Prognostic significance of lymphovascular invasion in patients with pT1b esophageal squamous cell carcinoma

BACKGROUND

Lymphovascular invasion (LVI) is a crucial predictor of lymph node metastasis (LNM). However, few studies have investigated the LVI positivity rate and its clinical significance in pT1b esophageal squamous cell carcinoma (ESCC) using immunohistochemistry and elastin staining.

METHODS

We collected data from158 patients with pT1b ESCC who had undergone radical esophagectomy. All paraffin blocks of invasive carcinoma from each patient were subjected to HE staining, elastin staining + CK (AE1/AE3) immunohistochemistry (E&IHC), and CD31/D2-40 + CK (AE1/AE3) double immunohistochemistry (D-IHC). The LVI was classified into types, i.e., vascular invasion (VI) and lymphatic vessel invasion (LI), and its location, quantity, and clinical significance were explored.

RESULTS

The positivity rates of VI by E&IHC (E-VI), VI by CD31D-IHC (CD31-VI), and LI by D2-40 D-IHC (D2-40-LI) were significantly higher than those obtained by HE staining (P < 0.001, respectively). CD31-VI and E-VI were independent adverse prognostic factors for recurrence-free survival (RFS), and they were significantly associated with poor distant metastasis-free survival and overall survival in pT1b ESCC. Intratumoral LVI was also crucial in pT1b ESCC, and L2 (the count of D2-40-LI was 5 or more) was the strongest predictor for LNM and RFS in pT1b ESCC.

CONCLUSION

E&IHC and D-IHC can dramatically improve the detection rate of LVI in pT1b ESCC, and the classification and grading of LVI can help to improve the prediction of LNM and prognosis.

[Study on the diagnostic value of transient elastography, APRI and FIB-4 for liver fibrosis in children with non-alcoholic fatty liver disease]

Objective: To evaluate the diagnostic value of transient elastography, aspartate aminotransferase-to-platelet ratio index (APRI), and fibrosis index based on 4 factors (FIB-4) for liver fibrosis in children with non-alcoholic fatty liver disease (NAFLD). Methods: A retrospective study was conducted on 100 cases of nonalcoholic fatty liver disease in Hunan Children's Hospital between August 2015 to October 2020 to collect liver tissue pathological and clinical data. The receiver operating characteristic curve (ROC curve) was used to analyze the diagnostic value of liver stiffness measurement (LSM), APRI and FIB-4 in the diagnosis of different stages of liver fibrosis caused by NAFLD in children. Results: The area under the ROC curve (AUC) value of LSM, APRI and FIB-4 for diagnosing liver fibrosis (S≥1) were 0.701 [95% confidence interval (CI): 0.579 ~ 0.822, P = 0.011], 0.606 (95%CI: 0.436 ~ 0.775, P = 0.182), and 0.568 (95%CI: 0.397 ~ 0.740, P = 0.387), respectively. The best cut-off values were 6.65 kPa, 21.20, and 0.18, respectively. The AUCs value of LSM, APRI, and FIB-4 for diagnosing significant liver fibrosis (S≥ 2) were 0.660 (95% CI: 0.552 ~ 0.768, P = 0.006), 0.578 (95% CI: 0.464 ~ 0.691, P = 0.182) and 0.541 (95% CI: 0.427 ~ 0.655, P = 0.482), respectively. The best cut-off values were 7.35kpa, 24.78 and 0.22, respectively. The AUCs value of LSM, APRI and FIB-4 for the diagnosis of advanced liver fibrosis (S≥ 3) were 0.639 (95% CI: 0.446 ~ 0.832, P = 0.134), 0.613 (95% CI: 0.447 ~ 0.779, P = 0.223) and 0.587 (95% CI: 0.411 ~ 0.764, P = 0.346), respectively. The best cut-off values were 8.55kpa, 26.66 and 0.27, respectively. Conclusion: The transient elastography technique has a better diagnostic value than APRI and FIB-4 for liver fibrosis in children with NAFLD.

P3610Prognostic implication of new-onset atrial fibrillation burden in patients with acute myocardial infarction

Background

New-onset atrial fibrillation (NOAF) complicating acute myocardial infarction (AMI) can be associated with adverse cardiovascular events. The prognostic implication of the burden of atrial fibrillation has been investigated in various settings.

Purpose

We aimed to explore the association of the burden of post-MI NOAF with the risk of adverse cardiovascular events during hospitalization.

Methods

All consecutive patients admitted forAMI between February 2014 and February 2018 were analyzed by continuous electronic monitoring (CEM) through hospitalization. AF burden was calculated by dividing the total AF duration by the total CEM duration. Patients were divided into 3 groups: sinus rhythm group, low burden (AF burden≤8.5%) group, and high burden (AF burden>8.5%) group. The primary outcome was a composite of in-hospital all-cause death, recurrent MI, acute heart failure, or cardiogenic shock.

Results

Overall, 2405 patients (mean age: 65.8 years; male: 76.6%) were included. NOAF was documented in 11.6% of patients, and the primary outcome was recorded in 288 patients (13.6%) of the sinus rhythm group, 42 (30.0%) in the low burden group, and 71 (50.7%) in the high burden group. Compared with patients with sinus rhythm, a greater burden of NOAF was associated with a higher risk of the primary outcome after multivariable analysis (low burden: hazard ratio, 1.22; 95% confidence interval [CI]: 0.87–1.70; high burden: hazard ratio, 1.90; 95% CI: 1.43–2.51; p for trend<0.001).

In-hospital cardiovascular events MACE Patients/Events, n Unadjusted HR (95% CI) Adjusted HR (95% CI)a Sinus rhythm 2125/288 1.00 (reference) 1.00 (reference) Low burden 140/42 2.05 (1.48–2.84) 1.22 (0.87–1.70) High burden 140/71 3.93 (3.03–5.10) 1.90 (1.43–2.51) P for trend – <0.001 <0.001 All-cause death Patients, n Unadjusted HR (95% CI) Adjusted HR (95% CI)a Sinus rhythm 2125/106 1.00 (reference) 1.00 (reference) Low burden 140/10 1.02 (0.53–1.97) 0.52 (0.27–1.02) High burden 140/32 3.62 (2.41–5.42) 1.37 (0.89–2.09) P for trend – <0.001 0.081 aAdjusted for age, sex, current smoking, hypertension, diabetes mellitus, dyslipidemia, CKD, previous MI, previous stroke, previous heart failure, symptom onset to emergency department duration, STEMI, pre-hospital cardiac arrest, LVEF, and on-admission HR, SBP and CS, peak TnT, reperfusion therapy and GPIIb/IIIa inhibitor.

Kaplan-Meier plots of in-hospital events

Conclusion

A greater burden of NOAF complicatingAMI was associated withan increased risks of in-hospital adverse events.

Acknowledgement/Funding

National Natural Science Foundation of China grant 81270193 and Natural Science Foundation of Shanghai grant 18ZR1429700

[Preliminary evaluation of endoscopic selective varices devascularization in children]

Objective: To investigate the effect of the endoscopic selective varices devascularization (ESVD) for the esophageal gastric varices bleeding (EGVB) in children. Methods: The clinical data of the patients diagnosed with EGVB and treated with ESVD from January 2018 to March 2018 were retrospectively analyzed. The effects, safety and complications of ESVD were evaluated. Results: There were five patients (including 2 males and 3 females, age ranged from 4 to 7 years) in the study. No rebleeding was found at the first follow-up on one week post operation. Three patients were treated with the endo-therapy at the twice follow-up (3 months after surgery): 2 patients had ESVD again and 1 patient had resection under endoscopy due to stenosis caused by surgical scar. After the second procedure, there was no rebleeding but one patient had abdominal pain caused by mesenteric thrombosis, cured with low molecular weight heparin. Conclusion: The ESVD for EGVB is safe and effective, but the long-term curative effect should be further studied.

A randomized trial comparing multiband mucosectomy and cap-assisted endoscopic resection for endoscopic piecemeal resection of early squamous neoplasia of the esophagus

BACKGROUND AND AIM

Piecemeal endoscopic resection for esophageal high grade intraepithelial neoplasia (HGIN) or early squamous cell carcinoma (ESCC) is usually performed by cap-assisted endoscopic resection. This requires submucosal lifting and multiple snares. Multiband mucosectomy (MBM) uses a modified variceal band ligator without submucosal lifting. In high-risk areas where ESCC is common and endoscopic expertise is limited, MBM may be a better technique. We aimed to compare MBM to the cap-assisted technique for piecemeal endoscopic resection of esophageal ESCCs.

METHODS

Patients with mucosal HGIN/ESCC (2 - 6 cm, maximum two-thirds of esophageal circumference) were included. Lesions, delineated by 1.25 % Lugol staining, were randomized to MBM or cap-assisted piecemeal resection. Endpoints were procedure time and costs, complete endoscopic resection, adverse events, and absence of HGIN/ESCC at 3-month and 12-month follow-up. 

RESULTS

Endoscopic resection was performed in 84 patients (59 men, mean age 60) using MBM (n = 42) or the endoscopic resection cap (n = 42). There were no differences in baseline characteristics. Endoscopic complete resection was achieved in all lesions. Procedure time was significantly shorter with MBM (11 vs. 22 minutes, P < 0.0001). One perforation, seen after using the endoscopic resection cap, was treated conservatively. Total costs of disposables were lower for MBM (€200 vs. €251, P = 0.04). At 3-month and 12-month follow-ups none of the patients had HGIN/ESCC at the resection site.

CONCLUSION

Piecemeal endoscopic resection of esophageal ESCC with MBM is faster and cheaper than with the endoscopic resection cap. Both techniques are highly effective and safe. MBM may have significant advantages over the endoscopic resection cap technique, especially in countries where ESCC is extremely common but limited endoscopic expertise and resources exist. (Netherlands trial register: NTR 3246.).

Endoscopic radiofrequency ablation for early esophageal squamous cell neoplasia: report of safety and effectiveness from a large prospective trial

BACKGROUND AND STUDY AIMS

Endoscopic radiofrequency ablation (RFA) is an established therapy for Barrett's esophagus. Preliminary reports, limited by low patient numbers, also suggest a possible role for RFA in early esophageal squamous cell neoplasia (ESCN). The aim of this study was to evaluate the safety and effectiveness of RFA for early ESCN (moderate/high grade intraepithelial neoplasia [MGIN/HGIN] and early flat-type esophageal squamous cell carcinoma [ESCC]).

PATIENTS AND METHODS

This prospective cohort study included patients with at least one flat (type 0-IIb) unstained lesion (USL) on Lugol's chromoendoscopy and a consensus diagnosis of MGIN, HGIN, or early ESCC. RFA was used at baseline to treat all USLs, and then biopsy (and focal RFA if USL persisted) was performed every 3 months until all biopsies were negative for MGIN, HGIN, and ESCC. The main outcome measurements were complete response at 3 and 12 months (absence of MGIN, HGIN, and ESCC), neoplastic progression, and adverse events.

RESULTS

A total of 96 patients participated (MGIN 45, HGIN 42, early ESCC 9). At 3 and 12 months, 73 % (70/96) and 84 % (81/96), respectively, showed a complete response. Two patients (2 %) progressed (MGIN to HGIN; HGIN to T1m2 ESCC); both were treated endoscopically and achieved complete response. Stricture occurred in 20 patients (21 %), all after circumferential RFA. Lugol's + RFA 12 J/cm(2) (single application, no cleaning) was the favored baseline circumferential RFA technique (82 % 12-month complete response [14/17], 6 % stricture [6/17]).

CONCLUSION

In patients with early ESCN, RFA was associated with a high complete response rate and an acceptable safety profile.

Diagnosis and staging of superficial esophageal precursor based on pre-endoscopic resection system comparable to endoscopic resection

Background

Endoscopic treatments for early esophageal squamous cell carcinoma and the esophageal neoplasm are two types: endoscopic resection (ER) and ablation. Resection enables evaluation of the lesion in the ER specimens, while ablation cannot. We sought to establish a pre-ER evaluated system with a diagnostic and staging accuracy similar to ER for the development of ablation therapy.

Methods

In our study, we collected data pertaining to early esophageal cancer and esophageal neoplasm treated with ER, analyzed the pre- and post-ER data of the lesions and evaluated the diagnostic accuracy of pre-ER system compared with the gold standard.

Results

The diagnostic accuracy rate was 91% based on the pre-ER system compared with the gold standard, and 93% based on the ER diagnosis. The AUC of the pre-ER system was 0.964, while the ER examination was 0.971.

Conclusion

These results suggest that the accuracy of pre-ER system was comparable to ER. The pre-ER system enables prediction of histological diagnosis and stage of the lesions, and the choice of treatment for superficial esophageal neoplasm.

[Comparative study of endoscopic mucous resection with transparent cap and endoscopic multi-band mucosectomy for early esophageal cancer and precancerous lesion]

OBJECTIVE

To evaluate the efficacy and safety of endoscopic mucous resection with transparent cap (EMR-Cap) and endoscopic multi-band mucosectomy (MBM) in the treatment of early esophageal cancer and precancerous lesion.

METHODS

A retrospective study was performed to review 30 EMR-Cap cases from December 2008 to December 2009 and 32 MBM cases from January 2010 to January 2011 of early esophageal cancer and precancerous lesions. The differences between these two techniques in efficacy, safety, and cost were compared.

RESULTS

In EMR-Cap group, the median resection time was 26(10-56) min and median procedure time was 43(22-81) min, significantly longer than those in MBM group [10(7-18) min and 32(28-45) min, P=0.036 and 0.038, respectively]. There were no significant differences between the two groups in total thickness and depth of resected lesions (P>0.05). In EMR-Cap group, the median cost was significantly higher than that of MBM group [(5466±354) vs. (4014±368) RMB, P=0.008)].

CONCLUSIONS

EMR-Cap and MBM are minimally invasive, safe and effective methods in the treatment of early esophageal cancer and precancerous lesions. Compared to the EMR-Cap, MBM is simple with shorter treatment time and lower cost.

[Effect of Curcuma zedoaria (Berg.) Bosc on the myoelectric activity of uterus in rats and study of its mechanisms]

OBJECTIVE

To investigate the effect of Curcuma zedoaria on the myoelectric activity of uterus in virgin rats and study its mech anisms.

METHOD

A pair of bipolar Ag-AgCl electrodes were implanted on the serosal surface of uterus in rats to observe the effect of C. zedoaria on the myoelectric activity of uterus before and after the five agonists were injected intraperitoneally.

RESULT

Decoction of C. zedoaria significantly increases the spike area, the duration and the number of bursts of action potentials of the uterine smooth muscle and its effect is related dosage. Atropine and phentolamine decreased the exciting effect of C. zedoaria, whereas verapamil, diphenhydramine and indomethacin have no effect on the excitation of C. zedoaria.

CONCLUSION

C. zedoaria has obvious exciting effect on the smooth muscle of uterus in rats, and its mechanisms may be associated with M-receptor and alpha-receptor.

[Agmatine inhibits the afferent activity of carotid baroreceptor in rats]

The effect of agmatine (Agm) on the carotid baroreceptor activity was examined in 24 anesthetized rats with perfused isolated carotid sinus by recording sinus nerve afferent discharges. The results are as follows. (1) By perfusing with 1 mmol/L Agm, the functional curve for the intrasinus pressure (ISP)-integral of sinus nerve activity (ISNA) relation was shifted to the right and downward with decreases in peak slope (PS) and peak integral value of carotid sinus afferent discharge (PIV). By perfusing with high concentrations of Agm (5 and 10 mmol/L), the curves were shifted to the right and downward further with marked decreases of PS and PIV. These results showed that Agm exerted an inhibitory action on the baroreceptor activity in a dose-dependent manner. (2) The Agm-induced decrease in sinus nerve afferent activity was eliminated by pretreatment with IR and alpha 2-AR blocker idazoxan (0.1 mmol/L). (3) Selective alpha 2-AR blocker yohimbine (15 mumol/L) partly abolished the inhibitory effect of Agm on baroreceptor. (4) Preperfusing with Bay K 8644 (500 nmol/L), an agonist of calcium channels, also eliminated the effect of Agm on carotid baroreceptor activity. These results indicate that Agm exerts an inhibitory action on carotid baroreceptor and such an action may be attributed to the reduction in calcium influx in carotid baroreceptor, which is mediated by IR and alpha 2-AR.

Agmatine inhibits carotid sinus baroreflex in anesthetized rats

AIM

To study the effect of agmatine (Agm) on carotid sinus baroreflex.

METHODS

The functional parameters of baroreflex were measured by perfusing the carotid sinus in anesthetized rats.

RESULTS

(1) Agm 1, 5, and 10 mmol/L shifted the functional curve of carotid sinus baroreflex to the right and upwards in a concentration-dependent manner with a reduction in peak slope and a reflex decrease in mean arterial pressure, indicating that Agm exerted an inhibitory effect on the carotid baroreflex. (2) The inhibitory effect of Agm (5 mmol/L) on baroreflex was eliminated by pretreatment with idazoxan (Ida, 0.1 mmol/L), an alpha2-adrenoceptor (alpha2-AR) and imidazoline receptor (IR) antagonist, and partially blocked by yohimbine (Yoh, 15 micromol/L), a selective alpha2-AR antagonist. (3) NG-nitro-L-arginine methyl ester (L-NAME, 500 micromol/L), an NOS inhibitor, did not affect the inhibitory effect of Agm.

CONCLUSION

Agm inhibits carotid baroreflex via IR and alpha2-AR.

[Role of calcium in the mechanism underlying the inhibitory effect of streptomycin on carotid sinus baroreflex in rats]

The effect of streptomycin (SM) on carotid baroreflex was examined in 23 anesthetized rats with isolated carotid sinus perfusion. The results obtained are as follows. (1) In response to perfusion with SM (200 micromol/L), the functional curve of carotid baroreflex was shifted to the right and upward with a decrease of peak slope (PS) and a reflex decrease in mean arterial pressure (RD)(P<0.01), indicating an inhibitory effect of SM on carotid sinus baroreflex. (2) By perfusing the isolated carotid sinus with high Ca(2+) solution (4 mmol/L), the inhibitory effect of SM on carotid baroreflex was partially eliminated. The functional curve of SM was shifted to the left and downward with PS increasing from 0.27+/-0.04 kPa to 0.37+/-0.02 kPa (P<0.01) and RD was enhanced from 4.32+/-0.14 kPa to 6.18+/-0.17 kPa (P<0.01). On the other hand, the threshold pressure (TP) and saturation pressure (SP) were significantly decreased from 10.29+/-0.29 kPa to 9.98+/-0.33 kPa (P<0.05) and from 27.26+/-0.42 kPa to 25.22+/-0.38 kPa (P<0.05), respectively. (3) By pretreatment with Bay K 8644 (500 nmol/L), an agonist of calcium channels, the effect of SM on carotid baroreflex was completely abolished. (4) Exposure of the carotid sinus to SM following pretreatment with charybdotoxin (ChTX,100 nmol/L), a blocker of the Ca(2+)-activated K(+) channel (KCa), still inhibited the baroreflex. These results suggest that the inhibitory action of SM on carotid baroreflex may be mediated by suppressing Ca(2+) influx.

Effects of metoclopramide on gastrointestinal myoelectric activity in rats

AIM

To investigate the effects of metoclopramide (MCP) action on myoelectric activity in the antrum and small intestine.

METHODS

Ten healthy male Wistar rats, weighing 250-350 g, were anesthetized with ketamine hydrochloride (100 mg/kg, intramuscularly). Four pairs of bipolar stainless steel electrodes 3 mm apart were implanted on the serosal surface of the antrum at one, 10 and 20 cm distal to the pylorus. Five to ten days following the operation, the gastrointestinal myoelectric activity of fasted rats after intramuscular injection of 2.5, six and 12 mg/kg MCP was recorded using a 8-channel EEG machine, and these values were quantitatively compared with the myoelectric activity after saline injection.

RESULTS

In fasted rats, 2.5 mg/kg MCP increased the amplitude of spike activity (402.0 ± 138.4 μV, vs 345 ± 163.4 μV, P < 0.05) and the percentage of the slow wave-containing spike bursts (60.4% ± 22.0% vs 47.4% ± 22.5%, P < 0.01) of small intestine (1 cm distal to the pylorus), but did not affect the myoelectric activity of the antrum. Six and 12 mg/kg MCP increased the amplitude of both the slow wave (332.8 ± 200.1 μV vs 191.2 ± 143.9 μV, P < 0.01; 330.0 ± 197.1 μV vs 191.2 ± 143.9 μV, P < 0.05) and the spike activity of the antrum (180.5 ± 69.7 μV vs 121.8 ± 63.3 μV, P < 0.05; 174.5 ± 71.7 μV vs 123.8 ± 63.3 μV, P < 0.05), while in small intestine (1 cm distal to the pylorus) only the amplitude of spike activity (407.3 ± 179.0 μV vs 345.0 ± 163.4 μV, P < 0.05; 456.0 ± 145.4 μV vs 345.0 ± 163.4 μV, P < 0.05) and the percentage of the slow wave containing spike bursts (61.7% ± 26.5% vs 47.4% ± 22.5%, P < 0.01; 59.1% ± 17.3% vs 47.4% ± 22.5%, P < 0.01) was increased and the latent period significantly prolonged (2.5 ± 0.35 min vs 0.77 ± 0.18 min, P < 0.01).

CONCLUSION

Different mechanisms may be involved in enhancing the myoelectric activity of the antrum and small intestine following MCP administration.

[Testing different diagnostic criteria of Behçet syndrome in Chinese patients]

In order to compare the sensitivity and specificity of different diagnostic criteria of Behçet Syndrome (BS), 98 patients with BS were collected from PUMC Hospital and China-Japan friendship Hospital in Beijing. 105 patients with other connective tissue diseases were taken as controls. Results of the study showed that the sensitivity of the diagnostic criteria of the Zhangs was 100%, O'Duffy's 78.1%, M + B's 71.9%, Japan committees (1987)72.9%, Dilsen's 87.5%, International study group A 81.3% and B 79.2%. The specificity of each of the above-mentioned criteria was 85.9%, 94.3%, 96.2%, 96.2%, 93.3%, 94.3% and 98.1% respectively. The specificity of oral ulceration could be increased to 97% only if it was found together with two other major criteria during the disease course. Ocular symptoms may be 100% specificity if found together with another major criterion. Pathergy test was found positive in 62.2% of the BS patients but rarely seen in control patients and normal subjects. Therefore, it may be considered as a specific test for BS and may well be used as one of the major diagnostic criteria. The authors are of the opinion that BS could be diagnosed only when 3 of the 5 major criteria, i.e. oral ulcer, genital ulcer, erythema nodosum, uveitis/retinitis and positive pathergy test are present, or if two each of the major and minor criteria are found.