Clinical impact of panel gene sequencing on therapy of advanced cancers of the digestive system: a retrospective, single center study

BACKGROUND

Panel gene sequencing is an established diagnostic tool for precision oncology of solid tumors, but its utility for the treatment of cancers of the digestive system in clinical routine is less well documented.

METHODS

We retrospectively identified patients with advanced or metastatic gastrointestinal, pancreaticobiliary or hepatic cancers who received panel gene sequencing at a tertiary university hospital from 2015 to 2022. For these cases, we determined the spectrum of genetic alterations, clinicopathological parameters and treatment courses. Assessment of actionability of genetic alterations was based on the OncoKB database, cancer-specific ESMO treatment guidelines, and recommendations of the local molecular tumor board.

RESULTS

In total, 155 patients received panel gene sequencing using either the Oncomine Focus (62 cases), Comprehensive (91 cases) or Childhood Cancer Research Assay (2 cases). The mean age of patients was 61 years (range 24-90) and 37% were female. Most patients suffered from either colorectal cancer (53%) or cholangiocellular carcinoma (19%). 327 genetic alterations were discovered in 123 tumor samples, with an average number of 2.1 alterations per tumor. The most frequently altered genes were TP53, KRAS and PIK3CA. Actionable gene alterations were detected in 13.5-56.8% of tumors, according to ESMO guidelines or the OncoKB database, respectively. Thirteen patients were treated with targeted therapies based on identified molecular alterations, with a median progression-free survival of 8.8 months.

CONCLUSIONS

Actionable genetic alterations are frequently detected by panel gene sequencing in patients with advanced cancers of the digestive tract, providing clinical benefit in selected cases. However, for the majority of identified actionable alterations, sufficient clinical evidence for targeted treatments is still lacking.

Impact of 68 Ga-FAPI-04 PET/CT on Staging and Therapeutic Management in Patients With Digestive System Tumors

PURPOSE

We aimed to determine the impact of fibroblast activation protein inhibitor (FAPI)-directed molecular imaging on staging and therapeutic management in patients affected with digestive system tumors when compared with guideline-compatible imaging (GCI).

PATIENTS AND METHODS

Thirty-two patients with tumors of the digestive system were included: colon adenocarcinoma, 2/32 (6.3%); hepatocellular carcinoma (HCC), 6/32 (18.8%); pancreatic duct adenocarcinoma (PDAC), 6/32 (18.8%), and gastroenteropancreatic neuroendocrine neoplasms, 18/32 (56.3%). All patients underwent GCI and 68 Ga-FAPI-04 PET/CT within median 4 days. Staging outcomes and subsequent treatment decisions were compared between GCI and 68 Ga-FAPI-04 PET/CT.

RESULTS

Compared with GCI, 68 Ga-FAPI-04 PET/CT led to staging changes in 15/32 patients (46.9%). Among those, downstaging was recorded in 3/15 cases (20.0%) and upstaging in the remaining 12/15 patients (HCC, 4/12 [33.3%]; PDAC, 4/12 [33.3%]; neuroendocrine neoplasms, 3/12 [25%]; colon adenocarcinoma, 1/12 [8.3%]). Therapeutic management was impacted in 8/32 patients (25.0%), including 4 instances of major and 4 instances of minor therapeutic changes. The highest proportion of treatment modifications was observed in patients diagnosed with PDAC and HCC in 6/8 (75%).

CONCLUSIONS

In patients affected with digestive system tumors, 68 Ga-FAPI-04 PET/CT resulted in staging changes in more than 46% and therapeutic modifications in 25% of the cases, in particular in patients with HCC and PDAC. In clinical routine, such findings may favor a more widespread adoption of FAP-directed imaging in those tumor types.

Effects of music therapy on cancer-related fatigue, anxiety, and depression in patients with digestive tumors: A protocol for systematic review and meta-analysis

BACKGROUND

Digestive tumor is one of the most common cancers, its symptoms and treatment will bring patients with anxiety, depression and other negative emotions, and cause cancer-related fatigue. As a new complementary replacement therapy, music therapy can greatly reduce cancer-related fatigue, anxiety and depression, and achieve good clinical results, but there is a lack of evidence-based medicine. The purpose of this study is to evaluate the effect of music therapy on cancer-related fatigue, anxiety, and depression in patients with digestive tumors by meta-analysis.

METHOD

Computer search of Chinese and English databases: Wanfang, VP Information Chinese Journal Service Platform, China National Knowledge Infrastructure, Chinese BioMedicine Literature Database and pubmed, embase, cochrane, web of science. A comprehensive collection of relevant studies on the effects of music therapy on digestive tract cancer-related fatigue, anxiety and depression, the retrieval time is from the date of establishment to March 2021. According to the inclusion and exclusion criteria, the literature is selected, the quality of the literature is evaluated and the data are extracted. The data are analyzed by meta-analysis.

RESULT

The purpose of this study is to evaluate the effect of music therapy on digestive tract cancer-related fatigue, anxiety, and depression by European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire, Hamilton Depression Scale, and Hamilton Anxiety Scale .

CONCLUSION

This study will provide reliable evidence-based evidence for the clinical application of music therapy in the treatment of digestive tract cancer-related fatigue and anxiety and depression.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/UR4GV.

Prognostic value of aldo-keto reductase family 1 member B10 (AKR1B10) in digestive system cancers: A meta-analysis

BACKGROUND

Numbers of studies have reported that the expression of aldo-keto reductase family 1 member B10 (AKR1B10) is abnormal in digestive system cancers, and could be used as a prognostic biomarker. However, the results are argued. Therefore, we conduct a meta-analysis to comprehensively evaluate the prognostic value of high AKR1B10 expression for overall survival (OS), disease specific survival (DSS), and disease-free survival/recurrence-free survival (DFS/PFS) in digestive system cancers.

METHODS

Hazard ratios (HRs) with its 95% confidence intervals (CIs) were calculated to assess the prognostic value of AKR1B10 by using the random effects model. The STATA version 12.0 software were used to perform all the analyses.

RESULTS

Eleven articles including 1428 patients involved in this meta-analysis. The pooled analysis suggested that high AKR1B10 expression was not associated with OS (HR: 1.18; 95% CI: 0.69-2.00) and DFS/PFS (HR: 1.08, 95% CI: 0.67-1.76) in digestive system cancers. However, Further analysis revealed that high AKR1B10 expression indicated poor OS in oral squamous cell carcinomas (OSCC) (HR: 2.92, 95% CI: 1.86-4.58) and favorable DSS in hepatocellular carcinoma (HCC) (HR: 0.71, 95% CI: 0.52-0.97).

CONCLUSIONS

The prognostic value of high AKR1B10 expression varied in different types of digestive system cancers. Further studies exploring the prognostic role of AKR1B10 in digestive system cancers are needed.

Impact of Oral Immunonutrition on Postoperative Morbidity in Digestive Oncologic Surgery: A Nation-wide Cohort Study

OBJECTIVE

The objective of the present study was to assess the effect of preoperative immunonutrition on a nationwide scale.

BACKGROUND

According to international guidelines, immunonutrition should be prescribed before major oncologic digestive surgery to decrease postoperative morbidity. Nevertheless, this practice remains controversial.

METHODS

We used a prospective national health database named "Echantillon généraliste des Bénéficiaires." Patients were selected with ICD10 codes of cancer and digestive surgery procedures from 2012 to 2016. Two groups were identified: with reimbursement of immunonutrition 45 days before surgery (IN-group) or not (no-IN-group). Primary outcome was 90-day severe morbidity. Secondary outcomes were postoperative length of stay (LOS) and overall survival. Logistic regression and survival analysis adjusted with IPW method were performed.

RESULTS

One thousand seven hundred seventy-one patients were included. The proportion of different cancers was as follows: 72% patients were included in the colorectal group, 14% in the hepato-pancreato-biliary group, and 12% in the upper gastrointestinal group. Patients from the IN-group (n = 606, 34%) were younger (67.1 ± 11.8 vs 69.2 ± 12.2 years, P < 0.001), with increased use of other oral nutritional supplements (49.5% vs 31.8%, P < 0.001) and had more digestive anastomoses (89.4% vs 83.0%, P < 0.001). There was no significant difference between the 2 groups for 90-day severe morbidity [odds ratio (OR): 0.91, 95% confidence interval (95% CI): 0.73-1.14] or in survival (hazard ratio: 0.89, 95% CI: 0.73-1.08). LOS were shorter in the IN-group [-1.26 days, 95% CI: -2.40 to -0.10)].

CONCLUSION

The preoperative use of immunonutrition before major oncologic digestive surgery was not associated with any significant difference in morbidity or mortality. However, the LOS was significantly shorter in the IN-group.

The Neuroendocrine Neoplasms of the Digestive Tract: Diagnosis, Treatment and Nutrition

Nuroendocrine neoplasms (NENs) are a group of rare neoplasms originating from dispersed neuroendocrine cells, mainly of the digestive and respiratory tract, showing characteristic histology and immunoprofile contributing to classification of NENs. Some NENs have the ability to produce biogenic amines and peptide hormones, which may be associated with clinical syndromes like, e.g., the carcinoid syndrome caused by unmetabolized overproduced serotonin, hypoglycemic syndrome in case of insulinoma, or Zollinger-Ellison syndrome accompanying gastrinoma. Diagnostics for these include ultrasound with endoscopic ultrasound (EUS), computed tomography (CT), magnetic resonance imaging (MRI), and positron-emission tomography/computed tomography (PET/CT). Different nuclear medicine procedures can also be used, like somatostatin analogues scintigraphy (SRS) and 68Ga-Dota-Peptide PET/CT, as well as biochemical methods to determine the level of general neuroendocrine markers, such as chromogranin A (CgA), 5-hydroxyindolacetic acid (5-HIAA), synaptopfysin and cell type-specific peptide hormones, and neurotransmitters like gastrin, insulin, serotonin, and histamine. NENs influence the whole organism by modulating metabolism. The treatment options for neuroendocrine neoplasms include surgery, somatostatin analogue therapy, radionuclide therapy, chemotherapy, molecular targeted therapies, alpha-interferon therapy, and inhibitors of serotonin production. In the case of hypersensitivity to biogenic amines, a diet that limits the main sources of amines should be used. The symptoms are usually connected with histamine, tyramine and putrescine. Exogenic sources of histamine are products that take a long time to mature and ferment. Patients with a genetic insufficiency of the diamine oxidase enzyme (DAO), and those that take medicine belonging to the group of monoamine oxidases (MAO), are particularly susceptible to the negative effects of amines. Diet plays an important role in the initiation, promotion, and progression of cancers. As a result of the illness, the consumption of some nutrients can be reduced, leading to nutritional deficiencies and resulting in malnutrition. Changes in metabolism may lead to cachexia in some patients suffering from NENs. The aim of this narrative review was to advance the knowledge in this area, and to determine possibilities related to dietary support. The authors also paid attention to role of biogenic amines in the treatment of patients with NENs. We can use this information to better understand nutritional issues faced by patients with gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs), and to help inform the development of screening tools and clinical practice guidelines.

Somatic gene mutation signatures predict cancer type and prognosis in multiple cancers with pan-cancer 1000 gene panel

Most cancers are caused by somatic mutations. Some common mutations in the same cancer type can form a "signature" to specifically predict the prognosis or to distinguish it from other cancers. In this study, 710 somatic cell mutations were identified in 142 cases, including digestive, lung and urogenital cancers, and the digestive cancers were further divided into liver, stomach, intestinal, esophageal and cardia cancer. The above mutations were located in 166 genes. In addition, a group of high-frequency mutation genes with specific characteristics were screened to form predictive signatures for each cancer. Verification using TCGA suggested that the signatures could predict the stages, progression-free survival, and overall survival of digestive, intestinal, and liver cancers (P < 0.05). The validation cases further confirmed the predictive role of digestive and liver cancers signatures in diagnosis and prognosis. Overall, this study established predictive signatures for different cancer systems and their subtypes. These findings enable a better understanding in cancer genome, and contribute to the personalized diagnosis and treatment.

[Analysis of non-scheduled consultations in patients with digestive neoplasms]

OBJECTIVE

Non-scheduled consultation is very frequent among patients with cancer, creating alterations and delays in programmed visits. We describe the incidence of non-scheduled consultations in patients with digestive cancer in our hospital.

METHODS

Descriptive, prospective, non-interventional study. In a six-month period (May-December 2017), non-scheduled visits were chronologically recorded in the medical oncology consultation of digestive tumours of Hospital Juan Ramón Jiménez de Huelva. We performed a descriptive analysis of the variables collected through the statistical program G-STAT v.2.0.

RESULTS

Patients with colon or rectal cancer generated most consultations (68.63%). followed by pancreatic (9.15%) and gastric (5.23%). Most patients had metastatic or advanced stage cancer (59.87%) and were under palliative or symptomatic treatment (58.82%). The most frequent reason for consultation was clinical symptoms (47.05%). followed by information demand (18.30 %).

CONCLUSIONS

Non-scheduled consultations in cancer patients are frequent; they cause interference in scheduled consultations and not always resolved satisfactorily. We propose several measures to reduce the number of non-scheduled consultation in oncology.

Hindgut and Midgut Neuroendocrine Tumors - Therapeutic Approach

Introduction: Neuroendocrine tumors of the gastro-entero-pancreatic system have a variety of components, clinical manifestations and prognostic indices according to their anatomical site. Therefore, their diagnostic and management strategies differ a great deal. Prognosis concerning NETs can be poor due to the degree of differentiation, early metastasizing and the high degree of invasiveness. Material and Methods: For the present study, the patient files were evaluated and the parameters of interest were followed. Results: Over the course of 6 years there were 37 patients diagnosed with and treated for NETs, regardless of primary tumor site. There were 9 patients with NETs of the primite mid- and hindgut thusly: 5 cases with colorectal NETs and 4 cases of small bowel NETs. 6 patients benefited from radical surgical treatment, 2 cases with palliative procedures and only one patient with tumor biopsy. The tumors were evaluated according to the 2010 WHO classification based on the number of mitoses and the Ki67 proliferation index. Adjuvant treatment was adapted according to staging and histopathological parameters. Conclusions: Despite recent progress in managing NETs, there are still many controversial aspects regarding the management of these cases, mainly about timing the right sequence of therapy.

MicroRNAs as Immunotherapy Targets for Treating Gastroenterological Cancers

Gastroenterological cancers are the most common cancers categorized by systems and are estimated to comprise 18.4% of all cancers in the United States in 2017. Gastroenterological cancers are estimated to contribute 26.2% of cancer-related death in 2017. Gastroenterological cancers are characterized by late diagnosis, metastasis, high recurrence, and being refractory to current therapies. Since the current targeted therapies provide limited benefit to the overall response and survival, there is an urgent need for developing novel therapeutic strategy to improve the outcome of gastroenterological cancers. Immunotherapy has been developed and underwent clinical trials, but displayed limited therapeutic benefit. Since aberrant expressions of miRNAs are found in gastroenterological cancers and miRNAs have been shown to regulate antitumor immunity, the combination therapy combining the traditional antibody-based immunotherapy and novel miRNA-based immunotherapy is promising for achieving clinical success. This review summarizes the current knowledge about the miRNAs and long noncoding RNAs that exhibit immunoregulatory roles in gastroenterological cancers and precancerous diseases of digestive system, as well as the miRNA-based clinical trials for gastroenterological cancers. This review also analyzes the ongoing challenge of identifying appropriate therapy candidates for complex and dynamic tumor microenvironment, ensuring efficient and targeted delivery to specific cancer tissues, and developing strategy for avoiding off-target effect.

Recent developments in the diagnosis and therapy of well-differentiated neuroendocrine tumours

Well-differentiated neuroendocrine tumours (NETs) of the digestive tract are being increasingly detected, which is partly explained by the increased use of endoscopic and cross-sectional imaging as well as improved recognition at histopathological evaluation. After the discovery of this relatively indolent type of epithelial malignancy over 100 years ago, their sporadic occurrence and divergent biological behaviour at multiple primary sites have hampered dedicated studies into NET pathogenesis and testing of drug efficacy in well-designed clinical trials. The last decade, however, has seen significant improvements in the NET field regarding our understanding of their pathophysiology. This has been substantiated by novel and exciting diagnostic and therapeutic options, including superior positron emission tomography imaging, treatment with unlabelled and radiolabelled somatostatin analogues and inhibitors of the mammalian target of rapamycin and vascular endothelial growth factor pathways. This review summarises contemporary studies within NET patients, which have enriched our clinical repertoire for this disease and have been instrumental in securing a remarkable improvement of overall survival within recent years.

Bile acid-microbiota crosstalk in gastrointestinal inflammation and carcinogenesis

Emerging evidence points to a strong association between the gut microbiota and the risk, development and progression of gastrointestinal cancers such as colorectal cancer (CRC) and hepatocellular carcinoma (HCC). Bile acids, produced in the liver, are metabolized by enzymes derived from intestinal bacteria and are critically important for maintaining a healthy gut microbiota, balanced lipid and carbohydrate metabolism, insulin sensitivity and innate immunity. Given the complexity of bile acid signalling and the direct biochemical interactions between the gut microbiota and the host, a systems biology perspective is required to understand the liver-bile acid-microbiota axis and its role in gastrointestinal carcinogenesis to reverse the microbiota-mediated alterations in bile acid metabolism that occur in disease states. An examination of recent research progress in this area is urgently needed. In this Review, we discuss the mechanistic links between bile acids and gastrointestinal carcinogenesis in CRC and HCC, which involve two major bile acid-sensing receptors, farnesoid X receptor (FXR) and G protein-coupled bile acid receptor 1 (TGR5). We also highlight the strategies and cutting-edge technologies to target gut-microbiota-dependent alterations in bile acid metabolism in the context of cancer therapy.

Role of modern immunotherapy in gastrointestinal malignancies: a review of current clinical progress

Gastrointestinal (GI) cancers are a group of highly aggressive malignancies with a huge disease burden worldwide. There is clearly a significant unmet need for new drugs and therapies to further improve the treatment outcomes of GI malignancies. Immunotherapy is a novel treatment strategy that is emerging as an effective and promising treatment option against several types of cancers. CTLA-4 and PD-1 are critical immune checkpoint molecules that negatively regulate T cell activation via distinct mechanisms. Immune checkpoint blockade with antibodies directed against these pathways has already shown clinical efficacy that has led to their FDA approval in the treatment of several solid tumors including melanoma, non-small cell lung cancer, renal cell carcinoma, urothelial carcinoma, and head and neck cancer. This review will summarize the current clinical progress of modern immunotherapy in the field of GI tumors, with a special focus on immune checkpoint blockade.

[Immunotherapy for gastroenterological cancer]

After the paradigm shift happened in malignant melanoma, the immune checkpoint inhibi- tors have been developed all over the world in the many types of cancer not the exception of the gastroenterological cancer. The authors showed a comprehensive review of the literature and update on the use of anti-CTLA-4, anti-PD-1 and anti-PD-LI therapy in the area of gastro- enterological cancer. The clinical evidence of the immune checkpoint inhibitors in gastroen- terological cancer remains limited, although the light come in this cancer type and immuno- therapy could play an important role in the year to come.

Inflammatory bowel disease and cancer: The role of inflammation, immunosuppression, and cancer treatment

In patients with inflammatory bowel disease (IBD), chronic inflammation is a major risk factor for the development of gastrointestinal malignancies. The pathogenesis of colitis-associated cancer is distinct from sporadic colorectal carcinoma and the critical molecular mechanisms underlying this process have yet to be elucidated. Patients with IBD have also been shown to be at increased risk of developing extra-intestinal malignancies. Medical therapies that diminish the mucosal inflammatory response represent the foundation of treatment in IBD, and recent evidence supports their introduction earlier in the disease course. However, therapies that alter the immune system, often used for long durations, may also promote carcinogenesis. As the population of patients with IBD grows older, with longer duration of chronic inflammation and longer exposure to immunosuppression, there is an increasing risk of cancer development. Many of these patients will require cancer treatment, including chemotherapy, radiation, hormonal therapy, and surgery. Many patients will require further treatment for their IBD. This review seeks to explore the characteristics and risks of cancer in patients with IBD, and to evaluate the limited data on patients with IBD and cancer, including management of IBD after a diagnosis of cancer, the effects of cancer treatment on IBD, and the effect of IBD and medications for IBD on cancer outcomes.

Diabetes mellitus and cancer of the digestive organs: An Italian population-based cohort study

AIMS

The association between diabetes mellitus and the occurrence of digestive organs cancers was investigated in the Italian region Friuli Venezia Giulia. The risk of cancer associated with oral antidiabetic drugs among subjects with type 2 diabetes was also assessed.

METHODS

This was a retrospective population-based cohort study based on the 2002-2014 regional administrative health data. Incident digestive cancers were identified through the hospital discharge diagnoses. The incidence rates of cancer at different sites were calculated for type 1 and 2 diabetics and for non-diabetics. Proportional hazard models were built to assess the risk of cancer associated with diabetes and antidiabetic drugs.

RESULTS

Diabetes was associated with increased risk of digestive cancers. Liver and pancreatic cancers were associated with the highest hazard ratios. Among type 2 diabetics, total number of metformin prescriptions was associated with reduced risk of most types of digestive cancers; sulfonylureas with reduced risk of stomach and pancreatic cancer.

CONCLUSIONS

In this Italian population the excess risk of digestive cancers for diabetic patients was confirmed. Further research is needed to clarify the role of antidiabetic drugs.

HIPEC in controversial digestive tumors

Local-regional and peritoneal metastases still develop despite improvements in surgical techniques. Intraperitoneal chemotherapy has been proved to be effective in reducing the rate of local-regional and peritoneal metastases in many malignancies. There is adequate evidence that intraperitoneal perioperative chemotherapy after aggressive resection of locally advanced tumors of the digestive system may be helpful in decreasing the rate of local-regional and peritoneal metastases. Prospective trials and meta-analyses have shown that patients with locally advanced gastric or colorectal carcinomas are offered significant survival benefit and develop reduced number of local-regional metastases with surgery combined with perioperative intraperitoneal chemotherapy. In pancreatic cancer the preliminary results have shown that these patients do not develop local-regional recurrences with R0 resection in combination with hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC). Further studies are required to document these findings.

Assessment of the relationship between resilience and quality of life in patients with digestive cancer

AIM: To study the relationship between resilience and quality of life (QOL) in patients with digestive cancer.

METHODS: The resilience of patients was measured prior to treatment, and their psychological distress, fatigue status, and treatment side effects were assessed 3 wk after. Their QOL was measured after their treatment ended. A relationship model of these variables was constructed using path analysis.

RESULTS: Resilience explained 33.2% of the variance in psychological distress, 16.1% of the variance in fatigue, and 1.23% of the variance in side effects. The relationship between resilience and QOL was statistically significant (β = 0.119, t = 4.499, P < 0.001) when psychological distress, fatigue, and side effects were absent from the regression model, whereas the adjusted regression coefficient of resilience was not statistically significant (t = 1.562, P > 0.05) when these variables were added. Psychological distress, together with fatigue and side effects, could explain 52.40% of the variance in QOL (P < 0.05). Physiological distress accounted for 28.94% of the total effect on QOL, fatigue accounted for 33.72%, side effects accounted for 22.53%, and resilience accounted for 14.80%.

CONCLUSION: Resilience is not an independent predictor of QOL in patients with digestive cancer, but it is a main factor influencing psychological distress and side effects.

Prognostic value of SOX2 in digestive tumors: a meta-analysis

BACKGROUND/AIMS

Sex determine region Y-box 2 (SOX2) is involved in tumor onset and progress. However its prognostic value for survival in patients with digestive tumors remains controversial.

METHODOLOGY

Publications related to the prognostic significance of SOX2 in digestive tumors were included up to 1 Oct 2013. We computed the pooled hazard ratio and subgroup stratification analysis for overall survival (OS) by software Stata.

RESULTS

A total of eight studies met the inclusion criteria. The pooled results showed that high SOX2 level was not significantly associated with OS in digestive tumors with significant heterogeneity. We then performed a subgroup analysis according to tumor types and patients’ numbers. SOX2 over-expression was associated with a poor OS in hepatocellular carcinoma (HR, 2.56; 95%CI, 1.77–3.71; P=0.000) with no heterogeneity. While in gastric carcinoma, SOX2 over-expression was not associated with OS (HR, 0.83; 95%CI, 0.23–3.03; P=0.773) with obvious heterogeneity. In addition, the sample size affected the pooled results.

CONCLUSIONS

Taken together, our findings suggested that SOX2 expression was associated with a poor prognosis in patients with hepatocellular carcinoma, while not for gastric carcinoma. The prognosis role for SOX2 in digestive tumors might vary from different tumor type and different pathology stage. Further large scale multicenter studies need to confirm these results.

E2F transcription factors and digestive system malignancies: How much do we know?

E2F family of transcription factors regulates various cellular functions related to cell cycle and apoptosis. Its individual members have traditionally been classified into activators and repressors, based on in vitro studies. However their contribution in human cancer is more complicated and difficult to predict. We review current knowledge on the expression of E2Fs in digestive system malignancies and its clinical implications for patient prognosis and treatment. E2F1, the most extensively studied member and the only one with prognostic value, exhibits a tumor-suppressing activity in esophageal, gastric and colorectal adenocarcinoma, and in hepatocellular carcinoma (HCC), whereas in pancreatic ductal adenocarcinoma and esophageal squamous cell carcinoma may function as a tumor-promoter. In the latter malignancies, E2F1 immunohistochemical expression has been correlated with higher tumor grade and worse patient survival, whereas in esophageal, gastric and colorectal adenocarcinomas is a marker of increased patient survival. E2F2 has only been studied in colorectal cancer, where its role is not considered significant. E2F4’s role in colorectal, gastric and hepatic carcinogenesis is tumor-promoting. E2F8 is strongly upregulated in human HCC, thus possibly contributing to hepatocarcinogenesis. Adenoviral transfer of E2F as gene therapy to sensitize pancreatic cancer cells for chemotherapeutic agents has been used in experimental studies. Other therapeutic strategies are yet to be developed, but it appears that targeted approaches using E2F-agonists or antagonists should take into account the tissue-dependent function of each E2F member. Further understanding of E2Fs’ contribution in cellular functions in vivo would help clarify their role in carcinogenesis.

Chemokines, chemokine receptors and the gastrointestinal system

The biological properties of tumor cells are known to be regulated by a multitude of cytokines and growth factors, which include epidermal growth factor receptor agonists and members of the transforming growth factor β family. Furthermore, the recent explosion of research in the field of chemokine function as mediators of tumor progression has led to the possibility that these small, immunomodulatory proteins also play key roles in carcinogenesis and may, therefore, be potential targets for novel therapeutic approaches. In this review, we will summarize recently reported findings in chemokine biology with a focus on the gastrointestinal tract.

Telephone hotline is an important part of overall patient management in upper gastrointestinal malignancies

INTRODUCTION

As seven out of every ten patients with upper gastrointestinal malignancies (UGIM) are not eligible for curative treatment, life after diagnosis is characterised by a rapid deterioration and uncertainty. To accommodate these issues, we established a telephone hotline.

MATERIAL AND METHODS

In a two-year period, all patients evaluated for UGIM were given the hotline phone number. The hotline was staffed by either a nurse or a secretary, and subsequently the specialist in charge of the patient would return the call. All calls were registered in a prospective database. The following data were recorded: diagnosis, time from call to return call, problem and solution to the problem.

RESULTS

A total of 477 patients were included, and 172 (36%) patients used the Hotline a total of 254 times. Of the 254 calls, 210 (83%) were returned the same day. A total of 104 (41%) calls were made due to elaborative questions and 89% of these were solved over the phone. Dysphagia was the problem in 51 cases which gave rise to an endoscopy in 86% of cases. Pain was the problem in 35. Overall, of the 254 calls, 152 (60%) problems were solved over the phone. Furthermore, 75 calls triggered a hospital visit and 27 calls led to the patient being referred for further examinations.

CONCLUSION

The establishment of a telephone hotline was feasible and it was used by some patients. Most of the callers only made one call. Nearly all calls (96%) were returned the day after the initial call, at the latest. The problem pattern did not differ between disease groups apart from dysphagia in oesophageal cancer. We found that the hotline was an effective and inexpensive part of overall patient management.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

[Current status and prospectives of proton and heavier-ion beam therapy for tumor in the digestive system]

Particle radiotherapy using proton and heavier-ion beam was first proposed for clinical application by Robert Wilson in 1946. Compared to conventional photon radiation, proton and heavier-ion beam has significant physical advantage, and heavier-ion has unique biological characteristics. With the development of accelerator and radiation technique, it is being investigated for tumor treatment in many clinical centers. This article reviews the current status of clinical application of particle therapy using proton and heavier-ion beam in digestive system tumor.

[Vaccine therapies against digestive-system cancers]

Cancer vaccine is a promising tool to achieve therapeutic responses in patients by inducing anti-tumor immunity. Several cancer vaccine trials have been performed in patients with digestive-system cancers. Two major candidates are peptide vaccine and dendritic cell (DC) vaccine. Since their clinical impacts are still limited, extensive studies are underway in order to identify more effective antigens or to potentiate DC functions. We developed a novel DC possessing potent stimulating activity for Th1, CTL, and NK cells, which are desirable for clinical DC vaccines. We performed the clinical trial using such DC for the treatment of colorectal cancer. In some of vaccinated patients, the capacity of NK cells and CTLs was successfully enhanced. Thus, cancer vaccines could be a therapeutic option for digestive-system cancers.

Recent progress in the understanding, diagnosis, and treatment of gastroenteropancreatic neuroendocrine tumors

Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are relatively rare tumors that arise from the diffuse neuroendocrine system. This heterogeneous group of tumors was often considered a single entity. This belied their biological diversity, and the biggest advance in understanding these tumors over the past decades has been in understanding this diversity. Diagnosis of these tumors has been aided by advances in pathological diagnosis and classification and tumor imaging with endoscopic ultrasound and somatostatin receptor fusion imaging. Genetic and molecular advances have identified molecular targets in the treatment of these tumors. Surgery remains the mainstay of treatment, amply supported by interventional radiological techniques, including embolization. Treatment of metastatic disease has improved significantly with the addition of several new agents, including tyrosine kinase inhibitors, mammalian target of rapamycin inhibitors, and yttrium-90-DOTA (1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid) and lutetium-177-DOTA octreotate. Despite significant advances in the understanding and management of GEP-NETs, the survival of patients remains largely unchanged and there remains a need for the development of national and international research collaborations to spearhead future efforts.

[Neuroendocrine tumors of the digestive tract and the pancreas]

Neuroendocrine tumors (NET) originate from hormone-producing cells and may appear in any organ. Approximately 230 NET tumors are detected in Finland annually. NET tumors of the digestive tract and the pancreas can be detected accidentally in emergency surgery, after years of abdominal symptoms, or based on symptoms caused by the hormones produced. Basic investigations include determination of 5-hydroxyindoleacetic acid in 24-hour urine sample and plasma chromogranin, as well as gamma-imaging of somatostatin receptors. A treatment plan is devised on the basis of the pathologic-anatomic classification of the tumor. Surgery and drug therapy are first-line treatments. Targeted radiation therapy has also appeared promising.

Trends in survival of patients diagnosed with cancer of the digestive organs in the Nordic countries 1964-2003 followed up to the end of 2006

Cancers of the digestive organs (including the oesophagus, stomach, small intestine, colon, rectum and anus, liver, gallbladder, and pancreas) constitute one-fifth of all cancer cases in the Nordic countries and is a group of diseases with diverse time trends and varying consequences for public health. In this study we examine trends in relative survival in relation to the corresponding incidence and mortality rates in the Nordic countries during the period 1964-2003.

MATERIAL AND METHODS

Data were retrieved from the NORDCAN database for the period 1964 to 2003, grouped into eight 5-year periods of diagnosis. The patients were followed up until the end of 2006. Analysis comprised trends in 5-year relative survival, excess mortality and age-specific relative survival.

RESULTS

Survival following cancers of the colon and rectum has increased continuously over the observed period, yet Danish patients fall behind those in the other Nordic countries. The largest inter-country variation is seen for the rare cancers in the small intestine. There has been little increase in prognosis for patients diagnosed with cancers of the liver, gallbladder or pancreas; 5-year survival is generally below 15%. Survival also remains consistently low for patients with oesophageal cancer, while minor increases in survival are seen among stomach cancer patients in all countries except Denmark. The concomitant incidence and mortality rates of stomach cancer have steadily decreased in each Nordic country at least since 1964.

CONCLUSION

While the site-specific variations in mortality and survival largely reflect the extent of changing and improving diagnostic and clinical practices, the incidence trends highlight the importance of risk factor modification. Alongside the ongoing clinical advances, effective primary prevention measures, including the control of alcohol and tobacco consumption as well as changing dietary pattern, will reduce the incidence and mortality burden of digestive cancers in the Nordic countries.

[Cancer of the upper aero-digestive tract: elevated incidence in Belgium, new risk factors and therapeutic perspectives]

The squamous cell carcinomas of the upper aero-digestive tracts are frequent cancers, with as much as 466831 and 168368 cases diagnosed in 2008 among men and women in the world, respectively. As such, they make up the sixth most frequent neoplasia among men and the eighth among women. Their frequency shows interesting variations covering the last twenty years, with an ascending tendency among women, which is maximal in Europe, and a descending tendency in men, maximal in the USA. The comparison with the Belgian official data reveals a striking elevation of incidence of these cancers among both sexes. Although the causal link between high-risk HPVs and cervical carcinoma is well-established, the implication of this viral infection in HNSCC remains debatable. 5 % to 65 % of head and neck cancers could be associated with oncogenic HPVs, in particular HPV type 16. The oropharynx--more precisely the tonsil--is the head and neck location presenting the highest incidence of HPV infection. Moreover, a clear increase of tonsillar carcinoma incidence has been described. As observed in cervical carcinomas, HPV positive HNSCCs are sexually transmitted and characterized by alterations of p53 and pRb signalling pathways. New studies regarding HPV status in HNSCCs are warranted to provide a rationale for large scale HPV vaccination in young male populations.

A prospective evaluation of venous thromboembolism in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

We sought to investigate the incidence of perioperative venous thromboembolism (VTE)--pulmonary embolism, superior mesenteris vein thrombosis and deep vein thrombosis--in patients with peritoneal carcinomatosis after cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy.

METHODS

We performed cytoreductive surgery and hyperthermic intraperitoneal chemotherapy on 60 consecutive patients with a mean age of 52 (range 24-76) years. We reviewed a prospective database recording complications and patient, tumour and surgical characteristics to determine the incidence of VTE. We reviewed hospital charts of patients with VTE to obtain clinical information including vital signs, risk factors, presence of comorbid conditions, VTE prophylaxis and subjective clinical symptoms.

RESULTS

A total of 6 of 60 patients (10%) who had cytoreductive surgery and hyperthermic intraperitoneal chemotherapy experienced VTE. All patients with VTE had extensive peritoneal disease and long durations of surgery: the median duration was 431 (range 330-683) minutes. Tachycardia (mean 104 beats/min) was the only consistent abnormal vital sign recorded, with only 33% of patients experiencing clinical symptoms.

CONCLUSION

This prospective study demonstrates a high rate of VTE in this patient population. Unfortunately, clinical signs and symptoms are a poor predictor of VTE. Therefore, routine screening of this specific population at high risk for VTE is warranted.

[Short-term efficacy of ct-guided radioactive seed 125I implantation on residual or relapsing metastatic lymph nodes in advanced tumor patients after multi-modality treatment]

BACKGROUND & OBJECTIVE

Lymph node metastasis is an important factor affecting tumor staging, treatment and prognosis. Residual or newly developed metastatic lymph nodes after combined therapy will bring difficulty in further treatment for cancer patients. This study was to investigate the clinical value of CT-guided radioactive seed 125I implantation in treating metastatic lymph nodes.

METHODS

From Nov. 2003 to Apr. 2007, 47 patients with pathologically confirmed malignant tumors received CT-guided radioactive seed 125I implantation to treat a total of 57 metastatic lymph nodes. The diameter of these metastatic lymph nodes ranged from 1.0 to 5.5 cm: 20 (35.1%) of them with diameter of < 2.0 cm, 21 (36.8%) with diameter of 2.0-2.9 cm, 10 (17.5%) with diameter of 3.0-3.9 cm, 6 (10.5%) with diameter of > or = 4.0 cm. Treatment planning system was used to design the distribution of seed 125I. Under CT guidance, 125I seeds of (2.2-3.3) x 10(7) Mq were implanted into the metastatic lymph nodes at a distance of 1.0-1.5 cm. CT or PET-CT re-examination was performed at 1-3 months after seed 125I implantation.

RESULTS

Seventeen patients had pain caused by metastatic lymph nodes and 13 of them had the pain relieved at 5-14 days after 125I implantation, with a response rate of 76.5%. Of the 47 patients, 38 (80.9%) achieved complete remission (CR), 4 (6.4%) achieved partial remission (PR), 3 (4.3%) had no change (NC), 2 (4.3%) had progressive disease (PD); the overall response rate was 89.4%. The major complication was slight hemorrhage developed in 7 patients (14.9%).

CONCLUSION

CT-guided radioactive seed 125I implantation is effective and safety in treating metastatic lymph nodes, with minimal damage and few complications.

Endoscopic ultrasound

Endoscopic ultrasound (EUS) is being used to diagnose and evaluate a number of conditions of the gastrointestinal tract. This article describes the type of EUS equipment that is being used in clinical practice, the type of conditions for which it is used to diagnose and evaluate, and its therapeutic uses.

[Key events from the 3rd Francophone Congress on Digestive and Hepatobiliary Surgery]

Colorectal carcinoma is the second leading cause of cancer in Europe and the third cause of cancer death in the United States. Every year in France, 36000 new cases are diagnosed, 50% of them with visceral metastases. Among these metastasis patients, 70% exhibit liver metastasis exclusively at time of diagnosis. In most patients, liver metastases are non resecables with chemotherapy offering poor long term survival. Surgery is the only curative treatment. Among patients with liver metastases, 10 to 20% are resecable with 40% of them surviving at 5 years. The aim of chemotherapy intensification schedules is to allow resection in 15 to 30% of initially non resecable metastatic patients and consequently offering some long term survivals. Regarding colon cancer liver metastases therapeutic strategy, confrontation between oncologists and surgeons is essential in order to give the opportunity to a significant number of metastatic patients to acces to cure.

[Trends in gastroenteropancreatic neuroendocrine tumors]

Carcinoids were first reported approximately 100 years ago and proposed to be neuroendocrine tumors of hormonal origin some 50 years later. The first edition of the WHO classification included neuroendocrine tumors of the digestive organs and pancreas, but thereafter it was pointed that neuroendocrine cells are distributed throughout the body and thus that carcinoids occur in various other organs. The most recent edition of the WHO classification takes into account the occurrence of neuroendocrine tumors throughout the body. In addition, carcinoids were originally thought to be variants of a benign tumor type with a low malignancy rate, but thereafter metastases were observed. The term "neuroendocrine tumors" is now preferred instead of "carcinoids," and the malignant potential of such tumors is recognized. This paper reviews the classification and treatment of gastroenteropancreatic neuroendocrine tumors.

Review. Animal models of carcinogenesis in the digestive system

Digestive system malignancies are quite common, accounting for 25% of deaths from cancer in the European Union. Various etiological factors of carcinogenesis include hereditary mutations and susceptibility polymorphisms, inflammation due to infectious agents, environmental and dietary factors. Transgenic, knockout or mutant animal models are very useful in reproducing cancers of the digestive tract that occur in humans. They offer the opportunity to study the disease phenotype and the function of the underlying mechanisms of carcinogenesis. In addition, animal models are valuable tools in cancer treatment attempts with the combined use of gene targeting or chemotherapy. This review illustrates the importance of the numerous animal models that have been developed by various methods in order to study carcinogenesis in the digestive tract and test potential therapeutic treatments.

[Neoadjuvant treatments in digestive cancer]

Neoadjuvant chemotherapy or chemoradiotherapy is an important concept in the treatment of colorectal liver metastasis, gastric cancer, and esophageal or rectal tumors. This treatment strategy improves disease-free survival and sometimes overall survival. It allows surgical resection of lesions that where not resectable at diagnosis. The new standards of neoadjuvant treatments in gastrointestinal oncology are described in this article.

Percutaneous ipsilateral portal vein embolization using a modified four-lumen balloon catheter with fibrin glue: initial clinical experience

PURPOSE

The purpose of the present study was to show the feasibility and safety of ipsilateral portal vein embolization (PVE) using an improved four-lumen balloon catheter with fibrin glue.

MATERIALS AND METHODS

To improve the ipsilateral PVE with fibrin glue, we modified a commercially available four-lumen balloon catheter to create a catheter comprising one lumen with a catheter tip for a guidewire, one lumen for an occlusion balloon, and two lumens, each with a side-hole just proximal to the balloon. Eight patients had hepatobiliary disease (three with bile duct carcinoma, two with gallbladder carcinoma, one with hepatocellular carcinoma, one with Caroli disease, and one with metastatic carcinoma).

RESULTS

All embolization procedures were technically successful. After embolization, the volume of the future remnant liver increased a mean of 131%. There was no inadvertent embolization of portal vein branches and no major procedure-related complications.

CONCLUSION

Our method is potentially easier and safer than the traditional ipsilateral method with fibrin glue using a three-lumen balloon catheter because the fourth lumen makes possible the use of a guidewire to access the targeted portal vein and measurement of any portal vein pressure elevation following PVE via the fourth lumen.

Epidemiology and treatment of extramammary Paget disease in the Netherlands

AIM

To determine the incidence of EMPD and to describe its epidemiology, treatment, survival and the risk of developing other malignancies.

METHOD

All cases of EMPD, diagnosed between 1989 and 2001, were selected from the Netherlands Cancer Registry.

RESULTS

In total, 178 cases of invasive and 48 cases of in situ EMPD had been registered. The overall relative 5-year survival for invasive tumours was 72%. Most patients with invasive as well as in situ cancer underwent surgery. Other malignancies were found in 32% of patients with invasive EMPD and 35% of patients with in situ EMPD. Patients had an increased risk of developing a second primary cancer (standardized incidence ratio: 1.7; 95% confidence interval 1.2-2.4). The most frequent localizations of the other cancers were the colorectum, the prostate, the breast and the extragenital skin.

CONCLUSIONS

For EMPD, which is a rare disease in the Netherlands, there are no clear diagnostic and treatment guidelines. The prognosis is fairly good. A thorough search for other tumours is recommended for these patients.