European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication

Population-based screening for early detection and treatment of colorectal cancer (CRC) and precursor lesions, using evidence-based methods, can be effective in populations with a significant burden of the disease provided the services are of high quality. Multidisciplinary, evidence-based guidelines for quality assurance in CRC screening and diagnosis have been developed by experts in a project co-financed by the European Union. The 450-page guidelines were published in book format by the European Commission in 2010.  They include 10 chapters and over 250 recommendations, individually graded according to the strength of the recommendation and the supporting evidence. Adoption of the recommendations can improve and maintain the quality and effectiveness of an entire screening process, including identification and invitation of the target population, diagnosis and management of the disease and appropriate surveillance in people with detected lesions. To make the principles, recommendations and standards in the guidelines known to a wider professional and scientific community and to facilitate their use in the scientific literature, the original content is presented in journal format in an open-access Supplement of Endoscopy. The editors have prepared the present overview to inform readers of the comprehensive scope and content of the guidelines.

Quality in the technical performance of screening flexible sigmoidoscopy: recommendations of an international multi-society task group

BACKGROUND

Flexible sigmoidoscopy (FS) is a complex technical procedure performed in a variety of settings, by examiners with diverse professional backgrounds, training, and experience. Potential variation in technical quality may have a profound impact on the effectiveness of FS on the early detection and prevention of colorectal cancer.

AIM

We propose a set of consensus and evidence based recommendations to assist the development of continuous quality improvement programmes around the delivery of FS for colorectal cancer screening.

RECOMMENDATIONS

These recommendations address the intervals between FS examinations, documentation of results, training of endoscopists, decision making around referral for colonoscopy, policies for antibiotic prophylaxis and management of anticoagulation, insertion of the FS endoscope, bowel preparation, complications, the use of non-physicians as FS endoscopists, and FS endoscope reprocessing. For each of these areas, continuous quality improvement targets are recommended, and research questions are proposed.

Familial colorectal cancer in Ashkenazim due to a hypermutable tract in APC

Approximately 130,000 cases of colorectal cancer (CRC) are diagnosed in the United States each year, and about 15% of these have a hereditary component. Two well-defined syndromes, familial adenomatous polyposis (FAP) and hereditary non-polyposis colorectal cancer (HNPCC), account for up to 5% of the total new cases of CRC. Truncating APC mutations are responsible for FAP, and defective mismatch repair genes cause HNPCC. However, the genes responsible for most of the familial cases are unknown. Here we report a mutation (T to A at APC nucleotide 3920) found in 6% of Ashkenazi Jews and about 28% of Ashkenazim with a family history of CRC. Rather than altering the function of the encoded protein, this mutation creates a small hypermutable region of the gene, indirectly causing cancer predisposition.

High levels of transforming growth factor beta 1 correlate with disease progression in human colon cancer

Several genes have identified that play a role in colon cancer development. However, less is known about factors that increase the rate of progression of colon cancers to metastasis. One candidate is transforming growth factor beta 1 (TGF beta 1), which can enhance the aggressiveness of human colorectal cell lines in vitro and in vivo. The amount of TGF beta 1, TGF beta 2, and TGF beta 3 protein isoforms expressed in primary site colorectal cancers were measured to determine whether any correlation existed between protein levels and disease recurrence in a series of Memorial Sloan-Kettering Hospital patients who underwent potentially curative resections. Intense staining for TGF beta 1 correlated significantly (P < 0.0013; odds ratio, 18) with disease progression to metastasis and was independent of nodal status and the degree of differentiation of the primary tumor. Therefore, in this study, patients with high TGF beta 1 protein levels in their primary site colorectal cancer were 18 times more likely to experience recurrence of their disease than were patients whose tumors exhibited low levels of TGF beta 1. In this case-control study, patients whose cancer recurred and those remaining cancer free were age and sex matched. The disease recurred at a mean of 26.8 +/- 4.3 (SE) months, whereas the mean follow-up time in patients whose disease did not recur was over twice as long, 57.3 +/- 6.6 months. Ninety-four % of the patients in each group were node positive at the time of resection, with equal mean numbers of positive nodes per patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Colon goblet cells lose proliferative response to TGF alpha as they differentiate

Two cell line models for colon goblet cells expressed 6- to 14-fold elevated levels of the EGF receptor, 3- to 5-fold levels of TGF alpha and 11- to 15-fold levels of amphiregulin compared with 2 cell lines which model colon enterocytic differentiation, suggesting a role for the EGF receptor and its ligands in goblet cell growth control. Two HT29 colon carcinoma sublines were used to model normal goblet cells at different stages of maturation. TGF alpha induced a 2-fold increase in growth of the HD8 subline but inhibited the growth of the more differentiated HD6 subline by 40%. EGF receptors were activated in each line by ligand, but signal transduction varied sharply. Both MAP kinase isoforms, p44 and p42, were markedly activated in HD8 cells for at least 20 min, while only a marginal activation was seen in HD6 cells. In contrast, the more differentiated HD6 cells showed an increase in 105 kDa MBP kinase activity with EGF treatment, while HD8 cells displayed constitutively elevated levels of this kinase. Thus, activated EGF receptors initiated different signalling pathways in model cell lines for colon goblet cells at different stages of maturation. TGF alpha protein levels have been shown by other investigators to be restricted to the top of the cylinder-like colonic crypt, where cells terminally differentiate and cease division, an unexpected location for an epithelial cell mitogen. Our data with model cell lines imply that normal colon goblet cells lose proliferative response to TGF alpha as they differentiate and the elevated levels of TGF alpha at the top of the colonic crypt in vivo serve to inhibit goblet cell growth.

The capacity for growth stimulation by TGF beta 1 seen only in advanced colon cancers cannot be ascribed to mutations in APC, DCC, p53 or ras

Human colon cancer development is associated with the accumulation of mutations and deletions in the suppressor genes DCC, APC and p53 and mutations in the dominant oncogene K-ras, with loss of wild type alleles. In earlier studies we had observed that about half of the resected human colon cancers placed into primary culture were growth stimulated by TGF beta 1. This group included the more advanced cancers which were either poorly differentiated primary-site cancers or metastases. In contract, the more differentiated colon cancers were inhibited or unaffected by TGF beta 1, indicating that a switch in response to TGF beta 1 occurs during colon cancer progression. Different sublines of the HT29 colon carcinoma cell line model the resected cancers, responding to TGF beta 1 by proliferation, inhibition or no growth modulation. The current study shows that while the poorly differentiated, TGF beta 1-stimulated sublines are most tumorigenic, all the sublines have the same spectrum of mutations: truncating mutations in both APC (adenomatous polyposis coli) alleles, no activated ras genes, mutated and thus overexpressed p53, and very low expression of DCC compared to normal colon cells. Genes other than the four already implicated in colon carcinoma evolution are responsible for the mitogenic response to TGF beta 1 found in the more advanced cancers.

The role of nm23 in transforming growth factor beta 1-mediated adherence and growth arrest

nm23 has properties of a metastasis suppressor gene and also has been implicated in the control of response to transforming growth factor beta 1 (TGF beta 1) by studies in melanoma cells. In this report, we have examined the role of nm23 in two HT29 colon carcinoma sublines at different stages in tumor progression with different responses to TGF beta 1: the HD3 subline, which shows TGF beta 1-induced growth arrest and differentiation; and the more invasive and tumorigenic U9 subline, which induces tumors 7-fold as large as those induced by HD3 cells with one-half the latency. Analysis by semiquantitative reverse transcription-polymerase chain reaction showed that antisense phosphorothiolated oligonucleotides to the nm23 initiation site (nm23 AS oligos) decreased nm23 mRNA levels 2-8-fold in HD3 and U9 cells when normalized to beta-actin mRNA levels. However, a role for nm23 in TGF beta 1-mediated responses could only be found in HD3 cells. nm23 AS oligos inhibited the differentiation property of cell adherence over 90% in HD3 cells, and this loss of adherence could be partially blocked by concurrent treatment with TGF beta 1. In contrast, U9 cell adherence was not detectably altered by nm23 AS oligos, whether added in the presence or absence of TGF beta 1. The TGF beta 1-induced inhibition of HD3 cell proliferation was blocked by nm23 AS oligos, whereas the TGF beta 1-induced proliferation of U9 cells was unaffected by nm23 AS oligos.(ABSTRACT TRUNCATED AT 250 WORDS)

Two different signal transduction pathways can be activated by transforming growth factor beta 1 in epithelial cells

Signal transduction initiated by transforming growth factor beta 1 (TGF beta 1) was studied in two sublines of the same colon carcinoma cell line, which respond in opposite ways to TGF beta 1, by proliferation or by growth inhibition. TGF beta 1 activates ras proteins within 5 min of addition when it acts to inhibit growth but not when it acts as a mitogen. In both cases TGF beta 1 also rapidly modulates the activities of three protein kinases, detected by their in gel kinase activity on the mitogen-activated protein kinase (MAP kinase) substrate, myelin basic protein (MBP). When TGF beta 1 acts as a mitogen for U9 cells, it increases the activity of MBP kinases of 57, 105, and 130 kDa within 10 min of the addition without detectably activating ras proteins. When TGF beta 1 inhibits the growth of HD3 cells, it activates ras proteins and the 57-kDa MBP kinase within 5 min but inhibits the activity of the 105- and 130-kDa MBP kinases. In HD3 cells ras activation occurred in two signal transduction pathways, one from TGF beta 1 leading to growth inhibition and one from epidermal growth factor (EGF) leading to proliferation. In addition to ras proteins, EGF activates a different set of MBP kinases in HD3 cells than does TGF beta 1, MBP kinases of 85, 57, and 44 kDa. The latter is likely to be the 44-kDa MAP kinase extracellular signal-regulated kinase (erk) 1, because EGF treatment of HD3 cells activates erk1 by increasing its phosphotyrosine level. Therefore, in two closely related epithelial cell lines TGF beta 1 activates two different signal transduction pathways, one ras-dependent and one ras-independent, and modulates the activities of a set of MBP kinases.

Colon carcinoma cells switch their response to transforming growth factor beta 1 with tumor progression

Transforming growth factor beta 1 (TGF-beta 1) switches from an inhibitor of tumor cell growth to a stimulator of growth and invasion during human colon carcinoma progression. We originally observed that metastatic colon carcinoma cells in primary culture responded to TGF-beta 1 by proliferation, whereas moderate to well-differentiated primary site colon carcinomas were growth inhibited by TGF-beta 1 (P. Schroy et al., Cancer Res., 50: 261-265, 1990). We then cloned several colon carcinoma cell lines which modeled these responses to TGF-beta 1 and expressed TGF-beta 1 (M. M. Hafez et al., Cell Growth & Differ., 1: 617-626, 1990; 3: 753-762, 1992). Two of these colon carcinoma cell lines, U9 and HD3, which activate approximately equal amounts of TGF-beta 1 and express equal amounts of TGF-beta receptors, are now used to compare the effects of TGF-beta 1 in modulating invasive behavior. The U9 cell line exhibits autocrine-positive growth regulation in vitro by TGF-beta 1, whereas the HD3 cell line shows the opposite response, autocrine-negative regulation. Blocking endogenous TGF-beta 1 with isotype-specific antibody inhibited U9 cell growth because autocrine TGF-beta 1 acts as a mitogen for U9 cells. In contrast, antibody to TGF-beta 1 stimulated HD3 cell proliferation because autocrine TGF-beta 1 inhibits growth of these cells. U9 cells were 13-fold more invasive in vitro through a collagen I layer than HD3 cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Colon carcinoma cells blocked in polarization exhibit increased expression of carcinoembryonic antigen

Carcinoembryonic antigen (CEA) is an oncofetal protein whose regulation is poorly understood, although CEA is commonly expressed on many carcinoma cell types and enhances experimental metastases. The abundance of membrane-associated CEA was increased 3-fold when HD6 colon carcinoma cells were prevented from polarizing by culture for 3 days in low calcium medium. Polarization is an early event in HD6 cell differentiation, with the polarized cells forming a tight, laterally adherent monolayer by culture in normal calcium medium. Lateral adherence can occur because 3 days of culture in normal calcium medium increases expression of calcium-dependent intercellular adhesion proteins: a 35-fold increase in membrane abundance of LCAM and a 16-fold increase in membrane abundance of the desmosomal protein desmoglein I. Polarized HD6 cells exhibit low levels of CEA only at their apical luminal surface. Rounded, unpolarized HD6 cells do not exhibit increases in either LCAM or desmoglein I membrane expression, but express increased levels of CEA molecules throughout their cell surface, where they act as intercellular adhesion molecules, allowing unpolarized cells to form random cell to cell contacts. Cells cultured in low calcium medium form calcium-independent cell aggregates whose formation can be blocked by Fab' fragments of anti-CEA monoclonal antibody col-1. The familiar pattern of random, multilayered associations of tumor cells both in vitro and in xenographs in vivo may be due to intercellular adhesion mediated by CEA which is up-regulated and expressed throughout the cell surface of unpolarized tumor cells.

Signal transduction through extracellular signal-regulated kinase-like pp57 blocked in differentiated colon carcinoma cells having low levels of c-src kinase

Basic fibroblast growth factor (FGF) induced a rapid increase in tyrosine phosphorylation of a 57-kDa cytoplasmic protein with functional myelin basic protein kinase activity and antigenic properties common to mitogen-activated kinases or extracellular signal-regulated kinases. Basic and acidic FGFs and the diacylglycerol diolein used the same signal transduction pathway to activate pp57. These FGFs, like diolein (Lee, H., Ghose-Dastidar, J., Winawer, S., and Friedman, E. (1993) J. Biol. Chem., 268, 5255-5263), increased the cellular concentration of long-chain diacylglycerols within the same short time period as they increased pp57 tyrosine phosphorylation. Both FGF and diolein increased phosphorylation of pp57 on the same V8 protease-generated fragments, suggesting a common pathway for the phosphorylation of pp57. FGF-induced signal transduction through pp57 mitogen-activated kinase led to cell growth in two undifferentiated colon carcinoma cell lines. In contrast, basic FGF neither increased tyrosine phosphorylation of pp57 nor increased cell growth in two colon goblet cell differentiated lines derived from the same parental line as the undifferentiated cells. Both goblet cell lines exhibited levels of protein-tyrosine kinase activity about one-fifth that of the undifferentiated lines. The decrease in tyrosine kinase activity was not due to down-regulation of FGF receptors or their tyrosine kinase activities. c-src kinase-specific activity was decreased 4-5-fold in both goblet cell lines, suggesting a role for c-src in pp57-mediated signal transduction.

Signal transduction through extracellular signal-regulated kinase-like pp57 blocked in differentiated cells having low protein kinase C beta activity

pp57 is a cytoplasmic kinase which is related antigenically and functionally to the extracellular signal regulated kinase or the mitogen-activated kinase family of signal transduction proteins. Two undifferentiated colon carcinoma cell lines responded to the diacylglycerol diolein by growth and a rapid 3-4-fold increase in tyrosine phosphorylation of pp57, and smaller increases in threonine and serine phosphorylation. By enhancing tyrosine phosphorylation of pp57, diolein increased pp57 kinase activity on myelin basic protein. Two enterocytic differentiated colon carcinoma cell lines, when treated with diolein, exhibited neither increased pp57 tyrosine phosphorylation nor increased growth. Both enterocytic lines exhibited 30% of the total PKC activity, 10-20% of the abundance of PKC beta as detected by Western blotting with anti-peptide antisera, and 10-20% of the PKC beta activity, by immune complex kinase reactions, that was expressed in the undifferentiated cell lines. The abundance of three other PKC isozymes, alpha, epsilon, and zeta appeared unchanged in the undifferentiated and enterocytic lines, reflecting their common parental cell line origin. The association between loss of PKC beta activity and blocked signaling through pp57 in each of two cell lines suggests that PKC beta is part of a signal transduction system activating pp57.

Two roles for transforming growth factor beta 1 in colon enterocytic cell differentiation

The role of transforming growth factor beta 1 (TGF-beta 1) in enterocytic differentiation was examined by treating two undifferentiated HT29 colon carcinoma sublines, U4 and U9, with hexamethylene bisacetamide to up-regulate their level of TGF-beta 1 mRNA expression. Although both lines after treatment secreted approximately equal levels of biologically active TGF-beta 1, only U4H cells were found to undergo enterocytic differentiation when cultured postconfluence on collagen I-coated transwells, forming polarized monolayer cells with an apical brush border, whereas U9H cells remained multilayered and undifferentiated. Enterocytic U4H cells exhibited four times as much cell surface expression of the collagen I-binding protein alpha 2-integrin, twice as much of the accessory collagen-binding protein carcinoembryonic antigen, and almost twice as much binding to collagen I films as undifferentiated U9H cells. TGF-beta 1 treatment doubled U4 cell collagen I binding, increased expression of alpha 2-integrin 4-fold, but increased carcinoembryonic antigen expression only marginally. U4H cells displayed cell cycle regulation by arresting reversibly at a restriction point in G1 when placed in the postconfluent culture conditions which initiated enterocytic differentiation. In contrast, undifferentiated U9H cells exhibited no restriction point but arrested throughout G1. TGF-beta 1 blocked synchronized U4H cells in G1, whereas it stimulated the growth of U9H cells. Thus, TGF-beta 1 has two roles in enterocytic differentiation: to increase levels of collagen I adhesion proteins and to block enterocytic cells in G1 so that they can differentiate.

Transforming growth factor beta 1 (TGF-beta 1) inhibits retinoblastoma gene expression but not pRB phosphorylation in TGF-beta 1-growth stimulated colon carcinoma cells

The response of the retinoblastoma (RB) gene and its product (pRB) to transforming growth factor beta 1 (TGF-beta 1) was studied in three types of colon carcinoma cells derived from the same parental line. TGF-beta 1 was a growth inhibitor for two enterocytic-differentiated lines, a growth stimulator for two undifferentiated lines, and had no effect on two goblet cell-differentiated lines. TGF-beta 1 treatment for 3 days decreased RB gene expression and pRB level two- to threefold in each responsive line. When treated with TGF-beta 1 beginning in early G1, enterocytic cells were arrested in G1 and pRB remained under-phosphorylated and in low abundance. Neither goblet cell line exhibited these responses to TGF-beta 1 because they were shown to lack TGF-beta 1 type I and II receptors. Thus during colonocyte differentiation goblet cells lose responsiveness to TGF-beta 1 by down-regulating TGF-beta 1 receptors, while enterocytic cells retain and exhibit responsiveness to TGF-beta 1 through modulations of pRB. Both of the undifferentiated lines exhibited mixed responses to TGF-beta 1: a decrease in total amount of RB mRNA and pRB protein yet an increase in pRB phosphorylation consistent with increased cell cycling. Therefore, TGF-beta 1 controls RB function by two separable mechanisms, the regulation of pRB phosphorylation and the control of RB mRNA and protein level.

Transforming growth factor beta 1 acts as an autocrine-negative growth regulator in colon enterocytic differentiation but not in goblet cell maturation

Previous studies from this laboratory (Schroy, P., Rifkin, J., Coffey, R.J., Winawer, S., and Friedman, E. (Cancer Res., 50: 261-265, 1990; Schroy, P.C., Winawer, S., and Friedman, E. Cancer Lett., 48: 53-58, 1989) found that a 7-day treatment of the human colon carcinoma cell line HT29 with the differentiation agent hexamethylene bisacetamide (HMBA) induces both a 4-5-fold increase in transforming growth factor beta 1 (TGF beta 1) mRNA levels and reduced tumorigenicity in vivo. A series of 15 cloned lines with different commitments to differentiation has been isolated from 20-day HMBA-treated HT29 cells, maintained without HMBA, and utilized to study the role of TGF beta 1 in colon carcinoma differentiation. Two such lines, HD6 and HD8, differentiate to 97 and 76% mucus-secreting goblet cells, respectively, in columnar monolayers in postconfluent culture. Both HD6 and HD8 cells exhibit low TGF beta 1 mRNA levels, little different from the undifferentiated HT29 parental line, and exhibit no growth modulation in response to exogenous TGF beta 1. In contrast, two other lines, HD3 and HD4, differentiate to fluid-transporting enterocytic cells with functional brush borders and exhibit autocrine-negative growth response to TGF beta 1. Both lines express TGF beta 1 mRNA at levels 11-12-fold higher than the parental line and respond to exogenous TGF beta 1 by growth inhibition. HD3 cells secrete biologically active TGF beta 1 into conditioned media, which inhibited growth of a TGF beta 1-sensitive mink cell line. This inhibition was blocked by antisera to TGF beta 1, proving the specificity of the inhibition. A range of concentrations of this TGF beta 1 antiserum stimulated HD3 cell growth in a dose-dependent manner, further documenting the autocrine-negative response of the cells to TGF beta 1. Another cell line, HI1, was blocked in enterocytic differentiation. HI1 cells synthesized as much TGF beta 1 mRNA as HD3 and HD4 cells, yet they responded to exogenous TGF beta 1 with less growth inhibition, suggesting some impairment in their response to TGF beta 1. A third class of response to TGF beta 1 was exhibited by the HP1 cell line, which was resistant to HMBA-induced differentiation, remaining undifferentiated with a multilayered growth pattern. HP1 cells synthesized TGF beta 1 mRNA at levels over 20 times the parental level but were stimulated to divide by TGF beta 1, exhibiting autocrine-positive response to this growth factor.(ABSTRACT TRUNCATED AT 400 WORDS)

Injury induced by fatty acids or bile acid in isolated human colonocytes prevented by calcium

Measurement of the modulation of the growth fraction of isolated normal colonocytes from adult subjects in primary monolayer culture was used as a sensitive quantitative assay to evaluate toxic effects of several endogenous compounds found within the colon. This assay was used to study the role of CaCl2 in blocking cell injury. When added simultaneously with the injurious agent, 5-10 mM CaCl2 blocked the toxicity of physiological concentrations of deoxycholic acid, oleic acid, palmitic acid and linoleic acid.

Urokinase secretion from human colon carcinomas induced by endogenous diglycerides

Colon tumor cells are more responsive to certain growth modulators in their local environment in vivo than are normal colonocytes. Examples of this class of compounds are the fecal diglycerides (DGs)(E. Friedman et al., Cancer Res., 49: 544-548, 1989), which may act as endogenous tumor promoters. At the concentration found in vivo, fecal DGs composed of oleic, myristic, and palmitic fatty acids induced mitogenesis of all classes of benign tumor cells and of half of the resected carcinomas tested in primary culture, but induced no detectable mitogenesis of normal colonocytes. Colon tumor cells also exhibit selective responses to these endogenous modulators as measured by another biological parameter, secretion of urokinase from carcinomas than from normal colonocytes. Fecal DGs also induced a 13-fold increase in urokinase mRNA synthesis in colon carcinoma cells and induced secretion of active urokinase from each of five resected carcinomas. Colon carcinomas, at both the primary site and metastatic to the liver, secreted the Mr 55,000 form of urokinase constitutively and secreted the same form upon treatment with fecal DGs. An increase in the steady-state level of urokinase secretion by saturated-chain DGs exhibited a strong dependency on the chain length of the fatty acid residues, those of 14 and 16 carbons having the greatest activity. Thus, fecal DGs composed of oleic, myristic, and palmitic acid residues induce two biological activities selectively in colon tumor cells, each of which would enhance tumor development. Selective mitogenesis would increase adenoma and carcinoma cell number relative to normal colonocyte number, and induction of the proteolytic enzyme urokinase would aid local invasion of the carcinoma within the bowel wall.

Role of transforming growth factor beta 1 in induction of colon carcinoma differentiation by hexamethylene bisacetamide

The differentiation agent hexamethylene bisacetamide (HMBA) increased expression of transforming growth factor beta 1 (TGF beta 1) mRNA in HT29 colon carcinoma cells. The increase was evident after 24 h and was maintained at levels 4-5-fold the control levels for at least 5-13 days. No increase in expression of TGF beta 2 or TGF alpha mRNA was observed. Both TGF beta 1 and HMBA induced loss of expression of a cell surface malignancy marker on HT29 cells, and both decreased cell growth in serum-free medium. Exogenously applied TGF beta 1 mimicked the growth-arresting effect of HMBA on three surgically resected moderately differentiated colon carcinomas in serum-free primary culture. Both TGF beta 1 and HMBA increased the tumor growth fraction in a second group of three more aggressive colon carcinomas, while neither agent had any measurable growth-modulating activity on two other colon carcinomas. The induction of TGF beta 1 mRNA by HMBA along with the parallel biological effects of HMBA and exogenously applied TGF beta 1 on resected carcinomas and on HT29 cells suggest that the effects of HMBA on colon carcinoma cells may be mediated in part by induction of TGF beta 1.

Effect on in vivo tumorigenicity of lengthy exposure of human colon cancer cells to the differentiation agent hexamethylene bisacetamide

The heterogeneity of tumor responses to maturation agents was studied using the multi-potential, non-cloned human colon carcinoma cell line HT29. Short-term treatment (5 cell doublings) with the differentiation agent hexamethylene bisacetamide (HMBA) induced a sharp decrease in tumorigenicity in vivo and loss of a cell surface malignancy marker. However, prolonged treatment (22 cell doublings) with the agent lead to loss of the HMBA-sensitive subpopulation from the mass culture, and enrichment of a tumorigenic, HMBA-resistant subpopulation.

Tyrosine phosphorylation of a Mr 63,000 protein induced by an endogenous mitogen in human colon carcinoma cells, but not in normal colonocytes

Transformation of normal human colonocytes makes them sensitive to new mitogenic signals. Long-chain diglycerides (LCDGs) found in the human colon are mitogens selective for colon tumor cells, inducing mitogenesis in premalignant cells from each of 13 adenomas and in malignant cells from two of four carcinomas, but having no mitogenic effects on normal colonocytes (E. Friedman, P. Isaksson, J. Rafter, B. Marian, S. Winawer, and H. Newmark, Cancer Res., 49:544-548, 1989). Parallel to this biological activity pattern, LCDGs induce protein phosphorylation only in adenomas and carcinomas. Immunoblotting with an anti-phosphotyrosine monoclonal antibody demonstrated that the LCDG dimyristin, at concentrations found within the body, induced a 6-fold increase of tyrosine phosphorylation of an Mr 63,000 protein found in the particulate fraction of colon carcinoma cells. Tyrosine phosphorylation was maximal 0.5 min after addition of the LCDG, then fell, but remained elevated 40% over constitutive levels for at least 6 h. The Mr 63,000 tyrosine phosphoprotein was found in each of four colon carcinoma cell lines and an adenoma, but not in normal colonocytes, suggesting that the tyrosine kinase is activated only in tumor cells. Constitutive levels of the Mr 63,000 substrate were enhanced 2-fold by incubation of cells for 20 h with sodium orthovanadate, a tyrosine phosphatase inhibitor. This result suggested that carcinoma cells continually phosphorylate and dephosphorylate this tyrosine kinase substrate during growth. Thus, the colon tumor cell mitogen, dimyristin, utilizes a signal transduction pathway, containing the Mr 63,000 tyrosine kinase substrate, which is already in use during cell growth, possibly by other mitogens or growth factors.

Heterogeneity in the response of familial polyposis epithelial cells and adenomas to increasing levels of calcium in vitro

A biomarker of increased risk for colon cancer is abnormally high proliferation of colonic epithelial cells. The authors developed an in vitro assay that measures the ability of human colonic epithelial cells that are in progressive stages of abnormal development to respond to direct application of calcium as the chloride in tissue culture medium. Incorporation of 3H-thymidine and autoradiography in situ was employed to measure the number of proliferating cells cultured at 0.1 mM CaCl2, the optimum level for growth, and 2.2 to 5 mM, both levels achievable in the colonic lumen. Abnormal cell proliferation was reduced in biopsies from 13 of 14 patients without familial polyposis but at increased risk for colon cancer because of previous colonic neoplasms or familial association; in cells from three of four asymptomatic individuals in familial polyposis families at risk for that disease; and in cells of three of ten patients symptomatic with familial polyposis. Growth of tubular adenoma cells from two of seven familial polyposis patients was also inhibited by calcium. Growth inhibition was not observed in more advanced colon tumors including eight adenomas, either villotubular or villous, and five carcinomas. These findings indicate heterogeneity within the familial polyposis phenotype for the normal cellular response to growth inhibition by calcium, and a further loss of response to calcium as these cells progress toward malignancy.

Fecal diglycerides as selective endogenous mitogens for premalignant and malignant human colonic epithelial cells

Diglycerides (DGs) have been found in fecal extracts at concentrations which induce mitogenesis of adenoma and some carcinoma cells but not normal cells in primary culture. DGs containing stearic, oleic, palmitic, and myristic acid side chains were found in fecal extracts from each of eight subjects. Synthetic 1,2-DGs, containing the fatty acids found in endogenous fecal DGs, induced mitogenesis in cultures of premalignant cells from each of 13 adenomas, covering all histological classes, and in cultures from two of four carcinomas. The potent adenoma mitogen, dimyristin, had no mitogenic activity on cultures of normal colonic epithelial cells from seven different subjects. These results suggest DGs may act as endogenous mitogens in the development of human colon cancer. The extent of adenoma mitogenesis was correlated with the chain length of the saturated R-groups: 16 greater than 14 greater than 12 greater than 10 greater than 8 much greater than 18. DGs with oleic acid residues, C18:1, were among the most active, while substitution of even one fatty acid residue with a stearic acid residue, C18:0, reduced or eliminated mitogenic activity. Dimyristin also induced enhanced levels of urokinase secretion from carcinoma cells, in parallel to the phorbol ester tumor promoter, 12-O-tetradecanoylphorbol-13-acetate. These results imply that DGs found in the colon induce a selective growth of benign colonic tumors and some carcinomas, and may enhance the invasive capacity of carcinomas, while leaving normal cells unaffected.

Effects of psyllium fiber and short-chain organic acids derived from fiber breakdown on colonic epithelial cells from high-risk patients

The effect of a purified fiber, psyllium and the short-chain organic acids derived from fiber breakdown, were assayed on isolated colonic epithelial cells primary-cultured from patients at high-risk of colon cancer, due to adenoma growth or family history of colon cancer. Psyllium fiber provided colonocytes some protection from deoxycholic acid-induced lysis. Propionic acid, a product of fiber breakdown, was a potent colonocyte mitogen, suggesting that fiber could indirectly protect the colon by providing colonocyte nutrients.

Proliferation of esophageal epithelial cells among residents of Linxian, People's Republic of China

Histopathologic and tritiated thymidine labeling subjects were carried out on esophageal biopsy specimens of 44 human subjects with cytologic evidence of dysplasia from Linxian, People's Republic of China, a high-risk area for esophageal cancer. With the use of histopathologic criteria, 10 cases showed evidence of dysplasia, 20 hyperplasia, and 14 a near-normal morphology when compared with 21 normal cases studied previously from Jiaoxian, a low-risk area for esophageal cancer in the People's Republic of China. Significantly increased labeling indices were found in the esophageal mucosa of the dysplasia and hyperplasia subjects. There was a gradient of increased expansion in the basal layer of proliferating cells progressing from normal to hyperplasia to dysplasia, with the expansion twice as high in the epithelial cell lining in dysplasia when compared with the findings in the normal and near-normal groups. The correlation of proliferative abnormalities with the severity of precancerous lesions of the esophagus indicates that labeling studies may provide a sensitive adjunct to evaluate risk status and any modifications that might result from nutritional intervention.

Defining conditions to promote the attachment of adult human colonic epithelial cells

An improved method for the attachment and growth of normal human colonic epithelial cells from minute 1 to 3-mm3 biopsies has been developed. This yields four times as many cultured cells per biopsy than older methods, with a success rate of 97% in a series of 29 biopsies. Fetal bovine serum was eliminated from the medium, the medium pH was decreased to 6.7, the oxygen tension in the incubator was decreased to 3%, and the NCTC 168 medium was supplemented with ethanolamine, phosphoethanolamine, hydrocortisone, ascorbic acid, transferrin, glutamine, insulin, epidermal growth factor, pentagastrin, and deoxycholic acid. The best substrate for cell attachment was a mixture of ungelled collagen I and bovine serum albumin. This substrate was better than the identical mixture with fibronectin added, fibronectin alone, a thin gelatin film, collagen IV with or without fibronectin, and basement membrane preparations from four different cell lines.

Screening for colorectal cancer in a high-risk population. Results of a mathematical model

A mathematical model was used to estimate the cost-effectiveness of colorectal cancer screening strategies for people who are at high risk because of a first-degree relative with colorectal cancer. The model uses indirect evidence about such factors as cancer incidence, sensitivity and specificity of different tests, and treatment effectiveness. The analysis indicates that for screening people over 40 yr old an annual fecal occult blood test may reduce colorectal cancer mortality by about one-third, either colonoscopy or barium enema may reduce mortality by approximately 85%, a 3-5-yr frequency for endoscopies or barium enemas preserves 70%-90% of the effectiveness of an annual frequency, and beginning screening at age 50 reduces effectiveness by 5%-10%. Although both barium enemas and colonoscopies appear to be effective in reducing mortality, the lower cost of the barium enema makes it a more cost-effective strategy. All of these estimates depend on the baseline estimates of each of the factors incorporated in the model; the conclusions are most sensitive to assumptions about the natural history of adenomatous polyps, the bleeding of adenomas and presymptomatic cancers, and the sensitivity of the fecal occult blood test. Recommendations about colorectal cancer screening must also consider factors such as discomfort, inconvenience, and the availability of various technologies.

Inhibition of human colonic epithelial cell proliferation in vivo and in vitro by calcium

Nine patients at high risk of developing colon cancer were placed on daily p.o. supplementation of 1500 mg of calcium for 4-8 weeks. The colonic epithelial cells in six of these patients showed a statistically significant decrease in their [3H]thymidine labeling indices in tissue culture so that they resembled those of patients at low risk of developing colon cancer. The three nonresponders had similar labeling indices before and after calcium supplementation. Biopsies from each of nine high-risk patients exhibited a decrease in proliferation when they were cultured in vitro with a high level of CaCl2 (2.2 mM compared with the 0.1 mM optimum value for proliferation). Two adenomas and two carcinomas showed a different pattern of response than normal cells, exhibiting no inhibition of growth at 2.2 mM CaCl2. These data indicate that the growth inhibition induced by high levels of extracellular calcium levels is lost at a stage in tumor development before cells become malignant.

Seventh-Day Adventist vegetarians have a quiescent proliferative activity in colonic mucosa

The proliferation of epithelial cells in colonic mucosa was studied in humans at varying degrees of risk for colon cancer. Seventh-Day Adventist vegetarians, known to have significantly lower mortality from colon cancer than the general U.S. population, had the most quiescent proliferative activity of mucosal epithelial cells. Increased replication and expansion of the proliferative compartment accompanied increased colon cancer risk. The analytical methods of this study may be useful in assessing the influence of dietary components involved in the initiation, promotion or inhibition of colon cancer, and in developing strategies for nutritional intervention.

Classification and risk assessment of individuals with familial polyposis, Gardner's syndrome, and familial non-polyposis colon cancer from [3H]thymidine labeling patterns in colonic epithelial cells

A probabilistic analysis has been developed to assist the binary classification and risk assessment of members of familial colon cancer kindreds. The analysis is based on the microautoradiographic observation of [3H]thymidine-labeled epithelial cells in colonic mucosa of the kindred members. From biopsies of colonic mucosa which are labeled with [3H]thymidine in vitro, the degree of similarity of each subject's cell-labeling pattern measured over entire crypts was automatically compared to the labeling patterns of high-risk and low-risk reference populations. Each individual was then presumptively classified and assigned to one of the reference populations, and a degree of risk for the classification was provided. In carrying out the analysis, a linear score was calculated for each individual relative to each of the reference populations, and the classification was based on the polarity of the score difference; the degree of risk was then quantitated from the magnitude of the score difference. When the method was applied to kindreds having either familial polyposis or familial non-polyposis colon cancer, it effectively segregated individuals affected with disease from others at low risk, with sensitivity and specificity ranging from 71 to 92%. Further application of the method to asymptomatic family members believed to be at 50% risk on the basis of pedigree evaluation revealed a biomodal distribution to nearly zero or full risk. The accuracy and simplicity of this approach and its capability of revealing early stages of abnormal colonic epithelial cell development indicate potential for preclinical screening of subjects at risk in cancer-prone kindreds and for assisting the analysis of modes of inheritance.

Actin cytoskeletal organization loss in the benign-to-malignant tumor transition in cultured human colonic epithelial cells

The colonic epithelium in vivo is a highly indented sheet one cell thick. Culture methods have been developed to allow the normal cellular migration of the cells comprising this sheet to flatten it into a patch on the surface of a Petri dish [Friedman, E. A., Higgins, P.J., Lipkin , M., Shinya , H., and Gelb , A.M., In Vitro (Rockville), 17: 632-644, 1981]. Actin cytoskeletal organization was analyzed in such epithelial "patches" derived from several human colonic adenocarcinomas and their precursors, adenomas (benign tumors). The actin cytoskeleton was visualized by fluorescence microscopy after the fixed, permeabilized cells were stained with rhodamine-conjugated phalloidin. This drug has a very high affinity for actin filaments and a much lower affinity for monomeric actin. Actin organization was scored from 0 (no cables) to 5 points (extensive intercellular cable network). The phalloidin-stained actin found in seven adenocarcinomas had a predominantly granular fluorescence pattern with very little cable organization, scoring an average of 0.9 +/- 0.8 (S. D.). Three established cell lines derived from human colon carcinomas contained no cables by this analysis, scoring 0.0 +/- 0.0. In marked contrast, all 12 of the cultured adenomas had extensive actin cable networks, scoring an average of 4.3 +/- 0.4. There was no statistical difference between adenomas of differing histopathology class and malignant potential. However, cytoskeletons of plasminogen-activator-secreting "late-stage" preneoplastic cells from adenomas became disorganized by exposure to 12-O-tetradecanoyl-phorbol-13-acetate or another tumor promoter, teleocidin B. They scored, respectively, average actin organization values of 0.0 +/- 0.0 and 0.4 +/- 0.6. In contrast, nonplasminogen -activator- secreting "early-stage" preneoplastic cells from less advanced benign tumors were unaffected by 12-O-tetradecanoyl-phorbol-13- acetate or teleocidin B and retained extensive actin organization. Most, if not all, adenocarcinomas arise from preexisting preneoplastic adenomatous cells. Thus, loss of actin organization appears to mark the transition of noninvasive benign colonic tumors to invasive malignant tumors in humans. This transition is mimicked in vitro by exposure of certain "late-stage" preneoplastic cells to a tumor promoter which induces secretion of a plasminogen activator.

A model for human colon carcinoma evolution based on the differential response of cultured preneoplastic, premalignant, and malignant cells to 12-O-tetradecanoylphorbol-13-acetate

Small colonic adenocarcinomas can be found in focal areas within benign tumors (adenomas), strongly suggesting an adenoma-to-carcinoma sequence. The induction of plasminogen activator (PA) secretion by the tumor promoter 12-O-tetradecanoylphorbol-13-acetate (TPA) has been used to order histologically distinct classes of human colonic adenomas in primary culture into a sequence from the most benign to the most advanced premalignant state. This ordering is based on the observation that each of five carcinomas examined in an earlier study by E. A. Friedman (Cancer Res., 41: 4588-4599, 1981) and each of seven carcinomas tested in this study released PA in response to TPA, inducing easily scored morphological alterations. Benign tumors either resembled carcinomas in their response to TPA or exhibited no morphological changes. The most benign adenomas by histopathology criteria were the small pure tubular adenomas without dysplasia. Six of seven of these adenomas did not secrete PA in response to TPA. We concluded that malignant cells had acquired the ability to respond to TPA by PA secretion, while tubular adenoma cells were not an advanced enough preneoplastic stage to so respond. TPA treatment of two cultured villous adenomas, one with infiltrating carcinoma and one with focus of moderately dysplastic cells, in the presence of low serum to decrease the plasmin concentration, demonstrated that only a subpopulation of cells secreted PA. Local areas of the monolayer were morphologically altered by the protease, forming clusters of cells loosely attached to the dish. The presence of such subpopulations within cultured adenomas was demonstrated by screening an additional five villous adenomas, 15 villotubular adenomas, and 11 tubular adenomas. The presence of dysplastic cells in 23 of 24 cases correlated with PA secretion. A subpopulation of villous cells, in the absence of dysplastic cells in each of three cases, also secreted PA. We conclude that, during tumor evolution, this villous subpopulation is the first preneoplastic cell type to acquire responsiveness to TPA by PA secretion. This property is maintained as the cells further evolve through premalignant dysplastic stages to carcinoma.