The identification of the ATR inhibitor VE-822 as a therapeutic strategy for enhancing cisplatin chemosensitivity in esophageal squamous cell carcinoma.

Inducing DNA damage is known to be one of the mechanisms of cytotoxic chemotherapy agents for cancer such as cisplatin. The endogenous DNA damage response confers chemoresistance to these agents by repairing DNA damage. The initiation and transduction of the DNA damage response (DDR) signaling pathway, which is dependent on the activation of ATM (ataxia-telangiectasia mutated) and ATR (ataxia telangiectasia and Rad3-related), is essential for DNA damage repair, the maintenance of genomic stability and cell survival. Therefore, ATM or ATR inhibition is considered as a promising strategy for sensitizing cancer cells to chemotherapy. This study is aimed to explore the effect of ATR inhibitor on sensitizing ESCC (esophageal squamous cell carcinoma) cells to cisplatin, and whether ATM deficiency could impact the sensitization. We found that 21.5% of ESCC cases had ATM deficiency and that patients with ATR activation after neoadjuvant chemotherapy had worse chemotherapy response and poorer overall survival than that without ATR activation (32 mons vs. >140mons). Then, it was shown that VE-822 inhibited ATR-CHK1 pathway activation, leading to the accumulation of cisplatin-modified DNA. And it inhibited cell proliferation, induced cell cycle arrest in G1 phase and enhanced cell apoptosis. Moreover, VE-822 significantly sensitized ESCC cells to cisplatin, and these two drugs had synergistic effects, especially in ATM-deficient cells, in vitro and in vivo. Our results suggest that ATR inhibition combining with cisplatin is a new strategy for managing patients with ESCC, especially those with ATM-deficiency. However, this is an idea that requires further validation.

The equivalent efficacy of multiple operations for multiple primary lung cancer and a single operation for single primary lung cancer.

BACKGROUND: The incidence of synchronous and metachronous multiple primary lung cancers (MPLCs) has been increasing recently. The new multidisciplinary classification of lung adenocarcinoma and TNM Classification of Lung Cancer (7(th) edition, 2009), have improved the understanding of MPLC. Most researchers recommend that surgical therapy should be actively pursued if the patient's physical condition and lung function permit it and if a complete cure can be achieved. However, few studies have reported the long-term efficacy of surgical treatment for MPLC, which we explored in this study. METHODS: A total of 1,290 Lung cancer patients from a prospectively maintained database, treated by a single surgeon group between January 2000 and July 2013, at Beijing Cancer Hospital, Peking University, were reviewed. We retrospectively analyzed the clinical data of 31 patients diagnosed with MPLC out of 1290 lung cancer patients, focusing on long-term survival. RESULTS: MPLC patients accounted for 2.4% (31/1,290) of the patient cohort: 27 had synchronous MPLC (87.1%) and 4 had metachronous MPLC (12.9%). The 1-, 3- and 5-year postoperative survival rates were 100%, 75.8% and 75.8%. On stratification according to TNM stage, the 1-, 3- and 5-year of patients with stage I cancer (20 patients) were 100%, 77.2% and 77.2%, not statistically significant with those for the entire cohort (1,290 patients; 95.4%, 80.5% and 66.2%, P=0.455). CONCLUSIONS: When the patient's physical condition and tumor-related factors permit it, surgery should be the first choice of treatment for MPLC; it is associated with an equivalent efficacy to that of surgery for single primary lung cancer.

Deregulated HOXB7 Expression Predicts Poor Prognosis of Patients with Esophageal Squamous Cell Carcinoma and Regulates Cancer Cell Proliferation In Vitro and In Vivo.

BACKGROUND: We observed abnormal HOXB7 expression in esophageal squamous cell carcinoma (ESCC) previously. This study was to evaluate the prognostic significance of HOXB7 and reveal the potential mechanism. METHODS: Immunohistochemistry was used to confirm the abnormal expression of HOXB7 in ESCC. The prognostic significance of HOXB7 expression was analyzed in two independent cohorts. RNAi was used to establish two stable HOXB7-knockdown cell strains. CCK8 assay, cell growth curve assay, colony formation assay, flow cycle analysis and tumorigenicity assay in nude mice were employed to investigate the effect of HOXB7 on proliferation in vitro and in vivo. RESULTS: Immunohistochemistry confirmed the abnormal expression of HOXB7 in ESCC compared with paracancerous mucosa (18/23 vs. 9/23, p=0.039). HOXB7 expression was positively correlated with the T stage, lymph node metastasis and TNM stage. The median survival of patients with high HOXB7 expression was significantly shorter than that with low expression (45 months vs. 137 months, p = 0.007 for cohort 1; 19 months vs. 34 months, p = 0.001 for cohort 2). Multivariate survival analysis showed that HOXB7 expression was another independent prognostic factor (HR [95% CI] = 0.573 [0.341-0.963], p = 0.036 for cohort 1; HR [95%CI] = 0.543 [0.350-0.844], p = 0.024 for cohort 2). Experiments in vitro and in vivo showed that after knockdown of HOXB7, the proliferation rate dropped, growth rate descended, colony-formation ability reduced, G1-phase arrest occurred and the tumorigenicity reduced remarkably. CONCLUSIONS: HOXB7 could promote cancer cell proliferation and might be an independent prognostic factor for patients with ESCC.

CT Signs Can Predict Treatment Response and Long-Term Survival: A Study in Locally Advanced Esophageal Cancer with Preoperative Chemotherapy.

BACKGROUND: Accurate prediction of treatment response and prognosis before surgery allows prompt therapy adjustment. This study aimed to evaluate the efficacy of computed tomography (CT) signs in predicting treatment response and survival for advanced esophageal squamous cell carcinoma patients who received preoperative chemotherapy. METHODS: This study retrospectively enrolled 135 consecutive patients with preoperative chemotherapy from September 2005 to December 2011. A logistic regression model was used to evaluate the association between pathologic response and CT signs. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method, and a Cox proportional hazards model was constructed to determine associations between CT signs after neoadjuvant chemotherapy and survival outcomes. RESULTS: Logistic regression showed that the significant predictors of a poor response were the total number of lymph nodes (LNs) (>6) at baseline [odds ratio (OR) 5.07; 95 % confidence interval (CI) 1.86-13.81; P = 0.002] and the CT value change rate (≤17 %) (OR 2.35; 95 % CI 1.05-5.23; P = 0.037). In the Cox analyses, the significant predictors of OS were preoperative tumor thickness (>10 mm) [hazard ratio (HR) 2.33; 95 % CI 1.36-4; P = 0.002), total number of LNs (>6) (HR 1.88; 95 % CI 1.12-3.17; P = 0.017), and short diameter of the largest LN (>10 mm) (HR 1.87; 95 % CI 1.07-3.28; P = 0.028), whereas only the short diameter of the largest LN was a significant predictor of DFS (HR 2.36; 95 % CI 1.23-4.54; P = 0.01). CONCLUSIONS: CT signs can predict therapeutic efficacy and survival outcomes and provide an opportunity to offer additional treatment options before surgery.

The survival predictive significance of HOXC6 and HOXC8 in esophageal squamous cell carcinoma.

BACKGROUND & AIM: Esophageal squamous cell carcinoma (ESCC), a common disease in China, is mainly treated surgically. We established a prospective database of patients with esophageal cancer between January 2000 and December 2010, including 486 subjects with ESCC who underwent surgical treatment. In this study, we explored the prognostic significance of the expressions of HOXC6 and HOXC8, responsible for embryonic development, by studying the specimens collected from clinical subjects during strict follow-up periods. MATERIALS & METHODS: Immunohistochemistry was used to detect the expressions of HOXC6 and HOXC8 in 274 ESCC subjects including 138 ESCC subjects treated with surgery alone and 136 ESCC subjects treated with neoadjuvant chemotherapy. Survival analysis was performed from the day of surgery to August 2013. RESULTS: The 5-y survival rate of the 274 ESCC subjects was 44.2%, with a median survival time of 44.12 mo. For the 274 ESCC subjects involved in the investigation of HOXC6 and HOXC8 expressions, the median survival time of subjects with high-level expressions of HOXC6 and HOXC8 was shorter than that for subjects with low-level expressions (P = 0.001, P < 0.001, respectively). Similar results were obtained from the analysis of the prognostic value of HOXC6 and HOXC8 in the group treated with surgery alone and the group treated with neoadjuvant chemotherapy. Multivariate analysis demonstrated that HOXC6 and HOXC8 expressions were independent prognostic factors in patients with ESCC. CONCLUSIONS: The HOXC6 and HOXC8 genes can be used as prognostic markers in patients with ESCC, but prospective studies are still needed to confirm.

[Multidisciplinary therapy for multi-focal esophageal cancer].

OBJECTIVE: To explore the management strategies and outcome of treatment for multi-focal esophageal carcinoma. METHODS: Twenty two patients with multi-focal esophageal carcinoma who underwent esophagectomy by a single surgeon team from March 2000 to March 2011 at the Beijing Cancer Hospital were reviewed retrospectively. The clinical and pathological characters were analyzed, and the outcome was compared with that of 471 patients with single esophageal carcinoma who received esophagectomy by the same surgeon team during the same period. RESULTS: Eighteen out of 22 patients with multi-focal esophageal cancer underwent esophagectomy via transthoracic approach while 4 patients via transhiatal. Eight patients received neoadjuvant chemotherapy and 15 patients received adjuvant chemotherapy. Four hundred and seventy-one out of 471 patients with single esophageal cancer underwent esophagectomy via transthoracic approach while 60 patients via transhiatal. One hundred and fourty-eight patients received neoadjuvant chemotherapy and 267 patients received adjuvant chemotherapy. The 3-year survival of the 22 patients with multi-focal esophageal carcinoma was 41.9%, and the median survival time was 29.2 months. The 3-year survival of the 471 patients with single esophageal carcinoma was 54.7%, and the median survival time was 46.8 months. There was no significant difference in survival between the two groups(P=0.051). CONCLUSIONS: The prognosis of patients with multi-focal occurrence esophageal carcinoma was poor. Extended esophageal resection may be beneficial to these patients with concurrent systemic chemotherapy.

[Evaluation of transhiatus esophagectomy for patients with esophageal cancer].

OBJECTIVE: To evaluate the transhiatus esophagectomy for patients with esophageal cancer. METHODS: Clinicopathological data of 46 patients with esophageal cancer undergone transhiatus esophagectomy by single surgeon team from May 2000 to July 2007 were analyzed retrospectively. RESULTS: These 46 patients included 44 esophageal squamous cell carcinomas,1 esophageal adenocarcinoma and 1 esophageal carcinoid. The lesions of 11 patients located at neck segment, 21 at upper segment, 5 at middle segment, and 9 at lower segment. All the patients were classified according to UICC TNM stage classification: 3 cases as stage 0, 6 cases as stage I, 17 cases as stage II a, 2 cases as stage II b, 16 cases as stage III. Six patients received preoperative chemotherapy and pathological complete response was seen in 2 cases. Reconstruction with stomach was performed in 42 cases and with colon interposition in 4 cases.All the tumors were resected, and there was no perioperative death. All the resected margins were pathologically clear. Postoperative complications occurred in 12 cases and were successfully treated, including 2 cases of hoarseness, 3 cases of cardiac arrhythmia,1 case of bilateral pleural effusion, and 6 cases of small anastomotic leakage at neck. CONCLUSION: Transhiatus esophagectomy is an ideal choice in surgical treatment for patients with esophageal cancer, especially for the ones of aged, poor cardiac or pulmonary function, who can not afford the thoracotomy.

[Effect of bilateral intercostal nerve protection on post-thoracotomy pain relief: a prospective single-blinded randomized study].

OBJECTIVE: To study the efficacy of bilateral intercostal nerve protection on pain relief after thoracotomy. METHODS: Sixty patients in need of thoracotomy were randomized into 3 groups: Group C (control group, undergoing standard posterolateral thoracotomy, n = 18), Group U (unilateral intercostal nerve protection group, undergoing protection of intercostal nerve above the incision based on the standard posterolateral thoracotomy, n = 20), and Group B (bilateral intercostal nerve protection group, undergoing protection of intercostal nerves above and below the incision based on the standard posterolateral thoracotomy, n = 22). Numeric rating scale (NRS) was adopted to document the severity of pain at different time points after surgery. The amount of analgesic use was recorded as well. RESULTS: The pain scores recorded on the postoperative days 2 to 7 and 1 month after surgery of Group B were all significantly lower than those of Group C (all P < 0.05). Significant pain relief was observed in Group U within the 7 postoperative days compared with Group C; however, there were not significant differences in pain scores among different groups 1 month after surgery. Pain relief after the removal of chest tubes was found only in Group B (P = 0.020). The incidence of morbidity was similar among the 3 groups. CONCLUSION: Protection of bilateral intercostal nerves around the incision contributes to significant pain relief after operation without increase of the morbidity of complications.

[Expression of TR4-associated protein in non-small cell lung cancer].

OBJECTIVE: To investigate the expression and significance of TR4-associated Protein (TRA16) in human non-small cell lung cancer (NSCLC) tissues. METHODS: Immunohistochemistry (IHC) and tissue array were employed to investigate the expression of TRA16 in NSCLC cases of different pathological types, benign lung lesions and normal lung tissues. RESULTS: The abundant expression of TRA16 was observed in nucleus and/or cytoplasm of NSCLC cells with a positive expression rate of 88.64%, whereas normal lung tissue and benign lung tumor rarely expressed TRA16 protein. The expression of TRA16 showed no apparent difference at pathotypes and differentiation levels. CONCLUSION: In this study we demonstrated an abnormal overexpression of TRA16 in NSCLC tissues. The unique expression pattern of TRA16 indicated its probable role in tumorigenesis and progression, supporting the development of TRA16 as a novel potential NSCLC marker.

[A clinical study of thoracic-abdominal double-incision and two-field lymphadenectomy in treatment of esophagogastric junction cancer].

OBJECTIVE: To explore the best operation pattern of esophagogastric junction (EGJ) cancer and the regularity of lymph node metastasis in EGJ cancer according to Siewert typing. METHODS: Twenty-six patients with EGJ cancer received esophagogastrectomy by thoracic-abdominal double incision and two-field lymphadenectomy (12 cases) or by traditional left postero-lateral thoracotomy and lymph node sampling (14 cases). The outcomes were analyzed with SPSS 10.0 software RESULTS: (1) The number of lymph node dissection group of the thoracic-abdominal double incision group was 7.3 lymph node groups, significantly more than that of the traditional left postero-lateral thoracotomy group (3.5 lymph node group, P < 0.001). The number of proved metastatic lymph nodes of the thoracic-abdominal double incision group was 1.9 groups, significantly higher than that of the traditional left postero-lateral thoracotomy group (0.9 group, P = 0.013). The distance between the esophageal incisal edge and the tumor was 5.8 cm in the thoracic-abdominal double incision, longer than that in the traditional left thoracotomy group (5.1 cm). The diaphragm was not damaged in the double-incision group, thus the influence to respiration and circulation was decreased. (2) The abdominal metastasis of Siewert type I cancer was not severe, the cancer of type II might metastasize to abdominal or thoracic cavity, and the main metastatic site of type III cancer was abdominal cavity. CONCLUSION: Thoracic-abdominal double incision and two-field lymphadenectomy helps increase the radical resection rate of EGJ cancer and study the regularity of lymph node metastasis.

[Clinical analysis of 123 gastric cardia carcinoma patients treated with surgical operation].

BACKGROUND & OBJECTIVE: The prevalence of gastric cardia carcinoma is increasing in recent decades, necessitating further research on it. However, there are still debates on its clinical management. This study was to summarize our experiences in surgical treatment of gastric cardia carcinoma. METHODS: A total of 123 gastric cardia carcinoma patients, received surgical operation, were divided into 3 groups according to surgical approaches: 72 in thoracic group, 40 in abdominal group, and 11 in thoracoabdominal group. Clinical data, including preoperative examination, surgical approach, lymph node dissection, and postoperative pathology, of the patients were analyzed. RESULTS: Setting pathologic results as golden standard, the correct diagnosis rates of preoperative ultrasound for serosal involvement, lymph node metastasis, distal esophageal involvement, and others (including liver metastases, extended invasion, and ascites) were 71.2%, 62.2%, 47.8%, and 100%, respectively; those of CT were 78.6%, 72.7%, 51.9%, and 100%, respectively. Endoscopy could indicate the distance between tumor and incisor, and barium meal showed the relationship between tumor and diaphragm. The curative resection rate was 94.3% (116/123); among the 116 cases, 108 (93.1%) were adenocarcinoma, 2 were squamous cell carcinoma, 2 were adenosquamous carcinoma, 2 were atypical carcinoid, and 2 were carcinoid; 84 (72.4%) had abdominal lymph node metastases, 6 (7.1%) had thoracic lymph node metastases, and 40 (34.5%) had distal esophageal involvement. CONCLUSIONS: Preoperative abdominal ultrasound and thoracoabdominal CT scan are helpful in evaluating respectability of gastric cardia carcinoma. Endoscopy and barium meal may be helpful in deciding the surgical approach. Abdominal lymph node is the main route of lymphatic dissemination of gastric cardia carcinoma. The efficacies of the 3 surgical approaches are similar; each has its benefit. Surgical modalities should be carried out individually according to Siewert classification and patient's conditions.

[Abnormal expression of Thy-1 as a novel tumor marker in lung cancer and its prognostic significance].

OBJECTIVE: The purpose of this study was to investigate the expression of Thy-1 immunohistochemically in different lung tumors and its prognostic significance in non-small cell lung cancer (NSCLC) cases. We also evaluate relationship between Thy-1 and p53 expression status so as to find any clue about the mechanism. METHODS: In this study, we used anti-Thy-1/CD90 antibody to detect the expression pattern of Thy-1 in different lung tumor sections, which were embedded in paraffin blocks. The expressions of Thy-1 in 175 lung tissue cases, including different pathological types, were analyzed as tissue array form. We also detect expression status in 91 NSCLC among these cases and analyze the relationship between Thy-1 and p53. The relationship between Thy-1 expression and patients' survival was studied. RESULTS: We first found that anti-Thy-1 antibody can strongly stain a nuclear molecule in different type of lung cancer cells. Among lung cancer cases, 89 (56.7%) cases showed strong nuclear staining for Thy-1 specially. In univariate and multivariate analysis for 91 NSCLC patients we found TNM staging, lymph node status and Thy-1 overexpression in nuclei were independent factors to affect the prognosis of NSCLC patients. In lymph node non metastasis subgroup cases, Thy-1 negative patients had significant longer survival than Thy-1 positive cases (mean survival: 46.42 mons vs 38.56 mons, P = 0.0207). There was a significant association between Thy-1 and p53 expression (P < 0.0001). CONCLUSION: There is a significant overexpressed Thy-1 located in lung cancer cell nucleus as compared to the normal tissue or benign tumor cells of lung, and it is one of the factors effected on the prognosis of NSCLC patients. This finding suggests that Thy-1 maybe a novel latent malignant marker in the lung cancer pathology. The association between Thy-1 and p53 expression in nucleus suggests that p53 protein and Thy-1 may have some interaction.