Impact of Tissue Enolase 1 Protein Overexpression in Esophageal Cancer Progression

Enolase (ENO) 1 is a key glycolytic enzyme and important player in tumorigenesis. ENO1 overexpression has been correlated with tumor progression and/or worse prognosis in several solid malignancies. However, data concerning the impact of ENO1 in cancer conflict. The study correlated local and circulating ENO1 protein levels in esophageal cancer (EC) with clinicopathological data, to assess its potential clinical value. ENO1 expression was analyzed by immunohistochemistry in paired tumor and non-tumor tissue samples from 40 EC cases and mucosal biopsies from 45 Barrett's esophagus (BE) cases, plus in plasma from these patients and 25 matched healthy controls. ENO1 was abnormally elevated in cancer-cell cytoplasm in both EC types, in esophageal squamous cell carcinoma and in adenocarcinoma (EAC), increasing significantly with tumor stage progression and the transition from BE to EAC. EAC patients exhibited significantly lower ENO1 plasma concentrations than normal subjects. Neither local nor systemic ENO1 expression levels were significantly associated with overall survival. These results indicate ENO1 as potential biomarker, delineating a population of patients with Barrett's esophagus at high risk of cancer, and as new therapeutic opportunity in EC patient management. However, further confirmation might be necessary.

Neoadjuvant chemo-radiotherapy for locally advanced esophageal cancer: A monocentric study

Aims and background

Multimodal therapy is a keystone of care in advanced esophageal cancer. Although neoadjuvant chemoradiotherapy is known to provide a survival advantage in selected cases, reliable prognostic and response predictive factors remain elusive. We report the outcome in a series of esophageal cancer patients treated at our center and the results of a retrospective analysis of epidermal growth factor receptor (EGFR) expression and EGFR/HER2 gene copy numbers taken as possible prognostic and predictive factors.

Methods and study design

Between 2001 and 2009, a total of 40 consecutive patients (34 men and 6 women; median age, 59 years) were treated for esophageal cancer. Treatment: cisplatin, 80 mg/m2 day 1, and 5-fluorouracil, 800 mg/m2/24 h on days 1–5, every 21 days, concomitant with 3D-conformal radiotherapy (54–59.4 in 30–33 fractions) for three up to four cycles. Surgery was performed in eligible patients 6–8 weeks after chemoradiation. EGFR expression and EGFR/HER2 amplification and gene copy number were studied by immunohistochemical analysis and fluorescence in situ hybridization, respectively.

Results

Acceptable toxicity following chemoradiation was recorded, with G3–G4 hematological toxicity in 20% of patients and G3–G4 dysphagia in less than 10%; 14 (35%) patients achieved complete response and 19 (48%) partial response; 18 underwent surgery after chemoradiation, of which 8 (20%) achieved pathologic complete response. The median survival was 29 months (95% CI, 25.7–32.1): 42 months for the resected and 20 for the unresected patients. EGFR and HER2 analysis in 28 patients showed that 89% had immunohistochemical EGFR expression, with 5 cases of EGFR and 10 of HER2 gene gain without a significant difference in response rate and survival in these patient subgroups.

Conclusions

Our results suggest a better outcome in patients who underwent surgery after chemoradiation. A larger sample size is necessary to clarify the role of EGFR and HER2 gene gain in predict response and survival.

Carcinosarcoma of the Esophagogastric Junction

Carcinosarcoma of the esophagus and the stomach are rare neoplasms characterized by the simultaneous presence of carcinomatous and sarcomatous elements. There is no report in the literature of carcinosarcoma of the esophagogastric junction. We present a case of carcinosarcoma of the esophagogastric junction whose unique clinical presentation, surgical issues, morphological and immunohistochemical features makes it quite distinctive from similar cases observed in the esophagus or in the stomach.

Neoadjuvant chemo-radiotherapy for locally advanced esophageal cancer: a monocentric study

AIMS AND BACKGROUND

Multimodal therapy is a keystone of care in advanced esophageal cancer. Although neoadjuvant chemoradiotherapy is known to provide a survival advantage in selected cases, reliable prognostic and response predictive factors remain elusive. We report the outcome in a series of esophageal cancer patients treated at our center and the results of a retrospective analysis of epidermal growth factor receptor (EGFR) expression and EGFR/HER2 gene copy numbers taken as possible prognostic and predictive factors.

METHODS AND STUDY DESIGN

Between 2001 and 2009, a total of 40 consecutive patients (34 men and 6 women; median age, 59 years) were treated for esophageal cancer.

TREATMENT

cisplatin, 80 mg/m² day 1, and 5-fluorouracil, 800 mg/m²/24 h on days 1-5, every 21 days, concomitant with 3D-conformal radiotherapy (54-59.4 in 30-33 fractions) for three up to four cycles. Surgery was performed in eligible patients 6-8 weeks after chemoradiation. EGFR expression and EGFR/HER2 amplification and gene copy number were studied by immunohistochemical analysis and fluorescence in situ hybridization, respectively.

RESULTS

Acceptable toxicity following chemoradiation was recorded, with G3-G4 hematological toxicity in 20% of patients and G3-G4 dysphagia in less than 10%; 14 (35%) patients achieved complete response and 19 (48%) partial response; 18 underwent surgery after chemoradiation, of which 8 (20%) achieved pathologic complete response. The median survival was 29 months (95% CI, 25.7-32.1): 42 months for the resected and 20 for the unresected patients. EGFR and HER2 analysis in 28 patients showed that 89% had immunohistochemical EGFR expression, with 5 cases of EGFR and 10 of HER2 gene gain without a significant difference in response rate and survival in these patient subgroups.

CONCLUSIONS

Our results suggest a better outcome in patients who underwent surgery after chemoradiation. A larger sample size is necessary to clarify the role of EGFR and HER2 gene gain in predict response and survival.

Abnormal expression of Endoglin and its receptor complex (TGF-β1 and TGF-β receptor II) as early angiogenic switch indicator in premalignant lesions of the colon mucosa

The precise timing of the angiogenic switch in colorectal cancer development is still unclear. The simultaneous expression of Endoglin (CD105), transforming growth factor (TGF)-β1 and TGF-β receptor (R) II were quantified in surgical specimens comprising normal human colon, pre-malignant dysplastic tissue, in situ, and invasive colon cancer specimens, at mRNA and protein levels, respectively by real-time PCR and immunohistochemistry. Serum concentrations of soluble Endoglin and TGF-β1 were evaluated. mRNA and CD105+-microvessel density (MVD) increased significantly in dysplastic colon and carcinoma versus normal tissues; values correlated respectively with dysplasia degree and Dukes' stages. TGF-β1 expression was significantly upregulated in most severe dysplastic adenoma specimens, while TGF-β1 transcript and protein signals were intense in carcinoma, positively-correlated with tumor progression. TGF-β1 RII was overexpressed in adenoma and carcinoma versus normal samples, but unrelated with dysplasia or Dukes' stage. Soluble Endoglin serum levels were equivalent in adenoma and normal tissues; in carcinoma the highest levels were in invasive tumor. Circulating TGF-β1 levels were increased in severe dysplasia and progressed with tumor progression. Correlations between adenoma dysplasia degree and TGF-β RII and CD105+-MVD, and between tumor Dukes' staging and TGF-β1 and CD105+-MVD, were significant. TGF-β1 and Endoglin and TGF-β1 serum levels, TGF-β1 staining and CD105+-MVD were significantly and inversely associated with disease-free survival. TGF-β1 levels were an independent and significant prognostic factor of disease-free survival. These findings suggest active angiogenesis occurs in many pre-malignant colon cases and supports more careful evaluation of different chemopreventive agents.

The diagnostic accuracy of the immunocytochemical markers in the pre-operative evaluation of follicular thyroid lesions

Aim of the study was to consider the diagnostic accuracy of galectine-3 (GAL3) in the pre-operative cytological evaluation of follicular lesions.

MATERIALS AND METHODS

We retrospectively evaluated 100 patients suffering from thyroid nodular disease submitted to thyroidectomy from 2006 to 2007 in our Institution. Before surgery all patients underwent fine needle aspiration biopsy. The immunocytochemical analysis was performed on fine needle aspiration specimens using species-specific monoclonal antibodies and a biotin-free detection system. Based on preoperative cytological reports, 40 patients had pre-operative malignant results, and 60 patients (46 females and 14 males) showed follicular lesions. The sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy of GAL3 was evaluated.

STATISTICAL ANALYSIS

Chi-square test was used to compare frequencies of GAL3 expression between the different hystopathological groups.

RESULTS

GAL3 proved to have 55% sensitivity, 100% specificity, 70% negative predictive value, and 78% diagnostic accuracy. The GAL3 expression in neoplastic and benign lesions was significantly different (GAL3+ in 16 out of 29 neoplastic lesions, GAL3+ 0 out of 31 benign lesions, p<0.01). Even comparing the GAL3 positivity between the follicular adenomas (0 GAL3+ out of 20) and the group of follicular carcinomas (5 GAL3+ out of 6), we found a statistically significant difference (p<0.01).

CONCLUSIONS

Based on the data from our experience, the patients with a cytological diagnosis of GAL3 positive follicular neoformation should be referred for surgery without any further immunocytological testing.

Successful surgical management of a delayed pharyngo-esophageal perforation after anterior cervical spine plating

A case report of a 41-year-old man who had a delayed pharyngo-esophageal perforation without instrumentation failure 7 years after anterior cervical spine plating is presented and the literature on this issue is reviewed. This injury resulted from repetitive friction/traction between the retropharyngo-esophageal wall and the cervical plate construct leading to a pseudodiverticulum and perforation. Successful treatment of the perforation was obtained after surgical repair using a sternocleidomastoid muscle flap. This case stresses the necessity of careful long-term follow-up in patients with anterior cervical spine plating for early detection of possible perforation and the use of muscle flap as the treatment of choice during surgical repair.

Transforming growth factor-beta binding receptor endoglin (CD105) expression in esophageal cancer and in adjacent nontumorous esophagus as prognostic predictor of recurrence

BACKGROUND

We hypothesized that the potent neovascularization marker endoglin (CD105), by differentially highlighting a subset of microvessels (MV) in esophageal cancer (EC), could provide better prognostic/therapeutic information than the panendothelial marker CD34, which also highlights MV.

METHODS

Endoglin messenger ribonucleic acid (mRNA) expression in normal, malignant, and adjacent nontumorous esophagus tissue was quantified by real-time reverse-transcription polymerase chain reaction (RT-PCR). Sections of formalin-fixed, paraffin-embedded tissues were analyzed immunohistochemically for CD105 and CD34. MV density was counted following a standard protocol. Circulating soluble endoglin levels were determined in patient and control sera, and compared with clinical outcome.

RESULTS

CD105 mRNA was upregulated by a median factor of 2.89 in ECs versus controls. In 28% of patients, CD105 mRNA was upregulated by a median factor of 2.65 in adjacent non-tumorous versus normal tissue. In tumor tissues, CD105 was stained negatively or positively only in a subset of MV. CD34 always showed positive extensive MV staining. In adjacent nontumorous esophagus, CD105 rarely showed diffuse MV staining, while CD34 stained blood-vessel endothelial cells in all non-neoplastic tissue. CD105 expression was high in residual highly dysplastic Barrett's-type mucosa associated with some adenocarcinomas. No statistically significant difference in endoglin serum levels appeared between patients and normal subjects. Correlation with clinicopathological data showed higher intra-tumor MV-CD105+ scores at more-advanced clinical stages. High-scoring MV-CD105+ patients had significantly shorter disease-free and overall survival; MV-CD34+ density was not survival related. Diffuse CD105 expression in adjacent nontumorous esophagus predicted poorer disease-free and overall survival.

CONCLUSIONS

Our findings could help identify EC patients who may benefit from targeted anti-angiogenic therapies.

KIT/stem cell factor expression in premalignant and malignant lesions of the colon mucosa in relationship to disease progression and outcomes

Autocrine/paracrine stimulation of KIT has been observed in colorectal carcinoma (CRC) cell lines. We investigated the expression of KIT and stem cell factor (SCF) in CRC in comparison with premalignant colon lesions and normal colonic mucosa to assess the prognostic and therapeutic relevance of this receptor/ligand system in CRC. Transcript levels of c-kit and the two SCF splicing variants were determined quantitatively by real-time RT-PCR using cDNA obtained from normal, premalignant and malignant snap frozen colon tissue specimens. Immunohistochemistry with specific anti-KIT and anti-SCF antibodies was performed on paraffin-embedded tissue sections in order to localize the relative protein expression in epithelial compartments. Approximately 10% of patients expressed KIT in their adenoma or primary tumor. The majority of KIT-positive carcinomas co-expressed SCF. Real-time RT-PCR showed expression of c-kit and SCF transcripts in all cDNA specimens examined. A significant association between the co-expression of KIT/SCF and a worse clinical outcome was found. In conclusion, KIT expression was observed in a proportion of premalignant and malignant colonic lesions, while it was virtually absent in normal colon mucosa. Moreover, the majority of KIT-positive carcinomas co-expressed SCF, suggesting the possibility of aberrant signaling by an autocrine loop, as confirmed by the negative prognostic value of this association. Therefore, in the subset of CRC patients with concomitant KIT/SCF expression, the activity of Imatinib mesylate, a selective inhibitor of specific tyrosine kinases including KIT, may be exploited in combination with standard therapy.

Giant fibrovascular polyp of the esophagus

Giant fibrovascular polyps are uncommon benign esophageal tumors almost always originating from the cervical esophagus, frequently from the upper esophageal sphincter. The case of a 74-year-old man with a long history of dysphagia and a weight loss of 9 kg is presented. Neither barium esophagogram, computed tomogram or magnetic resonance imaging correctly evidenced the lesion. Only fiberoptic endoscopy suggested the correct diagnosis because the mass fluctuated endoluminally with the spasm of vomiting. A left cervical exploratory incision with esophagotomy was performed following the experience of two previous similar cases. A giant fibrovascular polyp was observed and excised. If a malignant or benign extensive intramural tumor had been identified, a total esophagectomy would have been performed. In our opinion the possibility of the presence of a fibrovascular polyp should always be considered in the presence of an undetermined esophageal mass, and in these cases a left cervical incision is the preferred surgical access. Once the correct diagnosis is established, a major esophageal resection should always be avoided.

[The choice of surgical therapy in adenocarcinoma of the cardia]

AIM

From 1996 the adenocarcinoma of the esophago-gastric junction (AEG) is divided into 3 types according to Siewert's classification. For AEG type I and III the surgical treatment is codified, while for type II is still controversial. The aim of our study is to understand what is the better surgical treatment for AEG type II.

METHODS

From 1990 to 2002 we have performed 111 resections for adenocarcinoma of the cardia: 25 for AEG type I (all esophago-gastric resection), 39 for type II (22 esophago-gastric resection, 17 extended total gastrectomy with esophageal resection) and 47 for type III (8 esophago-gastric resection, 39 extended total gastrectomy with esophageal resection).

RESULTS

The morbidity and mortality rates are 17 and 5.4%, without significant difference between the different surgical treatment (p>0.01). The 5 year survival rate is 35%. Significant prognostic factors are the staging TNM (p=0.002) and principally the presence of metastatic lymph nodes (p=0.001). For AEG type II any significant difference in survival is associated with surgical strategy, also in early stage (p>0.01).

CONCLUSIONS

According to the results of our study and those of the other authors, who have showed that a 10 cm distance of the neoplasm by the gastric side and the esophageal one could assure oncologic radicality and also that metastatic lymph nodes below pylorus and near greater curvature are uncommon, we can consider esophago-gastric resection for AEG II a speedy, safe and oncologically correct surgical treatment.

[Adenocarcinoma of the cardia: surgical strategies compared]

BACKGROUND

The incidence of adenocarcinoma of the cardia is increasing. The choice of surgical strategy for AEG type II of Siewert classification is the subjects of controversial discussion. The aim of our retrospective study is to analyse the surgical results in 12 years.

MATERIAL AND METHODS

Since 1990 to 2002, 111 patients underwent resection for adenocarcinoma of the cardia at III Division of General Surgery, University of Turin. Twenty-five patients had AEG type I, 39 had type II and 47 type III. Transthoracic or transhiatal oesophagectomy with resection of the proximal stomach were performed in 55 cases and extended total gastrectomy with transthoracic or transhiatal oesophagectomy in 56.

RESULTS

The morbidity and mortality rates are 17% and 5.4%. The 5 years survival rate is poor (35%) for all Siewert type. Survival is significantly associated with stage and the presence of lymph node metastasis, but not correlated with Siewert classification and surgical approach. Also in the AEG II the survival is not modified by the surgical approach.

CONCLUSION

In patient with AEG I the therapy of choice is a radical transthoracic or transhiatal oesophagectomy with resection of the proximal stomach. For type III extended total gastrectomy with transthoracic or transhiatal oesophagectomy is the procedure of choice. The superiority of the thoracoabdominal approach is therefore evident in terms of oncologic radicality. Survival is similar in AEG type II patients for both operations. A oesophagectomy with proximal gastric resection should be adopted for these tumors as the standard procedure in the majority of cases.