Prediction of disease-free survival using relative change in FDG-uptake early during neoadjuvant chemoradiotherapy for potentially curable esophageal cancer: A prospective cohort study

18F-Fluorodeoxyglucose positron emission tomography (FDG-PET) has been investigated as a tool for monitoring response to neoadjuvant chemo- and chemoradiotherapy (CT and CRT, respectively) and as a predictor for survival in patients with esophageal cancer. In contrast to patients who undergo neoadjuvant CT, it is not known whether patients who are clinically identified as responders after neoadjuvant CRT show better disease-free survival (DFS) than patients identified as nonresponders. The aim of the study was to determine the predictive value of FDG-uptake measured prior to and early during neoadjuvant CRT. Patients treated with neoadjuvant CRT between 2004 and 2009 within a randomized trial were included. FDG-uptake was measured at baseline and after 14 days of CRT. According to the PERCIST-criteria, patients were allocated to have metabolic response, stable disease, or progression. Patients were followed until recurrence of disease or death. The predictive value of FDG-PET was determined with univariable and multivariable analysis in patients who underwent potentially curative surgery. One-hundred and six patients were included in the analysis. Minimal follow-up for surviving patients was 60 months. No significant differences in DFS were found between patients with metabolic response, stable disease, or progression, with 5-year DFS rates of 66%, 53%, and 67%, respectively (P = 0.39). Relative change in FDG uptake after 14 days of CRT is not associated with DFS in patients with esophageal cancer undergoing neoadjuvant chemoradiotherapy followed by surgery. These measurements should not be used for prognostication in this specific group of patients.

Dynamic clonal equilibrium and predetermined cancer risk in Barrett's oesophagus

Surveillance of Barrett's oesophagus allows us to study the evolutionary dynamics of a human neoplasm over time. Here we use multicolour fluorescence in situ hybridization on brush cytology specimens, from two time points with a median interval of 37 months in 195 non-dysplastic Barrett's patients, and a third time point in a subset of 90 patients at a median interval of 36 months, to study clonal evolution at single-cell resolution. Baseline genetic diversity predicts progression and remains in a stable dynamic equilibrium over time. Clonal expansions are rare, being detected once every 36.8 patient years, and growing at an average rate of 1.58 cm(2) (95% CI: 0.09-4.06) per year, often involving the p16 locus. This suggests a lack of strong clonal selection in Barrett's and that the malignant potential of 'benign' Barrett's lesions is predetermined, with important implications for surveillance programs.

The impact of PNPLA3 (rs738409 C>G) polymorphisms on liver histology and long-term clinical outcome in chronic hepatitis B patients

BACKGROUND & AIMS

We aimed to assess the association between the patatin-like phospholipase domain-containing-3 (PNPLA3) I148M polymorphism, liver histology and long-term outcome in chronic hepatitis B (CHB) patients.

METHODS

We enrolled 531 consecutive treatment naïve CHB patients diagnosed from 1985 to 2012 with an available liver biopsy for reassessment, and sample for genetic testing. Data on all-cause mortality and hepatocellular carcinoma (HCC) at long-term follow-up were obtained from national database registries.

RESULTS

The prevalence of steatohepatitis increased with PNPLA3 CC (14%), CG (20%) and GG (43%) (P < 0.001). The association was altered by both gender (P = 0.010) and overweight (P = 0.015): the effect of PNPLA3 on steatohepatitis was most pronounced among non-overweight females (adjusted OR 13.4, 95%CI: 3.7-51.6, P < 0.001), and non-overweight males (adjusted OR 2.4, 95%CI: 1.4-4.3, P = 0.002). Furthermore, PNPLA3 GG genotype was associated with iron depositions (OR 2.8, 95%CI: 1.2-6.4, P = 0.014) and lobular inflammation (OR 2.2, 95%CI: 1.1-4.5, P = 0.032), but not with advanced fibrosis (OR 1.1, 95%CI: 0.7-1.8, P = 0.566). The median follow-up was 10.1 years (interquartile range 5.6 - 15.8), during which 13 patients developed HCC and 28 died. Steatohepatitis was associated with all-cause mortality [Hazard ratio (HR) 3.1, 95%CI: 1.3-7.3, P = 0.006] and HCC (HR 2.8, 95%CI: 0.9-9.2, P = 0.078), but no significant association was observed for PNPLA3.

CONCLUSIONS

In this cohort of biopsied CHB patients, PNPLA3 was independently associated with steatosis, steatohepatitis, lobular inflammation and iron depositions, but not with advanced fibrosis, HCC development or all-cause mortality. The effect of PNPLA3 on steatohepatitis was particularly pronounced among female patients without severe overweight.

Radiofrequency ablation vs endoscopic surveillance for patients with Barrett esophagus and low-grade dysplasia: a randomized clinical trial

IMPORTANCE

Barrett esophagus containing low-grade dysplasia is associated with an increased risk of developing esophageal adenocarcinoma, a cancer with a rapidly increasing incidence in the western world.

OBJECTIVE

To investigate whether endoscopic radiofrequency ablation could decrease the rate of neoplastic progression.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter randomized clinical trial that enrolled 136 patients with a confirmed diagnosis of Barrett esophagus containing low-grade dysplasia at 9 European sites between June 2007 and June 2011. Patient follow-up ended May 2013.

INTERVENTIONS

Eligible patients were randomly assigned in a 1:1 ratio to either endoscopic treatment with radiofrequency ablation (ablation) or endoscopic surveillance (control). Ablation was performed with the balloon device for circumferential ablation of the esophagus or the focal device for targeted ablation, with a maximum of 5 sessions allowed.

MAIN OUTCOMES AND MEASURES

The primary outcome was neoplastic progression to high-grade dysplasia or adenocarcinoma during a 3-year follow-up since randomization. Secondary outcomes were complete eradication of dysplasia and intestinal metaplasia and adverse events.

RESULTS

Sixty-eight patients were randomized to receive ablation and 68 to receive control. Ablation reduced the risk of progression to high-grade dysplasia or adenocarcinoma by 25.0% (1.5% for ablation vs 26.5% for control; 95% CI, 14.1%-35.9%; P < .001) and the risk of progression to adenocarcinoma by 7.4% (1.5% for ablation vs 8.8% for control; 95% CI, 0%-14.7%; P = .03). Among patients in the ablation group, complete eradication occurred in 92.6% for dysplasia and 88.2% for intestinal metaplasia compared with 27.9% for dysplasia and 0.0% for intestinal metaplasia among patients in the control group (P < .001). Treatment-related adverse events occurred in 19.1% of patients receiving ablation (P < .001). The most common adverse event was stricture, occurring in 8 patients receiving ablation (11.8%), all resolved by endoscopic dilation (median, 1 session). The data and safety monitoring board recommended early termination of the trial due to superiority of ablation for the primary outcome and the potential for patient safety issues if the trial continued.

CONCLUSIONS AND RELEVANCE

In this randomized trial of patients with Barrett esophagus and a confirmed diagnosis of low-grade dysplasia, radiofrequency ablation resulted in a reduced risk of neoplastic progression over 3 years of follow-up.

TRIAL REGISTRATION

trialregister.nl Identifier: NTR1198.

Narrow band imaging does not reliably predict residual intestinal metaplasia after radiofrequency ablation at the neo-squamo columnar junction

BACKGROUND AND STUDY AIMS

After radiofrequency ablation (RFA) of Barrett's esophagus, it may be difficult to determine whether complete eradication of intestinal metaplasia at the neosquamocolumnar junction (neo-SCJ) in the cardia has been achieved. It is claimed that narrow band imaging (NBI) may predict the presence of intestinal metaplasia, which would enable immediate treatment. The aim of the current study was to evaluate whether inspection of the neo-SCJ with NBI after RFA results in reliable detection of intestinal metaplasia.

PATIENTS AND METHODS

Patients with a normal-appearing neo-SCJ who were scheduled for RFA were included in the study. Two expert endoscopists obtained images from the neo-SCJ in overview (high resolution white light and NBI mode) and from four areas using NBI zoom, followed by corresponding biopsies. Four other blinded expert endoscopists evaluated the images for the presence of intestinal metaplasia and type of mucosal pattern (round, small tubular, large tubular, villous). Endpoints were sensitivity and specificity for identifying patients and areas with intestinal metaplasia.

RESULTS

From 21 patients overview images from 21 neo-SCJs and NBI zoom images from 83 neo-SCJ areas were obtained. Intestinal metaplasia was present in five overview images (24 %) and nine zoom images (11 %). Using the overview images, sensitivity and specificity for identifying patients with intestinal metaplasia were 65 % (95 % confidence interval [CI] 38 - 86) and 46 % (95 %CI 33 - 60), respectively. For individual zoom images, sensitivity was 71 % (95 %CI 54 - 85) and specificity was 37 % (95 %CI 32 - 43).

CONCLUSIONS

After RFA, endoscopic inspection of the neo-SCJ with NBI in overview or zoom does not reliably predict presence or absence of intestinal metaplasia.

Pseudo-buried Barrett's post radiofrequency ablation for Barrett's esophagus, with or without prior endoscopic resection

BACKGROUND AND STUDY AIM

In our experience, biopsies from small residual islands of nonburied Barrett's mucosa after radiofrequency ablation (RFA) are occasionally reported by pathologists to contain "buried Barrett's" upon histological evaluation, despite the fact that these islands of columnar mucosa were visible endoscopically. The aim of this study was to evaluate the frequency of buried Barrett's in biopsies obtained from small residual Barrett's islands ( < 5 mm) sampled post-RFA, compared with biopsies from normal neosquamous epithelium.

PATIENTS AND METHODS

Biopsies obtained from normal-appearing neosquamous epithelium and from small Barrett's islands ( < 5 mm) in 69 consecutive Barrett's patients treated with RFA were evaluated for the presence of buried columnar mucosa.

RESULTS

A total of 2515 biopsies were obtained from neosquamous epithelium during follow-up post-RFA. Buried glands were found in 0.1 % of biopsies from endoscopically normal neosquamous epithelium. However, when small islands of columnar mucosa were biopsied, buried glands were detected in 21 % of biopsies.

CONCLUSION

To avoid accidental sampling of small islands resulting in a false-positive histological diagnosis of buried Barrett's, thorough inspection should be performed before obtaining biopsies during post-RFA follow-up.

microRNA-145 in Barrett's oesophagus: regulating BMP4 signalling via GATA6

OBJECTIVE

Barrett's oesophagus (BE) is a metaplastic condition of the distal oesophagus which predisposes to oesophageal adenocarcinoma (EAC). It has been suggested that microRNAs (miRNAs) are involved in the process of development of BE and EAC; however, few functional miRNA data are available. The aim of the study was to perform a tissue-specific miRNA profile and, based on this, to examine the function of miRNA-145 in the oesophagus.

DESIGN

miRNA expression profiling using microarray analysis in EAC, BE and normal squamous epithelium of the oesophagus (SQ) was performed and validated using real-time PCR in samples from 15 patients and in situ hybridisation in samples from 10 patients. The proliferative effect of miRNA-145 precursor transfection in the SQ (HET-1A) and BE cell line (BAR-T) was measured. Downstream targets of miRNA-145 were determined by analysing mRNA and protein expression from miRNA-145 transfected cells.

RESULTS

Three unique miRNA expression profiles were found in tissue from EAC, BE and SQ, which showed that miRNA-145 was upregulated in BE compared with EAC and SQ. Overexpression of miRNA-145 in HET-1A and BAR-T cells reduced cell proliferation and inhibited GATA6, BMP4 and SOX9 mRNA expression. Furthermore, altered BMP4 signalling was observed in vitro on miRNA-145 overexpression. These effects were blocked when cells were co-transfected with a miRNA-145 specific inhibitor. Additionally, BMP4 incubation of HET-1A cells altered miRNA-145 and GATA6 expression over time.

CONCLUSION

These results imply that miRNA-145 indirectly targets BMP4 via GATA6 and is potentially involved in the development of BE.

Immunohistochemical characteristics of hepatocellular carcinoma in non-cirrhotic livers

Hepatocellular carcinoma (HCC) typically develops in cirrhotic livers. In the absence of risk factors, for example, cirrhosis or hepatitis B or C virus infection, HCC diagnosis might be difficult. We aimed to explore the value of immunohistochemical characteristics to diagnostics and prognosis, and whether these immunohistochemical characteristics differ from those of HCC in a cirrhotic liver, possibly indicating an aberrant pathogenetic pathway. Paraffin-embedded, formalin-fixed tissue slides from liver resection specimens of the patients with HCC in a non-cirrhotic liver were analysed. From January 2000 through April 2011, 799 patients with HCC were admitted to our hospital; in total, 47 patients with 50 HCCs in a non-cirrhotic liver were operated. These tumours were stained positive for α-fetoprotein (AFP) in 30%, CD34 in 88%, cytokeratine 7 (CK7) in 44%, CK19 in 12%, glypican-3 (GPC-3) in 40%, glutamine synthetase in 62% and β-catenin in 32%. There was similarity in immunohistochemical expression of several markers comparing HCC in a non-cirrhotic liver with HCC in a cirrhotic liver. Moderate or poorly differentiated HCC more often expressed β-catenin and GPC-3 and showed a higher percentage of MIB-1-positive hepatocytes. A positive AFP immunohistochemical staining was significantly related with a high preoperative AFP serum level (p=0.001). None of the immunohistochemical stainings were associated with a worse overall survival. Of the patients treated with a surgical resection, 17 had recurrence of HCC and these patients more often had a positive CK19 staining (p=0.048). In conclusion, immunohistochemical expression of several markers in HCC in a non-cirrhotic and cirrhotic liver was comparable. Immunohistochemical markers have limited additional value to characterise HCC in non-cirrhoitc livers.

Whole slide images for primary diagnostics of paediatric pathology specimens: a feasibility study

INTRODUCTION

Whole slide images (WSI) have been used in many pathology applications such as teleconsultation, teaching and research, but not in primary diagnostics. The aim of this study was to test the feasibility of using WSI in primary diagnostics of paediatric pathology specimens and placental tissue.

MATERIALS AND METHODS

Eighty consecutive tissues biopsies and resections from patients under 18 years old were selected, as well as 20 placentas. These cases had been diagnosed in the year 2009 by a single pathologist. The same pathologist who had performed the original diagnosis based on light microscopy was asked to rediagnose these 100 cases on WSI scanned at 20× magnification as well as by light microscopy having the original clinical information available, but blinded to the original light microscopic diagnoses. The original diagnoses were compared with WSI based diagnoses and rediagnoses by light microscopy and classified as concordant, mildly discordant (without clinical consequences) and discordant (with clinical consequences).

RESULTS

The original diagnoses were concordant with WSI and light microscopic diagnoses in 90% and 93% of cases respectively, which was not significantly different. Digital reassessment yielded eight mild discrepancies and two discrepant cases (2%) where the difference in diagnoses could have clinical implications for the patient. Light microscopic reassessment showed seven mild discrepancies. It turned out to be difficult to identify nucleated red blood cells on WSI, even when scanned at 40×.

CONCLUSIONS

Primary diagnostics of paediatric tissue biopsies and resections can generally well be done on WSI. However, some difficulties were encountered in examining placenta tissue where the identification of nucleated red blood cells may need higher resolution or even scanning at multiple focus depths, which is well possible on most current slide scanners.

Additional value of upper GI tract endoscopy in the diagnostic assessment of childhood IBD

OBJECTIVES

For the choice of treatment in children with inflammatory bowel disease (IBD), it is important to make a distinction between Crohn disease (CD) and ulcerative colitis (UC). To look for pathognomonic features of CD, upper gastrointestinal tract (UGT) endoscopy has become part of the routine evaluation of children with suspected IBD; however, pathological changes can also be found in the UGT in patients with UC. The aims of the present study were to establish the role of UGT involvement in the diagnostic assessment of suspected IBD in children and to detect histopathological changes in the UGT mucosa, which can distinguish CD from non-CD (UC and non-IBD).

METHODS

Biopsies (colon, ileum, duodenum, stomach, esophagus) from children suspected of having IBD who underwent endoscopy between 2003 and 2008 were reassessed by a blinded, expert pathologist. The histological findings of the UGT were compared with the diagnosis based on ileocolonic biopsies and the final diagnosis.

RESULTS

In 11% of the children with CD, the diagnosis was based solely on the finding of granulomatous inflammation in the UGT. Focal cryptitis of the duodenum and focally enhanced gastritis were found significantly more frequently in children with CD compared with children with UC and non-IBD, with a specificity and positive predictive value of 99% and 93% and 87.1% and 78.6%, respectively.

CONCLUSIONS

Histology on ileocolonic biopsies alone is insufficient for a correct diagnosis of CD or UC in children. UGT endoscopy should, therefore, be performed in the diagnostic assessment of all children suspected of having IBD.

Omega-3 fatty acids reduce hepatic steatosis and consequently attenuate ischemia-reperfusion injury following partial hepatectomy in rats

AIM

The aim of this study was to investigate omega-3 fatty acids (FAs) treatment of experimental steatosis and the consequent effect on ischemia-reperfusion (IR) injury.

BACKGROUND

Fatty livers are more susceptible to IR injury and display decreased regenerative capacity. Consequently, restrictions exist for patients with fatty livers to undergo a major hepatectomy or to participate in living donor liver transplantation. Until recently, weight reduction constituted the only proven therapy for patients with fatty livers.

METHODS

Steatosis was induced by a 3-wk methionine/choline-deficient diet, followed by oral administration of omega-3 FAs (Omega-3), standard lipid solution (Lipid), or NaCl (Saline) during 2 wk. Control animals received a standard diet without treatment. Rats underwent partial (70%) hepatic IR combined with partial hepatectomy (PHx) of the non-ischemic lobes (30%) followed by 24-h reperfusion.

RESULTS

Histological analysis revealed mild (5-33%) macrovesicular steatosis in omega-3-treated animals vs. severe (>66%) macrovesicular steatosis in both Lipid and Saline groups. Following IR/PHx, omega-3-treated rats exhibited reduced serum ALT levels after 6- and 24-h reperfusion, a reduced hepatic TNF-α content, and an improved anti-oxidative capacity.

CONCLUSIONS

Omega-3 treatment significantly reduces experimental hepatic steatosis and associated pathophysiological features, resulting in significantly reduced IR injury following PHx.

Misclassification of dysplasia in patients with inflammatory bowel disease: consequences for progression rates to advanced neoplasia

BACKGROUND

The natural behavior of flat low-grade (LGD) and indefinite dysplasia (IND) in patients with inflammatory bowel disease (IBD) remains uncertain and seems to be dependent on the interpretation of the pathologist. We studied the progression rate of flat LGD and IND to advanced neoplasia (high-grade dysplasia [HGD] or colorectal cancer [CRC]) before and after histopathological review by a panel of gastrointestinal expert pathologists.

METHODS

A nationwide pathology database was used to identify IBD patients with dysplasia in six Dutch university medical centers between 1990 and 2006. Medical charts of patients with recorded flat LGD or IND were reviewed. Histological slides from three university medical centers were reviewed by a panel of three expert gastrointestinal pathologists.

RESULTS

We identified 113 flat LGD patients and 26 flat IND patients. Advanced neoplasia was found in 18 flat LGD patients (16%) after a median follow-up of 48 months, resulting in a 5-year progression rate of 12%. Five IND patients (19%) developed advanced neoplasia after a median follow-up of 24 months, resulting in a 5-year progression rate of 21%. Review of 1547 histological slides from 87 patients resulted in an increase of the 5-year progression rate of flat LGD to advanced neoplasia to 37%, whereas the progression rate of IND decreased to 5%.

CONCLUSIONS

A diagnosis of flat LGD that is confirmed by a panel of expert gastrointestinal pathologists is associated with a substantial risk of progression to advanced neoplasia, while confirmed IND is associated with a low risk of progression.

Endoscopic radiofrequency ablation combined with endoscopic resection for early neoplasia in Barrett's esophagus longer than 10 cm

BACKGROUND

Radiofrequency ablation (RFA) is safe and effective for eradicating Barrett's esophagus (BE) and BE-associated early neoplasia. Most RFA studies have limited the baseline length of BE (<10 cm), and therefore little is known about RFA for longer BE.

OBJECTIVE

To assess the safety and efficacy of RFA with or without prior endoscopic resection (ER) for BE ≥ 10 cm containing neoplasia.

DESIGN

Prospective trial.

SETTING

Two tertiary-care centers.

PATIENTS

This study involved consecutive patients with BE ≥ 10 cm with early neoplasia.

INTERVENTION

Focal ER for visible abnormalities, followed by a maximum of 2 circumferential and 3 focal RFA procedures every 2 to 3 months until complete remission.

MAIN OUTCOME MEASUREMENTS

Complete remission, defined as endoscopic resolution of BE and no intestinal metaplasia (CR-IM) or neoplasia (CR-neoplasia) in biopsy specimens.

RESULTS

Of the 26 patients included, 18 underwent ER for visible abnormalities before RFA. The ER specimens showed early cancer in 11, high-grade intraepithelial neoplasia (HGIN) in 6, and low-grade intraepithelial neoplasia (LGIN) in 1. The worst residual histology, before RFA and after any ER, was HGIN in 16 patients and LGIN in 10 patients. CR-neoplasia and CR-IM were achieved in 83% (95% confidence interval [CI], 63%-95%) and 79% (95% CI, 58%-93%), respectively. None of the patients had fatal or severe complications and 15% (95% CI, 4%-35%) had moderate complications. During a mean (± standard deviation) follow-up of 29 (± 9.1) months, no neoplasia recurred.

LIMITATIONS

Tertiary-care center, short follow-up.

CONCLUSION

ER for visible abnormalities, followed by RFA of residual BE is a safe and effective treatment for BE ≥ 10 cm containing neoplasia, with a low chance of recurrence of neoplasia or BE during follow-up.

Do we still need EUS in the workup of patients with early esophageal neoplasia? A retrospective analysis of 131 cases

BACKGROUND

EUS is often used for locoregional staging of early esophageal neoplasia. However, its value compared with that of endoscopic examination and diagnostic endoscopic resection (ER) may be questioned because diagnostic ER allows histological assessment of submucosal invasion and other risk factors for lymph node metastasis, eg, poor differentiation/lymphovascular invasion.

OBJECTIVE

To evaluate how often patients were excluded from endoscopic treatment of esophageal neoplasia based on EUS findings.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care institution.

PATIENTS

Patients with early esophageal neoplasia.

INTERVENTIONS

EUS, diagnostic ER.

MAIN OUTCOME MEASUREMENTS

Number of patients excluded from endoscopic treatment based on EUS results.

RESULTS

A total of 131 patients were included (98 men, 33 women; age 66 ± 13 years). In 105 of 131 patients (80%), EUS findings were unremarkable. In 25 of 105 patients (24%), diagnostic ER showed submucosal invasion (n = 17), deep resection margins positive for cancer (n = 2, confirmed at surgery), or poor differentiation/lymphovascular invasion (n = 6). In 26 of 131 patients (20%), EUS findings raised the suspicion of submucosal invasion and/or lymph node metastasis. In the 14 of 26 patients (54%) with abnormal EUS findings, endoscopy results were unremarkable. Diagnostic ER showed submucosal invasion in 7 of 14 (50%) patients, whereas no lymph node metastasis risk factors were found in 7 of 14 patients (50%), who subsequently underwent curative endoscopic treatment. In 12 of 26 patients (46%) with abnormal EUS, endoscopy also raised doubts on whether curative endoscopic treatment could be achieved. After diagnostic ER, no risk factors for lymph node metastasis were found in 3 of 12 patients (25%).

LIMITATION

Retrospective study.

CONCLUSIONS

This study shows that EUS has virtually no clinical impact on the workup of early esophageal neoplasia and strengthens the role of diagnostic ER as a final diagnostic step.

A comparative study of intraductal papillary neoplasia of the biliary tract and pancreas

Intraductal papillary mucinous neoplasm of the pancreas is a rare but well-established entity in contrast to intraductal papillary mucinous neoplasm of the biliary tract. The aim of this study was to compare the clinicopathologic features of intraductal papillary mucinous neoplasms of the biliary tract and of the pancreas. Twenty patients who underwent resection for intraductal papillary mucinous neoplasm of the biliary tract were compared with 29 cases resected for intraductal papillary mucinous neoplasm of the pancreas. Clinicopathologic characteristics and resection specimens of all patients were reassessed and immunohistochemically screened for expression of a distinct set of tumor markers. Median ages of patients with intraductal papillary mucinous neoplasms of the biliary tract and of the pancreas were 66 and 62 years, respectively (P < .05). Twelve patients with intraductal papillary mucinous neoplasm of the biliary tract (60%) had neoplasms with infiltrating carcinoma, compared with 6 patients with intraductal papillary mucinous neoplasm of the pancreas (21%, P < .05). Cytokeratin 7 and 20 expressions were equal in biliary and pancreatic intraductal papillary mucinous neoplasms. Cytokeratin 20 expression was mainly found in intestinal-type tumors. Gastric, pancreaticobiliary, and oncocytic subtypes were all observed in the intraductal papillary mucinous neoplasm of the biliary tract group. The distribution was significantly different from the intraductal papillary mucinous neoplasm of the pancreas group. The 3-year overall survival rate of malignant biliary and pancreatic intraductal papillary mucinous neoplasm was 63% and 65%, respectively (P = .798). Positive lymph nodes and a high expression of membranous mucin were associated with a significantly shorter overall survival in patients with malignant intraductal papillary mucinous neoplasm. Finally, p53 and Ki67 proliferation index were both associated with the carcinogenesis of intraductal papillary mucinous neoplasm, whereas DPC4 and CDX2 were not. Clinicopathologic features of intraductal papillary mucinous neoplasm of the biliary tract largely resemble those of intraductal papillary mucinous neoplasm of the pancreas, although intraductal papillary mucinous neoplasm of the biliary tract was associated with a higher malignancy rate at the time of surgical treatment. The level of membranous mucin expression and positive lymph nodes are significant prognosticators in patients with malignant intraductal papillary mucinous neoplasm.

Lymphatic micrometastases in patients with early esophageal adenocarcinoma

BACKGROUND

Both endoscopic and surgical treatments are recommended for m3- or sm1-adenocarcinomas of the esophagus, depending on patients' lymph nodal status. Lymphatic dissemination is related to tumor infiltration depth, but varying incidences have been reported in m3- and sm1-adenocarcinomas. The study aim was to investigate whether the presence of occult tumor cells in lymph nodes could explain this variation.

METHODS

Sixty-three node-negative (N0) patients with early esophageal adenocarcinoma (m2/m3/sm1-tumors) were included. Multilevel-sectioning of lymph nodes was performed; sections were stained by means of immunohistochemistry with cytokeratin marker CAM5.2. Two pathologists searched for micrometastases (0.2-2.0  mm) and isolated tumor cells (ITCs, <0.2  mm).

RESULTS

Positive CAM5.2 staining in lymph nodes was not seen in any of the 18 m2-patients. In 2/25 m3-tumors (8.0%) an ITC was found, but no micrometastases. Tumor cells were identified in 4/20 sm1-tumors (20.0%): three micrometastases and one ITC. Median follow-up was 121 months. Two m3-patients (3.2%) died due to disease recurrence, including one patient in whom an ITC was detected.

CONCLUSIONS

Lymphatic migration of tumor cells was found in node-negative m3- and sm1-adenocarcinomas of the esophagus (8.0% and 20.0%, respectively). However, the clinical relevance of these occult tumor cells should become apparent from large series of endoscopically treated patients.

[Outcomes of 16 years of oesophageal surgery: low postoperative mortality and improved long-term survival]

OBJECTIVE

To assess trends in patient characteristics and treatment outcomes in a large cohort of patients who underwent oesophagectomy for oesophageal carcinoma in a tertiary referral centre over a period of 16 years.

DESIGN

Retrospective cohort study.

METHODS

We carried out a trend analysis on collected data on demographic and clinico-pathological characteristics, complications and survival of patients who underwent oesophagectomy between January 1993 and December 2008 at the Academic Medical Center in Amsterdam (AMC), the Netherlands. Patients were subsequently divided into three comparably-sized groups according to the year of operation: group 1 (1993-1998; n = 332), group 2 (1999-2004; n = 312), and group 3 (2005-2008; n = 296).

RESULTS

A total of 940 patients underwent oesophagectomy during the total study period. Transhiatal oesophagectomy was performed more often during the first two time periods (65 and 64%, respectively), while the transthoracic approach was used more often in the third period (53%). The proportion of patients who underwent a microscopically radical resection increased significantly over the three periods of time. In-hospital mortality in all three periods was low, between 3.2%-3.4%. The three-year survival rate improved significantly over the three periods (p = 0.018), from 42% and 48% to 53% in the most recent period.

CONCLUSION

Over the past 16 years in-hospital mortality in patients undergoing oesophagectomy for a potentially curable oesophageal carcinoma at the AMC, has been stably low. The total number of complications increased during these periods. Long-term survival improved during this time to a three-year overall survival of more than 50% in the most recent period.

Assessment of promising protein markers for vulva cancer

OBJECTIVES

To validate the results of a previous study with the tissue microarray technology showing that cyclooxygenase 2 (COX-2) overexpression and absent caspase 3 expression are associated with poor disease-specific survival in univariate analysis.

METHODS

The study group comprised 80 consecutive patients with vulva cancer treated in the period from 1999 to 2003 in a university hospital. A tissue microarray with 3 tumor tissue cores per patient was constructed and stained with antibodies against COX-2, caspase 3, epidermal growth factor receptor, p16 INK4, cyclin D1, and Ki-67. The impact of the expression of these protein markers and selected clinicopathologic variables on disease-specific as well as disease-free survival was measured. Cox proportional hazard model was used for both univariate and multivariate analyses.

RESULTS

In multivariate analysis, lymph node metastases and strong COX-2 expression were related to disease-free (hazard ratio [HR], 8.33, 95% confidence interval [CI], 2.97-23.36; P < 0.001; and HR, 6.42; 95% CI, 2.33-17.72; P < 0.001) and disease-specific survival (HR, 6.04; 95% CI, 2.12-17.19; P = 0.001; and HR, 5.11; 95% CI, 1.82-14.36; P = 0.002). In the present series, no association was found between caspase 3 expression and survival.

CONCLUSION

The prognostic significance of COX-2 overexpression was confirmed. In contrast, in the present series, no relation was found between caspase 3 expression and survival.

Treatment of vulvar intraepithelial neoplasia with topical imiquimod

BACKGROUND

Alternatives to surgery are needed for the treatment of vulvar intraepithelial neoplasia. We investigated the effectiveness of imiquimod 5% cream, a topical immune-response modulator, for the treatment of this condition.

METHODS

Fifty-two patients with grade 2 or 3 vulvar intraepithelial neoplasia were randomly assigned to receive either imiquimod or placebo, applied twice weekly for 16 weeks. The primary outcome was a reduction of more than 25% in lesion size at 20 weeks. Secondary outcomes were histologic regression, clearance of human papillomavirus (HPV) from the lesion, changes in immune cells in the epidermis and dermis of the vulva, relief of symptoms, improvement of quality of life, and durability of response. Reduction in lesion size was classified as complete response (elimination), strong partial response (76 to 99% reduction), weak partial response (26 to 75% reduction), or no response (< or =25% reduction). The follow-up period was 12 months.

RESULTS

Lesion size was reduced by more than 25% at 20 weeks in 21 of the 26 patients (81%) treated with imiquimod and in none of those treated with placebo (P<0.001). Histologic regression was significantly greater in the imiquimod group than in the placebo group (P<0.001). At baseline, 50 patients (96%) tested positive for HPV DNA. HPV cleared from the lesion in 15 patients in the imiquimod group (58%), as compared with 2 in the placebo group (8%) (P<0.001). The number of immune epidermal cells increased significantly and the number of immune dermal cells decreased significantly with imiquimod as compared with placebo. Imiquimod reduced pruritus and pain at 20 weeks (P=0.008 and P=0.004, respectively) and at 12 months (P=0.04 and P=0.02, respectively). The lesion progressed to invasion (to a depth of <1 mm) in 3 of 49 patients (6%) followed for 12 months (2 in the placebo group and 1 in the imiquimod group). Nine patients, all treated with imiquimod, had a complete response at 20 weeks and remained free from disease at 12 months.

CONCLUSIONS

Imiquimod is effective in the treatment of vulvar intraepithelial neoplasia. (Current Controlled Trials number, ISRCTN11290871 [controlled-trials.com].).

Dendritic cell populations in colon and mesenteric lymph nodes of patients with Crohn's disease

Dendritic cells (DCs) are key cells in innate and adaptive immune responses that determine the pathophysiology of Crohn's disease. Intestinal DCs migrate from the mucosa into mesenteric lymph nodes (MLNs). A number of different markers are described to define the DC populations. In this study we have identified the phenotype and localization of intestinal and MLN DCs in patients with Crohn's disease and non-IBD patients based on these markers. We used immunohistochemistry to demonstrate that all markers (S-100, CD83, DC-SIGN, BDCA1-4, and CD1a) showed a different staining pattern varying from localization in T-cell areas of lymph follicles around blood vessels or single cells in the lamina propria and in the MLN in the medullary cords and in the subcapsular sinuses around blood vessels and in the T-cell areas. In conclusion, all different DC markers give variable staining patterns so there is no marker for the DC.

Gene expression in early stage cervical cancer

OBJECTIVE

Pelvic lymph node metastases are the main prognostic factor for survival in early stage cervical cancer, yet accurate detection methods before surgery are lacking. In this study, we examined whether gene expression profiling can predict the presence of lymph node metastasis in early stage squamous cell cervical cancer before treatment. In addition, we examined gene expression in cervical cancer compared to normal cervical tissue.

METHODS

Tumour samples of 35 patients with early stage cervical cancer who underwent radical hysterectomy and pelvic lymph node dissection, 16 with and 19 without lymph node metastasis, were analysed. Also five normal cervical tissues samples were analysed. We investigated differential expression and prediction of patient status for lymph node positive versus lymph node negative tumours and for healthy versus cancer tissue. Classifiers were built by using a multiple validation strategy, enabling the assessment of both classifier accuracy and variability.

RESULTS

Five genes (BANF1, LARP7, SCAMP1, CUEDC1 and PEBP1) showed differential expression between tumour samples from patients with and without lymph node metastasis. Mean accuracy of class prediction is 64.5% with a 95% confidence interval (CI) of 40-90%. For healthy cervical tissue versus early stage cervical cancer, the mean accuracy of class prediction is 99.5% (95% CI of 90-100%). A subset of genes involved in cervical cancer was identified.

CONCLUSION

No accurate class prediction for lymph node status in early stage cervical cancer was obtained. Replication studies are needed to determine the relevance of the differentially expressed genes according to lymph node status. Early stage cervical cancer can be perfectly differentiated from healthy cervical tissue by means of gene expression profiling.

Management of liver hemangiomas according to size and symptoms

BACKGROUND AND AIM

Liver hemangiomas are the most common benign liver tumors. These lesions are usually incidental findings during imaging studies of the abdomen performed for other reasons. The indication for surgical resection of these lesions remains controversial.

METHODS

Records of patients referred for evaluation of radiologically and/or histopathologically proven liver hemangiomas, from June 1991 to February 2006, were retrospectively analyzed. Reason for referral, results of imaging studies, and surgical treatment and outcome were reviewed.

RESULTS

There were 34 patients identified. The hemangioma size was <5 cm in 15 patients (44%) and >5 cm in 19 patients. The most common reason for referral was right upper abdominal pain in 59% (20/34) of patients. Abdominal ultrasound was conclusive in 66.7% (16/24) and four-phase computed tomography (CT) in 82.6% (19/23) of patients. Surgical resection was undertaken in 14 patients (41%) after a mean follow-up time of 36.5 months. The indication for treatment was progressive abdominal pain in 78.6% (11/14). Mean size of resected lesions was larger compared to non-resected lesions (10.3 vs 4.8 cm; P = 0.004). Postoperative morbidity occurred in three patients (21.4%). One patient had persisting abdominal pain after resection of an 8-cm hemangioma. Twenty patients were observed and showed no complications related to the liver hemangioma during follow-up.

CONCLUSIONS

Liver hemangiomas can be readily diagnosed by ultrasound or multiphase contrast-enhanced helical CT. The indications for surgical resection are progressive abdominal pain in combination with size >5 cm. Observation is justified in patients with minimal or no symptoms, even in patients with giant hemangiomas.

Factor V Leiden and the etiology of inflammatory bowel disease

Inflammatory bowel disease (IBD) refers to two chronic diseases that cause inflammation of the intestines: ulcerative colitis and Crohn's disease. Patients suffering from IBD have a three-fold increased risk of venous thrombosis compared with matched controls. Importantly, thromboembolic disease is a significant cause of morbidity and mortality in patients with IBD. However, despite several supporting observations it is still elusive whether activation of the blood coagulation cascade is involved in the etiology and pathogenesis of IBD. To confirm or refute the hypothesis that activated blood coagulation aggravates the development of IBD, we subjected wildtype and homozygous FV Leiden mice to a model of DSS-induced colitis. Experimental colitis led to a reduction in body weight, shortening of the colon and increased colon weight. In addition, DSS treatment led to ulcerations, edema formation, crypt loss, fibrosis and the influx of inflammatory cells into the colon. However, the FV Leiden genotype had no significant effect on any of the DSS-induced symptoms of colitis. We therefore conclude that the FV Leiden allele has no effect in murine colitis and we thus question the importance of activated blood coagulation in the etiology or pathogenesis of IBD.

Comparative analysis of colonic gene expression of three experimental colitis models mimicking inflammatory bowel disease

BACKGROUND

Mouse models of inflammatory bowel diseases (IBD) are used to unravel the pathophysiology of IBD and to study new treatment modalities, but their relationship to Crohn's disease (CD) or ulcerative colitis (UC) is speculative.

METHODS

Using Agilent mouse TOX oligonucleotide microarrays, we analyzed colonic gene expression profiles in three widely used models of experimental colitis. In 2 of the models (TNBS and DSS-induced colitis), exogenous agents induce the colitis. In the third model the colitis is induced after transfer of a T-cell population (CD4(+)CD45RB(high) T cells) that lacks regulatory cells into an immunodeficient host.

RESULTS

Compared with control mice, in DSS, TNBS, and the CD45RB transfer colitis mice, 387, 21, and 582 genes were more than 2-fold upregulated in the intestinal mucosa. Analyses of exclusively shared gene expression profiles between the different models revealed that DSS/transfer colitis share 69 concordantly upregulated genes, DSS/TNBS 6, and TNBS/transfer colitis 1. Seven genes were upregulated in all three models. The CD45RB transfer model expression profile included the most genes that are known to be upregulated in IBD. Of 32 genes that are known to change transcriptional activity in IBD (TNF, IFN-gamma, Ltbeta, IL-6, IL-16, IL-18R1, IL-22, CCR2, 7, CCL2, 3, 4, 5, 7, 11, 17, 20, CXCR3, CXCL1, 5, 10, Mmp3, 7,9, 14, Timp1, Reg3gamma, and Pap, S-100a8, S-100a9, Abcb1, and Ptgs2), 2/32 are upregulated in TNBS, 15/32 are upregulated or downregulated in DSS and 30/32 are upregulated or downregulated in the CD45RB transfer colitis.

CONCLUSION

The pattern of gene expression in the CD45RB transfer model most closely reflects altered gene expression in IBD.

Prognostic factors in adenocarcinoma of the esophagus or gastroesophageal junction

The incidence of adenocarcinoma of the esophagus is rising rapidly in Western Europe and North America. It is an aggressive disease with early lymphatic and hematogenous dissemination. TNM cancer staging systems predict survival on the basis of the anatomic extent of the tumor. However, the adequacy of the current TNM staging system for adenocarcinoma of the esophagus or gastroesophageal junction (GEJ) is questioned repeatedly. Numerous prognostic factors have been described, but are not included in the TNM system. This review describes clinical parameters, aspects of operative technique, response to preoperative chemoradiotherapy therapy, complications and established pathologic determinants found in the resection specimen that have a prognostic impact. Furthermore, their potential application in the clinical setting in patients with adenocarcinoma of the esophagus or GEJ is discussed. Future directions to improve staging systems are given.

Endoscopic video-autofluorescence imaging followed by narrow band imaging for detecting early neoplasia in Barrett's esophagus

BACKGROUND

Video-autofluorescence imaging (AFI) and narrow band imaging (NBI) are new endoscopic techniques that may improve the detection of high-grade intraepithelial neoplasia (HGIN) in Barrett's esophagus (BE). AFI improves the detection of lesions but may give false-positive findings. NBI allows for detailed inspection of the mucosal and (micro)vascular patterns, which are related to HGIN.

OBJECTIVE

A proof-of-principle study to combine AFI and NBI to improve the detection of HGIN and to reduce false-positive findings.

DESIGN

Cross-sectional study of consecutive eligible patients.

SETTING

Single-center.

PATIENTS

Twenty patients with BE with suspected or endoscopically treated HGIN were investigated with 2 prototype imaging systems: AFI (inspection with high-resolution videoendoscopy and autofluorescence imaging for detection of lesions) and NBI (for detailed inspection of mucosal and vascular patterns of identified lesions). Lesions were sampled for histopathologic evaluation.

MAIN OUTCOME MEASUREMENTS

The positive predictive value of AFI alone and of AFI-NBI for detecting HGIN and the reduction of false-positive findings because of the use of NBI.

RESULTS

All of the 28 lesions with HGIN were identified with AFI. Seventeen were identified with white light (61%). Forty-seven suspicious lesions were detected with AFI: 28 contained HGIN (60%) and 19 were false positive (40%). With NBI, 25 of the true-positive lesions had definitely suspicious patterns, and 3 had dubiously suspicious patterns. Of the 19 false positives, 14 were not suspicious on NBI. The false-positive rate, therefore, was reduced from 40% to 10%. Low-grade dysplasia was found in 4 of the remaining 5 false positives. All of the 14 patients with HGIN were identified by AFI-NBI (sensitivity 100%).

LIMITATIONS

Uncontrolled study in high-risk patients.

CONCLUSIONS

This proof-of-principle study confirms that AFI can be used as a red-flag technique to detect suspicious lesions. With NBI, detailed inspection of the surface patterns can be performed. This combination may increase the accuracy of detecting HGIN in BE.

Detection and classification of the mucosal and vascular patterns (mucosal morphology) in Barrett's esophagus by using narrow band imaging

BACKGROUND

The detection of the mucosal morphology (ie, mucosal and vascular patterns) in Barrett's esophagus (BE) by magnifying (chromo)endoscopy may improve the distinction of high-grade intraepithelial neoplasia (HGIN) from nondysplastic specialized intestinal metaplasia (SIM). Narrow band imaging (NBI) is a new technique that uses optical filters to enhance the mucosal contrast without the need for chromoendoscopy.

OBJECTIVE

To use NBI for the characterization and the classification of the mucosal morphology in nondysplastic BE and in BE with HGIN.

DESIGN

Descriptive study.

SETTING

Single-center study in a tertiary referral center for the diagnosis and treatment of patients with BE.

PATIENTS

We used NBI with magnifying endoscopy to image and biopsy randomly selected areas in 63 patients with BE. A systematic image and a biopsy specimen evaluation process was followed, including unblinded assessment of an exploratory set of images and biopsy specimens, and blinded evaluation of learning and validation sets.

MAIN OUTCOME MEASUREMENTS

The relationship between the mucosal morphology and the presence of SIM and HGIN.

RESULTS

SIM was characterized by either villous/gyrus-forming patterns (80%), which were mostly regular and had regular vascular patterns, or a flat mucosa with regular normal-appearing long branching vessels (20%). HGIN was characterized by 3 abnormalities: irregular/disrupted mucosal patterns, irregular vascular patterns, and abnormal blood vessels. All areas with HGIN had at least 1 abnormality, and 85% had 2 or more abnormalities. The frequency of abnormalities showed a significant rise with increasing grades of dysplasia. The magnified NBI images had a sensitivity of 94%, a specificity of 76%, a positive predictive value of 64%, and a negative predictive value of 98% for HGIN.

LIMITATIONS

No data on observer agreement.

CONCLUSIONS

NBI with magnification reveals the mucosal morphology characteristics of nondysplastic BE and HGIN, without the need for staining and has a relatively high diagnostic value for HGIN when used for targeted detailed examination of areas of interest.

Monitoring of response to pre-operative chemoradiation in combination with hyperthermia in oesophageal cancer by FDG-PET

PURPOSE

To evaluate the use of positron emission tomography using 18F-fluorodeoxyglucose (FDG-PET) to assess early response to pre-operative chemoradiation therapy in combination with external locoregional hyperthermia in patients with oesophageal cancer by correlating the reduction of metabolic activity with histopathologic response.

MATERIAL AND METHODS

Twenty-six patients with histopathologically proven intra-thoracic oesophageal cancer (with < or =2 cm gastric involvement), scheduled to undergo a 5-week course of pre-operative chemoradiation therapy and hyperthermia, were included. FDG-PET was performed before (n = 26) and 2 weeks after initiation of therapy (n = 17). FDG uptake was quantitatively assessed by standardized uptake values.

RESULTS

After neoadjuvant therapy, 24 of the 26 patients underwent surgery. In 16 patients changes in FDG uptake were correlated to histopathologic response. In these patients, histopathologic evaluation revealed less than 10% viable tumour cells in eight patients (responders) and more than 10% viable tumour cells in eight patients (non-responders). In responders, FDG uptake decreased by a median -44% (-75 to 2); in non-responders, it decreased by a median of -15% (-46 to 40). At a threshold of 31% decrease of FDG uptake compared with baseline, sensitivity to detect response was 75%, with a corresponding specificity of 75%. The positive and negative predictive values were both 75%.

CONCLUSION

FDG-PET is a promising tool for early response monitoring in patients undergoing chemoradiation therapy in combination with hyperthermia.

Validation of tissue microarray technology in endometrioid cancer of the endometrium

AIM

To validate tissue microarray (TMA) for endometrial cancer by comparing immunohistochemical staining results of triplicate core biopsies on TMA with the results of full-section analysis.

METHODS

The study material consisted of slides and selected tissue blocks of 41 patients with endometrioid cancer of the endometrium. A TMA was constructed. Both the TMA and the slides were stained with the same antibodies against progesterone receptor (PR), oestrogen receptor, p53 and epithelial membrane antigen (EMA). Concordance between results was expressed as the kappa statistic.

RESULTS

Concordance between the staining results of TMA and whole slides was good for PR (kappa = 0.69), oestrogen receptor (kappa = 0.78), p53 (kappa = 0.81) and EMA (kappa = 0.72). Concordance between the results on TMA and slides depends on the number of assessable cores per tumour. Three assessable cores per case result in outcomes that are at least 94% similar to those achieved using conventional tissue sections with a two-class scoring system. This is independent of focal or diffuse staining patterns.

CONCLUSION

TMA is a useful tool for further analysis of the molecular pathways in endometrial cancer. The effect of selection has to be taken into account when the prognostic value of protein expression on TMA is determined.

Stepwise radical endoscopic resection is effective for complete removal of Barrett's esophagus with early neoplasia: a prospective study

OBJECTIVES

Endoscopic therapy for early neoplasia in Barrett's esophagus (BE) is evolving rapidly. Aim of this study was to prospectively evaluate safety and efficacy of stepwise radical endoscopic resection (ER) of BE containing early neoplasia.

METHODS

Patients with early neoplasia (i.e., high-grade intraepithelial neoplasia or early cancer) in BE < or = 5 cm, without signs of submucosal infiltration or lymph node/distant metastases, were included. Patients underwent resection sessions (cap technique after submucosal lifting) with intervals of 6 wk.

RESULTS

Between January 2003 and December 2004, 39 consecutive patients were included. Therapy was discontinued in two patients due to unrelated comorbidity. Complete eradication of early neoplasia was achieved in all 37 treated patients in a median number of three sessions. Complete removal of all Barrett's mucosa was achieved in 33 (89%) patients: 4 patients (all had undergone APC [argon plasma coagulation]) were found to have small isles of Barrett's mucosa underneath neosquamous mucosa. Complications occurred in two out of 88 (2%) ER procedures: one asymptomatic perforation, one delayed bleeding. Symptomatic stenosis occurred in 10 of 39 (26%) patients and was effectively treated by endoscopic bougienage. During a median follow-up of 11 months, no patients died and none had recurrence of neoplasia or Barrett's mucosa.

CONCLUSIONS

Stepwise radical ER is effective for selected patients with early neoplasia in BE; provides optimal histopathological diagnosis; and may reduce recurrence rate, since all mucosa at risk is effectively removed. Use of APC should be limited to prevent buried Barrett's mucosa. Methods for prevention of stenosis should be developed.

Extracapsular lymph node involvement in node-positive patients with adenocarcinoma of the distal esophagus or gastroesophageal junction

In adenocarcinoma of the esophagus or gastroesophageal junction, little attention has been paid to the biologic significance of extracapsular lymph node involvement (LNI). In the present study, a consecutive series of 251 patients with lymph node dissemination were reviewed. All patients underwent esophagectomy for adenocarcinoma and were prospectively followed. A total of 1562 positive lymph nodes were reexamined. Extracapsular LNI was identified in 456 lymph nodes (29%) in 166 patients (66%). Extracapsular LNI was confined to one lymph node in 63 patients (38%). The occurrence of extracapsular LNI increased significantly with the depth of invasion, presence of positive resectable truncal nodes, number of resected nodes, number of positive nodes, and lymph node ratio. The median potential follow-up period was 58 months (range, 12-143 months). In this period, 178 patients died of recurrent disease. The pattern of recurrence was comparable between patients with and without extracapsular LNI (P = 0.938). The median survival in patients with extracapsular LNI was 15 months (95% confidence interval, 12-18 months) compared with 41 months (95% confidence interval, 19-64 months) in those without extracapsular LNI (P < 0.001). Median survival of patients with 2 or more lymph nodes was 12 months (95% confidence interval, 8-15 months). Multivariate analysis demonstrated that T-stage, extracapsular LNI, and lymph node ratio were independent prognostic factors. The presence of extracapsular LNI identifies a subgroup with a significantly worse long-term survival. Together with the T-stage and the lymph node ratio, extracapsular LNI reflects a particularly aggressive biologic behavior and has significant prognostic potential.

Neoadjuvant selective COX-2 inhibition down-regulates important oncogenic pathways in patients with esophageal adenocarcinoma

OBJECTIVES

To evaluate the effects of neoadjuvant therapy with the selective cyclooxygenase-2 (COX-2) inhibitor celecoxib in vitro and in patients with esophageal adenocarcinoma on COX-2 and MET expression.

SUMMARY BACKGROUND DATA

High COX-2 and/or MET expression levels are negative prognostic factors for adenocarcinoma of the esophagus. Nonsteroidal anti-inflammatory drugs (NSAIDs) and selective COX-2 inhibitors exert anticancer mechanisms as is evident from epidemiologic studies and from experimental models for esophageal cancer. The mechanisms and the significance of these findings in patients with adenocarcinoma of the esophagus are unknown.

METHODS

Esophageal adenocarcinoma cell lines were used to asses the effects in vitro. To study the clinical effects 12 patients with esophageal adenocarcinoma were included for neoadjuvant treatment (4 weeks) with celecoxib at 400 mg twice daily. Fifteen patients not receiving NSAIDs or celecoxib were included as a control. Effects were evaluated using the MTT-cell viability test, Western blot analysis, immunohistochemistry, and RT-PCR.

RESULTS

In vitro celecoxib administration resulted in decreased cell viability, increased apoptosis, and decreased COX-2 and MET expression levels. In patients, neoadjuvant treatment with celecoxib significantly down-regulated COX-2 and MET expression in the tumor when compared with the nontreated control group and when compared with pretreatment measurements.

CONCLUSIONS

This is the first study to show in vitro and in patients with esophageal adenocarcinoma that selective COX-2 inhibition down-regulates COX-2 and MET expression, both important proteins involved in cancer progression and dissemination. Therefore, (neo)adjuvant therapy with celecoxib might have clinical potential for patients with esophageal adenocarcinoma.

Outcome of surgical treatment for early adenocarcinoma of the esophagus or gastro-esophageal junction

Adenocarcinoma of the esophagus, or GEJ, has a poor prognosis. Early lesions [i.e. high grade dysplasia (HGD) or T1-carcinoma] are potentially curable. Local endoscopic therapies are promising treatment options for superficial lesions; however, for deeper lesions, surgical resection is considered to be the treatment of choice. To contribute to therapeutic decision-making, we retrospectively analysed the outcome of transhiatal esophagectomy in 120 patients with pathologically proven HGD (n=13) or T1-adenocarcinoma (n=107) of the distal esophagus or gastro-esophageal junction (GEJ). Tumors were subdivided into six different depths of invasion ('T1-mucosal' m1-m3, 'T1-submucosal' sm1-sm3), and the frequency of lymphatic dissemination and time to locoregional and/or distant recurrence were analysed. Only one of the 79 T1m1-3/sm1 tumors (1%) showed lymph node metastases as compared with 18 out of 41 T1sm2-3 tumors (44%). There was a significant difference in recurrence-free period between T1m1-m3/sm1 versus T1sm2-sm3 tumor patients (P log rank <0.0001), with 5-year recurrence-free percentages of 97% and 57%, respectively. In multivariate analysis including age, gender, tumor differentiation grade, N-stage and depth of invasion, only N-stage was an independent prognostic factor for recurrence-free period (hazard rate=5.9, 95% CI 1.7-20.7). However, if N-stage was excluded from analysis, only depth of invasion (T1sm2-3 versus T1m1-m3/sm1) was an independent prognostic factor for recurrence-free period (hazard rate=7.5, 95% CI 2.0-27.7). These data indicate that T1m1-m3/sm1 adenocarcinomas of esophagus or GEJ show a very low risk of lymphatic dissemination and are therefore eligible for local endoscopic therapy. After transhiatal surgical resection, almost half of the patients with T1sm2-sm3 lesions develop recurrent disease within 5 years, and therefore need additional therapy to improve survival.

Dedicated pinhole SPECT of intestinal neutrophil recruitment in a mouse model of dextran sulfate sodium-induced colitis

Evaluating the efficacy of therapy in experimental inflammatory bowel disease (IBD) requires information about inflammatory activity in bowel segments or leukocyte recruitment and about kinetics in the follow-up of treatment. This study evaluated a noninvasive scintigraphic technique able to assess neutrophil trafficking in a mouse model of dextran sulfate sodium (DSS)-induced colitis.

METHODS

Groups of 4 BALB/c mice were assessed at baseline and after 1, 3, 5, and 8 d of treatment with DSS. Donor neutrophils were harvested by rinsing of the peritoneal cavity with phosphate-buffered saline 5 h after intraperitoneal injection of proteose peptone contained in phosphate-buffered saline and labeled with freshly prepared (99m)Tc-hexamethylpropylene amine oxime (HMPAO). Pinhole SPECT of the abdomen was performed 1 h after reinjection of 50 MBq of labeled neutrophils. In addition, the severity of inflammation was determined by histologic examination. The possibilities of the technique were illustrated by scintigraphic assessment of neutrophil trafficking with and without blocking of neutrophil migration by a CD97 monoclonal antibody in mice with DSS-induced colitis.

RESULTS

Colonic uptake of (99m)Tc-HMPAO neutrophils was determined with dedicated animal pinhole SPECT in mice with DSS-induced colitis and correlated well with histologic findings (R = 0.81) and wet colon weight (R = 0.87) and moderately with clinical weight loss (R = 0.62). The neutrophil uptake ratio was reduced significantly (P < 0.01) by blocking of neutrophil migration capacity with the CD97 antibody.

CONCLUSION

Animal pinhole SPECT can be used to study inflammatory activity and neutrophil recruitment in vivo in experimental colitis.

Prediction of appropriateness of local endoscopic treatment for high-grade dysplasia and early adenocarcinoma by EUS and histopathologic features

BACKGROUND

Endoscopic techniques are being developed for the local treatment of early stage esophageal cancer. However, such therapy is not appropriate for patients with lymph node metastasis. The aim of this study was to analyze the histopathologic features of high-grade dysplasia and early stage adenocarcinoma and to relate these to lymph node involvement.

METHODS

Pathology reports were reviewed for all 367 patients who underwent subtotal esophagectomy for high-grade dysplasia or adenocarcinoma of the esophagus or the gastroesophageal junction between January 1993 and December 2001. Patients with histopathologically confirmed high-grade dysplasia or T1 carcinoma were included (n = 77). Pre-operative EUS results were assessed. All lesions were histopathologically subdivided in 6 different stages (mucosal 1-3 and submucosal 1-3).

RESULTS

EUS staged 61 patients as N0. EUS correctly predicted the absence of positive lymph nodes in 57 (93%) of these patients. Histopathologically, m1, m2, m3, and sm1 cancers never had lymph node metastases, whereas 3 of 13 sm2 tumors (23%) and 9 of 13 sm3 tumors (69%) had lymph node involvement. Lymphangio invasion was present exclusively in sm2 and sm3 cancers. Factors that predicted the presence of lymph node metastasis were the following: tumor diameter greater than 3 cm, infiltration of malignancy beyond sm1, poor differentiation grade, and lymphangio invasion, although only infiltration beyond sm1 remained significant in the definitive multivariate analysis.

CONCLUSIONS

EUS and the histopathologic features of high-grade dysplasia and early stage adenocarcinoma of the esophagus or the gastroesophageal junction can predict the presence of lymph node involvement. These data can be used to identify patients for whom local endoscopic treatment may be appropriate.

The presence and mucin histochemistry of cardiac type mucosa at the esophagogastric junction

OBJECTIVES

Traditionally, the gastric cardia has been described as a native part of the stomach connecting to the esophagus. In recent literature, however, it is suggested that the cardia is an acquired lesion that develops due to gastroesophageal reflux disease. As a contribution to this debate, we evaluated the presence of cardiac mucosa at the esophagogastric junction (EGJ) in a random group of patients who presented at our endoscopy unit.

METHODS

In 253 unselected patients, biopsies were taken from the EGJ. In order to prevent sampling error, we selected only those EGJ biopsies in which the squamocolumnar junction (SCJ) was present in the histological biopsy material. Fifty-five patients were excluded since the SCJ was located proximal to the EGJ in the esophagus. The type of columnar mucosa immediately distal to the SCJ, and its mucin histochemistry, were assessed. The columnar mucosa was categorized as purely cardiac, oxyntocardiac, or fundic mucosa.

RESULTS

In 63 of the 198 patients, the SCJ was actually present in the EGJ biopsies. Purely cardiac mucosa was present in 39 (62%) biopsies and oxyntocardiac mucosa was present in 24 (38%) biopsies. Fundic mucosa was not seen directly adjacent to squamous epithelium. Acid mucins were present in 23 (37%) patients and they correlated with histological esophagitis and presence of H. pylori in the cardia.

CONCLUSIONS

Cardiac mucosa was uniformly present adjacent to the squamous epithelium at the EGJ. This argues against the hypothesis that the gastric cardia is an acquired metaplastic lesion. The presence of acid mucins was frequently observed and could be a pathological condition as it was associated with histological esophagitis and the presence of H. pylori in the cardia.

Cholestatic interleukin-6-deficient mice succumb to endotoxin-induced liver injury and pulmonary inflammation

Circulating and hepatic interleukin (IL)-6 levels are strongly increased during clinical and experimental cholestasis. Cholestatic liver injury is associated with increased susceptibility to endotoxin-induced toxicity. To determine the role of IL-6 herein, extrahepatic cholestasis was induced by bile duct ligation (BDL) in IL-6-gene deficient (IL-6(-/-)) and normal (IL-6(+/+)) mice. BDL elicited increased levels of hepatic IL-6 mRNA and protein in normal mice. Hepatocellular injury 2 weeks after BDL was similar in IL-6(-/-) and IL-6(+/+) mice as demonstrated by clinical chemistry and histopathology. Administration of endotoxin to cholestatic mice 2 weeks after BDL was associated with enhanced cytokine release, severe liver damage, and death when compared with sham-operated mice. Effects of endotoxin were largely similar in sham-operated IL-6(-/-) and IL-6(+/+) mice, but cholestatic IL-6(-/-) mice were more susceptible to the toxic effects of endotoxin, as reflected by increased cytokine release, more profound liver injury and lung inflammation, and higher mortality. Although endogenous IL-6 is not important in the development of liver injury after experimentally induced obstructive jaundice, this cytokine plays an important role in decreasing hypersensitivity to endotoxin in cholestatic mice.

Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus

BACKGROUND

Controversy exists about the best surgical treatment for esophageal carcinoma.

METHODS

We randomly assigned 220 patients with adenocarcinoma of the mid-to-distal esophagus or adenocarcinoma of the gastric cardia involving the distal esophagus either to transhiatal esophagectomy or to transthoracic esophagectomy with extended en bloc lymphadenectomy. Principal end points were overall survival and disease-free survival. Early morbidity and mortality, the number of quality-adjusted life-years gained, and cost effectiveness were also determined.

RESULTS

A total of 106 patients were assigned to undergo transhiatal esophagectomy, and 114 to undergo transthoracic esophagectomy. Demographic characteristics and characteristics of the tumor were similar in the two groups. Perioperative morbidity was higher after transthoracic esophagectomy, but there was no significant difference in in-hospital mortality (P=0.45). After a median follow-up of 4.7 years, 142 patients had died--74 (70 percent) after transhiatal resection and 68 (60 percent) after transthoracic resection (P=0.12). Although the difference in survival was not statistically significant, there was a trend toward a survival benefit with the extended approach at five years: disease-free survival was 27 percent in the transhiatal-esophagectomy group, as compared with 39 percent in the transthoracic-esophagectomy group (95 percent confidence interval for the difference, -1 to 24 percent [the negative value indicates better survival with transhiatal resection]), whereas overall survival was 29 percent as compared with 39 percent (95 percent confidence interval for the difference, -3 to 23 percent).

CONCLUSIONS

Transhiatal esophagectomy was associated with lower morbidity than transthoracic esophagectomy with extended en bloc lymphadenectomy. Although median overall, disease-free, and quality-adjusted survival did not differ statistically between the groups, there was a trend toward improved long-term survival at five years with the extended transthoracic approach.

Indicators of prognosis after transhiatal esophageal resection without thoracotomy for cancer

BACKGROUND

Various techniques have been described for the surgical treatment of esophageal cancer. The transhiatal approach has been debated for its safety and oncologic results.

STUDY DESIGN

Between January 1993 and September 1996, 115 patients underwent a transhiatal esophagectomy with curative intent for adenocarcinoma or squamous cell carcinoma of the middle or distal esophagus or esophagogastric junction. Procedure-related hazards, pathologic results, and prognostic factors for survival were evaluated. Median duration of postoperative followup was 27 months (range 1 to 74 months) for all patients and 45 months (range 30 to 74 months) for those alive at final followup.

RESULTS

No emergency thoracotomies were experienced. In-hospital mortality was 3.5%. Vocal cord dysfunction (24%) and pulmonary complications (23%) were the most frequent early postoperative complications. A microscopically radical resection was achieved in 73% of patients. Overall survival was 45% at 3 years. In univariate analysis, the most pronounced indicators of longterm survival (p < 0.0001) were radicality of the resection, lymph node involvement, lymph node ratio (ie, the ratio of invaded to removed lymph nodes), and pathologic tumor stage. Multivariate analysis identified the lymph node ratio (p < 0.0001) as the strongest independent predictor of long-term survival, followed by radicality of the resection (p = 0.0064) and duration of ICU stay (p = 0.027).

CONCLUSION

Transhiatal esophagectomy without thoracotomy can be considered a safe procedure for resectable cancer of the midesophagus, distal esophagus, or esophagogastric junction. Radicality and survival results were in line with the data reported for traditional transthoracic approaches. A prognostic value of the lymph node ratio was observed. It emphasizes the need for controlled trials aimed at delineating the prognostic impact of an extended lymph node dissection.

Intestinal metaplasia of the esophagus or esophagogastric junction: evidence of distinct clinical, pathologic, and histochemical staining features

Our purpose was to evaluate the clinical, histologic, and histochemical staining characteristics of intestinal metaplasia (IM) at an endoscopically normal-appearing esophagogastric junction (IM-EGJ) compared with IM in a columnar-lined esophagus (IM-CLE). A prospective study included 253 patients referred for elective upper gastrointestinal endoscopy. Biopsy specimens were obtained from 2 cm above and immediately distal to the squamocolumnar junction, the gastric corpus, and the antrum. Any red mucosa above the EGJ was sampled. IM-CLE (prevalence, 5.5%) typically occurred in white male smokers with a long history of reflux symptoms. IM-EGJ (prevalence, 9.1%) was associated with corpus and antrum gastritis and with IM at these sites. IM-CLE usually (13/14 [93%]) was the incomplete type IM, whereas only 12 (52%) of 23 patients in the IM-EGJ group had incomplete IM. IM-EGJ and IM-CLE should be considered as separate entities. Further research is needed to evaluate whether neoplastic progression of IM-EGJ is related to its mucin profile.