Prognostic value of baseline FDG uptake on PET-CT in esophageal carcinoma

AIM: To evaluate the influence of baseline maximum standardized uptake value(SUVmax) on survival in a cohort of patients, undergoing positron emission tomography-computed tomography(PET-CT) scan for esophageal carcinoma. METHODS: The pre-treatment SUVmax numeric reading was determined in patients with confirmed esophageal or junctional cancer having PET-CT scan during the time period 1st January 2007 until 31 st July 2012. A minimum follow up of 12 mo was required. Patients were subdivided into quartiles according to SUVmax value and the influence of SUVmax on survival was assessed using univariate and multivariate analysis. The following pre-treatment factors were investigated: patient characteristics, tumor characteristics and planned treatment. RESULTS: The study population was 271 patients(191male) with esophageal or junctional carcinoma. The median age was 65 years(range 40-85) and histologic subtype was adenocarcinoma in 197 patients and squamous carcinoma in 74 patients. The treatment intent was radical in 182 and palliative in 89 patients. SUVmax was linked to histologic subtype(P = 0.008), tumor site(P = 0.01) and Union for International Cancer Control(UICC) stage(P < 0.001). On univariate analysis, prognosis was significantly associated with SUVmax(P = 0.001), T-stage(P < 0.001) and UICC stage(P < 0.001). On multivariate analysis, only T-stage and UICC stage remained significant. CONCLUSION: Pretreatment SUVmax was not a useful marker in isolation for determining prognosis of patients with esophageal carcinoma.

Combination of concurrent endoscopic submucosal dissection and modified peroral endoscopic myotomy for an achalasia patient with synchronous early esophageal neoplasms

Achalasia is generally accepted as a condition associated with an increased risk for developing esophageal squamous cell carcinoma. In our paper, we introduced an achalasia patient combined with synchronous early esophageal neoplasms. We performed a combination of concurrent endoscopic submucosal dissection(ESD) and peroral endoscopic myotomy(POEM). No complications other than postoperative pain that needed morphine treatment for two days had occurred. Dysphagia was significantly improved. Neither reflux nor cough occurred. The short-term efficacy and safety of our case is favorable and suggests that concurrent ESD and POEM could be a treatment option to such patients.

Can patients determine the level of their dysphagia?

AIM To determine if patients can localise dysphagia level determined endoscopically or radiologically and association of gender, age, level and pathology.METHODS Retrospective review of consecutive patients presenting to dysphagia hotline between March 2004 and March 2015 was carried out. Demographics, clinical history and investigation findings were recorded including patient perception of obstruction level (pharyngeal, mid sternal or low sternal) was documented and the actual level of obstruction found on endoscopic or radiological examination (if any) was noted. All patients with evidence of obstruction including oesophagealcarcinoma, peptic stricture, Schatzki ring, oesophageal pouch and cricopharyngeal hypertrophy were included in the study who had given a perceived level of dysphagia. The upper GI endoscopy reports (barium study where upper GI endoscopy was not performed) were reviewed to confirm the distance of obstructing lesion from central incisors. A previously described anatomical classification of oesophagus was used to define the level of obstruction to be upper, middle or lower oesophagus and this was compared with patient perceived level.RESULTS Three thousand six hundred and sixty-eight patients were included, 42.0% of who were female, mean age 70.7 ± 12.8 years old. Of those with obstructing lesions, 726 gave a perceived level of dysphagia: 37.2% had oesophageal cancer, 36.0% peptic stricture, 13.1% pharyngeal pouches, 10.3% Schatzki rings and 3.3% achalasia. Twenty-seven point five percent of patients reported pharyngeal level (upper) dysphagia, 36.9% mid sternal dysphagia and 25.9% lower sternal dysphagia (9.5% reported multiple levels). The level of obstructing lesion seen on diagnostic testing was upper (17.2%), mid (19.4%) or lower (62.9%) or combined (0.3%). When patients localised their level of dysphagia to a single level, the kappa statistic was 0.245 (P < 0.001), indicating fair agreement. 48% of patients reporting a single level of dysphagia were accurate in localising the obstructing pathology. With respect to pathology, patients with pharyngeal pouches were most accurate localising their level of dysphagia(P < 0.001). With respect to level of dysphagia, those with pharyngeal level lesions were best able to identify the level of dysphagia accurately (P < 0.001). No association (P > 0.05) was found between gender, patient age or clinical symptoms with their ability to detect the level of dysphagia.CONCLUSION Patient perceived level of dysphagia is unreliable in determining actual level of obstructing pathology and should not be used to tailor investigations.

Risk of progression of Barrett's esophagus in patients with cirrhosis

AIM To study Barrett's esophagus(BE) in cirrhosis and assess progression to esophageal adenocarcinoma(EAC) compared to non-cirrhotic BE controls.METHODS Cirrhotic patients who were found to have endoscopic evidence of BE confirmed by the presence of intestinal metaplasia on histology from 1/1/2000 to 12/1/2015 at Cleveland Clinic were included. Cirrhotic patients were matched 1:4 to BE controls without cirrhosis. Age, gender, race, BE length, hiatal hernia size, Child-Pugh(CP) class and histological findings were recorded. Cases and controls without high-grade dysplasia(HGD)/EAC and who had follow-up endoscopies were studied for incidence of dysplasia/EAC and to assess progression rates. Univariable conditional logistic regression was done to assess differences in baseline characteristics between the two groups. RESULTS A total of 57 patients with cirrhosis and BE were matched with 228 controls(BE without cirrhosis). The prevalence of dysplasia in cirrhosis and controls weresimilar with 8.8% vs 12% with low grade dysplasia(LGD) and 12.3 % vs 19.7% with HGD or EAC(P = 0.1). In the incidence cohort of 44 patients with median follow-up time of 2.7 years [interquartile range 1.0, 4.8], there were 7 cases of LGD, 2 cases of HGD, and 2 cases of EAC. There were no differences in incidence rates of HGD/EAC in nondysplastic BE between cirrhotic cases and noncirrhotic controls(1.4 vs 1.1 per 100 person-years, P = 0.8). In LGD, cirrhotic patients were found to have higher rates of progression to HGD/EAC compared to control group though this did not reach statistical significance(13.7 vs 8.1 per 100 personyears, P = 0.51). A significant association was found between a higher CP class and neoplastic progression of BE in cirrhotic patients(HR =7.9, 95%CI: 2.0-30.9, P = 0.003). CONCLUSION Cirrhotics with worsening liver function are at increased risk of progression of BE. More frequent endoscopic surveillance might be warranted in such patients.

Treatment of 104 Cases of Chemotherapy-Induced Leukopenia by Injection of Drugs into Zusanli

From April 1992 to April 1998, 104 cases of chemotherapy-induced leukopenia were treated by injection into Zusanli (ST 36) with a mixture consisting of dexamethasone, 654-2, ATP and inosine. The therapeutic results were satisfactory as reported in the following. Clinical Data In this series, all the 127 cases were definitely diagnosed by pathological examination. Of them, 93 were male and 34 female, ranging in age from 12 to 75 years. 38 cases were carcinoma of esophagus, 22 carcinoma of cardia of stomach, 21 cancer of lung, 11 hepatic carcinoma, 8 lymphoma, 8 mammary cancer, 7 carcinoma of colon, and 12 other kinds of the tumors. Leukocyte count was below 4.0×109/L in all the patients after being treated by chemotherapy.