The metabolic marker tumour pyruvate kinase type M2 (tumour M2-PK) shows increased expression along the metaplasia-dysplasia-adenocarcinoma sequence in Barrett's oesophagus.

BACKGROUND: Proliferating and tumour cells express the glycolytic isoenzyme, pyruvate kinase type M2 (M2-PK). In tumours cells, M2-PK usually exists in dimeric form (tumour M2-PK), causing the accumulation of glycolytic phosphometabolites, which allows cells to invade areas with low oxygen and glucose concentrations. AIMS: To investigate the expression of tumour M2-PK during the metaplasia-dysplasia-adenocarcinoma sequence of Barrett's oesophagus, and to assess the prognostic usefulness of tumour M2-PK in oesophageal cancer. MATERIALS/METHODS: One hundred and ninety cases selected from the histopathology archives as follows: 17 reflux oesophagitis, 37 Barrett's oesophagus, 21 high grade dysplasia, 112 adenocarcinomas, and three control tumours. Sections were stained immunohistochemically with antibody to tumour M2-PK. RESULTS: Tumour M2-PK was expressed in all cases, and increased cytoplasmic expression was seen with progression along the metaplasia-dysplasia-adenocarcinoma sequence. All cases of adenocarcinoma showed 100% staining so that tumour M2-PK was not a useful prognostic marker. CONCLUSIONS: Tumour M2-PK is not a specific marker of Barrett's adenocarcinoma, but may be important as a marker of transformed and highly proliferating clones during progression along the metaplasia-dysplasia-adenocarcinoma sequence.

Preoperative mitomycin, ifosfamide, and cisplatin followed by esophagectomy in squamous cell carcinoma of the esophagus: pathologic complete response induced by chemotherapy leads to long-term survival.

PURPOSE: Squamous cell carcinoma of the esophagus remains an aggressive disease with a poor prognosis, even after curative-intent surgery. This article analyzes the impact of preoperative chemotherapy with mitomycin, ifosfamide, and cisplatin (MIC) on a cohort of 68 patients. PATIENTS AND METHODS: From 1988 to 1994, 68 patients with potentially operable squamous cell carcinoma of the esophagus were entered onto two phase II trials of neoadjuvant chemotherapy with mitomycin 6 mg/m2, ifosfamide 3 g/m2, and cisplatin 50 mg/m2 and received between two and four cycles of treatment at 3-weekly intervals. Two patients were removed from the analysis when they were found to have malignancy other than squamous cell carcinoma of the esophagus. RESULTS: Forty (61%) of 66 patients had a radiologic response to chemotherapy (18 complete responses and 22 partial responses), and 52 (79%) of 66 patients went on to have the primary tumor resected. There were nine pathologic complete responders, seven of whom remain fit and well after at least 60 months of follow-up. The overall median survival was 12.4 months (95% confidence interval, 9.6 to 18.8 months). The complete response and node-negative patients survived significantly longer than those in other categories (log-rank chi2 = 18.8; P <.001): on average 13 months longer than the node-positive or nonresected category (22.0 v 9.4 months). The toxicity of the regimen was low. CONCLUSION: MIC is an easily administered, well-tolerated, and efficacious regimen as neoadjuvant therapy for patients with squamous cell carcinoma of the esophagus. These results warrant further investigation.

A primary tumour of the oesophagus with both melanocytic and schwannian differentiation. Melanocytic schwannoma or malignant melanoma?

A 76 year old white woman presented with a four month history of dysphagia and weight loss. Clinical, radiological, and endoscopic examination revealed a pigmented mass in the lower third of the oesophagus. The preoperative diagnosis, including biopsy examination, was that of malignant melanoma. Following oesophageal resection, the mass was found to be a localised, relatively superficial tumour with light, electron microscopic, and immunohistochemical features common to both Schwann cells and melanocytes. The patient survived 46 months after surgery and died of a stroke, with no evidence of tumour recurrence. The tumour is presented as a case of melanocytic schwannoma, with unique features when compared with oesophageal melanotic schwannomas and malignant melanomas described in the literature. The differential diagnosis is discussed and an origin from a common precursor cell of neural crest origin is postulated.

Combined results from three phase II trials of neoadjuvant chemotherapy in operable adenocarcinoma of the oesophagus.

Adenocarcinoma of the oesophagus is a systemic disease at presentation in the majority of patients. This article analyses the impact of preoperative chemotherapy on a cohort of 68 patients. From 1990 to 1996, 68 patients with potentially operable adenocarcinoma of the oesophagus were entered into three sequential Phase II trials of neoadjuvant chemotherapy with cisplatin/mitomycin C/ifosfamide, cisplatin/5-fluorouracil (5-FU) and mitomycin C/cisplatin/5-FU. Twenty-four (35%) patients had a radiological (4 complete; 20 partial) response to chemotherapy, and 52 (76%) went on to have the primary tumour resected. There was only one pathological complete responder. The overall median survival was 13 months (95% confidence interval (CI) 9-16). Survival for the 28 N(0) patients was 34 months (95% CI 14-60). The pattern of failure for resected patients was predominantly systemic (16/17). These results indicate that neoadjuvant chemotherapy followed by surgery for adenocarcinoma of the oesophagus achieves excellent local control. The dominance, however, of distant recurrence after surgery underlines the fact that, in the majority of patients, the only hope of improving results in the future is to develop better systemic therapies.

Human oesophageal adenocarcinoma cell lines JROECL 47 and JROECL 50 are admixtures of the human colon carcinoma cell line HCT 116.

In two recently described human oesophageal adenocarcinoma cell lines JROECL 47 and JROECL 50, derived from one tumour, we detected identical E-cadherin and beta-catenin gene mutations as in colon carcinoma cell line HCT 116. We demonstrate by HLA-typing, mutation analysis and microsatellite analysis that cell lines JROECL 47 and JROECL 50 are admixtures of the human colon adenocarcinoma cell line HCT 116.

What is the optimal distal resection margin for esophageal carcinoma?

BACKGROUND: Whereas a proximal resection margin of 12 cm is recommended for complete resection of esophageal cancer, the extent of distal resection is unclear. METHODS: We examined distal resection margins in a consecutive series of patients who underwent esophagectomy for squamous cell carcinomas (n = 50), primary esophageal adenocarcinomas (n = 100), and adenocarcinomas of the cardia (n = 39), in whom all macroscopic tumor was judged to be completely resected. RESULTS: Microscopic tumor was found at a 3-cm distal resection margin for one multifocal squamous cell carcinoma. Positive distal resection margins were seen in 12% (12 of 100 patients) of primary esophageal adenocarcinomas (median, 2 cm versus 4 cm if negative; p = 0.002, Wilcoxon) and 28% (11 of 39 patients) of cardia adenocarcinomas (median, 1 cm versus 3 cm if negative; p = 0.02, Wilcoxon). Although pathologic stage was shown to be the only significant predictor of overall survival (Hazard ratio [HR] 1.8; 95% confidence interval 1.2 to 2.6; p = 0.007), there was a trend toward reduced postoperative survival for patients with histologically positive distal resection margins, in particular for patients with cardia adenocarcinomas (median, 15.4 months versus 5.7 months if negative; p = 0.0001). CONCLUSIONS: To achieve consistently negative distal resection margins, we recommend resection of at least 5 cm of macroscopically normal foregut below the distal margin of the primary tumor.

The use of an anabolic steroid (nandrolone decanoate) to improve nutritional status after esophageal resection for carcinoma.

Anabolic steroids increase appetite and muscle mass. This randomized, double-blind trial investigates any nutritional benefits of anabolic steroid in patients after surgery for esophageal cancer. Forty patients were recruited: 19 patients had five injections of 50 mg nandrolone decanoate and 21 patients received placebo over 3 months, starting 1 month after surgery. Measurements of body weight, mid-arm muscle circumference (MAMC) and appetite were taken over a 6-month period. Nutrition was optimized by dietary advice and by esophageal dilatation if required. Percent ideal weight, percent ideal MAMC and appetite score did not show significant differences between steroid and placebo groups, but there was a trend to an increase over 6 months for percent ideal MAMC in the test group. With this protocol, we have experienced minimal side-effects. However, we have not demonstrated any therapeutic benefit with low-dose steroid. An increased dose schedule over a longer period might produce a significant response.

Sequential changes in cadherin-catenin expression associated with the progression and heterogeneity of primary oesophageal squamous carcinoma.

Maintenance of an adhesive function for cadherins requires appropriate membranous cellular expression and intact cadherin-catenin complexes. In normal squamous mucosa of the oesophagus there is membranous co-expression of E- and P-cadherin (E-cad, P-cad) in the basal compartment, whereas suprabasal stratification is associated with preservation of E-cad expression but loss of P-cad. Immunohistochemical staining of squamous dysplasia/carcinoma in situ shows a striking increase in the proportion of cells within the epithelial compartment showing co-expression of E- and P-cad with strong appropriate membranous expression of beta and gamma catenin. Strong membranous co-expression of E- and P-cad and beta catenin is seen on keratinocytes at the periphery of islands of invasive better-differentiated squamous carcinoma with keratinisation, mimicking normal mucosa. Beta catenin may be phosphorylated with implied loss of cadherin binding. Membranous cadherin and catenin expression is significantly down-regulated in poorly differentiated squamous carcinoma. No beta catenin mutations were demonstrated in squamous carcinomas following DNA extraction and sequencing, nor was any nuclear cadherin seen. Changes in cadherin-catenin complexes with cellular phenotype is well demonstrated in spindle cell carcinomas with a shift of cadherin expression from membranous to cytoplasmic between the epithelioid and spindle cell components of the tumour and with loss of expression in the sarcomatoid elements. In conclusion, we demonstrate an increased expression of P-cadherin early in tumourigenesis with loss of cadherin-catenin complexes in poorly differentiated invasive carcinomas. Cadherin/catenin expression may govern both the phenotype and biology of oesophageal squamous carcinomas.

A phase II trial of four courses of preoperative chemotherapy in squamous or anaplastic carcinoma of the oesophagus.

We have reported the results of a previous Phase II trial of two courses of neoadjuvant mitomycin (6 mg/m2), ifosfamide (3 g/m2) and cisplatin (50 mg/m2) (MIC) in squamous or anaplastic carcinoma of the oesophagus. In this current study, we have investigated whether there was any clinical benefit in extending the preoperative treatment to four courses for patients who responded after two courses. Response was assessed by barium swallow, which was compared with previous barium swallows performed prior to any treatment and after the second course of MIC. Of an initial 43 patients, 27 (63%) were assessed as responders after two courses of MIC. Twenty of these 27 patients were entered into the study with a view to receiving two further courses of MIC prior to surgery. Seventeen completed four courses. Five patients were complete responders after two courses and remained complete responders after four courses. Twelve patients were partial responders after two courses; six of these became complete responders after four courses, five remained partial responders, and one showed progression. Haematological toxicity and alopecia were increased after extending the number of courses beyond two. On pathological assessment, three patients with a complete response after four courses, and one with a complete response after three courses, had microscopic clearance of tumour. Extension beyond two courses of neoadjuvant MIC gives an improvement in response, as judged by barium assessment, but increases toxicity, cost of treatment and delay before surgery. Although the numbers are small, the results suggest that a worthwhile improvement in the radiological response of squamous or anaplastic oesophageal tumours may be gained by proceeding beyond two courses of MIC. A randomized trial, with larger numbers of patients, is needed to show whether there is any improvement in radiological and pathological response rates and in survival to be gained by the extension of treatment beyond two courses.

A phase II trial of cisplatin and 5-fluorouracil in adenocarcinoma of the oesophagus.

The effect of brief neoadjuvant chemotherapy in patients with apparently operable adenocarcinoma of the oesophagus has been investigated. Two courses of cisplatin and 5-fluorouracil (CFu) were given, followed by evaluation of the response by barium swallow. Twenty-one of 23 patients completed both courses. Two showed a complete response and five a partial response. In only one patient was there a pathological complete response. Toxicity was mild and consisted principally of nausea and vomiting. All patients underwent surgical exploration; resection was completed in 17. There were three hospital deaths (18%). Although CFu has produced two complete responses (on barium swallow) and one complete pathological clearance of tumour, the disappointing total response rate of 7/21 (33%; 95% CI 13-53) or 7/23 (30%; 95% CI 12-49) leads us to believe that further Phase II trials are needed to identify more efficacious agents and regimens.

A case of systemic pseudo-pseudoxanthoma elasticum with diverse symptomatology caused by long-term penicillamine use.

A 47 year old man presented with a two year history of increasing cervical dysphagia, dyspnoea, and cutaneous signs. He had been diagnosed 27 years previously with Wilson's disease and was treated with penicillamine (1.5 g daily). Systemic abnormality of elastic fibres was confirmed by light and electron microscopy following biopsy of skin, lung, oesophageal muscle, gum, pharyngeal tissue, and cervical connective tissue. Dysphagia was relieved by cricopharyngeal myotomy. Substitution of trientene dihydrochloride for penicillamine relieved cutaneous and systemic manifestations. This is possibly the first case demonstrating an association between prolonged penicillamine use and biopsy proved systemic pseudo-pseudoxanthoma elasticum. The presenting symptoms may have resulted from the abnormal numbers and properties of elastic fibres, and the changes were caused by penicillamine use, rather than by idiopathic, inherited pseudoxanthoma elasticum.

A phase II trial of preoperative mitomycin, cisplatin and 5-fluorouracil in adenocarcinoma of the oesophagus.

The effect of neoadjuvant chemotherapy in patients with apparently operable adenocarcinoma of the oesophagus has been investigated. Two courses of mitomycin, cisplatin and 5-fluorouracil (MCF) were given, followed by a radiological evaluation of response. Twenty-two of 25 patients completed both courses. Two showed a complete response and 12 a partial response. There was a pathological complete response of the primary tumour in only one patient (although there was residual secondary tumour in a local lymph node). The main toxicity was myelosuppression, with 9/22 patients having the second chemotherapy course delayed. There were three sudden deaths, one due to a pulmonary embolus and two due to complications of infections. Twenty-one patients underwent surgical exploration; there were 18 resections. Although the radiological response rate of MCF (14/25; 56%; 95% CI 37-75) appeared promising, there were no pathological complete responders. Further Phase II trials are needed to identify more efficacious agents and regimens that will yield a pathological response rate of at least 10%, before proceeding to randomized trials of neoadjuvant chemotherapy for adenocarcinoma of the oesophagus.

Expression of E-cadherin in oesophageal carcinomas from the UK and China: disparities in prognostic significance.

AIMS: To study the expression and prognostic significance of the cell adhesion molecule E-cadherin in oesophageal tumours from the UK (low risk area) and China (high risk area). METHODS: E-cadherin expression was measured immunohistochemically in resected tumours from 17 patients in the UK with adenocarcinoma, 23 patients from the UK with squamous carcinoma, and 30 patients from China with squamous carcinomas who survived for five years postoperatively and compared with similar tumours from patients in the same regions who did not survive (140 tumours in all). RESULTS: Normal squamous epithelial cells and well differentiated areas of tumours showed membranous staining for E-cadherin expression. Cytoplasmic staining, heterogeneous staining, or an absence of staining was seen in dysplastic epithelium and in less well differentiated areas of tumours. Only one of 140 primary tumours had homogeneous membranous expression. In tumours from UK patients with adenocarcinoma (p = 1.00) and from Chinese patients with squamous carcinomas (p = 0.06) there was no correlation between E-cadherin absence and non-survival. In tumours from UK patients with squamous carcinomas there was a significant correlation between absence of E-cadherin and non-survival (p = 0.009). Tumours from UK patients with squamous carcinoma who survived were significantly less likely to be E-cadherin absent than those from Chinese patients with squamous carcinomas who survived (p = 0.007). Multivariate analysis (n = 37 UK, paired data) showed that absence of E-cadherin in the primary tumour was a weak independent prognostic factor for non-survival (30% significance level; p = 0.26; odds ratio = 3.56). In UK nodal metastases there was no correlation between E-cadherin expression and survival. CONCLUSIONS: Squamous carcinomas from UK patients differed from both adenocarcinomas from UK patients and carcinomas from Chinese patients with respect to E-cadherin expression and prognostic significance. In tumours from UK patients, E-cadherin absence in the primary carcinoma (a weak independent prognostic factor) but not metastases correlated with non-survival.

Five newly established oesophageal carcinoma cell lines: phenotypic and immunological characterization.

The derivation of permanent cell lines from 40 resected oesophageal carcinomas has been attempted. Five long-term lines have been established from three adenocarcinomas, one mixed carcinoma and one squamous carcinoma. Molecular and cellular analyses have been carried out on the lines and clones derived from them. Karyotype analysis indicates genetic variation among the clones. HLA-A, -B and -C is expressed constitutively, but not HLA-DR. ICAM-1-expressing phenotypes may have arisen during adaptation to long-term culture. All lines are capable of response to interferon-gamma (IFN-gamma) and all produce transforming growth factor beta 1 (TGF-beta 1). Two lines are resistant to the inhibitory growth effects of the latter, possibly contributing to malignancy. It is anticipated that these lines, originating from histologically different carcinomas, will provide a valuable, continuous resource for the investigation and treatment of these aggressive tumours.

Lymphocyte infiltration in oesophageal carcinoma: lack of correlation with MHC antigens, ICAM-1, and tumour stage and grade.

Infiltration by T lymphocytes into oesophageal carcinomas was assessed immunohistochemically, total T lymphocyte numbers by staining for CD3 and activated T lymphocytes by staining for CD25. Five squamous carcinomas and seven adenocarcinomas, resected without neoadjuvant treatment, were studied. Computer aided quantitation showed that total numbers of tumour infiltrating CD3 positive cells were highly variable (range 48-1673 cells/mm2). They were located largely in the stromal (87.9-99.2%) rather than intratumoral regions. Up to 84% of tumour infiltrating T lymphocytes were CD25 positive, although the median figure was 33%. There was no correlation between T lymphocyte infiltration or activation and expression of class I and II histocompatibility antigens, intercellular adhesion molecule-1, tumour stage or grade. These results imply that the local inflammatory response in oesophageal carcinomas is deregulated, which may be a factor contributing to the aggressive nature of the tumours.

Tumour heterogeneity: a problem in biopsy assessment of the proliferation index of oesophageal adenocarcinomas.

Tumour heterogeneity may pose a problem when biopsy specimens are taken to measure proliferation (for example, in assessing response to therapy). Two "biopsy specimens" were taken from the centre and two from the edge of the luminal surface of 20 resected oesophageal adenocarcinomas. The proliferation index for each "biopsy specimen" was measured by counting Ki67 labelled nuclei in histological sections. The proliferation index was not associated with tumour differentiation or stage. There was site specific heterogeneity with a significant difference in proliferation index between the central (mean (SD) 36.4 (9.7)) and edge "biopsy specimens" (39.3 (9.9)). There was, however, a wide range of differences between pairs of "biopsy specimens" from both sites. In conclusion, if a tumour is to be sampled for measurement of the proliferation index before and after treatment, then the sequential biopsy specimens (preferably duplicated on each occasion) should be taken consistently from a leading edge of the lesion.

Phase II study of mitomycin, ifosfamide and cisplatin in adenocarcinoma of the oesophagus.

We evaluated the effect of brief neoadjuvant chemotherapy in patients with apparently operable adenocarcinoma of the oesophagus. Two courses of mitomycin (6 mg/m2), ifosfamide (3 g/m2) and cisplatin (50 mg/m2;MIC) were given followed by evaluation of response by barium swallow and computed tomography scan. Of 20 patients, 17 completed both courses and 4 (20%) showed a partial response. Toxicity was generally mild and consisted principally of nausea and vomiting. Altogether, 15 patients were surgically explored; resection was completed in 12 patients, 3 of whom died in hospital (25%). Neoadjuvant therapy with MIC offers no advantage over surgery alone.

Lack of correlation of P-glycoprotein expression with response to MIC chemotherapy in oesophageal cancer.

The multidrug resistance gene product P-glycoprotein (P-GP) was assessed immunohistochemically (by antibody JSB-1) in biopsy specimens from 27 oesophageal squamous carcinomas and 10 adenocarcinomas before treatment with mitomycin, ifosfamide and cisplatin (MIC). Tumours were assessed following treatment and correlation with response sought. Of the squamous carcinomas, 74% (20/27) responded to MIC but only one expressed P-GP before and after treatment. Of the adenocarcinomas, 30% (three of 10) responded. Seven of the 10 adenocarcinomas expressed P-GP before treatment but all 10 were P-GP positive after chemotherapy. The difference in prevalence and induction of P-GP between the histological types was highly significant and may correlate with the greater response to MIC seen in squamous carcinomas compared with adenocarcinomas. P-GP cannot be used as a predictive marker of response as tumours express it inconsistently with response to MIC. Resistance to MIC may be due to other mechanisms.