Refinement of screening for familial pancreatic cancer

OBJECTIVE

Surveillance programmes are recommended for individuals at risk (IAR) of familial pancreatic cancer (FPC) to detect early pancreatic cancer (pancreatic ductal adenocarcinoma, PDAC). However, the age to begin screening and the optimal screening protocol remain to be determined.

METHODS

IAR from non-CDKN2A FPC families underwent annual screening by MRI with endoscopic ultrasonography (EUS) in board-approved prospective screening programmes at three tertiary referral centres. The diagnostic yield according to age and different screening protocols was analysed.

RESULTS

253 IAR with a median age of 48 (25-81) years underwent screening with a median of 3 (1-11) screening visits during a median follow-up of 28 (1-152) months. 134 (53%) IAR revealed pancreatic lesions on imaging, mostly cystic (94%), on baseline or follow-up screening. Lesions were significantly more often identified in IAR above the age of 45 years (p<0.0001). In 21 IAR who underwent surgery, no significant lesions (PDAC, pancreatic intraepithelial neoplasia (PanIN) 3 lesions, high-grade intraductal papillary mucinous neoplasia (IPMN)) were detected before the age of 50 years. Potentially relevant lesions (multifocal PanIN2 lesions, low/moderate-grade branch-duct IPMNs) occurred also significantly more often after the age of 50 years (13 vs 2, p<0.0004). The diagnostic yield of potentially relevant lesions was not different between screening protocols using annual MRI with EUS (n=98) or annual MRI with EUS every 3rd year (n=198) and between IAR screened at intervals of 12 months (n=180) or IAR that decided to be screened at ≥24 months intervals (n=30).

CONCLUSIONS

It appears safe to start screening for PDAC in IAR of non-CDKN2a FPC families at the age of 50 years. MRI-based screening supplemented by EUS at baseline and every 3rd year or when changes in MRI occur appears to be efficient.

Increased Duodeno-Gastro-Esophageal Reflux (DGER) in symptomatic GERD patients with a history of cholecystectomy

BACKGROUND

Duodenal-Gastro-Esophageal Reflux (DGER) represents an independent risk factor for the development of complicated Gastro-esophageal-reflux-disease (GERD) and Barrett's esophagus. Clinical and epidemiological data suggest a potential association between cholecystectomy (CCE) and augmented bile reflux.

METHODS

132 patients (67 women, 65 men, median age 55) with typical symptoms of GERD were enrolled in the study and divided in cholecystectomized (CCE-group: n = 107) and non- cholecystectomized (nCCE-group: n = 25) patients. Standardized clinical work-up of patients included combined esophageal 24 h pH-measurement and Bilitec 2000 esophageal manometry and upper endoscopy.

RESULTS

In the statistical analysis no differences between the cholecystectomized group (CCE-group, n = 25) and the patients without cholecystectomy (nCCE-group, n = 107) could be observed in quantity or quality of reflux symptoms. Furthermore, neither acid reflux nor severity of inflammation and frequency of Barrett's esophagus significantly differed between the nCCE and CCE-group. However, the percentage of patients with pathological DGER were significantly higher in the CCE-group as compared to the nCCE-group (76 vs. 55 %, p < 0.01). Moreover, the CCE-group revealed significant higher levels of pathological DGER compared to the nCCE-group (15.5 % +/- 14.1 vs. 8.6 % +/- 15.4; p < 0.05).

CONCLUSION

To conclude, our data provide first evidence of elevated DGER after CCE in patients with typical clinical symptoms of GERD using the Bilitec device. Both the frequency and the extent of DGER was significantly increased in the CCE-group. Prospective studies are urgently needed to elucidate the impact of CCE on DGER in patients with clinical symptoms of a reflux disease.

Echo-rich and echo-poor periportal cuffing: pole position for inflammatory bowel diseases

PURPOSE

To determine the prevalence of echo-rich and echo-poor periportal cuffing in patients from a German tertiary referral hospital and correlate ultrasonographic findings with clinical data.

MATERIALS AND METHODS

From April 2002 till April 2008 about 10 500 abdominal examinations were performed by a single physician in our interdisciplinary ultrasound unit. During this time, n = 100 patients (62 male/ 38 female) with periportal cuffing of the liver were detected qualifying for the retrospective study design. Echomorphology of periportal cuffing was evaluated and clinical diagnoses of the underlying diseases were clustered in four main groups: Liver diseases, haematological diseases, bowel diseases and others. Furthermore, liver function tests and body mass index were determined.

RESULTS

The mean age of the patients was 57.06 years (SD +/- 19.47). Mean body-mass-index was 24.76 kg/m (2) (SD +/- 4.28). Periportal cuffing was echo-poor in n = 9 (9 %) and echo-rich in n = 91 (91 %). Echo-poor periportal cuffing was significantly more often associated with malignant diseases as compared to echo-rich periportal cuffing (78 vs. 36 %) (p < 0.025). Liver diseases (n = 33) were malign n = 10 (10 %), autoimmune n = 8 (8 %), infectious n = 8 (8 %) and cholestatic n = 7 (7 %). Bowel diseases (n = 34) originated from the upper gastrointestinal tract n = 7 (7 %), lower gastrointestinal tract n = 21 (21 %) and the pancreas n = 6 (6 %). Haematological disorders (n = 15, 15 %) were chronic myeloproliferative n = 2 (2 %), lymphoma n = 8 (8 %), leukemia n = 4 (4 %) and miscellaneous n = 1 (1 %). Other diseases accounted for 18 (18 %) of cases. Aspartat-aminotrasferase (AST) and alanin-aminotransferase (ALT) were elevated in 39 patients (40 %) and 34 patients (35 %), respectively. Total bilirubin was elevated in 35 patients (36 %). Alkaline phosphatase (AP) was detected above normal range in 49 patients (50 %) whereas g-glutamyl-transferase was elevated in 58 patients (59 %).

CONCLUSION

Periportal cuffing of the liver is an extremely rare ultrasonographic phenomenon with a prevalence of approximately 0.95 % in our unit. Echo-rich periportal cuffing occurs more frequently than echo-poor periportal cuffing. The majority of echo-poor periportal cuffing is associated with malignant disorders, in particular haematological diseases, whereas echo-rich periportal cuffing is most frequently seen in inflammatory bowel disease patients.

[The enteric glia and neurotrophic factors]

Enteric glia cells (EGCs) play an important role in the maintenance of tissue integrity in the gastrointestinal tract. Thus, genetic ablation of glial fibrillary acidic protein (GFAP)-positive EGCs in mice induced fatal haemorrhagic jejuno-ileitis and led to death within a few days. The exact mechanisms of EGC to contribute to gut homeostasis remain enigmatic. Several lines of evidence implicate that the secretion of neurotrophic factors by EGC may be a part of the glial regulation of gut homoeostasis. The secretion of glia cell-derived neurotrophic factor (GDNF), nerve growth factor (NGF) and transforming growth factor-beta (TGF-beta) contributes to the maintenance of epithelial integrity and the secretion of endothelins might be involved in vasoregulation. These new aspects of intestinal glial functions implicate new therapeutic strategies for diseases like Crohn's disease and irritable bowel syndrome.

Nerve growth factor secretion in cultured enteric glia cells is modulated by proinflammatory cytokines

The enteric nervous system is composed of neurones and glial cells. These enteric glia cells (EGC) appear to be essential for the maintenance of gut homeostasis and mucosal integrity. Neurotrophin nerve growth factor (NGF) also plays an important role for the gut integrity by regulating sensory and inflammatory processes in the intestines. Here, we demonstrate EGCs as one source of NGF and show increased levels of NGF mRNA/protein and tropomyosin receptor kinase A (TrkA) mRNA in cultured EGCs upon stimulation with proinflammatory cytokines and lipopolysaccharides. NGF is continuously secreted from cultured EGCs and proinflammatory cytokines and lipopolysaccharides stimulate the secretion of this neurotrophin in a time- and dose- dependent manner, whereas interleukin-4 had no effect on NGF expression. Furthermore, NGF secretion was sustained for more than 12 h after withdrawal of the proinflammatory cytokines, suggesting the involvement of transcriptional and/or translational processes. Thus, the release of proinflammatory cytokines can increase NGF secretion by EGCs and leads to a higher expression of TrkA in EGCs. NGF, in turn, can increase visceral sensitivity and, on the other hand, appears to improve gut inflammation. Therefore, NGF secreting EGCs may play a key role in modulating visceral sensitivity and might be involved in inflammatory processes of the gut.

Lack of Correlation between the Vitamin D Receptor Fokl Start Codon Polymorphism and Bone Mineral Density in Patients with Crohn's Disease

INTRODUCTION

We have examined the association of bone mineral density of patients with inflammatory bowel disease with a polymorphism in the gene encoding the vitamin D receptor. The thymine/cytosine (T/C) polymorphism in the first of two start codons can be defined by a restriction fragment length polymorphism using the restriction endonuclease FokI. Vitamin D receptor alleles containing the polymorphism have been denoted by f and alleles lacking the site by F.

METHODS

We report on an association analysis of a basic population of 244 caucasian patients with Crohn's disease. We have genotyped the FokI polymorphism of the VDR in these patients and associated the genotype with the bone mineral density of the lumbar spine and the femoral neck.

RESULTS

In the cohort 42% of the patients were scored FF homozygous, 43.7% Ff heterozygous, and 14.3% ff homozygous. 14.4% of the FF patients, 18.8% of the Ff patients, and 9.7% of the ff patients had osteoporosis of the lumbar spine and 21.25% of the FF patients, 25.3% of the Ff patients, and 18.5% of the ff patients had osteoporosis of the femoral neck. In this cohort no association between the genotype and the bone mineral density in the group as a whole nor when separated according to sex or age was found.

CONCLUSIONS

In summary in our cohort no association of the FokI polymorphism and the BMD of the lumbar spine and femoral neck in patients with inflammatory bowel disease was found.

Proinflammatory cytokines increase glial fibrillary acidic protein expression in enteric glia

BACKGROUND

Enteric glia protect the integrity of the gut, as loss of enteric glial fibrillary acidic protein (GFAP) positive (+) glia leads to a haemorrhagic jejunoileitis. Crohn's disease (CD) and necrotising enterocolitis (NEC) show pathological changes in enteric glia. Therefore, factors controlling GFAP+ enteric glia are of great interest. The aim of the present study was to characterise enteric glia and determine the effect of interleukin 1beta (IL-1beta), interleukin 4 (IL-4), tumour necrosis factor alpha (TNF-alpha), and lipopolysaccharides (LPS) on cultured enteric glia.

METHODS

Dissected rat colon and cultured enteric glia cells were double labelled with anti-GFAP and anti-S-100 antibodies. For regulatory studies, enteric glia cells were treated with cytokines and LPS. Proliferation was assayed using bromodeoxyuridine (BrdU) and mitosis of enteric glia was blocked by demecolcine.

RESULTS

We were able to distinguish GFAP negative (-) from GFAP+ glia subtypes in situ and in primary cultures. Incubation of cells with IL-1beta, TNF-alpha, and LPS led to a significant increase in GFAP+ enteric glia while IL-4 had no effect on GFAP expression. After incubation with IL-1beta, total intracellular GFAP of enteric glia cells was increased. Upregulation of GFAP+ enteric glia could also be observed after stimulation with IL-1beta on blocking mitosis. BrdU uptake in stimulated enteric glia showed no increased proliferation rate.

CONCLUSIONS

Two different types of enteric glia based on GFAP expression exist in the gut. Proinflammatory cytokines and LPS cause a dramatic increase in GFAP+ enteric glia. This suggests that cytokines play an important role in controlling GFAP+ enteric glia which might in turn be involved in modulating the integrity of the bowel during inflammation.

Therapy of osteoporosis in patients with Crohn's disease: a randomized study comparing sodium fluoride and ibandronate

BACKGROUND

Osteoporosis is a frequent complication in Crohn's disease. Although the efficacy of both sodium fluoride and aminobisphosphonates in postmenopausal osteoporosis has been investigated in long-term therapy studies, no long-term results are available regarding the effect of these agents in the management of osteoporosis in patients with Crohn's disease.

METHODS

Eighty-four patients with Crohn's disease and pathological bone mineral density findings were randomized to receive either vitamin D3 (1000 IU) and calcium citrate (800 mg) daily (group A) or sodium fluoride (25 mg b.d., group B) or intravenous ibandronate (1 mg every 3 months, group C) in addition to daily calcium/vitamin D substitution. On admission to the study and after 12 and 27 months, patients underwent dual-energy X-ray absorptiometry and radiological examination of the spine.

RESULTS

Sixty-eight patients completed the 1-year observation period and were available for the intention-to-treat analysis. No new vertebral fractures were diagnosed. In group A, lumbar bone density increased by 2.6% (P = 0.066, N.S.), in group B by 5.7% (P = 0.003) and in group C by 5.4% (P = 0.003). Therapy with sodium fluoride was associated with an increase in osteocalcin (N.S.), whereas administration of ibandronate was associated with a decrease in the resorption parameter, carboxy-terminal cross-linked type-I collagen telopeptide (P < 0.05). Both sodium fluoride and ibandronate resulted in significant decreases in the serum concentration of osteoprotegerin after 9 months (P < 0.001).

CONCLUSIONS

The findings of the present study show that both sodium fluoride and ibandronate are effective in combination with calcium and vitamin D substitution in the management of osteopenia and osteoporosis in patients with Crohn's disease. Both agents are safe and well tolerated, and induce continuous increases in lumbar bone density.

High prevalence of osteoporotic vertebral fractures in patients with Crohn's disease

BACKGROUND AND AIMS

Osteopenia and osteoporosis are frequent in Crohn's disease. However, there are few data on related vertebral fractures. Therefore, we evaluated prospectively the prevalence of osteoporotic vertebral fractures in these patients.

METHODS

A total of 293 patients were screened with dual energy x ray absorptiometry of the lumbar spine (L1-L4) and proximal right femur. In 156 patients with lumbar osteopenia or osteoporosis (T score <-1), x ray examinations of the thoracic and lumbar spine were performed. Assessment of fractures included visual reading of x rays and quantitative morphometry of the vertebral bodies (T4-L4), analogous to the criteria of the European Vertebral Osteoporosis Study.

RESULTS

In 34 (21.8%; 18 female) of 156 Crohn's disease patients with reduced bone mineral density, 63 osteoporotic vertebral fractures (50 fx. (osteoporotic fracture with visible fracture line running into the vertebral body and/or change of outer shape) and 13 fxd. (osteoporotic fracture with change of outer shape but without visible fracture line)) were found, 50 fx. in 25 (16%, 15 female) patients and 13 fxd. in nine (5.8%, three female) patients. In four patients the fractures were clinically evident and associated with severe back pain. Approximately one third of patients with fractures were younger than 30 years. Lumbar bone mineral density was significantly reduced in patients with fractures compared with those without (T score -2.50 (0.88) v -2.07 (0.66); p<0.025) but not at the hip (-2.0 (1.1) v -1.81 (0.87); p=0.38). In subgroups analyses, no significant differences were observed.

CONCLUSIONS

In patients with Crohn's disease and reduced bone mineral density, the prevalence of vertebral fractures-that is, manifest osteoporosis-was strikingly high at 22%, even in those aged less than 30 years, a problem deserving further clinical attention.

Energetic stress in combination with tumor necrosis factor-alpha (TNF-alpha) induces apoptosis of human fibroblasts (WI-38) in vitro: reduced responsiveness of senescent cells

The NaCl content of the culture medium of human fibroblasts (WI-38) was elevated from 0.12 M to 0.23 M. Previously it had been shown that exposure of fibroblasts to such high NaCl conditions resulted in a rise of both glycolysis and respiration ("energetic stress"), mainly due to increased demands of energy for active ion transport ("sodium pump"). While "young" (Phase II) and "senescent" (Phase III) cells did not show a significant increase of apoptosis over the basal rate (ca. 4%) under treatment with either a high-NaCl medium or TNF-alpha (10 nM) alone, combined treatment resulted in a strong increase in Phase II cells and a significantly lesser rise in the case of "senescent" Phase III cells. We conclude, therefore, that energetic stress stimulates sensitivity to apoptosis by (in the presence of) TNF-alpha, especially pronounced in potentially replicating "young" as compared with irreversible postmitotic ("senescent") fibroblasts. Possible causes of this differential responsiveness and implications for the in vivo situation (in the organism) were discussed.

Transforming growth factor-alpha in the regulation of enterocytic proliferation: part of a puzzle

The regulation of gut mucosal wound healing after mucosal injury is crucial in re-establishing the epithelial barrier function of the epithelium. However, the exact molecular mechanisms of gut epithelial restitution are still largely unknown. The proliferation and migration of epithelial cells, which contribute to the epithelial wound healing, are complex regulated and, until now, a variety of peptide and nonpeptide factors that take part in this regulation have been identified. Transforming growth factor (TGF)-alpha is one of the well-known proliferation and migration inducing factors in gut epithelial cells, and seems to play an important role in mucosal wound healing. However, less is known about the regulation of TGF-alpha expression itself. Here we discuss the recent advances concerning the role of TGF-alpha in the context of mucosal regeneration.

Protective role of neurotrophins in experimental inflammation of the rat gut

BACKGROUND & AIMS

Sensory neuropeptides modulate the mucosal response to inflammation in experimental colitis. Because nerve growth factor (NGF) regulates the expression of neuropeptides such as substance P and calcitonin gene-related peptide (CGRP) and is implicated as a link between the nervous system and the immune system in the inflammatory process, we investigated the functional role of NGF and neurotrophin-3 during experimental colitis.

METHODS

Immunoneutralizing antibodies specific for NGF and neurotrophin (NT)-3 were used to block their endogenous activity. Mild trinitrobenzene sulfonic acid (TNBS) colitis was induced, and damage scores were assessed after 1 week. Neuropeptide content in the colon and NT messenger RNA (mRNA) expression were determined.

RESULTS

The pretreatment with anti-NGF or anti-NT-3 caused a significant 2-3-fold increase in the severity of the experimental inflammation as assessed by a macroscopic damage score, histologic ulceration score, and myeloperoxidase activity in the tissue. CGRP, but not substance P, contents in the colon were significantly reduced by NGF immunoneutralization. NGF mRNA was slightly up-regulated after NGF immunoneutralization, but NT-3 mRNA was unchanged by NT-3 immunoneutralization. CGRP mRNA was not significantly changed after 1 week of colitis by NGF or NT-3 immunoneutralization, whereas beta-preprotachykinin mRNA was up-regulated after immunoneutralization.

CONCLUSIONS

These findings suggest a regulatory role for NGF and NT-3 in experimental inflammation of the gut. This effect may be partly caused by the reduction of mucosal CGRP content caused by the NGF blockade.

A phase II study of weekly 24-h infusion of high-dose 5-fluorouracil in advanced pancreatic cancer

No single agent or combination chemotherapy protocol, with the exception of gemcitabine, has so far proven superior to standard bolus 5-fluorouracil regimes for the treatment of advanced pancreatic cancer. The present phase II trial was designed to study whether the effectivity of 5-fluorouracil can be improved with a weekly high-dose 5-fluorouracil schedule. 26 patients with cytologically or histologically verified, metastasized (n = 21) or locally advanced (n = 5) previously untreated adenocarcinoma of the pancreas were included in this study. Treatment consisted of weekly applications of 2,600 mg/m2 5-fluorouracil as 24-h infusion on days 1, 8, 15, 22, 29, 36. Treatment was repeated at day 50 and was continued until disease progression. Primary endpoints of the study were response rates and toxicity, secondary endpoints were survival and clinical benefit in terms of performance status, body weight and analgesia consumption. Toxicity of the regimen was mild with only four instances of grade-3 toxicity. Response rates were 8% (95% CI = 1.2-13.7) with two partial remissions. Improvement of at least one parameter of clinical benefit for > or = four weeks was observed for 11.5% of the study patients. The most prominent effect was a transient stabilization of objective tumor measurements (48% [95% CI = 27.8-68.7]) and individual parameters of clinical benefit (50-75%). Median survival was 248 days (95% CI = 164-459) for all patients included in the study. The present study indicates that the high-dose 5-fluorouracil regimen shows weak activity in advanced pancreatic cancer which seems comparable to gemcitabine.

[The computed tomographic determination of intra-abdominal fat volume by single-layer measurement]

PURPOSE

Several studies emphasised the importance of the relationship between intra-abdominal and total body adipose tissue as a risk factor for the development of metabolic or cardiovascular diseases. Therefore, the aim of the present study was to examine whether a single-scan computed tomography is able to determine the whole intra-abdominal fat volume with high accuracy and reproducibility.

MATERIALS AND METHODS

Regions of interests (ROIs) were drawn manually for measuring intra-abdominal fat in 51 unsuspicious abdominal CT.

RESULTS

The sexual differentiation of adipose tissue already described in a lot of studies could be confirmed in this study. Fat still predominates in females in lower half of the body (gynecoid obesity). In men it predominates in the upper half (android obesity). Significant correlation concerning measuring the whole intra-abdominal fat volume could be found in L1-level in women (r = 0.992) and in L2-level in men (r = 0.992). Measurement of a single scan enables us to assess whole intra-abdominal fat volume due to a special formula.

CONCLUSION

The determination of intra-abdominal fat measured by a single-scan computed tomography is a procedure associated with high accuracy and reproducibility.