Treatment of locally advanced esophageal cancer with surgery and chemoradiation

Real-time Tracking and Classification of Tumor and Nontumor Tissue in Upper Gastrointestinal Cancers Using Diffuse Reflectance Spectroscopy for Resection Margin Assessment

Importance

Cancers of the upper gastrointestinal tract remain a major contributor to the global cancer burden. The accurate mapping of tumor margins is of particular importance for curative cancer resection and improvement in overall survival. Current mapping techniques preclude a full resection margin assessment in real time.

Objective

To evaluate whether diffuse reflectance spectroscopy (DRS) on gastric and esophageal cancer specimens can differentiate tissue types and provide real-time feedback to the operator.

Design, Setting, and Participants

This was a prospective ex vivo validation study. Patients undergoing esophageal or gastric cancer resection were prospectively recruited into the study between July 2020 and July 2021 at Hammersmith Hospital in London, United Kingdom. Tissue specimens were included for patients undergoing elective surgery for either esophageal carcinoma (adenocarcinoma or squamous cell carcinoma) or gastric adenocarcinoma.

Exposures

A handheld DRS probe and tracking system was used on freshly resected ex vivo tissue to obtain spectral data. Binary classification, following histopathological validation, was performed using 4 supervised machine learning classifiers.

Main Outcomes and Measures

Data were divided into training and testing sets using a stratified 5-fold cross-validation method. Machine learning classifiers were evaluated in terms of sensitivity, specificity, overall accuracy, and the area under the curve.

Results

Of 34 included patients, 22 (65%) were male, and the median (range) age was 68 (35-89) years. A total of 14 097 mean spectra for normal and cancerous tissue were collected. For normal vs cancer tissue, the machine learning classifier achieved a mean (SD) overall diagnostic accuracy of 93.86% (0.66) for stomach tissue and 96.22% (0.50) for esophageal tissue and achieved a mean (SD) sensitivity and specificity of 91.31% (1.5) and 95.13% (0.8), respectively, for stomach tissue and of 94.60% (0.9) and 97.28% (0.6) for esophagus tissue. Real-time tissue tracking and classification was achieved and presented live on screen.

Conclusions and Relevance

This study provides ex vivo validation of the DRS technology for real-time differentiation of gastric and esophageal cancer from healthy tissue using machine learning with high accuracy. As such, it is a step toward the development of a real-time in vivo tumor mapping tool for esophageal and gastric cancers that can aid decision-making of resection margins intraoperatively.

Primary impact of Gli1 on radioresistance in esophageal cancer

Radioresistance is the primary cause for the low efficacy of radiotherapy in the treatment of esophageal cancer (EC). Increasing evidence has demonstrated that the Sonic Hedgehog (Shh) signaling pathway may be involved in the pathology of various tumors, including EC. The present study aimed to examine the association between radioresistance in EC and the Sonic Hedgehog pathway, and to determine whether a downstream transcription factor of the Shh pathway, glioma-associated oncogene family zinc finger 1 (Gli1), serves a primary role in radioresistance. The radiation-resistant cell line Eca109R was established by repeated low dose (cumulative dose 60 Gy) irradiation of the human EC cell line Eca109. The level of cell radiosensitivity was determined by colony formation assay, and the localization of Gli1 was detected using immunofluorescence. Western blotting was used to determine the protein expression levels of Gli1, Shh, patched 1 (Ptch) and smoothened frizzled class receptor (Smo) in the two cell lines. Significantly higher levels of Gli1 were identified in the Eca109R cell line compared with those inEca109 cells (P<0.05). Additionally, western blotting analysis demonstrated an increased expression level of the Gli1, Shh, Ptch and Smo proteins in Eca109R, compared with Eca109 cells (P<0.05). Overexpression of Gli1 in the parental cell line led to decreased levels of radiosensitivity and radiosensitivity of the radioresistant cell line was restored through knockdown of Gli1. The present study demonstrated that Gli1 may be associated with the development of radioresistance in EC.

Surgery Is Associated With Survival Benefit in T4a Esophageal Adenocarcinoma: A National Analysis

BACKGROUND

The National Comprehensive Cancer Network guidelines recommend consideration of surgery for clinical T4a esophageal adenocarcinoma. There are limited data on the outcomes of patients with T4a adenocarcinoma treated with surgery vs definitive chemoradiation, however.

METHODS

The National Cancer Database was used to identify patients from 2010-2015 with clinical T4aN0-3M0 esophageal adenocarcinoma, and grouped by receipt of surgery (with or without perioperative therapy) or definitive, concurrent chemoradiation. Patients receiving incomplete definitive therapy or with missing survival information were excluded. Overall survival was evaluated with Kaplan-Meier and Cox proportional hazard analyses.

RESULTS

Of 182 patients in the study, 85 (47%) underwent esophagectomy and 97 (53%) underwent chemoradiation. In the surgery cohort, 79 patients (93%) received perioperative chemotherapy. Unadjusted and multivariable analyses demonstrated a significant survival benefit associated with surgery compared with definitive chemoradiotherapy (adjusted hazard ratio 0.32; 95% confidence interval 0.21, 0.50). A 1:1 propensity score-matched analysis of 63 patient pairs also revealed a significant overall survival benefit with surgery compared with chemoradiotherapy alone (hazard ratio 0.26; 95% confidence interval 0.16, 0.43).

CONCLUSIONS

In this national analysis, surgery for cT4a esophageal adenocarcinoma was associated with improved outcomes when compared with definitive chemoradiation. Surgery should be considered for medically fit patients with cT4aN0-3M0 esophageal adenocarcinoma.

Evaluation of Prognostic Factors for Esophageal Squamous Cell Carcinoma Treated with Neoadjuvant Chemoradiotherapy Followed by Surgery

BACKGROUND

Intensive trimodality therapy is needed for locally advanced esophageal squamous cell carcinoma (ESCC). However, some patients develop recurrence and die of cancer even after trimodality therapy.

METHODS

We evaluated prognostic factors based on data from 125 patients with ESCC who underwent neoadjuvant chemoradiotherapy (NCRT) comprising concurrent chemotherapy and 40 Gy of radiation, followed by curative-intent esophagectomy.

RESULTS

Thirty-four (27.2%) patients achieved a pathological complete response (pCR) after NCRT. The 5-year recurrence-free (RFS) and overall survival (OS) rates of all patients were 49.2 and 52.9%, respectively, and were significantly better for patients with pCR than without pCR (p = 0.01 and 0.02, respectively). Univariate and multivariate analyses selected performance status [PS 0 vs. 1: hazard ratio (HR) 2.05; 95% confidence interval (CI) 1.30-4.84; p = 0.01] and ypN (0 vs. 1: HR 2.33; 95% CI 1.12-4.84; p = 0.02; 0 vs. 2/3: HR 3.73; 95% CI 1.68-8.28; p = 0.001) as independent covariates for RFS. Furthermore, PS (0 vs. 1; HR 2.94; 95% CI 1.51-5.72; p = 0.002) and ypN (0 vs. 1; HR 2.26; 95% CI 1.09-4.69; p = 0.03; 0 vs. 2/3: HR 3.90; 95% CI 1.79-8.48; p = 0.001) were also independent covariates for OS.

CONCLUSIONS

Performance status 1 and ypN+ were significantly associated with a poor prognosis after trimodality therapy for ESCC.

A novel inflammation-based prognostic index for patients with esophageal squamous cell carcinoma: neutrophil lymphocyte ratio/albumin ratio

Background

We initially proposed a novel inflammation-based prognostic index, named neutrophil lymphocyte ratio/albumin ratio (NLR/Alb), for predicting the postoperative survival in esophageal squamous cell carcinoma (ESCC).

Materials and methods

A retrospective study of 329 cases with resectable ESCC was included. The optimal cut-off values were evaluated by X-tile program. The 5-year cancer-specific survival (CSS) was calculated by Kaplan–Meier method. Cox regression analyses were performed to evaluate the prognostic factors.

Results

The optimal cut-off value was 0.1 for NLR/Alb according to the X-tile program. There was a significantly better 5-year CSS in patients with NLR/Alb ≤ 0.1 than patients with NLR/Alb > 0.1 (39.1% vs. 11.0%, P < 0.001). According to multivariate analyses, NLR/Alb (P = 0.001) was an independent prognostic factor.

Conclusions

The NLR/Alb is a novel and usefull predictive factor in patients with ESCC.

Esophageal stent fixation with endoscopic suturing device improves clinical outcomes and reduces complications in patients with locally advanced esophageal cancer prior to neoadjuvant therapy: a large multicenter experience

BACKGROUND

Endoscopic placement of fully covered self-expanding metal stents (FCSEMS) to treat malignant dysphagia in patients with esophageal cancer significantly improves dysphagia; however, these stents have a high migration rate.

AIM

To determine whether FCSEMS fixation using an endoscopic suturing device treated malignant dysphagia and prevented stent migration in patients with locally advanced esophageal cancer receiving neoadjuvant therapy when compared to patients with FCSEMS placement alone.

METHOD

A review of patients with locally advanced esophageal cancer who underwent FCSEMS placement at 3 centers was performed. Patients were divided into two groups: Group A (n = 26) was composed of patients who underwent FCSEMS placement with suture placement, and Group B (n = 67) was composed of patients with FCSEMS placement alone.

RESULTS

There were no significant differences between Groups A and B in demographics, and tumor characteristics. The technical success rate for stent placement was 100 %. There was no difference between Groups A and B in the median stent diameter and stent lengths. Mean dysphagia score obtained at 1 week after stent placement had improved significantly from baseline (2.4 and 1, respectively, p < 0.001). Patients had a median follow-up of 4 months. Immediate adverse events were mild chest discomfort in 4 patients in Group A and 2 patients in Group B (p = 0.05), and significant acid reflux in 3 patient in Group A compared to 2 patients in Group B (p = 0.1). The stent migration rate was significantly lower in Group A compared to compared to Group B (7.7 vs 26.9 %, respectively, p = 0.004). There was a delayed perforation in 1 patient and 1 death due to aspiration pneumonia in Group B.

CONCLUSION

Fixation of esophageal FCSEMSs by using an endoscopic suturing device in patients receiving neoadjuvant therapy was shown to be feasible, safe, and relatively effective at preventing stent migration compared to those who had stent placed alone.

Examination of Surgical Specimens of the Esophagus

CONTEXT

Esophageal cancer continues to be one of the most lethal of all gastrointestinal malignancies. Its prognostic parameters are based on the gross and histopathologic examination of resected specimens by pathologists.

OBJECTIVE

To describe the implications of appropriate handling and examination of endomucosal resection and esophagectomy specimens from patients with esophageal carcinoma while considering the implications of the surgical techniques used to obtain such specimens. Parameters include histopathologic findings necessary for accurate staging, differences in the assessment of margins, residual malignancy, and criteria to evaluate for tumor regression after chemoradiation therapy as well as the role of immunohistochemistry and the judicious use of frozen sections.

DATA SOURCES

Sources were a review of the literature and the authors' experience handling these types of specimens.

CONCLUSIONS

Examining surgical specimens of the esophagus is critical in the management of patients with esophageal carcinoma, and it requires careful consideration of the diagnostic pitfalls, staging-related parameters, and results of molecular tests.

Determination of Effective Factors on Survival of GI Cancers: Results of Five Years Follow up in Iranian Population

Background:

The gastrointestinal cancers are among the most common cause of cancer-related death and their long term survival is very low. This study was aimed to determine the effective factors on survival of gastrointestinal cancers among Iranian population during 5 years of follow up.

Methods:

In total, 157 patients diagnosed as gastrointestinal cancers from 2007 to 2009 in the only center of endoscopy in Alvand city, northwest of Qazvin province were included and followed for five years. The univariate and multivariate analysis were done using Kaplan-Meier method and the Cox model respectively.

Results:

Observations of 146 patients were analyzed (99 (67.8%) males and 47 (32.2%) females). The mean age was 64.73± 13.23 and 58.28±13.91 for females and males respectively. The one and three years survival rates for esophageal cancer were 28% and 9% and the one, three and five years survival rates for gastric cancer were 31%, 26% and 14% and for colorectal cancer were 96%, 86% and 75% respectively. In the univariate analysis, variables of age, educational level, ethnicity, smoking, type of cancer, stage of disease and type of treatment had significant effects on survival. In the multivariate analysis, the type of cancer and type of treatment affected the survival of patients as effective factors (p<005).

Conclusion:

Patients with esophageal cancer and those who underwent RT &/or CT are exposed to higher risk of death. Combination therapies (Surgery and adjuvant or neoadjuvant therapy) were related to be her survival. Early diagnosis and use of extended cancer screening programs seem necessary to improve survival.

Safety and efficacy of esophageal stents preceding or during neoadjuvant chemotherapy for esophageal cancer: a systematic review and meta-analysis

BACKGROUND

Patients with locally advanced esophageal cancer who require neoadjuvant therapy have significant dysphagia and may severely impair nutritional status. We conducted a meta-analysis to assess the efficacy of self-expandable metal stents prior to neoadjuvant therapy.

METHODS

A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. Original data was abstracted from each study and used to calculate a pooled odd ratio (OR) and 95% confidence interval (95% CI).

RESULTS

Only nine studies comprising of 180 patients were included for analysis. The overall procedural success rate was 95% (95% CI, 0.895-0.977). There was a substantial decrease in the dysphagia scores standard difference in means (SDM) -0.81 [standard error (SE) 0.15, 95% CI, -1.1 to -0.51], similar increase in weight SDM 0.591 (SE 0.434, 95% CI, -0.261 to 1.442) and serum albumin SDM 0.35 (SE 0.271, 95% CI, -0.181 to 0.881). The incidence of major adverse events included stent migration 32% (95% CI, 0.258-0.395) and chest discomfort 51.4% (95% CI, 0.206-0.812).

CONCLUSIONS

Placement of stents in patients with locally advanced esophageal cancer significantly improves dysphagia and allows for oral nutrition during neoadjuvant therapy. Stents appear to be effective for palliating dysphagia. Stent migration was a common occurrence; however, migration may be a sign of tumor response to neoadjuvant therapy.

Combination of adenoviruses expressing melanoma differentiation-associated gene-7 and chemotherapeutic agents produces enhanced cytotoxicity on esophageal carcinoma

We examined the combinatory antitumor effects of adenoviruses expressing human mda-7/IL-24 gene (Ad-mda-7) and chemotherapeutic agents on nine kinds of human esophageal carcinoma cells. All the carcinoma cells expressed the melanoma differentiation-associated gene-7/interleukin-24 (MDA-7/IL-24) receptor complexes, IL-20R2 and either IL-20R1 or IL-22R1, and were susceptible to Ad-mda-7, whereas fibroblasts were positive only for IL-20R2 gene and resistant to Ad-mda-7-mediated cytotoxicity. Sensitivity of these esophageal carcinoma cells to Ad-mda-7 was however lower than that to Ad expressing the wild-type p53 gene. We thereby investigated a possible combination of Ad-mda-7 and anticancer agents and found that Ad-mda-7 with 5-fluorouracil (5-FU), cisplatin, mitomycin C or etoposide produced greater cytotoxic effects than those by Ad-mda-7 or the agent alone. Half-maximal inhibitory concentration values of the agents in respective cells were decreased by the combination with Ad-mda-7. Cell cycle analyses showed that Ad-mda-7 and 5-FU increased G2/M-phase and S-phase populations, respectively, and the combination augmented sub-G1 populations. Ad-mda-7-treated cells showed cleavages of caspase-8, -9 and -3 and poly (ADP-ribose) polymerase, but the cleavage levels were not different from those of the combination-treated cells. Ad-mda-7 treatments upregulated Akt phosphorylation but suppressed IκB-α levels, whereas 5-FU treatments induced phosphorylation of p53 and extracellular signal-regulated protein kinases 1 and 2. Molecular changes caused by the combination were similar to those by Ad-mda-7 treatments, but the Ad-mda-7-mediated upregulation of Akt phosphorylation decreased with the combination. These data collectively suggest that Ad-mda-7 induced apoptosis despite Akt activation and that the combinatory antitumor effects with 5-FU were produced partly by downregulating the Ad-mda-7-induced Akt activation.

Prognostic significance of Glasgow prognostic score in patients undergoing esophagectomy for esophageal squamous cell carcinoma

BACKGROUND/AIMS

Recent studies have revealed that Glasgow prognostic score (GPS), an inflammation-based prognostic score, is inversely related to prognosis in a variety of cancers; high levels of GPS is associated with poor prognosis. However, few studies regarding GPS in esophageal cancer (EC) are available. The aim of this study was to determine whether the GPS is useful for predicting cancer-specific survival (CSS) of patients for esophageal squamous cell carcinoma (ESCC).

PATIENTS AND METHODS

The GPS was calculated on the basis of admission data as follows: Patients with elevated C-reactive protein (CRP) level (>10 mg/L) and hypoalbuminemia (<35 g/L) were assigned to GPS2. Patients with one or no abnormal value were assigned to GPS1 or GPS0, respectively.

RESULTS

Our study showed that GPS was associated with tumor size, depth of invasion, and nodal metastasis (P<0.001). In addition, there was a negative correlation between the serum CRP and albumin (r=-0.412, P<0.001). The 5-year CSS in patients with GPS0, GPS1, and GPS2 were 60.8%, 34.7% and 10.7%, respectively (P<0.001). Multivariate analysis showed that GPS was a significant predictor of CSS. GPS1-2 had a hazard ratio (HR) of 2.399 [95% confidence interval (CI): 1.805-3.190] for 1-year CSS (P<0.001) and 1.907 (95% CI: 1.608-2.262) for 5-year CSS (P<0.001).

CONCLUSION

High levels of GPS is associated with tumor progression. GPS can be considered as an independent prognostic factor in patients who underwent esophagectomy for ESCC.

Incidence of brain metastases after trimodality therapy in patients with esophageal or gastroesophageal cancer: implications for screening and surveillance

BACKGROUND

It is unclear whether patients undergoing trimodality therapy (TMT) should be screened or surveyed for brain metastases.

METHODS

We retrospectively analyzed esophageal cancer (EC) patients who underwent TMT between the years 2000 and 2010. All were systematically staged and surveyed but none had screening or surveillance brain imaging.

RESULTS

The median follow-up time for 518 patients was 29.3 months (range 1-149.2); all patients had adenocarcinoma of the esophagus. Of 188 (36.3%) patients who developed distant metastases, 20 (10.6% of 188 patients or 3.9% of 518 patients) had brain metastases. A higher baseline clinical stage (stage III or IVa) was associated with brain metastases. Most (90%) patients with brain metastases were diagnosed within 24 months of surgery. Sixteen patients had central nervous system symptoms at diagnosis. Twelve (60%) patients had solitary metastasis and 8 (40%) patients had multiple metastases. Although 17 patients received therapy for brain metastases, the median overall survival time of 20 patients was only 10.5 months (95% CI 6.6-14.0).

CONCLUSION

After TMT, 3.9% of EC patients developed brain metastases and their prognosis was poor. Our data suggest that screening and/or surveillance for brain metastases in the EC population undergoing TMT is not warranted.

Placement of fully covered self-expandable metal stents in patients with locally advanced esophageal cancer before neoadjuvant therapy

BACKGROUND

Most patients with locally advanced esophageal cancer requiring neoadjuvant therapy have significant dysphagia.

OBJECTIVE

To report our experience in using a fully covered self-expandable metal stent (FCSEMS) to treat malignant dysphagia and for maintenance of nutritional support during neoadjuvant therapy.

DESIGN

Retrospective study.

SETTING

Two tertiary-care referral centers.

PATIENTS

This study involved 55 patients with locally advanced esophageal cancer (50 adenocarcinoma, 5 squamous cell carcinoma). Forty-three patients were men, and the mean age was 65.8 years.

INTERVENTION

EUS followed by FCSEMS placement.

MAIN OUTCOME MEASUREMENTS

Procedural success, dysphagia scores, patient weights, stent migration, and stent-related complications.

RESULTS

All stents were successfully placed. Tumors were located in the middle esophagus (n = 10) and distal esophagus (n = 45). The mean dysphagia score obtained at 1 week after stent placement had improved significantly from baseline (2.4 and 1, respectively; P < .001). Patients maintained their weights at 1 month follow-up when compared with baseline (153 and 149 pounds, respectively; P = .58). Immediate complications included chest discomfort in 13 patients; 2 patients required stent removal because of intractable pain. One patient had stent removal because of significant acid reflux. Stent migration occurred at some point in 17 of 55 patients (31%). There was a delayed perforation in 1 patient. Because of disease progression or the discovery of metastasis after neoadjuvant therapy, only 8 of 55 patients underwent curative surgery.

LIMITATIONS

Retrospective study.

CONCLUSION

Placement of FCSEMSs in patients with locally advanced esophageal cancer significantly improves dysphagia and allows for oral nutrition during neoadjuvant therapy. FCSEMSs appear to be effective for palliating dysphagia. Migration was not associated with injury or harm to the patient and usually represented a positive response to neoadjuvant therapy. Few patients undergoing stenting in this situation ultimately undergo surgery because of disease progression or poor operative candidacy.

Response to concurrent chemoradiotherapy as a prognostic marker in elderly patients with locally advanced esophageal cancer

AIMS AND BACKGROUND

Little is known about chemoradiotherapy in elderly patients with locally advanced esophageal cancer. We compared the efficacy and toxicity of chemoradiotherapy in elderly and non-elderly patients with locally advanced esophageal cancer and determined the variables affecting the treatment outcome in the elderly patients with locally advanced esophageal cancer who had received chemoradiotherapy.

METHODS

Fifty-seven elderly patients (age ≥ 65 years) and 30 non-elderly patients (age <65 years) were reviewed retrospectively.

RESULTS

The median age of the elderly group was 69 years and in the non-elderly group, 56.5 years. Although treatment compliance appeared to be poor, the response rate and median survival were similar in both the groups (elderly versus non-elderly; 84.4% vs 87.5%, and 11.2 months vs 11.3 months) and so were G3/4 hematologic and non-hematologic toxicities. The treatment-related mortality of the elderly patients appeared to be higher than that of the non-elderly group (7.0% vs 3.3%), but did not reach statistical significance. In prognostic factor analysis, a major response to chemoradiotherapy was a good prognostic indicator in the elderly group (response versus non-response; median overall survival times of 19.5 vs 5.4 months, respectively, P <0.001).

CONCLUSIONS

The study suggests that chemoradiotherapy for locally advanced esophageal cancer in elderly patients, even though treatment compliance appears to be poor, is as safe and effective as in non-elderly patients and that the response to chemoradiotherapy is related to prognosis in elderly patients.

Combinatory cytotoxic effects produced by E1B-55kDa-deleted adenoviruses and chemotherapeutic agents are dependent on the agents in esophageal carcinoma

We examined possible combinatory antitumor effects of replication-competent type 5 adenoviruses (Ad) lacking E1B-55kDa molecules (Ad-delE1B55) and chemotherapeutic agents in nine human esophageal carcinoma cells. Ad-delE1B55 produced cytotoxic effects on all the carcinoma cells and the cytotoxicity is not directly linked with the p53 status of the tumors or with the infectivity to respective tumors. A combinatory treatment with Ad-delE1B55 and an anticancer agent, 5-fluorouracil (5-FU), mitomycin C or etoposide, produced greater cytotoxic effects than that with either the Ad or the agent. Administration of 5-FU could minimally inhibit the viral replication and a simultaneous treatment with the Ad and 5-FU achieved better cytotoxicity than sequential treatments. We also confirmed the antitumor effects by the combination of Ad-delE1B55 with 5-FU in vivo. Cisplatin, however, did not achieve the combinatory effects in most of the cells tested. These data indicate that the Ad-delE1B55 produce combinatory antitumor effects with a chemotherapeutic agent irrespective of the administration schedule, but the effects depend on an agent in esophageal carcinoma.

Placement of Polyflex stents in patients with locally advanced esophageal cancer is safe and improves dysphagia during neoadjuvant therapy

BACKGROUND

Patients with locally advanced esophageal cancer who require neoadjuvant therapy have significant dysphagia.

OBJECTIVES

To prospectively evaluate Polyflex stents to treat malignant dysphagia and to ameliorate weight loss in patients with locally advanced esophageal cancer who will undergo neoadjuvant therapy.

DESIGN

A prospective nonrandomized study.

SETTING

Tertiary-referral cancer center.

PATIENTS

Thirteen patients with esophageal cancer (11 adenocarcinoma, 2 squamous-cell carcinoma). All patients were men, with a mean age of 63 years.

INTERVENTIONS

EUS followed by stent placement.

MAIN OUTCOME MEASUREMENTS

Dysphagia scores and patient weights.

RESULTS

There were no perforations and no episodes of bleeding. Immediate complications included chest discomfort in 12 of 13 patients. The mean dysphagia score at the time of stent placement was 3. Mean dysphagia scores obtained at 1, 2, 3, and 4 weeks after stent placement were 1.1 (P = .005), 0.8 (P = .01), 0.9 (P = .02), and 1.0 (P = .008), respectively. Stent migration occurred at some point in 6 of 13 patients (46%).

LIMITATIONS

A single center and small size of study.

CONCLUSIONS

Simultaneous EUS staging and Polyflex stent placement is safe and allows oral feeding during neoadjuvant therapy. Dysphagia scores improved in a statistically significant manner. Stent migration was a common event, although not all patients with a migrated stent will require stent replacement, because migration may be a sign of tumor response to neoadjuvant therapy.

Cytotoxicity of adenoviruses expressing the wild-type p53 gene to esophageal carcinoma cells is linked with the CAR expression level and indirectly with the endogenous p53 status

We examined cytotoxic effects of adenoviruses (Ad) expressing the p53 gene (Ad-p53) in nine human esophageal carcinoma cell lines with respect to the Ad receptor expression and the endogenous p53 gene status. Ad-p53-mediated cytotoxicity was related with an expression level of the coxsackievirus adenovirus receptor (CAR) but not with that of CD51, both of which are type 5 Ad receptors. Contrary to earlier studies, we found that the cytotoxicity was greater in tumor cells with the wild-type p53 gene than in those with mutated p53. The cytotoxic activity of Ad defective of E1B55kDa molecules (Ad-delE1B55), however, was not linked with the CAR expression level or the endogenous p53 status. We noticed that the tumor cells with the wild-type p53 gene showed greater CAR expression levels, although transduction with Ad-p53 did not upregulate the CAR expression in the mutated cells. We also examined the Ad-53-mediated cytotoxicity in two kinds of paired fibroblasts, parent and immortalized with loss of the p53 functions, and showed that the CAR expression level was more influential than the endogenous p53 status in the cytotoxicity. These data suggest that CAR expression level is a better predictive marker than endogenous p53 status for Ad-p53-mediated cytotoxicity in esophageal carcinoma.

Esophageal cancer

The incidence of esophageal cancer, in particular esophageal adenocarcinoma, is increasing, largely due to an increase in risk factors for adenocarcinoma. When esophageal cancer is confirmed by upper endoscopy, staging is required for the optimal selection of patients who should undergo esophageal resection. Neoadjuvant chemoradiation may be able to improve survival after esophageal cancer surgery. Endoscopic therapy for early esophageal neoplasia is effective and safe, with the best results being obtained by an individualized approach using endoscopic mucosal resection, ablative therapy, or both. Finally, dysphagia from esophageal cancer can be successfully treated with stent placement or single-dose brachytherapy. Future research should establish whether combinations of chemotherapy with or without radiation therapy play a role in survival.