Descriptive Epidemiology of Adenocarcinomas of the Cardia and Distal Stomach in the Swiss Canton of Vaud

Helicobacter pylori infection and gastric cardia cancer: systematic review and meta-analysis

OBJECTIVE

Helicobacter pylori infection is the most important risk factor for gastric cancer, but no association with cardia cancer has been recognized. However, a heterogeneous distribution of etiologically distinct types of cardia cancer may contribute to explain conflicting findings between studies in high- and low-risk settings. We aimed to quantify the association between H. pylori infection and gastric cardia cancer through meta-analysis, and to provide an explanation for the expected heterogeneity of results.

METHODS

We systematically reviewed published studies addressing the association between H. pylori infection and gastric cardia cancer (up to June 2009), and extracted relative risk (RR) estimates for the association with cardia and non-cardia cancers. Summary RR estimates and 95% confidence intervals (95% CI) were computed using random-effects models. Subgroup analyses were conducted, namely according to gastric cancer risk settings.

RESULTS

Thirty-four articles were considered for meta-analysis. For cardia cancer, summary RR was 1.08 (95% CI 0.83-1.40; I (2) = 52.8%), higher in high-risk (RR = 1.98; 95% CI 1.38-2.83; I (2) = 18.4%) than in low-risk settings (RR = 0.78; 95% CI 0.63-0.97; I (2) = 11.6%). For non-cardia cancer, RR estimates were similar in high- (RR = 3.02; 95% CI 1.92-4.74; I (2) = 90.7%) and low-risk settings (RR = 2.56; 95% CI 1.99-3.29; I (2) = 46.6%). These observations were consistent across different inclusion criteria and when accounting for the virulence of the infecting strains.

CONCLUSIONS

In high-risk settings, a positive association between H. pylori infection and gastric cancer was observed both for cardia and non-cardia cancers. The results support the hypothesis of a heterogeneous distribution of etiologically distinct types of cardia cancer.

A rising trend of gastric cardia cancer in Gansu Province of China

We evaluated the incidence, age, gender, and anatomical distribution of gastric cancers in 65,284 cases of upper GI endoscopies. A total of 5253 gastric cancer cases were identified. Cancers of the cardia, fundus, body and antrum account for 33.6%, 2.7%, 23.6% and 34.0% of all cases, respectively. The mean age for gastric cancers was 56.9+/-10.2 years and 69.7% of the cancer cases were found in the 50-69 year age group. Subjects with cardia cancer were slightly older than subjects with non-cardia cancer. Over the 12-year period, the incidence of the gastric antrum cancer had significantly declined, whereas the incidence of the gastric cancer in the cardia and body had risen steadily. Thus, there was a rising trend of cardia cancers and a decreasing trend of most non-cardia cancers.

Epidemiology of gastric cancer

The incidence and mortality of gastric cancer have fallen dramatically in US and elsewhere over the past several decades. Nonetheless, gastric cancer remains a major public health issue as the fourth most common cancer and the second leading cause of cancer death worldwide. Demographic trends differ by tumor location and histology. While there has been a marked decline in distal, intestinal type gastric cancers, the incidence of proximal, diffuse type adenocarcinomas of the gastric cardia has been increasing, particularly in the Western countries. Incidence by tumor sub-site also varies widely based on geographic location, race, and socio-economic status. Distal gastric cancer predominates in developing countries, among blacks, and in lower socio-economic groups, whereas proximal tumors are more common in developed countries, among whites, and in higher socio-economic classes. Diverging trends in the incidence of gastric cancer by tumor location suggest that they may represent two diseases with different etiologies. The main risk factors for distal gastric cancer include Helicobacter pylori (H pylori) infection and dietary factors, whereas gastroesophageal reflux disease and obesity play important roles in the development of proximal stomach cancer. The purpose of this review is to examine the epidemiology and risk factors of gastric cancer, and to discuss strategies for primary prevention.

Significance of matrix metalloproteinase 9 and CD34 expressions in esophageal carcinoma: correlation with DNA content

BACKGROUND

Esophageal carcinoma is common in many countries, and it is characterized by poor prognosis and rapid clinical progression with a high frequency of lymph node metastasis and recurrence. The present study was carried out to evaluate the correlation between vascular endothelial cell marker (CD34), matrix metalloproteinase type 9 (MMP9), and DNA content in esophageal carcinoma.

METHODS

A total of 38 patients were classified with histopathologic examination as 8 cases with adenocarcinoma, 24 cases with squamous cell carcinoma, and the last 6 cases with undifferentiated carcinoma. The obtained results of the patient group were compared with the results of 6 cases with proven normal esophageal mucosa as a control group. The samples of patients and controls were subjected to immunohistochemical evaluation of CD34 and MMP9 expression along with DNA index determination using flow cytometry.

RESULTS

There was a significant difference between patients and normal cases in DNA index, CD34, and MMP9 pattern (P = 0.003, <0.001, and 0.002, respectively). DNA index was positively correlated with MMP9 (r = 0.574, P < 0.001) and with CD34 (r = 0.562, P < 0.001). MMP9 was correlated with CD34 (r = 0.55, P < 0.001). A significant difference was found in both microvessel density and MMP9 expression with respect to tumor grade and stage. The microvessel density in patients with highly positive staining for MMP9 was higher than in those with negative and weak staining for MMP9 (P = 0.002).

CONCLUSION

The analysis of DNA content along with detection of CD34 and MMP9 in esophageal cancer can successfully differentiate the different pathologic lesions and hence can be used powerfully in disease prognosis reflecting valuable information about the aggressiveness and activity of those lesions.

Cytokeratin expression patterns in noncardia, intestinal metaplasia-associated gastric adenocarcinoma: implication for the evaluation of intestinal metaplasia and tumors at the esophagogastric junction

BACKGROUND

Barrett esophagus (BE)/Barrett adenocarcinoma and distal gastric intestinal metaplasia (IM)/adenocarcinoma are similar histologically, but they differ in their clinical presentation, epidemiology, and pathogenesis. Differentiating BE from gastric IM and Barrett adenocarcinoma from gastric adenocarcinoma is difficult, especially when IM is short or tumors are large and involve both sides of the esophagogastric junction. Previously, the authors identified unique cytokeratin (CK) immunoreactivity patterns that were associated strongly with BE and Barrett adenocarcinoma. The specificity of CK7 and CK20 (CK7/20) expression patterns in patients with IM-associated gastric adenocarcinoma, which is distinct epidemiologically from BE/Barrett adenocarcinoma, has not been evaluated. The objective of the current study was to evaluate the CK7/20 expression patterns in noncardia, IM-associated gastric adenocarcinoma in a Chinese population with a low risk for BE and esophageal adenocarcinoma and a high risk for Helicobacter pylori infection and gastric carcinoma.

METHODS

Endoscopic biopsy specimens of gastric IM and adjacent tumor from 50 consecutive patients with advanced noncardia gastric carcinoma were immunostained for CK7 and CK20. Clinical and endoscopic features and H. pylori status were documented. Two gastrointestinal pathologists, blinded to clinical and endoscopic data, independently assessed CK7/20 immunohistochemistry.

RESULTS

H. pylori infection was present in 43 of 50 patients (86%). In the area of IM, patchy CK7 staining was seen in 9 patients (18%), and diffuse CK20 staining was seen in all 50 patients (100%). The BE CK7/20 pattern characterized by CK7 staining in superficial and deep glands and the CK20 staining in surface epithelium was not seen in any of the 50 patients. Only one patient (2%) demonstrated a CK7 positive/CK20 negative immunophenotype characteristic of Barrett adenocarcinoma. The remaining 49 patients (98%) showed non-Barrett adenocarcinoma patterns of CK7/20 staining, i.e., a CK7 positive/CK20 positive pattern was seen in 33 patients (66%), a CK7 negative/CK20 positive pattern was seen in 12 patients (24%), and a CK7 negative/CK20 negative pattern was seen in 4 patients (8%).

CONCLUSIONS

In a patient population without risk factors for the development of BE/esophageal adenocarcinoma, the CK7/20 pattern characteristic of BE was not present in gastric IM adjacent to adenocarcinoma, and the CK7/20 pattern characteristic of Barrett adenocarcinoma also was extremely rare. These results support the hypothesis that, despite the presence of intestinalized mucosa in both disorders, BE/Barrett adenocarcinoma and gastric IM/adenocarcinoma are two distinct clinical entities with unique demographic, clinical, and CK immunophenotypic findings. These results may have application to the evaluation of patients with IM and adenocarcinoma arising at the esophagogastric junction.

Epidemiological study of oesophageal and gastric cancer in south-east England

BACKGROUND

This epidemiological study was carried out to establish the magnitude of the changing incidence of gastric and oesophageal cancer.

METHODS

Time-trend analyses of subsite-specific cancers of the oesophagus and stomach were performed using data from the Thames Cancer Registry database (1960-1996) for the South Thames Region. The changes in sex ratio and peak age of incidence are reported.

RESULTS

In the upper two-thirds of the oesophagus there was no significant change in the incidence rate, but the lower third of the oesophagus showed a marked rise for both sexes (average annual change + 0.05 for men, + 0.009 for women). For the gastric cardia, the incidence in males increased (average annual change + 0.025), while in females it remained unchanged. Cancers of the oesophagogastric junction showed a clear increase for both sexes (average annual change + 0.07 for men, + 0.009 for women). There were changes in the sex ratio and peak age of incidence for all subsite cancers for both sexes.

CONCLUSION

Over a 37-year period the incidence of cancer of the oesophagogastric junction increased threefold, while the incidence of cancers of the other subsites of the stomach decreased. Further studies are needed to investigate the aetiology of these changes.

The utility of cytokeratin subsets in distinguishing Barrett's-related oesophageal adenocarcinoma from gastric adenocarcinoma

AIMS

Accurate tumour classification is critical for meaningful epidemiological studies in the assessment of cancer incidence rates and trends. Differentiating primary gastric carcinoma from oesophageal carcinoma can be difficult, especially when tumours are large and involve both the oesophagus and stomach. Furthermore, adenocarcinomas of both organs typically are of intestinal histological type and arise in a background of intestinal metaplasia. Consequently, histological markers that reliably distinguish Barrett's-related oesophageal adenocarcinoma from gastric adenocarcinoma would be useful. Cytokeratins (CK)7 and 20 are cytoplasmic structural proteins with restricted expression that help to determine the origin of many epithelial tumours including those of the gastrointestinal tract. The aim of this study was to determine the utility of co-ordinate CK7 and 20 expression in the distinction of Barrett's-related oesophageal adenocarcinoma from gastric adenocarcinoma arising in a background of intestinal metaplasia.

METHODS AND RESULTS

CK7 and 20 immunostaining was performed on randomly selected surgical resection specimens from patients with Barrett's-related oesophageal adenocarcinoma (n = 30) and intestinal type gastric adenocarcinoma (n = 14) arising in a background of intestinal metaplasia. A CK7+ CK20- immunophenotype was demonstrated in 27 of 30 (90%) patients with Barrett's-related oesophageal adenocarcinoma and only three of 14 (21%) gastric adenocarcinomas. The sensitivity, specificity and positive predictive value of a CK7+/20- immunophenotype for a diagnosis of Barrett's-related oesophageal adenocarcinoma was 90%, 79%, and 90%, respectively.

CONCLUSIONS

A CK7+/20- tumour immunophenotype is associated with Barrett's-related oesophageal adenocarcinoma and may be useful in accurate tumour classification, thus facilitating improving epidemiological evaluation of tumours at the oesophagogastric junction.

The epidemiology of oesophageal adenocarcinoma: has the cancer of gastric cardia an influence on the rising incidence of oesophageal adenocarcinoma?

BACKGROUND

Owing to overgrowth and definitional problems in classification, the cancer of gastric cardia may affect significantly the epidemiological analysis of oesophageal adenocarcinoma. The purpose of the present study was to evaluate the changes in the incidence of all the adenocarcinomas near the gastrooesophageal junction.

METHODS

Trends in the incidence rates of adenocarcinoma of the oesophagus and the gastric cardia were described through the Finnish Cancer Registry. The annual age-standardized incidence rates during 1976-95 were analysed by a linear regression technique.

RESULTS

The total incidence of oesophageal carcinoma remained around 3.5/100,000 in men, and decreased from 2.8 to 1.3/100,000 in women. The incidence of oesophageal adenocarcinoma increased from 0.28 to 0.77/100,000 (nearly 300%) in males, and from 0.08 to 0.11 per 100,000 in females. There were no significant changes with time in the incidence rate of gastric cardia cancer in either sex. Combined gastric cardia and oesophageal adenocarcinoma incidence rates remained stable in women, and increased slightly, but significantly, from 2.4 to 2.9/100,000 in men.

CONCLUSION

Oesophageal adenocarcinoma has increased significantly in men in Finland, but the combined incidence of cancers of the gastro-oesophageal junction has increased only slightly. To overcome the difficulties in classification of oesophageal adenocarcinoma and the cancer of gastric cardia in the epidemiological studies, the focus should be on all adenocarcinomas at or near the oesophagogastric junction.

Trends in incidence of adenocarcinoma of the oesophagus and gastric cardia in ten European countries

BACKGROUND

In many western countries an increase in incidence of adenocarcinoma of the oesophagus and/or gastric cardia have been reported. The aim of this study was to describe and compare trends in incidence of adenocarcinoma of the oesophagus and gastric cardia in several areas of Europe, 1968-1995, using Eurocim (a database of cancer incidence and mortality data from 95 European cancer registries).

METHODS

Time-trends in age-standardized incidence rates of adenocarcinomas of the oesophagus and gastric cardia are described in 11 population-based cancer registries from 10 countries in North, South, East, West and Central Europe, 1968-1995. The statistical significance of the time-trends in incidence was assessed using Poisson regression analysis.

RESULTS

An increase in incidence of adenocarcinomas of the oesophagus and gastric cardia was observed in Northern Europe (Denmark), Southern Europe (Italy, Varese), Eastern Europe (Slovakia) and Western Europe (England and Wales, Scotland). In Central Europe (Switzerland, Basel) and in the cancer registries of Iceland (Northern Europe), France, Bas-Rhin and Calvados, Southern Ireland, and the Netherlands, Eindhoven (Western Europe) no rise in incidence was observed. The increase in incidence of adenocarcinomas of the oesophagus and gastric cardia was accompanied by a decrease in incidence of both adenocarcinomas and non-adenocarcinomas of the non-cardia part of the stomach in almost all of the 11 cancer registries studied. Increased histological verification of tumours of the oesophagus and stomach and improvement in precision of histological diagnosis may partly explain the increase in incidence of adenocarcinomas in some registries.

CONCLUSIONS

This study, using Eurocim data, supports the findings from other time-trend studies of population-based cancer registries in western countries.

Esophageal and gastric carcinoma in Norway 1958-1992: incidence time trend variability according to morphological subtypes and organ subsites

The occurrence of adenocarcinoma (AC) of the esophagus and gastric cardia has shown large increases in many but not all examined populations. This trend is in contrast with a decrease in distal gastric AC and a relative stability of esophageal squamous cell carcinoma. Our study aimed to describe esophageal and gastric carcinoma time trends in the Norwegian population between 1958 and 1992 based on data from the Cancer Registry of Norway. Estimated esophageal AC rates have accelerated over the study period, reaching average annual increases of 17% in men and 14% in women between 1983 and 1992. The occurrence of esophageal squamous cell carcinoma was relatively stable in both sexes. Proximal gastric cancer rates were stable in males and decreased somewhat in females. Distal gastric tumors showed decreases in both sexes, but were more pronounced in females. The strong increase in esophageal AC incidence parallels similar increases in the United States and some other countries. Although the observed increase may be explained to some extent by a shift in the classification of esophago-cardial adenocarcinomas, the figures are compatible with a real increase. AC of the esophagus, the proximal stomach and the distal stomach exhibit different epidemiological features, both in terms of sex ratios and time trends, suggesting risk factor differences between the subsites.

Changes in the site- and histology-specific incidence of gastric cancer during a 50-year period

BACKGROUND & AIMS

In contrast to the dramatic decrease in the overall incidence of gastric cancer, there has been a reported increase in the incidence of cases located in the gastric cardia. The aim of this study was to identify changes in site- and histology-specific incidence rates of gastric adenocarcinoma during a 50-year period.

METHODS

The Rochester Epidemiology Project medical records linkage system was used to identify all cases of gastric adenocarcinoma among residents of Olmsted County, Minnesota, between 1941 and 1990 (n = 342). Each patient's complete (inpatient and outpatient) medical records were reviewed and tumor location determined from pathological, surgical, endoscopic, and radiological reports. All available histological specimens (n = 246) were reviewed independently.

RESULTS

The overall incidence of gastric cancer decreased from 48.8 per 100,000 person-years in the 1940s to 11.6 per 100,000 in the 1980s, whereas the incidence of adenocarcinoma of the cardia did not change significantly during the 50-year period. The incidence of adenocarcinoma of the esophagogastric junction increased from 0.0 to 1.9 per 100,000 person-years, but the number of cases was small.

CONCLUSIONS

The incidence of adenocarcinoma of the gastric cardia has not increased in this population. The reported increase in cardia cancer in other populations may be due to an increasing incidence of adenocarcinoma of the esophagogastric junction.

The time trend and age-period-cohort effects on incidence of adenocarcinoma of the stomach in Connecticut from 1955-1989

BACKGROUND

Adenocarcinoma of the gastric cardia has been be increasing in Connecticut, and the risk factors responsible for the increasing incidence are unknown. This study examined the incidence pattern of adenocarcinoma of the gastric cardia and distal stomach in Connecticut during the past decades and identified components of birth cohort, period, and age as determinants of the observed time trends by regression modeling.

METHODS

This study was based on all histologically confirmed incident cases of gastric adenocarcinoma reported to the Connecticut Tumor Registry between 1955 and 1989. Stomach cancers were grouped into cancers of the gastric cardia, distal stomach, or unknown/unspecified subsite. Age-adjusted incidence rates were calculated by the direct method standardized to the 1970 United States population. A regression model was used to identify birth cohort, period, and age as determinants of the observed time trends.

RESULTS

The results indicated that the incidence rate of adenocarcinoma of the cardia is increasing, particularly in white males, whereas adenocarcinoma of the distal stomach is now decreasing in both sexes in Connecticut. Regression modeling suggests that the increase of adenocarcinoma of the cardia may be explained partly by a birth cohort phenomenon.

CONCLUSION

There is little information regarding the risk factors that might be responsible for the observed increasing trend for adenocarcinoma of the cardia, although smoking, alcohol intake, retinol intake, and hiatal hernia have been associated with an increased risk of adenocarcinoma of the cardia or gastric cancer. Considering the different epidemiologic features of adenocarcinoma of the cardia and distal stomach, future analytic studies should separate cancer of the gastric cardia and cancer of the distal stomach in searching for etiologic factors.

Increasing incidence of carcinoma of the gastric cardia in Sweden from 1970 to 1985

Several American, Japanese and European centres have reported an increase in carcinoma of the gastric cardia, contrary to the general trend in the incidence of gastric cancer. The aim of this nationwide population-based study was to describe trends in the incidence of tumours of the gastric cardia in Sweden over the 16-year period from 1970 to 1985. The Swedish cancer register, which is more than 95 per cent complete, was used to identify cases. There were 1514 men and 481 women with cancer of the gastric cardia. The age-standardized rates increased in men from 1.9 per 10(5) population in 1970-1973 to 3.0 per 10(5) in 1982-1985, corresponding to a mean annual increase of 2.5 per cent (95 per cent confidence interval (c.i.) 1.6-3.4 per cent). In women, the age-standardized rates increased from 0.5 per 10(5) in 1970-1973 to 0.8 per 10(5) in 1982-1985, the mean annual increase being 0.9 per cent (95 per cent c.i. 0.0-1.8 per cent). The highest incidences were found in southern Sweden, contrary to the geographical distribution of gastric cancer in general, which shows a south-to-north gradient. The disparate epidemiological features of cancer of the cardia and gastric cancer at other sites suggest that the aetiologies may also be different. Since little is known about the aetiology of cancer of the cardia, and the incidence seems to be rising rapidly, analytical studies are urgently needed.

Time trend and age-period-cohort effects on incidence of esophageal cancer in Connecticut, 1935-89

The purpose of this study was to examine the incidence pattern of esophageal cancer in Connecticut (USA) during the past decades, and to identify components of birth cohort, period, and and age as determinants of the observed time trends by regression modelling. This study is based on all of the esophageal cancer cases reported to the Connecticut Tumor Registry between 1935 and 1989. A total of 6,310 incident cases were included. Results indicate that among males, the overall age-adjusted incidence rate of esophageal cancer increased after 1935 and peaked between 1955 and 1959. Since then, incidence rates have been relatively stable. Among females, the overall esophageal cancer rate has not changed markedly since 1935. Analysis by histologic type indicates that the incidence rate of squamous cell carcinoma has been declining in this population; adenocarcinoma, however, showed a continuous increase. A fivefold increase among males and a threefold increase among females were observed for adenocarcinoma of the esophagus between 1970 and 1989. If cancers of the esophagus and gastric cardia are considered together, the incidence rate of adenocarcinoma exceeds that of squamous cell carcinoma among males during 1985-89. The observed increasing trend for adenocarcinoma of the esophagus is mainly from cancers arising in the lower third of the esophagus and primarily among Whites, especially White males. The results from regression modeling indicate that both period and birth cohort may have contributed to the observed increasing trend, and adenocarcinoma of the esophagus is likely to increase continuously in this population in the coming years.

Epidemiological research in stomach cancer: progress over the last ten years

In this paper the progress of epidemiological research in stomach cancer during 1980-1990 is reviewed in respect to regional variation, etiology, and formation of carcinogens. The evaluation of 4 cohort and 16 case-control studies revealed a consistently inverse relationship of stomach cancer risk with raw vegetables, fruit, and wholemeal bread consumption and with vitamin C and carotene intake. Milk, cooked vegetables and vitamins A and E were not consistently found to be related to stomach cancer risk. Positive associations of increasing consumption with stomach cancer risk were occasionally found for processed or particularly prepared meat and fish, and for nitrite. Dietary nitrate intake did not appear to be related to stomach cancer risk in these studies. This latter observation is also supported by metabolic studies in high- and low-risk areas for stomach cancer. Consistently among studies, increased risk for stomach cancer was also found for later availability of refrigeration facilities in the household, non-centralized water supply (especially well water), and high salt intake. Prospective studies agreed in an increased risk for stomach cancer for cigarette smoking, but not for alcohol drinking, whereas case-control studies showed divergent results on these factors. Recent metabolic studies in high- and low-risk areas for stomach cancer or in groups with precursor lesions, with the N-nitrosoproline test as a marker for endogenous nitrosation, revealed inconsistent results. Higher nitrite concentration and increased pH in stomach juice were found to be associated with precursor conditions for stomach cancer. It is still not clear whether intake of preformed carcinogens or endogenous formation in the stomach with or without the inclusion of nitrite is the most important source of tumor-initiating or -promoting substances. Preservation or preparation of meat and fish may play an important role in this process, and vitamin C may be an inhibiting substance.