Targets for molecular therapy in esophageal squamous cell carcinoma: an immunohistochemical analysis

SUMMARY.  Neoadjuvant chemotherapy may improve the outcome of esophageal cancer after esophagectomy, but is accompanied by considerable toxicity by collateral destruction of normal cells. Such side effects may be avoided by developing therapies that specifically target molecular characteristics of tumors. The aim of the present study was to determine the proportion of esophageal squamous cell carcinoma (ESCC) patients that could possibly benefit from (a combination of) currently available targeted therapies, by assessing the frequency of immunohistochemical expression of their target molecular markers in ESCC tissues. Sections from a validated tissue microarray comprising 108 ESCCs were immunohistochemically stained for Bcl-2, c-KIT, cyclo-oxygenase-2 (COX-2), cyclin D1, estrogen receptor (ER), epidermal growth factor receptor (EGFR), Her-2/neu, progesterone receptor (PR), and vascular endothelial growth factor (VEGF). VEGF, cyclin D1, EGFR, and COX-2 could be detected in 55, 42, 40, and 40%, respectively. Her-2/neu, Bcl-2, and c-KIT were detected in 12, 11, and 10% of the tumors, respectively. No nuclear expression of ER or PR was noticed. Concurrent expression of two markers was noticed in 28% of ESCCs, whereas 25% of ESCCs showed concurrent expression of three markers. The concurrent expression of two of the most frequently expressed markers (VEGF, cyclin D1, EGFR, and COX-2) ranged from 11 (COX-2 and EGFR) to 26% (cyclin D1 and VEGF). The expression of all of these four markers was seen in 5% of ESCCs. Promising targets for molecular therapy in ESCC appear to be COX-2, VEGF, EGFR, and cyclin D1, as they are frequently overexpressed. Phase II clinical studies on these molecular markers may therefore be warranted. The role for targeted therapy against ER, PR, Her-2/neu, c-KIT, or Bcl-2 in ESCC seems limited.     

食管癌核基质抗体的免疫组化研究

目的研究食管癌核基质抗体的肿瘤特异性和组织学特异性．方法用人食管癌组织提取核基质抗原，制备核基质抗体，采用免疫组织化学方法对食管癌４１例（男２６例，女１５例，年龄５３岁±７２岁）、正常食管粘膜８例、食管粘膜异型增生１５例、肺鳞癌１０例、喉癌１０例、胃腺癌１０例以及大鼠食管癌５例进行免疫组化染色．结果食管癌核基质抗体在食管癌组织中表达有特异性（３２／４１，７８０％），与正常食管粘膜（１／８，１２５％）及胃腺癌（２／１０，２００％）有非常显著差异（Ｐ＜００１），与食管异常增生（７／１５，４６７％）、肺鳞癌（３／１０，３００％）、喉鳞癌（４／１０，４００％）差异明显（Ｐ＜００５），但与大鼠食管癌组织（２／５，４００％）差异不明显．食管癌核基质的表达，在不同分化程度的食管癌组织中无明显差异（Ｐ＞００５）；在淋巴结转移阳性组高于淋巴结转移阴性组（１７／１８，９４４％ｖｓ１５／２３，６５２％，Ｐ＜００５）．结论食管癌核基质抗体具有较好肿瘤和组织学特异性，对肿瘤转移有一定影响，可作为食管癌的一项新标记物．     

自身免疫性肝炎的标准治疗和潜在治疗靶点

自身免疫性肝炎(AIH)是一种由自身免疫反应介导的肝脏炎症性疾病,未经积极治疗可发展为肝衰竭、肝硬化。AIH的治疗目标为获得生化缓解和组织学缓解。目前标准治疗方案为免疫抑制剂疗法,即泼尼松(龙)联合硫唑嘌呤或泼尼松(龙)单药治疗。患者对标准治疗方案不耐受或应答不佳时,可考虑启动包括吗替麦考酚酯在内的二线治疗方案。近年来研究表明,免疫功能、肠道菌群、维生素D、心理状态等多种因素参与AIH的发生发展,可作为AIH的潜在治疗靶点。综述了近年来AIH治疗方案的相关研究及潜在治疗靶点。     

Comparative outcomes for three‐dimensional conformal versus intensity‐modulated radiation therapy for esophageal cancer

Emerging data suggests a benefit for using intensity modulated radiation therapy (IMRT) for the management of esophageal cancer. We retrospectively reviewed patients treated at our institution who received definitive or preoperative chemoradiation with either IMRT or 3D conformal radiation therapy (3DCRT) between October 2000 and January 2012. Kaplan Meier analysis and the Cox proportional hazard model were used to evaluate survival outcomes. We evaluated a total of 232 patients (138 IMRT, 94 3DCRT) who received a median dose of 50.4 Gy (range, 44–64.8) to gross disease. Median follow up for all patients, IMRT patients alone, and 3DCRT patients alone was 18.5 (range, 2.5–124.2), 16.5 (range, 3–59), and 25.9 months (range, 2.5–124.2), respectively. We observed no significant difference based on radiation technique (3DCRT vs. IMRT) with respect to median overall survival (OS) (median 29 vs. 32 months; P = 0.74) or median relapse free survival (median 20 vs. 25 months; P = 0.66). On multivariable analysis (MVA), surgical resection resulted in improved OS (HR 0.444; P < 0.0001). Superior OS was also associated on MVA with stage I/II disease (HR 0.523; P = 0.010) and tumor length ≤5 cm (HR 0.567; P = 0.006). IMRT was also associated on univariate analysis with a significant decrease in acute weight loss (mean 6% + 4.3% vs 9% + 7.4%, P = 0.012) and on MVA with a decrease in objective grade ≥3 toxicity, defined as any hospitalization, feeding tube, or >20% weight loss (OR 0.51; P = 0.050). Our data suggest that while IMRT‐based chemoradiation for esophageal cancer does not impact survival there was significantly less toxicity. In the IMRT group there was significant decrease in weight loss and grade ≥3 toxicity compared to 3DCRT.     

Targeted therapy in esophageal cancer

An increasing number of patients are diagnosed with esophageal cancer at an advanced stages, and only a small group of them can benefit from the traditional chemotherapy and radiotherapy. So far, multiple monoclonal antibodies and tyrosine kinase inhibitors have been developed, alone or in combination with traditional therapy, to improve the prognosis of patients with advanced esophageal cancer. This review summarizes the recent advances of targeted therapies against EGFR, HER2, VEGFR and c-MET in esophageal cancer. More clinical trials should be performed to evaluate the efficacy and safety of various targeted therapy regimens. Future basic research should focus on investigating the molecular mechanisms of therapeutic targets in esophageal cancer.     

Array comparative genomic hybridization identifies novel potential therapeutic targets in cholangiocarcinoma

Background

Cholangiocarcinoma (CC) is a rare tumour with a dismal prognosis. As conventional medical management offers minimal survival benefit, surgery currently represents the only chance of cure. We evaluated DNA copy number (CN) alterations in CC to identify novel therapeutic targets.

Methods

DNA was extracted from 32 CC samples. Bacterial artificial chromosome (BAC) array comparative genomic hybridization was performed using microarray slides containing 3400 BAC clones covering the whole human genome at distances of 1 Mb. Data were analysed within the R statistical environment.

Results

DNA CN gains (89 regions) occurred more frequently than DNA CN losses (55 regions). Six regions of gain were identified in all cases on chromosomes 16, 17, 19 and 22. Twenty regions were frequently gained on chromosomes 1, 5, 7, 9, 11, 12, 16, 17, 19, 20 and 21. The BAC clones covering ERBB2, MEK2 and PDGFB genes were gained in all cases. Regions covering MTOR, VEGFR 3, PDGFA, RAF1, VEGFA and EGFR genes were frequently gained.

Conclusions

We identified CN gains in the region of 11 useful molecular targets. Findings of variable gains in some regions in this and other studies support the argument for molecular stratification before treatment for CC so that treatment can be tailored to the individual patient.     

Concurrent erlotinib and radiotherapy for chemoradiotherapy‐intolerant esophageal squamous cell carcinoma patients: results of a pilot study

Concurrent chemoradiotherapy is the standard treatment for patients with locally advanced esophageal squamous cell carcinoma. However, a number of patients present intolerance to chemoradiotherapy because of advanced age or malnutrition. Erlotinib, an inhibitor of epidermal growth factor receptor tyrosine kinase, was shown to be effective in treating esophageal carcinoma, with mild toxicities. In this pilot study, we investigated the safety and efficacy of concurrent erlotinib and radiotherapy as an alternative treatment modality for esophageal carcinoma patients who are intolerant to chemoradiotherapy. Pathologically diagnosed esophageal squamous cell carcinoma patients who could not tolerate concurrent chemoradiotherapy were enrolled. All patients were treated with concurrent erlotinib and intensity‐modulated radiation therapy. Erlotinib was given orally for 60 days (150 mg per day). Radiotherapy (total dose, 60 Gy) was given at dosages of 2 Gy for a total of 30 times. Immunohistochemical staining was performed to assess epidermal growth factor receptor expression. Toxicities were evaluated according to the National Cancer Institute Common Terminology Criteria for Adverse Events (version 3.0). The overall survival, progression‐free survival, and local–regional relapse‐free survival were calculated using the Kaplan–Meier method. Between December 2007 and March 2011, 18 patients were enrolled. The median age was 71.5 years. Primary disease was stages II, III, and IV in 3, 8, and 4 patients, respectively. There were three patients with recurrent disease after radical surgery. The median follow‐up time was 17.2 months. Grade 3 esophagitis and skin rash were observed in five (27.8%) and two (11.1%) patients, respectively. Radiation pneumonitis of grades 2 and 5 was observed in one patient each. No grade 3/4 impaired liver function or hematological toxicity was observed. At 1 month after radiotherapy, two (11.1%) patients achieved complete response, 11 (61.1%) patients achieved partial response, and 5 (27.8%) patients had stable disease. The median time of overall survival and progression‐free survival was 21.1 and 12 months, respectively. Two‐year overall survival, progression‐free survival, and local–regional relapse‐free survival were 44.4%, 38.9%, and 66.7%, respectively. Five of six patients examined for epidermal growth factor receptor had high expression levels (3+). The relationship between epidermal growth factor receptor expression and treatment outcomes could not be concluded. For esophageal squamous cell carcinoma patients who cannot tolerate chemoradiotherapy, concurrent erlotinib and radiotherapy are tolerable and effective. Valuable markers to predict the effect of erlotinib should be exploited in future studies.     

Advances in understanding the molecular mechanism of pancreatic cancer metastasis

BACKGROUND: Pancreatic cancer (PC) is usually diagnosed at the late-stage and therefore, has widespread metastasis and a very high mortality rate. The mechanisms underlying PC metastasis are not well understood. Recent advances in genomic sequencing have identiifed groups of gene mutations that affect PC metastasis, but studies elucidating their roles are lacking. The present review was to investigate the molecu-lar mechanisms of PC metastasis.
DATA SOURCES: Relevant articles on PC metastasis were searched in MEDLINE via PubMed prior to April 2015. The search was limited in English publications.
RESULTS: PC metastatic cascades are multi-factorial events including both intrinsic and extrinsic elements. This review highlights the most important genetic alterations and other mechanisms that account for PC invasion and metastasis, with particular regard to epithelial-mesenchymal transition, inlfammation, stress response, and circulating tumor cells.
CONCLUSIONS: Analyses of relevant gene functions and signaling pathways are needed to establish the gene regula-tory network and to deifne the pivotal modulators. Another promising area of study is the genotyping and phenotyping of circulating tumor cells, which could lead to a new era of per-sonalized therapy by identifying speciifc markers and targets.     

Therapy‐related leukemia following chemoradiotherapy for esophageal cancer

Chemoradiotherapy has improved the outcome of patients with esophageal cancer. Although a sufficiently long‐time survival has resulted in the increase of several treatment‐related late toxicities, little is still known about the incidence of secondary malignancies. In our hospital, 348 patients with esophageal cancer received chemotherapy consisting of nedaplatin and 5‐fluorouracil and concurrent irradiation. Median and average follow‐up durations were 8 and 21 months (1–92), respectively. Four patients developed leukemia after 19–48 months of follow‐up. Two patients were diagnosed with overt leukemia from myelodysplastic syndrome presenting a complex karyotype, including the deletion of chromosome 5 or 7. Notably, one patient showed an additional chromosomal abnormality with t(9;22)(q34;q11). Other patients developed acute myeloid leukemia with t(9;22)(q34;q11) and Burkitt leukemia with t(8;14)(q24;q32). All patients eventually succumbed to leukemia. Platinum and fluorouracil have shown relatively lower risks for secondary malignancies in comparison with alkylating agents and topoisomerase II inhibitors. Especially, nedaplatin has never been described to introduce secondary neoplasms. Our report supports the idea that the concurrent administration of radiotherapy with these agents affects the risk of leukemia. Interestingly, rare balanced chromosomal abnormalities were observed in the present cases, thus providing new insights into the leukemogenesis of therapy‐related leukemia.     

Utility of weekly docetaxel combined with preoperative radiotherapy for locally advanced esophageal cancer from pathological analysis

Esophageal squamous cell cancer (ESCC) is a high‐grade carcinoma that is treated with multidisciplinary approaches, including chemoradiotherapy (CRT) followed by surgery. Despite some success with these therapies, overall survival remains poor. In order to investigate a newer CRT regimen, we designed a comparative study to evaluate preoperative CRT using docetaxel (DOC) or 5‐Fluorouracil and cisplatin (FU+CDDP [FP] therapy) for treatment of resectable ESCC. In a retrospective review of patients with resectable, locally advanced ESCC, 95 patients received preoperative CRT between 2001 and 2007. CRT was administered using either FP (n = 40) or DOC (n = 55). Pathological response and clinical outcomes were compared between the two groups. Hazard ratios and time‐to‐event analyses were used to assess outcomes; the ratios were controlled by multivariate logistic regression analysis of potential prognostic factors, and survival was presented with Kaplan–Meier curves. In the FP group, a significant curative effect was observed on the basis of pathological examination of postoperative lesions. However, the DOC group presented a significantly better prognosis on the basis of cumulative survival rates. Logistic regression analysis revealed that the presence of five or more lymph node metastases was an independent predictor of reduced survival. Patients with lymph node metastasis exhibited a better prognosis in the DOC group than those in the FP group. Preoperative CRT for locally advanced esophageal cancer using DOC results in similar or better long‐term outcomes compared with FP‐based CRT. Therefore, CRT using DOC is a promising therapy option for esophageal cancer.     

原发性肝癌的分子靶向治疗进展

肝细胞癌的发生率在全世界排名第五，在中国也是较常见的恶性肿瘤。其主要的致病因素包括慢性B型肝炎及慢性C型肝炎病毒的感染、黄曲毒素（ariatoxin）对食物的污染、及长期饮酒造成的肝脏损害^[1]。手术切除是原发性肝癌的基本治疗手段，相对早期或病灶局限的中晚期患者可接受手术。     

Predictive and prognostic molecular markers in outcome of esophageal cancer

Despite improvements in detection, surgical resection and (neo-) adjuvant therapy, the overall survival in esophageal cancer remains lower than in other solid tumors. In fact, less than 20% of patients with advanced esophageal cancer benefit from a neoadjuvant therapy. Therefore predictive/prognostic markers are needed to allow tailored (radio-) chemotherapy with increased efficacy and decreased toxicity. Recently potential predictive/prognostic factors have been characterized by innovative molecular-based technologies. These factors include growth-factor receptors, enzymes of angiogenesis, tumor suppressor genes, cell cycle regulators, enzymes involved in the DNA repair system, in apoptosis and in the degradation of extracellular matrix. The results of these mostly retrospective studies are promising but prospective studies are needed to validate those markers in the multimodal therapy of esophageal cancer.     

Current concepts and future potential in neoadjuvant chemotherapy for esophageal cancer

Many trials have evaluated preoperative chemotherapy for the treatment of locally advanced esophageal cancer (LAEC). Most studies were small with conflicting results and no clear evidence of survival advantage. However, two large trials that included squamous cell carcinomas and adenocarcinomas of the esophagus produced opposite outcomes with one showing limited benefit and the other showing none. Recent meta-analyses suggest only a modest benefit from induction chemotherapy in the treatment of LAEC. Two factors associated with prolonged survival are: (1) an R0 resection and (2) pathological complete remission. Preoperative chemotherapy is preferred in Europe for adenocarcinomas; however, chemoradiation has been the treatment of choice in the US. The individualization and optimization of therapy for esophageal cancer patients may come from an in-depth understanding of molecular biology and the development of predictive biomarkers. The use of targeted and immunotherapy agents in the preoperative setting are also promising and warrant further evaluation.     

Is tissue still the issue in detecting molecular alterations in lung cancer?

Molecular biomarker testing of advanced‐stage NSCLC is now considered standard of care and part of the diagnostic algorithm to identify subsets of patients for molecular‐targeted treatment. Tumour tissue biopsy is essential for an accurate initial diagnosis, determination of the histological subtype and for molecular testing. With the increasing use of small biopsies and cytological specimens for diagnosis and the need to identify an increasing number of predictive biomarkers, proper management of the limited amount of sampling materials available is important. Many patients with advanced NSCLC do not have enough tissue for molecular testing and/or do not have a biopsy‐amenable lesion and/or do not want to go through a repeat biopsy given the potential risks. Molecular testing can be difficult or impossible if the sparse material from very small biopsy specimens has already been exhausted for routine diagnostic purposes. A limited diagnostic workup is recommended to preserve sufficient tissue for biomarker testing. In addition, tumour biopsies are limited by tumour heterogeneity, particularly in the setting of disease resistance, and thus may yield false‐negative results. Hence, there have been considerable efforts to determine if liquid biopsy in which molecular alterations can be non‐invasively identified in plasma cell‐free ctDNA, a potential surrogate for the entire tumour genome, can overcome the issues with tissue biopsies and replace the need for the latter.     

肺癌分子靶向治疗的研究现状

肺癌是当今世界上严重威胁人类生命与健康的恶性肿瘤性疾病之一,每年有超过100万人死于肺癌.其发病率和病死率逐年增高,引起了越来越多研究者的关注.其中,非小细胞肺癌占肺癌总数的80％～85％.肺癌的分子靶向治疗成为新近研究的热点,是21世纪肺癌治疗最具希望的方法和策略,让人们看到了曙光.     

Prospective comparison of transthoracic versus transhiatal esophagectomy following neoadjuvant therapy for esophageal cancer

Transthoracic esophagectomy (TT) has been championed as a better cancer operation than transhiatal esophagectomy (TH) because the approach facilitates meticulous wide tumor excision and lymphadenectomy. However, neoadjuvant chemoradiotherapy (CRTS) and chemotherapy (CS) have been reported to improve outcomes, and we aimed to compare outcomes after multimodal therapy related to the operative approach. One hundred and fifty-one consecutive patients were studied prospectively. All patients were staged with computed tomography and endoluminal ultrasound, and treatment decisions were related to stage and performance status. One hundred and nineteen TT (median age 58 years, 92 male, 54 CRTS, 65 CS) were performed compared to 32 TH (median age 57 year, 27 male, 14 CRTS, 18 CS). Primary outcome measure was survival. Post-operative morbidity and mortality were 54% and 4%, respectively, after TT compared with 59% and 6% after TH (chi2 0.239 df 1, P=0.625). Recurrent cancer was no less frequent after TT (52%) than after TH (37.5%, chi2 2.151 df=1, P=0.142). Cumulative uncorrected 5-year survival was 34% after TT compared with 53% after TH (log rank 1.44, df=1, P=0.2298). Median survival was also similar in lymph node positive patients (TT vs. TH, 23 months vs. 22 months, respectively, log rank 0.25, df=1, P=0.6199). Despite the fact that patients receiving multimodal therapy and a TH esophagectomy were less fit, operative morbidity, mortality and recurrence were similar, and survival did not differ significantly when compared with multimodal TT esophagectomy.     

Insights into the potential use of microRNAs as a novel class of biomarkers in esophageal cancer

MicroRNAs (abbreviated miRNAs) have been demonstrated to be involved in tumorigenesis and cancer development and proposed as promising biomarkers in cancer diagnosis. Numerous studies have observed the aberrant expression of miRNAs in esophageal cancer. However, there are some discrepant results. Thus, we conducted this meta‐analysis to identify the overall accuracy of miRNAs in the diagnosis of esophageal cancer. A comprehensive literature search was conducted in PubMed and other databases using combinations of key words. The summary receiver operator characteristic curves were plotted to assess the overall diagnostic performance of miRNAs. Chi‐squared and I² tests were used to assess the heterogeneity between studies. Additionally, we conducted subgroup and sensitivity analyses to analyze the potential sources of heterogeneity. In total, 33 studies from 12 articles were available in this meta‐analysis. The pooled sensitivity, specificity, positive and negative likelihood ratio (PLR, NLR) diagnostic odds ratio, and area under the curve were 0.80, 0.80, 4.0, 0.25, 16, and 0.87, respectively. Subgroup analyses based on the sample types (saliva‐, serum‐ and plasma‐based) showed no differences in the diagnostic accuracy of each subgroup. An independent meta‐analysis of eight articles was conducted to evaluate the diagnostic accuracy of miRNAs in patients with esophageal squamous cell carcinoma, with a pooled sensitivity of 0.77, specificity of 0.83, PLR of 4.4, NLR of 0.27, diagnostic odds ratio of 16, and area under the curve of 0.87. In conclusion, this meta‐analysis demonstrates the feasibility of using miRNAs as non‐invasive biomarkers to discriminate esophageal cancer from healthy controls. However, further high‐quality studies on more clearly defined esophageal cancer patient are needed to confirm our conclusion.     

凋亡抑制蛋白家族在食管癌分子靶向治疗中的研究进展

细胞凋亡与抗细胞凋亡信号通路在胚胎及淋巴细胞发育、免疫系统调控、组织稳定及肿瘤发生中发挥着重要作用.研究发现凋亡抑制蛋白(inhibitor of apoptosis proteins,IAPs)在多种恶性肿瘤组织中高表达,并与肿瘤的发生、发展、放化疗抵抗性及预后密切相关,使其成为肿瘤分子靶向治疗的研究热点.近年来,多种靶向IAPs药物正在进行临床试验评估,并在试验中显示出较好的治疗前景.同样,IAPs在食管癌发生发展中有着重要的地位,使其成为食管癌分子靶向治疗潜在的靶点.本文主要对IAPs在食管癌分子靶向治疗的研究进展进行综述.