for 5-year survival).

CONCLUSION: There was no significant difference of survival among each period; however, the survival rate of the 2000s was remarkably higher than that of the 1980s.

Increasing incidence of Barrett's oesophagus: a population-based study

Oesophageal adenocarcinoma, a highly fatal cancer, has risen in incidence in Western societies, but it is unclear whether this is due to increasing incidence of its pre-cursor condition, Barrett's oesophagus (BO) or whether the proportion of BO patients undergoing malignant progression has increased in the face of unchanged BO incidence. Data from population-based studies of BO incidence is limited, with equivocal results to date difficult to distinguish from changes in endoscopic practices. The aim of this study was to assess population trends in Barrett's oesophagus (BO) diagnoses in relation to endoscopy and biopsy rates over a 13 year period. The Northern Ireland Barrett's oesophagus Register (NIBR) is a population-based register of all 9,329 adults diagnosed with columnar epithelium of the oesophagus in Northern Ireland between 1993 and 2005, of whom 58.3% were male. European age-standardised annual BO incidence rates were calculated per 100,000 of the population, per 100 endoscopies and per 100 endoscopies including an oesophageal biopsy. Average annual BO incidence rates rose by 159% during the study period, increasing from 23.9/100,000 during 1993-1997 to 62.0/100,000 during 2002-2005. This elevation far exceeded corresponding increases in rates of endoscopies and oesophageal biopsies being conducted. BO incidence increased most markedly in individuals aged < 60 years, and most notably amongst males aged < 40 years. This study points towards a true increase in the incidence of BO which would appear to be most marked in young males. These findings have significant implications for future rates of oesophageal adenocarcinoma and surveillance programmes.

Helicobacter pylori infection and gastric cardia cancer: systematic review and meta-analysis

OBJECTIVE

Helicobacter pylori infection is the most important risk factor for gastric cancer, but no association with cardia cancer has been recognized. However, a heterogeneous distribution of etiologically distinct types of cardia cancer may contribute to explain conflicting findings between studies in high- and low-risk settings. We aimed to quantify the association between H. pylori infection and gastric cardia cancer through meta-analysis, and to provide an explanation for the expected heterogeneity of results.

METHODS

We systematically reviewed published studies addressing the association between H. pylori infection and gastric cardia cancer (up to June 2009), and extracted relative risk (RR) estimates for the association with cardia and non-cardia cancers. Summary RR estimates and 95% confidence intervals (95% CI) were computed using random-effects models. Subgroup analyses were conducted, namely according to gastric cancer risk settings.

RESULTS

Thirty-four articles were considered for meta-analysis. For cardia cancer, summary RR was 1.08 (95% CI 0.83-1.40; I (2) = 52.8%), higher in high-risk (RR = 1.98; 95% CI 1.38-2.83; I (2) = 18.4%) than in low-risk settings (RR = 0.78; 95% CI 0.63-0.97; I (2) = 11.6%). For non-cardia cancer, RR estimates were similar in high- (RR = 3.02; 95% CI 1.92-4.74; I (2) = 90.7%) and low-risk settings (RR = 2.56; 95% CI 1.99-3.29; I (2) = 46.6%). These observations were consistent across different inclusion criteria and when accounting for the virulence of the infecting strains.

CONCLUSIONS

In high-risk settings, a positive association between H. pylori infection and gastric cancer was observed both for cardia and non-cardia cancers. The results support the hypothesis of a heterogeneous distribution of etiologically distinct types of cardia cancer.

Epidemiology of adenocarcinoma of the esophagus, gastric cardia, and upper gastric third

The incidence of adenocarcinoma of the esophagus and esophagogastric junction (gastric cardia) has risen rapidly over the past three decades in the United States and northern Europe. This increase had been most dramatic among White males. The majority of these cancers arise from Barrett's esophagus. However, less than 10% of the patients with esophageal adenocarcinoma were known to have Barrett's esophagus before. Current evidence indicates that gastroesophageal reflux and obesity are major risk factors for adenocarcinoma of the esophagus. Abdominal obesity, more prevalent in males, and independent of body mass index, seems to be associated with an increased risk of esophageal adenocarcinoma but not of cardia adenocarcinoma. This observation may explain the high male:female ratio observed in esophageal adenocarcinoma. Tobacco use has also been found as a possible risk factor for adenocarcinoma of the esophagus and gastric cardia. Infection with Helicobacter pylori and the use of nonsteroidal anti-inflammatory drugs might reduce the risk. On the other hand, low intake of fruits, vegetables, and cereal fibers seem to increase the risk of esophageal adenocarcinoma. Currently, there is no evidence that strongly supports any specific strategy to screen a subgroup of the population at risk for adenocarcinoma of the esophagus or esophagogastric junction. Future strategies to decrease obesity and tobacco use might help to reduce the burden of esophageal adenocarcinoma at least partially.

The changing face of esophageal cancer

The two main histological esophageal cancer types, adenocarcinoma and squamous cell carcinoma, differ in incidence, geographic distribution, ethnic pattern and etiology. This article focuses on epidemiology with particular reference to geographic and temporal variations in incidence, along with a review of the evidence supporting environmental and genetic factors involved in esophageal carcinogenesis. Squamous cell carcinoma of the esophagus remains predominantly a disease of the developing world. In contrast, esophageal adenocarcinoma is mainly a disease of western developed societies, associated with obesity and gastro-esophageal reflux disease. There has been a dramatic increase in the incidence of adenocarcinoma in developed countries in parallel with migration of both esophageal and gastric adenocarcinomas towards the gastro-esophageal junction.

Trends in incidence of oesophageal and stomach cancer subtypes in Europe

OBJECTIVE

Time trend studies in the USA have shown that the incidences of adenocarcinomas of the oesophagus and gastric cardia have risen strongly since the 1970s, whereas the incidence of squamous cell carcinomas of the oesophagus has declined. Earlier, we found that the incidence of these adenocarcinomas also rose in some European countries until the early 1990s. The main goal of this study was to investigate more recent trends in the incidence of oesophageal and stomach cancer subtypes in the European countries.

METHODS

Eurocim cancer incidence data of 23 cancer registries from 13 European countries were used to investigate the incidence trends in oesophageal and stomach cancer subtypes during the 1983-1997 period. We calculated estimated annual percentage changes (EAPCs) in European age-standardized incidence rates and 95% confidence intervals.

RESULTS

The incidence of adenocarcinomas of the oesophagus and gastric cardia rose in most, but not all, registration areas (EAPCs were usually 1-7%), the strongest in the UK and Ireland. Oesophageal squamous cell carcinoma incidence rose mostly in Northern European and Slovakian men (EAPCs: 1-5%) and in women from all regions (EAPCs: 1-8%), but declined mostly in Southern and Western European men (EAPCs: -1 to -5%).

CONCLUSION

Our results are partly in line with earlier findings on adenocarcinomas of the oesophagus and gastric cardia. There was, however, substantial heterogeneity in trends of subtypes of these cancers within Europe. There may be different risk factors for these cancers, and the prevalence of these risk factors may differ among countries.

Surgical outcomes associated with oesophagectomy in New South Wales: an investigation of hospital volume

INTRODUCTION

Resection remains the standard treatment for curable oesophageal cancer. By linking the NSW Central Cancer Registry (CCR) and the NSW Admitted Patient Data Collection (APDC) databases, mortality, post-resection complication and survival associated with oesophagectomy were investigated.

METHODS

All patients diagnosed with oesophageal cancer from 2000 to 2005 as recorded in the CCR (n = 2,082) were linked with records in the APDC, giving a total of 17,205 episodes of care. Over 15% (n = 321) of all patients underwent an oesophagectomy.

RESULTS AND DISCUSSION

The overall 30-day mortality rate following resection was 3.7%, ranging from 2.6% in high volume hospitals to 6.4% in low volume hospitals. Three-year absolute survival for localised-regional disease following oesophagectomy was 64% (95%CI 54-73%) in high-volume hospitals, 58% (95%CI 46-68%) in mid-volume and 45% (95%CI 23-65%) in low-volume hospitals. The post-resection complication rate was 19% (95%CI 13-26%) for high-volume hospital, 24% (95%CI 13-40%) in low-volume and 31% (95%CI 22-41%) in mid-volume hospitals.

CONCLUSION

Oesophagectomy in NSW is performed with satisfactory results. However, there is a suggestion that higher- rather than lower-volume hospitals have better post-resection outcomes.

Stromal regulatory T-cells are associated with a favourable prognosis in gastric cancer of the cardia

Background

Recent evidence suggests that CD4⁺CD25⁺FoxP3⁺ regulatory T-cells (Treg) may be responsible for the failure of host anti-tumour immunity by suppressing cytotoxic T- cells. We assessed the prognostic significance of tumour infiltrating lymphocytes (TIL) in intestinal-type gastric cardiac cancer.

Methods

Tumour infiltrating lymphocyte (TIL) subsets and tumour infiltrating macrophages (TIM) were investigated in 52 cases using tissue microarrays. The interrelationship between the cell populations (CD3+, CD8+, CD20+, CD68+, GranzymeB+, FoxP3+) in different compartments and NED-survival was investigated (median follow-up time: 61 months).

Results

Intraepithelial infiltration with TIL and TIM including Treg was generally low and not related to NED-survival. However, patients with large numbers of FoxP3⁺ Treg in the tumour stroma (>125.9 FoxP3⁺TILs/mm²) had a median survival time of 58 months while those with low FoxP3⁺ TIL counts (<125.9 FoxP3⁺TILs/mm²) had a median survival time of 32 months (p = 0.006). Patients with high versus low stromal CD68⁺/FoxP3⁺ cell ratios in primary tumour displayed median survivals of 32 and 55 months, respectively (p = 0.008).

Conclusion

Our results suggest that inflammatory processes within the tumour stroma of gastric intestinal-type adenocarcinomas located at the gastric cardia may affect outcome in two ways. Tumour-infiltrating macrophages are likely to promote carcinogenesis while large numbers of Treg are associated with improved outcome probably by inhibiting local inflammatory processes promoting carcinogenesis. Thus, inhibition of Treg may not be a feasible treatment option in gastric adenocarcinoma.

Clinical puzzle: Barrett's oesophagus

The incidence of oesophageal adenocarcinoma has increased dramatically in the Western world over the past two decades. Owing to its dismal 5-year prognosis in advanced stages, early diagnosis is required in order to improve survival rates. Barrett's oesophagus (Barrett's) has been recognised as a pre-cancerous condition generally associated with chronic and severe gastro-oesophageal reflux disease (GORD). Barrett's is defined as the substitution of the normal stratified squamous epithelium of the oesophagus with a columnar cell lining with intestinal-type differentiation; a phenomenon commonly referred to as intestinal metaplasia. Clinical challenges include finding cost-effective ways to identify patients with Barrett's, stratifying them according to their cancer risk and improving the diagnostic potential of endoscopic sampling. Research has generally focused on identifying tissue biomarkers to predict cancer risk in these patients. The oesophagus is easily accessible, making it possible to work with human samples, but most studies have been retrospective and underpowered. Endoscopic surveillance programmes are problematic due to sampling bias and the subjective grading of dysplasia. The lack of an animal model has hampered studies to elucidate markers of the transition from Barrett's to cancer and to test potential therapeutics. However, a number of in vitro model systems are ripe for further development into more physiologically complete systems.

Sorafenib triggers antiproliferative and pro-apoptotic signals in human esophageal adenocarcinoma cells

BACKGROUND AND PURPOSE

Current therapies offer scant benefit to patients with advanced esophageal adenocarcinoma. We investigated the effects of Sorafenib, a multifunctional kinase inhibitor, on several growth regulatory pathways that control cell growth and survival in SEG-1 cells derived from Barrett's adenocarcinoma.

METHODS

SEG-1 cells were exposed to acidified medium or taurocholic acid, with and without pre-incubation with Sorafenib. Cyclin D1 and E, c-Myc, and Bcl-2 expression levels as well as STAT3 activations were determined by Western blotting. Cyclin D1 mRNA was measured by real-time PCR. Apoptosis was assessed by TUNEL assay.

RESULTS

Sorafenib significantly inhibited SEG-1 cell proliferation stimulated by acid or bile acid treatments and reduced cell survival. This drug significantly reduced the up-regulations of cyclin D1, cyclin E, c-Myc, and Bcl-2 as well as the activation of STAT3 in SEG-1 cells.

CONCLUSIONS

These results support a rational basis for future clinical studies to assess the therapeutic benefit of Sorafenib in esophageal adenocarcinoma.

Survival trends in patients with gastric and esophageal adenocarcinomas: a population-based study

OBJECTIVE

To use a population-based approach to describe survival trends in patients diagnosed as having gastric or esophageal adenocarcinoma.

PATIENTS AND METHODS

A population-based complete chart review of all inpatient and outpatient records, using the resources of the Rochester Epidemiology Project, was conducted in Olmsted County, Minnesota (population 124,277), a primarily rural county with one large urban area. All residents of Olmsted County who were diagnosed as having gastric or esophageal adenocarcinoma from January 1, 1971, through December 31, 2000, were included in the study. The main outcomes were median survival and 2-year and 5-year survival rates, by decade of diagnosis.

RESULTS

From 1971 through 2000, median survival for patients with gastric adenocarcinoma (n=121) decreased from 5.5 months to 3.2 months, whereas median survival for patients with esophageal adenocarcinoma (n=65) increased from 8.5 months to 11.7 months. Decade of diagnosis was not significantly associated with patient survival for either gastric or esophageal adenocarcinoma (P>.05). There was no significant shift in stage of disease at diagnosis during the 30-year period for either gastric or esophageal adenocarcinoma (P>.05).

CONCLUSION

No significant change has occurred in the survival rates of this patient population with gastric or esophageal adenocarcinoma, which is representative of the US white population.

Impact of gastroesophageal reflux on survival in the community

BACKGROUND

Concerns have been raised regarding the risks associated with gastroesophageal reflux (GER). We examined the association of gastroesophageal reflux with survival.

METHODS

Between 1988 and 1993, valid symptom surveys were mailed to population-based cohorts. Respondents were classified into 4 GER symptom categories: daily, at least weekly (not daily), infrequent (less than weekly), and none. Administrative records were used to identify deaths during the follow-up (through June 2006). Association between survival and GER subgroups was assessed using proportional hazards regression to compute hazard ratios (HRs, 95% confidence intervals), adjusting for age, gender, education level, Charlson Comorbidity Index, alcohol, and tobacco.

RESULTS

At baseline, 5,288 eligible subjects (mean age 53 yr, 51% female) responded (response rates over 70%); 2% reported daily heartburn, 13% weekly (not daily) heartburn, 40% infrequent heartburn, and 35% no heartburn. At 10 yr, 83% (95% CI 81-84%) of the no heartburn group was alive. An overall association between heartburn category and survival was detected (P < 0.001). Compared to no heartburn, daily heartburn was not associated with an increased risk of death (HR 1.16, 95% CI 0.82-1.65), but better survival was observed for weekly (HR 0.67, 95% CI 0.55-0.83) and infrequent (HR 0.80, 95% CI 0.70-0.92) heartburn. Increasing age, male gender, greater Charlson index, and tobacco use all predicted worse survival.

CONCLUSIONS

In this population-based study with over 50,000 person-years of follow-up, reflux symptoms were not associated with worse survival. The vast majority of heartburn sufferers can be reassured of the benign nature of their condition.

Epidemiology of upper gastrointestinal cancers in Iran: A sub site analysis of 761 cases

AIM: To define the sub site distribution of upper gastrointestinal cancers in three provinces of Iran.

METHODS: The study was carried out in three provinces in Iran: Ardabil, Golestan, and Tehran. In Arbabil and Golestan, the data was collected from the sole referral center for gastrointestinal cancers and the local cancer registry. For Tehran province, data from two major private hospitals were used. All gastric and esophageal cancer patients diagnosed during the period from September 2000 and April 2002 were included in the study.

RESULTS: A total of 761 patients with upper gastrointestinal cancers were identified, 314 from Ardabil, 261 from Golestan, and 186 from Tehran. In Tehran, the relative rate of cancer increased from the upper esophagus to the distal stomach. In Golestan, the reverse pattern was observed. In Ardabil, the mid portion (distal esophagus and proximal stomach) was involved most frequently.

CONCLUSION: There were considerable variations in the sub site of upper gastrointestinal cancers in the three provinces studied. We cannot provide any explanation for this variation. Further research aimed at explaining the discrepancies in sub site distribution of upper gastrointestinal cancers may help identify important risk factors.

Subsite-specific risk factors for esophageal and gastric adenocarcinoma

BACKGROUND

The incidence rates of adenocarcinoma involving specific gastric and esophageal subsites are changing significantly, but the risk factors associated with those subsite changes remain controversial. We aimed to describe the site-specific risk factors associated with adenocarcinoma of the stomach and esophagus.

METHODS

Using the Rochester Epidemiology Project, all cases of gastric and esophageal adenocarcinoma among Olmsted County, Minnesota, residents first diagnosed between 1971 and 2000 were identified. Complete inpatient and outpatient records were reviewed and specific subsites defined. Risk factors were assessed in cases, and age- and sex-matched controls.

RESULTS

A total of 186 incident cases of gastric or esophageal adenocarcinoma were identified between 1971 and 2000, in Olmsted County. Gastroesophageal reflux disease (GERD) was a significant risk factor for both esophageal (OR 5.5, 95% CI 1.2-25) and esophagogastric junction adenocarcinoma (OR 13.0, 95% CI 1.7-99), but not for either proximal or distal gastric cancer. Smoking (OR 2.8, 95% CI 1.0-7.8) was associated with distal gastric cancer. Proton pump inhibitor (PPI) exposure was limited and was not a significant risk factor at any subsite.

CONCLUSIONS

This identification of distinct risk factors by subsite supports the concept that esophageal and gastric adenocarcinomas are two different diseases. Adenocarcinoma of the junction is probably a form of esophageal cancer and should not be coded with gastric neoplasms.