A randomised controlled trial of ablation of Barrett's oesophagus with multipolar electrocoagulation versus argon plasma coagulation in combination with acid suppression: long term results.

BACKGROUND: Many modalities have been used to ablate Barrett's oesophagus (BO). However, long term results and comparative effectiveness are unknown. AIMS: Our aim was to compare the long term efficacy of achieving complete reversal (endoscopic and histological) between multipolar electrocoagulation (MPEC) and argon plasma coagulation (APC) in BO patients and assess factors influencing successful ablation. METHODS: Patients with BO, 2-6 cm long, underwent 24 hour pH testing on proton pump inhibitor (PPI) therapy. Patients were then randomised by BO length to undergo ablation with MPEC or APC every 4-8 weeks until endoscopic reversal or maximal of six treatment sessions. RESULTS: Thirty five BO patients have been followed for at least two years following endoscopic ablation, 16 treated with MPEC and 19 with APC. There was complete reversal of BO in 24 patients (69%); 75% with MPEC and 63% with APC (p = 0.49). There was no difference in the number of sessions required in the two groups. There was no difference in age, pH results, BO length, PPI dose, or hiatal hernia size between patients with and without complete reversal. One patient developed an oesophageal stricture but there were no major complications such as bleeding or perforation. CONCLUSIONS: In BO patients treated with MPEC or APC in combination with acid suppression, at long term follow up, complete reversal of BO can be maintained in approximately 70% of patients, irrespective of the technique. There are no predictors associated with achieving complete reversal of BO. Continued surveillance is still indicated in the post ablative setting. As yet, these techniques are not ready for clinical application (other than for high grade dysplasia or early oesophageal adenocarcinoma) and cannot be offered outside the research arena.

Lack of predictors of normalization of oesophageal acid exposure in Barrett's oesophagus.

BACKGROUND: Barrett's oesophagus patients may continue to have abnormal oesophageal acid exposure on proton pump inhibitor therapy. The effect of factors such as Barrett's oesophagus length, hiatal hernia size and Helicobacter pylori infection on intra-oesophageal pH in Barrett's oesophagus patients has not been adequately studied. AIM: To evaluate oesophageal acid exposure in a large Barrett's oesophagus population on b.d. proton pump inhibitor therapy and determine clinical factors predicting normalization of intra-oesophageal pH on therapy. METHODS: Barrett's oesophagus patients were studied using 24 h pH monitoring to evaluate intra-oesophageal acid suppression on b.d. dosing of rabeprazole. RESULTS: Forty-six Barrett's oesophagus patients completed the study. Median total percentage time pH < 4 was 1.05% (range: 0-29.9%) in the entire group and respective values for upright and supine percentage time pH < 4 were 1.15% and 0%. However, 34 of the Barrett's oesophagus patients (73.9%) had a normal pH study (median total percentage time pH < 4: 0.2%) and 12 patients (26.1%) had an abnormal result (median total percentage time pH < 4: 9.3%). There were no significant differences between patients with a normal and abnormal 24 h pH result with respect to age, Barrett's oesophagus length, hiatal hernia size and presence of H. pylori infection. CONCLUSIONS: Approximately 25% of Barrett's oesophagus patients continue to have abnormal total intra-oesophageal pH profiles despite b.d. proton pump inhibitor therapy. Factors such as age, Barrett's oesophagus length and hiatal hernia size cannot be used to predict persistent abnormal intra-oesophageal pH on proton pump inhibitor.

Magnification chromoendoscopy for the detection of intestinal metaplasia and dysplasia in Barrett's oesophagus.

BACKGROUND: The presence of intestinal metaplasia (IM) in the columnar lined distal oesophagus defines Barrett's oesophagus with the risk of future malignant transformation. The distribution of both IM and dysplasia (low grade (LGD) and high grade (HGD)) within the columnar lined oesophagus is patchy and mosaic requiring random biopsies. Techniques that could help target areas of high yield within Barrett's mucosa would be helpful. AIM: To study the utility of high magnification chromoendoscopy (MCE) in the detection of IM, LGD, and HGD in patients with Barrett's oesophagus. METHODS: Consecutive patients detected with columnar mucosa in the distal oesophagus were studied using an Olympus magnification endoscope (GIF-Q16OZ, 115x). The distal oesophagus was sprayed with indigo carmine solution and the oesophageal columnar mucosa patterns were noted under high magnification and targeted for biopsy. All biopsies were read by pathologists blinded to the endoscopic findings. RESULTS: Eighty patients with suspected Barrett's oesophagus (that is, columnar lined distal oesophagus) were studied: mean age 62.7 years (range 35-81). Mean length of columnar mucosa was 3.7 cm (range 0.5-17). Three types of mucosal patterns were noted within the columnar mucosa after spraying indigo carmine and using MCE: ridged/villous pattern, circular pattern, and irregular/distorted pattern. The yield of IM on target biopsies according to the patterns was: ridged/villous 57/62 (97%) and circular 2/12 (17%). Six patients had an irregular/distorted pattern and all had HGD on biopsy (6/6 (100%)). Eighteen patients had LGD on target biopsies; all had the ridged/villous pattern. All patients with long segment Barrett's were identified using MCE whereas 23/28 patients (82%) with short segment Barrett's had the ridged/villous pattern. CONCLUSIONS: MCE helps visually identify areas with IM and HGD having specific patterns but not patients with LGD (appear similar to IM). MCE may be a useful clinical tool for the increased detection of patients with IM as well as for surveillance of patients for the detection of HGD. If these preliminary results are validated, MCE would help identify high yield areas, potentially eliminating the need for random biopsies.

Methylene blue chromoendoscopy for detection of short-segment Barrett's esophagus.

BACKGROUND: The yield of intestinal metaplasia (IM) with randomly obtained biopsy specimens in patients with short lengths of columnar-appearing mucosa in the distal esophagus is low (30%-50%). Vital staining would be beneficial if it identified more patients with short-segment Barrett's esophagus (SSBE). Our aim was to compare the confirmation of IM in patients with suspected SSBE (columnar-appearing mucosa <3 cm in length) by using methylene blue (MB)-directed versus random biopsies. METHODS: Consecutive patients undergoing EGD in whom columnar-appearing mucosa less than 3 cm in length was visualized underwent MB staining. Stained areas within suspected SSBE segments were targeted for biopsies. All biopsy specimens were stained with H & E with alcian blue at pH 2.5 and evaluated by a single pathologist. A historical control group (different from patients undergoing MB staining) consisted of patients with less than 3 cm of columnar-appearing mucosa in whom biopsy specimens were obtained randomly without MB staining. RESULTS: The MB group included 75 patients (mean age 63.8 +/- 10.9 years) with a mean length of columnar-appearing mucosa of 1.2 cm (range 0.5-2.5 cm). The control group included 83 patients (mean age 60.5 +/- 12.9 years) with a mean length of columnar-appearing mucosa of 1.16 cm (range 0.5-2.5 cm). IM (i.e., confirmed SSBE) was detected in 61% of the MB group versus 42% of the control group (p = 0.0237). Patients in the MB group required significantly fewer biopsies (4.3 +/- 1.5 vs. 5.1 +/- 12.3, p = 0.0162). Confirmation of IM by length was as follows: less than 1 cm (irregular Z line), MB 17.4% versus control 25% (p = 0.73); 1 to less than 2 cm, MB 77% versus control 45% (p = 0.03); 2 to less than 3 cm, MB 90% versus control 58% (p = 0.02). CONCLUSIONS: MB chromoendoscopy significantly increases the detection of IM and requires fewer biopsies in patients with suspected SSBE with greater than 1 cm of columnar-appearing mucosa. It does not appear to be beneficial in patients with irregular Z lines (<1 cm).

p53 protein overexpression in low grade dysplasia (LGD) in Barrett's esophagus: immunohistochemical marker predictive of progression.

OBJECTIVES: The presence of low grade dysplasia (LGD) within Barrett's esophagus (BE) has a multitude of ramifications. Identification of markers that could risk stratify LGD would be of great clinical benefit. We aimed to prospectively evaluate the prognosis of the immunohistochemical overexpression of p53 protein in BE colocalized to LGD. METHODS: Consecutive BE patients in whom LGD was found had a repeat esophagogastroduodenoscopy within 8-12 wk per an ongoing prospective study. At each esophagogastroduodenoscopy, a therapeutic scope was used in conjunction with the Seattle Biopsy Protocol. Patients were observed until development of multifocal high grade dysplasia (mHGD), presence of an HGD dysplasia-associated lesion or mass (DALM) lesion, or frank adenocarcinoma. p53 protein overexpression was determined by computerized immunoquantitation using image analysis software on step serial-sectioned specimens of BE segment(s) harboring LGD. Kaplan-Meier survival curves were made on the ability of p53 staining colocalized to areas of LGD to predict progression to mHGD, HGD DALM, or cancer during prospective follow-up. RESULTS: Forty-eight BE patients with LGD were observed for a mean of 41.2+/-22.5 months. During this period, five of 48 patients progressed to mHGD with a focus in which intramucosal cancer could not be excluded (one), mHGD/DALM with one or more foci in which intramucosal cancer could not be excluded (two), cancer (one), or mHGD (one). Twelve had persistent LGD and 31 had regressed to no dysplasia. p53 staining was positive and colocalized to areas of LGD in 4/31 of patients that regressed, 3/12 that persisted, and 3/5 that progressed. Kaplan-Meier curves differed significantly between p53 positive and negative patients for outcome defined as progression of LGD. CONCLUSIONS: p53 colocalization with LGD at index LGD diagnosis is a risk factor for progression of LGD. This can potentially be used to risk stratify BE LGD patients in terms of surveillance intervals or enrollment into secondary prevention studies.

Incidence and management of esophageal stricture formation, ulcer bleeding, perforation, and massive hematoma formation from sclerotherapy versus band ligation.

OBJECTIVES: The aim of this study was to compare the incidence and endoscopic management of esophageal stricture formation, significant ulcer bleeding, massive esophageal hematoma, and perforation resulting from endoscopic band ligation or sclerotherapy of esophageal varices. METHODS: Consecutive esophagogastroduodenoscopies in which band ligation or sclerotherapy was performed for acute or obliterative therapy were entered into a computerized endoscopy database during a 7-yr period. Patients were excluded if they died within 72 h of treatment session from complications unrelated to the procedure. Sclerotherapy was performed using a 25-gauge needle with 1.5% sodium tetradecyl sulfate and banding was primarily performed with a Wilson-Cook 6 or 10 shooter. Complications were assessed at scheduled endoscopy and outpatient clinic visits, review of quality assurance data tallied on a monthly basis, and patient records. RESULTS: Two hundred twenty-one cases of sclerotherapy were performed in 59 patients compared to 110 cases of band ligation in 52 patients. Five patients were excluded because of death within 72 h of the procedure. The incidence of complications from sclerotherapy:banding on a per patient basis included: esophageal stricture formation 25.6%:1.9%, ulcer bleed 25.4%:5.7%, esophageal perforation 2.2%:0%, and massive esophageal hematoma 1.6%:0%. A significant difference in complications between sclerotherapy and band ligation was noted for both stricture formation (p < 0.0005) and ulcer bleeding (p < 0.0001). The majority of ulcer bleeds required no therapeutic intervention, whereas stricture formation required multiple dilation sessions. CONCLUSIONS: Band ligation has a significantly lower incidence of stricture formation and ulcer bleeding compared to sclerotherapy. The majority of complications can be managed with endoscopic interventions.

Identification of genomic imbalances in gastric MALT lymphoma using arbitrarily primed PCR DNA fingerprinting.

Arbitrarily primed PCR (AP-PCR) is a unique method to identify the cancer cell specific losses and gains of chromosomal regions by targeting specific genes or chromosomal segments. In the present study, introducing the AP-PCR technique with a single primer, we have ascertained the gains and losses of DNA fingerprints in 15 MALT lymphoma samples. Out of 15 prominent DNA fingerprints, the signal intensity of two fingerprints, labeled bands G and I, were significantly lower in 40 and 50% of tumors as compared to adjacent normal DNA fingerprints, respectively. Similarly, gains of signal intensity of DNA fingerprints (bands A and C) were detected in 13% of tumor samples studied. Variations in signal intensities were also found in other bands within a few samples. Although, the functional importance of these bands is unknown, this study indicates that the AP-PCR generated under or over amplified DNA fingerprints may participate during the progression of MALT lymphoma in human stomach. Moreover, these studies also suggest that the AP-PCR technique, with different primers, can be utilized for the determination of new chromosomal segments in MALT lymphoma samples that can be used for the identification of these diseases.

Helicobacter pylori eradication dramatically improves inflammation in the gastric cardia.

OBJECTIVES: Inflammation of the gastric cardia, i.e., "carditis," has been associated with Helicobacter pylori (H. pylori) infection; however, some investigators believe carditis to be a histological marker for gastroesophageal reflux disease. The aim of this study was to investigate the role of H. pylori eradication on the grade of carditis scored according to the updated Sydney classification. METHODS: Consecutive patients presenting for upper endoscopy underwent systematic gastric biopsies (eight antral, 12 corpus, and four cardia). Patients with H. pylori infection and carditis were identified and followed prospectively before and after H. pylori treatment. At pretreatment and, on average, 2 yr after eradication of H. pylori, the degree of inflammation in the gastric cardia and H. pylori status were blindly assessed by a single pathologist. RESULTS: A total of 31 patients with H. pylori infection and carditis were identified. The mean age was 70 yr (range: 37-81 yr); all were male. Four were African-American and 27 were Caucasian. All patients were treated with standard anti-H. pylori therapy, including a proton pump inhibitor in combination with two antibiotics for 2 wk. Eradication of H. pylori was successful in 23 patients (group I), whereas eight patients had persistent infection (group II). Patients were followed after eradication therapy for a mean of 23.2 months (range: 6-48 months). After eradication therapy, there was a significant decrease (p < 0.0001) in the carditis scores (activity and inflammation scores) in group I, whereas the scores remained unchanged in group II patients. In both groups, there were no significant changes in the degree of intestinal metaplasia or atrophy. There were four patients with intestinal metaplasia, and one with atrophy. CONCLUSIONS: There is a dramatic improvement in the degree of inflammation and activity scores in the gastric cardia of patients with successful H. pylori eradication compared to those with persistent infection. By fulfilling one of Koch's postulates (i.e., improvement in the disease after cure of the possible etiological organism), these data support H. pylori as being the etiological agent for carditis in this group of patients.

2-Methoxyestradiol blocks estrogen-induced rat pituitary tumor growth and tumor angiogenesis: possible role of vascular endothelial growth factor.

Natural and synthetic estrogens have been associated with several types of human and animal cancers including prolactin-secreting pituitary tumors in Fischer 344 rats. These prolactin-secreting tumors are highly angiogenic and their growth is angiogenic dependent. In the present study we have utilized this model to evaluate the effect of 2-methoxyestradiol (2-ME), an endogenous estrogen metabolite that is a potent inhibitor of endothelial cell proliferation in vitro, on estrogen-induced pituitary tumor growth and angiogenesis. Adult female rats were implanted (subcutaneously) with a silastic capsule containing estradiol-17beta (E2). After seven days of constant E2 exposure animals were injected (sc) daily with 25 mg/kg of 2-ME and killed either three or 8 days later. Changes in pituitary weight and proliferating cell nuclear antigen (PCNA) labeling index indicated growth while degree of angiogenesis was determined immunohistochemically using factor VIII related antigen. The results indicate that 2-ME inhibited estrogen-induced lactotroph growth by 32% and tumor angiogenesis by 89%. Furthermore, vascular endothelial growth factor (VEGF) expression, evaluated by immunohistochemical analysis, was down-regulated concomitant with tumor angiogenic suppression. These studies suggest that 2-ME may have therapeutic potential for hormone-induced cancer and that its angiostatic activity may be modulated through down-regulation of VEGF expression.

Long-term follow-up of Barrett's high-grade dysplasia.

OBJECTIVE: The management of Barrett's high-grade dysplasia (HGD) remains controversial. The aims of this study were to evaluate prospectively the outcome of unifocal HGD (uHGD) in patients with Barrett's esophagus, and to determine demographic and endoscopic features predictive of progression to multifocal HGD (mHGD) and/or adenocarcinoma. METHODS: Consecutive Barrett's patients in whom uHGD was found at initial endoscopy or during surveillance underwent intensification of medical treatment and repeat endoscopy. The study endpoint was progression to mHGD or adenocarcinoma or HGD in conjunction with a dysplasia-associated lesion or mass (DALM). HGD diagnosis was confirmed by a second, blinded pathologist. RESULTS: A total of 15 Barrett's patients with uHGD met inclusion criteria and have been prospectively followed for a mean +/- SD of 36.8 +/- 23.2 months. All were white and male, with a mean age +/- SD of 61.4 +/- 14.9 yr. Barrett's length varied from 1 to 13 cm (mean, +/- SD, 6.8 +/- 4 cm). Overall, eight (53.3%) uHGD progressed: four of 15 (26.7%) to frank cancer between 17 and 35 months of follow-up, two of 15 (13.3%) to mHGD with DALM in conjunction with one or more foci of possible intramucosal cancer after 12-91 months of follow-up, one of 15 (6.7%) to mHGD with a focus of possible intramucosal cancer after 14 months, and one of 15 (6.7%) to mHGD after 29 months. Seven of 15 (46.7%) uHGD have regressed, five to no dysplasia and two to LGD, over the course of follow-up ranging from 24 to 73 months (mean +/- SD, 43.3 +/- 19.9). All three patients with short-segment Barrett's esophagus with uHGD regressed. Fisher's exact test revealed that Barrett's length > or =3 cm and presence of hiatal hernia approached significance (p < 0.08) in predicting uHGD progression to mHGD/DALM/cancer. However, use of the log-rank test to account for differences in length of follow-up show no significance for hiatal hernia or Barrett's length. CONCLUSIONS: Barrett's uHGD has a high risk for progressing to mHGD or cancer. Justification of an observational approach to uHGD should be discouraged. Markers of uHGD progression, as well as regression, are needed.

Tumor angiogenesis in chronic pancreatitis and pancreatic adenocarcinoma: impact of K-ras mutations.

Chronic pancreatitis (CP) is one condition in which epidemiologic studies have demonstrated a definite association with pancreatic adenocarcinoma (PAC). The pathophysiologic and molecular events that either predispose to the development of, or potentiate the growth of, PAC are unknown. Mutation of the codon 12 K-ras gene is one genetic aberration commonly associated with development of PAC. Tumor angiogenesis, or microvascular proliferation of new capillaries, is another pathophysiologic alteration associated with PAC. Although activated ras oncogenes modulate tumor angiogenesis/neovascularization in some tumors, the importance of tumor angiogenesis and the role of K-ras mutation in regulating angiogenesis in CP and PAC are unknown. The aim of this study was to elucidate the relationship between angiogenesis and K-ras mutations in CP and PAC. Tumor angiogenesis and K-ras mutations were evaluated in resected specimens from 25 CP (23 CP plus two CP with PAC) and 16 PAC patients. Tumor angiogenesis was determined using immunohistochemistry of factor VIII-related antigen (FVIIIRAg) and ras mutations were identified by enriched-nested polymerase chain reaction. The mean number of FVIIIRAg-positive blood vessels was significantly (p < 0.005) higher in PAC (23.0 +/- 7.5), CP with a mutant K-ras genome (17.7 +/- 2.8) and CP with a normal K-ras genome (6.5 +/- 3.8), compared to unaffected areas. Codon 12 K-ras mutations were detected in three of 25 CP specimens (12%) and in 15 of 16 PAC specimens (94%). In CP patients with mutant K-ras in their genome, microvessel density was significantly (p < 0.01) elevated, compared to patients with a normal K-ras genome. Statistical analyses (Spearman rank-difference correlation coefficient, Student t test, and chi2 analysis) indicated a significant association between codon 12 K-ras mutations and tumor angiogenesis in both CP and PAC. This study demonstrates a significant association between angiogenesis and K-ras mutation in both PAC and CP. At a minimum, K-ras mutation is associated with the events that increase angiogenesis and it may potentiate or promote tumor angiogenesis.

Prospective evaluation of the prevalence of gastric Helicobacter pylori infection in patients with GERD, Barrett's esophagus, Barrett's dysplasia, and Barrett's adenocarcinoma.

OBJECTIVE: This study was undertaken to prospectively determine the prevalence of gastric H. pylori infection in Barrett's esophagus and Barrett's complicated by dysplasia or adenocarcinoma. METHODS: The prevalence of H. pylori was determined in Barrett's esophagus patients compared to a control population of patients with gastroesophageal reflux disease (GERD) only. All patients had a minimum of 10 gastric surveillance biopsies obtained. H. pylori colonization was determined upon the basis of hematoxylin and eosin and use of a modified Giemsa and or Steiner's silver stain of all gastric biopsy specimens. RESULTS: Two hundred and eighty-nine Barrett's patients and 217 GERD control patients were included in the study. H. pylori was found in 95/289 (32.9%) of the Barrett's patients, compared with 96/217 (44.2%) of the GERD controls (NS). Forty-seven of the Barrett's patients had low-grade dysplasia/indefinite dysplasia, 14 high-grade dysplasia, and 20 Barrett's adenocarcinoma. When Barrett's was subgrouped according to absence of dysplasia, and presence of low-grade dysplasia, high-grade dysplasia, or adenocarcinoma, H. pylori prevalence was found to be significantly less for patients with Barrett's high-grade dysplasia (14.3%) and adenocarcinoma (15.0%) versus patients with GERD alone (44.2%), Barrett's alone (35.1%), or Barrett's with low-grade dysplasia (36.2%) (p = 0.016). This difference could not be explained by differences between Barrett's esophagus patients infected with H. pylori and those who were not with respect to gender, smoking history, alcohol consumption, use of proton pump inhibitor, or length of Barrett's mucosa. CONCLUSIONS: Barrett's high-grade dysplasia and adenocarcinoma are significantly more prevalent in patients who are not infected with H. pylori. H. pylori appears to have a protective effect against the development of Barrett's adenocarcinoma.

Expression of cdc2 and cyclin B1 in Helicobacter pylori-associated gastric MALT and MALT lymphoma : relationship to cell death, proliferation, and transformation.

Mucosa-associated lymphoid tissue (MALT) may accumulate within gastric mucosa as a result of long standing Helicobacter pylori infection, and this acquired MALT may eventually develop into low-grade B-cell MALT lymphoma. To determine the possible association of cell cycle regulatory proteins and apoptotic cell death in the transformation of H. pylori gastritis to MALT lymphoma, the extent of cell proliferation, cell viability, expression of Cdc2/Cdk1 and cyclin B in gastric mucosal from patients with H. pylori-positive chronic gastritis (n = 7), MALT (n = 12), or MALT lymphoma (n = 12) were undertaken. Control tissue was obtained from H. pylori- negative patients (n = 5). Proliferating cell nuclear antigen (PCNA), Cdc2, and cyclin B1 were examined in paraffin embedded tissue by immunohistochemistry, while the apoptotic index (AI) was determined using the TUNEL assay. H&E staining for histology and modified Giemsa staining for the detection of H. pylori was conducted simultaneously. When compared to chronic gastritis tissue, those with MALT or MALT lymphoma had an increase in PCNA labeling index of 3.3- and 2.7-fold, while that for Cdc2/Cdk1 increased 2.3- and 3.1-fold, respectively. cyclin B1 labeling was 1.9 and 3.0 fold, while the AI was 3.4- and 1.4-fold higher in MALT and MALT lymphoma tissue, respectively, in the same comparison. On the other hand, the AI index of MALT lymphoma was 2. 5-fold lower than that for MALT tissues. The labeling scores for Cdc2/Cdk1 and cyclin B1 were significantly higher in the germinal center when compared to the mantle and marginal zones of MALT tissues. Using chi(2) and Pearson/Spearman's rho correlation coefficient with regression analyses, there was an inverse correlation between the AI and Cdc2/Cdk1 or cyclin B1 in MALT and MALT lymphoma tissues. There was no correlation between AI and PCNA labeling in any of the tissues. These results suggest that Cdc2/Cdk1 and cyclin B1 expression may be actively associated in the modulation of cellular death by apoptosis, as well as cellular proliferation and transformation during the evolution of H. pylori-associated gastritis to MALT lymphoma. Subclassification of high labeling score (>/=40) for Cdc2/Cdk1 and cyclin B1 and low labeling index (<0.6) for apoptotic cells in H. pylori-associated MALT may help in identifying a population of patients with an increased risk of developing MALT lymphoma.

Overexpression of vascular endothelial growth factor164 and its co-receptor neuropilin-1 in estrogen-induced rat pituitary tumors and GH3 rat pituitary tumor cells.

We have shown previously that the VEGF system plays a crucial role in regulation of tumor angiogenesis during the development of estrogen-induced prolactin-secreting pituitary tumors in Fisher 344 rats. Studies also suggested that both endothelial and non-endothelial cells expressed VEGF. However, several questions concerning the VEGF signals in regulation of estrogen-induced angiogenesis in rat pituitary remained unanswered. VEGF exists in a number of isoforms in human and rodent tissue (i.e., VEGF206h/205r, VEGF189h/188r, VEGF165h/164r, VEGF145h/144r and VEGF121) that differ in their molecular masses and biological activities. The VEGF isoforms bind with two tyrosine-kinase receptors, KDR/flk-1 and flt-1. In addition, VEGF165 binds with a newly identified co-receptor, neuropilin-1, which is expressed in human endothelial cells and several types of non-endothelial cells including tumor cells. The present study was undertaken to elucidate which isoforms of VEGF are predominantly expressed in normal Fisher 344 rat pituitaries, estrogen-induced prolactin secreting rat pituitary tumors and in prolactin secreting rat pituitary tumor cell line (GH3 cell line). To identify the isoform, RT-PCR with primer pairs derived from exon 1 and exon 8 of the VEGF gene, cloning, sequencing and Western blot analysis were performed. The status of neuropilin-1 in the rat pituitaries (normal and transformed) and GH3 pituitary tumor cell line has also been investigated using RT-PCR and Western blot analysis. These studies demonstrate that normal rat pituitaries, estrogen-induced rat pituitary tumors and GH3 pituitary tumor cells expressed VEGF164 and co-receptor, neuropilin-1. The VEGF164 was the predominant form in all of these cells. The VEGF164 and neuropilin-1 mRNA and protein levels were significantly higher in the estrogen-induced pituitary tumors and GH3 tumor cell line, as compared to normal pituitary. The data suggest that both VEGF164 and neuropilin-1 may actively participate in modulation of tumor angiogenesis and the development of pituitary tumors in Fisher 344 rats.

Relative risk of dysplasia for patients with intestinal metaplasia in the distal oesophagus and in the gastric cardia.

BACKGROUND: Biopsy specimens obtained from the gastro-oesophageal junction can reveal intestinal metaplasia in patients presenting for routine upper endoscopy. The site of biopsy may play a critical role in determining the dysplasia risk of a patient. AIMS: To evaluate prospectively the dysplasia risk in patients with intestinal metaplasia of the distal oesophagus or within the gastric cardia. METHODS: Patients with short segment Barrett's oesophagus (SSBO) and cardia intestinal metaplasia (CIM) were followed prospectively. RESULTS: 177 patients with SSBO were identified (mean age 62 years, range 38-82; 91% whites). Twenty prevalence cases of dysplasia in SSBO were detected: 17 low grade dysplasia (LGD), three high grade dysplasia (HGD). Seventy six patients with CIM were identified (mean age 67 years, range 37-81; 81% whites). A single prevalence case of LGD in CIM was detected. During follow up of 78 SSBO and 34 CIM patients, dysplasia developed in nine (seven LGD, two HGD) with SSBO and in one (LGD) with CIM. There were significant differences between the two groups with respect to age, ethnicity, dysplasia prevalence, and incidence. Time to dysplasia progression was significantly longer in CIM compared with SSBO patients. Of the five patients with SSBO and HGD, one developed adenocarcinoma of the oesophagus on follow up. No HGD or cancers have been detected over this time period in CIM patients. CONCLUSIONS: The dysplasia risk is significantly greater in SSBO than in CIM patients, indicating two potentially different clinical processes. Future studies should separate SSBO from CIM in order to enhance the understanding of the pathophysiology and malignant potential of each entity.

Prospective multivariate analysis of clinical, endoscopic, and histological factors predictive of the development of Barrett's multifocal high-grade dysplasia or adenocarcinoma.

OBJECTIVE: Our goal was a prospective follow-up of Barrett's esophagus to determine what clinical, endoscopic, and histological features at the time of initial diagnosis are predictive of the development of Barrett's adenocarcinoma or multifocal high-grade dysplasia (HGD). METHODS: Newly diagnosed Barrett's esophagus patients were prospectively followed with a standardized endoscopic and bioptic surveillance protocol. Features examined by chi2 and stepwise logistic regression analyses as potential predictors the development of multifocal HGD or adenocarcinoma included age, length of Barrett's segment, hiatal hernia size, severity of dysplasia at diagnosis, severity of dysplasia during surveillance, and type of long-term medical treatment. RESULTS: One hundred-eight Barrett's patients have had follow-up ranging from 12 months to 101 months (mean +/- SD, 39.9+/-20.8 months), for a total of 361.8 patient-years. Overall, five patients developed multifocal HGD and five developed adenocarcinoma. The incidence of adenocarcinoma as well as multifocal HGD was 1 per 71.9 patient-years. Chi2 analysis showed progression to Barrett's multifocal HGD/adenocarcinoma was associated with hiatal hernia (p = 0.02), the length of Barrett's (p = 0.001), the presence of dysplasia at diagnoses (p < 0.001) or anytime during surveillance (p < 0.001). Stepwise logistic regression analysis revealed progression to multifocal HGD or adenocarcinoma was significantly and independently associated with presence of dysplasia at diagnosis (p < 0.0001) or anytime during follow-up (p < 0.03), hiatal hernia size (p < 0.02, for hernia > or =3 cm), and length of Barrett's (p = 0.009, >2 cm). CONCLUSIONS: Endoscopic and histological features of Barrett's esophagus patients at initial diagnosis are predictive of risk of progression to cancer.

Prospective multivariate analysis of factors predictive of complete regression of Barrett's esophagus.

OBJECTIVE: Demographic, endoscopic, and histological features of Barrett's esophagus at initial diagnosis were examined for their ability to predict complete endoscopic and histological regression of Barrett's during long-term follow-up. METHODS: Barrett's patients who have been followed up for a minimum of 2 yr and who have had at least two follow-up surveillance examinations were included in the analysis. Complete regression of Barrett's was defined as total disappearance of all tongues and patches of Barrett's epithelium at endoscopy (confirmed with Lugol's iodine) in conjunction with only squamous epithelium on biopsy. Chi2 and stepwise logistic regression analyses were performed on the following clinical, endoscopic, and histological variables with regards to their ability to predict complete Barrett's regression: patient age in years (<65 or > or =65), length in cm of Barrett's (< or =2, >2<6, and > or =6), presence of a hiatal hernia (yes or no), presence of dysplasia at diagnosis (yes or no), and type of long-term medical treatment (histamine antagonists, proton pump inhibitor [PPI], or PPI and cisapride). RESULTS: Ninety-nine patients, all men with a mean age +/- SD in years of 61.6+/-13.1 have been followed prospectively for 24-106 months (mean +/- SD, 48.0+/-19.8). Seven patients have had complete regression of Barrett's. Univariate analysis showed that complete regression of Barrett's was associated only with absence of a hiatal hernia (p = 0.012). Stepwise logistic regression analysis revealed that complete regression was significantly and independently associated again only with absence of a hiatal hernia (p = 0.025). Stepwise logistic regression analysis utilizing only hiatal hernia (yes vs no) and length of Barrett's (<6 cm vs > or =6 cm) as variables revealed that absence of a hiatal hernia (p = 0.0447) and shorter lengths (<6 cm) of Barrett's (p = 0.0418) were significantly and independently predictive of complete Barrett's regression. CONCLUSIONS: The absence of a hiatal hernia was noted to be the most important factor associated with Barrett's regression. Complete regression of Barrett's esophagus occurs in a minority of patients, primarily in those with no hiatal hernia and shorter lengths of Barrett's epithelium.

Prospective long-term endoscopic and histologic follow-up of gastric lymphoproliferative disease of early stage IE low-grade B-cell mucosa-associated lymphoid tissue type following Helicobacter pylori eradication treatment.

Long-term endoscopic and histologic follow-up of Stage IE gastric lymphoproliferative disease of the low-grade B-cell mucosa-associated lymphoid tissue (MALT) type following cure of H. pylori was undertaken. Clinical and endoscopic features (age, race, endoscopic appearance, cure of H. pylori and duration of follow-up) were also evaluated as potential prognostic indicators for complete or near-complete regression of low-grade MALT lymphoma. Sixty-eight MALT lymphoma patients prospectively underwent H. pylori eradication. follow-up at periodic intervals with endoscopy and extensive mucosal biopsy protocol on 65 patients ranging from 12 weeks up to 73 months (mean +/- SD of 22.5+/-15.8 months) has been completed. H. pylori was eradicated in 89.2% of MALT lymphoma patients with complete histologic regression noted in 58.5%, near-complete regression in 18.5%, partial in 4.6%, and no change in 18.5%. Univariate analysis revealed two factors predictive of complete and/or near complete MALT lymphoma regression, H. pylori cure (p=0. 001) and duration of follow-up (p=0.001). Stepwise logistic regression also demonstrated that both H. pylori cure (p<0.0001) and duration of follow-up (p<0.02) were independently associated with complete and near complete MALT lymphoma regression. Age, race, and endoscopic appearance were not predictive of regression. We conclude that this lymphoproliferative disease predictably undergoes complete to near-complete histologic regression at variable rates following cure of H. pylori in a majority of patients.

2-methoxyestradiol-induced growth suppression and lethality in estrogen-responsive MCF-7 cells may be mediated by down regulation of p34cdc2 and cyclin B1 expression.

MCF-7 breast cancer cells increase their rate of proliferation, as indicated by incorporation of tritiated thymidine into DNA, when exposed to estrogen. In confirmation of other studies, 10 nM 17beta-estradiol (E2) increased proliferation by 2.8-fold after 6 days of exposure. As indicated by trypan blue exclusion and TUNEL assays, cell survival was increased and apoptosis decreased by the presence of E2. The estradiol metabolite 2-methoxyestradiol (2-ME) when present in the culture medium in concentrations greater than 1 microM for three days, dose-dependently reduced the effectiveness of E2 on cell proliferation by increasing the rate of apoptosis. To examine a mechanism for the increase in apoptosis, expression of p34cdc2 and cyclin B1 protein levels were monitored by examination of immunoblots of their proteins. E2 increased p34cdc2 and cyclin B1 protein levels significantly after 6 days of exposure. This effect was inhibited significantly by the presence of 2-ME. The results indicate that up-regulation of p34cdc2 and cyclin B1 is closely associated with increased survivability and lack of apoptosis in estrogen-induced proliferation of MCF-7 cells. Further, anti-estrogenic effects of 2-ME in these cells can be accounted for by its activation of apoptotic functions, which are correlated with reductions in expression of p34cdc2 and cyclin B1 genes.

Adenocarcinoid of ileum and appendix, incidentally discovered during exploratory laparotomy for gastric MALT lymphoma, with subsequent diffuse prostatic metastases: report of a case with light, immunohistochemical, and electron microscopic studies.

The diagnosis of adenocarcinoid (mucinous/goblet cell carcinoid) is usually unexpected by both clinicians and pathologists. We report here the case of a 74-year-old man with gastric lymphoma (B-cell MALToma) diagnosed by endoscopy, who was found on exploratory laparotomy also to have extensive intraabdominal involvement by adenocarcinoid, arising from the ileum and/or appendix. The patient died two years after diagnosis with bladder outlet and small bowel obstruction due to diffuse metastases. In addition to mucin positivity, immunohistochemical stains demonstrated the tumor to be positive for chromogranin, synaptophysin, serotonin, gastrin, and glucagon. Of histogenetic interest, some individual neoplastic cells appeared to be positive for both mucin and chromogranin, and this was confirmed by the electron microscopic finding of microvilli, intracytoplasmic mucin droplets, and neurosecretory granules involving the same neoplastic cells. This also appears to be the first reported case of adenocarcinoid associated with lymphoma and demonstration of histochemical/immunohistochemical and ultrastructural evidence of cellular components with dual mucinous adenocarcinoma and neuroendocrine features, and the second reported case to have prostatic metastases.