| ObjectivesTo explore whether routine biopsies at the high incidence spot of EGJA are justified in endoscopic screening; To investigate the trend of the incidence on EGJA among areas with high incidence of esophageal cancer in China; To evaluate the etiological association between EGJA and gastroesophageal reflux using Meta analysis.Material and Methods1. Evaluation of routine biopsies in endoscopic screening for EGJA:This was a multicenter population-based study conducted in eight high-risk areas in China. A total of37396participants underwent endoscopic examination. Biopsies were obtained from visible mucosal abnormalities or from normal-appearing mucosa at the high incidence spot of esophagogastric junction cancer when no abnormality was detected. Specimens showing high-grade intraepithelial neoplasia (HIN) or higher grade lesions were deemed as pathologically "positive". The ratios of positive pathologic diagnosis between participants with abnormal and normal-appearing mucosa were compared using the Pearson x2test. Odds ratios and95%confidence intervals, adjusted for potential confounders, were calculated using logistic regression.2. Trend analysis of EGJC:Total number of EGJA, gastric cancer and esophageal cancer cases of each site were obtained from the National Cancer Registry. Frequency table and tendency chart were made by SPSS.17.0. Spearman coefficients were calculated between time and the number of EGJA cases. The numbers of EGJA cases were also compared with the numbers of cases detected from screening program from2006to2008.3. Meta analysis on the association between gastroesophageal reflux and EGJA: relevant literature on the etiological association between EGJA and gastroesophageal reflux were retrieved from Pubmed, EMBase; SpringerLink Journals, Wiley Online Library Journals and Wangfang, Weipu, CNK1, as well as Sinomed. Studies were included when certain inclusion and exclusion criteria were met. STROBE statement was used for quality assessment. Primary data and odds ratio (OR) were extracted. Summary OR estimates and95%confidence intervals (95%CI) were calculated using random-effects model. We used Stata12.0to draw forest plots and funnel plots. Analyses for heterogeneity, publication bias and sensitivity were also conducted.Results1. A total of37520individuals participated in this study and37396(99.7%) participants had full information and were suitable for analyses. During endoscopic examinations,9.11%(3405/37396) participants were found to have visible mucosal lesions. Of the participants who had normal-appearing mucosa at the EGJ, only0.28%(94/33991) were diagnosed with HIN or higher grade lesions, whereas6.05%(206/3405) of participants with abnormalities at the EGJ had a positive pathologic result. After controlling for other variables, visible abnormal mucosa detected under endoscopy strongly predicted a positive pathologic result (OR=32.51,95%CI:23.96-44.09).2. From1988to2009,7973new cases of EGJA were reported in Linzhou and2817in Cixian. The new cases reported from Linzhou in2009were1.82fold of those in1988, and the situation was6.17fold in Cixian. The Spearman coefficients were0.711and0.933respectively for Linzhou and Cixian between time and cases reported3. Six articles were considered for Meta analysis. A total of4127participants were included, with963cases and3209controls. For EGJA, summary OR was2.104,95%CI=1.134-3.903. Heterogeneity tests showed that Q=42.43,I2=88.2%,P<0.1, indicating significant heterogeneity between included studies. Meta regression results showed that detected heterogeneity could be attributed to sample size, study origins, diagnosis criteria and year of publishing. No publication bias was detected by Egger tests. Sensitivity tests showed that no significant difference was observed when one given study was omitted.Conclusions1. We found that visible mucosal abnormalities of the EGJ at endoscopy were strongly associated with pathologic diagnoses of high-grade intraepithelial neoplasia or higher grade lesions. When no abnormalities were detected, routine biopsies from normal-appearing mucosa at the high incidence spot in endoscopic screening were unjustified in high-risk populations.2. The clustering of upper gastrointestinal carcinomas was observed in areas traditionally with only high incidence of esophageal cancer.3. EGJA is increasingly prevalent among regions traditionally with high incidence of esophageal cancer. And the screening program for EGJA has little effect on the rising incidence of EGJA in these areas.4. Gastroesophageal reflux is significantly associated with EGJA, OR=2.104,95%CI=1.134-3.903, providing new additional evidence for the two-etiology theory of EGJA. |
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