Upper Gastrointestinal Malignancies Research Articles

Radiomic applications in upper gastrointestinal cancer surgery.

Cross-sectional imaging plays an integral role in the management of upper gastrointestinal (UGI) cancer, from initial diagnosis and staging to determining appropriate treatment strategies. Subjective imaging interpretation has known limitations. The field of radiomics has evolved to extract quantitative data from medical imaging and relate these to biological processes. The key concept behind radiomics is that the high-throughput analysis of quantitative imaging features can provide predictive or prognostic information, with the goal of providing individualised care. Radiomic studies have shown promising utility in upper gastrointestinal oncology, highlighting a potential role in determining stage of disease and degree of tumour differentiation and predicting recurrence-free survival. This narrative review aims to provide an insight into the concepts underpinning radiomics, as well as its potential applications for guiding treatment and surgical decision-making in upper gastrointestinal malignancy. Outcomes from studies to date have been promising; however, further standardisation and collaboration are required. Large prospective studies with external validation and evaluation of radiomic integration into clinical pathways are needed. Future research should now focus on translating the promising utility of radiomics into meaningful patient outcomes.

Prevalence and Risk Factors Associated with Upper Gastrointestinal Malignancies in Post-Menopausal Patients on Hormone Replacement Therapy: A Population-Based Study

Background and Aim: In the United States, approximately 40% of post-menopausal women use hormone replacement therapy (HRT); estrogen with or without progesterone. Treatment of menopausal symptoms such as hot flashes, urogenital atrophy is an indicator of short-term use of HRT. However, in some cross-sectional studies, it is reported that women use HRTs for far longer than the intended duration.

State of the Art: ctDNA in Upper Gastrointestinal Malignancies.

Circulating tumor DNA (ctDNA) has emerged as a promising non-invasive source to characterize genetic alterations related to the tumor. Upper gastrointestinal cancers, including gastroesophageal adenocarcinoma (GEC), biliary tract cancer (BTC) and pancreatic ductal adenocarcinoma (PADC) are poor prognostic malignancies, usually diagnosed at advanced stages when no longer amenable to surgical resection and show a poor prognosis even for resected patients. In this sense, ctDNA has emerged as a promising non-invasive tool with different applications, from early diagnosis to molecular characterization and follow-up of tumor genomic evolution. In this manuscript, novel advances in the field of ctDNA analysis in upper gastrointestinal tumors are presented and discussed. Overall, ctDNA analyses can help in early diagnosis, outperforming current diagnostic approaches. Detection of ctDNA prior to surgery or active treatment is also a prognostic marker that associates with worse survival, while ctDNA detection after surgery is indicative of minimal residual disease, anticipating in some cases the imaging-based detection of progression. In the advanced setting, ctDNA analyses characterize the genetic landscape of the tumor and identify patients for targeted-therapy approaches, and studies show variable concordance levels with tissue-based genetic testing. In this line, several studies also show that ctDNA serves to follow responses to active therapy, especially in targeted approaches, where it can detect multiple resistance mechanisms. Unfortunately, current studies are still limited and observational. Future prospective multi-center and interventional studies, carefully designed to assess the value of ctDNA to help clinical decision-making, will shed light on the real applicability of ctDNA in upper gastrointestinal tumor management. This manuscript presents a review of the evidence available in this field up to date.

Impact of Covid-19 pandemic on upper gastrointestinal cancer services: Experience from an oncosurgical unit.

Background The Covid-19 pandemic continues to affect the delivery of cancer care across the world. We evaluated the impact of the pandemic on the delivery of cancer care, to patients diagnosed with upper gastrointestinal (UGI) tract malignancies, during the first 4 months of the pandemic in India. Methods We retrospectively analysed a database of patients with UGI malignancies discussed in the Multidisciplinary Tumour Board (MDTB) between 24 March and 24 July 2020. The results in the study group were compared to that of a similar group of patients from the corresponding period in 2019. Results A total of 117 and 61 patients were discussed in the MDTB in 2019 and 2020, respectively, thereby showing a 48% reduction in the number of new cases seen in 2020. The reduction in the number of new cases was huge for oesophageal cancer (53-13; 75.5% reduction), compared to gastric cancer (53-43; 18.9%). The proportion of patients with metastatic disease at presentation was significantly higher in 2020, compared to 2019 (39.3% v. 23.1%; p=0.023). In 8 (13.1%) patients, the pre-existing treatment protocol had to be modified to suit the prevailing pandemic situation. Two patients with gastric cancer acquired asymptomatic Covid-19 infection during the treatment, which delayed the delivery of further therapy. Oncosurgeries were less in 2020 compared to 2019 (25 v. 63). The rate of 30-day major postoperative complications in 2020 was comparable with that in 2019 (12% v. 6.3%; p=0.4). Conclusions The number of new patients with UGI cancer, seeking elective cancer care and the number of oncosurgical procedures reduced during the Covid-19 pandemic. Continuous delivery of UGI cancer services was ensured during the pandemic through clinical prioritization, the adaptation of specific care pathways and selective modification of protocols, to suit the prevailing local conditions.

Outcomes of Transaortic Celiac Plexus Block for Upper Abdominal Malignancies Performed as a Day-care Procedure: A Retrospective Observational Study

Background: Severe abdominal pain refractory to opioids significantly affects the quality of life (QoL) in patients with abdominal primary cancer or metastatic disease. A neurolytic celiac plexus block (CPB) would be necessary to alleviate pain and improve QoL until death. Aims: The aim of this retrospective study is to investigate pain relief after a transaortic celiac plexus neurolysis for patients with upper gastrointestinal malignancies. Settings and Design: This retrospective observational study was done in the Pain Department, Shri Siddhivinayak Cancer Hospital, Miraj from January 2005 to January 2015. Materials and Methods: One hundred and twenty-four patients with upper abdominal malignancy received a computed trans-aortic celiac plexus block (TAoCPB) on a day-care basis. The primary outcome was pain as assessed with numerical rating scale ranging from 0 to 10; the secondary outcome measures were morphine consumption per day, QoL, and complications, if any. These were recorded before intervention, on day 1 after the block and at 1 month interval until 6 months. Statistical Analysis Used: Bonferroni correction for multiple comparisons and a P < 0.0167 (0.05/3) was considered to be statistically significant due to 3 co-primary outcomes being measured (visual analog scale [VAS] scores, morphine consumption, and QoL). Results: Up to 4.5 months, the VAS score, daily morphine consumption, and the QoL showed improvement for the duration of the study. Pain gradually increased at 6 months with a deterioration of QoL. Respiratory distress and burning sensation in chest occurred in one patient each. Conclusions: A low-volume TAoCPB is effective and established procedure as a day-care procedure. Although pain relief occurs until 4.5 months, a gradual increase was perceived with a decline of quality of health at 6 months.

Celiac Plexus Radio-Surgery for Pain Management in Advanced Cancer: An International Phase II Trial

Celiac Plexus Radio-Surgery for Pain Management in Advanced Cancer: An International Phase II Trial

S953 The Influence of Inflammatory Bowel Disease on Upper Gastrointestinal Malignancy

Introduction: It is well known that Inflammatory Bowel Disease (IBD) increases the risk of developing Colorectal cancer. However, older works from the 1990’s examined how Ulcerative Colitis and Crohn’s Disease separately influence gastric and small bowel cancers as well. The aim of this nationwide investigation is to explore the current relationship between upper gastrointestinal malignancies and both Crohn’s Disease and Ulcerative Colitis. Methods: The National Inpatient Sample was queried for patients with a primary diagnosis of upper gastrointestinal malignancy and a secondary diagnosis of either Ulcerative Colitis or Crohn’s Disease in 2014. Upper gastrointestinal malignancies were defined as esophageal cancer, gastric cancer, small bowel malignancy, or cholangiocarcinoma. The primary outcome is the relationship between Ulcerative Colitis, Crohn’s Disease, and various forms of upper gastrointestinal cancer. Multivariate logistic regression was conducted using Stata v.13. Results: In 2014, there were 175 patients with IBD, 105 of which had Crohn’s Disease. Regression analyses demonstrated an increased association with upper gastrointestinal malignancies in both Crohn’s Disease (aOR 2.08, p< 0.00) and Ulcerative Colitis (aOR 1.91, p=0.05). When stratified, there was a greater association between cholangiocarcinoma and Ulcerative Colitis (aOR 4.30, p< 0.00), as compared to Crohn’s Disease (aOR 2.14, p=0.04). However, there was a strong relationship between small bowel cancer and Crohn’s disease (aOR 11.88, p< 0.00), but no significant association with Ulcerative Colitis. With regard to esophageal and gastric malignancies, no significant relationship with either form of IBD was established. Conclusion: There have been limited studies evaluating the relationship between upper gastrointestinal malignancies and either Crohn’s Disease or Ulcerative Colitis. This study demonstrated that both conditions have an increased association with development of cholangiocarcinoma. Ulcerative Colitis poses a two-fold greater risk, likely due to its relationship with Primary Sclerosing Cholangitis. Moreover, Crohn’s Disease offers a nearly six-fold increased risk of developing small bowel malignancy. Given its propensity to cause ileitis and intestinal strictures, dysplasia and cancer are worrisome possibilities. This is the first study in recent years to highlight the ability of both forms of IBD to influence development of extracolonic malignancies, which can be used to improve clinical evaluation in this population.

PD-L1 evaluation in the gastrointestinal tract: from biological rationale to its clinical application.

Immune-checkpoint inhibitors targeting the PD-1/PD-L1 axis have brought significant clinical benefit in many solid cancer types, including gastrointestinal malignancies. However, it has been estimated that only 20-40% of patients respond to treatment. The pattern of expression and potential predictive value of PD-L1 as an immunohistochemical biomarker has been extensively studied in gastrointestinal neoplasms. Until now, its predictive value has been demonstrated, and is currently in use only in upper gastrointestinal malignancies (gastroesophageal adenocarcinoma and esophageal squamous cell carcinoma).In this Review, we describe the technical aspects and challenges related to PD-L1 immunohistochemical assays, the current role of PD-L1 as a biomarker in clinical practice and we outline the main studies and clinical trials analyzing the prognostic and predictive value of PD-L1 in gastrointestinal cancers.

PO243 / #898 USE OF FLUOROSCOPY-GUIDED BILATERAL SPLANCHNIC NERVE BLOCK AS AN OPTIMAL ALTERNATIVE TO CELIAC PLEXUS BLOCK FOR MANAGEMENT OF CHRONIC INTRACTABLE PAIN SECONDARY TO CHRONIC PANCREATITIS: E-POSTER VIEWING

The pain associated with chronic pancreatitis (CP) can be debilitating, often leading to excessive use and misuse of narcotic analgesics. Splanchnic nerve block is a technique aimed at interrupting the neural conduction causing abdominal pain [1]. Previous studies focused, predominantly, on using this technique for treating pain associated with upper gastrointestinal malignancies. However, it can provide great relief for those with persistent pain from CP [2]. We describe a case report for management of intractable pain from CP with fluoroscopic guided bilateral splanchnic nerve block in a young female with opioid-use disorder (OUD) and status post distal pancreatectomy.

Upper Gastrointestinal Cancer and Liver Cirrhosis.

Simple SummaryThere is a higher incidence rate of upper gastrointestinal cancer in those with liver cirrhosis. The contributing factors include gastric ulcers, congestive gastropathy, zinc deficiency, alcohol drinking, tobacco use and gut microbiota. Most of the de novo malignancies that develop after liver transplantation for cirrhotic patients are upper gastrointestinal cancers. The surgical risk of upper gastrointestinal cancers in cirrhotic patients with advanced liver cirrhosis is higher.The extended scope of upper gastrointestinal cancer can include esophageal cancer, gastric cancer and pancreatic cancer. A higher incidence rate of gastric cancer and esophageal cancer in patients with liver cirrhosis has been reported. It is attributable to four possible causes which exist in cirrhotic patients, including a higher prevalence of gastric ulcers and congestive gastropathy, zinc deficiency, alcohol drinking and tobacco use and coexisting gut microbiota. Helicobacter pylori infection enhances the development of gastric cancer. In addition, Helicobacter pylori, Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans also contribute to the development of pancreatic cancer in cirrhotic patients. Cirrhotic patients (especially those with alcoholic liver cirrhosis) who undergo liver transplantation have a higher overall risk of developing de novo malignancies. Most de novo malignancies are upper gastrointestinal malignancies. The prognosis is usually poor. Considering the surgical risk of upper gastrointestinal cancer among those with liver cirrhosis, a radical gastrectomy with D1 or D2 lymph node dissection can be undertaken in Child class A patients. D1 lymph node dissection can be performed in Child class B patients. Endoscopic submucosal dissection for gastric cancer or esophageal cancer can be undertaken safely in selected cirrhotic patients. In Child class C patients, a radical gastrectomy is potentially fatal. Pancreatic radical surgery should be avoided in those with liver cirrhosis with Child class B or a MELD score over 15. The current review focuses on the recent reports on some factors in liver cirrhosis that contribute to the development of upper gastrointestinal cancer. Quitting alcohol drinking and tobacco use is important. How to decrease the risk of the development of gastrointestinal cancer in those with liver cirrhosis remains a challenging problem.

Abstract No. : ABS2796: Comparative evaluation of transaortic coeliac plexus rhizolysis with bilateral splanchnic nerve radio frequency ablation in patients of upper gastro-intestinal malignancies with intractable pain : A prospective interventional study.

Background and Aims:This study aimed for a comparative evaluation of transaortic coeliac plexus rhizolysis with bilateral splanchnic nerve radio frequency ablation for decrease in visual analogue scale(VAS) score and oral morphine requirements, in patients having upper gastrointestinal (GI) malignancies with intractable pain.Methods:Patients were randomly allocated in two group of 30 eackGroup 1 received bilateral splanchnic nerve radio-frequency ablation(SRF group) and group 2 had trans-aortic coeliac plexus rhizolysis (CPR group). Study was conducted over a period of 18 months. Following data were collected:VAS score, oral morphine requirement , adverse effects, and improvement in the quality of life.Results:Total of 33 patients (17 in SRF and 16 in CPR group) completed full 6 months follow-up Other patients were followed up until their demise. At the end of 6 months VAS score was reduced to 2.13±1.48 (cm) and 3.28±1.4 (cm) in SRF and CPR groups respectively and mean morphine consumption was 13.4 ± 15.3 mg/day and 26.11 ± 23.5 mg/day in SRF group and CPR group respectively..Conclusion:In upper GI cancer patients with severe intractable abdominal pain, interventional approach along with pharmacological management provides better analgesic efficacy . Both the techniques (bilateral splanchnic nerve RFA and trans-aortic coeliac plexus rhizolysis) were effective for the relief of severe intractable abdominal pain in upper GI malignancies.

Value of Endoscopic Ultrasound in Detection of Hepatic Occult Metastasis During Staging of Pancreatic and Upper Gastro Intestinal Malignancies

Value of Endoscopic Ultrasound in Detection of Hepatic Occult Metastasis During Staging of Pancreatic and Upper Gastro Intestinal Malignancies

Celiac plexus chemical neurolysis for refractory pain associated with superior mesenteric artery syndrome

Superior mesenteric artery (SMA) syndrome is caused by the compression of a part of the intestine between the aorta and SMA. It may lead to severe epigastric pain that is even refractory to conservative and surgical forms of therapy. Celiac plexus chemical neurolysis has been used in the past for debilitating pain associated with upper gastrointestinal malignancies and chronic pancreatitis. However, to date, this intervention has never been described in the literature for managing pain in SMA syndrome patients. Here, we describe the case of SMA syndrome whose pain was successfully managed with celiac plexus chemical neurolysis.

Age Cutoff and Yield of Prompt Esophagogastroduodenoscopy to Detect Malignancy in Vietnamese with Upper Gastrointestinal Symptoms: An Endoscopic Database Review of 472,744 Patients from 2014 to 2019.

Background and Aims Age cutoff is an important factor in deciding whether esophagogastroduodenoscopy (EGD) is necessary for patients presenting with upper gastrointestinal symptoms. However, the cutoff value is significantly different across populations. We aimed to determine the age cutoff for EGD that assures a low rate of missing upper gastrointestinal malignancy (UGIM) and to assess the yield of prompt EGD in Vietnamese patients presenting with upper gastrointestinal symptoms. Methods All EGDs performed in outpatients during a 6-year period (2014–2019) at a tertiary hospital that provided an open-access endoscopy service were retrospectively reviewed. Repeat or surveillance EGDs were excluded. Different age cutoffs were evaluated in terms of their prediction of the absence of UGIM. The yield of endoscopy to detect one malignancy (YoE) was also calculated. Results Of 472,744 outpatients presenting with upper gastrointestinal symptoms, there were 2198 (0.4%) patients with UGIM. The median age and male-to-female ratio of patients with UGIMs were 57.9 ± 12.5 years and 2.5 : 1, respectively. The YoEs in patients <40, 40–60, and >60 years of age were <1, 1–10, and >10 per 1000 EGDs, respectively. The age cutoffs of 30 years in females and 35 years in males could detect 98.2% (95% CI: 97.7%–98.8%) of UGIM cases with a YoE of about 1 per 1000 EGDs. Conclusions The age cutoff for EGD in Vietnamese should be lower than that recommended by current international guidelines. The strategy of prompt EGD showed a low YoE, and its cost-effectiveness requires further investigation.

Prospective observational study to build the body weight change model during modern concurrent chemo-radiotherapy in head and neck cancer patients

Rationale: Nutrition plays major roles in many aspects of cancer treatment. Malnutrition can have a profound effect on the cancer patient that typically affected experience loss of weight. Patients with upper gastrointestinal malignancies or head and neck cancers are highest risk group with malnutrition may be up to 40-80%. Therefore, the maintenance of body weight during concurrent chemo-radiotherapy (CCRT) is a critical issue to solve. We want to build the model to find the trend of body weight loss during CCRT and predict the body weight change by related factors.

Age is the only predictor for upper gastrointestinal malignancy in Chinese patients with uncomplicated dyspepsia: a prospective investigation of endoscopic findings

BackgroundDyspepsia is a common cause of physician visits. If and when endoscopy should be performed depend on the regions and the populations. This study aimed to identify the current risk factors predictive of upper gastrointestinal malignancy or peptic ulcer in China with high prevalence of gastric cancer.MethodsA questionnaire was conducted among consecutive outpatients undergoing their first esophagogastroduodenoscopy for dyspepsia. Symptoms other than alarm symptoms in this study were defined as uncomplicated dyspepsia.Results4310 outpatients (mean age 44, median 42, range 14–86) were included in the final analyses. Significant pathology was found in 13.8% (595/4310) patients including peptic ulcer (12.3%) and upper gastrointestinal malignancy (1.5%). Age, male sex and alarm symptoms were significantly associated with malignancy. The age cut-off identified for upper gastrointestinal malignancy was 56 years among patients with uncomplicated dyspepsia, which was similar to the combined cutoff of age and gender.ConclusionsAge should be considered as the primary predictor for upper gastrointestinal malignancy in Chinese patients with uncomplicated dyspepsia. 56 could probably be the optimal age to identify those lesions in this population. Trial registration: Chictr.org (ChiCTR2000040775).

ASO Visual Abstract: Diagnostic Performance of Artificial Intelligence-Centered Systems in the Diagnosis and Postoperative Surveillance of Upper Gastrointestinal Malignancies Using Computed Tomography Imaging: A Systematic Review and Meta-Analysis of Diagnostic Accuracy

ASO Visual Abstract: Diagnostic Performance of Artificial Intelligence-Centered Systems in the Diagnosis and Postoperative Surveillance of Upper Gastrointestinal Malignancies Using Computed Tomography Imaging: A Systematic Review and Meta-Analysis of Diagnostic Accuracy

Immunotherapy Efficacy in the Initial Lines of Treatment in Advanced Upper Gastrointestinal Malignancies: A Systematic Review of the Literature.

BackgroundThe therapeutic role of immune checkpoint inhibitors (ICIs) has represented the cutting edge of clinical research in upper gastrointestinal (GI) malignancies, with these agents now included in the armamentarium of treatment options for advanced gastric and esophageal cancers.MethodsWe performed a systematic literature review and pooled analysis to map out the currently available robust clinical evidence for the use of ICIs in upper GI cancers. Immunotherapy (IO), either as monotherapy or in combination with chemotherapy, and its role in first-line, maintenance, and second-line settings, as well as in specific clinical and biological subgroups, were critically appraised. All statistical tests were 2-sided.ResultsICIs, in combination with chemotherapy, have provided statistically significant overall survival benefit in the first-line setting in gastric and gastro-esophageal adenocarcinomas (hazard ratio [HR] = 0.83, 95% confidence interval [CI] = 0.76 to 0.90, P < .001; based on 4 studies) and esophageal squamous cell carcinoma (HR = 0.72, 95% CI = 0.64 to 0.81, P < .001; based on 3 studies), albeit with heterogeneous efficacy according to biomarker expression. Patients with esophageal squamous cell carcinoma, and in particular high programmed cell death ligand-1 expression, derive survival benefit when treated with IO in the second-line setting (HR = 0.74, 95% CI = 0.68 to 0.82, P < .001; for any level of programmed cell death ligand-1 expression). Clinical trials interrogating the combination of IO with chemotherapy in second-line treatment should be seriously considered in upper GI adenocarcinomas. The role of maintenance IO after initial disease control is still unclear and cannot be recommended. Impressive response rates and survival benefit from IO have been reported in patients with microsatellite instability-high tumors (HR = 0.33, 95% CI = 0.19 to 0.57, P < .001), and this warrants further prospective biomarker-driven studies.ConclusionsIO is changing the treatment landscape in upper GI malignancies. The rapidly developing evidence in the field needs to be critically appraised while further validation of the existing information from ongoing trials is awaited.

Value of age and alarm features for predicting upper gastrointestinal malignancy in patients with dyspepsia: an endoscopic database review of 4664 patients in Thailand

ObjectiveAge and alarm features are commonly used as indicators for endoscopy in dyspeptic patients; however, the age cut-off and the predictive value of these parameters for identifying upper gastrointestinal (UGI)...

A comparative study of transdiscal versus transaortic celiac plexus neurolytic block for upper gastrointestinal cancer patients. A prospective, randomized control study

Aim: To compare transdiscal and transaortic techniques of neurolytic celiac plexus block for upper gastrointestinal cancer patients. Methods: In this prospective randomized study 60 patients with upper gastrointestinal malignancies were included and randomly divided into two groups, group TD and group TA, receiving neurolytic celiac plexus blocks via transdiscal and transaortic techniques, respectively. The primary outcome was quality of life (QoL) as assessed by WHOQOL BREF questionnaire and secondary outcomes were pain relief using visual analogue scale (VAS), and occurrence of complications like hypotension, loose motion, bleeding and discitis. Result: QoL and VAS score were significantly improved in both groups post procedure. Transdiscal approach is more effective in improving VAS score than transaortic approach (1 vs 3) after 1 week and the relief of pain was better in TD group (3 vs 6) at the end of 2 months. Transdiscal approach was found to be more effective in improving QoL (227.00±28.85 vs 191.17±35.78) as compared to transaortic approach. However, post-procedural QoL improved in both groups when compared to pre-procedural QoL (p&lt;0.05). Hypotension, diarrhea and bleeding from aorta were higher in TA group; however, no serious complications were seen in any of the groups. Conclusion: Transdiscal technique is better in terms of adequate pain relief and improving QoL as compared to transaortic technique of NCPB in patients of upper GI malignancies and is associated with lesser incidences of complications.