Vitamin D in esophageal cancer: Is there a role for chemoprevention?

Vitamin D has emerged as a promising anti-cancer agent due to its diverse biological effects on tumor differentiation, apoptosis and suppression of cellular proliferation. Current evidence suggests a protective role of vitamin D in colon cancer. The effect of vitamin D on esophageal cancer remains controversial. Multiple studies investigated the association between vitamin D and esophageal cancer, employing different modes of assessment of vitamin D status such as serum 25-hydroxyvitamin D levels, vitamin D dietary intake or exposure to ultraviolet B(UVB) radiation. Genetic variations of the vitamin D receptor(VDR) gene and VDR expression in esophageal specimens have also been investigated. Ecological studies evaluating exposure to UVB radiation yielded an inverse correlation with esophageal cancer. When vitamin D dietary intake was assessed, direct association with esophageal cancer was observed. However, circulating 25-hydroxyvitamin D concentrations showed inconsistent results. In this review article, we present a detailed summary of the current data on the effects of vitamin D on various histological subtypes of esophageal cancer and their precursor lesions. Well-powered prospective studies with accurate measurement of vitamin D status are needed before chemoprevention with vitamin D is recommended, as current evidence does not support a chemopreventive role of vitamin D against esophageal cancer. Future studies looking at the incidence of esophageal cancer in patients with pre-cancerous lesions(Barrett's esophagus and squamous cell dysplasia) receiving vitamin D supplementation are needed.

Lymphocytic esophagitis: Still an enigma a decade later

Lymphocytic esophagitis (LE) is a clinicopathologic entity first described by Rubio et al in 2006. It is defined as peripapillary intraepithelial lymphocytosis with spongiosis and few or no granulocytes on esophageal biopsy. This definition is not widely accepted and the number of lymphocytes needed to make the diagnosis varied in different studies. Multiple studies have described potential clinical associations and risk factors for LE, such as old age, female gender and smoking history. This entity was reported in inflammatory bowel disease in the pediatric population but not in adults. Other associations include gastroesophageal reflux disease and primary esophageal motility disorders. The most common symptom is dysphagia, with a normal appearing esophagus on endoscopy, though esophageal rings, webs, nodularities, furrows and strictures have been described. Multiple treatment modalities have been used such as proton pump inhibitors and topical steroids. Esophageal dilation seems to be therapeutic when dysphagia is present along with esophageal narrowing secondary to webs, rings or strictures. The natural history of the disease remains unclear and needs to be better delineated. Overall, lymphocytic esophagitis seems to have a chronic and benign course, except for two cases of esophageal perforation in the literature, thought to be secondary to this entity.

Successful liver transplantation for acute sickle cell intrahepatic cholestasis: A case report and review of the literature

BACKGROUND Sickle cell hepatopathy(SCH)is an inclusive term referring to any liver dysfunction among patients with sickle cell disease.Acute sickle cell intrahepatic cholestasis is one of the rarest and most fatal presentations of SCH.We present the 23rd reported case of liver transplantation(LT)for SCH;a rare case of acute sickle cell intrahepatic cholestasis managed with LT from a hepatitis C virus(HCV)nucleic acid amplification test positive donor.CASE SUMMARY A 29-year-old male with a past medical history of sickle cell disease presented with vaso-occlusive pain crisis.On examination,he had jaundice and a soft,nontender abdomen.Initially he was alert and fully oriented;within 24 h he developed new-onset confusion.Laboratory evaluation was notable for hyperbilirubinemia,leukocytosis,anemia,thrombocytopenia,acute kidney injury and elevated international normalized ratio(INR).Imaging by ultrasound and computed tomography scan suggested a cirrhotic liver morphology with no evidence of biliary ductal dilatation.The patient was diagnosed with acute sickle cell intrahepatic cholestasis after excluding competing etiologies of acute liver injury.He underwent LT from an HCV nucleic acid amplification test positive donor 9 d after initial presentation.The liver explant was notable for widespread sinusoidal dilatation with innumerable clusters of sickled red blood cells and cholestasis.On postoperative day 3,HCV RNA was detectable in the patient's peripheral blood and anti-HCV therapy with glecaprevir/pibrentasvir was initiated on postoperative day 23.He subsequently achieved sustained virologic response after completing 3 mo of therapy and has been followed clinically for 12 mo post-transplant.CONCLUSION This case highlights the utility of LT as a viable treatment option for acute sickle cell intrahepatic cholestasis.