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Samuels TL, Blaine‐Sauer S, Yan K, Johnston N. Amprenavir inhibits pepsin-mediated laryngeal epithelial disruption and E-cadherin cleavage in vitro. Laryngoscope Investig Otolaryngol 2023; 8:953-962. [PMID: 37621274 PMCID: PMC10446255 DOI: 10.1002/lio2.1102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/12/2023] [Indexed: 08/26/2023] Open
Abstract
Background Laryngopharyngeal reflux (LPR) causes chronic cough, throat clearing, hoarseness, and dysphagia and can promote laryngeal carcinogenesis. More than 20% of the US population suffers from LPR and there is no effective medical therapy. Pepsin is a predominant source of damage during LPR which disrupts laryngeal barrier function potentially via E-cadherin cleavage proteolysis and downstream matrix metalloproteinase (MMP) dysregulation. Fosamprenavir (FDA-approved HIV therapeutic and prodrug of amprenavir) is a pepsin-inhibiting LPR therapeutic candidate shown to rescue damage in an LPR mouse model. This study aimed to examine amprenavir protection against laryngeal monolayer disruption and related E-cadherin proteolysis and MMP dysregulation in vitro. Methods Laryngeal (TVC HPV) cells were exposed to buffered saline, pH 7.4 or pH 4 ± 1 mg/mL pepsin ± amprenavir (10-60 min). Analysis was performed by microscopy, Western blot, and real time polymerase chain reaction (qPCR). Results Amprenavir (1 μM) rescued pepsin acid-mediated cell dissociation (p < .05). Pepsin acid caused E-cadherin cleavage indicative of regulated intramembrane proteolysis (RIP) and increased MMP-1,3,7,9,14 24-h postexposure (p < .05). Acid alone did not cause cell dissociation or E-cadherin cleavage. Amprenavir (10 μM) protected against E-cadherin cleavage and MMP-1,9,14 induction (p < .05). Conclusions Amprenavir, at serum concentrations achievable provided the manufacturer's recommended dose of fosamprenavir for HIV, protects against pepsin-mediated cell dissociation, E-cadherin cleavage, and MMP dysregulation thought to contribute to barrier dysfunction and related symptoms during LPR. Fosamprenavir to amprenavir conversion by laryngeal epithelia, serum and saliva, and relative drug efficacies in an LPR mouse model are under investigation to inform development of inhaled formulations for LPR.
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Affiliation(s)
- Tina L. Samuels
- Department of Otolaryngology and Communication Sciences, Medical College of WisconsinMilwaukeeWisconsinUSA
| | - Simon Blaine‐Sauer
- Department of Otolaryngology and Communication Sciences, Medical College of WisconsinMilwaukeeWisconsinUSA
| | - Ke Yan
- Department of Pediatrics Quantitative Health Sciences, Medical College of WisconsinMilwaukeeWisconsinUSA
| | - Nikki Johnston
- Department of Otolaryngology and Communication Sciences, Medical College of WisconsinMilwaukeeWisconsinUSA
- Department of Microbiology and ImmunologyMedical College of WisconsinMilwaukeeWisconsinUSA
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Samuels TL, Blaine-Sauer S, Yan K, Plehhova K, Coyle C, Johnston N. Topical Alginate Protection against Pepsin-Mediated Esophageal Damage: E-Cadherin Proteolysis and Matrix Metalloproteinase Induction. Int J Mol Sci 2023; 24:ijms24097932. [PMID: 37175640 PMCID: PMC10178445 DOI: 10.3390/ijms24097932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/18/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
Epithelial barrier dysfunction is a hallmark of gastroesophageal reflux disease (GERD) related to symptom origination, inflammatory remodeling and carcinogenesis. Alginate-based antireflux medications were previously shown to topically protect against peptic barrier disruption, yet the molecular mechanisms of injury and protection were unclear. Herein, Barrett's esophageal (BAR-T) cells were pretreated with buffered saline (HBSS; control), dilute alginate medications (Gaviscon Advance or Gaviscon Double Action, Reckitt Benckiser), a viscosity-matched placebo, or ADAM10 and matrix metalloproteinase (MMP) inhibitors before exposure to HBSS pH7.4 or pH4 ± 1 mg/mL pepsin for 10-60 min. Cell viability was assessed by ATP assay; mediators of epithelial integrity, E-cadherin, ADAM10, and MMPs were examined by Western blot and qPCR. Alginate rescued peptic reduction of cell viability (p < 0.0001). Pepsin-pH4 yielded E-cadherin fragments indicative of regulated intramembrane proteolysis (RIP) which was not rescued by inhibitors of known E-cadherin sheddases. Transcriptional targets of E-cadherin RIP fragments were elevated at 24 h (MMP-1,2,9,14; p < 0.01). Alginate rescued E-cadherin cleavage, ADAM10 maturation, and MMP induction (p < 0.01). Results support RIP as a novel mechanism of peptic injury during GERD. Alginate residue after wash-out to mimic physiologic esophageal clearance conferred lasting protection against pepsin-induced molecular mechanisms that may exacerbate GERD severity and promote carcinogenesis in the context of weakly acidic reflux.
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Affiliation(s)
- Tina L Samuels
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Simon Blaine-Sauer
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Ke Yan
- Department of Pediatrics Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | | | | | - Nikki Johnston
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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Blaine-Sauer S, Samuels TL, Yan K, Johnston N. The Protease Inhibitor Amprenavir Protects against Pepsin-Induced Esophageal Epithelial Barrier Disruption and Cancer-Associated Changes. Int J Mol Sci 2023; 24:6765. [PMID: 37047737 PMCID: PMC10095080 DOI: 10.3390/ijms24076765] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/30/2023] [Accepted: 04/04/2023] [Indexed: 04/08/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) significantly impacts patient quality of life and is a major risk factor for the development of Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC). Proton pump inhibitors (PPIs) are the standard-of-care for GERD and are among the most prescribed drugs in the world, but do not protect against nonacid components of reflux such as pepsin, or prevent reflux-associated carcinogenesis. We recently identified an HIV protease inhibitor amprenavir that inhibits pepsin and demonstrated the antireflux therapeutic potential of its prodrug fosamprenavir in a mouse model of laryngopharyngeal reflux. In this study, we assessed the capacity of amprenavir to protect against esophageal epithelial barrier disruption in vitro and related molecular events, E-cadherin cleavage, and matrix metalloproteinase induction, which are associated with GERD severity and esophageal cancer. Herein, weakly acidified pepsin (though not acid alone) caused cell dissociation accompanied by regulated intramembrane proteolysis of E-cadherin. Soluble E-cadherin responsive matrix metalloproteinases (MMPs) were transcriptionally upregulated 24 h post-treatment. Amprenavir, at serum concentrations achievable given the manufacturer-recommended dose of fosamprenavir, protected against pepsin-induced cell dissociation, E-cadherin cleavage, and MMP induction. These results support a potential therapeutic role for amprenavir in GERD recalcitrant to PPI therapy and for preventing GERD-associated neoplastic changes.
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Affiliation(s)
- Simon Blaine-Sauer
- Department of Otolaryngology and Communication Science, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (S.B.-S.)
| | - Tina L. Samuels
- Department of Otolaryngology and Communication Science, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (S.B.-S.)
| | - Ke Yan
- Department of Pediatrics Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Nikki Johnston
- Department of Otolaryngology and Communication Science, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (S.B.-S.)
- Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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Kasiri K, Sherwin CM, Rostamian S, Heidari-Soureshjani S. Assessment of the Relationship Between Gastric-Acid Suppressants and the Risk of Esophageal Adenocarcinoma: A Systematic Review and Meta-Analysis. CURRENT THERAPEUTIC RESEARCH 2023; 98:100692. [PMID: 36798525 PMCID: PMC9925855 DOI: 10.1016/j.curtheres.2023.100692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/15/2023] [Indexed: 01/26/2023]
Abstract
Background Esophageal cancer is a cancerous tumor that develops in the esophagus. It is the 10th most common cancer and has a low survival rate. Esophageal adenocarcinoma (EAC) is increasing in incidence globally. Those with EAC are affected by Barrett's esophagus metaplasia, which is attributed to genetic predisposition and is more common in men. Studies suggest that gastric acid suppressants, like proton pump inhibitors and histamine-2 receptor antagonists, have anticancer properties and reduce EAC. However, other research has suggested that they are not cancer-protective, and the use of antisecretory drugs is a risk factor for developing EAC. Objective This systematic review and meta-analysis investigated the properties and risk factors associated with using gastric acid suppressants in patients with EAC. Methods This meta-analysis used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Information from selected articles, including the lead author's name, year of publication, study setting, sample size, and gender, was extracted and recorded into an Excel (Microsoft, Redmond, Washington) form. Statistical data included odds ratio, hazard ratio, and/or risk ratio, with a 95% CI associated with patients with EAC and receiving gastric acid suppressants. Data were compared with individuals not receiving treatment. Publication bias was assessed using Begg's and Egger's tests. Statistical analyzes used Stata 14.0 (Stata LLC, College Station, Texas). Results The initial electronic literature search retrieved 3761 titles/abstracts. Extensive screening selected 20 articles for analysis. Odds ratios associated with EAC in the individuals using gastric acid suppressants were 0.77 (95% CI, 0.49-1.22; P = 0.274) and 0.67 (95% CI, 0.39-1.29; P = 0.240) for proton pump inhibitors and 1.02 (95% CI, 0.44-2.36; P = 0.967) for histamine-2 receptor antagonists. Conclusions The results found that gastric acid suppressants do not have a protective role in EAC and are not risk factors. Future studies of confounding variables and risk factors are needed to understand what affects EAC development.
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Affiliation(s)
- Karamali Kasiri
- Department of Pediatrics, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Catherine M.T. Sherwin
- Pediatric Clinical Pharmacology and Toxicology, Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, Ohio
| | - Sahar Rostamian
- Shahrekord University of Medical Science, Student Research Committee, Shahrekord, Iran
| | - Saeid Heidari-Soureshjani
- Modeling in Health Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran,Address correspondence to: Saeid Heidari-Soureshjani, Kashani street, Shahrekord University of Medical Sciences, Shahrekord, Iran.
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Holmberg D, Mattsson F, Xie S, Ness-Jensen E, El-Serag H, Lagergren J. Risk of gastric and oesophageal adenocarcinoma following discontinuation of long-term proton-pump inhibitor therapy. J Gastroenterol 2022; 57:942-951. [PMID: 36258093 PMCID: PMC9663349 DOI: 10.1007/s00535-022-01930-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/02/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is uncertainty whether long-term use of proton-pump inhibitors can cause gastric adenocarcinoma (GAC) and oesophageal adenocarcinoma (OAC). This study aimed to determine how discontinuation of long-term PPI therapy influences the risk of GAC and OAC. METHODS This population-based cohort study included all long-term users of PPI therapy in Sweden in 2005-2018 was based on Swedish nationwide health registry data. The exposure was discontinuation of long-term PPI therapy, defined as no dispensation of PPI following inclusion and used as a time-varying variable, compared to remaining on PPI. Main outcomes were GAC and OAC, while oesophageal squamous cell carcinoma (OSCC) was included as a comparison outcome. Incidence rate ratios (IRR) with 95% CI adjusted for age, sex, comorbidity, obesity, diabetes, hyperlipidaemia, NSAIDs/aspirin, and statins were calculated with Poisson regression. RESULTS Among 730,176 long-term PPI users (mean age 65.6 years, 58.4% females) with 4,210,925 person-years at risk (median 5.5 person-years), 439,390 (60.2%) discontinued PPIs. In total, 495 developed GAC, 598 OAC, and 188 developed OSCC. PPI discontinuation was associated with decreased risk of GAC (IRR 0.81, 95% CI 0.67-0.98) and OAC (IRR 0.80, 95% CI 0.68-0.96), but not OSCC (IRR 1.10, 95% CI 0.82-1.49) compared to continued PPI use. Stratified analyses showed decreased point estimates across most age categories and both sexes for GAC and OAC risk among participants discontinuing PPI therapy. CONCLUSION Discontinuation of long-term PPI therapy may decrease the risk of GAC and OAC, suggesting that physicians should consider ceasing prescribing long-term PPI in patients without continued indication for its use.
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Affiliation(s)
- Dag Holmberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Retzius Street 13a, 17177, Stockholm, Sweden.
| | - Fredrik Mattsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Retzius Street 13a, 17177, Stockholm, Sweden
| | - Shaohua Xie
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Retzius Street 13a, 17177, Stockholm, Sweden
| | - Eivind Ness-Jensen
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Retzius Street 13a, 17177, Stockholm, Sweden
- Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Levanger, Norway
- Department of Medicine, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Hashem El-Serag
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Retzius Street 13a, 17177, Stockholm, Sweden
- Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Jesper Lagergren
- School of Cancer and Pharmacological Sciences, King's College London, London, UK
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Possible Association between the Use of Proton Pump Inhibitors and H 2 Receptor Antagonists, and Esophageal Cancer: A Nested Case-Control Study Using a Korean National Health Screening Cohort. Pharmaceuticals (Basel) 2022; 15:ph15050517. [PMID: 35631344 PMCID: PMC9146181 DOI: 10.3390/ph15050517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 12/22/2022] Open
Abstract
Although safety concerns regarding proton pump inhibitor (PPI)/H2-receptor antagonists (H2RA) in the incident esophageal cancer have been raised, the Asian-based report is unclear. We investigated the estimated likelihood of incident esophageal cancer—its mortality depending on prior history of PPI/H2RA use—and gastroesophageal reflux disease (GERD) in Koreans. Using the Korean National Health Insurance Service-Health Screening Cohort data (2002−2015), a case−control study was retrospectively conducted, including 811 patients with incident esophageal cancer and 3244 controls matched with sex, age, income, and residence. Propensity score overlap weighting was adjusted to balance the baseline covariates. Overlap propensity score-weighted logistic regression analyses were assessed to determine associations of the prior exposure of PPI/H2RA (current vs. past) and the medication duration (<30-, 30−90-, vs. ≥90-days) with incident esophageal cancer and its mortality among the total participants or those with/without the GERD episodes, after adjusting for multiple covariates including PPI/H2RA. The current exposure to either PPI or H2RA showed higher odds for incident esophageal cancer than the nonuser group ([13.23; 95%CI 10.25−17.06] and [4.34; 95%CI 3.67−5.14], respectively), especially in all adults over the age of 40 years without GERD. Both current and past exposures to PPI showed a decreased probability of mortality compared with those of the nonuser group ([0.62; 95%CI 0.45−0.86] and [0.41; 95%CI 0.25−0.67], respectively). However, current or past exposure to H2RA harbored the mutually different likelihoods for mortality depending on the presence of GERD and old age. This study carefully speculates on the possible link between PPI/H2RA and incident esophageal cancer in the Korean population. Mortality appears to be affected by certain risk factors depending on drug types, exposure history, old age, and the presence of GERD.
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Tan WK, di Pietro M. Barrett’s Oesophagus: Today’s Mistake and Tomorrow’s Wisdom in Screening and Prevention. Visc Med 2022; 38:161-167. [DOI: 10.1159/000522015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 01/10/2022] [Indexed: 11/19/2022] Open
Abstract
<b><i>Background:</i></b> Oesophageal adenocarcinoma (OAC) is a lethal cancer with an overall 5-year survival of <20%. Given the presence of a pre-invasive disease stage, also known as Barrett’s oesophagus (BO), and the availability of minimally invasive treatments for BO-related neoplasia, it is thought that early detection is the best strategy to improve patient outcomes. Clinical guidelines recommend endoscopic screening in patients with symptoms of acid reflux and additional risk factors. This strategy is flawed by the cost and invasiveness of endoscopy as well as by the fact that a significant proportion of OAC patients deny a history of reflux symptoms. <b><i>Summary:</i></b> New research on the use of epidemiologic and clinical data has allowed the creation of risk-prediction algorithms to identify the population at risk. In addition, newer less-invasive devices such as transnasal endoscopy, Cytosponge, volumetric laser endomicroscopy, and volatile organic compounds are emerging as promising options to allow screening in the primary care setting. Finally, there is an opportunity to intervene at the pre-invasive stage with pharmacological strategies to reduce the risk burden. <b><i>Key Messages:</i></b> In this review, we provide a critical appraisal of the different screening approaches and chemopreventive strategies and a guide to readers on how to implement research evidence in clinical practice.
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Evaluation of Antireflux Mucosectomy for Severe Gastroesophageal Reflux Disease: Medium-Term Results of a Pilot Study. Gastroenterol Res Pract 2022; 2022:1606944. [PMID: 35237316 PMCID: PMC8885295 DOI: 10.1155/2022/1606944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 01/31/2022] [Indexed: 11/24/2022] Open
Abstract
Background Antireflux mucosectomy, a new endoscopic treatment for gastroesophageal reflux disease, consists of endoscopic mucosal resection at the esophagogastric junction. This study aim was to evaluate the medium-term efficacy of the antireflux mucosectomy technique for patients with severe gastroesophageal reflux disease symptoms (proton pump inhibitor treatment-dependent or proton pump inhibitor treatment-resistant gastroesophageal reflux disease). Methods Between January 2017 and June 2018, 13 patients with severe gastroesophageal reflux disease without hiatal hernia, with positive pH reflux, were included in this monocentric prospective pilot study. The primary outcome was clinical success, defined by improvement evaluated by the Gastroesophageal Reflux Disease Health Related Quality of Life Questionnaire at 24 months. Secondary outcomes were technical success, decreased use of proton pump inhibitors, patient satisfaction, and adverse events. Results Thirteen patients [females = 8 (62%)], mean age 59 (range, 54-68), were included. The antireflux mucosectomy procedure had technical success in all patients. At 24 months, for 11 patients, gastroesophageal reflux disease symptoms were significantly improved, and mean gastroesophageal reflux disease score decreased from 33 (range, 26-42) to 3 (range, 0-7) (p = 0.001). Ninety-one percent (n = 10) of patients had a lower proton pump inhibitor intake at 24 months. One patient had 3 endoscopic balloon dilatations for EGJ stenosis, two patients had melena ten days after procedure, and seven patients had thoracic or abdominal pain. Patient's satisfaction at 24 months was 81%. Conclusions In patients with severe gastroesophageal reflux disease, despite occurrence of several short-term adverse events, antireflux mucosectomy seemed effective in improving gastroesophageal reflux disease symptoms at 24 months. This trial is registered with ClinicalTrials: NCT03357809.
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Yao H, Wang L, Li H, Xu S, Bai Z, Wu Y, Chen H, Goyal H, Qi X. Proton pump inhibitors may reduce the risk of high-grade dysplasia and/or esophageal adenocarcinoma in Barrett's esophagus: a systematic review and meta-analysis. Expert Rev Clin Pharmacol 2022; 15:79-88. [PMID: 34806503 DOI: 10.1080/17512433.2022.2008909] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Barrett's esophagus (BE) is an important risk factor for high-grade dysplasia (HGD) and/or esophageal adenocarcinoma (EAC). The effect of proton pump inhibitors (PPIs) on the chemoprevention of HGD and/or EAC arising from BE remains controversial. RESEARCH DESIGN AND METHODS PubMed, EMBASE, and Cochrane Library databases were systematically searched. Risk ratios (RRs) or odds ratios (ORs) with 95% confidence intervals (CIs) were pooled by a random-effect model. Heterogeneity and its potential source were assessed. RESULTS Fifteen studies with 26,291 BE patients were included. Meta-analysis of eight cohort studies showed that PPIs can significantly reduce the risk of HGD and/or EAC in BE patients (RR = 0.46; P < 0.001), but meta-analysis of six case-control studies showed no significant benefit of PPIs (OR = 0.64; P = 0.334). Heterogeneity was significant among both cohort and case-control studies, which might be attributed to the information sources of PPIs. There was no significant protective effect of high-dose PPIs on HGD and/or EAC in one RCT (RR = 0.84; P = 0.21), meta-analysis of two cohort studies (RR = 0.61; P = 0.28), or meta-analysis of two case-control studies (OR = 0.32; P = 0.08). CONCLUSIONS Chemoprevention of HGD and/or EAC by PPIs may be considered in BE patients. However, there might not be further preventive effect of high-dose PPIs.
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Affiliation(s)
- Haijuan Yao
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, P.R. China
| | - Le Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Dalian Medical University, Dalian, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Hongyu Li
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
| | - Shixue Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Zhaohui Bai
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Yanyan Wu
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Jinzhou Medical University, Jinzhou, China
| | - Hongxin Chen
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, P.R. China
| | - Hemant Goyal
- Department of Medicine, The Wright Center for Graduate Medical Education, Scranton, PA, USA
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
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Teufel A, Quante M, Kandulski A, Hirth M, Zhan T, Eckardt M, Thieme R, Kusnik A, Yesmembetov K, Wiest I, Riemann JF, Schlitt HJ, Gockel I, Malfertheiner P, Ebert MP. [Prevention of gastrointestinal cancer]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:964-982. [PMID: 34507375 DOI: 10.1055/a-1540-7539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Throughout the past decades, considerable progress has been made in the (early) diagnosis and treatment of gastrointestinal cancers. However, the prognosis for advanced stages of gastrointestinal tumors remains limited for many patients and approximately one third of all tumor patients die as a result of gastrointestinal tumors. The prevention and early detection of gastrointestinal tumors is therefore of great importance.For this reason, we summarize the current state of knowledge and recommendations for the primary, secondary and tertiary prevention of esophageal, stomach, pancreas, liver and colorectal cancer in the following.
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Affiliation(s)
- Andreas Teufel
- II. Medizinische Klinik, Sektion Hepatologie, Medizinische Fakultät Mannheim, Universität Heidelberg, Universitätsklinikum Mannheim, Mannheim.,Klinische Kooperationseinheit Healthy Metabolism, Zentrum für Präventivmedizin und Digitale Gesundheit Baden-Württemberg, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim
| | - Michael Quante
- Klinik für Innere Medizin II, Medizinische Universitätsklinik, Universitätsklinikum Freiburg, Freiburg im Breisgau
| | - Arne Kandulski
- Klinik und Poliklinik für Innere Medizin I, Universitätsklinikum Regensburg, Regensburg
| | - Michael Hirth
- II. Medizinische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Universitätsklinikum Mannheim, Mannheim
| | - Tianzuo Zhan
- II. Medizinische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Universitätsklinikum Mannheim, Mannheim
| | - Maximilian Eckardt
- II. Medizinische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Universitätsklinikum Mannheim, Mannheim
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Department für Operative Medizin (DOPM), Universitatsklinikum Leipzig, Leipzig
| | - Alexander Kusnik
- II. Medizinische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Universitätsklinikum Mannheim, Mannheim
| | - Kakharman Yesmembetov
- Klinik für Gastroenterologie, Stoffwechselerkrankungen und Internistische Intensivmedizin (Med. III), RWTH Universitätsklinikum Aachen, Aachen
| | - Isabella Wiest
- II. Medizinische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Universitätsklinikum Mannheim, Mannheim
| | | | - Hans Jürgen Schlitt
- Klinik und Poliklinik für Chirurgie, Universitatsklinikum Regensburg, Regensburg
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Department für Operative Medizin (DOPM), Universitatsklinikum Leipzig, Leipzig
| | - Peter Malfertheiner
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Medizinische Fakultät Magdeburg, Magdeburg
| | - Matthias Philip Ebert
- II. Medizinische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Universitätsklinikum Mannheim, Mannheim.,Klinische Kooperationseinheit Healthy Metabolism, Zentrum für Präventivmedizin und Digitale Gesundheit Baden-Württemberg, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim
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Alkhayyat M, Kumar P, Sanaka KO, Thota PN. Chemoprevention in Barrett's esophagus and esophageal adenocarcinoma. Therap Adv Gastroenterol 2021; 14:17562848211033730. [PMID: 34434254 PMCID: PMC8381453 DOI: 10.1177/17562848211033730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 06/29/2021] [Indexed: 02/04/2023] Open
Abstract
There has been a dramatic increase in the incidence of Barrett's esophagus and esophageal adenocarcinoma over the past several decades with a continued rise expected in the future. Several strategies have been developed for screening and surveillance of patients with Barrett's esophagus and endoscopic treatment of Barrett's associated dysplasia and early esophageal cancer; however, they have not made a substantial impact on the incidence of cancer. Herein, chemoprevention becomes an attractive idea for reducing the incidence of cancer in Barrett's patients. Several agents appear promising in preclinical and observational studies but very few have been evaluated in randomized controlled trials. Strongest evidence to date is available for proton-pump inhibitors and Aspirin that have been evaluated in a large randomized controlled trial. Other agents such as statins, metformin, ursodeoxycholic acid, and dietary supplements have insufficient evidence for chemoprevention in Barrett's patients.
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Affiliation(s)
- Motasem Alkhayyat
- Department of Internal Medicine, Cleveland
Clinic, Cleveland, OH, USA
| | - Prabhat Kumar
- Department of Gastroenterology and Hepatology,
Cleveland Clinic, Cleveland, OH, USA
| | - Krishna O. Sanaka
- Department of Gastroenterology and Hepatology,
Cleveland Clinic, Cleveland, OH, USA
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12
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Zhang L, Sun B, Zhou X, Wei Q, Liang S, Luo G, Li T, Lü M. Barrett's Esophagus and Intestinal Metaplasia. Front Oncol 2021; 11:630837. [PMID: 34221959 PMCID: PMC8252963 DOI: 10.3389/fonc.2021.630837] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 05/31/2021] [Indexed: 02/05/2023] Open
Abstract
Intestinal metaplasia refers to the replacement of the differentiated and mature normal mucosal epithelium outside the intestinal tract by the intestinal epithelium. This paper briefly describes the etiology and clinical significance of intestinal metaplasia in Barrett’s esophagus. This article summarizes the impact of intestinal metaplasia on the diagnosis, monitoring, and treatment of Barrett’s esophagus according to different guidelines. We also briefly explore the basis for the endoscopic diagnosis of intestinal metaplasia in Barrett’s esophagus. The identification techniques of goblet cells in Barrett’s esophagus are also elucidated by some scholars. Additionally, we further elaborate on the current treatment methods related to Barrett’s esophagus.
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Affiliation(s)
- Lu Zhang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou City, China
| | - Binyu Sun
- Department of Endoscope, Public Health Clinical Medical Center of Chengdu, Chengdu City, China
| | - Xi Zhou
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou City, China
| | - QiongQiong Wei
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou City, China
| | - Sicheng Liang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou City, China
| | - Gang Luo
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou City, China
| | - Tao Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu City, China
| | - Muhan Lü
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou City, China
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13
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Fedorova E, Watson TJ. Antireflux and Endoscopic Therapies for Barrett Esophagus and Superficial Esophageal Neoplasia. Surg Clin North Am 2021; 101:391-403. [PMID: 34048760 DOI: 10.1016/j.suc.2021.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Barrett esophagus (BE), defined as intestinal metaplasia of the distal esophageal mucosa, typically results from chronic gastroesophageal reflux disease and is the only known precursor of esophageal adenocarcinoma. The standard of care for the management of early esophageal neoplasia in the setting of BE has changed drastically over the past 15 years. Further investigation into diagnostic and therapeutic adjuncts will continue to improve our ability to control or cure BE before its advancement to a life-threatening malignancy.
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Affiliation(s)
- Ekaterina Fedorova
- MedStar Franklin Square Medical Center, 9000 Franklin Square Drive, Department of Surgery, Baltimore, MD 21237, USA
| | - Thomas J Watson
- MedStar Georgetown University Hospital, 3800 Reservoir Rd, NW, 4PHC Department of Surgery, Washington, DC 20007, USA.
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14
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Li J, Fan Y. Commentary on: Do proton pump inhibitors prevent Barrett's esophagus progression to high-grade dysplasia and esophageal adenocarcinoma? An updated meta-analysis. J Cancer Res Clin Oncol 2021; 147:2801-2802. [PMID: 34086128 DOI: 10.1007/s00432-021-03667-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Jia Li
- Department of Oncology, The First Affiliated Hospital of Kangda College of Nanjing Medical University, Lianyungang, 222061, Jiangsu Province, China
| | - Yuwei Fan
- Department of Oncology, The First Affiliated Hospital of Kangda College of Nanjing Medical University, Lianyungang, 222061, Jiangsu Province, China.
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15
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Kew GS, Soh AYS, Lee YY, Gotoda T, Li YQ, Zhang Y, Chan YH, Siah KTH, Tong D, Law SYK, Ruszkiewicz A, Tseng PH, Lee YC, Chang CY, Quach DT, Kusano C, Bhatia S, Wu JCY, Singh R, Sharma P, Ho KY. Multinational survey on the preferred approach to management of Barrett’s esophagus in the Asia-Pacific region. World J Gastrointest Oncol 2021; 13:279-294. [PMID: 33889279 PMCID: PMC8040063 DOI: 10.4251/wjgo.v13.i4.279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 12/31/2020] [Accepted: 03/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Major societies provide differing guidance on management of Barrett’s esophagus (BE), making standardization challenging.
AIM To evaluate the preferred diagnosis and management practices of BE among Asian endoscopists.
METHODS Endoscopists from across Asia were invited to participate in an online questionnaire comprising eleven questions regarding diagnosis, surveillance and management of BE.
RESULTS Five hundred sixty-nine of 1016 (56.0%) respondents completed the survey, with most respondents from Japan (n = 310, 54.5%) and China (n = 129, 22.7%). Overall, the preferred endoscopic landmark of the esophagogastric junction was squamo-columnar junction (42.0%). Distal palisade vessels was preferred in Japan (59.0% vs 10.0%, P < 0.001) while outside Japan, squamo-columnar junction was preferred (59.5% vs 27.4%, P < 0.001). Only 16.3% of respondents used Prague C and M criteria all the time. It was never used by 46.1% of Japanese, whereas 84.2% outside Japan, endoscopists used it to varying extents (P < 0.001). Most Asian endoscopists (70.8%) would survey long-segment BE without dysplasia every two years. Adherence to Seattle protocol was poor with only 6.3% always performing it. 73.2% of Japanese never did it, compared to 19.3% outside Japan (P < 0.001). The most preferred (74.0%) treatment of non-dysplastic BE was proton pump inhibitor only when the patient was symptomatic or had esophagitis. For BE with low-grade dysplasia, 6-monthly surveillance was preferred in 61.9% within Japan vs 47.9% outside Japan (P < 0.001).
CONCLUSION Diagnosis and management of BE varied within Asia, with stark contrast between Japan and outside Japan. Most Asian endoscopists chose squamo-columnar junction to be the landmark for esophagogastric junction, which is incorrect. Most also did not consistently use Prague criteria, and Seattle protocol. Lack of standardization, education and research are possible reasons.
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Affiliation(s)
- Guan Sen Kew
- Department of Gastroenterology and Hepatology, University Medicine Cluster, National University Health System, Singapore 119228, Singapore
| | - Alex Yu Sen Soh
- Department of Gastroenterology and Hepatology, National University Hospital, National University Health System, Singapore 119074, Singapore
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Penang 11800, Malaysia
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo 173-8610, Japan
| | - Yan-Qing Li
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Yan Zhang
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Yiong Huak Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Kewin Tien Ho Siah
- Department of Gastroenterology and Hepatology, University Medicine Cluster, National University Health System, Singapore 119228, Singapore
| | - Daniel Tong
- Department of Surgery, The University of Hong Kong, Hong Kong Pokfulam, Hong Kong, China
| | - Simon Ying Kit Law
- Department of Surgery, The University of Hong Kong, Hong Kong Pokfulam, Hong Kong, China
| | | | - Ping-Huei Tseng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Yi-Chia Lee
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Chi-Yang Chang
- Department of Internal Medicine, Fu Jen Catholic University Hospital, Taipei 24352, Taiwan
| | - Duc Trong Quach
- Department of Internal Medicine, University of Medicine and Pharmacy at Hochiminh City, Vietnam, Hochiminh 70000, Viet Nam
| | - Chika Kusano
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo 173-8610, Japan
| | - Shobna Bhatia
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai 400012, India
| | - Justin Che-Yuen Wu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Rajvinder Singh
- Department of Gastroenterology, Lyell McEwin Hospital, University of Adelaide, Adelaide 64128, Australia
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, KS 64128, United States
| | - Khek-Yu Ho
- Department of Medicine, National University Hospital, Singapore 119074, Singapore
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16
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Do proton pump inhibitors prevent Barrett's esophagus progression to high-grade dysplasia and esophageal adenocarcinoma? An updated meta-analysis. J Cancer Res Clin Oncol 2021; 147:2681-2691. [PMID: 33575855 DOI: 10.1007/s00432-021-03544-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 01/21/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Previous research on the association between proton pump inhibitor (PPI) use and the risk of progression to high-grade dysplasia (HGD)/esophageal adenocarcinoma (EAC) in Barrett's Esophagus (BE) patients has generated inconsistent findings. This meta-analysis was performed to clarify the association. METHODS We performed a comprehensive search strategy to select relevant studies up to September 2020. Heterogeneity was assessed using the I-squared statistic. Odds ratios (OR) and 95% confidence intervals (CI) were calculated through either fixed-effects or random-effects model. Duration-response was also performed to assess the gain effects of different PPI intake duration. Sensitivity analysis, subgroup analyses, and tests for publication bias or other small-study effects were conducted. RESULTS Twelve studies with 155,769 subjects were included. The PPI use was associated with the reduced risk of BE progression to HGD/EAC (OR = 0.47, 95% CI = 0.32-0.71). In the duration-response analysis, the estimated OR for decreased risk of HGD/EAC with PPI intake duration of 12 months was 0.81 (95% CI = 0.71-0.91). Sensitivity analysis suggested the results of this meta-analysis were stable. No publication bias was detected. CONCLUSIONS PPI use is associated with a decreased risk of HGD/EAC in patients with BE. For further investigation, that more well-designed studies are still needed to elucidate the protective effect of PPI usage on BE patients to prevent HGD/EAC.
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17
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Valenzano MC, Rybakovsky E, Chen V, Leroy K, Lander J, Richardson E, Yalamanchili S, McShane S, Mathew A, Mayilvaganan B, Connor L, Urbas R, Huntington W, Corcoran A, Trembeth S, McDonnell E, Wong P, Newman G, Mercogliano G, Zitin M, Etemad B, Thornton J, Daum G, Raines J, Kossenkov A, Fong LY, Mullin JM. Zinc Gluconate Induces Potentially Cancer Chemopreventive Activity in Barrett's Esophagus: A Phase 1 Pilot Study. Dig Dis Sci 2021; 66:1195-1211. [PMID: 32415564 PMCID: PMC7677901 DOI: 10.1007/s10620-020-06319-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 05/02/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Chemopreventive effects of zinc for esophageal cancer have been well documented in animal models. This prospective study explores if a similar, potentially chemopreventive action can be seen in Barrett's esophagus (BE) in humans. AIMS To determine if molecular evidence can be obtained potentially indicating zinc's chemopreventive action in Barrett's metaplasia. METHODS Patients with a prior BE diagnosis were placed on oral zinc gluconate (14 days of 26.4 mg zinc BID) or a sodium gluconate placebo, prior to their surveillance endoscopy procedure. Biopsies of Barrett's mucosa were then obtained for miRNA and mRNA microarrays, or protein analyses. RESULTS Zinc-induced mRNA changes were observed for a large number of transcripts. These included downregulation of transcripts encoding proinflammatory proteins (IL32, IL1β, IL15, IL7R, IL2R, IL15R, IL3R), upregulation of anti-inflammatory mediators (IL1RA), downregulation of transcripts mediating epithelial-to-mesenchymal transition (EMT) (LIF, MYB, LYN, MTA1, SRC, SNAIL1, and TWIST1), and upregulation of transcripts that oppose EMT (BMP7, MTSS1, TRIB3, GRHL1). miRNA arrays showed significant upregulation of seven miRs with tumor suppressor activity (-125b-5P, -132-3P, -548z, -551a, -504, -518, and -34a-5P). Of proteins analyzed by Western blot, increased expression of the pro-apoptotic protein, BAX, and the tight junctional protein, CLAUDIN-7, along with decreased expression of BCL-2 and VEGF-R2 were noteworthy. CONCLUSIONS When these mRNA, miRNA, and protein molecular data are considered collectively, a cancer chemopreventive action by zinc in Barrett's metaplasia may be possible for this precancerous esophageal tissue. These results and the extensive prior animal model studies argue for a future prospective clinical trial for this safe, easily-administered, and inexpensive micronutrient, that could determine if a chemopreventive action truly exists.
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Affiliation(s)
- M C Valenzano
- The Lankenau Institute for Medical Research, 100 Lancaster Avenue, Wynnewood, PA, 19096, USA
| | - E Rybakovsky
- The Lankenau Institute for Medical Research, 100 Lancaster Avenue, Wynnewood, PA, 19096, USA
| | - V Chen
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - K Leroy
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - J Lander
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - E Richardson
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - S Yalamanchili
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - S McShane
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - A Mathew
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - B Mayilvaganan
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - L Connor
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - R Urbas
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - W Huntington
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - A Corcoran
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - S Trembeth
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - E McDonnell
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - P Wong
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - G Newman
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - G Mercogliano
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - M Zitin
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - B Etemad
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - J Thornton
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA
| | - G Daum
- The Department of Pathology, Lankenau Medical Center, Wynnewood, USA
| | - J Raines
- The Lankenau Institute for Medical Research, 100 Lancaster Avenue, Wynnewood, PA, 19096, USA
| | | | - L Y Fong
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA, USA
| | - J M Mullin
- The Division of Gastroenterology, Lankenau Medical Center, Wynnewood, USA.
- The Lankenau Institute for Medical Research, 100 Lancaster Avenue, Wynnewood, PA, 19096, USA.
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA.
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18
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Scarpignato C, Sloan JA, Wang DH, Hunt RH. Gastrointestinal pharmacology: practical tips for the esophagologist. Ann N Y Acad Sci 2020; 1481:90-107. [PMID: 32822080 DOI: 10.1111/nyas.14447] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/19/2020] [Accepted: 07/05/2020] [Indexed: 12/22/2022]
Abstract
Gastroesophageal reflux disease (GERD) is primarily a motor disorder, and its pathogenesis is multifactorial. As a consequence, treatment should be able to address the underlying pathophysiology. Proton pump inhibitors (PPIs) are the mainstay of medical therapy for GERD, but these drugs only provide the control of symptoms and lesions without curing the disease. However, continuous acid suppression with PPIs is recommended for patients with Barrett's esophagus because of their potential chemopreventive effects. In addition to the antisecretory activity, these compounds display several pharmacological properties, often overlooked in clinical practice. PPIs can indeed affect gastric motility, exert a mucosal protective effect, and an antioxidant, anti-inflammatory, and antineoplastic activity, also protecting cancer cells from developing chemo- or radiotherapeutic resistance. Even in the third millennium, current pharmacologic approaches to address GERD are limited. Reflux inhibitors represent a promise unfulfilled, effective and safe prokinetics are lacking, and antidepressants, despite being effective in selected patients, give rise to adverse events in a large proportion of them. While waiting for new drug classes (like potassium-competitive acid blockers), reassessing old drugs (namely alginate-containing formulations), and paving the new avenue of esophageal mucosal protection are, at the present time, the only reliable alternatives to acid suppression.
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Affiliation(s)
- Carmelo Scarpignato
- Department of Health Sciences, United Campus of Malta, Msida, Malta.,Faculty of Medicine, Chinese University of Hong Kong, ShaTin, Hong Kong
| | - Joshua A Sloan
- Division of Gastroenterology and Hepatology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David H Wang
- Division of Hematology and Oncology, UT Southwestern Medical Center and VA North Texas Health Care System, Dallas, Texas
| | - Richard H Hunt
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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19
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Snider EJ, Kaz AM, Inadomi JM, Grady WM. Chemoprevention of esophageal adenocarcinoma. Gastroenterol Rep (Oxf) 2020; 8:253-260. [PMID: 32843972 PMCID: PMC7434588 DOI: 10.1093/gastro/goaa040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 12/12/2022] Open
Abstract
Esophageal adenocarcinoma (EAC) is a major cause of cancer-related death, particularly in Western populations, and is rapidly rising in Asian populations at this time. Virtually all EACs develop from the precursor lesion Barrett's esophagus (BE), which is the most significant risk factor for EAC. However, the rates of progression from BE to EAC are low and patients with BE are asymptomatic. Thus, any strategy for EAC prevention must carry a low risk of harm in order to be clinically useful. Since current EAC-screening and BE-surveillance methods carry some procedural risk and are burdensome, there is an opportunity for chemoprevention, i.e. medications or dietary factors that may prevent BE from progressing to EAC. A variety of candidate chemoprevention therapies have been assessed to date. Proton-pump inhibitors (PPIs) are the best studied and have modest EAC-chemoprevention efficacy in BE patients, with a recent randomized trial showing that high-dose PPI may be more effective than low-dose PPI. Aspirin and other non-steroidal anti-inflammatory drugs have moderate quality observational and randomized-trial evidence for preventing progression of BE to EAC, but their risks for harm have precluded their routine clinical use. Other therapies (statins, metformin, female sex hormones) generally do not have strong evidence to support their use in EAC chemoprevention. Although progress has been made in this field, there is still a need for more effective and safe chemoprevention therapies for EAC.
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Affiliation(s)
- Erik J Snider
- Division of Gastroenterology, Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Andrew M Kaz
- Division of Gastroenterology, Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Gastroenterology Section, VA Puget Sound Health Care System, Seattle, WA, USA
| | - John M Inadomi
- Division of Gastroenterology, Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - William M Grady
- Division of Gastroenterology, Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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20
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Yin CY, Zhang SS, Zhong JT, Zhou SH. Pepsin and Laryngeal and Hypopharyngeal Carcinomas. Clin Exp Otorhinolaryngol 2020; 14:159-168. [PMID: 32734742 PMCID: PMC8111387 DOI: 10.21053/ceo.2020.00465] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 07/17/2020] [Indexed: 02/08/2023] Open
Abstract
Laryngeal and hypopharyngeal carcinomas are common malignant tumors of the head and neck, and the incidence of both is increasing. Laryngopharyngeal reflux refers to the retrograde flow of gastric contents into the larynx, oropharynx, and/or nasopharynx. It remains controversial whether laryngopharyngeal reflux is a risk factor for laryngeal and hypopharyngeal cancers. The refluxing substances mainly include hydrochloric acid, pepsin, and occasionally bile acids and bile salts, as well as bacteria that colonize the gastrointestinal tract. Loss of epithelium in the mucous membrane of the larynx and hypopharynx is thought to be caused by pepsin. Here, we review the relationships between laryngopharyngeal reflux and both laryngeal and hypopharyngeal carcinomas, as well as the significance of pepsin, methods of clinical detection, and the mechanism of carcinogenesis.
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Affiliation(s)
- Cheng-Yi Yin
- Department of Otolaryngology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Department of Otolaryngology, The First People's Hospital of Huzhou City, Zhejiang, China
| | - Sha-Sha Zhang
- Department of Otolaryngology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jiang-Tao Zhong
- Department of Otolaryngology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Shui-Hong Zhou
- Department of Otolaryngology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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21
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Rosemurgy A, Wilfong C, Craigg D, Co F, Sucandy I, Ross S. The Evolving Landscape of Esophageal Cancer: A Four-Decade Analysis. Am Surg 2020. [DOI: 10.1177/000313481908500933] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The incidence of esophageal cancer in the United States seems to have significantly increased since the 1970s. In undertaking this study, we sought to describe changes in the incidence, histologic type, and presenting stage of esophageal cancer over the past four decades. With Institutional Review Board approval, the Surveillance, Epidemiology, and End Results database of the National Cancer Institute was queried. Regression analysis was used to analyze data, and significance was accepted with 95 per cent probability. Forty-two thousand seven hundred thirty-nine patients had squamous cell carcinoma or adenocarcinoma located in their upper, middle, and/ or lower esophagus from 1973 through 2010, reflecting a 7.5-fold annual increase from 1973 through 2010. Squamous cell carcinoma increased annually 2.5-fold ( P < 0.001) and esophageal adenocarcinoma increased annually 57-fold from 1973 through 2010 ( P < 0.001), whereas the overall population in the United States increased only 43 per cent (215,092,900 to 308,745,538) in the same period. From 1973 through 2010, there was a significant increase in the incidence of esophageal cancer in the United States. This increase was much greater than the increase in the population in the United States. The incidence of adenocarcinoma increased much more than that of squamous cell carcinoma of the esophagus from 1973 through 2010.
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Affiliation(s)
| | | | | | - Franka Co
- From Advent Health Tampa, Tampa, Florida
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22
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Klimara MJ, Randall DR, Allen J, Figueredo E, Johnston N. Proximal reflux: biochemical mediators, markers, therapeutic targets, and clinical correlations. Ann N Y Acad Sci 2020; 1481:127-138. [PMID: 32401362 DOI: 10.1111/nyas.14366] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/14/2020] [Accepted: 04/21/2020] [Indexed: 12/12/2022]
Abstract
Airway reflux is implicated in the pathophysiology of a wide range of adult and pediatric upper and lower airway diseases. However, the diagnosis of proximal reflux-associated disease remains challenging due to evolving clinical criteria and institutional and regional variances in diagnostic practices. Evidence suggests that nonacidic contents of reflux may serve as both pathologic mediators of and biomarkers for reflux in the upper airway. Furthermore, they offer potential pharmaceutical and surgical intervention targets and are the focus of novel clinical diagnostic tools currently under investigation.
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Affiliation(s)
- Miles J Klimara
- Department of Otolaryngology-Head & Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Derrick R Randall
- Department of Surgery, Section of Otolaryngology-Head & Neck Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Jacqueline Allen
- Department of Otolaryngology-Head & Neck Surgery, University of Auckland, Auckland, New Zealand
| | - Edgar Figueredo
- Minimally Invasive Surgery, Surgical Critical Care, Department of Surgery, Seattle VA Medical Center, University of Washington, Seattle, Washington
| | - Nikki Johnston
- Department of Otolaryngology & Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin
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McCormick CA, Samuels TL, Battle MA, Frolkis T, Blumin JH, Bock JM, Wells C, Yan K, Altman KW, Johnston N. H+/K+ATPase Expression in the Larynx of Laryngopharyngeal Reflux and Laryngeal Cancer Patients. Laryngoscope 2020; 131:130-135. [PMID: 32250454 DOI: 10.1002/lary.28643] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/27/2020] [Accepted: 03/03/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The gastric H+/K+ ATPase proton pump has previously been shown to be expressed in the human larynx, however its contribution to laryngopharyngeal reflux (LPR) signs, symptoms and associated diseases such as laryngeal cancer is unknown. Proton pump expression in the larynx of patients with LPR and laryngeal cancer was investigated herein. A human hypopharyngeal cell line expressing the proton pump was generated to investigate its effects. STUDY DESIGN In-vitro translational. METHODS Laryngeal biopsies were obtained from three LPR and eight LSCC patients. ATP4A, ATP4B and HRPT1 were assayed via qPCR. Human hypopharyngeal FaDu cell lines stably expressing proton pump were created using lentiviral transduction and examined via transmission electron microscopy and qPCR for genes associated with inflammation or laryngeal cancer. RESULTS Expression of ATP4A and ATP4B was detected in 3/3 LPR, 4/8 LSCC-tumor and 3/8 LSCC-adjacent specimens. Expression of ATP4A and ATP4B in FaDu elicited mitochondrial damage and expression of IL1B, PTGS2, and TNFA (P < .0001); expression of ATP4B alone did not. CONCLUSIONS Gastric proton pump subunits are expressed in the larynx of LPR and LSCC patients. Mitochondrial damage and changes in gene expression observed in cells expressing the full proton pump, absent in those expressing a single subunit, suggest that acid secretion by functional proton pumps expressed in upper airway mucosa may elicit local cell and molecular changes associated with inflammation and cancer. LEVEL OF EVIDENCE NA Laryngoscope, 131:130-135, 2021.
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Affiliation(s)
- Caroline A McCormick
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Tina L Samuels
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Michele A Battle
- Department of Cell Biology, Neurobiology, & Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Talia Frolkis
- Department of Cell Biology, Neurobiology, & Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Joel H Blumin
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Jonathan M Bock
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Clive Wells
- Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Ke Yan
- Department of Pediatrics Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Kenneth W Altman
- Department of Otolaryngology, Geisinger Health System, Danville, California, U.S.A
| | - Nikki Johnston
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A.,Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
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Samuels TL, Zimmermann MT, Zeighami A, Demos W, Southwood JE, Blumin JH, Bock JM, Johnston N. RNA Sequencing Reveals Cancer-Associated Changes in Laryngeal Cells Exposed to Non-Acid Pepsin. Laryngoscope 2020; 131:121-129. [PMID: 32202667 DOI: 10.1002/lary.28636] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/07/2020] [Accepted: 02/25/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Laryngopharyngeal reflux (LPR) is a common affliction that contributes to laryngeal inflammation, symptoms that impact quality of life, and life-threatening illnesses such as cancer. Effective treatment strategies for LPR are lacking. Pepsin is a proinflammatory and carcinogenic element of refluxate. Investigation of molecular pathways involved in pepsin-mediated damage may lead to identification of novel biomarkers and therapeutic targets for LPR. In this study, RNA sequencing was used to examine changes in human laryngeal epithelial cells following brief pepsin insult. Cells were immortalized to generate a model to aid future study of laryngeal injury and therapeutics. STUDY DESIGN In vitro translational. METHODS Laryngeal epithelial cells were cultured from a patient without signs or symptoms of LPR or laryngeal cancer. Cells were treated with 0.1 mg/ml pepsin for 1 hour or normal growth media (control) prior to RNA sequencing. Cells were immortalized via HPV E6/7 and characterized by microscopy, immunohistochemistry, G-banding, and soft agar assay. RESULTS Three hundred ninety-seven genes exhibited differences in expression with pepsin treatment (P < .05). Pathway analysis revealed association with cancer and related signaling processes including dysregulation of cancer-associated molecules, Metastasis-Associated Lung Adenocarcinoma Transcript 1 and KRT82, and the long-noncoding RNA, lipoprotein receptor-related protein 1 (LRP1)-AS, which regulates the putative pepsin receptor LRP1. CONCLUSIONS A single, brief exposure to pepsin activated cancer-associated signaling pathways in laryngeal cells in vitro, revealing novel mechanisms by which chronic reflux may contribute to carcinogenesis. The cell line developed herein represents a novel tool in which to investigate pepsin-dysregulated pathways identified by RNA sequencing and disparities of tumor proneness of laryngeal subsites. LEVEL OF EVIDENCE N/A Laryngoscope, 131:121-129, 2021.
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Affiliation(s)
- Tina L Samuels
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Michael T Zimmermann
- Bioinformatics Research and Development Laboratory, Genomic Sciences and Precision Medicine Center, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
- Clinical and Translational Science Institute, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Atefeh Zeighami
- Bioinformatics Research and Development Laboratory, Genomic Sciences and Precision Medicine Center, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Wendy Demos
- Bioinformatics Research and Development Laboratory, Genomic Sciences and Precision Medicine Center, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Jessica E Southwood
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Joel H Blumin
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Jonathan M Bock
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Nikki Johnston
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
- Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
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Broide E, Eindor-Abarbanel A, Shirin H, Richter V, Matalon S, Leshno M. Is administration of proton pump inhibitors in functional dyspepsia worth the risk of developing gastric cancer: a Markov model to bridge the gap between scientific evidence and clinical practice. BMJ Open 2020; 10:e031091. [PMID: 32051298 PMCID: PMC7045183 DOI: 10.1136/bmjopen-2019-031091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To formulate a decision analysis model based on recently published data that addresses the dilemma, whether improvement in quality of life rationalises continued proton pump inhibitors (PPI) use despite the risk of gastric cancer (GC) in patients with functional dyspepsia (FD). DESIGN A Markov model consisting of an initial decision regarding treatment with PPI (denoting it by PPI strategy) or any other treatment without PPI (denoting it by placebo strategy) was designed. DATA SOURCES Data from prospective cross-sectional studies indicating risk stratification for GC after the use of PPI, combined with a Markov model that comprised the following states: Live, GC stages 1-4, Death. OUTCOME MEASURES The primary outputs included quality-adjusted life years (QALYs) and life expectancy (LE). The improvement in utility in FD without PPI as compared with PPI use was tested (PPI vs placebo strategies). Sensitivity analyses were performed to evaluate the robustness of the model and address uncertainty in the estimation of model parameters. SETTING We considered only patients whose symptoms were relieved with PPIs and thus, had a better quality of life compared with patients who did not receive PPIs. RESULTS The base case model showed that PPIs compared with placebo decreased LE by 58.4 days with a gain of 2.1 QALY. If utility (quality of life of patients with FD using PPI compared with patients with FD without PPI) improved by more than 0.8%, PPI use is considered better than placebo. Older patients benefited less from PPI treatment than did younger patients. CONCLUSION To bridge the gap between evidence and decision making, we found that even a small improvement in the QALY justified continuing PPI treatment.
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Affiliation(s)
- Efrat Broide
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center (Assaf Harofeh Medical), Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Eindor-Abarbanel
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center (Assaf Harofeh Medical), Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Shirin
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center (Assaf Harofeh Medical), Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vered Richter
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center (Assaf Harofeh Medical), Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shay Matalon
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center (Assaf Harofeh Medical), Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Leshno
- Coller School of Management, Tel Aviv University, Tel Aviv, Israel
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Lee L, Ramos-Alvarez I, Ito T, Jensen RT. Insights into Effects/Risks of Chronic Hypergastrinemia and Lifelong PPI Treatment in Man Based on Studies of Patients with Zollinger-Ellison Syndrome. Int J Mol Sci 2019; 20:ijms20205128. [PMID: 31623145 PMCID: PMC6829234 DOI: 10.3390/ijms20205128] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/08/2019] [Accepted: 10/13/2019] [Indexed: 02/07/2023] Open
Abstract
The use of proton pump inhibitors (PPIs) over the last 30 years has rapidly increased both in the United States and worldwide. PPIs are not only very widely used both for approved indications (peptic ulcer disease, gastroesophageal reflux disease (GERD), Helicobacter pylori eradication regimens, stress ulcer prevention), but are also one of the most frequently off-label used drugs (25–70% of total). An increasing number of patients with moderate to advanced gastroesophageal reflux disease are remaining on PPI indefinitely. Whereas numerous studies show PPIs remain effective and safe, most of these studies are <5 years of duration and little data exist for >10 years of treatment. Recently, based primarily on observational/epidemiological studies, there have been an increasing number of reports raising issues about safety and side-effects with very long-term chronic treatment. Some of these safety issues are related to the possible long-term effects of chronic hypergastrinemia, which occurs in all patients taking chronic PPIs, others are related to the hypo-/achlorhydria that frequently occurs with chronic PPI treatment, and in others the mechanisms are unclear. These issues have raised considerable controversy in large part because of lack of long-term PPI treatment data (>10–20 years). Zollinger–Ellison syndrome (ZES) is caused by ectopic secretion of gastrin from a neuroendocrine tumor resulting in severe acid hypersecretion requiring life-long antisecretory treatment with PPIs, which are the drugs of choice. Because in <30% of patients with ZES, a long-term cure is not possible, these patients have life-long hypergastrinemia and require life-long treatment with PPIs. Therefore, ZES patients have been proposed as a good model of the long-term effects of hypergastrinemia in man as well as the effects/side-effects of very long-term PPI treatment. In this article, the insights from studies on ZES into these controversial issues with pertinence to chronic PPI use in non-ZES patients is reviewed, primarily concentrating on data from the prospective long-term studies of ZES patients at NIH.
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Affiliation(s)
- Lingaku Lee
- Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20892-1804, USA.
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka 812-8582, Japan.
| | | | - Tetsuhide Ito
- Neuroendocrine Tumor Centra, Fukuoka Sanno Hospital, International University of Health and Welfare 3-6-45 Momochihama, Sawara-Ku, Fukuoka 814-0001, Japan.
| | - Robert T Jensen
- Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20892-1804, USA.
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Samuels TL, Altman KW, Gould JC, Kindel T, Bosler M, MacKinnon A, Hagen CE, Johnston N. Esophageal pepsin and proton pump synthesis in barrett's esophagus and esophageal adenocarcinoma. Laryngoscope 2019; 129:2687-2695. [DOI: 10.1002/lary.28051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/28/2019] [Accepted: 04/16/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Tina L. Samuels
- Department of Otolaryngology and Communication SciencesMedical College of Wisconsin Milwaukee Wisconsin
| | - Kenneth W. Altman
- Department of Otolaryngology–Head and Neck SurgeryBaylor College of Medicine Houston Texas U.S.A
| | - Jon C. Gould
- Department of SurgeryMedical College of Wisconsin Milwaukee Wisconsin
| | - Tammy Kindel
- Department of SurgeryMedical College of Wisconsin Milwaukee Wisconsin
| | - Matthew Bosler
- Department of SurgeryMedical College of Wisconsin Milwaukee Wisconsin
| | | | | | - Nikki Johnston
- Department of Otolaryngology and Communication SciencesMedical College of Wisconsin Milwaukee Wisconsin
- Department of Microbiology and ImmunologyMedical College of Wisconsin Milwaukee Wisconsin
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Chwiesko A, Kowal-Bielecka O, Sierakowski S. Perspectives on the interlinked nature of systemic sclerosis and reflux disease. Expert Rev Gastroenterol Hepatol 2019; 13:213-227. [PMID: 30791766 DOI: 10.1080/17474124.2019.1561274] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Systemic sclerosis (SSc) is a multisystem connective tissue disease, characterized by chronic inflammation and vascular changes that result in esophageal smooth muscle atrophy and fibrosis. Subsequent progressive loss of peristalsis in the distal esophagus and loss of lower esophageal sphincter function lead to problems with the protective barrier and exposure of sensitive tissues to the gastroduodenal contents, a disorder called reflux disease. Areas covered: Depending on the range, nature and symptoms of the disease, the term 'reflux disease' may refer to gastroesophageal reflux, laryngopharyngeal reflux, microaspiration into the airways and silent reflux. Despite the links between these visceral complications, this connection remains controversial. This is due to a lack of complete understanding, the asymptomatic nature of the disease and the limited diagnostic accuracy of tests, which can delay diagnosis. Such delays are problematic, given that the early detection of GERD in SSc patients, the timing of assessment, the treatment of the organs involved are critical aspects of patient prognosis and disease outcome. Expert commentary: This review summarizes the most recent knowledge about the pathophysiology, diagnosis and prospective treatment of GERD in SSc patients and highlights how innovative technologies applied through an integrative, interdisciplinary approach may soon lead to effective treatment strategies.
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Affiliation(s)
- Adam Chwiesko
- a Department of Gastroenterology and Internal Medicine , Medical University of Bialystok , Bialystok , Poland
| | - Otylia Kowal-Bielecka
- b Department of Rheumatology and Internal Medicine , Medical University of Bialystok , Bialystok , Poland
| | - Stanislaw Sierakowski
- b Department of Rheumatology and Internal Medicine , Medical University of Bialystok , Bialystok , Poland
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Proton pump inhibitors and the risk of severe adverse events – A cardiovascular bombshell? REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.repce.2017.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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30
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Triadafilopoulos G, Singh G. Editorial: less acid, less cancer? Is this the question? Aliment Pharmacol Ther 2018; 48:877-878. [PMID: 30281839 DOI: 10.1111/apt.14958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Gurkirpal Singh
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
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31
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Triadafilopoulos G, Friedland S. Precision care for Barrett's esophagus. Transl Gastroenterol Hepatol 2018; 3:67. [PMID: 30363757 DOI: 10.21037/tgh.2018.09.10] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 09/04/2018] [Indexed: 12/18/2022] Open
Abstract
Modern recognition and management of Barrett's esophagus, a precursor to esophageal adenocarcinoma depends on diagnostic accuracy, risk assessment, technical expertise and consideration of many options to best tailor therapy for every patient. Concomitant management of acid reflux is essential, frequently with proton pump inhibitors. Ablation and resection favorably affect the evolution towards cancer. Using precision medicine tools, such as imaging, molecular diagnostics and analytics may lead to cost- and comparatively-effective therapies ultimately aiming at cancer prevention. Knowledge of the risk factors for Barrett's esophagus and progression to dysplasia and cancer can help tailor a precision medicine approach with more aggressive screening and surveillance targeted at patients that are most likely to benefit.
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Affiliation(s)
- George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Shai Friedland
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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32
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Hvid-Jensen F, Drewes AM. Should aspirin and PPIs be recommended for patients with Barrett's oesophagus? Lancet 2018; 392:362-364. [PMID: 30057101 DOI: 10.1016/s0140-6736(18)31618-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 07/11/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Frederik Hvid-Jensen
- Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus 8200, Denmark.
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
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Tan MC, El-Serag HB, Yu X, Thrift AP. Acid suppression medications reduce risk of oesophageal adenocarcinoma in Barrett's oesophagus: a nested case-control study in US male veterans. Aliment Pharmacol Ther 2018; 48:469-477. [PMID: 29956826 DOI: 10.1111/apt.14895] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 04/23/2018] [Accepted: 06/13/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) may reduce the risk of oesophageal adenocarcinoma (OAC) in Barrett's oesophagus; however, current epidemiologic studies are inconclusive. AIM To evaluate the independent effects of PPIs and H2RAs on risk of OAC in patients with Barrett's oesophagus. METHODS We conducted a nested case-control study of male veterans diagnosed with Barrett's oesophagus. Cases with incident OAC were matched by incidence density sampling on birth year and Barrett's diagnosis date to controls with Barrett's oesophagus who did not develop OAC. We identified prescription medication usage 1 year prior to Barrett's oesophagus diagnosis to 3 months prior to the OAC diagnosis. Odds ratios (OR) and 95% CI were estimated using conditional logistic regression. RESULTS Compared with 798 controls, the 300 cases were less likely to use PPIs (90.0% vs 94.5%, P = 0.01) and H2RAs (19.7% vs 25.7%, P = 0.04). In the multivariable model including the use of statins, H2RAs, aspirin and nonsteroidal anti-inflammatory drugs, PPI use was associated with 41% lower risk of OAC (OR 0.59, 95% CI 0.35-0.99). While risk reduction of OAC was stronger for high-dose PPIs (omeprazole daily dose >40 mg, adjusted OR 0.11, 95% 0.04-0.36), we did not find a dose-response relationship with PPI duration (P trend = 0.45). Likewise, H2RA use was independently associated with 30% lower risk of OAC (OR 0.70, 95% CI 0.50-0.99). CONCLUSION Use of PPIs and H2RAs among patients with Barrett's oesophagus are associated with lower risk of OAC. Further clinical trials are needed to confirm this possible chemopreventive effect.
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Affiliation(s)
- M C Tan
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - H B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - X Yu
- Department of Preventive Medicine and Community Health, Office of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
| | - A P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
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Cunha N, Machado AP. Proton pump inhibitors and the risk of severe adverse events - A cardiovascular bombshell? Rev Port Cardiol 2018; 37:859-863. [PMID: 29804887 DOI: 10.1016/j.repc.2017.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 10/08/2017] [Indexed: 10/16/2022] Open
Abstract
Proton pump inhibitors are currently one of the most prescribed pharmacological classes in developed countries, given their effectiveness and safety profile, which has until now been considered favorable. However, in recent years, several papers have been published that associate prolonged use of these drugs with a wide range of adverse effects, posing doubts about their safety. Among the adverse effects described is an increased risk of cardiovascular events. This relationship was first described in subjects after acute coronary syndrome due to the interference of proton pump inhibitors in the cytochrome P450 2C19 and the conversion of clopidogrel to its active metabolite. More recent studies have also reported this relationship with the use of antiplatelet agents that do not depend on cytochrome P450 2C19 activation. The proposed mechanism is inhibition of dimethylarginine dimethylaminohydrolase, a physiological inhibitor of asymmetric dimethylarginine, which increases plasma concentrations of the latter enzyme, leading to lower levels of nitric oxide. By reviewing in this article the relationship between the use of proton pump inhibitors and increased risk of cardiovascular and cerebrovascular events, the authors aim to alert the medical community to the potentially harmful effects of these drugs, and recommend the setting of a moratorium on their prolonged use.
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Affiliation(s)
- Nelson Cunha
- Serviço de Cardiologia, Hospital Universitário de Santa Maria (CHLN), Centro Académico de Medicina de Lisboa e CCUL, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
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Gastrin stimulates a cholecystokinin-2-receptor-expressing cardia progenitor cell and promotes progression of Barrett's-like esophagus. Oncotarget 2018; 8:203-214. [PMID: 27448962 PMCID: PMC5352112 DOI: 10.18632/oncotarget.10667] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/13/2016] [Indexed: 12/20/2022] Open
Abstract
Objective The incidence of esophageal adenocarcinoma (EAC) is increasing, but factors contributing to malignant progression of its precursor lesion, Barrett's esophagus (BE), have not been defined. Hypergastrinemia caused by long-term use of proton pump inhibitors (PPIs), has been suggested as one possible risk factor. The gastrin receptor, CCK2R, is expressed in the cardia and upregulated in BE, suggesting the involvement of the gastrin-CCK2R pathway in progression. In the L2-IL-1β mouse model, Barrett's-like esophagus arises from the gastric cardia. Therefore, we aimed to analyze the effect of hypergastrinemia on CCK2R+ progenitor cells in L2-IL-1β mice. Design L2-IL-1β mice were mated with hypergastrinemic (INS-GAS) mice or treated with PPIs to examine the effect of hypergastrinemia in BE progression. CCK2R-CreERT crossed with L2-IL-1β mice were used to analyze the lineage progenitor potential of CCK2R+ cells. Cardia glands were cultured in vitro, and the effect of gastrin treatment analyzed. L2-IL-1β mice were treated with a CCK2R antagonist YF476 as a potential chemopreventive drug. Results Hypergastrinemia resulted in increased proliferation and expansion of Barrett's-like esophagus. Lineage tracing experiments revealed that CCK2R+ cells are long-lived progenitors that can give rise to such lesions under chronic inflammation. Gastrin stimulated organoid growth in cardia culture, while CCK2R inhibition prevented Barrett's-like esophagus and dysplasia. Conclusions Our data suggest a progression model for BE to EAC in which CCK2R+ progenitor cells, stimulated by hypergastrinemia, proliferate to give rise to metaplasia and dysplasia. Hypergastrinemia can result from PPI use, and the effects of hypergastrinemia in human BE should be studied further.
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Maintenance proton pump inhibition therapy and risk of oesophageal cancer. Cancer Epidemiol 2018; 53:172-177. [PMID: 29477057 DOI: 10.1016/j.canep.2018.02.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 02/13/2018] [Accepted: 02/14/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The association of long-term use of proton pump inhibitors (PPIs) with oesophageal adenocarcinoma has been poorly defined. Our aim was to assess the risk of oesophageal cancer assessing confounding by indication. METHODS This population-based cohort study included all 796,492 adults exposed to maintenance therapy with PPIs in Sweden in 2005-2012. Standardised incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated to assess the risk of oesophageal adenocarcinoma (and squamous cell carcinoma as a comparison) among long-term PPI users relative to the corresponding background population. The different indications for maintenance PPI therapy were analysed separately. RESULTS Among all individuals using maintenance PPI therapy, the overall SIR of oesophageal adenocarcinoma was 3.93 (95% CI 3.63-4.24). The SIRs of adenocarcinoma were increased also among individuals without gastro-oesophageal reflux disease who used PPIs for indications not associated with any increased risk of oesophageal adenocarcinoma. For example, the SIRs among participants using maintenance PPI therapy because of maintenance treatment with non-steroidal anti-inflammatory drugs and aspirin were 2.74 (95% CI 1.96-3.71) and 2.06 (95% CI 1.60-2.60), respectively. The SIRs of oesophageal squamous cell carcinoma were increased for most investigated indications, but to a lesser degree than for oesophageal adenocarcinoma. CONCLUSION In conclusion, the long term use of PPIs is associated with increased risk of oesophageal adenocarcinoma in the absence of other risk factors. Long term use of PPIs should be addressed with caution.
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Abstract
Tumorigenesis begins long before the growth of a clinically detectable lesion and, indeed, even before any of the usual morphological correlates of pre-malignancy are recognizable. Field cancerization, which is the replacement of the normal cell population by a cancer-primed cell population that may show no morphological change, is now recognized to underlie the development of many types of cancer, including the common carcinomas of the lung, colon, skin, prostate and bladder. Field cancerization is the consequence of the evolution of somatic cells in the body that results in cells that carry some but not all phenotypes required for malignancy. Here, we review the evidence of field cancerization across organs and examine the biological mechanisms that drive the evolutionary process that results in field creation. We discuss the clinical implications, principally, how measurements of the cancerized field could improve cancer risk prediction in patients with pre-malignant disease.
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Affiliation(s)
- Kit Curtius
- Centre for Tumour Biology, Barts Cancer Institute, EC1M 6BQ London, UK
| | - Nicholas A Wright
- Centre for Tumour Biology, Barts Cancer Institute, EC1M 6BQ London, UK
| | - Trevor A Graham
- Centre for Tumour Biology, Barts Cancer Institute, EC1M 6BQ London, UK
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38
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Quante M, Graham TA, Jansen M. Insights Into the Pathophysiology of Esophageal Adenocarcinoma. Gastroenterology 2018; 154:406-420. [PMID: 29037468 DOI: 10.1053/j.gastro.2017.09.046] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/21/2017] [Accepted: 09/21/2017] [Indexed: 02/07/2023]
Abstract
Although researchers have identified genetic alterations that contribute to development of esophageal adenocarcinoma, we know little about features of patients or environmental factors that mediate progression of chronic acid biliary reflux to Barrett's esophagus and cancer. Increasing our understanding of the mechanisms by which normal squamous epithelium progresses to early-stage invasive cancer will help formulate rational surveillance guidelines and allow us to divest resources away from patients at low risk of malignancy. We review the cellular and genetic alterations that occur during progression of Barrett's esophagus, based on findings from clinical studies and mouse models of disease. We review the features of the luminal and mucosal microenvironment of Barrett's esophagus that promote, in a small proportion of patients, development of esophageal adenocarcinoma. Markers of clonal evolution can be used to determine patient risk for cancer and set surveillance intervals.
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Affiliation(s)
- Michael Quante
- II. Medizinische Klinik, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany.
| | - Trevor A Graham
- Evolution and Cancer Laboratory, Barts Cancer Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Marnix Jansen
- University College London Cancer Institute, London, United Kingdom; University College London Hospital, London, United Kingdom
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39
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Riegler M, Kristo I, Asari R, Rieder E, Schoppmann SF. Dietary sugar and Barrett's esophagus. Eur Surg 2017; 49:279-281. [PMID: 29250105 PMCID: PMC5725502 DOI: 10.1007/s10353-017-0494-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 10/05/2017] [Indexed: 01/20/2023]
Abstract
Introduction Barrett’s esophagus (BE) represents the premalignant morphology of gastroesophageal reflux disease (GERD). Evidence indicates a positive correlation between GERD vs. obesity and increased sugar consumption. Methods Here we analyzed recently published data (2006–2017) on the role of dietary sugar intake for BE development (main focus year 2017). Results Recent investigations found a positive association between obesity, hip waist ratio and dietary sugar intake and Barrett’s esophagus. Conclusion Sugar intake positively associates with BE. A low carbohydrate diet should be recommended for persons with BE and GERD.
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Affiliation(s)
- M Riegler
- Reflux Medical Vienna, Vienna, Austria
| | - I Kristo
- Upper-GI Service, CCC-GET, University Clinic of Surgery, Vienna General Hospital - Medical University Vienna, Vienna, Austria
| | - R Asari
- Upper-GI Service, CCC-GET, University Clinic of Surgery, Vienna General Hospital - Medical University Vienna, Vienna, Austria
| | - E Rieder
- Upper-GI Service, CCC-GET, University Clinic of Surgery, Vienna General Hospital - Medical University Vienna, Vienna, Austria
| | - S F Schoppmann
- Upper-GI Service, CCC-GET, University Clinic of Surgery, Vienna General Hospital - Medical University Vienna, Vienna, Austria
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40
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Prichard DO, Byrne AM, Murphy JO, Reynolds JV, O'Sullivan J, Feighery R, Doyle B, Eldin OS, Finn SP, Maguire A, Duff D, Kelleher DP, Long A. Deoxycholic acid promotes development of gastroesophageal reflux disease and Barrett's oesophagus by modulating integrin-αv trafficking. J Cell Mol Med 2017; 21:3612-3625. [PMID: 28941013 PMCID: PMC5706496 DOI: 10.1111/jcmm.13271] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 05/07/2017] [Indexed: 01/14/2023] Open
Abstract
The fundamental mechanisms underlying erosive oesophagitis and subsequent development of Barrett's oesophagus (BO) are poorly understood. Here, we investigated the contribution of specific components of the gastric refluxate on adhesion molecules involved in epithelial barrier maintenance. Cell line models of squamous epithelium (HET‐1A) and BO (QH) were used to examine the effects of bile acids on cell adhesion to extracellular matrix proteins (Collagen, laminin, vitronectin, fibronectin) and expression of integrin ligands (α3, α4, α5, α6 and αν). Experimental findings were validated in human explant oesophageal biopsies, a rat model of gastroesophageal reflux disease (GORD) and in patient tissue microarrays. The bile acid deoxycholic acid (DCA) specifically reduced adhesion of HET‐1A cells to vitronectin and reduced cell‐surface expression of integrin‐ανvia effects on endocytic recycling processes. Increased expression of integrin‐αv was observed in ulcerated tissue in a rat model of GORD and in oesophagitis and Barrett's intestinal metaplasia patient tissue compared to normal squamous epithelium. Increased expression of integrin‐αν was observed in QH BO cells compared to HET‐1A cells. QH cells were resistant to DCA‐mediated loss of adhesion and reduction in cell‐surface expression of integrin‐αν. We demonstrated that a specific component of the gastric refluxate, DCA, affects the epithelial barrier through modulation of integrin αν expression, providing a novel mechanism for bile acid‐mediated erosion of oesophageal squamous epithelium and promotion of BO. Strategies aimed at preventing bile acid‐mediated erosion should be considered in the clinical management of patients with GORD.
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Affiliation(s)
- David O Prichard
- Cell and Molecular Biology Group, Department of Clinical Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland.,Division of Gastroenterology, Mayo Clinic Health System La Crosse - Franciscan Healthcare, La Crosse, WI, USA.,Division of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Anne Marie Byrne
- Cell and Molecular Biology Group, Department of Clinical Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland.,Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
| | - James O Murphy
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
| | - John V Reynolds
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
| | - Jacintha O'Sullivan
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
| | - Ronan Feighery
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
| | - Brendan Doyle
- Department of Histopathology, St James's Hospital, Dublin 8, Ireland.,Department of Histopathology, Beaumont Hospital, Dublin 9, Ireland
| | - Osama Sharaf Eldin
- Department of Histopathology, St James's Hospital, Dublin 8, Ireland.,Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Stephen P Finn
- Department of Histopathology, St James's Hospital, Dublin 8, Ireland.,Department of Histopathology and Morbid Anatomy, Trinity College Dublin, Dublin, Ireland
| | - Aoife Maguire
- Department of Histopathology, St James's Hospital, Dublin 8, Ireland
| | - Deirdre Duff
- Cell and Molecular Biology Group, Department of Clinical Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
| | - Dermot P Kelleher
- Cell and Molecular Biology Group, Department of Clinical Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland.,Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Aideen Long
- Cell and Molecular Biology Group, Department of Clinical Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
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41
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Tan WK, di Pietro M, Fitzgerald RC. Past, present and future of Barrett's oesophagus. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2017; 43:1148-1160. [PMID: 28256346 PMCID: PMC6839968 DOI: 10.1016/j.ejso.2017.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 02/06/2017] [Accepted: 02/06/2017] [Indexed: 02/08/2023]
Abstract
Barrett's oesophagus is a condition which predisposes towards development of oesophageal adenocarcinoma, a highly lethal tumour which has been increasing in incidence in the Western world over the past three decades. There have been tremendous advances in the field of Barrett's oesophagus, not only in diagnostic modalities, but also in therapeutic strategies available to treat this premalignant disease. In this review, we discuss the past, present and future of Barrett's oesophagus. We describe the historical and new evolving diagnostic criteria of Barrett's oesophagus, while also comparing and contrasting the British Society of Gastroenterology guidelines, American College of Gastroenterology guidelines and International Benign Barrett's and CAncer Taskforce (BOBCAT) for Barrett's oesophagus. Advances in endoscopic modalities such as confocal and volumetric laser endomicroscopy, and a non-endoscopic sampling device, the Cytosponge, are described which could aid in identification of Barrett's oesophagus. With regards to therapy we review the evidence for the utility of endoscopic mucosal resection and radiofrequency ablation when coupled with better characterization of dysplasia. These endoscopic advances have transformed the management of Barrett's oesophagus from a primarily surgical disease into an endoscopically managed condition.
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Affiliation(s)
- W K Tan
- MRC Cancer Unit, University of Cambridge, Cambridge, United Kingdom
| | - M di Pietro
- MRC Cancer Unit, University of Cambridge, Cambridge, United Kingdom
| | - R C Fitzgerald
- MRC Cancer Unit, University of Cambridge, Cambridge, United Kingdom.
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42
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Proton Pump Inhibitors Do Not Reduce the Risk of Esophageal Adenocarcinoma in Patients with Barrett's Esophagus: A Systematic Review and Meta-Analysis. PLoS One 2017; 12:e0169691. [PMID: 28072858 PMCID: PMC5224998 DOI: 10.1371/journal.pone.0169691] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 12/19/2016] [Indexed: 02/06/2023] Open
Abstract
Objectives Proton pump inhibitors (PPIs) have been used for treatment of Barrett's esophagus (BE) for many years. However, the connection between PPIs and esophageal adenocarcinoma (EAC) in patients with BE has still been controversial. The current systematic review and meta-analysis was designed to evaluate the association between PPIs and the risk of EAC or high-grade dysplasia (HGD) in patients with BE. Methods A systematic literature search of studies reporting the association between PPIs and the risk of EAC and/or HGD in patients with BE was conducted in PubMed, Embase, Web of Science and the Cochrane Library. Next, literature was screened using previously established criteria and relevant data were extracted from included studies. Finally, the software program Review Manage 5.2 was applied to aggregate data and analyze the results. Results Nine observational studies, comprising five cohort and four case-control studies (including a total of 5712 patients with BE), were identified. Upon meta-analysis, PPIs were found to have no association with the risk of EAC and/or HGD in patients with BE (unadjusted OR 0.43, 95% CI 0.17–1.08). Analysis for duration response relationship revealed no significant trend toward protection against EAC or HGD with PPIs usage for >2~3 years (one study using 7-year cutoff) when compared to usage for shorter time periods (PPIs usage >2~3 years vs. <2~3 years: OR 0.91 (95% CI 0.25–3.31) vs. 0.91 (0.40–2.07)).There also was considerable heterogeneity between studies. Conclusion No dysplasia- or cancer-protective effects of PPIs usage in patients with BE were identified by our analysis. Therefore, we conclude that clinicians who discuss the potential chemopreventive effects of PPIs with their patients, should be aware that such an effect, if exists, has not been proven with statistical significance.
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43
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Hayakawa Y, Chang W, Jin G, Wang TC. Gastrin and upper GI cancers. Curr Opin Pharmacol 2016; 31:31-37. [DOI: 10.1016/j.coph.2016.08.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/16/2016] [Accepted: 08/22/2016] [Indexed: 02/06/2023]
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44
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Maret-Ouda J, El-Serag HB, Lagergren J. Opportunities for Preventing Esophageal Adenocarcinoma. Cancer Prev Res (Phila) 2016; 9:828-834. [PMID: 27623934 DOI: 10.1158/1940-6207.capr-16-0170] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 08/31/2016] [Indexed: 11/16/2022]
Abstract
Esophageal adenocarcinoma (EAC) is rapidly increasing in incidence in many Western societies, requires demanding treatment, and is associated with a poor prognosis, therefore preventive measures are highly warranted. To assess the opportunities for prevention, we reviewed the available literature and identified seven main potentially preventive targets. Preventive effects were found on the basis of medium-level observational evidence following treatment of gastroesophageal reflux disease (using both medication and surgery) and tobacco smoking cessation, which should be clinically recommended among exposed patients. Nonsteroidal anti-inflammatory drugs appear to prevent EAC, and the limited existing data also indicate a protective effect of medication with statins or hormone replacement therapy in women, but current evidence is insufficient to guide clinical decision-making regarding these drugs. The evidence is presently insufficient to assess the potentially preventive role of weight loss. Whether avoidance of eradication of Helicobacter pylori prevents EAC is not studied, but there is no evidence that such eradication increases symptoms of gastroesophageal reflux or prevalence of erosive esophagitis. The introduction of preventive actions should be tailored toward high-risk individuals, that is, older men with obesity and gastroesophageal reflux disease and individuals with Barrett esophagus rather than the population at large. Cancer Prev Res; 9(11); 828-34. ©2016 AACR.
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Affiliation(s)
- John Maret-Ouda
- Upper Gastrointestinal Surgery, Department of Molecular medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Jesper Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Section of Gastrointestinal Cancer, Division of Cancer Studies, King's College London, United Kingdom
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45
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Fock KM, Talley N, Goh KL, Sugano K, Katelaris P, Holtmann G, Pandolfino JE, Sharma P, Ang TL, Hongo M, Wu J, Chen M, Choi MG, Law NM, Sheu BS, Zhang J, Ho KY, Sollano J, Rani AA, Kositchaiwat C, Bhatia S. Asia-Pacific consensus on the management of gastro-oesophageal reflux disease: an update focusing on refractory reflux disease and Barrett's oesophagus. Gut 2016; 65:1402-15. [PMID: 27261337 DOI: 10.1136/gutjnl-2016-311715] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/15/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Since the publication of the Asia-Pacific consensus on gastro-oesophageal reflux disease in 2008, there has been further scientific advancement in this field. This updated consensus focuses on proton pump inhibitor-refractory reflux disease and Barrett's oesophagus. METHODS A steering committee identified three areas to address: (1) burden of disease and diagnosis of reflux disease; (2) proton pump inhibitor-refractory reflux disease; (3) Barrett's oesophagus. Three working groups formulated draft statements with supporting evidence. Discussions were done via email before a final face-to-face discussion. We used a Delphi consensus process, with a 70% agreement threshold, using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria to categorise the quality of evidence and strength of recommendations. RESULTS A total of 32 statements were proposed and 31 were accepted by consensus. A rise in the prevalence rates of gastro-oesophageal reflux disease in Asia was noted, with the majority being non-erosive reflux disease. Overweight and obesity contributed to the rise. Proton pump inhibitor-refractory reflux disease was recognised to be common. A distinction was made between refractory symptoms and refractory reflux disease, with clarification of the roles of endoscopy and functional testing summarised in two algorithms. The definition of Barrett's oesophagus was revised such that a minimum length of 1 cm was required and the presence of intestinal metaplasia no longer necessary. We recommended the use of standardised endoscopic reporting and advocated endoscopic therapy for confirmed dysplasia and early cancer. CONCLUSIONS These guidelines standardise the management of patients with refractory gastro-oesophageal reflux disease and Barrett's oesophagus in the Asia-Pacific region.
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Affiliation(s)
- Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Nicholas Talley
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
| | - Khean Lee Goh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kentaro Sugano
- Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Peter Katelaris
- Gastroenterology Department, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Gerald Holtmann
- Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - John E Pandolfino
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Prateek Sharma
- University of Kansas and VA Medical Center, Kansas City, Kansas, USA
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Michio Hongo
- Department of Comprehensive Medicine, Tohoku University, Sendai, Japan
| | - Justin Wu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, China
| | - Minhu Chen
- Division of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Myung-Gyu Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ngai Moh Law
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Bor-Shyang Sheu
- Department of Internal Medicine, National Cheng Kung University Hospital, Medical College, National Cheng Kung University, Tainan, Taiwan
| | - Jun Zhang
- The Second Affiliated Hospital, Xian Jiaotong University, Xian, China
| | - Khek Yu Ho
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore, Singapore
| | - Jose Sollano
- Department of Medicine, University of Sano Tomas, Manila, Philippines
| | - Abdul Aziz Rani
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Chomsri Kositchaiwat
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Shobna Bhatia
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
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46
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Hayakawa Y, Sethi N, Sepulveda AR, Bass AJ, Wang TC. Oesophageal adenocarcinoma and gastric cancer: should we mind the gap? Nat Rev Cancer 2016; 16:305-18. [PMID: 27112208 DOI: 10.1038/nrc.2016.24] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Over recent decades we have witnessed a shift in the anatomical distribution of gastric cancer (GC), which increasingly originates from the proximal stomach near the junction with the oesophagus. In parallel, there has been a dramatic rise in the incidence of oesophageal adenocarcinoma (OAC) in the lower oesophagus, which is associated with antecedent Barrett oesophagus (BO). In this context, there has been uncertainty regarding the characterization of adenocarcinomas spanning the area from the lower oesophagus to the distal stomach. Most relevant to this discussion is the distinction, if any, between OAC and intestinal-type GC of the proximal stomach. It is therefore timely to review our current understanding of OAC and intestinal-type GC, integrating advances from cell-of-origin studies and comprehensive genomic alteration analyses, ultimately enabling better insight into the relationship between these two cancers.
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Affiliation(s)
- Yoku Hayakawa
- Division of Digestive and Liver Diseases and Herbert Irving Cancer Research Center, Columbia University College of Physicians and Surgeons, 1130 St Nicholas Avenue, New York, New York 10032, USA
| | - Nilay Sethi
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, Massachusetts 02215, USA
| | - Antonia R Sepulveda
- Division of Clinical Pathology and Cell Biology, Department of Pathology, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
| | - Adam J Bass
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, Massachusetts 02215, USA
| | - Timothy C Wang
- Division of Digestive and Liver Diseases and Herbert Irving Cancer Research Center, Columbia University College of Physicians and Surgeons, 1130 St Nicholas Avenue, New York, New York 10032, USA
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47
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48
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Domper Arnal MJ, Ferrández Arenas &A, Lanas Arbeloa &A. Esophageal cancer: Risk factors, screening and endoscopic treatment in Western and Eastern countries. World J Gastroenterol 2015; 21:7933-7943. [PMID: 26185366 PMCID: PMC4499337 DOI: 10.3748/wjg.v21.i26.7933] [Citation(s) in RCA: 659] [Impact Index Per Article: 73.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 03/11/2015] [Accepted: 04/17/2015] [Indexed: 02/07/2023] Open
Abstract
Esophageal cancer is one of the most unknown and deadliest cancers worldwide, mainly because of its extremely aggressive nature and poor survival rate. Esophageal cancer is the 6th leading cause of death from cancer and the 8th most common cancer in the world. The 5-year survival is around 15%-25%. There are clear differences between the risk factors of both histological types that affect their incidence and distribution worldwide. There are areas of high incidence of squamous cell carcinoma (some areas in China) that meet the requirements for cost-effectiveness of endoscopy for early diagnosis in the general population of those areas. In Europe and United States the predominant histologic subtype is adenocarcinoma. The role of early diagnosis of adenocarcinoma in Barrett’s esophagus remains controversial. The differences in the therapeutic management of early esophageal carcinoma (high-grade dysplasia, T1a, T1b, N0) between different parts of the world may be explained by the number of cancers diagnosed at an early stage. In areas where the incidence is high (China and Japan among others) early diagnoses is more frequent and has led to the development of endoscopic techniques for definitive treatment that achieve very effective results with a minimum number of complications and preserving the functionality of the esophagus.
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49
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Kapoor H, Agrawal DK, Mittal SK. Barrett's esophagus: recent insights into pathogenesis and cellular ontogeny. Transl Res 2015; 166:28-40. [PMID: 25701368 DOI: 10.1016/j.trsl.2015.01.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/24/2015] [Accepted: 01/27/2015] [Indexed: 02/06/2023]
Abstract
Esophageal adenocarcinoma (EAC) has increased 6-fold in its incidence in the last 2 decades. Evidence supports the hypothesis of stepwise progression from normal squamous epithelium → reflux esophagitis → metaplasia (Barrett's esophagus, BE) → dysplasia → adenocarcinoma. The precursor, BE, stands as the bridge connecting the widespread but naive reflux disease and the rare but fatal EAC. The step of metaplasia from squamous to intestine-like columnar phenotype is perhaps pivotal in promoting dysplastic vulnerability. It is widely accepted that chronic inflammation because of gastroesophageal reflux disease leads to the development of metaplasia, however the precise molecular mechanism is yet to be discovered. Additionally, how this seemingly adaptive change in the cellular phenotype promotes dysplasia remains a mystery. This conceptual void is deterring further translational research and clouding clinical decision making. This article critically reviews theories on the pathogenesis of Barrett's esophagus and the various controversies surrounding its diagnosis. We further discuss unanswered questions and future directions, which are vital in formulating effective preventive and therapeutic guidelines for Barrett's esophagus.
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Affiliation(s)
- Harit Kapoor
- Esophageal Center, Department of Surgery, Creighton University School of Medicine, Omaha, Neb; Center for Clinical and Translational Sciences, Creighton University School of Medicine, Omaha, Neb
| | - Devendra K Agrawal
- Center for Clinical and Translational Sciences, Creighton University School of Medicine, Omaha, Neb
| | - Sumeet K Mittal
- Esophageal Center, Department of Surgery, Creighton University School of Medicine, Omaha, Neb.
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50
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Samuels T, Hoekzema C, Gould J, Goldblatt M, Frelich M, Bosler M, Lee SH, Johnston N. Local Synthesis of Pepsin in Barrett's Esophagus and the Role of Pepsin in Esophageal Adenocarcinoma. Ann Otol Rhinol Laryngol 2015; 124:893-902. [PMID: 26077392 DOI: 10.1177/0003489415590657] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Despite widespread use of proton pump inhibitors (PPIs), the incidence of esophageal adenocarcinoma (EAC) continues to rise. PPIs reduce reflux acidity, but only transiently inactivate gastric enzymes. Nonacid reflux, specifically nonacid pepsin, contributes to carcinogenesis in the larynx. Given the carcinogenic potential of pepsin and inefficacy of PPIs to prevent EAC, the presence and effect of pepsin in the esophagus should be investigated. METHODS Normal and Barrett's biopsies from 8 Barrett's esophagus patients were collected for pepsin analysis via Western blot and reverse transcriptase-polymerase chain reaction (RT-PCR). Human esophageal cells cultured from healthy patients were treated with pepsin (0.01-1 mg/mL; 1-20 hours), acid (pH 4)±pepsin (5 minutes); real-time RT-PCR, ELISA, and cell migration were assayed. RESULTS Pepsin was detected in all 8 Barrett's and 4 of 8 adjacent normal specimens. Pepsinogen mRNA was observed in 22 Barrett's, but not in normal adjacent samples. Pepsin induced PTSG2 (COX-2) and IL-1β expression and cell migration in vitro. CONCLUSIONS Pepsin is synthesized by metaplastic, Barrett's esophageal mucosa. Nonacid pepsin increases metrics of tumorigenicity in esophageal epithelial cells in vitro. These findings implicate refluxed and locally synthesized pepsin in development and progression of EAC and, in part, explain the inefficacy of PPIs in the prevention of EAC.
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Affiliation(s)
- Tina Samuels
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Craig Hoekzema
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jon Gould
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Matthew Goldblatt
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Matthew Frelich
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Matthew Bosler
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sang-Hyuk Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Nikki Johnston
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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