Multiple management modalities in esophageal cancer: epidemiology, presentation and progression, work-up, and surgical approaches

Oesophageal cancer awareness and anticipated time to help-seeking: results from a population-based survey

BACKGROUND

Modifying public awareness of oesophageal cancer symptoms might help to decrease late-stage diagnosis and, in turn, improve cancer outcomes. This study aimed to explore oesophageal cancer symptom awareness and determinants of lower awareness and anticipated time to help-seeking.

METHODS

We invited 18,156 individuals aged 18 to 75 years using random sampling of the nationwide Dutch population registry. A cross-sectional web-based survey containing items adapted from the Awareness and Beliefs about Cancer measure (i.e., cancer symptom awareness, anticipated time to presentation with dysphagia, health beliefs, and sociodemographic variables) was filled out by 3106 participants (response rate: 17%). Descriptive statistics were calculated and logistic regression analyses were performed to explore determinants of awareness and anticipated presentation (dichotomised as <1 month or ≥1 month).

RESULTS

The number of participants that recognised dysphagia as a potential symptom of cancer was low (47%) compared with symptoms of other cancer types (change in bowel habits: 77%; change of a mole: 93%; breast lump: 93%). In multivariable analyses, non-recognition of dysphagia was associated with male gender (OR 0.50, 95% CI 0.43-0.58), lower education (OR 0.44, 0.35-0.54), and non-western migration background (OR 0.43, 0.28-0.67). Anticipated delayed help-seeking for dysphagia was associated with not recognising it as possible cancer symptom (OR 1.58, 1.27-1.97), perceived high risk of oesophageal cancer (OR 2.20, 1.39-3.47), and negative beliefs about oesophageal cancer (OR 1.86, 1.20-2.87).

CONCLUSION

Our findings demonstrate a disconcertingly low public awareness of oesophageal cancer symptoms. Educational interventions targeting groups with decreased awareness and addressing negative cancer beliefs may lead to faster help-seeking behaviour, although additional studies are needed to determine the effect on clinical cancer outcomes.

The utility of a symptom model to predict the risk of oesophageal cancer

OBJECTIVE

To assess whether extra-oesophageal symptoms are predictive of oesophageal malignancy.

METHODS

A prospective, single-centre cross-sectional questionnaire study at a tertiary referral unit for oesophageal cancer using the Comprehensive Reflux Symptoms Scale (CReSS) questionnaire tool. Respondents with oesophageal malignancy were compared with historical cohorts undergoing airway examination or upper gastrointestinal endoscopy and found to have benign diagnoses. We developed a model for predicting oesophageal cancer using linear discriminant analysis and logistic regression, assessed by Monte Carlo cross validation.

RESULTS

Respondents with oesophageal malignancy (n = 146; mean age 70.5; male: female, 71:29) were compared with those undergoing airway examination (n = 177) and upper gastrointestinal endoscopy (n = 351), found to have benign diagnoses. No single questionnaire item, or group of co-varying items (factors), reliably discriminated oesophageal cancer from other diagnoses. Individual items which suggested higher risk of oesophageal malignancy included dysphagia (area under the curve (AUC) 0.68), low appetite (AUC 0.66), and early satiety (AUC 0.58). Conversely, throat pain (AUC 0.38), bloating (AUC 0.38) and heartburn (AUC 0.37) were inversely related to cancer risk. A forward stepwise regression analysis including a subset of 12 CReSS questionnaire items together with age and sex derived a model predictive of oesophageal malignancy in this cohort (AUC 0.89).

CONCLUSION

We demonstrate a model comprised of 12 questionnaire items and 2 demographic parameters as a potential predictive tool for oesophageal malignancy diagnosis in this study population. Translating this model for predicting oesophageal malignancy in the general population is a valuable topic for future research.

MET overexpression and intratumor heterogeneity in esophageal squamous cell carcinoma

Esophageal squamous cell carcinoma (ESCC) is among the ten most frequent and deadly cancers, without effective therapies for most patients. More recently, drugs targeting deregulated growth factor signaling receptors have been developed, such as HGF-MET targeted therapy. We assessed MET and HGF genetic alterations and gene and protein expression profiles in ESCC patients from the Brazilian National Cancer Institute and publicly available datasets, as well as the intratumor heterogeneity of the alterations found. Our analyses showed that HGF and MET genetic alterations, both copy number and mutations, are not common in ESCC, affecting 5 and 6% of the cases, respectively. HGF showed a variable mRNA expression profile between datasets, with no alterations (GSE20347), downregulation (GSE45670), and upregulation in ESCC (our dataset and GSE75241). On the other hand, MET was found consistently upregulated in ESCC compared to non-tumor surrounding tissue, with median fold-changes of 5.96 (GSE20347), 3.83 (GSE45670), 6.02 (GSE75241), and 5.0 (our dataset). Among our patients, 84% of the tumors showed at least a two-fold increase in MET expression. This observation was corroborated by protein levels, with 55% of cases exhibiting positivity in 100% of the tumor cells. Intratumor heterogeneity was evaluated in at least four tumor biopsies from five patients and two cases showed a consistent increase in MET expression (at least two-fold) in all tumor samples. Our data suggested that HGF-MET signaling pathway was likely to be overactivated in ESCC, representing a potential therapeutic target, but eligibility for this therapy should consider intratumor heterogeneity.

Long Noncoding RNA LINC00634 Functions as an Oncogene in Esophageal Squamous Cell Carcinoma Through the miR-342-3p/Bcl2L1 Axis

Many long noncoding RNAs reportedly have tumor suppressive roles or are oncogenic in esophageal cancer. We have previously performed a chip-based expression analysis of primary esophageal cancer tissues and found that the expression of LINC00634 in these tissues was higher than that in nontumor tissues. Quantitative real-time–polymerase chain reaction, cell counting kit-8, flow cytometry, caspase3/7 assay, dual-luciferase reporter assay, and restore assay were used to detect the proliferative and apoptotic effects of LINC00634 in esophageal cancer cells. The results showed that the expression of LINC00634 in these tissues was higher than that in nontumor tissues and associated with tumor–node–metastasis (TNM) stage of patients. Knockdown of LINC00634 decreased cell viability and increased cell apoptosis levels in EC9706 and EC1 cells. LINC00634 could target Bcl2L1 through miR-342-3p. In this study, we show that LINC00634 is upregulated in esophageal cancer. We also show that the knockdown of LINC00634 decreased cell viability and increased cell apoptosis levels in EC9706 and EC1 cells through the miR-342-3p/Bcl2L1 axis.

Intratumoral Metabolic Heterogeneity and Other Quantitative 18F-FDG PET/CT Parameters for Prognosis Prediction in Esophageal Cancer

PURPOSE

To evaluate the impact of intratumoral metabolic heterogeneity (IMH) and other quantitative fluorine 18 (¹⁸F) fluorodeoxyglucose (FDG) PET/CT parameters for predicting progression-free survival (PFS) and overall survival (OS) in patients with esophageal cancer.

MATERIALS AND METHODS

In this retrospective study, an automated gradient-based segmentation method was used to assess the maximum standardized uptake value, mean standardized uptake value, metabolic tumor volume (MTV), and IMH index of the primary tumor in patients with biopsy-proven adenocarcinoma or squamous cell carcinoma of the esophagus with an initial staging ¹⁸F-FDG PET/CT. Data were collected between July 2006 and February 2016. OS and PFS were calculated using multivariable Cox proportional hazards regression with the adjustment (as covariates) of age, sex, weight, stage, tumor type, tumor grade, and treatment. All PET parameters were standardized before analysis. Log-rank tests were performed, and corresponding Kaplan-Meier survival plots were generated.

RESULTS

A total of 71 patients (mean age, 64 years ± 10 [standard deviation], 62:9 men:women) were included. Median follow-up time was 28.2 months (range, 4-38 months), and median survival was 16.1 months (range, 0.1-60.3 months). Higher MTV was associated with reduced PFS for every standard deviation increase (hazard ratio [HR], 0.193; 95% CI: 0.052, 0.711; P = .01). Higher IMH was associated with reduced PFS for every standard deviation decrease in the area under the curve (HR, 10.78; 95% CI: 1.31, 88.96; P = .03).

CONCLUSION

PFS for patients with esophageal cancer was associated with MTV and with IMH.Keywords: Esophagus, Neoplasms-Primary, PET/CT, Tumor Response © RSNA, 2020.

Cellular molecular and proteomic profiling deciphers the SIRT1 controlled cell death pathways in esophageal adenocarcinoma cells

Worldwide prevalence of esophageal adenocarcinomas with high rates of mortality coupled with increased mutations in esophageal cells warrants investigation to understand deregulation of cell signaling pathways leading to cancer. To this end, the current study was undertaken to unravel the cell death signatures using the model human esophageal adenocarcinoma cell line-OE33. The strategy involved targeting the key epigenetic modulator SIRT1, a histone deacetylase by a small molecule inhibitor - sirtinol. Sirtinol induced a dose-dependent inhibition of cell viability under both normoxic and hypoxic conditions with long term impact on proliferation as shown by clonogenic assays. Signature apoptotic signaling pathways including caspase activation and decreased Bcl-2 were observed. Proteomic analysis highlighted an array of entities affected including molecules involved in replication, transcription, protein synthesis, cell division control, stress-related proteins, spliceosome components, protein processing and cell detoxification/degradation systems. Importantly, the stoichiometry of the fold changes of the affected proteins per se could govern the cell death phenotype by sirtinol. Sirtinol could also potentially curb resistant and recurrent tumors that reside in hypoxic environments. Overall, in addition to unraveling the cellular, molecular and proteomics basis of SIRT1 inhibition, the findings open up avenues for designing novel strategies against esophageal adenocarcinoma.

Anatomic distribution of supraclavicular lymph node in patients with esophageal cancer

PURPOSE

Definitive chemoradiation therapy remains the standard of care for patients with localized esophageal carcinoma who choose nonsurgical management. However, there is no consensus regarding delineation of the nodal clinical target volume (CTVn), especially for lower cervical lymph nodes. This study aimed to map the location of metastatic supraclavicular lymph nodes in thoracic esophageal carcinoma patients with supraclavicular node involvement and generate an atlas to delineate the CTVn for elective nodal radiation of esophageal squamous cell carcinoma.

PATIENTS AND METHODS

In this study, the supraclavicular regional lymph node was further divided into four subgroups. The locations of the involved supraclavicular nodes for all patients were then transferred onto a template computed tomography (CT) image. A volume probability map was then generated with nodal volumes, and was displayed on the template CT to provide a visual impression of nodal frequencies and anatomic distribution.

RESULTS

We identified 154 supraclavicular nodal metastases based on CT image in 96 patients. Of these, 29.2% were located in group I region, 59.7% in group II region, 10.4% in group III region, and 0.7% in group IV region.

CONCLUSION

On the basis of our study, we suggest that the appropriate radiation field of CTVn should include the group I and II regions and the CTVn exterior margin along the lateral side of the internal jugular vein may be suitable.

Involvement of microRNA-141-3p in 5-fluorouracil and oxaliplatin chemo-resistance in esophageal cancer cells via regulation of PTEN

microRNAs (miRNAs) act as a major regulator of acquired chemo-resistance in various types of cancer therapeutics. This study investigated the contribution of miRNAs in influencing multiple drug resistance in esophageal squamous cell carcinoma (ESCC). The sensitivity of four ESCC cell lines (EC109, EC9706, TE-1 and KYSE-150) to 5-fluorouracil (5-FU) and oxaliplatin (OX) was determined by MTT assay. A 5-FU and OX-resistant subline, EC9706R, was established by continuous exposure to stepwise increasing concentration of 5-FU and OX. Microarray technology was used to compare the differential expression of miRNAs between resistant cells and parental cells. Chemo-sensitivity assay was performed to evaluate drug response in EC9706R cells transfected with miRNA mimic or inhibitor. The direct targets of miRNA were identified by employing pathway analysis and then confirmed with luciferase assay. Sixty ESCC tissue samples and their paired adjacent normal tissues were collected to validate the expression of identified miRNA. Mouse models were further utilized to investigate the function of miRNA on acquired chemo-resistance. MicroRNA panel results indicated that a total of 12 miRNAs were differentially expressed and miR-141-3p was highly over expressed in resistant cells. Inhibition of miR-141-3p reversed acquired chemo-resistance in EC9706R cells by stimulating apoptosis. The expression of miR-141-3p was significantly increased in ESCC tissue samples compared to their matched distant normal tissues. In addition, the elevated miR-141-3p expression was found to be associated with ESCC differentiation status and TNM stage. Moreover, Phosphatase and tensin homolog (PTEN) was identified as direct target of miR-141-3p. Western blot exhibited altered protein levels of PTEN, Akt, and PI3k with miR-141-3p inhibitor. An inverse correlation between PTEN expression and miR-141-3p expression was also observed in tissue samples. EC9706R xenograft mouse model became sensitized to 5-FU and OX treatment following miR-141-3p inhibitor transfection in vivo. Our study demonstrated that miR-141-3p contributed to an acquired chemo-resistance through PTEN modulation both in vitro and in vivo.

Comparison of planning target volumes based on three-dimensional and four-dimensional CT imaging of thoracic esophageal cancer

Background and purpose

To investigate the definition of planning target volumes (PTVs) based on four-dimensional computed tomography (4DCT) compared with conventional PTV definition and PTV definition using asymmetrical margins for thoracic primary esophageal cancer.

Materials and methods

Forty-three patients with esophageal cancer underwent 3DCT and 4DCT simulation scans during free breathing. The motions of primary tumors located in the proximal (group A), middle (group B), and distal (group C) thoracic esophagus were obtained from the 4DCT scans. PTV_3D was defined on 3DCT using the tumor motion measured based on 4DCT, PTV conventional (PTV_conv) was defined on 3DCT by adding a 1.0 cm margin to the clinical target volume, and PTV_4D was defined as the union of the target volumes contoured on the ten phases of the 4DCT images. The centroid positions, volumetric differences, and dice similarity coefficients were evaluated for all PTVs.

Results

The median centroid shifts between PTV_3D and PTV_4D and between PTV_conv and PTV_4D in all three dimensions were <0.3 cm for the three groups. The median size ratios of PTV_4D to PTV_3D were 0.80, 0.88, and 0.71, and PTV_4D to PTV_conv were 0.67, 0.73, and 0.76 (χ²=−3.18, −2.98, and −3.06; P=0.001, 0.003, and 0.002) for groups A, B, and C, respectively. The dice similarity coefficients were 0.87, 0.90, and 0.81 between PTV_4D and PTV_3D and 0.80, 0.84, and 0.83 between PTV_4D and PTV_conv (χ² =−3.18, −2.98, and −3.06; P=0.001, 0.003, and 0.002) for groups A, B, and C, respectively. The difference between the degree of inclusion of PTV_4D in PTV_3D and that of PTV_4D in PTV_conv was <2% for all groups. Compared with PTV_conv, the amount of irradiated normal tissue for PTV_3D was decreased by 11.81% and 11.86% in groups A and B, respectively, but was increased by 2.93% in group C.

Conclusion

For proximal and middle esophageal cancer, 3DCT-based PTV using asymmetrical margins provides good coverage of PTV_4D; however, for distal esophageal cancer, 3DCT-based PTV using conventional margins provides ideal conformity with PTV_4D.

Clinical Research on Albumin-Bound Paclitaxel-Based Chemotherapy for Advanced Esophageal Cancer

BACKGROUND

To evaluate the efficacy and safety of albumin-bound paclitaxel-based chemotherapy in treatment for patients with advanced esophageal cancer who failed in first-line chemotherapy.

MATERIALS AND METHODS

We collected29 advanced esophageal cancer patients who received albumin-bound paclitaxel-based chemotherapy fromJune 2009 to September 2013, and the efficacy and safety of the compound were evaluated. These patients were treated with 100-150mg/m2 nab-paclitaxel on days 1,8.The cycle was repeated every 3 weeks. Clinical efficacy was evaluated every two cycles.

RESULTS

Of the 29 patients, two persons interrupted treatment because of adverse reactions, failed to evaluate efficacy effect. The rest of27 patients who could be evaluated for short-term response, 10 patients (37%) achieved partial response, 2 (7.4%) remained stable disease, and 15 (55.6%) had progressivedisease. The objective response rate was 37%, and the disease control rate was 44.4%.The median time to progression was 6.6 months.The major adverse reactions includedalopecia (62.07%), neutropenia (65.5%), gastrointestinalreaction (10.3%) andsensory neuropathy(6.8%).

CONCLUSIONS

The albumin-bound paclitaxel- based chemotherapy is efficacy and safety in treatment for patients with advanced esophageal cancer who failed in first-line chemotherapy.

Computed tomography-based distribution of involved lymph nodes in patients with upper esophageal cancer

BACKGROUND

Delineating the nodal clinical target volume (ctvn) remains a challenging task in patients with cervical or upper thoracic esophageal carcinoma (ec). In particular, the extent of the lymph area that should be included in the irradiation field remains controversial. In the present study, the extent of the ctvn was determined based on the incidence of lymph node involvement mapped by computed tomography (ct) imaging.

METHODS

Our study included 468 patients who were diagnosed with cervical and upper thoracic ec and who received staging information between June 2005 and April 2011. The anatomic distribution of metastatic regional lymph nodes was mapped using ct images and grouped using the levels established by the Radiation Therapy Oncology Group. The probability of the various groups being involved was examined. If a lymph node group had a probability of 10% or more of being involved, it was considered at high risk for metastasis, and elective treatment as part of the ctvn was recommended.

RESULTS

Lymph node involvement was mapped by ct in 256 patients (54.7%). Not all lymph node groups should be included in the ctvn. For cervical lesions, the involved lymph nodes were located mainly between the hyoid bone and the arcus aortae; the recommended ctvn should consist of the neck lymph nodes at levels iii and iv (supraclavicular group) and thoracic groups 2 and 3P. In upper thoracic ec patients, most of the involved lymph nodes were distributed between the cricoid cartilage and the subcarinal area; the ctvn should cover the supraclavicular group and thoracic nodal groups 2, 3P, 4, 5, and 7.

CONCLUSIONS

Our ct-based study indicates a specific distribution and incidence of metastatic lymph node groups in patients with cervical and upper thoracic ec. The results suggest that regional lymph node groups should be electively included in the ctvn for precise radiation administration.

Roles of neutrophil gelatinase-associated lipocalin (NGAL) in human cancer

Cancer remains one of the major cause of death in the Western world. Although, it has been demonstrated that new therapies can improve the outcome of cancer patients, still many patients relapse after treatment. Therefore, there is a need to identify novel factors involved in cancer development and/or progression. Recently, neutrophil gelatinase-associated lipocalin (NGAL) has been suggested as a key player in different cancer types. Its oncogenic effect may be related to the complex NGAL/MMP-9. In the present study, NGAL was analyzed at both transcript and protein levels in different cancer types by analysing 38 public available microarray datasets and the Human Protein Atlas tool.

NGAL transcripts were significantly higher in the majority of solid tumors compared to the relative normal tissues for every dataset analyzed. Furthermore, concordance of NGAL at both mRNA and protein levels was observed for 6 cancer types including bladder, colorectal, liver, lung, ovarian, and pancreatic. All metastatic tumors showed a decrease of NGAL expression when compared to matched primary lesions.

According to these results, NGAL is a candidate marker for tumor growth in a fraction of solid tumors. Further investigations are required to elucidate the function of NGAL in tumor development and metastatic processes.

Omentoplasty for oesophagogastrostomy after oesophagectomy

BACKGROUND

Oesophagectomy followed by oesophagogastrostomy is the preferred treatment for early-stage oesophageal cancer. It carries the risk of anastomotic leakage after oesophagogastric anastomosis, which causes considerable morbidity and mortality and is one of the most dangerous complications. Omentoplasty has been recommended by some researchers to prevent anastomotic leaks associated with oesophagogastrostomy. However, the value of omentoplasty for oesophagogastrostomy after oesophagectomy has not been systematically reviewed.

OBJECTIVES

To assess the effects of omentoplasty for oesophagogastrostomy after oesophagectomy in patients with oesophageal cancer.

SEARCH METHODS

A comprehensive search to identify eligible studies for inclusion was conducted using the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PubMed and other reliable resources.

SELECTION CRITERIA

Randomised controlled trials comparing omentoplasty versus no omentoplasty for oesophagogastrostomy after oesophagectomy in patients with oesophageal cancer were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors (Yong Yuan and Xiaoxi Zeng) independently assessed the quality of included studies and extracted data; disagreements were resolved through arbitration by another review author. Results of dichotomous outcomes were expressed as risk ratios (RRs) with 95% confidence intervals (CIs), and continuous outcomes were expressed as mean differences (MDs) with 95% CIs. Meta-analysis was performed when available data were sufficiently similar. Subgroup analysis was carried out on the basis of different approaches to surgery.

MAIN RESULTS

Three randomised controlled trials (633 participants) were included in this updated review. No significant differences in hospital mortality were noted between the study group (with omentoplasty) and the control group (without omentoplasty) (RR 1.28, 95% CI 0.49 to 3.39). None of the included studies reported differences in long-term survival between the two groups. The incidence of postoperative anastomotic leakage was significantly less among study participants treated with omentoplasty than among those treated without (RR 0.25, 95% CI 0.11 to 0.55), but the additional benefit was seen in the subgroup analysis only for participants undergoing a transhiatal oesophagogastrectomy (THE) procedure (RR 0.23, 95% CI 0.07 to 0.79); transthoracic oesophagogastrectomy (TTE) (RR 0.19, 95% CI 0.03 to 1.03); or three-field oesophagectomy (RR 0.33, 95% CI 0.09 to 1.19 ). Omentoplasty did not significantly improve other surgery-related complications, such as anastomotic stricture (RR 0.91, 95% CI 0.33 to 2.57). However, participants treated with omentoplasty could reduce the duration of hospitalisation compared with that seen in the control group (MD -2.13, 95% CI -3.57 to -0.69).

AUTHORS' CONCLUSIONS

Omentoplasty may provide additional benefit in decreasing the incidence of anastomotic leakage after oesophagectomy and oesophagogastrostomy for patients with oesophageal cancer without increasing or decreasing other complications, especially among those treated with THE. It also has the potential to reduce the duration of hospital stay after operation. Further randomised controlled trials are needed to investigate the influences of omentoplasty on the incidence of anastomotic leakage and anastomotic stricture, long-term survival, duration of hospital stay and quality of life after oesophagectomy and oesophagogastrostomy when different surgical approaches are used.

Combined chemotherapy plus endostar with sequential stereotactic radiotherapy as salvage treatment for recurrent esophageal cancer with severe dyspnea: A case report and review of the literature

For the majority of inoperable esophageal cancer cases, chemoradiotherapy is the most suitable treatment option. Cetuximab may provide certain benefits, however, this can be an expensive therapy. Additionally, stereotactic body radiation therapy (SBRT) is typically contraindicated for esophageal cancer due to the potential for esophageal perforation and stenosis. The use of combined chemotherapy plus endostar with sequential SBRT for the treatment of esophageal squamous cancer has not been reported. In the current study, the case of a 71-year-old female with esophageal squamous cancer diagnosed 2 years prior is presented. Surgery and four cycles of cisplatin plus 5-fluorouracil chemotherapy had been administered. The patient showed recurrence at the paratracheal lymph node, exhibited severe dyspnea (grade III) and required a semi-liquid diet. Four cycles of the docetaxel, 5-fluorouracil and nedaplatin regimen plus endostar (3 mg; days 1-14; intravenously) with sequential SBRT (3300 cGy in 10 fractions) was administered. Following treatment, the symptoms of the patient completely disappeared, and objective efficacy evaluation indicated complete remission. At the time of writing, the patient is living without discomfort and the progression-free survival is >8 months. In conclusion, the present case indicates that combined treatment of chemotherapy and endostar with sequential stereotactic radiotherapy is a safe and effective option for the management of esophageal cancer.

Omentoplasty for esophagogastrostomy after esophagectomy

BACKGROUND

Esophagectomy followed by esophagogastrostomy is the preferred treatment for early-stage esophageal cancer. It carries the risk of anastomotic leakage after esophagogastric anastomosis, which is one of the most dangerous complications and causes considerable morbidity and mortality. Omentoplasty was recommended in some studies to preventing anastomotic leaks associated with esophagogastrostomy. However, the value of omentoplasty for esophagogastrostomy after esophagectomy has not been systematically reviewed.

OBJECTIVES

To assess the effects of omentoplasty for esophagogastrostomy after esophagectomy in esophageal cancer patients.

SEARCH METHODS

A comprehensive search strategy was carried out to identify eligible studies for inclusion in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PubMed and other reliable resources.

SELECTION CRITERIA

Randomized controlled trials comparing omentoplasty with no omentoplasty for esophagogastrostomy after esophagectomy in esophageal cancer patients were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors (Yong Yuan and Xiaoxi Zeng) independently assessed the quality of included studies and extracted data, with disagreements resolved by arbitration by another review author. Results of dichotomous outcomes were expressed as risk ratios (RR) with 95% confidence intervals (CI), while continuous outcomes were expressed as mean differences (MD) with 95% CI. Meta-analysis was performed where the data available were sufficiently similar. Subgroup analysis was carried out based on different operation approaches.

MAIN RESULTS

Two randomized controlled trials (449 participants) were included in the review. There was no significant difference for hospital mortality between the study (with omentoplasty) and the control group (without omentoplasty) (RR 1.00; 95% CI 0.25 to 3.92). Neither of the included studies reported the difference of long-term survival between two groups. The incidence of postoperative anastomotic leakage was significantly lower in patients treated with omentoplasty than those without (RR 0.22; 95% CI 0.08 to 0.58); but the additional benefit only showed in patients receiving a transhiatal esophagogastrectomy (THE) procedure in subgroup analysis (THE: RR 0.23; 95% CI 0.07 to 0.79; transthoracic esophagogastrectomy (TTE): RR 0.19; 95% CI 0.03 to 1.03). Omentoplasty did not significantly improve other surgical-related complications, anastomotic strictures (RR 0.73; 95% CI 0.21 to 2.58) and duration of hospitalization (MD -2.70; 95% CI -6.01 to 0.61).

AUTHORS' CONCLUSIONS

Omentoplasty may provide an additional benefit to decrease the incidence of anastomotic leakage after esophagectomy and esophagogastrostomy for esophageal cancer patients without increasing or decreasing other complications, especially for those patients treated with THE. Further randomized controlled trials are still needed to investigate the influences of omentoplasty in different operation procedures of esophagectomy and esophagogastrostomy on the incidence of anastomotic leakage, anastomotic stricture, long-term survival rate and quality of life after esophagectomy and esophagogastrostomy.

How radical should surgery be for early esophageal cancer?

BACKGROUND

We have compared the oncologic effectiveness of limited resection (LR) techniques such as transhiatal (TH) or limited resection of the esophagogastric junction with intestinal interposition (LREGJ) in the treatment of early esophageal carcinoma with that of the extended resection such as the classical thoracoabdominal (TA) en bloc esophagectomy.

METHODS

We performed a retrospective analysis of prospectively collected data of 113 patients with T1 esophageal cancer (57 adeno- and 56 squamous cell carcinomas) who had surgical resection with systematic lymphadenectomy. Forty-one underwent extensive (TA) and 72 limited resection (51 TH and 21 LREGJ).

RESULTS

Complete resection (R0) was achieved in all cases. Lymphatic metastases were seen in none of the mucosal but in 26.8% of the submucosal T1 cancers. The median lymph node yield was significantly higher in patients with extensive resection (24 vs. 15 lymph nodes; p=0.036), but this did not affect the overall survival (median=88 vs. 102 months, 5-year survival probability=57.8 vs. 67.7%; log rank=0.578). The median hospital stay and ICU stay were significantly shorter in the LR group (p=0.039 and p = 0.044, respectively).

CONCLUSION

Limited resection leads to lower lymph node yield but similar oncologic effectiveness as the extensive surgery. It may represent a valuable alternative in the treatment of patients with early (submucosal) esophageal carcinoma.

Expression of immunoglobulin G in esophageal squamous cell carcinomas and its association with tumor grade and Ki67

We and other research groups have previously shown that various cancer types can express immunoglobulin G, but investigation on of immunoglobulin G expression in esophageal cancer, a highly malignant tumor, and its biological significance has been lacking. In this study, we examined immunoglobulin G protein and its messenger RNA, as well as the expressions of recombination-activating gene 1, recombination-activating gene 2, and activation-induced cytidine deaminase in 142 cases of esophageal cancer tissues, and 2 esophageal cancer cell lines (Eca109, SHEEC). We also compared their expressions with tumor grade and a proliferation marker, Ki67. We used immunohistochemistry, immunofluorescence, in situ hybridization, laser microdissection coupled with reverse transcriptase polymerase chain reaction, and Western blot analysis. We detected transcripts of immunoglobulin G 1 heavy-chain constant region, immunoglobulin-κ and λ-light chains, immunoglobulin G variable region, and recombination-activating genes 1 and 2 in both esophageal cancer tissues and cell lines, whereas activation-induced cytidine deaminase was not detected. No immunoglobulin G receptor subtypes were detected. Statistic analysis revealed that immunoglobulin G expression correlated well with tumor grades (P < .001) and with the proliferation marker Ki67 (P < .001). Our results indicate that human esophageal cancer cells are capable of synthesizing immunoglobulin G, which is likely involved in the growth and proliferation of this highly malignant cancer and might also be used as a prognostic indicator in esophageal squamous cell carcinomas.

POSSUM and its related models as predictors of postoperative mortality and morbidity in patients undergoing surgery for gastro-oesophageal cancer: a systematic review

BACKGROUND

Gastro-oesophageal surgery is associated with appreciable postoperative morbidity and mortality. POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity) and its related models P-POSSUM and O-POSSUM have been developed to predict such events in general surgery. The aim was to undertake the first systematic review of the use of these models in gastro-oesophageal surgery patients.

METHODS

An online database search was carried out from 1991 to December 2008.

RESULTS

Twenty-two published studies in gastro-oesophageal cancer surgery were identified. Twelve studies were found not to address the above aim, leaving ten relevant publications for analysis. Pooled data from these studies showed the weighted observed-to-expected ratio (O/E) for postoperative mortality using POSSUM (n = 1189), P-POSSUM (n = 2314), and O-POSSUM (n = 1755) was 0.37, 0.83, and 0.51, respectively. The weighted O/E for morbidity using POSSUM (n = 1038) was 0.86.

CONCLUSION

POSSUM and O-POSSUM most significantly overestimated postoperative mortality in gastro-oesophageal cancer patients. In contrast, P-POSSUM had the least overestimation and may be the most useful predictor of likely postoperative mortality in these patients.

Technological advances in radiotherapy for esophageal cancer

Radiotherapy with concurrent chemotherapy and surgery represent the main treatment modalities in esophageal cancer. The goal of modern radiotherapy approaches, based on recent technological advances, is to minimize post-treatment complications by improving the gross tumor volume definition (positron emission tomography-based planning), reducing interfraction motion (image-guided radiotherapy) and intrafraction motion (respiratory-gated radiotherapy), and by better dose delivery to the precisely defined planning target volume (intensity-modulated radiotherapy and proton therapy). Reduction of radiotherapy-related toxicity is fundamental to the improvement of clinical results in esophageal cancer, although the dose escalation concept is controversial.

The use of self-expanding metallic stents (SEMS) is effective in symptom palliation from recurrent tumor after esophagogastrectomy for cancer

The efficacy of using self-expanding metallic stent (SEMS) for palliation of symptoms because of tumor recurrence after prior esophagogastrectomy has not been properly assessed despite the well recognized use of SEMS in patients without prior surgery. The aim of this study is to evaluate the efficacy and safety of using SEMS in patients who had prior esophagogastrectomy. The study group included 35 patients with carcinoma of esophagus or cardia documented to have loco-regional recurrence after esophagogastrectomy and in whom SEMS were placed for palliation. The median age was 67 (ranged 41-85). The indications for stenting were dysphagia caused by recurrence at the esophageal anastomosis (n= 4) and in the esophageal remnant (n= 5), or extrinsic compression from mediastinal nodal disease (n= 7); gastric outlet obstruction produced by extrinsic tumor compression (n= 13); and tracheo-esophageal fistulae (n= 6). Forty-three stenting procedures were performed, and the technical success rate was 97.6%. The dysphagia score improved from 4.66 to 2.54 (P < 0.001). All patients with tracheo-esophageal fistula had their symptoms successfully palliated. The immediate complication rate was 14% (n= 5); two patients had stent malpositioning, two had inadequate opening of their stents, and one had a failed stenting procedure. On follow-up, 15 (42.8%) patients required a total of 22 re-intervention procedures for various reasons: endoscopic dilatation (five dilatations in three patients), removal of foreign bodies (nine procedures in four patients), and insertion of a second SEMS related to tumor growth (eight stents in eight patients). There was no procedure-related mortality. The median survival was short at 42 days (range 5-290 days), mostly related to advanced disease stage. SEMS in patients with recurrent tumor after esophagogastrectomy is safe and effective.

Radical treatment for oesophageal cancer patients unfit for surgery and chemotherapy. A 10-year experience from the Norwegian Radium Hospital

BACKGROUND

Over a 10-year period from 1990, 445 patients with carcinoma of the oesophagus were admitted to the Norwegian Radium Hospital and 184 of these patients received treatment with curative intent. Even though surgery is the treatment of choice for these patients, many of them suffer from medical conditions that increase the risk for postoperative mortality and morbidity. In a retrospective study, the effect of the curative treatment offered to patients was explored with a particular focus on patients unfit for surgery.

METHODS

Medical data of the 184 patients treated with curative intent were reviewed and additional clinical information was retrieved from local hospitals and general practitioners. Preoperative radiotherapy followed by surgery was the standard curative treatment for operable patients. Medically inoperable patients were offered radical split-course hyperfractionated radiotherapy followed by a brachytherapy boost.

RESULTS

More than 50% (103/184) received non-surgical treatment only. Patients who received radical surgery (n = 81) were younger, had better performance status, less weight loss and dysphagia compared to patients treated with radical radiotherapy (n = 102). One patient received only photodynamic therapy. The 3-year survival was 29% for patients treated with radical surgery, and 8% for patients who received radical radiotherapy. The overall median crude survival for the two groups of patients were 20 months and seven months respectively.

CONCLUSION

The hyperfractionated radiotherapy provided symptom relief without extensive toxicity and with a possibility for cure for patients with oesophageal cancer who are unfit for surgery and chemoradiotherapy. The literature supports the curative potential of high dose accelerated hyperfractionated radiotherapy even though the optimal radiotherapy regimen still needs to be explored.

Predicting response to treatment in gastroesophageal junction adenocarcinomas: combining clinical, imaging, and molecular biomarkers

The incidence of adenocarcinomas of the gastroesophageal junction (GEJ) is rapidly rising, and even in early-stage locoregional confined disease the 5-year survival rate rarely exceeds 25%-35%. Randomized trials and meta-analyses have demonstrated a benefit with neoadjuvant or perioperative chemotherapy and with neoadjuvant chemoradiotherapy. However, the optimal approach in individual patients is not clear and remains controversial. A consistent finding is that patients who have a histopathological response to neoadjuvant therapy are more likely to receive a survival benefit. These clinical data provide a strong argument for the urgent development of methods to predict histopathological response to neoadjuvant therapies for GEJ adenocarcinoma. Published data demonstrate that clinicopathological features (tumor location), imaging (fluorodeoxyglucose-positron emission tomography "metabolic response"), and tissue/molecular biomarkers may all have a predictive value for neoadjuvant therapies. However, it is uncertain from published data whether or not they will be useful for clinical decision making in individual patients. Existing candidate biomarkers need to be properly qualified and validated and novel biomarkers are required; and an optimal approach should involve the combination and integration of clinical, imaging, and molecular biomarkers. This review presents the evidence base and discusses novel experimental approaches for the combination of biomarker modalities to allow optimization of an individualized treatment approach in GEJ adenocarcinoma patients that may be relevant to other tumor types as well.

[CD-34 and CASPASE-3 biomarkers expression in esophageal epidermoid carcinoma]

OBJECTIVES

To analyze by cytophotometry study the expression of CD-34 angiogenesis and caspase-3 apoptosis markers in the esophagus squamous cell carcinoma and to correlate markers themselves.

METHODS

Twenty-nine esophageal squamous cell carcinoma specimens were submitted to immunohystochemical analysis, based on label index of CD-34 and caspase-3 antibodies, using cytophotometry computer system. Variables considered in the correlation analysis were biomarkers expression quantification, patient age, lesion size, and TNM classification system.

RESULTS

Index label median value for CD-34 was 72,6% and for caspase-3 represented 96,5%. Statistical significant correlation was not demonstrated between the respective biomarkers and lesion size (p=0,96) or patient age (p=0,95). There was a slightly tendency to a positive correlation between CD-34 index label and TNM classification system (p=0,11). Although presenting a higher index label than CD-34 marker (p=0,007), caspase-3 did not show any relationship with the studied variables (p>0,19). The correlation between CD-34 and caspase-3 presented a small positive tendency (r=0,09 and p=0,65).

CONCLUSION

Both studied biomarkers showed good expression in esophageal squamous cell carcinoma, whereas CD-34 marker presented lower expression than caspase-3 in this specific tumor. The respective biomarkers do not demonstrate any correlation between themselves.

Esophagectomy for the treatment of esophageal cancer

Esophageal cancer is an aggressive disease with an overall poor prognosis. Esophagectomy remains a key therapeutic option in treating patients who have this disease. Tailoring the surgical approach to the patient and the nature of his or her malignancy is essential. Over time, advances in staging, preoperative assessment, operative techniques, and postoperative care have resulted in decreased operative mortality and better long-term outcomes.

Clinicopathological features and prognosis of esophageal cancer in young patients. Is there a difference in outcome?

The aim of this study was to define the clinicopathological features and prognosis of esophageal cancer in patients 40 years and younger. Between 1990 and 2007, 549 patients with esophageal cancer were enrolled in a retrospective database. Patients were divided into two age groups: Group A was under 40 years old, and group B over 40 years old. The findings for 50 patients (9.1%) aged 40 years or less were compared with those of 499 patients over 40 years old. In the younger group, there were significantly more women (35/15 vs. 231/268, P < 0.001). In the young and old groups, the most frequent histological morphology was squamous cell carcinoma (88% and 75%, respectively), although the percentages were significantly different (P < 0.005). In the younger group, lesions were more frequently located in the middle one-third of the esophagus than in the older group (64% vs. 28.3%, P < 0.001). Group A was more likely to have Stage IIa than older patients. In both groups, the surgical removal of the tumor was the most frequently used choice (70% vs. 56.5%). Survival rates in younger patients at 5 years after resection were 11.4%, similar to those in older patients (16.9%, difference not significant). In the group under age 40, women predominated. Squamous cell carcinoma was the most common histology, followed by adenocarcinoma. Younger patients did not have improved 5-year survival compared with their older counterparts.

Endoscopic OCT with forward-looking probe: clinical studies in urology and gastroenterology

In the current paper we present results of application of endoscopic time-domain OCT (EOCT) with lateral scanning by forward looking miniprobe. We analysed material of clinical studies of 554 patients: 164 patients with urinary bladder pathology, and 390 with gastrointestinal tract pathology. We reviewed the materials obtained in different clinics using the OCT device elaborated at the Institute of Applied Physics. We demonstrate results of EOCT application in detection of early cancer and surgery guidance, examples of combined use of OCT and fluorescence imaging. As a result, we show the diagnostic accuracy of EOCT in specific clinical tasks. The sensitivity of EOCT cancer determination in Barrett's esophagus is from 71% to 85% at different stages of neoplasia with specificity 68% for all stages. As for bladder carcinoma, the sensitivity and specificity are 85% and 68%, respectively. In colon dysplasia EOST demonstrates high efficacy: sensitivity 92% and specificity 84%.

Barrett's esophagus: incidence and prevalence estimates in a rural Mid-Western population

BACKGROUND AND AIMS

Barrett's esophagus (BE) predisposes to adenocarcinoma of the esophagus and survival in esophageal adenocarcinoma is low. We studied patients diagnosed with BE in the Marshfield Epidemiologic Study Area (MESA). Our objectives were to estimate the prevalence of diagnosed BE, estimate the annual incidence of initial diagnosis of BE, and characterize the demographics of patients diagnosed with BE.

METHODS

We retrospectively reviewed medical records of patients diagnosed with BE until December 31, 2002. The esophagogastroduodenoscopy (EGD) reports were reviewed to establish the presence of columnar epithelium. All slides were retrieved and reviewed by a gastrointestinal pathologist to establish the presence of intestinal metaplasia and dysplasia. Chart abstraction was conducted using a standardized form.

RESULTS

BE was histologically confirmed in 216 patients. All were white, 165 (76%) were male, and 81% had a hiatal hernia. Median age at diagnosis was 65.5 yr (range 17-94). Long-segment BE (LSBE) was present in 112 (51.9%) patients. The prevalence of histologically confirmed BE in MESA was 261.8 (95% CI 222.5-301.1) per 100,000 people. The incidence of an initial diagnosis of BE between 1996 and 2002 was 32.7 per 100,000 person-years (95% CI 27.1-38.2) and did not change significantly over the study period despite an increase in EGD rates. At the initial diagnosis, 41.7% of the patients were on proton pump inhibitors. Dysplasia was present in 24.5% of patients.

CONCLUSION

The incidence of initial diagnosis of BE in a stable white population did not change significantly over a 7-yr period, despite an increase in EGD rates.

Psychiatric illness delays diagnosis of esophageal cancer

Evidence suggests that patients with psychiatric illnesses may be more likely to experience a delay in diagnosis of coexisting cancer. The association between psychiatric illness and timely diagnosis and survival in patients with esophageal cancer has not been studied. The specific aim of this retrospective cohort study was to determine the impact of coexisting psychiatric illness on time to diagnosis, disease stage and survival in patients with esophageal cancer. All patients with a diagnosis of esophageal cancer between 1989 and 2003 at the Portland Veteran's Administration hospital were identified by ICD-9 code. One hundred and sixty patients were identified: 52 patients had one or more DSM-IV diagnoses, and 108 patients had no DSM-IV diagnosis. Electronic charts were reviewed beginning from the first recorded encounter for all patients and clinical and demographic data were collected. The association between psychiatric illness and time to diagnosis of esophageal cancer and survival was studied using Cox proportional hazard models. Groups were similar in age, ethnicity, body mass index, and history of tobacco and alcohol use. Psychiatric illness was associated with delayed diagnosis (median time from alarm symptoms to diagnosis 90 days vs. 35 days in patients with and without psychiatric illness, respectively, P < 0.001) and the presence of advanced disease at the time of diagnosis (37% vs. 18% of patients with and without psychiatric illness, respectively, P= 0.009). In multivariate analysis, psychiatric illness and depression were independent predictors for delayed diagnosis (hazard ratios 0.605 and 0.622, respectively, hazard ratio < 1 indicating longer time to diagnosis). Dementia was an independent risk factor for worse survival (hazard ratio 2.984). Finally, psychiatric illness was associated with a decreased likelihood of receiving surgical therapy. Psychiatric illness is a risk factor for delayed diagnosis, a diagnosis of advanced cancer, and a lower likelihood of receiving surgical therapy in patients with esophageal cancer. Dementia is associated with worse survival in these patients. These findings emphasize the importance of prompt evaluation of foregut symptoms in patients with psychiatric illness.

Multidetector CT in patients with esophageal stent as a palliative treatment for stenosing esophageal cancer: a feasibility study

OBJECTIVE

The self-expanding metallic stent (SEMS) is widely used in the palliative treatment of stenosing esophageal cancer. Multidetector computed tomography (MDCT) allows volumetric investigation including virtual endoscopy. The aim of this study was to determine the feasibility of MDCT follow-up of esophageal SEMS and to describe the imaging patterns encountered as well as correlating them with fibroscopic evaluation.

MATERIAL AND METHODS

Thirteen consecutive patients (10 M, mean age 64 years) with esophageal SEMS as a palliative treatment underwent MDCT for recurrent dysphagia (n =7), chest pain and fever (n = 1) or follow-up without symptoms (n = 5). Patency and esophageal wall patterns were studied and compared with diagnosis by fibroscopy.

RESULTS

No metallic artefact related to the SEMS was observed. At the SEMS level, MDCT revealed a tissular lump (n = 1), a thin recurrent layer of tissue (n = 1), extrinsic compression (n = 1), fluid stasis (n =7) and intussusception of the gastric wall into the SEMS (n =4). The esophageal wall was analyzed by MDCT (peripheral thickening around the stent (n = 8), tumor overgrowth under or above the SEMS level (n = 8)) and showed tracheal compression (n = 3). At the level of the SEMS, fibroscopy showed tumor recurrence (n = 2), a thin recurrent layer of tissue (n = 1), a distorted SEMS (n = 1) and a tumor overgrowth under or above the SEMS level (n = 6). In comparison with fibroscopy, MDCT satisfactorily diagnosed the SEMS patency in 92% of cases and the esophageal wall in 73%.

CONCLUSIONS

Morphology, patency of the SEMS and analysis of the esophageal wall can be performed by MDCT with a good degree of accuracy as compared to fibroscopy. In such patients in palliative care, a non-invasive investigation is worth promoting as a first-line procedure.

Comparison of P-POSSUM and O-POSSUM in predicting mortality after oesophagogastric resections

BACKGROUND

P-POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and morbidity) predicts mortality and morbidity in general surgical patients providing an adjunct to surgical audit. O-POSSUM was designed specifically to predict mortality and morbidity in patients undergoing oesophagogastric surgery.

AIM

To compare P-POSSUM and O-POSSUM in predicting surgical mortality in patients undergoing elective oesophagogastric cancer resections.

METHODS

Elective oesophagogastric cancer resections in a district general hospital from 1990 to 2002 were scored by P-POSSUM and O-POSSUM methods. Observed mortality rates were compared to predicted mortality rates in six risk groups for each model using the Hosmer-Lemeshow goodness-of-fit test. The power to discriminate between patients who died and those who survived was assessed using the area under the receiver-operator characteristic (ROC) curve.

RESULTS

313 patients underwent oesophagogastric resections. 32 died within 30 days (10.2%). P-POSSUM predicted 36 deaths (chi2 = 15.19, df = 6, p = 0.019, Hosmer-Lemeshow goodness-of-fit test), giving a standardised mortality ratio (SMR) of 0.89. O-POSSUM predicted 49 deaths (chi2 = 16.51, df = 6, p = 0.011), giving an SMR of 0.65. The area under the ROC curve was 0.68 (95% confidence interval 0.59 to 0.76) for P-POSSUM and 0.61 (95% confidence interval 0.50 to 0.72) for O-POSSUM.

CONCLUSION

Neither model accurately predicted the risk of postoperative death. P-POSSUM provided a better fit to observed results than O-POSSUM, which overpredicted total mortality. P-POSSUM also had superior discriminatory power.

Upregulation of neutrophil gelatinase-associated lipocalin in oesophageal squamous cell carcinoma: significant correlation with cell differentiation and tumour invasion

BACKGROUND

Neutrophil gelatinase-associated lipocalin (NGAL) is a member of the lipocalin family. Recently, an elevated NGAL expression was reported in several types of cancers. However, the characteristics of NGAL expression in oesophageal squamous cell carcinoma (ESCC) are still unknown.

AIM

To demonstrate the role of NGAL in ESCC.

METHODS

NGAL expression in 81 paraffin sections, including ESCC, normal mucosa, simple hyperplasia and dysplasia, and in 73 fresh specimens of ESCC was analysed by immunohistochemistry, western blot and gelatin zymography.

RESULTS

On immunohistochemical study, ESCC showed a diverse staining pattern for NGAL. However, only a weak positive signal was present within a restricted cytoplasmic area in the normal oesophageal epithelium. In dysplasia, altered NGAL expression could also be observed. On western blot study, NGAL expression level was found to be significantly higher in ESCC than in normal mucosa (p=0.030), and to be positively correlated with cell differentiation. However, no significant association was observed between NGAL expression and cell proliferation. In addition, the enzymic activity of the NGAL/matrix metalloproteinase 9 complex was much higher in ESCC than in normal mucosa, and was significantly correlated with the depth of tumour invasion in zymography analysis (p=0.006).

CONCLUSIONS

The findings suggest that NGAL is involved in the differentiation pathway and invasive progression of ESCC.

pRB expression in esophageal mucosa of individuals at high risk for squamous cell carcinoma of the esophagus

AIM: To investigate the pRb expression in a large group of patients with history of chronic exposure to the main risk factors for development of squamous cell carcinoma of the esophagus.

METHODS: One hundred and seventy asympto-matic individuals at high risk for esophageal squamous cell carcinoma (consumption of more than 80 g of ethanol and 10 cigarettes/d for at least 10 years) underwent upper gastrointestinal endoscopy with biopsies of the esophageal mucosa. As a control group, specimens of esophageal mucosa obtained from 20 healthy subjects were also studied. Immunohistochemical assessment of the tissues was performed using a monoclonal antibody anti-pRB protein.

RESULTS: Absence of the pRB staining, indicating loss of RB function, was observed in 33 (19.4%) of the individuals at risk for esophageal cancer, but in none of the healthy controls (P < 0.02). Loss of pRb expression increased in a stepwise fashion according to the severity of the histological findings (P < 0.005): normal mucosa (11/97 or 11.3%), chronic esophagitis (17/60 or 28.3%), low-grade dysplasia (3/10 or 30%), high-grade dysplasia 1/2 or 50%) and squamous cell carcinoma (1/1 or 100%).

CONCLUSION: Our findings suggest that abnormal expression of the pRB protein may be implicated in the process of esophageal carcinogenesis. Additional studies are warranted to define the role of the pRB protein as a biomarker for development of esophageal squamous cell carcinoma in individuals at high risk for this malignancy.

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.

Palliative treatment of esophageal carcinoma with self-expanding plastic stents: a report on 69 cases

OBJECTIVES

The use of self-expandable plastic stents has offered a reasonable alternative of self-expandable metal stents in palliative treatment of esophageal malignancies, in the recent years. Studies and clinical data on the use of self-expandable plastic stents in esophageal cancer are, however, available in a very limited number. Here, we present the results of our 3-year study designed to evaluate the efficacy of self-expandable plastic stents in palliation of advanced esophageal carcinoma.

PATIENTS AND METHODS

Between January 2001 and February 2004, 69 patients with advanced nonoperable esophageal cancer were enrolled in the study and followed up until their death, after insertion of Polyflex self-expandable plastic stents. Dysphagia scores, Karnofsky indices and body weights were determined and compared in order to evaluate the effect of the stent insertion on general status and well-being of the patients.

RESULTS

Insertion of Polyflex self-expandable plastic stents and covered self-expandable metal stents was performed in 66 cases and in eight cases, respectively; in certain patients, owing to complications, more than one stent had to be inserted. In all cases, the insertion of stents has been performed without major complication and it has led to an instant improvement in swallowing and dysphagia scores. The rates of tumoral overgrowth and of stent migration were low. The mean follow-up time of our patients was 129 days (10-312 days).

CONCLUSION

In concordance with previous studies, according to our results, the use of self-expandable plastic stents in palliation of esophageal cancer seems to be safe and effective in improving the quality of life of these patients.

Squamous cell carcinoma-antigen messenger RNA level in peripheral blood predicts recurrence after resection in patients with esophageal squamous cell carcinoma

BACKGROUND

The aim of this study was to clarify whether preoperative squamous cell carcinoma-antigen messenger RNA (SCC-Ag mRNA) level in peripheral blood can be used to predict tumor recurrence after curative resection for esophageal squamous cell carcinoma.

METHODS

A prospective analysis was conducted for 46 consecutive patients who underwent curative esophagectomy and who had no residual tumor. The SCC-Ag mRNA level in the peripheral blood of each patient was measured preoperatively by using quantitative reverse transcriptase-polymerase chain reaction. Median follow-up period was 34 months.

RESULTS

Receiver operating characteristic analysis demonstrated that the optimal cutoff level of SCC-Ag mRNA was 40. Patients were divided into the high SCC-Ag mRNA level group (n = 14) and the low SCC-Ag mRNA level group (n = 32). The cumulative probabilities of tumor recurrence were higher in the high SCC-Ag mRNA level group (probability of recurrence was 71% at 2 years) than in the low group (22% at 2 years; P = .0005). SCC-Ag mRNA level (relative risk, 3.00; 95% confidence interval, 1.05-8.54; P = .040) was the strongest independent predictor of recurrence by multivariate analysis.

CONCLUSIONS

Preoperative SCC-Ag mRNA levels in the peripheral blood are the best predictive factor for recurrence in patients with esophageal squamous cell carcinoma who undergo curative resection (R0).

Targeting the epidermal growth factor receptor by erlotinib (Tarceva) for the treatment of esophageal cancer

Esophageal cancer is the sixth most common cause of cancer-related death worldwide. Because of very poor 5-year survival new therapeutic approaches are mandatory. Erlotinib (Tarceva), an inhibitor of epidermal growth factor receptor tyrosine kinase (EGFR-TK), potently suppresses the growth of various tumors but its effect on esophageal carcinoma, known to express EGFR, remains unexplored. We therefore studied the antineoplastic potency of erlotinib in human esophageal cancer cells. Erlotinib induced growth inhibition of the human esophageal squamous cell carcinoma (ESCC) cell lines Kyse-30, Kyse-70 and Kyse-140, and the esophageal adenocarcinoma cell line OE-33, as well as of primary cell cultures of human esophageal cancers. Combining erlotinib with the EGFR-receptor antibody cetuximab, the insulin-like growth factor receptor tyrosine kinase inhibitor tyrphostin AG1024, or the 3-hydroxy-3-methylglutaryl coenzyme. A reductase (HMG-CoAR) inhibitor fluvastatin resulted in additive or even synergistic antiproliferative effects. Erlotinib induced cell cycle arrest at the G1/S checkpoint. The erlotinib-mediated signaling involved the inactivation of EGFR-TK and ERK1/2, the upregulation of the cyclin-dependent kinase inhibitors p21(Waf1/CIP1) and p27(Kip1), and the downregulation of the cell cycle promoter cyclin D1. However, erlotinib did not induce immediate cytotoxicity or apoptosis in esophageal cancer cells. The inhibition of EGFR-TK by erlotinib appears to be a promising novel approach for innovative treatment strategies of esophageal cancer, as it powerfully induced growth inhibition and cell cycle arrest in human esophageal cancer cells and enhanced the antineoplastic effects of other targeted agents.

Minimally invasive treatment of esophageal cancer: laparoscopic staging to robotic esophagectomy

Minimally invasive surgical (MIS) procedures have become commonplace in modern surgical practice. The term minimally invasive surgery has been and continues to be interchangeably applied to describe laparoscopic, laparoscopic-assisted, thoracoscopic, and telesurgical (robotic) procedures. Minimally invasive surgical procedures for the treatment of benign and malignant disorders of the esophagus are being developed, refined, and clinically applied in parallel with the exponential availability of novel technologies and instrumentation. Herein, we review the progression from laparoscopic/thoracoscopic esophagectomy to telesurgical esophagectomy, presently termed minimally invasive esophagectomy, and describe the telesurgical procedure as well as early the clinical outcome experience.

The emerging role of endoscopic ultrasonography in cancer staging

The management of solid organ cancers relies on accurate staging. Once distal metastasis has been excluded by conventional radiographic methods, local staging of the tumor and its nodal involvement is essential to determine the most optimal therapeutic approach. Many radiographic imaging modalities are unable to determine subtle tumor involvement. However, the emergence of endoscopic ultrasonography (EUS) has given promise to improved staging with its unique ability to examine tumors from within the gastrointestinal lumen with extremely close proximity. An additional advantage is the ability to perform fine-needle aspiration (FNA) biopsy to confirm or exclude tumor involvement. Many studies have shown superior accuracy in staging with EUS and EUS-FNA for tumors of the esophagus, stomach, pancreas, rectum, and mediastinum, including lung cancer. This review illustrates the principles of EUS and its role in staging of a variety of cancers and particularly its role alongside other imaging modalities.

Induction of apoptosis of lung and esophageal cancer cells treated with the combination of histone deacetylase inhibitor (trichostatin A) and protein kinase C inhibitor (calphostin C)

OBJECTIVE

Histone deacetylase inhibitors mediate a potent growth-inhibitory effect in cancer cells through induction of cell-cycle arrest and apoptosis. Moreover, these agents significantly induce transcriptional activation of nuclear factor kappaB, as well as p21 regulated by protein kinase C, and are thought to negatively influence the ability of histone deacetylase inhibitor to effectively mediate apoptosis. This study aimed to evaluate the effect of calphostin C (a protein kinase C inhibitor) on trichostatin A (a histone deacetylase inhibitor)-mediated upregulation of nuclear factor kappaB and p21 promotor transcriptional activity, as well as induction of apoptosis in lung and esophageal cancer cells.

METHODS

Cultured lung and esophageal cancer cells were treated with calphostin C and trichostatin A. Nuclear factor kappaB transcriptional activity was quantitated by using the nuclear factor kappaB-luciferase assay. Transcription of p21 gene and p21 protein levels was evaluated by using the p21 promoter-luciferase assay and the p21 enzyme-linked immunoassay, respectively. Apoptosis was evaluated by using the terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling-based ApoBrdU assay. Levels of expression of nuclear factor kappaB-dependent antiapoptotic and proapoptotic proteins were evaluated by means of Western blotting.

RESULTS

Exposure of lung or esophageal cancer cells to trichostatin A resulted in a dose- and cell-dependent 2-fold to greater than 20-fold increase of nuclear factor kappaB and p21 transcriptional activity. Treatment with trichostatin A and calphostin C led to a 50% to 90% decrease of trichostatin A- mediated upregulation of nuclear factor kappaB and p21 activation. Inhibition of nuclear factor kappaB activity resulted in significant reduction (30% to >99%) of trichostatin A- mediated activation of not only nuclear factor kappaB transcription but also p21 promotor activity. Importantly, 90% to 96% of thoracic cancer cells under-went apoptosis after exposure to the combination of trichostatin A plus calphostin C.

CONCLUSION

Inhibition of protein kinase C abrogates trichostatin A-mediated upregulation of nuclear factor kappaB transcriptional activity and p21 expression that is associated with profound induction of apoptosis in lung or esophageal cancer cells. Protein kinase C might be a novel target for enhancing the efficacy of histone deacetylase inhibitor in cancer therapy.

Multiple Management Modalities in Esophageal Cancer: Combined Modality Management Approaches

The overall success rate nationally in treating esophageal carcinomas remains poor, with over 90% of patients succumbing to the disease. In part I of this two-part series, we explored epidemiology, presentation and progression, work-up, and surgical approaches. In part II, we explore the promising suggestions of integrating chemotherapy and radiation therapy into the multimodal management of esophageal cancers. Alternative approaches to resection alone have been sought because of the overall poor survival rates of esophageal cancer patients, with failures occurring both local-regionally and distantly. Concomitant chemotherapy and radiation therapy (XRT) have been shown, by randomized trial, to be more effective than XRT alone in treating unresectable esophageal cancers and also have shown promise as a neoadjuvant treatment when combined with surgery in the multimodal treatment of this disease. Various studies have also addressed issues such as preoperative chemotherapy, radiation dose escalation, chemotherapy/XRT as a definitive treatment versus use as a surgical adjuvant, and alternative chemotherapy regimens. There are suggestions of some progress, but this remains a difficult problem area in which management is continuing to evolve.