Treatment and outcome of young patients with esophageal cancer in the Netherlands

Comparison of postoperative survival prognosis between early-onset and late-onset esophageal cancer: A Population-based study

The prognosis of non-distant metastatic early-onset esophageal cancer (EC) patients undergoing surgical treatment remains unclear, this study aims to compare the prognosis of early-onset and late-onset EC. Information on non-distant metastatic EC patients who underwent surgical treatment and were initially diagnosed between 2004 and 2015 was collected from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was used to balance the baseline differences between early-onset and late-onset EC patients. Univariate and multivariate Cox regression analyses were used to calculate hazard ratio (HR) and 95% confidence interval (CI). The Kaplan-Meier method and log-rank test were used to compare the overall survival (OS) between the two groups of patients. Atotal of 5320 EC patients were included, with 571 in the early-onset group and 4749 in the late-onset group. Multivariate Cox regression analysis showed that early-onset EC patients had better OS (HR = 0.732, 95% CI: 0.655-0.819, p<0.001). Using PSM analysis at a 1:1 ratio, we matched 557 early-onset EC patients with 557 late-onset EC patients. After matching, the multivariate Cox regression model still showed a favorable prognosis for early-onset EC (HR = 0.728, 95% CI: 0.630-0.842, p<0.001). Additionally, subgroup analysis indicated that early-onset EC patients had better long-term prognosis. Non-distant metastatic early-onset EC patients undergoing surgical treatment demonstrated better OS outcomes, confirmed by regression analysis and subgroup analysis in the matched cohort.

Survival outcomes in early-onset oesophageal adenocarcinoma patients: A systematic review and meta-analyses

BACKGROUND

The incidence of oesophageal adenocarcinoma (OAC) has been reported to be increasing in many countries. Alongside this trend, an increase in incidence of early-onset OAC, defined as OAC in adults aged under 50 years, has been observed. It is unclear whether survival outcomes for early-onset OAC patients differ from older age groups.

AIM

To investigate survival outcomes in early-onset OAC patients.

METHODS

Ovid Medline and Embase were searched from inception to January 2022 for relevant studies relating to early-onset OAC and survival outcomes. Results regarding the overall five-year survival and risk of death of younger and older patients with OAC were extracted and pooled using meta-analyses to produce pooled estimates and 95%CIs where possible.

RESULTS

Eleven studies which compared survival of early-onset OAC, defined as age at diagnosis of < 50 years, with older patients were included. A narrative review of median and mean survival demonstrated conflicting results, with studies showing early-onset OAC patients having both better and worse outcomes compared to older age groups. A meta-analysis of five-year survival demonstrated similar outcomes across age groups, with 22%-25% of patients in the young, middle and older age groups alive after five years. A meta-analysis of four studies demonstrated that early-onset OAC patients did not have a significantly increased risk of death compared to middle-aged patients (hazard ratio 1.12, 95%CI: 0.85-1.47).

CONCLUSION

Results suggest that early-onset OAC patients do not have a significantly different survival compared to older patients, but further population-based research, taking into account stage and treatment, is required.

Case Report: Esophageal squamous cell carcinoma in a 13-year-old boy with a history of esophageal atresia with tracheoesophageal fistula

In adults, esophageal cancers are a global health concern. Esophageal squamous cell carcinoma (ESCC) accounts for approximately 90% of esophageal carcinomas. The prognosis of esophageal cancers remains dismal, with a five-year survival rate below 20%. It typically affects older patients, and for now, ESCC after esophageal atresia has not been reported in patients younger than 18 years. We present an exceptional case of an ESCC in a 13-year-old boy with a history of esophageal atresia and corrective surgery in infancy. After the surgery the patient was lost to surgical follow up for over ten years and then presented to our emergency department with respiratory distress requiring antibiotic therapy and supplemental oxygen. Radiologic imaging revealed a volume reduction of the right lung with bronchiectasis, as well as esophageal stenosis at the level of the previous anastomosis, with an adjacent abscess in the right lung. These changes may have arisen due to a chronic fistula from the esophagus to the right lung. Initial interventional therapy with a stent implantation had no lasting success and, in an effort to prevent further aspiration into the right lung, a cervical esophagus stoma was established, and the patient received prolonged antibiotic treatment. However, a thoracic CT scan performed 4 months later revealed a large, retrospectively progressive prevertebral mass originating from the distal portion of the esophagus below the stenosis, compressing the trachea and the right main bronchus. The patient's condition rapidly worsened and he developed respiratory failure, requiring veno-venous extracorporeal membrane oxygenation. Unfortunately, an endoscopic biopsy revealed an advanced ESCC. With no rational treatment options available, we changed the goals of care to a palliative setting. The key message of this case is that in adolescents with chronic infections, an abscess can potentially mask a malignant transformation. Therefore, in adolescents, with an history of corrective surgery for esophageal atresia and chronic complications, consideration should also be given to the possibility of squamous cell carcinoma of the esophagus.

Two distinct age-prognosis patterns in patients with esophageal cancer undergoing surgical and radiotherapy treatments: a combined analysis of 3JECROG and SEER databases

Background

Age is a known prognostic factor for various cancers. However, few studies explored the association between age and prognosis of esophageal cancer (EC) comprehensively, especially from a nonlinear perspective.

Design

Retrospective cohort study.

Objectives

Our study aims to explore the possible nonlinear associations between age and prognosis in EC patients receiving curative surgery and radiotherapy, respectively.

Methods

Cox regression models with restricted cubic splines were used to model the possible nonlinear relationship between age and prognosis in surgical and radiotherapy groups, respectively. Surveillance, Epidemiology, and End Results database was used to validate the age-prognosis patterns found in Jing-Jin-Ji Esophageal and Esophagogastric Cancer Radiotherapy Oncology Group database. Age-prognosis patterns were further validated by survival comparisons between different age subgroups and in subsequent sensitivity and subgroup analyses. Primary endpoint is overall survival. Secondary endpoints are cancer-specific survival and progression-free survival.

Results

A total of 56,457 patients from two large cancer databases were included. Patients receiving surgery and radiotherapy showed two distinct nonlinear age-prognosis patterns. Age showed a U-/J-shaped association with prognosis in the radiotherapy group, with a nadir at approximately 65- to 70-years-old. As for surgical cohort, relative risk for all-cause mortality and cancer-specific mortality increased with age with p for nonlinearity <0.05. The above age-prognosis relationships were validated by sensitivity, subgroup, and comparative survival analyses. Youngest and middle-aged patients showed better survival results compared to that of other age subgroups in surgical and radiotherapy cohorts, respectively [Radiotherapy, youngest/middle: hazard ratio (HR) = 1.06, 95% confidence interval (CI): 1.02-1.10, p = 0.001; Radiotherapy, oldest/middle: HR = 1.21, 95% CI: 1.18-1.24, p < 0.001; Surgical, middle/youngest: HR = 1.19, 95% CI: 1.14-1.25, p < 0.001; surgical, oldest/youngest: HR = 1.85, 95% CI: 1.75-1.97, p < 0.001].

Conclusion

Patients receiving surgery and radiotherapy showed two distinct age-prognosis patterns. Younger and middle-aged patients were associated with better survival in surgical and radiotherapy groups, respectively. Additional studies are warranted to explore the underlying mechanisms and clinical implications of this phenomenon.

Comparison of postoperative survival between early-onset and late-onset adenocarcinoma of esophagogastric junction: a population-based study

BACKGROUND AND AIM

The prognosis of early-onset adenocarcinoma of esophagogastric junction (AEG) remains unclear. This research aimed at comparing the prognosis between early-onset and late-onset AEGs.

METHODS

We extracted eligible patients with surgically resected, pathologically confirmed, nonmetastatic AEG from the Surveillance, Epidemiology, and End Results database from 2004 to 2015. The cutoff age of early-onset AEG was set at ≤50 years old. Univariate and multivariate Cox analysis as well as competing risk model were adopted for comparing overall survival (OS) and cancer-specific survival (CSS) between early-onset and late-onset AEGs. In addition, multiple imputation and propensity score matching (PSM) were also carried out for sensitivity analysis.

RESULTS

In total, 4610 eligible AEG patients were collected in this study, including 610 early-onset AEGs and 4000 late-onset AEGs. Kaplan-Meier curves revealed significantly better survival in early-onset AEGs than late-onset AEGs. After interpolating missing data by multiple imputation, multivariate Cox regression analysis similarly showed better OS and CSS in early-onset AEGs. By using PSM analysis at a ratio of 1:1, we matched 610 early-onset AEG patients with 610 late-onset AEG patients. After PSM, univariate Cox regression model still revealed favorable prognosis in early-onset AEGs. Similar results were confirmed by performing PSM analysis at a ratio of 1:2 and 1:3. In addition, competing risk model demonstrated significantly lower cancer-specific death in early-onset AEGs compared to late-onset AEGs before and after matching.

CONCLUSION

By applying several effective sensitivity analyses, we reported significantly favorable OS and CSS in early-onset AEGs compared to late-onset AEGs.

Recurrent Disease After Esophageal Cancer Surgery: A Substudy of The Dutch Nationwide Ivory Study

OBJECTIVE

This study investigated the patterns, predictors, and survival of recurrent disease following esophageal cancer surgery.

BACKGROUND

Survival of recurrent esophageal cancer is usually poor, with limited prospects of remission.

METHODS

This nationwide cohort study included patients with distal esophageal and gastroesophageal junction adenocarcinoma and squamous cell carcinoma after curatively intended esophagectomy in 2007 to 2016 (follow-up until January 2020). Patients with distant metastases detected during surgery were excluded. Univariable and multivariable logistic regression were used to identify predictors of recurrent disease. Multivariable Cox regression was used to determine the association of recurrence site and treatment intent with postrecurrence survival.

RESULTS

Among 4626 patients, 45.1% developed recurrent disease a median of 11 months postoperative, of whom most had solely distant metastases (59.8%). Disease recurrences were most frequently hepatic (26.2%) or pulmonary (25.1%). Factors significantly associated with disease recurrence included young age (≤65 y), male sex, adenocarcinoma, open surgery, transthoracic esophagectomy, nonradical resection, higher T-stage, and tumor positive lymph nodes. Overall, median postrecurrence survival was 4 months [95% confidence interval (95% CI): 3.6-4.4]. After curatively intended recurrence treatment, median survival was 20 months (95% CI: 16.4-23.7). Survival was more favorable after locoregional compared with distant recurrence (hazard ratio: 0.74, 95% CI: 0.65-0.84).

CONCLUSIONS

This study provides important prognostic information assisting in the surveillance and counseling of patients after curatively intended esophageal cancer surgery. Nearly half the patients developed recurrent disease, with limited prospects of survival. The risk of recurrence was higher in patients with a higher tumor stage, nonradical resection and positive lymph node harvest.

Age-specific incidence, treatment, and survival trends in esophageal cancer: a Dutch population-based cohort study

BACKGROUND

Data on the age-specific incidence of esophageal cancer are lacking. Our aim was to investigate the age-stratified incidence, treatment, and survival trends of esophageal cancer in the Netherlands, with a focus on adults <50 years.

MATERIAL AND METHODS

Patients diagnosed with esophageal cancer were included from the nationwide Netherlands Cancer Registry (1989-2018). Follow-up data were available until 31 December 2018. Annual percentage changes of incidence were analyzed according to age group (<50, 50-74, and ≥75 years) and histology type: adenocarcinoma (EAC) and squamous cell carcinoma (ESCC). Treatment trends and relative survival rates (RSR) were estimated by age and stage grouping.

RESULTS

A total 59,584 patients were included. In adults <50 years, EAC incidence tripled (mean increase per year: males 1.5%, females 3%), while the incidence of ESCC decreased (mean decrease per year: males -5.3%, females -4.3%). Patients <50 years more often presented with advanced disease stages compared to older patients and were more likely to receive multimodality treatments. Most patients <50 years with potentially curable disease were treated with neoadjuvant chemoradiotherapy followed by surgery compared to patients 50-74 and ≥75 years (74% vs. 55% vs. 15%, respectively; p < .001), and received more frequent systemic therapy once staged with palliative disease (72% vs. 54% vs. 19%, respectively; p < .001). The largest RSR improvement was seen in patients <50 years with early-stage (five years: +47%), potentially curable (five years: +22%), and palliative disease (one year: +11%). Over time, a trend of increasing survival difference was seen between patients <50 and ≥75 years with potentially curable (five-year difference: 17% to 27%) and palliative disease (one-year difference: 11% to 20%).

CONCLUSION

The incidence of EAC is increasing in adults <50 years in the Netherlands. Differences in the use of multimodality treatments with curative or life-prolonging intent in different age categories may account for increasing survival gaps.

Advanced Esophageal Squamous Cell Carcinoma in Young Female Patient With Durable Complete Response on Treatment

Esophageal carcinoma is the seventh most common cancer and the sixth most lethal cancer worldwide. There are two main histological types of esophageal carcinoma: adenocarcinoma (AC) and squamous cell carcinoma (SCC). Both histological types are more common in males than females. Menopause is an independent risk factor for esophageal cancer while usage of hormonal therapy (estrogen plus progesterone) is associated with a lower risk of esophageal SCC in postmenopausal women. Gender differences have an impact on SCC incidence, however, it is unclear if gender has a prognostic value for survival. The present case report describes a young woman who developed SCC of the esophagus. The disease was diagnosed in the locally advanced stage. Definitive chemo-radiotherapy induced complete response. These findings might suggest that in young women esophageal SCC may have a better prognosis.

Nomograms for predicting survival in early-onset esophageal cancer

Background: This study aimed to develop nomograms predicting the overall survival (OS) of patients younger than 50 years old with esophageal cancer.Methods: We selected patients included 2004-2015 in the Surveillance, Epidemiology, and End Results (SEER) database. Nomograms were constructed using significant variables from multivariable Cox analyses. The discrimination and calibration power of the models were evaluated using concordance indexes (C-indexes) and calibration curves. Decision curve analysis was used to assess the clinical net benefits of the nomograms.Results: Of 1,997 selected patients, 53.2% had advanced-stage tumor. Race, grade, T stage, N stage, and treatment were independent factors affecting OS in early-stage patients. The C-indexes of the corresponding nomogram were 0.710 (95% CI = 0.684-0.736) and 0.681 (95% CI = 0.640-0.722) in training and validation sets, respectively. Grade, marital status, and treatment were independent factors affecting OS in advanced-stage patients. The C-indexes of the corresponding nomogram were 0.677 (95% CI = 0.653-0.701) and 0.675 (95% CI = 0.638-0.712) in training and validation sets, respectively. Calibration curves demonstrated high consistency between predicted and actual survival.Conclusion: We constructed and verified nomograms that could accurately predict the survival rate of esophageal cancer in patients younger than 50 years old. This may help clinicians better understand prognostic factors.

The Overexpression of Kinesin Superfamily Protein 2A (KIF2A) was Associated with the Proliferation and Prognosis of Esophageal Squamous Cell Carcinoma

Aim

Kinesin family member 2A (KIF2A) is a member of the kinesin-13 superfamily protein. KIF2A played a role in the development of many tumors. However, the role of KIF2A in esophageal squamous cell carcinoma (ESCC) remains unclear. In this study, we aimed to investigate the role of KIF2A in ESCC.

Methods

We used bioinformatics analysis to study the expression levels and prognosis of KIF2A in ESCC and normal tissues. We also used our own samples to verify the results by immunohistochemistry. Then, the biological functions of KIF2A in ESCC was studied by cell experiments and animal experiments.

Results

Both the TCGA database and our samples showed that KIF2A was relatively highly expressed in ESCC tissues and was significantly associated with disease-free survival (P =0.037) in TCGA database. Colony formation assay, CCK8 and Western blotting results showed that knockdown of KIF2A can significantly reduce colony forming ability and proliferation ability. The results of animal experiments showed that knocking down KIF2A can significantly reduce the tumor volume of mice.

Conclusion

KIF2A might be used as a prognostic factor for ESCC, and knockdown of KIF2A could inhibit ESCC proliferation in vitro and in vivo, respectively. KIF2A could serve as a potential prognostic biomarker and therapeutic target for future ESCC.

Is the age of diagnosis of esophageal adenocarcinoma getting younger? Analysis at a tertiary care center

There are emerging data that patients <50 years are diagnosed with esophageal adenocarcinoma (EAC) more frequently, suggesting that the age threshold for screening should be revisited. This study aimed to determine the age distribution, outcomes, and clinical features of EAC over time. The pathology database at the Hospital of the University of Pennsylvania was reviewed from 1991 to 2018. The electronic health records and pathology were reviewed for age of diagnosis, pathology grade, race, and gender for a cohort of 630 patients with biopsy proven EAC. For the patients diagnosed from 2009 to 2018, the Penn Abramson Cancer Center Registry was reviewed for survival and TNM stage. Of the 630 patients, 10.3% (65 patients) were <50 years old [median 43 years, range 16-49]. There was no increase in the number of patients <50 years diagnosed with EAC (R = 0.133, P = 0.05). Characteristics of those <50 years versus >50 years showed no difference in tumor grade. Among the 179 eligible patients in the cancer registry, there was no significant difference in clinical or pathological stage for patients <50 years (P value = 0.18). There was no association between diagnosis age and survival (P = 0.24). A substantial subset of patients with EAC is diagnosed at <50 years. There was no increasing trend of EAC in younger cohorts from 1991 to 2018. We could not identify more advanced stage tumors in the younger cohort. There was no significant association between diagnosis age and survival.

Young Adults With Esophageal Adenocarcinoma Present With More Advanced Stage Tumors and Have Shorter Survival Times

BACKGROUND & AIMS

Obesity is increasing in younger populations. Barrett's esophagus is associated with central obesity, so we investigated the occurrence of esophageal adenocarcinoma (EAC) in younger patients and compared them with older patients to determine differences in features at presentation and survival times.

METHODS

We performed a single-center, retrospective study of 682 patients with a diagnosis of EAC treated from 2009 through 2012. We used a Cox proportional hazards model to compare survival times among young (less than 50 years, n = 105), middle age (51-70 years, n = 383), and older age (more than 70 years, n = 194) patients. We collected data on demographic features of patients and information from medical records. Baseline characteristics were compared using χ2 analysis for categorical variables and analysis of variance for continuous variables.

RESULTS

Higher proportions of patients in the young group presented with stage III EAC (43.8%) or stage IV EAC (33.3%), compared to the middle age group (39.7% with stage III and 21.7% with stage IV; P < .001) and older group (30.4% with stage III and 20.6% with stage IV; P < .001). The mean time of survival after diagnosis in the young group was 4 ± 4.2 years, compared to 5 ± 3.9 years in the middle age group (P = .03). The unadjusted model demonstrated an increased risk of death in the young group compared to the middle age group (hazard ratio, 1.5; 95% CI, 1.1-1.9; P = .004). Controlling for confounders such as sex, comorbidity index, stage, and the presence of intestinal metaplasia resulted in an adjusted hazard ratio of 1.34 for the young group (95% CI, 1.02-1.75; P = Intestinal metaplasia was detected in a higher proportion of patients in the middle age group (51.7%) than the young group (37.1%) (P < .001).

CONCLUSION

In a retrospective analysis of patients with EAC treated at a single center, we found that a higher proportion of young patients (younger than 50 years) present advanced-stage tumors than middle age patients; young patients also have shorter survival times than middle age patients with EAC. Studies are needed to determine whether this difference is due to a lack of symptoms or endoscopic screening or distinct mechanisms of more aggressive tumors.

Higher clinical suspicion is needed for prompt diagnosis of esophageal adenocarcinoma in young patients

BACKGROUND

Esophageal cancer is considered a disease of the elderly. Although the incidence of esophageal adenocarcinoma in young patients is increasing, current guidelines for endoscopic evaluation of gastroesophageal reflux disease and Barrett's esophagus include age as a cutoff. There is a paucity of data on the presentation and treatment of esophageal cancer in young patients. Most studies are limited by small sample sizes, and conflicting findings are reported regarding delayed diagnosis and survival compared with older patients.

METHODS

A retrospective cohort study was performed using the National Cancer Database between 2004 and 2015. Patients with esophageal adenocarcinoma were divided into quartiles by age (18-57, 58-65, 66-74, 75+ years) for comparison. Clinicopathologic and treatment factors were compared between groups.

RESULTS

A total of 101,596 patients were identified with esophageal cancer. The youngest patient group (18-57 years) had the highest rate of metastatic disease (34%). No difference in tumor differentiation was observed between age groups. Younger patient groups were more likely to undergo treatment despite advanced stage at diagnosis. Overall 5-year survival was better for younger patients with local disease, but the difference was less pronounced in locoregional and metastatic cases.

CONCLUSIONS

In this study, young patients were more likely to have metastatic disease at diagnosis. Advanced stage in young patients may reflect the need for more aggressive clinical evaluation in high-risk young patients.

PAQR3 Inhibits the Proliferation and Tumorigenesis in Esophageal Cancer Cells

Progestin and adipoQ receptor family member III (PAQR3), a member of the PAQR family, is frequently downregulated in different types of human cancer. However, its expression and functions in esophageal cancer are still unknown. This study aimed to explore the expression of PAQR3 in esophageal cancer cell lines and to investigate the role of PAQR3 in the development of esophageal cancer. Our data showed that PAQR3 is expressed in low amounts in human esophageal cancer cell lines. Overexpression of PAQR3 significantly suppressed the proliferation, migration, and invasion of esophageal cancer cells. In addition, overexpression of PAQR3 downregulated the protein expression levels of RAF1, p-MEK1, and p-ERK1/2 in esophageal cancer cells. Furthermore, overexpression of PAQR3 attenuated the tumor growth in a tumor xenograft model. In conclusion, we demonstrated that overexpression of PAQR3 suppresses cell proliferation, migration, and invasion in esophageal cancer in vitro and in vivo. Therefore, PAQR3 may act as a therapeutic target for human esophageal cancer.

Prognostic value of right upper mediastinal lymphadenectomy in Sweet procedure for esophageal cancer

BACKGROUND

The prognostic value of the right upper mediastinal lymph node dissection (RUMLND) for patients with middle or lower thoracic esophageal squamous cell carcinoma (ESCC-MLT) is still not well established yet. Our objective is to evaluate the prognostic role of the Sweet procedure plus right upper mediastinal lymph node dissection (MS) by comparing with the Sweet procedure with standard lymph node dissection (SS) in terms of long-term survival.

METHODS

Totally 1,477 ESCC-MLT patients underwent radical intent surgery (186 with MS, 1,291 with SS) at our department between January 2007 and September 2013. After propensity score matching (PSM), 186 patients from each group were matched and analyzed. The 5-year survival rates in two groups were compared by detailed stratifications in terms of clinical characteristics.

RESULTS

As for the prognostic role of RUMLND, patients treated with MS tended to obtain higher 5-year survival rate than patients treated with SS in univariate analysis (48.1% vs. 37.4%). Moreover, in multivariate analysis, MS yielded significant higher 5-year survival rate compared with SS (P=0.041). In addition, subgroup analyses of the survival between the MS and SS patients by detailed stratifications demonstrated the survival superiority in the MS group with age <60 years old, TNM stage III, number of lymph node dissection (LND) ≥15, as well as no using of postoperative adjuvant treatment.

CONCLUSIONS

The RUMLND in Sweet procedure is an independent prognostic factor for ESCC-MLT patients, especially for those with thoracic middle segment-located tumor, stage III or younger.

Early onset esophageal adenocarcinoma: a distinct molecular entity?

Esophageal adenocarcinoma (EAC) is typically diagnosed in elderly with a median age of 68 years. The incidence of EAC has been rising over the last decades, also among young adults. The aim of the study was to investigate whether early onset EAC is a distinct molecular entity. To identify early onset EACs, the nationwide network and registry of histo- and cytopathology in the Netherlands (PALGA) was searched. Twenty-eight tumors of patients aged ≤40 years were selected and matched with 27 tumors of patients aged ≥68 years. DNA was isolated from surgically resected specimen and sequenced on the Ion Torrent Personal Genome Machine with the Ion AmpliSeq Cancer Panel. No differences in mutational load between early onset and conventional EACs were observed (P=0.196). The most frequently mutated genes were TP53 (73%) and P16 (16%). Additional mutations in early onset EACs occurred exclusively in: APC, CDH1, CTNNB1, FGFR2, and STK11. In the conventional EACs additional mutations were exclusively identified in: ABL1, FBXW7, GNA11, GNAS, KRAS, MET, SMAD4, and VHL. Additional mutations besides TP53 and P16 seem to occur in different genes related to cell fate pathways for early onset EACs, while the additional mutations in conventional EACs are related to survival pathways.