Foregut Cancers Research Articles

Exploring rural-urban differences in the receipt of nonelective cancer-specific gastrointestinal surgery using a multilevel mixed-effects approach

BackgroundRural communities constitute a populace marked by various social challenges influencing health outcomes. As such, nonelective surgeries for cancer may have a disproportionate impact on rural populations. We explored patient and county-level factors contributing to differences in the receipt of nonelective cancer-specific surgery between rural and urban residents. MethodsThis retrospective study included adult patients captured in the Surveillance, Epidemiology, and End Results–Medicare data between January 2008 and December 2015 with an incident stage I to IV cancer of the stomach, liver/intrahepatic bile duct, pancreas, gallbladder/other biliary origin, or small intestine who underwent a cancer-specific surgery. The primary outcome was a nonelective cancer-directed surgery among rural vs urban residents. We conducted a multivariable mixed-effects logistic regression model to adjust for confounders while accounting for county-level clustering. ResultsThe sample included 10,136 patients who underwent a surgical intervention; 2941 (29%) were nonelective. The incidence of nonelective surgery was lower among rural than urban patients (351 [27%] and 2590 [29%]; P = .05). There was no statistically significant difference in the unadjusted and adjusted odds of nonelective surgery between rural and urban residents (odds ratio, 0.88; 95% CI, 0.76–1.03; P = .11; adjusted odds ratio [aOR], 0.86; 95% CI, 0.72–1.02; P = .080). In addition, high social vulnerability index (SVI) counties or Black race was significantly associated with increase odds of nonelective surgery (aOR, 1.33; 95% CI, 1.07–1.65; P = .009; aOR, 1.49; 95% CI, 1.26–1.77; P < .0001, respectively). ConclusionThis study found no difference in the odds of receiving nonelective surgery for gastrointestinal foregut cancers between rural and urban populations. However, Black race and high SVI were associated with higher odds of the receipt of nonelective surgery. Further research is warranted to explore whether disparities in clinical outcomes exist despite the comparable likelihood of receiving nonelective surgery between rural and urban communities.

Understanding Barriers to Guideline-Concordant Treatment in Foregut Cancer: From Data to Solutions

BackgroundA large proportion of patients with foregut cancers do not receive guideline-concordant treatment (GCT). This study sought to understand underlying barriers to GCT through a root cause analysis approach.MethodsA single-institution retrospective review of 498 patients with foregut (gastric, pancreatic, and hepatobiliary) adenocarcinoma from 2018 to 2022 was performed. Guideline-concordant treatment was defined based on National Comprehensive Cancer Network guidelines. The Ishikawa cause and effect model was used to establish main contributing factors to non-GCT.ResultsOverall, 34% did not receive GCT. Root causes of non-GCT included Patient, Physician, Institutional Environment and Broader System-related factors. In decreasing order of frequency, the following contributed to non-GCT: receipt of incomplete therapy (N = 28, 16.5%), deconditioning on chemotherapy (N = 26, 15.3%), delays in care because of patient resource constraints followed by loss to follow-up (N = 19, 11.2%), physician factors (N = 19, 11.2%), no documentation of treatment plan after referral to oncologic expertise (N = 19, 11.2%), loss to follow-up before oncology referral (N = 17, 10%), nonreferral to medical oncologic expertise (N = 16, 9.4%), nonreferral to surgical oncology in patients with resectable disease (N = 15, 8.8%), and complications preventing completion of treatment (N = 11, 6.5%). Non-GCT often was a function of multiple intersecting patient, physician, and institutional factors.ConclusionsA substantial percentage of patients with foregut cancer do not receive GCT. Solutions that may improve receipt of GCT include development of automated systems to improve patient follow-up; institutional prioritization of resources to enhance staffing; financial counseling and assistance programs; and development and integration of structured prehabilitation programs into cancer treatment pathways.

Understanding barriers to guideline-concordant treatment in foregut cancer: From data to solutions.

e13521 Background: Receipt of guideline concordant treatment (GCT) is associated with improved prognosis in foregut (gastric, pancreatic, and hepatobiliary) cancers. However, a large proportion of patients with foregut cancers do not receive GCT. This single institution study from the Deep South sought to understand barriers to receipt of GCT using a root cause analysis (RCA) approach. Methods: A retrospective review of 498 patients with foregut adenocarcinoma diagnosed between 2018-2022 was performed. GCT was defined using National Comprehensive Cancer Network guidelines. The Ishikawa cause and effect model was used to establish main contributing factors to non-receipt of GCT. Results: Overall, 170 patients (34.1%) did not receive GCT. Median (Interquartile range [IQR] time from symptoms to start of workup was 8.8 weeks (4.3-16.4); time from diagnosis to first oncology appointment was 4.6 weeks (1.6- 6.6), and time from oncology appointment to start of treatment was 11 weeks (3.7- 18.2). Root causes of non-GCT included Patient, Physician, Institutional Environment and Broader System-related factors. Non-GCT was often a function of multiple intersecting patient, physician, and institutional factors. Barriers to receipt of GCT along the cancer care continuum included: receipt of incomplete therapy due lack of follow-up with surgical oncologist after initial appointment (16.5%), deconditioning on chemotherapy resulting in non-receipt of surgical therapy (15.3%), multiple delays in care due to patient resource constraints resulting in loss to follow-up after receipt of some therapy (11.2%), physician factors including provider knowledge (leading to delayed or non-diagnosis) or specialist non- adherence to GCT (11.2%), lack of documented treatment plan after referral to oncologist (11.2%), loss to follow up before oncology referral without record of health system attempt to re-establish care (10%), non-referral to oncologist (9.4%), non-referral to surgical oncologist in patients with resectable disease (8.8%), and complications during treatment preventing completion of treatment (6.5%). Findings from this study will allow us to propose targeted solutions to improve receipt of GCT, such as development of automated systems to improve patient follow-up and compliance with GCT; institutional prioritization of resources to enhance staffing for navigation, physical therapy, social services, and care coordination; financial counselling and assistance programs; and development and integration of structured prehabilitation programs into cancer treatment pathways. Conclusions: A substantial percentage of patients with foregut cancer do not receive GCT due to multiple barriers along the cancer care continuum. This RCA approach allows us to propose and develop solutions that may improve receipt of GCT.

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Discussion.

The Association of Hospital Volume and Utilization of Palliative Surgery in Metastatic Foregut Cancers

Rasic, Gordana; Beaulieu-Jones, Brendin Ryan MD; Papageorge, Marianna MD; de Geus, Susanna WL MD, PhD; Ng, Sing Chau MS; Devaiah, Anand K MD, FACS; Tseng, Jennifer F MD, MPH, FACS; Sachs, Teviah E MD, MPH, FACS Author Information

Cancer cachexia impact on chemotherapy dose reduction, treatment discontinuation, and survival: A qualitative systematic review.

e24103 Background: Cachexia is a syndrome of muscle wasting, weight loss, and anorexia, that frequently affects patients with advanced cancer across all major areas of oncology (surgical, medical, radiation, and chemotherapy), contributing to poorer treatment outcomes, including survival. In this qualitative systematic literature review, we reviewed the recent literature to assess the impact of cancer cachexia on chemotherapy dose reduction, treatment discontinuation, and survival. Methods: A systematic search was conducted on PubMed and Embase on November 26th, 2021, using the following search terms, among others: “cancer”, “cachexia”, “sarcopenia”, “muscle loss”, “body weight loss”, “chemotherapy”, “drug dose reduction”, “survival”, “treatment withdrawal”, and “treatment interruption”. 1,559 entries published between 2018 and 2021 were identified, of which 175 were duplicates. Publications were screened for eligibility and only original research in peer-reviewed journals were considered eligible. Inclusion criteria included: chemotherapy-specific studies; studies reporting on cachexia, body weight, or body composition changes; and studies reporting data on survival, chemotherapy dose reduction or treatment discontinuation, or occurrence of toxicities which may lead to chemotherapy dose reduction or treatment discontinuation in these patients. All studies that did not analyze the impact of cachexia on these outcomes were excluded. Results: A total of 63 studies, comprising a total of 15,832 patients, were considered eligible and selected for further analysis. The majority of analyzed studies, comprising 14,493 patients, reported associations between cancer cachexia (or its characteristics, such as weight loss or muscle wasting) and chemotherapy dose reductions in 7% of the studies, treatment discontinuation in 20% of the studies, and increased toxicity in 25% of the reports. Cachexia parameters were associated with inferior survival in 90% of the studies. The types of cancer most commonly associated with this effect were pancreatic (31% of studies), foregut (gastric, esophageal, and others, 17%), and lung cancer (14%). Conclusions: More than 70% of studies identified in the literature were retrospective assessments of patient records, while the remaining were prospective observational and interventional studies. In this review, cancer cachexia parameters were associated with reduced treatment delivery and inferior survival in multiple types of advanced cancer. These observations could have important implications for clinical practice, as early detection and successful treatment of cachexia might provide better outcomes for cancer patients undergoing chemotherapy. Disclosure: This study was funded by Helsinn Healthcare SA. Contact: Gianluca.Ballinari@helsinn.com .

Underutilization of Palliative Care in Metastatic Foregut Cancer Patients Is Associated with Socioeconomic Disparities

BackgroundMetastatic foregut cancers (MFC) are associated with debilitating symptoms that negatively impact patients’ quality of life. Palliative care (PC) is effective in mitigating disease-, psychosocial-, and treatment-related effects and may improve survival in select cases. Our study characterizes PC utilization rates in MFC and identifies factors associated with PC receipt. MethodsWe conducted a retrospective review of 228,027 National Cancer Database patients diagnosed with MFC between 2004 and 2016. Chi-squared tests were used to analyze differences between groups receiving and not receiving PC. Logistic regression was performed to assess the impact of factors on the likelihood of receiving PC. ResultsOverall PC utilization was low (17.8%). A greater proportion of patients not receiving PC were in the lowest median income quartile of < $38,000/year versus those receiving PC (18.1% vs 17.8%, p < 0.0001). Higher education was associated with increased likelihood of receiving PC (OR 1.23 for communities with < 6.3% no high school degree vs ≥ 17.6%, p < 0.0001). Hispanics were significantly less likely to receive PC compared to Whites (OR 0.72, 95% CI 0.68–0.76). Patients treated at academic centers were also more likely to receive PC compared to those treated in the community (OR 1.10, 95% CI 1.05–1.14). ConclusionsPC is a key component in improving quality of life among MFC patients. Despite slight increases in PC rates over time, PC remains drastically underutilized. Significant racial and socioeconomic disparities in patterns of PC delivery exist. Further studies are needed to understand these disparities in order to identify key targets for interventions aimed at improving equity.

671 SENTINEL LYMPH NODE SAMPLING AND EMPIRIC CHEMORADIATION AS AN ORGAN SPARING APPROACH AFTER ENDOSCOPIC RESECTION OF INTERMEDIATE RISK EARLY FOREGUT CANCERS: A US PILOT STUDY

For low risk early foregut cancers, endoscopic submucosal dissection (ESD) is curative. For high-risk cancers, esophagectomy/gastrectomy is required for definitive staging and treatment. For ‘intermediate risk’ patients at ∼5-20% risk of lymph node (LN) metastasis, however, local resection in conjunction with systemic therapy could rival radical surgery. In this context, after local resection, Sentinel LN sampling (SLNS) may offer added value compared to a ‘wait and watch’ or ‘empiric chemotherapy’ approach. SLNS has not been used in clinical practice after ESD of T1 Barrett’s cancers. For gastric cancers it represents an emerging technique limited to Asia. We report the 1st US pilot study on SLNS after ESD for these foregut cancers. Patients who had ESD for T1 Barrett’s or gastric carcinomas and met both criteria below were offered SLNS: 1) ESD pathology with high-risk T1 cancer (deep invasion; lymhovascular invasion, G3,4 grade). 2) Patient with high surgical risk or refusing surgery. Indocyanine green (ICG) was injected endoscopically in the submucosa around the ESD site intra-operatively and fluorescent LNs were harvested including paraesophageal/EGJ stations in Barrett’s patients. Pts with positive SLNs and high-risk patients with negative SLNs were offered adjuvant therapy. 10 pts received ESD with SLNS. Mean age 70 (50-79). 9 males. The ASA class was 3 in 8 and 2 in 2 patients. There were 7 EGJ Barrett’s cancers (5 with T1a m3 invasion as the only risk factor) and 3 gastric cancers. We consider Barrett’s T1a m3 carcinomas as high-risk based on reports of LN involvement in up to 5%. Our finding of a positive SLN in 1/5 of these patients supports this. Median cancer size 1.3 cm (0.5-3.5). Grade: G1 in 4 patients, G2 in 5 and G4 in 1. T stage was T1a m3 in 5 and T1b in 5. R0 ESD achieved in 8 patients. SLNS was successful in all patients and returned a median of 9 LNs (4-20). 9 pts discharged on the same day and 1 on the next day. No significant adverse events. 4 patients had positive SLNs (1 N1, 2 N2, and 1 N3) and received adjuvant chemotherapy +/- radiation. Of the 6 N0 patients 1 received a 2nd ESD for indeterminate lateral margin and one with SM2 Barrett’s cancer and only 4 SLNs sampled was offered chemotherapy. After a median follow-up of 30 months (range 15-64), 8 patients including all 6 with negative SLNs were in remission. 2/4 patients with positive SLNs died, one from disseminated cancer, and one while in remission, from unrelated cause. This pilot study in patients with ESD of T1 Barrett’s and gastric cancers with high risk histologic features suggests potential feasibility of SLNS to risk-stratify and direct further treatment in patients in whom the standard of care of organ resection and lymphadenectomy is not possible due to high surgical risk or patient preference.

Abstract C006: Underutilization of palliative care in metastatic foregut cancer patients is associated with socioeconomic disparities

Abstract Introduction: Metastatic cancers of the foregut are frequently associated with debilitating symptoms that negatively impact quality of life. We aim to determine the rate of palliative care (PC) use in metastatic neoplasms of the foregut and the factors which are associated with receipt of PC. Methods: Using the National Cancer Database (NCDB), patients with metastatic cancers of the foregut were selected. Receipt of PC as defined by the NCDB participant use file was correlated to demographic and clinicopathologic factors. PC treatment included surgery, radiation, systemic therapy, and pain management to alleviate symptoms. Logistic regression was performed to assess the impact of factors on the likelihood of receiving PC. Overall survival was estimated using the Kaplan-Meier method and compared using log-rank tests. Results: Between 2004 and 2013, 277957 patients with metastatic foregut cancers (MFC) including gastric (42626, 15.3%), pancreas (109219, 39.2%), bile duct (8890, 3.2%), gall bladder (10058, 3.6%) and esophagus cancer (107164, 38.6%) were identified. Median age was 66 years (IQR: 55-76 years) and 64% were male. Among all cancer types, PC utilization was 14.7% (40787). PC utilization increased over time (2004-6 12.3%, 2007-10 14.7%, 2011-13 16.4%; p&amp;lt;0.001). PC utilization was different between cancer types [gastric 6965 (16.3%), pancreas 18814 (17.2%), bile duct 1922 (21.6%), gall bladder 1593 (15.8%) and esophagus cancer 11493 (10.7%)]. There were differences in types of PC interventions utilized in the entire group: surgery 6569 (16.1%), radiation 6964 (17.1%), systemic therapy 12951 (31.8%), pain management 5100 (12.5%) and combination therapy 9203 (22.6%). Factors associated with PC on univariate analysis included sex, race, insurance status, median income, education level, Charlson/Deyo comorbidity score, and year of diagnosis (all p&amp;lt;0.01). On multivariate analysis, female gender (1.09, 95% CI: 1.06-1.11), higher education level (Level 4: 1.36, 95%CI: 1.31-1.42), higher Charlson/Deyo Score (Score: 2: 1.28, 95%CI: 1.23-1.32), and a later year of diagnosis (2011-2013: 1.39, 95%CI: 1.35-1.43) were associated with greater receipt of PC. Furthermore, older patients (75+ years: 0.90, 95%CI: 0.85-0.96), HS race (0.78, 95%CI: 0.74-0.82), private insurance (0.80, 95%CI: 0.76-0.85) and higher income (0.78, 95%CI: 0.75-0.81) were associated with less receipt of PC. Overall survival for the entire cohort is poor at 4.45 months (p&amp;lt;0.001) for the PC group and 6.60 months (p&amp;lt;0.001) for the no PC group. Conclusion: Although PC use has increased over time, it remains underutilized in MFC. Disparities exist in receipt of PC in regard to age, race, gender, insurance status, education, comorbidities and year of diagnosis. Additional research is necessary to better optimize PC use in metastatic cancers of the foregut and mitigate potential disparities. Note: This abstract was not presented at the conference. Citation Format: Michelle Ju, Subhadeep Paul, Adam Yopp, Sam Wang, Matthew Porembka. Underutilization of palliative care in metastatic foregut cancer patients is associated with socioeconomic disparities [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C006.

Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: A matched case-control study.

Pharyngolaryngeal and oesophagogastric cancers present with swallowing symptoms and as such, their clinical evaluation traverses boundaries between different specialties. We studied the incidence and significance of interspecialty cancer referrals (ICRs), that is, pharyngolaryngeal cancers first evaluated by gastroenterology and oesophagogastric cancers first evaluated by otolaryngology. A subset analysis of our Integrated Aerodigestive Partnership's audit dataset, of all ICR patients, and an equal number of controls matched for age, sex and cancer subsite. Information about patient age and presenting symptoms was recorded. The relationship between symptoms and ICR risk was examined with binary logistic regression. Referral-to-diagnosis latency was compared between ICR and control patients with unpaired Student's t test. Cox regression was used to identify independent predictors of overall survival. Of 1130 patients with pharyngolaryngeal and oesophagogastric cancers between 2008 and 2018, 60 diagnoses (5.3%) were preceded by an ICR. Referral-to-diagnosis latency increased from 43±50days for control patients to 115±140days for ICR patients (P<.0001). Dysphagia significantly increased the risk of an ICR (odds ratio 3.34; 95% CI 1.30-8.56), and presence ofclassic gastroesophagealreflux symptoms (heartburn or regurgitation; OR 0.25; 95% CI 0.08-0.83) and "distal" symptoms (nausea/vomiting, abdominal pain or dyspepsia; OR 0.23; 95% CI 0.08-068) significantly reduced the risk. Eleven pharyngolaryngeal cancers (of 26; 42%) were missed by gastroenterology, and eight (of 34; 24%) oesophageal cancers were missed by otolaryngology. An ICR was an independent adverse prognostic risk factor on multivariable analysis (hazard ratio 1.76; 95% CI 1.11-2.73; P<.02; log-rank test). Two systemic root causes were poor visualisation of pharynx and larynx by per-oraloesophago-gastro-duodenoscopy (OGD) for pharyngolaryngeal cancers, and poor sensitivity (62.5%) of barium swallow when it was used to 'evaluate' oesophageal mucosa. An interspecialty cancer referral occurs in a significant proportion of patients with foregut cancers. It almost triples the time to cancer diagnosis and is associated with a high incidence of missed cancers and diminished patient survival. It is a complex phenomenon, and its reduction requires an integrated approach between primary and secondary care, and within secondary care, to optimise referral pathways and ensure appropriate and expeditious specialist evaluation.

Association of socioeconomic disparities with underutilization of palliative care in patients with metastatic foregut cancer.

502 Background: Metastatic foregut cancers (MFC) are frequently associated with debilitating symptoms that have significant negative impact on patients’ quality of life. Palliative care (PC) is effective in mitigating disease-, psychosocial-, and treatment-related effects. However, PC remains heavily underutilized. The aim of our study was to characterize the rate of PC utilization in MFC and determine the impact of various clinicopathologic and socioeconomic factors associated with the receipt of PC. Methods: We conducted a retrospective review of 277,957 National Cancer Database patients diagnosed with MFC between 2004-2013. Chi-squared tests were used to analyze differences between groups. Logistic regression was performed to assess the impact of factors on the likelihood of receiving PC. Results: PC utilization increased among all groups over time (12.3% 2004-2006 vs. 14.7% 2007-2010 vs. 16.4% 2011-2013 for all cancers). Female sex, Medicaid, median income &lt; $46,000/year, higher education level, higher Charlson/Deyo Score, and pancreatic or biliary cancers were associated with increased likelihood of PC interventions. Additionally, patients treated at an academic center or integrated network cancer program were more likely to receive PC than patients treated in the community setting. When receipt of PC was stratified by race, Hispanics were significantly less likely to have undergone palliative interventions compared to non-Hispanic Whites (OR 0.70, 95% CI 0.66-0.73). Patients with Medicare or private insurance were less likely to receive PC than uninsured patients (OR 0.92, 95% CI 0.87-0.97 and 0.81, 95% CI 0.77-0.89, respectively). Conclusions: Differences in palliative care receipt rates exist with regards to racial/ethnic and socioeconomic factors such as insurance status, median household income, and education level. Patients receiving care in the community setting were also less likely to receive palliative care than those treated at academic or integrated network cancer program centers. Further studies are needed to delineate why these disparities exist with regards to palliative care utilization.

Mo1225 OUTCOMES OF ESD FOR GASTRIC AND ESOPHAGEAL CANCER AT A HIGH VOLUME US CENTER

Foregut carcinomas in the US differ from those typical in Asia. Esophageal cancers are mainly Barrett’s and gastric cancers tend to be more advanced. Aim: Assess post ESD outcomes of foregut cancers at a high volume US center.

Establishment of a multi-disciplinary prehabilitation program for patients with hepatopancreaticobiliary and foregut cancer in a community hospital

Establishment of a multi-disciplinary prehabilitation program for patients with hepatopancreaticobiliary and foregut cancer in a community hospital

Loss of skeletal muscle during systemic chemotherapy is prognostic of poor survival in patients with foregut cancer.

BackgroundMalnutrition, weight loss, and muscle wasting are common in patients with foregut cancers (oesophagus, stomach, pancreas, liver, and bile ducts) and are associated with adverse clinical outcomes. However, little is known about the changes in body composition that occur in these patients during chemotherapy and its impacts clinical outcomes.Patients and methodsA prospective study of adult foregut cancer patients undergoing chemotherapy between 2012 and 2016 was conducted. Computed tomography images were evaluated for cross‐sectional skeletal muscle area (SMA) and adipose tissue area (ATA) at two time points [interval 118 days (IQR 92–58 days)]. Longitudinal changes in SMA and ATA were examined using paired t‐tests. Sarcopenia and low muscle attenuation (MA) were defined using published cut‐points. Cox proportional hazards models were used to estimate mortality hazard ratios for key predictors.ResultsA total of 225 foregut cancer patients were included (67% male, median age 66 years). At baseline, 40% were sarcopenic, 49% had low MA, and 62% had cancer cachexia. Longitudinal analysis (n = 163) revealed significant reductions in SMA [−6.1 cm2 (3.9%)/100 days, P < 0.001]. Patients treated with neoadjuvant chemotherapy experienced greater losses in SMA and skeletal muscle mass compared with patients receiving palliative chemotherapy [−6.6 cm2 (95%, confidence interval, CI: −10.2 to −3.1), P < 0.001 and −1.2 kg (95% CI: −1.8 to −0.5), P < 0.001, respectively]. Neither sarcopenia nor low MA at baseline was associated with reduced survival. A loss of SMA >6.0%/100 days (highest fourth) independently predicted overall survival in patients receiving palliative chemotherapy [hazard ratio: 2.66, (95% CI: 1.42 to 4.97), P = 0.002].ConclusionsPatients with foregut cancers, particularly those treated with neoadjuvant chemotherapy, experience significant losses of muscle during chemotherapy. A high level of SMA loss is prognostic of reduced survival in patients treated with palliative chemotherapy. Multimodal interventions to stabilize or increase muscle mass and influence outcome warrant further investigation.

English

INTRODUCTION : Carcinoma esophagus is the 6th most common cancer in the world. Worldwide incidence is 160/100000. Incidence is more in kazakhastan. Squamous cell carcinoma accounts for most of the esophageal cancers. In USA adenocarcinoma is prevalent. Male to female ratio is 3:1 in squamous cell carcinoma. In adenocarcinoma it is 15:1. Mostly seen in fifth decade of life. Rare before the age of 30 years. squamous cell cancers arise from the squamous epithelium of the esophagus. Smoking and alcohol increases the risk for foregut cancers. Nitrosamines, longterm ingestion of hot liquids, vitamin A deficiency, zinc deficiency, achalasia, bulimia,Plummer Winson syndrome also accounts for causative factors. Adenocarcinomas are due to increasing incidence of GERD, western diet, increased use of acid suppression drugs. In recent years the improved standard of investigations and surgical technique and perioperative and post operative care substantial reduction in morbidity and mortality has been achieved. But still most of the patients could not be diagnosed earlier because of the late Presention. Study of the carcinoma esophagus is interesting because of its biological behavior. It infilterates locally, involves adjacent lymphnodes, and metastasizes widely by hematogenous spread. The prognosis and survival rate is poor in esophageal carcinoma. Overall 5 year survival rate is with treated tumour is only 5-12% AIM OF THE STUDY : The objectives of this prospective clinical study are 1) To know the incidence of carcinoma with regards to age, sex in our region 2) To study the common histological types of carcinoma esophagus 3) To know the clinical features & possible investigations to aid the diagnosis 4) To know the common site of carcinoma in esophagus 5) To know the operability of the carcinoma esophagus MATERIALS AND METHODS This is a prospective study of 88 patients of carcinoma esophagus who were admitted in thanjavur medical college hospital from September 2013-june 2015. Total number of 52 carcinoma esophagus admitted in our hospital during this study period were 112. Out of which 24 patients in whom the carcinoma arising from cervical esophagus were excluded from the study. METHODS : The methods include, obtaining the important information from the patients through history thorough clinical examination and doing the investigations, what ever is necessary to aid the diagnosis and respectability. All the informations were entered in a proforma, specially designed for this study. METHODOLOGY : The following factors were taken into consideration while evaluating the patients. Age and sex incidence, Geographical factors, Socio economic status, Personal habits, Symptoms and duration, Predisposing factors. In all these patients, nourishment was noted. RESULTS : The incidence of carcinoma esophagus, by this study in our institution is 5.2% (112/2120). Total number of cancer patients in our hospital during this study period were 2120. CONCLUSION : Carcinoma esophagus is one among the cancers that have increased male: female ratio. More commonly occuring in a low socioeconomic groups. • The predominant histology is squamous cell variety. • There is significant rise of adenocarcinoma. • A strong association coexists between carcinoma esophagus with smoking and Alcoholism. • Transhiatal esophagectomy and thoracoscopic esophagectomy scores significant role in surgical management of lower 1/3 and middle 1/3 carcinomas. • Around 50% of the patients when diagnosed is in inoperable stage. • Inoperability is due to biological nature of the disease, in which feeding jejunostomy and followup RT is the treatment option. • Significant 1 year survival rate can be achieved by with transhiatal as well as thoracoscopic esophagectomy.

Anastomotic Leakage after Esophagectomy for Cancer: A Mortality-Free Experience

Leakage is a serious complication of esophagectomy and is historically associated with high mortality. This study aimed to describe the morphology and strategies for clinical management of leakage after esophagectomy. A database prospectively maintained from July 2002 to July 2005 at a referral unit for foregut cancer was used to identify patients with leakage of saliva or gastrointestinal contents after esophagectomy and reconstruction with stomach. Contrast swallow was routinely performed on postoperative day 7. Leakage was diagnosed and classified by well-defined criteria. There were 99 men and 27 women, yielding an institutional volume of 42 esophagectomies per year. There was no in-hospital mortality from any cause. Actual 1-year survival was 87%. An Ivor Lewis operation was performed on 103 patients (82%); 4 patients had leakage within 5 days of operation and all had immediate rethoracotomy. An additional 8 patients with Ivor Lewis operation had leakage after day 5, and this was detected by contrast swallow in only 3 patients; 2 patients had no intervention, 4 patients had radiology-guided drainage, 1 had thoracoscopy, and 1 had rethoracotomy. Leakage was from the actual esophagogastric anastomosis in eight patients, from the linear gastric staple line in three patients, or from gastric necrosis in one patient. Twenty-three patients had a transhiatal or three-stage operation; leakage was from the actual anastomosis in five patients or gastric necrosis in one patient. After Ivor Lewis esophagectomy, leakage was from the actual anastomosis in two-thirds of patients or from the gastric conduit in the remaining one-third. Prompt reoperation is recommended for early postoperative leakage. Most patients with leakage after day 5 can be treated nonoperatively.

Oral immune tolerance mediated by suppressor T cells may be responsible for the poorer prognosis of foregut cancers

The poor prognosis of foregut cancers might, in part, be due to the immune tolerising effect of tumour antigens which are shed into the gastrointestinal tract and processed by the gut immune system. This would create a tumour specific tolerance without compromise of global immune functions. Experimental data shows that orally fed cancer tissue induces a non cross reactive attenuation of the cellular anti tumour host responses and confers a growth advantage specific to individual cancers. Although the cellular basis of such pro-tumourogenic responses has yet to be established, it is likely, based on studies of oral tolerance mechanisms, that recruitment of immune suppressive T cells (T(regs)) may be responsible. Abrogation of oral immune tolerance to the tumour by immune based therapy could represent a significant advance in the management of upper gastrointestinal cancers.

Oral immune tolerance to tumor specific antigens may confer growth advantage to esophageal and gastric cancers*

Oral administration of antigens induces antigen-specific systemic immune tolerance (Oral Tolerance). We postulate that the poorer prognosis of foregut cancers might, in part be explained by the systemic immune tolerizing effect of tumor specific antigens shed into and processed by the gut immune system thus conferring a growth advantage specific to individual cancers. Immunocompetent Balb/c mice were fed by gavage, either tumor tissue (JBS/CarB) in phosphate buffered saline (PBS) or PBS alone, daily for 14 days. On day 15 either subcutaneous tumors were induced or animals were immunized with cells in adjuvant. JBS tumors appeared earlier and grew faster in the JBS tumor fed mice than in either the PBS (P = 0.025) or CarB (P = 0.168) fed animals. The delayed type hypersensitivity response in tolerized mice was significantly abrogated (P < 0.01) compared to controls. These experiments demonstrate antigen specific oral immune tolerance for tumors, which is reflected in a faster growth rate and impaired delayed type hypersensitivity response. Similar mechanisms may be operational in human esophagogastric malignancy and may in part explain their poorer outcome.

Inhibition of telomerase by site-specific ribonucleases in gastric and esophageal adenocarcinoma.

Increased expression of telomerase is critical in the pathogenesis of cancer. Telomerase expression is reported variably in foregut cancers, possibly as a result of telomerase inhibition or ribonucleases. We performed experiments to assess telomerase and telomerase RNA expression in foregut cancers and to quantify and characterize telomerase inhibition. Cancer specimens were obtained from 27 patients. Telomerase activity of cancers was determined by the telomeric repeat amplification protocol, the presence of telomerase RNA component (hTERC) by reverse transcription PCR, and the quantity of telomerase inhibitors in mixing experiments. Ribonuclease activity was measured by assessing degradation of labeled RNA by cancers. Telomerase was found in 8/11 adenocarcinomas of the esophagus or gastroesophageal junction and 6/16 distal gastric adenocarcinomas; hTERC was detectable in all cancers. Telomerase inhibition was more marked in distal compared to proximal adenocarcinomas (P = 0.01) and correlated with ribonuclease activity (rS = 0.65). Ribonucleases contribute significantly to telomerase inhibitory activity detectable in foregut cancer specimens. In vitro, the presence of telomerase inhibitors in some specimens did not prevent the detection of telomerase by the TRAP assay. This suggests a more complex relationship between telomerase and its inhibitors. Site-specificity of telomerase inhibitors generally and ribonuclease activity specifically suggests a putative regulatory role in vivo.

Micrometastases in foregut cancer: High detection rate in rib marrow compared with iliac crest

Micrometastases in foregut cancer: High detection rate in rib marrow compared with iliac crest