Three different subsite classification systems for carcinomas in the proximity of the GEJ, but is it all one disease?

Comparison of gastro-oesophageal junction carcinomas in Chinese versus American patients

AIMS

To compare the clinical and pathological features of gastro-oesophageal junction (GEJ) carcinomas in Chinese and American patients.

METHODS AND RESULTS

Eighty consecutive patients with a GEJ carcinoma (43 from mainland China, and 37 from the USA) were evaluated for association with Barrett oesophagus (BO), chronic Helicobacter pylori gastritis, intestinal metaplasia, and outcome. GEJ carcinomas were defined as tumours that were located within 20 mm of, and crossed, the GEJ. Overall, GEJ carcinomas from Chinese patients revealed significantly more frequent location in the proximal stomach, higher pathological stage, larger size, younger patient age, and association with chronic H. pylori gastritis. In contrast, GEJ cancers from American patients showed a strong association with distal oesophageal location, BO, and associated intestinal metaplasia and dysplasia. Pathologically, GEJ carcinomas from American patients were predominantly adenocarcinomas, whereas Chinese patients showed a higher proportion of mucinous, adenosquamous, acinar or neuroendocrine tumours. Overall, 3- and 5-year survival rates were statistically similar between both patient groups, but upon multivariate analysis, Chinese patients showed statistically better survival rates for stage III tumours.

CONCLUSIONS

Most GEJ carcinomas in patients from China represent proximal gastric cancers associated with chronic H. pylori gastritis, and BO-associated carcinomas are rare among this patient population.

Controversies of cardiac glands in the proximal stomach: a critical review

Cardiac glands (CG), along with oxyntocardiac glands, in a normal human constitute cardiac mucosa (CM) that is positioned in the proximal stomach with a length of 10-30 mm, according to traditional teaching. This doctrine has been recently challenged. On the basis of studies on autopsy and biopsy materials in the esophagogastric junction region, some investigators have reported the presence of CG in only 50% of the general US population. They believed that CG were an acquired, metaplastic lesion as a result of gastroesophageal reflux disease. Subsequent recent study results from other research groups showed the presence of CG in the proximal stomach in embryos, fetuses, pediatric, and adult patients in most Europeans and Americans, and almost all Japanese and Chinese patients. These new data showed the following important findings: (i) CG are confirmed to be congenital in the proximal stomach; (ii) the length of CM is much shorter, approximately 5 mm in Caucasians in Europe and North America, and approximately 13 mm in Japanese and probably also in Chinese; (iii) CG are also present in the distal superficial esophagus underneath squamous mucosa in almost all Japanese and Chinese patients, but not so common in Caucasians in Europe, and not clear in Caucasians in North America. The recent data indicate a clear difference in the distribution of CG in the proximal stomach among different ethnic populations, and might explain different disease pathogenesis mechanisms among various ethnic patient groups.

Unchanging trend of esophagogastric junction adenocarcinoma in Korea: experience at a single institution based on Siewert's classification

The incidence of adenocarcinoma of the esophagogastric junction (AEG) has been increasing in Western countries. It is unclear, however, whether similar changes are occurring in Asia. We therefore investigated the incidence of AEG in Korea, and assessed the clinical characteristics of three types of AEG based on Siewert's classification. We retrospectively reviewed the medical records of 16 811 patients diagnosed with esophageal squamous cell carcinoma (ESC, n= 1450) or gastric noncardiac adenocarcinoma (GNCA, n= 14 751) between 1992 and 2006. The patients were divided into three 5-year cohorts (cohort A [1992-1996], n= 2734, cohort B [1997-2001], n= 5727, and cohort C [2002-2006], n= 8350), and the ratios of AEG (n= 610) to non-AEG (ESC and GNCA) in each cohort were compared. Using Siewert's classification, the tumors were categorized into one of three types, and patient demographic features and 5-year survival rates were compared. The ratio of AEG to non-AEG cases did not change over time (0.037, 0.034, and 0.039 for cohorts A, B, and C, respectively; P= 0.40). Of the 610 patients with AEG, 23 (3.7%) had type 1 tumors, 47 (7.7%) had type 2, and 540 (88.5%) had type 3. The 5-year survival rate of patients with type 1 AEG was much lower (4.8 +/- 4.7%) than that of those with type 2 (47.9 +/- 7.8%) and type 3 (47.4 +/- 2.5%) tumors. Unlike in Western countries, the ratio of AEG to non-AEG cases has not increased over time in Korea. Type 1 AEG was rarer and associated with a more unfavorable prognosis in Korea than in Western countries.

Physical activity and esophageal and gastric carcinoma in a large prospective study

BACKGROUND

Few studies have investigated the relationship of physical activity to esophageal and gastric carcinoma according to histology and anatomic site.

METHODS

This study prospectively investigated the association between physical activity and esophageal and gastric carcinoma in a cohort of 487,732 U.S. men and women, followed from 1995-1996 to December 31, 2003. All analyses were performed in 2007-2008.

RESULTS

During 8 years of follow-up study, 523 cases of esophageal carcinoma (149 squamous cell and 374 adenocarcinoma) and 642 cases of gastric carcinoma (313 cardia and 329 noncardia) were documented. Physical activity was associated with reduced risk of esophageal and gastric adenocarcinomas but was unrelated to esophageal squamous cell carcinoma. The inverse association with physical activity was strongest for gastric noncardia adenocarcinoma (multivariate relative risk [RR] for highest versus lowest physical activity level=0.62, 95% CI=0.44, 0.87). Relationships were weaker but evident for gastric cardia adenocarcinoma (RR=0.83; 95% CI=0.58, 1.19) and esophageal adenocarcinoma (RR=0.75; 95% CI=0.53, 1.06). No significant relationship with physical activity was observed for esophageal squamous cell carcinoma (RR=1.05; 95% CI=0.64, 1.74). Exclusion of cases diagnosed during the first 2 follow-up years did not change those estimates, indicating that the findings are not due to decreased activity levels among participants with undiagnosed cancer at entry.

CONCLUSIONS

Physical activity may play a role in the prevention of upper gastrointestinal tract adenocarcinomas. No association was seen between physical activity and esophageal squamous cell carcinoma.

A prospective study of BMI and risk of oesophageal and gastric adenocarcinoma

The incidence of oesophageal adenocarcinoma (EADC) is rapidly increasing in Western countries and obesity is thought to be a major risk factor. We examined the association between BMI and EADC, gastric cardia adenocarcinoma and gastric non-cardia adenocarcinoma in a cohort of approximately 500,000 people in the United States (US). We used Cox proportional hazards regression to estimate hazard ratios (HR) and 95% confidence intervals (CI) with control for many potential confounders. We found that compared to people with a BMI of 18.5-25kg/m2, a BMI > or = 35 was associated with significantly increased risk of EADC, HR (95% CI)=2.27 (1.44-3.59) and gastric cardia adenocarcinoma 2.46 (1.60-3.80), but not gastric non-cardia adenocarcinoma 0.84 (0.50-1.42). Using non-linear models, we found that higher BMI was associated with increased risk of EADC even within the normal BMI. Increased adiposity was associated with higher risk of EADC even within the normal weight range.

Clear cell (glycogen rich) gastric adenocarcinoma: a distinct tubulo-papillary variant with a predilection for the cardia/gastro-oesophageal region

AIMS

To explore the clinicopathological and immunohistochemical profile of clear cell gastric cancers with a tubulo-papillary pattern.

METHODS

Twelve cases of clear cell gastric cancer (containing a minimum of 10% of clear cells) were studied. The cases were stained with: CK7, CK20, CEA, AFP, cyclin D1, E-cadherin and CDX-2.

RESULTS

There were nine males and three females with an age range of 62 to 82 years (mean 71.4 years). Ten cases were located in the gastric cardia with extension into the gastro-oesophageal junction and two were in the pylorus/pre-pyloric area. Tumours ranged from 2 to 9 cm (mean 4.5 cm), nine were polypoid, exophytic grossly and all had a tubulo-papillary histological pattern. Five cases contained intracytoplasmic hyaline globules. Lymph node involvement was present in eight cases. Eight cases were CK7 positive, four were CK20 positive and all 12 were CEA, cyclin D1, E-cadherin and CDX-2 positive. All cases were AFP negative. Five patients had recurrence and/or metastasis within 6 months.

CONCLUSION

Clear cell gastric cancers have a predilection for the gastro-oesophageal junction, are polypoid, have a tubulopapillary pattern, and show over-expression of cyclin D1 but normal E-cadherin.

Disparities in the classification of esophageal and cardia adenocarcinomas and their influence on reported incidence rates

OBJECTIVE

To evaluate the diagnostic accuracy of esophageal and cardia adenocarcinoma in the Swedish Cancer Register.

SUMMARY BACKGROUND DATA

Based on cancer registers, a rising incidence of esophageal and cardia adenocarcinoma has been reported in several populations, but possible influence of differences in tumor classification has not been evaluated.

METHODS

In a nationwide study in 1995 through 1997, all Swedish patients, born in Sweden and younger than 80 years with esophageal or cardia adenocarcinoma and half of all patients with esophageal squamous cell carcinoma, were prospectively, uniformly, and thoroughly classified. This study classification was compared with the tumor classification in the Swedish Cancer Register, which is based on routine clinical practice.

RESULTS

The overall completeness of the Cancer Register was high (98.3%), whereas the site-specific completeness of the Register was 63% for esophageal adenocarcinoma, 74% for cardia adenocarcinoma, and 91% for esophageal squamous cell carcinoma. The incidence of esophageal adenocarcinomas was 16% higher in the study classification compared with that of the Register during the study period, whereas the incidence of cardia adenocarcinoma was 2% lower in the study classification.

CONCLUSIONS

There is a diagnostic mismatch between esophageal and cardia adenocarcinoma in the clinical setting and, therefore, also in Cancer Registers. In etiologic and therapeutic research, this problem needs consideration, since these tumors have distinct risk factor profiles and could be subjected to different treatment strategies. The increasing incidence rate of esophageal adenocarcinoma in Sweden is unlikely to be explained by such differences in tumor classification, however.

Perinatal Risk Factors for Cancer of the Esophagus and Gastric Cardia: A Nested Case-Control Study

BACKGROUND

We have previously hypothesized that preterm birth or impaired fetal growth may cause esophageal adenocarcinomas through gastroesophageal reflux early in life. In this study, we aimed to test if there is an association between gestational duration and birth weight on the one hand, and risk of esophageal and cardia adenocarcinoma on the other.

METHODS

We conducted a nested case-control study of 67 cases of esophageal adenocarcinoma and 93 cases of cardia adenocarcinoma, whereas 50 cases of squamous cell carcinoma were studied for comparison. Birth records of cases were traced. Three matched controls per case were randomly selected. Perinatal data were extracted from birth records.

RESULTS

Long gestational duration was associated with a decreased risk of cardia adenocarcinoma (P(trend) = 0.001) and a nonsignificant decreased risk of esophageal adenocarcinoma (P = 0.07), whereas no such association was found for esophageal squamous cell carcinoma (P = 0.96). Birth weight was not associated with risk of any of the studied cancers. Compared with lower maternal age (</=24 years) at giving birth, maternal age of 25 to 29 years were associated with a decreased risk of esophageal adenocarcinoma and squamous cell carcinoma (odds ratio, 0.4; 95% confidence interval, 0.2-0.9 and odds ratio, 0.3; 95% confidence interval, 0.1-0.8, respectively).

CONCLUSIONS

Numerical constraints hamper inference, but our results are somewhat consistent with the idea that future risk of esophageal and cardia cancer may in part be determined already perinatally or in infancy and give some limited support to the hypothesis that timing of birth influences risk.

Pathogenesis and classification of cancer around the gastroesophageal junction--not so different in Japan

Japanese patients with early adenocarcinoma of the esophagus have well-preserved gastric acid secretion, consistent with other parts of the world, reinforcing the likely importance of the luminal environment for pathogenesis. Progress in researching carcinomas that occur around the gastroesophageal junction would be facilitated by consensus-based review of the inadequate approaches currently used for classification of these tumors with subsequent development and widespread adoption of improved criteria.