Gallbladder cancer in India: a dismal picture

BACKGROUND

Gallbladder cancer (GBC) is one of the most common gastrointestinal malignancies. The data regarding GBC are, however, limited.

METHODS

Records of 634 patients with GBC over a 10-year period were examined with regard to the clinical presentation, investigative findings, treatment, operative findings and outcome.

RESULTS

The mean age of patients was 51 +/- 11 years and men : women ratio was 0.36:1.00. Pain, jaundice and hepatomegaly were seen in 81.0%, 76.0% and 61.5% patients, respectively. On imaging, a mass replacing the gallbladder was seen in 73% patients. Gallstones were present in 54% patients. Surgery was carried out in 291 (46%) patients and endoscopic treatment in 72 (19%) patients but no intervention was carried out in the remaining patients because of disseminated disease. Among the patients who were operated on, 2.0% had stage I GBC, 3.4% stage II, 17.5% stage III, 47.0% stage IVa and 29.8% stage IVb. Radical resection was possible in 133 (46%) patients. The 30-day mortality was 10% with most (90%) deaths in patients with stage IV disease. The median survival after simple cholecystectomy and radical surgery was 33.5 and 12.0 months, respectively. However, among those who underwent debulking, palliative bypass or exploratory laparotomy alone, the survival ranged between 1 and 3 months. Logistic regression analysis showed that only radical resection improved the long-term survival (P < 0.05).

CONCLUSIONS

The majority of patients with GBC in India have advanced unresectable disease. Detection of GBC at an early stage is incidental and rare but is associated with long-term survival. Radical surgery, when feasible, is the only option for achieving long-term survival.

Circulating p53 antibodies, p53 gene mutational profile and product accumulation in esophageal squamous-cell carcinoma in India

Esophageal cancer (EC) in the Indian population presents in advanced stages with poor prognosis and warrants the identification of a non-invasive marker for early detection and better prognostic assessment. We have previously reported high prevalence of p53 protein accumulation in esophageal squamous-cell carcinomas (ESCCs). The present study was designed to determine (i) if esophageal cancer patients elicit a humoral immune response to intra-tumoral p53 protein accumulation and (ii) their relationship with p53 gene mutations. The goal was to compare the cellular events, p53 protein accumulation and gene mutations with the presence of serum anti-p53 antibodies (p53-Abs) and to assess the utility of serological p53-Ab analysis as a surrogate marker for p53 alterations in esophageal cancer. A high prevalence of circulating p53-Abs was observed in 36 of 60 (60%) ESCC patients. In a subset of 44 ESCCs, exons 5-9 of the p53 gene were examined for mutations by PCR and direct sequencing of PCR products. Mutational data have been correlated with p53-Abs and p53 protein accumulation in ESCCs. Circulating p53-Abs in ESCC patients were significantly associated with intra-tumoral p53 protein accumulation (p=0.0005). A strong correlation observed between humoral immune response against p53 protein, missense gene mutations and protein accumulation warrants the application of serological p53-Abs as a non-invasive surrogate marker in screening high-risk populations for early detection of malignancy.

Thoracic duct injury during esophagectomy: 20 years experience at a tertiary care center in a developing country

Thoracic duct injury is an uncommon complication of esophagectomy. Experience in managing these cases is limited to large centers performing esophagectomies in good numbers. We analyzed the prospectively maintained esophageal diseases database of patients presenting to a surgical unit between 1982 and 2002. Among 552 esophagectomies during this period we had encountered 14 cases of chylothorax (2.54%). We analyzed the type and site of lesion and the impact of neoadjuvant therapy on the incidence of thoracic duct injury. Among 459 patients of transhiatal esophagectomy, 11 developed postoperative chylothorax (2.40%). In 93 transthoracic resections, there were three cases of chylothorax (3.23%; (P = 0.9185)). The incidence following preoperative radiotherapy was 2.17%. None of the 31 patients, who had undergone esophagectomy for benign diseases had developed chylothorax. In the carcinoma group the incidence in middle third lesions was 5.85% and in lower third lesions was 0.80% (P = 0.0018). Seven patients were managed conservatively. Two of these patients, for whom surgery had been planned, died before they could be taken up for surgery. In the remaining seven patients transthoracic ligation of the thoracic duct was performed. Two patients in this group died. The average hospital stay was 20 days in the conservative group and 12 days in the surgery group. Among the factors studied, patients with middle third lesions were at increased risk of developing postoperative chylothorax, when compared to upper or lower third lesions.

Ets-1 and VEGF expression correlates with tumor angiogenesis, lymph node metastasis, and patient survival in esophageal squamous cell carcinoma

PURPOSE

Esophageal squamous cell carcinoma (ESCC) in the Indian population exhibits insidious symptomatology, late clinical presentation, aggressive behavior, and high propensity for metastasis. Ets-1, a transcription factor, is expressed in esophageal tumors and associated with poor prognosis. The aim of the present study was to determine the relationship between Ets-1 expression, tumor angiogenesis [vascular endothelial growth factor (VEGF) and microvessel density (MVD)] and the biological behavior of ESCCs.

METHODS

In a prospective study the expression of Ets-1, VEGF, and PECAM-1 (CD-31) was determined in 55 ESCCs, by immunohistochemical analysis, correlated with clinicopathological parameters and outcome of the patients.

RESULTS

Overexpression of Ets-1 and VEGF proteins was observed in 44/55 (80%) and 38/55 (69%) of ESCCs, respectively. VEGF immunopositivity was associated with lymph node metastasis ( P=0.002). Analysis of mRNA isoforms using RT-PCR revealed increased expression of VEGF 121 transcripts in ESCCs and MVD was correlated with de-differentiation status of the tumors ( P=0.049). Kaplan-Meier survival analysis showed significant correlation between poor disease-free survival and tumor stage ( P=0.02) and with nodal metastasis ( P=0.05). Concomitant expression of VEGF, Ets-1 proteins, and high MVD was correlated with poor disease-free survival ( P=0.004).

CONCLUSION

Significant association of Ets-1 and VEGF proteins with tumor angiogenesis (MVD), lymph node invasion, and poor disease-free survival underscores their relevance regarding aggressive tumor behavior and highlights their potential utility as adverse prognostic factors in esophageal carcinomas.

Is pyloroplasty necessary following intrathoracic transposition of stomach? Results of a prospective clinical study

Twenty four patients underwent oesophagectomy for oesophageal cancer. The oesophagogastric anastomosis was performed in the neck in all patients. Following oesophagectomy and gastric mobilization patients were randomly selected into pyloroplasty and no pyloroplasty groups. Pre and postoperative gastric emptying of these patients evaluated by radioisotope technique were then compared. The results suggest significantly delayed postoperative gastric emptying in both the groups though it was less pronounced in the pyloroplasty group. All patients were then carefully followed until death (period varying between 6 months and 4 years) for ill effects of delayed gastric emptying which were present in some patients of both the groups. It was thus concluded that emptying of thoracic stomach is delayed and pyloroplasty fails to improve it completely. Postoperatively patients behave much the same way with or without pyloroplasty.

Differential expression of G-protein coupled receptor 56 in human esophageal squamous cell carcinoma

Herein, we describe the identification of GPCR56, an orphan G-protein coupled receptor, to be differentially expressed in esophageal squamous cell carcinoma. Although, GPCRs have been demonstrated to be altered in various human cancers, much is still unknown about GPCR56 expression in tumors. To evaluate the expression of these genes in esophageal tissues, we performed semi-quantitative Reverse-Transcription Polymerase Chain Reaction in ESCCs, dysplasia and matched normal esophageal epithelium. Increased transcript levels of GPCR56 were detected in 48% of ESCCs, while the adjacent non-malignant esophageal tissue did not show the expression of this transcript. Interestingly, most of the dysplastic tissues analyzed also exhibited increased expression of GPCR56 suggesting that alteration in GPCR56 expression is an early event in esophageal tumorigenesis. In depth analysis of GPCR56 in different stages of development and progression of esophageal tumorigenesis is warranted to explore its utility as potential early diagnostic marker and its function in esophageal cancer.

Modulated Magnetic Phases in Rare Earth Metallic Systems

Neutron scattering has played a key role in the microscopic understanding of the static and dynamic properties of magnetic materials. Modulated magnetic structures first discovered in the late fifties can no longer be referred to as exotic; more than a hundred such phases have already been found in a variety of magnetic systems. Neutron and x-ray magnetic scattering have played a complementary role in the recent discovery and understanding of the modulated magnetic phases in rare earth metallic systems.

Bcl-2 expression is correlated with low apoptotic index and associated with histopathological grading in esophageal squamous cell carcinomas

The aim of this study was to examine the relationship between apoptosis, protein expression of apoptosis mediator and inhibitor genes p53 and bcl-2 and various histopathological grades of squamous cell carcinoma of the esophagus. Apoptotic index was evaluated in thirty human esophageal squamous cell carcinomas and adjoining normal tissue by terminal deoxynucleotidyl transferase-mediated dUTP nick end labelling (TUNEL). Protein expression of bcl-2 and p53 was measured by immunohistochemical staining of cryocut sections and Western blotting. Apoptototic cells were seen mainly around areas of keratinization and the apoptotic index was highest in well-differentiated squamous cell carcinomas. High Bcl-2 expression correlated inversely with the apoptotic index. p53 protein expression did not correlate with the grade of the tumor or the apoptotic index. We propose that deregulation of apoptosis contributes to the pathogenesis of esophageal squamous cell carcinoma.

TC21/R-Ras2 Upregulation in Esophageal Tumorigenesis: Potential Diagnostic Implications

OBJECTIVES

Early detection of esophageal cancer is hampered by paucity of molecular markers for diagnosis of this aggressive gastrointestinal malignancy in early stages. We recently identified TC21/R-Ras2, a small GTP-binding protein (SMG) in esophageal squamous cell carcinomas (ESCCs) by differential display. This study was designed to test the hypothesis that differential expression of TC21 in normal, dysplastic and malignant esophageal tissues may be of clinical relevance in esophageal tumorigenesis.

METHODS

Immunohistochemical analysis of TC21 was carried out in 83 ESCCs, 37 dysplasias and 29 matched histologically normal esophageal tissues and correlated with clinicopathological parameters. The cellular localization of TC21 was determined by confocal microscopy.

RESULTS

Expression of TC21 protein was observed in 60/83 (73%) ESCCs predominantly localized in tumor nuclei. Intriguingly, intense TC21 immunoreactivity was observed in all endoscopic biopsies with histological evidence of dysplasia (16 cases) as well as in dysplastic areas distant to ESCCs (21 cases), while matched distant histologically normal epithelia did not show detectable TC21 expression. Immunoblotting and semi-quantitative RT-PCR confirmed TC21 expression in dysplastias and ESCCs. Confocal microscopy showed nuclear as well as cytoplasmic TC21 expression in ESCCs and TE13 cells.

CONCLUSIONS

To our knowledge, this is the first report demonstrating differential expression of TC21 in normal, dysplastic and ESCC tissues, suggesting that TC21 expression is associated with early stages of esophageal tumorigenesis. Nuclear localization of TC21 makes it the third of over 100 small SMGs identified to be localized in the nucleus.

Prognostic Significance of Stromelysin-3 and Tissue Inhibitor of Matrix Metalloproteinase-2 in Esophageal Cancer

OBJECTIVE

Stromelysins (matrix metalloproteinases: MMP-10 or ST-2 and MMP-11 or ST-3) and tissue inhibitors of matrix metalloproteinases (TIMP-1 and 2) have been shown to be associated with human tumor progression, invasion and metastasis. The aim of the present study was to determine the prognostic significance of these proteins in esophageal squamous cell carcinoma (ESCC).

METHODS

Immunohistochemical analysis was carried out in 65 surgically resected ESCCs and 49 distant histologically normal esophageal tissues and 16 cases of dysplasias. Statistical analyses were performed to determine the associations between the protein expression and clinicopathological parameters and survival of esophageal cancer patients.

RESULTS

Expression of ST-2, ST-3, TIMP-1 and TIMP-2 was observed in 43/65 (66%), 51/65 (78%), 43/65 (66%) and 47/65 (72%) ESCC cases, respectively. Univariate analysis showed that TIMP-2 expression was associated with tumor site (OR = 2.63, p = 0.017). TIMP-1+/TIMP-2+ phenotype was inversely correlated with nodal invasiveness of the tumor (OR = 0.4, p = 0.04). Interestingly, p53 expression was associated with increased levels of ST-3 (OR = 0.11, p = 0.02) and TIMP-1 (OR = 3.2, p = 0.007) suggesting possible involvement of p53 in the regulation of these proteins. An increased expression of ST-2, ST-3, TIMP-1 and TIMP-2 was observed in 11/16 (69%), 7/17 (44%), 11/16 (69%) and 8/16 (50%) dysplasias also suggesting that these alterations are early events in esophageal tumorigenesis. All the ESCC patients were followed up postesophagectomy for a maximum period of 59 months (mean disease-free survival = 12 months). Kaplan-Meier survival analysis showed that patients with ST-3-positive and TIMP-2-negative carcinoma had a significantly shorter disease-free survival (median disease-free survival time of 4 months) as compared to patients in the other groups (median disease-free survival time of 20 months; p = 0.0016). To our knowledge this is the first report showing that ST-3+/TIMP-2- phenotype remained of significant predictive value for disease-free survival (p = 0.0007) in multivariate analysis including a conventional clinicopathological factor, tumor stage (p = 0.051).

CONCLUSION

Our results suggest that ST-3+/TIMP-2- phenotype is an adverse prognosticator in esophageal cancer patients.

Intragastric bile acid and symptoms in patients with an intrathoracic stomach after oesophagectomy

Bile acid concentration and symptoms were evaluated in 24 patients after total oesophagectomy and gastric pull-up. Patients were randomly allocated to receive pyloroplasty or not. After operation all were followed for a minimum of 6 months. Bile acid concentration in the gastric juice was estimated. The mean(s.d.) bile acid concentration 6 months after surgery was similar in patients with and without pyloroplasty (34.9(30.1) and 25.0(24.2) mg/dl respectively). Postprandial discomfort and bilious eructations were the two most commonly observed symptoms in both groups. Other features noted were vomiting, anaemia and anorexia. These did not however seem to be related to intragastric bile acid concentration of individual patients in either group and occurred irrespective of whether pyloroplasty was performed or not.

Tuberculosis of the thyroid gland associated with thyrotoxicosis

Tuberculosis of the thyroid gland is rare. A case of tuberculosis of the thyroid gland associated with thyrotoxicosis is reported.

Adenocarcinoma of distal esophagus and gastroesophageal junction: long-term results of surgical treatment in a North Indian Center

This retrospective study reports our experience managing 78 patients with adenocarcinoma of the esophagus and gastroesophageal junction operated between January 1982 and December 1996. Altogether 18 patients presented with stage I and II disease, and 60 patients had stage III and IV disease at presentation; 56 patients (71.8%) were found to have resectable disease. Of these, transhiatal esophagectomy was possible in 51 patients. Transthoracic esophagectomy was done in 3 patients, and a left thoracoabdominal approach was used in 2 patients. The stomach was used as conduit in 50 patients and the colon in 6 patients. Twenty-two patients were found to have unresectable lesions at laparotomy and underwent various palliative procedures. Overall operative mortality was 6.3%. Mortality in the resectable group was only 3.6%. Follow-up ranges from 3 to 128 months, with four patients lost to follow-up at 1, 6, 8, and 10 months. The 5-year survival of the whole group according to Kaplan and Meier survival analysis was 21.27% with a median survival of 13.48 months. Univariate analysis using the log-rank test revealed stage of the disease and resectability to be significant predictors of survival. On multivariate analysis, curative resection appeared to be the most significant predictor of survival in patients undergoing resection.

Emptying of the intrathoracic stomach using three different pylorus drainage procedures--results of a comparative study

Patterns of gastric emptying in the vagotomized intrathoracic stomach (used for esophageal replacement) were studied using radioisotope techniques. Following esophagectomy and gastric mobilization, the patients were randomized into three groups: group 1, pyloroplasty; group 2, pyloromyotomy; and group 3, pylorus stretching. A total of 30 patients surviving the operation and who were still alive at least 3 months afterwards were included in this study. Gastric emptying (GE) was evaluated 6-8 weeks after the operation. The mean GE time for liquids was 3.3 +/- 2.7, 4.1 +/- 3.1, and 5.5 +/- 4.3 min in the three groups, respectively. The corresponding GE time for solids in the three groups was 9.9 +/- 5.1, 10.31 +/- 6.6, and 7.7 +/- 3.4 min. No statistical difference was observed in the GE in the three groups even though liquids tend to empty faster than solids. Clinically there was also no significant difference in their ability to tolerate normal meals. When evaluated for clinical evidence of altered GE (effect of vagotomy) there did not appear to be any significant differences between the three groups. It is therefore concluded that all pylorus drainage procedures behave in much the same way. Patients may develop some problems, but these disappear in due course after proper adjustments have been made in both posture and diet.

Impact on outcome of the route of conduit transposition after transhiatal oesophagectomy: A randomized controlled trial

AIM

To assess the influence of the route of conduit transposition after transhiatal oesophagectomy on the postoperative morbidity and mortality and late outcome at 6 months.

METHODS

Patients with oesophageal carcinoma, undergoing transhiatal oesophagectomy (gastric conduit), were randomized to either anterior or posterior route of conduit transposition. Patients with advanced tumour, distant metastasis, extensive invasion of the stomach, previous gastric surgery, any anterior mediastinal abnormality detected on preoperative imaging, ASA grade III/IV and poor preoperative pulmonary function were excluded. Intraoperative complications, postoperative morbidity and mortality and late outcomes were compared.

RESULTS

Of the 49 patients (34 men), 24 patients were randomized to the anterior mediastinal route and 25 to the posterior. The mean duration of the operative procedure (anterior: 235min; posterior: 225min) and the mean blood loss (anterior: 531ml; posterior: 538ml) were not statistically different. The most common complications were pulmonary and cardiac and comparable in both groups. Four patients died postoperatively. At 6-month follow-up the incidence of dysphagia, anastomotic stricture, anastomotic recurrence, aspiration and reflux symptoms and weight gain were similar.

CONCLUSIONS

The route of conduit transposition did not affect the outcome. However, an individualized approach depending upon the operative findings, radicality of the procedure, and perceived need for postoperative adjuvant therapy may be useful.