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Afzal Z, Gourgiotis S, Hardwick RH, Safranek PM, Sujendran V, Bennett J, O'Neill JR, Noorani A, Hindmarsh A. Management of Upper Gastrointestinal Tract Leaks Using Endoluminal Vacuum Therapy: 10-years’ Experience of a Specialist Esophago-gastric Center. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Morton J, Hardwick RH, Tilney HS, Gudgeon AM, Jah A, Stevens L, Marecik S, Slack M. Preclinical evaluation of the versius surgical system, a new robot-assisted surgical device for use in minimal access general and colorectal procedures. Surg Endosc 2021; 35:2169-2177. [PMID: 32405893 PMCID: PMC8057987 DOI: 10.1007/s00464-020-07622-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 05/02/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the utility of a new robot-assisted surgical system (the Versius Surgical System, CMR Surgical, Cambridge, UK) for use in minimal access general and colorectal surgery, in a preclinical setting. Robot-assisted laparoscopy has been developed to overcome some of the important limitations of conventional laparoscopy. The new system is designed to assist surgeons in performing minimal access surgery and overcome some of the challenges associated with currently available surgical robots. METHODS Cadaveric sessions were conducted to evaluate the ability of the system to provide adequate surgical access and reach required to complete a range of general and colorectal procedures. Port and bedside unit positions were recorded, and surgical access and reach were evaluated by the lead surgeon using a visual analogue scale. A live animal (porcine) model was used to assess the surgical device's safety in performing cholecystectomy or small bowel enterotomy. RESULTS Nine types of procedure were performed in cadavers by nine lead surgeons; 35/38 procedures were completed successfully. The positioning of ports and bedside units reflected the lead surgeons' preferred laparoscopic set-up and enabled good surgical access and reach. Cholecystectomy (n = 6) and small bowel enterotomy (n = 5) procedures performed in pigs were all completed successfully by two surgeons. There were no device-related intra-operative complications. CONCLUSIONS This preclinical study of a new robot-assisted surgical system for minimal access general and colorectal surgery demonstrated the safety and effectiveness of the system in cadaver and porcine models. Further studies are required to assess its clinical utility.
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Affiliation(s)
- Jonathan Morton
- Department of Gastrointestinal Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Richard H Hardwick
- Department of Gastrointestinal Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Henry S Tilney
- Department of Surgery, Frimley Health NHS Foundation Trust, Frimley Park Hospital, Surrey, UK
| | - A Mark Gudgeon
- Department of Surgery, Frimley Health NHS Foundation Trust, Frimley Park Hospital, Surrey, UK
| | - Asif Jah
- Cambridge Hepato-Pancreato-Biliary and Transplant Centre, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Lewis Stevens
- Department of Molecular Oncology, Barts Cancer Institute, Queen Mary University London, London, UK
| | - Slawomir Marecik
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital and University of Illinois at Chicago, Illinois, USA
| | - Mark Slack
- CMR Surgical Ltd, 1 Evolution Business Park, Milton Road, Cambridge, CB24 9NG, UK.
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Antakia R, Xanthis A, Georgiades F, Hudson V, Ashcroft J, Rooney S, Singh AA, O'Neill JR, Fearnhead N, Hardwick RH, Davies RJ, Bennett JMH. P21 Appendicitis during the COVID-19 pandemic: to operate or not to operate, that is the question. BJS Open 2021. [PMCID: PMC8030156 DOI: 10.1093/bjsopen/zrab032.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background During the Covid-19 pandemic, non‐operative management for acute appendicitis (AA) was implemented in the UK. Aim of this study was to determine the efficacy and outcomes of conservative versus surgical management of AA during the pandemic. Materials & Methods We conducted an observational study in a tertiary referral centre. Data was collected from patients (≥16 years) with a diagnosis of AA between 1st November 2019 to 10th March 2020 (pre-COVID period) and 10th March 2020 to 5th July 2020 (COVID period). Results A total of 116 patients in the pre-COVID period were included versus 91 in the COVID period. 43.1% (n = 50) of patients pre-COVID were classified as ASA 2 compared to 26.4% (n = 24) during the COVID period (p-value=0.042). 72.5% (n = 66) of the patients during the COVID period scored as high risk using the Alvarado score compared to 24.1% (n = 28) in the pre-COVID period (p-value<0.001). We observed a significant increase in radiological evaluation, 69.8% versus 87.5% of patients had a CT in the pre-COVID and COVID periods respectively (p-value=0.008). 94.9% of patients were managed operatively in the pre-COVID period compared to 60.4% in the COVID period (p-value<0.001). We observed more open appendicectomies (37.3% versus 0.9%; p-value<0.001) during the COVID period compared to the pre-COVID period. More abscess formation and free fluid were found intraoperatively in the COVID period (p-value= 0.021 and 0.023 respectively). Re-attendance rate due to appendicitis-related issues was significantly higher in the COVID period (p = 0.027). Conclusion Radiological diagnosis of AA was more frequent during the COVID period. More conservative management for AA was employed during the COVID-19 pandemic, and for those managed operatively an open approach was preferred. Intra-operative findings were suggestive of delayed presentation during the COVID period without this affecting the length of hospital stay.
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Affiliation(s)
- Ramez Antakia
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
| | | | | | - Victoria Hudson
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
| | - James Ashcroft
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
| | - Siobhan Rooney
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
| | - Aminder A Singh
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
| | - John R O'Neill
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
| | - Nicola Fearnhead
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
| | | | - R Justin Davies
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
| | - John M H Bennett
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
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Antakia R, Xanthis A, Georgiades F, Hudson V, Ashcroft J, Rooney S, Singh AA, O'Neill JR, Fearnhead N, Hardwick RH, Davies R, Bennett JM. Acute appendicitis management during the COVID-19 pandemic: A prospective cohort study from a large UK centre. Int J Surg 2021; 86:32-37. [PMID: 33465496 PMCID: PMC7985094 DOI: 10.1016/j.ijsu.2020.12.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/13/2020] [Accepted: 12/28/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND During the Covid-19 pandemic, non-operative management for acute appendicitis (AA) was implemented in the UK. The aim of this study was to determine the efficacy and outcomes of conservative versus surgical management of AA during the pandemic. MATERIALS & METHODS We conducted an observational study in a tertiary referral centre. Data was collected from all patients (≥16 years) with a diagnosis of AA between November 1, 2019 to March 10, 2020 (pre-COVID period) and March 10, 2020 to July 5, 2020 (COVID period). RESULTS A total of 116 patients in the pre-COVID period were included versus 91 in the COVID period. 43.1% (n = 50) of patients pre-COVID were classified as ASA 2 compared to 26.4% (n = 24) during the COVID period (p-value = 0.042). 72.5% (n = 66) of the patients during the COVID period scored as high risk using the Alvarado score compared to 24.1% (n = 28) in the pre-COVID period (p-value<0.001). We observed a significant increase in radiological evaluation, 69.8% versus 87.5% of patients had a CT in the pre-COVID and COVID periods respectively (p-value = 0.008). 94.9% of patients were managed operatively in the pre-COVID period compared to 60.4% in the COVID period (p-value<0.001). We observed more open appendicectomies (37.3% versus 0.9%; p-value<0.001) during the COVID period compared to the pre-COVID period. More abscess formation and free fluid were found intraoperatively in the COVID period (p-value = 0.021 and 0.023 respectively). Re-attendance rate due to appendicitis-related issues was significantly higher in the COVID period (p = 0.027). CONCLUSION Radiological diagnosis of AA was more frequent during the COVID period. More conservative management for AA was employed during the COVID-19 pandemic, and for those managed operatively an open approach was preferred. Intra-operative findings were suggestive of delayed presentation during the COVID period without this affecting the length of hospital stay.
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Affiliation(s)
- Ramez Antakia
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK,Corresponding author. Division of Digestive Diseases, level E7 Addenbrooke's Hospital, Hills Road, CB2 0QQ, United Kingdom
| | | | | | - Victoria Hudson
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
| | - James Ashcroft
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
| | - Siobhan Rooney
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
| | - Aminder A. Singh
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
| | - John R. O'Neill
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Nicola Fearnhead
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge, UK
| | | | - R.Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge, UK
| | - John M.H. Bennett
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge, UK
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Blair VR, McLeod M, Carneiro F, Coit DG, D'Addario JL, van Dieren JM, Harris KL, Hoogerbrugge N, Oliveira C, van der Post RS, Arnold J, Benusiglio PR, Bisseling TM, Boussioutas A, Cats A, Charlton A, Schreiber KEC, Davis JL, Pietro MD, Fitzgerald RC, Ford JM, Gamet K, Gullo I, Hardwick RH, Huntsman DG, Kaurah P, Kupfer SS, Latchford A, Mansfield PF, Nakajima T, Parry S, Rossaak J, Sugimura H, Svrcek M, Tischkowitz M, Ushijima T, Yamada H, Yang HK, Claydon A, Figueiredo J, Paringatai K, Seruca R, Bougen-Zhukov N, Brew T, Busija S, Carneiro P, DeGregorio L, Fisher H, Gardner E, Godwin TD, Holm KN, Humar B, Lintott CJ, Monroe EC, Muller MD, Norero E, Nouri Y, Paredes J, Sanches JM, Schulpen E, Ribeiro AS, Sporle A, Whitworth J, Zhang L, Reeve AE, Guilford P. Hereditary diffuse gastric cancer: updated clinical practice guidelines. Lancet Oncol 2020; 21:e386-e397. [PMID: 32758476 DOI: 10.1016/s1470-2045(20)30219-9] [Citation(s) in RCA: 199] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/26/2020] [Accepted: 03/31/2020] [Indexed: 02/07/2023]
Abstract
Hereditary diffuse gastric cancer (HDGC) is an autosomal dominant cancer syndrome that is characterised by a high prevalence of diffuse gastric cancer and lobular breast cancer. It is largely caused by inactivating germline mutations in the tumour suppressor gene CDH1, although pathogenic variants in CTNNA1 occur in a minority of families with HDGC. In this Policy Review, we present updated clinical practice guidelines for HDGC from the International Gastric Cancer Linkage Consortium (IGCLC), which recognise the emerging evidence of variability in gastric cancer risk between families with HDGC, the growing capability of endoscopic and histological surveillance in HDGC, and increased experience of managing long-term sequelae of total gastrectomy in young patients. To redress the balance between the accessibility, cost, and acceptance of genetic testing and the increased identification of pathogenic variant carriers, the HDGC genetic testing criteria have been relaxed, mainly through less restrictive age limits. Prophylactic total gastrectomy remains the recommended option for gastric cancer risk management in pathogenic CDH1 variant carriers. However, there is increasing confidence from the IGCLC that endoscopic surveillance in expert centres can be safely offered to patients who wish to postpone surgery, or to those whose risk of developing gastric cancer is not well defined.
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Affiliation(s)
- Vanessa R Blair
- Department of Surgery, University of Auckland, Auckland, New Zealand; St Marks Breast Centre, Auckland, New Zealand
| | - Maybelle McLeod
- Kimihauora Health and Research Clinic, Mt Maunganui, New Zealand
| | - Fátima Carneiro
- Instituto de Investigação e Inovação em Saúde & Institute of Molecular Pathology and Immunology of the University of Porto, Department of Pathology, University of Porto, Porto, Portugal
| | - Daniel G Coit
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical School, New York, NY, USA
| | | | - Jolanda M van Dieren
- Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Nicoline Hoogerbrugge
- Department of Human Genetics, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Carla Oliveira
- Instituto de Investigação e Inovação em Saúde & Institute of Molecular Pathology and Immunology of the University of Porto, Department of Pathology, University of Porto, Porto, Portugal
| | | | - Julie Arnold
- New Zealand Familial Gastrointestinal Cancer Service, Auckland Hospital, Auckland, New Zealand
| | - Patrick R Benusiglio
- Consultation d'Oncogénétique, Unité Fonctionnelle d'Oncogénétique, Département de Génétique, DMU BioGeM, Groupe Hospitalier Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Tanya M Bisseling
- Department of Gastroenterology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Alex Boussioutas
- Department of Medicine, Royal Melbourne Hospital and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Annemieke Cats
- Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Amanda Charlton
- Department of Histopathology, Auckland Hospital, Auckland, New Zealand
| | | | - Jeremy L Davis
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | | | | | - James M Ford
- Division of Oncology, Departments of Medicine and Genetics, Stanford University School of Medicine, Stanford, CA, USA
| | - Kimberley Gamet
- Genetic Health Service New Zealand Northern Hub, Auckland Hospital, Auckland, New Zealand
| | - Irene Gullo
- Instituto de Investigação e Inovação em Saúde & Institute of Molecular Pathology and Immunology of the University of Porto, Department of Pathology, University of Porto, Porto, Portugal
| | - Richard H Hardwick
- Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
| | - David G Huntsman
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Pardeep Kaurah
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada; Hereditary Cancer Program, British Columbia Cancer, Vancouver, BC, Canada
| | - Sonia S Kupfer
- Section of Gastroenterology, Nutrition and Hepatology, University of Chicago, Chicago, IL, USA
| | - Andrew Latchford
- St Mark's Hospital, London, UK; Department of Cancer and Surgery, Imperial College, London, UK
| | | | - Takeshi Nakajima
- Department of Clinical Genetic Oncology, Cancer Institute Hospital, Tokyo, Japan
| | - Susan Parry
- New Zealand Familial Gastrointestinal Cancer Service, Auckland Hospital, Auckland, New Zealand
| | - Jeremy Rossaak
- Department of Surgery, Tauranga Hospital, Tauranga, New Zealand
| | - Haruhiko Sugimura
- Department of Tumor Pathology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Magali Svrcek
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Department of Pathology, Hôpital Saint-Antoine, Paris, France
| | - Marc Tischkowitz
- Department of Medical Genetics, National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Toshikazu Ushijima
- Division of Epigenomics, National Cancer Centre Research Institute, Tokyo, Japan
| | - Hidetaka Yamada
- Department of Tumor Pathology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | | | - Adrian Claydon
- Department of Gastroenterology, Tauranga Hospital, Tauranga, New Zealand
| | - Joana Figueiredo
- Instituto de Investigação e Inovação em Saúde & Institute of Molecular Pathology and Immunology of the University of Porto, Department of Pathology, University of Porto, Porto, Portugal
| | - Karyn Paringatai
- Te Tumu School of Māori, Pacific and Indigenous Studies, University of Otago, Dunedin, New Zealand
| | - Raquel Seruca
- Instituto de Investigação e Inovação em Saúde & Institute of Molecular Pathology and Immunology of the University of Porto, Department of Pathology, University of Porto, Porto, Portugal
| | - Nicola Bougen-Zhukov
- Cancer Genetics Laboratory, Te Aho Matatū, Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Tom Brew
- Cancer Genetics Laboratory, Te Aho Matatū, Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | | | - Patricia Carneiro
- Instituto de Investigação e Inovação em Saúde & Institute of Molecular Pathology and Immunology of the University of Porto, Department of Pathology, University of Porto, Porto, Portugal
| | | | | | - Erin Gardner
- Kimihauora Health and Research Clinic, Mt Maunganui, New Zealand
| | - Tanis D Godwin
- Cancer Genetics Laboratory, Te Aho Matatū, Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Katharine N Holm
- Department of Biochemistry and Molecular Medicine, University of California Davis School Of Medicine, Davis, CA, USA
| | - Bostjan Humar
- Laboratory of the Swiss Hepato-Pancreato-Biliary and Transplantation Centre, Department of Surgery, University Hospital Zürich, Zurich, Switzerland
| | - Caroline J Lintott
- Genetic Health Service New Zealand South Island Hub, Christchurch Hospital, Christchurch, New Zealand
| | | | | | - Enrique Norero
- Esophagogastric Surgery Unit, Digestive Surgery Department, Hospital Dr Sotero del Rio, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Yasmin Nouri
- Cancer Genetics Laboratory, Te Aho Matatū, Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Joana Paredes
- Instituto de Investigação e Inovação em Saúde & Institute of Molecular Pathology and Immunology of the University of Porto, Department of Pathology, University of Porto, Porto, Portugal
| | - João M Sanches
- Institute for Systems and Robotics, Instituto Superior Técnico, Lisbon, Portugal
| | - Emily Schulpen
- Cancer Genetics Laboratory, Te Aho Matatū, Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Ana S Ribeiro
- Instituto de Investigação e Inovação em Saúde & Institute of Molecular Pathology and Immunology of the University of Porto, Department of Pathology, University of Porto, Porto, Portugal
| | - Andrew Sporle
- Healthier Lives National Science Challenge, University of Otago, Dunedin, New Zealand
| | - James Whitworth
- Department of Medical Genetics, National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Liying Zhang
- Department of Pathology and Laboratory Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Anthony E Reeve
- Cancer Genetics Laboratory, Te Aho Matatū, Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Parry Guilford
- Cancer Genetics Laboratory, Te Aho Matatū, Department of Biochemistry, University of Otago, Dunedin, New Zealand.
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Noorani A, Li X, Goddard M, Crawte J, Alexandrov LB, Secrier M, Eldridge MD, Bower L, Weaver J, Lao-Sirieix P, Martincorena I, Debiram-Beecham I, Grehan N, MacRae S, Malhotra S, Miremadi A, Thomas T, Galbraith S, Petersen L, Preston SD, Gilligan D, Hindmarsh A, Hardwick RH, Stratton MR, Wedge DC, Fitzgerald RC. Genomic evidence supports a clonal diaspora model for metastases of esophageal adenocarcinoma. Nat Genet 2020; 52:74-83. [PMID: 31907488 PMCID: PMC7100916 DOI: 10.1038/s41588-019-0551-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 11/19/2019] [Indexed: 01/23/2023]
Abstract
The poor outcomes in esophageal adenocarcinoma (EAC) prompted us to interrogate the pattern and timing of metastatic spread. Whole-genome sequencing and phylogenetic analysis of 388 samples across 18 individuals with EAC showed, in 90% of patients, that multiple subclones from the primary tumor spread very rapidly from the primary site to form multiple metastases, including lymph nodes and distant tissues-a mode of dissemination that we term 'clonal diaspora'. Metastatic subclones at autopsy were present in tissue and blood samples from earlier time points. These findings have implications for our understanding and clinical evaluation of EAC.
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Affiliation(s)
| | - Xiaodun Li
- MRC Cancer Unit, University of Cambridge, Cambridge, UK
| | - Martin Goddard
- Department of Histopathology, Papworth Hospital NHS Trust, Cambridge, UK
| | - Jason Crawte
- MRC Cancer Unit, University of Cambridge, Cambridge, UK
| | - Ludmil B Alexandrov
- Cellular and Molecular Medicine, University of California, San Diego, San Diego, CA, USA
| | - Maria Secrier
- Cancer Research UK Cambridge Research Institute, Cambridge, UK
| | | | - Lawrence Bower
- Cancer Research UK Cambridge Research Institute, Cambridge, UK
| | - Jamie Weaver
- MRC Cancer Unit, University of Cambridge, Cambridge, UK
| | | | | | | | - Nicola Grehan
- MRC Cancer Unit, University of Cambridge, Cambridge, UK
| | - Shona MacRae
- MRC Cancer Unit, University of Cambridge, Cambridge, UK
| | - Shalini Malhotra
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ahmad Miremadi
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Sarah Galbraith
- Department of Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Stephen D Preston
- Department of Histopathology, Papworth Hospital NHS Trust, Cambridge, UK
| | - David Gilligan
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew Hindmarsh
- Cambridge Oesophago-Gastric Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Richard H Hardwick
- Cambridge Oesophago-Gastric Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - David C Wedge
- Big Data Institute, University of Oxford, Oxford, UK.
- Oxford NIHR Biomedical Research Centre, Oxford, UK.
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Bornschein J, Wernisch L, Secrier M, Miremadi A, Perner J, MacRae S, O'Donovan M, Newton R, Menon S, Bower L, Eldridge MD, Devonshire G, Cheah C, Turkington R, Hardwick RH, Selgrad M, Venerito M, Malfertheiner P, Fitzgerald RC. Transcriptomic profiling reveals three molecular phenotypes of adenocarcinoma at the gastroesophageal junction. Int J Cancer 2019; 145:3389-3401. [PMID: 31050820 PMCID: PMC6851674 DOI: 10.1002/ijc.32384] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 03/24/2019] [Accepted: 04/04/2019] [Indexed: 12/17/2022]
Abstract
Cancers occurring at the gastroesophageal junction (GEJ) are classified as predominantly esophageal or gastric, which is often difficult to decipher. We hypothesized that the transcriptomic profile might reveal molecular subgroups which could help to define the tumor origin and behavior beyond anatomical location. The gene expression profiles of 107 treatment-naïve, intestinal type, gastroesophageal adenocarcinomas were assessed by the Illumina-HTv4.0 beadchip. Differential gene expression (limma), unsupervised subgroup assignment (mclust) and pathway analysis (gage) were undertaken in R statistical computing and results were related to demographic and clinical parameters. Unsupervised assignment of the gene expression profiles revealed three distinct molecular subgroups, which were not associated with anatomical location, tumor stage or grade (p > 0.05). Group 1 was enriched for pathways involved in cell turnover, Group 2 was enriched for metabolic processes and Group 3 for immune-response pathways. Patients in group 1 showed the worst overall survival (p = 0.019). Key genes for the three subtypes were confirmed by immunohistochemistry. The newly defined intrinsic subtypes were analyzed in four independent datasets of gastric and esophageal adenocarcinomas with transcriptomic data available (RNAseq data: OCCAMS cohort, n = 158; gene expression arrays: Belfast, n = 63; Singapore, n = 191; Asian Cancer Research Group, n = 300). The subgroups were represented in the independent cohorts and pooled analysis confirmed the prognostic effect of the new subtypes. In conclusion, adenocarcinomas at the GEJ comprise three distinct molecular phenotypes which do not reflect anatomical location but rather inform our understanding of the key pathways expressed.
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Affiliation(s)
- Jan Bornschein
- MRC Cancer Unit, Hutchison/MRC Research CentreUniversity of CambridgeCambridgeUnited Kingdom
- Department of Gastroenterology, Hepatology and Infectious DiseasesOtto‐von‐Guericke UniversityMagdeburgGermany
- Translational Gastroenterology UnitOxford University HospitalsOxfordUnited Kingdom
| | - Lorenz Wernisch
- MRC Biostatistics UnitUniversity of CambridgeCambridgeUnited Kingdom
| | - Maria Secrier
- Cancer Research UK Cambridge InstituteUniversity of CambridgeCambridgeUnited Kingdom
| | - Ahmad Miremadi
- Department of Histopathology, Addenbrooke's HospitalCambridge University HospitalsCambridgeUnited Kingdom
| | - Juliane Perner
- Cancer Research UK Cambridge InstituteUniversity of CambridgeCambridgeUnited Kingdom
| | - Shona MacRae
- MRC Cancer Unit, Hutchison/MRC Research CentreUniversity of CambridgeCambridgeUnited Kingdom
| | - Maria O'Donovan
- Department of Histopathology, Addenbrooke's HospitalCambridge University HospitalsCambridgeUnited Kingdom
| | - Richard Newton
- MRC Biostatistics UnitUniversity of CambridgeCambridgeUnited Kingdom
| | - Suraj Menon
- Cancer Research UK Cambridge InstituteUniversity of CambridgeCambridgeUnited Kingdom
| | - Lawrence Bower
- Cancer Research UK Cambridge InstituteUniversity of CambridgeCambridgeUnited Kingdom
| | - Matthew D. Eldridge
- Cancer Research UK Cambridge InstituteUniversity of CambridgeCambridgeUnited Kingdom
| | - Ginny Devonshire
- Cancer Research UK Cambridge InstituteUniversity of CambridgeCambridgeUnited Kingdom
| | - Calvin Cheah
- MRC Cancer Unit, Hutchison/MRC Research CentreUniversity of CambridgeCambridgeUnited Kingdom
| | | | - Richard H. Hardwick
- Department of Surgery, Addenbrooke's HospitalCambridge University HospitalsCambridgeUnited Kingdom
| | - Michael Selgrad
- Department of Gastroenterology, Hepatology and Infectious DiseasesOtto‐von‐Guericke UniversityMagdeburgGermany
| | - Marino Venerito
- Department of Gastroenterology, Hepatology and Infectious DiseasesOtto‐von‐Guericke UniversityMagdeburgGermany
| | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious DiseasesOtto‐von‐Guericke UniversityMagdeburgGermany
| | - Rebecca C. Fitzgerald
- MRC Cancer Unit, Hutchison/MRC Research CentreUniversity of CambridgeCambridgeUnited Kingdom
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8
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Dye FS, Larraufie P, Kay R, Darwish T, Rievaj J, Goldspink DA, Meek CL, Middleton SJ, Hardwick RH, Roberts GP, Percival-Alwyn JL, Vaughan T, Ferraro F, Challis BG, O'Rahilly S, Groves M, Gribble FM, Reimann F. Characterisation of proguanylin expressing cells in the intestine - evidence for constitutive luminal secretion. Sci Rep 2019; 9:15574. [PMID: 31666564 PMCID: PMC6821700 DOI: 10.1038/s41598-019-52049-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/10/2019] [Indexed: 12/14/2022] Open
Abstract
Guanylin, a peptide implicated in regulation of intestinal fluid secretion, is expressed in the mucosa, but the exact cellular origin remains controversial. In a new transgenic mouse model fluorescent reporter protein expression driven by the proguanylin promoter was observed throughout the small intestine and colon in goblet and Paneth(-like) cells and, except in duodenum, in mature enterocytes. In Ussing chamber experiments employing both human and mouse intestinal tissue, proguanylin was released predominantly in the luminal direction. Measurements of proguanylin expression and secretion in cell lines and organoids indicated that secretion is largely constitutive and requires ER to Golgi transport but was not acutely regulated by salt or other stimuli. Using a newly-developed proguanylin assay, we found plasma levels to be raised in humans after total gastrectomy or intestinal transplantation, but largely unresponsive to nutrient ingestion. By LC-MS/MS we identified processed forms in tissue and luminal extracts, but in plasma we only detected full-length proguanylin. Our transgenic approach provides information about the cellular origins of proguanylin, complementing previous immunohistochemical and in-situ hybridisation results. The identification of processed forms of proguanylin in the intestinal lumen but not in plasma supports the notion that the primary site of action is the gut itself.
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Affiliation(s)
- Florent Serge Dye
- Wellcome/MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.,Department of Antibody Discovery and Protein Engineering, R&D, AstraZeneca, Cambridge, UK
| | - Pierre Larraufie
- Wellcome/MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Richard Kay
- Wellcome/MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Tamana Darwish
- Wellcome/MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juraj Rievaj
- Wellcome/MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.,Dosage Form Design & Development, AstraZeneca, Cambridge, UK
| | - Deborah A Goldspink
- Wellcome/MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Claire L Meek
- Wellcome/MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Stephen J Middleton
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Richard H Hardwick
- Barrett's Oesophagus and Oesophago-gastric Cancer, Gastroenterology Services, Addenbrooke's Hospital, Cambridge, UK
| | - Geoffrey P Roberts
- Wellcome/MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | | | - Tris Vaughan
- Department of Antibody Discovery and Protein Engineering, R&D, AstraZeneca, Cambridge, UK
| | - Franco Ferraro
- Department of Antibody Discovery and Protein Engineering, R&D, AstraZeneca, Cambridge, UK
| | - Benjamin G Challis
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Stephen O'Rahilly
- Wellcome/MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Maria Groves
- Department of Antibody Discovery and Protein Engineering, R&D, AstraZeneca, Cambridge, UK.
| | - Fiona M Gribble
- Wellcome/MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Frank Reimann
- Wellcome/MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
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9
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Noorani A, Anthony-Pillai A, Pournaras D, Safranek PM, Sujendran VS, Bennett JM, Hardwick RH, Gourgiotis S, Hindmarsh A. Endoluminal Vacuum Therapy: Changing the Management of Upper Gastrointestinal Leaks. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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10
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Panagiotopoulou IG, Bennett J, Tweedle EM, Di Saverio S, Gourgiotis S, Hardwick RH, Wheeler J, Justin Davies R. Enhancing the emergency general surgical service: an example of the aggregation of marginal gains. Ann R Coll Surg Engl 2019; 101:479-486. [PMID: 31155901 DOI: 10.1308/rcsann.2019.0061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We aimed to enhance the emergency general surgical service in our high-volume centre in order to reduce four-hour target breaches, to expedite senior decision making and to avoid unnecessary admissions. MATERIALS AND METHODS The aggregation of marginal gains theory was applied. A dual consultant on-call system was established by the incremental employment of five emergency general surgeons with a specialist interest in colorectal or oesophagogastric surgery. A surgical ambulatory care unit, which combines consultant-led clinical review with dedicated next-day radiology slots, and a dedicated working week half-day gastrointestinal urgent theatre session were instituted to facilitate ambulatory care pathways. RESULTS The presence of two consultant surgeons being on call during weekday working hours decreased the four-hour target breaches and allowed consultant presence in the surgical ambulatory care clinic and the gastrointestinal urgent theatre list. Of 1371 surgical ambulatory care clinic appointments within 30 months, 1135 (82.7%) avoided a hospital admission, corresponding to savings of £309,752 . The coordinated functioning of the surgical ambulatory care clinic and the gastrointestinal urgent theatre list resulted in statistically significantly reduced hospital stays for patients operated for abscess drainage (gastrointestinal urgent theatre median 11 hours (interquartile range 3, 38) compared with emergency median 31 hours (interquartile range 24, 53), P < 0.001) or diagnostic laparoscopy/appendicectomy (gastrointestinal urgent theatre median 52 hours (interquartile range 41, 71) compared with emergency median 61 hours (interquartile range 43, 99), P = 0.005). Overnight surgery was reduced with only surgery that was absolutely necessary occurring out of hours. CONCLUSION The expansion of the 'traditional' on-call surgical team, the establishment of the surgical ambulatory care clinic and the gastrointestinal urgent theatre list led to marginal gains with a reduction in unnecessary inpatient stays, expedited decision making and improved financial efficiency.
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Affiliation(s)
- I G Panagiotopoulou
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jmh Bennett
- Oesophagogastric Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - E M Tweedle
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S Di Saverio
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S Gourgiotis
- Oesophagogastric Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - R H Hardwick
- Oesophagogastric Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jmd Wheeler
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - R Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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11
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Roberts GP, Larraufie P, Richards P, Kay RG, Galvin SG, Miedzybrodzka EL, Leiter A, Li HJ, Glass LL, Ma MKL, Lam B, Yeo GSH, Scharfmann R, Chiarugi D, Hardwick RH, Reimann F, Gribble FM. Comparison of Human and Murine Enteroendocrine Cells by Transcriptomic and Peptidomic Profiling. Diabetes 2019; 68:1062-1072. [PMID: 30733330 PMCID: PMC6477899 DOI: 10.2337/db18-0883] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/23/2018] [Indexed: 02/02/2023]
Abstract
Enteroendocrine cells (EECs) produce hormones such as glucagon-like peptide 1 and peptide YY that regulate food absorption, insulin secretion, and appetite. Based on the success of glucagon-like peptide 1-based therapies for type 2 diabetes and obesity, EECs are themselves the focus of drug discovery programs to enhance gut hormone secretion. The aim of this study was to identify the transcriptome and peptidome of human EECs and to provide a cross-species comparison between humans and mice. By RNA sequencing of human EECs purified by flow cytometry after cell fixation and staining, we present a first transcriptomic analysis of human EEC populations and demonstrate a strong correlation with murine counterparts. RNA sequencing was deep enough to enable identification of low-abundance transcripts such as G-protein-coupled receptors and ion channels, revealing expression in human EECs of G-protein-coupled receptors previously found to play roles in postprandial nutrient detection. With liquid chromatography-tandem mass spectrometry, we profiled the gradients of peptide hormones along the human and mouse gut, including their sequences and posttranslational modifications. The transcriptomic and peptidomic profiles of human and mouse EECs and cross-species comparison will be valuable tools for drug discovery programs and for understanding human metabolism and the endocrine impacts of bariatric surgery.
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Affiliation(s)
- Geoffrey P Roberts
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge, U.K
| | - Pierre Larraufie
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
| | - Paul Richards
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
- INSERM U1016, Institut Cochin, Université Paris-Descartes, Paris, France
| | - Richard G Kay
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
| | - Sam G Galvin
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
| | - Emily L Miedzybrodzka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
| | - Andrew Leiter
- Division of Gastroenterology, Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - H Joyce Li
- Division of Gastroenterology, Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Leslie L Glass
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
| | - Marcella K L Ma
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
| | - Brian Lam
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
| | - Giles S H Yeo
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
| | - Raphaël Scharfmann
- INSERM U1016, Institut Cochin, Université Paris-Descartes, Paris, France
| | - Davide Chiarugi
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
| | - Richard H Hardwick
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge, U.K
| | - Frank Reimann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K.
| | - Fiona M Gribble
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K.
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12
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Larraufie P, Roberts GP, McGavigan AK, Kay RG, Li J, Leiter A, Melvin A, Biggs EK, Ravn P, Davy K, Hornigold DC, Yeo GSH, Hardwick RH, Reimann F, Gribble FM. Important Role of the GLP-1 Axis for Glucose Homeostasis after Bariatric Surgery. Cell Rep 2019; 26:1399-1408.e6. [PMID: 30726726 PMCID: PMC6367566 DOI: 10.1016/j.celrep.2019.01.047] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/14/2018] [Accepted: 01/11/2019] [Indexed: 02/07/2023] Open
Abstract
Bariatric surgery is widely used to treat obesity and improves type 2 diabetes beyond expectations from the degree of weight loss. Elevated post-prandial concentrations of glucagon-like peptide 1 (GLP-1), peptide YY (PYY), and insulin are widely reported, but the importance of GLP-1 in post-bariatric physiology remains debated. Here, we show that GLP-1 is a major driver of insulin secretion after bariatric surgery, as demonstrated by blocking GLP-1 receptors (GLP1Rs) post-gastrectomy in lean humans using Exendin-9 or in mice using an anti-GLP1R antibody. Transcriptomics and peptidomics analyses revealed that human and mouse enteroendocrine cells were unaltered post-surgery; instead, we found that elevated plasma GLP-1 and PYY correlated with increased nutrient delivery to the distal gut in mice. We conclude that increased GLP-1 secretion after bariatric surgery arises from rapid nutrient delivery to the distal gut and is a key driver of enhanced insulin secretion.
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Affiliation(s)
- Pierre Larraufie
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Geoffrey P Roberts
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Anne K McGavigan
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Richard G Kay
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Joyce Li
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Andrew Leiter
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Audrey Melvin
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Emma K Biggs
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Peter Ravn
- Department of Antibody Discovery and Protein Engineering, MedImmune, Granta Park, Cambridge CB21 6GH, UK
| | - Kathleen Davy
- Department of Cardiovascular and Metabolic Disease, MedImmune, Granta Park, Cambridge, UK
| | - David C Hornigold
- Department of Cardiovascular and Metabolic Disease, MedImmune, Granta Park, Cambridge, UK
| | - Giles S H Yeo
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Richard H Hardwick
- Cambridge Oesophago-gastric Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Frank Reimann
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Fiona M Gribble
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK.
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13
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Pournaras DJ, Hardwick RH, Safranek PM, Sujendran V, Bennett J, Macaulay GD, Hindmarsh A. Endoluminal Vacuum Therapy (E-Vac): A Treatment Option in Oesophagogastric Surgery. World J Surg 2018; 42:2507-2511. [PMID: 29372375 PMCID: PMC6060786 DOI: 10.1007/s00268-018-4463-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Leaks from the upper gastrointestinal tract often pose a management challenge, particularly when surgical treatment has failed or is impossible. Vacuum therapy has revolutionised the treatment of wounds, and its role in enabling and accelerating healing is now explored in oesophagogastric surgery. Methods A piece of open cell foam is sutured around the distal end of a nasogastric tube using a silk suture. Under general anaesthetic, the foam covered tip is placed endoscopically through the perforation and into any extra-luminal cavity. Continuous negative pressure (125 mmHg) is then applied. Re-evaluation with change of the negative pressure system is performed every 48–72 h depending on the clinical condition. Patients are fed enterally and treated with broad-spectrum antibiotics and anti-fungal medication until healing, assessed endoscopically and/or radiologically, is complete. Results Since April 2011, twenty one patients have been treated. The cause of the leak was postoperative/iatrogenic complications (14 patients) and ischaemic/spontaneous perforation (seven patients). Twenty patients (95%) completed treatment successfully with healing of the defect and/or resolution of the cavity and were subsequently discharged from our care. One patient died from sepsis related to an oesophageal leak after withdrawing consent for further intervention following a single endoluminal vacuum (E-Vac) treatment. In addition, two patients who were successfully treated with E-Vac for their leak subsequently died within 90 days of E-Vac treatment from complications that were not associated with the E-Vac procedure. In two patients, E-Vac treatment was complicated by bleeding. The median number of E-Vac changes was 7 (range 3–12), and the median length of hospital stay was 35 days (range 23–152). Conclusions E-Vac therapy is a safe and effective treatment for upper gastrointestinal leaks and should be considered alongside more established therapies. Further research is now needed to understand the mechanism of action and to improve the ease with which E-Vac therapy can be delivered.
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Affiliation(s)
- D J Pournaras
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals, Hills Rd, Cambridge, CB2 0QQ, UK.
| | - R H Hardwick
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals, Hills Rd, Cambridge, CB2 0QQ, UK
| | - P M Safranek
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals, Hills Rd, Cambridge, CB2 0QQ, UK
| | - V Sujendran
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals, Hills Rd, Cambridge, CB2 0QQ, UK
| | - J Bennett
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals, Hills Rd, Cambridge, CB2 0QQ, UK
| | - G D Macaulay
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals, Hills Rd, Cambridge, CB2 0QQ, UK
| | - A Hindmarsh
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals, Hills Rd, Cambridge, CB2 0QQ, UK
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14
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Roberts GP, Kay RG, Howard J, Hardwick RH, Reimann F, Gribble FM. Gastrectomy with Roux-en-Y reconstruction as a lean model of bariatric surgery. Surg Obes Relat Dis 2018; 14:562-568. [PMID: 29548882 PMCID: PMC6191023 DOI: 10.1016/j.soard.2018.01.039] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/21/2017] [Accepted: 01/29/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Altered enteroendocrine hormone responses are widely believed to underlie the beneficial effects of bariatric surgery in type 2 diabetes. While elevated postprandial glucagon-like peptide-1 (GLP-1) is considered one of the mediators, increased postprandial glucagon levels have recently been implicated. OBJECTIVES We investigated hormonal responses in lean patients after prophylactic total gastrectomy (PTG), as a model of Roux-en-Y gastric bypass without the confounding effects of obesity or massive weight loss. SETTING University hospital, United Kingdom. METHODS Ten participants after PTG and 9 healthy volunteers were recruited for oral glucose tolerance tests. Plasma glucose, insulin, GLP-1, peptide YY, glucose-dependent insulinotropic-polypeptide, glucagon, oxyntomodulin, glucagon(1-61), and glicentin levels were assessed using immunoassays and/or mass spectrometry. RESULTS PTG participants exhibited accelerated plasma glucose appearance, followed, in 3 of 10 cases, by hypoglycemia (<3 mM glucose). Plasma GLP-1, peptide YY, glucose-dependent insulinotropic-polypeptide, glicentin, and oxyntomodulin responses were elevated, and glucagon appeared to rise in PTG participants when measured with a glucagon-specific enzyme-linked immunosorbent assay. We revisited the specificity of this assay, and demonstrated significant cross-reactivity with glicentin and oxyntomodulin at concentrations observed in PTG plasma. Reassessment of glucagon with the same assay using a modified protocol, and by liquid chromatography-mass spectrometry, demonstrated suppression of glucagon secretion after oral glucose tolerance tests in both PTG and control cohorts. CONCLUSIONS Care should be taken when assessing glucagon levels in the presence of elevated plasma levels of other proglucagon products. Substantial elevation of GLP-1 and insulin responses after PTG likely contribute to the observed hypoglycemia, and mirror similar hormone levels and complications observed in bariatric weight loss patients.
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Affiliation(s)
- Geoffrey P Roberts
- Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom; Cambridge Oesophago-gastric centre, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Richard G Kay
- Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - James Howard
- LGC Limited, Newmarket Road, Fordham, Cambridgeshire, United Kingdom
| | - Richard H Hardwick
- Cambridge Oesophago-gastric centre, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Frank Reimann
- Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Fiona M Gribble
- Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom.
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15
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Mi EZ, Mi EZ, di Pietro M, O'Donovan M, Hardwick RH, Richardson S, Ziauddeen H, Fletcher PC, Caldas C, Tischkowitz M, Ragunath K, Fitzgerald RC. Comparative study of endoscopic surveillance in hereditary diffuse gastric cancer according to CDH1 mutation status. Gastrointest Endosc 2018; 87:408-418. [PMID: 28688938 PMCID: PMC5780354 DOI: 10.1016/j.gie.2017.06.028] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 06/20/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Hereditary diffuse gastric cancer (HDGC) accounts for 1% of gastric cancer cases. For patients with a germline CDH1 mutation, risk-reducing gastrectomy is recommended. However, for those delaying surgery or for families with no causative mutation identified, regular endoscopy is advised. This study aimed to determine the yield of signet ring cell carcinoma (SRCC) foci in individuals with a CDH1 pathogenic variant compared with those without and how this varies with successive endoscopies. METHODS Patients fulfilling HDGC criteria were recruited to a prospective longitudinal cohort study. Endoscopy was performed according to a strict protocol with visual inspection followed by focal lesion and random biopsy sampling to detect foci of SRCC. Survival analysis determined progression to finding of SRCC according to CDH1 mutation status. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and 36-item Short Form Health Survey questionnaires assessed quality of life before surveillance and each endoscopy. RESULTS Eighty-five individuals fulfilling HDGC criteria underwent 201 endoscopies; 54 (63.5%) tested positive for CDH1 mutation. SRCC yield was 61.1% in CDH1 mutation carriers compared with 9.7% in noncarriers, and mutation-positive patients had a 10-fold risk of SRCC on endoscopy compared with those with no mutation detected (P < .0005). Yield of SRCC decreased substantially with subsequent endoscopies. Surveillance was associated with improved psychological health. CONCLUSIONS SRCC foci are prevalent in CDH1 mutation carriers and can be detected at endoscopy using a standardized, multiple biopsy sampling protocol. Decreasing yield over time suggests that the frequency of endoscopy might be reduced. For patients with no CDH1 pathogenic variant detected, the cost-to-benefit ratio needs to be assessed in view of the low yield.
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Key Words
- aei, allelic expression imbalance
- cdh1+, cdh1 pathogenic variant
- cdh1-npvd, cdh1 no pathogenic variant detected
- dgc, diffuse gastric cancer
- eortc-qol-c30, european organization for research and treatment of cancer quality of life questionnaire core 30
- gc, gastric cancer
- hdgc, hereditary diffuse gastric cancer
- ppi, proton pump inhibitor
- qol, quality of life
- rrtg, risk-reducing total gastrectomy
- sf-36, 36-item short form health survey
- srcc, signet ring cell carcinoma
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Affiliation(s)
- Emma Z Mi
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Ella Z Mi
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Maria O'Donovan
- Department of Histopathology, Cambridge University Hospitals NHS Trust and University of Cambridge, Cambridge, UK
| | - Richard H Hardwick
- Department of Oesophago-Gastric Surgery, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Susan Richardson
- Familial Gastric Cancer Study, Department of Oncology, Cambridge University Hospitals NHS Trust and University of Cambridge, Cambridge, UK
| | | | - Paul C Fletcher
- Department of Psychiatry, University of Cambridge, Cambridge, UK; Cambridge and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Carlos Caldas
- Cancer Research UK Cambridge Institute, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Marc Tischkowitz
- Department of Medical Genetics, University of Cambridge and Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Krish Ragunath
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Rebecca C Fitzgerald
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK
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16
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Hallowell N, Badger S, Richardson S, Caldas C, Hardwick RH, Fitzgerald RC, Lawton J. High-risk individuals' perceptions of reproductive genetic testing for CDH1 mutations. Fam Cancer 2017; 16:531-535. [PMID: 28204904 PMCID: PMC6061929 DOI: 10.1007/s10689-017-9976-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Reproductive genetic testing- PreNatal Diagnosis (PND) and Preimplantation Genetic Diagnosis (PGD)-for CDH1 mutations associated with Hereditary Diffuse Gastric Cancer (HDGC)is available in the UK. This qualitative interview study examined high-risk individuals' (n = 35) views of CDH1 reproductive genetic testing. Interviewees generally regarded reproductive genetic testing as an acceptable form of HDGC risk management. However, some were concerned that their genetic risks required them to plan reproduction and anticipated difficulties communicating this to reproductive partners. Individuals had a preference for PGD over PND because it avoided the need for a termination of pregnancy. However, those who had not yet had children expressed concerns about having to undergo IVF procedures and worries about their effectiveness and the need for embryo selection in PGD. It is suggested that high-risk individuals are provided with access to reproductive genetic counselling.
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Affiliation(s)
- Nina Hallowell
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Shirlene Badger
- PHG Foundation and Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Sue Richardson
- Cambridge University Hospitals Trust, Addenbrookes Hospital, Cambridge, UK
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - Carlos Caldas
- Cambridge University Hospitals Trust, Addenbrookes Hospital, Cambridge, UK
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - Richard H Hardwick
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- PHG Foundation and Institute of Public Health, University of Cambridge, Cambridge, UK
- Cambridge University Hospitals Trust, Addenbrookes Hospital, Cambridge, UK
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
- MRC Cancer Unit, University of Cambridge, Cambridge, UK
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Rebecca C Fitzgerald
- Cambridge University Hospitals Trust, Addenbrookes Hospital, Cambridge, UK
- MRC Cancer Unit, University of Cambridge, Cambridge, UK
| | - Julia Lawton
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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17
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Hallowell N, Lawton J, Badger S, Richardson S, Hardwick RH, Caldas C, Fitzgerald RC. The Psychosocial Impact of Undergoing Prophylactic Total Gastrectomy (PTG) to Manage the Risk of Hereditary Diffuse Gastric Cancer (HDGC). J Genet Couns 2017; 26:752-762. [PMID: 27837291 DOI: 10.1007/s10897-016-0045-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 10/26/2016] [Indexed: 12/13/2022]
Abstract
Individuals identified as at high risk of developing Hereditary Diffuse Gastric Cancer (HDGC) are advised to undergo prophylactic surgery - have their stomach removed - in their early twenties. Research with (older) cancer patients who undergo gastrectomy for curative reasons suggests that gastric resection has a number of physical and psychosocial sequelae. Because it is difficult to extrapolate the findings of studies of older cancer patients to younger healthy patients who are considering prophylactic total gastrectomy (PTG), the aim of this qualitative interview study was to determine the psychosocial implications of undergoing prophylactic surgery to manage genetic risk. Fourteen men and 13 women from the UK's Familial Gastric Cancer study who had undergone PTG were invited to participate in qualitative interviews. Most reported that undergoing surgery and convalescence was easier than anticipated. There was evidence that age affected experiences of PTG, with younger patients tending to report faster recovery times and more transient aftereffects. All saw the benefits of risk reduction as outweighing the costs of surgery. Surgery was described as having a range of physical impacts (disrupted appetite, weight loss, fatigue, GI symptoms) that had related psychological, social and economic implications. Those considering PTG need to be aware that its impact on quality of life is difficult to predict and negative sequelae may be ongoing for some individuals.
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Affiliation(s)
- Nina Hallowell
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Old Road, Oxford, OX3 7LF, UK.
| | - Julia Lawton
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Shirlene Badger
- PHG Foundation, Cambridge, UK
- Institute of Public Health, University of Cambridge, Cambridge, UK
| | | | - Richard H Hardwick
- Cambridge University Hospitals Trust, Addenbrookes Hospital, Cambridge, UK
| | - Carlos Caldas
- Cambridge University Hospitals Trust, Addenbrookes Hospital, Cambridge, UK
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - Rebecca C Fitzgerald
- Cambridge University Hospitals Trust, Addenbrookes Hospital, Cambridge, UK
- MRC Cancer Unit, University of Cambridge, Cambridge, UK
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18
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Pournaras DJ, Hardwick RH, le Roux CW. Gastrointestinal surgery for obesity and cancer: 2 sides of the same coin. Surg Obes Relat Dis 2016; 13:720-721. [PMID: 28161354 DOI: 10.1016/j.soard.2016.12.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 12/15/2016] [Indexed: 01/04/2023]
Affiliation(s)
- Dimitri J Pournaras
- Cambridge Oesophago-Gastric Centre Addenbrookes Hospital Cambridge, United Kingdom
| | - R H Hardwick
- Cambridge Oesophago-Gastric Centre Addenbrookes Hospital Cambridge, United Kingdom
| | - Carel W le Roux
- Diabetes Complication Research Centre, UCD Conway Institute School of Medicine and Medical Science University College Dublin Dublin, Ireland
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19
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Hallowell N, Badger S, Richardson S, Caldas C, Hardwick RH, Fitzgerald RC, Lawton J. An investigation of the factors effecting high-risk individuals' decision-making about prophylactic total gastrectomy and surveillance for hereditary diffuse gastric cancer (HDGC). Fam Cancer 2016; 15:665-76. [PMID: 27256430 PMCID: PMC5935221 DOI: 10.1007/s10689-016-9910-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hereditary diffuse gastric cancer has an early onset and poor prognosis, therefore, individuals who carry a pathogenic (CDH1) mutation in the E-cadherin gene (CDH1) are offered endoscopic surveillance and advised to undergo prophylactic total gastrectomy (PTG) in their early to mid-twenties. Patients not ready or fit to undergo gastrectomy, or in whom the genetic testing result is unknown or ambiguous, are offered surveillance. Little is known about the factors that influence decisions to undergo or decline PTG, making it difficult to provide optimal support for those facing these decisions. Qualitative interviews were carried out with 35 high-risk individuals from the Familial Gastric Cancer Study in the UK. Twenty-seven had previously undergone PTG and eight had been identified as carrying a pathogenic CDH1 mutation but had declined surgery at the time of interview. The interviews explored the experience of decision-making and factors influencing risk-management decisions. The data suggest that decisions to proceed with PTG are influenced by a number of potentially competing factors: objective risk confirmation by genetic testing and/or receiving a positive biopsy; perceived familial cancer burden and associated risk perceptions; perceptions of post-surgical life; an increasing inability to tolerate endoscopic procedures; a concern that surveillance could miss a cancer developing and individual's life stage. These findings have implications for advising this patient group.
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Affiliation(s)
- Nina Hallowell
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Shirlene Badger
- PHG Foundation and Institute of Public Health, University of Cambridge, Cambridge, UK
| | | | - Carlos Caldas
- Cambridge University Hospitals Trust, Addenbrookes Hospital, Cambridge, UK
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - Richard H Hardwick
- Cambridge University Hospitals Trust, Addenbrookes Hospital, Cambridge, UK
| | - Rebecca C Fitzgerald
- Cambridge University Hospitals Trust, Addenbrookes Hospital, Cambridge, UK
- MRC Cancer Unit, University of Cambridge, Cambridge, UK
| | - Julia Lawton
- Centre for Population Health Sciences, University of Edinburgh, Cambridge, UK
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20
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Chadwick G, Groene O, Taylor A, Riley S, Hardwick RH, Crosby T, Greenaway K, Cromwell DA. Management of Barrett's high-grade dysplasia: initial results from a population-based national audit. Gastrointest Endosc 2016; 83:736-42.e1. [PMID: 26283273 DOI: 10.1016/j.gie.2015.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 08/04/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Previous studies reported significant variation in the management of patients with Barrett's esophagus. However, these are based on self-reported clinical practice. The aim of this study was to examine the management of high-grade dysplasia in Barrett's esophagus in England by using patient-level data and to compare practice with guidelines. METHODS From April 2012 to March 2013, National Health Service (NHS) trusts in England prospectively collected data on patients newly diagnosed with high-grade dysplasia (HGD) of the esophagus as part of the National Oesophago-Gastric Cancer Audit. Data were collected on patient characteristics, diagnosis and endoscopic findings, treatment planning, and therapy. RESULTS Between April 2012 and March 2013, NHS trusts reported 465 cases of HGD. Diagnosis was confirmed by a second pathologist in 79.4% of cases (270/340), and 86.0% (374/465) had their treatment planned at a multidisciplinary team meeting. A total of 290 patients (62.4%) were managed endoscopically (frequently with endoscopic resection or radiofrequency ablation), whereas 26 patients (5.6%) had esophagectomy. The proportion of patients managed by surveillance varied by age (P < .001), ranging from 19.5% in patients aged <65 years to 63.8% in patients aged ≥85 years. More patients received active treatment if their cases were discussed at a multidisciplinary meeting (73.5% vs 44.3%; P < .001) or managed at higher-volume trusts (87.8% vs 55.4%; P < .001). CONCLUSIONS There was marked variation in the management of HGD across England, with a third of patients receiving no active treatment. Patients discussed at a specialist multidisciplinary meeting or managed in high-volume trusts were more likely to receive active treatment.
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Affiliation(s)
- Georgina Chadwick
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Imperial College, Department of Surgery and Cancer, London, United Kingdom
| | - Oliver Groene
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Angelina Taylor
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Stuart Riley
- Department of Gastroenterology, Northern General Hospital, Sheffield, United Kingdom
| | | | - Tom Crosby
- Velindre Cancer Centre, Cardiff, Wales, United Kingdom
| | | | - David A Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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21
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Chadwick G, Riley S, Hardwick RH, Crosby T, Hoare J, Hanna G, Greenaway K, Varagunam M, Cromwell DA, Groene O. Population-based cohort study of the management and survival of patients with early-stage oesophageal adenocarcinoma in England. Br J Surg 2016; 103:544-52. [PMID: 26865114 DOI: 10.1002/bjs.10116] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/12/2015] [Accepted: 12/21/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Until recently, oesophagectomy was the treatment of choice for early oesophageal cancer. Endoscopic treatment has been introduced relatively recently. This observational national database study aimed to describe how endoscopic therapy has been introduced in England and to examine the safety of this approach. METHODS A population-based cohort study was undertaken of patients diagnosed with oesophageal adenocarcinoma between October 2007 and June 2009 using three linked national databases. Patients with early-stage disease (T1 tumours with no evidence of spread) were identified, along with the primary treatment modality where treatment intent was curative. Short-term outcomes after treatment and 5-year survival were evaluated. RESULTS Of 5192 patients diagnosed with oesophageal adenocarcinoma, 306 (5·9 per cent) were considered to have early-stage disease before any treatment, of whom 239 (79·9 per cent of 299 patients with data on treatment intent) were managed with curative intent. Of 175 patients who had an oesophagectomy, 114 (65·1 (95 per cent c.i. 57·6 to 72·7) per cent) survived for 5 years. Among these, 47 (30·3 per cent of 155 patients with tissue results available) had their disease upstaged after pathological staging; this occurred more often in patients who did not have staging endoscopic ultrasonography before surgery. Of 41 patients who had an endoscopic resection, 27 (66 (95 per cent c.i. 49 to 80) per cent) survived for 5 years. Repeat endoscopic therapy was required by 23 (56 per cent) of these 41 patients. CONCLUSION Between 2007 and 2009, oesophagectomy remained the initial treatment of choice (73·2 per cent) among patients with early-stage oesophageal cancer treated with curative intent; one in five patients were managed endoscopically, and this treatment was more common in elderly patients. Although the groups had different patient characteristics, 5-year survival rates were similar.
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Affiliation(s)
- G Chadwick
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Department of Gastroenterology, St Mary's Hospital, London, UK
| | - S Riley
- Department of Gastroenterology, Northern General Hospital, Sheffield, UK
| | - R H Hardwick
- Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - T Crosby
- Velindre Cancer Centre, Cardiff, UK
| | - J Hoare
- Department of Gastroenterology, St Mary's Hospital, London, UK
| | - G Hanna
- Department of Surgery and Cancer, Imperial College, London, UK
| | - K Greenaway
- Health and Social Care Information Centre, Leeds, UK
| | - M Varagunam
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - D A Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - O Groene
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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22
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Messager M, de Steur WO, van Sandick JW, Reynolds J, Pera M, Mariette C, Hardwick RH, Bastiaannet E, Boelens PG, van deVelde CJH, Allum WH. Variations among 5 European countries for curative treatment of resectable oesophageal and gastric cancer: A survey from the EURECCA Upper GI Group (EUropean REgistration of Cancer CAre). Eur J Surg Oncol 2015; 42:116-22. [PMID: 26461256 DOI: 10.1016/j.ejso.2015.09.017] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 09/20/2015] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION EURECCA (EUropean REgistration of Cancer CAre) is a network aiming to improve cancer care by auditing outcome. EURECCA initiated an international survey to share and compare patient outcome for oesophagogastric cancer. The present study assessed how a uniform dataset could be introduced for oesophagogastric cancer in Europe. METHODS Participating countries presented data using common data items describing patients', disease, strategies, and outcome characteristics. Patients treated with curative surgery for squamous cell carcinoma (SCC) or adenocarcinoma (ACA) were included. RESULTS United Kingdom, the Netherlands, France, Spain and Ireland participated. There were differences in data source ranging from national registries to large collaborative groups. 4668 oesophagogastric cancer cases over a 12 months period were included. The predominant histological type was ACA. Disease stage tended to be earlier in France and Ireland. In oesophageal and junctional cancers neoadjuvant chemoradiotherapy was preferred in the Netherlands and Ireland contrasting with chemotherapy in the UK and France. All countries used perioperative chemotherapy in gastric cancer but 1/3 of patients received this treatment. The mean R0 resection rate was 86% for oesophageal and junctional resections and 88% for gastric resections. Postoperative mortality varied from 1% to 7%. CONCLUSION This European survey shown that implementing a uniform treatment and outcome data format of oesophagogastric cancer is feasible. It identified differences in disease presentation, treatment approaches and outcome, which need to be investigated, especially by increasing the number of participating countries. Future comparisons will facilitate developments in treatment for the benefit of patient outcomes.
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Affiliation(s)
- M Messager
- Department of Surgery, Royal Marsden NHS Foundation Trust, London, United Kingdom; Department of Digestive and Oncological Surgery, C Huriez University Hospital, Lille, France
| | - W O de Steur
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - J W van Sandick
- Department of Surgery, Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, The Netherlands
| | - J Reynolds
- Department of Surgery, St James's Hospital and Trinity College, Dublin, Ireland
| | - M Pera
- Section of Gastrointestinal Surgery, Hospital Universitario del Mar, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - C Mariette
- Department of Digestive and Oncological Surgery, C Huriez University Hospital, Lille, France
| | - R H Hardwick
- Department of Surgery, Addenbrookes Hospital, Cambridge, United Kingdom
| | - E Bastiaannet
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - P G Boelens
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - C J H van deVelde
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - W H Allum
- Department of Surgery, Royal Marsden NHS Foundation Trust, London, United Kingdom.
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23
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van der Post RS, Vogelaar IP, Carneiro F, Guilford P, Huntsman D, Hoogerbrugge N, Caldas C, Schreiber KEC, Hardwick RH, Ausems MGEM, Bardram L, Benusiglio PR, Bisseling TM, Blair V, Bleiker E, Boussioutas A, Cats A, Coit D, DeGregorio L, Figueiredo J, Ford JM, Heijkoop E, Hermens R, Humar B, Kaurah P, Keller G, Lai J, Ligtenberg MJL, O'Donovan M, Oliveira C, Pinheiro H, Ragunath K, Rasenberg E, Richardson S, Roviello F, Schackert H, Seruca R, Taylor A, ter Huurne A, Tischkowitz M, Joe STA, van Dijck B, van Grieken NCT, van Hillegersberg R, van Sandick JW, Vehof R, van Krieken JH, Fitzgerald RC. Hereditary diffuse gastric cancer: updated clinical guidelines with an emphasis on germline CDH1 mutation carriers. J Med Genet 2015; 52:361-74. [PMID: 25979631 PMCID: PMC4453626 DOI: 10.1136/jmedgenet-2015-103094] [Citation(s) in RCA: 365] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 03/18/2015] [Indexed: 02/06/2023]
Abstract
Germline CDH1 mutations confer a high lifetime risk of developing diffuse gastric (DGC) and lobular breast cancer (LBC). A multidisciplinary workshop was organised to discuss genetic testing, surgery, surveillance strategies, pathology reporting and the patient's perspective on multiple aspects, including diet post gastrectomy. The updated guidelines include revised CDH1 testing criteria (taking into account first-degree and second-degree relatives): (1) families with two or more patients with gastric cancer at any age, one confirmed DGC; (2) individuals with DGC before the age of 40 and (3) families with diagnoses of both DGC and LBC (one diagnosis before the age of 50). Additionally, CDH1 testing could be considered in patients with bilateral or familial LBC before the age of 50, patients with DGC and cleft lip/palate, and those with precursor lesions for signet ring cell carcinoma. Given the high mortality associated with invasive disease, prophylactic total gastrectomy at a centre of expertise is advised for individuals with pathogenic CDH1 mutations. Breast cancer surveillance with annual breast MRI starting at age 30 for women with a CDH1 mutation is recommended. Standardised endoscopic surveillance in experienced centres is recommended for those opting not to have gastrectomy at the current time, those with CDH1 variants of uncertain significance and those that fulfil hereditary DGC criteria without germline CDH1 mutations. Expert histopathological confirmation of (early) signet ring cell carcinoma is recommended. The impact of gastrectomy and mastectomy should not be underestimated; these can have severe consequences on a psychological, physiological and metabolic level. Nutritional problems should be carefully monitored.
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Affiliation(s)
- Rachel S van der Post
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ingrid P Vogelaar
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fátima Carneiro
- Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- Department of Pathology and Oncology, Medical Faculty of the University of Porto, Porto, Portugal
- Centro Hospitalar São João, Porto, Portugal
| | - Parry Guilford
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - David Huntsman
- British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Nicoline Hoogerbrugge
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carlos Caldas
- Department of Oncology, University of Cambridge, Cambridge, UK
| | | | - Richard H Hardwick
- Department of Oesophago-Gastric Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - Margreet G E M Ausems
- Department of Medical Genetics, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Linda Bardram
- Department of Surgical Gastroenterology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Tanya M Bisseling
- Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Eveline Bleiker
- Division of Psychosocial Research and Epidemiology/Family Cancer Clinic, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Alex Boussioutas
- Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Annemieke Cats
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute/ Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Daniel Coit
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Lynn DeGregorio
- The DeGregorio Family Foundation for Stomach and Esophageal Cancer Research, Pleasantville, New York, USA
| | - Joana Figueiredo
- Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - James M Ford
- Division of Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Esther Heijkoop
- Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Rosella Hermens
- Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bostjan Humar
- Division of Surgical Research, University of Zurich, Zurich, Suisse
| | - Pardeep Kaurah
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gisella Keller
- Institute of Pathology, Technische Universität, Munich, Germany
| | - Jennifer Lai
- No Stomach For Cancer, Inc., Madison, Wisconsin, USA
| | - Marjolijn J L Ligtenberg
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maria O'Donovan
- Department of Histopathology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Carla Oliveira
- Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- Department of Pathology and Oncology, Medical Faculty of the University of Porto, Porto, Portugal
| | - Hugo Pinheiro
- Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - Krish Ragunath
- NIHR Biomedical Research Unit, Nottingham Digestive Diseases Centre, Queens Medical Centre campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Susan Richardson
- Department of Oncology, Familial Gastric Cancer Registry, Cambridge University Hospital, Cambridge, UK
| | - Franco Roviello
- Department of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Hans Schackert
- Department of Surgical Research, Technical University Dresden, Dresden, Germany
| | - Raquel Seruca
- Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- Department of Pathology and Oncology, Medical Faculty of the University of Porto, Porto, Portugal
| | - Amy Taylor
- Cambridge University Hospital, Cambridge, UK
| | | | - Marc Tischkowitz
- Department of Medical Genetics, University of Cambridge, Cambridge, UK
| | - Sheena Tjon A Joe
- Division of Oncology, Stanford University School of Medicine, Stanford, California, USA
| | | | | | | | - Johanna W van Sandick
- Department of Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Rianne Vehof
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Han van Krieken
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rebecca C Fitzgerald
- Cambridge NIHR Biomedical Research Centre, University of Cambridge NHS Foundation Trust
- MRC Cancer Unit, Hutchison/MRC Research Centre, Cambridge, UK
- Department Gastroenterology, Cambridge University Hospitals, UK
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Chadwick G, Groene O, Hoare J, Hardwick RH, Riley S, Crosby TD, Hanna GB, Cromwell DA. A population-based, retrospective, cohort study of esophageal cancer missed at endoscopy. Endoscopy 2014; 46:553-60. [PMID: 24971624 DOI: 10.1055/s-0034-1365646] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND STUDY AIMS Several studies have suggested that a significant minority of esophageal cancers are missed at endoscopy The aim of this study was to estimate the proportion of esophageal cancers missed at endoscopy on a national level, and to investigate the relationship between miss rates and patient and tumor characteristics. PATIENTS AND METHODS This retrospective, population-based, cohort study identified patients diagnosed with esophageal cancer between April 2011 and March 2012 in England, using two linked databases (National Oesophago-Gastric Cancer Audit and Hospital Episode Statistics). The main outcome was the rate of previous endoscopy within 3 - 36 months of cancer diagnosis. This was calculated for the overall cohort and by patient characteristics, including tumor site and disease stage. RESULTS A total of 6943 new cases of esophageal cancer were identified, of which 7.8 % (95 % confidence interval 7.1 - 8.4) had undergone endoscopy in the 3 - 36 months preceding diagnosis. Of patients with stage 0/1 cancers, 34.0 % had undergone endoscopy in the 3 - 36 months before diagnosis compared with 10.0 % of stage 2 cancers and 4.5 % of stage 3/4 cancers. Of patients with stage 0/1 cancers, 22.1 % were diagnosed after ≥ 3 endoscopies in the previous 3 years. Patients diagnosed with an upper esophageal lesion were more likely to have had an endoscopy in the previous 3 - 12 months (P = 0.040). The most common diagnosis at previous endoscopy was an esophageal ulcer (48.2 % of investigations). CONCLUSION Esophageal cancer may be missed at endoscopy in up to 7.8 % of patients who are subsequently diagnosed with cancer. Endoscopists should make a detailed examination of the whole esophageal mucosa to avoid missing subtle early cancers and lesions in the proximal esophagus. Patients with an esophageal cancer may be misdiagnosed as having a benign esophageal ulcer.
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Affiliation(s)
- Georgina Chadwick
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Oliver Groene
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Jonathan Hoare
- Department of Gastroenterology, St. Mary's Hospital, London, United Kingdom
| | | | - Stuart Riley
- Department of Gastroenterology, Northern General Hospital, Sheffield, United Kingdom
| | - Tom D Crosby
- Velindre Cancer Centre, Cardiff, Wales, United Kingdom
| | - George B Hanna
- Department of Surgery and Cancer, St. Mary's Hospital, London, United Kingdom
| | - David A Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
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25
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Lim YC, di Pietro M, O'Donovan M, Richardson S, Debiram I, Dwerryhouse S, Hardwick RH, Tischkowitz M, Caldas C, Ragunath K, Fitzgerald RC. Prospective cohort study assessing outcomes of patients from families fulfilling criteria for hereditary diffuse gastric cancer undergoing endoscopic surveillance. Gastrointest Endosc 2014; 80:78-87. [PMID: 24472763 DOI: 10.1016/j.gie.2013.11.040] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 11/27/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prophylactic total gastrectomy is performed in hereditary diffuse gastric cancer (HDGC) patients carrying the CDH1 mutation because endoscopic surveillance often fails to detect microscopic disease. OBJECTIVE The aim of this study was to determine the natural history and outcomes of patients with HDGC undergoing endoscopy. DESIGN Prospective, cohort observational study. SETTINGS Tertiary referral center. PATIENTS Patients fulfilling criteria for HDGC who opted to undergo endoscopy. INTERVENTION Research surveillance program using high-resolution white-light endoscopy with autofluorescence and narrow-band imaging combined with targeted and multiple random biopsies assessed by an expert histopathologist for the presence of signet ring cell carcinoma. MAIN OUTCOME MEASUREMENTS The primary endpoint was the endoscopic yield of microscopic signet ring cell carcinoma according to patient mutation status and subsequent decision to undergo surgery. The secondary endpoint was the additional yield of targeted biopsies compared with random biopsies. RESULTS Between September 2007 and March 2013, 29 patients from 17 families underwent 70 surveillance endoscopies. Signet ring cell carcinoma foci were identified in 14 of 22 (63.6%) patients with confirmed CDH1 germline mutations and 2 of 7 (28.6%) with no pathogenic mutation identified. Eleven of 16 (9 CDH1-positive) patients proceeded to gastrectomy in a median 5.7 months. Five patients delayed surgery. In 1 patient, advanced gastric cancer developed 40.2 months after the first endoscopic findings. LIMITATIONS No control group. CONCLUSIONS Careful white-light examination with targeted and random biopsies combined with detailed histopathology can identify early lesions and help to inform decision making with regard to gastrectomy. Autofluorescence and narrow-band imaging are of limited utility. Delaying gastrectomy in individuals with signet ring cell carcinoma foci carries a high risk and has to be weighed carefully.
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Affiliation(s)
- Yean Cheant Lim
- Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
| | | | - Maria O'Donovan
- Department of Histopathology, Cambridge University Hospitals NHS Trust, University of Cambridge, Cambridge, United Kingdom
| | - Susan Richardson
- Familial Gastric Cancer Registry, University Department of Oncology, Cambridge, United Kingdom
| | - Irene Debiram
- Familial Gastric Cancer Registry, University Department of Oncology, Cambridge, United Kingdom
| | - Susan Dwerryhouse
- Department of Oesophago-Gastric Surgery, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
| | - Richard H Hardwick
- Department of Oesophago-Gastric Surgery, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
| | - Marc Tischkowitz
- Department of Medical Genetics, University of Cambridge and Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
| | - Carlos Caldas
- MRC Cancer Unit, Hutchison-MRC Research Centre, Cambridge, United Kingdom
| | - Krish Ragunath
- Nottingham Digestive Diseases Centre, Nottingham, United Kingdom
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Worster E, Liu X, Richardson S, Hardwick RH, Dwerryhouse S, Caldas C, Fitzgerald RC. The impact of prophylactic total gastrectomy on health-related quality of life: a prospective cohort study. Ann Surg 2014; 260:87-93. [PMID: 24424140 DOI: 10.1097/sla.0000000000000446] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The advice to individuals with identified CDH1 mutations is generally to undertake prophylactic total gastrectomy (PTG). This study evaluated the effect of PTG on health-related quality of life (HRQL) in asymptomatic individuals with identified CDH1 mutations at high risk for gastric cancer. METHODS Individuals with hereditary diffuse gastric cancer (HDGC) were recruited to a prospective, multicenter UK study. Questionnaires, including the European Organization for Research and Treatment for Cancer core Quality-of-Life Questionnaire (EORTC QLQ C30); the gastric cancer specific module (EORTC QLQ STO22); and the 36-item short form health survey version 2.0, were completed before and at regular intervals after surgery. RESULTS Sixty individuals fulfilled HDGC criteria; 38 (63%) had a CDH1 mutation and 32 (53%) underwent PTG. At baseline, there was no significant difference in mental health depending on CDH1 mutation status and treatment preference. Physical functioning reduced in the first month after surgery but recovered to baseline by 12 months. Similarly mental functioning reduced in the first month after surgery but recovered by 3 to 9 months. However, specific symptoms were identified, such as diarrhoea (70%), fatigue (63%), discomfort when eating (81%), reflux (63%), eating restrictions (45%), and body image (44%), which persisted after PTG. CONCLUSIONS Patients contemplating prophylactic gastrectomy can be reassured about the long-term HRQL outcomes, but some residual symptoms require adjustment.
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Affiliation(s)
- Elizabeth Worster
- *MRC Cancer Unit, University of Cambridge, UK †Department of Oncology, Addenbrooke's Hospital, Cambridge, UK ‡Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge, UK §Cancer Research UK Cambridge Institute, Cambridge, UK
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Ong CAJ, Shannon NB, Ross-Innes CS, O'Donovan M, Rueda OM, Hu DE, Kettunen MI, Walker CE, Noorani A, Hardwick RH, Caldas C, Brindle K, Fitzgerald RC. Amplification of TRIM44: pairing a prognostic target with potential therapeutic strategy. J Natl Cancer Inst 2014; 106:dju050. [PMID: 24777112 PMCID: PMC4112924 DOI: 10.1093/jnci/dju050] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 01/24/2014] [Accepted: 02/03/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Many prognostic biomarkers have been proposed recently. However, there is a lack of therapeutic strategies exploiting novel prognostic biomarkers. We aimed to propose therapeutic options in patients with overexpression of TRIM44, a recently identified prognostic gene. METHODS Genomic and transcriptomic data of epithelial cancers (n = 1932), breast cancers (BCs; n = 1980) and esophago-gastric cancers (EGCs; n = 163) were used to identify genomic aberrations driving TRIM44 overexpression. The driver gene status of TRIM44 was determined using a small interfering RNA (siRNA) screen of the 11p13 amplicon. Integrative analysis was applied across multiple datasets to identify pathway activation and potential therapeutic strategies. Validation of the in silico findings were performed using in vitro assays, xenografts, and patient samples (n = 160). RESULTS TRIM44 overexpression results from genomic amplification in 16.1% of epithelial cancers, including 8.1% of EGCs and 6.1% of BCs. This was confirmed using fluorescent in situ hybridization. The siRNA screen confirmed TRIM44 to be a driver of the amplicon. In silico analysis revealed an association between TRIM44 and mTOR signalling, supported by a decrease in mTOR signalling after siRNA knockdown of TRIM44 in cell lines and colocalization of TRIM44 and p-mTOR in patient samples. In vitro inhibition studies using an mTOR inhibitor (everolimus) decreased cell viability in two TRIM44-amplified cells lines by 88% and 70% compared with 35% in the control cell line. These findings were recapitulated in xenograft models. CONCLUSIONS Genomic amplification drives TRIM44 overexpression in EGCs and BCs. Targeting the mTOR pathway provides a potential therapeutic option for TRIM44-amplified tumors.
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Affiliation(s)
- Chin-Ann Johnny Ong
- Affiliations of authors: MRC Cancer Unit, Cambridge, UK (C-AJO, CSR-I, MO, CEW, AN, RCF); Cancer Research UK Cambridge Institute, Cambridge, UK (NBS, OMR, D-eH, MIK, CC, KB); UK Cambridge Esophagogastric Centre, Addenbrooke's Hospital, Cambridge, UK (RHH)
| | - Nicholas B Shannon
- Affiliations of authors: MRC Cancer Unit, Cambridge, UK (C-AJO, CSR-I, MO, CEW, AN, RCF); Cancer Research UK Cambridge Institute, Cambridge, UK (NBS, OMR, D-eH, MIK, CC, KB); UK Cambridge Esophagogastric Centre, Addenbrooke's Hospital, Cambridge, UK (RHH)
| | - Caryn S Ross-Innes
- Affiliations of authors: MRC Cancer Unit, Cambridge, UK (C-AJO, CSR-I, MO, CEW, AN, RCF); Cancer Research UK Cambridge Institute, Cambridge, UK (NBS, OMR, D-eH, MIK, CC, KB); UK Cambridge Esophagogastric Centre, Addenbrooke's Hospital, Cambridge, UK (RHH)
| | - Maria O'Donovan
- Affiliations of authors: MRC Cancer Unit, Cambridge, UK (C-AJO, CSR-I, MO, CEW, AN, RCF); Cancer Research UK Cambridge Institute, Cambridge, UK (NBS, OMR, D-eH, MIK, CC, KB); UK Cambridge Esophagogastric Centre, Addenbrooke's Hospital, Cambridge, UK (RHH)
| | - Oscar M Rueda
- Affiliations of authors: MRC Cancer Unit, Cambridge, UK (C-AJO, CSR-I, MO, CEW, AN, RCF); Cancer Research UK Cambridge Institute, Cambridge, UK (NBS, OMR, D-eH, MIK, CC, KB); UK Cambridge Esophagogastric Centre, Addenbrooke's Hospital, Cambridge, UK (RHH)
| | - De-En Hu
- Affiliations of authors: MRC Cancer Unit, Cambridge, UK (C-AJO, CSR-I, MO, CEW, AN, RCF); Cancer Research UK Cambridge Institute, Cambridge, UK (NBS, OMR, D-eH, MIK, CC, KB); UK Cambridge Esophagogastric Centre, Addenbrooke's Hospital, Cambridge, UK (RHH)
| | - Mikko I Kettunen
- Affiliations of authors: MRC Cancer Unit, Cambridge, UK (C-AJO, CSR-I, MO, CEW, AN, RCF); Cancer Research UK Cambridge Institute, Cambridge, UK (NBS, OMR, D-eH, MIK, CC, KB); UK Cambridge Esophagogastric Centre, Addenbrooke's Hospital, Cambridge, UK (RHH)
| | - Christina Elaine Walker
- Affiliations of authors: MRC Cancer Unit, Cambridge, UK (C-AJO, CSR-I, MO, CEW, AN, RCF); Cancer Research UK Cambridge Institute, Cambridge, UK (NBS, OMR, D-eH, MIK, CC, KB); UK Cambridge Esophagogastric Centre, Addenbrooke's Hospital, Cambridge, UK (RHH)
| | - Ayesha Noorani
- Affiliations of authors: MRC Cancer Unit, Cambridge, UK (C-AJO, CSR-I, MO, CEW, AN, RCF); Cancer Research UK Cambridge Institute, Cambridge, UK (NBS, OMR, D-eH, MIK, CC, KB); UK Cambridge Esophagogastric Centre, Addenbrooke's Hospital, Cambridge, UK (RHH)
| | - Richard H Hardwick
- Affiliations of authors: MRC Cancer Unit, Cambridge, UK (C-AJO, CSR-I, MO, CEW, AN, RCF); Cancer Research UK Cambridge Institute, Cambridge, UK (NBS, OMR, D-eH, MIK, CC, KB); UK Cambridge Esophagogastric Centre, Addenbrooke's Hospital, Cambridge, UK (RHH)
| | - Carlos Caldas
- Affiliations of authors: MRC Cancer Unit, Cambridge, UK (C-AJO, CSR-I, MO, CEW, AN, RCF); Cancer Research UK Cambridge Institute, Cambridge, UK (NBS, OMR, D-eH, MIK, CC, KB); UK Cambridge Esophagogastric Centre, Addenbrooke's Hospital, Cambridge, UK (RHH)
| | - Kevin Brindle
- Affiliations of authors: MRC Cancer Unit, Cambridge, UK (C-AJO, CSR-I, MO, CEW, AN, RCF); Cancer Research UK Cambridge Institute, Cambridge, UK (NBS, OMR, D-eH, MIK, CC, KB); UK Cambridge Esophagogastric Centre, Addenbrooke's Hospital, Cambridge, UK (RHH)
| | - Rebecca C Fitzgerald
- Affiliations of authors: MRC Cancer Unit, Cambridge, UK (C-AJO, CSR-I, MO, CEW, AN, RCF); Cancer Research UK Cambridge Institute, Cambridge, UK (NBS, OMR, D-eH, MIK, CC, KB); UK Cambridge Esophagogastric Centre, Addenbrooke's Hospital, Cambridge, UK (RHH).
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Groene O, Chadwick G, Riley S, Hardwick RH, Crosby T, Greenaway K, Allum W, Cromwell DA. Re-organisation of oesophago-gastric cancer services in England and Wales: a follow-up assessment of progress and remaining challenges. BMC Res Notes 2014; 7:24. [PMID: 24406032 PMCID: PMC3896679 DOI: 10.1186/1756-0500-7-24] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 01/08/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study is an update on an earlier article in 2007 to assess the implementation of the Cancer Plan reform strategy in England and Wales. FINDINGS A national online survey to upper gastro-intestinal leads at network and trust level. The questionnaire was designed based on existing clinical practice guidelines and addressed governing principles and operational procedures related to the delivery of cancer care. It was sent in January 2012 to upper gastro-intestinal network and trusts leads at all cancer networks and acute NHS organisations in England and Wales. Responses were received from 100% of Cancer Networks and 91% of NHS organisations. Centralisation of surgery has improved with all but two trusts (5.4%) now meeting the minimum staffing level for oesophago-gastric cancer surgery. This is a substantial improvement since the 2007 survey when 21 trusts (46.7%) did not meet this requirement. The use of formal assessment for nutritional needs has improved, too. In 2007, the involvement of the palliative care team in multi-disciplinary teams was poor. While this has improved, 27 trusts (19.7%) still report that none of the palliative care team members routinely attend the multi-disciplinary team discussion. CONCLUSIONS The survey demonstrates improved compliance with organisational recommendations since the last assessment in 2007. Centralisation of surgery has improved and is nearly fully compliant with the reform strategy. Areas that require further improvement are nutritional support and inclusion of palliative care in multi-disciplinary team meetings.
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Affiliation(s)
- Oliver Groene
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Georgina Chadwick
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Stuart Riley
- Department of Gastroenterology, Northern General Hospital, Sheffield, UK
| | - Richard H Hardwick
- Cambridge Oesophago-Gastric Centre, Addenbrookes Hospital, Cambridge, UK
| | - Tom Crosby
- Velindre Cancer Centre, Velindre NHS Trust, Cardiff, UK
| | - Kimberley Greenaway
- Clinical Audit Support Unit, The Health and Social Care Information Centre, Leeds, UK
| | - William Allum
- National Cancer Intelligence Network (NCIN), London, UK
| | - David A Cromwell
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
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Ong CAJ, Shapiro J, Nason KS, Davison JM, Liu X, Ross-Innes C, O'Donovan M, Dinjens WNM, Biermann K, Shannon N, Worster S, Schulz LKE, Luketich JD, Wijnhoven BPL, Hardwick RH, Fitzgerald RC. Three-gene immunohistochemical panel adds to clinical staging algorithms to predict prognosis for patients with esophageal adenocarcinoma. J Clin Oncol 2013; 31:1576-82. [PMID: 23509313 DOI: 10.1200/jco.2012.45.9636] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Esophageal adenocarcinoma (EAC) is a highly aggressive disease with poor long-term survival. Despite growing knowledge of its biology, no molecular biomarkers are currently used in routine clinical practice to determine prognosis or aid clinical decision making. Hence, this study set out to identify and validate a small, clinically applicable immunohistochemistry (IHC) panel for prognostication in patients with EAC. PATIENTS AND METHODS We recently identified eight molecular prognostic biomarkers using two different genomic platforms. IHC scores of these biomarkers from a UK multicenter cohort (N = 374) were used in univariate Cox regression analysis to determine the smallest biomarker panel with the greatest prognostic power with potential therapeutic relevance. This new panel was validated in two independent cohorts of patients with EAC who had undergone curative esophagectomy from the United States and Europe (N = 666). RESULTS Three of the eight previously identified prognostic molecular biomarkers (epidermal growth factor receptor [EGFR], tripartite motif-containing 44 [TRIM44], and sirtuin 2 [SIRT2]) had the strongest correlation with long-term survival in patients with EAC. Applying these three biomarkers as an IHC panel to the validation cohort segregated patients into two different prognostic groups (P < .01). Adjusting for known survival covariates, including clinical staging criteria, the IHC panel remained an independent predictor, with incremental adverse overall survival (OS) for each positive biomarker (hazard ratio, 1.20; 95% CI, 1.03 to 1.40 per biomarker; P = .02). CONCLUSION We identified and validated a clinically applicable IHC biomarker panel, consisting of EGFR, TRIM44, and SIRT2, that is independently associated with OS and provides additional prognostic information to current survival predictors such as stage.
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Palser TR, Cromwell DA, Hardwick RH, Riley SA, Greenaway K, van der Meulen JHP. Impact of route to diagnosis on treatment intent and 1-year survival in patients diagnosed with oesophagogastric cancer in England: a prospective cohort study. BMJ Open 2013; 3:bmjopen-2012-002129. [PMID: 23408076 PMCID: PMC3585975 DOI: 10.1136/bmjopen-2012-002129] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To investigate the relationship between the route to diagnosis, patient characteristics, treatment intent and 1 -year survival among patients with oesophagogastric (O-G) cancer. SETTING Cohort study in 142 English NHS trusts and 30 cancer networks. PARTICIPANTS Patients diagnosed with O-G cancer between October 2007 and June 2009. DESIGN Prospective cohort study. Route to diagnosis defined as general practitioner (GP) referral-urgent (suspected cancer) or non-urgent, hospital consultant referral, or after an emergency admission. Logistic regression was used to estimate associations and adjust for differences in casemix. MAIN OUTCOME MEASURES Proportion of patients diagnosed by route of diagnosis; proportion of patients selected for curative treatment; 1-year survival. RESULTS Among 14 102 cancer patients, 66.3% were diagnosed after a GP referral, 16.4% after an emergency admission and 17.4% after a hospital consultant referral. Of the 9351 GP referrals, 68.8% were urgent. Compared to urgent GP referrals, a markedly lower proportion of patients diagnosed after emergency admission had a curative treatment plan (36% vs 16%; adjusted OR=0.62, 95% CI 0.52 to 0.74) and a lower proportion survived 1 year (43% vs 27%; OR 0.78; 95% CI 0.68 to 0.89). Urgency of GP referral did not affect treatment intent or survival. Routes to diagnosis varied across cancer networks, with the adjusted proportion of patients diagnosed after emergency admission ranging from 8.7 to 32.3%. CONCLUSIONS Outcomes for cancer patients are worse if diagnosed after emergency admission. Primary care and hospital services should work together to reduce rates of diagnosis after emergency admission and the variation across cancer networks.
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Affiliation(s)
- Thomas R Palser
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
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Coupland VH, Lagergren J, Konfortion J, Allum W, Mendall MA, Hardwick RH, Linklater KM, Møller H, Jack RH. Ethnicity in relation to incidence of oesophageal and gastric cancer in England. Br J Cancer 2012; 107:1908-14. [PMID: 23059745 PMCID: PMC3504951 DOI: 10.1038/bjc.2012.465] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/04/2012] [Accepted: 09/18/2012] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND This study investigated the variation in incidence of all, and six subgroups of, oesophageal and gastric cancer between ethnic groups. METHODS Data on all oesophageal and gastric cancer patients diagnosed between 2001 and 2007 in England were analysed. Self-assigned ethnicity from the Hospital Episode Statistics dataset was used. Male and female age-standardised incidence rate ratios (IRRs) were calculated for each ethnic group, using White groups as the references. RESULTS Ethnicity information was available for 83% of patients (76 130/92 205). White men had a higher incidence of oesophageal cancer, with IRR for the other ethnic groups ranging from 0.17 95% confidence interval (CI) (0.15-0.20) (Pakistani men) to 0.58 95% CI (0.50-0.67) (Black Caribbean men). Compared with White women, Bangladeshi women (IRR 2.02 (1.24-3.29)) had a higher incidence of oesophageal cancer. For gastric cancer, Black Caribbean men (1.39 (1.22-1.60)) and women (1.57 (1.28-1.92)) had a higher incidence compared with their White counterparts. In the subgroup analysis, White men had a higher incidence of lower oesophageal and gastric cardia cancer compared with the other ethnic groups studied. Bangladeshi women (3.10 (1.60-6.00)) had a higher incidence of upper and middle oesophageal cancer compared with White women. CONCLUSION Substantial ethnic differences in the incidence of oesophageal and gastric cancer were found. Further research into differences in exposures to risk factors between ethnic groups could elucidate why the observed variation in incidence exists.
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Affiliation(s)
- V H Coupland
- King's College London, Thames Cancer Registry, 1st Floor Capital House, 42, Weston Street, London SE1 3QD, UK.
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Coupland VH, Allum W, Blazeby JM, Mendall MA, Hardwick RH, Linklater KM, Møller H, Davies EA. Incidence and survival of oesophageal and gastric cancer in England between 1998 and 2007, a population-based study. BMC Cancer 2012; 12:11. [PMID: 22239958 PMCID: PMC3274437 DOI: 10.1186/1471-2407-12-11] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 01/12/2012] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Major changes in the incidence of oesophageal and gastric cancers have been reported internationally. This study describes recent trends in incidence and survival of subgroups of oesophageal and gastric cancer in England between 1998 and 2007 and considers the implications for cancer services and policy. METHODS Data on 133,804 English patients diagnosed with oesophageal and gastric cancer between 1998 and 2007 were extracted from the National Cancer Data Repository. Using information on anatomical site and tumour morphology, data were divided into six groups; upper and middle oesophagus, lower oesophagus, oesophagus with an unspecified anatomical site, cardia, non-cardia stomach, and stomach with an unspecified anatomical site. Age-standardised incidence rates (per 100,000 European standard population) were calculated for each group by year of diagnosis and by socioeconomic deprivation. Survival was estimated using the Kaplan-Meier method. RESULTS The majority of oesophageal cancers were in the lower third of the oesophagus (58%). Stomach with an unspecified anatomical site was the largest gastric cancer group (53%). The incidence of lower oesophageal cancer increased between 1998 and 2002 and remained stable thereafter. The incidence of cancer of the cardia, non-cardia stomach, and stomach with an unspecified anatomical site declined over the 10 year period. Both lower oesophageal and cardia cancers had a much higher incidence in males compared with females (M:F 4:1). The incidence was also higher in the most deprived quintiles for all six cancer groups. Survival was poor in all sub-groups with 1 year survival ranging from 14.8-40.8% and 5 year survival ranging from 3.7-15.6%. CONCLUSIONS An increased focus on prevention and early diagnosis, especially in deprived areas and in males, is required to improve outcomes for these cancers. Improved recording of tumour site, stage and morphology and the evaluation of focused early diagnosis programmes are also needed. The poor long-term survival reinforces the need for early detection and multidisciplinary care.
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Affiliation(s)
- Victoria H Coupland
- King's College London, Thames Cancer Registry, 1st Floor Capital House, 42, Weston Street, London SE1 3QD, UK
| | | | - Jane M Blazeby
- University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | - Karen M Linklater
- King's College London, Thames Cancer Registry, 1st Floor Capital House, 42, Weston Street, London SE1 3QD, UK
| | - Henrik Møller
- King's College London, Thames Cancer Registry, 1st Floor Capital House, 42, Weston Street, London SE1 3QD, UK
| | - Elizabeth A Davies
- King's College London, Thames Cancer Registry, 1st Floor Capital House, 42, Weston Street, London SE1 3QD, UK
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Hardwick RH. [Centralisation of upper gastrointestinal surgical services]. Cir Esp 2011; 89:563-4. [PMID: 21835397 DOI: 10.1016/j.ciresp.2011.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 06/01/2011] [Indexed: 11/18/2022]
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Peters CJ, Rees JRE, Hardwick RH, Hardwick JS, Vowler SL, Ong CAJ, Zhang C, Save V, O'Donovan M, Rassl D, Alderson D, Caldas C, Fitzgerald RC. A 4-gene signature predicts survival of patients with resected adenocarcinoma of the esophagus, junction, and gastric cardia. Gastroenterology 2010; 139:1995-2004.e15. [PMID: 20621683 DOI: 10.1053/j.gastro.2010.05.080] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 05/17/2010] [Accepted: 05/26/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS The incidence of esophageal and junctional adenocarcinoma has increased 6-fold in the past 30 years and 5-year survival remains approximately 20%. Current staging is limited in its ability to predict survival which has ramifications for treatment choices. The aim of this study was to generate and validate a molecular prognostic signature for esophageal adenocarcinoma. METHODS Gene expression profiling was performed and the resulting 42,000 gene signatures correlated with clinical and pathologic features for 75 snap-frozen esophageal and junctional resection specimens. External validation of selected targets was performed on 371 independent cases using immunohistochemistry to maximize clinical applicability. RESULTS A total of 119 genes were associated significantly with survival and 270 genes with the number of involved lymph nodes. Filtering of these lists resulted in a shortlist of 10 genes taken forward to validation. Four genes proved to be prognostic at the protein level (deoxycytidine kinase [DCK], 3'-phosphoadenosine 5'-phosphosulfate synthase 2 [PAPSS2], sirtuin 2 [SIRT2], and tripartite motif-containing 44 [TRIM44]) and were combined to create a molecular prognostic signature. This 4-gene signature was highly predictive of survival in the independent external validation cohort (0/4 genes dysregulated 5-year survival, 58%; 95% confidence interval [CI], 36%-80%; 1-2/4 genes dysregulated 5-year survival, 26%; 95% CI, 20%-32%; and 3-4/4 genes dysregulated 5-year survival, 14%; 95% CI, 4%-24% (P = .001). Furthermore, this 4-gene signature was independently prognostic in a multivariable model together with the existing clinical TNM staging system (P = .013). CONCLUSIONS This study has generated a clinically applicable prognostic gene signature that independently predicts survival in an external validation cohort and may inform management decisions.
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Kadri SR, Lao-Sirieix P, O'Donovan M, Debiram I, Das M, Blazeby JM, Emery J, Boussioutas A, Morris H, Walter FM, Pharoah P, Hardwick RH, Fitzgerald RC. Acceptability and accuracy of a non-endoscopic screening test for Barrett's oesophagus in primary care: cohort study. BMJ 2010; 341:c4372. [PMID: 20833740 PMCID: PMC2938899 DOI: 10.1136/bmj.c4372] [Citation(s) in RCA: 223] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To determine the accuracy and acceptability to patients of non-endoscopic screening for Barrett's oesophagus, using an ingestible oesophageal sampling device (Cytosponge) coupled with immunocytochemisty for trefoil factor 3. DESIGN Prospective cohort study. SETTING 12 UK general practices, with gastroscopies carried out in one hospital endoscopy unit. PARTICIPANTS 504 of 2696 eligible patients (18.7%) aged 50 to 70 years with a previous prescription for an acid suppressant (H(2) receptor antagonist or proton pump inhibitor) for more than three months in the past five years. MAIN OUTCOME MEASURES Sensitivity and specificity estimates for detecting Barrett's oesophagus compared with gastroscopy as the ideal method, and patient anxiety (short form Spielberger state trait anxiety inventory, impact of events scale) and acceptability (visual analogue scale) of the test. RESULTS 501 of 504 (99%) participants (median age 62, male to female ratio 1:1.2) successfully swallowed the Cytosponge. No serious adverse events occurred. In total, 3.0% (15/501) had an endoscopic diagnosis of Barrett's oesophagus (≥1 cm circumferential length, median circumferential and maximal length of 2 cm and 5 cm, respectively) with intestinal metaplasia. Compared with gastroscopy the sensitivity and specificity of the test was 73.3% (95% confidence interval 44.9% to 92.2%) and 93.8% (91.3% to 95.8%) for 1 cm or more circumferential length and 90.0% (55.5% to 99.7%) and 93.5% (90.9% to 95.5%) for clinically relevant segments of 2 cm or more. Most participants (355/496, 82%, 95% confidence interval 78.9% to 85.1%) reported low levels of anxiety before the test, and scores remained within normal limits at follow-up. Less than 4.5% (2.8% to 6.1%) of participants reported psychological distress a week after the procedure. CONCLUSIONS The performance of the Cytosponge test was promising and the procedure was well tolerated. These data bring screening for Barrett's oesophagus into the realm of possibility. Further evaluation is recommended.
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Affiliation(s)
- Sudarshan R Kadri
- MRC Cancer Cell Unit, Hutchison-MRC Research Centre, Cambridge CB2 2XZ
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Shannon NB, Peters CJ, Rees JR, Hardwick JS, Zhang C, Hardwick RH, Fitzgerald RC. Abstract 789: Determination of MAPK and Wnt pathway activity in esophageal cancer. Cancer Res 2010. [DOI: 10.1158/1538-7445.am10-789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction:
Gastro-esophageal adenocarcinomas are rapidly increasing in incidence and have a five year survival of less than 14%. Analysis of signaling pathways in gastro-esophageal adenocarcinomas can be used as a route to identifying possible therapeutic targets.
Aims and methods:
We had already identified MAPK and Wnt pathways as important in this disease. The aim of this work was to identify biomarkers of pathway activation for future application to primary tumors for selection of targeted therapies.
Three cell lines (CP-B, CP-C, CP-D) without constitutive activation were stimulated with exogenous ligands for the Wnt or MAPK or pathways. The TGFβ pathway was also stimulated as a negative control to test biomarker specificity. The expression of potential biomarkers of transcriptional activity was then profiled using real time PCR. To determine applicability of these markers to human tissue the expression of these markers was assessed in an expression array data set consisting of 75 gastro-esophageal adenocarcinomas.
Results:
Out of 8 (MAPK) and 13 (Wnt) potential markers, three markers were selected as specific for the MAPK pathway (EGR-1, JUN and FOSL1) or the Wnt pathway (BMP4, TCF7, LEF1). All markers had upregulation of expression of at least 2 fold that were specific to activation of the relevant pathway (Table 1).Table 1.Fold changes of expression upon activation by stimulation with exogenous ligandsMarkerEGF (MAPK pathway)LiCl (Wnt pathway)TGFβ (TGFβ pathway)P-value (ANOVA)EGR-1130.50.91.3< 10-4JUN3.31.21.0< 10-4FOSL111.02.60.6< 10-4BMP42.18.31.5< 10-4LEF10.523.30.5< 10-4TCF72.44.80.7< 10-4
Next we assessed the expression of selected markers in 75 gastro-esophageal adenocarcinomas for which expression profiling data was available. In these tumors 27 (36%) had activation of the MAPK pathway alone, 10 (13%) had activation of the Wnt pathway alone, and a further 12 (16%) had activation of both pathways.
Conclusions:
We have determined a set of markers which can be used to assess pathway activation of the MAPK and Wnt pathways in gastro-esophageal adenocarcinomas. External validation of these pathway activation markers is ongoing using multiplex PCR as a prelude to a clinical trial of targeted therapy.
Note: This abstract was not presented at the AACR 101st Annual Meeting 2010 because the presenter was unable to attend.
Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 789.
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Affiliation(s)
| | | | | | | | - Chunsheng Zhang
- 3Molecular Profiling, Merck Research Laboratories, North Wales, PA
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Palser TR, Cromwell DA, Hardwick RH, Riley SA, Greenaway K, Allum W, van der Meulen JH. Re-organisation of oesophago-gastric cancer care in England: progress and remaining challenges. BMC Health Serv Res 2009; 9:204. [PMID: 19909525 PMCID: PMC2779810 DOI: 10.1186/1472-6963-9-204] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Accepted: 11/12/2009] [Indexed: 12/04/2022] Open
Abstract
Background Oesophago-gastric cancer services in England have been extensively reorganised since 2001 to deliver a centralised, specialist-led service. Our aim was to assess how well the National Health Service (NHS) in England met organisational standards for oesophago-gastric cancer care. Methods Questionnaires that asked about the provision of staging investigations, curative and palliative treatments and key personnel were sent in September 2007 to the lead clinician for oesophago-gastric cancer at all 30 cancer networks and 156 NHS acute trusts in England. Results Responses were received from all networks and 81% of NHS trusts. All networks provided essential staging investigations and a range of endoscopic palliative therapies. Only 16 of the 30 cancer networks discussed all patients at the specialist multi-disciplinary team meeting and 11 networks had not fully centralised curative surgery. There was also variation between NHS trusts in the integration of the palliative care team, the availability of nurse specialists and the use of dieticians to provide nutritional support. Conclusion There has been considerable progress in reforming oesophago-gastric cancer services but the process of reorganisation is still incomplete and regional differences in service provision exist that may lead to variation in patient outcomes.
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Affiliation(s)
- Thomas R Palser
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London WC2A3PE, UK
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Peters CJ, Hardwick RH, Vowler SL, Fitzgerald RC. Generation and validation of a revised classification for oesophageal and junctional adenocarcinoma. Br J Surg 2009; 96:724-33. [PMID: 19526624 DOI: 10.1002/bjs.6584] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Oesophageal adenocarcinoma is the commonest oesophageal malignancy in the West, but is staged using a system designed for squamous cell carcinoma. The aim was to develop and validate a staging system for oesophageal and junctional adenocarcinoma. METHODS Patients with oesophageal adenocarcinoma (Siewert types I and II) undergoing oesophagectomy with curative intent were randomly assigned to generation (313 patients) and validation (131) data sets. Outcome in the generation data set was associated with histopathological features; a revised node (N) classification was derived using recursive partitioning and tested on the validation data set. RESULTS A revised N classification based on number of involved lymph nodes (N0, none; N1, one to five; N2, six or more) was prognostically significant (P < 0.001). Patients with involved nodes on both sides of the diaphragm, regardless of number, had the same outcome as the N2 group. When applied to the validation data set, the revised classification (including nodal number and location) provided greater discrimination between node-positive patients than the existing system (P < 0.001). CONCLUSION A revised N classification based on number and location of involved lymph nodes provides improved prognostic power and incorporates features that may be useful before surgery in clinical management decisions.
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Affiliation(s)
- C J Peters
- Medical Research Council (MRC) Cancer Cell Unit, Hutchison/MRC Research Centre, Cambridge, UK
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Barber ME, Save V, Carneiro F, Dwerryhouse S, Lao-Sirieix P, Hardwick RH, Caldas C, Fitzgerald RC. Histopathological and molecular analysis of gastrectomy specimens from hereditary diffuse gastric cancer patients has implications for endoscopic surveillance of individuals at risk. J Pathol 2008; 216:286-94. [PMID: 18825658 DOI: 10.1002/path.2415] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hereditary diffuse gastric cancer (HDGC) is caused by germline E-cadherin (CDH1) mutations in 25-40% of tested families. Management options for asymptomatic mutation carriers are fraught, since endoscopic surveillance can miss cancer foci and prophylactic gastrectomy has profound clinical sequelae. The aims of this study were to evaluate the impact of current surveillance practices on pre-operative diagnosis and to characterize the microscopic lesions in gastrectomy specimens to better inform clinical practice. Histological assessment and mapping of endoscopic surveillance and gastrectomy specimens were performed for eight asymptomatic CDH1 mutation carriers. E-cadherin expression and proliferation were analysed and evidence of epithelial-mesenchymal transition (EMT) was sought by immunohistochemistry for vimentin and cytokeratin 8/18. Four of eight patients had lesions detected at endoscopic surveillance. A median of 20.5 (range 0-66) signet ring foci were identified per gastrectomy (including in situ lesions and pagetoid spread). Foci were predominantly identified in the fundus and body (90% endoscopic biopsies and 85% in gastrectomy). The likelihood of detecting foci pre-operatively was positively correlated with the number of biopsies taken and the number of lesions in the gastrectomy specimen. E-cadherin expression in gastrectomy specimens was reduced or absent in all of the foci compared with the intervening gastric tissue, suggesting that these lesions are polyclonal. The foci had a low proliferative index (<2%) and there was no evidence for EMT. Multiple endoscopic biopsy sampling of the gastric mucosa increases the yield of microscopic cancer foci. The low proliferative index and lack of EMT suggests that these foci may represent an indolent stage of HDGC.
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Affiliation(s)
- M E Barber
- MRC Cancer Cell Unit, Hutchison/MRC Research Centre, Hills Road, Cambridge, UK
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Abstract
BACKGROUND Definitive chemoradiotherapy (CRT) is one treatment option for locally advanced oesophageal carcinoma. CRT typically consists of high-dose (50-66 Gy) external beam radiotherapy concurrent with 5-fluorouracil and cisplatin. When definitive CRT fails to achieve local control, salvage oesophagectomy is frequently the only treatment available that can offer a chance of long-term survival. METHODS Online databases were searched for publications relating to salvage oesophagectomy and definitive CRT. Nine series containing a total of 105 patients were reviewed. Demographics, indications for surgery, type of resection, complications and outcome data were extracted. RESULTS Each centre performed one to three salvage resections per year comprising 1.7-4.1 per cent of the oesophagectomy workload. The overall anastomotic leak rate was 17.1 per cent. The in-hospital mortality rate was 11.4 per cent. Five-year survival rates of 25-35 per cent were achieved. Prognostic factors for increased survival were R0 resection (P = 0.006) and longer interval between CRT and recurrence (P = 0.002). CONCLUSION Salvage resection after CRT is feasible for selected patients but is a formidable undertaking. Restaging investigations after CRT for potentially resectable tumours in fit candidates should include endoscopy and positron emission tomography-computed tomography. Salvage oesophagectomy is carried out with the goal of cure and it should be attempted only if an R0 resection is technically possible.
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Affiliation(s)
- J Gardner-Thorpe
- Oesophagogastric Centre, Box 201, Addenbrooke's Hospital, Cambridge, UK
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Abstract
Enteroenteric intussusception is a condition in which full-thickness bowel wall becomes telescoped into the lumen of distal bowel. In adults, there is usually an abnormality acting as a lead point, usually a Meckels' diverticulum, a hamartoma or a tumour. Duodeno-duodenal intussusception is exceptionally rare because the retroperitoneal situation fixes the duodenal wall. The aim of this report is to describe the first published case of this condition. A patient with duodeno-duodenal intussusception secondary to an ampullary lesion is reported. A 66 year-old lady presented with intermittent abdominal pain, weight loss and anaemia. Ultrasound scanning showed dilated bile and pancreatic ducts. CT scanning revealed intussusception involving the full-thickness duodenal wall. The lead point was an ampullary villous adenoma. Congenital partial (type II) malrotation was found at operation and this abnormality permitted excessive mobility of the duodenal wall such that intussusception was possible. This condition can be diagnosed using enhanced CT. Intussusception can be complicated by bowel obstruction, ischaemia or bleeding, and therefore the underlying cause should be treated as soon as possible.
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Affiliation(s)
- J Gardner-Thorpe
- Cambridge Surgical HPB Unit, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 2QQ, United Kingdom
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White V, Hardwick RH, Rees JRE, Slack M. Massive urinary ascites after removal of a supra-pubic catheter: case report and review of the literature. Int Urogynecol J 2006; 18:831-3. [PMID: 17093890 DOI: 10.1007/s00192-006-0247-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2006] [Accepted: 10/02/2006] [Indexed: 10/23/2022]
Abstract
Urinary ascites is a rare diagnosis usually associated with intra-peritoneal bladder perforation. We present a case of massive urinary ascites in a patient who presented 1 week after a total abdominal hysterectomy and sacrocolpopexy. We discuss how the diagnosis was made, the mechanism of biochemical changes associated with urinary ascites and the management. In summary, we show that a combination of serum and ascitic biochemistry are essential to make a diagnosis of urinary ascites.
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Affiliation(s)
- Victoria White
- MRC Cancer Cell Unit, Hutchison/MRC Research Centre, Hills Road, Cambridge, CB2 2XZ, UK.
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Barnes G, Bulusu VR, Hardwick RH, Carroll N, Hatcher H, Earl HM, Save VE, Balan K, Jamieson NV. A review of the surgical management of metastatic gastrointestinal stromal tumours (GISTs) on imatinib mesylate (Glivec™). Int J Surg 2005; 3:206-12. [PMID: 17462285 DOI: 10.1016/j.ijsu.2005.04.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Gastrointestinal stromal tumours (GISTs) are defined as a group of C-KIT positive mesenchymal tumours of the gastrointestinal tract. Although they may arise throughout the gut, the commonest sites are stomach and small intestine. Over 80% of metastases are to the liver and omentum. Targeted therapy (imatinib) can inhibit C-KIT and thereby aberrant tumoural proliferation. Imatinib may induce shrinkage of lesions and cystic change. Such physical changes often correspond with reduced metabolic activity demonstrated by (18-FDG)PET scans. These changes may enable metastatectomy reducing tumour pain and the risk of haemorrhage and rupture in the short term. In the long term, resection may lessen the risk of recurrence by removing potentially resistant clones. The precise role of palliative resection for GIST metastases on imatinib remains unclear. Imatinib has changed the natural history of metastatic GISTs, with increased survival times. Surgery remains an important management strategy in the metastatic setting because complete pathological responses are rare with imatinib. Surgery is likely to provide the best palliation, greatest reduction in tumour burden and eliminate resistant clones. A multidisciplinary team approach with expertise concentrated in a few centres specialising in the management of these rare tumours is vital to the successful outcome. Future issues regarding the management of differential response of the metastases to imatinib are highlighted. With the emergence of techniques enabling identification of the precise mutational status of the C-KIT oncogene, the imatinib/surgery sequence could be tailored to the type of C-KIT mutation.
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Affiliation(s)
- G Barnes
- Directorate of Surgery, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
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Affiliation(s)
- Richard H Hardwick
- Cambridge Upper GI Unit, Oesophago-gastric Service, PO Box 201, Addenbrookes NHS Trust, Hills Rd, Cambridge CB2 2QQ, UK
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Hollowood AD, Kavadas V, Vickery CW, Hardwick RH, Barham CP, Alderson D. Prediction of need for multiple dilatations after cervical oesophagogastrostomy. Br J Surg 2003. [DOI: 10.1046/j.1365-2168.1999.1062f.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Background
The aim of this study was to investigate the frequency of anastomotic stricture formation after subtotal oesophagectomy with cervical oesophagogastrostomy.
Methods
Patients undergoing surgery over a 3-year period using an identical handsewn single-layer anastomotic technique were studied. Details of the operations, complications and need for anastomotic dilatation were recorded.
Results
Sixty-two patients (41 men) with a mean age of 64 (range 36–90) years were included. Fifty-eight underwent surgery for carcinoma, two for stromal tumours, one for achalasia and one for Crohn's disease. Thirty-two (2 per cent) developed a benign anastomotic stricture requiring a median of 4 (range 1–22) dilatations. The median time from operation to first dilatation was 50 days. There was a significant correlation between the time to first dilatation and the total number of dilatations (P = 0·006). Patients who developed symptomatic strictures within 30 days of operation required a median of 9·5 dilatations compared with 3·5 in those who presented beyond this time (P = 0·01). The development of a clinical leak significantly increased the number of dilatations required, from a mean of 5·2 to 10·4 (P = 0·04).
Conclusion
The incidence of benign anastomotic stricture formation requiring dilatation after cervical oesophagogastrostomy is about 50 per cent. Patients who require dilatation within 30 days of surgery to restore swallowing to normal are likely to require the procedure on multiple occasions and should be counselled accordingly.
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Affiliation(s)
- A D Hollowood
- University Department of Surgery, Bristol Royal Infirmary, Bristol, UK
| | - V Kavadas
- University Department of Surgery, Bristol Royal Infirmary, Bristol, UK
| | - C W Vickery
- University Department of Surgery, Bristol Royal Infirmary, Bristol, UK
| | - R H Hardwick
- University Department of Surgery, Bristol Royal Infirmary, Bristol, UK
| | - C P Barham
- University Department of Surgery, Bristol Royal Infirmary, Bristol, UK
| | - D Alderson
- University Department of Surgery, Bristol Royal Infirmary, Bristol, UK
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Vickery CW, Hollowood AD, Barham CP, Hardwick RH, Alderson D. Investigating the proximal limit of lymphadenectomy in patients with adenocarcinoma of the oesophagus in the mid-thoracic region. Br J Surg 2002. [DOI: 10.1046/j.1365-2168.2000.01383-27.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Aims
The benefit of extended lymphadenectomy in patients with squamous cell carcinoma of the oesophagus is established, but there is little evidence to support this in patients with adenocarcinoma. The aim of this study was to investigate the extent of lymphatic spread of oesophageal adenocarcinomas, and particularly the proximal spread in tumours located in the mid thorax.
Methods
Twenty-six consecutive patients with tumours arising between 29 and 35 cm from the incisor teeth underwent three-stage oesophagectomy with two-field lymphadenectomy, including nodes in the recurrent laryngeal chains. The proximal extent was measured by endoscopic ultrasonography and confirmed at operation, with division of the lymph node harvest into anatomical sites according to the Japanese classification of oesophageal cancer.
Results
There were 21 men and five women, with a mean age of 64 (range 42–78) years; seven patients were lymph node negative in both the mediastinal and abdominal fields. Six patients had nodal metastases more than 2 cm above the tumour and all had extensive involvement of other nodes at the level of the tumour or below, with 7, 7, 9, 12, 15 and 18 nodes positive. There were no patients in whom nodes above the tumour contained metastases while those at the level or below were clear.
Conclusions
Dissection of proximal lymph nodes along the recurrent laryngeal nerve chains in patients with adenocarcinoma of the oesophagus is not warranted. Lymphatic spread above the level of the tumour occurs in association with extensive lymph node involvement elsewhere and removal of proximal nodes from difficult locations is not warranted as a means of improving staging or survival.
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Affiliation(s)
- C W Vickery
- University Department of Surgery, Bristol, UK
| | | | - C P Barham
- University Department of Surgery, Bristol, UK
| | | | - D Alderson
- University Department of Surgery, Bristol, UK
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Affiliation(s)
- R H Hardwick
- Cambridge Upper Gastrointestinal Unit, Addenbrookes NHS Trust, Hills Road, Cambridge CB2 2QQ, UK.
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Hardwick RH, Taylor A, Thompson MH, Jones E, Roe AM. Association between Streptococcus milleri and abscess formation after appendicitis. Ann R Coll Surg Engl 2000; 82:24-6. [PMID: 10700762 PMCID: PMC2503455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
Abscesses after appendicitis occur in some patients despite timely surgery and antibiotics. The Streptococcus milleri group of bacteria are commonly associated with gastrointestinal abscesses. This study investigated the relationship between S. milleri and abscess formation after appendicectomy a total of 301 patients (172 males, 129 females, median age 22 years) with appendicitis were identified retrospectively from the hospital PAS computer system who had an appendicectomy and peritoneal bacteriology swabs taken. All but one patient had prophylactic antibiotics. Patients were divided into three groups according to peritoneal bacteriology: group 1 (S. milleri +/- mixed faecal organisms, n = 61); group 2 (mixed faecal organisms, n = 126); and group 3 (sterile, n = 114). The chi squared and Student t-tests were used for statistical analysis. Thirteen (21%) of group 1 patients developed an intra-abdominal abscess compared with 4 (3%) in group 2 and 2 (1.7%) in group 3 (P < 0.0001). There was no difference in the prevalence of gangrenous or perforated appendicitis between groups 1 and 2 (56% versus 52%) but these worse forms of appendicitis were less common in group 3 (22%). Group 1 patients had a mean total hospital stay of 10 days versus 6 days for group 2 and 4 days for group 3 (P < 0.001). S. milleri was associated with a 7-fold increase in abscess formation after appendicectomy and a longer hospital stay. Antibiotic prophylaxis did not prevent this complication.
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Affiliation(s)
- R H Hardwick
- Department of Surgery, Southmead Hospital, Westbury on Trym, Bristol, UK.
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Abstract
A laparoscopic splenectomy during pregnancy is described in this case report. The operation took place at 18 weeks' gestation for life-threatening thrombocytopaenia secondary to antiphospholipid syndrome that had failed to respond to medical therapy. The patient made a full and rapid recovery and was delivered of a healthy baby girl at term.
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Affiliation(s)
- R H Hardwick
- Department of Surgery, Southmead Hospital, Westbury-on-Trym, Bristol, United Kingdom
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