Hui-Shan Chen

Antinucleosome antibodies as a potential biomarker for the evaluation of renal pathological activity in patients with proliferative lupus nephritis

The objective of this study is to evaluate the correlation between antinucleosome antibodies and renal pathological activity in patients with proliferative lupus nephritis (LN). We evaluated 36 patients with proliferative LN, 14 non-renal lupus patients and 10 healthy volunteers. Lupus activity was assessed using the British Isles Lupus Assessment Group 2004 (BILAG 2004) index, serum anti-double stranded DNA (anti-dsDNA) levels, serum complement levels and daily urinary protein levels. All 36 lupus nephritis patients received renal biopsy. Antinucleosome antibodies were detected by enzyme-linked immunosorbent assay (ELISA). Our results showed that levels of serum antinucleosome antibodies were significantly higher in LN patients (median 90.35 units/ml, interquartile range [IQR] 37.38–135.23) than in non-renal SLE patients (median 5.45 units/ml, IQR 2.6–28.93, p <0.05) and in healthy volunteers (median 3.35 units/ml, IQR 2.95–5.23, p <0.001). Serum levels of antinucleosome antibodies were positively correlated with BILAG index (Spearman’s r = 0.645, p <0.001) and serum anti-dsDNA antibody levels (rs = 0.644, p <0.01), while serum levels of antinucleosome antibodies were negatively correlated with serum levels of C3 (rs = -0.400, p <0.01) and C4 (rs = -0.300, p <0.05). Serum levels of antinucleosome antibodies were positively correlated with the histological activity index of LN (rs = 0.368, p <0.05). However, there was no significant correlation between serum levels of antinucleosome antibodies and the histological chronicity index. In conclusion, the serum level of antinucleosome antibodies is a potential biomarker for early recognition of renal involvement and evaluation of disease activity in SLE. Our preliminary results suggested that serum levels of antinucleosome antibodies might be a potential biomarker in evaluating pathological activity of LN.

A Propensity-matched Analysis Comparing Survival After Esophagectomy Followed by Adjuvant Chemoradiation to Surgery Alone for Esophageal Squamous Cell Carcinoma.

Background: The role of adjuvant chemoradiation in esophageal cancer has been underestimated in the literature. This study was undertaken to determine whether adjuvant chemoradiation improves survival compared with surgery alone. Methods: Data of 1095 esophageal squamous cell carcinoma (ESCC) patients, including 679 in surgery alone group (group 1) and 416 in surgery followed adjuvant chemoradaition group (group 2), were obtained from the Taiwan Cancer Registry database. Propensity score matching (PSM) analysis was used to identify 147 well-balanced patients in each group for overall survival comparison. Results: After PSM, the 3-year survival rates and median survival were 44.9% and 27.2 (95% confidence interval [CI]: 17.6–40.3) months in group 2, which is significantly higher than that in group 1 (28.1% and 18.2 [95% CI: 14.3–24.5] months, P = 0.0043). In the multivariate survival analysis, pT3/4 stage (Hazard Ratio [HR]: 2.03, 95% CI: 1.38–2.97, P < 0.001), pN+ stage (HR: 1.83, 95% CI: 1.31–2.57, P = 0.0004), tumor length more than 32 mm (HR: 1.93, 95% CI: 1.33–2.79, P < 0.001), R1/2 resection (HR: 1.75, 95% CI: 1.15–2.66, P = 0.009), and adjuvant chemoradiation (HR: 0.57, 95% CI: 0.42–0.78, P < 0.0001) were independent prognostic factors. Subgroup analysis suggested patients with pT3/4 stage, pN+ stage tumors, larger tumor size, poorly differentiated tumors, and R1/2 resections were more likely to demonstrate survival benefit from adjuvant chemoradiation. Conclusions: Compared with surgery alone, adjuvant chemoradiation provides a survival benefit to ESCC patients, especially those with pT3/4 stage, N+ tumors, larger tumor size, poorly differentiated tumors, and R1/2 resections.

Pre- versus postoperative chemoradiotherapy for locally advanced esophageal squamous cell carcinoma

Objectives Although preoperative chemoradiation followed by surgery has been recognized as an efficient strategy for esophageal cancer treatments, several studies demonstrate survival benefits of postoperative chemoradiation for those undergoing upfront resection. The optimal sequence of surgery and chemoradiation remains unclear. Methods Data of 1647 patients with clinical stage II/III esophageal squamous cell carcinoma (ESCC), including 1245 receiving preoperative chemoradiation followed by esophagectomy (pre‐OP CRT group) and 402 receiving primary esophagectomy followed postoperative chemoradiation (post‐OP CRT group), were obtained from a nationwide database. Propensity score matching identified 286 well‐balanced pairs for outcome comparison. Results In matched patients, the 3‐year overall survival (OS) rates/median survival were not significantly different between the 2 groups (44.0% 3‐year OS/26.0 months; 95% confidence interval [CI], 18.9‐89 38.0 months) in the pre‐OP CRT group, versus 37.9% 3‐year OS/23.5 months (95% CI, 18.5‐29.9 months) in the post‐OP CRT group, P = .3152). The 3‐year disease‐free survival rates (DFS)/median survival after surgery were 38.7% 3‐year DFS/16.7 months (95% CI, 11.9‐29.6 months) in the pre‐OP CRT group, compared with 30.2% 3‐year DFS/10.4 months (95% CI, 7.6‐14.0 months) in the post‐OP CRT group (P = .0674). In patients who had complete resection, the freedom from recurrence rate at 1 year after surgery was 74.8% and 67.6% in pre‐OP CRT and post‐OP CRT groups, respectively (P = .2696). In the multivariable analysis, treatment modality (pre‐ or post‐OP CRT) was not a significant factor for OS (P = .258) or disease‐free survival (P = .521). Conclusions Similar outcome can be achieved with postoperative chemoradiotherapy compared with preoperative chemoradiotherapy in patients with locally advanced ESCC. There is little difference between these 2 strategies.

Impact of hospital volume on long-term survival after resection for oesophageal cancer: a population-based study in Taiwan

OBJECTIVES Previous studies have shown that patients who undergo oesophageal cancer surgery in high-volume hospitals have lower postoperative mortality rates. However, the impact of hospital volume on long-term survival is controversial. METHODS We identified 2151 patients who were diagnosed with oesophageal cancer between 2008 and 2011 from a national population-based cancer registry in Taiwan. High-volume hospitals were defined as those performing more than 86 oesophagectomies during that period (22 cases/year). Patients were stratified by whether they received preoperative chemoradiation. Cox regression analyses were used to determine the survival impact of hospital volume. RESULTS The 3-year overall survival rates after oesophagectomies were 44.9% in high-volume hospitals, compared with 40.2% in low-volume hospitals (P = 0.002). For patients who received preoperative chemoradiation (n = 850), the 1- and 3-year overall survival rates were 74.7 and 36.8%, respectively, in high-volume hospitals, compared with 73.5 and 42.6%, respectively, in low-volume hospitals (P = 0.333). For patients who did not receive preoperative chemoradiation (n = 1301), the 1- and 3-year overall survival rates were 78.1 and 50.0%, respectively, in high-volume hospitals, compared with 67.9 and 38.8%, respectively, in low-volume hospitals (P < 0.001). Multivariate analysis showed that hospital volume, resection margin, cT, pT and pN stages are significant independent prognostic factors. CONCLUSIONS Overall survival rate of patients who undergo oesophagectomies without preoperative chemoradiation at high-volume hospitals is significantly higher than at low-volume hospitals. However, there was no significant correlation between hospital volume and long-term outcome in patients who received preoperative chemoradiation.

Suicidal drug overdose in patients with systemic lupus erythematosus, a nationwide population-based case-control study

Objective A four-fold increase of suicide mortality has been demonstrated in systemic lupus erythematosus (SLE) patients. Prior studies showed that the most common method of suicide attempts in SLE patients involves drug overdose. Therefore, we conducted a nationwide population-based case-control study to elucidate factors associated with drug overdose as suicide attempt in SLE patients. Methods This study was based on the National Health Insurance Research Database in Taiwan. We identified all SLE patients from January 1, 2000 to December 31, 2010. Patients who had suicidal drug overdose (SDO) were selected as cases while age- and gender-matched patients who did not have SDO were selected as controls. Results The incidence rate of SDO in SLE patients was 291 cases per 100,000 person-years, higher than that in the general population (160 cases per 100,000 person-years). In a multivariate logistic regression analysis, we observed that SDO was associated with psychiatric disorders such as depressive disorders (odds ratio: 8.36, 95% confidence interval (CI): 5.60–12.48) and insomnia (odds ratio: 2.71, 95% CI: 1.73–4.25), and lower monthly income (odds ratios: 2.74 to 3.50) in SLE patients. Conclusion SDO is associated with psychiatric disorders such as depressive disorders and insomnia, and lower monthly income in SLE patients.

The prognostic value of metastatic lymph node number and ratio in oesophageal squamous cell carcinoma patients with or without neoadjuvant chemoradiation

OBJECTIVES We aim to evaluate the prognostic value of metastatic lymph node number (MLN) and ratio (MLR) in oesophageal squamous cell carcinoma (OSCC) patients with or without neoadjuvant chemoradiation. METHODS Two thousand one hundred and fifty-one OSCC patients receiving oesophagectomy with (n = 850) or without (n = 1301) neoadjuvant chemoradiation were included. The MLN was categorized into 0 (N0), 1-2 (N1), 3-6 (N2) and more than 7 (N3); the MLR was categorized into 0, 0-0.2 and >0.2. The prognostic value was evaluated with survival analysis using the Cox proportional hazards regression model and the Kaplan-Meier method. RESULTS In patients without neoadjuvant chemoradiation, the 3-year overall survival rates were 54.8, 34.4, 21.8 and 6.5% with MLN = 0, 1-2, 3-6 and more than 7, respectively (P < 0.001). The 3-year overall survival rates were 54.7, 31.2 and 14.2% with MLR = 0, 0-0.2 and more than 0.2, respectively (P < 0.001). In patients with neoadjuvant chemoradiation, the 3-year overall survival rates were 49.0, 28.4, 12.5 and 0.0% with MLN = 0, 1-2, 3-6 and more than 7, respectively (P < 0.001). However, the survival curves of MLN = 3-6 and MLN ≥7 overlapped on the Kaplan-Meier plots. In contrast, MLR demonstrated good ability to show the survival differences on the Kaplan-Meier plots. The 3-year overall survival rates were 48.9, 27.3 and 0.0% with MLR = 0, 0-0.2 and more than 0.2, respectively (P < 0.001). CONCLUSIONS Both MLN and MLR were significant prognostic factors in OSCC patients regardless of neoadjuvant chemoradiation. But in patients with neoadjuvant chemoradiation, the survival rates were similar between ypN2 and ypN3 patients, suggesting that there was no necessity of separating patients into ypN2 and ypN3 stages.

The Prognostic Impact of Preoperative and Postoperative Chemoradiation in Clinical Stage II and III Esophageal Squamous Cell Carcinomas: A Population Based Study in Taiwan.

Abstract While preoperative chemoradiation followed by surgery (pre-OP CRT) has been widely applied in the treatment of patients with esophageal cancer, some studies have shown a survival benefit of postoperative chemoradiation (post-OP CRT). The optimal combination of multimodality therapy and the sequence of surgery and chemoradiation for esophageal cancer remain to be investigated. A total of 1385 patients with clinical stage II and III esophageal squamous cell carcinoma (ESCC) were included. On the basis of the sequence of surgery and chemoradiation, the patients were grouped as follows: preoperative chemoradiation followed by surgery (pre-OP CRT+S), surgery alone (S), and surgery followed by postoperative chemoradiation (S+post-OP CRT). Propensity score matching analysis was used to identify 78 well-balanced patients in each group for outcome comparison. In all, 753, 339, and 293 patients were in the pre-OP CRT+S, S, and S+post-OP CRT groups, respectively. Before matching, no differences were observed in the overall survival among the patients in these 3 groups (P = 0.422). After matching, both the pre-OP CRT+S and S+post-OP CRT groups were significantly associated with a better survival compared with the S group (pre-OP CRT+S vs. S: P < 0.001; S+post-OP CRT vs. S: P = 0.005). In contrast, the survival was similar between the pre-OP CRT+S and S+post-OP CRT groups (P = 0.544). In the subgroup analysis, patients with clinical T3/4 stage tumors or those with a tumor size greater than 5 cm were more likely to demonstrate an overall survival benefit from pre-OP CRT compared with post-OP CRT. Both pre-OP CRT and post-OP CRT demonstrated a survival benefit compared with surgery alone, which indicates the importance of trimodality therapy in patients with clinical stage II/III ESCC. However, no survival difference was observed among patients in the pre-OP CRT+S and S+post-OP CRT groups, which suggests that the sequence of surgery and chemoradiation may be irrelevant to the outcome.

Factors associated with survival in patients with oesophageal cancer who achieve pathological complete response after chemoradiotherapy: a nationwide population-based study.

OBJECTIVES Few data are currently available on the factors associated with survival in oesophageal cancer patients who achieve pathological complete response (pCR) after chemoradiotherapy (CRT). Using a nationwide database, we investigated the predictors of survival in this patient group. METHODS Data were retrieved from the Taiwan Cancer Registry to identify patients with oesophageal squamous cell carcinoma (OSCC) who achieved pCR after CRT followed by oesophagectomy between 2008 and 2013. The median number of dissected nodes (20) was used as the cut-off to classify the extent of lymph node dissection (LND). Tumour location was defined according to the seventh edition of the American Joint Committee on Cancer staging system. Cox proportional hazard regression analyses were used to identify factors associated with survival. RESULTS Of the 1103 patients who underwent CRT followed by surgery, 319 (28.9%) achieved pCR. Thirty- and 90-day mortality rates were 3.5 and 4.7%, respectively. The 3-year overall survival rate was 55.9%. Multivariate Cox survival analysis identified age ≥55 years [hazard ratio (HR): 1.72, 95% confidence interval (CI): 1.07 to 2.78, P = 0.025], an LND number of <20 (HR: 1.62, 95% CI: 1.01 to 2.61, P = 0.047) and lesions located in the upper third (HR: 2.35, 95% CI: 1.18 to 4.65, P = 0.015) as adverse prognostic factors for survival in pCR patients. CONCLUSIONS Patient age ≥55 years, upper third lesions and an LND number of <20 are adverse prognostic factors in OSCC patients who achieve pCR following CRT. High-risk patients should be strictly followed.

Impact of Treatment Modalities on Survival of Patients With Locoregional Esophageal Squamous-Cell Carcinoma in Taiwan.

AbstractThe optimal treatment modality for locoregional esophageal squamous-cell carcinoma (ESCC) is still undetermined. This study investigated the treatment modalities affecting survival of patients with ESCC in Taiwan.Data on 6202 patients who underwent treatment for locoregional esophageal squamous-cell carcinoma during 2008 to 2012 in Taiwan were collected from the Taiwan Cancer Registry. Patients were stratified by clinical stage. The major treatment approaches included definitive chemoradiotherapy, preoperative chemoradiation followed by esophagectomy, esophagectomy followed by adjuvant therapy, and esophagectomy alone. The impact of different treatment modalities on overall survival was analyzed.The majority of patients had stage III disease (n = 4091; 65.96%), followed by stage II (n = 1582, 25.51%) and stage I cancer (n = 529, 8.53%). The 3-year overall survival rates were 60.65% for patients with stage I disease, 36.21% for those with stage II cancer, and 21.39% for patients with stage III carcinoma. Surgery alone was associated with significantly better overall survival than the other treatment modalities for patients with stage I disease (P = 0.029) and was associated with significantly worse overall survival for patients with stage III cancer (P < 0.001). There was no survival risk difference among the different treatment methods for patients with clinical stage II disease.Multimodality treatment is recommended for patients with stage II–III esophageal squamous-cell carcinoma. Patients with clinical stage I disease can be treated with esophagectomy without preoperative therapy.