A single center's 30 years' experience of esophageal adenocarcinoma

[Treatment of Superficial Esophageal Cancer: An Update]

Superficial esophageal squamous cell carcinoma (SESCC) is an esophageal squamous cell carcinoma confined to the mucosa or superficial submucosa. Recent Korean Guidelines recommend an endoscopic resection as the first-line treatment for SESCC without a distant or lymph node metastasis (LNM) after excluding those with an obvious submucosal invasion. Before endoscopic treatment of SESCC, Lugol chromoendoscopy or image-enhanced endoscopy is recommended to define the extent of the lesion, and endoscopic ultrasound is recommended to determine the T stage. The tumor size, macroscopic type of tumor, pathologic differentiation, depth of tumor, and lymphovascular invasion (LVI) are risk factors of LNM in SESCC. No additional treatment is necessary after an en bloc complete resection of SESCC invading no more than the lamina propria without LVI. Although the risk of LNM in a SESCC invading into muscularis mucosa without LVI is low, a close follow-up is recommended without additional treatment. On the other hand, additional treatment is recommended in the case of a tumor with submucosal invasion or an LVI positive or positive vertical resection margin. Adjuvant therapy includes esophagectomy or chemoradiotherapy (CRT), but it is unclear which treatment is better. The 5-year overall survival rates were reportedly 90-100% for esophagectomy and 75-85% for CRT. Nevertheless, patients with high-risk features including poorly differentiated histology, LVI positive, perineural invasion positive, T1b-SM2/T1b-SM3 cancer, and vertical resection margin positive need to be treated with an additional esophagectomy. Elderly patients, those with a physical condition and co-morbidities, and those with LNM or cancer-specific mortality require additional treatment after a non-curative endoscopic resection of SESCC.

Association between the National Cancer Screening Programme (NSCP) for gastric cancer and oesophageal cancer mortality

Background

The aim was to evaluate whether this gastric cancer-screening programme was effective in reducing oesophageal cancer mortality.

Methods

A population-based retrospective cohort study was conducted using the Korean National Cancer Screening Programme (NCSP) database. The study cohort comprised 16,969 oesophageal cancer patients who had been diagnosed in 2007–2014. We analysed the association between the history of NSCP for gastric cancer and oesophageal cancer mortality.

Results

Compared with never-screened subjects, ever-screened subjects had an overall HR for oesophageal cancer mortality of 0.647 (95% CI, 0.617–0.679). According to the time interval since screening, the HRs of death were 0.731 (95% CI, 0.667–0.801) for 6–11 months, 0.635 (95% CI, 0.594–0.679) for 12–23 months, 0.564 (95% CI, 0.522–0.610) for 24–35 months and 0.742 (95% CI, 0.679–0.810) for ≥36 months. According to the last screening modality, the HRs of death were 0.497 (95% CI, 0.464–0.531) for upper endoscopy, and 0.792 (95% CI, 0.749–0.838) for UGIS. Upper endoscopy reduced the mortality consistently in all age groups over 50 years, whereas UGIS could not.

Conclusion

The NCSP for gastric cancer was effective in reducing the mortality of oesophageal cancer, and upper endoscopy was superior to UGIS.

Cumulative evidence for the relationship between body mass index and the risk of esophageal cancer: An updated meta-analysis with evidence from 25 observational studies

BACKGROUND AND AIM

A large number of papers reporting the relationships between body mass index (BMI) and esophageal cancer (EC) risk have been published in the past few decades; however, these results are inconsistent. Therefore, we carried out meta-analyses to explore the relationships between BMI and the risk of EC (including esophageal squamous cell carcinoma [ESCC] and esophageal adenocarcinoma [EADC]).

METHODS

We used the Web of Science, PubMed, and Embase to identify all published/online articles before December 30, 2018, which yielded 25 articles eligible for data extraction (including 16,561 cases and 11,954,161 controls), and then pooled the relative risks (RRs) and corresponding 95% confidence intervals (CIs) using random-effects model.

RESULTS

Our study presented that underweight had statistically significant association with the risk of EC (RR = 1.78, 95% CI = 1.48, 2.14, P < 0.001) and ESCC (RR = 1.57, 95% CI = 1.20, 2.06, P = 0.001) when compared with normal weight. Interestingly, both overweight and obesity could increase the risk of EADC (RR = 1.56, 95% CI = 1.42, 1.71, P < 0.001; RR = 2.34, 95% CI = 2.02, 2.70, P < 0.001) while decrease the risk of ESCC (RR = 0.71, 95% CI = 0.60, 0.84, P < 0.001; RR = 0.63, 95% CI = 0.60, 0.84, P = 0.002). Additionally, obesity could increase the risk of EC (RR = 1.51, 95% CI = 1.21, 1.89, P < 0.001).

CONCLUSION

These meta-analyses provide a comprehensive and updated epidemiological evidence to confirm the associations between BMI and EC risk. These findings have public health implications with respect to better control bodyweight and then reduce the occurrence of EC (including ESCC and EADC).

Abdominal obesity increases risk for esophageal cancer: a nationwide population-based cohort study of South Korea

BACKGROUND

The relationship between overall obesity, as measured by body mass index (BMI) and risk of esophageal squamous cell carcinoma (ESCC) has been reported to show a negative correlation. However, the relationship of ESCC, which accounts for around 90% of esophageal cancers in South Korea, with abdominal obesity, as measured by waist circumference (WC), may be different. Thus, we investigated the association between abdominal obesity and esophageal cancer in a nationwide population-based cohort.

METHODS

A retrospective cohort study of 22,809,722 individuals who had undergone regular health check-ups provided by the National Health Insurance Corporation between 2009 and 2012 (median follow-up period, 6.4 years) in South Korea was conducted. Abdominal obesity was defined as a WC > 90 cm for men and > 85 cm for women. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) using χ² test and Cox proportional hazards model adjusted for confounding factors. The primary outcome was newly developed esophageal cancer.

RESULTS

After adjusting for BMI, abdominal obesity increased the risk of esophageal cancer (HR 1.29, 95% CI 1.23-1.36). WC increased the risk for esophageal cancer in a dose-dependent manner (p values for trend < 0.0001). Among overweight (BMI 23-24.9 kg/m²) and obese I (BMI 25-29.9 kg/m²) individuals, abdominal obesity was a risk factor for esophageal cancer (HR 1.22, 95% CI 1.11-1.34; HR 1.28, 95% CI 1.18-1.39, respectively).

CONCLUSION

Increasing abdominal obesity may be associated with an increased risk for esophageal cancer. Further studies are warranted to confirm the relationship.

Coffee consumption and risk of esophageal cancer incidence: A meta-analysis of epidemiologic studies

BACKGROUND

In epidemiologic studies, association between coffee consumption and esophageal cancer risk is inconsistent.

OBJECTIVE

The aim of tjis study was to evaluate the effect of coffee on esophageal cancer by combining several similar studies.

METHODS

We conducted a meta-analysis for association of coffee intake and esophageal cancer incidence. Eleven studies, including 457,010 participants and 2628 incident cases, were identified. A relative risk (RR, for cohort study) or odds ratio (OR, for case-control study) of heavy coffee drinkers was calculated, compared with light coffee drinkers or non-drinkers. The analysis was also stratified by cancer types (esophageal squamous cell carcinoma and esophageal adenocarcinoma), sex, and geographic region.

RESULTS

The summarized OR of having esophageal cancer in heavy coffee drinkers was 0.93 (95% confidence interval [CI]: 0.73-1.12), compared with light coffee drinkers. When stratified by sex, pathologic type of esophageal cancer, and type of epidemiologic study, we did not find any association of coffee consumption and esophageal cancer incidence. However, an inverse association between coffee consumption and incidence of esophageal cancer was found in East Asia participants with OR of 0.64 (95% CI: 0.44-0.83), but not in Euro-America participants (OR = 1.05; 95% CI: 0.81-1.29).

CONCLUSION

There is a protective role of coffee consumption against esophageal cancer in East Asians, but not in Euro-Americans.

The relationship between drinking alcohol and esophageal, gastric or colorectal cancer: A nationwide population-based cohort study of South Korea

BACKGROUND

Epidemiologic findings of low-volume alcohol consumption in relation to gastrointestinal cancers including gastric cancer are inconsistent.

METHODS

The association between alcohol intake and esophageal, gastric and colorectal cancer risk was examined in a population-based prospective cohort of 23,323,730 adults in Korea who had undergone a biennial evaluation provided by the National Health Insurance Corporation between the years 2009 and 2012. After median 5.4 years of follow-up, 9,171 esophageal, 135,382 gastric and 154,970 colorectal cancer cases were identified. Cox regression models were used to estimate hazard ratios (HR) and corresponding 95% confidence intervals (95% CI).

RESULTS

Light drinking as well as moderate to heavy alcohol consumption significantly increased the risks of the three gastrointestinal cancers (HR 1.51; 95% CI, 1.43-1.60; HR 1.08; 95% CI, 1.06-1.09; HR 1.12; 95% CI, 1.11-1.14) compared with non-drinkers after adjusting for age, sex, smoking, exercise, income, body mass index, and diabetes. The synergistically increased cancer risk between excessive amount of alcohol consumption and currently smoking or underweight individuals was observed only in the esophageal cancers.

CONCLUSIONS

Light drinking including even one alcoholic drink a day is associated with increased risks of esophageal, gastric and colorectal cancer.

Joint Effects of Low Body Mass Index and Alcohol Consumption on Developing Esophageal Squamous Cell Cancer: a Korean Nationwide Population-Based Cohort Study

Objective:

In Korea, 95% of esophageal cancer (EC) was the squamous cell-type. We sought to determine the combined risk of alcohol consumption on developing esophageal squamous cell carcinoma (ESCC) in pre-diagnostic underweight subjects using Korean national data.

Methods:

We analyzed the clinical data from a total of 264,084 individuals aged 40 years or older, who received healthcare checkups arranged by the national insurance program, between 2003 and 2008 in Korea. Cox proportional hazards regression was used after adjusting confounding factors.

Result:

Newly diagnosed 278 EC was identified using the claims data during a median follow-up duration of 7.9 years. It was determined that underweight and obesity-compared with normal weight-were significantly associated with 73% increased risk and 30% decreased risk of EC, respectively. Weight gain reduced the risk of EC. Alcohol consumption increased risk for EC in a dose-dependent manner. Heavy alcohol consumption in individuals with underweight increased the risk of developing EC dramatically.

Conclusion:

Underweight was a risk factor for ESCC and alcohol consumption raised the risk synergistically with low BMI. Achieving normal range of BMI could reduce the risk of ESCC.

Elevated serum gamma-glutamyltransferase is associated with an increased risk of oesophageal carcinoma in a cohort of 8,388,256 Korean subjects

Gamma-glutamyltransferase (GGT) is a marker for hepatic injury and alcohol consumption. However, the association of GGT with the risk of oesophageal carcinoma (OC) has not been fully recognized to date. Therefore, this study aimed to determine the association between elevated GGT and OC, by also considering the body mass index (BMI) of the subjects. Clinical data from 8,388,256 Korean individuals, who were aged 40 years and over and who received healthcare check-ups arranged by the national insurance program in 2007 and 2008, were analysed. Newly diagnosed OC was identified using claims data during a median follow-up duration of 8.72 years. During the study period, 6,863 individuals (0.08%) developed OC. We found that there was an increased risk of OC in subjects with serum GGT values >18 IU/L. Furthermore, a BMI <18.5 kg/m² (underweight) was associated with increased OC risk, while a BMI ≥23.0 kg/m² was associated with a reduced OC risk. Individuals who were both underweight and in the highest GGT quartile (≥40 IU/L) had a far greater risk of OC compared to other individuals (hazard ratio: 3.65, 95% confidence interval: 3.10–4.30). In conclusion, increased serum GGT was associated with an increased risk of developing OC in the general Korean population, regardless of age, sex, smoker status, or alcohol consumption.

The increasing incidence of esophageal squamous cell carcinoma in women in Turkey

BACKGROUND/AIM

This study assessed the trend changes in the histological types of esophageal cancer in a 25-year period in eastern Turkey.

MATERIALS AND METHODS

We searched all cases of esophageal cancer from 1990 to 2015 according to their histological diagnosis and sex, grouping the patients in 5-year time periods to evaluate time trends.

RESULTS

We identified 1462 cases of esophageal cancer. In terms of patient make-up, 742 were male and 720 were female. In general, 75.86% of the patients had squamous cell carcinoma (SCC), 19.56% of the patients had adenocarcinoma (ADC), and the remaining 4.58% patients were found to have other histopathologic disorders. While the SCC to ADC ratio was 1.76 between 1990 and 1994, this rate increased to 8.73 between 2010 and 2014; during these periods, the male to female ratio decreased from 1.43 to 0.86. Between these two periods, statistically significant changes were observed of SCC and the number of female patients (P < 0.001, P = 0.008, respectively).

CONCLUSION

While the incidence of esophagus ADC and the number of male patients increased recently in Western countries, the number of female patients and SCC cases increased in our region in the last 25 years.

Recent advances in proximal gastric carcinoma

The American Joint Committee on Cancer (AJCC) staging scheme requires staging proximal gastric carcinoma (PGC) as esophageal adenocarcinoma (EAC), which has been shown to be controversial by recent research results. To update the current research findings on PGC, we systematically reviewed and analyzed the scientific evidence on key arguments related to PGC. The data of high-quality research articles showed that PGC arised in the cardiac mucosa in the proximal stomach within 3 cm below the gastroesophageal junction. Its incidence is rising in East Asian countries, but decreasing in the West, and plateaued at a low level in the United States. PGC is a slowly progressive cancer with unknown independent risk factors and the mechanisms of pathogenesis. This carcinoma exhibits a wide histopathological spectrum and heterogeneous post-resection patient survival characteristics, and cannot be adequately staged for prognotic stratification by the current AJCC staging classification. The results on PGC genomics reveal unique genetic profiles, especially in East Asian populations. In conclusion, mounting evidence defies a simple placement of PGC in a single category of EAC for disease classification; further investigations on the mechanisms of PGC pathogenesis are urgently needed.

Non-Invasive Detection of Esophageal Cancer using Genetic Changes in Circulating Cell-Free DNA

Cell free DNA (cfDNA) is a genetic biomarker that is present in serum or plasma in high concentration in many types of cancer. Identification of circulating cancer related DNA molecules in serum or plasma is a non-invasive tool for early diagnosis and prognosis in many cancer patients. For this review, study selection and data extraction were performed by the authors. Detection of point mutations, microsatellite alterations, DNA hypermethylations and losses of heterozygosity in circulating cell free DNA have been characterized in esophagus cancer. Application of circulating cell free DNA as a biomarker, provide the best opportunity for constructing non-invasive tests for early detection, prognosis and management of cancer patients, after therapy in many types of cancer.

Prevalence of Barrett's esophagus remains low in the Korean population: nationwide cross-sectional prospective multicenter study

PURPOSE

In contrast to the Western population, the prevalence of Barrett's esophagus (BE) is rare in the Korean population. However, the recent increase in prevalence of gastroesophageal reflux disease (GERD) may affect the prevalence of BE. The aim of this study was to survey the prevalence of BE and evaluate its risk factors.

METHODS

Patients between 18 and 75 years of age who visited 11 Korean tertiary referral centers between April and July 2006 for routine upper endoscopic examination were surveyed using a symptom questionnaire. Biopsies were performed on the columnar lined epithelium (CLE) of the distal esophagus, and diagnosis was confirmed with detection of specialized intestinal metaplasia.

RESULTS

The study comprised 2,048 patients (mean age 51.4 years, 965 males). The frequency of heartburn or acid regurgitation was 8.7% and 13.1%, respectively. Reflux esophagitis was diagnosed in 10.1% of patients (207 patients); however, most patients had mild reflux. CLE was found in 82 patients; however, only one patient had long-segment CLE. The prevalence of BE was 1% (21 patients). The risk factors for BE were age (P = 0.006), presence of heartburn [odds ratio (OR) 4.33, 95% confidence interval (CI) 1.66-11.34, P = 0.007], acid regurgitation (OR 3.37, 95% CI 1.35-8.42, P = 0.01), sliding hernia (OR 6.21, 95% CI 1.78-21.72, P = 0.001), and reflux esophagitis (OR 10.28, 95% CI 4.31-24.50, P < 0.0001) on univariate analysis. On multivariate analysis, presence of typical reflux symptoms (P = 0.02) and reflux esophagitis (P < 0.001) were significant.

CONCLUSIONS

Prevalence of Barrett's esophagus remains low in Koreans; however, risk of developing BE has increased in patients with GERD symptoms and reflux esophagitis.

Epidemiology of esophageal cancer: Orient to Occident. Effects of chronology, geography and ethnicity

Esophageal adenocarcinoma (EAC) has been rapidly increasing in Western countries during the past half century, especially in white men. Esophageal squamous cell carcinoma (ESCC) used to be the dominant type of esophageal malignancy both in Western and Asian countries. The rapid increase of EAC in Western countries has occurred in parallel with an increased prevalence of gastroesophageal reflux disease (GERD) and its major determinant, obesity. Such an increase in EAC has not yet been observed in Asia, despite a recent increase in prevalence of GERD. In this mini-review, we analyze possible factors influencing such east-west ('Orient to Occident') differences, particularly possible roles of ethnicity and environmental factors, such as Helicobacter pylori infection and nutritional factors, and how these might interact with socioeconomic differences. Development of Barrett's esophagus and esophageal adenocarcinoma appears to be strongly affected by ethnic factors, with populations resident at the west end of the Eurasian continent, such as Anglo-Celtics, being more prone to both conditions. On the other hand, ethnic groups from the eastern and southern ends of Eurasia, such as Chinese, Koreans and Japanese, and Africans might be more prone to developing esophageal squamous cell carcinoma. Future trends will also be discussed.

Unchanging trend of esophagogastric junction adenocarcinoma in Korea: experience at a single institution based on Siewert's classification

The incidence of adenocarcinoma of the esophagogastric junction (AEG) has been increasing in Western countries. It is unclear, however, whether similar changes are occurring in Asia. We therefore investigated the incidence of AEG in Korea, and assessed the clinical characteristics of three types of AEG based on Siewert's classification. We retrospectively reviewed the medical records of 16 811 patients diagnosed with esophageal squamous cell carcinoma (ESC, n= 1450) or gastric noncardiac adenocarcinoma (GNCA, n= 14 751) between 1992 and 2006. The patients were divided into three 5-year cohorts (cohort A [1992-1996], n= 2734, cohort B [1997-2001], n= 5727, and cohort C [2002-2006], n= 8350), and the ratios of AEG (n= 610) to non-AEG (ESC and GNCA) in each cohort were compared. Using Siewert's classification, the tumors were categorized into one of three types, and patient demographic features and 5-year survival rates were compared. The ratio of AEG to non-AEG cases did not change over time (0.037, 0.034, and 0.039 for cohorts A, B, and C, respectively; P= 0.40). Of the 610 patients with AEG, 23 (3.7%) had type 1 tumors, 47 (7.7%) had type 2, and 540 (88.5%) had type 3. The 5-year survival rate of patients with type 1 AEG was much lower (4.8 +/- 4.7%) than that of those with type 2 (47.9 +/- 7.8%) and type 3 (47.4 +/- 2.5%) tumors. Unlike in Western countries, the ratio of AEG to non-AEG cases has not increased over time in Korea. Type 1 AEG was rarer and associated with a more unfavorable prognosis in Korea than in Western countries.

Clinicopathologic Characteristics of Barrett's Cancer in Korea

BACKGROUND/AIMS

The incidence of Barrett's cancer is increasing in Western countries, but there have been only a few case reports of this condition in Korea. The aim of this study was to elucidate the endoscopic and pathologic characteristics of Barrett's cancer in a single center in Korea.

METHODS

We retrospectively reviewed the demographic, endoscopic, and pathologic characteristics of six patients with Barrett's cancer, defined as a tumor centered above the esophagogastric junction and surrounded by Barrett's esophagus.

RESULTS

All six patients were male, and three (50%) were symptomatic. Barrett's cancer had developed from short-segment Barrett's esophagus in all patients. All tumors were located on the right side of the lower esophagus and showed hyperemic mucosal changes. Three patients were treated surgically and three by endoscopic resection. All cases had pathologic evidence of Barrett's cancer.

CONCLUSIONS

Early detection of Barrett's cancer requires meticulous endoscopic observations of subtle mucosal color and morphological changes around the esophagogastric junction.

Decreasing trend of esophageal adenocarcinoma in Hong Kong

BACKGROUND

The incidence of esophageal adenocarcinoma was increasing in the Western Europe and United States, but not in East Asian countries. Population based study on the trend of esophageal adenocarcinoma in Hong Kong was not available.

MATERIALS AND METHODS

Population-based data of Hong Kong Cancer Registry from 1984 to 2003 were used. Cases were grouped into four 5-year periods. Average age standardized rate (WSR) of each period was calculated by averaging the WSR of the 5 years in each period, basing on the world standard population, with adjustment made for cases with missing histology.

RESULTS

10,751 new cases of esophageal neoplasm were studied (8,637 males and 2,114 females). Esophageal adenocarcinoma declined among both males and females, with the total number decreased from 224 in 1984 to 1988 to 131 in 1998 to 2003. WSR decreased from 1.10 of 100,000 in 1984 to 1988 to 0.34 of 100,000 in 1998 to 2003. The decline was faster than that for esophageal squamous cell carcinoma so that the relative ratio of esophageal adenocarcinoma decreased from 11.7% in 1984 to 1988 to 6.4% in 1998 to 2003.

CONCLUSIONS

The incidence of esophageal adenocarcinoma and ratio of esophageal adenocarcinoma versus esophageal squamous cell carcinoma decreased in Hong Kong.