First-Line Nivolumab Plus Chemotherapy for Advanced Gastric, Gastroesophageal Junction, and Esophageal Adenocarcinoma: 3-Year Follow-Up of the Phase III CheckMate 649 Trial

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.We report 3-year efficacy and safety results from the phase III CheckMate 649 trial. Patients with previously untreated advanced or metastatic gastroesophageal adenocarcinoma were randomly assigned to nivolumab plus chemotherapy or chemotherapy. Primary end points were overall survival (OS) and progression-free survival (PFS) by blinded independent central review (BICR) in patients whose tumors expressed PD-L1 combined positive score (CPS) ≥5. With 36.2-month minimum follow-up, for patients with PD-L1 CPS ≥5, the OS hazard ratio (HR) for nivolumab plus chemotherapy versus chemotherapy was 0.70 (95% CI, 0.61 to 0.81); 21% versus 10% of patients were alive at 36 months, respectively; the PFS HR was 0.70 (95% CI, 0.60 to 0.81); 36-month PFS rates were 13% versus 8%, respectively. The objective response rate (ORR) per BICR was 60% (95% CI, 55 to 65) with nivolumab plus chemotherapy versus 45% (95% CI, 40 to 50) with chemotherapy; median duration of response was 9.6 months (95% CI, 8.2 to 12.4) versus 7.0 months (95% CI, 5.6 to 7.9), respectively. Nivolumab plus chemotherapy also continued to show improvement in OS, PFS, and ORR versus chemotherapy in the overall population. Adding nivolumab to chemotherapy maintained clinically meaningful long-term survival benefit versus chemotherapy alone, with an acceptable safety profile, supporting the continued use of nivolumab plus chemotherapy as standard first-line treatment for advanced gastroesophageal adenocarcinoma.

ApoA-I and ApoB levels, and ApoB-to-ApoA-I ratio as candidate pre-treatment biomarkers of pathomorphological response to neoadjuvant therapy in gastric and esophago-gastric junction adenocarcinoma

<b><br>Introduction:</b> Neoadjuvant chemotherapy (NAC) is a part of the current standard of care in a locally advanced gastric adenocarcinoma (GA) and esophagogastric junction adenocarcinoma (EGJA), but only patients with good pathomorphological response (pR) to NAC benefit from prolonged overall survival.</br> <b><br>Aim:</b> The study aims to evaluate ApoA-I and ApoB as candidate pre-treatment biomarkers of pR to NAC in patients with GA and EGJA.</br> <b><br>Materials and methods:</b> Serum samples were collected from 18 patients with GA and 9 with EGJA before the initiation of NAC to determine the ApoA-I and ApoB levels. After NAC tumor regression grade (TRG) was evaluated in resected specimens according to the Mandard's tumor regression grading system and correlated with pre-treatment ApoA-I and ApoB serum concentration, and ApoB-to-ApoA-I serum concentration ratio.</br> <b><br>Results:</b> We found a positive correlation of ApoA-I level and pR (95% CI: -0.863 to -0.467; P < 0.0001), a negative correlation of ApoB level and pR (95% CI: 0.445 to 0.857; P < 0.0001), a negative correlation of ApoB-to-ApoA-I ratio and pR (95% CI: 0.835 to 0.964; P < 0.0001).</br> <b><br>Conclusions:</b> ApoA-I and ApoB levels, and ApoB-to-ApoA-I ratio are candidate pre-treatment predictors of pR to NAC in GA and may help to guide personalized therapy.</br>Our work fits into the dynamically developing trend of personalized treatment. It describes a potentially important rationale for further evaluation of apolipoprotein A-I and apolipoprotein B as predictors of cancer response to neoadjuvant therapy.

Influence of Clinical Factors on miR-3613-3p Expression in Colorectal Cancer

Colorectal cancer (CRC) is the second most common cause of cancer-related death globally. Because of a tendency to be an asymptomatic primary tumor and therefore resulting in late detection, most CRC patients are diagnosed in the advanced stage. Several miRNAs have the potential to become novel noninvasive biomarkers measured as diagnostic and prognostic indicators of CRC to guide surgical therapies and promote the understanding of the carcinogenesis of CRC. Since the change of miR-3613-3p was associated with several types of cancer other than colorectal cancer, there is a lack of functional evidence and the results are inconsistent. We conducted a pilot microarray study in which we noted a decreased expression of miR-3613-3p in colorectal cancer cells, then we confirmed the expression of miR-3613-3p by qPCR on a group of 83 patients, including 65 patients with colorectal cancer, 5 with a benign tumor and 13 from the control group. We noted that in both malignant and benign tumors, miR-3613-3p is downgraded relative to the surrounding tissue. As a result of the study, we also observed colorectal tumor tissue and surrounding tissue in patients with colorectal cancer who received radiotherapy before surgery, which showed a significantly higher expression of miR-3613-3p compared to patients who did not receive radiotherapy. In addition, we noted that the tissue surrounding the tumor in patients with distant metastases showed a significantly higher expression of miR-3613-3p compared to patients without distant metastases. The increased expression of miR-3613-3p in patients after radiotherapy suggests the possibility of using this miR as a therapeutic target for CRC, but this requires confirmation in further studies.

Dissecting the genetic heterogeneity of gastric cancer

BACKGROUND

Gastric cancer (GC) is clinically heterogenous according to location (cardia/non-cardia) and histopathology (diffuse/intestinal). We aimed to characterize the genetic risk architecture of GC according to its subtypes. Another aim was to examine whether cardia GC and oesophageal adenocarcinoma (OAC) and its precursor lesion Barrett's oesophagus (BO), which are all located at the gastro-oesophageal junction (GOJ), share polygenic risk architecture.

METHODS

We did a meta-analysis of ten European genome-wide association studies (GWAS) of GC and its subtypes. All patients had a histopathologically confirmed diagnosis of gastric adenocarcinoma. For the identification of risk genes among GWAS loci we did a transcriptome-wide association study (TWAS) and expression quantitative trait locus (eQTL) study from gastric corpus and antrum mucosa. To test whether cardia GC and OAC/BO share genetic aetiology we also used a European GWAS sample with OAC/BO.

FINDINGS

Our GWAS consisting of 5816 patients and 10,999 controls highlights the genetic heterogeneity of GC according to its subtypes. We newly identified two and replicated five GC risk loci, all of them with subtype-specific association. The gastric transcriptome data consisting of 361 corpus and 342 antrum mucosa samples revealed that an upregulated expression of MUC1, ANKRD50, PTGER4, and PSCA are plausible GC-pathomechanisms at four GWAS loci. At another risk locus, we found that the blood-group 0 exerts protective effects for non-cardia and diffuse GC, while blood-group A increases risk for both GC subtypes. Furthermore, our GWAS on cardia GC and OAC/BO (10,279 patients, 16,527 controls) showed that both cancer entities share genetic aetiology at the polygenic level and identified two new risk loci on the single-marker level.

INTERPRETATION

Our findings show that the pathophysiology of GC is genetically heterogenous according to location and histopathology. Moreover, our findings point to common molecular mechanisms underlying cardia GC and OAC/BO.

FUNDING

German Research Foundation (DFG).

Pre-therapeutic molecular biomarkers of pathological response to neoadjuvant chemotherapy in gastric and esophago-gastric junction adenocarcinoma: A systematic review and meta-analysis

PURPOSE

Multimodal treatment is the standard of care in patients with locally advanced gastric cancer. Unfortunately, the response rate after neoadjuvant treatment remains limited. The ability to predict the response has a potential to improve patient outcomes by promoting a more individualized approach. We sought to describe the current state of research in pre-treatment molecular biomarkers of response to neoadjuvant therapy in gastric adenocarcinoma available for testing before the initiation of treatment and to perform a systematic review and meta-analysis in order to summarize and evaluate the potential methods.

METHODS

A systematic MEDLINE, EMBASE and CENTRAL literature search was conducted to extract articles on potentially predictive molecular biomarkers of pathological response to neoadjuvant therapy in patients with gastric- and esophago-gastric junction adenocarcinoma. Fixed and random effects models were used to undertake the meta-analysis when appropriate.

RESULTS

Data on predictive biomarkers was reported in 38 studies. These articles described 47 biomarkers showing statistical significance. After evaluation of all reported biomarkers, 3 of them met the inclusion criteria for meta-analysis. The meta-analysis results indicate that >5 ​ng/mL pre-therapeutic serum concentration of carcinoembryonic antigen (CEA; norm <5 ​ng/mL) is significantly associated with tumor response (RR ​= ​5.13, 95% CI 2.53-10.43, P ​= ​0.026).

CONCLUSION

Previous studies describe a large number of candidate biomarkers. Our meta-analysis indicated pre-therapeutic serum concentration of CEA >5 ​ng/mL as a potential and easy-accessible biomarker available for use before initiation of treatment. However, it could be only an additional tool for complex qualification for neoadjuvant therapy.

A plain language summary of the CheckMate 649 study: nivolumab in combination with chemotherapy compared to chemotherapy alone for untreated advanced or metastatic cancer of the stomach or esophagus

WHAT IS THIS SUMMARY ABOUT?

This is a summary of the 1-year results of a clinical research study known as CheckMate 649 published in The Lancet in June 2021. The 2-year results on the participants' health and overall quality of life from the same study are in a second publication in Nature in March 2022. Until recently, chemotherapy was the only first treatment option for people with advanced or metastatic gastroesophageal adenocarcinoma who had not been treated before. Patients receiving chemotherapy lived on average for less than 1 year. Nivolumab is an immunotherapy that works by activating a person's immune system to fight back against cancer cells. The goal of CheckMate 649 was to find out if the combination of nivolumab and chemotherapy would help patients with advanced or metastatic gastroesophageal adenocarcinoma live longer and without their cancer getting worse.

WHAT WERE THE RESULTS?

Results from the final analysis are reported here. Of 1581 people who took part in the study, 789 received nivolumab and chemotherapy and 792 received chemotherapy. Researchers found that, on average, participants who received nivolumab and chemotherapy lived longer overall than those who received chemotherapy alone. The length of time participants lived without their cancer getting worse was also longer on average with nivolumab and chemotherapy than chemotherapy treatment alone. However, more participants in the nivolumab and chemotherapy group had side effects than those in the chemotherapy group. The three most common side effects in both types of treatment were nausea (urge to vomit), diarrhea and peripheral neuropathy. Participants who received nivolumab and chemotherapy had a lower risk of their cancer symptoms worsening and reported that they were 'less bothered' from side effects of treatment than those receiving chemotherapy alone.

WHAT DO THE RESULTS MEAN?

The nivolumab and chemotherapy combination is considered a new standard treatment option and is approved in several countries as a treatment for adults who have not been treated before for their advanced or metastatic gastroesophageal cancer based on results from CheckMate 649. Clinical Trial Registration: NCT02872116 (ClinicalTrials.gov).

Nivolumab (NIVO) plus chemotherapy (chemo) vs chemo as first-line (1L) treatment for advanced gastric cancer/gastroesophageal junction cancer/esophageal adenocarcinoma (GC/GEJC/EAC): 3-year follow-up from CheckMate 649

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Background: NIVO + chemo demonstrated superior overall survival (OS) and clinically meaningful progression-free survival (PFS) benefit vs chemo and an acceptable safety profile in previously untreated patients (pts) with advanced GC/GEJC/EAC, leading to approvals in multiple countries including the US. NIVO + chemo continued to demonstrate clinically meaningful improvement in efficacy after 2 years of follow-up. We present efficacy and safety analyses from NIVO + chemo vs chemo from the 3-year follow-up of CheckMate 649. Methods: Adults with previously untreated, unresectable advanced, or metastatic GC/GEJC/EAC were enrolled, regardless of programmed death ligand 1 (PD-L1) expression. Pts with known HER2-positive status were excluded. Randomized pts received NIVO (360 mg Q3W or 240 mg Q2W) + chemo (XELOX Q3W or FOLFOX Q2W), NIVO + ipilimumab, or chemo. Dual primary endpoints for NIVO + chemo vs chemo were OS and PFS by blinded independent central review (BICR) in pts with PD-L1 combined positive score (CPS) ≥ 5. Results: 581 pts were concurrently randomized to NIVO + chemo or chemo. With 36-month (mo) minimum follow-up, NIVO + chemo continued to demonstrate OS and PFS benefit vs chemo in pts with PD-L1 CPS ≥ 5 and all randomized pts. The objective response rate (ORR) per BICR in pts with PD-L1 CPS ≥ 5 who had measurable lesions at baseline was 60% (95% CI 55–65) with NIVO + chemo vs 45% (95% CI 40–50) with chemo; in all randomized pts, ORR per BICR was 58% (95% CI 54–62) with NIVO + chemo vs 46% (95% CI 42–50) with chemo. Responses were more durable with NIVO + chemo vs chemo in pts with PD-L1 CPS ≥ 5 (median [m] duration of response [mDOR] 9.6 mo [95% CI 8.2–12.4] vs 7.0 mo [95% CI 5.6–7.9], respectively) and in all randomized pts (mDOR 8.5 mo [95% CI 7.7–9.9] vs 6.9 mo [95% CI 5.8–7.2], respectively). OS benefit with NIVO + chemo was observed across most prespecified subgroups. No new safety signals were identified. A summary of treatment-related adverse events (TRAEs) is shown here. Conclusions: After 3 years of follow-up, NIVO + chemo continued to demonstrate clinically meaningful long-term survival benefit with an acceptable safety profile, further supporting its use as a standard 1L treatment in previously untreated pts with advanced GC/GEJC/EAC. Clinical trial information: NCT02872116 . [Table: see text]

Nivolumab (NIVO) plus chemotherapy (chemo) versus chemo as first-line (1L) treatment for advanced gastric cancer/gastroesophageal junction cancer/esophageal adenocarcinoma (GC/GEJC/EAC): Expanded efficacy, safety, and subgroup analyses from CheckMate 649

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Background: CheckMate 649 is a randomized, global phase 3 study of 1L programmed death-1 (PD-1) inhibitor–based therapies in advanced non-HER2-positive GC/GEJC/EAC that demonstrated superior overall survival (OS) with NIVO + chemo vs chemo, leading to approvals in the US and other countries. Clinically meaningful long-term survival benefit with NIVO + chemo vs chemo was observed with 24 months (mo) of minimum follow-up in all randomized patients (pts) for both OS (HR 0.79 [95% CI 0.71–0.88]) and progression-free survival (PFS; HR 0.79 [95% CI 0.70–0.89]; Janjigian YY et al; ESMO 2021). We present expanded analyses of NIVO + chemo vs chemo with minimum follow-up of 24 mo. Methods: Adults with previously untreated, unresectable advanced or metastatic GC/GEJC/EAC were enrolled regardless of PD-ligand (L)1 expression. Pts with known HER2-positive status were excluded. Pts were randomized to NIVO (360 mg Q3W or 240 mg Q2W) + chemo (XELOX Q3W or FOLFOX Q2W), NIVO 1 mg/kg + IPI 3 mg/kg Q3W (4 doses, then NIVO 240 mg Q2W), or chemo. Dual primary endpoints were OS and PFS (per blinded independent central review) in pts with PD-L1 combined positive score (CPS) ≥ 5 for NIVO + chemo vs chemo. Hierarchically tested secondary endpoints included OS in NIVO + chemo vs chemo (PD-L1 CPS ≥ 1, then all randomized). Results: Of 2031 pts, 1581 were randomized to NIVO + chemo or chemo. In all randomized pts, 41% of pts (NIVO + chemo) and 44% of pts (chemo) received subsequent therapy. Median PFS2 (time from randomization to progression after subsequent systemic therapy, initiation of second subsequent systemic therapy, or death, whichever is earlier) was 12.2 (95% CI 11.3–13.5) mo with NIVO + chemo and 10.4 (95% CI 9.7–11.2) mo with chemo (HR 0.75 [95% CI 0.67–0.84]). 51% of pts (NIVO + chemo) and 43% of pts (chemo) had > 50% reduction from baseline in tumor burden, while 24% and 17% had > 80% reduction, respectively. The HR (95% CI) for OS was 0.66 (0.56–0.77) among pts with a PD-L1 CPS ≥ 10 (median OS for NIVO + chemo vs chemo: 15.0 [95% CI 13.7–16.7] vs 10.9 [95% CI 9.8–11.9] mo). OS benefit was observed with NIVO + chemo vs chemo across multiple additional subgroups, and these data will be presented. No new safety signals were identified. The majority of the treatment-related adverse events with potential immunologic etiology were grade 1 or 2 and grade 3 or 4 events were reported in ≤ 5% of pts in both treatment arms. Conclusions: NIVO + chemo continued to demonstrate clinically meaningful efficacy and an acceptable safety profile with longer follow-up, further supporting the use of NIVO + chemo as a standard 1L therapy in previously untreated pts with advanced GC/GEJC/EAC. Clinical trial information: NCT02872116.

Successful Late Endoscopic Stent-Grafting in a Patient with Boerhaave Syndrome

Patient: Male, 53-year-old

Final Diagnosis: Spontaneous esophageal rupture

Symptoms: Chest pain • dyspena • hydropneumothorax • purulent discharge from the umbilicus • vomiting

Medication: —

Clinical Procedure: Endoscopic stent-grafting • enteral feeding • pleural drainage

Specialty: Gastroenterology and Hepatology • Surgery

First-line nivolumab plus chemotherapy versus chemotherapy alone for advanced gastric, gastro-oesophageal junction, and oesophageal adenocarcinoma (CheckMate 649): a randomised, open-label, phase 3 trial

BACKGROUND

First-line chemotherapy for advanced or metastatic human epidermal growth factor receptor 2 (HER2)-negative gastric or gastro-oesophageal junction adenocarcinoma has a median overall survival (OS) of less than 1 year. We aimed to evaluate first-line programmed cell death (PD)-1 inhibitor-based therapies in gastric, gastro-oesophageal junction, and oesophageal adenocarcinoma. We report the first results for nivolumab plus chemotherapy versus chemotherapy alone.

METHODS

In this multicentre, randomised, open-label, phase 3 trial (CheckMate 649), we enrolled adults (≥18 years) with previously untreated, unresectable, non-HER2-positive gastric, gastro-oesophageal junction, or oesophageal adenocarcinoma, regardless of PD-ligand 1 (PD-L1) expression from 175 hospitals and cancer centres in 29 countries. Patients were randomly assigned (1:1:1 while all three groups were open) via interactive web response technology (block sizes of six) to nivolumab (360 mg every 3 weeks or 240 mg every 2 weeks) plus chemotherapy (capecitabine and oxaliplatin every 3 weeks or leucovorin, fluorouracil, and oxaliplatin every 2 weeks), nivolumab plus ipilimumab, or chemotherapy alone. Primary endpoints for nivolumab plus chemotherapy versus chemotherapy alone were OS or progression-free survival (PFS) by blinded independent central review, in patients whose tumours had a PD-L1 combined positive score (CPS) of five or more. Safety was assessed in all patients who received at least one dose of the assigned treatment. This study is registered with ClinicalTrials.gov, NCT02872116.

FINDINGS

From March 27, 2017, to April 24, 2019, of 2687 patients assessed for eligibility, we concurrently randomly assigned 1581 patients to treatment (nivolumab plus chemotherapy [n=789, 50%] or chemotherapy alone [n=792, 50%]). The median follow-up for OS was 13·1 months (IQR 6·7-19·1) for nivolumab plus chemotherapy and 11·1 months (5·8-16·1) for chemotherapy alone. Nivolumab plus chemotherapy resulted in significant improvements in OS (hazard ratio [HR] 0·71 [98·4% CI 0·59-0·86]; p<0·0001) and PFS (HR 0·68 [98 % CI 0·56-0·81]; p<0·0001) versus chemotherapy alone in patients with a PD-L1 CPS of five or more (minimum follow-up 12·1 months). Additional results showed significant improvement in OS, along with PFS benefit, in patients with a PD-L1 CPS of one or more and all randomly assigned patients. Among all treated patients, 462 (59%) of 782 patients in the nivolumab plus chemotherapy group and 341 (44%) of 767 patients in the chemotherapy alone group had grade 3-4 treatment-related adverse events. The most common any-grade treatment-related adverse events (≥25%) were nausea, diarrhoea, and peripheral neuropathy across both groups. 16 (2%) deaths in the nivolumab plus chemotherapy group and four (1%) deaths in the chemotherapy alone group were considered to be treatment-related. No new safety signals were identified.

INTERPRETATION

Nivolumab is the first PD-1 inhibitor to show superior OS, along with PFS benefit and an acceptable safety profile, in combination with chemotherapy versus chemotherapy alone in previously untreated patients with advanced gastric, gastro-oesophageal junction, or oesophageal adenocarcinoma. Nivolumab plus chemotherapy represents a new standard first-line treatment for these patients.

FUNDING

Bristol Myers Squibb, in collaboration with Ono Pharmaceutical.

First-line (1L) nivolumab (NIVO) plus chemotherapy (chemo) versus chemo in advanced gastric cancer/gastroesophageal junction cancer/esophageal adenocarcinoma (GC/GEJC/EAC): Expanded efficacy and safety data from CheckMate 649

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Background: CheckMate 649 is the largest randomized, global phase 3 study of 1L programmed death (PD)-1 inhibitor–based therapy in GC/GEJC/EAC. 1L NIVO + chemo demonstrated superior overall survival (OS) vs chemo, with progression-free survival (PFS) benefit and an acceptable safety profile in pts whose tumors expressed PD-ligand (L)1 at combined positive score (CPS) ≥ 5 and ≥ 1, and in all randomized pts (Moehler et al. Ann Oncol 2020). We report additional data for all randomized pts. Methods: Eligible pts had previously untreated, unresectable advanced or metastatic GC/GEJC/EAC. Known HER2-positive pts were excluded. Pts were randomized to receive NIVO (360 mg Q3W or 240 mg Q2W) + chemo (XELOX Q3W or FOLFOX Q2W), NIVO + ipilimumab, or chemo. Dual primary endpoints for NIVO + chemo vs chemo were OS and PFS by blinded central review in PD-L1 CPS ≥ 5 pts. Hierarchically tested secondary endpoints were OS in PD-L1 CPS ≥ 1 and all randomized pts. Results: At 12-month minimum follow-up for 1581 randomized pts, NIVO + chemo had a statistically significant OS benefit vs chemo (HR 0.80 [99.3% CI 0.68–0.94; P = 0.0002]) in all randomized pts; PFS benefit was also seen (HR 0.77 [95% CI 0.68–0.87]). OS benefit was observed in multiple prespecified subgroups, consistent with the primary population. Grade 3–4 treatment-related adverse events (TRAEs) were reported in 59% (NIVO + chemo) and 44% (chemo) of pts. TRAEs with potential immunologic etiology (select TRAEs; sTRAEs) are shown in the table. Pts in the NIVO + chemo arm had decreased risk of symptom deterioration on treatment vs those in the chemo arm (HR 0.77 [95% CI 0.63–0.95; P = 0.0129]). Tolerability as measured by the FACT-Ga GP5 item was similar in both treatment groups. Conclusions: The addition of NIVO to chemo demonstrated improved OS and PFS benefit in all randomized pts, along with an acceptable safety profile and maintained tolerability as well as QoL, providing further support for NIVO + chemo as a standard 1L treatment for advanced GC/GEJC/EAC. Clinical trial information: NCT02872116. [Table: see text]

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

BACKGROUND

80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.

METHODS

This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.

FINDINGS

Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

INTERPRETATION

Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.

FUNDING

National Institute for Health Research Global Health Research Unit.

HER2 gene assessment in liquid biopsy of gastric and esophagogastric junction cancer patients qualified for surgery

BACKGROUND

Amplification of HER2 gene (ERBB2) and overexpression of HER2 protein on cancer cells are found in 10-26% of gastric cancer (GC) and esophagogastric junction cancer (EGJC). Gene copy number variation (CNV) could be detected in these patients in liquid biopsy and in cancer cells.

METHODS

We analysed HER2 gene CNV used qPCR method in 87 sera collected from GC and EGJC patients before surgical treatment and in 40 sera obtained from healthy donors. HER2 gene CNV was also assessed in formalin-fixed paraffin-embedded (FFPE) tumor tissue. Furthermore, we assessed the number of HER2 gene copies and HER2 expression in cancer cells using the fluorescent in situ hybridization method (FISH) and immunohistochemistry (IHC).

RESULTS

We found that the HER2 gene copy number in liquid biopsy was higher in GC and EGJC patients compared to healthy people (p = 0.01). Moreover, EGJC patients had higher number of HER2 gene copies than healthy donors (p = 0.0016). HER2 CNV examination could distinguish healthy individuals and patients with gastric or esophagogastric junction cancers with sensitivity and specificity of 58% and 98% (AUC = 0.707, 95% CI 0.593-0.821, p = 0.004). We found that patients with a high copy number of the HER2 gene in the tumor tissue assessed by qPCR (but not by FISH) have significantly more often a high number of HER2 gene copies in liquid biopsy (p = 0.04).

CONCLUSIONS

We suggested that HER2 testing in liquid biopsy could be used as an auxiliary method to analysis of HER2 status in tumor tissue in gastric or esophagogastric junction cancers.

Yield of staging laparoscopy in gastric cancer is influenced by Laurén histologic subtype

BACKGROUND

Staging laparoscopy (SL) with cytologic lavage is a useful staging procedure that allows tailoring the treatment of advanced gastric cancer (GC). The current study aimed to evaluate the total yield of SL in patients with various Laurén histo-types of GC, before planned neoadjuvant chemotherapy and gastrectomy.

METHODS

After exclusion of distant metastatic disease on imaging modalities, 173 patients with primary advanced gastric adenocarcinoma who underwent SL between August 2016 and September 2018, were eligible for the analysis. Patients sex, age, Lauren histo-type, tumor location, grade, cT, and cN were assessed in bivariate analysis. Multivariable logistic regression analysis was used to identify independent factors associated with peritoneal metastases.

RESULTS

Peritoneal metastases, ascites, and positive cytology were found in 39 (22.5%), 17 (9.8%) and 38 (22%) patients, respectively. The total yield of the SL in the current study was 36.4%. Multivariable logistic regression analysis revealed that serosal involvement (cT4) and diffuse histo-type were independent predictors of peritoneal metastases (OR, 15; 95% CI, 1.9-119, P = .02 and OR, 2.4; 95% CI, 1.2-4.6, P = .01, respectively).

CONCLUSIONS

Although cT4 and diffuse tumors show the highest association with peritoneal metastases, SL is a valuable diagnostic procedure in all advanced GC patients.

Blast from the past: Perioperative use of the Maruyama computer program for prediction of lymph node involvement in the surgical treatment of gastric cancer following neoadjuvant chemotherapy

BACKGROUND

Surgical quality assurance is a key element of gastric cancer treatment. The Maruyama Computer Program (MCP) allows to predict lymph node involvement in stations no. 1-16. The aim of the current study was to evaluate the accuracy of the MCP predictions in GC patients treated with neoadjuvant chemotherapy (nCTH) followed by gastrectomy with adequate lymphadenectomy.

METHODS

101 patients who underwent preoperative nCTH followed by D2 gastrectomy with curative intent were analysed. The response to nCTH was measured using the tumour regression grade system.

RESULTS

Test sensitivity, specificity, PPV, NPV and accuracy of the MCP were 92%, 33%, 41%, 89%, and 53%, respectively. In patients with response to nCTH, number of false positive (FP) results was significantly higher than in patients who did not respond to nCTH both in the N1 (56.3% vs 28.9%, p < 0.0001) and in the N2 (59% vs 41%, p < 0.0001) trier. The risk for FP results was 6 times higher in N1 (OR = 6.50, 95%CI: 3.91-10.82,; p < 0.0001) and N2 (OR = 5.84, 95%CI: 2.85-11.96; p < 0.0001) triers. In patients with intestinal type GC, the risk for FP results was 4 times higher than in other histologic types of GC in both N1 (OR = 4.23, 95%CI: 2.58-6.95; p < 0.0001) and N2 (OR = 4.23, 95%CI: 2.02-9.62; p = 0.0002) triers.

CONCLUSIONS

MCP predictions in the GC patients treated with nCTH have low specificity due to significantly high number of FP results. Noticeably low accuracy level of predictions indicate a need for new prediction models, based on Laurén classification, since it may provide some information on expected regression grade.

Perfusion CT - A novel quantitative and qualitative imaging biomarker in gastric cancer

OBJECTIVES

The aim of this research was to examine whether Perfusion Computed Tomography (P-CT) can qualitatively and quantitatively help detect gastric cancer neoangiogenesis in vivo as well as treatment response evaluation. We attempted to explore which P-CT parameters are best used in neoangiogenesis and neoadjuvant therapy for most effective evaluation. We also tried to recognize a positive prediction value of P-CT in early responders and non-responders patients identification.

MATERIALS AND METHODS

Twenty-four patients with positive biopsy results and/or clinically proven gastric cancer were enrolled in the P-CT exam. Patients were qualified for systemic treatment (16 patients received chemotherapy and 8 patients received radiochemotherapy). The baseline Perfusion-CT exam and after neoadjuvant treatment Perfusion-CT exam were conducted using a 64-row GE tomograph based on a deconvolution model in first-pass protocol perfusion. The P-CT examined the following parameters: Blood Flow (BF), Blood Volume (BV), Mean Transit Time (MTT) and Permeability Surface (PS). Positive clinical response to neoadjuvant treatment (CHT and RCT) was defined as tumor size reduction 25% or more.

RESULTS

Tumor dimension reduction after neoadjuvant therapy was significantly correlated with the BF and the PS. Neoadjuvant therapy was more effective for patients with higher output BF and PS values. We did not register a significant relationship between BV and MTT parameters and tumor dimension reduction. Patients with a positive treatment response showed a decrease in BF, BV and PS perfusion parameters with an increase in MTT.

CONCLUSIONS

P-CT examination allows a noninvasive neoangiogenesis assessment in vivo, leading to early identification of responding and non-responding patients. As a standard procedure, a full evaluation of treatment response should include a P-CT exam assessing neoangiogenesis.

The Influence of Patient-related Constutional and Environmental Factors on Early Results of a Combined Modality Therapy of Esophageal Cancer

Among many various factors affecting the outcome of cancer treatment one can distinguish patient, tumor- and treatment-related factors. The association of patient-related factors and results of a combined modality therapy of esophageal cancer has not been extensively explored. The aim of the study was to analyze the impact of patient-related constitutional and environmental factors on early results of combined modality therapy of esophageal squamous cell carcinoma.

MATERIAL AND METHODS

We retrospectively analyzed prospectively collected data of 84 patients with esophageal cancer randomly assigned to a combined modality treatment. We evaluated the relationship between early outcome of neoadjuvant therapy (overall toxic events, serious toxic events, treatment-related mortality, clinical and pathological response to the treatment) or surgical treatment (postoperative morbidity, mortality and curative resections - R0) and constitutional (age, gender, height, body mass index, Karnofski Performance Status - KPS, blood type) or environmental (inhabitation, smoking duration and intensity, frequency and amount of alcohol consumption and occupational exposure) patient-related factors.

RESULTS

Significantly more neoadjuvant therapy related deaths were found in patients with KPS 70-80 (p=0.0016). Interestingly, significantly more toxic events (p=0.0034) after neoadjuvant therapy and a higher postoperative morbidity rate (p=0.0293) were observed in nonsmokers. Similarly, significantly more toxic events (p=0.0029) after neoadjuvant therapy and a higher postoperative mortality rate (p=0.0405) were found in light drinkers.

CONCLUSIONS

Smoking and consumption of excessive amount of alcohol may attenuate toxic effect of neoadiuvant and surgical therapy in patients treated due to esophageal cancer. The information regarding the mentioned above addictions should not result in giving up an attempt to provide a curative treatment.

Salivary bicarbonate as a major factor in the prevention of upper esophageal mucosal injury in gastroesophageal reflux disease

BACKGROUND

It has been previously demonstrated that the exposure of the lower esophageal mucosa to acid and pepsin results in significant increase in salivary protective factors secretion, mediated by the esophago-salivary reflex. The impact of the upper esophageal mucosal exposure to acid and pepsin on salivary secretory response remains unknown.

AIMS

To investigate the rate of salivary protective factors secretion during the upper esophageal mucosal exposure to acid and pepsin and to compare with the corresponding results recorded during the lower esophageal mucosal exposure, in the same group of asymptomatic volunteers.

METHODS

The study was conducted in 10 asymptomatic volunteers. Salivary samples were collected during the esophageal mucosal exposure to saline, followed by acid/pepsin and the final saline, using the esophageal perfusion catheter. Salivary bicarbonate and non-bicarbonate buffers were analyzed using TitraLab. Salivary mucin and protein were quantified through PAS and Lowry methodologies, respectively, whereas PE2 using radioimmunoassay. Statistical analysis was performed using Σ-Stat software.

RESULTS

The rate of salivary bicarbonate secretion was significantly higher (3.1-fold) during the upper versus the lower esophageal mucosal exposure to acid and pepsin (87.5 ± 14.4 vs. 28.0 ± 7.70 μEq/min, p < 0.05). The volumes of saliva, pH, salivary protein, mucin and PE2 were similar in both esophageal perfusions.

CONCLUSIONS

Threefold stronger secretion of salivary bicarbonate could be a major factor protecting the upper esophageal mucosa. This phenomenon may represent an ultimate defense mechanism potentially preventing further complications within the upper esophageal mucosa; however, it needs to be confirmed in patients of gastroesophageal reflux disease.

Significance of ultrasonography in selecting methods for the treatment of acute cholecystitis

Surgical removal of the gallbladder is indicated in nearly all cases of complicated acute cholecystitis. In the 1990s, laparoscopic cholecystectomy became the method of choice in the treatment of cholecystolithiasis. Due to a large inflammatory reaction in the course of acute inflammation, a laparoscopic procedure is conducted in technically difficult conditions and entails the risk of complications.

The value of percutaneous ultrasound in predicting conversion from laparoscopic to open cholecystectomy due to acute cholecystitis

Background

Laparoscopic cholecystectomy has become the treatment of choice for gallstone disease. Advantages of the laparoscopic approach include lower morbidity and mortality rates, reduced length of hospital stay, and earlier return to work. In acute cholecystitis, severe inflammation makes laparoscopic dissection technically more demanding, with a higher risk of related complications that require conversion to open cholecystectomy.

Methods

We reviewed the records of 5,596 patients who underwent cholecystectomy between 1993 and 2011 in a single institution. A laparoscopic approach was undertaken in 4,105 patients (73.4 %). The ultrasound signs of acute cholecystitis were found in 542 patients (13.2 %) who underwent laparoscopic cholecystectomy. We analyzed the ultrasound presentations of acute cholecystitis in patients who required conversion to open cholecystectomy and compared them with the ultrasound signs of acute cholecystitis in patients who had a completed laparoscopic cholecystectomy.

Results

A conversion to open cholecystectomy in patients with acute cholecystitis was necessary in 24 % (n = 130) of the patients compared to 3.4 % of the patients with uncomplicated gallstone disease. The most frequent ultrasound findings in patients requiring conversion were a pericholecystic exudate in 42 %, a difficult identification of anatomical structures due to local severe inflammation in 34 %, and gallbladder wall thickening of >5 mm in 31 %. Additionally, when the duration of symptoms exceeded 3 days, more than half of the patients required conversion to open cholecystectomy and the conversion rate was fivefold higher than for those with a shorter duration of acute cholecystitis.

Conclusions

In patients with severe acute cholecystitis found on ultrasound, combined with gallbladder wall thickening to >5 mm, pericholecystic exudates or abscess adjacent to the gallbladder, difficulty identifying anatomical structures within Calot’s triangle, specifically when the duration of symptoms exceeds 3 days, cholecystectomy should be done as an open approach because of the high risk of conversion.

Incidence of human papilloma virus in esophageal squamous cell carcinoma in patients from the Lublin region

AIM: To assess the prevalence of human papilloma virus (HPV) in esophageal squamous cell carcinoma (ESCC) in the south-eastern region of Poland.

METHODS: The study population consisted of 56 ESCC patients and 35 controls. The controls were patients referred to our department due to other non-esophageal and non-oncological disorders with no gross or microscopic esophageal pathology as confirmed by endoscopy and histopathology. In the ESCC patients, samples were taken from normal mucosa (56 mucosa samples) and from the tumor (56 tumor samples). Tissue samples from the controls were taken from normal mucosa of the middle esophagus (35 control samples). Quantitative determination of DNA was carried out using a spectrophotometric method. Genomic DNA was isolated using the QIAamp DNA Midi Kit. HPV infection was identified following PCR amplification of the HPV gene sequence, using primers MY09 and MY11 complementary to the genome sequence of at least 33 types of HPV. The sequencing results were computationally analyzed using the basic local alignment search tool database.

RESULTS: In tumor samples, HPV DNA was identified in 28 of 56 patients (50%). High risk HPV phenotypes (16 or/and 18) were found in 5 of 56 patients (8.9%), low risk in 19 of 56 patients (33.9%) and other types of HPV (37, 81, 97, CP6108) in 4 of 56 patients (7.1%). In mucosa samples, HPV DNA was isolated in 21 of 56 patients (37.5%). High risk HPV DNA was confirmed in 3 of 56 patients (5.3%), low risk HPV DNA in 12 of 56 patients (21.4%), and other types of HPV in 6 of 56 patients (10.7%). In control samples, HPV DNA was identified in 4 of 35 patients (11.4%) with no high risk HPV. The occurrence of HPV in ESCC patients was significantly higher than in the controls [28 of 56 (50%) vs 4 of 35 (11.4%), P < 0.001]. In esophageal cancer patients, both in tumor and mucosa samples, the predominant HPV phenotypes were low risk HPV, isolated 4 times more frequently than high risk phenotypes [19 of 56 (33.9%) vs 5 of 56 (8.9%), P < 0.001]. A higher prevalence of HPV was identified in female patients (71.4% vs 46.9%). Accordingly, the high risk phenotypes were isolated more frequently in female patients and this difference reached statistical significance [3 of 7 (42.9%) vs 2 of 49 (4.1%), P < 0.05]. Of the pathological characteristics, only an infiltrative pattern of macroscopic tumor type significantly correlated with the presence of HPV DNA in ESCC samples [20 of 27 (74.1%) vs 8 of 29 (27.6%) for ulcerative or protruding macroscopic type, P < 0.05]. The occurrence of total HPV DNA and both HPV high or low risk phenotypes did not significantly differ with regard to particular grades of cellular differentiation, phases in depth of tumor infiltration, grades of nodal involvement and stages of tumor progression.

CONCLUSION: Low risk HPV phenotypes could be one of the co-activators or/and co-carcinogens in complex, progressive, multifactorial and multistep esophageal carcinogenesis.

Cancer antigens 19-9 and 125 in the differential diagnosis of pancreatic mass lesions

HYPOTHESIS

Accurate differentiation between inflammatory and neoplastic tumors of the pancreas remains a diagnostic dilemma for surgeons. The aim of the study was to assess the utility of 2 neoplastic markers, cancer antigen (CA) 19-9 and CA 125, in the differential diagnosis of pancreatic tumors.

DESIGN

The patients were assigned to a malignant or benign group based on cytological and histological evaluation of pancreatic lesion samples. The serum from each patient was tested for CA 19-9 and CA 125.

SETTING AND PATIENTS

One hundred ten patients with heterogeneous pancreatic lesions (inflammatory and malignant tumors) treated at a surgical department of a university hospital were analyzed.

INTERVENTIONS

Samples for cytological and histological evaluation were taken during ultrasonography-guided fine-needle aspiration biopsy or open surgery.

MAIN OUTCOME MEASURES

Sensitivity, specificity, and positive and negative predictive values of each test in the differential diagnosis of pancreatic tumors were determined.

RESULTS

The sensitivity, specificity, positive predictive value, and negative predictive value of the CA 19-9 test were 80.8%, 89.1%, 93.7%, and 89.2%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of the CA 125 test were 60.8%, 83.3%, 88.2%, and 50.8%, respectively. The sensitivity and specificity of a combined evaluation of both CA 19-9 and CA 125 tests were 87.8% and 77.8%, respectively.

CONCLUSIONS

Taking into account the high but still limited sensitivity and specificity of the CA 19-9 and CA 125 tests, their results in the differential diagnosis of pancreatic tumors should be interpreted consistently and in reference to imaging techniques such as ultrasonography and computed tomography.

Cancer antigens 19-9 and 125 in the differential diagnosis of pancreatic mass lesions

HYPOTHESIS

Accurate differentiation between inflammatory and neoplastic tumors of the pancreas remains a diagnostic dilemma for surgeons. The aim of the study was to assess the utility of 2 neoplastic markers, cancer antigen (CA) 19-9 and CA 125, in the differential diagnosis of pancreatic tumors.

DESIGN

The patients were assigned to a malignant or benign group based on cytological and histological evaluation of pancreatic lesion samples. The serum from each patient was tested for CA 19-9 and CA 125.

SETTING AND PATIENTS

One hundred ten patients with heterogeneous pancreatic lesions (inflammatory and malignant tumors) treated at a surgical department of a university hospital were analyzed.

INTERVENTIONS

Samples for cytological and histological evaluation were taken during ultrasonography-guided fine-needle aspiration biopsy or open surgery.

MAIN OUTCOME MEASURES

Sensitivity, specificity, and positive and negative predictive values of each test in the differential diagnosis of pancreatic tumors were determined.

RESULTS

The sensitivity, specificity, positive predictive value, and negative predictive value of the CA 19-9 test were 80.8%, 89.1%, 93.7%, and 89.2%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of the CA 125 test were 60.8%, 83.3%, 88.2%, and 50.8%, respectively. The sensitivity and specificity of a combined evaluation of both CA 19-9 and CA 125 tests were 87.8% and 77.8%, respectively.

CONCLUSIONS

Taking into account the high but still limited sensitivity and specificity of the CA 19-9 and CA 125 tests, their results in the differential diagnosis of pancreatic tumors should be interpreted consistently and in reference to imaging techniques such as ultrasonography and computed tomography.

Dukes' classification as a prognostic factor in patients with squamous cell carcinoma of the thoracic esophagus undergoing combined-modality treatment

BACKGROUND

Several disadvantages of the TNM classification have resulted in a search for a simpler, clearer, and more reliable staging system for esophageal cancer. We evaluated Dukes' classification as a prognostic indicator in 81 patients with squamous cell carcinoma of the thoracic esophagus treated with combined-modality therapy.

MATERIAL/METHODS

The pathological staging was determined according to the TNM and Dukes' classification. The cumulative survival rates were calculated using the Kaplan-Meier method. The differences in survival between the patients in particular stages of both classifications were estimated with the log-rank test.

RESULTS

The differences in cumulative survival rates between TNM I and TNM IIa, between TNM IIa and TNM IIb and between TNM IIb and TNM III patients were 20.2% (37.2 vs. 46.6), 27.5% (46.6 vs. 33.8) and 60.7% (33.8 vs. 13.3), respectively, and were not statistically significant (P = 0.58, P = 0.53 and P = 0.18). The cumulative survival rates for TNM III and TNM IV patients were similar (13.3 and 14.3). The difference in cumulative survival rates between Dukes' A and B patients amounted to 52.5% (54.3 vs. 25.8), which was statistically significant (P = 0.02). The difference in cumulative survival rates between Dukes' B and C patients was 41.5% (25.8 vs. 15.1), but fell short of statistical significance (P = 0.12). The cumulative survival rates for Dukes' C and D patients were similar (15.1 and 16.6).

CONCLUSIONS

Dukes' staging system for esophageal cancer is simpler, clearer and more accurate, and could thus be a better prognostic tool than the TNM classification.

[Palliative treatment of esophageal carcinoma]

The choice of the most beneficial method of the treatment of patients with esophageal cancer still remains a matter of debate. According majority of epidemiological reports only 10% of esophageal cancer patients has a chance for 5-year survival. Unfortunately, the curative surgical treatment is possible in relatively small number of patients, nevertheless esophagectomy is regarded as a principle method of treatment. Usually it referrers to the group of 50% of patients with locally advanced cancer. Thus, the management of the majority of esophageal cancer patients is palliative. Its main objective is to improve esophageal passage compromised by tumor narrowing esophageal lumen. Maintenance of esophageal passage facilitates food intake and usually postpones the stage of terminal cachexia and thus results in quality of life improvement. As it has been evident from up-to-date research currently used methods of palliative treatment do not significantly improve survival. In this paper we demonstrate a review of currently available methods of palliative treatment of patients with esophageal cancer and brief discussion on our own experience from last four years.

[Endoscopic mucosal resection in the treatment of early cancer of the gastrointestinal tract]

Endoscopic mucosal resection is a minimally invasive technique of resection of large pieces of the superficial layers (the mucosa and partially the submucosa) of the gut wall. In the present study we are presenting currently established indications, recent advances in the technique, early and long-term results of the treatment of esophageal, gastric and colorectal early cancer by endoscopic mucosal resection based on the review of the literature, educational materials and personal experience from the training of the first author (KZ) at the National Cancer Center in Tokyo, Japan. Endoscopic mucosal resection should be indicated for every superficial neoplastic lesion of the gut wall that can be safely removed in its entirety by experienced endoscopic team, and subsequently processed and evaluated properly by cooperating histopathologist specializing in gastrointestinal pathology. Eventually a detailed analysis of a resected specimen enables the precise assessment of curability of the procedure and establishment of the rational management of a patient. Curative endoscopic resection allows for regarding this procedure as sufficient and includes a patient into a follow-up program. Potentially curative endoscopic resection requires to consider the risk of lymph node involvement and discuss with a patient potential benefits and risk associated with surgical treatment or its withholding in reference to patients' age and health condition. Non-curative endoscopic resection requires to recommend an additional local (endoscopic resection, endoscopic ablation, brachytherapy) or surgical treatment after a detailed analysis with a patient a potential benefit and risk associated with each option. Despite enormous advance in medical knowledge the outcome of the gastrointestinal cancer treatment is still far unsatisfactory. Early diagnosis and treatment of less advanced cancer remains the most promising method of improvement of the outcome. We hope that popularization of the knowledge regarding early gastrointestinal cancer may improve their early detection rate and thereby the outcome of the treatment.

Unusual clinical course of metachronous melanomas of the upper digestive system

Melanoma of the gastrointestinal tract is a rare, highly malignant neoplasm of poor prognosis. This is description of an unusual case of surgically treated patient with two metachronous malignant melanomas of the stomach and the esophagus. The former lesion was located in the cardia and effectively treated with R0 total gastrectomy. The latter was recognized after 67 mo and appeared as irregular, flat, pigmented areas located in the mid esophagus. Subtotal esophagectomy via right-sided thoracotomy, laparotomy and left-sided cervicotomy was performed, but neoplastic cells were found in distal margin (R1). Fourteen months after esophagectomy multiple lung metastases were detected. Patient died 2 mo later.

[Diagnostic and therapeutic difficulties in a patient with primary malignant melanoma of the esophagus--case report]

We are presenting a case report of 57-year-old patient operated on due to primary malignant melanoma of the esophagus. Melanoma was misdiagnosed in biopsy taken during endoscopy. Final precise establishing the character of the lesion was able during histopathological examination of the specimen obtained during surgery. The outcome of the treatment was poor--survival time did not exceed 14 months. Patient died because of pulmonary metastases.

Elevated tumor marker CA 19-9 in the differential diagnosis of pancreatic mass lesions

Inflammatory and neoplastic tumors of the pancreas still remain a diagnostic dilemma for a surgeon mainly due to subtle differences between these two sorts of tumors. The aim of the study was to assess the utility of the serum marker, CA 19-9, in the differential diagnosis of pancreatic tumors. 150 patients with heterogenic pancreatic lesion were diagnosed and treated at 2nd Department of General Surgery, Medical University of Lublin between June 1998 and Dec. 2003. Their age ranged between 26 and 78 years. Based upon cytology and histology, patients were assigned to malignant or benign group. The serum from all the patients was assayed for the CA 19-9 test and sensitivity and specificity of the CA 19-9 test was determined. Finally pancreatic cancer was diagnosed in 98 patients, benign pancreatic lesion in 52 patients. Based upon the serum level of the CA 19-9 true positive results were found in 82 patients, true negative results in 47 patients, false negative results in 16 patients and false positive results in 5 patients. Sensitivity of the CA 19-9 assay was 83.7% and specificity was 90.4%. An elevated serum level of the CA 19-9 in the presence of pancreatic lesions usually suggests malignant nature of the lesion. A high CA 19-9 level is typical of advanced inoperable pancreatic cancer. Taking into account a limited sensitivity and specificity of the CA 19-9 assay, its results should be interpreted in consistency with an analysis of imaging examinations such as US and CT.

Significant enhancement of gastric mucin content after rabeprazole administration: its potential clinical significance in acid-related disorders

Rabeprazole is the only proton pump inhibitor that enhances the content of gastric mucin in experimental animals. We have studied, therefore, the effect of rabeprazole on the content of gastric mucin, mucus, and its viscosity in 21 asymptomatic volunteers in a double-blind study. The mucus content during rabeprazole administration significantly increased both in pentagastrin-stimulated (3.36 +/- 0.39 vs 1.50 +/- 0.32 mg/ml, P < 0.001) and basal (3.31 +/- 0.38 vs 2.28 +/- 0.36 mg/ml, P < 0.01) conditions. The content of mucin during rabeprazole was 2.6-fold (0.96 +/- 0.08 vs 0.36 +/- 0.06 mg/ml, P < 0.0001) and 41% (0.82 +/- 0.09 vs 0.58 +/- 0.09 mg/ml, P < 0.05) higher in stimulated and basal conditions, respectively. The viscosity of gastric juice during rabeprazole administration was also significantly higher both in stimulated (P < 0.01) and basal (P < 0.05) conditions. In conclusion, the unique pharmacological property of rabeprazole, significantly augmenting production of gastric mucus and mucin, may translate to additional clinical benefits in protecting the upper alimentary tract mucosa during the acid-related challenge.

Esophageal motility impairment--the cause or consequence of gastroesophageal reflux disease?

There are at least three, well-known, different groups of motor activity disturbances of the upper part of alimentary tract which can induce the development of gastroesophageal reflux disease (GERD) and enlarge the risk of excessive exposure of the esophageal mucous membrane on gastric juice and/or biliary contents. Most important is insufficiency of the lower esophageal sphincter (LES), which causes gastroesophageal reflux at 50-60% of patients suffering from GERD. Other reasons include impairment of stomach function (increase of intra-gastric pressure, late emptying and/or hypersecretion), and impairment of esophageal clearance. The question: does motility impairment of the esophagus occur primary or secondary to the gastroesophageal reflux, is still not enough clarified. Motor activity of the esophagus before and after the antireflux operation was prospectively assessed in 57 patients. Motility of the esophagus was determined by estimation: the efficacy of LES, general motor activity of the body of the esophagus and motor activity of the body during the reflux episodes, basing on 24-h manometry. Comparison of general pre- and postoperative data revealed significantly positive influence of Nissen-Rossetti fundoplication on improvement of motor activity of the esophagus, but the results differed in relation to the height of the measurements. Moreover comparison of the data during gastroesophageal reflux episodes revealed negative changes of the manometric parameters in the upper and middle esophagus. We conclude that post-operative improvement of esophageal motility confirms the secondary dysfunction in the peristalsis, connected with pathological reflux. However, lack of the complete normalization in motor activity after operation suggests that disorder may partially occur as primary impairment of motor activity or as the secondary dysfunction, which is fixed in the course of GERD.