Do dysplastic proximal resection margins predict the risk of anastomotic recurrence and overall survival in patients with esophageal squamous cell carcinoma?

Positive proximal resection margins are strongly associated with anastomotic recurrence in esophageal cancer. However, the prognostic significance of dysplastic proximal resection margins remains unclear. The aim of this study is to investigate whether the dysplastic proximal resection margin can predict anastomotic recurrence and overall survival in patients with esophageal squamous cell carcinoma. Between 2000 and 2014, patients with esophageal squamous cell carcinoma who received a nonpalliative resection and survived the perioperative period were included. Two expert pathologists independently reviewed the proximal resection margin status, which was classified as negative, dysplastic, or positive. The kappa statistic was used to test interobserver reliability. Anastomotic recurrence and overall survival served as the main outcome measures. The study cohort consisted of 469 patients (445 males and 27 females). There was an excellent interobserver agreement for negative (kappa = 0.88), dysplastic (kappa = 0.88), and positive (kappa = 1) proximal resection margins-which were identified in 418 (89.1%), 37 (7.9%), and 14 (3.0%) patients, respectively. After a median follow-up of 21.6 months, 30 (6.4%) patients developed an anastomotic recurrence. Compared with patients with negative proximal resection margins (24/418, 5.7%), the occurrence of anastomotic recurrence was more commonly observed in those with positive proximal resection margins (3/14, 21.4%, P = 0.017) but not in those with dysplastic proximal resection margins (3/37, 8.1%, P = 0.56). Multivariable Cox regression analysis identified positive proximal resection margins (hazard ratio: 5.93, P = 0.010) and advanced clinical stage (hazard ratio: 12.04, P = 0.023) as independent risk factors for anastomotic recurrence. Dysplastic proximal resection margins were not retained in the model as an independent predictor (hazard ratio: 1.38, P = 0.602). The 5-year overall survival rates of patients with negative (38.2%) and dysplastic margins (27.0%) were similar (P = 0.814), and significantly higher than that observed in those with positive proximal resection margins (9.5%, P = 0.015). In conclusion, dysplastic proximal resection margins can be identified in at least 7.9% of patients with esophageal squamous cell carcinoma, but neither they are associated with an increased risk of anastomotic recurrence nor they portend a poor overall survival.

Characterization of residual tumours at the primary site in patients with a near pathological complete response after neoadjuvant chemoradiotherapy for oesophageal cancer.

BACKGROUND: A 'surgery as needed' strategy has been proposed for patients with oesophageal cancer who truly achieve a pathological complete response (pCR) following neoadjuvant chemoradiotherapy (nCRT). However, the ability to detect residual disease remains problematic. This study investigated the anatomical locations and pathological characteristics of residual cancer in patients with oesophageal squamous cell carcinoma (SCC) who achieved a near pCR following nCRT. METHODS: Patients with oesophageal SCC who achieved a near pCR after nCRT were eligible. Near pCR was defined as residual cancer in the resection specimen representing less than 10 per cent of the apparent original tumour area. RESULTS: Detailed histopathological reassessment of 76 consecutive patients (mean age 54·4 years) with a near pCR was undertaken. Some 32 patients (42 per cent) with a near pCR had no detectable mucosal lesions. Residual tumour was identified most frequently in the submucosal layer (54, 71 per cent), followed by the mucosa (44, 58 per cent), muscle layer (36, 47 per cent) and adventitia (22, 29 per cent) (P < 0·001). Among patients without ypT1a disease, increasing depth of tumour invasion correlated negatively with the likelihood of mucosal involvement. Of patients with ypT3 disease, 16 of 22 had no detectable cancer located in the mucosa, compared with six of 29 with ypT1b disease (P < 0·001). CONCLUSION: Better tools for predicting pCR are required before considering a 'surgery as needed' approach in the management of oesophageal cancer.

Association between the thoroughness of the histopathological examination and survival in patients with esophageal squamous cell carcinoma who achieve pathological complete response after chemoradiotherapy.

The College of American Pathologists guidelines recommend examining at least four representative tumor blocks for determining pathological T stage in patients with primarily resected esophageal cancer. Whether the same pathological requirements are adequate in patients undergoing esophagectomy following neoadjuvant chemoradiotherapy (nCRT) remains unclear. We hypothesized that current examination protocols may underestimate the presence of microscopical residual disease after nCRT, potentially leading to under-staging. We retrospectively reviewed the records of patients with esophageal squamous cancer (ESCC) who were diagnosed as having pathological complete response (pCR) following nCRT. The thoroughness of the pathological examination in pCR patients was examined using (i) the number of blocks examined in suspicious tumor area (≤4 vs. >4), and (ii) the block quotient (calculated as the pretreatment tumor length divided by the number of blocks examined in suspicious tumor area). A total of 91 patients were enrolled. The mean number of blocks used to confirm pCR was 4.8 (range: 2-14). The 5-year overall survival (OS) and disease-free survival (DFS) in the entire cohort were 55% and 65%, respectively. Multivariate analyses identified the block quotient as the only independent predictor of OS and DFS. Receiver operating characteristic curve analysis indicated an optimal cutoff value of 1.4 for the block quotient. Among the patients who achieved pCR, the 5-year DFS differed significantly between subjects with a low (≤1.4) or high (>1.4) block quotient (76% vs. 47%, respectively, P = 0.03). The block quotient (calculated by the pretreatment tumor length divided by the number of blocks) - which reflects the meticulousness of the histopathological examination for confirming pCR - is associated with survival in ESCC patients.

Statins can increase the risk of herpes zoster infection in Asia.

This study evaluated whether statin therapy increases the risk of herpes zoster (HZ) infection in Asia. This retrospective cohort study used the Longitudinal Health Insurance Database (LHID2000). From the LHID2000, patients aged 20 years were divided into two cohorts according to their statin use and were matched at a 1:1 ratio according to propensity scores, which were calculated using a logistic regression for estimating the probability of treatment assignment. The primary outcome was HZ infection. All patients were followed from the index date until the date of HZ infection, withdrawal from the insurance system, or the end of 2011. The study included 53,069 patients receiving statin therapy as a statin cohort and 53,069 patients without statin therapy as a nonstatin cohort. The mean follow-up durations for the statin cohort and nonstatin cohort were 4.89 [standard deviation (SD) = 2.86] years and 4.75 (SD = 2.90) years, respectively. The patients in the statin cohort had a 21 % higher risk of contracting HZ infection than the patients in the nonstatin cohort [95 % confidence interval (CI) = 1.13-1.29]. The incidence of HZ infection increased with the Charlson comorbidity index (CCI) score in both cohorts. A high mean defined daily dose of the six types of statins considered in this study was associated with a significantly increased risk of HZ infection. Statin therapy can increase HZ infection in Asia. More benefit-risk evaluations for statin use are necessary in Asia.

Impact of interleukin-8 gene polymorphisms and environmental factors on oral cancer susceptibility in Taiwan.

OBJECTIVES: Interleukin-8 (IL-8), which is an angiogenic chemokine with a high expression level in tumor tissues, plays important roles in developing many human malignancies including oral squamous cell carcinoma (OSCC). This study was designed to examine the association of IL-8 gene polymorphisms with the susceptibility and clinicopathological characteristics of OSCC. METHODS: A total of 270 patients with OSCC and 350 healthy control subjects were recruited. Four single nucleotide polymorphisms (SNPs) of IL-8 genes were analyzed using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) genotyping analysis. RESULTS: Results showed that four IL-8 SNPs (-251 T/A, +781 C/T, +1633 C/T, and +2767 A/T) were not associated with oral cancer susceptibility as well as clinicopathological parameters. But among 345 smokers, IL-8 polymorphisms carriers with betel quid chewing were found to have a 17.41- to 23.14-fold risk to have oral cancer compared to IL-8 wild-type carriers without betel quid chewing. Among 262 betel quid chewers, IL-8 polymorphisms carriers with smoking have a 10.54- to 20.44-fold risk to have oral cancer compared to those who carried wild type without smoking. CONCLUSIONS: Our results suggest that the combination of IL-8 gene polymorphisms and environmental carcinogens might be highly related to the risk of oral cancer.

Midlife Body Mass Index Trajectory and Risk of Frailty 8 Years Later in Taiwan.

OBJECTIVES: Few studies have focused on weight change and frailty, especially in Asia. This research aimed to evaluate midlife body mass index (BMI) trajectory and assess its relationship with frailty 8 years later in Taiwan. DESIGN: A prospective cohort study. SETTING AND PARTICIPANTS: Data were retrieved from the Taiwan Longitudinal Study on Aging conducted from 1999 to 2007. The analysis was restricted to respondents aged between 50 to 69 years old, who were not frail in 1999 and were alive in 2007 (n=1609). MEASUREMENTS: Frailty was defined using the Fried criteria. The group-based model of trajectory was used to estimate BMI trajectories among elderly participants. Logistic regression analysis was used to examine the association between BMI change and frailty. RESULTS: Four trajectory classes were identified and each remained stable during the 8-year follow-up. There were 316 participants (20.3%) in the low-normal weight group (baseline BMI=20.38 kg/m2), 737 participants (44.7%) in the high-normal weight group (baseline BMI=23.22 kg/m2), 449 participants (28.4%) in the overweight group (baseline BMI=26.24 kg/m2), and 107 participants (6.6%) in the obesity group (baseline BMI=30.65 kg/m2). After adjustment for confounding factors, the low-normal weight group and obesity group were associated with increased frailty compared with the high-normal weight group. CONCLUSION: Our results showed that the BMI trajectories of midlife individuals tended to be constant and those in both the low-normal weight group and obesity group had an increased risk of developing frailty in later life. Therefore, an optimal weight-targeting strategy should be considered for Asian elderly individuals.

Prognosis of patients with esophageal squamous cell carcinoma who achieve major histopathological response after neoadjuvant chemoradiotherapy.

BACKGROUND: The purpose of this study was to investigate the prognosis and its predictors in patients with esophageal squamous cell carcinoma (ESCC) who achieve major histopathological response (MaHR) after neoadjuvant chemoradiotherapy (nCRT). METHODS: We examined a total of 187 ESCC patients who achieved MaHR following nCRT and survived the perioperative period. MaHR was defined as either absence or <10% vital residual tumor cells (VRTC) in the resected esophagus without nodal involvement. Univariate and multivariate analyses were used to identify factors significantly associated with overall survival (OS). RESULTS: At the time of analysis, 113 patients (60.4%) were dead (5-year OS = 48%; median survival time = 54.8 months). The amount of VRTC (1-10% versus 0% VRTC; hazard ratio [HR] = 1.9, P < 0.001) and the thoroughness of histopathological examination (standard [≤ 4 tumor blocks] versus thorough [> 4 tumor blocks], HR = 1.57; P = 0.013) were independent predictors of OS in multivariate analysis. A stepwise increase in OS was observed in the following groups: patients with 1-10% VRTC identified by the standard protocol, patients with 1-10% VRTC identified by the thorough protocol, patients with 0% VRTC identified by the standard protocol, and patients with 0% VRTC identified by the thorough protocol (5-year OS rates = 20%, 40%, 50%, and 62%, respectively, P < 0.001). CONCLUSIONS: In ESCC patients who achieve MaHR after nCRT, the presence of microscopical residual disease and the thoroughness of histopathological examination are associated with survival.

Perineural invasion through the sheath in posttherapy esophagectomy specimens predicts poor survival in patients with esophageal squamous cell carcinoma.

BACKGROUND: The prognostic impact of perineural invasion (PNI) in patients with esophageal cancer who receive neoadjuvant chemoradiotherapy (nCRT) remains unclear. METHODS: A thorough pathological review of PNI was performed on post-nCRT esophagectomy specimens obtained from non-ypT0 patients with esophageal squamous cell carcinoma (ESCC). When PNI was identified, it was classified according to the presence or absence of penetration through the nerve sheath (i.e., PNI surrounding the nerve sheath [PNI-SS] versus PNI penetrating through the nerve sheath [PNI-TS]). The impact of PNI on overall survival (OS) was assessed in combination with clinical and pathological risk factors. RESULTS: A total of 177 eligible patients were identified between 1998 and 2008. PNI was identified in 43.5% (77/177) of participants. Of them, 33 and 44 had PNI-SS and PNI-TS, respectively. The 5-year OS rate of patients with PNI-TS was significantly lower (6.7%) than that observed in those without PNI (30.6%, P < 0.001). However, the 5-year OS observed in the latter group did not differ significantly from that of patients with PNI-SS (26%, P = 0.68). Multivariate analysis identified PNI-TS (hazard ratio [HR] = 1.965, P = 0.02), LVI (HR = 1.514, P = 0.048), and ypN2 stage (HR = 2.39, P = 0.007) as independent adverse prognostic factors for OS. CONCLUSIONS: The presence of PNI-TS after nCRT is associated with poor survival. A thorough assessment of distinct PNI patterns (i.e., PNI-TS versus PNI-SS) should be part of the routine post-nCRT histopathological work-up of ESCC patients.

Providing instrumental social support is more beneficial to reduce mortality risk among the elderly with low educational level in Taiwan: a 12-year follow-up national longitudinal study.

BACKGROUND: To evaluate whether the effects of providing or receiving social support are more beneficial to reduce mortality risk among the elderly with different educational levels. METHODS: In this long-term prospective cohort study, data were retrieved from the Taiwan Longitudinal Study on Aging. This study was initiated from 1996 until 2007. The complete data from 1492 males and 1177 females aged ≥67 years were retrieved. Participants received financial, instrumental, and emotional support, and they actively provided instrumental and emotional support to others and involved in social engagement. Education attainment was divided into two levels: high and low. The low education level included illiterate and elementary school. The high education level included junior high school to senior high school and above college. Cox regression analysis was used to examine the association between providing or receiving social support on mortality with different educational levels. RESULTS: The average age of the participants in 1996 was 73.0 (IQR=8.0) years, and the median survival following years (1996-2007) of participants was 10.3 (IQR=6.7) years. Most participants were low educational level including illiterate (39.3%) and elementary school (41.2%). Participants with high educational level tend to be younger and more male significantly. On the contrary, participants with low educational level tend to have significant more poor income, more depression, more cognition impairment, more with IADL and ADL disability than high educational level. Most participants received instrumental support from others (95.5%) and also provided emotional support to others (97.7%). Providing instrumental support can reduce 17% of mortality risk among the elderly with a low level of education after adjusting several covariates [Hazard ratio (HR) = 0.83; 95% confidence interval (CI) = 0.70-0.99; p = 0.036]. CONCLUSIONS: Providing instrumental social support to others confer benefits to the giver and prolong life expectancy among the elderly with low educational levels.

Identification of a 37 kilodalton protein at the epidermal basement membrane by an antiserum to human amnion.

A protein which is recognized by an antibody to human amniotic epithelial basement membrane was identified at the basal lamina of human epidermis by immunohistology. This protein was localized at the lamina lucida of human epidermal basement membrane by immunoelectron microscopy. Studies of normal human keratinocyte cultures and epidermal wound healing suggested that the protein was probably produced by keratinocytes. By immunoblotting, a basic apparent isoelectric pH (pHiapp = 7.3) protein band of 37 kD was seen. These data indicate that this 37 kD protein, clearly different from other known basement membrane components, is present in simple and stratified epithelia of ectodermal origin, and is associated with hemidesmosomes.

Propidium iodide as a nuclear marker in immunofluorescence. II. Use with cellular identification and viability studies.

The use of a fluorescence method employing propidium iodide to determine nuclear morphology of different cell types by epi-illumination in membrane immunofluorescence is described. Its usefulness is illustrated by differentiating nucleated and anuclear transferrin receptor-bearing cells as well as by simultaneously determining the viability of cell suspension without requiring a change from fluorescence microscopy, this causing no loss of visual accommodation.

Monoclonal antibodies to human amnion recognize different components of the rabbit eye.

The epithelium of the eye originates from embryonic ectoderm, whereas the amnion is an extra-embryonic membrane that bears close relationship with many ectodermal tissues. Shared antigens have been identified between human amnion and cornea using rabbit antisera to human amnion. Three monoclonal antibodies to human amnion, GB4, GB9, and GB11 were studied by immunofluorescence on the anterior segment of the rabbit eye. GB4 recognized the epithelium of the conjunctiva and the subcapsular epithelium of the lens. GB9 reacted only with the central four fifths of the corneal epithelium; the peripheral epithelium near the limbus was not reactive. GB11 detected the pigmented epithelial cells in ciliary processes.

Curvilinear relations between age and hemostatic parameters in Chinese.

The role of hemostatic factors in the pathogenesis of cardiovascular disease has gained much attention recently. Information about hemostatic factors, and their age patterns is sparse for orientals. With the data collected in the Cardiovascular Disease Risk Factor Two-township Study in Taiwan, this study shows that, in general, the older the age, the stronger the tendency toward thrombosis. With advancing age, prothrombin time, activated partial thromboplastin time, and antithrombin-III level decreased steadily; but mean values of fibrinogen, factor VIIc, and factor VIIIc increased. Gender differences in the age patterns of the above factors are carefully described. Curvilinear relations between hemostatic factors and age were demonstrated for adults aged 18 and above for all hemostatic factors studied. This curvilinearity should be taken into consideration when adjusting for the effect of age in data analysis to avoid residual confounding, particularly when the age range of the study subjects is wide.

Monoclonal antibody GB36 raised against human trophoblast recognizes a novel epithelial antigen.

Monoclonal antibody GB36, which was raised against human term syncytiotrophoblastic microvilli, was found to recognize a novel epithelial antigen. The antibody immunoprecipitated several membrane proteins from BeWo (choriocarcinoma) and HT-29 (colon adenocarcinoma) cells. Under non-reducing conditions, four peptides of 180, 155, 135 and 130 kDa were revealed by SDS-PAGE analysis. Three peptides of slightly higher molecular weights were revealed under reducing conditions; these three peptides had identical pI (6.2) as shown by two-dimensional gel electrophoresis. By immunofluorescence, GB36 reacted with villous cytotrophoblasts and cytotrophoblasts of chorion laeve, as well as with the basal surface of syncytiotrophoblast and amniotic epithelium. Extravillous trophoblasts of cytotrophoblastic shell in the basal plate and the cytotrophoblastic cell island were non-reactive. It is suggested that the antigen of GB36 may play a role in the polarity of epithelial cells and the adhesion of epithelial cells to extracellular matrix.

Histocompatibility antigens, transferrin receptors and extra-embryonic markers of human amniotic epithelial cells in vitro.

This study has shown that fresh amniotic epithelial cells which are negative by indirect immunofluorescence for HLA and Trf receptors become positive for both of these markers following prolonged culture. In addition, the amniotic antigens which are characteristic of fresh amniotic epithelial cells are lost and replaced by trophoblast antigens subsequent to maintenance of the cells in vitro. These observations suggest that, although the expression of HLA and Trf receptors are apparently negative in vivo, such gene products become activated and manifest in plasma membranes following exposure of the cells to culture conditions. In addition, the normal manifestation of the amnion antigens is lost following prolonged periods of culture. These findings indicate that the coding and expression of normally accepted transplantation antigens undergo a significant perturbation in vitro, and that markers of normal extra-embryonic epithelium in vivo are lost after the cells have been cultured in vitro.

Human amniochorion: tissue-specific markers, transferrin receptors and histocompatibility antigens.

Human amniochorion was studied by immunofluorescence with the use of antisera to human trophoblast, amniotic epithelium and transferrin as well as with monoclonal antibodies to beta 2M and HLA. The results showed that cytotrophoblast of amniochorion, like its counterpart in placenta, manifests a trophoblast-specific membrane marker and lacks beta 2M and HLA. This tissue also did not react with antisera to amniotic epithelium, and unlike its placental counterpart no evidence for transferrin receptors could be obtained. Amniotic epithelium was found to lack trophoblast antigens, beta 2M, HLA and transferrin receptors, but contained a plasma membrane marker not found on any other extra-embryonic tissues. These results show that extra-embryonic cells with characteristic membrane markers fail to manifest histocompatibility antigens, almost as though they were mutually exclusive. This is supported by the observation that transformed amnion epithelial cells lose their unique surface antigens, react with monoclonal anti-beta 2M and acquire transferrin receptors, raising the possibility that the histocompatibility neutrality of extra-embryonic cells is maintained by the normal insertion of specific fetal markers into their plasma membranes.

Characterization of antibodies to antigens of the human amnion.

The specificities of antisera produced in nine rabbits to seven different preparations of human amniotic epithelium and controls were studied by immunofluorescence on cryostat sections of human amniochorions, placentae and a large collection of other tissues. Three different groups of reaction patterns were identified with the use of these antibodies, indicating the presence of at least three antigenic groupings which have been tentatively designated as amnion antigens 1 (AA1), amnion antigens 2 (AA2) and amnion antigens 3 (AA3). The AA1 group was found on the ectodermal tissues of breast ductal and corneal epithelium as well as on Hassall's corpuscles, while the AA2 group was also found on breast ductal and corneal epithelium and basal keratinocytes, but not on Hassall's corpuscles. The AA3 group was found on basement membranes of ectodermally derived epithelium, but was negative on kidney. The identification of the distribution of antigens in common with ectodermal tissues and extra-embryonic membranes suggests that human amnion and chorion may have a close embryological relationship with embryonic ectoderm and its subsequent products of organogenesis.

Monoclonal antibodies (GB16, GB18, GB19, GB22) raised against human placental microvilli recognize the transferrin receptor.

GB16, GB18, GB19 and GB22 are mouse monoclonal antibodies produced against full-term human placental microvilli. These antibodies reacted predominantly with the apical surface of the syncytiotrophoblast from first-trimester and full-term placentae, and also reacted with several cell lines derived from non-haematopoietic tissues by immunofluorescence. The radioiodinated BeWo (choriocarcinoma) cell surface proteins were immunoprecipitated with these four antibodies and analysed by sodium dodecyl sulphate-polyacrylamide gel electrophoresis. The results demonstrated that the immunoprecipitates migrated at 180 and 90 kilodaltons under non-reducing and reducing conditions, respectively. Using enzyme-linked immunosorbent assay, the antigens recognized by GB16, GB18, GB19, and GB22 were able to bind human transferrin. Immunoabsorption studies showed that these four antibodies bound to the same molecule as OKT9, an antibody to the transferrin receptor. Moreover, the reactivities of these antibodies with HL-60 (promyelocytic leukaemia) cells diminished following dimethyl sulphoxide-induced differentiation by flow cytometric analysis. These data indicate that these four antibodies recognize the transferrin receptor. By competition assay, GB18 bound to an epitope different from those recognized by GB16, GB19 and GB22. In addition, GB22 displayed significant growth inhibition against the activated lymphocytes and Daudi cells, but not against HL-60 or Jurkat cells. These data suggest that these four monoclonal anti-transferrin receptor antibodies will provide additional means to investigate the physiological roles played by the transferrin receptor.

Immunohistology of clotting factor V in human extraembryonic membranes.

Blood clotting Factor V was studied on fixed and unfixed cryostat sections of term human placentae, basal plates, amniochorions, and first-trimester placentae by using one- and two-colour immunofluorescence. A monoclonal antibody (GB36) which reacts with cytotrophoblast was used to identify cytotrophoblast. Factor V was identified in villous cytotrophoblast of term chorionic villi and very weakly or not at all in first-trimester chorionic villi. Other extra-embryonic tissues were non-reactive with anti-Factor V. These data show that Factor V is a useful marker of term villous cytotrophoblast. Immunopathological consequences of this are considered.

Monoclonal antibodies to T cell receptor gamma/delta complex react with human endometrial glandular epithelium.

We have tested a panel of four monoclonal antibodies to the T cell receptor (TCR) gamma/delta heterodimer (delta TCS-1, TS-8, TCR delta-1, anti- C gamma m 1) in pregnant and non-pregnant uteri. The TCR gamma/delta complex was not detected on stromal lymphocytes, but was localized in the cytoplasm of the endometrial glandular epithelium from most pregnant uteri. These antibodies also reacted with endometrial glandular epithelium in a majority of non-pregnant uteri; the reactivity was more consistent in secretory phase glands than that in the proliferative phase of menstrual cycle. However, three different monoclonal antibodies to CD3 (OKT3, leu 4, UCHT-1) failed to show any reactivity, suggesting that the presence of the TCR gamma/delta complex was not associated with CD3 complex. The TCR gamma/delta-positive glandular epithelial cells did not react with two monoclonal antibodies to the TCR alpha/beta complex, and they were also CD4- and CD8-negative. Together with the loss of the class 1 MHC antigens from these endometrial glandular epithelial cells in early pregnancy, these data suggest that these TCR gamma/delta-bearing endometrial glandular cells may undergo phenotypic alterations under local regulation of gene expression.