Mary P. Bronner

Radiofrequency Ablation in Barrett's Esophagus with Dysplasia

BACKGROUND Barretts esophagus, a condition of intestinal metaplasia of the esophagus, is associated with an increased risk of esophageal adenocarcinoma. We assessed whether endoscopic radiofrequency ablation could eradicate dysplastic Barretts esophagus and decrease the rate of neoplastic progression. METHODS In a multicenter, sham-controlled trial, we randomly assigned 127 patients with dysplastic Barretts esophagus in a 2:1 ratio to receive either radiofrequency ablation (ablation group) or a sham procedure (control group). Randomization was stratified according to the grade of dysplasia and the length of Barretts esophagus. Primary outcomes at 12 months included the complete eradication of dysplasia and intestinal metaplasia. RESULTS In the intention-to-treat analyses, among patients with low-grade dysplasia, complete eradication of dysplasia occurred in 90.5% of those in the ablation group, as compared with 22.7% of those in the control group (P<0.001). Among patients with high-grade dysplasia, complete eradication occurred in 81.0% of those in the ablation group, as compared with 19.0% of those in the control group (P<0.001). Overall, 77.4% of patients in the ablation group had complete eradication of intestinal metaplasia, as compared with 2.3% of those in the control group (P<0.001). Patients in the ablation group had less disease progression (3.6% vs. 16.3%, P=0.03) and fewer cancers (1.2% vs. 9.3%, P=0.045). Patients reported having more chest pain after the ablation procedure than after the sham procedure. In the ablation group, one patient had upper gastrointestinal hemorrhage, and five patients (6.0%) had esophageal stricture. CONCLUSIONS In patients with dysplastic Barretts esophagus, radiofrequency ablation was associated with a high rate of complete eradication of both dysplasia and intestinal metaplasia and a reduced risk of disease progression. (ClinicalTrials.gov number, NCT00282672.)

Ursodiol Use Is Associated with Lower Prevalence of Colonic Neoplasia in Patients with Ulcerative Colitis and Primary Sclerosing Cholangitis

Patients with ulcerative colitis have an increased risk for colorectal neoplasia; this risk approaches 0.5% to 1% per year of disease. The extent and duration of colitis, as well as age at onset of disease, are important risk factors for neoplastic progression (1, 2). Primary sclerosing cholangitis is a chronic inflammatory disease of the biliary tract that occurs in 2% to 4% of patients with ulcerative colitis (3-5). Although the data are still controversial, most studies have shown that patients with ulcerative colitis and primary sclerosing cholangitis are at even higher risk for colonic neoplasia than are those with ulcerative colitis alone (6-11). The risk for colonic dysplasia or cancer in patients with ulcerative colitis and primary sclerosing cholangitis approaches 50% after 25 years of colitis (6-8). Epidemiologic studies suggest that environmental and dietary factors are important in the development of colorectal cancer (12). High-fat diets predispose to colorectal cancer, in part because they generate tumor-promoting secondary bile acids (13, 14). Conversely, the use of aspirin and other nonsteroidal anti-inflammatory drugs is associated with reduced risk for colorectal cancer and adenomatous polyps (15-17). Controversy surrounds the potential chemoprotective role of sulfasalazine in patients with ulcerative colitis (18, 19). Ursodiol, the 7--epimer of chenodeoxycholic acid, has been used in patients with primary sclerosing cholangitis because it substantially improves biochemical indices of liver function, although overall disease progression does not appear to be affected (20). Ursodiol use reduces the colonic concentration of the secondary bile acid deoxycholic acid (21). Although experimental evidence in animal models suggests that ursodiol administration inhibits colonic carcinogenesis, no clear evidence of inhibitory activity has been demonstrated in human studies (7, 22, 23). We sought to determine whether ursodiol use is associated with lower risk for colonic dysplasia, the precursor to colon cancer, in patients with ulcerative colitis and primary sclerosing cholangitis. Methods Patients We studied 59 patients with ulcerative colitis and primary sclerosing cholangitis who were enrolled in the colonoscopic surveillance program at the University of Washington, Seattle, Washington. These patients were involved in a research study of colonic surveillance in ulcerative colitis according to a protocol approved by the Human Subjects Division of the University of Washington. Forty-three patients were male and 16 were female. The diagnosis of primary sclerosing cholangitis was based on conventional cholangiographic criteria. Confirmatory histologic findings in the 35 patients who underwent liver biopsy included concentric periductal fibrosis, destructive inflammatory lesions of ducts, changes of ductal obstruction, or ductopenia ( 50% of at least 20 portal tracts without a duct). The diagnosis of ulcerative colitis was made according to standard histologic criteria: presence of basal lymphoplasmacytosis and distortion of crypt architecture, defined by the presence of two or more branched or irregularly shaped crypts in a single mucosal biopsy specimen. Clinical Variables Clinical variables were abstracted from the medical record and patient interview. Study groups were defined according to whether patients had ever used ursodiol. For all patients whose medical records failed to mention ursodiol use, confirmation was made by direct patient interview. All medications were carefully noted: specifically, the dates of use of ursodiol, sulfasalazine, other 5-aminosalicylic acid preparations, prednisone, azathioprine, cyclosporine, and methotrexate. Estrogen use and menstrual status were assessed in women. Age at onset of symptomatic colitis and date of diagnosis of sclerosing cholangitis were also noted. To estimate the severity of liver disease, ChildPugh class was calculated at the time of each surveillance colonoscopy. For patients who had previously undergone orthotopic liver transplantation, a separate classification was created to reflect the fact that they had had severe liver disease despite a normal current ChildPugh score. Surveillance Colonoscopy for Diagnosis of Dysplasia Colonoscopy was performed every 3 years unless indefinite or low-grade dysplasia or aneuploidy was detected, in which case-patients underwent yearly colonoscopy. Patients who had high-grade dysplasia were referred for colectomy. At colonoscopy, biopsy samples were obtained from flat mucosa (by using a large cupped biopsy forceps) from four quadrants at 10-cm intervals from the cecum through the descending colon and at 5-cm intervals in the sigmoid colon and rectum. Any mucosal irregularity or polyp was sampled separately. The mean number of biopsy samples obtained per colonoscopy was 46.8 1.5. The biopsy samples were oriented submucosal-side-down on monofilament plastic mesh and placed in Hollande fixative. All biopsy samples were step-serial sectioned, stained with hematoxylin and eosin, and evaluated by an experienced gastrointestinal pathologist who had no knowledge of the clinical history or colonoscopic findings. The histologic criteria for the diagnosis and grading of dysplasia established by the Inflammatory Bowel Disease/Dysplasia Morphology Study Group were applied, except that the category indefinite for dysplasia was not subdivided (24). Statistical Analysis Study groups were defined according to whether the patient had ever used ursodiol. The primary outcome studied was occurrence of colonic dysplasia. A patient was defined as having achieved the outcome if he or she was known to have dysplasia at any point up to the last surveillance. Hence, the fraction of patients with the dysplasia outcome represented the prevalence of ever having had a diagnosis of dysplasia. For the primary analysis, patients whose biopsies were read as indefinite for dysplasia were combined with those whose biopsies were negative for dysplasia. Two secondary analyses were performed. In the first, all patients classified as indefinite for dysplasia were excluded from the analysis. In the second, the outcome was changed to high-grade dysplasia rather than low-grade dysplasia and high-grade dysplasia. For all analyses, ursodiol use and other variables were assessed up to the time of the outcome or last surveillance. Other variables assessed were use of sulfasalazine, other 5-aminosalicylic acid preparations, prednisone, cyclosporine, azathioprine, or methotrexate; duration of sclerosing cholangitis; duration of ulcerative colitis; ChildPugh class; duration of ursodiol use; age at onset of colitis; and sex. Unpaired t-tests and the Fisher exact test were used to compare means and proportions, respectively. Unadjusted odds ratios were estimated directly from 2 2 tables for ursodiol use versus outcome status, and adjusted odds ratios were estimated by using logistic regression. MathSoft S-Plus 3.4 (MathSoft, Inc., Seattle, Washington) and GraphPad Prism 2.01 (GraphPad Software, San Diego, California) statistical software packages were used. Role of the Funding Source The funding source had no role in the collection, analysis, or interpretation of the data or in the decision to submit the study for publication. Results Fifty-nine patients with ulcerative colitis and primary sclerosing cholangitis were enrolled in the colonoscopic surveillance program. Forty-one patients (69%) had used ursodiol, and 18 (31%) had never used ursodiol. Characteristics of ursodiol users and nonusers are shown in Table 1. Twenty-six patients (44%) had a diagnosis of dysplasia at some time during surveillance; no patient developed cancer. Table 1. Patient Characteristics Of the 26 patients who had dysplasia, 50% (13 of 26) had used ursodiol compared with 85% (28 of 33) of patients with no dysplasia. This difference in ursodiol use was highly significant, with an odds ratio of 0.18 (CI, 0.05 to 0.61; P=0.005) (Table 2). The negative association between dysplasia and ursodiol use remained after adjustment for sex, age at onset of ulcerative colitis, duration of ulcerative colitis, duration of sclerosing cholangitis, ChildPugh class, and use of sulfasalazine (adjusted odds ratio, 0.14 [CI, 0.03 to 0.64]; P=0.01) (Table 3). Results were similar when treatment with 5-aminosalicylic acid, prednisone, cyclosporine, azathioprine, or methotrexate and number of surveillance colonoscopies were included in the model. Because a large number of covariates were included in the final logistic regression model relative to the sample size of 59, computer simulations were performed to check the stability of the modeling procedure. Both the Pvalue and the 95% confidence interval were reliable when the true odds ratio was assumed to be 0.14 to 1.0. Table 2. Medication Use and Development of Dysplasia Table 3. Multivariate Analysis of Risk Factors for Dysplasia Among patients who used ursodiol, the mean duration of use was 3.5 years for those who progressed to dysplasia compared with 4.2 years for those who did not progress to dysplasia (P>0.2). The mean dosage was 9.9 0.7 mg/kg per day in those who progressed to dysplasia and 8.9 0.5 mg/kg per day in those who did not progress to dysplasia (P>0.2). The relationship between total accumulated ursodiol dose (dose duration of use) and progression to dysplasia was not significant (P>0.2). Sixteen of 59 patients (27%) were indefinite for dysplasia at their most advanced colonic histologic stage. In a secondary analysis that excluded these 16 patients, ursodiol use was still negatively associated with colonic dysplasia (odds ratio, 0.21 [CI, 0.05 to 0.99]; P=0.05). After controlling for sex, age at onset of colitis, duration of colitis, duration of sclerosing cholangitis, ChildPugh class, and use of sulfasalazine, the adjusted odds ratio was 0.20 (CI, 0.03 to 1.5; P=0.12). Eleven of the 59 patients (19%) had a diagnosis of high-grade dysplasia duri

Early Diagnosis and Treatment of Pancreatic Dysplasia in Patients with a Family History of Pancreatic Cancer

Pancreatic cancer is the fourth leading cause of cancer death in the United States, and its incidence is increasing. At the time of diagnosis, 96% to 99% of patients are incurable and have a median survival of less than 1 year (1-3). Hereditary predisposition accounts for at least 10% of cases of pancreatic cancer (4). Some inherited syndromes that confer a high risk for pancreatic cancer include familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer, cystic fibrosis, and hereditary pancreatitis. However, patients who inherit pancreatic cancer in an autosomal dominant fashion (familial pancreatic cancer) are at the highest risk, which can approach 50% (4, 5). Management of patients with a family history of pancreatic cancer has not been prospectively studied. Theoretically, the poor prognosis of patients with pancreatic cancer could be improved if a method for detecting precancerous, or dysplastic, changes in the pancreas was available. Current methods for evaluating patients with suspected pancreatic adenocarcinoma include endoscopic retrograde cholangiopancreatography (ERCP), abdominal computed tomography, transabdominal and endoscopic ultrasonography, and serum tumor markers. These methods of diagnosis are usually used after pancreatic cancer has developed. No prospective studies to detect precancerous lesions in the pancreas have previously been performed. We sought to determine whether laboratory, radiologic, or endoscopic findings aid in the diagnosis of early precancerous conditions of the pancreas in patients with a strong family history of pancreatic cancer. Methods Patients Fourteen patients were drawn from three separate, consecutive, unrelated kindreds (families X, Y, and Z) that had two or more members in at least two generations with pancreatic cancer (Figure 1). Primary care physicians referred the probands from the kindreds to the gastroenterology clinic at the University of Washington for pancreatic evaluation because of the strong family history of pancreatic cancer. All family members were eligible for evaluation if they were between 18 and 80 years of age and were willing to have imaging studies done and be assessed by the authors. The cohort included 8 of 20 eligible members of family X, 1 of 10 eligible members of family Y, and 5 of 6 eligible members of family Z. Patients were interviewed to ascertain the presence of diarrhea, abdominal or back pain, weight loss, and diabetes (Table 1). Eleven symptomatic patients and 3 asymptomatic patients were evaluated. The institutional review board of the University of Washington approved any K- ras analysis and genetic testing. Informed consent was obtained from all patients for all tests and procedures. Figure 1. Families X, Y, and Z. Table 1. Patient History Family X is a large pedigree of 75 members spanning five generations (Figure 1) (5). Nine family members have died of adenocarcinoma of the pancreas. Two patients in generation II and all patients in generation III had pathologic confirmation of their diagnosis. No other types of cancer are present in the family. Family X was previously tested for the hereditary pancreatitis gene, hereditary nonpolyposis colon cancer genes, and the p16 gene; no evidence of mutation was found (unpublished data). Members of this family frequently develop pancreatic endocrine or exocrine insufficiency before cancer is diagnosed; this fact can be used as a clinical marker for family members who are at greatest risk for pancreatic cancer. Eight members of family X were evaluated (Table 1). Four family members (patients X.III.2, X.III.12, X.III.17, and X.IV.30) had frequent diarrhea (one to five loose stools per day), and 1 family member (patient X.III.1) had occasional diarrhea (loose stools a few times per month). One family member with frequent diarrhea (patient X.III.17) also had chronic lower abdominal pain. Four family members had diabetes (patients X.III.1, X.III.2, X.III.12, and X.III.14), and 1 family member had a history of lightheadedness associated with hypoglycemia (patient X.IV.28). One family member was asymptomatic (patient X.IV.29). Family Y includes more than 39 members, 2 of whom died of pancreatic cancer (patients Y.III.2 and Y.IV.9); other types of cancer in the family include breast cancer, oropharyngeal cancer, and bladder cancer (Figure 1). Five family members had diabetes, including 4 who did not develop pancreatic cancer (patients Y.II.2, Y.III.3, Y.III.5, and Y.V.19) and 1 who developed cancer several months after diabetes was diagnosed (patient Y.III.20). One family member (patient Y.IV.5) with recurrent epigastric pain and frequent diarrhea was evaluated. Family Z consists of 29 members (Figure 1). Three members died of pancreatic cancer (patients Z.II.5, Z.III.7, and Z.IV.5), which was present in both sides of the family; however, the maternal lineage seemed to develop cancer at an earlier age than the paternal lineage (45 years compared with 63 years). Prostate, stomach, and breast cancer were present in paternal family members, and diabetes and suspected liver cancer were present in maternal family members (the diagnosis of liver cancer is uncertain because objective medical information was not available). Five family members were available for evaluation (Table 1). One patient (patient Z.IV.1) had frequent loose stools, and two patients (patient Z.IV.2 and Z.V.3) had occasional loose stools (Table 1). Patients Z.IV.1 and Z.V.3 also had intermittent abdominal pain. Two family members were asymptomatic (patients Z.III.6 and Z.IV.4). Patient Z.III.6 was the link between two generations with pancreatic cancer: her mother (patient Z.II.5) and her son (patient Z.IV.5). Interventions Diagnostic Tests Laboratory tests consisted of carcinoma embryonic antigen analysis, CA19-9 analysis, and, when possible, a 3-hour glucose tolerance test (unless the patient was already known to have diabetes). Analysis for the K -ras mutation was performed in patients who underwent ERCP if sufficient pancreatic juice could be obtained. Exon 1 of the K -ras oncogene was amplified by polymerase chain reaction, and products were directly sequenced as previously described (5, 6). Imaging studies included spiral computed tomography, endoscopic ultrasonography, and ERCP. Endoscopic ultrasonography was done after conscious sedation with a mechanical radial scanning ultrasonography endoscope (Olympus UM-20, Olympus Optical Co., Tokyo, Japan). Images were recorded as prints and were videotaped. Videotapes were reviewed after examinations were done to confirm the findings. Findings on endoscopic ultrasonography and ERCP were examined by the same observer to avoid interobserver variation. Computed tomography with dual-phase and helical technique was performed by using intravenous contrast, negative oral contrast, and intravenous glucagon to maximize distention of the duodenum. Thin collimation of 3 mm was used for initial noncontrast images and for the arterial and delay phases. Needle biopsies guided by computed tomography were not done for histologic evaluation because of the risk for pancreatitis and the high risk for sampling error (most patients had no focal lesions to target). Surgery Seven patients were referred for surgery because they had abnormal findings on endoscopic ultrasonography and ERCP. They received pneumococcal, influenza, and meningococcal vaccines approximately 3 weeks before surgery in anticipation of splenectomy and subsequently had abdominal exploration and en bloc total pancreaticoduodenectomy and splenectomy to remove all pancreatic tissue. Total pancreatectomy rather than partial pancreatectomy was performed because of concerns that cancer could develop in any pancreatic remnant left in situ. Reconstruction was done by using duodenojejunostomy followed by end-side choledochojejunostomy using an antecolic jejunal limb. A feeding jejunostomy tube was placed to allow early postoperative enteral nutrition. Postoperative therapy included H2-blockers or proton-pump inhibitors as prophylaxis against marginal ulcers. One patient required segmental jejunal resection for an intramural mass found to contain a pancreatic rest on histologic examination. Results Fourteen patients were evaluated for evidence of pancreatic abnormalities, and 7 were referred for pancreatectomy on the basis of ERCP findings and family history. All 7 patients were found to have widespread dysplasia throughout the pancreas; 6 of these patients were from family X, and 1 was from family Z (Table 2). Table 2. Endoscopic, Radiologic, and Histologic Findings Diagnostic Tests Initial history showed that 6 of the 14 patients had frequent symptoms of pancreatic endocrine or exocrine insufficiency, 3 patients had occasional diarrhea, 1 patient had weight loss, 1 patient had lightheadedness associated with hypoglycemia, and 3 patients were asymptomatic. Of the patients found to have dysplasia, 6 had symptoms and 1 was asymptomatic. Of the 7 patients who did not undergo surgery, 5 had symptoms and 2 were asymptomatic (Table 1). Physical examinations were noncontributory. Laboratory analysis showed diabetes or glucose intolerance in half of the patients (7 of 14); however, most of these patients (6 of 7) were from family X, in which diabetes is a phenotypic component of the hereditary syndrome. Carcinoembryonic antigen and CA19-9 levels were tested in 8 of the 14 patients and found to be normal in all patients except patient X.III.17, who had an elevated carcinoembryonic antigen level of 10.6 g/L (normal range<5.0 g/L) but a normal CA19-9 level of 34 U/mL (normal range<35 U/mL). Analysis for the K- ras mutation was performed on pancreatic juice obtained on ERCP in 4 of the 7 patients who were subsequently found to have dysplasia. Three patients (patients X.III.1, X.III.2, and X.III.17) were positive for the K- ras mutation, and 1 patient (patient X.III.14) had no detectable mutation. Endoscopic ultrasonography was perfo

Durability of Radiofrequency Ablation in Barrett's Esophagus With Dysplasia

BACKGROUND & AIMS Radiofrequency ablation (RFA) can eradicate dysplasia and intestinal metaplasia in patients with dysplastic Barretts esophagus (BE), and reduce rates of esophageal adenocarcinoma. We assessed long-term rates of eradication, durability of neosquamous epithelium, disease progression, and safety of RFA in patients with dysplastic BE. METHODS We performed a randomized trial of 127 subjects with dysplastic BE; after cross-over subjects were included, 119 received RFA. Subjects were followed for a mean time of 3.05 years; the study was extended to 5 years for patients with eradication of intestinal metaplasia at 2 years. Outcomes included eradication of dysplasia or intestinal metaplasia after 2 and 3 years, durability of response, disease progression, and adverse events. RESULTS After 2 years, 101 of 106 patients had complete eradication of all dysplasia (95%) and 99 of 106 had eradication of intestinal metaplasia (93%). After 2 years, among subjects with initial low-grade dysplasia, all dysplasia was eradicated in 51 of 52 (98%) and intestinal metaplasia was eradicated in 51 of 52 (98%); among subjects with initial high-grade dysplasia, all dysplasia was eradicated in 50 of 54 (93%) and intestinal metaplasia was eradicated in 48 of 54 (89%). After 3 years, dysplasia was eradicated in 55 of 56 of subjects (98%) and intestinal metaplasia was eradicated in 51 of 56 (91%). Kaplan-Meier analysis showed that dysplasia remained eradicated in >85% of patients and intestinal metaplasia in >75%, without maintenance RFA. Serious adverse events occurred in 4 of 119 subjects (3.4%); the rate of stricture was 7.6%. The rate of esophageal adenocarcinoma was 1 per 181 patient-years (0.55%/patient-years); there was no cancer-related morbidity or mortality. The annual rate of any neoplastic progression was 1 per 73 patient-years (1.37%/patient-years). CONCLUSIONS In subjects with dysplastic BE, RFA therapy has an acceptable safety profile, is durable, and is associated with a low rate of disease progression, for up to 3 years.

Chromosomal instability in ulcerative colitis is related to telomere shortening

Ulcerative colitis, a chronic inflammatory disease of the colon, is associated with a high risk of colorectal carcinoma that is thought to develop through genomic instability. We considered that the rapid cell turnover and oxidative injury observed in ulcerative colitis might accelerate telomere shortening, thereby increasing the potential of chromosomal ends to fuse, resulting in cycles of chromatin bridge breakage and fusion and chromosomal instability associated with tumor cell progression. Here we have used quantitative fluorescence in situ hybridization to compare chromosomal aberrations and telomere shortening in non-dysplastic mucosa taken from individuals affected by ulcerative colitis, either with (UC progressors) or without (UC non-progressors) dysplasia or cancer. Losses, but not gains, of chromosomal arms and centromeres are highly correlated with telomere shortening. Chromosomal losses are greater and telomeres are shorter in biopsy samples from UC progressors than in those from UC non-progressors or control individuals without ulcerative colitis. A mechanistic link between telomere shortening and chromosomal instability is supported by a higher frequency of anaphase bridges—an intermediate in the breakage and fusion of chromatin bridges—in UC progressors than in UC non-progressors or control individuals. Our study shows that telomere length is correlated with chromosomal instability in a precursor of human cancer.

Palladin Mutation Causes Familial Pancreatic Cancer and Suggests a New Cancer Mechanism

Background Pancreatic cancer is a deadly disease. Discovery of the mutated genes that cause the inherited form(s) of the disease may shed light on the mechanism(s) of oncogenesis. Previously we isolated a susceptibility locus for familial pancreatic cancer to chromosome location 4q32–34. In this study, our goal was to discover the identity of the familial pancreatic cancer gene on 4q32 and determine the function of that gene. Methods and Findings A customized microarray of the candidate chromosomal region affecting pancreatic cancer susceptibility revealed the greatest expression change in palladin (PALLD), a gene that encodes a component of the cytoskeleton that controls cell shape and motility. A mutation causing a proline (hydrophobic) to serine (hydrophilic) amino acid change (P239S) in a highly conserved region tracked with all affected family members and was absent in the non-affected members. The mutational change is not a known single nucleotide polymorphism. Palladin RNA, measured by quantitative RT-PCR, was overexpressed in the tissues from precancerous dysplasia and pancreatic adenocarcinoma in both familial and sporadic disease. Transfection of wild-type and P239S mutant palladin gene constructs into HeLa cells revealed a clear phenotypic effect: cells expressing P239S palladin exhibited cytoskeletal changes, abnormal actin bundle assembly, and an increased ability to migrate. Conclusions These observations suggest that the presence of an abnormal palladin gene in familial pancreatic cancer and the overexpression of palladin protein in sporadic pancreatic cancer cause cytoskeletal changes in pancreatic cancer and may be responsible for or contribute to the tumors strong invasive and migratory abilities.

The role of cyclooxygenase 2 in ulcerative colitis-associated neoplasia.

Cyclooxygenase 2 (COX-2) overexpression has been described in sporadic colonic neoplasia, but its role in ulcerative colitis (UC) neoplastic progression remains unexplored. Although the specific role of cyclooxygenase in colonic neoplasia is uncertain, its inhibition by nonsteroidal anti-inflammatory drugs decreases the risk of sporadic colonic adenocarcinoma and causes regression of adenomas in familial adenomatous polyposis. To investigate the role of COX-2 in UC-associated neoplasia, we assessed COX-2 protein and mRNA expression throughout the spectrum of UC-associated neoplastic lesions in four total colectomy specimens, using immunocytochemistry and a novel TaqMan reverse transcriptase-polymerase chain reaction assay. The findings were correlated with DNA ploidy and inflammatory activity. We found COX-2 overexpression throughout the neoplastic spectrum in UC (P: < 0.0001, R:(2)=0.53), even in diploid samples that were negative for dysplasia. Overall, neoplastic change explained 53% of the variation in COX-2 expression, whereas inflammatory activity explained only 11%. COX-2 was overexpressed in all aneuploid samples and in 38% of diploid samples (P: = 0.0074). cDNA representational difference analysis was also performed and revealed that COX-2 mRNA was an up-regulated cDNA representational difference analysis difference product. COX-2 overexpression occurs early in UC-associated neoplasia, and the increase cannot be explained by inflammatory activity alone. The data suggest that COX-2-specific inhibitors may have a chemopreventative role in UC but the possibility that they could exacerbate UC inflammatory activity needs to be tested.

Quantitative proteomics analysis reveals that proteins differentially expressed in chronic pancreatitis are also frequently involved in pancreatic cancer.

The effective treatment of pancreatic cancer relies on the diagnosis of the disease at an early stage, a difficult challenge. One major obstacle in the development of diagnostic biomarkers of early pancreatic cancer has been the dual expression of potential biomarkers in both chronic pancreatitis and cancer. To better understand the limitations of potential protein biomarkers, we used ICAT technology and tandem mass spectrometry-based proteomics to systematically study protein expression in chronic pancreatitis. Among the 116 differentially expressed proteins identified in chronic pancreatitis, most biological processes were responses to wounding and inflammation, a finding consistent with the underlining inflammation and tissue repair associated with chronic pancreatitis. Furthermore 40% of the differentially expressed proteins identified in chronic pancreatitis have been implicated previously in pancreatic cancer, suggesting some commonality in protein expression between these two diseases. Biological network analysis further identified c-MYC as a common prominent regulatory protein in pancreatic cancer and chronic pancreatitis. Lastly five proteins were selected for validation by Western blot and immunohistochemistry. Annexin A2 and insulin-like growth factor-binding protein 2 were overexpressed in cancer but not in chronic pancreatitis, making them promising biomarker candidates for pancreatic cancer. In addition, our study validated that cathepsin D, integrin β1, and plasminogen were overexpressed in both pancreatic cancer and chronic pancreatitis. The positive involvement of these proteins in chronic pancreatitis and pancreatic cancer will potentially lower the specificity of these proteins as biomarker candidates for pancreatic cancer. Altogether our study provides some insights into the molecular events in chronic pancreatitis that may lead to diverse strategies for diagnosis and treatment of these diseases.

Ulcerative colitis is a disease of accelerated colon aging: evidence from telomere attrition and DNA damage

BACKGROUND & AIMS Telomere shortening is implicated in cancer and aging and might link these 2 biologic events. We explored this hypothesis in ulcerative colitis (UC), a chronic inflammatory disease that predisposes to colorectal cancer and in which shorter telomeres have been associated with chromosomal instability and tumor progression. METHODS Telomere length was measured by quantitative polymerase chain reaction in colonocytes and leukocytes of 2 different sets of UC patients and compared with normal controls across a wide range of ages. For a subset of patients, telomere length was measured in epithelium and stroma of right and left colon biopsy specimens. A third set of biopsy specimens was analyzed for phosphorylation of histone H2AX (gammaH2AX), a DNA damage signal, by immunofluorescence and for telomere length by quantitative fluorescence in situ hybridization. Relationships between telomere length, gammaH2AX intensity, age, disease duration, and age of disease onset were explored. RESULTS Colonocyte telomeres shorten with age almost twice as rapidly in UC patients as in normal controls. This extensive shortening occurs within approximately 8 years of disease duration. Leukocyte telomeres are slightly shorter in UC patients than in controls, but telomeres of colon stromal cells are unaffected. gammaH2AX intensity is higher in colonocytes of UC patients than in controls and is not dependent on age or telomere length. CONCLUSIONS Colonocytes of UC patients show premature shortening of telomeres, which might explain the increased and earlier risk of cancer in this disease. Shorter leukocyte telomeres and increased gammaH2AX in colonocytes might reflect oxidative damage secondary to inflammation.

A new susceptibility locus for autosomal dominant pancreatic cancer maps to chromosome 4q32-34.

Pancreatic cancer is the fifth leading cause of cancer death in the United States. Nearly every person diagnosed with pancreatic cancer will die from it, usually in <6 mo. Familial clustering of pancreatic cancers is commonly recognized, with an autosomal dominant inheritance pattern in approximately 10% of all cases. However, the late age at disease onset and rapid demise of affected individuals markedly hamper collection of biological samples. We report a genetic linkage scan of family X with an autosomal dominant pancreatic cancer with early onset and high penetrance. For the study of this family, we have developed an endoscopic surveillance program that allows the early detection of cancer and its precursor, before family members have died of the disease. In a genomewide screening of 373 microsatellite markers, we found significant linkage (maximum LOD score 4.56 in two-point analysis and 5.36 in three-point analysis) on chromosome 4q32-34, providing evidence for a major locus for pancreatic cancer.