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W1029 Development and Validation of a Simple Scoring System for Prediction of Lymph Node Metastases in Esophageal Cancer
AGA Abstracts
is defined by SNPs rs10505477 and rs7014346, thereby limiting the susceptibility region to 17 Kilobases of genomic sequence. In the subgroup analysis, association was confined to MSI-stable tumors with an odds ratio of 1.71. Conclusion: This study confirms the role of 8q24.21 as a risk factor for CRC, that is relevant across populations and excerts it's effect mainly in MSI-stable tumors. The haplotype structure in Germans allows refinement of the susceptibility interval to 17 Kilobases of genomic sequence.
W1029 Development and Validation of a Simple Scoring System for Prediction of Lymph Node Metastases in Esophageal Cancer Gregory Zuccaro, John J. Vargo, John A. Dumot, Tyler Stevens, Rocio Lopez, Thomas Rice Accurate detection of lymph nodes metastases in esophageal cancer (EC) is essential to determine prognosis and guide therapy. Endoscopic Ultrasound (EUS) is often used for this purpose, but is costly, operator dependent, and not universally available. Purpose Develop and validate a simple, non-EUS based scoring system for lymph node evaluation in EC Methods Learning set 314 pts with EC underwent clinical evaluation with endoscopy, followed by esophagectomy. No patient received preop chemoradiotherapy. The gold standard was pathologic lymph node classification (pN0=no lymph node metastases, pN1=lymph node metastases). A logistic regression model to predict pN1 was created considering these factors: age, gender, weight loss, dysphagia, tumor traversibility, length, location, and morphology, histopathologic type and grade. Coefficients from model were used to create a scoring system to predict pN1. Validation set 106 subsequent consecutive pts with EC had pre-operative score, followed by esophagectomy and pathologic lymph node classification. Results Learning set 143/314 pts (46%) were pN1. The scoring system: presence of dysphagia=3 points, poor differentiation=3 points, tumor length=4 points per cm. A score of ≥ 17 points appeared to be optimum cut point to maximize sensitivity (sens) and specificity (spec) Validation set 39/106 (37%) pts were pN1. ROC curves from learning set and validation set virtually identical (area under curve 0.85 and 0.89 respectively) (see figure). Using score of ≥ 17 points to predict pN1, scoring system test characteristics (with 95% CI): accuracy 83% (75-89), sens 69% (54-81), spec 91% (82-96). Conclusions A simple scoring system using information available to any endoscopist is very useful in predicting pN1 disease in EC.
W1027 Epidemiology of Gastric MALT Lymphoma: A Long-Term Nationwide Study in the Netherlands Lisette G. Capelle, Annemarie C. de Vries, Caspar W. Looman, Gerrit A. Meijer, M. K. Casparie, E. J. Kuipers Background: H. pylori is an important risk factor for the development of peptic ulcer disease, atrophic gastritis and gastric adenocarcinoma. Consequently, the declining incidence of these gastric conditions are attributed to the declining H. pylori prevalence in Western countries. Although gastric MALT lymphomas (GL) are associated with H. pylori infection in 90% of cases, the number of diagnoses seems to increase according to previous observations. Whether this is a true increase with a shift in outcomes of H. pylori infection, or due to changes in diagnostic criteria and number of endoscopic procedures is unknown. Therefore, the aim of this study was to evaluate epidemiological time trends of GL in the Netherlands. Methods: Patients with a first diagnosis of GL between 1991 and 2006 were identified in the Dutch nationwide histopathology registry (PALGA). World-standardized incidence rates (WSR) were evaluated for the investigated period. In addition, the number of new diagnoses per year were calculated relative to total number of patients with a first gastric biopsy. Logistic regression analysis was performed to evaluate time trends of GL in the Netherlands. Results: In total, 1419 patients (M/F 737/682) were newly diagnosed with GL during the study period. Overall, 68.5% of patients were diagnosed with low-grade, 25.2% with intermediate to high-grade and 6.3% with undefined GL. No significant differences in male to female ratios were observed between patients with low-grade GL, intermediate to high-grade GL or undefined grade GLs (p=0.78). Overall, the median age of patients at diagnosis of GL was 68.0 (range 14 - 98 years) and the peak incidence of MALT lymphomas both in men and women was between 70 and 74 years. The age standardized incidence rate was 0.41 per 100.000 persons (WSR). The average number of new diagnoses of GL was 88.7 cases per year, however, the incidence varied greatly over the study period. From 1991 to 1997, the proportional number of new cases increased with 5.8% per year (95% CI 1.9-9.9), but this was followed by a decline of 8.8% per year (95% CI 6.2-11.4) from 1998 until 2006. Conclusions: The incidence of gastric MALT lymphoma is approximately 0.4/100.000/yr in the Netherlands. Although an increase in the number of diagnoses of gastric MALT lymphoma was demonstrated between 1991 and 1997, the incidence is currently rapidly declining. This decline is likely in part related to the current decline in the prevalence of H. pylori in Western countries. However, as GL incidence declines much more rapid than the prevalence of H. pylori, other factors must additionally play a role and need to be further investigated. W1028
W1030 Fast-Track Services for Upper GI Cancer: Target: A Patient Screening Tool to Detect Delayed and Inappropriate ‘Two Week Rule' Referrals and a Survey of Family Practitioner Preferences for Service Organisation Guy Pritchard, Neil Kapoor, Richard Sturgess, Keith Bodger
Minimally Invasive Oesophagectomy for Cancer Leads to Early Recovery of Health-Related Quality of Life Rajeev Parameswaran, Jane M. Blazeby, Keith Mitchell, Richard G. Berrisford, Saj Wajed Introduction Conventional open surgery for oesophageal cancer is a high-risk procedure with a profound negative impact on health-related quality of life (HRQL). Indeed most series show that HRQL takes between 9 and 12 months to recover after surgery. Minimally invasive techniques considerably reduce surgical trauma and may allow an earlier recovery but current evidence for this hypothesis is lacking. Aim This study evaluated clinical and patient reported outcomes (HRQL) after MIO for cancer. Methods Prospective clinical data from consecutive patients undergoing MIO (thoracoscopic oesophageal mobilisation, laparoscopic gastric mobilisation and conduit formation with open cervical anastomosis) were collected into a database between April 2005 to November 2006. Patients completed the validated cancer specific questionnaire, the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30 and the oesophageal module, the OES18 before surgery and at 6 weeks, 3, 6 and 12 months post-operatively. A change of 10 points on the 0 to 100 scale of the EORTC questionnaires represents a clinical significant change in HRQL. Results Some 53 patients (5 females, median age 68) were considered suitable for curative resection. Adenocarcinoma was the predominant histological subtype (83%) and 37 (70%) had received neoadjuvant chemotherapy. One in-hospital mortality occurred, another 24 (45%) patients had complications, and 3(5%) procedures were not performed due to occult unsuspected metastases. One year after surgery 42(80%) of patients were alive. Questionnaire response rates were high at each time point (compliance 86%). Six weeks after MIO, patients reported marked reduction in role and social function (difference between means > 25 points) and more problems with diarrhoea (difference between means > 30 points). However, most functional aspects of HRQL and symptoms recovered by 3 months, and reached baseline levels by six months and these levels were maintained one year after surgery. At one year, patients reported an improvement in role and emotional function along with fewer problems with taste (difference between means > 10 points) whilst diarrhoea and problems with coughing was worse compared to baseline levels (difference between means > 10 points). Conclusion Minimally invasive oesophagectomy leads to a rapid restoration and an earlier recovery of HRQL, thereby offering an attractive alternative to conventional open surgery provided long term survival data support this surgical approach.
In the UK patients with suspected upper GI cancer (UGC) defined by the prescence of alarm symptoms must undergo fast track hospital evaluation within 2 weeks of referral from primary care. This Two Week Rule (TWR) aims to improve early diagnosis of cancer and various models of service delivery have been applied. Whilst hospitals are closely monitored to ensure compliance with the TWR, primary care is not. AIMS: To quantify rates of delayed or inappropriate referrals to a rapid access UGC service (RAUGICS) based in a UK university hospital and to establish GP's favoured model of service delivery. METHODS: A self-administered patient questionnaire containing validated symptom scores for alarm symptoms and items about consultation behaviour (The Aintree Rapid Gastroscopy Evaluation Tool, TARGET) was sent to all TWR referrals. Responses were compared to information provided by the GP in the referral proforma. Inappropriate referral was defined as absence of a TWR referral criterion in patient-elicited responses. A questionnaire containing items about preferred model of initial evaluation and follow up was mailed to all GP practices referring > 1 case per annum to RAUGICS. RESULTS: PATIENT SURVEY Data from 474 respondents: symptom duration > 6 months in 35%; Time from 1st consultation to referral > 6 months in 20%; 3 or more GP consultations before referral in 34%. Inappropriate referral rate 6.64%. PRIMARY CARE SURVEY Survey response rate 80% (74/92). Preferred model of TWR assessment: Direct-to-Test, 74% (Single partner practices 65% v Multipartner 89% p<0.05); Gastroenterology Clinic, 14.9%; Surgical Clinic, 0%; No preference, 12.2%. Preferred follow-up after gastroscopy: RAUGICS system (selective follow-up for serious pathology or ongoing symptoms on telephone review), 78.4% (Single partner practices 97% v Multipartner 81% p<0.05); Hospital follow-up of all TWR referrals, 6.7%; No preference, 14.9%. CONCLUSION The TARGET questionnaire identified delays in consultation and referral for at least 20% patients with alarm symptoms. Inappropriate referrals are less than 10% GP's prefer the RAUGICS model of direct-to-test followed by selective follow-up. Improved patient and GP education are required to encourage earlier access into the system.
AGA Abstracts
A-618
is defined by SNPs rs10505477 and rs7014346, thereby limiting the susceptibility region to 17 Kilobases of genomic sequence. In the subgroup analysis, association was confined to MSI-stable tumors with an odds ratio of 1.71. Conclusion: This study confirms the role of 8q24.21 as a risk factor for CRC, that is relevant across populations and excerts it's effect mainly in MSI-stable tumors. The haplotype structure in Germans allows refinement of the susceptibility interval to 17 Kilobases of genomic sequence.
W1029 Development and Validation of a Simple Scoring System for Prediction of Lymph Node Metastases in Esophageal Cancer Gregory Zuccaro, John J. Vargo, John A. Dumot, Tyler Stevens, Rocio Lopez, Thomas Rice Accurate detection of lymph nodes metastases in esophageal cancer (EC) is essential to determine prognosis and guide therapy. Endoscopic Ultrasound (EUS) is often used for this purpose, but is costly, operator dependent, and not universally available. Purpose Develop and validate a simple, non-EUS based scoring system for lymph node evaluation in EC Methods Learning set 314 pts with EC underwent clinical evaluation with endoscopy, followed by esophagectomy. No patient received preop chemoradiotherapy. The gold standard was pathologic lymph node classification (pN0=no lymph node metastases, pN1=lymph node metastases). A logistic regression model to predict pN1 was created considering these factors: age, gender, weight loss, dysphagia, tumor traversibility, length, location, and morphology, histopathologic type and grade. Coefficients from model were used to create a scoring system to predict pN1. Validation set 106 subsequent consecutive pts with EC had pre-operative score, followed by esophagectomy and pathologic lymph node classification. Results Learning set 143/314 pts (46%) were pN1. The scoring system: presence of dysphagia=3 points, poor differentiation=3 points, tumor length=4 points per cm. A score of ≥ 17 points appeared to be optimum cut point to maximize sensitivity (sens) and specificity (spec) Validation set 39/106 (37%) pts were pN1. ROC curves from learning set and validation set virtually identical (area under curve 0.85 and 0.89 respectively) (see figure). Using score of ≥ 17 points to predict pN1, scoring system test characteristics (with 95% CI): accuracy 83% (75-89), sens 69% (54-81), spec 91% (82-96). Conclusions A simple scoring system using information available to any endoscopist is very useful in predicting pN1 disease in EC.
W1027 Epidemiology of Gastric MALT Lymphoma: A Long-Term Nationwide Study in the Netherlands Lisette G. Capelle, Annemarie C. de Vries, Caspar W. Looman, Gerrit A. Meijer, M. K. Casparie, E. J. Kuipers Background: H. pylori is an important risk factor for the development of peptic ulcer disease, atrophic gastritis and gastric adenocarcinoma. Consequently, the declining incidence of these gastric conditions are attributed to the declining H. pylori prevalence in Western countries. Although gastric MALT lymphomas (GL) are associated with H. pylori infection in 90% of cases, the number of diagnoses seems to increase according to previous observations. Whether this is a true increase with a shift in outcomes of H. pylori infection, or due to changes in diagnostic criteria and number of endoscopic procedures is unknown. Therefore, the aim of this study was to evaluate epidemiological time trends of GL in the Netherlands. Methods: Patients with a first diagnosis of GL between 1991 and 2006 were identified in the Dutch nationwide histopathology registry (PALGA). World-standardized incidence rates (WSR) were evaluated for the investigated period. In addition, the number of new diagnoses per year were calculated relative to total number of patients with a first gastric biopsy. Logistic regression analysis was performed to evaluate time trends of GL in the Netherlands. Results: In total, 1419 patients (M/F 737/682) were newly diagnosed with GL during the study period. Overall, 68.5% of patients were diagnosed with low-grade, 25.2% with intermediate to high-grade and 6.3% with undefined GL. No significant differences in male to female ratios were observed between patients with low-grade GL, intermediate to high-grade GL or undefined grade GLs (p=0.78). Overall, the median age of patients at diagnosis of GL was 68.0 (range 14 - 98 years) and the peak incidence of MALT lymphomas both in men and women was between 70 and 74 years. The age standardized incidence rate was 0.41 per 100.000 persons (WSR). The average number of new diagnoses of GL was 88.7 cases per year, however, the incidence varied greatly over the study period. From 1991 to 1997, the proportional number of new cases increased with 5.8% per year (95% CI 1.9-9.9), but this was followed by a decline of 8.8% per year (95% CI 6.2-11.4) from 1998 until 2006. Conclusions: The incidence of gastric MALT lymphoma is approximately 0.4/100.000/yr in the Netherlands. Although an increase in the number of diagnoses of gastric MALT lymphoma was demonstrated between 1991 and 1997, the incidence is currently rapidly declining. This decline is likely in part related to the current decline in the prevalence of H. pylori in Western countries. However, as GL incidence declines much more rapid than the prevalence of H. pylori, other factors must additionally play a role and need to be further investigated. W1028
W1030 Fast-Track Services for Upper GI Cancer: Target: A Patient Screening Tool to Detect Delayed and Inappropriate ‘Two Week Rule' Referrals and a Survey of Family Practitioner Preferences for Service Organisation Guy Pritchard, Neil Kapoor, Richard Sturgess, Keith Bodger
Minimally Invasive Oesophagectomy for Cancer Leads to Early Recovery of Health-Related Quality of Life Rajeev Parameswaran, Jane M. Blazeby, Keith Mitchell, Richard G. Berrisford, Saj Wajed Introduction Conventional open surgery for oesophageal cancer is a high-risk procedure with a profound negative impact on health-related quality of life (HRQL). Indeed most series show that HRQL takes between 9 and 12 months to recover after surgery. Minimally invasive techniques considerably reduce surgical trauma and may allow an earlier recovery but current evidence for this hypothesis is lacking. Aim This study evaluated clinical and patient reported outcomes (HRQL) after MIO for cancer. Methods Prospective clinical data from consecutive patients undergoing MIO (thoracoscopic oesophageal mobilisation, laparoscopic gastric mobilisation and conduit formation with open cervical anastomosis) were collected into a database between April 2005 to November 2006. Patients completed the validated cancer specific questionnaire, the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30 and the oesophageal module, the OES18 before surgery and at 6 weeks, 3, 6 and 12 months post-operatively. A change of 10 points on the 0 to 100 scale of the EORTC questionnaires represents a clinical significant change in HRQL. Results Some 53 patients (5 females, median age 68) were considered suitable for curative resection. Adenocarcinoma was the predominant histological subtype (83%) and 37 (70%) had received neoadjuvant chemotherapy. One in-hospital mortality occurred, another 24 (45%) patients had complications, and 3(5%) procedures were not performed due to occult unsuspected metastases. One year after surgery 42(80%) of patients were alive. Questionnaire response rates were high at each time point (compliance 86%). Six weeks after MIO, patients reported marked reduction in role and social function (difference between means > 25 points) and more problems with diarrhoea (difference between means > 30 points). However, most functional aspects of HRQL and symptoms recovered by 3 months, and reached baseline levels by six months and these levels were maintained one year after surgery. At one year, patients reported an improvement in role and emotional function along with fewer problems with taste (difference between means > 10 points) whilst diarrhoea and problems with coughing was worse compared to baseline levels (difference between means > 10 points). Conclusion Minimally invasive oesophagectomy leads to a rapid restoration and an earlier recovery of HRQL, thereby offering an attractive alternative to conventional open surgery provided long term survival data support this surgical approach.
In the UK patients with suspected upper GI cancer (UGC) defined by the prescence of alarm symptoms must undergo fast track hospital evaluation within 2 weeks of referral from primary care. This Two Week Rule (TWR) aims to improve early diagnosis of cancer and various models of service delivery have been applied. Whilst hospitals are closely monitored to ensure compliance with the TWR, primary care is not. AIMS: To quantify rates of delayed or inappropriate referrals to a rapid access UGC service (RAUGICS) based in a UK university hospital and to establish GP's favoured model of service delivery. METHODS: A self-administered patient questionnaire containing validated symptom scores for alarm symptoms and items about consultation behaviour (The Aintree Rapid Gastroscopy Evaluation Tool, TARGET) was sent to all TWR referrals. Responses were compared to information provided by the GP in the referral proforma. Inappropriate referral was defined as absence of a TWR referral criterion in patient-elicited responses. A questionnaire containing items about preferred model of initial evaluation and follow up was mailed to all GP practices referring > 1 case per annum to RAUGICS. RESULTS: PATIENT SURVEY Data from 474 respondents: symptom duration > 6 months in 35%; Time from 1st consultation to referral > 6 months in 20%; 3 or more GP consultations before referral in 34%. Inappropriate referral rate 6.64%. PRIMARY CARE SURVEY Survey response rate 80% (74/92). Preferred model of TWR assessment: Direct-to-Test, 74% (Single partner practices 65% v Multipartner 89% p<0.05); Gastroenterology Clinic, 14.9%; Surgical Clinic, 0%; No preference, 12.2%. Preferred follow-up after gastroscopy: RAUGICS system (selective follow-up for serious pathology or ongoing symptoms on telephone review), 78.4% (Single partner practices 97% v Multipartner 81% p<0.05); Hospital follow-up of all TWR referrals, 6.7%; No preference, 14.9%. CONCLUSION The TARGET questionnaire identified delays in consultation and referral for at least 20% patients with alarm symptoms. Inappropriate referrals are less than 10% GP's prefer the RAUGICS model of direct-to-test followed by selective follow-up. Improved patient and GP education are required to encourage earlier access into the system.
AGA Abstracts
A-618