Pattern of recurrence following complete resection of esophageal carcinoma and factors predictive of recurrent disease

Is there a role of whole-body bone scan in patients with esophageal squamous cell carcinoma

Background

Correct detection of bone metastases in patients with esophageal squamous cell carcinoma is pivotal for prognosis and selection of an appropriate treatment regimen. Whole-body bone scan for staging is not routinely recommended in patients with esophageal squamous cell carcinoma. The aim of this study was to investigate the role of bone scan in detecting bone metastases in patients with esophageal squamous cell carcinoma.

Methods

We retrospectively evaluated the radiographic and scintigraphic images of 360 esophageal squamous cell carcinoma patients between 1999 and 2008. Of these 360 patients, 288 patients received bone scan during pretreatment staging, and sensitivity, specificity, positive predictive value, and negative predictive value of bone scan were determined. Of these 360 patients, surgery was performed in 161 patients including 119 patients with preoperative bone scan and 42 patients without preoperative bone scan. Among these 161 patients receiving surgery, 133 patients had stages II + III disease, including 99 patients with preoperative bone scan and 34 patients without preoperative bone scan. Bone recurrence-free survival and overall survival were compared in all 161 patients and 133 stages II + III patients, respectively.

Results

The diagnostic performance for bone metastasis was as follows: sensitivity, 80%; specificity, 90.1%; positive predictive value, 43.5%; and negative predictive value, 97.9%. In all 161 patients receiving surgery, absence of preoperative bone scan was significantly associated with inferior bone recurrence-free survival (P = 0.009, univariately). In multivariate comparison, absence of preoperative bone scan (P = 0.012, odds ratio: 5.053) represented the independent adverse prognosticator for bone recurrence-free survival. In 133 stages II + III patients receiving surgery, absence of preoperative bone scan was significantly associated with inferior bone recurrence-free survival (P = 0.003, univariately) and overall survival (P = 0.037, univariately). In multivariate comparison, absence of preoperative bone scan was independently associated with inferior bone recurrence-free survival (P = 0.009, odds ratio: 5.832) and overall survival (P = 0.029, odds ratio: 1.603).

Conclusions

Absence of preoperative bone scan was significantly associated with inferior bone recurrence-free survival, suggesting that whole-body bone scan should be performed before esophagectomy in patients with esophageal squamous cell carcinoma, especially in patients with advanced stages.

USP22 nuclear expression is significantly associated with progression and unfavorable clinical outcome in human esophageal squamous cell carcinoma

PURPOSE

To detect the expression levels of ubiquitin-specific protease 22 (USP22) in human esophageal squamous cell carcinoma (ESCC) and to correlate it with clinicopathologic and prognostic data.

METHODS

The immunoreactivity of USP22 protein was analyzed in 157 pathologically characterized ESCC tissues by immunohistochemistry. All statistical analyses were performed with SPSS statistical software to evaluate the association of USP22 protein with clinicopathologic factors and survival.

RESULTS

High expression of USP22 protein was detected in 50.96 % of 157 ESCC tissues and significantly associated with invasion depth, lymph node metastasis, pathologic stage and tumor relapse (P < 0.05, respectively). Univariate survival analysis showed that patients with high expression of USP22 protein had a significantly poorer 5-year disease-specific survival (P = 0.002), and multivariate survival analysis showed that high expression of USP22 protein was an independent prognosticator for unfavorable disease-specific survival (P = 0.039). Further survival analysis stratified by pathologic stage demonstrated that high expression of USP22 protein significantly predicted unfavorable clinical outcome (P = 0.029) among patients with pathologic stage II(b)-III diseases.

CONCLUSION

USP22 protein plays an essential role in ESCC progression and has clinical potentials not only as a promising biomarker to identify the subgroup of patients with more aggressive tumors and poor prognostic potential but also as an attractively therapeutic target for ESCC.

Systematic review: potential preventive effects of statins against oesophageal adenocarcinoma

BACKGROUND

The incidence of oesophageal adenocarcinoma (OAC) has risen dramatically in recent decades, and its prognosis remains extremely poor. There is emerging evidence that statins may prevent OAC.

AIM

To systematically review both the experimental and epidemiological evidence to determine whether statins reduce the risk of developing OAC.

METHODS

Relevant laboratory and epidemiological studies were identified by systematically searching the PUBMED and EMBASE electronic databases for data on statins and oesophageal cancer (OC). The evidence was assessed according to the nine Bradford Hill criteria (BHC) of causality. Pooled effect sizes (ES) were calculated for the risk of OC with prior statin use.

RESULTS

Many of the BHC were supported including: 'plausible biological mechanisms', 'coherence', 'strong associations', 'consistency', 'biological gradient', 'analogy' and 'temporality'. Three experimental studies reported that statins inhibited proliferation, induced apoptosis and may limit metastatic potential in OAC cell lines. Fixed effects meta-analysis of two prospective studies in Barrett's oesophagus cohorts, involving 1382 participants, showed an ES of 0.53 (95% CI = 0.36-0.78, P = 0.001, I(2)  = 0%) for risk of OAC with prior statin use. Meta-analysis of three prospective studies in general population cohorts, involving 35 214 participants, showed an ES of 0.86 (95% CI = 0.78-0.94, P = 0.001, I(2)  = 0%) for risk of OC with prior statin use. The most important criterion, 'experiment', is as yet unfulfilled as to date there are no clinical trials which investigate this hypothesis.

CONCLUSION

There is some evidence that statins may protect against the development of OAC, although to be conclusive, data from randomised clinical trials are required.

Lower Mediastinal Lymph Node Metastasis is an Independent Survival Factor of Siewert Type II and III Adenocarcinomas in the Gastroesophageal Junction

We examined clinicopathological features and surgical outcomes in patients with adenocarcinoma in the gastroesophageal junction (GEJ), while also analyzing the survival factors that have a prognostic impact. Between 1991 and 2009, 61 patients with tumors in the GEJ (Siewert type II and III) underwent primary surgical resection. Thirty of 61 patients had type II tumors (49.2%) and 31 had type III tumors (50.8%). The tumor size was larger in type III tumors than type II tumors ( P = 0.0026). The overall 5-year survival rates in patients with type II tumors and type III tumors were 44.2 per cent and 41.4 per cent, respectively, with no significant differences ( P = 0.1888). The independent survival factors were lower mediastinal lymph node metastasis ( P = 0.0323) and a noncurative resection ( P = 0.0442). The independent survival factors for patients who underwent curative resections were the tumor size ( P = 0.0422), M category ( P = 0.0489), and lower mediastinal lymph node metastasis ( P = 0.0482). This study showed lower mediastinal lymph node metastasis to be an independent survival factor, and also suggested that lower mediastinal lymph node metastasis was associated with distant metastasis in patients with adenocarcinoma in the GEJ (Siewert type II and III). Therefore, the preoperative early detection of such metastasis is important to improve patient survival.

Metastasis-associated protein 1 nuclear expression is closely associated with tumor progression and angiogenesis in patients with esophageal squamous cell cancer

BACKGROUND

The purposes of the present study were to detect the expression of metastasis-associated protein 1 (MTA1) in patients with esophageal squamous cell cancer (ESCC), and to evaluate the relevance of MTA1 protein expression to the tumor progression, angiogenesis, and prognosis.

METHODS

Both MTA1 protein and intratumoral microvessels were examined by immunohistochemical staining in 131 ESCC patients who successfully underwent subtotal esophagectomy and esophagogastric anastomosis at Qilu Hospital between Jan 2004 and Dec 2005. Intratumoral microvessel density (MVD) was recorded by counting CD-34 positive immunostained endothelial cells. All statistical analyses were performed with SPSS 13.0 statistical software.

RESULTS

High expression of MTA1 protein was detected in 57 cases and significantly correlated with tumor invasion depth (P = 0.041), lymph node metastasis (P = 0.021), pathologic stage (P = 0.003), and MVD (P = 0.044). Survival analysis showed that patients with MTA1 protein high expression had significantly poor overall 5-year survival (P = 0.002), and the factor found on multivariate analysis to significantly affect overall survival was only pathologic stage (P = 0.040). Further stratified survival analysis split by pathologic stage demonstrated that MTA1 protein high expression significantly predicted unfavorable prognosis among patients with pathologic stage II disease (P = 0.006).

CONCLUSIONS

High expression of the MTA1 protein is common in ESCC, and is closely associated with tumor progression, increased tumor angiogenesis, and poor survival. These findings indicate that MTA1 protein has clinical potentials as a useful indicator of progressive phenotype, a promising prognostic predictor to identify patients with poor prognosis, and a potential novel therapeutic target of antiangiogenesis for patients with ESCC.

Patterns and time of recurrence after complete resection of esophageal cancer

PURPOSE

The results and outcomes of surgical resection for esophageal carcinoma have improved remarkably in recent years; however, recurrence still frequently develops, even after complete resection. The purpose of this study is to clarify the characteristics of recurrence in this patient population.

METHODS

Among 208 patients, who underwent R0 resection for esophageal carcinoma, recurrence developed in 61. Clinical data were available for 56 of these patients, who were the subjects of this study. We evaluated the time, patterns, and treatment of recurrence in these patients.

RESULTS

Recurrence developed within 1 and 2 years after esophagectomy in 71 and 84% of the patients, respectively, and was classified as loco-regional (54%), hematogenous (36%), or mixed type (10%). The prognosis of patients with loco-regional recurrence tended to be better than that of those with distant metastasis, although the difference was not significant (P = 0.088). Patients with recurrence treated by chemotherapy alone or multimodal therapy, such as radiation or surgery combined with systemic chemotherapy, survived significantly longer than those with untreatable recurrence (P = 0.016).

CONCLUSION

These findings reinforce the importance of careful follow-up for both loco-regional and hematogenous recurrence after esophagectomy, particularly during the first 2 years.

Diagnosis and treatment of non-metastatic esophagogastric junction adenocarcinoma: what are the current options?

While the prevalence of distal gastric cancer is decreasing in the western world, there has been an alarming rise in the incidence of esophagogastric junction adenocarcinoma (EGJA) during recent decades. Current reports show that the prognosis of EGJA remains poor. Therapy strategies are complex due to the anatomical location of the junction between the esophagus and stomach. Surgery, based on Siewert's classification and associated with regional lymphadenectomy, is the mainstay of treatment. Transthoracic esophagectomy is recommended for type I EGJA, while total gastrectomy is recommended for type III EGJA; both approaches can be considered for type II EGJA. Surgery alone can be indicated only for stage I and IIa tumors. Perioperative chemotherapy should be considered for stage IIb, III and non-metastatic stage IV tumors. Adjuvant chemoradiation can be proposed for tumors with high-risk of recurrence in the absence of neoadjuvant therapy. Neoadjuvant chemoradiation can be proposed for predominantly esophageal EGJA, and might well become a standard treatment for all EGJA tumors in the near future. A multidisciplinary approach is essential for optimal diagnosis and management.

Oesophageal cancer: how radical should surgery be?

INTRODUCTION

Oesophagectomy for carcinoma can be viewed as comprising two components: resection of the oesophagus and resection of the enveloping lymphatics. Controversy exists regarding how extensive these two components should be.

METHODS

Through a literature overview, the aim of this educational article is to provide surgeons with arguments to understand which operation is the most oncologically sound according to patient and tumour parameters.

RESULTS

Non-randomised comparative studies evaluating radical lymphadenectomy have reported controversial survival benefit. Independent association found between the number of surgically removed lymph nodes and overall survival is an indirect evidence supporting radical lymphadenectomy. The only phase III trial comparing non-radical transhiatal oesophagectomy with transthoracic oesophagectomy for patients with oesophageal adenocarcinoma found 5-year survival rates of 29% vs. 39%, respectively. Although not statistically significant due to underpowered study, specialists would consider less of an increase in survival to be clinically relevant. For squamous OC, the first small randomised controlled trial comparing 2-field lymphadenectomy to 3-field lymphadenectomy did not found significant 5-year survival difference (48% vs. 66%) and the second one comparing 2-field lymphadenectomy to lymph node sampling identified a survival benefit favoring radical resection (36% vs. 25%).

CONCLUSION

Radical transthoracic oesophagectomy with two-field lymphadenectomy appears to offer an optimal balance between benefits and risks to a majority of OC patients, especially in the growing area of neoadjuvant treatments. Non-radical resection should be probably reserved for patients with a poor general status whereas 3-field lymphadenectomy may be reserved to selected patients with loco-regional disease in experienced hands, surely for patients with upper OC.

Long-term results of radiochemotherapy for solitary lymph node metastasis after curative resection of esophageal cancer

PURPOSE

To evaluate the long-term efficacy and toxicity of definitive radiochemotherapy for solitary lymph node metastasis after curative surgery of esophageal cancer.

METHODS AND MATERIALS

We performed a retrospective review of 35 patients who underwent definitive radiochemotherapy at Tohoku University Hospital between 2000 and 2009 for solitary lymph node metastasis after curative esophagectomy with lymph node dissection for esophageal cancer. Radiotherapy doses ranged from 60 to 66 Gy (median, 60 Gy). Concurrent chemotherapy was platinum based in all patients. The endpoints of the present study were overall survival, cause-specific survival, progression-free survival, irradiated-field control, overall tumor response, and prognostic factors.

RESULTS

The median observation period for survivors was 70.0 months. The 5-year overall survival was 39.2% (median survival, 39.0 months). The 5-year cause-specific survival, progression-free survival, and irradiated-field control were 43.3%, 31.0% and 59.9%, respectively. Metastatic lesion, size of the metastatic lymph node, and performance status before radiochemotherapy were significantly correlated with prognosis. Complete response and partial response were observed in 22.9% and 57.1% of the patients, respectively. There was no Grade 3 or higher adverse effect based on the Common Terminology Criteria for Adverse Events (CTCAE v3.0) in the late phase.

CONCLUSIONS

Based on our study findings, approximately 40% of patients with solitary lymph node metastasis after curative resection for esophageal cancer have a chance of long-term survival with definitive radiochemotherapy.

High phosphorylated 4E-binding protein 1 expression after chemoradiotherapy is a predictor for locoregional recurrence and worse survival in esophageal squamous cell carcinoma patients

BACKGROUND

As a well-known pivotal factor of 4E-binding protein 1 (4E-BP1) in controlling cancer proliferation, high expression of its phosphorylated form (p-4E-BP1) has been reported to be associated with poor outcome in various human cancers without pretreated with chemoradiotherapy (CRT). However, no data is available regarding the implication of p-4E-BP1 expression after CRT. Therefore, we conducted this study.

METHODS

The expression of p-4E-BP1 was semiquantitatively examined with immunohistochemical staining in 60 ypT1T2 esophageal squamous cell carcinoma (SCC) patients and verified by western blot analysis in representative cases. The impact of p-4E-BP1 expression intensity on cancer recurrence and survival was assessed in combination with clinical and pathological descriptors.

RESULT

The 5-year disease specific survival (DSS) rate of patients with high p-4E-BP1 expression was significantly lower than that of patients with lower p-4E-BP1 expression (5 year DSS: 58% vs. 8.6%, P = 0.00064). Furthermore, in a multivariate analysis by Cox regression model, high p-4E-BP1 expression was confirmed to be an independent prognostic factor (HR: 2.269; unfavorable, P = 0.024) for DSS, while lymph node (HR: 3.016; unfavorable, P = 0.005) was also significant prognostic factor. High p-4E-BP1 expression was specifically associated with locoregional recurrence (LR; P < 0.05). The locoregional control rate reached 97.1% in low p-4E-BP1 tumors.

CONCLUSION

High p-4E-BP1 expression after CRT is a predictor for LR and worse survival in esophageal SCC patients.

Prognosis of patients with esophageal carcinoma after radiotherapy: an analysis of 85 cases

AIM: To investigate the efficacy of radiotherapy for esophageal carcinoma and to analyze prognostic factors for esophageal carcinoma after radiotherapy.

METHODS: Eighty-five patients with esophageal carcinoma who underwent comprehensive non-surgical treatment from April 2004 to April 2009 were enrolled in this study. Clinical factors influencing prognosis were evaluated. Survival was analyzed by Kaplan-Meier method. Univariate analysis was completed by using log-rank test (Log-rank test method), and multivariate analysis was performed using Cox proportional hazards regression model.

RESULTS: The follow-up rate was 100%. The 1- and 3-year survival rates were 65.9% and 29.4%, respectively. Univariate analysis showed that age, tumor site, lesion length, clinical stage, treatment mode, radiation techniques, and short-term effect were prognostic factors for esophageal carcinoma. Multivariate Cox regression analysis revealed that treatment mode, clinical stage and short-term effect were independent prognostic factors.

CONCLUSION: The long-term survival of patients with esophageal carcinoma after radiotherapy is poor. Treatment mode, clinical stage and short-term effect are main factors affecting the prognosis of esophageal carcinoma.

Multimodal treatment for resectable esophageal cancer

Surgical resection has been traditionally the mainstay of treatment for localized esophageal cancers. However, survival after surgery alone for advanced esophageal cancer is not satisfactory. In Japan, the development of multimodal therapy for esophageal cancers has centered mainly on systemic chemotherapy plus surgery to control distant metastasis. Based on the results of the recent Japan Clinical Oncology Group (JCOG) 9907 study, preoperative chemotherapy (consisting of 5-FU and cisplatin) followed by surgery has emerged as the standard treatment. In Western countries, where chemoradiotherapy followed by surgery has been mainly explored for patients with resectable esophageal cancers, two large controlled trials that evaluated the effectiveness of preoperative chemotherapy reported conflicting results. However, a recent meta-analysis reported significant survival benefits for preoperative chemotherapy in patients with adenocarcinoma of the esophagus. We need to find new effective preoperative chemotherapeutic regimens, including molecular target agents, with response rates higher than that of the conventional chemotherapy of 5-FU and cisplatin. However, we also must compare the survival benefits of preoperative chemotherapy with preoperative chemoradiotherapy.

Survival factors in patients with recurrence after curative resection of esophageal squamous cell carcinomas

BACKGROUND

Approximately half of patients who undergo curative resection for esophageal cancers develop recurrence postoperatively. The factors affecting survival after such recurrence remain largely unknown.

METHODS

To investigate factors affecting survival after recurrence in patients who had undergone curative resection for esophageal cancer, we retrospectively reviewed data for 461 patients who underwent curative esophagectomy with or without preoperative therapy for esophageal squamous cell carcinoma from January 1996 to December 2007. The correlations between several clinicopathological factors and survival after recurrence were examined.

RESULTS

Recurrence occurred in 196 of 461 patients (42.5%), with a median survival time after recurrence of 8.2 months. Multivariate analysis identified advanced tumor stage, preoperative chemoradiotherapy (CRT), number of recurrent tumors, and the presence of recurrence at the local site and liver as associated with shortened survival after recurrence. The analysis also indicated that treatment of the recurrence prolonged survival regardless of the treatment type. Although the pattern of recurrence did not significantly differ according to type of preoperative therapy, patients who underwent preoperative CRT were less often treated with radiotherapy for recurrence. Patients with multiple recurrent tumors less often received radiotherapy or surgery than those with a solitary recurrence. Chemotherapy for recurrence was not associated with either preoperative therapy or the number of recurrences.

CONCLUSIONS

Our retrospective study showed that multiple recurrent tumors and preoperative CRT limit the available treatment for recurrence and thereby are associated with poor prognosis. Vigorous treatment for recurrence can extend survival after recurrence in patients who undergo esophagectomy.

Prognostic factors for post-recurrence survival in esophageal squamous cell carcinoma patients with recurrence after resection

OBJECTIVE

The survival of recurrent esophageal cancer is poor. But reports regarding prognostic factors for post-recurrence survival are limited. We analyzed the recurrence pattern and the prognostic factors for post-recurrence survival in esophageal squamous cell carcinoma with recurrence after resection.

METHODS

Two hundred sixty-eight patients were included. Tumor recurrence occurred in 115 (42.9%) patients. Recurrence pattern was classified as locoregional, distant, and combined recurrence. The post-recurrence survival was defined as the interval between initial recurrence and either death or the last follow-up.

RESULTS

Mediastinum lymphadenopathy was the most common site for locoregional recurrence, whereas lung, liver, and bone were the most common sites for distant recurrence. The overall 1- and 2-year post-recurrence survival rates were 32.6% and 12.6% with a median survival after recurrence of 6.0 months. The independent prognostic factors included liver recurrence (HR = 2.255, 95%CI = 1.073-4.741, p = 0.032), time to recurrence ≤10 months (HR = 2.657, 95%CI = 1.438-4.911, p = 0.002), and no treatment for recurrences (HR = 2.745, 95%CI = 1.635-4.608, p < 0.001).

CONCLUSIONS

We identify liver recurrence, early recurrence, and no treatment for recurrence as risk factors for dismal post-recurrence survival.

Early recurrence and death after esophagectomy in patients with esophageal squamous cell carcinoma

BACKGROUND

The aim of this retrospective study is to analyze recurrence and death within 1 year after esophagectomy in patients with esophageal carcinoma.

METHODS

The records of 533 consecutive patients with esophageal squamous cell carcinoma who underwent surgery from January 2002 to January 2005 were reviewed. Patients who died of recurrence within 1 year after operation (group A) were compared with patients who survived more than 5 years without any recurrence (group B). Their clinicopathologic characteristics were evaluated by univariate and multivariate analyses.

RESULTS

The overall 1-year and 5-year survival rates for the entire cohort were 76.1% and 32.3%, respectively, with the follow-up rate of 93.4%. Of the 119 patients who died within 1 year after the esophagectomy, local recurrence or distant metastasis or both were documented in 62 patients (52.1%). The radicality of resection, size of tumor, radicality of resection, grade of differentiation, depth of invasion, status of lymph node metastasis, number of lymph node metastases, and marginal status were shown by univariate analysis to be the significant prognostic factors. By multivariate analysis, they were also the independent prognostic factors, except for the size of tumor and the radicality of resection.

CONCLUSIONS

More than half of early death in esophageal squamous cell carcinoma patients after esophagectomy were still tumor recurrence related, especially hematogeneous spreading. The grade of differentiation, depth of invasion, lymph node metastasis, number of lymph node metastases, and marginal status are valuable prognostic factors in predicting early death.

[Salvage surgery: cancer of the esophagus]

Neoadjuvant chemoradiotherapy is the gold standard of the treatment of advanced oesophageal cancer. The role of surgery after chemoradiotherapy is still debated. Feasibility of curative resection depends on dose of radiotherapy, morbimortality rates, and nutrition status at the end of the protocol especially for non-responders patients. Adding surgery to radiochemotherapy improves local tumour control but does not increase overall survival of patients with advanced oesophageal cancer. According to the two randomised trials published on the subject, surgery is not recommended after chemoradiotherapy for responders. Recommendations of French National Thesaurus are: exclusive chemoradiotherapy as reference, esophagectomy for residual tumour as alternative for operable patients. Surgery may be proposed for selected non-responders patients and some complete pathological response in expert center.

Functional polymorphisms associated with disease-free survival in resected carcinoma of the esophagus

PURPOSE

The aim of this study was to determine whether clinical outcome after surgical resection of esophageal adenocarcinoma (EAC) or esophageal squamous cell carcinoma (ESCC) could be predicted by functional polymorphisms in different proto-oncogenes and tumor suppressor genes.

EXPERIMENTAL DESIGN

Six single nucleotide polymorphisms (SNPs) in the AURKA (rs2273535), ERBB2 (rs1136201), MDM2 (rs2279744), CDH1 (rs5030625), CDKN2A (rs11515), and TP73 (rs2273953) genes were genotyped in a consecutive cohort of 346 esophageal cancer patients, who had underwent surgical resection with curative intent. Associations with disease-free survival (DFS) were analyzed with Kaplan-Meier curves and Cox regression, adjusting for potential confounders.

RESULTS

Univariate analysis showed no significant associations between the tested polymorphisms and DFS in patients with EAC or ESCC. However, in a multivariate analysis, patients with EAC carrying the heterozygous MDM2 (rs2279744) T/G genotype had significantly improved DFS compared with patients carrying the wild-type genotype (adjusted hazard ratio (AHR), 0.63; 95% confidence interval (CI) [0.45-0.88]). Patients with EAC harboring the homozygous CDH1 (rs5030625) GA/GA genotype had a significantly reduced survival as compared with patients carrying the wild-type genotype AHR 4.0, 95% CI [1.4-11].

CONCLUSIONS

In a large cohort of esophageal cancer patients, the MDM2 T/G and CDH1 GA/GA genotype confer risk of death in patients with EAC. These data suggest that inter-individual differences in germ-line DNA have an impact on DFS in patients with EAC.

Comparison of open three-field and minimally-invasive esophagectomy for esophageal cancer

The aim was to compare the early outcomes between thoracoscopic and laparoscopic esophagectomy (TLE) and open three-field esophagectomy for esophageal cancer. We retrospectively analyzed clinical data from 96 patients with esophageal cancer who underwent TLE, and 78 patients who underwent open three-field esophagectomy from March 2008 to September 2010. All the operations were successful. There was no significant difference between TLE and open three-field esophagectomy with regard to the number of lymph nodes procured (17.75±5.56 vs. 18.03±6.20, P>0.05), complications (32.3% vs. 46.2%, P>0.05), and operative mortality (2.1% vs. 3.8%, P>0.05). However, hospital stay was significantly shorter in the TLE group than the open esophagectomy group (12.64±8.82 vs. 17.53±6.40 days, P<0.01), and the TLE group had significantly less blood loss (346.68±41.13 vs. 519.26±47.74 ml, P<0.01). This showed that TLE for esophageal cancer offers results as good as or better than those with open three-field esophagectomy.

Prognostic biomarkers for esophageal adenocarcinoma identified by analysis of tumor transcriptome

Background

Despite many attempts to establish pre-treatment prognostic markers to understand the clinical biology of esophageal adenocarcinoma (EAC), validated clinical biomarkers or parameters remain elusive. We generated and analyzed tumor transcriptome to develop a practical biomarker prognostic signature in EAC.

Methodology/Principal Findings

Untreated esophageal endoscopic biopsy specimens were obtained from 64 patients undergoing surgery and chemoradiation. Using DNA microarray technology, genome-wide gene expression profiling was performed on 75 untreated cancer specimens from 64 EAC patients. By applying various statistical and informatical methods to gene expression data, we discovered distinct subgroups of EAC with differences in overall gene expression patterns and identified potential biomarkers significantly associated with prognosis. The candidate marker genes were further explored in formalin-fixed, paraffin-embedded tissues from an independent cohort (52 patients) using quantitative RT-PCR to measure gene expression. We identified two genes whose expression was associated with overall survival in 52 EAC patients and the combined 2-gene expression signature was independently associated with poor outcome (P<0.024) in the multivariate Cox hazard regression analysis.

Conclusions/Significance

Our findings suggest that the molecular gene expression signatures are associated with prognosis of EAC patients and can be assessed prior to any therapy. This signature could provide important improvement for the management of EAC patients.

Thoracoscopic-assisted esophagectomy for esophageal cancer: analysis of patterns and prognostic factors for recurrence

OBJECTIVE

The authors report the recurrence pattern of esophageal cancer after thoracoscopic-assisted esophagectomy (TAE), comparing it to the recurrence pattern after open surgery and identify prognostic factors for recurrence.

SUMMARY OF BACKGROUND DATA

To improve long-term survival for esophageal cancer radical surgery has been proposed increasingly, however, recurrent disease remains a problem. Opinion is divided as to the adequacy of resection possible using minimally invasive techniques with concerns that there may be an increased incidence in locoregional recurrence.

METHODS

A total of 221 patients who underwent esophagectomy at the Princess Alexandra Hospital without any neoadjuvant or adjuvant therapy were identified from a prospective database. Patients were followed up for the detection of symptomatic recurrence for a median of 59 months.

RESULTS

Within this group 165 patients underwent TAE and 56 an open transthoracic esophagectomy (TTE). The 5-year overall recurrence rate was 133/221 (60%). The 5-year rates of symptomatic first recurrence following TAE was 4%, 9%, and 47% for local, regional, and distant recurrence, respectively. The 5-year rates of symptomatic first recurrence following TTE was 5%, 18%, and 55% for local, regional, and distant recurrence, respectively. Operative approach was not a prognostic factor for any type of recurrence. Independent prognostic factors associated with locoregional recurrence were positive margins and number of positive nodes. Distant recurrence was associated with T stage, differentiation, tumor length >6 cm, and number of positive nodes.

CONCLUSION

Distant recurrence remains a significant problem in esophageal cancer. TAE achieved adequate locoregional control and compared favorably with open TTE.

Proposed follow up programme after curative resection for lower third oesophageal cancer

The incidence of oesophageal adenocarcinoma has risen throughout the Western world over the last three decades. The prognosis remains poor as many patients are elderly and present with advanced disease. Those patients who are suitable for resection remain at high risk of disease recurrence. It is important that cancer patients take part in a follow up protocol to detect disease recurrence, offer psychological support, manage nutritional disorders and facilitate audit of surgical outcomes. Despite the recognition that regular postoperative follow up plays a key role in ongoing care of cancer patients, there is little consensus on the nature of the process. This paper reviews the published literature to determine the optimal timing and type of patient follow up for those after curative oesophageal resection.

Impact of neoadjuvant chemoradiotherapy on surgery and survival in patients with esophageal carcinoma

Neoadjuvant chemotherapy is often used to treat solid tumors before surgery or during the perioperative period. It is often combined with radiotherapy to improve survival and cure rate and to protect normal organs. Surgery is still the most effective therapy for esophageal cancer. Preoperative (neoadjuvant) chemotherapy and radiotherapy as a treatment modality has been in existence for nearly 20 years. However, it remains controversial over whether neoadjuvant chemoradiotherapy can be used as the standard treatment for esophageal cancer. This paper sums up the impact of neoadjuvant chemotherapy on surgery and survival in patients with esophageal cancer. Moreover, we discuss the limitations and future directions of neoadjuvant chemotherapy for esophageal carcinoma.

Postoperative radiotherapy improved survival of poor prognostic squamous cell carcinoma esophagus

BACKGROUND

The purpose of this study was identify prognostic factors and to investigate the association between postoperative radiotherapy and overall survival of thoracic esophageal squamous cell carcinoma patients.

METHODS

From January 1993 to March 2007, 1,715 patients underwent extended esophagectomy with three-field lymph node dissection with or without postoperative radiotherapy and were eligible for analysis. Patients were grouped to surgery only (n = 1,277) and surgery plus postoperative radiotherapy (n = 438). Radiation dose was 50 Gy in 25 fractions.

RESULTS

The overall survival rates at 1, 3, 5, and 10 years were 86.6%, 61.3%, 49.4%, and 36.1%, respectively. Univariate and multivariate analyses showed that age 60 years or more, male sex, tumor more than 5 cm long, poorly differentiated histology, T4 tumor, presence of a vascular cancer thrombus in the surgical specimen, lymph node positivity, 3 or more positive lymph nodes, and disease stage II or higher were negative prognostic factors for overall survival. Postoperative radiation therapy improved overall survival for patients with poor disease-related prognostic factors: positive nodal disease, 3 or more positive lymph nodes, stage III/IV, and large or deeply invading tumor. Postoperative radiation had no survival benefit for patients who did not have the poor disease-related prognostic factors.

CONCLUSIONS

Postoperative radiotherapy is indicated for patients with poor disease-related prognostic factors.

Comparison of survival and recurrence pattern between two-field and three-field lymph node dissections for upper thoracic esophageal squamous cell carcinoma

INTRODUCTION

It is controversial to routinely perform three-field lymph node dissection in patients with upper thoracic esophageal carcinoma. The objective of this study was to compare survival and recurrence according to the extent of lymph node dissection in patients with upper thoracic esophageal squamous cell cancer.

METHODS

Between 1995 and 2007, 91 patients underwent R0 esophagectomy (with no residual tumor) for squamous cell carcinoma of the upper thoracic esophagus at our institution. Of these, 57 patients received three-field (cervical, mediastinal, and abdominal stations) lymph node dissection (3 FL group), whereas 34 received two-field (mediastinal and abdominal stations) lymph node dissection (2 FL group). We retrospectively compared the early and late postoperative outcomes between the two groups.

RESULTS

No differences were observed between the two groups with regard to age, gender, and pathologic stage. There was no in-hospital mortality in either group. The 5-year survival rate was 52% for the 2 FL group and 44% for the 3 FL group (p = 0.65). The disease-free 5-year survival rate was 39% for the 2 FL group and 38% for the 3 FL group (p = 0.97). The overall recurrence rate and the incidence of cervical nodal recurrence were not significantly different between the two groups.

CONCLUSIONS

Our findings suggest that there was no survival benefit from the addition of cervical nodal dissection in patients with upper thoracic esophageal squamous cell carcinoma who had no evidence of cervical lymph node metastasis.

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.

Prognostic factors and patterns of recurrence in esophageal cancer assert arguments for extended two-field transthoracic esophagectomy

BACKGROUND

High recurrence rates determine the dismal outcome in esophageal cancer. We reviewed our experiences and defined prognostic factors and patterns of recurrences after curatively intended transthoracic esophagectomy.

METHODS

Between January 1991 and December 2005, 212 consecutive patients underwent a radical transthoracic esophagectomy with extended 2-field lymphadenectomy. Recurrence rates, survival, and prognostic factors were analyzed (minimal follow-up period, 2 y).

RESULTS

Radicality was obtained in 85.6%. The median follow-up period was 26.6 months. The overall recurrence rate at 1, 3, and 5 years was 28%, 44%, and 64%, respectively, and locoregional recurrence rate was 17%, 27%, and 43%, respectively. Overall survival rates, including postoperative deaths, were 45% and 34% at 3 and 5 years, respectively. pT stage and lymph node (LN) ratio greater than .20 were independent prognostic factors for survival and recurrences. Radicality was most prognostic for survival, and for N+ greater than 4 positive LN for recurrences.

CONCLUSIONS

Radicality and LN ratio are strong prognostic factors. High radicality and adequate nodal assessment are guaranteed by an extended transthoracic approach.

Metachronous adenocarcinoma in a gastric tube after radical surgery for oesophageal cancer

In recent years the prognosis for oesophageal squamous cell carcinoma patients has improved. Together with this improvement, the occurrence of second primary carcinoma, especially gastric carcinoma, in tubes constructed from the stomach after oesophagectomy must be taken into account. We report a case of a patient who had this clinical presentation, which was revealed not in the normal follow-up, but in a consecutive operation carried out because of an anastomotic problem.

Radiotherapy with or without concurrent chemotherapy for lymph node recurrence after radical surgery of thoracic esophageal squamous cell carcinoma

PURPOSE

To retrospectively compare the outcomes of patients with lymph node recurrence after radical surgery of esophageal cancer, when given radiotherapy with or without concurrent chemotherapy.

METHODS AND MATERIALS

Between January 1996 and December 2005, the data from 73 patients with lymph node recurrence after radical surgery of thoracic esophageal squamous cell carcinoma were retrospectively reviewed. The patients were separated into two groups: radiochemotherapy (RC, 31 patients) and radiotherapy alone (RA, 42 patients). Patients in the RC group received at least two cycles of 5-fluorouracil/cisplatin chemotherapy concurrently with radiotherapy.

RESULTS

The median duration of follow-up was 11 months (range, 2-48). The overall survival rate for all patients was 46.7% and 4.7% at 1 and 3 years, respectively. The median overall survival time was 9 months (95% confidence interval, 6.96-11.04) and 17 months (95% confidence interval, 13.61-20.39) for RA and RC groups, respectively. The survival rate at 1 and 3 years was 62.5% and 10.5% in the RC group and 33.8% and 0% in the RA group (p = .0049, log-rank test; hazard ratio for death, 0.52; 95% confidence interval, 0.30-0.92). Acute toxicities were more frequent in the RC group than in the RA group. No significant differences were found in the late toxicity profiles between the two groups.

CONCLUSION

The results of the present retrospective analysis suggest that RC should be considered an effective and well-tolerated treatment of patients with thoracic esophageal squamous cell carcinoma and postoperative lymph node recurrence.

Involvement of CYR61 and CTGF in the fascin-mediated proliferation and invasiveness of esophageal squamous cell carcinomas cells

Fascin is overexpressed in esophageal squamous cell [corrected] carcinoma (ESCC) and involved in the proliferation and invasiveness of ESCC cells. In this study, we retrospectively examined the expression of fascin in ESCC samples by immunohistochemistry and revealed that overexpression of fascin was related to poor patient survival. RNAi-mediated knockdown of fascin in ESCC cells significantly inhibited cell proliferation and invasiveness, whereas forced expression of fascin in immortalized esophageal epithelial cells accelerated cell proliferation and invasiveness. To explore the underlying mechanism, cDNA microarray was performed to identify the differential gene expression profiles between a fascin-depleted cell line by RNAi and the corresponding control ESCC cells. Results showed that 296 genes were differentially expressed on fascin depletion. In this study, we focused on two down-regulated genes: CYR61 and CTGF. We found that restored expression of either CYR61 or CTGF led to a recovery of the suppression of cellular proliferation and invasiveness induced by down-regulation of fascin expression; the protein level of CYR61 and CTGF were up-regulated in ESCCs and their expression pattern correlated with fascin overexpression. Finally, analysis of signal transduction revealed that fascin affected the expressions of CYR61 and CTGF through transforming growth factor (TGF)-beta pathway. Taken together, we propose that fascin regulates the proliferation and invasiveness of ESCC cells by modulating the expression of CTGF and CYR61 via TGF-beta pathway.

Id-1 promotes tumorigenicity and metastasis of human esophageal cancer cells through activation of PI3K/AKT signaling pathway

Id-1 (inhibitor of differentiation or DNA binding) is a helix-loop-helix protein that is overexpressed in many types of cancer including esophageal squamous cell carcinoma (ESCC). We previously reported that ectopic Id-1 expression activates the phosphatidylinositol-3-kinase (PI3K)/protein kinase B (AKT) signaling pathway in human esophageal cancer cells. In this study, we confirmed a positive correlation between Id-1 and phospho-AKT (Ser473) expressions in ESCC cell lines, as well as in ESCC on a tissue microarray. To investigate the significance of Id-1 in esophageal cancer progression, ESCC cells with stable ectopic Id-1 expression were inoculated subcutaneously into the flank of nude mice and were found to form larger tumors that showed elevated Ki-67 proliferation index and increased angiogenesis, as well as reduced apoptosis, compared with control cells expressing the empty vector.The Id-1-overexpressing cells also exhibited enhanced metastatic potential in the experimental metastasis assay. Treatment with the PI3K inhibitor LY294002 attenuated the tumor promotion effects of Id-1, indicating that the effects were mediated by the PI3K/AKT signaling pathway. In addition, our in vitro experiments showed that ectopic Id-1 expression altered the expression levels of markers associated with epithelial-mesenchymal transition and enhanced the migration ability of esophageal cancer cells. The Id-1-overexpressing ESCC cells also exhibited increased invasive potential, which was in part due to PI3K/AKT-dependent modulation of matrix metalloproteinase-9 expression. In conclusion, our results provide the first evidence that Id-1 promotes tumorigenicity and metastasis of human esophageal cancer in vivo and that the PI3K inhibitor LY294002 can attenuate these effects.

Effects of neoadjuvant radiochemotherapy on pathological staging and prognosis for locally advanced esophageal squamous cell carcinoma

The role of neoadjuvant therapy in the treatment of locally advanced esophageal carcinoma still remains controversial. The aim of this study was to evaluate the effects of neoadjuvant radiochemotherapy on pathological staging and prognosis in the patients with locally advanced esophageal squamous cell carcinoma. Between January 1991 and December 2000, 473 patients with advanced esophageal carcinoma diagnosed by endoscopic biopsy underwent surgical resection in our center. With informed consent, they were randomized into four groups: neoadjuvant chemotherapy, neoadjuvant radiotherapy, neoadjuvant radiochemotherapy, and surgery alone (control group). The preoperative computed tomography staging criteria were the following: Stage I, the tumor limited to the esophageal lumen or the thickness of the esophageal wall varied between 3-5 mm; Stage II, the thickness exceeds 5 mm but no invasion to the mediastinum or distant metastasis; Stage III, the tumor invades adjacent mediastinal structure; and Stage IV, there is distant metastasis. The tumor resection rate, pathological stage, treatment-related complication, and survival among groups were compared. The radical resection rate for the patients in radiotherapy and radiochemotherapy groups was increased in comparison with the control group (P < 0.05). Their pathological stage after esophagectomy was regressed significantly than that of the control group (50.85%, 55.08% vs. 0%, P < 0.05). The adjuvant chemotherapy group did show significant improvement on resection rate and pathological staging compared with the control group. The treatment-related complication in the three neoadjuvant groups had no significant difference from that of the control group (P > 0.05). The 3-year survival rate of radiotherapy and radiochemotherapy groups were significantly higher than that of the control group (69.49%, 73.73% vs. 53.38%, P < 0.05). The 5-year survival rate of radiochemotherapy group was higher than that of the radiotherapy group although did not show a statistical difference (P > 0.05). Rational application of neoadjuvant radiochemotherapy seems to provide a modest benefit in radical resection and survival in patients with locally advanced esophageal carcinoma.

Antibody-based proteomics for esophageal cancer: Identification of proteins in the nuclear factor-kappaB pathway and mitotic checkpoint

To identify the molecular background of esophageal cancer, we conducted a proteomics study using an antibody microarray consisting of 725 antibodies and surgical specimens from three cases. The microarray analysis identified 24 proteins with aberrant expression in esophageal cancer compared with the corresponding normal mucosa. The overexpression of 14 of the 24 proteins was validated by western blotting analysis of the same samples. These 14 proteins were examined by immunohistochemistry, in which nine proteins showed consistent results with those obtained by western blotting. Among the nine proteins, seven were localized in tumor cells, and two in infiltrating cells. The former included proteins associated with mitotic checkpoint control and the nuclear factor (NF)-kappaB pathway. Although mitotic checkpoint gene products (budding uninhibited by benzidazoles 1 homolog beta (BubR1) and mitotic arrest deficient-like 1 (Mad2)) have previously been reported to be involved in esophageal cancer, the association of NF-kappaB-activating kinase, caspase 10, and activator protein-1 with esophageal cancer has not been previously reported. These proteins play a key role in the NF-kappaB pathway, and NF-kappaB is a signal transduction factor that has emerged as an important modulator of altered gene programs and malignant phenotype in the development of cancer. The association of these proteins with esophageal cancer may indicate that mitotic checkpoint gene products and NF-kappaB play an important part in the carcinogenesis of esophageal cancer.

Targeting NF-kappaB signaling pathway suppresses tumor growth, angiogenesis, and metastasis of human esophageal cancer

Esophageal cancer is the eighth most common malignancy, and one of the leading causes of cancer-related deaths worldwide. The overall 5-year survival rate of patients with esophageal cancer remains low at 10% to 40% due to late diagnosis, metastasis, and resistance of the tumor to radiotherapy and chemotherapy. NF-kappaB is involved in the regulation of cell growth, survival, and motility, but little is known about the role of this signaling pathway in the tumorigenesis of human esophageal squamous cell carcinoma (ESCC), the most common form of esophageal cancer. This study aims to explore the functions of NF-kappaB in human ESCC progression and to determine whether targeting the NF-kappaB signaling pathway might be of therapeutic value against ESCC. Our results from human ESCC cell lines and ESCC tissue indicated that NF-kappaB is constitutively active in ESCC. Exposure of ESCC cells to two NF-kappaB inhibitors, Bay11-7082 and sulfasalazine, not only reduced cancer cell proliferation, but also induced apoptosis and enhanced sensitivity to chemotherapeutic drugs, 5-fluorouracil, and cisplatin. In addition, Bay11-7082 and sulfasalazine suppressed the migration and invasive potential of ESCC cells. More importantly, the results from tumor xenograft and experimental metastasis models showed that Bay11-7082 had significant antitumor effects on ESCC xenografts in nude mice by promoting apoptosis, and inhibiting proliferation and angiogenesis, as well as reduced the metastasis of ESCC cells to the lungs without significant toxic effects. In summary, our data suggest that NF-kappaB inhibitors may be potentially useful as therapeutic agents for patients with esophageal cancer.

Triterpenes augment the inhibitory effects of anticancer drugs on growth of human esophageal carcinoma cells in vitro and suppress experimental metastasis in vivo

The antineoplastic effects of combinations of anticancer drugs (5-fluorouracil, irinotecan and cisplatin) and triterpenes (ursolic acid, betulinic acid, oleanolic acid and a Japanese apricot extract (JAE) containing triterpenes) on esophageal squamous carcinoma cells were examined by the WST-8 (2-(2-methoxy- 4-nitrophenyl)-3-(4-nitrophenyl)-5-(2,4-disulfophenyl)-2H-tetrazolium, monosodium salt) assay in vitro and by an animal model in vivo. Triterpenes and JAE showed additive and synergistic cytotoxic effects, respectively, on esophageal squamous carcinoma cells (YES-2 cells) by combinational use of 5-fluorouracil. JAE and 5-fluorouracil induced cell cycle arrest at G2/M phase and at S phase, respectively, and caused apoptosis in YES-2 cells. A new animal model of esophageal cancer causing tumor colonization of the peritoneal cavity and producing bloody ascites was made by injecting YES-2 cells into the peritoneal cavity of a severe combined immunodeficiency mouse. In this model, 5-fluorouracil inhibited colonization of tumor cells in the peritoneum. The addition of JAE to 5-fluorouracil augmented the suppression of experimental metastasis of the peritoneum. The numbers of peritoneal nodules of more than 2 mm in diameter in mice treated with 5-fluorouracil and JAE were less than those in mice treated with 5-fluorouracil alone or JAE alone. These results suggest that triterpenes, especially JAE, are effective supplements for enhancing the chemotherapeutic effect of 5-fluorouracil on esophageal cancer.

Evidence-based radiation oncology: oesophagus

Oesophageal cancer remains to be a therapeutic and diagnostic challenge in multidisciplinary oncology. Radiotherapy is a crucial component of most curative and palliative approaches for oesophageal cancer. Aim of this educational review is to summarize the available evidence and to define the role of radiation-based treatment options for oesophageal cancer.

Pretreatment T3-4 stage is an adverse prognostic factor in patients with esophageal squamous cell carcinoma who achieve pathological complete response following preoperative chemoradiotherapy

BACKGROUND

Preoperative chemoradiotherapy (CRT) followed by esophagectomy is becoming one of the standard treatment strategies for esophageal cancer. Pathologic complete response (pCR) after CRT is the best predictor of survival in squamous cell carcinoma (SCC) of the esophagus. Although no adjuvant treatment is recommended for individuals who achieve pCR, approximately 30% of these patients develop recurrence. Herein we sought to retrospectively investigate the independent predictors of tumor recurrence in this patient group.

METHODS

Between 1995 and 2004, we investigated seventy patients (69 males and 1 female; mean age: 56.1 years) with esophageal SCC who achieved pCR following preoperative chemoradiotherapy. Study end points included tumor recurrence, disease-specific survival (DSS), and disease-free survival (DFS). Univariate and multivariate analyses were used to identify risk factors for the study end points.

RESULTS

Mean follow-up time for patients who survived was 65.8 months. At the time of analysis, 18 patients (25.7%) died of the disease and 22 patients (31.4%) developed recurrence. Multivariate analysis showed that pretherapy T3-4 disease was the most important adverse factor for tumor recurrence (P = 0.007), DFS (P = 0.005), and DSS (P = 0.026). The 5-year DFS was 45% for patients with clinical T3-4 disease and 85% for those with clinical T1-2 disease (P = 0.02).

CONCLUSIONS

We have shown that up to 31.4% of patients with esophageal SCC who achieve pCR develop tumor recurrence thereafter. Pretherapy T3-4 disease was a strong and independent adverse risk factor for 5-year tumor recurrence, DSS and DFS. High-risk patients with T3-4 disease should be followed with a strict surveillance protocol.

Transglutaminase 3 as a prognostic biomarker in esophageal cancer revealed by proteomics

To develop a prognostic biomarker for esophageal squamous cell carcinoma (ESCC), we examined the proteomic profile of ESCC using two-dimensional difference gel electrophoresis (2D-DIGE), and identified proteins associated with prognosis by mass spectrometry. The prognostic performance of the identified proteins was examined by immunohistochemistry in additional cases. We identified 22 protein spots whose intensity was statistically different between ESCC cases with good (N = 9; survived more than 5 years without evidence of recurrence) and poor (N = 24; died within 2 years postsurgery) prognosis, within the patient group that had two or more lymph node metastases. Mass spectrometric protein identification resulted in 18 distinct gene products from the 22 protein spots. Transglutaminase 3 (TGM3) was inversely correlated with shorter patient survival. The prognostic performance of TGM3 was further examined by immunohistochemistry in 76 ESCC cases. The 5-year disease-specific survival rate was 64.5% and 32.1% for patients with TGM3-positive and TGM3-negative tumors, respectively (p = 0.0033). Univariate and multivariate analyses revealed that TGM3 expression was an independent prognostic factor among the clinicopathologic variables examined. It is noteworthy that the prognostic value of TGM3 was shown to be higher than those of the lymph node metastasis, intramural metastasis and vascular invasion status. These results establish TGM3 as a novel prognostic biomarker for ESCC for the first time. Examination of TGM3 expression may provide novel therapeutic strategies to prevent recurrence of ESCC.

Use of positron emission tomography in surgery follow-up of esophageal cancer

INTRODUCTION

Although the prognosis of patients with esophageal cancer has been improved by extended dissection, the incidence of recurrence still remains high. In esophageal cancer, positron emission tomography (PET) using (18)F-fluorodeoxyglucose (FDG) already demonstrated to be useful for initial staging and monitoring response to therapy. This prospective study compared the ability of FDG-PET and conventional imaging to detect early recurrence of esophageal cancer after initial surgery in asymptomatic patients.

MATERIALS AND METHODS

Between October 2003 and September 2006, 41 patients with esophageal cancer were included in a prospective study after initial radical esophagectomy. FDG-PET, thoracoabdominal computed tomography (CT), abdominal ultrasonography, and endoscopy were performed every 6 months after initial treatment.

RESULTS AND DISCUSSION

Twenty-three patients had recurrent disease (56%), mostly within the first 6 months after surgery (70%). Despite two false-positive scans due to postoperative changes, FDG-PET was more accurate than CT (91% vs. 81%, p = 0.02) for the detection of recurrence with a sensitivity of 100% (vs. 65%), a specificity of 85% (vs. 91%), and a negative predictive value of 100% on a patient-by-patient-based analysis. For the detection of locoregional recurrence, FDG-PET was more accurate than CT (96.2% vs. 88.9%). FDG-PET was also more accurate than CT for the detection of distant metastases (92.5% vs. 84.9%), especially when involving either bones (100%) or liver (98.1%). A lower sensitivity of FDG-PET (57%) for the early detection of small lung metastases did not affect patient management (accuracy = 92.5%).

CONCLUSION

FDG-PET appears to be very useful for the systematic follow-up of asymptomatic patients after esophagectomy with an initial scan performed 6 months after surgery.

The changing use of palliative chemotherapy for recurrent esophagogastric cancer: a single center retrospective 15-year review

BACKGROUND

Palliative chemotherapy is often recommended in the treatment of recurrent esophagogastric (EG) cancer with limited evidence of its benefit. This study aims to define the current practice and benefit of this treatment.

METHODS

Retrospective analysis of patients who developed EG cancer recurrence between 1991 and 2006 following surgery with curative intent.

RESULTS

There were 336 recurrences. Median time to disease recurrence was 13.4 months (range 1.3-118). Survival after recurrence ranged from 0-93.2 months (six patients are currently alive). A significant increase in the use of chemotherapy was observed rising from 10% prior to 1999 (n = 100) to 23% (n = 236) after 1999. The median survival for patients receiving chemotherapy (n = 64) was 10.6 months (range 1.5-75.7), patients undergoing nonchemotherapy palliative intervention (n = 142) median survival was 2.85 months (range 0-93.2), and for patients having no active intervention (n = 130), median survival was 1.3 months (range 0-16.2). Median duration of chemotherapy was 3.1 months (range 0.5-9.2). Median survival for these patients after chemotherapy treatment was 6.6 months (range 0.4-73.5). Twenty-eight patients (44%) experienced side effects of chemotherapy. Ten cases required treatment to be modified or stopped and two patients died during chemotherapy.

CONCLUSION

There has been a significant increase in the use of palliative chemotherapy for recurrent EG cancer. While survival appears improved, a substantial proportion of this time was spent receiving chemotherapy with many patients experiencing significant comorbidity. Further studies assessing both quality and quantity of life are required to fully evaluate the use of palliative chemotherapy and to identify patients most likely to benefit.