Long-term esophageal cancer risk in patients with primary achalasia: a prospective study

OBJECTIVES

Achalasia patients are considered at increased risk for esophageal cancer, but the reported relative risks vary. Identification of this risk is relevant for patient management. We performed a prospective evaluation of the esophageal cancer risk in a large cohort of achalasia patients with long-term follow-up.

METHODS

Between 1975 and 2006, all patients diagnosed with primary achalasia in our hospital were treated and followed by the same protocol. After graded pneumatic dilatation, all patients were offered a fixed surveillance protocol including gastrointestinal endoscopy with esophageal biopsy sampling.

RESULTS

We surveyed a cohort of 448 achalasia patients (218 men, mean age 51 years at diagnosis, range 4-92 years) for a mean follow-up of 9.6 years (range 0.1-32). Overall, 15 (3.3%) patients (10 men) developed esophageal cancer (annual incidence 0.34 (95% confidence interval 0.20-0.56)). The mean age at cancer diagnosis was 71 years (range 36-90) after a mean of 11 years (range 2-23) following initial presentation, and a mean of 24 years (range 10-43) after symptom onset. The relative hazard rate of esophageal cancer was 28 (confidence interval 17-46) compared with an age- and sex-identical population in the same timeframe. Five patients received a potential curative treatment.

CONCLUSIONS

Although the gastro-esophageal cancer risk in patients with longstanding achalasia is much higher than in the general population, the absolute risk is rather low. Despite structured endoscopical surveillance, most neoplastic lesions remain undetected until an advanced stage. Efforts should be made to identify high-risk groups and develop adequate surveillance strategies.

Validation study of automatically generated codes in colonoscopy using the endoscopic report system Endobase

OBJECTIVE

Gastrointestinal endoscopy databases are important for surveillance, epidemiology, quality control and research. A good quality of automatically generated databases to enable drawing justified conclusions based on the data is of key importance. The aim of this study is to validate the correctness of coding of a national automatically generated anonymous endoscopy database.

MATERIAL AND METHODS

We evaluated a total of 500 colonoscopies performed in five larger hospitals of the TRANS.IT project focusing on endoscopy reporting. Randomly 500 examinations were selected from a total of 5,000 examinations and their generated endoscopic terminology codes as well as complete reports were analysed. Indications for the examination and described findings were scored for correctness and clinical relevance of the coding that would be exported to the anonymous database.

RESULTS

Indications were correctly coded in 92% of all examinations (range 76-100%) per hospital. Correct coding of findings ranged from 42% to 93% per hospital (mean 77%). Different correct coding proportions were seen varying with the diagnosis, with the highest correct coding rates in polyps, carcinoma and diverticular disease. Incorrect coded examinations were scored for clinical relevance. Overall 11% of the investigated examinations were incorrectly coded with clinical relevance.

CONCLUSIONS

Accuracy of clinically relevant endoscopy data recorded in the TRANS.IT anonymous central database is high. Further improvement is desirable, which may be achieved by education of individual endoscopists and enhancement of the program.

Helicobacter pylori infection and nonmalignant diseases

Several interesting studies have been published on nonmalignant Helicobacter pylori-related conditions over the past year, which are reviewed in this article. A revival of interest in the histologic classification of gastritis has led to grading of gastritis into stages correlating with risk of neoplastic progression, new data to improve this concept have been published. Unselected prescription of proton-pump inhibitors in patients with dyspepsia has been questioned by the finding that withdrawal of proton-pump inhibitors induces acid-related symptoms in healthy volunteers, probably by the mechanism of rebound gastric acid hypersecretion. Additional data on the rationale of tapering proton-pump inhibitor therapy are therefore awaited. Moreover, new data on peptic ulcer disease and its complications provide clear recommendations for daily clinical practice. Testing and eradication of H. pylori in patients with peptic ulcer bleeding is essential. However, in H. pylori-negative peptic ulcer disease, high overall patient mortality should be acknowledged, and this should guide considering continuation of nonsteroidal anti-inflammatory drugs. The role of H. pylori in the pathogenesis of gastroesophageal reflux disease is still unclear. An association has been described by several studies; however, it cannot be translated to individual risks for development of gastroesophageal reflux disease after H. pylori eradication. Possibly, additional data on subgroups, such as gastric ulcer, duodenal ulcer patients, and associated gastric mucosal changes, will solve this issue.

Performance improvements of stool-based screening tests

Stool testing is a widely accepted, non-invasive, technique for colorectal cancer (CRC) screening. Guaiac-based faecal occult blood test (gFOBT) screening has been proven to decrease CRC-related mortality; however gFOBT is hampered by a low sensitivity. Faecal immunochemical tests (FITs) have several advantages over gFOBT. First of all, FIT has a better sensitivity and higher uptake. Furthermore, the quantitative variant of the FIT allows choices on cut-off level for test-positivity according to colonoscopy resources available, personal risk profile, and/or intended detection rate in the screened population. Stool-based DNA (sDNA) tests aiming at the detection of specific DNA alterations may improve detection of CRC and adenomas compared to gFOBT screening, but large-scale population based studies are lacking. This review focuses on factors influencing test performance of those three stool based screening tests.

Biopsy strategies for endoscopic surveillance of pre-malignant gastric lesions

BACKGROUND

Endoscopic surveillance of pre-malignant gastric lesions may add to gastric cancer prevention. However, the appropriate biopsy regimen for optimal detection of the most advanced lesions remains to be determined. Therefore, we evaluated the yield of endoscopic surveillance by standardized and targeted biopsy protocols.

MATERIALS AND METHODS

In a prospective, multi-center study, patients with intestinal metaplasia (IM) or dysplasia (DYS) underwent a surveillance gastroscopy. Both targeted biopsies from macroscopic lesions and 12 non-targeted biopsies according to a standardized protocol (antrum, angulus, corpus, cardia) were obtained. Appropriate biopsy locations and the yield of targeted versus non-targeted biopsies were evaluated.

RESULTS

In total, 112 patients with IM (n = 101), or low-grade (n = 5) and high-grade DYS (n = 6) were included. Diagnosis at surveillance endoscopy was atrophic gastritis (AG) in one, IM in 77, low-grade DYS in two, high-grade DYS in three, and gastric cancer in one patient. The angulus (40%), antrum (35%) and lesser curvature of the corpus (33%) showed the highest prevalence of pre-malignant conditions. Non-targeted biopsies from the lesser curvature had a significantly higher yield as compared to the greater curvature of the corpus in diagnosing AG and IM (p = .05 and p = .03). Patients with extensive intragastric IM, which was also present at the cardia were at high risk of a concurrent diagnosis of dysplasia or gastric cancer. High-grade DYS was detected in targeted biopsies only.

CONCLUSIONS

At surveillance endoscopies, both targeted and non-targeted biopsies are required for an appropriate diagnosis of (pre-)malignant gastric lesions. Non-targeted biopsies should be obtained in particular from the antrum, angulus and lesser curvature of the corpus.

Risk of malignant progression in patients with Barrett's oesophagus: a Dutch nationwide cohort study

BACKGROUND

Reported incidence rates of oesophageal adenocarcinoma (OAC) in Barrett's oesophagus (BO) vary widely. As the effectiveness of BO surveillance is crucially dependent on this rate, its clarification is essential.

METHODS

To estimate the rate of malignant progression in patients with BO, all patients with a first diagnosis of BO with no dysplasia (ND) or low-grade dysplasia (LGD) between 1991 and 2006 were identified in the Dutch nationwide registry of histopathology (PALGA). Follow-up data were evaluated up to November 2007.

RESULTS

42 207 patients with BO were included; 4132 (8%) of them had LGD. Re-evaluation endoscopies at least 6 months after initial diagnosis were performed in 16 365 patients (39%), who were significantly younger than those not re-examined (58+/-13 vs 63+/-16 years, p<0.001). These patients were followed-up for a total of 78 131 person-years, during which 666 (4%) high-grade dysplasia (HGD)/OACs occurred, affecting 4% of the surveillance patient population (mean age: 69+/-12 years, 76% male). After excluding HGD/OAC cases detected within 1 year after BO diagnosis (n=212, 32%), incidence rates per 1000 person-years were 4.3 (95% CI 3.4 to 5.5) for OAC and 5.8 (95% CI 4.6 to 7.0) for HGD/OAC combined. Risk factors for HGD/OAC were increased age (eg, >75 years HR 12; 95% CI 8.0 to 18), male sex (2.01; 1.68 to 2.60) and presence of LGD at baseline (1.91; 1.53 to 2.40).

CONCLUSION

In this largest reported cohort of unselected patients with BO, the annual risk of OAC was 0.4%. Male sex, older age and LGD at diagnosis are independent predictors of malignant progression, and should enable an improved risk assessment in BO.

Measuring quality of care in patients with nonvariceal upper gastrointestinal hemorrhage: development of an explicit quality indicator set

OBJECTIVES

With an increasing emphasis on quality in health care and recognition of inconsistencies in the management of patients with nonvariceal upper gastrointestinal hemorrhage (NVUGIH), it is critical to establish a set of explicit quality indicators (QIs) in NVUGIH.

METHODS

We conducted a nine-member, multidisciplinary expert panel and followed modified Delphi methods to systematically identify a set of QIs for NVUGIH. The panel performed independent ratings of each candidate QI using a nine-point RAND appropriateness scale, then met in person and re-voted using an iterative process of discussion. The final set comprised QIs with a median RAND Appropriateness Score >or=7 and no disagreement among experts.

RESULTS

Among 116 candidate QIs, the panel rated 26 as valid measures of quality care. The selected QIs cover pre-endoscopy, endoscopy, and post-endoscopy care, including diagnosis, early resuscitation, risk stratification, endoscopic care, Helicobacter pylori management, and proton pump inhibitor therapy.

CONCLUSIONS

We have developed an explicit set of evidence-based QIs in NVUGIH, providing physicians and institutions with a tool to identify processes amenable to quality improvement. This tool is intended to be applicable in all institutions providing care for NVUGIH patients.

Systematic review: steroid withdrawal in anti-TNF-treated patients with inflammatory bowel disease

BACKGROUND

The increasing awareness of increased risk for opportunistic infections when combining several immunosuppressant drugs led to new treatment goals for inflammatory bowel disease including limited use of steroids.

AIM

To conduct a systematic review to establish figures for steroid withdrawal in anti-TNF treated inflammatory bowel disease-patients.

METHODS

Medline was searched using the search-terms Ulcerative Colitis (UC) [Mesh], Crohn Disease (CD) [Mesh], IBD [Mesh], crohn, colitis, IBD and steroid sparing, all combined with infliximab and adalimumab. We selected English-language publications that addressed the effect of anti-TNF on steroid withdrawal. Studies had to assess patients with luminal CD or UC. Numbers of patients who were able to withdraw steroids were calculated.

RESULTS

Six studies could be included; five reporting on infliximab and one on adalimumab. Studies were heterogeneously designed. Overall, in the adult population, up to 38% of the patients were able to withdraw corticosteroids during infliximab therapy. In the paediatric population, up to 75% of the patients were able to withdraw corticosteroids during infliximab therapy.

CONCLUSIONS

Although a consensus on the definition of steroid-sparing is lacking, approximately two-thirds of the inflammatory bowel disease-patients are unable to withdraw corticosteroid treatment during anti-TNF therapy.

Expression of p53 as predictor for the development of esophageal cancer in achalasia patients

Patients with longstanding achalasia have an increased risk of developing esophageal cancer. Surveillance is hampered by chronic stasis. We investigated whether aberrant expressions of tumor suppressor gene p53 and proliferation marker ki67 are early predictors for progression to malignancy. In 399 achalasia patients, 4% died of esophageal cancer despite surveillance. We performed a cohort study, using surveillance biopsies from 18 patients (11 carcinoma, one high-grade dysplasia [HGD], and six low-grade dysplasia [LGD]) and 10 controls (achalasia patients without cancer or dysplasia development). One hundred sixty-four biopsies were re-evaluated and studied for p53 and ki67 expression using immunohistochemistry. Eighty-two percent of patients with cancer/HGD showed p53 overexpression in surveillance biopsies at a mean of 6 (1-11) years prior to cancer development. In 67% of patients with LGD and only in 10% of the controls p53 overexpression was present. The proportion of samples with p53 overexpression increased with increasing grades of dysplasia. We found no difference for ki67 overexpression. p53 overexpression may identify achalasia patients at increased risk of developing esophageal carcinoma. Further study is needed to determine if patients with p53 overexpression would benefit from intensive surveillance to detect esophageal neoplasia at a potential curable stage.

Esophageal stents for the palliation of malignant dysphagia and fistula recurrence after esophagectomy

BACKGROUND

Despite advances in staging methods, surgical techniques, and adjuvant treatment, recurrent cancer after esophagectomy is a major cause of morbidity and mortality.

OBJECTIVE

Our purpose was to investigate the safety and efficacy of a self-expandable metal stent (SEMS) in patients with dysphagia or fistula caused by recurrent cancer after esophagectomy.

DESIGN

Prospective, observational study with standardized treatment and follow-up.

SETTING

Single university center.

PATIENTS

In 81 patients with recurrent cancer after previous surgical esophagectomy, 100 esophageal SEMSs were inserted for dysphagia (n = 66) or fistula formation (n = 15).

INTERVENTIONS

Stent placement.

MAIN OUTCOME MEASUREMENTS

Technical and functional outcome, complications, and survival.

RESULTS

The SEMSs restored luminal patency in 65 (98%) of 66 patients and sealed malignant fistulae in 14 (93%) of 15 patients. Stent dysfunction occurred in 24 (30%) of 81 patients. They all were successfully managed by subsequent endoscopic intervention. After stent placement, a total of 16 complications were observed. Major complications occurred in 9 (11%) of 81 patients, mild complications occurred in 7 (9%) of 81 patients. The overall 30-day mortality rate after stent insertion was 25%. Progression of the disease resulted in death after a median interval of 70 days (range 1 day to 91 months).

LIMITATIONS

Nonrandomized design.

CONCLUSIONS

SEMS placement in recurrent esophageal cancer after surgical resection offers adequate palliation by relieving dysphagia and sealing off esophageal respiratory fistulae. Therefore, in these patients who have a relatively short life expectancy, SEMS placement should be considered the treatment of choice.

Liver grafts contain a unique subset of natural killer cells that are transferred into the recipient after liver transplantation

In contrast to other solid organ transplantations, liver grafts have tolerogenic properties. Animal models indicate that donor leukocytes transferred into the recipient after liver transplantation (LTX) play a relevant role in this tolerogenic phenomenon. However, the specific donor cell types involved in modulation of the recipient alloresponse are not yet defined. We hypothesized that this unique property of liver grafts may be related to their high content of organ-specific natural killer (NK) and CD56(+) T cells. Here, we show that a high proportion of hepatic NK cells that detach from human liver grafts during pretransplant perfusion belong to the CD56bright subset, and are in an activated state (CD69(+)). Liver NK cells contained perforin and granzymes, exerted stronger cytotoxicity against K562 target cells when compared with blood NK cells, and secreted interferon-gamma, but no interleukin-10 or T helper 2 cytokines, upon stimulation with monokines. Interestingly, whereas the CD56bright subset is classically considered as noncytolytic, liver CD56bright NK cells showed a high content of cytolytic molecules and degranulated in response to K562 cells. After LTX, but not after renal transplantation, significant numbers of donor CD56dim NK and CD56(+) T cells were detected in the recipient circulation for approximately 2 weeks. In conclusion, during clinical LTX, activated and highly cytotoxic NK cells of donor origin are transferred into the recipient, and a subset of them mixes with the recirculating recipient NK cell pool. The unique properties of the transferred hepatic NK cells may enable them to play a role in regulating the immunological response of the recipient against the graft and therefore contribute to liver tolerogenicity.

Esophageal stents for the relief of malignant dysphagia due to extrinsic compression

BACKGROUND AND STUDY AIMS

In patients with primary esophageal cancer, luminal patency can be restored by placement of a self-expandable metal stent (SEMS). The use of SEMS in patients with dysphagia caused by malignant extrinsic compression has largely been unreported. In this study we evaluated the efficacy of SEMS in a large cohort of patients with malignant extrinsic compression.

PATIENTS AND METHODS

This was a prospective single-center study. Between 1995 and 2009, 50 consecutive patients with malignant extrinsic compression who had undergone SEMS placement were included (mean age 64 years; 37-males). In the majority of patients, extrinsic esophageal compression was caused by obstructive pulmonary cancer (n = 23) and by mediastinal metastasis after esophagectomy for esophageal cancer (n = 16).

RESULTS

Stent placement was technically successful in all patients. Severe complications occurred in 5 / 50 patients (10 %) including perforation during dilation prior to stent insertion (n = 2) and hemorrhage (n = 3). Two patients (4 %) died from bleeding. Mild complications were seen in 9 / 50 patients (18 %). Recurrent dysphagia occurred in eight patients (16 %) and was successfully managed by subsequent endoscopic intervention. Median survival after stent placement was 44 days (range 5 days - 2 years). The median stent patency of 46 days in this series exceeded median patient survival.

CONCLUSIONS

Insertion of an SEMS is an effective palliative treatment for patients with dysphagia due to malignant extrinsic compression. In spite of the short survival, some patients present with recurrent dysphagia, which can be managed effectively by endoscopic re-intervention.

A back-to-back comparison of white light video endoscopy with autofluorescence endoscopy for adenoma detection in high-risk subjects

OBJECTIVE

To compare the sensitivity of autofluorescence endoscopy (AFE) and white light video endoscopy (WLE) for the detection of colorectal adenomas in high-risk patients belonging to Lynch syndrome (LS) or familial colorectal cancer (CRC) families.

METHODS

This was a prospective single-centre study carried out in a tertiary referral centre. The subjects were 75 asymptomatic patients originating from LS or familial CRC families. Patients were examined with either WLE followed by AFE or AFE followed by WLE. Back-to-back colonoscopy was performed by two blinded endoscopists. All lesions were removed during the second endoscopic procedure. Lesions missed during the second procedure were identified and removed on third pass. The sensitivity calculations for colorectal adenomas were based on histology results. The main outcome measures were the difference in sensitivity between WLE and AFE for the detection of adenomas in patients with LS or familial CRC.

RESULTS

At least one adenoma was detected in 41 (55%) patients. WLE identified adenomas in 28/41 patients and AFE in 37/41 patients, corresponding to a 32% increase. In total 95 adenomas were detected, 65 by WLE and 87 by AFE, resulting in a significantly higher sensitivity of AFE compared with WLE (92% vs 68%; p=0.001). The additionally detected adenomas with AFE were significantly smaller than the adenomas detected by WLE (mean 3.0 mm vs 4.9 mm, p<0.01).

CONCLUSIONS

AFE improves the detection of colorectal adenomas in patients with LS or familial CRC. The results of this study suggest that AFE may be preferable for surveillance of these high-risk patients.

Single-balloon-assisted colonoscopy in patients with previously failed colonoscopy

BACKGROUND

Despite advances in training and equipment, complete colonoscopy fails, even in experienced hands, in up to 10% of cases. Double-balloon endoscopy (DBE) has been successfully used to complete colonoscopy in these patients. Single-balloon endoscopy (SBE) has become established for small-bowel enteroscopy. However, it has yet to be studied for use in colonoscopy.

OBJECTIVE

To assess the efficacy, performance, and safety of single-balloon colonoscopy.

DESIGN

Prospective cohort study.

SETTING

Academic tertiary referral center.

PATIENTS

Patients with previously failed conventional colonoscopy.

RESULTS

23 single-balloon colonoscopy procedures were performed in 22 patients: median age 53 (range 19-75) years; 14 females, 8 males. SBE colonoscopy succeeded in cecal intubation in 22 (96%) procedures, with a median total procedure time of 30 (range 20-60) minutes. SBE colonoscopy was normal in 9 cases but resulted in a positive diagnosis in 13 (57%) procedures, including polyps (n = 6), active Crohn's disease (n = 4), Crohn's-related stricture (n = 1), and diverticulosis (n = 2). Seven (30%) procedures were therapeutic including 1 case with balloon dilation and 6 cases with polypectomy. No complications were encountered.

LIMITATIONS

Limited sample size, no direct comparison with double-balloon endoscopy.

CONCLUSIONS

Single-balloon-assisted colonoscopy seems a safe and effective method for completing colonoscopy in patients with previously failed or difficult colonoscopy. The outcomes are similar compared with previous studies with DBE colonoscopy in this patient group.

Patients' preferences regarding shared decision-making in the treatment of inflammatory bowel disease: results from a patient-empowerment study

BACKGROUND

Shared decision-making is gaining favor in clinical practice, although the extent to which patients want to be involved in choosing their treatment varies substantially. Because data are lacking on the preferences of patients with chronic diseases such as inflammatory bowel disease (IBD), we wanted to assess IBD patients' preferences about being involved in such decisions.

METHODS

Adult IBD patients were asked to anonymously complete an online survey on their preferences. Non-parametric tests (chi(2)) were used to determine the relationship between responses and respondents.

RESULTS

The questionnaire was completed by 1,067 patients, 617 with Crohn's disease and 450 with ulcerative colitis. Patients' mean age was 43 (SD 13.7) years; the majority were female (66%). In total, 866 patients (81%) reported it as 'very important' to be actively involved in the decision-making process, and another 177 (17%) rated it as 'quite important'. When asked how their treatment could be improved, 537 patients (50%) wanted close, equitable collaboration with their physician. This preference was significantly associated with a disease duration of <or=8 years (p = 0.03). Gender and type of IBD were not significantly associated with patients' preferences.

CONCLUSIONS

This study demonstrates IBD patients' desire to be actively involved in the decision-making process. Further research is needed on physicians' perspectives on shared decision-making, and on finding predictive factors for developing a model for shared decision-making in IBD.

Study protocol: population screening for colorectal cancer by colonoscopy or CT colonography: a randomized controlled trial

Background

Colorectal cancer (CRC) is the second most prevalent type of cancer in Europe. Early detection and removal of CRC or its precursor lesions by population screening can reduce mortality. Colonoscopy and computed tomography colonography (CT colonography) are highly accurate exams and screening options that examine the entire colon. The success of screening depends on the participation rate. We designed a randomized trial to compare the uptake, yield and costs of direct colonoscopy population screening, using either a telephone consultation or a consultation at the outpatient clinic, versus CT colonography first, with colonoscopy in CT colonography positives.

Methods and design

7,500 persons between 50 and 75 years will be randomly selected from the electronic database of the municipal administration registration and will receive an invitation to participate in either CT colonography (2,500 persons) or colonoscopy (5,000 persons) screening. Those invited for colonoscopy screening will be randomized to a prior consultation either by telephone or a visit at the outpatient clinic. All CT colonography invitees will have a prior consultation by telephone. Invitees are instructed to consult their general practitioner and not to participate in screening if they have symptoms suggestive for CRC. After providing informed consent, participants will be scheduled for the screening procedure. The primary outcome measure of this study is the participation rate. Secondary outcomes are the diagnostic yield, the expected and perceived burden of the screening test, level of informed choice and cost-effectiveness of both screening methods.

Discussion

This study will provide further evidence to enable decision making in population screening for colorectal cancer.

Trial registration

Dutch trial register: NTR1829

WITHDRAWN: Chemotherapy for metastatic carcinoma of the esophagus and gastro-esophageal junction

BACKGROUND

More than 50% of patients with esophageal cancer have metastatic disease at presentation. The use of chemotherapy for this patient group is increasing with the intention of local and distant tumor control, improving quality of life and prolongation of survival.

OBJECTIVES

To assess the effectiveness of a) chemotherapy versus best supportive care or b) different chemotherapy regimes against each other, in metastatic esophageal carcinoma.

SEARCH STRATEGY

Trials were identified by searching MEDLINE 1950- November week 3 2008, Central (Cochrane Library 4th Quarter 2008), Embase 1980 - 2008 week 50. We did not confine our search to English language publications. Searches in all databases were updated in February 2005, February 2006 and December 2008.The Cochrane Highly Sensitive Search Strategy for identifying randomized trials in MEDLINE, Sensitivity maximising version; Ovid format was combined with the following search terms to identify RCTs in MEDLINE. The MEDLINE search strategy was adapted for use in the other databases searched. Members of the Cochrane UGPD Group, and experts in the field were contacted and asked to provide details of outstanding clinical trials and any relevant unpublished materials.

SELECTION CRITERIA

Randomized controlled trials comparing chemotherapy versus best supportive care, or different chemotherapy regimes against each other in patients with metastatic carcinoma of the esophagus or gastro-esophageal junction.

DATA COLLECTION AND ANALYSIS

Two authors (MYVH/EJK) extracted data and assessed trial quality. Study authors were contacted to obtain subgroup results of patients with metastatic esophageal carcinoma.

MAIN RESULTS

Only two RCTs with a total of 42 participants compared chemotherapy with best supportive care for metastatic esophageal cancer. No survival benefit was shown for chemotherapy treatment in these RCTs. Five RCTs with a total of 1242 participants compared different chemotherapy regimes. Due to variation in patient population and chemotherapy regimes, it was not possible to perform a formal pooled analysis. There was no consistent benefit of any specific chemotherapy regimen.

AUTHORS' CONCLUSIONS

There is a need for well designed, adequately powered, phase III trials comparing chemotherapy versus best supportive care for patients with metastatic esophageal cancer. Chemotherapy agents with promising response rates and tolerable toxicity are cisplatin, 5-fluorouracil (5-FU), paclitaxel and antracyclins. Future trials comparing palliative treatment modalities should assess quality of life with validated quality of life measures.

Colorectal cancer in post-liver transplant recipients

PURPOSE

Several malignancies have been reported to occur more often after liver transplantation. Whether this is also true for colorectal carcinoma is controversial. Our aims were 1) to compare the observed rate of colorectal carcinoma in a post-liver transplantation cohort with incidence data from the general Dutch population, and 2) to stratify for patients with and without primary sclerosing cholangitis, because primary sclerosing cholangitis is well established as a risk factor for colorectal carcinoma.

METHODS

We searched the medical records of liver transplantation patients who had a liver transplantation in our center between 1986 and 2007 with a follow-up of at least 3 months. Incidence data from the general population were retrieved from the Dutch Comprehensive Cancer Registry. Outcome measures were defined as standardized incidence ratio and incidence rate per 100,000 person-years.

RESULTS

Three hundred ninety-four patients (58% men; mean age at liver transplantation, 46.6 y) were included in the 1986 to 2007 period. Bowel investigation before liver transplantation had been performed in 73% of patients. Median follow-up was 5.1 years (range, 0.25-20 y). The mean age at the end of follow-up was 52 years (SD, 13 y). Colorectal carcinoma was diagnosed in four patients (1%) during follow-up. The overall standardized incidence ratio for colorectal carcinoma in post-liver transplant recipients was 2.16 (95% CI: 0.81-5.76) compared with the general population and 1.26 (95% CI: 0.31-5.03) for nonprimary sclerosing cholangitis post-liver transplant recipients.

CONCLUSION

This study suggests that the incidence of colorectal carcinoma is not increased in non-primary sclerosing cholangitis post-liver transplantation compared with the general population. A more intense colorectal carcinoma surveillance program based on this result remains controversial in nonprimary sclerosing cholangitis post-liver transplant recipients.

Complications of single-balloon enteroscopy: a prospective evaluation of 166 procedures

BACKGROUND AND STUDY AIM

Double-balloon enteroscopy (DBE) has proven to be a relatively safe method for small-bowel evaluation, with a complication rate of 1 %. The main concern after diagnostic DBE is acute pancreatitis. Single-balloon enteroscopy (SBE) has emerged as a viable alternative to DBE. Until now, no incidence of pancreatitis has been reported for SBE. The aims were to evaluate complication rate and occurrence of hyperamylasemia and to identify the risk factors for hyperamylasemia after SBE.

PATIENTS AND METHODS

Prospectively, consecutive patients undergoing peroral ("proximal") or combined approach SBE were included. Complications were assessed at 1 and 30 days afterwards. Serum amylase and C-reactive protein (CRP) were assessed immediately before and 2 - 3 hours after SBE.

RESULTS

166 SBE procedures were performed in 105 patients (53-male; mean age 51 years, range 9 - 87). The indications for SBE were: anemia (n = 55), Crohn's disease (n = 31) and abdominal complaints suspicious for inflammatory bowel disease (n = 5), Peutz-Jeghers syndrome (n = 1) and other (n = 13). Therapeutic interventions were performed during 21 procedures (13 %). One perforation (1 / 21 therapeutic interventions, 4.8 %) occurred after dilation of a benign stricture. While 13 patients (16 %) had post-SBE hyperamylasemia, none had complaints suggesting acute pancreatitis. Factors such as sex, indication, procedure duration, number of passes, route of SBE, findings, and/or treatment showed no significant correlation with presence of hyperamylasemia.

CONCLUSIONS

SBE appears to be a safe diagnostic endoscopic procedure. The incidence of hyperamylasemia and pancreatitis after peroral SBE seems comparable to that after DBE.

Cost comparison of gastrojejunostomy versus duodenal stent placement for malignant gastric outlet obstruction

BACKGROUND

Gastrojejunostomy (GJJ) and stent placement are the most commonly used palliative treatments for malignant gastric outlet obstruction (GOO). In a recent randomized trial, stent placement was preferred in patients with a relatively short survival and GJJ in patients with a longer survival. As health economic aspects have only been studied in general terms, we estimated the cost of GJJ and that of stent placement in such patients.

METHODS

In the SUSTENT study, patients were randomized to GJJ (n = 18) or stent placement (n = 21). Pancreatic cancer was the most common cause of GOO. We compared initial costs and costs during follow-up. For cost-effectiveness, the incremental cost-effectiveness ratio was calculated.

RESULTS

Food intake improved more rapidly after stent placement than after GJJ, but long-term relief of obstructive symptoms was better after GJJ. More major complications (P = 0.02) occurred and more reinterventions were performed (P < 0.01) after stent placement than after GJJ. Initial costs were higher for GJJ compared to stent placement (euro8315 vs. euro4820, P < 0.001). We found no difference in follow-up costs. Total costs per patient were higher for GJJ compared to stent placement (euro12433 vs. euro8819, P = 0.049). The incremental cost-effectiveness ratio of GJJ compared to stent placement was euro164 per extra day with a gastric outlet obstruction scoring system (GOOSS) >or=2 adjusted for survival.

CONCLUSIONS

Medical effects were better after GJJ, although GJJ had higher total costs. Since the cost difference between the two treatments was only small, cost should not play a predominant role when deciding on the type of treatment assigned to patients with malignant GOO (ISRCTN 06702358).

Abstract 4156: Generation of an inducible Wnt5a transgenic mouse model to study the contribution of increased Wnt5a expression to intestinal tumor growth

Introduction: The importance of the interaction between tumor cells and stromal tissue for tumor invasion and metastasis is becoming well-recognized lately. In this respect, tumor-associated macrophages are of special interest as they appear to promote angiogenesis and invasiveness. One of the factors expressed at increased levels by macrophages in intestinal tumors is noncanonical Wnt5a. Interestingly, despite the well known importance of Wnt signaling in colorectal cancer, Wnt5a is one out of only two Wnt ligands described to be upregulated in gastrointestinal tumors. In vitro data suggest that Wnt5a is involved in tumor cell growth and migration, angiogenesis and epithelial to mesenchymal transition, all key steps in cancer progression. At present, it is however unclear to which extent and through which mechanisms, Wnt5a contributes to the malignant behavior of colorectal tumors in vivo. Therefore, we have generated a mouse model in which expression of Wnt5a can be controlled in a tissue-specific and temporal fashion.

Methods: We generated a transgenic mouse line carrying the Wnt5a gene driven by a doxycycline (dox)-responsive promoter, which was crossed with hnRNP-rtTA animals expressing the rtTA2 transcription factor in all their tissues. In this way a model was generated in which Wnt5a expression can be induced by dox administration in double transgenic animals. Subsequently, double transgenics were crossed with Apc1638N mice that develop gastrointestinal tumors spontaneously. These mice were provided with dox in their drinking water from the age of 3-8 months, where after they were analyzed for the development of intestinal tumors.

Results: We identified transgenic lines showing a tightly controllable dox-induced expression of Wnt5a in vitro and in vivo. Whereas induced Wnt5a expression appears well-tolerated in adult mice, the induction during embryonic development results in a severe embryonic phenotype. Currently, the contribution of transgenic Wnt5a expression during the development of intestinal tumors in Apc mutant mice is being analyzed. Successful induction of Wnt5a expression in the developing tumors has been confirmed. Preliminary results suggest that induced Wnt5a expression underlies a shift in distribution pattern of the tumors along the gastrointestinal tract.

Conclusions: We have successfully generated a transgenic model in which robust and tightly controllable Wnt5a expression can be induced upon dox administration. Although induced Wnt5a expression appears to be well-tolerated in adult animals, embryonic development is severely affected. Additionally we have successfully induced Wnt5a expression within the intestinal tumors developing in an Apc mutant model, of which we are currently investigating the possible contribution to tumor progression.

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 4156.

Impact of double-balloon enteroscopy findings on the management of Crohn's disease

OBJECTIVE

It is estimated that 10%-30% of Crohn's disease (CD) patients have small-bowel lesions, but the exact frequency and clinical relevance of these findings are unknown. Double-balloon enteroscopy (DBE) enables endoscopic visualization of the small bowel. The aim of this study was to evaluate the use of DBE for detecting small-bowel lesions in CD patients suspected of having small-bowel involvement. Furthermore, the clinical impact of adjusting treatment in these patients was assessed.

MATERIAL AND METHODS

A prospective study was performed in a tertiary referral center. CD patients suspected of small-bowel involvement and in whom distal activity had previously been excluded were included. All patients underwent DBE, followed by step-up therapy in patients with small-bowel lesions. The presence of small-bowel lesions during DBE was noted and clinical outcome was assessed after adjusting therapy.

RESULTS

Thirty-five patients (70%) showed small-bowel lesions; these lesions could not be assessed by conventional endoscopy in 23 (46%). At 1-year follow-up, step-up therapy in 26 patients (74%) led to clinical remission in 23 (88%). This was confirmed by a significant decrease in Crohn's disease activity index and mucosal repair on second DBE.

CONCLUSIONS

DBE showed a high frequency of small-bowel lesions in known CD patients with clinically suspected small-bowel activity. Most of these lesions were not accessible for conventional endoscopy. Adjusting treatment in patients with small-bowel CD involvement led to clinical remission and mucosal repair in the majority of cases.

Risk of colorectal carcinoma in post-liver transplant patients: a systematic review and meta-analysis

Liver transplant patients (LTx) have an increased risk for developing de novo malignancies, but for colorectal cancer (CRC) this risk is less clear. We aimed to determine whether the CRC risk post-LTx was increased. A systematic search was performed in MEDLINE and Cochrane databases to identify studies published between 1986 and 2008 reporting on the risk of CRC post-LTx. The outcomes were (1) CRC incidence rate (IR per 100,000 person-years (PY)) compared to a weighted age-matched control population using SEER and (2) relative risk (RR) for CRC compared to the general population. If no RR data were available, the RR was estimated using SEER. Twenty-nine studies were included. The overall post-LTx IR was 119 (95% CI 88-161) per 100,000 PY. The overall RR was 2.6 (95% CI 1.7-4.1). The non-primary sclerosing cholangitis (PSC) IR was 129 per 100,000 PY (95% CI 81-207). Compared to SEER (71 per 100,000 PY), the non-PSC RR was 1.8 (95% CI 1.1-2.9). In conclusion, the overall transplants and the subgroup non-PSC transplants have an increased CRC risk compared to the general population. However, in contrast to PSC, non-PSC transplants do not need an intensified screening strategy compared to the general population until a prospective study further defines recommendations.