The Esophagus: Do Sex and Gender Matter?

Risk factors of stent migration in esophageal cancer patients who underwent fully-covered self-expanding metal stents for malignant dysphagia or tracheoesophageal fistula

BACKGROUND

More than 50% of esophageal cancer patients are diagnosed with advanced diseases and commonly experience dysphagia, some of whom even have tracheoesophageal fistula. Self-expandable metal stent (SEMS) is one of the recommended palliative methods, although complications such as chest pain and stent migration are not uncommon. The goal of this study was to examine the predictors of stent migration.

METHODS

We conducted a retrospective cohort study to include patients with esophageal cancer and dysphagia/tracheoesophageal fistula. Clinicopathological information, stent characteristics and patient outcomes were collected for analysis, while side-effects of SEMS were recorded, potential predictors were examined, and patients' nutritional outcomes were compared in the migration and non-migration groups.

RESULTS

A total of 54 patients with esophageal cancer who received fully covered SEMS between 2013 and 2022 were included. We found tumor across the esophagogastric junction (adjusted odds ratio (OR) = 32.64, P = 0.01) and the female sex (adjusted OR = 12.5, P = 0.02) were significant predictors for stent migration. There was a decreasing tendency in body mass index/body weight in migration and non-migration groups, but the former had a steeper downslope.

CONCLUSION

Fully covered SEMS is a safe and effective strategy to palliate dysphagia or fistula. Tumor across esophagogastric junction and the female sex were higher risk predictors of stent migration. A careful patient selection would optimize the effects of SEMS placement, especially in those with short-expected lifespan.

Race and Gender Influences the Presentation of Eosinophilic Esophagitis

Our understanding of the influence of race and gender on the presentation of eosinophilic esophagitis (EoE) is incomplete. To address this gap, we examined the effect of race and gender on the presentation of EoE. In this retrospective study, we reviewed the medical records of 755 EoE patients and recorded their demographic, clinical, endoscopic, and histologic information. Descriptive statistics were used to characterize the cohort. Multivariate logistic regression was used to identify predictors of race and gender after accounting for potential confounders. There was a bimodal distribution for age at diagnosis of EoE. Approximately 43% had pediatric onset EoE, while 57% had adult onset EoE. Male (68%) predominance was observed. Dysphagia (57%) and abdominal pain (20%) were among the most common presenting symptoms. Multivariate analysis revealed that African Americans (AAs) were diagnosed earlier [aOR: 0.96 (95% CI: 0.95-0.99); P = 0.01] and had significantly lower odds of manifesting furrows [aOR: 0.30 (95% CI: 0.12-0.77); P = 0.01] as compared with Whites. Males were diagnosed earlier [aOR 0.98 (0.97-0.99; P = 0.04] and had higher odds of having abnormal endoscopic findings [aOR: 1.43 (1.05-1.97); P = 0.02] when compared with females. Race and gender influence the presentation of EoE. Future studies aimed at investigating the interplay between race, gender, and molecular mechanisms of EoE are warranted.

Sex differences in cancer-specific survival for locally advanced esophageal cancer after neoadjuvant chemoradiotherapy: A population-based analysis

Objective

Neoadjuvant chemoradiotherapy (nCRT) is the recommended standard treatment for locally advanced esophageal cancer (LA-EC). This study aimed to determine whether sex makes a difference in cancer-specific survival (CSS) and construct a novel nomogram model to predict CSS for LA-EC after nCRT based on the SEER database.

Methods

Patients coded by 04–15 were identified from the SEER database. Patients with systemic treatment and radiotherapy before surgery were defined as nCRT. We further divided this population into a training group and a verification group at a ratio of 7:3. Univariate and multivariate cox analyses were applied to determine the prognostic risk factors based on the training cohort, and then the Nomogram model was established. The area under the curve (AUC) was used to evaluate the predictive ability of the model. We used the calibration curve to evaluate the consistency between the predicted status and actual status and decision curve analysis (DCA) to evaluate the clinical value. We used X-tile software to determine the best cut-off value of nomogram scores and divided the population into low-risk, medium-risk, and high-risk groups, and Kaplan-Meier analysis was applied to compare the CSS.

Results

A total of 2096 LA-EC patients were included for further analysis, with 1,540 in the training cohort and 656 in the validation group. Male (HR: 1.29, 95% CI, 1.04 −1.58), T stage, N stage, and M stage were identified as independent risk factors of CSS based on the training cohort. A Nomogram model was constructed to predict the 3-, 5- and 7-years CSS. ROC curve and AUC confirmed that this nomogram has median discrimination ability. The calibration curve showed good agreement between predicted status and actual status. The DCA curves confirmed the clinical value. Kaplan-Meier analysis indicated that patients in the high-risk subgroup had poorer CSS in both the training cohort and validation cohort (P < 0.001).

Conclusion

Male patients had poorer CSS in LA-EC patients after nCRT. A nomogram model composed of sex, T stage, N stage, and M stage was constructed to identify the high-risk population and provide a personalized follow-up plan.

Risk Factors, Clinical and Endoscopic Features, and Clinical Outcomes in Patients with Cytomegalovirus Esophagitis

Cytomegalovirus (CMV) esophagitis is the second most common CMV disease of the gastrointestinal tract. This study aims to comprehensively analyze risk factors, clinical characteristics, endoscopic features, outcomes, and prognostic factors of CMV esophagitis. We retrospectively collected data of patients who underwent esophageal CMV immunohistochemistry (IHC) staining between January 2003 and April 2021 from the pathology database at the Chang Gung Memorial Hospital. Patients were divided into the CMV and non-CMV groups according to the IHC staining results. We enrolled 148 patients (44 CMV and 104 non-CMV patients). The risk factors for CMV esophagitis were male sex, immunocompromised status, and critical illness. The major clinical presentations of CMV esophagitis included epigastric pain (40.9%), fever (36.4%), odynophagia (31.8%), dysphagia (29.5%), and gastrointestinal bleeding (29.5%). Multiple diffuse variable esophageal ulcers were the most common endoscopic feature. The CMV group had a significantly higher in-hospital mortality rate (18.2% vs. 0%; p < 0.001), higher overall mortality rate (52.3% vs. 14.4%; p < 0.001), and longer admission duration (median, 24 days (interquartile range (IQR), 11−47 days) vs. 14 days (IQR, 7−24 days); p = 0.015) than the non-CMV group. Acute kidney injury (odds ratio (OR), 174.15; 95% confidence interval (CI), 1.27−23,836.21; p = 0.040) and intensive care unit admission (OR, 26.53; 95% CI 1.06−665.08; p = 0.046) were predictors of in-hospital mortality. In conclusion, the mortality rate of patients with CMV esophagitis was high. Physicians should be aware of the clinical and endoscopic characteristics of CMV esophagitis in high-risk patients for early diagnosis and treatment.

Disparities in esophageal cancer: less treatment, less surgical resection, and poorer survival in disadvantaged patients

The incidence of esophageal cancer has increased steadily in the last decades in the United States. The aim of this paper was to characterize disparities in esophageal cancer treatment in different racial and socioeconomic population groups and compare long-term survival among different treatment modalities. A retrospective analysis of the National Cancer Database was performed including adult patients (≥18 years old) with a diagnosis of resectable (stages I-III) esophageal cancer between 2004 and 2015. Multivariable logistic regression models were used to determine the odds of being offered no treatment at all and surgical treatment across race, primary insurance, travel distance, income, and education levels. Multivariable Cox proportional hazards models were used to compare 5-year survival rates across different treatment modalities. A total of 60,621 esophageal cancer patients were included. Black patients, uninsured patients, and patients living in areas with lower levels of education were more likely to be offered no treatment. Similarly, black race, female patients, nonprivately insured patients, and those living in areas with lower median residential income and lower education levels were associated with lower rates of surgery. Patients receiving surgical treatment, compared to both no treatment and definitive chemoradiation, had significant better long-term survival in stage I, II, and III esophageal cancer. In conclusion, underserved patients with esophageal cancer appear to have limited access to surgical care, and are, in fact, more likely to not be offered any treatment at all. Considering the survival benefits associated with surgical resection, greater public health efforts to reduce disparities in esophageal cancer are needed.

Pediatric Eosinophilic Esophagitis Endotypes: Are We Closer to Predicting Treatment Response?

Eosinophilic esophagitis (EoE) is a chronic, food antigen-driven gastrointestinal disease that is characterized by esophageal eosinophilia. Currently, there are no Food and Drug Administration (FDA)-approved treatments for EoE, but the two most commonly prescribed therapies include topical corticosteroids and food elimination diets. Clinical trials have revealed a significant proportion of cases that are resistant to topical corticosteroids, and although we define EoE as a food antigen-driven disease, not all patients with EoE respond to elimination diets or even elemental diets. The varied response to treatments highlights the heterogeneity of EoE and the need for new treatment strategies. Despite the clinical differences in treatment response, predicting the outcome remains difficult since factors including age, histologic severity at diagnosis, atopic history, and anthropometrics are not predictive of treatment response. In our practice at an academic pediatric referral center, we observe distinct clinical EoE phenotypes, including cases with atopy, connective tissue disorders, or responsiveness to a proton pump inhibitor. Similar to the work in progress with asthma, stratification of patients with EoE by clinical phenotypes and/or molecular endotypes will likely assist with therapy selection and prediction of natural history. Molecular analysis with gene expression panels also shows promise in helping us classify patients based on molecular endotypes. In additional to the clinical and molecular classifications, more accurate histologic diagnostic criteria for EoE may help us tease out small differences between patient cohorts. Despite the leaps in knowledge over the past decade regarding EoE pathogenesis, it remains a challenge to predict the response to treatment. Future studies focused on molecular, genetic, and immunologic analyses of larger patient cohorts are needed to assist in identifying EoE phenotypes and endotypes as we attempt to improve patient outcomes in pediatric EoE.

Estrogen Receptors in Regulating Cell Proliferation of Esophageal Squamous Cell Carcinoma: Involvement of Intracellular Ca2+ Signaling

Esophageal cancer is a deadly disease in the esophagus with a poor prognosis. Over 90 % of esophageal cancer is esophageal squamous cell carcinoma (ESCC) and its pathogenic mechanisms remain unclear. Epidemiology study found a strong gender difference with a sex ratio of 8-9:1 in favor of males, but the molecular mechanisms for so striking gender difference are poorly understood so far. In the present study, we demonstrated the expression of estrogen receptors in human ESCC cells. 17β-E2 but not 17α-E2 was found to dose-dependently suppress the cell proliferation of human ESCC cells, which was attenuated by estrogen receptor antagonist ICI1 82,780. Furthermore, 17β -E2 but not 17α-E2 10 nM markedly induced both intracellular Ca²⁺ release and extracellular Ca²⁺ entry into ESCC cells, which was again attenuated by estrogen receptor antagonist ICI182,780. Taken together, our data clearly demonstrate that estrogen exerts anti-proliferative action on human ESCC cells likely through estrogen receptor-Ca²⁺ signaling pathway, which may provide a reasonable explanation on the striking male predominance of ESCC.

Gender is a determinative factor in the initial clinical presentation of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease resulting in symptoms of esophageal dysmotility. Abnormalities include dysphagia, food impaction and reflux. Although men appear to comprise a majority of the EoE population, few studies have directly assessed gender-associated clinical differences. The aim of this study is to identify the effect of gender on the initial clinical presentation of adult-onset EoE patients. We reviewed our electronic medical record database from January 2008 to December 2011 for adults diagnosed with EoE per the 2011 updated consensus guidelines. Patient demographics, presenting symptoms, endoscopy findings and complications were recorded. Proportions were compared using chi-squared analysis, and means were compared using the Student's t-test. A total of 162 patients met the inclusion criteria and 71 (44%) were women. Women were more likely to report chest pain (P = 0.03) and heartburn (P = 0.06), whereas men more commonly reported dysphagia (P = 0.04) and a history of food impaction (P = 0.05). Endoscopic findings were similar between groups. No patients suffered esophageal perforations. These data suggest that men report more fibrostenotic symptoms and women report more inflammatory symptoms at the time of diagnosis. There was no difference in endoscopic findings between genders. This is one of the only reviews comparing differences in clinical presentation, endoscopic findings and complications between gender for EoE. The current recommended guidelines state that any patient with symptoms of esophageal dysfunction should be biopsied for EoE. Our findings support biopsying patients with typical and atypical symptoms of dysmotility including heartburn and chest pain.

The Effect of Male Sex on Survival in Systemic Sclerosis

Objective.

Systemic sclerosis (SSc) has a female predominance, however, little is understood about the effect of sex on SSc manifestations and survival. The objectives of our study were to evaluate differences in disease manifestations, and survival rates between males and females with SSc.

Methods.

A retrospective cohort study of the Toronto Scleroderma Program was conducted to evaluate sex-based differences in disease manifestations and survival. A relative survival analysis compared SSc survival to the general population.

Results.

There were 959 patients (791 females, 168 males) identified, with a female:male ratio of 4.7:1. Males more frequently had diffuse SSc [45% vs 30%, relative risk (RR) 1.44, 95% CI 1.18–1.75] and interstitial lung disease (ILD; 41% vs 33%, RR 1.24, 95% CI 1.01–1.52). There were 324 deaths (65 males, 259 females). Males had increased unadjusted mortality compared to females (HR 1.57, 95% CI 1.19–2.06). In an adjusted model including immunosuppressive use, male sex (HR 1.40, 95% CI 1.06–1.85), ILD (HR 1.58, 95% CI 1.26–1.98), and older age at diagnosis (HR 1.05, 95% CI 1.04–1.06) were independently associated with increased mortality, whereas the limited subtype (HR 0.70, 95% CI 0.49–0.77) and anticentromere antibodies (HR 0.70, 95% CI 0.49–0.98) were independently associated with decreased mortality. Male sex was associated with increased risk of mortality (HR 1.16, p = 0.003) in patients with SSc above that observed for males in the general population.

Conclusion.

The differential effect of disease between sexes is small, yet males have decreased survival compared to females with SSc.