Adherence to prescription proton pump inhibitor therapy amongst individuals diagnosed with Barrett's esophagus

INTRODUCTION

In the United States, clinical guidelines recommend daily use of proton pump inhibitors (PPIs) amongst individuals diagnosed with Barrett's esophagus to decrease the risk of progression to dysplasia and neoplasia. Prior studies documenting adherence to PPIs in this population have not characterized heterogeneity in adherence patterns. Factors that may relate to adherence are incompletely described.

METHODS

We used administrative claims data from the Merative MarketScan Commercial Claims and Encounters database to conduct a retrospective study of adherence to prescription PPIs. A cohort of individuals diagnosed with incident Barrett's esophagus between 2010 and 2019 was identified. Group-based trajectory models were generated to detect longitudinal adherence subgroups.

RESULTS

79 701 individuals with a new diagnosis of Barrett's esophagus were identified. The best fitting model detected five distinct adherence trajectory groups: consistently high (44% of the population), moderate decline (18%), slow decline (12%), rapid decline (10%), and decline-then-increase (16%). Compared to individuals starting PPIs, those already using PPIs were less likely to have a declining adherence pattern. Other factors associated with membership in a declining adherence group included (but were not limited to): female sex, having a past diagnosis of anxiety or depression, and having one or more emergency department visits in the past year.

DISCUSSION

Using an exploratory method, we detected heterogeneity in adherence to prescription PPIs. Less than half of individuals were classified into the consistently high adherence group, suggesting that many individuals with Barrett's esophagus receive inadequate pharmacologic therapy.

Antireflux Surgery Versus Antireflux Medication and Risk of Esophageal Adenocarcinoma in Patients With Barrett's Esophagus

BACKGROUND & AIMS

Antireflux treatment is recommended to reduce esophageal adenocarcinoma in patients with Barrett's esophagus. Antireflux surgery (fundoplication) counteracts gastroesophageal reflux of all types of carcinogenic gastric content and reduces esophageal acid exposure to a greater extent than antireflux medication (eg, proton pump inhibitors). We examined the hypothesis that antireflux surgery prevents esophageal adenocarcinoma to a larger degree than antireflux medication in patients with Barrett's esophagus.

METHODS

This multinational and population-based cohort study included all patients with a diagnosis of Barrett's esophagus in any of the national patient registries in Denmark (2012-2020), Finland (1987-1996 and 2010-2020), Norway (2008-2020), or Sweden (2006-2020). Patients who underwent antireflux surgery were compared with nonoperated patients using antireflux medication. The risk of esophageal adenocarcinoma was calculated using multivariable Cox regression, providing hazard ratios (HRs) and 95% CIs adjusted for age, sex, country, calendar year, and comorbidity.

RESULTS

The cohort consisted of 33,939 patients with Barrett's esophagus. Of these, 542 (1.6%) had undergone antireflux surgery. During up to 32 years of follow-up, the overall HR was not decreased in patients having undergone antireflux surgery compared with nonoperated patients using antireflux medication, but rather increased (adjusted HR, 1.9; 95% CI, 1.1-3.5). In addition, HRs did not decrease with longer follow-up, but instead increased for each follow-up category, from 1.8 (95% CI, 0.6-5.0) within 1-4 years of follow-up to 4.4 (95% CI, 1.4-13.5) after 10-32 years of follow-up.

CONCLUSIONS

Patients with Barrett's esophagus who undergo antireflux surgery do not seem to have a lower risk of esophageal adenocarcinoma than those using antireflux medication.

Revisiting Proton Pump Inhibitors as Chemoprophylaxis Against the Progression of Barrett's Esophagus

PURPOSE OF REVIEW

Barrett's esophagus (BE) is associated with chronic gastroesophageal reflux disease and is a known precursor to esophageal adenocarcinoma. While endoscopic surveillance strategies and the role for endoscopic eradication therapy have been well established, there has been much interest in identifying chemopreventive agents to disrupt or halt the metaplasia-dysplasia-carcinoma sequence in patients with BE.

RECENT FINDINGS

No pharmacological agent has held more hope in reducing the risk of neoplastic progression in BE than proton pump inhibitors (PPIs). However, data supporting PPIs for chemoprevention have largely been from observational cohort and case-control studies with mixed results. In this review, we revisit the literature and highlight the role of PPIs in patients with BE as it pertains to chemoprophylaxis against the progression of BE to dysplasia and esophageal adenocarcinoma.

AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors: Expert Review

DESCRIPTION

Proton pump inhibitors (PPIs) are among the most commonly used medications in the world. Developed for the treatment and prevention of acid-mediated upper gastrointestinal conditions, these agents are being used increasingly for indications where their benefits are less certain. PPI overprescription imposes an economic cost and contributes to polypharmacy. In addition, PPI use has been increasingly linked to a number of adverse events (PPI-associated adverse events [PAAEs]). Therefore, de-prescribing of PPIs is an important strategy to lower pill burden while reducing real costs and theoretical risks. The purpose of this clinical update was to provide Best Practice Advice (BPA) statements about how to approach PPI de-prescribing in ambulatory patients.

METHODS

Our guiding principle was that, although PPIs are generally safe, patients should not use any medication when there is not a reasonable expectation of benefit based on scientific evidence or prior treatment response. Prescribers are responsible for determining whether PPI use is absolutely or conditionally indicated and, when uncertainty exists, to incorporate patient perspectives into PPI decision making. We collaboratively outlined a high-level "process map" of the conceptual approach to de-prescribing PPIs in a clinical setting. We identified the following 3 key domains that required BPA guidance: documentation of PPI indication; identifying suitable candidates for consideration of de-prescribing; and optimizing successful de-prescribing. Co-authors drafted 1 or more potential BPAs, supported by literature review, for each domain. All co-authors reviewed, edited, and selected or rejected draft BPAs for inclusion in the final list submitted to the American Gastroenterological Association Governing Board. Because this was not a systematic review, we did not carry out a formal rating of the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: All patients taking a PPI should have a regular review of the ongoing indications for use and documentation of that indication. This review should be the responsibility of the patient's primary care provider. BEST PRACTICE ADVICE 2: All patients without a definitive indication for chronic PPI should be considered for trial of de-prescribing. BEST PRACTICE ADVICE 3: Most patients with an indication for chronic PPI use who take twice-daily dosing should be considered for step down to once-daily PPI. BEST PRACTICE ADVICE 4: Patients with complicated gastroesophageal reflux disease, such as those with a history of severe erosive esophagitis, esophageal ulcer, or peptic stricture, should generally not be considered for PPI discontinuation. BEST PRACTICE ADVICE 5: Patients with known Barrett's esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis should generally not be considered for a trial of de-prescribing. BEST PRACTICE ADVICE 6: PPI users should be assessed for upper gastrointestinal bleeding risk using an evidence-based strategy before de-prescribing. BEST PRACTICE ADVICE 7: Patients at high risk for upper gastrointestinal bleeding should not be considered for PPI de-prescribing. BEST PRACTICE ADVICE 8: Patients who discontinue long-term PPI therapy should be advised that they may develop transient upper gastrointestinal symptoms due to rebound acid hypersecretion. BEST PRACTICE ADVICE 9: When de-prescribing PPIs, either dose tapering or abrupt discontinuation can be considered. BEST PRACTICE ADVICE 10: The decision to discontinue PPIs should be based solely on the lack of an indication for PPI use, and not because of concern for PAAEs. The presence of a PAAE or a history of a PAAE in a current PPI user is not an independent indication for PPI withdrawal. Similarly, the presence of underlying risk factors for the development of an adverse event associated with PPI use should also not be an independent indication for PPI withdrawal.

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

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.

Zinc Gluconate Induces Potentially Cancer Chemopreventive Activity in Barrett's Esophagus: A Phase 1 Pilot Study

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.

Identification of Subtypes of Barrett's Esophagus and Esophageal Adenocarcinoma Based on DNA Methylation Profiles and Integration of Transcriptome and Genome Data

BACKGROUND & AIMS

Esophageal adenocarcinomas (EACs) are heterogeneous and often preceded by Barrett's esophagus (BE). Many genomic changes have been associated with development of BE and EAC, but little is known about epigenetic alterations. We performed epigenetic analyses of BE and EAC tissues and combined these data with transcriptome and genomic data to identify mechanisms that control gene expression and genome integrity.

METHODS

In a retrospective cohort study, we collected tissue samples and clinical data from 150 BE and 285 EAC cases from the Oesophageal Cancer Classification and Molecular Stratification consortium in the United Kingdom. We analyzed methylation profiles of all BE and EAC tissues and assigned them to subgroups using non-negative matrix factorization with k-means clustering. Data from whole-genome sequencing and transcriptome studies were then incorporated; we performed integrative methylation and RNA-sequencing analyses to identify genes that were suppressed with increased methylation in promoter regions. Levels of different immune cell types were computed using single-sample gene set enrichment methods. We derived 8 organoids from 8 EAC tissues and tested their sensitivity to different drugs.

RESULTS

BE and EAC samples shared genome-wide methylation features, compared with normal tissues (esophageal, gastric, and duodenum; controls) from the same patients and grouped into 4 subtypes. Subtype 1 was characterized by DNA hypermethylation with a high mutation burden and multiple mutations in genes in cell cycle and receptor tyrosine signaling pathways. Subtype 2 was characterized by a gene expression pattern associated with metabolic processes (ATP synthesis and fatty acid oxidation) and lack methylation at specific binding sites for transcription factors; 83% of samples of this subtype were BE and 17% were EAC. The third subtype did not have changes in methylation pattern, compared with control tissue, but had a gene expression pattern that indicated immune cell infiltration; this tumor type was associated with the shortest time of patient survival. The fourth subtype was characterized by DNA hypomethylation associated with structure rearrangements, copy number alterations, with preferential amplification of CCNE1 (cells with this gene amplification have been reported to be sensitive to CDK2 inhibitors). Organoids with reduced levels of MGMT and CHFR expression were sensitive to temozolomide and taxane drugs.

CONCLUSIONS

In a comprehensive integrated analysis of methylation, transcriptome, and genome profiles of more than 400 BE and EAC tissues, along with clinical data, we identified 4 subtypes that were associated with patient outcomes and potential responses to therapy.

Proton Pump Inhibitors and Radiofrequency Ablation for Treatment of Barrett's Esophagus

Gastroesophageal Reflux Disease (GERD) is characterized by acid and bile reflux in the distal oesophagus, and this may cause the development of reflux esophagitis and Barrett's oesophagus (BE). The natural histological course of untreated BE is non-dysplastic or benign BE (ND), then lowgrade (LGD) and High-Grade Dysplastic (HGD) BE, with the expected increase in malignancy transfer to oesophagal adenocarcinoma (EAC). The gold standard for BE diagnostics involves high-resolution white-light endoscopy, followed by uniform endoscopy findings description (Prague classification) with biopsy performance according to Seattle protocol. The medical treatment of GERD and BE includes the use of proton pump inhibitors (PPIs) regarding symptoms control. It is noteworthy that long-term use of PPIs increases gastrin level, which can contribute to transfer from BE to EAC, as a result of its effects on the proliferation of BE epithelium. Endoscopy treatment includes a wide range of resection and ablative techniques, such as radio-frequency ablation (RFA), often concomitantly used in everyday endoscopy practice (multimodal therapy). RFA promotes mucosal necrosis of treated oesophagal region via high-frequency energy. Laparoscopic surgery, partial or total fundoplication, is reserved for PPIs and endoscopy indolent patients or in those with progressive disease. This review aims to explain distinct effects of PPIs and RFA modalities, illuminate certain aspects of molecular mechanisms involved, as well as the effects of their concomitant use regarding the treatment of BE and prevention of its transfer to EAC.

Possible application of trefoil factor family peptides in gastroesophageal reflux and Barrett's esophagus

Gastroesophageal reflux disease (GERD) is a chronic disorder of the digestive tract characterised mainly by a heartburn. Being one of the most common gastrointestinal diseases, the prevalence of GERD reaches up to 25.9% in Europe. Barrett's esophagus (BE) is an acquired condition characterized by the replacement of the normal stratified squamous epithelium with metaplastic columnar epithelium. BE is believed to develop mainly from chronic GERD and is the most important risk factor of esophageal adenocarcinoma. Despite the availability of drugs such as proton pomp inhibitors and antacids, GERD is still a burden to local economy and impairs health-related quality of life in patients. Also, the endoscopic surveillance in patients with BE is burdensome and expensive what drives the need for biomarker of intestinal metaplasia and dysplasia. Trefoil factor family (TFF), consisting of TFF1, TFF2 and TFF3 peptides is gaining more and more attention due to its unique biochemical features and numerous functions. In this review the role of TFF1, TFF2 and TFF3 as potential treatment option and/or biomarker in the upper GI tract is discussed with particular focus on GERD and BE.

Esomeprazole and aspirin in Barrett's oesophagus (AspECT): a randomised factorial trial

BACKGROUND

Oesophageal adenocarcinoma is the sixth most common cause of cancer death worldwide and Barrett's oesophagus is the biggest risk factor. We aimed to evaluate the efficacy of high-dose esomeprazole proton-pump inhibitor (PPI) and aspirin for improving outcomes in patients with Barrett's oesophagus.

METHODS

The Aspirin and Esomeprazole Chemoprevention in Barrett's metaplasia Trial had a 2 × 2 factorial design and was done at 84 centres in the UK and one in Canada. Patients with Barrett's oesophagus of 1 cm or more were randomised 1:1:1:1 using a computer-generated schedule held in a central trials unit to receive high-dose (40 mg twice-daily) or low-dose (20 mg once-daily) PPI, with or without aspirin (300 mg per day in the UK, 325 mg per day in Canada) for at least 8 years, in an unblinded manner. Reporting pathologists were masked to treatment allocation. The primary composite endpoint was time to all-cause mortality, oesophageal adenocarcinoma, or high-grade dysplasia, which was analysed with accelerated failure time modelling adjusted for minimisation factors (age, Barrett's oesophagus length, intestinal metaplasia) in all patients in the intention-to-treat population. This trial is registered with EudraCT, number 2004-003836-77.

FINDINGS

Between March 10, 2005, and March 1, 2009, 2557 patients were recruited. 705 patients were assigned to low-dose PPI and no aspirin, 704 to high-dose PPI and no aspirin, 571 to low-dose PPI and aspirin, and 577 to high-dose PPI and aspirin. Median follow-up and treatment duration was 8·9 years (IQR 8·2-9·8), and we collected 20 095 follow-up years and 99·9% of planned data. 313 primary events occurred. High-dose PPI (139 events in 1270 patients) was superior to low-dose PPI (174 events in 1265 patients; time ratio [TR] 1·27, 95% CI 1·01-1·58, p=0·038). Aspirin (127 events in 1138 patients) was not significantly better than no aspirin (154 events in 1142 patients; TR 1·24, 0·98-1·57, p=0·068). If patients using non-steroidal anti-inflammatory drugs were censored at the time of first use, aspirin was significantly better than no aspirin (TR 1·29, 1·01-1·66, p=0·043; n=2236). Combining high-dose PPI with aspirin had the strongest effect compared with low-dose PPI without aspirin (TR 1·59, 1·14-2·23, p=0·0068). The numbers needed to treat were 34 for PPI and 43 for aspirin. Only 28 (1%) participants reported study-treatment-related serious adverse events.

INTERPRETATION

High-dose PPI and aspirin chemoprevention therapy, especially in combination, significantly and safely improved outcomes in patients with Barrett's oesophagus.

FUNDING

Cancer Research UK, AstraZeneca, Wellcome Trust, and Health Technology Assessment.

Does the treatment of proton pump inhibitors reduce dysplasia or adenocarcinoma development in Barrett's esophagus?

Besides reducing the reflux symptoms, the benefit of proton pump inhibitors (PPI) in the treatment of Barrett's esophagus (BE) is not exactly known. The data in the literature show that although the PPI treatment does not reduce the Barrett's segment length, it can reduce dysplasia or the development of early-stage adenocarcinoma (odds ratio (OR): 0.46). Therefore, treatments with PPI may be considered in patients with a diagnosis of BE and at a high risk of adenocarcinoma, even though they are not symptomatic.

A nonrandomized trial of vitamin D supplementation for Barrett's esophagus

Background

Vitamin D deficiency may increase esophageal cancer risk. Vitamin D affects genes regulating proliferation, apoptosis, and differentiation and induces the tumor suppressor 15-hydroxyprostaglandin dehydrogenase (PGDH) in other cancers. This nonrandomized interventional study assessed effects of vitamin D supplementation in Barrett’s esophagus (BE). We hypothesized that vitamin D supplementation may have beneficial effects on gene expression including 15-PGDH in BE.

Methods

BE subjects with low grade or no dysplasia received vitamin D₃ (cholecalciferol) 50,000 international units weekly plus a proton pump inhibitor for 12 weeks. Esophageal biopsies from normal plus metaplastic BE epithelium and blood samples were obtained before and after vitamin D supplementation. Serum 25-hydroxyvitamin D was measured to characterize vitamin D status. Esophageal gene expression was assessed using microarrays.

Results

18 study subjects were evaluated. The baseline mean serum 25-hydroxyvitamin D level was 27 ng/mL (normal ≥30 ng/mL). After vitamin D supplementation, 25-hydroxyvitamin D levels rose significantly (median increase of 31.6 ng/mL, p<0.001). There were no significant changes in gene expression from esophageal squamous or Barrett’s epithelium including 15-PGDH after supplementation.

Conclusion

BE subjects were vitamin D insufficient. Despite improved vitamin D status with supplementation, no significant alterations in gene expression profiles were noted. If vitamin D supplementation benefits BE, a longer duration or higher dose of supplementation may be needed.

The Role of Esophagogastroduodenoscopy Surveillance for Patients with Barrett Esophagus

Approximately 10% to 15% of patients who experience chronic gastroesophageal reflux disease have Barrett esophagus, which is associated with an increased risk of esophageal adenocarcinoma. If symptoms persist after 8 weeks of adhering to treatment and lifestyle modifications, or if alarm symptoms develop, patients should be referred for screening upper endoscopy. Those with evidence of Barrett esophagus with dysplasia should be monitored in an endoscopic surveillance program, and those with high-grade dysplasia should consider surgical treatment.

Phase Ib Randomized, Double-Blinded, Placebo-Controlled, Dose Escalation Study of Polyphenon E in Patients with Barrett's Esophagus

This study was conducted to determine the safety and efficacy of the green tea-derived Polyphenon E (Poly E) in patients with Barrett's Esophagus (BE). Subjects were randomized to a 6-month, twice daily (BID) oral treatment of placebo or Poly E (200, 400, or 600 mg). Endoscopic evaluation, including biopsies, was performed before and after treatment. The primary objective was to demonstrate safety; secondary objectives investigated catechin accumulation and effects in clinical specimens. Of the 44 enrolled subjects, 11 received placebo, and 33 received Poly E. No dose-limiting toxicities were encountered, and a maximum tolerated dose (MTD) was not reached. The recommended phase II dose was 600 mg twice daily. The most common treatment-related adverse events (AE) in Poly E-treated subjects were grade I and II nausea, grade I belching, and grade I lactate dehydrogenase (LDH) elevation. No treatment-related AEs were reported in placebo-treated subjects, aside from grade I laboratory abnormalities. Pill counts and subject diaries were not consistently collected, and compliance was difficult to determine. However, on the basis of an intention-to-treat analysis, there was a significant relationship between Poly E dose and esophageal EGCG level--mean changes (pmol/g) of 0.79 (placebo), 6.06 (200 mg), 35.67 (400 mg), and 34.95 (600 mg); P = 0.005. There was a possible relationship between Poly E dose and urine PGE-M concentration. In conclusion, Poly E was well-tolerated, and treatment with Poly E (400 and 600 mg) but not Poly E (200 mg) or placebo resulted in clinically relevant and detectable EGCG accumulation in the target organ, esophageal mucosa.

Chemoprevention in Barrett's oesophagus

Increasing incidence of oesophageal adenocarcinoma along with poor survival entails novel preventive strategies. Agents that target pro-oncogenic pathways in Barrett's mucosa could halt this neoplastic transformation. In this review, we will use epidemiological associations and molecular mechanisms to identify novel chemoprevention targets in Barrett's oesophagus. We will also discuss recent chemoprevention trials.

NSAIDs, statins, low-dose aspirin and PPIs, and the risk of oesophageal adenocarcinoma among patients with Barrett's oesophagus: a population-based case-control study

OBJECTIVES

Non-steroidal anti-inflammatory drugs (NSAIDs), proton pump inhibitors (PPIs), low-dose aspirin and statins may decrease the risk of oesophageal adenocarcinoma (OAC) among patients with Barrett's oesophagus (BO). However, previous studies did not adequately address bias and confounding. Our objective was to estimate the risk of OAC among patients with BO exposed to NSAIDs, statins and PPIs.

DESIGN

Case-control study nested within a BO cohort.

SETTING

Two primary care databases (the UK and the Netherlands (NL)).

PARTICIPANTS

Cases were adults ≥18 years of age with OAC or high-grade dysplasia (HGD) diagnosis ≥1 year after BO diagnosis. Controls were matched on age, sex, year of BO diagnosis and database.

EXPOSURE

Drug use was assessed from BO diagnosis until matching date.

OUTCOME MEASURE

Adjusted ORs with 95% CI were calculated by conditional logistic regression.

RESULTS

Within the BO cohort (n=15 134), 45 OAC (UK: 40, NL: 5) and 12 HGD cases (NL: 12) were identified. ORa for OAC during NSAID use was 1.2 (95% CI 0.6 to 2.5) and during statin use for >3 years 0.5 (95% CI 0.1 to 1.7). When including HGD cases (n=57), ORa for NSAID use was 0.9 (95% CI 0.5 to 1.8) and for statin use >3 years 0.5 (95% CI 0.1 to 1.7). Higher doses of statins showed lower estimates for OAC and HGD, though not statistically significant. Low-dose aspirin and PPIs did not significantly decrease the risk of OAC and HGD.

CONCLUSIONS

In this population-based nested case-control study, use of NSAIDs, PPIs, low-dose aspirin or statins did not reduce the risk of HGD and OAC among patients with BO. These findings indicate that for an unselected group of patients with BO chemoprevention by use of drugs to reduce progression to HGD and OAC should not be directly considered as routine care.

Cost-effectiveness of chemoprevention with proton pump inhibitors in Barrett's esophagus

BACKGROUND

Proton pump inhibitors (PPIs) may reduce the risk of esophageal adenocarcinoma (EAC) in patients with Barrett's esophagus. PPIs are prescribed for virtually all patients with Barrett's esophagus, irrespective of the presence of reflux symptoms, and represent a de facto chemopreventive agent in this population. However, long-term PPI use has been associated with several adverse effects, and the cost-effectiveness of chemoprevention with PPIs has not been evaluated.

AIM

The purpose of this study was to assess the cost-effectiveness of PPIs for the prevention of EAC in Barrett's esophagus without reflux.

METHODS

We designed a state-transition Markov microsimulation model of a hypothetical cohort of 50-year-old white men with Barrett's esophagus. We modeled chemoprevention with PPIs or no chemoprevention, with endoscopic surveillance for all treatment arms. Outcome measures were life-years, quality-adjusted life years (QALYs), incident EAC cases and deaths, costs, and incremental cost-effectiveness ratios.

RESULTS

Assuming 50% reduction in EAC, chemoprevention with PPIs was a cost-effective strategy compared to no chemoprevention. In our model, administration of PPIs cost $23,000 per patient and resulted in a gain of 0.32 QALYs for an incremental cost-effectiveness ratio of $12,000/QALY. In sensitivity analyses, PPIs would be cost-effective at $50,000/QALY if they reduce EAC risk by at least 19%.

CONCLUSIONS

Chemoprevention with PPIs in patients with Barrett's esophagus without reflux is cost-effective if PPIs reduce EAC by a minimum of 19%. The identification of subgroups of Barrett's esophagus patients at increased risk for progression would lead to more cost-effective strategies for the prevention of esophageal adenocarcinoma.

[Relationship between Helicobacter pylori status and the development of reflux esophagitis or Barrett's esophagus]

To date, there are many studies on the association between Helicobacter pylori (H. pylori) infection and gastroesophageal reflux disease. Here we reviewed the relationship between H. pylori status and the development of reflux esophagitis (RE) or Barrett's esophagus (BE). According to many case-controlled studies, H. pylori infection may play a protective role in the development of RE. However, the frequency of RE development does not increase following successful H. pylori treatment based on the previous studies including meta-analysis and systematic review. Even though RE newly develops after H. pylori eradication, endoscopic findings reveal mild such as grade A or B according to the Los Angeles Classification System. With regard to BE, there is an inverse significant relationship. Since there are few studies indicating that BE increases after treatment of H. pylori, the eradication should be recommended for patients with H. pylori infection irrespective of the presence of RE or BE even in terms of the prevention of gastric cancer.

The dose of omeprazole required to achieve adequate intraesophageal acid suppression in patients with gastroesophageal junction specialized intestinal metaplasia and Barrett's esophagus

BACKGROUND

The mainstay of medical therapy for Barrett's esophagus is normalization of esophageal acid exposure with proton pump inhibitors (PPIs). However, the optimal dose and whether once daily or twice daily is required for acid suppression is unknown.

AIM

The purpose of this study was to assess whether adequate intra-esophageal acid suppression could be achieved with once daily versus twice daily omeprazole in patients with gastroesophageal specialized intestinal metaplasia (GEJSIM), short-segment (SSBE) and long-segment Barrett's esophagus (LSBE).

METHODS

Patients with GEJSIM and Barrett's esophagus underwent upper endoscopy with 48-h wireless pH capsule while on once daily 20 mg omeprazole for at least 1 week. If intra-esophageal acid was not adequately controlled, defined as pH value <4 for greater than 4.2 % of the time during the second 24-h period, omeprazole was increased to twice daily for 1 week and upper endoscopy with wireless pH capsule was repeated.

RESULTS

A total of 36 patients completed the study (10 patients had GEJSIM, 16 patients had SSBE, and 10 patients had LSBE). Normalization of intraesophageal pH was achieved in 28 patients (78 %) with once daily PPI and eight patients required twice daily PPI. There was no significant difference between the three groups in the proportion of patients requiring high dose PPI (GEJSIM 10 %, SSBE 25 %, LSBE 30 %, p = 0.526).

CONCLUSIONS

The majority of patients with Barrett's esophagus were controlled with once daily low dose PPI and only a minority required twice daily dosing, regardless of the length of Barrett's mucosa.

A second-generation 2-Methoxyestradiol prodrug is effective against Barrett's adenocarcinoma in a mouse xenograft model

2-Methoxyestradiol (2-ME2) is an endogenous metabolite of estradiol. In preclinical models, 2-ME2 is effective against different types of tumors. Unfortunately, only low systemic concentrations of 2-ME2 can be achieved following oral administration, even after very high doses are administered to patients. In an effort to solve this problem, we have now synthesized and tested a new prodrug of 2-ME2 that is water-soluble due to a bioreversible hydrophilic group added at the 3-position and that more effectively resists metabolic inactivation due to an ester moiety added to mask the 17-position alcohol. We are reporting here for the first time that this double prodrug of 2-ME2 is effective as an antiproliferative and anticancer agent for both in vitro and in vivo studies against Barrett esophageal adenocarcinoma (BEAC) and provided greater potency than 2-ME2 in inhibiting the growth of BEAC xenografts. Finally, studies indicate that, like 2-ME2, the 2-ME2-PD1 exhibits anticancer effect through possible disruption of microtubule network.

Effective intra-esophageal acid control is associated with improved radiofrequency ablation outcomes in Barrett's esophagus

BACKGROUND

Endoscopic radiofrequency ablation (RFA) is a promising new treatment of Barrett's esophagus (BE). Adjunctive intra-esophageal pH control with proton pump inhibitors and/or anti-reflux surgery is generally recommended to optimize squamous re-epithelialization after ablation.

AIMS

The aims of this study were to examine the association between intra-esophageal pH control and RFA outcomes and to identify predictive factors to achieve complete elimination (CE) of BE following RFA.

METHODS

We retrospectively studied the outcomes of BE patients treated with RFA. Esophageal acid exposure (EAE) was assessed utilizing 24-h pH monitoring on therapy. CE was endoscopically defined as no area suspicious for residual metaplasia following RFA.

RESULTS

Of 45 patients (33 men; mean age 61.6, mean BE length C4.1 M4.6) examined for EAE, 29 % exhibited moderate-severe EAE despite therapy. Reduction in BE surface area and CE rate were higher in the normal-mild EAE group compared with the moderate-severe EAE group (99 vs. 95 %, p = 0.02; 44 vs. 15 %, p = 0.09, respectively). Using univariate analysis, age, gender, race, aspirin/NSAIDs use, baseline worst histology, baseline BE surface area, and the number or types of RFA had no correlation with CE. By multivariate multiple logistic regression analysis, normal-mild EAE and smaller hiatal hernia were independent factors associated with CE.

CONCLUSIONS

Effective intra-esophageal pH control is associated with improved RFA outcomes of BE. Normal to mild EAE and smaller hiatal hernia are predictive factors to achieve CE. Given the frequent persistence of acid reflux despite therapy in BE patients, in order to maximize the RFA effects esophageal pH optimization and hernia repair should be considered.

[An experimental study on chemoprevention of esophageal adenocarcinoma by celecoxib, a selective cyclooxygenase-2 inhibitor]

OBJECTIVE

To study the feasibility of chemoprevention of esophageal adenocarcinoma by celecoxib, a selective cyclooxygenase-2(COX-2) inhibitor using a rat model.

METHODS

Rats were divided into 3 groups: model group, celecoxib group, and control group. The rat surgical model was established by performing a gastrojejunostomy plus an esophagojejunostomy 5 mm distal to the gastrojejunal anastomosis. Twenty-eight weeks after surgery, all the animals were sacrificed and the pathological changes in the esophagus were examined macroscopically. COX-2 expression was analyzed by immunohistochemistry. Prostaglandin E2(PGE2) level was measured by enzyme-linked immunosorbent assay(ELISA).

RESULTS

The incidence of Barrett's esophagus and esophageal adenocarcinoma in the model group was 84% and 57% respectively, significantly higher than those in the control group(P<0.01). The incidence of esophageal adenocarcinoma in the celecoxib-treated group was significantly lower than that in the model group(P<0.01), and no esophageal adenocarcinoma was detected in the control group. COX-2 expression was detected in 100% of reflux esophagitis, Barrett esophagus and esophageal adenocarcinoma, but not found in the normal tissue from the esophagus and the jejunum(P<0.01). The PGE2 level in the esophageal tissue in the model group was significantly higher than that in the control group(P<0.01). Rats in the celecoxib-treated group had significantly lower PGE2 level than that in the model group(P<0.01). The PGE2 levels were significantly higher in rats with cancer than those without cancer(P<0.01).

CONCLUSION

Celecoxib successfully prevents the development of esophageal adenocarcinoma in a rat surgical model with mixed reflux of acid and duodenal juice and significantly decreases the risk of Barrett esophagus developing esophageal adenocarcinoma. COX-2 maybe an effective selective target of chemoprevention for esophageal adenocarcinoma.

Aspirin and NSAIDs; benefits and harms for the gut

Despite modern advances in cancer research, screening and treatment options, gastrointestinal tumours remain a leading cause of death worldwide. Both oesophageal and colorectal malignancies carry high rates of morbidity and mortality, presenting a challenge to clinicians in search of effective management strategies. In recent years, the increasing burden of disease has led to a paradigm shift in our approach from treatment to prevention. Among several agents postulated as having a chemopreventive effect on the gastrointestinal tract, aspirin has been most widely studied and has gained universal acknowledgement. There is an expanding evidence base for aspirin as a key mediator in the prevention of dysplastic change in Barrett's oesophagus and colorectal adenomas. Its cardioprotective effects also impact positively on the patient population in question, many of whom have ischaemic vascular disease. The major side effects of aspirin have been well-characterised and may cause significant morbidity and mortality in their own right. Complications such as peptic ulceration, upper gastrointestinal bleeding and haemorrhagic stroke pose serious threats to the routine administration of aspirin and hence a balance between the risks and benefits must be struck if chemoprevention is to be effective on a large scale. In this review, we address the current evidence base for aspirin use in gastrointestinal oncology, as well as several key questions surrounding its safety, cost effectiveness and optimal dose.

The association of manganese superoxide dismutase expression in Barrett's esophageal progression with MnTBAP and curcumin oil therapy

BACKGROUND

The aim of this study was to investigate the relationship between reflux induced bile insult and MnSOD expression, as well as to examine therapies to preserve MnSOD expression. Additionally, we sought to examine the relationship between MnSOD protein expression and MnSOD enzymatic activity.

METHODS

MnSOD protein expression was determined by Western blot assay and enzymatic activity was determined by SOD assay. The enzymatic activity of the Het-1A and Bar-T cells were compared both before and after treatments.

RESULTS

MnSOD expression in Het-1A cells was decreased after bile salt exposure. The cells that received MnTBAP or curcumin oil pretreatment showed increased MnSOD expression compared with control untreated cells. The Bar-T cells showed an increase in MnSOD expression after treatment with bile salts. The cells that were pretreated with MnTBAP displayed a larger increase in MnSOD expression compared with the cells that were not pretreated prior to bile salt exposure. The MnSOD activity was significantly different between the untreated cell lines (P = 0.01) and after treatment with bile salt (P = 0.03). Additionally, Bar-T cells had significantly less MnSOD activity than Het-1A cells after each of the pretreatments.

CONCLUSIONS

We demonstrated preservation of MnSOD expression in Het-1A cells that were pretreated with antioxidants including MnTBAP, curcumin oil, and certain berry extracts. Additionally, we demonstrated that Bar-T cells have significantly less MnSOD activity than Het-1A cells. These finding have important implications for future studies regarding chemoprevention and the treatment of esophageal cancer.

[Modern aspects of photodynamic therapy of esophageal]

This review presents the current possibilities of photodynamic therapy in the treatment of precancerous lesions and cancer of the esophagus. Mechanisms of photodynamic effects on tumor and especially the accumulation of photosensitizer in tumor tissue, results of studies on the use of photodynamic therapy in the treatment of early esophageal cancer, esophageal cancer stenosis and combinations with other treatment techniques. Results of treatment of Barrett's esophagus using photodynamic therapy were analyzed and a compared with other methods of treatment.

[Remote results of the treatment of patients for Barrett's esophagus]

Prospective analysis of the results of clinic-laboratory investigations in patients, treated for Barrett's esophagus (BE) in 2000 - 2006 yrs, was conducted. In some of the patients BE was diagnosed together with other complications of gastroesophageal reflux disease. Statistical analysis of remote results concerning the patients surgical and conservative treatment, using mathematic method, according to the rule 3s and 3s(1), was performed. Higher efficacy of surgical method was established concerning the treatment of hiatal hernia, shortened esophagus, reflux-esophagitis, gastroesophageal and duodenogastric refluxes, duodenal ulcer and esophageal epithelium dysplasia.

Neoadjuvant chemotherapy in Barrett's carcinoma - prognosis and response prediction

In spite of endoscopic surveillance programs, 90% of patients initially presenting with Barrett's carcinoma have locally advanced disease. In these patients, preoperative chemotherapy increases the chance of a curative resection in responding patients. Unfortunately, response occurs in only 50% of patients after chemotherapy with cisplatin, 5-fluorouracil and leucovorin. Response prediction seems to be possible by measuring metabolic activity by positron emission tomography (PET) scan. Differentiation of responders from non-responders even before starting chemotherapy might be possible using microarray technology and immunhistology in tumour biopsies. A pattern of at least two-fold differentially regulated genes comparing responding and non-responding oesophageal adenocarcinomas was identified. The strongest difference can be seen for tumour necrosis factor, polyribonucleotide nucleotidyltransferase and the ephrin-B3-receptor. In conclusion, our experience suggests that it may be possible to characterize patients responding to chemotherapy by PET two weeks after starting the chemotherapy or even before treatment using customized microarray analysis.

[Barrett's esophagus: endoscopic and immunomorphological parallels]

Barrett esophagus is the most serious sequela of the gastroesophageal reflux disease being an obligate precancer with a high index of the neoplastic transformation as to an adenocarcinoma esophagus.

THE PURPOSE OF THE PAPER

To reveal the extent of the susceptibility to oncogenesis of the Barrett esophagus-patients and to determine high-risk groups.

MATERIALS AND METHODS

Our paper has shown the examination results of the 55 Barrett esophagus-patients (29 women and 26 men at the age of 39 to 62 years old), including 40 intestinal metaplasia-patients and 15 patients of the intestinal metaplasia + dysplasia of long clinical course given corresponding correcting cure. In our investigation a DNA-flow cytometry was a method of determining the adenocarcinoma esophagus risk secondary to the Barrett esophagus as well as an index of the proliferation and an index of the aneuploidy were the factors analyzed.

THE RESULTS

1) As the pathosis histology-progresses from metaplasia to dysplasia and adenocarcinoma esophagus the increase in the aneuploidy rate, the proliferation index, and S-cycling state cells portion is observed; 2) the proliferation index is a rather stable factor of the human body susceptibility to oncogenesis and varies only slightly in the course of the cure. The index of the aneuploidy is a labile factor that can be subject to decrease down to normal figures given corresponding cure (p > 0.05); 3) the increased aneuploidy index in the presence of the intestinal metaplasia free of esophagus dysplasia can serve as an objective factor for neoplastic progression.

[Drug UDCA (Ursosan) in therapeutic management of patients Barrett's esophagus]

OBJECTIVE

to evaluate the five-year prospective study the possibility of using the drug UDCA (Ursosan) for the therapeutic management of patients with BE older.

MATERIALS AND METHODS

A prospective open randomized, parallel-group 62 patients of BE with a length of metaplasia less than 3 cm in average age 72.8 +/- 2.8 years. Method of "sealed envelopes" were divided into two equal groups. Patients first--received omeprazole at a daily dose of 40 mg, the second--to combine the same dose of omeprazole drug-Ursosan a daily dose of 10 mg/kg. At baseline and after 4.8+1.2 years assessed the frequency of esophageal, extraesophageal and dyspeptic complaints, endoscopic and morphological pattern of esophageal-gastric junction and lower third of the esophagus. Confirm or exclude the diagnosis of BE during follow-up study was performed after a two-fold endoscopy upper GIT using subdivision techniques for sampling biopsy material and subsequent analysis of biopsy samples pathomorphology of various medical institutions.

RESULTS

The combination therapy with omeprazole and drug UDCA contributed to the positive dynamics is the lack of intestinal metaplasia in 32.3% of patients with Barrett's esophagus, whereas monotherapy with omeprazole in a daily dose of 40 mg possible to achieve a similar result in 6.5% of patients (p = 0,01). The frequency of diagnosis of erosive esophagitis decreased after 5 years of therapy with 80.6% to 51.6% (p = 0.016) in the omeprazole group and 86.7% to 16.7% (p < 0.001) in the group receiving omeprazole and the preparation of UDCA.

CONCLUSION

This study suggests the possibility of combined therapy with omeprazole and the preparation of UDCA (Ursosan) as a promising means for hemopreventciya Barrett's esophagus in the elderly.

Medication usage and the risk of neoplasia in patients with Barrett's esophagus

BACKGROUND & AIMS

Experimental evidence indicates that proton pump inhibitors (PPIs), nonsteroidal anti-inflammatory drugs (NSAIDs)/aspirin, and statins can protect patients with Barrett's esophagus (BE) from developing neoplasias. However, only limited data are available on chemoprevention in patients with BE.

METHODS

A retrospective observational study was performed using data from patients with documented BE. Prescription information was collected from pharmacy records. Cox regression analyses were performed to examine the association between prescriptions for PPIs, NSAIDs/aspirin, or statins and the risk of developing esophageal dysplasia or adenocarcinoma during follow-up (from 1982 to 2005).

RESULTS

We examined 344 patients diagnosed with BE (mean age 61 years, 90.4% Caucasian, 94.2% male). After BE diagnosis, 67.2% of the patients were prescribed PPIs for a mean duration of 5.1 years; 49.1% were prescribed NSAIDs for a mean duration of 3.6 years, and 25.3% were prescribed statins for a mean duration of 2.8 years. During 2620 patient-years, high grade dysplasia or esophageal adenocarcinoma developed in 33 patients. PPI treatment after BE diagnosis was associated with a reduced risk of high grade dysplasia or cancer; this association persisted after adjustment for gender, age, and the length of BE. NSAID and/or aspirin therapy were associated with a nonsignificant trend toward lower incidence of high grade dysplasia or esophageal cancer.

CONCLUSIONS

PPI therapy reduces the risk of neoplasms in patients with BE. NSAIDs/aspirin appear to reduce cancer risk whereas statin use is not significantly associated with the risk of neoplasia in patients with BE.

[Gastro-esophageal reflux through gastric antisecretory drugs]

During the 20th century, gastro-esophageal reflux moved from the status of a rare and severe disease to that of a frequent disease occurring mostly, in the absence of any significant lesions. Proton pump inhibitors (PPIs) are the mainstay of its therapy and are prescribed mainly in an empirical way. Extradigestive manifestations require more accurate diagnostic tests and therapeutic management. The modalities of prescription of the PPIs quickly progressed toward the on-demand therapy and over-the-counter PPIs should become widespread. The relative failures of PPIs led to a profusion of new antisecretory agents but clinical improvements are presently disappointing and the rationale of this escalation is questionable. The concept of non acid gastro-esophageal reflux opens more innovative diagnostic and therapeutic perspectives which, however, must be validated. In this respect, endoscopic treatment needs more reliable techniques and more rigorous trials. Gastro-esophageal reflux refractory to PPIs corresponds mainly to functional esophageal disorders that need diagnostic and therapeutic improvements. Barrett's esophagus constitutes a major challenge for the next few years. Its screening and its prevention seem, for the moment, inaccessible. Its survey and the prevention of its complications should benefit from progress of diagnostic and interventional endoscopy.

Inflammation and esophageal carcinogenesis

The incidence of esophageal adenocarcinoma is increasing largely in Western populations, and patients diagnosed with this cancer continue to have a poor prognosis. The major risk factors are gastroesophageal reflux disease and Barrett's esophagus, both of which are associated with inflammation of the esophageal squamous epithelium, a condition called reflux esophagitis. The cellular mechanisms contributing to cancer development in the esophagus are poorly understood. The chronic inflammation that is present in Barrett's esophagus creates an environment suitable for DNA damage and altered expression of genes involved in cellular proliferation and inhibition of apoptosis. Key players in the inflammatory cascade include generation of free radicals, activation of kinases pathways and transcription factors, and production of cytokines and inflammatory enzymes. The current review highlights the link between reflux-induced inflammation and esophageal carcinogenesis. Understanding the molecular pathways involved in inflammation-associated esophageal tumorigenesis could enable the development of targeted therapies and offer a better therapeutic treatment in esophageal cancer.

[Endoscopic diagnosis and complex treatment of Barrett's esophagus complicated by hernia of esophageal foramen of the diaphragm]

A protocol is suggested of complex diagnosis and treatment of Barrett's esophagus using sparing endoscopic removal of Barrett's epithelium in combination with surgery and medicinal antireflux therapy. Eighty-three patients were diagnosed and treated for hernia of esophageal foramen of the diaphragm and gastro-esophageal reflux complicated by Barrett's esophagus. Ninety-two percent of patients receiving our four-component treatment were cured; no recurrent esophageal adenocarcinoma was reported during the 56.7 +/- 2.4 month follow-up. Conversely, in patients receiving three-component treatment, efficacy was 56%; esophageal adenocarcinoma was reported in 3 (12%).

[Barrett esophagus: modern diagnosis, drug therapy and reduce risk of cancer]

This article describes ways of risk reducing of esophageal adenocarcinoma with the use of modern screening treatment methods of GERD and Barrett esophagus.

Chemoprevention and Barrett's esophagus: decisions, decisions

The incidence of esophageal adenocarcinoma continues to increase at a rate greater than that of any other cancer in the western world. Current strategies to deal with this situation are problematic, and the time has come for new approaches to this problem. Chemoprevention is one such approach. In this issue of the American Journal of Gastroenterology, Hur et al. examined Barrett's esophagus patient preferences for cancer chemoprevention with either aspirin or celecoxib. They found that 93% of their patients were willing to take one of these two drugs, but that nearly five times as many patients preferred aspirin to celecoxib (76%vs 15%). The most important reason for willingness to use celecoxib or aspirin was cancer prevention, while the most important reason for not using celecoxib was risk of myocardial infarction and for aspirin gastrointestinal adverse events. While this study indicates that there is a strong interest among Barrett's esophagus patients for chemoprevention, it is still premature for our patients to embark on such an approach. The role of chemoprevention in Barrett's esophagus still awaits the results of ongoing clinical trials in the United Kingdom and North America.

[Heartburn: gastro-oesophageal reflux in 9 pictures]

This article summarises the conference which took place during the " Centre Universitaire de Médecine Générale de l'Université Libre de Bruxelles" (C.U.M.G.-U.L.B.) Seminar in April 7-14, 2007. It is in no way an extensive review about gastro-oesophageal reflux disease (GERD), but instead an attempt of answering the most frequently asked questions by the general practitioner, reported in 9 pictures: 1. Definition, prevalence and physiopathology. 2. Work up and role of endoscopy. 3. Medical treatment. 4. PPI: Equivalence of the medications? Equivalence of the generic drugs? 5. Barrett's esophagus. 6. Reflux and negative endoscopy. 7. Extra-oesophageal manifestations. 8. Surgical treatments. 9. Endoscopic treatments.

Photodynamic therapy of Barrett's esophagus: ablation of Barrett's mucosa and reduction in p53 protein expression after treatment

BACKGROUND

The effectiveness of photodynamic therapy (PDT) for ablation of high grade dysplasia (HGD) in Barrett's esophagus (BE) is typically reported histologically. Following successful PDT, Barrett's mucosa is replaced with neosquamous mucosa. The objective of this study was to compare the expression of p53 protein in neosquamous mucosa as compared to that in HGD samples not treated with PDT.

PATIENTS AND METHODS

The patients were divided into two groups. Group I patients (n = 12) had been treated with PDT for HGD and provided 23 biopsy samples of neosquamous mucosa. Group II patients (n = 10) had not received any ablative therapies for BE and provided 14 HGD samples. The immunohistochemical (IHC) staining for p53 protein was performed using mouse anti-human monoclonal antibody DO-1. The degree of p53 protein expression in the cell nuclei was scored using an established IHC scoring system (0 for negative samples and range of 2 to 8 for positive samples).

RESULTS

The HGD samples showed diffuse strong p53 staining. The median IHC score for HGD was 7.0. The median IHC score for neosquamous mucosa following PDT was 4.0, with positive scores indicating weak staining in the basal layer of the neosquamous samples. There was significantly lower p53 expression in the neosquamous samples compared to that in the HGD samples (p < 0.001).

CONCLUSION

Significantly lower p53 protein expression was detected in neosquamous mucosa of patients who had received PDT for HGD, suggesting a decreased risk for neoplastic progression after treatment.

Management of Barrett's esophagus

Barrett's esophagus represents replacement of normal distal esophageal squamous epithelium with specialized columnar epithelium containing goblet cells. Typically arising in the setting of chronic gastroesophageal reflux disease, the presence of Barrett's esophagus carries a 50- to 100-fold increased risk of developing esophageal cancer. Risk factors include male sex, smoking history, obesity, Caucasian ethnicity, age > 50 and > 5-year history of reflux symptoms. Aggressive medical or surgical antireflux therapy may ameliorate symptoms, but have not yet been proven to affect the risk of developing esophageal adenocarcinoma in randomized trials. Although dysplasia is an imperfect biomarker for the development of subsequent malignancy, random sampling of esophageal tissue for dysplasia remains the clinical standard. There have been no studies to establish that endoscopic screening/surveillance programs decrease the rates of death from cancer. Fit patients with Barrett's esophagus and high-grade dysplasia should undergo esophagectomy to prevent the risk of developing esophageal adenocarcinoma. For non-operative candidates, endoscopic ablative approaches may represent a reasonable therapeutic alternative.

Induction Chemotherapy in Barrett Cancer

OBJECTIVE

To study the impact of induction chemotherapy on surgical risk and outcome in locally advanced Barrett cancer.

BACKGROUND

Induction chemotherapy has become an accepted choice for the treatment of locally advanced adenocarcinoma of the esophagus and the esophagogastric junction. It has been shown that early assessment of metabolic response using positron emission tomography predicts response to chemotherapy. Metabolic response has also been revealed to be an independent prognostic factor.

METHODS

Surgical risk and outcome in metabolic responders were compared with those in nonresponders. The study design predefined a 12-week multicourse preoperative chemotherapy regimen in metabolic responders. In contrast, chemotherapy was stopped after a 2-week induction period in metabolic nonresponders. All patients were scheduled for surgical resection.

RESULTS

Of 110 evaluable patients, 50 metabolic responders and 54 nonresponders underwent resection. Postoperative complications occurred in 34%. Two patients (1.8%) died. There were no significant differences between responders and nonresponders in terms of postoperative morbidity and mortality. Major histologic remissions were seen in 58% of metabolic responders. Metabolic responders had an increased chance of having an R0 resection (96% vs. 74%; P=0.002) and a decreased risk of developing hematogenous or distant lymphatic recurrence (32% vs. 54%, P=0.019). This translated into better recurrence-free and overall survival.

CONCLUSIONS

Induction chemotherapy and early metabolic response assessment is a new concept in the treatment of locally advanced Barrett cancer. Metabolic responders undergoing multicourse preoperative chemotherapy have a good prognosis. The best treatment strategy for nonresponders remains to be defined.

Effects of long-term cyclo-oxygenase 2 selective and acid inhibition on Barrett's oesophagus

BACKGROUND

There is an overexpression of cyclo-oxygenase 2 (COX-2) in Barrett's oesophagus (BO).

AIM

To determine the long-term effect of a COX-2 inhibitor on cellular mechanisms involved in BO.

METHODS

A randomized controlled trial was conducted in BO patients allocated to continue the usual proton pump inhibitor (PPI) alone treatment, or PPI combined with rofecoxib (25 mg/day) for 6 months. Cell proliferation index and COX-2 expression in BO glands was determined in biopsy specimens at baseline and after treatment. Cell apoptosis, cyclin D1, p53 and vascular endothelial growth factor (VEGF) expression was also explored in a subset of patients. Student-t test and the U-Mann-Whitney test were used for quantitative and ordinal variables.

RESULTS

Of 62 patients, 58 completed the study. A higher proportion of patients on rofecoxib + PPI exhibited a decrease in COX-2 expression compared to those treated with PPI alone, but cell proliferation index was not affected. Unlike PPI alone, rofecoxib + PPI was associated with an increase in the apoptotic cell index, a decrease in p53 cell staining and VEGF expression in mucosal vessels. No effect on low-grade dysplasia or cyclin D1 was observed.

CONCLUSIONS

The addition of rofecoxib to PPI therapy does not affect cell proliferation index in BO cells after 6 months of therapy, but does reduce COX-2 and VEGF expression and increases cell apoptosis.