Carcinoma of the gastroesophageal junction in Chinese patients

Radiomics in esophagogastric junction cancer: A scoping review of current status and advances

PURPOSE

This scoping review aimed to understand the advances in radiomics in esophagogastric junction (EGJ) cancer and assess the current status of radiomics in EGJ cancer.

METHODS

We conducted systematic searches of PubMed, Embase, and Web of Science databases from January 18, 2012, to January 15, 2023, to identify radiomics articles related to EGJ cancer. Two researchers independently screened the literature, extracted data, and assessed the quality of the studies using the Radiomics Quality Score (RQS) and the METhodological RadiomICs Score (METRICS) tool, respectively.

RESULTS

A total of 120 articles were retrieved from the three databases, and after screening, only six papers met the inclusion criteria. These studies investigated the role of radiomics in differentiating adenocarcinoma from squamous carcinoma, diagnosing T-stage, evaluating HER2 overexpression, predicting response to neoadjuvant therapy, and prognosis in EGJ cancer. The median score percentage of RQS was 34.7% (range from 22.2% to 38.9%). The median score percentage of METRICS was 71.2% (range from 58.2% to 84.9%).

CONCLUSION

Although there is a considerable difference between the RQS and METRICS scores of the included literature, we believe that the research value of radiomics in EGJ cancer has been revealed. In the future, while actively exploring more diagnostic, prognostic, and biological correlation studies in EGJ cancer, greater emphasis should be placed on the standardization and clinical application of radiomics.

Dual-layer dual-energy CT for improving differential diagnosis of squamous cell carcinoma from adenocarcinoma at gastroesophageal junction

Objective

To examine the clinical values of dual-energy CT parameters derived from dual-layer spectral detector CT (SDCT) in the differential diagnosis of squamous cell carcinoma (SCC) and adenocarcinoma (AC) of the gastroesophageal junction (GEJ).

Methods

Totally 66 patients with SCC and AC of the GEJ confirmed by pathological analysis were retrospectively enrolled, and underwent dual-phase contrast-enhancement chest CT with SDCT. Plain CT value, CT attenuation enhancement (△CT), iodine concentration (IC), spectral slope (λHU), effective atomic number (Zeff) and 40keV CT value (CT40keV) of the lesion in the arterial phase (AP) and venous phase (VP) were assessed. Multivariate logistic regression analysis was performed to evaluate the diagnostic efficacies of different combinations of dual-energy CT parameters. Receiver operating characteristic (ROC) curves were used to analyze the accuracy of dual-energy CT parameters and Delong test was used to compare AUCs.

Results

IC, λHU, Zeff and CT40keV in AP and VP and △CT in VP were significantly higher in the AC group than those in the SCC group (all P<0.05). ROC curve analysis showed that IC, λHU, Zeff and CT40keV in VP had high diagnostic performances, with AUCs of 0.74, 0.74, 0.79 and 0.78, respectively. Logistic regression showed the combination of ICVP, λHU VP, CT40keV VP and Zeff VP had the highest AUC (0.84), with a threshold of 0.40, sensitivity and specificity in distinguishing SCC and AC were 93.1% and 73.0%, respectively. Delong test showed that the AUC of △CTVP was lower than other AUCs of dual-energy CT parameters.

Conclusion

Dual-energy CT parameters derived from SDCT provide added value in the differential diagnosis of SCC and AC of the GEJ, especially the combination of IC, λHU, CT40keV and Zeff in VP.

Advances in knowledge

Dual-energy CT parameters derived from dual-layer spectral detector CT provide added value to differentiate AC from SCC at the GEJ, especially the combination of effective atomic number, spectral slope, iodine concentration and 40keV CT value in VP.

Application of computed tomography-based radiomics in differential diagnosis of adenocarcinoma and squamous cell carcinoma at the esophagogastric junction

BACKGROUND

The biological behavior of carcinoma of the esophagogastric junction (CEGJ) is different from that of gastric or esophageal cancer. Differentiating squamous cell carcinoma of the esophagogastric junction (SCCEG) from adenocarcinoma of the esophagogastric junction (AEG) can indicate Siewert stage and whether the surgical route for patients with CEGJ is transthoracic or transabdominal, as well as aid in determining the extent of lymph node dissection. With the development of neoadjuvant therapy, preoperative determination of pathological type can help in the selection of neoadjuvant radiotherapy and chemotherapy regimens.

AIM

To establish and evaluate computed tomography (CT)-based multiscale and multiphase radiomics models to distinguish SCCEG and AEG preoperatively.

METHODS

We retrospectively analyzed the preoperative contrasted-enhanced CT imaging data of single-center patients with pathologically confirmed SCCEG (n = 130) and AEG (n = 130). The data were divided into either a training (n = 182) or a test group (n = 78) at a ratio of 7:3. A total of 1409 radiomics features were separately extracted from two dimensional (2D) or three dimensional (3D) regions of interest in arterial and venous phases. Intra-/inter-observer consistency analysis, correlation analysis, univariate analysis, least absolute shrinkage and selection operator regression, and backward stepwise logical regression were applied for feature selection. Totally, six logistic regression models were established based on 2D and 3D multi-phase features. The receiver operating characteristic curve analysis, the continuous net reclassification improvement (NRI), and the integrated discrimination improvement (IDI) were used for assessing model discrimination performance. Calibration and decision curves were used to assess the calibration and clinical usefulness of the model, respectively.

RESULTS

The 2D-venous model (5 features, AUC: 0.849) performed better than 2D-arterial (5 features, AUC: 0.808). The 2D-arterial-venous combined model could further enhance the performance (AUC: 0.869). The 3D-venous model (7 features, AUC: 0.877) performed better than 3D-arterial (10 features, AUC: 0.876). And the 3D-arterial-venous combined model (AUC: 0.904) outperformed other single-phase-based models. The venous model showed a positive improvement compared with the arterial model (NRI > 0, IDI > 0), and the 3D-venous and combined models showed a significant positive improvement compared with the 2D-venous and combined models (P < 0.05). Decision curve analysis showed that combined 3D-arterial-venous model and 3D-venous model had a higher net clinical benefit within the same threshold probability range in the test group.

CONCLUSION

The combined arterial-venous CT radiomics model based on 3D segmentation can improve the performance in differentiating EGJ squamous cell carcinoma from adenocarcinoma.

SIRGs score may be a predictor of prognosis and immunotherapy response for esophagogastric junction adenocarcinoma

Background

Esophagogastric junction adenocarcinoma (EGJA) is a special malignant tumor with unknown biological behavior. PD-1 checkpoint inhibitors have been recommended as first-line treatment for advanced EGJA patients. However, the biomarkers for predicting immunotherapy response remain controversial.

Methods

We identified stromal immune-related genes (SIRGs) by ESTIMATE from the TCGA-EGJA dataset and constructed a signature score. In addition, survival analysis was performed in both the TCGA cohort and GEO cohort. Subsequently, we explored the differences in tumor-infiltrating immune cells, immune subtypes, immune-related functions, tumor mutation burden (TMB), immune checkpoint gene expression, immunophenoscore (IPS) between the high SIRGs score and low SIRGs score groups. Finally, two validation cohorts of patients who had accepted immunotherapy was used to verify the value of SIRGs score in predicting immunotherapy response.

Results

Eight of the SIRGs were selected by LASSO regression to construct a signature score (SIRGs score). Univariate and multivariate analyses in the TCGA and GEO cohort suggested that SIRGs score was an independent risk factor for the overall survival (OS) and it could increase the accuracy of clinical prediction models for survival. However, in the high SIRGs score group, patients had more immune cell infiltration, more active immune-related functions, higher immune checkpoint gene expression and higher IPS-PD1 and IPS-PD1-CTLA4 scores, which indicate a better response to immunotherapy. The external validation illustrated that high SIRGs score was significantly associated with immunotherapy response and immune checkpoint inhibitors (ICIs) can improve OS in patients with high SIRGs score.

Conclusion

The SIRGs score may be a predictor of the prognosis and immune-therapy response for esophagogastric junction adenocarcinoma.

Golgi scaffold protein PAQR3 as a candidate suppressor of gastric cardia adenocarcinoma via regulating TGF ‐β/Smad pathway

Objectives

To investigate the function of PAQR3 in gastric cardia adenocarcinoma (GCA) and understand the possible mechanism of PAQR3 in regulating epithelial–mesenchymal transition (EMT).

Methods

We detected PAQR3 protein in 146 GCA tissues and paired normal adjacent tissues (PNTs) specimens using immunohistochemical analysis, and explored its clinical significance. The expression levels of PAQR3 protein in 20 GCA tissues, their paired PNTs, HGC27, SGC7901, and GES‐1 cells were analyzed by Western blot. Wild‐type PAQR3 was overexpressed in HGC27 cells. The effects of PAQR3 overexpression on the function of HGC27 cells and its underlying mechanisms were then analyzed through a series of cell and molecular biology experiments.

Results

PAQR3 was significantly down‐regulated in GCA tissues when compared with paired PNTs (p < 0.0001). The expression level of PAQR3 in GCA tissues was significantly negatively correlated with Helicobacter pylori infection (p = 0.000), venous invasion (p = 0.000), invasion depth (p = 0.000), lymph node metastasis (p = 0.022), tumor stage (p = 0.000), and patient survival (p = 0.009). Downregulation of PAQR3 was highly correlated with increased EMT signature and activated TGF‐β/Smad pathway in GCA tissues. Overexpression of PAQR3 in HGC27 cells negatively regulates its cellular functions, such as cell proliferation and migration, and suppresses EMT. Mechanistically, overexpression of PAQR3 significantly down‐regulates the protein expression levels of TGF‐1, p‐Smad2, and p‐Smad3 in HGC27 cells.

Conclusion

PAQR3 was significantly down‐regulated in GCA tissues, HGC27, and SGC7901 cells. PAQR3 significantly inhibits the proliferation, migration, and invasion of HGC27 cells. Mechanistically, PAQR3 can inhibit the EMT process in HGC27 cells by regulating TGF‐β/Smad signaling pathway.

Clinical and prognostic features of MMP-2 and VEGF in AEG patients

Adenocarcinoma of the esophagogastric junction (AEG) has been increased in recent years and has become a worldwide problem that seriously affects human health. The purpose of the study is to investigate the clinical and prognostic characteristics of the matrix metalloproteinase-2 (MMP-2) and vascular endothelial growth factor (VEGF) expression in AEG patients. A total of 69 patients were enrolled in this study. The result showed that the high expression of MMP-2 was significantly associated with tumor differentiation (P < 0.05) and depth of invasion (pT, P < 0.05). The high expression of VEGF was significantly associated with pT (P < 0.05) and lymph node metastasis (pN, P < 0.05). There was a positive correlation between MMP-2 and VEGF expression (P < 0.01). The 5-year survival rate for the 69 AEG patients was 40.6% and it was significantly associated with tumor differentiation (P < 0.05), pN (P < 0.01), pTNM stage (P < 0.01), MMP-2 expression (P < 0.05), and VEGF expression (P < 0.05). Cox multivariate regression demonstrated that tumor differentiation and pN were independent factors for the 5-year survival rate. Our study showed that MMP-2 and VEGF could work synergistically in AEG development.

Unraveling the identity of gastric cardiac cancer

The classification of gastric cardiac carcinoma (GCC) is controversial. It is currently grouped with esophageal adenocarcinoma (EAC) as an adenocarcinoma of the gastroesophageal junction (GEJ). Recently, diagnostic criteria for adenocarcinoma in the GEJ were established and GCC was separated from EAC. We viewed published evidence to clarify the GCC entity for better patient management. GCC arises in the cardiac mucosa located from 3 cm below and 2 cm above the GEJ line. Compared with EAC, GCC is more like gastric cancer and affects a higher proportion of female patients, younger patients, those with a lower propensity for reflux disease, a wider histopathologic spectrum, and more complex genomic profiles. Although GCC pathogenesis mechanisms remain unknown, the two-etiology proposal is appealing: in high-risk regions, the Correa pathway with Helicobacter pylori infection, chronic inflammation, low acid and intestinal metaplasia, dysplasia and carcinoma may apply, while in low-risk regions the sequence from reflux toxin-induced mucosal injury and high acid, to intestinal metaplasia, dysplasia and carcinoma may occur. In early GCC a minimal risk of nodal metastasis argues for a role of endoscopic therapy, whereas in advanced GCC, gastric cancer staging rules and treatment strategy appear to be more appropriate than the esophageal cancer staging scheme and therapy for better prognosis stratification and treatment. In this brief review we share recent insights into the epidemiology, histopathology and genetics of GCC and hope that this will stimulate further investigations in order to improve the clinical management of patients with GCC.

Identification of the distinct genomic features in gastroesophageal junction adenocarcinoma and its Siewert subtypes

Rates of gastroesophageal junction adenocarcinomas (GEJAs) have shown an alarming increase; however, the genetic background of GEJA and its Siewert classification have yet to be uncovered. Here, 60 paired tumor and normal DNA samples from GEJA patients were analyzed by whole-exome sequencing. Among them, 13 were Siewert type I, 14 were type II, and 33 were type III. A predominance of C/G>T/A substitutions was discovered in GEJA, followed by C/G>A/T substitutions. Notably, Siewert type I and type II/III display distinct sets of driver genes, mutational spectrum, and recurrently disrupted pathways. Siewert type I showed similarity to esophageal adenocarcinomas (EACs) and the chromosomal instability subtype of stomach adenocarcinomas, while Siewert type II/III showed similarity to the genomic stable subtype of stomach adenocarcinoma. We also found that mutation of FBXW7, a driver gene of GEJA, was enriched in Siewert type I. Our data identify differences between GEJA and stomach/EACs at the genomic level and provide evidence for differential treatment based on Siewert classification of GEJA. © 2020 The Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Spectral Computed Tomography for the Quantitative Assessment of Patients With Carcinoma of the Gastroesophageal Junction: Initial Differentiation Between a Diagnosis of Squamous Cell Carcinoma and Adenocarcinoma

OBJECTIVE

This study aimed to distinguish between esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC) using spectral computed tomography (CT) and to discuss the accuracy according to an optimal threshold of single and combined parameters.

METHODS

In this monoinstitution study, 61 patients, 35 of whom had ESCC and 26 had EAC confirmed by surgery or esophagoscopy, were recruited from August 2016 to March 2017. Enrolled patients underwent dual-phase chest CT enhancement. The spectral CT parameters (NIC, NICD, NICratio, Zeff, Zeff-C, K40-70 keV, K80-100 keV, and K110-140 keV) were measured during arterial phase (AP) and venous phase (VP). Binary logistic regression was used to calculate combined predictive probability. Thresholds of quantitative parameters and diagnostic accuracy were calculated using receiver operating characteristic curve.

RESULTS

Compared with ESCC, higher NICAP, NICVP, NICD, Zeff AP, Zeff VP, Zeff-C AP, and Zeff-C VP were observed for EAC, whereas NICratio was lower for EAC. Higher K40-70 keV, K80-100 keV, and K110-140 keV were exhibited in EAC than in ESCC. Area under the curve (AUC) of NICAP, K40-70 keV AP, and Zeff AP were 0.720, 0.730, and 0.706, respectively. The area under the curve of new combined predictive value of NICAP and λ40-0 keV AP was 0.804. The sensitivity and specificity were 77.80% and 80.60%, respectively, when the threshold of new predictive value was 0.60.

CONCLUSION

The diagnostic accuracy obtained by using NICAP and K40-70 keV AP combined is better than that obtained using a single parameter in differentiation between a diagnosis of squamous cell carcinoma and adenocarcinoma.

Analysis of the clinicopathological features and prognostic factors in 734 cases of Chinese Hui and Han patients with adenocarcinoma of the esophagogastric junction

OBJECTIVE

To explore the clinicopathological features and prognostic factors of 734 cases of Chinese Hui and Han patients with adenocarcinoma of the esophagogastric junction (AEG).

METHODS

In total, 734 patients were confirmed to have AEG by gastroscopy and pathology at the General Hospital of Ningxia Medical University between January 2002 and December 2012. Univariate and multivariate analyses of demographic, clinicopathological, and prognostic data were performed.

RESULTS

In total, 734 AEG patients underwent surgical intervention, including 169 Hui patients and 565 Han patients. The male to female ratio was 9.5:1 in Hui patients and 6.4:1 in Han patients, and the average age in both groups was approximately 61 years. The Han patients were more likely to have a cigarette smoking history and an alcohol consumption history than the Hui patients (58.8% vs. 29.4%, p = 0.000; 45.8% vs. 14.6%, p = 0.000). The 5-year survival rate in the Hui and Han patients was 54.3% and 39.9%, respectively (p = 0.024). Age (p = 0.005), sex (p = 0.015), pathologic T stage (p = 0.056), pathologic N stage (p = 0.000), pathologic M stage (p = 0.001), number of resected lymph nodes (p = 0.001) and adjuvant chemoradiotherapy (p = 0.002) were significant independent prognostic factors.

CONCLUSION

The AEG patients were primarily male and elderly in both Hui and Han groups with the prognosis of Hui patients better than Han patients. Age, sex, pathologic T3-4 stage, pathologic N stage, pathologic M stage, number of resected lymph nodes, and adjuvant chemoradiotherapy were significant independent factors predictive of the prognosis of AEG in both groups.

Clinical comparison of antrum-preserving double tract reconstruction vs roux-en-Y reconstruction after gastrectomy for Siewert types II and III adenocarcinoma of the esophagogastric junction

AIM: To explore a reasonable method of digestive tract reconstruction, namely, antrum-preserving double-tract reconstruction (ADTR), for patients with adenocarcinoma of the esophagogastric junction (AEG) and to assess its efficacy and safety in terms of long-term survival, complications, morbidity and mortality.

METHODS: A total of 55 cases were retrospectively collected, including 18 cases undergoing ADTR and 37 cases of Roux-en-Y reconstruction (RY) for AEG (Siewert types II and III) at North Sichuan Medical College. The cases were divided into two groups. The clinicopathological characteristics, perioperative outcomes, postoperative complications, morbidity and overall survival (OS) were compared for the two different reconstruction methods.

RESULTS: Basic characteristics including sex, age, body mass index (BMI), Siewert type, pT status, pN stage, and lymph node metastasis were similar in the two groups. No significant differences were found between the two groups in terms of perioperative outcomes (including the length of postoperative hospital stay, operating time, and intraoperative blood loss) and postoperative complications (consisting of anastomosis-related complications, wound infection, respiratory infection, pleural effusion, lymphorrhagia, and cholelithiasis). For the ADTR group, perioperative recovery indexes such as time to first flatus (P = 0.002) and time to resuming a liquid diet (P = 0.001) were faster than those for the RY group. Moreover, the incidence of reflux esophagitis was significantly decreased compared with the RY group (P = 0.048). The postoperative morbidity and mortality rates for overall postoperative complications and the rates of tumor recurrence and metastasis were not significantly different between the two groups. Survival curves plotted using the Kaplan-Meier method and compared by log-rank test demonstrated similar outcomes for the ADTR and RY groups. Multivariate analysis of significantly different factors that presented as covariates on Cox regression analysis to assess the survival and recurrence among AEG patients showed that age, gender, BMI, pleural effusion, time to resuming a liquid diet, lymphorrhagia and tumor-node-metastasis stage were important prognostic factors for OS of AEG patients, whereas the selection of surgical method between ADTR and RY was shown to be a similar prognostic factor for OS of AEG patients.

CONCLUSION: ADTR by jejunal interposition presents similar rates of tumor recurrence, metastasis and long-term survival compared with classical reconstruction with RY esophagojejunostomy; however, it offers considerably improved near-term quality of life, especially in terms of early recovery and decreased reflux esophagitis. Thus, ADTR is recommended as a worthwhile digestive tract reconstruction method for Siewert types II and III AEG.

Obesity and related risk factors in gastric cardia adenocarcinoma

Over recent decades, the incidence of cancers of the gastroesophageal junction, including gastric cardia tumors, has increased markedly. This is a trend that has been well documented, especially in studies from the USA and northern Europe that have also demonstrated a concomitant rise in the ratio of cardia to distal gastric cancers. The rise in the prevalence of gastric cardia adenocarcinoma has been paralleled by the worldwide obesity epidemic, with almost all epidemiological studies reporting increased body mass index and obesity increase the risk of cardia cancer development. However, the strength of this association is less marked than the link between obesity and esophageal adenocarcinoma, and the mechanisms remain poorly understood. Other possible confounders of the relationship between obesity and cardia cancer include the decline in Helicobacter pylori infection and the widespread use of proton pump inhibitors, although these have rarely been controlled for in case-control and cohort studies investigating associations between obesity and cardia cancer. We review these epidemiological trends and discuss proposed mechanisms for the association, drawing attention to controversies over the difficulty of defining cardia cancer. The relative paucity of high-quality epidemiological studies from other regions of the world should prompt further investigation of this issue, especially in populations undergoing rapid socioeconomic change.

Molecular mechanisms responsible for pathogenesis of Barrett's esophagus

Barrett's esophagus (BE) is defined as the metaplastic conversion of the distal esophageal squamous epithelium to intestinalized columnar epithelium. It is a premalignant condition associated with esophageal adenocarcinoma (EAC) and is the major risk factor for EAC. Recent studies suggest that the molecular mechanisms responsible for the pathogenesis of BE are closely related to transcription factors, signaling proteins and microRNAs (miRNAs). MiRNAs are expected to be used as novel biomarkers for the diagnosis, prognosis assessment and targeted treatment of EAC. This article summarizes recent results involving stem cells, immune factors, transcription factors, DNA methylation, nitric oxide, signaling pathways, microRNAs in the development of BE. Understanding of the molecular mechanisms behind the pathogenesis of BE has important implications for improved management of BE and EAC.