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near the end of life: is it a quality-of care issue? J Clin Oncol 2008; 26:

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with metastatic non-small-cell lung cancer. N Engl J Med 2010; 363: 733742.

Annals of Oncology24: 24492455, 2013

doi:10.1093/annonc/mdt204

Published online 29 May 2013

Diabetes mellitus, insulin treatment, diabetes duration,

and risk of biliary tract cancer and hepatocellular

carcinoma in a European cohort

S. Schlesinger1,2*, K. Aleksandrova2, T. Pischon2,3, M. Jenab4, V. Fedirko4,5, E. Trepo6, K. Overvad7,N. Roswall8, A. Tjnneland8, M. C. Boutron-Ruault9,10,11, G. Fagherazzi9,10,11, A. Racine9,10,11,R. Kaaks12, V. A. Grote12, H. Boeing2, A. Trichopoulou13,14, M. Pantzalis14, M. Kritikou14,

A. Mattiello15, S. Sieri16, C. Sacerdote17, D. Palli18, R. Tumino19, P. H. Peeters20,21, H. B. Bueno-de-Mesquita22,23, E. Weiderpass24,25,26,27, J. R. Quirs28, R. Zamora-Ros29, M. J. Snchez30,31,L. Arriola31,32, E. Ardanaz31,33, M. J. Tormo31,34, P. Nilsson35, B. Lindkvist36, M. Sund37,O. Rolandsson38, K. T. Khaw39, N. Wareham40, R. C. Travis41, E. Riboli42 & U. Nthlings43,441Institute of Epidemiology, Christian-Albrechts University of Kiel, Kiel; 2Department of Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrcke, Nuthetal;3Molecular Epidemiology Group, Max Delbrck Center for Molecular Medicine Berlin-Buch, Germany; 4International Agency for Research on Cancer (IARC-WHO), Lyon,

France; 5Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, USA; 6Centre de Biologie Rpublique, Lyon, France; 7Section for

Epidemiology, Department of Public Health, Aarhus University, Aarhus; 8Diet, Genes and Environment, Danish Cancer Society Research Center, Copenhagen, Denmark;9Inserm, Centre for research in Epidemiology and Population Health (CESP), U1018, Nutrition, Hormones and Womens Health team, Villejuif; 10Univ Paris Sud, UMRS

1018, Villejuif; 11IGR, Villejuif, France; 12Division of Cancer Epidemiology, German Cancer Research Center, Heidelberg, Germany; 13WHO Collaborating Center for Food

and Nutrition Policies, Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, Athens; 14Hellenic Health Foundation, Athens,

Greece; 15Department of Clinical and Experimental Medicine, Federico II University of Naples, Naples; 16Nutritional Epidemiology Unit, Department of Preventive and

Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan; 17Center for Cancer Prevention (CPO-Piemonte), Human Genetic Foundation (HuGeF), Torino;18Molecular and Nutritional Epidemiology Unit, Cancer Research and Prevention Institute ISPO, Florence; 19Cancer Registry and Histopathology Unit, Civile M.P. Arezzo

Hospital, ASP Ragusa, Italy;20

Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht,The Netherlands; 21Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Medicine, Imperial College, London, UK; 22National Institute for Public

Health and the Environment, (RIVM), Bilthoven; 23Department of Gastroenterology and Hepatology, University Medical Centre, Utrecht, The Netherlands; 24Department of

Community Medicine, Faculty of Health Sciences, University of Troms, Troms; 25Cancer Registry of Norway, Oslo, Norway; 26Department of Medical Epidemiology and

Biostatistics, Stockholm, Sweden; 27Department of Genetic Epidemiology, Samfundet Folkhlsan, Helsinki, Finland; 28Public Health Directorate, Asturias; 29Unit of Nutrition,

Environment and Cancer, CatalanInstitute of Oncology (ICO-IDIBELL), Barcelona; 30Andalusian School of Public Health, Granada; 31CIBER Epidemiologa y Salud Pblica

(CIBERESP), Granada; 32Public Health Division of Gipuzkoa, Basque Government, San Sebastian; 33Navarre Public Health Institute, Pamplona; 34Department of Epidemiology,

Murcia Regional Health Council, Murcia, Spain; 35Department of Health Sciences, Lund University, University Hospital, Malm; 36Instituteof Medicine, Sahlgrenska Academy,

University of Gothenburg, Gothenburg; 37Department of Surgical and Perioperative Sciences, Surgery and Public Health, Nutrition Research, University Ume, Ume;38Department of Public Health and Clinical Medicine, Ume University, Ume, Sweden; 39University of Cambridge, Cambridge; 40Medical Research

Council Epidemiology Unit, Cambridge; 41Cancer Epidemiology Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford; 42The School of Public Health,

Imperial College London, London, UK; 43Nutritional Epidemiology, I nstitute of Nutritional and Food Science, University Bonn, Bonn; 44Section of Epidemiology, Institute of

Experimental Medicine, Christian-Albrechts Universityof Kiel, Kiel, Germany

Received 11 December 2012; revised 22 April 2013; accepted 23 April 2013

Background: Evidence on associations between self-reported diabetes mellitus, diabetes duration, age at diabetes

diagnosis, insulin treatment, and risk of biliary tract cancer (BTC) and hepatocellular carcinoma (HCC), independent of

general and abdominal obesity is scarce.

*Correspondence to: Msc Sabrina Schlesinger, Institute of Epidemiology,

Christian-Albrechts University of Kiel, Campus Kiel, UKSH, Arnold-Hellerstr. 3, Haus 1,

24105 Kiel, Germany, Tel: +49-431-597-8685; Fax: +49-431-597-1887. E-mail: sabrina.

[email protected]

Annals of Oncology original articles

The Author 2013. Published by Oxford University Press on behalf of the European Society for Medical Oncology.

All rights reserved. For permissions, please email: [email protected].


2/7

Patients and methods: We conducted a prospective analysis in the EPIC-cohort study among 363 426 participants

with self-reported diabetes data. Multivariable adjusted relative risks and 95% confidence intervals were estimated from

Cox regression models. In a nested casecontrol subset, analyses were carried out in HCV/HBV-negative individuals.

Results: During 8.5 years of follow-up, 204 BTC cases [including 75 gallbladder cancer (GBC) cases], and 176 HCC

cases were identified. Independent of body mass index and waist-to-height ratio diabetes status was associated with

higher risk of BTC and HCC [1.77 (1.003.13) and 2.17 (1.363.47)]. For BTC, the risk seemed to be higher in

participants with shorter diabetes duration and those not treated with insulin. Regarding cancer subsites, diabetes was

only associated with GBC [2.72 (1.176.31)]. The risk for HCC was particularly higher in participants treated with insulin.

The results were not appreciably different in HCV/HBV-negative individuals.Conclusion(s):This study supports the hypothesis that diabetes is a risk factor for BTC ( particularly GBC) and HCC.

Further research is required to establish whether diabetes treatment or duration is associated with these cancers.

Key words: biliary tract neoplasms, diabetes duration, diabetes mellitus, gallbladder neoplasms, hepatocellular

carcinoma, insulin treatment

introduction

Epidemiological studies suggest that individuals with diabetes

mellitus are at higher risk of cancer [1]. Studies on biliary tractcancer (BTC), including extrahepatic bile duct (EBD) and

gallbladder cancer (GBC), have shown inconsistent results

regarding diabetes status [2], whereas the evidence for anassociation between diabetes and hepatocellular carcinoma

(HCC) has been more straightforward [3, 4].

The possible mechanisms that may link diabetes with risk of

BTC and HCC include hyperinsulinemia, insulin resistance,hyperglycemia, chronic inflammation, and exogenous insulin

treatment in diabetic patients [1]. Furthermore, diabetes is alsoassociated with gallstone diseases [5, 6]; one of the major risk

factors for GBC [7]. Diabetes is associated with nonalcoholic

fatty liver disease, which might be another potentially link

between diabetes and HCC [8].

However, it is not completely understood whether theassociation between diabetes and these cancers is mediated by

obesity. Particularly, findings on BTC were inconsistent after

controlling for obesity [2]. Furthermore, most of the studiesaccounted for general obesity, but not for abdominal obesity,

which we have previously shown to be an independent risk

factor for GBC and HCC [9]. Also, most previous efforts have

focused on diabetes status only, and little is known about towhat extent diabetes duration and treatment may influence the

risk [1]. Indeed, previous studies provided inconsistent resultson the association between diabetes duration and HCC [1017].

For BTC, the few studies that have examined these factors did

not find any associations [10, 12].

The main aim of this study was to investigate the associationsbetween diabetes status, diabetes duration, age at diabetes

diagnosis and insulin treatment with BTC (including GBC), and

HCC. Particular emphasis was put on controlling for generaland abdominal obesity.

methods

study design

The EPIC study is an ongoing prospective cohort study investigating

associations between lifestyle factors and cancer incidence. Details on the

EPIC study have been reported elsewhere [18]. In brief, between 1992 and

2000, 520 000 participants (2570 years) were recruited in 10 European

countries. Participants who gave informed consent were asked to complete

questionnaires about their diet, lifestyle, and medical history. Blood samples

were collected, and in most centers, anthropometric measurements were

taken by trained staff. Ethical approval was obtained from the IARC Ethics

Review Committee and EPIC centers.

The present analysis was based on 363 426 eligible participants, after

exclusion of participants with any prevalent cancer at baseline (n = 23 818),

incomplete follow-up data (n = 4385), metastasis or ineligible histology code

(n = 78), unknown diabetes status at baseline (n = 19 961), missing

information on diabetes treatment (n = 3466), and missing information on

date of diagnosis of diabetes or an implausible date after baseline (n = 918).

Furthermore, we excluded participants with missing information on weight,

height, and waist or hip circumference, which excluded the cohort of

Norway (n = 28 624), 47 488 participants from the French cohort and 24 389

participants from Sweden, and with missing information on alcohol

consumption at baseline (n = 4777).

assessment of diabetes, anthropometric data,

and lifestyle factors

Information on self-reported diabetes was inquired by using standardized

questionnaires at baseline. Participants were asked if they had ever been

diagnosed with diabetes, and information on age at diabetes diagnosis and

use of insulin treatment was obtained. Diabetes duration at baseline was

calculated by subtracting self-reported age at diabetes diagnosis from the age

at baseline examination.

Weight, height, and waist circumference were measured at baseline as

described elsewhere [19]. Body mass index (BMI; weight/height2) and

waist-to-height ratio (WHtR; waist circumference/height), a measure of

abdominal obesity [20], were calculated. Information on past alcohol

consumption (at ages 20/30/40/50) was available for 311 706 participants.

Information on lifestyle-related and socioeconomic characteristics (e.g.

smoking status and level of education) was obtained by using standardized

questionnaires [18].

assessment of end pointsAssessment of vital status has been reported in detail elsewhere [9]. Briefly,

incident BTC and HCC cases were determined through record linkage with

regional cancer registries or by a combination of methods, including health

insurance records, contacts to cancer, and pathology registries together with

an active follow-up. Time of follow-up began with baseline and ended with

diagnosis offirst primary cancer, death, emigration, or end of follow-up.

Cancer incidence data were coded following ICD-10. HCC was defined as

tumors in the liver (C22.0); and BTC as gallbladder cancer (GBC) (C23),

and non-GBC, including tumors of the ampulla of Vater (C24.1) and biliary

tract (C24.0/C24.8/C24.9). Intrahepatic bile duct (IBD)cancer was defined

original articles Annals of Oncology

| Schlesinger et al. Volume 24 | No. 9 | September 2013


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as tumor in the IBDs (C22.1) and cholangiocarcinoma was defined as IBD

and EBD with morphology code 8160/3.

nested casecontrol subset

In a nested casecontrol subset, information on HBV/HCV infection status

was available for 113 HCC cases and 221 matched controls. The design and

methods have been described previously [21] and are shown in the

supplementary Data, available at Annals of Oncologyonline.

statistical analyses

We calculated relative risks (RR) and 95%confidence intervals (95% CI) as

hazard rate ratios using Cox proportional hazard models to investigate the

associations between diabetes, diabetes duration (by median:


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Table 2. Relative risks (RR) and 95% confidence intervals (95% CI) of biliary tract cancer (BTC), including gallbladder cancer (GBC) and non-gallbladder

cancer (non-GBC) according to diabetes

No. of person-years No. of cases Model 1a Model 2b

RR (95% CI) RR (95% CI)

Total BTC 204

Diabetes status

No 3 103 576 190 1 1

Yes 70 488 14 1.80 (1.02

3.18) 1.77 (1.00

3.13)Diabetes duration

No diabetes 3 103 576 190 1 1


5/7

For both, BTC and HCC, highest risk was observed for

participants with diabetes and a BMI 30 kg/m2 compared with

the reference group (participants without diabetes and a BMI


6/7

independent of general and abdominal obesity. Whether

diabetes treatment or duration are directly associated with these

cancers, or whether they are surrogates for severity of diabetes,remains to be answered by future research. Further studies

should consider potential risk differences by subsites of BTC

and investigate associations between diabetes duration andtreatment.

acknowledgements

The authors thank all EPIC participants and staff for their

contribution to the study. Reagents for the hepatitis infection

determinations were provided by Abbott Diagnostics Division,

Lyon, France. The funding sources had no influence on thedesign of the study; the collection, analysis, and interpretation

of data; the writing of the report; or the decision to submit the

paper for publication.

funding

This work was supported by the Federal Ministry of Education

and Research, the German Research Foundation, ExcellenceCluster Inflammation at Interfaces (EXC306 and EXC306/2),grants from the German Research Foundation (DFG NO446/7-

1) (Germany); and the French National Cancer Institute

(LInstitut National du Cancer; INCA) (grant number 2009-139). The coordination of EPIC is financially supported by the

European Commission (DG-SANCO); and the International

Agency for Research on Cancer. The national cohorts aresupported by Danish Cancer Society (Denmark); Ligue Contre

le Cancer; Institut Gustave Roussy; Mutuelle Gnrale de

lEducation Nationale; and Institut National de la Sant et de laRecherche Mdicale (INSERM) (France); Deutsche Krebshilfe,

Deutsches Krebsforschungszentrum; the Hellenic Health

Foundation, the Stavros Niarchos Foundation and the HellenicMinistry of Health and Social Solidarity (Greece); ItalianAssociation for Research on Cancer (AIRC); National Research

Council; and AIRE-ONLUS Ragusa, AVIS Ragusa, Sicilian

Government (Italy); Dutch Ministry of Public Health, Welfareand Sports (VWS); Netherlands Cancer Registry (NKR); LK

Research Funds; Dutch Prevention Funds; Dutch ZON (Zorg

Onderzoek Nederland); World Cancer Research Fund (WCRF);and Statistics Netherlands (The Netherlands); European

Research Council (ERC) (grant number ERC-2009-AdG

232997) and Nordforsk; and Nordic Center of Excellence

Programme on Food, Nutrition and Health (Norway); HealthResearch Fund (FIS); Regional Governments of Andaluca,

Asturias, Basque Country, Murcia (No. 6236) and Navarra; andISCIII RETIC (RD06/0020) (Spain); Swedish Cancer Society;Swedish Scientific Council; and Regional Government of Skne

and Vsterbotten (Sweden); Cancer Research UK; Medical

Research Council; Stroke Association; British Heart Foundation;

Department of Health; Food Standards Agency; and WellcomeTrust (UK).

disclosure

The authors have declared no conflicts of interest.

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liver cancer. Int J Cancer 1997; 73: 204207.

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24. Carstensen B, Witte DR, Friis S. Cancer occurrence in Danish diabetic patients:

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Annals of Oncology24: 24552461, 2013doi:10.1093/annonc/mdt215

Published online 11 June 2013

Renal Ewing tumors

S. Zllner, U. Dirksen, H. Jrgens & A. Ranft*

Department of Pediatric Hematology and Oncology, University Hospital, Muenster, Germany

Received 5 November 2012; revised 6 March 2013; accepted 29 April 2013

Background: Renal Ewings sarcoma/primitive neuroectodermal tumor (ES/PNET) is extremely rare. Clinical symptoms

are nonspecific presenting abdominal pain, palpable mass, and hematuria. Owing to advanced technology

demonstrating the ES-specific EWS/ETS translocation, this differential diagnosis has become feasible.

Patients and methods:The German database of GPOH Ewings sarcoma trials from 1980 to 2009 was searched for

kidney as primary site. Twenty-four patients were identified and analyzed. The median time of observation was 3.71 years

(range 0.278.75 years). Additionally, we carried out a Medline search for renal ES/PNET.

Results:The median age was 24.9 years (range 1160 years). In 37.5%, patients presented with primary metastases.

Tumor thrombi in the adjacent renal vessels occurred in 56.2%. In 90.9%, rearrangements oft(11;22) were found. All

patients received a combined chemotherapy according to the EURO-E.W.I.N.G.99 protocol. In accordance, local control

consisted predominantly of combined modality surgery and radiation (47%). At 3 years, overall survival (OS) was 0.80

(SE = 0.09), and event-free survival (EFS) 0.66 (SE = 0.11).

Conclusions: ES/PNET should be considered in the differential diagnosis of renal tumors. Patients with renal ES/PNET

respond to and benefit from conventional ES treatment according to ES study protocols. Therefore, an accurate

diagnostic approach and a guideline-adapted therapy should be facilitated.Key words: Ewings sarcoma, kidney, outcome, PNET

introduction

The major differential consideration for small-round celltumors of the kidney encompasses a wide range of unrelated

neoplasms with overlapping morphologic features, and differing

therapeutic approaches and prognosis [1]. This includes

malignant lymphoma, embryonal rhabdomyosarcoma, renalneuroblastoma, Wilms tumor, small-cell osteosarcoma,

desmoplastic small-cell tumor, synovial sarcoma, small-cell

neuroendocrine carcinoma, and Ewings sarcoma (ES) or itsvariant with neural differentiation, primitive neuroectodermal

tumor (PNET), now both being classified as ES [2]. In this

group of tumors, ES is an extremely rare primary tumor of thekidney. Advances in immunohistochemistry and molecular

pathology allow for a better differential diagnosis of renal

tumors. Thus, case reports have been accumulating in the past

few years. In 1975, Seemayer et al. [3] were the first to provideevidence of PNETs affecting the kidney. More than 100 cases

have since been reported worldwide. Aside from the Parham

Series, which consolidates up to 67 pathologically confi

rmedmalignant neuroepithelial tumors of the kidney into one range

[4], there are only four published series with small collectives

[58]. The remaining literature on renal ES consists of single-case reports. Our study adds a series of 24 patients who received

an ES guideline-based therapy. This represents the largest

collective of similarly treated renal ES in todays literature.

Clinical symptoms and signs are nonspecific, comprising atriad offlank or abdominal pain, palpable mass, and hematuria

in decreasing order. Systemic symptoms such as weight lossPrevious presentation of this study: initial and preliminary results were presented at the

Annual Meeting of the Socit Internationale D Oncologie Pdiatrique (SIOP), Geneva,

September 2006.

*Correspondence to: Dr Andreas Ranft, Department of Pediatric Hematology and

Oncology, Muenster University Hospital, Albert Schweitzer Campus 1, Building A1,

48149 Muenster, Germany. Tel: +49-251-83-56486; Fax: +49-251-83-56489;

E-mail: [email protected]

Annals of Oncology original articles

The Author 2013. Published by Oxford University Press on behalf of the European Society for Medical Oncology.

All rights reserved. For permissions, please email: [email protected].
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Diabetes Mellitus, el tratamiento con insulina,