Real-time rapid reverse transcriptase-polymerase chain reaction for intraoperative diagnosis of lymph node micrometastasis: clinical application for cervical lymph node dissection in esophageal cancers

Extension of lymph node dissection in the surgical treatment of esophageal and gastroesophageal junction cancer: seven questions and answers

The role of two- or three-field nodal dissection in the surgical treatment of esophageal and gastroesophageal junction cancer in the minimally invasive era is still controversial. This review aims to clarify the extension of nodal dissection in esophageal and gastroesophageal junctional cancer. A basic evidence-based analysis was designed, and seven research questions were formulated and answered with a narrative review. Reports with little or no data, single cases, small series and review articles were not included. Three-field lymph node dissection improves staging accuracy, enhances locoregional disease control and might improve survival in the group of patients with cervical and upper mediastinal metastatic lymph nodal involvement from middle and proximal-third esophageal cancer.

Cervical or thoracic anastomosis for patients with cervicothoracic esophageal squamous cell carcinoma

Background

For cervical and higher-level esophageal tumors, the choice of cervical anastomosis or thoracic anastomosis is still controversial. The goal of this study was to explore the optimal surgical approach for cervicothoracic esophageal squamous tumors.

Methods

We retrospectively analyzed 3,802 consecutive patients with esophageal squamous cell tumors in Nanjing Drum Tower Hospital from Jan 2001 to Jan 2017. Twenty-six patients with cervical anastomosis and twenty-eight patients with thoracic anastomosis were evaluated.

Results

The cervical anastomosis group exhibited a greater number of resected lymph nodes (36.5±7.3 vs. 19.9±5.7, P<0.001). In addition, the cervical anastomosis group exhibited a higher recurrence rate (71.4% vs. 41.7%, P=0.047) and increased locoregional recurrence (P=0.040). Overall survival was not significantly different between groups (P=0.331). Moreover, multivariate Cox regression analysis revealed that postoperative locoregional recurrence is an independent risk factor for survival (P=0.031, 95% CI: 1.114-8.952).

Conclusions

Thoracic anastomosis led to satisfactory results in patients with cervicothoracic esophageal squamous tumors.

Patterns and Prognostic Significance of Cervical Lymph Node Metastasis and the Efficacy of Cervical Node Dissection in Esophageal Cancer

Background

The clinical value of 3-field lymph node dissection (3FLND) in esophageal squamous cell carcinoma (ESCC) remains controversial. This study aimed to identify the patterns and prognostic significance of cervical lymph node metastasis (CLNM) in ESCC.

Methods

A retrospective review of 77 patients with ESCC who underwent esophagectomy and 3FLND between 2002 and 2016 was conducted. For each cervical node level, the efficacy index (EI), overall survival, recurrence rate, and complication rate were compared.

Results

CLNM was identified in 34 patients (44.2%) who underwent 3FLND. Patients with CLNM had a significantly lower overall survival rate (22.7% vs. 58.2%) and a higher recurrence rate (45.9% vs. 16.3%) than patients without CLNM. CLNM was an independent predictor of recurrence in ESCC patients. Moreover, in patients with pathologic N3 tumors, the odds ratio of CLNM was 10.8 (95% confidence interval, 2.0 to 57.5; p= 0.005). Level IV dissection had the highest EI, and level IV metastasis was significantly correlated with overall survival (p=0.012) and recurrence (p=0.001).

Conclusion

CLNM was a significant prognostic factor for ESCC patients and was more common among patients with advanced nodal stages. Level IV exhibited the highest risk of metastasis, and dissection at level IV may be crucial when performing 3FLND, especially in advanced nodal stage disease.

The pattern of cervical lymph node metastasis in thoracic esophageal squamous cell carcinoma may affect the target decision for definitive radiotherapy

BACKGROUND

Metastasis to lymph nodes is a key determinant of thoracic esophageal squamous cell carcinoma (TE-SCC) prognosis. We sought to identify factors linked with cervical lymph node metastasis, which could be used to inform the decision of surgical and definitive radiotherapy.

METHODS

We retrospectively reviewed records from 1715 patients who had had radical esophagectomy with three-field lymphadenectomy between January 1993 and March 2007 in our hospital. All patients included in the study had pathologically confirmed TE-SCC and no clinical evidence of cervical metastasis.

RESULTS

Cervical node metastases were found in 547 patients (31.9%); rates of cervical-node positivity were 44.2% for those with upper-thoracic tumors, 31.5% for mid-thoracic tumors, and 14.4% for lower-thoracic tumors. Univariate analysis showed that cervical node metastasis was associated with tumor site, differentiation, and length, pathologic T status, and pN status (P<0.05); however, only tumor site and pN status retained significance in multivariate analysis (P<0.05). Positive cervical nodes were most often found in the paraesophageal region (72.3%), followed by supraclavicular (24.4%); involvement of deep cervical (2.4%) or retropharyngeal nodes (0.9%) was rare (P<0.0001). Positive cervical nodes were most often associated with upper TE-SCCs (60.1%), followed by middle TE-SCCs (31.2%) and lower TE-SCCs (10.6%).

CONCLUSIONS

Upper TE-SCC with multiple involved nodes at any site was associated with a high rate of cervical node metastasis. These findings provide critical information for clinical decision-making regarding the extent of nodal dissection or the size of radiation fields in definitive radiotherapy.

Three-field lymph node dissection in treating the esophageal cancer

There are many controversies in lymphadenectomy for thoracic esophageal cancer, and whether 3-field lymphadenectomy or 2-field lymphadenectomy is better have still been in doubt. The aim of this article is to review the role of the lymph node dissection by introducing the merits and demerits in 3-field lymphadenectomy, and the development in lymphadenectomy's selection, treatment and diagnosis. All the literatures related to esophageal lymphadenectomy and minimally invasive surgery (MIE) were searched in PubMed database and the cross references were added and reviewed to complete the reference list. Several researches elucidated that better overall survival (OS) in patients with esophageal cancer after 3-field lymphadenectomy had been reported worldwide, and 3-field lymphadenectomy is more suitable for treating esophageal cancer with cervical and/or upper mediastinal lymph nodes metastasis than 2-field lymphadenectomy regardless of the tumor's histology and location. Many approaches based on the characteristics of esophageal cancer lymph node metastasis are taken to improve the accuracy of 3-field lymphadenectomy and decrease the postoperative morbidity and mortality, while every approach needs further studies to demonstrate its feasibility. The benefits of the recently rapid-developed techniques performed in treating esophageal cancer: the MIE and the robotic-assisted thoracoscopic esophagectomy are illuminated as well, and both of them are technically safe and feasible for esophageal cancer, whereas further evaluations are still necessary.

Role of genetic detection in peritoneal washes with gastric carcinoma: The past, present and future

The most frequent cause of treatment failure following surgery for gastric cancer is peritoneal dissemination, mainly caused by the seeding of free cancer cells from the primary gastric cancer, which is the most common type of spread. Unfortunately, there is no standard modality of intraperitoneal free cancer cells detection to predict peritoneal metastasis until now. We reviewed English literature in PubMed was done using the MeSH terms for gastric cancer, peritoneal wash, and reverse transcriptase polymerase chain reaction. All the articles were reviewed and core information was tabulated for reference. After a comprehensive review of all articles, the data was evaluated by clinical implication and predictive value of each marker for peritoneal recurrence. There are still many limitations to overcome before the genetic diagnosis for free cancer cells detection can be considered as routine assay. To make it a reliable diagnostic tool for detecting free cancer cells, the process and method of genetic detection with peritoneal washes should be standardized, and the development of simple diagnostic devices and easily available kits are necessary. Herein, we reviewed the past, present and future perspectives of the peritoneal lavage for the detection of intraperitoneal free cancer cells in patients with gastric cancer.

Impact of the route of reconstruction on post-operative morbidity and malnutrition after esophagectomy: a multicenter cohort study

BACKGROUND

Reconstruction after esophagectomy is mainly performed through the retrosternum (RS) or posterior mediastinum (PM). However, the best approach is not clear. This study aimed to assess the impact of the route of gastric conduit reconstruction, after esophagectomy for esophageal squamous cell carcinoma (ESCC), on post-operative outcomes.

METHODS

We analyzed 298 patients who underwent radical esophagectomy for ESCC at three high volume centers between 2008 and 2009. Among them, the RS was selected in 166 patients and PM in 118; while, the antethoracic route was used in 14 patients. Post-operative morbidity, mortality, and long-term outcome were compared.

RESULTS

There were no differences between patients of the two routes with respect to operative blood loss (RS: 753 ± 519, PM: 748 ± 414 g) and post-operative complications, including pulmonary problems (RS: 15 %, PM: 10.2 %) and anastomotic leakage (RS: 9.0 %, PM: 5.1 %); although, the operating time (RS: 566 ± 97, PM: 472 ± 79 min; p < 0.0001) was shorter in the PM group than the RS group. The percentage weight loss after surgery was significantly less in the PM group than the RS group at 1 year (8.6 vs. 11.1 %; p = 0.025); although, the percentage at discharge was not different between the groups (PM: 4.9 %, RS: 6.3 %; p = 0.072). Multivariate analysis identified pre-operative body weight and the reconstruction route as significant and independent factors associated with 1-year weight loss.

CONCLUSIONS

The results indicate gastric tube reconstruction through the posterior mediastinal route after esophagectomy may relieve post-operative 1-year malnutrition without increasing post-operative complications.

Intraoperative photodynamic diagnosis of lymph node metastasis in esophageal cancer patients using 5-aminolevulinic acid

Lymph node metastasis is the strongest prognostic factor in esophageal cancer patients who have undergone esophagectomy. The accurate diagnosis of lymph node metastasis is important, but the pre-operative diagnostic accuracy is poor. The intraoperative diagnosis based on histopathological examination of frozen tissue specimens is complicated and time-consuming. Therefore, the establishment of a simple and rapid intraoperative diagnostic method is essential. Exogenous application of 5-aminolevulinic acid (ALA) causes a selective accumulation of protoporphyrin IX, which is a fluorescent substrate, in cancer cells. The present study evaluated the feasibility of photodynamic diagnosis using ALA (ALA-PDD) for lymph node metastasis in esophageal cancer. A total of 292 lymph nodes were analyzed from 8 esophageal squamous cell cancer patients treated with esophagectomy. The patients were administered ALA orally prior to surgery. Excised lymph nodes were cut in half and examined by spectrometer. The diagnostic results of ALA-PDD were compared to those of the histopathological examination. Among the 292 lymph nodes, 19 nodes (6.5%) were histologically metastatic and 21 nodes (7.2%) were PDD-positive. The sensitivity and specificity of ALA-PDD were 84.2% (16/19) and 98.2% (268/273), respectively. The area of cancer nests of the PDD-negative lymph nodes was <2 mm². Metastatic lymph nodes, including cancer nests >4 mm², were correctly diagnosed by ALA-PDD. In conclusion, this study demonstrated that ALA-PDD of lymph node metastasis in patients with esophageal cancer is feasible. Further investigation would make this method a simple and rapid intraoperative diagnostic tool.

Therapeutic value of lymph node dissection for esophageal squamous cell carcinoma after neoadjuvant chemotherapy

BACKGROUND AND OBJECTIVES

The optimal extent of lymphadenectomy in patients with esophageal cancer is controversial. This study aimed to examine the therapeutic value of lymph node (LN) dissection for each LN station in patients with esophageal squamous cell carcinoma (ESCC) who receive neoadjuvant chemotherapy.

METHODS

In 304 patients with ESCC who underwent neoadjuvant chemotherapy, Efficacy Index (EI) was calculated by multiplying the incidence of metastasis by the 3-year survival rate of patients with positive nodes for each LN station.

RESULTS

Prognosis was better in responders to neoadjuvant chemotherapy than non-responders (3-year survival; 66.3% vs 48.1%, P = 0.0035). The total number of resected LNs did not affect survival although the number of positive LNs did. The number of resected LNs did not correlate with the number of metastatic LNs. Cardiac LN and recurrent nerve LN showed high EI, irrespective of tumor location. EI for each LN station did not vary according to the response to neoadjuvant therapy.

CONCLUSIONS

The present study showed that therapeutic value of each LN was not affected by preoperative chemotherapy. The location of resected LNs rather than the total number of resected LNs may be more important to maximize the survival benefit of lymphadenectomy.

LOH detected by microsatellite markers reveals the clonal origin of recurrent laryngeal squamous cell carcinoma

BACKGROUND

The question of whether "recurrent" laryngeal carcinoma is truly a new tumour with a clonal origin that differs from that of the primary tumour has remained unanswered. The objective of this study was to determine whether recurrent tumours have the same genetic basis as primary tumours, as the answer to this question is important for the development of treatment strategies.

MATERIALS AND METHODS

Matched samples consisting of primary tumour, recurrent tumour and normal tissue were obtained from the same patient. A total of 37 patients with laryngeal cancer were examined for loss of heterozygosity (LOH) on the 3p, 5p, 7q, 8p, 9p, 13p, 17p and 18q chromosomal arms using PCR to amplify microsatellite markers. All patients were routinely followed up and 5-year survival rates were calculated using directly calculating method and Kaplan-Meier's method.

RESULTS

A total of 28 out of 37 (75.6%) patients showed LOH at a minimum of one locus, and 19 out of 37 (51.3%) patients showed LOH at two loci. Primary and recurrent tumours in each patient showed identical allelic loss patterns and incidence rates. Patients without LOH had a longer average time to recurrence than patients with LOH (P<0.05). Additionally, patients with LOH had a longer average smoking duration prior to surgery than patients without LOH (P<0.05). The 5-year survival rates were 32.14%in patients with LOH versus 44.4% in patients without LOH.

CONCLUSIONS

The data indicate that primary and recurrent tumours have the same clonal origin. This result implies that we failed to radically resect the primary tumours and/or micrometastases in these patients. Consequently, some form of adjunctive therapy may be necessary. Additionally, the data indicate that the recurrence of laryngeal squamous cell carcinoma is closely related to chromosomal aberrations (specifically LOH).

Prognostic value of genetic detection using CEA and MAGE in peritoneal washes with gastric carcinoma after curative resection: result of a 3-year follow-up

Peritoneal metastasis is the most frequent cause of death in patients with gastric cancer. Reverse transcriptase-polymerase chain reaction (RT-PCR) assay of peritoneal washes has been used to predict peritoneal metastasis of gastric carcinoma. We applied carcinoembryonic antigen (CEA) and melanoma-associated gene (MAGE) RT-PCR for the detection of peritoneal metastasis of gastric carcinoma after curative surgery and evaluated its clinical significance. Peritoneal washes were obtained from 117 patients with gastric carcinoma. MAGE A1-A6 and CEA RT-PCR were performed, and the results were evaluated according to their clinicopathologic characteristics. Three-year follow-up clinical studies were periodically performed, and disease-free survival rates were retrospectively investigated using the medical records. Among 117 peritoneal fluids, 11 cases (9.4%) revealed MAGE expression and 38 cases (32.5%) revealed CEA expression. When focusing on recurrence rates, RT-PCR-positive had much higher recurrence rates than RT-PCR-negative cases (32.5% vs 5.2%, P < 0.01). Univariate analysis revealed that depth of invasion, lymph node metastasis, tumor node metastasis (TNM) stage, Lauren classification, and MAGE and CEA expressions were independent prognostic factors for recurrence. In a multivariate analysis, MAGE expression and TNM stage were significantly and independently related to recurrence in patients who underwent curative resection. MAGE expression was determined to be the most important prognostic factor for recurrence (hazard ratio: 12.487, P < 0.01). It is feasible to identify free cancer cells in peritoneal lavage by using a MAGE A1-A6 and CEA RT-PCR. MAGE RT-PCR results disclosed significant associations with peritoneal recurrence and proved to be the most important factor for the recurrence rate in patients with gastric carcinoma who had undergone radical resection.

Assessment of sentinel node concept in esophageal cancer based on lymph node micrometastasis

PURPOSE

The clinical significance of lymph node micrometastasis remains unclear in patients with esophageal cancer. Therefore, accurate assessment of lymph node status including micrometastasis is important when performing sentinel node (SN) navigation surgery. The purpose of the present study was to investigate the adequacy of SN concept based on lymph node micrometastasis determined by immunohistochemistry (IHC) and reverse transcription-polymerase chain reaction (RT-PCR) in patients with esophageal cancer.

METHODS

A total of 57 patients with esophageal cancer who were preoperatively diagnosed as having T1-T2 (cT1-T2) and N0 (cN0) were enrolled. They underwent standard esophagectomy with lymph node dissection. One day before surgery, a total of 3 mCi of 99mTechnetium-tin colloid was endoscopically injected into the submucosa around the tumor. During the operation, radioisotope uptake in the lymph nodes was measured using Navigator GPS. All dissected lymph nodes were investigated by RT-PCR using the double marker of CEA and SCC, hematoxylin-eosin (HE) staining, and IHC.

RESULTS

Node-positive incidence identified by HE and IHC was 12.3% (7/57) and 19.3% (11/57), respectively. RT-PCR demonstrated micrometastasis in four of 46 patients without nodal metastasis determined by HE staining and IHC. No non-SN metastases were found in 42 patients without micrometastasis identified by IHC and RT-PCR of SN. Accuracy and false negative rates were 100% (57/57) and 0% (0/42), respectively.

CONCLUSIONS

SN concept might be acceptable in patients with cT1-T2 and cN0 esophageal cancer, even in the presence of micrometastasis identified by IHC and RT-PCR.

Intraoperative diagnosis of lymph node metastasis by transcription-reverse transcription concerted reaction assay in gastric cancer

BACKGROUND

Increasing evidence has been accumulated to substantiate the clinical usefulness of quantitative evaluation of gene expression. This study was undertaken to assess diagnosis of metastasis in dissected lymph nodes through quantitative evaluation of the expression of carcinoembryonic antigen mRNA (CEA mRNA) by a rapid, simple transcription-reverse transcription concerted reaction (TRC) assay using dissected lymph node washings.

METHODS

A total of 110 dissected lymph nodes from 40 patients undergoing surgery for gastric cancer were studied. Each dissected lymph node was cut crosswise and washed with physiological saline. The washings were assayed for CEA mRNA and the assay results were assessed in comparison with the pathological diagnosis [hematoxylin and eosin (H&E) staining]. All lymph nodes were also subjected to immunostaining for cytokeratin (CK staining) and assessed comparatively.

RESULTS

By H&E staining, 29 lymph nodes were found to be positive and 81 to be negative for metastasis. By TRC assay, 38 lymph nodes were found to be positive and 72 to be negative. According to the results of CK staining, there were 37 metastasis-positive lymph nodes and 73 negative nodes. The sensitivity and specificity of H&E staining relative to those of CK staining were 78.4 and 100 %, respectively, while the sensitivity and specificity of TRC assay relative to those of CK staining were 91.9 and 94.5 %, respectively.

CONCLUSIONS

The TRC assay method using lymph node washings is a rapid, simple genetic diagnosis with greater sensitivity than conventional diagnosis by H&E staining of permanent specimens, and enables conservation of lymph nodes in toto as permanent specimens. This TRC method would enable rapid diagnosis even in town hospitals where no pathologist is ordinarily stationed, and is considered to contribute to the clinical application of the sentinel node theory of gastric cancer treatment.

Overexpression of PFTK1 predicts resistance to chemotherapy in patients with oesophageal squamous cell carcinoma

Background:

Recently, PFTK1 was identified as a member of the cyclin-dependent kinase family; however, its expression and clinical significance in oesophageal squamous cell carcinoma (ESCC) have not been evaluated.

Methods:

PFTK1 expression was initially examined by expression microarray in 77 ESCC patients. Using independent samples of 223 patients, PFTK1 expression was evaluated immunohistochemically to assess the relationship between expression and various clinicopathological parameters. The association between PFTK1 and the response to chemotherapy was also investigated in pretreatment samples of 85 patients who received chemotherapy as first treatment.

Results:

Significant upregulation of PFTK1 expression was noted in ESCC compared with normal epithelium. PFTK1 expression was positive in 51.6% (115 out of 223) of the tumours, but did not correlate with any clinicopathological parameter. The 5-year overall survival rate was poorer in patients positive for PFTK1 (43.6%) than those with negative expression (66.2%, P<0.001). Uni- and multivariate analyses identified PFTK1 as an independent marker of prognosis (RR=2.428, 95% CI=1.615–3.711, P<0.001). Out of 85 biopsy samples, 40 (47.1%) tumours showed PFTK1-positive expression, and the response rate to chemotherapy was significantly lower than PFTK1-negative tumours (27.9% vs 72.1%, P<0.001).

Conclusion:

PFTK1 is not only useful as a prognostic marker, but also as a predictor of the response to chemotherapy.

Oncofetal protein, IMP-3, a potential marker for prediction of postoperative peritoneal dissemination in gastric adenocarcinoma

BACKGROUND

The aim of this study was to determine the expression of insulin-like growth factor-II messenger RNA (mRNA)-binding protein-3 (IMP-3) and its clinical significance in gastric cancers, as well the prognostic value of its expression in the peritoneal lavage fluid after surgery.

METHODS

IMP-3 expression was examined by immunohistochemistry in 96 primary gastric tumors. IMP-3 mRNA expression in peritoneal lavage fluid obtained at laparotomy was determine by real-time quantitative reverse transcriptase-polymerase chain reaction (RT-PCR).

RESULTS

Positive staining for IMP-3 was observed in 74% (71/96) of the tumors. IMP-3 expression in gastric tumors correlated significantly with worst overall survival (OS) and recurrence-free survival. Multivariate analyses identified pathological N stage and IMP-3 expression as significant independent prognostic factors for disease-free survival. Eight (28%) of 36 peritoneal lavage samples were cytologically negative but positive for IMP-3 mRNA expression by RT-PCR. The OS of patients with IMP-3-positive peritoneal lavage was significantly worse than of those with negative expression.

CONCLUSIONS

IMP-3 expression in primary gastric tumors was an independent poor prognostic factor. IMP-3 mRNA expression in peritoneal lavage fluid was a predictor of recurrence after surgery in gastric cancer and a marker of poor prognosis.

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.

p53 genotype predicts response to chemotherapy in patients with squamous cell carcinoma of the esophagus

BACKGROUND

Response to chemotherapy and anatomical spread are significant prognostic factors in patients with esophageal squamous cell carcinoma (ESCC) treated by chemotherapy then surgery. Predicting the response to chemotherapy would allow significant optimization of cancer treatment.

METHODS

Genomic mutation and protein expression of p53 were investigated retrospectively by polymerase chain reaction (PCR) single-strand conformation polymorphism (SSCP) and immunohistochemistry (IHC) using biopsy specimens from 77 ESCC patients before chemotherapy with 5-fluorouracil, adriamycin, and cisplatin. p53 status was correlated with various clinicopathological factors. Thereafter, we performed a prospective study of 20 consecutive patients to test our prediction model.

RESULTS

The retrospective study showed mutant p53 genotype and positive p53 IHC staining in 46.8 and 55.8% of patients, respectively, which was not associated with patient's clinicopathological findings including initial tumor stage. Objective response to chemotherapy was observed in 65.9% of patients with wild genotype, but in only 16.7% of patients with mutant genotype. Patients with mutations in p53 therefore showed significantly poorer prognosis than those without mutant p53. In contrast, p53 IHC staining did not correlate with response to chemotherapy, curative resection rate or prognosis. In the prospective study, p53 mutation was seen in 50% (10/20) of patients and was again consistently associated with poorer response to chemotherapy and poorer prognosis.

CONCLUSIONS

p53 genotype of pretreatment biopsy is a potentially useful predictor of response to chemotherapy and prognosis in ESCC patients. This information might be valuable to clinicians in deciding on the optimal clinical strategy in patients with ESCC.

Molecular diagnosis of sentinel lymph node metastases in cervical cancer using squamous cell carcinoma antigen

PURPOSE

To clarify the prognostic value of molecular diagnosis of SLN metastases in cervical cancer using SCCA.

EXPERIMENTAL DESIGN

All SLNs and primary tumors, part of non-SLNs, were harvested from 36 patients with cervical cancer. Expression levels of SCCA, cytokeratin 19 (CK19), and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) mRNA in 178 samples (29 primary tumors, 5 histologic positive nodes, 60 histologic negative SLNs, 69 non-SLNs, and 15 normal nodes) were assessed by quantitative reverse transcription-PCR assay. The quantitative value of SCCA or CK19 mRNA was described as each value relative to GAPDH mRNA. The cutoff value was set at the upper limit of the quantitative value of nodes from noncancer patients, and those above this value constituted the molecular metastasis group.

RESULTS

The SCCA mRNA expression values were more than 1 x 10(3) in 28 primary tumors and all histologic positive nodes, and its expression levels in SLNs were higher than in non-SLNs. SLNs from patients with adverse prognostic features had higher SCCA mRNA expression levels. Four histologic negative SLNs were diagnosed molecular metastases based on SCCA mRNA. Two cases with histologically uninvolved pelvic nodes recurred. Survival analysis indicates that molecular lymphatic metastasis based on elevated SCCA mRNA level is the best predictor of recurrence. However, CK19 is not a suitable marker due to its low specificity and relative higher baseline expression in normal nodes.

CONCLUSIONS

SCCA mRNA levels for molecular diagnosis of SLN metastases in cervical cancer more accurately identifies patients at risk for recurrence than the routine histology does.

Histological features of lymph node metastasis in patients with biliary tract cancer

BACKGROUND AND OBJECTIVES

The presence of lymph node (LN) metastases is an important prognostic factor in patients with biliary cancers. The aim of this study was to characterize systematically the morphological features of metastatic LNs in biliary cancers.

METHODS

Four hundred ninety-six LNs (including 112 para-aortic LNs) dissected from 47 patients with biliary cancer were examined. The diameter of the long axis (size) and the percent metastatic area relative to whole-node area were measured from histologic specimens.

RESULTS

The average size of metastatic LNs (9.5 mm) was significantly larger than those without metastasis (6.5 mm; P < 0.01). The optimum cut-off size for positive LNs was >7.5 mm, but the sensitivity of this predictor of metastasis was low (60.8%). In general, metastatic area correlated significantly with the size of metastatic LNs (P = 0.023). Para-aortic LNs contained metastasis in 7.1% of cases, and only 25% of para-aortic LNs with a high ratio of metastatic area could be evaluated from preoperative CT scans.

CONCLUSIONS

Although large LNs are highly suggestive of metastasis, poor detection of many small LNs with a low percentage of metastatic area can increase risk in patients with biliary tract cancer.

Circulating micrometastases of esophageal cancer detected by carcinoembryonic antigen mRNA reverse transcriptase-polymerase chain reaction: clinical implications

In some patients without distant metastases according to conventional preoperative investigations, relapse occurs in distant organs within a few years after radical resection of esophageal cancer. Various attempts have been made to detect micrometastases that are not found by conventional techniques. A quantitative real-time reverse-transcriptase polymerase chain reaction was used to detect messenger RNA for carcinoembryonic antigen in 147 blood samples from 49 patients scheduled for radical resection of esophageal cancer at Juntendo University Hospital between September 2003 and June 2004. The number of circulating cancer cells was assessed and the clinical significance of detecting such micrometastases was analyzed. Multivariate analysis showed that positivity of this assay was significantly associated with pT1 or pT2 disease and stage III or stage IV disease. Patients with more than 40-50 carcinoembryonic antigen mRNA copies among 10(4) normal cells on quantitative analysis had a higher recurrence rate. The number of tumor cells circulating in the blood may have more influence on the prognosis of esophageal cancer than the presence of tumor cells.

Sentinel lymph node as a target of molecular diagnosis of lymphatic micrometastasis and local immunoresponse to malignant cells

The sentinel lymph node (SLN) is defined as the lymph node(s) first receiving lymphatic drainage from the site of the primary tumor. The histopathological status of SLN is one of the most significant predictors of recurrence and overall survival for most clinical stage I/II solid tumors. Recent progress in molecular techniques has demonstrated the presence of micrometastatic tumor cells in SLN. There is now a growing body of data to support the clinical relevance of SLN micrometastasis in a variety of solid tumors. Increasing the sensitivity of occult tumor cell detection in the SLN, using molecular-based analysis, should enable a more accurate understanding of the clinical significance of various patterns of micrometastatic nodal disease. The establishment of metastasis to SLN might not be simply reflected by the flow dynamics of lymphatic fluid that drains from the primary site to the SLN, and the transportation of viable cancer cells. Recent studies have demonstrated that primary tumors can actively induce lymphangiogenesis and promote SLN metastasis. Moreover chemokine receptors in tumor cells may facilitate organ-specific tumor metastasis in many human cancers and some experimental models. In contrast, recent clinical and preclinical studies regard SLN as the first lymphoid organ to respond to tumor antigenic stimulation. SLN dramatically show morphological, phenotypical and functional changes that indicate immune suppression by tumor cells. The immune suppression in SLN results in failure of prevention or eradication of tumor metastasis. The mechanism of immunomodulation remains unclear; however, several regulatory molecules produced by tumor cells and tumor-associated macrophages or lymphocytes are likely to be responsible for inducing the immune suppression in SLN. Further studies may develop a novel immunotherapy that overcomes tumor-induced immune suppression and can prevent or eradicate SLN metastasis.

Genetic detection of free cancer cells in the peritoneal cavity of the patient with gastric cancer: present status and future perspectives

The purpose of this review is to examine the current status and future perspectives of the molecular analysis of peritoneal lavage fluid in patients with gastric cancer. During the past 10 years, the polymerase chain reaction (PCR) has been applied for the molecular detection of free cancer cells in the abdominal cavity of patients with gastric cancer, and its clinical significance in establishing the presence of peritoneal dissemination has been assessed by several groups especially in Japan. The majority of these studies have confirmed the predictive value of the molecular detection of peritoneal metastasis and recurrence using peritoneal lavage fluid. Based on these findings, since April 2006, the genetic diagnosis of body fluids has been included in the Japanese Government public health insurance program for patients with solid tumors. However, there are still many obstacles to overcome before the genetic diagnosis of micrometastasis can be considered a routine laboratory assay. Here we review the importance of the molecular detection of cancer cells in the abdominal cavity, and the molecular techniques used for such diagnosis; we also provide some clinical examples to illustrate the value of molecular diagnosis.

The current management of esophageal cancer

The divergence in epidemiology between the East and West has made interpretation of data in the literature more difficult and has affected the choice of the most appropriate surgical technique and treatment strategies. The management of esophageal cancer certainly has evolved, and many more options are available. Stage-directed strategies and individualization of treatment are important considerations. Surgeons play a central role in directing management of this disease by advising how best to integrate surgical therapy with nonoperative programs. Surgeons should aim at improving their results further, so that the best results of surgery are compared with seemingly "safer" nonsurgical therapies. Low death rates have been achieved in specialized centers, but there still is much room for improvement in morbidity rates. Even with the best surgical resection and chemoradiation therapy, distant failure remains a barrier to improved survival rates. Therapeutic improvements will require more effective systemic drugs and a better ability to predict responders with precision. Management strategies will evolve further, with improvements in molecular techniques, imaging methods, and introduction of more novel tumoricidal agents. The challenge for the future is to test strategies critically in a scientific, unbiased manner and to explore other innovative treatments.

Circulating tumor cells in perioperative esophageal cancer patients: quantitative assay system and potential clinical utility

PURPOSE

To establish a quantitative system for evaluating the role of circulating tumor cells (CTC) in peripheral blood samples in patients who undergo surgery for treatment of esophageal cancer.

EXPERIMENTAL DESIGN

One hundred fifty-five peripheral blood samples from 53 esophageal cancer patients were collected before surgery (B-1), immediately after surgery (B0), and on the 3rd day postoperatively (B+3). Eighty-nine samples from 22 benign patients who underwent thoracotomy and 30 healthy volunteers were obtained as controls. A real-time reverse transcription-PCR quantitative analysis system based on carcinoembryonic antigen (CEA) mRNA gene expression was designed for detection of CTC.

RESULTS

This developed system can detect CEA mRNA-positive cells down to 3 cells per milliliter of peripheral blood. The cells in negative control groups were lower than the detection limit. The medians of 188 [95% confidence interval (95% CI), 155-498], 1513 (95% CI, 660-7,974) and 707 (95% CI, 737-3,005) CEA mRNA-positive cells per mL with the CEA-positive rates of 28.3%, 60.4%, and 42.9% in B-1, B0, and B+3 peripheral blood samples were obtained, respectively. There was statistically significant difference between B-1 and B0 (P=0.0001) and between B-1 and B+3 (P=0.0209). Fifty percent of patients with R>0.4 showed metastasis in 1 year after surgery, whereas the probability was only 14.3% for patients with R<0.4 (where R is CTC ratio of B+3 to B0, P=0.043).

CONCLUSIONS

Esophageal cancer operation results in tumor cells dissemination and significant increase of CTC in peripheral blood, which is related to the developed metastasis. CTC are helpful for evaluating micrometastasis and have the potential for predicting recurrence in esophageal cancer.

Lymph node dissection in surgical treatment of esophageal neoplasms

The optimal lymphadenectomy for esophageal cancer remains controversial. The choice of surgical access determines to a great extent the type of lymphadenectomy possible. En bloc resections and three-field lymphadenectomy are concepts pioneered in the West and East, respectively; both should be performed in specialized centers because such extended lymph node dissection has substantial morbidity rates. Recent focus in research is on refining the indications for these procedures. Patient management strategies should be individualized.

Postoperative gastrointestinal dysfunction after 2-field versus 3-field lymph node dissection in patients with esophageal cancer

PURPOSE

Using an instrument we developed to assess postoperative dysfunction objectively (Surg Today 2005;35:535-42), we compared postoperative dysfunction after 2 - field versus 3 - field lymph node dissection retrospectively, in patents undergoing esophageal cancer surgery.

METHODS

Subjects were selected randomly from among patients who had undergone radical surgery for squamous cell carcinoma of the thoracic esophagus followed by reconstruction with a gastric tube and a cervical anastomosis. Patients rated 32 items related to postoperative dysfunction according to a 5-grade scale. Postoperative gastrointestinal dysfunction was evaluated on the basis of the total score and the scores for seven symptom categories: decreased physical activity, symptoms of reflux, dumping-like syndrome, nausea and vomiting, passage dysfunction, pain, and diarrhea or soft feces.

RESULTS

We studied 42 patients, 22 of whom underwent 2-field lymph node dissection and 20 of whom underwent 3-field dissection. The total gastrointestinal dysfunction score was significantly higher in the 3-field group than in the 2-field group (78.4 +/- 14.1 points vs 67.9 +/- 16.9 points, P = 0.038). When we analyzed the data according to the symptom categories, the 3-field group had higher scores for decreased physical activity, symptoms of reflux, dumping-like syndrome, nausea and vomiting, and passage dysfunction.

CONCLUSION

Three-field lymph node dissection was associated with greater postoperative gastrointestinal dysfunction than 2-field lymph node dissection. Thus, the preoperative identification of those patients with esophageal cancer who are most likely to benefit from concurrent cervical lymph node dissection is essential.

Quantitative Detection of Micrometastases in Pelvic Lymph Nodes in Patients with Clinically Localized Prostate Cancer by Real-time Reverse Transcriptase-PCR

PURPOSE

Routine pathologic examination can miss micrometastatic tumor foci in the lymph nodes of patients with prostate cancer, resulting in confusion during tumor staging and clinical decision-making. The objective of this study was to clarify the significance of micrometastases in pelvic lymph nodes in patients who underwent radical prostatectomy for prostate cancer.

EXPERIMENTAL DESIGN

The expression of prostate-specific antigen (PSA) and prostate-specific membrane antigen (PSMA) in 2,215 lymph nodes isolated from 120 patients with clinically localized prostate cancer was assessed by a fully quantitative real-time reverse transcriptase-PCR. We regarded specimens in which either PSA or PSMA mRNAs were positive as proof of the "presence of micrometastasis." Immunohistochemical staining of lymph node specimens with an antibody against PSA was also done.

RESULTS

Pathologic examinations detected tumor cells in 29 lymph nodes from 11 patients, and real-time reverse transcriptase-PCR further identified micrometastasis in 143 lymph nodes from 32 patients with no pathologic evidence of lymph node involvement. The presence of micrometastatic cancer cells was confirmed by immunohistochemical staining in 61 lymph nodes from 17 patients with pathologically negative lymph nodes. The presence of micrometastases was significantly associated with other conventional prognostic variables, including serum PSA value, pathologic stage, Gleason score, and tumor volume. Biochemical recurrence was detected in 32 patients, 17 of whom were negative for lymph node metastasis by pathologic examination (including 4 patients with pathologically organ-confined disease), but were diagnosed as having micrometastasis. Biochemical recurrence-free survival rate in patients without micrometastasis was significantly higher than in those with micrometastasis irrespective of the presence of pathologically positive nodes. Furthermore, only the presence of micrometastasis was independently associated with biochemical recurrence regardless of other factors examined.

CONCLUSIONS

These findings suggest that approximately 30% of clinically localized prostate cancers shed cancer cells to the pelvic lymph nodes, and that biochemical recurrence after radical prostatectomy could be explained, at least in part, by micrometastases in pelvic lymph nodes.

Preliminary multi-institutional prospective pathologic and molecular studies support preservation of sublevel IIB and level IV for laryngeal squamous carcinoma with clinically negative neck

Level II-IV selective neck dissection, often performed bilaterally, has become the procedure of choice for elective dissection of the clinically negative (N0) neck in the treatment of laryngeal cancer. The most significant morbidity of this procedure is dysfunction of the accessory nerve, incurred by the necessity of mobilization and retraction of the nerve in order to remove the contents of sublevel IIB. Other morbidity includes possible injury to the phrenic nerve and chylous fistula. These complications are associated with the dissection of level IV. A number of prospective multi-institutional studies of the distribution of cervical lymph node metastases in the neck indicate that lymph nodes in sublevel IIB and level IV are rarely involved in cases of laryngeal cancer with N0 neck. Information was obtained by the study of neck dissection specimens by conventional light microscopy, and by molecular analysis of the specimens. Molecular analysis reveals a significant number of metastases that are not discovered by light microscopy, and is thus essential for this type of evaluation. The authors conclude that these preliminary studies indicate that it is safe and appropriate to eliminate dissection of sublevel IIB and level IV from the elective neck dissection performed for laryngeal cancer with N0 neck. This practice will reduce both operating time and morbidity, particularly accessory nerve dysfunction, without compromising the oncologic result. Further prospective studies are needed to confirm these conclusions.

Anatomy of right recurrent nerve node: why does early metastasis of esophageal cancer occur in it?

Early, distant and/or skip metastasis of squamous-cell thoracic esophageal cancer frequently occurs in the right recurrent nerve node (recR). However, the specific lymphatic route without a nodal relay, such as the submucosal ascending route, was not known for the recR afferent. Using 20 donated cadavers, macroscopic, and histological observations were performed on the recR and its surrounding lymphatics, especially afferent routes from the esophagus to the recR. Most afferent vessels of the recR originated from the right paratracheal node. However, the recR often (12/20) received a major submucosal lymphatic drainage route ascending along the thoracic esophagus. The submucosal vessel came out of the esophagus and ran in a longitudinal connective tissue mass along the right tracheo-esophageal groove. A direct drainage route was often (13/20) seen from the recR to the venous system. Moreover, because of the specific histology, collaterals seemed to be present around the recR. In the regional nodes of the intrathoracic esophagus, the recR histology was characterized by the high proportion of lymphocyte accumulating areas or the cortex. From the midthoracic level, metastatic cancer cells seemed to reach the recR via esophageal submucosal vessels in the early stage. Large lymphocyte accumulating areas of the recR suggested higher filtration capacity than other distal nodes. However, the collateral of the recR and its direct drainage to the venous system suggested that the recR involvement often corresponds to a systemic disease.

Pre-implantation multiple cytokine mRNA expression analysis of donor lung grafts predicts survival after lung transplantation in humans

While current donor selection with clinical findings is generally effective, the imprecise nature of the assessment forces clinicians to remain on the conservative side. A reliable biological marker would assist donor selection and would improve donor organ utilization. We collected biopsies from 169 donor lungs before implantation. Expression levels of IL-6, IL-8, IL-10, TNF-alpha, IFN-gamma and IL-1beta were measured by quantitative real-time RT-PCR (qRT-PCR). Seventeen cases died within 30 days after transplantation. No donor factor was significantly associated with 30-day mortality. Univariate analysis of the 84 cases for development of the prediction model showed that IL-6, IL-8, TNF-alpha and IL-1beta were risk factors for mortality and IL-10 and IFN-gamma were protective factors. We analyzed the cytokine expression ratios of risk to protective cytokines. A stepwise logistic regression for 30-day mortality demonstrated that a model containing the ratio of IL-6/IL-10 was the most predictive (p = 0.0013). When applied to the remaining 85 cases for validation, the test of model fit was significant (p = 0.039). Using the cytokine ratio, we were able to define three risk groups with striking differences in survival (p = 0.0003). Multi-cytokine analysis of the donor lung graft with qRT-PCR shows significant promise as a strategy to biologically evaluate the donor lung prior to implantation.

Expression of cancer testis antigens in head and neck squamous cell carcinomas

BACKGROUND

There is considerable interest in the expression of cancer testis (CT) antigens in human cancers, because they may serve as the basis for diagnostic tests or an immunologic approach to therapy, or as prognostic markers.

METHODS

On this basis, we evaluated by semiquantitative reverse-transcriptase polymerase chain reaction (RT-PCR) the expression of genes that code for tumor antigens (melanoma antigen-1 [MAGE-1], MAGE-4, MAGE-10, MAGE-12, B melanoma antigen, CTL-recognized antigen melanoma antigen (CT antigen 2) [LAGE], New York esophageal squamous cell carcinoma antigen (CT antigen 1) [NYESO-1], and preferentially expressed antigen of melanoma [PRAME]) in surgical samples of the tumors, margins, and lymph nodes (when present) from patients with a diagnosis of head and neck carcinoma. The study was conducted on 33 patients (31 men and two women), aged 31 to 94 years (mean, 56 years), with squamous cell carcinomas located in the mouth (15 cases), larynx (14 cases), and pharynx (four cases).

RESULTS

The findings were compared with the clinical course and laboratory data. Expression of at least one antigen was observed in 66.6% of cases, with different rates of expression according to tumor staging (100% of T4, 57% of T3, 50% of T1 and T2) and smoking habit. There was a significantly higher expression of multiple genes (two or more) in tumors in advanced stages.

CONCLUSIONS

We conclude that the tumor-specific antigen genes are expressed in variable frequencies and intensities in the primary lesions of head and neck squamous cell carcinomas and in their metastases, with expression of the PRAME gene being always present in the metastastatic lymph nodes. In primary lesions, gene expression correlated with smoking habit and with advanced tumors with a higher malignant potential, with the frequent expression of two or more of these genes.

A prospective trial for avoiding cervical lymph node dissection for thoracic esophageal cancers, based on intra-operative genetic diagnosis of micrometastasis in recurrent laryngeal nerve chain nodes

BACKGROUND AND OBJECTIVES

The aim of this study was to evaluate the usefulness of intra-operative genetic diagnosis of RN node micrometastasis in the decision-making of 3FL for thoracic esophageal cancers.

METHODS

Eighty-nine patients with middle and lower thoracic esophageal cancer were enrolled in a prospective study, in which 3FL was performed when RN node metastasis was revealed by intra-operative histological examination and/or genetic analysis using real-time RT-PCR assay. For other cases, 2FL was performed.

RESULTS

Of the 89 patients, 3FL was performed for 33 patients and 2FL for 56 patients. In the 3FL group, RN node metastasis was both histologically and genetically positive in 19 patients, histologically negative and genetically positive in 11, and histologically positive and genetically negative in 3, with cervical node metastasis being detected in 7, 3, and 0 patients, respectively. In the 2FL group, only one patient had cervical node recurrence during the follow-up period. The post-operative survival in this study was equivalent to that of the historical controls (3-year survival rates 63.9% vs. 52.3%, P = 0.1513) of 66 3FL patients when 3FL was the first choice for thoracic esophageal cancers.

CONCLUSIONS

Intra-operative histological and genetic diagnosis of RN node metastasis may help avoid unnecessary cervical node resection. A Phase III trial should be done.

A Strategy for Determining Which Thoracic Esophageal Cancer Patients Should Undergo Cervical Lymph Node Dissection

BACKGROUND

There is controversy about performing cervical lymph node dissections in all middle and lower thoracic esophageal squamous cell carcinoma patients. The purpose of this study was to evaluate whether intraoperative examination of thoracic paratracheal lymph node by real-time reverse transcription-polymerase chain reaction was worthwhile for selecting patients for cervical lymph node dissection.

METHODS

Under informed consent, 30 middle and lower thoracic esophageal squamous cell carcinoma patients were examined for thoracic paratracheal lymph node metastasis intraoperatively by hematoxylin-eosin staining and real-time reverse transcription-polymerase chain reaction for messenger RNA encoding squamous cell carcinoma antigen. When thoracic paratracheal lymph node metastasis was found, cervical lymph node dissection was performed. If the patients had no thoracic paratracheal lymph node metastasis, a randomized study for selection of cervical lymph node dissection was performed.

RESULTS

Eleven of 30 patients with middle or lower third thoracic esophageal squamous cell carcinoma had thoracic paratracheal lymph node metastasis. Five of these 11 patients had cervical lymph node metastasis. Nineteen patients who had no metastasis in the thoracic paratracheal lymph nodes were enrolled in a randomized study. Eight of the 19 patients received cervical lymph node dissection and they were found not to have cervical lymph node metastasis. The other 11 patients did not receive cervical lymph node dissection, and there was no cervical lymph node recurrence.

CONCLUSIONS

The intraoperative diagnosis of metastasis in the thoracic paratracheal lymph node may be used as an indicator for cervical lymph node dissection in middle and lower thoracic esophageal cancer patients.

Detection of Micrometastases in Pelvic Lymph Nodes in Patients Undergoing Radical Cystectomy for Focally Invasive Bladder Cancer by Real-time Reverse Transcriptase-PCR for Cytokeratin 19 and Uroplakin II

PURPOSE

The objective of this study was to clarify the significance of micrometastases in pelvic lymph nodes in patients who underwent radical cystectomy for bladder cancer.

EXPERIMENTAL DESIGN

We included 40 patients with locally invasive bladder cancer who underwent radical cystectomy and pelvic lymphadenectomy. Expression of cytokeratin 19 (CK19), uroplakin II (UP II), and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) in 760 lymph nodes were assessed by a fully quantitative real-time reverse transcription-PCR (RT-PCR) assay. The quantification value of CK19 or UP II mRNA was described as each value relative to GAPDH mRNA. In this study, we regarded specimen in which either CK19 or UP II mRNA was positive as "presence of micrometastasis."

RESULTS

Routine pathologic examinations detected tumor cells in 29 lymph nodes from six patients. Real-time RT-PCR identified positive expression of CK19 and UP II mRNAs in 49 lymph nodes from 10 patients and 98 lymph nodes from 16 patients, respectively. Of 633 lymph nodes from 34 patients with no pathologic evidence of nodal involvement, 13 nodes from five patients and 58 nodes from 10 patients were diagnosed as positive for CK19 and UP II mRNAs expression, respectively, by real-time RT-PCR. Presence of micrometastases was significantly associated with other conventional prognostic variables, including pathologic stage and microvascular invasion. Disease recurrence was occurred in eight patients, among whom four patients were negative for lymph node metastasis by routine pathologic examination and diagnosed as having micrometastasis by real-time RT-PCR assay. Furthermore, cause-specific survival rate in patients without micrometastasis was significantly higher than that in those with micrometastasis, irrespective of the presence of pathologic-positive nodes.

CONCLUSIONS

Approximately 30% of locally invasive bladder cancer shed cancer cells to pelvic lymph nodes, and disease recurrence after radical cystectomy could be explained, at least in part, by micrometastases in pelvic lymph nodes.

Application of fuzzy inference to European patients to predict cervical lymph node metastasis in carcinoma of the tongue

In head and neck cancers, the presence of cervical lymph node metastasis is an important determinant of outcome. Many attempts have been made to predict cervical lymph node metastasis, but the accuracy of currently available techniques remains inadequate. We used fuzzy inference to predict cervical lymph node metastasis retrospectively in 75 patients with squamous cell carcinoma of the tongue and prospectively in 23 patients. Our model was based on three variables: tumor size, keratinization, and mode of invasion. The accuracy of fuzzy inference for the prediction of cervical lymph node metastasis in the 75 patients studied retrospectively was 86.7%, the sensitivity was 70.8%, and the specificity was 94.1%. In the 23 patients studied prospectively, the accuracy was 91.3%, the sensitivity was 50.0%, and the specificity was 95.2%. The accuracy obtained in this European series of patients was similar to that previously obtained in Japanese patients. We conclude that fuzzy inference may be a useful method for predicting cervical lymph node metastasis. Its high specificity is likely to reduce the number of unnecessary neck dissections. However, the current level sensitivity is inadequate for routine clinical use. Therefore, other predictors of lymph node metastasis should be identified to refine the current model.

Rapid genetic diagnosis with the transcription-reverse transcription concerted reaction system for cancer micrometastasis

BACKGROUND

Detection of cancer micrometastases is required for improvement of cancer therapy. The aim of this study was to establish a rapid and practical genetic assay to detect micrometastasis in gastric cancer and to assess its clinical significance with respect to prognosis.

METHODS

A novel RNA amplification system with transcription-reverse transcription concerted reaction (TRC) was introduced for quantitative detection of cancer-specific carcinoembryonic antigen messenger RNA. The sensitivity and quantitative aspects of the assay were assessed with the full-length carcinoembryonic antigen messenger RNA, a gastric cancer cell line (MKN-45), and metastatic lymph nodes obtained from patients with gastric cancer. Peritoneal lavage fluid specimens that were collected from gastric cancer surgery were subjected to the assay, and the clinical significance of the results was examined for prediction of recurrence and survival.

RESULTS

The quantification, sensitivity, and reproducibility of the assay with the TRC reaction were equal to those of quantitative reverse transcriptase-polymerase chain reaction with LightCycler. The most important advantages of the assay were its simplicity and rapidity. Molecular diagnosis of peritoneal lavage fluid by the TRC reaction significantly correlated with depth of invasion, peritoneal metastasis, clinical stage, overall survival, and peritoneal recurrence-free survival.

CONCLUSIONS

Molecular diagnosis of peritoneal lavage fluid with the TRC reaction could be a useful prognostic indicator for peritoneal recurrence and survival. Because the TRC reaction is more rapid and simpler than reverse transcriptase-polymerase chain reaction as a format for detecting RNA sequences, it may enhance the genetic diagnosis of cancer micrometastasis and may improve cancer therapy.

Intraoperative real-time genetic diagnosis for sentinel node navigation surgery

Sentinel node navigation surgery (SNNS) has received considerable attention for its role in deciding whether to perform neck dissection in patients with early oral cancer. However, diagnostic accuracy and its intraoperative availability of results remain important concerns. First, we shortened the examination time required for genetic diagnosis. Second, we assessed the quality of the extracted mRNA. Third, 10 patients with early N0 oral cancer underwent SNNS, using our new technique for genetic diagnosis to determine whether neck dissection was required. The examination time of our one-step reverse-transcriptase polymerase chain reaction method using a minicolumn and LightCycler was successfully shortened to 2 h, permitting intraoperative genetic diagnosis. The extracted mRNA was of high quality. Six sentinel nodes in four patients were diagnosed to be metastatic on genetic diagnosis; these patients underwent neck dissection. The other six patients avoided unnecessary surgery. We conclude that intraoperative genetic diagnosis of micrometastasis holds promise of being a sensitive method that can be used to support SNNS.

Application of molecular diagnosis for detection of peritoneal micrometastasis and evaluation of preoperative chemotherapy in advanced gastric carcinoma

BACKGROUND

In advanced gastric cancer, peritoneal recurrence is the main cause of death after curative surgical resection. The aim of this report was to describe a novel approach for quantitative genetic diagnosis using peritoneal lavage for the identification of patients at high risk for peritoneal recurrence and for evaluation of the clinical response to intraperitoneal chemotherapy in advanced gastric cancer.

METHODS

Nineteen patients with advanced gastric cancer who underwent staging laparoscopy and intraperitoneal chemotherapy before surgical resection or systemic chemotherapy between June 1999 and September 2001 were enrolled in this study. All peritoneal lavage specimens, collected at both staging laparoscopy and gastrectomy, were subjected to real-time quantitative genetic diagnosis.

RESULTS

The reverse transcriptase polymerase chain reaction (RT-PCR) values decreased in 8 cases, stabilized as negative in 5, and increased in 6 during therapy. Patients whose RT-PCR values diminished and were ultimately negative survived except for one, and all but one patient whose values increased during treatment died of recurrence.

CONCLUSIONS

Quantitative evaluation of genetic changes can provide accurate, useful information on the effects of preoperative intra-abdominal chemotherapy and overall prognosis for patients with advanced gastric cancer.

Reduction in PSA messenger-RNA expression and clinical recurrence in patients with prostatic cancer undergoing neoadjuvant therapy before radical prostatectomy

BACKGROUND: We assessed the incidence of micro-metastases at surgical margins (SM) and pelvic lymph nodes (LN) in patients submitted to radical retropubic prostatectomy (RP) after neoadjuvant therapy (NT) or to RP alone. We compared traditional staging to molecular detection of PSA using Taqman-based quantitative real-time PCR (qrt-PCR) never used before for this purpose. METHODS: 29 patients were assigned to NT plus RP (arm A) or RP alone (arm B). Pelvic LN were dissected for qrt-PCR analysis, together with right and left lateral SM. RESULTS: 64,3% patients of arm B and 26.6% of arm A had evidence of PSA mRNA expression in LN and/or SM. 17,2% patients, all of arm B, had biochemical recurrence. CONCLUSIONS: Qrt-PCR may be more sensitive, compared to conventional histology, in identifying presence of viable prostate carcinoma cells in SM and LN. Gene expression of PSA in surgical periprostatic samples might be considered as a novel and reliable indicator of minimal residual disease after NT.

Pathological staging and therapy of oesophageal and gastric cancer

Oesophageal and gastric cancers are a significant cause of morbidity and mortality worldwide. Despite improvements in surgical techniques, radiation and chemotherapy, the prognosis of both cancers remains poor. Immunohistochemical and experimental studies indicate that the concept of micrometastasis is applicable to oesophageal and gastric cancer. New staging approaches, including immunohistochemistry and real-time reverse transcriptase-polymerase chain reaction (RT-PCR) of various markers, have been proposed for a more accurate staging of oesophageal and gastric cancer. Preliminary results suggest that real-time RT-PCR of markers for intestinal differentiation, such as guanylyl cyclase C (GC-C), might be useful for both the detection of premalignant conditions, such as intestinal metaplasia and the detection of micrometastasis from adenocarcinoma of the upper intestinal tract. Standard curative treatment options for oesophageal cancer include surgery or chemoradiotherapy. Chemotherapy is an option for the treatment of advanced and recurrent oesophageal cancer. Standard curative treatment for gastro-oesophageal junction and gastric cancer includes surgery and adjuvant chemoradiotherapy. Chemotherapy is an option for the treatment of advanced and recurrent gastric cancer.