Yasuaki Nakajima

Multiple Primary Cancers Associated with Esophageal Carcinoma

Abstract This study was conducted to examine the characteristics of esophageal cancers with primary synchronous or metachronous cancer in another organ. We retrospectively evaluated 744 patients who underwent esophagectomy for esophageal cancers between 1985 and 1998. The patients were divided into two groups according to whether they had multiple primary cancer (MPC) or nonmultiple primary cancer (NPC). Stage I cancer was significantly more frequent among patients with MPC than among those with NPC (P < 0.0001). Among patients with MPC, another primary cancer was found in the head and neck region in 70 (42.4%), in the stomach in 51 (30.9%), and in the colon, lung, breast, and other locations in the remaining patients. Of the 70 patients with another primary cancer in the head and neck region, 32 (45.7%) had pharyngeal cancer. Furthermore, the incidence of intraesophageal multiple cancer in the patients with primary cancer in the head and neck region was significantly higher than that in those whose other primary cancers were gastric cancer or in those with NPC (P = 0.0135, P < 0.0001). The 5-year survival rate of the patients with MPC was 51.28%, which was significantly higher than that of those with NPC (P = 0.019). In conclusion, a better knowledge of the relationships between esophageal carcinoma and cancers in other organs may lead to earlier detection of other primary cancers and improved therapeutic results.

Methylation of the calcium channel-related gene, CACNA2D3, is frequent and a poor prognostic factor in gastric cancer.

BACKGROUND & AIMS The calcium channel voltage-dependent alpha2delta subunit consists of 4 genes, CACNA2D1 to CACNA2D4, of which CACNA2D2 and CACNA2D3 are located on 3p21.3 and 3p21.1, respectively. Here, we examined the relation between alpha2delta subunit gene alterations and gastric carcinogenesis. METHODS The expression and methylation status of the alpha2delta subunit genes were analyzed by reverse transcription-polymerase chain reaction (RT-PCR) and methylation-specific PCR in gastric cancers (GCs). The effects of CACNA2D3 expression were examined by cell proliferation and adhesion assays, and they predicted target gene alterations. RESULTS Aberrant methylation of CACNA2D1 and CACNA2D3 mostly corresponded to their expression status in GC cell lines. CACNA2D1/3 methylation was detected in 10 (12.5%) and 24 (30%) of the 80 GC cases, respectively, but no CACNA2D2 methylation was seen in 32 cases. CACNA2D3 methylation was more frequently found in diffuse type than in intestinal type (16/38 [42.1%] vs 8/42 [19.0%]; P = .025) GCs. Among the 53 patients with advanced GCs, patients with cancers showing CACNA2D3 methylation had a significantly shorter survival time than patients without this methylation (P = .003). Exogenous CACNA2D3 expression strongly inhibited cell growth and adhesion and up-regulated p21 and p27 expression in HEK-293T and NUGC4 cells. Inverse effects were seen by CACNA2D3 small interfering RNA treatment in the CACNA2D3-positive cell lines, indicating that CACNA2D3 may have tumor suppressive functions. CONCLUSIONS Loss of CACNA2D3 expression through aberrant promoter hypermethylation may contribute to gastric carcinogenesis, and CACNA2D3 methylation is a useful prognostic marker for patients with advanced GC.

A longer duration of polymyxin B-immobilized fiber column hemoperfusion improves pulmonary oxygenation in patients with septic shock.

Endotoxin plays an important role in the pathogenesis of septic shock. Exposure of endothelial cells to endotoxin activates endothelial cells and increases the surface expression of adhesion molecules, markers of endothelial damage in organ dysfunction. Endotoxin adsorption therapy by polymyxin B-immobilized fiber column (PMX) hemoperfusion has been used for the treatment of septic shock patients. In this study, we measured plasma concentrations of endotoxin and soluble adhesion molecules in septic shock patients before and after the PMX treatment then observed on the relationships between actual duration of use and various outcomes. Sixteen patients with septic shock were studied. The 28-day mortality rate was 50%. The elevated plasma concentrations of endotoxin decreased after the PMX treatment in the survivors but not in the nonsurvivors. The norepinephrine dose and plasma concentrations of soluble endothelial leukocyte adhesion molecule 1 and soluble intercellular adhesion molecule 1 significantly (P < 0.05) decreased in the PMX greater-than-2-h (prolonged) group than in the PMX 2-h (conventional) group (−17.8 ± 14.6 vs. −1.8 ± 2.7 &mgr;g/min, −143.0 ± 111.0 vs. 0 ± 2.8 ng/mL, and −126.2 ± 144.9 vs. 16.5 ± 108.1 ng/mL, respectively). Changes in the PaO2-FiO2 ratio and the Sequential Organ Failure Assessment score were significantly (P < 0.05) more improved in the PMX greater-than-2-h group than in the PMX 2-h group (75.4 ± 80.7 vs. 1.2 ± 49.2 and −0.8 ± 1.8 vs. 2.2 ± 1.9 torr, respectively). We thus suggest that a longer duration of PMX treatment may improve the pulmonary oxygenation associated with decreased adhesion molecules in septic shock.

Evaluation of an Indicator for Lymph Node Metastasis of Esophageal Squamous Cell Carcinoma Invading the Submucosal Layer

Lymph node metastasis is a major prognostic factor for esophageal squamous cell carcinoma (ESCC). In recent years, endoscopic mucosal resection (EMR) has been developed with excellent results for the treatment of the superficial ESCC. To make the EMR treatment successful, it is important to establish a good indicator to identify ESCC patients at a high risk of lymph node metastasis. In this study, we examined clinicopathological and immunohistochemical factors to investigate the factors involved in lymph node metastasis of ESCC invading to the submucosal layer (sm‐ESCC). Surgical specimens from 84 sm‐ESCC patients were examined. Among 84 sm‐ESCC patients, 33 (39.3%) had lymph node metastases. Clinicopathologically, tumor depth, lymphatic invasion and blood vessel invasion showed significant correlations with lymph node metastasis by univariate analysis. Tumor depth and lymphatic invasion showed significant correlations by multivariate analysis of these factors. Immunohistochemically, P53 accumulation was observed in 45 cases (53.6%), cyclin D1 overexpression in 25 (29.8%), and pRB in 65 (77.4%). P53 accumulation, cyclin D1 overexpression and MIB‐1 Labeling Index were significantly associated with lymph node metastasis by univariate analysis, and P53 accumulation showed a significant correlation with lymph node metastasis by multivariate analysis. Among tumor depth, lymphatic invasion and P53 accumulation, tumor depth and lymphatic invasion were significantly correlated with lymph node metastasis (P=0.0023 and P=0.0092, respectively) by multivariate analysis. These data suggest that tumor depth and lymphatic invasion can be considered as good indicators for lymph node metastasis among patients with sm‐ESCC. In addition, P53 accumulation could be helpful to identify the patients who need additional treatment after EMR.

Internal Pressure of the Conduit during Endoscopy on the Day after Esophagectomy

Background: In gastrointestinal surgery, anastomosis can result in various complications. Anastomosis is evaluated using classical examinations. The most reliable one is endoscopy, which provides direct information on the anastomosis and conduit. But the influence of endoscopy on anastomosis is uncertain. Methods: The internal pressure of a graft during endoscopy was measured in 36 patients who received esophagectomy, by utilizing the decompression tube which was inserted into the graft during operation. We filled the tube with water and measured the maximum water level in a centimeter water column. All examinations were routinely performed on the day after operation, and thin endoscopes were selected for reducing the stress. Results: The internal pressure before endoscopy ranged from 6 to 20 cm H2O, and during endoscopy ranged from 9 to 27 cm H2O. The difference in the internal conduit pressure in each patient ranged from 1 to 9 cm H2O. There was no increase in complications caused by endoscopy, including anastomotic leakage. Conclusion: This study is the first to report changes in internal pressure due to the endoscope by direct measurement. The pressure gradient observed was below the physiological pressure during swallowing. These results suggest that endoscopy is a safe examination even after surgery.

Prevalence of Barrett's esophagus in Japan

Norman Barrett originally described two special conditions, namely, a congenital short esophagus with an intrathoracic gastric columnar lining and congenital gastric heterotropia in the esophagus with ulceration. Thereafter, these conditions began to be known as “Barretts esophagus.” It is an acquired condition of esophageal columnar metaplasia following chronic gastroesophageal reflux, and the classical Barretts esophagus has been defined as having a circumferential columnar metaplasia spreading minimally 3 cm or more upward from the esophagogastric junction, because the esophagogastric junction still tends to be difficult to recognize precisely. Recently, from the point of view of adenocarcinogenesis of the esophagus, the term and concept of short-segment Barretts esophagus (SSBE) as a developing condition of the classical Barretts esophagus and the confirmation of intestinal metaplasia has been required; however, the definition of Barretts esophagus still remains controversial. In Japan, although the prevalence of short-segment Barretts esophagus has been reported to vary considerably, from 1% to 52%, the prevalence of long-segment Barretts esophagus (LSBE) tends to range from 0% to 2%, which is a quite lower rate than that observed in Western countries. The great difference in the prevalence of SSBE is caused by the differences in the criteria of the esophagogastric junction and the definition concerning the necessity of intestinal metaplasia. A universally accepted definition of Barretts esophagus is thus needed to accurately determine its actual prevalence.

CPT‐11 May Provide Therapeutic Efficacy for Esophageal Squamous Cell Cancer and the Effects Correlate with the Level of DNA Topoisomerase I Protein

CPT‐11 is a potent anti‐cancer drug and a specific inhibitor of DNA topoisomerase I (Topo I). In this study, we aim to evaluate the effects of CPT‐11 on esophageal squamous cell cancers (ESCC) and to determine the correlation between the effects and the levels of Topo I expression. We examined the growth‐inhibitory effect caused by SN‐38, an active metabolite of CPT‐11, in 14 human ESCC cell lines established from 10 primary and 4 metastatic lesions. CPT‐11 was considered effective against 5 cell lines from primary lesions and one from metastatic lesions, and thus may show therapeutic efficacy against both primary and metastatic ESCC tumors. Although Topo I mRNA levels in these 14 ESCC cell lines, as quantitated by northern blot analysis, showed no correlation with the IC50 values, Topo I protein levels, as quantitated by western blot analysis, showed an inverse correlation with the IC50 values. Topo I protein levels could be an indicator of sensitivity to CPT‐11. We also determined Topo I protein levels in 40 ESCC tumors and matched normal mucosae. Thirty‐four tumors showed 1.2‐22.3‐fold increases in Topo I levels. Two patients receiving pre‐operative chemotherapy and one receiving radiotherapy exhibited increased Topo I protein levels in their tumor lesions. It appeared that CPT‐11 could provide selective therapeutic efficacy against ESCC tumors. CPT‐11 may be effective for the treatment of metastatic ESCC tumors and as a second‐line anti‐cancer drug for ESCC.

Subcutaneous reconstruction using ileocolon with preserved ileocolic vessels following esophagectomy or in esophageal bypass operation.

Background: When forming an esophageal substitute with an ileocolon in esophageal reconstruction with cervical anastomosis, the ileocolic vessels should be divided in many cases and this may be followed by the occurrence of poor blood circulation in the pulled-up substitute. Methods: Twenty-two consecutive esophageal reconstructions using an all-main-vessel-preserving ileocolon had been performed in the past 4 years and we evaluated the usefulness of this surgical modality. Results: In every case, the extension length of the ileocolon was sufficient for esophageal reconstruction. There were no serious surgical complications concerning the esophageal substitutes such as necrosis of the pulled-up ileocolon. Conclusions: Although it was thought that the surgical techniques shown here were possible only in selected patients, successful esophageal reconstructions were achieved with this new concept in 22 consecutive patients with various backgrounds. The procedures shown here are not new; however, the concept of using the all-main-vessel-preserving ileocolon as an esophageal substitute for every patient requiring esophageal reconstruction is new.

NEW ARGON PLASMA COAGULATION METHOD FOR SUPERFICIAL ESOPHAGEAL CARCINOMAS: ARGON PLASMA COAGULATION‐SUBEPITHELIAL ABLATION

Argon plasma coagulation (APC) has been introduced to the field of therapeutic endoscopy and is now widely used. A new ablation technique is herein proposed for the treatment of superficial esophageal carcinomas. According to this technique, after the initial ablation, we exfoliate the epithelium and then perform a second ablation (APC‐subepithelial ablation). APC is applied at a power/gas setting of 60 W and 2l min in the esophagus. The APC applicator is inserted through the working channel of the endoscope, and a transparent hood is then set at the tip of the endoscope. At first, lines are traced around the tumor. Next, the initial ablation is made in a uniform manner. A transparent hood is then attached to the ablated tumor and, thereafter, the epithelium is easily exfoliated. The muscularis mucosae are preserved. We next identify any remaining non‐uniform ablation areas and then a second ablation is made on those areas. To obtain a complete eradication of the mucosal and submucosal tissue, the endoscopic appearance of brownish subepithelial tissue following the secondary argon plasma irradiation after epithelial exfoliation with initial argon plasma irradiation is needed. The secondary ablation could thus safely ablate at the esophageal gland level. The procedure is minimally invasive and easy to apply. A total of 48 patients with superficial esophageal squamous cell carcinoma were treated between February 2000 and April 2006 (median follow up 46 months). One hundred and sixty one sessions were performed with no major complications (no bleeding, no perforation, and no stenosis). The technique is thus considered to be safe.

The expressions of p21 and pRB may be good indicators for the sensitivity of esophageal squamous cell cancers to CPT-11: Cell proliferation activity correlates with the effect of CPT-11

Previously, we demonstrated that CPT‐11 is an effective agent against esophageal squamous cell cancers (ESCC), and that the protein level of DNA topoisomerase I can be a predictor for sensitivity to CPT‐11 (Jpn J Cancer Res 2001; 92: 1335–41). Here, we describe our search for additional predictors of sensitivity to CPT‐11, mainly among cell cycle‐regulating proteins, because the cytotoxicity of CPT‐11 is significantly correlated with the percentage of ESCC cells in S‐phase. To this end, we selected and examined the expressions of 5 proteins involved in G1‐S transition, i.e., p53, cyclin D1, p21, p27, and pRB, in 14 ESCC cell lines by western blot analysis. Among these proteins, the expression levels of p21 and pRB showed significant differences that were associated with the IC50 values for CPT‐11 (P=0.0339 and P=0.0109, respectively). Namely, the expression of p21 or pRB independently could be a good indicator of CPT‐11 efficacy in ESCC. In addition, the cell proliferation activities examined by enzyme‐linked immunosorbent assay (ELISA) using 5‐bromo‐2′‐deoxyuridine (BrdU) showed a significant correlation with the percentage of total S‐phase cells (correlation coefficient=0.568, P=0.0324), and an inverse correlation with the IC50 values for CPT‐11 (correlation coefficient=−0.601, P=0.0213). Because, as in the case of DNA topoisomerase I, the cell proliferation activity determined using BrdU shows a close relationship with the MIB‐1 labeling index, immunohistochemical studies of p21, pRB, and MIB‐1 in resected ESCC specimens and/or biopsy samples could make it possible to predict more precisely the sensitivity of ESCC patients to CPT‐11 prior to treatment.