Esophageal cancer. American College of Gastroenterology

Clinical Utility of 18F-2-Fluoro-deoxy-d-glucose PET Imaging in Locally Advanced Esophageal/Gastroesophageal Junction Adenocarcinoma

Esophageal adenocarcinoma, including adenocarcinoma of the gastroesophageal junction, is uncommon in the United States, but is associated with a rising incidence in young adults, and has a traditionally poor prognosis. Despite the incremental benefits that have been made with multimodality approaches to locally advanced disease, most patients will go on to develop metastatic disease, and long-term outcomes remain suboptimal. Over the last decade, PET-CT has emerged as a key tool in the management of this disease, with several prospective and retrospective studies evaluating its role in this disease. Herein, we review the key data pertaining to the use of PET-CT in the management of locally advanced esophageal and GEJ adenocarcinoma, with a focus on staging, prognostication, PET-CT adapted therapy in the neoadjuvant setting, and surveillance.

Patterns of metastasis and prognosis of elderly esophageal squamous cell carcinoma patients in stage IVB: a population-based study

Background

Esophageal squamous cell carcinoma (ESCC) has been listed among the most common esophageal cancers (ECs). Patients are generally relatively old in terms of their age at diagnosis of ESCC. A retrospective, population-based study appraising 537 elderly ESCC patients who suffered distant metastasis (DM) in stage IVB from 2010 to 2016 was performed. To this end, data pertaining to Surveillance, Epidemiology, and End Results (SEER) were adopted.

Methods

A total of 537 elderly patients with IVB-stage ESCC suffering DM treated from 2010 to 2016 were taken as subjects. Prognosis was determined by using Kaplan-Meier analysis, as well as univariate and multivariate Cox regression. In accordance with sites of metastasis, these patients were classified into five groups: bone-, lung-, brain-, liver-only, and multiple-site (metastases to two or more organs) groups. In order to assess the prognosis, the cancer-specific survival (CSS), median survival time (MST), overall survival (OS), and survival rate (SR) were examined.

Results

The lung was found to be the organ most vulnerable to metastasis in the population with single-organ metastasis, and liver, bone and brain followed in descending rank order. Relative to the group only having bone metastasis, the multiple-site group had the lowest CSS (HR: 1.067; 95% CI: 0.767–1.485; P=0.700) and OS (HR: 1.051; 95% CI: 0.759–1.454; P=0.766). The MST (MST: both 2 months in CSS and OS) and SR (6-month SR: 28.2% in CSS, 27.7% in OS; 1-year SR: 7.5% in CSS, 6.7% in OS; 3-year SR: 2.5% in CSS, 1.5% in OS) were also found to be the lowest for the multiple-site group among the total population. These patients benefited from treatment with chemotherapy (C), radiotherapy (R), and surgery (S), as evinced by the prognosis (CSS and OS: P<0.001), in comparisons with untreated patients (N) in the total population. The S or/and R + C resulted in no statistically significant differences to C alone (CSS: P=0.593; OS: P=0.510) in terms of the prognostic results, which indicated that C alone can have almost the same prognostic effect as multimodal therapy.

Conclusions

Population-based research was used to determine patterns of metastasis and survival outcomes of elderly patients with IVB-stage ESCC suffering DM. The worst CSS and OS were found in patients with multiple-site metastasis across all groups. The treatment is an independent prognostic factor affecting prognosis. Chemotherapy plays a vital role in prognosis. Active therapies are beneficial to elderly patients with IVB-stage ESCC suffering DM, particularly chemotherapy.

Circulating Tumor Cells in Esophageal Squamous Cell Carcinoma - Mini Review

Esophageal cancer has high incidence and mortality rates and a low five-year survival rate of <15% owing to its strong capabilities of invasion, relapse and metastasis. The classic view holds that metastasis and diffusion is an advanced event during cancer progression, but recent studies show that distant diffusion of primary cancer cells may actually be an early event. Detection of circulating tumor cells (CTCs) in the circulation may indicate tumor spread, so CTCs are considered to be the key factor of metastatic cascade. In recent years, despite research progress on CTCs, there is a lack of systematic and important evidence to confirm the diagnostic, monitoring and prognostic values of CTCs in esophageal squamous cell carcinoma (ESCC). In this review, we clarify the relationship between CTC values and ESCC and provide more reliable evidence to improve the management and treatment of ESCC.

Metastasis Patterns and Prognosis of Elderly Patients With Esophageal Adenocarcinoma in Stage IVB: A Population-Based Study

Background

Esophageal adenocarcinoma (EAC) is the most common kind of esophageal cancer. Age at diagnosis of advanced EAC is greater. Studies about practice patterns for elderly EAC patients with distant metastasis (DM) in stage IVB are limited. This retrospective, population-based study was conducted using data from the Surveillance, Epidemiology, and End Results (SEER) to evaluate 855 elderly EAC patients with DM in stage IVB from 2010 to 2015.

Methods

855 elderly EAC patients with DM in stage IVB between 2010 and 2015 were included in this study. Univariate and multivariate Cox-regression and Kaplan-Meier analyses were used to assess prognosis. These patients were classified to bone-only, brain-only, lung-only, liver-only, and multiple (patients with two or more organs in metastasis)-site group according to the site of metastasis. Overall survival (OS), cancer-specific survival (CSS), median survival time (MST), and survival rate (SR) were evaluated to analyze the survival outcomes.

Results

The most common metastasis site was the liver among the single-organ metastasis population, followed by lung, bone, and brain. Compared with the bone-only group, the multiple-site group was associated with worst OS (HR: 1.037, 95% CI: 0.811–1.327, p = 0.770) and CSS (HR: 1.052, 95% CI: 0.816–1.357, p = 0.695). The multiple-site group also had the lowest MST in the population (MST: 2 months in OS and 3 months in CSS) and SR (6-month SR: 27.1% in OS, 29.9% in CSS, 1-year SR: 10.7% in OS, 12.0% in CSS, 3-year SR: 2.5% in OS, 2.8% in CSS). Compared to untreated patients (N) in the total population, other patients who were treated with surgery (S), radiotherapy (R), and chemotherapy (C) are beneficial for the prognosis (OS and CSS: p < 0.001).

Conclusion

This population-based study was conducted to ascertain metastasis patterns and survival outcomes of EAC patients with DM in stage IVB. Elderly patients with multiple-site metastasis exhibited the worst OS and CSS among all the populations, and patients with bone-only metastasis had the worst OS and CSS among single-organ metastasis populations. Active treatment is beneficial for elderly EAC patients with DM in stage IVB, especially chemotherapy. This study also shows that more than one third of the patients had not received any therapy.

Clinical Value of Tumor Marker Index Based on Preoperative CYFRA 21-1 and SCC-Ag in the Evaluation of Prognosis and Treatment Effectiveness in Patients with Esophageal Squamous Cell Carcinoma

BACKGROUND

This study aimed to investigate the prognostic value of tumor marker index (TMI) based on preoperative cytokeratin 19 fragment (CYFRA 21-1) and squamous cell carcinoma antigen (SCC-Ag) and the relationship between preoperative TMI and treatment effectiveness of postoperative adjuvant chemotherapy for patients with esophageal squamous cell carcinoma (ESCC).

PATIENTS AND METHODS

Between January 2009 and December 2014, a total of 267 patients with ESCC who underwent radical resection were retrospectively enrolled. The TMI was defined as the geometric mean of normalized CYFRA 21-1 and SCC-Ag levels. The clinical and prognostic values of TMI were determined using univariate and multivariate survival analyses.

RESULTS

Preoperative TMI level was associated with age, tumor size, pT stage, pN stage, and CYFRA 21-1, SCC-Ag, neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR) levels. The 5-year overall survival rate of patients with high TMI was significantly lower than that of patients with low TMI (P < 0.001). Univariate and multivariate analyses revealed that TMI (P = 0.031) was an independent prognostic factor. Patients with ESCC with high TMI level who underwent surgery combined with postoperative chemotherapy had a significantly better prognosis than those who underwent surgery alone (P = 0.015). However, no significant difference was observed in patients with low TMI level (P = 0.682).

CONCLUSION

TMI as a prognostic indicator of ESCC is superior to CYFRA 21-1 and SCC-Ag. The TMI might be useful in predicting the therapeutic effectiveness of postoperative chemotherapy and selecting patients who may benefit from postoperative chemotherapy.

Analysis of the National Cancer Database Esophageal Squamous Cell Carcinoma in the United States

BACKGROUND

Esophageal squamous cell carcinoma (ESCC) has been poorly studied, approached with therapeutic nihilism, and likely undertreated. We studied the impact of clinical and patient factors on the survival of ESCC in the United States.

METHODS

We selected patients with stage I to III ESCC from 2004 to 2013, using the National Cancer Database. Patients were categorized into the following treatment modalities: (1) definitive chemoradiation therapy (CR), (2) neoadjuvant therapy followed by esophageal resection (ER), (3) ER alone, and (4) ER followed by adjuvant therapy. Our main outcome measure was overall survival.

RESULTS

We identified 11,229 patients with ESCC undergoing definitive CR (78.6%); neoadjuvant therapy followed by ER (8.5%), ER alone (10.1%), and ER followed by adjuvant therapy (2.6%). Compared with neoadjuvant therapy, both ER alone and definitive CR were associated with substantially increased mortality. Patients treated at high-volume centers (>20), regardless of whether they underwent ER, had improved survival compared with facilities that performed 10 to 19, 5 to 9, and less than 5 ERs per year.

CONCLUSIONS

Patients treated at high-volume facilities were more likely to receive neoadjuvant therapy, and there was a marked inverse relationship between annual surgical volume and long-term survival for both surgically and non-surgically treated patients with stage I to III ESCC.

Prognostic value of lymphovascular invasion in patients with esophageal squamous cell carcinoma

Background

Whether lymphovascular invasion (LVI) in esophageal squamous cell carcinoma (ESCC) should be considered an independent prognostic factor for survival is controversial. The aim of this report was to investigate the prognostic value of LVI for patients with ESCC.

Methods

Between October 2010 and July 2011, 152 ESCC patients were retrospectively reviewed. All of the patients underwent curative resection as their primary treatment. Clinicopathological features and overall survival (OS) rate were investigated. Kaplan-Meier curves were used to calculate the OS rate, and the prognostic factors were identified by Cox regression model.

Results

Positive LVI was found in 49 (32.2%) patients. Patients with negative LVI had a significantly better 5-year OS rate than those with positive LVI (52.9% vs. 28.8%; P=0.000). The age, T stage, N stage, tumor differentiation, and LVI were demonstrated to be significant prognostic factors for OS through univariate analyses. LVI was confirmed as an independent prognostic factor for OS through multivariate survival analyses. Subgroup analyses revealed that LVI was associated with a decreased OS in node-negative patients, and no significant difference was observed in node-positive cases.

Conclusions

Our study highlighted that LVI is an independent prognostic factor in patients with resectable ESCC. LVI may facilitate the stratification of patients with poor survival.

Palliation of dysphagia

Palliation of dysphagia is the cornerstone of palliative treatment in patients with incurable oesophageal cancer. Available palliative options for dysphagia are oesophageal stent placement and radiotherapy. In general, oesophageal stent placement is the preferred therapeutic option in patients with a relatively poor prognosis because of its rapid relief of dysphagia. Regardless of ongoing technical developments, recurrence of dysphagia and stent-related complications are still occurring. For patients with a relatively good prognosis, intra-luminal brachytherapy is advised because of its sustained palliation of dysphagia. Due to limited availability of intra-luminal brachytherapy in clinical practice, fractionated external beam radiation therapy is commonly applied as an alternative. Selection of the optimal palliative approach for patients remains however challenging as conclusive high-quality evidence is limited. Moreover, with the introduction of new palliative treatment options (e.g. palliative chemotherapeutic and radiotherapeutic options) and the concurrent change of patient characteristics, supporting evidence from large randomised studies is warranted.

Clinical relevance of PD-L1 and PD-L2 overexpression in patients with esophageal squamous cell carcinoma

Background

Even with the advance of diagnosis and the treatment, the 5-year survival rate for esophageal cancer patients is still poor. The checkpoint protein inhibition provides another choice to improve the survival. The expression of the programmed death ligand-1 (PD-L1) was reported but the clinical relevance remained inconsistent in esophageal cancer. Besides, there were few references about the other ligand, programed death ligand-2 (PD-L2). In this study, we evaluated the expressions of PD-L1 and PD-L2 in patients with esophageal squamous cell carcinoma (ESCC) and assessed their clinical relevance.

Methods

From 1996 to 2011, 150 patients undergone complete surgical resection for ESCC were enrolled. Clinical data were recorded. Expression of PD-L1 and PD-L2 on cytoplasm in paraffin embedded tumor samples were analyzed by immunohistochemistry staining and scored with a semi-quantitative method.

Results

Of the patients, 96 (64.0%) patients had PD-L1 overexpression and 63 (42.0%) had PD-L2 overexpression. There was a correlation between the expression of PD-L1 and PD-L2 (P<0.001). Patients without overexpression of PD-L1, pathological T1-2 and N0 status, pathological stage I-II and no post-operative adjuvant treatment had a better disease free survival (DFS). In multivariate analysis, PD-L1 expression and pathological stage were the independent prognostic factors for DFS. The expression of PD-L2 did not influence the DFS. Although not statistically significant, patients without overexpression of PD-L1 and PD-L2 seem to have a better overall survival (OS).

Conclusions

The overexpression of PD-L1 on cytoplasm, not PD-L2, is an independent prognostic factor for DFS in patients with ESCC undergone esophagectomy. However, there is a trend which suggested that patients without overexpression of PD-L1 and PD-L2 had a better OS.

Esophageal luminal stenosis is an independent prognostic factor in esophageal squamous cell carcinoma

BACKGROUND

Predictive value of preoperative endoscopic characteristic of esophageal tumor has not been fully evaluated. The aim of this study is to investigate the impact of esophageal luminal stenosis on survival for patients with resectable esophageal squamous cell carcinoma (ESCC).

METHODS

The clinicopathologic characteristics of 623 ESCC patients who underwent curative resection as the primary treatment between January 2005 and April 2009 were retrospectively reviewed. The esophageal luminal stenosis measured by endoscopy was defined as a uniform measurement preoperatively. The impact of esophageal luminal stenosis on patients' overall survival (OS) and relation with other clinicopathological features were assessed. A Cox regression model was used to identify prognostic factors.

RESULTS

The results showed that OS significantly decreased in patients with manifest stenotic tumor compared with patients without luminal obstruction (P<0.05). Considerable esophageal luminal stenosis was associated with a higher T stage, longer tumor length, and poorer differentiation (all P<0.05). In multivariate survival analysis, esophageal luminal stenosis remained as an independent prognostic factor for OS (P= 0.036).

CONCLUSIONS

Esophageal luminal stenosis could have a significant impact on the OS in patients with resected ESCC and may provide additional prognostic value to the current staging system before any cancer-specific treatment.

Response to Concurrent Chemoradiotherapy as a Prognostic Marker in Elderly Patients with Locally Advanced Esophageal Cancer

Aims and background

Little is known about chemoradiotherapy in elderly patients with locally advanced esophageal cancer. We compared the efficacy and toxicity of chemoradiotherapy in elderly and non-elderly patients with locally advanced esophageal cancer and determined the variables affecting the treatment outcome in the elderly patients with locally advanced esophageal cancer who had received chemoradiotherapy.

Methods

Fifty-seven elderly patients (age ≥65 years) and 30 non-elderly patients (age <65 years) were reviewed retrospectively.

Results

The median age of the elderly group was 69 years and in the non-elderly group, 56.5 years. Although treatment compliance appeared to be poor, the response rate and median survival were similar in both the groups (elderly versus non-elderly; 84.4% vs 87.5%, and 11.2 months vs11.3 months) and so were G3/4 hematologic and non-hematologic toxicities. The treatment-related mortality of the elderly patients appeared to be higher than that of the non-elderly group (7.0% vs 3.3%), but did not reach statistical significance. In prognostic factor analysis, a major response to chemoradiotherapy was a good prognostic indicator in the elderly group (response versus non-response; median overall survival times of 19.5 vs 5.4 months, respectively, P <0.001).

Conclusions

The study suggests that chemoradiotherapy for locally advanced esophageal cancer in elderly patients, even though treatment compliance appears to be poor, is as safe and effective as in non-elderly patients and that the response to chemoradiotherapy is related to prognosis in elderly patients.

Survival based radiographic-grouping for esophageal squamous cell carcinoma may impact clinical T stage

Most patients diagnosed with thoracic esophageal squamous cell carcinoma (ESCC) have progressed beyond surgical resection as a therapeutic option. Difficulties in the proper assessment of tumor invasion depth before treatment complicate determination of the type and extent of therapy. Therefore, accurate tumor clinical staging is a necessity for identifying treatment options and aiding in patient prognosis. We investigated radiographic factors as prognostic indicators for survival in ESCC. Between July 2006 - July 2010, 324 thoracic ESCC patients who underwent surgery were selected. All patients received contrast enhanced preoperative chest CT scans and esophageal barium swallow examinations. Measurement of maximal lesion cross-sectional area, the largest long diameter, largest short diameter, CT-indicated lesion length, barium-indicated lesion length and the length of pericardial fat reduction were performed. Relationships between these indicators and post-surgical survival time and the cutoff values of related factors were analyzed. Maximum long diameter, maximum lesion area and lesion length, as measured by CT imaging, were correlated with survival. Survival effects were clearly associated with group intervals, calculated by a genetic algorithm, and tumor stages. Risk-stratification intervals of esophageal lesions from radiographic imaging included: maximum long diameter < 28.7, 28.7-34.6mm, 34.6-41.4mm and >41.4mm; maximum lesion area < 355.8mm², 355.8-568.0mm², 568.0-907.3mm² and >907.3mm²; and CT-indicated lesion length <30.9mm, 30.9-57.3mm, 57.3-70.6mm and > 70.6mm. The reasonable stratification of maximum esophageal lesion area, largest long diameter and lesion length measured in CT is valuable for clinical T staging of ESCC. Radiographic parameters may have prognostic clinical value in the staging of esophageal carcinoma.

SURGERY VERSUS ENDOSCOPIC THERAPIES FOR EARLY CANCER AND HIGH-GRADE DYSPLASIA IN THE ESOPHAGUS: a systematic review

BACKGROUND

Esophageal cancer occurs as a local disease in 22% of cases, and a minority of this disease is limited to the mucosa or submucosa (early lesions). Endoscopic mucosal resection, endoscopic submucosal dissection, photodynamic therapy, laser therapy, and argon plasma coagulation have emerged as alternatives to surgical resection for early lesions.

OBJECTIVE

The aim of this systematic review is to identify studies that statistically compare survival, disease-free survival, morbidity and mortality associated with the procedure, and mortality associated with cancer in the endoscopic versus surgical therapies.

DATA SOURCES

A systematic review using MEDLINE, COCHRANE, EMBASE, EBSCO, LILACS, Library University of Sao Paulo, BVS, and SCOPE.

STUDY SELECTION

Randomized controlled trial, controlled clinical trial, clinical trial, and cohort study.

CRITERIA

- Studies that statistically compare survival, disease-free survival, morbidity and mortality associated with the procedure, and mortality associated with cancer in patients who underwent endoscopic and surgical therapy for early lesions of esophageal cancer.

DATA EXTRACTION

Independent extraction of the articles by two authors using predefined data fields, including study quality indicators.

LIMITATION

Only retrosprospective cohort studies comparing the endoscopic and surgical therapies were recovered.

RESULTS

The survival rates after 3 and 5 years were different and exhibited superiority with the surgical therapies over time. Endoscopy is superior in the control of mortality related to cancer with a high rate of disease recurrence. With regard to the comorbidity and the mortality associated with the procedure, endoscopy is superior.

CONCLUSION

There is no evidence from clinical trials. In this systematic review, surgical therapies showed superiority for survival, and endoscopic therapies showed superiority in the control of mortality related to cancer with a high rate of disease recurrence; also, for the comorbidity and the mortality associated with the procedure, endoscopy is superior. Prospective, controlled trials with large sample sizes are necessary to confirm the results of the current analysis.

Circulating Cell-Free DNA Levels Could Predict Oncological Outcomes of Patients Undergoing Esophagectomy for Esophageal Squamous Cell Carcinoma

Circulating cell-free DNA (cfDNA) is a potential biomarker for cancer progression but its role is unclear in patients with esophageal squamous cell carcinoma (ESCC) after esophagectomy. We investigated relationships between plasma cfDNA levels and clinicopathological parameters in ESCC patients. Eighty-one ESCC patients who received esophagectomy were enrolled. Plasma samples from these patients and 95 normal controls were collected. DNA copy numbers were measured by real-time quantitative PCR. Subjects were divided into two groups by cfDNA level. Clinicopathological data were collected retrospectively and relationships between cfDNA levels and clinical parameters were evaluated. The cfDNA level in normal controls ranged from 0–4157 copies/mL. The cfDNA level of 96.3% ESCC patients was higher than the cutoff value (2447.26 copies/mL) with a specificity of 94.1%. The mean cfDNA concentration was 5918 copies/mL in lower and 53,311 copies/mL in higher cfDNA groups. No correlations were found between clinicopathological factors and cfDNA levels except for lymphovascular invasion. Higher cfDNA levels were associated with tumor relapse (p = 0.018). Five-year disease-free survival (DFS) and overall survival (OS) rates were 34.7% and 33.8%, respectively. Patients with higher cfDNA levels had poorer DFS (p = 0.013). Patients with higher cfDNA levels had poorer OS, but not significantly (p = 0.164). Circulating cfDNA could be a biomarker for tumor relapse of ESCC with high sensitivity and specificity. Higher cfDNA levels were associated with tumor relapse and shorter DFS after esophagectomy in ESCC patients.

Survivin activates NF‑κB p65 via the IKKβ promoter in esophageal squamous cell carcinoma

Survivin and transcription factor p65 (NF‑κB p65) participate in the progression of esophageal squamous cell carcinoma (ESCC). However, the mechanism of NF‑κB p65 activation in ESCC remains to be elucidated. The aim of the present study was to investigate the role of survivin in the activation of NF‑κB p65 in ESCC. The expression levels of survivin, NF‑κB p65, inhibitor of nuclear factor κB kinase subunit α (IKKα) and inhibitor of nuclear factor κB kinase subunit β (IKKβ) were detected in ESCC tissue samples. Eca109 and KYSE150 cells were cultured and survivin activity was modulated via transfection with an overexpression plasmid, a small hairpin RNA plasmid and a specific inhibitor. Quantitative reverse transcription-polymerase chain reaction and western blotting assays were conducted to assess the effects of survivin on the expression levels of IKKα, IKKβ and NF‑κB p65. Cell cycle and apoptosis assays were conducted to detect surviving-dependent cellular behavior changes. In addition, the luciferase reporter gene assay and chromatin immunoprecipitation assay were conducted to determine the genomic sites responsible for surviving-induced activation of NF‑κB p65. The present study demonstrated that the expression of survivin is positively correlated with IKKα and IKKβ in ESCC tissues. Survivin affected the mRNA and protein expression levels of IKKα, IKKβ, and NF‑κB p65 in Eca109 and KYSE150 cells. Furthermore, survivin increased the transcriptional activity of the IKKβ promoter and bound to the IKKβ promoter region in the Eca109 cells. Downregulation of survivin arrested the cell cycle at the G2/M phase and induced apoptosis. Results of the present study suggest that survivin activates NF‑κB p65 in Eca109 cells via binding to the IKKβ promoter region and upregulating IKKβ promoter transcriptional activity. Survivin overexpression activates NF‑κB p65, which is important in the acquisition and maintenance of the oncogenic characteristics of ESCC.

Significance of 18F-Fluorodeoxyglucose Uptake at the Gastroesophageal Junction: Comparison of PET to Esophagogastroduodenoscopy

BACKGROUND

Positron emission tomography-computed tomography (PET/CT) occasionally reveals unexpected uptake of (18)F-fluorodeoxyglucose ((18)F-FDG) at the gastroesophageal junction (GEJ). The aim of this study was to determine the importance of unexpected (18)F-FDG uptake at the GEJ on PET/CT by correlating this finding with endoscopy results.

METHODS

We reviewed medical records from June 2009 to October 2012 to identify patients in our Veterans Affairs Medical Center who had an esophagogastroduodenoscopy (EGD) performed within 6 months of a PET/CT. Metabolic activity at the GEJ was quantified with standardized uptake values (SUV) and correlated with EGD and histopathology results.

RESULTS

A total of 219 patients were identified and assigned to one of five groups based upon EGD findings: esophageal malignancy (n = 34), esophagitis (n = 21), Barrett's esophagus (n = 8), other non-malignant disorders (n = 5), and normal (n = 151). The mean SUV Max for the groups was 6.72, 2.47, 2.40, 3.48, and 2.06, respectively. SUV Max and SUV Mean were significantly higher in the esophageal malignancy group than in all other groups (p < 0.001). SUV for patients with high-grade esophagitis was greater than in patients with low-grade esophagitis. A SUV Max ≥ 3.5 was found to predict necessity for EGD with a positive predictive value of 79 %. A SUV Max ≤ 2.2 yielded a negative predictive value of 86 %.

CONCLUSION

Differentiation between benign and potentially significant disease at the GEJ may be possible with quantification of incidental (18)F-FDG uptake at PET/CT. Our results suggest thresholds that may help determine need for further endoscopic evaluation in patients with abnormal metabolic activity at the GEJ.

Accuracy of endoscopic ultrasound in the diagnosis of T2N0 esophageal cancer

BACKGROUND

Accurate staging of esophageal carcinoma (EC) is important since it directs further management. Endoscopic ultrasound (EUS) is the best tool available in the locoregional staging of EC; however, differentiating depth of tumor invasion (T) and nodal involvement (N) can be challenging. Accurate staging is particularly important to differentiate T1-2 N0 cancers, which can proceed directly to surgical resection versus TXN1 or T3N0/1 cancers, which benefit from induction chemoradiation prior to surgery. We report the accuracy of EUS staging for cT2N0 lesions.

PATIENTS AND INTERVENTIONS

Six hundred six patients underwent EUS for staging of EC between October 2003 and February 2013 by a single interventional endoscopist specially trained in endoscopic ultrasound. Thirty-eight patients were diagnosed with T2N0 tumors and underwent surgical resection without preoperative chemoradiation. EUS staging was compared to surgical pathology to evaluate accuracy. Patient follow-up was obtained from a retrospective chart review.

RESULTS

Thirty-eight patients (34 men, mean age 65.8 ± 10.5 years) with cT2N0 tumors by EUS underwent surgical resection of EC without chemoradiation after a mean of 22.4 ± 13.7 days post-EUS. When compared with final pathologic outcomes, 12 (32%) were understaged by EUS and 18 (47%) were overstaged. Understaging occurred due to tumor depth (T) in two patients (17%), nodal disease (N) in six (50%), and both in four (33%). Overstaging occurred due to pathology consistent with pT1b tumors instead of T2 tumors in all 17 cases. Based on EUS, 74% were referred for appropriate therapy.

CONCLUSION

While EUS is highly accurate in staging EC, it is less accurate in staging tumors which are not on either ends of the spectrum (mucosally based or clearly transmural). In this challenging group of patients, EUS understaged EC in 32% of cases resulting in surgical resection when neoadjuvant chemoradiation may have been beneficial. We suspect that newer generation EUS systems, which provide better imaging, will result in improved accuracy in staging this group of patients.

Preoperative evaluation of oesophageal adenocarcinoma

The preoperative evaluation of oesophageal adenocarcinoma involves endoscopic ultrasound (EUS), computed tomography (CT), and positron emission tomography (PET). With routine Barrett's oesophagus surveillance, superficial cancers are often identified. EUS, CT and PET have a limited role in the staging of superficial tumours. Standard EUS has limited accuracy, but high frequency ultrasound miniprobes are valuable for assessing tumour stage in superficial tumours. However, the best method for determining depth of invasion, and thereby stage of disease, is endoscopic mucosal resection. In contrast, in advanced oesophageal cancers, a multi-modality approach is crucial. Accurate tumour staging is very important since the treatment of advanced cancers involves a combination of chemotherapy, radiation, and surgery. EUS is very useful for staging of the tumour and nodes. High frequency ultrasound miniprobes provide the ability to perform staging when the lesion is obstructing the oesophageal lumen. CT and PET provide valuable information regarding node and metastasis staging.

Significance of tumor length as prognostic factor for esophageal cancer

Our study indicated the relationship between tumor length and clinicopathologic characteristics as well as long-term survival in esophageal cancer. A total of 116 patients who underwent curative surgery for thoracic esophageal cancer with standard lymphadenectomy in 2 fields between 2000 and 2010 were included in the study. The medical records of these patients were retrospectively reviewed. The patients with tumor length 3 cm had a highly significant difference in the involvement of adventitia and lymph node stations. The patients with tumor length 3 cm had significantly lower rates of involvement of the adventitia and lymph node stations. Tumor length could have a significant impact on both the overall survival and disease-free survival of patients with resected esophageal carcinomas and may provide additional prognostic value to the current tumor, node, and metastasis staging system before patients receive any cancer-specific treatment.

Acylglycerol kinase augments JAK2/STAT3 signaling in esophageal squamous cells

JAK2 activity is tightly controlled through a self-inhibitory effect via its JAK homology domain 2 (JH2), which restricts the strength and duration of JAK2/STAT3 signaling under physiological conditions. Although multiple mutations within JAK2, which abrogate the function of JH2 and sustain JAK2 activation, are widely observed in hematological malignancies, comparable mutations have not been detected in solid tumors. How solid tumor cells override the autoinhibitory effect of the JH2 domain to maintain constitutive activation of JAK2/STAT3 signaling remains puzzling. Herein, we demonstrate that AGK directly interacted with the JH2 domain to relieve inhibition of JAK2 and activate JAK2/STAT3 signaling. Overexpression of AGK sustained constitutive JAK2/STAT3 activation, consequently promoting the cancer stem cell population and augmenting the tumorigenicity of esophageal squamous cell carcinoma (ESCC) cells both in vivo and in vitro. Furthermore, AGK levels significantly correlated with increased STAT3 phosphorylation, poorer disease-free survival, and shorter overall survival in primary ESCC. More importantly, AGK expression was significantly correlated with JAK2/STAT3 hyperactivation in ESCC, as well as in lung and breast cancer. These findings uncover a mechanism for constitutive activation of JAK2/STAT3 signaling in solid tumors and may represent a prognostic biomarker and therapeutic target.

Low impact of staging EUS for determining surgical resectability in esophageal cancer

BACKGROUND

Although studies have shown that EUS has a high sensitivity and specificity for T and N staging, the value of EUS for staging tumors as resectable or nonresectable after CT of the chest and abdomen and US neck assessment, is largely unknown. This study was designed to assess the diagnostic value of EUS for determining resectability of esophageal cancer.

METHODS

A retrospective analysis of all consecutive patients with esophageal carcinoma who underwent staging EUS, CT, and US. Tumors were considered resectable when there was no evidence of metastases or ingrowth in adjacent structures. Sensitivity, specificity, positive (PPV), and negative (NPV) predictive value of CT/US neck and CT/US neck + EUS for predicting surgical resectability were calculated. PPVs of CT/US alone and CT/US + EUS together were compared for assessing the diagnostic value of EUS.

RESULTS

In total, 211 patients (155 men; mean age of 64 ± 9.4 years) were included, of which 176 (83 %) underwent all three staging investigations. Based on preoperative staging, 173 (82 %) patients were considered resectable and 38 (18 %) nonresectable. Of all 173 initially resectable patients, 145 were operated on. Of these patients, five (3.4 %) tumors were found nonresectable during surgery. Postoperative sensitivity, specificity, PPV, and NPV of CT/US and CT/US + EUS for predicting surgical resectability were 88 versus 87 %, 20 versus 40 %, 97 versus 98 %, and 6 versus 10 %, respectively.

CONCLUSIONS

Although EUS adds to the specificity of preoperative esophageal cancer staging after CT chest and abdomen, and US of the neck have been performed, the overall added value of EUS is limited.

An overview of esophageal squamous cell carcinoma proteomics

Esophageal squamous cell carcinoma (ESCC) still remains the leading cancer-caused mortality in northern China, in particular in areas nearby Taihang Mountain. Late-stage diagnosis of ESCC increases the mortality and morbidity of ESCC. Therefore, it is imperative to identify biomarkers for early diagnosis, monitoring of tumor progression and identifying potential therapeutic targets of ESCC. Proteomics provides a functional translation of the genome and represents a richer source for the functional description of diseases and biomarkers implicated in cancer. In this review, we discuss the dysregulated proteins associated with ESCC identified by proteomic approaches and aim to enhance our understanding of molecular mechanisms implicated in ESCC development and progression from a proteomics perspective and discuss the potential biomarkers of ESCC as well.

Endoscopic tumor length is an independent prognostic factor in esophageal squamous cell carcinoma

PURPOSE

To investigate the impact of endoscopic esophageal tumor length on survival for patients with resected esophageal squamous cell carcinoma (ESCC).

METHODS

We retrospectively reviewed the clinicopathologic characteristics of 244 ESCC patients who underwent curative resection as the primary treatment at Taipei Veterans General Hospital between January 2000 and November 2010. The endoscopic tumor length was defined as a uniform measurement before completion of the esophagectomy. The impact of endoscopic tumor length on a patient's overall survival (OS) and disease-free survival (DFS) were assessed. A Cox regression model was used to identify prognostic factors.

RESULTS

The 1-, 3-, and 5-year OS rates were 81.2, 48.2, and 39.6%, respectively, with a median survival time of 18.0 months. The 1-, 3-, and 5-year DFS rates were 66.2, 34.7, and 32.4%, respectively, with a median DFS of 15.0 months. Endoscopic tumor length correlated with pathologic tumor length [Pearson correction (r)=0.621; P<0.001] Regression trees analyses suggested an optimum cutoff point of >4 cm to identify patients with decreased long-term survival. In multivariate survival analysis, endoscopic tumor length (more or less than 4 cm) remained an independent prognostic factor for both OS (P=0.006) and DFS (P=0.002).

CONCLUSIONS

Endoscopic tumor length could have a significant impact on both the OS and DFS of patients with resected ESCC and may provide additional prognostic value to the current tumor, node, and metastasis staging system before patients receive any cancer-specific treatment.

Metastatic esophageal adenocarcinoma of the great toe: a case report

Owing to the rarity of metastatic disease to the bones of the foot, the guidelines for the proper care and workup of such conditions are inconsistent. The present case illustrates the evaluation of a patient with established esophageal adenocarcinoma that metastasized to involve the hallux, which had not been confirmed by previous imaging scans. The purpose of reporting the present case was to aid in establishing a protocol for a multidisciplinary approach to patient care and evaluating the entire body when performing metastatic disease treatment. As the present case has shown, evaluation of various abnormalities such as chronic paronychia could mask additional underlying conditions related to the patient's primary cancer.

An Auxetic structure configured as oesophageal stent with potential to be used for palliative treatment of oesophageal cancer; development and in vitro mechanical analysis

Oesophageal cancer is the ninth leading cause of malignant cancer death and its prognosis remains poor. Dysphagia which is an inability to swallow is a presenting symptom of oesophageal cancer and is indicative of incurability. The goal of this study was to design and manufacture an Auxetic structure film and to configure this film as an Auxetic stent for the palliative treatment of oesophageal cancer, and for the prevention of dysphagia. Polypropylene was used as a material for its flexibility and non-toxicity. The Auxetic (rotating-square geometry) structure was made by laser cutting the polypropylene film. This flat structure was welded together to form a tubular form (stent), by an adjustable temperature control soldering iron station: following this, an annealing process was also carried out to ease any material stresses. Poisson's ratio was estimated and elastic and plastic deformation of the Auxetic structure was evaluated. The elastic and plastic deformation behaviours of the Auxetic polypropylene film were evaluated by applying repetitive uniaxial tensile loads. Observation of the structure showed that it was initially elastically deformed, thereafter plastic deformation occurred. This research discusses a novel way of fabricating an Auxetic structure (rotating-squares connected together through hinges) on Polypropylene films, by estimating the Poisson's ratio and evaluating the plastic deformation relevant to the expansion behaviour of an Auxetic stent within the oesophageal lumen.

Outcomes of multimodality therapy for stage IVB esophageal cancer with distant organ metastasis (M1-Org)

Esophageal cancer patients with distant organ metastasis have usually been treated only to palliate symptoms without multimodality therapy. The current study evaluates the role of multimodality therapy in esophageal squamous cell cancer patients with distant organ metastasis. Between February 1988 and January 2007, 80 esophageal squamous cell cancer patients with distant organ metastases were treated at our institution. Multimodality therapy was performed in 58 patients: 43 patients received chemoradiotherapy, 13 underwent surgery followed by chemotherapy and/or radiation therapy, and two received chemotherapy or chemoradiotherapy followed by surgery. Thirteen patients received single-modality therapy; chemotherapy, radiotherapy, or surgery alone. The remaining nine patients received best supportive care alone. The metastatic organ was the liver (n= 40), the lungs (n= 33), bone (n= 10), and other (n= 6). Nine patients had metastasis in two organs. There was no difference in the median survival among the sites of organ metastasis, lung, liver, or bone (P= 0.8786). The survival of patients treated with multimodality therapy was significantly better than that of the patients who received single-modality therapy or best supportive care alone (P < 0.0001). In patients treated with multimodallity therapy, there was no difference in survival for patients treated with surgery compared with patients treated without surgery (P= 0.1291). This retrospective study involves an inevitable issue of patient selection bias. However, these results suggested that multimodality therapy could improve survival of the esophageal squamous cell cancer patients with distant organ metastasis.

A cost and benefit study of esophagectomy for patients with esophageal cancer

INTRODUCTION

The incidence of esophageal cancer is increasing all over the world but the cost-and-benefit of esophagectomy for esophageal cancer patients was rarely studied. The aim of this study is to compare the cost-and-benefit of esophagectomy in different stages of esophageal cancer.

MATERIALS AND METHODS

Clinical and utilization data, including medical expenses and reason for treatment, of esophageal cancer patients were collected, summed and followed up for 5 years. The patients were divided into two groups according to their treatments, with or without esophagectomy. The monthly medical expense and relative expense performance index (REPI) were then calculated. Factors influenced total and monthly medical expense and survival time were further analyzed.

RESULTS

A total of 310 esophageal cancer patients, 281 male and mean age of 64.3, were included in this study. One hundred forty-nine patients had undergone esophagectomy. The 5-year survival rate, total and monthly medical expense for two groups was 36.0% and 10.2% (p<0.001), USD $22,532.8 vs. 12,256.4 (p<0.001) and USD $2,101.65 vs. 2,033.94 (p=0.831), respectively. The REPIs in four different stages were 7.573, 2.422, 2.446 and 0.705. Both esophagectomy and tumor stage were the sole factors that could influence total and monthly medical expense respectively. Both esophagectomy and tumor stage could influence a patient's survival time.

CONCLUSIONS

Esophagectomy has better performance than non-esophagectomy for patients with stages I to III esophageal cancer. Therefore, adding economical considerations, esophagectomy is recommended for patients, at least earlier than stage III.

New potential biomarkers in the diagnosis of esophageal squamous cell carcinoma

OBJECTIVE

To analyse the alterations of serum proteins in cases of esophageal squamous cell carcinoma (ESCC) in order to screen and validate serum marker patterns for the diagnosis of ESCC in the high-risk populations of Xinjiang, China.

METHODS

The serum proteomic patterns of 188 cases, including 139 patients with ESCC (54 Uygur, 45 Kazakh and 40 Han subjects) and 49 sex- and age-matched healthy controls, were detected using the SELDI-TOF-MS (surface-enhanced laser desorption/ionization-time of flight-mass spectrometry) technology with the CM10 ProteinChip. Differences in protein peaks between patients with ESCC and controls were analysed using the Biomarker Pattern Software, and a primary diagnosis model of ESCC was developed and validated with SVM (support vector machines). This model was further evaluated by a large-scale blind test.

RESULTS

Two hundred and eighty-three protein peaks were detected within the molecular range of 0-20 kDa, among which, 140 peaks were significantly different between ESCC cases and controls (p < 0.05). A diagnostic pattern consisting of six protein peaks (m/z 5667, 5709, 5876, 5979, 6043 and 6102) was established with a sensitivity of 97.12% and a specificity of 83.87%. The large-scale blind test generated a sensitivity of 91.43% and a specificity of 88.89%.

CONCLUSIONS

The differential protein peaks analysed by SELDI-TOF-MS may contain promising serum biomarkers for screening ESCC. The diagnostic model which combined only six protein peaks had a satisfactory discriminatory power. The model should be further evaluated in other populations of ESCC patients and tested against controls. The nature and function of the discriminating proteins have yet to be elucidated.

Detection of lymph node metastases with ultrasmall superparamagnetic iron oxide (USPIO)-enhanced magnetic resonance imaging in oesophageal cancer: a feasibility study

Aim: In this feasibility study we investigated whether magnetic resonance imaging (MRI) with ultrasmall superparamagnetic iron oxide (USPIO) can be used to identify regional and distant lymph nodes, including mediastinal and celiac lymph node metastases in patients with oesophageal cancer.

Patients and methods: Ten patients with a potentially curative resectable cancer of the oesophagus were eligible for this study. All patients included in the study had positive lymph nodes on conventional staging (including endoscopic ultrasound, computed tomography and fluorodeoxyglucose-positron emission tomography). Nine patients underwent MRI + USPIO before surgery. Results were restricted to those patients who had both MRI + USPIO and histological examination. Results were compared with conventional staging and histopathologic findings.

Results: One patient was excluded due to expired study time. Five out of 9 patients underwent an exploration; in 1 patient prior to surgery MRI + USPIO diagnosed liver metastases and in 3 patients an oesophageal resection was performed. USPIO uptake in mediastinal lymph nodes was seen in 6 out of 9 patients; in 3 patients non-malignant nodes were not visible. In total, 9 lymph node stations (of 6 patients) were separately analysed; 7 lymph node stations were assessed as positive (N1) on MRI+USPIO compared with 9 by conventional staging. According to histology findings, there was one false-positive and one false-negative result in MRI + USPIO. Also, conventional staging modalities had one false-positive and one false-negative result. MRI + USPIO had surplus value in one patient. Not all lymph node stations could be compared due to unforeseen explorations. No adverse effects occurred after USPIO infusion.

Conclusion: MRI+USPIO identified the majority of mediastinal and celiac (suspect) lymph nodes in 9 patients with oesophageal cancer. MRI+USPIO could have an additional value in loco-regional staging; however, more supplementary research is needed.

Impact of fluorodeoxyglucose PET on the management of esophageal cancer

Esophageal cancer is the third most common malignancy of the alimentary tract. The incidence of esophageal cancer has steadily increased over the past three decades. Almost all therapeutic modalities for esophageal cancer are associated with a considerable mortality and morbidity. Consequently, there has been growing concern regarding effective management of esophageal cancer. 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) is playing an increasing role in the management of esophageal cancer, offering potential advantages in the accuracy of disease assessment at a number of decision points in the management pathway. This review evaluates the critical role of FDG-PET in (i) diagnosis, (ii) preoperative staging, (iii) monitoring of response to neoadjuvant therapy, (iv) assessment of recurrence and (v) prediction of prognosis of esophageal cancer. We have also compared diagnostic performance of FDG-PET and other current technologies such as computed tomography scan and endoscopic ultrasonography based on available evidence.

International survey on esophageal cancer: part II staging and neoadjuvant therapy

The outcome of esophagectomy could be improved by optimal diagnostic strategies leading to adequate preoperative patient selection. Neoadjuvant therapy could improve outcome by increasing the number of radical resections and by controlling metastatic disease. The purposes of this study were to gain insight into the current worldwide practice of staging modalities and neoadjuvant therapy in esophageal cancer, and to detect intercontinental differences. Surgeons with particular interest in esophageal surgery, including members of the International Society for Diseases of the Esophagus, the European Society of Esophagology - Group d'Etude Européen des Maladies de l'Oesophage, and the OESO, were invited to participate in an online questionnaire. Questions were asked regarding staging modalities, neoadjuvant therapy, and response evaluation applied in esophageal cancer patients. Of 567 invited surgeons, 269 participated resulting in a response rate of 47%. The responders currently performing esophagectomies (n= 250; 44%) represented 41 countries across the six continents. Esophagogastroscopy with biopsy and computed tomography (CT) scanning were routinely performed by 98% of responders for diagnosing and staging esophageal cancer, while endoscopic ultrasound (EUS) and barium esophagography were routinely applied by 58% and 51%, respectively. Neoadjuvant therapy is routinely administered by 33% and occasionally by 63% of responders. Of the responders that administer identical neoadjuvant regimens to esophageal adenocarcinoma (AC) and squamous cell carcinoma, 54% favor chemoradiotherapy. For AC, chemotherapy is preferred by 31% of the responders that administer neoadjuvant therapy, whereas for squamous cell carcinoma, the majority of responders (38%) prefer chemoradiotherapy. Response to neoadjuvant therapy is predominantly assessed by CT scanning of the chest and abdomen (86%). Barium esophagography, EUS, and combined CT/PET scan are requested for response monitoring in equal frequency (25%). Substantial differences in applied staging modalities and neoadjuvant regimens were detected between surgeons from different continents. In conclusion, currently the most commonly applied diagnostic modalities for staging and restaging esophageal cancer are CT scanning of the chest and abdomen, gastroscopy, barium esophagography and EUS. Neoadjuvant therapy is routinely applied by one third of the responders. Intercontinental differences have been detected in the diagnostic modalities applied in esophageal cancer staging and in the administration of neoadjuvant therapy. The results of this survey provide baseline data for future research and for the development of international guidelines.

Proteomic identification of malignant transformation-related proteins in esophageal squamous cell carcinoma

Esophageal cancer (EC) persists to be a leading cancer-related death in northern China. Clinical outcome of EC is the most dismal among many types of digestive tumors because EC at early stage is asymptomatic. The current study used 2-DE-based proteomics to identify differentially expressed proteins between esophageal cancer cell lines and immortal cell line. Fifteen proteins were identified with differences of more than five folds, comprising the down-regulation of annexin A2, histone deacetylase 10 isoform beta and protein disulfide-isomerase ER-60 precursor, and the up-regulation of heat shock 70 kDa protein 9B precursor, solute carrier family 44 Member 3, heterogeneous nuclear ribonucleoprotein L (hnRNP L), eukaryotic translation initiation factor 4A isoform 2, triosephosphate isomerase1 (TPI), peroxiredoxin1 (PRX1), forminotransferase cyclodeaminase form (FTCD), fibrinogen gamma-A chain precursor, kinesin-like DNA binding protein, lamin A/C, cyclophilin A (CypA), and transcription factor MTSG1. Expression pattern of annexin A2 was verified by Western blotting, immunocytochemistry and immunohistochemistry analysis. The implication of these protein alterations correlated to the esophageal malignant transformation is discussed.

Observation of normal appearance and wall thickness of esophagus on CT images

PURPOSE

This study sought to observe the appearance of normal esophagus, measure and record the thickness of esophageal wall in order to offer reference for estimating esophageal wall abnormalities and delineating gross tumor target of esophageal carcinomas on CT images.

MATERIALS AND METHODS

From September 2006 to February 2007, 110 consecutive CT films from adult patients without esophageal diseases were collected and studied. On CT images the entire esophagus was divided into cervical, thoracic, retrocardiac and intraabdominal segments. The appearance of esophagus was described when the esophagus contracted or dilated. Thickness of esophageal wall and diameters of esophageal cavities were measured by hard-copy reading with a magnifying glass. Age, sex and the thickness of subcutaneous fat of each patient were recorded.

RESULTS

It was observed that the esophagus presented both contracted and dilated status on CT images. In each segment there were certain portions of esophagus in complete contraction or dilatation. 47 images (42.7%) showed contracted esophagus in each segment available for measurement. The largest wall thickness when esophagus was in contraction and dilatation was 4.70 (95%CI: 4.44-4.95)mm and 2.11 (95%CI: 2.00-2.23)mm, respectively. When contracting, the intraabdominal esophagus was thicker than the cervical, thoracic and retrocardiac parts, and the average thickness was 5.68 (95%CI: 5.28-6.09)mm, 4.67 (95%CI: 4.36-4.86)mm, 4.56 (95%CI: 4.31-4.87)mm, and 4.05 (95%CI: 3.71-4.21)mm, respectively. When the esophagus was dilating, the average esophageal wall thickness was between 1.87 and 2.70 mm. The thickest part was cervical esophagus. Thickness of esophageal wall was larger in males than that of females (5.26 mm vs. 4.34 mm p<0.001). Age and the thickness of subcutaneous fat had no significant impact on the thickness of esophageal wall (p-value was 0.056 and 0.173, respectively).

CONCLUSION

The Observation of normal appearance and wall thickness of esophagus helps us to identify thickened esophageal wall on CT images using new CT scan technologies. Thus it is probably helpful in judging esophageal diseases and delineating gross tumor target of esophageal carcinomas in modern radiotherapy.

Epidemiological trends in oesophageal cancer in the Nordic countries

OBJECTIVE

The incidence rates of oesophageal cancer vary more than those of any other cancer, world-wide. The aim of this study was to examine the epidemiological features of oesophageal cancer in the Nordic countries.

MATERIAL AND METHODS

Epidemiological data from the Nordic Cancer Registry (NORDCAN Database, http://www.ancr.nu/nordcan.asp) were used for the study analysis.

RESULTS

From 1971 to 2000 in the Nordic countries, 18,034 oesophageal cancers were detected in males and 8216 in females. In males, the incidence rates (world age standardized incidence per 100,000) of oesophageal cancer in 1971-75 and 1996-2000 were 2.7 and 6.0 in Denmark, 4.2 and 3.2 in Finland, 3.4 and 5.6 in Iceland, 2.6 and 3.3 in Norway, and 2.9 and 3.3 in Sweden, respectively. In females, the corresponding figures were: Denmark 1.1 and 1.8, Finland 3.1 and 1.3, Iceland 2.5 and 1.3, Norway 0.7 and 0.9, and Sweden 1.1 and 1.0. Each Nordic country showed a significant geographical variation in the incidence of oesophageal cancer. In both males and females the incidence curves began rising after 40 years of age, but significantly more steeply in males than in females. Over the study period, oesophageal cancer mortality increased from 2.97 to 3.68 per 100,000 in males but decreased from 1.30 to 1.08 in females. The incidence rates of oesophageal adenocarcinoma increased in males in all Nordic countries, and the increase was most marked in Denmark. The incidence of oesophageal adenocarcinoma also increased among Danish females, but compared with males, the incidence rate remained significantly lower.

CONCLUSIONS

The time trends in incidence of oesophageal cancer differ between the Nordic countries, and there has also been geographical variation within them. On a global comparison, the incidence rates of oesophageal cancer are low in the Nordic region. Oesophageal cancer is a male-predominant disease in all Nordic countries, and the incidence rates of oesophageal adenocarcinoma have increased in males and Danish females.

Is positron emission tomography useful in locoregional staging of esophageal cancer? Results of a multidisciplinary initiative comparing CT, positron emission tomography, and EUS

BACKGROUND

Various modalities including CT, positron emission tomography (PET), and EUS are being used for esophageal cancer staging.

OBJECTIVE

We compared results of locoregional staging by CT, PET, and EUS with histologic staging.

DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS AND INTERVENTIONS

Patients with esophageal cancer proven by endoscopy and biopsy underwent a CT scan of the chest and abdomen and a PET scan. Patients with no evidence of distant metastatic disease on CT and PET were referred for EUS for locoregional staging.

MAIN OUTCOME MEASUREMENT

The tumor size (T) and lymph node (N) stage as determined by EUS were compared with surgical pathology or EUS-guided FNA cytology. The results of N staging with CT, PET, and EUS were compared with surgical pathology or EUS-FNA cytology.

RESULTS

Between May 2005 and April 2006, 29 patients (24 men, mean age 68 years) underwent EUS. EUS was successful in 25 of 29 patients (86%). There were no EUS-related complications. Eleven of 16 patients with available lymph node histologic study had confirmed metastasis. Nodal metastasis was correctly identified by CT in 6 of 11 patients, by PET in 4 of 11 patients, and by EUS in 10 of 11 patients. Overall accuracy for N staging was 69% for CT, 56% for PET, and 81% for EUS. Fifteen patients had confirmed T staging by surgical pathologic examination. The percentage of agreement for T staging between EUS and surgical pathology was 80% (12/15 patients).

LIMITATIONS

Single center, retrospective chart review.

CONCLUSION

EUS is safe and accurate for tumor and node staging in esophageal cancer. The combination of CT plus EUS appears to be accurate for locoregional staging in esophageal cancer.

Identification of alpha-actinin 4 and 67 kDa laminin receptor as stage-specific markers in esophageal cancer via proteomic approaches

BACKGROUND

Esophageal squamous cell carcinoma (ESCC) is one of the most common malignancies in the world with a very poor prognosis. The majority of ESCC patients present with advanced metastatic disease upon diagnosis. Therefore, it is important to understand the molecular mechanism in the tumor invasion process and to find new biomarkers for early diagnosis and prognostic evaluation.

METHODS

Differentially expressed proteins among different stages of primary ESCCs and their matched surrounding normal tissues were compared by proteomics-based technology. The correlations between interesting proteins and clinical features of ESCC were further investigated by using ESCC tissue microarray (TMA) by immunohistochemical staining.

RESULTS

Compared with normal tissues, a total of 18 differentially expressed proteins were identified in ESCC in this study. Among them, expression levels of alpha-actinin 4 (ACTN4) and 67 kDa laminin receptor (67LR) were progressively increased from stage I to III. Clinicopathological correlation using TMA revealed that overexpression of ACTN4 was significantly associated with advanced tumor stage (P = .026) and lymph node metastasis (P = .049), whereas overexpression of 67LR was significantly correlated with advanced tumor stage (P = .019) but not lymph node metastasis.

CONCLUSIONS

These findings suggested that overexpression of ACTN4 and 67 LR is associated with ESCC progression and that these biomarkers may potentially be useful to prognostic evaluation, molecular biological classification, and therapeutic targeting.

Detection of distant metastases in patients with oesophageal or gastric cardia cancer: a diagnostic decision analysis

Computed tomography (CT) is presently a standard procedure for the detection of distant metastases in patients with oesophageal or gastric cardia cancer. We aimed to determine the additional diagnostic value of alternative staging investigations. We included 569 oesophageal or gastric cardia cancer patients who had undergone CT neck/thorax/abdomen, ultrasound (US) abdomen, US neck, endoscopic ultrasonography (EUS), and/or chest X-ray for staging. Sensitivity and specificity were first determined at an organ level (results of investigations, i.e., CT, US abdomen, US neck, EUS, and chest X-ray, per organ), and then at a patient level (results for combinations of investigations), considering that the detection of distant metastases is a contraindication to surgery. For this, we compared three strategies for each organ: CT alone, CT plus another investigation if CT was negative for metastases (one-positive scenario), and CT plus another investigation if CT was positive, but requiring that both were positive for a final positive result (two-positive scenario). In addition, costs, life expectancy and quality adjusted life years (QALYs) were compared between different diagnostic strategies. CT showed sensitivities for detecting metastases in celiac lymph nodes, liver and lung of 69, 73, and 90%, respectively, which was higher than the sensitivities of US abdomen (44% for celiac lymph nodes and 65% for liver metastases), EUS (38% for celiac lymph nodes), and chest X-ray (68% for lung metastases). In contrast, US neck showed a higher sensitivity for the detection of malignant supraclavicular lymph nodes than CT (85 vs 28%). At a patient level, sensitivity for detecting distant metastases was 66% and specificity was 95% if only CT was performed. A higher sensitivity (86%) was achieved when US neck was added to CT (one-positive scenario), at the same specificity (95%). This strategy resulted in lower costs compared to CT only, at an almost similar (quality adjusted) life expectancy. Slightly higher specificities (97–99%) were achieved if liver and/or lung metastases found on CT, were confirmed by US abdomen or chest X-ray, respectively (two-positive scenario). These strategies had only slightly higher QALYs, but substantially higher costs. The combination of CT neck/thorax/abdomen and US neck was most cost-effective for the detection of metastases in patients with oesophageal or gastric cardia cancer, whereas the performance of CT only had a lower sensitivity for metastases detection and higher costs. The role of EUS seems limited, which may be due to the low number of M1b celiac lymph nodes detected in this series. It remains to be determined whether the application of positron emission tomography will further increase sensitivities and specificities of metastases detection without jeopardising costs and QALYs.

Staging of esophageal cancer by EUS: staging accuracy revisited

BACKGROUND

EUS plays an important role in the preoperative staging of esophageal cancer. Recent data have called into question the staging accuracy of EUS, particularly in patients with early disease.

OBJECTIVE

Our goals were to assess our institution's EUS staging accuracy by experienced endosonographers in a contemporary cohort of patients encompassing a wide range of disease stages and to assess staging accuracy after dilation of malignant strictures.

DESIGN

Retrospective data review.

SETTING

Single tertiary care center.

PATIENTS AND INTERVENTIONS

A total of 42 patients with esophageal cancer undergoing preoperative EUS staging without neoadjuvant chemoradiotherapy between December 1999 and December 2004 were evaluated.

MAIN OUTCOME MEASUREMENTS

EUS T and N stage sensitivity, specificity, positive predictive value, negative predictive value, and accuracy.

RESULTS

EUS accurately predicted T stage in 76% of cases and N stage in 89% of cases. Staging accuracy for T3 versus T1 and T2 disease and for N0 versus N1 disease was not significantly different. In 11 cases, malignant strictures required dilation, with 6 tumors being passable post dilation. Post dilation, T staging accuracy was 80% in impassable tumors and 100% in passable tumors, and N staging accuracy was 100% in the passable tumors.

LIMITATIONS

Relatively small number of patients.

CONCLUSIONS

EUS accurately predicts T and N stage in patients with a range of disease stages. EUS provides good staging accuracy after dilation of malignant strictures regardless of whether full tumor traversal post dilation is possible.

Endoscopic Ultrasound Compared With Laparoscopy for Staging Esophageal Cancer

BACKGROUND

Endoscopic ultrasonography (EUS) is an accurate modality for locoregional staging of esophageal cancer. Given an increasing prevalence of distal esophageal adenocarcinoma, some centers employ laparoscopic staging (LS) in addition to noninvasive staging methods. We sought to compare EUS and LS for nodal staging in patients with esophageal cancer.

METHODS

All newly diagnosed, EUS-staged esophageal cancer cases during an 18-month period were reviewed. Patients who underwent both EUS and LS comprised the study cohort; EUS records, operative notes, and pathology reports were reviewed. Inability to pass the radial echoendoscope through the malignant stricture despite dilation was considered an incomplete EUS examination.

RESULTS

Forty-seven patients were identified who underwent both modalities for staging; of these, 70% had complete EUS evaluation. For nodal staging, EUS-fine-needle aspiration was 90% accurate as compared with LS. Overall, staging accuracy of EUS compared with LS was 72%. Accuracy was 76% for patients with complete EUS staging compared with 64% for patients with incomplete EUS examinations. Staging differences were mostly reflected in distant metastases detected at LS (17%).

CONCLUSIONS

Endoscopic ultrasonography is nearly as accurate as LS in nodal staging for esophageal cancer. The value of LS is accurate abdominal nodal staging and detection of occult distant metastases. Laparoscopic staging should, therefore, be incorporated into staging algorithms for neoadjuvant protocols. In the absence of preoperative therapy, LS should be performed at the time of planned esophagectomy. In those without occult metastases, curative resection may be attempted.

Expression level of hepatoma-derived growth factor correlates with tumor recurrence of esophageal carcinoma

BACKGROUND

Hepatoma-derived growth factor (HDGF) is thought to play an important role in the development and progression of carcinomas. In the present study, association of HDGF expression with recurrence and prognosis of esophageal carcinoma (EC) was examined.

METHODS

HDGF expression in 111 patients with EC (101 men and 10 women) with ages ranging from 38 to 82 (median, 61) years was analyzed by immunohistochemistry. Samples in which >90% of tumor cells exhibited nuclear and cytoplasmic HDGF immunoreactivity at levels greater than or equal to what is observed in the endothelial cells were regarded as HDGF expression level 1, and others as HDGF expression level 0.

RESULTS

Thirty-seven of 111 patients showed level 1 HDGF expression. There was no correlation between HDGF expression and other clinicopathologic factors. Patients with level 1 expression showed poorer disease-free and overall survival (P < .05 for both) compared with those with level 0 expression. HDGF expression was an independent prognostic factor for patients with early (pT1-2) stage of the disease, but not for those with advanced (pT3-4) stage.

CONCLUSIONS

HDGF expression level was shown to be a prognostic factor for EC.

Cryospray ablation (CSA) in the palliative treatment of squamous cell carcinoma of the esophagus

Background

Esophageal carcinoma is the ninth most prevalent cancer worldwide with squamous cell carcinoma (SCCA) and adenocarcinoma accounting for the vast majority of new cases (13,900 in 2003). Cure rates in the U.S. are less than 10%, similar to lung cancer. More than 50% of patients with esophageal carcinoma present with unresectable or metastatic disease, are not surgical candidates, or display disease progression despite the addition of neoadjuvant chemoradiotherapy to surgery. Need for improved palliation exits.

Case presentation

This case describes a 73-year-old African American male who presented with recurrent squamous cell carcinoma (SCCA) of the esophagus who has a achieved complete remission for 24 months via endoscopic cryospray ablation.

Conclusion

Endoscopic cryo spray ablation warrants further investigation as a palliative treatment modality for esophageal cancer. This is the first reported case in the medical literature.

Circumferential endoscopic resection of Barrett's esophagus with high-grade dysplasia or early adenocarcinoma

BACKGROUND

Barrett's esophagus-related high-grade dysplasia or mucosal cancer can be treated by endoscopic mucosal resection (EMR), but the adjacent metaplastic epithelium remains at risk for developing further lesions. Our objective was to evaluate the results of the circumferential EMR in removing not only the neoplastic lesion but also the remaining Barrett's epithelium.

METHODS

Forty-one consecutive patients (mean age: 66 years) with Barrett's esophagus were submitted to 63 EMR sessions in one single-referral endoscopic unit. All patients had high-grade dysplasia, and cancer was detected in 23 of these cases, most of them classified as T1N0 (20 patients) by endosonography. Mucosectomy after saline submucosal injection was performed for the neoplastic lesions and, if necessary, the residual Barrett's epithelium was removed by the same technique one month later.

RESULTS

A retrospective evaluation showed that, during a mean follow-up of 31.6 months, Barrett's epithelium was completely replaced by squamous epithelium in 31 (75.6%) cases. There were 10 complications, all of which were managed endoscopically: 8 cases of bleeding and two perforations occurred in 9 (14.3%) patients. One patient developed an esophageal stricture. Barrett's epithelium recurred in 10 (24.4%) patients and recurrent or metachronous early cancer was detected in 5 (12.2%), all but one of which were treated again by EMR; the fifth patient was referred to surgery. Argon plasma coagulation was used in 6 cases to treat Barrett's epithelium, and two patients received concomitant chemoradiotherapy as adjuvant therapy.

CONCLUSIONS

Circumferential EMR provides an effective endoscopic approach to the management of Barrett's esophagus-related high-grade dysplasia and mucosal cancer. Additional studies are necessary to evaluate the long-term results.

[Endoscopic treatment of squamous cell esophageal cancer]

OBJECTIVE

In this article, it was evaluated the role of endoscopic procedures for the management of squamous cell esophageal cancer.

DATA SOURCE

Relevant publications cited at PubMed database in the last 10 years were analyzed and compared with the experience developed at the Gastrointestinal Endoscopy Division of the Department of Gastroenterology of the University of São Paulo School of Medicine. Mucosectomy and advanced tumor tunnelization were the most important developments in that area.

DATA SYNTHESIS

Endoscopic mucosal resection of early epidermoid cancer of the esophagus is indicated when the lesion is confined to the epithelium (m1) or to the lamina propria (m2). The described 5-year survival rate after endoscopic mucosal resection of intramucosal epidermoid tumor of the esophagus approaches 95%. Based on the available evidence, it seems reasonable to indicate endoscopic mucosal resection as a first-choice treatment for patients with intramucosal epidermoid esophageal carcinoma. There are a variety of endoscopic palliative methods for dysphagia relief in advanced esophageal cancer.

CONCLUSIONS

The choice will vary according to the anatomical features and location of the tumor, patient preferences, local and expertise availability. The technical success rate for placement of metal stents across the malignant stenosis is close to 100%. The rate of long-term palliation of dysphagia approaches 80% which makes expandable metal stents the treatment of choice for palliation of obstructive symptoms caused by advanced squamous cell cancer of the esophagus.

The role of socio-economic status in the decision making on diagnosis and treatment of oesophageal cancer in The Netherlands

In the United States (USA), a correlation has been demonstrated between socio-economic status (SES) of patients on the one hand, and tumour histology, stage of the disease and treatment modality of various cancer types on the other hand. It is unknown whether such correlations are also involved in patients with oesophageal cancer in The Netherlands. Between 1994 and 2003, 888 oesophageal cancer patients were included in a prospective database with findings on the diagnostic work-up and treatment of oesophageal cancer. Socio-economic status of patients was defined as the average net yearly income. Linear-by-linear association testing revealed that oesophageal adenocarcinoma was more frequently observed in patients with higher SES and squamous cell carcinoma in patients with lower SES (P=0.02). Multivariable logistic regression analysis showed no correlation between SES and staging procedures and preoperative TNM stage. The adjusted odds ratio (OR) for stent placement was 0.82 (95% CI 0.71–0.95), indicating that with an increase in SES by 1200 €, the likelihood that a stent was placed declined by 18%. Patients with a higher SES more frequently underwent resection or were treated with chemotherapy (OR: 1.15; 95% CI 1.01–1.32 and OR: 1.16; 95% CI 1.02–1.32, respectively). Socio-economic factors are involved in oesophageal cancer in The Netherlands, as patients with a higher SES are more likely to have an adenocarcinoma and patients with a lower SES a squamous cell carcinoma. Moreover, the correlations between SES and different treatment modalities suggest that both patient and doctor determinants contribute to the decision on the most optimal treatment modality in patients with oesophageal cancer.