Quantitative assessment of gastric ischemic preconditioning on conduit perfusion in esophagectomy: propensity score weighting study

BACKGROUND

Gastric ischemic preconditioning prior to esophagectomy has been studied as a method to improve gastric conduit perfusion and reduce anastomotic complications, without conclusive results. The aim of this study is to evaluate the feasibility and safety of gastric ischemic preconditioning in terms of post-operative outcomes and quantitative gastric conduit perfusion.

METHODS

Patients who underwent an esophagectomy with gastric conduit reconstruction between January 2015 and October 2022 at a single high-volume academic center were reviewed. Patient characteristics, surgical approach, post-operative outcomes, and indocyanine green fluorescence angiography data (ingress index for arterial inflow and ingress time for venous outflow, and the distance from the last gastroepiploic branch to the perfusion assessment point) were analyzed. Two propensity score weighting methods were used to investigate whether gastric ischemic preconditioning reduces anastomotic leaks. Multiple linear regression analysis was used to evaluate the conduit perfusion quantitatively.

RESULTS

There were 594 esophagectomies with gastric conduit performed, with 41 having a gastric ischemic preconditioning. Among 544 with cervical anastomoses, leaks were seen in 2/30 (6.7%) in the ischemic preconditioning group and 114/514 (22.2%) in the control group (p = 0.041). Gastric ischemic preconditioning significantly reduced anastomotic leaks on both weighting methods (p = 0.037 and 0.047, respectively). Ingress index and time of the gastric conduit with ischemic preconditioning were significantly better than those without preconditioning (p = 0.013 and 0.025, respectively) after removing the effect of the distance from the last gastroepiploic branch to the perfusion assessment point.

CONCLUSION

Gastric ischemic preconditioning results in a statistically significant improvement in conduit perfusion and reduction in post-operative anastomotic leaks.

Implementation and Effectiveness of Opioid Prescribing Guidelines After Hiatal Hernia Repair

INTRODUCTION

We defined institutional opioid prescribing patterns, established prescribing guidelines, and evaluated the adherence to and effectiveness of these guidelines in association with opioid prescribing after hiatal hernia repair (HHR).

METHODS

A retrospective chart review was completed for patients who underwent transthoracic (open) or laparoscopic HHR between January and December 2016. Patient-reported opioid use after surgery was used to establish prescribing recommendations. Guideline efficacy was then evaluated among patients undergoing HHR after implementation (August 2018 to June 2019). Data are reported in oral morphine equivalents (OMEs).

RESULTS

The initial cohort included n = 87 patients (35 open; 52 laparoscopic) with a 68% survey response rate. For open repair, median prescription size was 338 mg OME (interquartile range [IQR] 250-420) with patient-reported use of 215 mg OME (IQR 78-308) (P = 0.002). Similarly, median prescription size was 270 mg OME (IQR 200-319) with patient-reported use of 100 mg OME (IQR 4-239) (P < 0.001) for laparoscopic repair. Opioid prescribing guidelines were defined as the 66th percentile of patient-reported opioid use. Postguideline implementation cohort included n = 108 patients (36 open; 72 laparoscopic). Median prescription amount decreased by 54% for open and 43% laparoscopic repair, with no detectable change in the overall refill rate after guideline implementation. Patient education, opioid storage, and disposal practices were also characterized.

CONCLUSIONS

Evidence-based opioid prescribing guidelines can be successfully implemented for open and laparoscopic HHR with a high rate of compliance and without an associated increase in opioid refills.

Wider Gastric Conduit Morphology Is Associated with Improved Blood Flow During Esophagectomy

BACKGROUND

It remains unclear what is the ideal conduit shape. The aim of this study was to evaluate association between specific gastric conduit morphology, considering width and length, with its perfusion and the incidence of anastomotic leaks after esophagectomy.

METHODS

Patients who underwent an esophagectomy with cervical esophagogastric anastomosis between 2015 and 2021 were evaluated. Indocyanine green angiography was performed to evaluate gastric conduit perfusion, and ingress index (arterial inflow) and ingress time (venous outflow) were measured. The conduit width at the middle of the conduit and the short gastric length as the length from the last gastroepiploic branch to the perfusion assessment point were measured. Propensity score matching was performed to compare wide conduits with narrow conduits. Narrow and wide conduits were defined as < 4 and ≥ 5 cm, respectively.

RESULTS

Three hundred fifty-eight patients were reviewed. After applying matching, the wide conduits had higher ingress index (48.2 vs 33.3%, p < 0.001) and shorter ingress time (51.2 vs 66.3 s, p = 0.004) compared to the narrow conduits. Including the short gastric length in analysis, creating a wide conduit is a significant factor for better ingress index (p = 0.001), especially when the perfusion assessment point is 5 cm or farther from the last gastroepiploic branch. Anastomotic leaks did not differ between the groups.

CONCLUSIONS

Conduit width is a significant factor of gastric conduit perfusion, especially when the estimated anastomotic site was > 5 cm from the last gastroepiploic branch. Wide conduits seem to have better perfusion and creating a wider conduit might reduce anastomotic leaks.

Quantitative perfusion assessment of gastric conduit with indocyanine green dye to predict anastomotic leak after esophagectomy

Impaired gastric conduit perfusion is a risk factor for anastomotic leak after esophagectomy. The aim of this study is to evaluate the feasibility of intraoperative quantitative assessment of gastric conduit perfusion with indocyanine green fluorescence angiography as a predictor for cervical esophagogastric anastomotic leak after esophagectomy. Indocyanine green fluorescence angiography using the SPY Elite system was performed in patients undergoing a transhiatal or McKeown esophagectomy from July 2015 through December 2020. Ingress (dye uptake) and Egress (dye exit) at two anatomic landmarks (the tip of a conduit and 5 cm from the tip) were assessed. The collected data in the leak group and no leak group were compared by univariate and multivariable analyses. Of 304 patients who were evaluated, 70 patients developed anastomotic leak (23.0%). There was no significant difference in patients' demographic between the groups. Ingress Index, which represents a proportion of blood inflow, at both the tip and 5 cm of the conduit was significantly lower in the leak group (17.9 vs. 25.4% [P = 0.011] and 35.9 vs. 44.6% [P = 0.019], respectively). Ingress Time, which represents an estimated time of blood inflow, at 5 cm of the conduit was significantly higher in the leak group (69.9 vs. 57.1 seconds, P = 0.006). Multivariable analysis suggested that these three variables can be used to predict future leak. Variables of gastric conduit perfusion correlated with the incidence of cervical esophagogastric anastomotic leak. Intraoperative measurement of gastric conduit perfusion can be predictive for anastomotic leak following esophagectomy.

Transhiatal robot-assisted minimally invasive esophagectomy: unclear benefits compared to traditional transhiatal esophagectomy

Esophagectomy is a high-risk operation, regardless of technique. Minimally invasive transthoracic esophagectomy could reduce length of stay and pulmonary complications compared to traditional open approaches, but the benefits of minimally invasive transhiatal esophagectomy are unclear. We performed a retrospective review of prospectively gathered data for open transhiatal esophagectomies (THEs) and transhiatal robot-assisted minimally invasive esophagectomies (TH-RAMIEs) performed at a high-volume academic center between 2013 and 2017. Multivariate logistic regression was used to calculate adjusted odds ratios (aORs) for outcomes. 465 patients met inclusion criteria (378 THE and 87 TH-RAMIE). THE patients more likely had an ASA score of 3 + (89.1% vs 77.0%, p = 0.012), whereas TH-RAMIE patients more likely had a pathologic staging of 3+ (43.7% vs. 31.2%, p = 0.026). TH-RAMIE patients were less likely to receive epidurals (aOR 0.06, 95% confidence interval [CI] 0.03-0.14, p < 0.001), but epidural use itself was not associated with differences in outcomes. TH-RAMIE patients experienced higher rates of pulmonary complications (adjusted odds ratio [OR] 1.82, 95% CI 1.03-3.22, p = 0.040), particularly pulmonary embolus (aOR 5.20, 95% CI 1.30-20.82, p = 0.020). There were no statistically significant differences in lymph node harvest, unexpected ICU admission, length of stay, in-hospital mortality, or 30-day readmission or mortality rates. The TH-RAMIE approach had higher rates of pulmonary complications. There were no statistically significant advantages to the TH-RAMIE approach. Further investigation is needed to understand the benefits of a minimally invasive approach to the open transhiatal esophagectomy.

Long-Term Quality of Life Following Endoscopic Therapy Compared to Esophagectomy for Neoplastic Barrett's Esophagus

INTRODUCTION

Endoscopic therapy (ET) and esophagectomy result in similar survival for Barrett's esophagus (BE) with high-grade dysplasia (HGD) or T1a esophageal adenocarcinoma (EAC), but the long-term quality of life (QOL) has not been compared.

AIMS

We aimed to compare long-term QOL between patients who had undergone ET versus esophagectomy.

METHODS

Patients were included if they underwent ET or esophagectomy at the University of Michigan since 2000 for the treatment of HGD or T1a EAC. Two validated survey QOL questionnaires were mailed to the patients. We compared QOL between and within groups (ET = 91, esophagectomy = 62), adjusting for covariates.

RESULTS

The median time since initial intervention was 6.8 years. Compared to esophagectomy, ET patients tended to be older, had a lower prevalence of EAC, and had a shorter duration since therapy. ET patients had worse adjusted physical and role functioning than esophagectomy patients. However, the adjusted odds ratio (OR) of having symptoms was significantly less with ET for diarrhea (0.287; 95% confidence interval [CI] = 0.114, 0.724), trouble eating (0.207; 0.0766, 0.562), choking (0.325; 0.119, 0.888), coughing (0.291; 0.114, 0.746), and speech difficulty (0.306; 0.0959, 0.978). Amongst the ET patients, we found that the number of therapy sessions and need for dilation were associated with worse outcomes.

DISCUSSION

Multiple measures of symptom status were better with ET compared to esophagectomy following treatment of BE with HGD or T1a EAC. We observed worse long-term physical and role functioning in ET patients which could reflect unmeasured baseline functional status rather than a causal effect of ET.

Similar Quality of Life After Conventional and Robotic Transhiatal Esophagectomy

BACKGROUND

Patient-reported outcomes (PROs) for minimally invasive esophagectomy (MIE) have demonstrated benefits compared to open transthoracic or 3-hole esophagectomy. PROs including quality of life (QoL) and fear of recurrence (FoR) comparing open transhiatal esophagectomy (THE) and transhiatal robotic-assisted MIE (Th-RAMIE) have been limited.

METHODS

At a single, high-volume academic center, patients undergoing THE and Th-RAMIE with gastric conduit for clinical stage I-III esophageal cancer from 2013 to 2018 were evaluated. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30), EORTC Quality of Life Questionnaire in Esophageal Cancer (QLQ-OES18), and FoR survey were administered preoperatively, and at 1, 6- and 12-months post-operatively. Linear mixed-effects models were used for QoL and FoR score comparisons. Perioperative outcomes were also compared.

RESULTS

309 patients (212 THE and 97 Th-RAMIE) were included. The Th-RAMIE cohort had a significantly higher number of lymph nodes harvested (14 ±0.8 vs. 11.2 ±0.4; p = 0.01), shorter length of stay (days, 10.0 ± 6.7 vs. 12.1 ±7.0; p = 0.03), lower rates of postoperative ileus (5% vs. 15%; p = 0.02), and had fewer opioids prescribed at discharge (71% vs. 85%; p = 0.03). After adjustment, there were no significant differences in QLQ-C30, QLQ-OES18, and FoR scores between groups out to 1 year following surgery.

CONCLUSIONS

There were no clear patient-reported benefits of Th-RAMIE over THE for esophageal cancer. However, Th-RAMIE conferred a number of perioperative benefits.

How Many Nodes Need to be Removed to Make Esophagectomy an Adequate Cancer Operation, and Does the Number Change When a Patient has Chemoradiotherapy Before Surgery?

INTRODUCTION AND DESIGN

Node dissection during esophagectomy is an important aspect of esophageal cancer staging. Controversy remains as to how many nodes need to be resected in order to properly stage a patient and whether the removal of more nodes carries a stage-independent survival benefit. A review of the literature performed by a group of experts in the subject may help define a minimum accepted number of lymph nodes to be resected in both primary surgery and post-induction therapy scenarios.

RESULTS AND CONCLUSIONS

The existing evidence generally supports the goal of obtaining a minimum of 15 lymph nodes for pathological examination in both primary surgery and post-induction therapy scenarios.

Constitutively Higher Level of GSTT2 in Esophageal Tissues From African Americans Protects Cells Against DNA Damage

BACKGROUND & AIMS

African American and European American individuals have a similar prevalence of gastroesophageal reflux disease (GERD), yet esophageal adenocarcinoma (EAC) disproportionately affects European American individuals. We investigated whether the esophageal squamous mucosa of African American individuals has features that protect against GERD-induced damage, compared with European American individuals.

METHODS

We performed transcriptional profile analysis of esophageal squamous mucosa tissues from 20 African American and 20 European American individuals (24 with no disease and 16 with Barrett's esophagus and/or EAC). We confirmed our findings in a cohort of 56 patients and analyzed DNA samples from patients to identify associated variants. Observations were validated using matched genomic sequence and expression data from lymphoblasts from the 1000 Genomes Project. A panel of esophageal samples from African American and European American subjects was used to confirm allele-related differences in protein levels. The esophageal squamous-derived cell line Het-1A and a rat esophagogastroduodenal anastomosis model for reflux-generated esophageal damage were used to investigate the effects of the DNA-damaging agent cumene-hydroperoxide (cum-OOH) and a chemopreventive cranberry proanthocyanidin (C-PAC) extract, respectively, on levels of protein and messenger RNA (mRNA).

RESULTS

We found significantly higher levels of glutathione S-transferase theta 2 (GSTT2) mRNA in squamous mucosa from African American compared with European American individuals and associated these with variants within the GSTT2 locus in African American individuals. We confirmed that 2 previously identified genomic variants at the GSTT2 locus, a 37-kb deletion and a 17-bp promoter duplication, reduce expression of GSTT2 in tissues from European American individuals. The nonduplicated 17-bp promoter was more common in tissue samples from populations of African descendant. GSTT2 protected Het-1A esophageal squamous cells from cum-OOH-induced DNA damage. Addition of C-PAC increased GSTT2 expression in Het-1A cells incubated with cum-OOH and in rats with reflux-induced esophageal damage. C-PAC also reduced levels of DNA damage in reflux-exposed rat esophagi, as observed by reduced levels of phospho-H2A histone family member X.

CONCLUSIONS

We found GSTT2 to protect esophageal squamous cells against DNA damage from genotoxic stress and that GSTT2 expression can be induced by C-PAC. Increased levels of GSTT2 in esophageal tissues of African American individuals might protect them from GERD-induced damage and contribute to the low incidence of EAC in this population.

Positron Emission Tomography 18F-Fluorodeoxyglucose Uptake Correlates with KRAS and EMT Gene Signatures in Operable Esophageal Adenocarcinoma

BACKGROUND

18F-fluorodeoxyglucose positron emission tomography is an imaging modality critical to the diagnosis and staging of esophageal cancer. Despite this, the genetic abnormalities associated with increased 18F-fluorodeoxyglucose (FDG)-maximum standardized uptake value (SUVmax) have not been previously explored in esophageal adenocarcinoma.

MATERIALS AND METHODS

Treatment-naïve patients, for whom frozen tissue and 18F-fluorodeoxyglucose positron emission tomography data were available, undergoing esophagectomy from 2003 to 2012, were identified. Primary tumor FDG-uptake (SUVmax) was quantified as low (<5), moderate, or high (>10). Genome-wide expression analyses (e.g., microarray) were used to examine gene expression differences associated with FDG-uptake.

RESULTS

Eighteen patients with stored positron emission tomography data and tissue were reviewed. Overall survival was similar between patients with high (n = 9) and low (n = 6) FDG-uptake tumors (P = 0.71). Differences in gene expression between tumors with high and low FDG-uptake included enriched expression of various matrix metalloproteinases, extracellular-matrix components, oncogenic signaling members, and PD-L1 (fold-change>2.0, P < 0.05) among the high-FDG tumors. Glycolytic gene expression and pathway involvement were similar between the high- and low-FDG tumor subsets (P = 0.126). Gene ontology analysis of the most differentially expressed genes demonstrated significant upregulation of gene sets associated with extracellular matrix organization and vascular development (P < 0.005). Gene set enrichment analysis further demonstrated associations between FDG-uptake intensity and canonical oncogenic processes, including hypoxia, angiogenesis, KRAS signaling, and epithelial-to-mesenchymal transition (P < 0.001). Interestingly, KRAS expression did not predict worse survival in a larger cohort (n = 104) of esophageal adenocarcinomas (P = 0.64).

CONCLUSIONS

These results suggest that elevated FDG-uptake is associated with a variety of oncogenic alterations in operable esophageal adenocarcinoma. These pathways present potential therapeutic targets among tumors exhibiting high FDG-uptake.

18F-FDG PET intensity correlates with a hypoxic gene signature and other oncogenic abnormalities in operable non-small cell lung cancer

BACKGROUND

18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is critical for staging non-small-cell lung cancer (NSCLC). While PET intensity carries prognostic significance, the genetic abnormalities associated with increased intensity remain unspecified.

METHODS

NSCLC samples (N = 34) from 1999 to 2011 for which PET data were available were identified from a prospectively collected tumor bank. PET intensity was classified as mild, moderate, or intense based on SUVmax measurement or radiology report. Associations between genome-wide expression (RNAseq) and PET intensity were determined. Associations with overall survival were then validated in two external NSCLC cohorts.

RESULTS

Overall survival was significantly worse in patients with PET-intense (N = 11) versus mild (N = 10) tumors (p = 0.039). Glycolytic gene expression patterns were markedly similar between intense and mild tumors. Gene ontology analysis demonstrated significant enhancement of cell-cycle and proliferative processes in FDG-intense tumors (p<0.001). Gene set enrichment analysis (GSEA) suggested associations between PET-intensity and canonical oncogenic signaling pathways including MYC, NF-κB, and HIF-1. Using an external cohort of 25 tumors with PET and genomic profiling data, common genes and gene sets were validated for additional study (P<0.05). Of these common gene sets, 20% were associated with hypoxia or HIF-1 signaling. While HIF-1 expression did not correlate with poor survival in the NSCLC validation cohort (N = 442), established targets of hypoxia signaling (PLAUR, ADM, CA9) were significantly associated with poor overall survival.

CONCLUSIONS

PET-intensity is associated with a variety of oncogenic alterations in operable NSCLC. Adjuvant targeting of these pathways may improve survival among patients with PET-intense tumors.

Silencing of Long Noncoding RNA MIR22HG Triggers Cell Survival/Death Signaling via Oncogenes YBX1, MET, and p21 in Lung Cancer

The long noncoding RNA (lncRNA) MIR22HG has previously been identified as a prognostic marker in hepatocellular carcinoma. Here, we performed a comprehensive analysis of lncRNA expression profiles from RNA-Seq data and report that MIR22HG plays a similar role in lung cancer. Analysis of 918 lung cancer and normal lung tissues and lung cancer cell lines revealed that MIR22HG was significantly downregulated in lung cancer; this decreased expression was associated with poor patient survival. MIR22HG bound and stabilized the YBX1 protein. Silencing of MIR22HG triggered both cell survival and cell death signaling through dysregulation of the oncogenes YBX1, MET, and p21. In this MIR22HG network, p21 played an oncogenic role by promoting cell proliferation and antiapoptosis in lung cancers. MIR22HG played a tumor-suppressive role as indicated by inhibition of multiple cell cycle-related genes in human primary lung tumors. These data show that MIR22HG has potential as a new diagnostic and prognostic marker and as a therapeutic target for lung cancer.Significance: The lncRNA MIR22HG functions as a tumor suppressor, with potential use a diagnostic/prognostic marker and therapeutic target in lung cancer. Cancer Res; 78(12); 3207-19. ©2018 AACR.

Genomic similarity between gastroesophageal junction and esophageal Barrett's adenocarcinomas

The current high mortality rate of esophageal adenocarcinoma (EAC) reflects frequent presentation at an advanced stage. Recent efforts utilizing fluorescent peptides have identified overexpressed cell surface targets for endoscopic detection of early stage Barrett's-derived EAC. Unfortunately, 30% of EAC patients present with gastroesophageal junction adenocarcinomas (GEJAC) and lack premalignant Barrett's metaplasia, limiting this early detection strategy. We compared mRNA profiles from 52 EACs (tubular EAC; tEAC) collected above the gastroesophageal junction with 70 GEJACs, 8 normal esophageal and 5 normal gastric mucosa samples. We also analyzed our previously published whole-exome sequencing data in a large cohort of these tumors. Principal component analysis, hierarchical clustering and survival-based analyses demonstrated that GEJAC and tEAC were highly similar, with only modest differences in expression and mutation profiles. The combined expression cohort allowed identification of 49 genes coding cell surface targets overexpressed in both GEJAC and tEAC. We confirmed that three of these candidates (CDH11, ICAM1 and CLDN3) were overexpressed in tumors when compared to normal esophagus, normal gastric and non-dysplastic Barrett's, and localized to the surface of tumor cells. Molecular profiling of tEAC and GEJAC tumors indicated extensive similarity and related molecular processes. Identified genes that encode cell surface proteins overexpressed in both Barrett's-derived EAC and those that arise without Barrett's metaplasia will allow simultaneous detection strategies.

Increased Variance in Oral and Gastric Microbiome Correlates With Esophagectomy Anastomotic Leak

BACKGROUND

Anastomotic leak after esophagectomy remains a significant source of morbidity and mortality. The gastrointestinal (GI) microbiome has been found to play a significant role in tumor oncogenesis and postoperative bowel anastomotic leak. We hypothesized that the GI microbiome could differentiate between esophageal cancer histologies and predict postoperative anastomotic leak.

METHODS

A prospective study of esophagectomy patients was performed from May 2013 to August 2014, with the collection of oral saliva, intraoperative esophageal and gastric mucosa, and samples of postoperative infections (neck swab or sputum). The presence and level for each bacterial probe as end points were used to analyze correlations with tumor histology, tumor stage, and presence of postoperative complications by unequal variances t tests for multiple comparisons and principal coordinate analysis.

RESULTS

Esophagectomy was successful in 55 of 66 patients who were enrolled. Among those, the diagnosis was adenocarcinoma in 44 (80%) squamous cell carcinoma in (13%), and benign disease in 4 (7%). The 30-day mortality was 1.8% (1 of 55). Complications included anastomotic leak requiring local drainage in 18% (10 of 55) and postoperative pneumonia in 2% (1 of 55). No correlation was noted between GI microbiome flora and tumor histology or tumor stage. A significant difference (p = 0.015) was found when the variance in bacterial composition between the preoperative oral flora was compared with intraoperative gastric flora in patients who had a leak but not in patients with pneumonia.

CONCLUSIONS

Patients with anastomotic leaks had increased variance in their preoperative oral and gastric flora. Microbiome analysis could help identify patients at higher risk for leak after esophagectomy.

Poor Prognosis Indicated by Venous Circulating Tumor Cell Clusters in Early-Stage Lung Cancers

Early detection of metastasis can be aided by circulating tumor cells (CTC), which also show potential to predict early relapse. Because of the limited CTC numbers in peripheral blood in early stages, we investigated CTCs in pulmonary vein blood accessed during surgical resection of tumors. Pulmonary vein (PV) and peripheral vein (Pe) blood specimens from patients with lung cancer were drawn during the perioperative period and assessed for CTC burden using a microfluidic device. From 108 blood samples analyzed from 36 patients, PV had significantly higher number of CTCs compared with preoperative Pe (P < 0.0001) and intraoperative Pe (P < 0.001) blood. CTC clusters with large number of CTCs were observed in 50% of patients, with PV often revealing larger clusters. Long-term surveillance indicated that presence of clusters in preoperative Pe blood predicted a trend toward poor prognosis. Gene expression analysis by RT-qPCR revealed enrichment of p53 signaling and extracellular matrix involvement in PV and Pe samples. Ki67 expression was detected in 62.5% of PV samples and 59.2% of Pe samples, with the majority (72.7%) of patients positive for Ki67 expression in PV having single CTCs as opposed to clusters. Gene ontology analysis revealed enrichment of cell migration and immune-related pathways in CTC clusters, suggesting survival advantage of clusters in circulation. Clusters display characteristics of therapeutic resistance, indicating the aggressive nature of these cells. Thus, CTCs isolated from early stages of lung cancer are predictive of poor prognosis and can be interrogated to determine biomarkers predictive of recurrence. Cancer Res; 77(18); 5194-206. ©2017 AACR.

Neoadjuvant twice daily chemoradiotherapy for esophageal cancer: Treatment-related mortality and long-term outcomes

OBJECTIVE

Because of the short potential doubling time of esophageal cancer, there is a theoretical benefit to using an accelerated radiation treatment schedule. This study evaluates outcomes and treatment-related mortality and morbidity of patients treated with neoadjuvant hyperfractionated accelerated chemoradiation for resectable esophageal cancer.

METHODS AND MATERIALS

Outcomes from 250 consecutive patients with resectable esophageal cancer treated with preoperative hyperfractionated accelerated chemoradiotherapy (45 Gy in 30 twice-daily fractions over 3 weeks) followed by planned transhiatal esophagectomy were analyzed. Grade 3 or greater treatment related toxicity, surgical complications, and treatment-related mortality were determined. Additionally, available surgical specimens were graded for pathological response to chemoradiation. Overall survival (OS) and locoregional control were calculated using the Kaplan-Meier method. The log rank test was used to determine statistical significance.

RESULTS

Median follow-up was 59 months for surviving patients; 87% of patients had adenocarcinoma and 13% had squamous cell carcinoma. Eleven percent of patients did not have surgery because of the development of metastases, declining performance status, or refusal. Twenty-seven patients were found to have unresectable and/or metastatic disease at the time of surgery. Overall, 10 of 223 operated patients died within 3 months, resulting in a perioperative mortality rate of 4%. Median OS was 28.4 months (95% confidence interval, 22.3-35.6 months) for all patients and 35.1 months (95% confidence interval, 27.4-47 months) for patients who underwent esophagectomy. There were 32 isolated locoregional failures with a 3-year locoregional control rate of 83%. Of 129 patients who had independent pathology review, 29% had complete response to treatment. This group had a median OS of 98.9 months and 3-year OS of 74%.

CONCLUSION

Neoadjuvant twice-daily chemoradiation for esophageal cancer is a safe and effective alternative to daily fractionation with low treatment-related mortality and long-term outcomes similar to standard fractionation courses.

Worldwide Esophageal Cancer Collaboration: pathologic staging data

We report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for patients with pathologically staged cancer of the esophagus and esophagogastric junction after resection or ablation with no preoperative therapy from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted de-identified data using standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 13,300 patients, 5,631 had squamous cell carcinoma, 7,558 adenocarcinoma, 85 adenosquamous carcinoma, and 26 undifferentiated carcinoma. Patients were older (62 years) men (80%) with normal body mass index (51%), little weight loss (1.8 kg), 0-2 ECOG performance status (83%), and a history of smoking (70%). Cancers were pT1 (24%), pT2 (15%), pT3 (50%), pN0 (52%), pM0 (93%), and pG2-G3 (78%); most involved distal esophagus (71%). Non-risk-adjusted survival for both squamous cell carcinoma and adenocarcinoma was monotonic and distinctive across pTNM. Survival was more distinctive for adenocarcinoma than squamous cell carcinoma when pT was ordered by pN. Survival for pTis-1 adenocarcinoma was better than for squamous cell carcinoma, although monotonic and distinctive for both. WECC pathologic staging data is improved over that of the 7th edition, with more patients studied and patient and cancer variables collected. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient, cancer, and treatment characteristics, and should direct 9th edition data collection. However, the role of pure pathologic staging as the principal point of reference for esophageal cancer staging is waning.

Gastric Cancer, Version 3.2016, NCCN Clinical Practice Guidelines in Oncology

Gastric cancer is the fifth most frequently diagnosed cancer and the third leading cause of death from cancer in the world. Several advances have been made in the staging procedures, imaging techniques, and treatment approaches. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Gastric Cancer provide an evidence- and consensus-based treatment approach for the management of patients with gastric cancer. This manuscript discusses the recommendations outlined in the NCCN Guidelines for staging, assessment of HER2 overexpression, systemic therapy for locally advanced or metastatic disease, and best supportive care for the prevention and management of symptoms due to advanced disease.

Osteopontin (OPN/SPP1) isoforms collectively enhance tumor cell invasion and dissemination in esophageal adenocarcinoma

Esophageal adenocarcinoma (EAC) is often diagnosed at an advanced stage, thus understanding the molecular basis for EAC invasion and metastasis is critical. Here we report that SPP1/OPN was highly overexpressed in primary EACs and intracellularly localized to tumor cells. We further demonstrate that all known OPN isoforms (OPNa, b, c, 4 and 5) were frequently co-overexpressed in primary EACs. Distinct pro-invasion and dissemination phenotypes of isoform-specific OPNb and OPNc stable transfectants were observed. Expression of OPNb significantly enhanced cell migration and adhesion to laminin. In contrast, OPNc cells showed significantly decreased cell migration yet increased cell detachment. Enhanced invasion, both in vitro and in vivo, was observed for OPNb- but not OPNc-expressing cells. Inhibition of RGD integrins, one family of OPN receptors, attenuated OPNb cell migration, abrogated OPNb cell adhesion and significantly reduced OPNb cell clonogenic survival but did not affect OPNc phenotypes, indicating that OPNb but not OPNc acts through integrin-dependent signaling. Differential expression of vimentin, E-cadherin and β-catenin in OPN stable cells may account for the variation in cell adhesion and detachment between these isoforms. We conclude that while all OPN isoforms are frequently co-overexpressed in primary EACs, isoforms OPNb and OPNc enhance invasion and dissemination through collective yet distinct mechanisms.

IGFBP2 modulates the chemoresistant phenotype in esophageal adenocarcinoma

Esophageal adenocarcinoma (EAC) patients commonly present with advanced stage disease and demonstrate resistance to therapy, with response rates below 40%. Understanding the molecular mechanisms of resistance is crucial for improvement of clinical outcomes. IGFBP2 is a member of the IGFBP family of proteins that has been reported to modulate both IGF and integrin signaling and is a mediator of cell growth, invasion and resistance in other tumor types. In this study, high IGFBP2 expression was observed in a subset of primary EACs and was found to be significantly higher in patients with shorter disease-free intervals as well as in treatment-resistant EACs as compared to chemonaive EACs. Modulation of IGFBP2 expression in EAC cell lines promoted cell proliferation, migration and invasion, implicating a role in the metastatic potential of these cells. Additionally, knockdown of IGFBP2 sensitized EAC cells to cisplatin in a serum-dependent manner. Further in vitro exploration into this chemosensitization implicated both the AKT and ERK pathways. Silencing of IGFBP2 enhanced IGF1-induced immediate activation of AKT and reduced cisplatin-induced ERK activation. Addition of MEK1/2 (selumetinib or trametinib) or AKT (AKT Inhibitor VIII) inhibitors enhanced siIGFBP2-induced sensitization of EAC cells to cisplatin. These results suggest that targeted inhibition of IGFBP2 alone or together with either the MAPK or PI3K/AKT signaling pathway in IGFBP2-overexpressing EAC tumors may be an effective approach for sensitizing resistant EACs to standard neoadjuvant chemotherapy.

Esophageal and esophagogastric junction cancers, version 1.2015

Esophageal cancer is the sixth most common cause of cancer deaths worldwide. Adenocarcinoma is more common in North America and Western European countries, originating mostly in the lower third of the esophagus, which often involves the esophagogastric junction (EGJ). Recent randomized trials have shown that the addition of preoperative chemoradiation or perioperative chemotherapy to surgery significantly improves survival in patients with resectable cancer. Targeted therapies with trastuzumab and ramucirumab have produced encouraging results in the treatment of advanced or metastatic EGJ adenocarcinomas. Multidisciplinary team management is essential for patients with esophageal and EGJ cancers. This portion of the NCCN Guidelines for Esophageal and EGJ Cancers discusses management of locally advanced adenocarcinoma of the esophagus and EGJ.

Pulmonary venous blood sampling significantly increases the yield of circulating tumor cells in early-stage lung cancer

OBJECTIVE

To identify circulating tumor cells (CTCs) in the blood of patients with early-stage lung cancer and to show that sampling pulmonary vein (PV) blood using microfluidic chip technology will yield significantly more CTCs. Improving early detection of lung cancer is critical to improving lung cancer survival. Reproducible detection of CTCs is limited currently in early stage tumors.

METHODS

Patients undergoing pulmonary resection had PV blood drawn before resection. Peripheral blood was sampled at preoperative, intraoperative, and postoperative times. Samples were analyzed on microfluidic chips using antibody-based capture.

RESULTS

A total of 32 patients with primary lung cancer were evaluated. Twenty patients had 1 or more CTCs detected in at least 1 sample (62.5%). The mean number of CTCs from peripheral vein sources at the preoperative, intraoperative, and postoperative time points was 1.3, 1.9, and 0.6 respectively. The average number of CTCs in the PV was 340.0 (range, 0.0-5422.50; P > .01). When PV CTCs were present, the number of CTCs was correlated with pathological tumor size (P = .0236). The number of PV CTCs was not correlated with any other clinical feature (eg, smoking status, preoperative or postoperative stage). Furthermore, the number of PV CTCs was significantly higher when preoperative bronchoscopic biopsy was performed, compared with computed tomography-guided biopsy (P = .0311). Seven patients had evidence of CTC clusters, or microemboli.

CONCLUSIONS

With a single vein draining the entire tumor basin, lung cancers are unique, allowing the high-yield isolation of CTCs from the PV. This method may facilitate future studies to improve the detection and analysis of early-stage lung CTCs.

Abstract 1581: A study of pulmonary and peripheral vein blood as sources of circulating tumor cells in early lung cancer

Lung cancer is one of the most prevalent cancers world-wide. It is usually diagnosed at an advanced stage with low survival rates. Early detection and intervention can have a profound impact in improving survival. Circulating tumor cells (CTCs), or cells shed by the tumor into the blood circulation, offer a less invasive method of tumor biopsy. Surgical lobectomy for early stage lung cancers provides access to the pulmonary vein (PV) draining the affected lobe, and is presumably an enriched source of CTCs shed by the primary lung tumor. Analyzing peripheral (Pe) and pulmonary vein (PV) blood combined could potentially shed light onto optimal markers and disease progression. We hypothesize that blood from the pulmonary vein has a higher abundance of CTCs than peripheral blood, thereby providing a larger yield of CTCs from early lung cancer patients for downstream analysis. A cohort of greater than 30 lung cancer patients was enrolled in a pilot study. PV and Pe blood specimens from these patients were obtained at different time points in the perioperative time period, and were processed through a high-throughput microfluidic device, the OncoBean Chip that isolates CTCs by immuno-affinity based capture. A higher number of PV CTCs were detected than from Pe. In addition, rare CTC clusters were observed in the PV blood in some cases, which were further characterized for protein expression. Gene expression analysis was performed for comparison of CTCs obtained from these two different sources. Evaluating different CTC sources along the venous drainage of a tumor could potentially offer an insight into CTC biology and spread of the disease.

Citation Format: Vasudha Murlidhar, Rishindra M. Reddy, Ebrahim Azizi, Lili Zhao, Svetlana Grabauskiene, Zhuo Zhang, Nithya Ramnath, Jules Lin, Andrew C. Chang, Philip W. Carrott, William R. Lynch, Mark B. Orringer, Max S. Wicha, Nallasivam Palanisamy, David G. Beer, Sunitha Nagrath. A study of pulmonary and peripheral vein blood as sources of circulating tumor cells in early lung cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1581. doi:10.1158/1538-7445.AM2015-1581

Abstract 1494: MicroRNAs encoded at the 14q32 cluster are associated with poor outcome in lung adenocarcinoma

The aim of this study was to determine whether different histologic subtypes of lung adenocarcinoma have distinct microRNA (miR) expression profiles and to identify miRs associated with aggressive subgroups of surgically-resected lung adenocarcinoma (AC). We profiled the miR expression of 91 surgically-resected lung adenocarcinomas and 10 matched nonmalignant lung tissues using TaqMan OpenArray Human microRNA panel. The top 3 prognostic miRs (miR-411, miR-370 and miR-376a) were validated by quantitative PCR in an independent cohort of 60 lung AC. To determine potential underlying biological processes associated with selected miRs, we used Affymetrix U133A gene expression microarray data from 51 miR profiled lung AC tumors. Two lung AC cells (SK-LU-1 and NCI-H2228) overexpressing miR-411 were transfected with miRCURY LNA microRNA power inhibitors for miR-411 or non-target using Lipofectamine RNAimax and plated into Boyden chambers for assessing cell migration. No significant differences in clinical characteristics were observed among the training (n=91) and the test set (n=60). Patients' characteristics: 45% male; 86% smokers; 52% stage I, 25% stage II, 19% stage III and 3% stage IV; 26% adjuvant treatment. Unsupervised hierarchical clustering of 356 expressed miRs identified 3 major clusters of lung AC that correlated with stage (P = 0.023), tumor differentiation (P &lt; 0.003) and histological type of lung AC based on IASLC-based classification (P &lt; 0.005). Cluster 1 was enriched in lepidic and mucinous invasive AC while cluster 3 included the most solid AC. Patients classified in cluster 3 had a shorter median overall survival (16.8 months) as compared to the other clusters (60 months for cluster 1 and 2, Log-rank P = 0.002). We identified 22 miRs significantly overexpressed in cluster 3 and associated with poor survival. Strikingly, 11 out of 22 were structurally associated by their genomic location on the long arm of chromosome 14 (14q32). The top prognostic miRs encoded at 14q32.2 (miR-370) and 14q32.31 (miR-411 and miR-376a) were validated by qPCR in an independent cohort of 60 lung AC. In the multivariate analysis, higher levels of these 3 miRs had significantly worse overall survival (HR = 3.12, 95% CI 1.32 - 7.34, P = 0.009) after adjusting by age, gender and stage. Gene Ontology enrichment analysis based on genes significantly correlated with miR-411, miR-370 and miR-376a expression revealed an association with cell migration and cell adhesion. MiR-411 knockdown significantly reduced cell migration (P &lt; 0.05) in 2 lung AC cells. This study demonstrated that different histological types of lung AC have distinct miRNA expression profiles. We identified and validated 3 prognostic miRNAs (miR-411, miR-370 and miR-376a) which are encoded at 14q32. These miRNAs associated with aggressive subtypes of lung adenocarcinoma may have potential to be actionable targets in the future.

Citation Format: Ernest Nadal, Jules Lin, Rishindra M. Reddy, Nithya Ramnath, Mark B. Orringer, Andrew C. Chang, David G. Beer, Guoan Chen. MicroRNAs encoded at the 14q32 cluster are associated with poor outcome in lung adenocarcinoma. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 1494. doi:10.1158/1538-7445.AM2014-1494

A MicroRNA cluster at 14q32 drives aggressive lung adenocarcinoma

PURPOSE

To determine whether different subtypes of lung adenocarcinoma (AC) have distinct microRNA (miRNA) expression profiles, and to identify miRNAs associated with aggressive subgroups of resected lung AC.

EXPERIMENTAL DESIGN

miRNA expression profile analysis was performed in 91 resected lung AC and 10 matched nonmalignant lung tissues using a PCR-based array. An independent cohort of 60 lung ACs was used for validating by quantitative PCR the top 3 prognostic miRNAs. Gene-expression data from 51 miRNA profiled tumors was used for determining transcript-specific miRNA correlations and gene-enrichment pathway analysis.

RESULTS

Unsupervised hierarchical clustering of 356 miRNAs identified 3 major clusters of lung AC correlated with stage (P = 0.023), tumor differentiation (P < 0.003), and IASLC histologic subtype of lung AC (P < 0.005). Patients classified in cluster 3 had worse survival as compared with the other clusters. Eleven of 22 miRNAs associated with poor survival were encoded in a large miRNA cluster at 14q32. The top 3 prognostic 14q32 miRNAs (miR-411, miR-370, and miR-376a) were validated in an independent cohort of 60 lung AC. A significant association with cell migration and cell adhesion was found by integrating gene-expression data with miR-411, miR-370, and miR-376a expression. miR-411 knockdown significantly reduced cell migration in lung AC cell lines and this miRNA was overexpressed in tumors from patients who relapsed systemically.

CONCLUSIONS

Different morphologic subtypes of lung AC have distinct miRNA expression profiles, and 3 miRNAs encoded at 14q32 (miR-411, miR-370, and miR-376a) were associated with poor survival after lung AC resection.

Herbert Sloan, MD, October 10, 1914 - May 17, 2013

Dr Herbert Sloan was the 10th president of The Society of Thoracic Surgeons and served for 15 years as the second editor of The Annals of Thoracic Surgery. One of few thoracic surgeons to lead both organizations, he also served as the 60th president of the American Association for Thoracic Surgery. Deeply committed to the mission of the American Board of Thoracic Surgery to maintain the highest standards for our specialty, he served on the American Board of Thoracic Surgery for 20 years, 13 as its secretary-treasurer. He left a legacy of thoracic surgery resident education as head of the Section of Thoracic Surgery at the University of Michigan.

Preoperative pulmonary artery pressure and mortality after lung transplantation

BACKGROUND

The purpose of this study was to determine the influence of changes in pulmonary artery pressure during the waiting period on survival after lung transplantation for pulmonary fibrosis.

METHODS

We identified 65 patients with pulmonary fibrosis who underwent lung transplantation from 2003 to 2010. Pulmonary artery pressure determined at listing was compared with intraoperative pressure. The primary outcome was overall survival. Co-variates included type of transplantation (single or bilateral), ischemic time, recipient and donor age and sex.

RESULTS

The median age of the 65 patients undergoing transplantation was 58 years, and 27 (43%) underwent bilateral sequential transplantation. Twenty-two (35%) patients presented at transplantation with a mean pulmonary artery pressure increased by at least 10% compared to the initial pressure at the time of listing. Rising pulmonary artery pressure at transplantation was associated with increased mortality (p = 0.022). Other factors including type of operation, ischemic time, age, and sex, were not significantly associated with mortality. Post-transplantation survival was worse among recipients who had pulmonary artery pressure increased by at least 10% at transplantation (p = 0.003, logrank).

CONCLUSIONS

Increasing pulmonary artery pressure while awaiting lung transplantation is associated with worse long-term survival following transplantation, and is a sign of progressively worsening disease for which greater urgency of donor organ allocation should be considered.

Gastric cancer, version 2.2013: featured updates to the NCCN Guidelines

The NCCN Clinical Practice Guidelines in Oncology for Gastric Cancer provide evidence- and consensus-based recommendations for a multidisciplinary approach for the management of patients with gastric cancer. For patients with resectable locoregional cancer, the guidelines recommend gastrectomy with a D1+ or a modified D2 lymph node dissection (performed by experienced surgeons in high-volume centers). Postoperative chemoradiation is the preferred option after complete gastric resection for patients with T3-T4 tumors and node-positive T1-T2 tumors. Postoperative chemotherapy is included as an option after a modified D2 lymph node dissection for this group of patients. Trastuzumab with chemotherapy is recommended as first-line therapy for patients with HER2-positive advanced or metastatic cancer, confirmed by immunohistochemistry and, if needed, by fluorescence in situ hybridization for IHC 2+.

Imaging in thoracic oncology: case studies from Multidisciplinary Thoracic Tumor Board (part 1 of 2 part series)

Multidisciplinary tumor board conferences foster collaboration among health care providers from a variety of specialties and help to facilitate optimal patient care. Typical cases from thoracic tumor board conferences include patients with known or suspected bronchogenic and esophageal carcinomas, as well as less common diseases such as thymomas and mesotheliomas. In most instances, the clinical questions revolve around the best options for establishing a diagnosis, staging the disease and directing treatment. This article describes and illustrates the clinical scenarios of three patients who were presented at our tumor board, focusing on management issues and the role of imaging. These patients had non-small cell lung cancer and mediastinal lymph node metastases; a small, growing ground glass nodule; and oligometastatic non-small cell lung cancer, respectively.

Imaging in thoracic oncology: case studies from Multidisciplinary Thoracic Tumor Board: (part 2 of 2 part series)

Multidisciplinary tumor board conferences foster collaboration among health care providers from a variety of specialties and help to facilitate optimal patient care. Generally, the clinical questions revolve around the best options for establishing a diagnosis, staging the disease and directing treatment. This article describes and illustrates the clinical scenarios of three patients who were presented at our thoracic Tumor Board, focusing on management issues and the role of imaging. These patients had invasive thymoma; concurrent small cell lung cancer and non-small cell lung cancer; and esophageal cancer with celiac lymph node metastases, respectively.

Endoscopic ultrasound is inadequate to determine which T1/T2 esophageal tumors are candidates for endoluminal therapies

OBJECTIVES

Esophageal endoscopic ultrasound is now regarded as essential in the staging of esophageal carcinoma. There is an increasing trend toward endoluminal therapies (ie, endoscopic mucosal resection and radiofrequency ablation) for pre-cancer or early-stage cancers because of concerns of high morbidity associated with esophagectomy. This study reviews our institutional experience with preoperative endoscopic ultrasound staging of early esophageal cancers in patients who underwent an esophagectomy to evaluate the accuracy of staging by endoscopic ultrasound and how this affects treatment recommendations.

METHODS

A prospective esophagectomy database of all patients undergoing an esophagectomy for esophageal cancer at a single high-volume institution was retrospectively reviewed for patients with early-stage esophageal cancer. This study analyzed patients with clinical Tis to T1 disease, as predicted by preoperative endoscopic ultrasound, and correlated this with the pathologic stages after esophagectomy. The surgical outcomes were evaluated to assess the safety of esophagectomy as a treatment modality.

RESULTS

From 2005 to 2011, 107 patients (93 male, 14 female) with a mean age of 66 years (range, 39-91 years) were staged by preoperative endoscopic ultrasound to have esophageal high-grade dysplasia, carcinoma in situ, or T1 cancer and underwent an esophagectomy. Tumor depth was correctly staged by endoscopic ultrasound in only 39% (23/59) of pT1a tumors (invading into the lamina propria or muscularis mucosa) and 51% (18/35) of pT1b tumors (submucosal). Of the endoscopic ultrasound-staged cT1a-lpN0 lesions, there were positive lymph nodes in 15% of pathologic specimens (2/13). Patients with pT1a-mm lesions had a 9% rate of pathologic lymph node involvement (1/11), and those with pT1b tumors had a 17% rate of lymph node spread (6/35). Esophagectomy was performed in all 107 patients with a 30-day mortality rate of less than 1% (1/107).

CONCLUSIONS

The sensitivity and specificity of endoscopic ultrasound for determining true pathologic staging are poor for early-stage esophageal cancers. Lesions thought to be cT1a-lpN0 by endoscopic ultrasound have at least pN1 disease in 15% of cases. Endoluminal therapy of these lesions based on endoscopic ultrasound undertreats a significant number of patients. Esophagectomy is still the standard therapy for early-stage esophageal cancers in the majority of patients.

Abstract 3879: Osteopontin (SPP1/OPN) alternative splice variants and metastatic potential in esophageal adenocarcinoma

Objective: The incidence of esophageal adenocarcinoma (EAC) has increased over 300% in the past decades in western countries. EAC is characterized by an early metastasis, with a 5-year survival rate of only 19%, making the identification of clinically-targetable proteins critical for improving patient outcome. Osteopontin (SPP1/OPN) is a secreted glycosylated phosphoprotein that is found overexpressed in many cancer types including EAC. OPN protein functions in cell adhesion and cell migration by regulating cell-matrix interactions and cellular signaling through binding with integrin and CD44 receptors. However, little is known about the role of OPN in EAC invasion and metastasis.

Methods: We analyzed the OPN gene expression in a series of 46 esophageal samples including esophageal Barrett's, low-grade dysplasia, high-grade dysplasia and adenocarcinomas mRNA using Affymetrix U133A arrays. Real-time RT-PCR was performed to validate array results and examine a larger cohort of 130 EAC samples. Tissue microarrays (TMA) were made containing 64 EACs, eight lymph node metastases, eight dysplastic and 11 none dysplastic Barrett's mucosa sections from 59 patients. Primers flanking the potential gene alternative splice regions were designed and the in-frame transcript variants were sequenced. Expression of OPN in EAC cell lines was analyzed using RT-PCR and western blot analysis. Ectopic OPN expression of splice variants and OPN knockdown in EAC cell lines have been performed to examine its roles in tumor invasion and EMT assays.

Results: OPN is highly overexpressed in EAC and overexpression of the gene is associated with poorer survival in patients. Three OPN splice variants were identified with their expression either proportionally increased or differentially expressed in the primary EAC and EAC-derived cells. Highly overexpressed OPN is a transcriptional event as no OPN gene amplification was found in the corresponding EACs. In addition, abundant OPN protein was found primarily in tumor cells in the tissue sections using immunohistochemical (IHC)-TMA assays. OPN variants differ in their N-terminal thrombin fragment with either exon 6 or 5 being absent in OPN-b or OPN-c, respectively. We found that EAC cells treated with the medium containing different OPN variants demonstrated distinctive morphological phenotypes. We further identified that OPN variants played different roles in tumor cell proliferation, epithelial-mesenchymal transition (EMT), and chemosensitivity.

Conclusion: Upregulation of OPN is predominant event in primary EACs and associated with poorer survival in patients. The alternative splice variants demonstrate differential tumor invasion, EMT transition and chemosensitivity in EAC cells.

Citation Format: Zhuwen Wang, Kimmy Leverenz, Dafydd G. Thomas, Amy L. Myers, Andrew C. Chang, Mark B. Orringer, Thomas J. Giordano, Jules Lin, David G. Beer, Lin Lin. Osteopontin (SPP1/OPN) alternative splice variants and metastatic potential in esophageal adenocarcinoma. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 3879. doi:10.1158/1538-7445.AM2013-3879

Abstract 3379: Overexpression of CTGF is associated with chemoresistance in esophageal adenocarcinoma

Esophageal adenocarcinoma is the most rapidly increasing solid malignancy with an overall 5-year survival of only 19%. Neoadjuvant chemoradiation is standard practice in most large centers but results in a complete pathologic response in only 21%, although this subset has an improved 5-year survival. In this study, connective tissue growth factor (CTGF), which is associated with increased cell migration, tissue invasion, and angiogenesis, was evaluated for its role in chemoresistance in esophageal adenocarcinoma. CTGF was found to be overexpressed in 33.3% (5 of 15; mean 3.1-fold) of esophageal adenocarcinomas on oligonucleotide microarray relative to Barrett's metaplasia. Elevated expression of CTGF was also found in 5/5 advanced stage IV esophageal adenocarcinomas on Western blot. Overexpression of CTGF was observed in 70.6% of chemoresistant esophageal adenocarcinomas (n=17) as determined using qRT-PCR and was significantly higher compared to chemo-naïve esophageal adenocarcinomas (n=102; p&lt;0.0005). Stable inhibition with an shRNA against CTGF in the esophageal adenocarcinoma cell line Flo, which expresses endogenous CTGF, led to a significantly increased response to the chemotherapeutic agents 5-FU (9.4-fold increase), cisplatin (5.5-fold), and etoposide (4.4-fold) at 24 hours (p&lt;0.005). These findings suggest that CTGF may be important in mediating chemoresistance in esophageal adenocarcinoma and that inhibition of CTGF could be useful in modulating chemoresistance to current neoadjuvant regimens in esophageal adenocarcinomas overexpressing CTGF.

Citation Format: Zhuwen Wang, Lin Lin, Dafydd G. Thomas, Mark B. Orringer, Andrew C. Chang, David G. Beer, Jules Lin. Overexpression of CTGF is associated with chemoresistance in esophageal adenocarcinoma. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 3379. doi:10.1158/1538-7445.AM2013-3379

Pre-operative chemoradiation followed by post-operative adjuvant therapy with tetrathiomolybdate, a novel copper chelator, for patients with resectable esophageal cancer

Introduction This phase II trial investigated chemoradiation followed by surgery and 2 years of adjuvant tetrathiomolybdate (TM) for resectable esophageal cancer. Methods Patients with resectable, locally advanced esophageal cancer received neoadjuvant cisplatin 60 mg/m(2) (days 1 and 22), paclitaxel 60 mg/m(2) (days 1, 8, 15, and 22), and 45 Gy hyperfractionated radiotherapy for 3 weeks followed by transhiatal esophagectomy. TM 20 mg PO QD was started 4 weeks post-op, and continued for 2 years to maintain the ceruloplasmin level between 5 and 15 mg/dl. Results Sixty-nine patients were enrolled (median age, 60 years). Sixty-six patients underwent surgery and 61 patients had a complete resection. Histologic complete response rate was 10 %. Twenty-one patients did not receive TM (metastases noted in the peri-operative period, prolonged post-operative recovery time, or patient refusal). Forty-eight patients started TM; 14 completed 24 months of treatment, 11 completed 10-18 months, 15 completed 2-8 months, and 8 completed ≤1 month. Twenty-seven patients had disease recurrence. With a median follow-up of 55 months, 25 patients were alive without disease, 1 was alive with disease, and 43 have died. Three-year recurrence-free survival was 44 % (95 % CI, 32-55 %) and the three-year overall survival was 45 % (95 % CI 33-56 %). Conclusions TM is an antiangiogenic agent that is well tolerated in the adjuvant setting. Disease-free survival and overall survival are promising when compared to historical controls treated at our institution with a similar regimen that did not include TM. However, the challenges associated with prolonged administration limit further investigation.

Abstract 4147: Ratio of miR-146b/miR-191 in serum predicts prognosis in surgically resected lung squamous cell carcinomas

Background: We profiled 61 lung squamous cell carcinomas (SCC) and 10 matched adjacent normal lung tissue using the Ambion mirVana Bioarray that contains 328 human micro-RNA (miR) probes (Raponi et al. Cancer Research 2009). MiR-146b and miR-191 showed the strongest prediction accuracy for stratifying the prognostic groups. We hypothesize that these miRs can be detectable in serum and its expression in serum might be prognostic. Methods: Using the mirVana PARIS kit (Ambion), total RNA was isolated from 0.5 ml serum samples from 60 resected lung SCC patients, 30 healthy controls and 17 patients with benign lung disease. Reverse transcription reaction using Megaplex RT primers (Applied Biosystems) and preamplification using Megaplex PreAmp primers (Applied Biosystems) were performed. Expression of mature miRs, miR-146b and miR-191, were examined by real-time quantitative polymerase chain reaction using the comparative cycle threshold (Ct) method. Since the normalization of miRNA data in blood samples is still controversial, the ratio between the expression values of miR-146b and miR-191 was calculated and data log transformed. Results: miR-146b and miR-191 expression was detectable in the serum from all lung SCC patients and the serum miR-146b/miR-191 ratio was significantly higher in lung SCC patients (0.29±0.25) than in cancer-free subjects (0.16±0.11) (p-value=0.001). The miR-146b/miR-191 ratio showed a modest discriminative receiver-operator characteristic (ROC) curve, distinguishing cancer patients from cancer-free subjects with areas under the ROC curve at 0.69 (95% CI 0.59-0.79). In 20 SCC patients, the primary tumor miR-146b/miR-191 ratio (calculated using our microarray data) was compared with the miR ratio in serum and a significant correlation was observed (Pearson coefficient=0.455; p-value&lt;0.001). Median overall survival of patients with high miR-146b/miR-191 ratio was significantly shorter (2.25 years ±0.32) than in patients with low miR ratio (5 years ±0.23, log-rank p-value=0.020). After adjusting by clinical covariates (sex, age and stage), miR-146b/miR-191 ratio remained as independent prognostic markers individually. Using the median of miR-146b/miR-191 ratio as a cutoff, the adjusted hazard ratio (HR) for death in those patients with higher miR ratio was 2.24 (95% CI 1.18-4.23). A validation of this miR-146b/miR-191 ratio as a prognostic marker in an independent cohort of resected lung SCC is warranted. Conclusions: Serum miR-146b/miR-191 ratio was significantly higher in lung SCC patients than in cancer-free subjects, but its accuracy to detect lung cancer is limited. Serum miR-146b/miR-191 ratio was significantly correlated with the primary tumor expression and the serum expression has a potential utility as independent prognostic marker in resected lung SCC.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4147. doi:1538-7445.AM2012-4147

Abstract 4137: Identification of diagnostic and prognostic miRNAs in lung cancer tissue and serum

Micro-RNAs (miRNAs) are measurable in tissues and also in serum and plasma in a stable form protected from endogenous RNase activity. Recent studies have shown that not only can miRNAs be used to sub-classify NSCLC, but specific miRNA profiles may also predict prognosis and disease recurrence in early-stage NSCLC. Although this finding has the potential to enhance the utility of miRNAs as biomarkers for diagnosis, prognosis and monitoring lung cancer patients following resection via non-invasive methods, few were used for clinical practice. In this study, we have performed miRNA profile analysis in lung cancer tissues and sera in order to discover new miRNAs for lung cancer diagnosis and prognosis. Total RNA was isolated from 91 lung adenocarcinoma tissues and 10 matched non-tumoral samples using miRNeasy Mini kit. Serum RNA was isolated from 0.5 ml serum using mirVana PARIS kit from 120 resected NSCLC patients, and 48 no-cancer controls. Reverse transcription reaction using Megaplex RT primers (Applied Biosystems) and pre-amplification using Megaplex PreAmp primers were performed on all the samples. ABI TagMan miRNA OpenArrays that contain more than 700 miRNAs probes were used for miRNA profile analysis on 101 lung tissues. Expressions of selected miRNAs in sera were examined by real-time quantitative polymerase chain reaction. The miRNA profiling analysis indicated that 501 out of 754 probes were detectable in more than 10% samples, and 373 probes were detected in more than 50% samples. We also found U6r RNA was constant expressed in tumor and normal than RNU44 or RNU48. Of the 373 probes, 145 probes showed a significantly different between tumor and normal controls with a p value less 0.001. More than half of them were not reported previously. Sixty five miRNAs were found to be significantly related to patient survival (p &lt; 0.05, Cox model). Individual miRNAs were also significantly associated with other clinical variables including tumor stage, nodal metastasis, and smoking status, etc. In order to determine the potential for clinical use for diagnosis and prognosis in serum, 10 miRNAs were selected to assess the expression levels in sera of 120 NSCLC and 48 no-cancer controls using TaqMan real-time Rt-PCR. We found that all the 10 miRNAs were detectable in serum with some showing significant differences between tumor and control and others related to patient survival. Verification using additional samples for selected miRNAs and in vitro functional analyses are ongoing. This study identified new diagnostic and prognostic miRNAs in lung cancer and indicated that sera-derived miRNAs could be used for not only cancer detection, but also defining patient outcome.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4137. doi:1538-7445.AM2012-4137

Abstract 2662: Racial disparities in the surgical outcomes after esophagectomy for esophageal cancer

Introduction: Despite advances in the management of esophageal cancer, African American patients continue to have poorer outcomes following esophagectomy for esophageal cancer. The reasons for this are multifactorial, including access to care and cultural perceptions of treatments. For those patients who underwent esophagectomy, we sought to evaluate if there were disparities in outcomes for African American patients. Method: We identified African American and Caucasian patients who underwent esophagectomy for esophageal cancer at a single, high volume institution. from 1974 to 2011. Using Chi-square and Fisher's exact test, we evaluated for differences in perioperative risk factors, postoperative complications and long term survival. Results: 2090 (2.7% African Americans, 97.3% Caucasians) patients were included in the study. No significant difference was seen in anastomotic leaks, chylothoraces, hoarseness, or other postop complications. However, more African Americans were sent to the intensive care unit during their postop hospitalization (62% versus 46%, p= 0.02). In addition, African Americans had a significantly longer hospitalization compared to their Caucasian counterparts (19 versus 12 days, p&lt;0.0001). This difference persisted even after adjusting for histology, preoperative staging, age, gender, alcohol and tobacco use. Squamous cell cancer was more likely to be seen in African Americans than in Caucasians (79% versus 20% respectively, p&lt;0.0001). Adenocarcinoma was more often seen in Caucasians than African Americans (78% vs 21%, p&lt;0.0001) as were Barrett's changes (33% versus 10%, p=0.003). Despite the longer hospitalizations, there was no significant difference in the long term survival (weeks) between African Americans and Caucasians. Conclusion: African Americans have equal survival to Caucasians after esophagectomy for esophageal cancer at single, high volume institution. Despite having longer hospitalizations with more ICU admissions after surgery, there were no significant differences in postoperative complications or long term survival based on race. Differences in outcomes in patients with esophageal cancer may be related to initial access to care, but there doesn't appear to be a difference in outcomes once patients proceed to surgery at an experienced center.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2662. doi:1538-7445.AM2012-2662