Esophageal small cell carcinomas: clinicopathologic parameters, p53 overexpression, proliferation marker, and their impact on pathogenesis

Substance use and esophageal neuroendocrine neoplasm: A case-control study

Esophageal neuroendocrine neoplasms (NEN) are extremely rare and little is known about their risk factors. To identify the potential risk factors, we evaluated whether the history of substance use, including alcohol, tobacco and areca nut consumption was associated with esophageal NEN. Forty-one esophageal NEN patients diagnosed between 2002 and 2019 from 17 hospital in Taiwan were enrolled as the cases. Controls were participants who received complete esophagogastroduodenoscopy in an endoscopic cohort and 123 eligible controls were matched to 41 cases (3:1) on age and gender. Alcohol drinking and cigarette smoking significantly increased the risk of esophageal NEN, with about a fourfold risk increase in alcohol drinkers as well as cigarette smokers. Moreover, use of cigarette smoking and alcohol consumption in combination demonstrated the highest risk of esophageal NEN with the risk increasing up to 20 times compared with non-users. Alcohol consumption and cigarette smoking significantly increase risk of esophageal NEN and both alcohol and cigarette users had the highest risk.

Use of Chemoradiotherapy as a Treatment Option for Patients with Limited-Stage Primary Small Cell Carcinoma of the Esophagus

Purpose

Currently, there are no standard treatments for primary small cell carcinoma of the esophagus (PSCCE), particularly in cases of limited-stage disease. This retrospective study aimed to assess the treatment strategies and the relevant prognostic factors of limited-stage PSCCE (LS-PSCCE).

Patients and Methods

We retrospectively evaluated 129 patients with LS-PSCCE between June 2009 and December 2018. The χ2 test was performed to examine the frequencies between different groups. The Kaplan-Meier and log-rank methods were used to estimate and compare survival rates. Univariate and multivariate analyses were performed to determine the prognostic factors for overall survival (OS).

Results

Through a median follow-up of 23 months, the median OS of all patients was 25.0 months and the median recurrence-free survival (RFS) was 15.0 months. Univariate and multivariate analyses showed that alcohol abuse (p=0.046) and TNM stage (p<0.001) were independent prognostic factors. There was no significant difference in OS and RFS rates between the patients treated with chemoradiotherapy (CRT) and those treated with surgery and chemotherapy with or without radiotherapy (S+CT±RT) (p>0.05). Patients who received concurrent CRT had better OS and RFS than those who received sequential CRT (p<0.05). Postoperative adjuvant RT for high-risk patients can further improve the local control rate but has no significant effect on OS.

Conclusion

LS-PSCCE patients treated with CRT had similar OS and RFS compared to those treated with S+CT±RT. This study shows that concurrent CRT confers a survival advantage for patients with LS-PSCCE compared to those with sequential CRT.

Updates on World Health Organization classification and staging of esophageal tumors: implications for future clinical practice

The Fifth edition of the World Health Organization classification of digestive system and American Joint Committee on Cancer staging manual contain substantial refinements of information for esophageal tumors. The epithelial tumors of esophagus are classified as benign, dysplasia, and malignant groups. Dysplasia is divided into Barrett dysplasia and squamous dysplasia and graded into either low-grade or high-grade. Malignant esophageal tumors are often adenocarcinoma or squamous cell carcinoma. The main update in cancer staging in esophageal tumors is the subdivision of the prognostic staging into 3 groups; squamous cell carcinoma, adenocarcinoma, and carcinoma after adjuvant therapy. HER-2 amplification is recognized as a molecular target for therapy of esophagogastric adenocarcinoma. The other esophageal tumors are adenoid cystic carcinoma, mucoepidermoid/adenosquamous carcinoma, undifferentiated carcinoma and neuroendocrine neoplasms. Overall, the incorporation of new data and definitions on histopathology, prognostic factors, and genetics are important for personalized management of patients with esophageal tumors.

Immunohistochemistry for Protein Detection in Esophageal Squamous Cell Carcinoma

Immunohistochemistry is the identification of a cell protein by a specific antibody targeting that protein. It is the most common ancillary test to study the pathology of cancer. Immunohistochemical protein markers are used to differentiate poorly differentiated squamous cell carcinoma from poorly differentiated adenocarcinoma or neuroendocrine carcinomas. They could be used to identify and type the carcinoma in metastatic locations. Importantly, immunodetection of markers also helps in prediction of response to therapies as well as assessing the different biomarkers related to the pathogenesis and clinical behavior of esophageal squamous cell carcinoma. Successful application of the immunochemistry depends on understanding the mechanisms and principles as well as the limitations of the procedure. Automation of the procedure by different models of automatic stainers is widely used in diagnostic laboratories. The use of autostainers streamlines the workflows and certainly reduces the labor, time, and cost of using immunohistochemistry in clinical and research settings.

Tenascin-C is involved in promotion of cancer stemness via the Akt/HIF1ɑ axis in esophageal squamous cell carcinoma

Although tenascin-C (TNC), an extracellular matrix protein, has been shown to be widely expressed in stromal fibroblasts in various cancers, the role of its expression in esophageal squamous cell carcinoma (ESCC) cells remains unclear. Using immunohistochemistry, we investigated the expression of cancer stem-like cell (CSC) markers, epithelial-to-mesenchymal transition (EMT)-related genes, and the Akt/hypoxia-inducible factor-1α (HIF1α) signal pathway in ESCC tissue specimens from 154 patients. We further addressed the effects of TNC on the Akt/HIF1α axis and its putative association with cancer stemness in several ESCC cell lines by immunofluorescence imaging and western blot analysis. Our data suggest that TNC expression was positively correlated with the expression of the CSC marker SOX2 (p = .002), and TNC-expressing cancer cells expressed SOX2 in ESCC tissues. Moreover, TNC expression was strongly associated with EMT-related gene Snail (p = .022) and positively correlated with pAkt-Ser473 (p = .004) and HIF1α (p = .003). Furthermore, TNC-silencing down-regulated the expression of CSC marker SOX2 (p < .001) and EMT-related marker Snail (p < .001). The Akt inhibitor Perifosine inhibited the protein expression of pAkt-Ser473, Akt, HIF1α, and TNC in TE10 (an ESCC cell line) cells. Short-term exposure of TE10 cells to cobalt chloride caused an increase in protein expression of HIF1α, TNC, and SOX2 in a time-dependent manner. Taken together, these results suggest that TNC may enhance the cancer stem-like properties and promote EMT-like changes via the Akt/HIF1α axis.

A rare rarity: Neuroendocrine tumor of the esophagus

Esophageal Neuroendocrine tumors (NETs) are rare, aggressive and lacking specific symptoms. This causes a diagnostic delay, worsening the prognosis. Numerous cases are reported in literature, without a consensus on the management. Our aim was to clarify epidemiology, clinical presentation, diagnostic, therapeutic management of esophageal NETs. Extensive literature search identified a total of 226 articles. One hundred twenty-five articles (n = 1676) met the inclusion criteria, showing that: the incidence of esophageal NET varies geographically; men (60-70 years) are more affected; smoking and alcohol abuse are the major risk factors; dysphagia, weight loss, appetite loss are the most common clinical features. The histotypes include high-grade small and large cell esophageal carcinomas and low-grade carcinoid tumors. Mixed neuroendocrine/non-neuroendocrine neoplasms are the most common. Often the diagnosis occurs randomly on endoscopic examination. Circulating markers, functional combined with conventional imaging contributes to the diagnosis and management. Treatment depends on type, grade and stage of the tumor.

Small Cell/Neuroendocrine Tumors of the Esophagus: Presentation of Two Cases and Review of the Literature

Small cell cancers of the gastrointestinal tract are part of a family of extrapulmonary small cell carcinomas. These tumors can occur anywhere in the body and generally carry a poor prognosis. Treatment usually consists of a combination of chemotherapy and radiation therapy. We present two cases illustrating diagnostic and treatment issues and review the literature on the treatment of this uncommon but aggressive family of tumors. Free full text available at www.tumorionline.it

Treatment Strategies and Prognostic Factors of Limited-Stage Primary Small Cell Carcinoma of the Esophagus

INTRODUCTION

Primary small cell carcinoma of the esophagus (PSCCE) is characterized by high malignancy, early metastasis, and poor prognosis. This retrospective study aimed to review the clinical characteristics of patients with limited-stage PSCCE and determine the relevant prognostic factors and optimal treatment strategies.

METHODS

We retrospectively evaluated 152 consecutive patients with limited-stage PSCCE between January 2007 and December 2015. Prognostic factors were analyzed using univariate analysis and a Cox regression model. Subgroup analysis was applied to evaluate the effect of treatment strategy on survival.

RESULTS

Univariate and multivariate analyses showed that treatment modality (p = 0.034) and N stage (p = 0.002) were independent prognostic factors. Patients with stage I or IIA PSCCE who underwent an operation alone exhibited better survival than those who did not undergo an operation (median survival time 29 versus 17.4 months [p = 0.031]), and postoperative adjuvant therapy did not increase overall survival or disease-free survival (p > 0.05). The overall survival rate of patients with stage III PSCCE who underwent neoadjuvant chemotherapy (nCT) was significantly better than that of patients who underwent an operation alone or did not undergo an operation (p = 0.021 and p = 0.026, respectively); additionally, nCT could increase disease-free survival (p = 0.031).

CONCLUSIONS

Treatment modalities and N stage are independent prognostic factors. Radical esophagectomy should be considered as the primary treatment for stage I or IIA PSCCE, and nCT followed by esophagectomy could be an effective treatment option for stage III PSCCE. Multicenter randomized studies are required to confirm the role of nCT in the management of limited-stage PSCCE.

High expression of Ki-67 is an independent favorable prognostic factor for esophageal small cell carcinoma

BACKGROUND

The prognostic value of Ki-67 expression in small cell carcinoma of the esophagus (SCCE) has not been explored in any previous studies. Therefore, we conducted this retrospective study to investigate the prognostic role of Ki-67 in SCCE for the first time.

RESULTS

A total of 44 patients were included for analysis. The baseline clinicopathological data of these SCCE patients shared similar characteristics with previous studies. Ten patients were at stage I, 17 at stage II, and the remaining 17 were at stage III. Postoperatively, 23 patients received adjuvant therapy. Twenty-eight patients were found to have a high expression of Ki-67 (> 50%). After a median follow-up time of 54.8 months, the median survival time of those patients was 22.1 months. Early TNM stage, application of adjuvant therapy, and high expression of Ki-67 (Hazard Ratio = 0.314, 95% CI: 0.127-0.774; P = 0.012) were found to be favorable prognostic factors of patients with SCCE. In subgroup analysis, adjuvant therapy could only bring significant survival benefit for patients with high expression of Ki-67 (P = 0.008).

MATERIALS AND METHODS

Patients undergoing esophagectomy with lymphadenectomy for SCCE from January 2009 to January 2015 in our department were retrospectively analyzed. Data for analysis included demographic data, pathologic findings, tumor stage, adjuvant therapy, and survival time as well as Ki-67 index.

CONCLUSIONS

This study suggested that high expression of Ki-67 may not only serve as a favorable prognostic factor of SCCE but also an indication of providing adjuvant therapy for SCCE patients with surgical resection.

Gold-loaded nanoporous iron oxide nanocubes: a novel dispersible capture agent for tumor-associated autoantibody analysis in serum

Autoantibodies are produced against tumor associated antigens (TAAs) long before the appearance of any symptoms and thus can serve as promising, non-invasive biomarkers for early diagnosis of cancer. Current conventional methods for autoantibody detection are highly invasive and mostly provide diagnosis in the later stages of cancer. Herein we report a new electrochemical method for early detection of p53 autoantibodies against colon cancer using a strategy that combines the strength of gold-loaded nanoporous iron oxide nanocube (Au@NPFe₂O₃NC)-based capture and purification while incorporating the inherent simplicity, inexpensive, and portable nature of the electrochemical and naked-eye colorimetric readouts. After the functionalisation of Au@NPFe₂O₃NC with p53 antigens, our method utilises a two-step strategy that involves (i) magnetic capture and isolation of autoantibodies using p53/Au@NPFe₂O₃NC as 'dispersible nanocapture agents' in serum samples and (ii) subsequent detection of autoantibodies through a peroxidase-catalyzed reaction on a commercially available disposable screen-printed electrode or naked-eye detection in an Eppendorf tube. This method has demonstrated a good sensitivity (LOD = 0.02 U mL^-1) and reproducibility (relative standard deviation, %RSD = <5%, for n = 3) for detecting p53 autoantibodies in serum and has also been successfully applied to analyse a small cohort of clinical samples obtained from colorectal cancer. We believe that the highly inexpensive, rapid, sensitive, and specific nature of our assay could potentially aid in the development of an early diagnostic tool for cancer and related diseases.

Primary neuroendocrine neoplasm of the esophagus - Report of 14 cases from a single institute and review of the literature

BACKGROUND:

Most prevalent esophageal neoplasm is squamous cell carcinoma and adenocarcinoma. Other tumors are uncommon and poorly studied. Primary neuroendocrine esophageal neoplasm is a rare carcinoma and most of its therapy management is based on lung neuroendocrine studies. Neuroendocrine tumors can be clustered in the following subtypes: high grade (small cell carcinoma or large cell carcinoma) and low grade (carcinoids).

OBJECTIVE:

The present study aims to assess clinical and pathological neuroendocrine esophageal tumors in a single oncologic center.

METHODS:

A retrospective analysis of patients and review of the literatures was performed.

RESULTS:

Fourteen patients were identified as neuroendocrine tumors, 11 male and 3 female patients. Mean age was 67.3 years old. Ten patients were classified as small cell, 3 as large cell and 1 as carcinoid. Four patients presented squamous cell carcinoma simultaneously and 1 also presented adenocarcinoma. Main sites of metastasis were liver, peritoneum, lung and bones. Most patients died before 2 years of follow-up. Patient with longer survival died at 35 months after diagnosis.

CONCLUSION:

Neuroendocrine esophageal tumors are rare; affect mainly men in their sixties or seventies. High grade tumors can be mixed to other subtypes neoplasms, such as adenocarcinoma and squamous cell carcinoma. Most of these patients have poor overall survival rates.

Adjuvant Therapeutic Modalities in Primary Small Cell Carcinoma of Esophagus Patients: A Retrospective Cohort Study of Multicenter Clinical Outcomes

To evaluate the treatment pattern and survival of patients receiving radical resection for primary small cell carcinoma of the esophagus (PSCCE).This retrospective study included 150 patients who received radical resection of PSCCE. Data were retrieved from 4 centers in Western China. Thirty-nine of 150 patients received postoperative chemo-radiotherapy, 62 received postoperative chemotherapy, and 49 received radical resection only. The median radiation dosage was 50 Gy. The chemotherapeutic regimen was platinum-based and lasted for 2 to 6 cycles (median, 3).Median disease-free survival (mDFS) and overall survival (mOS) were 12.0 and 18.3 months, respectively. Subgroup analysis revealed that postoperative therapy did not improve survival in limited stage I (LSI) disease, whereas postoperative chemotherapy improved survival in limited stage II (LSII) disease. Relative to chemotherapy alone, chemoradiotherapy did not improve survival in patients with completely resected LSII disease. A multivariate analysis indicated an association of no postoperative chemotherapy with shorter DFS (P = 0.050) and OS (P = 0.010). Higher lymph node stage and length of disease longer than 3 cm were poor prognostic factors for both DFS and OS.Adjuvant chemotherapy improves survival in PSCCE patients with completely resected LSII disease. Adjuvant treatment with postoperative chemotherapy alone or postoperative chemo-radiotherapy does not increase survival in completely resected LSI disease.

Dysregulation of PAK1 Is Associated with DNA Damage and Is of Prognostic Importance in Primary Esophageal Small Cell Carcinoma

Primary esophageal small cell carcinoma (PESCC) is a rare, but fatal subtype of esophageal carcinoma. No effective therapeutic regimen for it. P21-activated kinase 1 (PAK1) is known to function as an integrator and an indispensable node of major growth factor signaling and the molecular therapy targeting PAK1 has been clinical in pipeline. We thus set to examine the expression and clinical impact of PAK1 in PESCC. The expression of PAK1 was detected in a semi-quantitative manner by performing immunohistochemistry. PAK1 was overexpressed in 22 of 34 PESCC tumors, but in only 2 of 18 adjacent non-cancerous tissues. Overexpression of PAK1 was significantly associated with tumor location (p = 0.011), lymph node metastasis (p = 0.026) and patient survival (p = 0.032). We also investigated the association of PAK1 with DNA damage, a driven cause for malignancy progression. γH2AX, a DNA damage marker, was detectable in 18 of 24 (75.0%) cases, and PAK1 expression was associated with γH2AX (p = 0.027). Together, PAK1 is important in metastasis and progression of PESCC. The contribution of PAK1 to clinical outcomes may be involved in its regulating DNA damage pathway. Further studies are worth determining the potentials of PAK1 as prognostic indicator and therapeutic target for PESCC.

Cancer stem cells in oesophageal squamous cell carcinoma: Identification, prognostic and treatment perspectives

Cancer stem cells (CSCs) are a vital subpopulation of cells to target for the treatment of cancers. In oesophageal squamous cell carcinoma (ESCC), there are several markers such as CD44, ALDH, Pygo2, MAML1, Twist1, Musashi1, Side population (SP), CD271 and CD90 that have been proposed to identify the cancer stem cells in individual cancer masses. It has also been demonstrated that stem cell markers like ALDH1, HIWI, Oct3/4, ABCG2, SOX2, SALL4, BMI-1, NANOG, CD133 and podoplanin are associated with patient's prognosis, pathological stages, cancer recurrence and therapy resistance. Finding new cancer stem cell targets or designing drugs to manipulate the known molecular targets in CSCs could be useful for improvements in clinical outcomes of the disease. To conclude, data suggest that CSCs in oesophageal squamous cell carcinoma are related to resistance to therapy and poor prognosis of patients with ESCC. Therefore, innovative insights into CSC biology and CSC-targeted therapies will help to achieve more effective management of patients with oesophageal squamous cell carcinoma.

Neuroendocrine Carcinomas of the Gastroenteropancreatic System: A Comprehensive Review

To date, empirical literature has generally been considered lacking in relation to neuroendocrine carcinomas (NECs), the highly malignant subgroup of neuroendocrine neoplasms. NECs are often found in the lungs or the gastroenteropancreatic (GEP) system and can be of small or large cell type. Concentrating on GEP-NECs, we can conclude that survival times are poor, with a median of only 4–16 months depending on disease stage and primary site. Further, this aggressive disease appears to be on the rise, with incidence numbers increasing while survival times are stagnant. Treatment strategies concerning surgery are often undecided and second-line chemotherapy is not yet established. After an analysis of over 2600 articles, we can conclude that there is indeed more empirical literature concerning GEP-NECs available than previously assumed. This unique review is based on 333 selected articles and contains detailed information concerning all aspects of GEP-NECs. Namely, the classification, histology, genetic abnormalities, epidemiology, origin, biochemistry, imaging, treatment and survival of GEP-NECs are described. Also, organ-specific summaries with more detail in relation to disease presentation, diagnosis, treatment and survival are presented. Finally, key points are discussed with directions for future research priorities.

Detailed analysis of prognostic factors in primary esophageal small cell carcinoma

BACKGROUND

Primary small cell carcinoma of the esophagus (SCCE) is characterized as highly aggressive with a poor prognosis. To identify potential prognostic factors and to assess the role of surgical procedures, chemotherapy, and radiotherapy for SCCE, we retrospectively analyzed patients with SCCE from three large institutions in China.

METHODS

All of the SCCE patients between 1998 and 2012 were identified from three clinical databases of the Sun Yat-Sen University Cancer Center, Peking Union Cancer Hospital and Shantou Cancer Hospital. Potential prognostic factors were analyzed with univariate analysis and a Cox regression model. Subgroup analysis based on the 2002 American Joint Committee on Cancer staging system for esophageal cancer was applied to examine the effect of treatment on survival.

RESULTS

In patients with stage I/II SCCE, 85% underwent operations and showed improved survival (median survival time [MST] 29 vs 17.4 months, p = 0.082). However, chemotherapy did not further improve survival. In patients with stage IIB/III SCCE, chemotherapy, instead of operation, improved survival (MST 13.0 vs 6.1 months, p = 0.003), and radiotherapy resulted in improved survival. In stage IV patients, chemotherapy improved survival (MST 12.5 vs 4.0 months, p < 0.001), and chemotherapy combined with radiotherapy was superior to chemotherapy alone (MST 13.2 vs 8.9 months, p = 0.014).

CONCLUSIONS

Surgical procedures alone can be recommended for stage I/IIA patients. In patients with stage IIB disease or above, chemotherapy should be the main treatment approach, and chemotherapy combined with radiotherapy tended to improve survival.

Clinical impact of tumor-infiltrating inflammatory cells in primary small cell esophageal carcinoma

Primary small cell esophageal carcinoma is a rare and aggressive type of gastrointestinal cancer with poor prognosis. In the present study, the impact of tumour infiltrating inflammatory cells on clinico-pathological characteristics and the patients' prognosis were analysed. A total of 36 small cell esophageal carcinomas, 19 adjacent normal tissues and 16 esophageal squamous cell carcinoma samples were collected. Qualified pathologists examined eosinophils, neutrophils, lymphocytes and macrophages on histochemical slides. The infiltration of eosinophils and macrophages in small cell esophageal carcinoma was significantly increased as compared with tumor adjacent normal tissues, and was significantly less in esophageal squamous cell carcinoma. Macrophage count was significantly associated with (p = 0.015) lymph node-stage in small cell esophageal carcinoma. When we grouped patients into two groups by counts of infiltrated inflammatory cells, Kaplan-Meier analysis revealed that high macrophage infiltration group (p = 0.004) and high eosinophil infiltration group (p = 0.027) had significantly enhanced survival. In addition, multivariate analysis unveiled that eosinophil count (p = 0.002) and chemotherapy (Yes vs. No, p = 0.001) were independent prognostic indicators. Taken together, infiltration of macrophages and eosinophils into the solid tumor appear to be important in the progression of small cell esophageal carcinoma and patients' prognosis.

Primary small cell carcinoma of the esophagus: clinicopathological study of 44 cases

Background

Primary small cell carcinoma of the esophagus (SCCE) is a highly aggressive disease characterized by early dissemination and poor prognosis. Because of the rarity of this disease, few previous studies have investigated the biomarkers associated with its prognosis. Leucine-rich repeat-containing G-protein coupled receptor 5 (Lgr5) is a stem cell marker and a member of the canonical Wnt-signaling cascade. However, the clinical role of Lgr5 in SCCE remains unknown.

Methods

Tissue sections were obtained from 44 patients diagnosed with SCCE and expression of Lgr5 was examined by immunohistochemistry. The correlations between Lgr5 expression, and clinical parameters and prognostic significance were evaluated.

Results

Lgr5 was expressed in SCCE cancer tissues. High Lgr5 expression was significantly correlated with lymph node metastasis (p = 0.003), late stage (p = 0.003) and unfavorable response to chemotherapy (p = 0.013) according to RECIST 1.0 criteria. Patients with higher Lgr5 expression levels had shorter overall survival times than those with lower expression levels.

Conclusions

These results demonstrated that overexpression of Lgr5 was significantly correlated with lymph node metastasis, tumor stage, and response to chemotherapy. Furthermore, high levels of Lgr5 expression appeared to be associated with poorer survival in patients with SCCE.

Limited stage small cell carcinoma of the gastrointestinal tract: a clinicopathologic and prognostic analysis of 27 cases

Small cell carcinoma of the gastrointestinal tract is a rare and aggressive neuroendocrine tumor. This study aims to analyze the clinical characteristics and potential prognostic factors for patients with limited stage small cell carcinoma of the gastrointestinal tract. The records of 27 patients with limited stage small cell carcinoma of the gastrointestinal tract, who all received surgery with lymphadenectomy, were retrieved and analyzed retrospectively. The median age of patients was 60 years old (range 38–79). The primary locations of tumor were the esophagus (74.1%) and stomach (14.8%). The rate of preoperative accurate diagnosis (16.7%) was low for small cell carcinoma of the esophagus and stomach. 40.7% of all the patients had regional lymph node metastases. Five patients underwent surgery alone, and the other 22 were treated with surgery + postoperative chemotherapy. All patients had disease progression or recurrence. The overall median survival time was 10 months and the 1-year survival rate was 37.0%. Patients who received postoperative chemotherapy had a median survival time of 12 months, which was superior to the 5-month survival of for those who only had surgery (P<0.0001). TNM stage (P=0.02) and postoperative chemotherapy (P<0.0001) were considered as two prognostic factors in uni-variate analysis. Postoperative chemotherapy was a significant independent prognostic factor in multivariate analysis (P=0.01). The prognosis for patients with limited stage small cell carcinoma of the gastrointestinal tract remains dismal, however, postoperative chemotherapy may have the potential to improve the outcome for these patients.

p14ARF repression induced by promoter methylation associated with metastasis in esophageal squamous cell carcinoma

The objective of this study is to evaluate the promoter methylation status of the p14ARF in esophageal squamous cell carcinoma (ESCC). Cell lines were treated with the demethylation agent 5-aza-2'-deoxycytidine, and p14ARF messenger RNA (mRNA) expression was detected by reverse transcription-polymerase chain reaction. We analyzed the methylation status of p14ARF promoter by methylation-specific polymerase chain reaction in 50 ESCC and their noncarcinoma tissues. Then demethylation caused by 5-aza-2'-deoxycytidine increased the p14ARF mRNA expression level in esophagus cancer cell lines. p14ARF methylation was found in 48% (24 of 50) of ESCC patients but only in 18% (9 of 50) corresponding noncarcinoma tissues (P = 0.001). There was a statistically significant correlation between the presence of methylation and tumor metastasis (P < 0.001). The p14ARF mRNA was lower in ESCC tissues than nontumor tissues (mean ± standard deviation, 0.47 ± 0.32 vs. 1.40 ± 0.58; P = 0.002). Meanwhile, a signification association was found between the methylation status of p14ARF promoter and p14ARF mRNA expression in tissues (P < 0.05). The aberrant promoter methylation of p14ARF is a common phenomenon in ESCC, which may be an important mechanism of downregulating p14ARF mRNA expression.

Connective tissue growth factor expression in precancerous lesions of human esophageal epithelium and prognostic significance in esophageal squamous cell carcinoma

Connective tissue growth factor (CTGF, CCN2), a secreted protein, is involved in the development and progression of esophageal squamous cell carcinoma (ESCC). However, it remains unclear how CTGF expression affects the progression of ESCC. Our study implicated differences of CTGF protein status in precancerous lesions, and retrospectively examined the associations of CTGF mRNA and protein levels with clinical prognosis in ESCC patients. Here immunohistochemistry and the quantitative real-time real-time reverse transcription polymerase were performed for predicting the CTGF protein status and mRNA levels in ESCC patients, respectively. Different degrees of CTGF protein status presented in normal human esophageal epithelium and precancerous lesions, and CTGF protein was highly expressed in ESCCs. Survival analysis showed that CTGF protein status was significantly related to poor survival of ESCC patients (P= 0.024), while no significant difference was observed between CTGF mRNA levels and the survival of ESCC patients (P= 0.196). Multivariate Cox analysis demonstrated that CTGF protein status was the independent factor in prognosis of ESCC patients. In that way, CTGF protein status might elevate the progression of ESCC, and would be significant for the diagnosis of precancerous lesions or early ESCC.

Small cell carcinoma of the esophagus: a multicentre Rare Cancer Network study

Small cell carcinoma of the esophagus (SCCE) is a rare and aggressive malignant tumor with a poor prognosis. The aims of this retrospective study were to analyze the epidemiology, clinical characteristics, and treatment outcomes of these patients. Between 1994 and 2004, 24 patients with SCCE from several centers were reviewed for data on demographics, presenting symptoms, diagnosis, disease stage, type of treatment, and outcome. SCCE occurs in the sixth decade: median age (interquartile range [IQR]): 65 (59-69) years with a male predominance (63%). The most common complaining symptoms were rapidly progressive dysphagia (79%), weight loss (54%), and retrosternal/epigastric pain (46%). The tumor arises primarily in the middle (52%) or in the lower (35%) third of the esophagus. History of tobacco and alcohol exposure was present in 90% and 70% of case, respectively. Extensive disease was present in 13 cases (54%) at initial diagnosis. The overall median survival (IQR) was 11 (8-20) months for all 24 patients, and the 2-year overall survival was 25.1%. Four patients were alive more than 2 years after treatment. Chemotherapy increased the survival compared with symptomatic management in extensive disease (median survival [IQR]: 9.5 [6-14] vs. 6 [4-7] months, P= 0.05). In limited disease, concurrent chemo-radiotherapy was more effective than non-concurrent treatment (median survival [IQR]: 36 [14-93] vs. 11 [9-15] months, P= 0.04). Two patients were treated by surgery and chemoradiation therapy with a survival of 35 and 66 months. Chemotherapy is the cornerstone of treatment of SCCE in all stage. For limited disease SCCE, concurrent chemo-radiotherapy is the primary choice compared with sequential approach. The role of surgery was not assessable in our study.

A complete response in small cell carcinoma of the esophagus treated by s-1/cisplatin combined chemotherapy and radiotherapy

Small cell carcinoma of the esophagus (SmCCE) is a rare disease which is considered to be more malignant than the most common types of esophageal cancer. The optimal treatment strategy for this disease still remains controversial. A 69-year-old male was diagnosed to have SmCCE (stage IIIA, T3N1M0). Due to the patient's poor general condition, chemo-radiotherapy consisting of S-1/cisplatin therapy and a total of 60 Gy of radiotherapy was performed. After the treatment, the main lesion completely disappeared while some ulceration remained. A histological examination revealed no viable cancer cells in biopsy specimens obtained by endoscopy. Computed tomographic examinations showed a decreased wall thickness of the esophagus and an improvement in the swelling of the lymph nodes. S-1 monotherapy was administered following the main chemoradiation therapy, and it was performed for a total of 20 courses. The patient has been doing well without recurrence for over 3 years. We judged the effect to be a complete response. This combination chemo-radiotherapy with S-1 and cisplatin may therefore be one of the effective treatments against SmCCE.

Adenocarcinoma of the esophagogastric junction: relationship between clinicopathological data and p53, cyclin D1 and Bcl-2 immunoexpressions

CONTEXT

Esophagogastric junction adenocarcinoma has an aggressive behavior, and TNM (UICC) staging is not always accurate enough to categorize patient's outcome.

OBJECTIVES

To evaluated p53, cyclin D1 and Bcl-2 immunoexpressions in esophagogastric junction adenocarcinoma patients, without Barrett's esophagus, and to compared to clinicopathological characteristics and survival rate.

METHODS

Tissue sections from 75 esophagogastric junction adenocarcinomas resected from 1991 to 2003 were analyzed by immunohistochemistry for p53, cyclin D1 and Bcl-2 using streptavidin-biotin-peroxidase method. The mean follow-up time was 60 months SD = 61.5 (varying from 4 to 273 months).

RESULTS

Fifty (66.7%) of the tumors were intestinal type and 25 (33.3%) were diffuse. Vascular, lymph node and perineural infiltration were verified in 16%, 80% and 68% of the patients, respectively. The patients were distributed according to the TNM staging in IA in 4 (5.3%), IB in 10 (13.3%), II in 15 (20%), IIA in 15 (20%), IIIB in 15 (20%) and IV in 16 (21.3%). Immunohistochemical analysis was positive for p53, cyclin D1 and bcl-2 in 68%, 18.7% and 100%, respectively. There was no association between immunoexpression and vascular and/or perineural invasions, clinicopathological characteristics and patients' survival rate.

CONCLUSION

In this selected population, there was no association between the immunomarkers, p53, cyclin D1 and bcl-2 and clinicopathological data and/or overall survival.

Expression and prognostic significance of THBS1, Cyr61 and CTGF in esophageal squamous cell carcinoma

Background

Thrombospondin1 (THBS1), cystene-rich protein 61 (Cyr61) and connective tissue growth factor (CTGF) are all involved in the transforming growth factor-beta (TGF-β) signal pathway, which plays an important role in the tumorigenesis. The purpose of this study is to explore the expression and prognostic significance of these proteins in esophageal squamous cell carcinoma (ESCC).

Methods

We used immunohistochemistry and western blotting to examine the expression status of THBS1, Cyr61 and CTGF in ESCC. Correlations of THBS1, Cyr61 and CTGF over-expressions with various clinicopathologic factors were also determined by using the Chi-square test or Fisher's exact probability test. Survival analysis was assessed by the Kaplan-Meier analysis and the log-rank test. Relative risk was evaluated by the multivariate Cox proportional hazards model.

Results

THBS1, Cyr61 and CTGF were all over-expressed in ESCC. THBS1 over-expression was significantly associated with TNM stage (P = 0.029) and regional lymph node involvement (P = 0.026). Kaplan-Meier survival analysis showed that over-expression of THBS1, Cyr61 or CTGF was related to poor survival of ESCC patients (P = 0.042, P = 0.020, P = 0.018, respectively). Multivariate Cox analysis demonstrated that Cyr61 and CTGF were independent factors in prognosis of ESCC.

Conclusion

Cyr61, CTGF and THBS1 were all over-expressed in ESCC and might be new molecular markers to predict the prognosis of ESCC patients.

Retrospective study of clinicopathologic features and prognosis of high-grade neuroendocrine carcinoma of the esophagus

Clinicopathologic features of esophageal neuroendocrine carcinoma (NEC), apart from those of small-cell carcinoma, have not been characterized. We evaluated the clinicopathologic features and prognosis including overall survival of NEC of the esophagus. We identified 40 patients with esophageal NEC from our institutional database. All cancers had been clinically staged using endoscopic ultrasonography, computed tomography, and positron emission tomography. Neuroendocrine differentiation was confirmed by immunohistochemical staining. The NEC component was classified into small-cell and large-cell subtypes, and non-neuroendocrine components were evaluated. Patients with locoregional disease were treated with chemoradiation with or without surgery or with surgery only. Patients with distant metastasis were treated with systemic therapy. The extent of residual tumors was evaluated in esophagectomy specimens after preoperative chemoradiation. Twenty-seven patients had large-cell NEC, and 13 had small-cell neuroendocrine carcinoma. An adenocarcinoma component was present in 15 patients and squamous carcinoma component in 1 patient. Synaptophysin was positive in all cases, and chromogranin was positive in 31 cases. Seventeen patients had distant metastasis, and 21 had locoregional disease. Seventeen patients with locoregional disease received preoperative chemoradiation. Disease progressed in 7 patients, and 10 had residual tumor in resection specimens. Overall survival was better with locoregional disease than with distant metastasis (P=0.006). Overall survival was better in patients with non-neuroendocrine component than in patients with pure NEC (P=0.031). There was no difference in prognosis between patients with large-cell NEC and those with small-cell neuroendocrine carcinoma. Esophageal NEC is an aggressive tumor, and patients with mix NEC have better outcome.

hTERT expression in colorectal adenocarcinoma: correlations with p21, p53 expressions and clinicopathological features

BACKGROUND

The clinicopathological roles and relationships of hTERT, p21 and p53 proteins have not been studied in depth in colorectal cancer. The aim of the present study is to investigate the clinicopathological roles of expression of hTERT protein expression and its relationship with the expression of p21 and p53 proteins in a large cohort of patients with colorectal adenocarcinoma.

MATERIALS AND METHODS

Expressions of hTERT, p21 and p53 proteins were investigated in 188 patients with colorectal adenocarcinomas by immunohistochemistry. The findings were correlated with the clinicopathological features and survival data of colorectal adenocarcinomas.

RESULTS

hTERT, p53 and p21 proteins were detected in 63%, 100% and 62% of the patients with colorectal carcinoma. High level of hTERT protein expression was noted in patients with metastases (p = 0.038) and in patients with rectal cancer (p = 0.046). Loss or low level of p21 protein was often noted in non-mucinous colorectal adenocarcinoma when compared with mucinous adenocarcinoma (p = 0.001). Furthermore, p53 expression was more frequently noted in non-mucinous adenocarcinoma (p = 0.001). The level of expression of p21 protein was positively correlated with expression of level of hTERT protein (p = 0.00001). The survival of the patients was related to staging (p = 0.001) and p53 protein expression (p = 0.038) of the tumours.

CONCLUSIONS

hTERT protein expression is an indicator of the biological aggressiveness of the cancer. The level of expression of the protein was also related to the distal location and level of p21 expression of the tumours.

Clinicopathologic features and histochemical analyses of proliferative activity and angiogenesis in small cell carcinoma of the esophagus

BACKGROUND

We investigated clinicopathologic features in patients with esophageal small cell carcinoma (SCEC), and its proliferative activity and angiogenesis.

METHODS

Ten patients with SCEC from 335 esophageal carcinoma patients were analyzed clinicopathologically. For analyses of cell proliferation, apoptosis, and angiogenesis of SCEC, Ki-67 immunostaining, the TUNEL method, and CD31 and CD68 immunostaining were used.

RESULTS

Esophagectomy was performed in nine patients, while one with extensive SCEC was treated by repeated chemotherapy and radiotherapy. Four patients received chemotherapy both before and after surgery, one only before surgery, and four only after surgery. Cisplatin and etoposide were given to five patients, while irinotecan and cisplatin were given to three. Five survived more than 18 months, and two more than 36 months. One of these two had limited SCEC treated by surgery and chemotherapy, whereas the other had extended SCEC treated by repeated chemotherapy and radiotherapy. The microvessel count and the Ki-67 labeling index of SCEC were higher than those of squamous cell carcinoma (P = 0.0033 and P = 0.0005, respectively). Between SCEC with and without preoperative chemotherapy, the Ki-67 labeling index was lower (P = 0.027) and the apoptotic index was higher in the treated SCEC (P = 0.014). Between SCEC patients who survived more or less than 18 months, the microvessel count was lower in those who survived more than 18 months (P = 0.049).

CONCLUSIONS

Esophagectomy may be indicated for limited SCEC combined with chemotherapy. SCEC has high proliferative activity and rich neovascularization, and its proliferative activity may be suppressed by chemotherapy.

Primary colorectal small cell carcinoma: a clinicopathological and immunohistochemical study of 10 cases

Colorectal small cell carcinoma (SmCC) is a rare tumor with an aggressive course. The aim of this study is to summarize our experience with this tumor and to highlight its immunohistochemical profile. Ten cases of colorectal SmCC were identified in our files and a panel of immunostains was performed. Follow up was available for the average of 3 years, during which 7 patients died and 3 were alive with disease. All cases were positive for LMWK, CK 19 and pancytokeratin but were negative for TTF-1 and CA 125. EGFR was positive in 7 cases. TTF-1 negative staining may be valuable in differentiating it from its pulmonary counterpart. CDX2, mCEA, CD56, synaptophysin, NSE and chromogranin can help differentiate it from non-endocrine poorly differentiated adenocarcinoma. The expression of EGFR in a subset of patients has not been reported earlier and has to be evaluated in larger series to assess its role in the planning of targeted biologic therapy.

The pathology of extrapulmonary small cell carcinoma

Extrapulmonary small cell carcinomas (EPSCCs) are uncommon malignant neoplasms with a reported incidence of 0.1% to 0.4% in the United States. Since their first description in 1930, they have been seen in nearly every organ system. Like their more common pulmonary counterparts, EPSCCs are thought to arise from a multipotential stem cell. However, there is recent molecular evidence that small cell elements may arise as a late-stage phenomenon in the genetic progression of more organ-typical carcinomas. The morphologic, immunohistochemical, and ultrastructural features are similar to those described in pulmonary small cell carcinomas (PSCCs). The differential diagnosis of EPSCC includes PSCC, other neuroendocrine tumors, small round blue cell tumors, metastatic melanoma, lymphoma, and poorly differentiated non-small cell carcinomas. Molecular alterations reported to occur in EPSCCs include abnormalities described in PSCC and changes found in carcinomas more typically encountered in the organ from which they arise. In this article we discuss the pathology of EPSCC with a review of theories of histogenesis, sites of occurrence, diagnostic features, differential diagnosis, molecular alterations, and clinical behavior.

Small cell carcinomas of the gastrointestinal tract: clinicopathological features and treatment approach

Small cell undifferentiated carcinoma (SmCC) of the gastrointestinal tract (GIT) is a rare and highly aggressive malignancy. To date, fewer than 1,000 cases have been reported, with an estimated prevalence of 0.1% to 1% of all gastrointestinal (GI) tumors. Data on the disease are scarce due to its rarity and the fact that most authors have focused on one site within the GIT. In light of the limited data and its perceived similarity to SmCC of the lung, the disease has usually been treated as the latter. Nevertheless, recent clinicopathologic and molecular data imply several differences between the two entities, questioning the extent to which extrapolations from one to the other can be made. We review the available data on GI SmCC with emphasis on outlining its clinicopathologic features and the recommended treatment approach.

Clinical significance of p16INK4a and p53 overexpression in endocrine tumors of the gastrointestinal tract

This study was designed to determine the expression of p16, p53, and CD117 in gastrointestinal tract endocrine tumors. Immunohistochemical studies of p16, p53, and CD117 were performed in 57 gastrointestinal tract endocrine tumors, including 22 poorly differentiated endocrine carcinomas (PDECs) and 35 well-differentiated endocrine tumors (WDETs). Overexpression of p16 and p53 was observed in 16 (73%) and 10 (45%) of the PDECs, respectively, whereas only 1 WDET showed overexpression of p53 and none showed overexpression of p16. A total of 18 (82%) of the PDECs showed overexpression of p16 or p53 proteins. This is closely associated with PDEC (P < .0001). By using overexpression of p16 or p53 as the criteria for PDEC, the sensitivity and specificity are 81.8% and 97.1%, respectively, with positive and negative predictive values of 94.7% and 89.5%, respectively. CD117 was not detected in any of the 57 gastrointestinal endocrine tumors by immunohistochemical analysis.

Small-cell carcinoma of the gastrointestinal tract: a retrospective study of 64 cases

Small-cell carcinoma (SmCC) of the gastrointestinal tract is a very rare and aggressive malignancy. To better define its clinicopathological features, the records of all patients with this disease seen at Memorial Sloan Kettering Cancer Center between 1980 and 2002 (n=64) were reviewed. The most common primary tumour locations were in the large bowel and oesophagus. Predisposing medical conditions for non-small-cell cancers, positive family cancer history, and metachronous tumours were common. In all, 37% had mixed tumour histology and 48% presented with extensive disease, according to the Veterans' Administration Lung Study group (VALSG) staging system used for small-cell lung cancer. Treatment outcome in limited disease (LD) suggested a role for surgery and chemotherapy. Platinum-based regimens resulted in a 50% response rate. The 2-year survival was 23% and two prognostic factors were identified, the extent of disease according to the VALSG system (P<0.01) and TNM stage (P=0.03). Anatomic location had no clinical impact. In conclusion, SmCC from various gastrointestinal sites can be viewed as one clinical entity. Mixed tumour histology is common and may affect therapy. Surgery, combined with chemotherapy, should be considered for LD. The value of the VALSG system was implied and possible differences from small-cell lung cancer were noted.

Small-Cell Carcinomas of the Gastrointestinal Tract: A Review

Purpose

To improve our understanding of the entity of small-cell carcinoma (SmCC) of the gastrointestinal (GI) tract.

Methods

A MEDLINE search was done, using the terms “small cell carcinoma” or “oat cell carcinoma” combined with “gastrointestinal” or with any of the GI sites, for the period 1970 to 2003. The 138 eligible reports identified in this way were reviewed for clinical data.

Results

To date, approximately 544 cases of GI SmCC have been reported. The disease represents 0.1% to 1% of all GI malignancies, with the esophagus being the most common primary site. A majority of patients present with overt distant metastases. Systemic symptoms are common; ectopic hormonal secretion may occur. By light microscopy, GI SmCCs are essentially indistinguishable from primary pulmonary SmCC. The presence of non-SmCC components is common. Data from molecular analysis of the disease has identified some similarities to pulmonary SmCC. Chemotherapy represents the main treatment option, with modest impact on survival. In locoregional disease, the literature suggests that treatment be initiated using chemoradiotherapy and then, if metastatic disease is still excluded, surgical resection be considered. The disease is highly aggressive, and survival is in the range of several weeks for untreated patients and of 6 to 12 months for those receiving therapy.

Conclusion

SmCC of the GI tract is a rare and lethal disease. Although there are many similarities to pulmonary SmCC, some differences between the two entities are suggested. While chemotherapy can achieve significant palliation, surgery may have a potential impact on long-term survival of patients with locoregional disease.

Molecular aspects of esophageal squamous cell carcinoma carcinogenesis

BACKGROUND

The development of human esophageal cancer is a multistep, progressive process. An early indicator of this process is an increased proliferation of esophageal epithelial cells morphologically including basal cell hyperplasia, dysplasia, carcinoma in situ and advanced esophageal squamous cell carcinoma. The process of tumorigenesis at cellular level is related to disorders of the control of cell proliferation and differentiation and controlled cell death (apoptosis). Most of cancer cells contain genetic alterations related to the control of these processes, including transcription factors and apoptosis related proteins.

AIM

In this review, the current knowledge of the genetic profile of this subtype of esophageal tumor is discussed, focusing on the potential of the development of novel tools for clinical management of esophageal squamous cell carcinoma.

CONCLUSIONS

The advances in the field of molecular biology have let us to deeper our knowledge of the process of carcinogenesis of esophagus. Ideally, this knowledge should be translated in benefits for patients suffering from cancer. Thus, better understanding of molecular alterations during carcinogenesis is expected to improve tumor control and prevention and also may lead to better disease management.

Image analysis system for assessment of immunohistochemically stained proliferative marker (MIB-1) in oesophageal squamous cell carcinoma

The prognosis of oesophageal cancer patients is related to the portion of MIB-1 positively stained tumour nuclei. In this study, an image analysis system was developed based on LEICA Image Processing and Analysis System to reduce the subjective, tedious and inaccurate manual counting of nuclei staining. Representative oesophageal cancer tissues were collected and immunohistochemical preparations of MIB-1 were made. The MIB-1 positive nuclei in these tumours were assessed by quantitative counting, semi-quantitative counting, and three computer assessment methods using LEICA QWIN PRO. Our results showed that computer assessment methods were reliable and consistent. The procedure using the system could be accomplished within 15 min. Overlapped or missed counting of nuclei by the observer were eliminated. The image analysis system can really assist experts in obtaining reliable data for the prognosis of oesophageal cancer patients quickly.

Telomerase activity in small cell esophageal carcinoma

Small cell carcinoma of the esophagus is a rare and aggressive malignant tumor. Telomerase activation is common in human cancers. There is a lack of data on telomerase activity in esophageal small cell cancers. The present report studied the role of telomerase activity in esophageal small cell carcinoma. The clinicopathologic data of five patients with small cell carcinoma of the esophagus who underwent primary surgical treatment between 1991 and 2000 were studied. Telomeric repeat amplification protocol assays were used to investigate telomerase activity in these tumors. The proliferative activity (MIB-1) and p53 expression of these tumors were also studied using immunohistochemistry and correlated with the telomerase activity. All five small cell carcinomas showed detectable telomerase activity in the primary tumor. Two out of the five morphologically normal esophageal mucosae adjacent to the primary tumor had detectable telomerase activity. There was no correlation between the p53 expression, tumor stage, survival of patients, and the presence of telomerase activity. High MIB-1 expression in esophageal small cell carcinomas was associated with high telomerase activity. Telomerase activation is common in small cell carcinoma of the esophagus. This fact may find application in anti-telomerase treatment for this aggressive tumor.