Simon Paterson-Brown

Elevated tumour interleukin-1β is associated with systemic inflammation: a marker of reduced survival in gastro-oesophageal cancer

Systemic inflammation is associated with adverse prognosis cancer but its aetiology remains unclear. We investigated the expression of proinflammatory cytokines within normal mucosa from healthy controls and tumour tissue in cancer patients and related these levels with markers of systemic inflammation and with the presence of a tumour inflammatory infiltrate. Tissue was collected from 56 patients with gastro-oesophageal cancer and from 12 healthy controls. Tissue cytokine mRNA concentrations were measured by real-time PCR and tissue protein concentrations by cytometric bead array. The degree of chronic inflammatory cell infiltrate was recorded. Serum cytokine and acute phase protein concentrations (including C-reactive protein (CRP)) were measured by enzyme-linked immunosorbent assay. Proinflammatory cytokines were significantly overexpressed (interleukin (IL)-1β, IL-6, IL-8 and tumour necrosis factor-α) both at mRNA and protein levels in the cancer specimens compared with mucosa from controls. Interleukin-1β was expressed in greatest (10–100-fold) concentration and protein levels correlated significantly with systemic inflammation (CRP) (P=0.05, r=0.31). A chronic inflammatory infiltrate was observed in 75% of the cancer specimens and was associated with systemic inflammation (CRP: P=0.01). However, the presence of chronic inflammation per se was not associated with altered cytokine expression within the tumour. Both a chronic inflammatory infiltrate and systemic inflammation (CRP) were associated with reduced survival (P=0.05 and P=0.03, respectively). Tumour chronic inflammatory infiltrate and tumour tissue IL-1β overexpression are potential independent factors influencing systemic inflammation in oesophagogastric cancer patients.

Defining a positive circumferential resection margin in oesophageal cancer and its implications for adjuvant treatment

A positive circumferential resection margin (CRM) has been associated with a poorer prognosis in oesophageal and oesophagogastric junctional (OGJ) cancer. The College of American Pathologists defines the CRM as positive if tumour cells are present at the margin, whereas the Royal College of Pathologists also include tumour cells within 1 mm of this margin. The relevance of these differences is not clear and no study has investigated the impact of adjuvant therapy. The aim was to identify the optimal definition of an involved CRM in patients undergoing resection for oesophageal or OGJ cancer, and to determine whether adjuvant radiotherapy improved survival in patients with an involved CRM.

mRNA profiling of the cancer degradome in oesophago-gastric adenocarcinoma

Background:Degradation of the extracellular matrix is fundamental to tumour development, invasion and metastasis. Several protease families have been implicated in the development of a broad range of tumour types, including oesophago–gastric (OG) adenocarcinoma. The aim of this study was to analyse the expression levels of all core members of the cancer degradome in OG adenocarcinoma and to investigate the relationship between expression levels and tumour/patient variables associated with poor prognosis.Methods:Comprehensive expression profiling of the protease families (matrix metalloproteinases (MMPs), members of the ADAM metalloproteinase-disintegrin family (ADAMs)), their inhibitors (tissue inhibitors of metalloproteinase), and molecules involved in the c-Met signalling pathway, was performed using quantitative real-time reverse transcription polymerase chain reaction in a cohort of matched malignant and benign peri-tumoural OG tissue (n=25 patients). Data were analysed with respect to clinico-pathological variables (tumour stage and grade, age, sex and pre-operative plasma C-reactive protein level).Results:Gene expression of MMP1, 3, 7, 9, 10, 11, 12, 16 and 24 was upregulated by factors >4-fold in OG adenocarcinoma samples compared with matched benign tissue (P<0.01). Expression of ADAM8 and ADAM15 correlated significantly with tumour stage (P=0.048 and P=0.044), and ADAM12 expression correlated with tumour grade (P=0.011).Conclusion:This study represents the first comprehensive quantitative analysis of the expression of proteases and their inhibitors in human OG adenocarcinoma. These findings implicate elevated ADAM8, 12 and 15 mRNA expression as potential prognostic molecular markers.

Frequency of the mitochondrial DNA 4977bp deletion in oesophageal mucosa during the progression of Barrett's oesophagus

PURPOSE The mechanisms of the progression of Barretts oesophagus (BO) to oesophageal adenocarcinoma (OA) are poorly understood. The frequency of the 4977bp deletion in mitochondrial DNA (mtDNA) was investigated in specimens ranging from normal oesophageal tissue to OA in order to investigate whether this deletion represents a useful biomarker of disease progression. METHODS The presence of the 4977bp deletion was screened by PCR amplification from 70 specimens in total. RESULTS The frequency of specimens with the 4977bp deletion increased in relation to the degree of dysplasia (8.3% in normal squamous epithelium; 15.4% in BO; 40% in low grade dysplasia (LGD); 69.2% in high-grade dysplasia and 90% in para-tumoural tissue). However, the frequency of the deletion reduced sharply in OA specimens (16.7%; p<0.001). CONCLUSION The mtDNA 4977bp deletion may be useful as a biomarker to detect the severity of dysplasia but not the presence of OA.

Surgical management of emergency and elective giant paraesophageal hiatus hernias.

BACKGROUND Uncertainty exists surrounding the laparoscopic approach to the repair of giant paraesophageal hiatus hernias (GPHHs), in regard to both long-term outcomes and its role in the emergency presentation. The aim of this study was to assess the outcome of laparoscopic GPHH repair, compared with traditional open surgery, in both the elective and emergency setting. SUBJECTS AND METHODS Data regarding all patients who underwent GPHH repair between January 1994 and June 2008 were retrieved from the prospectively maintained Lothian Surgical Audit database. Demographic details, surgical approach (open/laparoscopic), conversion to an open procedure, complications, and recurrences were analyzed. RESULTS Sixty-four patients had GPHH repair. Attempted laparoscopic repair and conversion rates were 52 of 64 (81.2%) and 12 of 52 (23.1%), respectively. Including these conversions, 24 of 64 patients had an open repair. The mean postoperative hospital stay, complications, and mortality were significantly lower among the laparoscopic cohort. Twenty-five of 64 patients had surgery as an emergency admission. Postoperative mortality after emergency surgery was 5 of 25 (20.0%) compared with 3 of 39 (7.6%) among elective patients (P=.146). The recurrence rate after laparoscopic and open repair was 25.0% (10 of 40) and 8.3% (2 of 24), respectively (P=.184). CONCLUSIONS This study has confirmed that surgical repair of GPHH is associated with a significant morbidity and mortality, in both the elective and emergency setting. Although the laparoscopic approach should be attempted in the first instance, the open approach appears to have a lower recurrence rate.

Gastrointestinal stromal tumor in ascitic fluid: A case report

BACKGROUND There are few published data on the cytologic features of gastrointestinal stromal tumors (GISTs) in ascitic fluid and whether these features may mimic those of other malignancies. CASE An 80-year-old woman presented with ascitics associated with multiple intraperitoneal masses. Cytologic examination of the ascitic fluid showed numerous three-dimensional clusters of epithelioid cells. These features and the presence of large, intracytoplasmic vacuoles raised a possible diagnosis of adenocarcinoma. However, mucin could not be demonstrated in the vacuoles, and the cells showed immunoreactivity for vimentin and c-kit but not for cytokeratins. Eighteen months earlier the patient had undergone a partial gastrectomy for a GIST, which predominantly comprised vacuolated, epithelioid cells. The immunoprofile of the primary tumor was identical to that of the ascitic fluid cells. CONCLUSION GIST cells may closely mimic adenocarcinoma cells in ascitic fluid. Distinguishing between the two neoplasms has important clinical repercussions and is aided by histochemical and immunocytochemical studies--in particular, c-kit immunostaining.

Quantitative Shotgun Proteomics Unveils Candidate Novel Esophageal Adenocarcinoma (EAC)-specific Proteins

Esophageal cancer is the eighth most common cancer worldwide and the majority of patients have systemic disease at presentation. Esophageal adenocarcinoma (OAC), the predominant subtype in western countries, is largely resistant to current chemotherapy regimens. Selective markers are needed to enhance clinical staging and to allow targeted therapies yet there are minimal proteomic data on this cancer type. After histological review, lysates from OAC and matched normal esophageal and gastric samples from seven patients were subjected to LC MS/MS after tandem mass tag labeling and OFFGEL fractionation. Patient matched samples of OAC, normal esophagus, normal stomach, lymph node metastases and uninvolved lymph nodes were used from an additional 115 patients for verification of expression by immunohistochemistry (IHC). Over six thousand proteins were identified and quantified across samples. Quantitative reproducibility was excellent between technical replicates and a moderate correlation was seen across samples with the same histology. The quantitative accuracy was verified across the dynamic range for seven proteins by immunohistochemistry (IHC) on the originating tissues. Multiple novel tumor-specific candidates are proposed and EPCAM was verified by IHC. This shotgun proteomic study of OAC used a comparative quantitative approach to reveal proteins highly expressed in specific tissue types. Novel tumor-specific proteins are proposed and EPCAM was demonstrated to be specifically overexpressed in primary tumors and lymph node metastases compared with surrounding normal tissues. This candidate and others proposed in this study could be developed as tumor-specific targets for novel clinical staging and therapeutic approaches.

PWE-029 Objective assessment of physical activity as a measure of functional recovery and quality of life following oesophago-gastric cancer resection

Introduction Functional recovery following surgery is determined by the interaction between pre-operative performance, post-operative catabolism, nutritional status, and mood. Physical activity (PA) is an important domain of health-related quality-of-life (HRQL), and may be a useful objective index of recovery. We aimed to use an accelerometer-based activity metre (ActivPAL) to monitor post-operative PA in oesophago-gastric (OG) cancer patients undergoing surgery with curative intent. Methods PA measures, including step count, time spent in various body positions, and energy expenditure of activity, were assessed over 7-day periods in patients undergoing oesophagectomy or gastrectomy (n=16). Nutritional status, HRQL (FAACT, FACIT-F and EORTC-QLQC30 questionnaires), and mood (HADS questionnaire) were also assessed. Time-points were pre-operatively and 1–2 weeks, 5–6 weeks, 3 months and 6 months post-operatively. Results Compared with pre-operative results, PA measures were decreased by 23–89% (p<0.05) 1–2 weeks post-operatively, and were still decreased by 15–57% (p<0.05) 5–6 weeks post-operatively. At 3 months, all PA measures except time spent upright (p=0.009) and time spent standing (p=0.013) had recovered. Measures of PA correlated positively with physical and functional domains of HRQL, including EORTC-QLQ30 Global Health Status, FAACT Trial Outcome Index (TOI) and FACIT-TOI (p<0.001), and inversely with HADS-Depression (p<0.001). Conclusion There is marked impairment of PA at the time of hospital discharge and a gradual recovery over 3–6 months. This carries significant implications in a disease where surgical patients may survive <2 years. PA measures are suitable outcomes for evaluating the impact of enhanced recovery programmes on functional recovery and HRQL. Competing interests None declared.

PWE-155 The effect of excluding neoadjuvant chemotherapy on survival from locally advanced oesophageal or oesophagogastric junctional (ogj) cancer

Introduction Patients clinically staged with > T2 or node positive (>cT2/cN+) oesophageal or OGJ cancer are routinely considered for neoadjuvant chemotherapy prior to attempted curative resection (NA). Patients with cardiovascular comorbidity are often precluded from NA and the effect on survival in a contemporary setting is not clear. Method Single centre retrospective study of all patients undergoing attempted curative therapy for >cT2/cN+ mid or lower oesophageal or OGJ adenocarcinoma or squamous cell carcinoma diagnosed between 2001 and 2013. Uni and multivariable survival analyses were performed using a prospectively-maintained audit database. Results A total of 371 patients were included and 289 (78%) commenced NA comprising predominantly 2 cycles of cisplatin and 5-fluorouracil (n = 264; 91%) with 274 (95%) undergoing subsequent resection. Patients undergoing surgery alone (S) were significantly older (mean = 8 years, p < 0.001) but were well matched with patients undergoing NA for clinical stage, gender and histology. Based on intention to treat, NA was associated with a significantly improved median overall survival compared to S (29 months compared to 21 months; P = 0.008). Recurrence-free survival did not, however, differ between NA and S (p = 0.585). The 90 day in-hospital mortality rate was higher in S compared to NA (10% vs. 3%; P = 0.011), likely reflecting the increased comorbidity of these patients. When patients dying in hospital within 90 post-operative days were excluded, the overall survival benefit of NA over S was reduced to a median of 2.7 months (p = 0.04). Pathological tumour size, differentiation, pT, pN and R stage were associated with survival (all P < 0.01) but did not differ significantly between patients undergoing NA or S suggesting a limited down-staging effect of NA. To assess histological response to chemotherapy, the Mandard tumour regression grade (TRG) was determined, blinded to outcome, in a subset of 111 patients undergoing NA. Only 21 patients (19%) exhibited a histological response to NA (TRG I-III) and TRG was not associated with survival (P = 0.08). Conclusion Resection carries a significantly higher perioperative mortality risk in patients with >cT2/cN+ oesophageal or OGJ cancer and comorbidity precluding neoadjuvant therapy. In clinically stage-matched patients, neoadjuvant chemotherapy was associated with a significant survival benefit over surgery alone. A low histological response rate to chemotherapy was noted and in those patients surviving to discharge the overall survival benefit of NA was limited to a median of <3 months. More effective therapies are needed. Disclosure of interest None Declared.

PMO-093 MRNA profiling of the cancer degradome in oesophago-gastric adenocarcinoma

Introduction Degradation of the extracellular matrix is fundamental to tumour development, invasion and metastasis. Several protease families have been implicated in the development of a broad range of tumour types, including oesophago-gastric (OG) adenocarcinoma. The aim of this study was to analyse expression levels of all core members of the cancer degradome in OG adenocarcinoma, and to investigate the relationship between expression levels and tumour/patient variables associated with poor prognosis. Methods Comprehensive expression profiling of the protease families [matrix metalloproteinases (MMPs), members of the ADAM metalloproteinase-disintegrin family (ADAMs)], their inhibitors [tissue inhibitors of metalloproteinase (TIMPs)], and molecules involved in the c-Met signalling pathway, was performed using quantitative real-time reverse transcription PCR in a cohort of matched malignant and benign peri-tumoural OG tissue (n=25 patients). Data were analysed with respect to clinico-pathological variables (tumour stage and grade, age, sex and pre-operative plasma C-reactive protein level). Results Gene expression of MMP1, 3, 7, 9, 10, 11, 12, 16 and 24 was upregulated by factors greater than fourfold in OG adenocarcinoma samples compared with matched benign tissue (p<0.01). Expression of ADAM8 and ADAM15 correlated significantly with tumour stage (p=0.048 and p=0.044), and ADAM12 expression correlated with tumour grade (p=0.011). Conclusion This study represents the first comprehensive quantitative analysis of the expression of proteases and their inhibitors in human OG adenocarcinoma. These findings implicate elevated ADAM8, 12 and 15 mRNA expression as potential prognostic molecular markers. Competing interests None declared.