The Temporal Trends And Clinical Characteristics In Patients With Easophageal Carcinoma And Barrettt’s Esophagus

BackgroundEsophageal cancer is one of the most common malignancies worldwide. The incidences of esophageal cancer are different in different regions and races. Studies has confirmed that esophageal cancer ranks the sixth most common form of cancers and a common cause of death in the whole world. Besides, the incidence of esophageal cancer increased year by year.The major pathological type of esophageal cancer in China is still the esophageal squamous cell carcinoma (ESCC, accounted for more than 90%), and the incidence of esophageal adenocarcinoma is low and mainly occurs in the lower segment of the esophagus. Barrett’s Esophagus (BE) refers to the pathological phenomenon that esophageal squamous epithelium is replaced by metaplastic columnar epithelium, which has been proved to be a risk factor of EA. There is a rising trend in its incidence in the world at present. According to the reports of the past 20 years, USA and some Western European countries such as Britain, France, Finland, and Holland, the incidence of EA has been higher than that of ESCC, and become the fastest rise in malignant tumor.In the western countries, BE is considered as the major risk factor of EAdevelopment. Studies showed that 2% to 5% of BE patients might develop into adenocarcinoma.This risk is 30-150 times of the normal population. The prognosis of EA is poor, and the 5 year survival rate is only 13%～15%.The development of BE into EA is a process of multi-period and multi-steps, followed by a series of changes including intestinal metaplasia, mild dysplasia, severe dysplasia, carcinoma in situ and invasive adenocarcinoma. Therefore, early detection and treatment of BE is an important way to prevent the development of BE into EA.To investigate the incidence of BE and the endoscopic andclinical features and treatment methods of its related adenocarcinoma, is also the clinical problems to be solved.Objectives1.To evaluate the trend of clinical characteristics of esophageal cancer in Guangdong General Hospital in recent 10 years, which may provide reference data for the epidemiological investigation of esophageal cancer;2.To investigate the trend and the clinical characteristics of BE inrecent 10 years and the correlationships between EA and its lesion precancerous BE.Methods1.The clinical datas of 1108 patients with esophageal cancer and 612 patients with Barrett’s esophagus confirmed pathologically were collected and analysised. All patients were diagnosed by endoscopy in Weilun Endoscopy Center of Guangdong General Hospital from 2005 to 2014.2.The patients with esophageal cancer were divided into two groups from 2005 to 2009 and from 2010 to 2014 according to the time of receiving gastroscopy examinations. The differences of age, gender, location, pathological type, histological type of the two groups were compared.3.The trends of the incidence, endoscopic findings, histological type of BE from 2005 to 2014 were also analysised.4.The correlationship between esophageal adenocarcinoma and precancerous lesions of Barrett’s esophagus was evaluated.Results1. Changes on clinical characteristics of esophageal cancer1.1 Basic clinical characteristics of patients with esophageal cancerA total of 87805 patients undertook gastroscopy from 2005 to 2014 in Guangdong General Hospital, in which 1108 patients were diagnosed as esophageal cancer. The overall detection rate was 1.3%(1108/87805), among which 881 cases were male, accounting for 79.5%, women in 227 cases, accounting for 20.5%. The male-female ratio was 3.9:1. Male patients with esophageal cancer were more than female.Among all the 1108 cases of esophageal malignant tumor with clear parts, large percentage of the cohort (50.9%) had esophageal cancers in the lower esophageal, most esophageal cancers were located in the middle part of esophageal(29.7%), some were located in the upper part of esophageal(19.4%).At the same time, in 51 cases of EA with clear parts, There were 43 cases in the lower segment of esophagus,5 cases in middle part of esophageal,3 cases in the upper part of esophageal, accounted for 84.3%,9.8%,5.9% of esophageal adenocarcinoma despectively.The difference was statistically significant(χ2=75.03, p<0.001).Indicated that the vast majority of esophageal carcinoma was in the lower segment of esophagus, especially EA was most common in the lower esophageal.Among 1108 cases of esophageal cancer with clear general types, A total of 451 cases were medullar type, accounting for 40.7%,was the most; The second is the ulcer type with 418 cases, accounting for 37.7%;The sclerotic type% and mushroom type were 161 cases (14.5%),81 cases (7.1%), respectively,the proportion is less. The major type of esophageal adenocarcinoma was medullar type, followed by ulcerative type. These two types accounted for 78.4% of esophageal malignant tumor; the constituent ratio of sclerotic type is close to that of mushroom type.In 678 cases of esophageal cancer with clear lesion length, the length less than 5cm accounted for 65.9%(447/678),the length between 6cm and 10cm accounted for 31.6%(214/678),the length more than 10cm accounted for 2.5%(17/678),illustrated that the main lesion length is less than 5cm.The difference was statistically significant(χ2=88.9, p<0.001).According to the classification standard of the 2002 edition of WHO of esophageal cancer, The major pathological type of esophageal cancer is squamouscell carcinoma, there were 1023 cases(1023/1108), accounting for 92.3%,the second type was adenocarcinoma, with 51 cases(51/1108), accounting for 4.6%,In addition, it have been found 19 cases of small cell carcinoma,5 cases of adenosquamous carcinoma,4 cases of mucinous adenocarcinoma,3 cases of neuroendocrine carcinoma,2 cases of sarcomatoid carcinoma,1 cases of spindle cell carcinoma.Among 1108 cases of esophageal cancer, tumor differentiation was available for 585 cases (55.8%), of which 26 (4.4%) were well differentiated; 433 (70.0%) were moderately differentiated and 126(21.5%) were poorly differentiated. The difference was statistically significant(χ2=75.03, p<0.001).This indicated that the major differentiation degree of esophageal cancer was moderately differentiated. There were 975 cases (94.8%) of advanced esophageal cancer and 53 cases (5.2%) of early esophageal cancer in 1028 cases which were available for esophageal cancer staging.1.2 Analysis of Change in clinical characteristics of esophageal cancerThe detection numbers of esophageal cancer in the first group(2005-2009)were509 cases(509/40763),with 12 EA cases, accounting for 2.4%;the second group(2010-2014); the detection of that in the second group(2010-2014) were 599 cases(599/47042,1.3%),with 39 EA cases, accounting for 6.5%, the detection rate of esophageal cancer between two groups has no significant difference. While the constituent ratio of EA of the second group was significantly increased than that of the first one(6.5% VS 2.4%,χ2=4.264, p=0.04). Patients were getting older in the 2nd period (median age 62 years old) than the 1st period (60 years; p> 0.05). Esophageal cancer mostly occurred in the old people(50-69years old), accounting for 63.5%, and 13.2% in those patients younger than50 years old;23.3% in those older than70 years.The sex ratio of the two period was 4.2:1 (407:102)and 3.8:1 (474:125)respectively, there was no significant difference(χ2=3.5, p=0.06)Besides the changes in factors of esophageal cancer, the percentage of the upper esophageal carcinoma, the middle esophageal carcinoma and the lower esophageal cancer of the two peroids were 15.7%、28.9%、53.6% and 22.7%、28.2%、 49.1%,respectively;with statistical significance(p<0.01).Its proved that the detection rate of upper esophageal cancer in the 2nd period was significantly high than that of the 1 st period,but the predilection site of esophageal cancer was in the low esophagus. Esophageal cancer of early stage in 2nd period (2009-2014) was more common than 1st period (2005-2009) (χ2=4.8, p=0.03).2. Analysis of the clinicopathologic feature of Barrett’s esophagus2.1 The data of patients with Barrett’s esophagusA total of 612 patients undertook gastroscopy from 2005 to 2014 in Guangdong General Hospital were diagnosed as Barrett’s esophagus in overall 87805 patients, the canceration rate was 0.7% and the male-female ratio was 1.7:1 (388:224). The median age of the patients was 49 years old (18-86). All the patients were divided into young-age(0-44years old), middle-aged(45-59years old) and elderly ones(≥60years old). The percentage of patients with BE in younger-age (38.9%,238/612) was higher than those in middle-age (37.9%,232/612) and those older than 60 years old (23.2%, 142/612),indicated that the youth and middle-aged people were the main disease groups of BE.2.2 The data of Barrett’s esophagus under gastroscopyThe endoscopic morpholophy of Barrett’s esophagus have three types.They are island type、tongue type and full week type.Most of the diagnosed Barrett’s esophagus are island type, accounting for 73.4%(499/612).Then the tongue type,accounting for 24.5%(150/612),the full week type were just 2.1%,(13/612),which indicated that the major endoscopic morphology of BE was island type.2.3 Pathologic characteristics of Barrett’s esophagusAccording to the histopathological types, BE could be divided into the fundic type、the cardiac type、intestinal metaplasia type、mild dysplasia and severe dysplasi.The intestinal metaplasia is precancerous lesions. Among all the 612 patients of BE in 10 years,fundic type were the major type, counting for 41.0%(251/612),then the cardiac type,the percentage is 39.0% (238/612),the percentage of intestinal metaplasia type and mild dysplasia were 13.8%(85/612)、 6.2%, (38/612),respectively. The type of severe dysplasia didn’t found.2.4 Analysis of trend of clinical characteristics of Barrett’s esophagusDetection rates in different groups (2005-2009,2010-2014) were 0.4% (153/40763) and 1.0%(459/47042), respectively, with significant difference (χ2=4.3, p=0.04), illustrated that the incidence of BE is rising in recent years. And the median age of the patients between two periods without increasing trend. (Both 48 years).All the patients were divided into young-age(<45 years old), middle-aged (45-59years old) and elderly ones(≥60years old). In the 1st five years, the number of the young-age、 middle-aged and elderly ones were 62 cases (62/153,40.5%),58cases (58/153,37.9%) and 33cases(33/153,21.6%), seperately, while in the 2nt five years, the proportion of the three groups were 38.3%(176/459)、37.9%)(174/459) and 23.7%(109/459),which indicated that despite of the rising incidence of BE, the age of onset is still dominated by the young people. The sex ratio of the two period was 1.9:1(100:53) and 1.7:1(288:171) respectively, there was no significant difference (p=0.06).The major endoscopicmorpholophy of BE in two period were both island type (56.7%VS 58.5%), without significant difference. While the histopathological type of intestinal metaplasia was more likely to occur in the 2nd period (2010-2014) than those in the 1st one (χ2=34.06, p<0.04). The constituent ratio of intestinal metaplasia in the second group was higher than that of the first one.Conclusionsl.The detection rate of Barrett’s esophagus by gastroscopy rises from 2005 to 2014, which reflects the rising trend in incidence of Barrett’s esophagus in Guangzhou area.2. The major pathological type of esophageal cancer is still squamous cell carcinoma, while the constituent ratio of EA has increased significantly in recent years.3. The constituent ratio of intestinal metaplasia type of BE is growing, which supports the viewpoint that intestinal metaplasia is the precancerous lesion of EA, early endoscopic intervention should be taken to reduce the progression from BE to EA.