Huangqin tang alleviates colitis-associated colorectal cancer via amino acids homeostasisand PI3K/AKT/mtor pathway modulation

ETHNOPHARMACOLOGICAL RELEVANCE

Huangqin Tang (HQT), a traditional Chinese medicine formula, is commonly used in clinical practice for the treatment of inflammatory bowel diseases. It has been reported that HQT exerts antitumor effects on colitis-associated colorectal cancer (CAC). However, the mechanism by which HQT interferes with the inflammation-to-cancer transformation remains unclear.

AIMS OF THE STUDY

The purpose of this study was to dynamically evaluate the efficacy of HQT in alleviating or delaying CAC and to reveal the underlying mechanism.

METHODS

We established a mouse model of CAC using azoxymethane combined with 1.5% dextran sodium sulphate. The efficacy of HQT was evaluated based on pathological sections and serum biochemical indices. Subsequently, amino acids (AAs) metabolism analyses were performed using ultra-performance liquid chromatography-tandem mass spectrometry, and the phosphatidylinositol 3 kinase/protein kinase B/mechanistic target of rapamycin (PI3K/AKT/mTOR) pathway was detected by western blotting.

RESULTS

The data demonstrated that HQT could alleviate the development of CAC in the animal model. HQT effectively reduced the inflammatory response, particularly interleukin-6 (IL-6), in the inflammation induction stage, as well as in the stages of proliferation initiation and tumorigenesis. During the proliferation initiation and tumorigenesis stages, immunohistochemistry staining showed that the expression of the proliferation marker Ki67 was reduced, while apoptosis was increased in the HQT group. Accordingly, HQT substantially decreased the levels of specific AAs in the colon with CAC, including glutamic acid, glutamine, arginine, and isoleucine. Furthermore, HQT significantly inhibited the activated PI3K/AKT/mTOR pathway, which may contribute to suppression of cell proliferation and enhancement of apoptosis.

CONCLUSION

HQT is effective in alleviating and delaying the colon "inflammation-to-cancer". The mechanism of action may involve HQT maintained AAs metabolism homeostasis and regulated PI3K/AKT/mTOR pathway, so as to maintain the balance between proliferation and apoptosis, and then interfere in the occurrence and development of CAC.

Solute carrier family 12 member 2 as a proteomic and histological biomarker of dysplasia and neoplasia in ulcerative colitis

BACKGROUND AND AIMS

Ulcerative colitis (UC) patients have a greater risk of developing colorectal cancer through inflammation-dysplasia-carcinoma sequence of transformation. The histopathological diagnosis of dysplasia is therefore of critical clinical relevance, but dysplasia may be difficult to distinguish from inflammatory changes.

METHODS

A proteomic pilot study on 5 UC colorectal dysplastic patients highlighted proteins differentially distributed between paired dysplastic, inflammatory and normal tissues. The best candidate marker was selected and immunohistochemistry confirmation was performed on AOM/DSS mouse model lesions, 37 UC dysplasia, 14 UC cancers, 23 longstanding UC, 35 sporadic conventional adenomas, 57 sporadic serrated lesions and 82 sporadic colorectal cancers.

RESULTS

Differential proteomics found 11 proteins significantly more abundant in dysplasia compared to inflammation, including Solute carrier family 12 member 2 (SLC12A2) which was confidently identified with 8 specific peptides and was below the limit of quantitation in both inflammatory and normal colon. SLC12A2 immunohistochemical analysis confirmed the discrimination of preneoplastic and neoplastic lesions from inflammatory lesions in mice, UC and in sporadic contexts. A specific SLC12A2 staining pattern termed "loss of gradient" reached 89% sensitivity, 95% specificity and 92% accuracy for UC-dysplasia diagnosis together with an inter-observer agreement of 95.24% (multirater κfree of 0.90; IC95%: 0.78 - 1.00). Such discrimination could not be obtained by Ki67 staining. This specific pattern was also associated with sporadic colorectal adenomas and cancers.

CONCLUSIONS

We found a specific SLC12A2 immunohistochemical staining pattern in precancerous and cancerous colonic UC-lesions which could be helpful for diagnosing dysplasia and cancer in UC and non-UC patients.

Comparative Histologic Assessment of Proctocolectomy Specimens from Japanese and American Patients with Ulcerative Colitis with or Without Dysplasia

There have been no reports of histologic differences in ulcerative colitis (UC) between Japanese and American patients. We therefore compared histology in proctocolectomy resection specimens between Japanese patients with UC (19 cases with and 21 without dysplasia) at the Kitasato University East Hospital and American patients with UC (21 cases with and 24 without dysplasia) at the University of Washington Medical Center. In cases of UC with, but not without dysplasia, cryptitis (p = 0.010) and epithelial apoptosis (p < 0.001) in the nondysplastic mucosa were more frequently observed in Japanese than in American cases, whereas lamina propria fibrosis was more prominent in American counterparts (p = 0.008). In patients with UC with dysplasia, the duration of disease was significantly longer in American than in Japanese patients (median, 17 vs 14 years, respectively; p = 0.038). This might, in part, explain the histologic variation. Another possibility for the differences is that the preoperative medications may have differed in the populations.

Surveillance in ulcerative colitis: is chromoendoscopy-guided endomicroscopy always better than conventional colonoscopy? A randomized trial

BACKGROUND

Ulcerative colitis (UC) is associated with an increased risk of colorectal cancer. Chromoendoscopy showed superiority to conventional colonoscopy (CC) in surveillance studies including high-risk patients. We aimed to compare chromoendoscopy-guided endomicroscopy (CGE) with CC for intraepithelial neoplasia (IN) detection in patients with longstanding UC without primary sclerosing cholangitis and/or history of IN.

METHODS

One hundred sixty-two patients with longstanding (≥ 8 yr) distal/extensive UC and without primary sclerosing cholangitis and/or history of IN were prospectively randomized to undergo CGE (group A) or CC (group B). Seventeen patients were excluded. In group A (n = 72), circumscribed lesions highlighted by pan-chromoendoscopy were evaluated by endomicroscopy, and targeted biopsy/polypectomy was performed. In group B (n = 73), 4 random biopsies every 10 cm and targeted biopsy/polypectomy of detected lesions were performed.

RESULTS

Thirteen IN, all low grade, were detected: 7 IN in group A and 6 in group B (P > 0.05), distributed, respectively, by 6 and 4 patients (P > 0.05). Significantly, more biopsies were performed in group B (4.7 ± 4.9 versus 36.0 ± 6.2, P < 0.001), and the per-biopsy yield of IN was higher in group A (1/48 versus 1/438, P < 0.001). Examination time was 61.5 ± 15.6 minutes in group A and 40.7 ± 8.7 minutes in group B (P < 0.001). The IN detection by endomicroscopy revealed: sensitivity = 85.7%, specificity = 97.9%, positive predictive value = 75.0%, and negative predictive value = 98.9%.

CONCLUSIONS

CGE does not improve the detection of IN in the endoscopic screening of patients with longstanding UC without primary sclerosing cholangitis and/or history of IN. CGE takes longer than CC, but it decreases the number of biopsies performed and significantly increases the per-biopsy yield of IN. Endomicroscopy is an accurate tool for IN detection.

FOXE1 and SYNE1 genes hypermethylation panel as promising biomarker in colitis-associated colorectal neoplasia

BACKGROUND

Colitis-associated colorectal cancer affects individuals with inflammatory bowel disease (IBD) more often and earlier than cancer in the general population. Colonoscopy provides the surveillance gold standard. Changes to the surveillance intervals depending on endoscopic activity have been made, given data demonstrating that this is an important predictor of future dysplasia or cancer, but adjuvant, noninvasive clinical tools are still warranted to improve surveillance outcomes and to assist in management and interpretation of dysplasia. Methylation markers may be able to do this.

METHODS

SYNE1, FOXE1, NDRG4, and PHACTR3 genes were screened using methylation-specific PCR that permit the methylation status of the genes to be determined directly on biopsies. Ninety-three patients with long-standing IBD undergoing a cancer surveillance program, and 30 healthy controls were studied. These included colorectal adenocarcinomas on a background of IBD of various stages (n = 25), IBD-associated dysplastic lesions (n = 29), adenomas arising on a background of ulcerative colitis (n = 8), samples from patients with no evidence of dysplasia or cancer but long-standing IBD (n = 31), and symptomatic patients found to have normal colonoscopy (controls) (n = 30).

RESULTS

Gene promotor hypermethylation of SYNE1 and FOXE1 genes varied significantly between the groups and was increasingly likely with increased disease severity. Neither occurred in controls, whereas promotor hypermethylation was detected in biopsies of 60% of patients with colitis-associated colorectal cancer for FOXE1 and 80% for SYNE1. Promotor hypermethylation of either gene was highly significantly different between the groups overall.

CONCLUSIONS

FOXE1 and SYNE1 hypermethylation markers demonstrated significantly increased expression in neoplastic tissue. Promoter methylation analysis of these genes might be a useful marker of neoplasia in long-standing IBD.

Magnifying narrow-band imaging of surface maturation in early differentiated-type gastric cancers after Helicobacter pylori eradication

BACKGROUND

Even after successful Helicobacter pylori eradication, primary or metachronous gastric cancers are sometimes discovered. The endoscopic features of these cancers may be modified by controlling inflammation. Characteristic findings for such lesions in terms of narrow-band imaging with magnifying endoscopy (NBI-ME) and histopathology need to be clarified to allow accurate diagnosis.

METHODS

Distinctive NBI-ME characteristics were examined retrospectively in intramucosal or minimally submucosal and differentiated-type adenocarcinomas from a successful eradication group (42 patients, 50 lesions) and a non-eradicated control group (44 patients, 50 lesions) matched in age and sex. A "gastritis-like" appearance under NBI-ME was characterized by uniform papillae and/or tubular pits with a whitish border, regular or faint microvessels and unclear demarcation, resembling the adjacent noncancerous mucosa. Histological differentiation at the luminal surface of the cancer was evaluated according to Ki-67 immunoreactivity restricted at the middle or lower portion of the tubules. NBI-ME alteration was prospectively confirmed in 29 patients (30 lesions) after eradication therapy.

RESULTS

The frequency of a "gastritis-like" appearance was 44% (22/50) for the eradication group, which was significantly higher than the 4% (2/50) for the control group (p < 0.001). In the eradication group, the "gastritis-like" appearance was significantly correlated with histological surface differentiation (p < 0.001). In the prospective study, NBI-ME showed changes to heterogeneous papillary microstructures in 43% (10/23) of the lesions after successful eradication at short-term follow-up.

CONCLUSIONS

Identification of surface maturation under NBI-ME offers a promising approach for accurate diagnosis of early gastric cancers after successful eradication.

Role of immunohistochemical markers in predicting progression of dysplasia to advanced neoplasia in patients with ulcerative colitis

BACKGROUND

Although dysplasia is thought to be the precursor lesion in the development of colitis-associated colorectal cancer (CRC), a significant proportion of patients with ulcerative colitis (UC) and low-grade (LGD) or indefinite (IND) dysplasia remain cancer-free during endoscopic follow-up. There is a need for biomarkers that predict neoplastic progression. We studied the value of a series of immunohistochemical markers in UC patients with flat LGD or IND with regard to neoplastic progression.

METHODS

Tissue samples were collected from 12 UC patients (six flat LGD, six IND) without progression and from 10 UC patients (eight flat LGD, two IND) with documented progression to HGD and/or CRC during a median of 25 and 23 months of colonoscopic follow-up, respectively. Immunohistochemistry using monoclonal antibodies was performed for p53, CD44, Ki67, AMACR, β-catenin, cyclin D1, p21, and ALDH. Positive and negative staining patterns were compared for progression to advanced neoplasia.

RESULTS

When patients showed coexpression of p53 and AMACR, 6/7 patients (86%) developed advanced neoplasia, compared to 4/15 patients (27%) without p53/AMACR coexpression (P = 0.02). Patients with p53/AMACR coexpression developed advanced neoplasia in a time period of 19 months (median, range 1-101) compared to 80 months (median, range 8-169) in patients without p53/AMACR coexpression (P = 0.14). Interestingly, in three patients with progression and previous dysplasia-negative biopsies, two out of three biopsies were p53-positive a median of 12 months (range 10-14) before the LGD/IND diagnosis.

CONCLUSIONS

This study suggests a role for p53/AMACR coexpression as a potential marker of neoplastic progression in patients with UC.

Toll-like receptor 4 signaling integrates intestinal inflammation with tumorigenesis: lessons from the murine model of colitis-associated cancer

Chronic inflammation has long been implicated as a predisposition for cancer, but the underlying mechanism for how this occurs has remained obscure. Ulcerative colitis (UC) is a chronic inflammatory disorder of the large intestine which is known to be highly linked to colorectal cancer. During chronic inflammation the intestinal mucosa is in a constant cycle of injury and repair resulting in aberrant epithelial proliferation, a process that increases the risk of neoplastic transformation. In particular, the coexistence of commensal flora in the intestine plays an important role in the regulation of mucosal restitution after epithelial injury. It has become apparent that signaling through toll-like receptors (TLRs), the receptor family recognizing pathogen-associated molecular patterns, is crucial to intestinal epithelial proliferation and mucosal restitution. We have recently described two important downstream pathways underlying TLR4-mediated epithelial proliferation in a mouse model of colitis-associated cancer; i.e., cyclooxygenase 2 (COX-2)-mediated production of prostaglandin E₂ (PGE₂), and induction of specific ligands for epidermal growth factor receptor (EGFR). These two pathways are closely involved with mucosal levels of PGE₂ and other prostanoids such as 15-deoxy-delta 12,14-prostaglandin-J2 (15d-PGJ2). Understanding the fine interplay between the TLR signaling and intestinal tumorigenesis in the setting of chronic inflammation can contribute to establishing a novel treatment strategy for inflammation-associated cancers.

Pathogenesis and biomarkers of carcinogenesis in ulcerative colitis

One of the most serious complications of ulcerative colitis is the development of colorectal cancer. Screening patients with ulcerative colitis by standard histological examination of random intestinal biopsy samples might be inefficient as a method of cancer surveillance. This Review focuses on the current understanding of the pathogenesis of ulcerative colitis-associated colorectal cancer and how this knowledge can be transferred into patient management to assist clinicians and pathologists in identifying patients with ulcerative colitis who have an increased risk of colorectal cancer. Inflammation-driven mechanisms of DNA damage, including the generation and effects of reactive oxygen species, microsatellite instability, telomere shortening and chromosomal instability, are reviewed, as are the molecular responses to genomic stress. We also discuss how these mechanisms can be translated into usable biomarkers. Although progress has been made in the understanding of inflammation-driven carcinogenesis, markers based on these findings possess insufficient sensitivity or specificity to be usable as reliable biomarkers for risk of colorectal cancer development in patients with ulcerative colitis. However, screening for mutations in p53 could be relevant in the surveillance of patients with ulcerative colitis. Several other new biomarkers, including senescence markers and α-methylacyl-CoA-racemase, might be future candidates for preneoplastic markers in ulcerative colitis.

The value of histological changes and immunohistochemical markers Ki67 and p53 in the assessment of ulcerative colitis related dysplasia

The risk of carcinoma increases in patients with a 10-year or longer duration of ulcerative colitis (UC). To search for a more objective parameter to assess epithelial dysplasia. The study comprised 25 cases of longstanding UC: 7 cases with regenerative atypia, 7 with low grade dysplasia, 7 with high grade dysplasia, and 4 cases indefinite for dysplasia. The colonic biopsies obtained during endoscopy were stained with H&E to identify the aforementioned categories. Seventy-five sections from biopsy specimens were stained immunohistochemically to detect differences in the frequency and pattern of nuclei positive for the proliferation marker Ki67 and p53. In high grade dysplasia, the distribution of Ki67 positive cells was diffuse throughout the full length of the crypt, whereas low grade dysplasia and epithelium indefinite for dysplasia, as well as regenerative epithelium, showed an expanded basal zone. None of the regenerative atypia cases showed strong intensity p53 staining compared to dysplasia cases. None of the high grade dysplasia cases showed restricted p53 staining to the lower two thirds of the crypt. All the cases of HGD showed extension of Ki67 and p53 staining above the basal two thirds of the crypt. Ki67 and p53 immunostained cell assessment combined with routine histological evaluation of colorectal mucosa can improve the diagnostic accuracy, as well as the assessment of malignant transformation risk.

Colorectal dysplasia in chronic inflammatory bowel disease: pathology, clinical implications, and pathogenesis

CONTEXT

Colorectal cancer, the most lethal long-term complication of chronic inflammatory bowel disease (IBD), is the culmination of a complex sequence of molecular and histologic derangements of the intestinal epithelium that are initiated and at least partially sustained by chronic inflammation. Dysplasia, the earliest histologic manifestation of this process, plays an important role in cancer prevention by providing the first clinical alert that this sequence is underway and serving as an endpoint in colonoscopic surveillance of patients at high risk for colorectal cancer.

OBJECTIVE

To review the histology, nomenclature, clinical implications, and molecular pathogenesis of dysplasia in IBD.

DATA SOURCE

Literature review and illustrations from case material.

CONCLUSIONS

The diagnosis and grading of dysplasia in endoscopic surveillance biopsies play a decisive role in the management of patients with IBD. Although interpathologist variation, endoscopic sampling problems, and incomplete information regarding the natural history of dysplastic lesions are important limiting factors, indirect evidence that surveillance may be an effective means of reducing cancer-related mortality in the population with IBD has helped validate the histologic criteria, nomenclature, and clinical recommendations that are the basis of current practice among pathologists and clinicians. Emerging technologic advances in endoscopy may permit more effective surveillance, but ultimately the greatest promise for cancer prevention in IBD lies in expanding our thus far limited understanding of the molecular pathogenetic relationships between neoplasia and chronic inflammation.

Effect of mesalazine on epithelial cell proliferation in colonic diverticular disease

BACKGROUND AND AIMS

Increased epithelial cell proliferation may be detected in diverticular disease, but antibiotics have failed in reducing it. We assess therefore the effect of mesalazine on epithelial cell proliferation in diverticular disease.

METHODS

A prospective study was conducted on 20 consecutive patients with a new endoscopic diagnosis of symptomatic uncomplicated diverticular disease. The patients were treated with mesalazine 1.6 mg/day for 1 year. The Ki-67 antigen index of the whole crypt and in the upper third was separately evaluated before and after starting the treatment.

RESULTS

Cell proliferation index was higher in diverticular disease patients than healthy controls both in the whole crypt (median 6.7%, range 2-9% vs. median 1.6%, range 1-3%, p=0.001) and in the upper third of the crypt (median 6.8%, range 2-8% vs. median 1.8%, range 1-3%, p=0.001). Cell proliferation decreased throughout the follow-up. In the whole crypt it was 6.7% at entry and 3.8% at the end of treatment (p<0.005), whereas it was 6.8% at entry and 2.9% at the end of treatment in the upper third of the crypt (p<0.005).

CONCLUSIONS

We found mesalazine effective in reducing the colonic cell proliferation in long-term treatment for colonic diverticular disease.

Neoplastic precursor lesions related to the development of cancer in inflammatory bowel disease

Dysplasia is an intermediate stage in the progression from inflammation to cancer in patients with inflammatory bowel disease. Clinically, dysplasia is used to define appropriate endpoints for colectomy in high-risk patients undergoing endoscopic surveillance. Surveillance is currently the only credible alternative to prophylactic colectomy for high-risk patients. The success of surveillance can be maximized by adherence of gastroenterologists to recommended procedural guidelines, adherence of pathologists to standardized histological criteria and nomenclature, and a joint commitment to close clinical-pathological communication. Technical enhancements to conventional endoscopy hold promise of improved efficiency and accuracy. Molecular-based testing may have a future role for risk stratification and early detection of neoplasia in inflammatory bowel disease.

Insulin-like growth factor binding protein-3 inhibits colitis-induced carcinogenesis

PURPOSE

Chronic inflammation in the setting of inflammatory bowel disease is thought to result in altered epithelial cell growth regulation and ultimately carcinogenesis. This loss in cell growth regulation may be partially caused by a decrease in circulating intact insulin-like growth factor binding protein-3 (IFGB-3) as a result of chronic inflammation. This study evaluates the effect of IFGB-3 on carcinogenesis in the setting of colitis.

METHODS

A previously described animal model for colitis-induced carcinogenesis was used. Colitis was induced in both wild-type and IFGB-3 transgenic CD1 mice with a one-week oral exposure to dextran sodium sulfate (2 percent in drinking water). All mice received a single intraperitoneal administration (10 mg/kg body weight) of a genotoxic colonic carcinogen, azoxymethane. At Week 20, the animals were killed and their colons were excised. The colons were examined by a pathologist under blinded conditions. Criteria assessed included the severity of colitis, number of aberrant crypt foci per mouse colon, incidence of colonic adenomas, and mean size of colonic adenomas.

RESULTS

A total of 20 mice (10 in each group) were included in the study. The severity of colitis was not significantly different between the two groups (mean colitis score wild-type = 13.2; IFGB-3 transgenic = 11; P = not significant). The average number of aberrant crypt foci per colon was significantly lower in the IFGB-3 transgenic mice compared with the wild-type mice (1.5 +/- 1.4 vs. 4.5 +/- 2.7, respectively; P < 0.0001). The number of adenomas per colon was significantly lower in IFGB-3 transgenic group (1.2 +/- 1.8) compared with the wild-type mice (3.7 +/- 2.7; P = 0.005). In addition the average size of adenomas was significantly smaller in IFGB-3 transgenic mice (1.4 +/- 1.3 mm) compared with the wild-type mice (2.6 +/- 2 mm; P = 0.013).

CONCLUSIONS

IFGB-3 significantly reduces the development of colonic tumors and precursor lesions in the setting of induced murine colitis. It is possible that the loss of IFGB-3 as a result of chronic inflammation may be associated with an increased rate of carcinogenesis in the inflammatory bowel disease setting. Although further studies are necessary, in theory, inhibiting the depletion of IFGB-3 or replacement of IFGB-3 may serve as a novel treatment strategy to prevent the development of colitis-induced carcinogenesis.

Proliferative capacity of enterochromaffin cells in guinea-pigs with experimental ileitis

Enterochromaffin (EC) cells regulate gut motility and secretion in response to luminal stimuli, via the release of serotonin (5-HT). Inflammatory bowel disease and other gastrointestinal disorders are associated with increased numbers of EC cells and 5-HT availability. Our aim was to determine whether proliferation of EC cells contributed to the hyperplasia associated with intestinal inflammation. Ileitis was induced in guinea-pigs by intraluminal injection of 2,4,6-trinitrobenzene sulphonic acid (TNBS). A single pulse of 5-bromo-2'-deoxyuridine (BrdU) was injected 1 or 24 h before the collection of tissue, 6 or 7 days after TNBS treatment. In the controls, the labelling index (percentage of BrdU-labelled EC cells) was less than 1%. Despite a significant increase in EC cells in the inflamed ileum, the labelling index was similar in the TNBS-treated animals to that of controls. An increased occurrence of EC cells in the BrdU-labelled zone accounted for the increase in EC cells in the inflamed ileum. Goblet cell numbers were also significantly increased in the inflamed ileum, indicating that cell hyperplasia was not limited to the enteroendocrine cell lineage. This study demonstrates that a small portion of EC cells retain some proliferative capacity; however, hyperplasia associated with ileitis is not attributable to the increased proliferation of EC cells and is not limited to one cell lineage. Therefore, EC cell hyperplasia most probably occurs at the level of the stem cell or recruitment from the progenitor pool.

Pathology of dysplasia and cancer in inflammatory bowel disease

Morphologic identification of dysplasia in mucosal biopsies is the best and most reliable marker of an increased risk for malignancy in patients who have inflammatory bowel disease, and it forms the basis of the recommended endoscopic surveillance strategies that are in practice for patients who have this illness. In ulcerative colitis (UC) and Crohn's disease (CD), dysplasia is defined as unequivocal neoplastic epithelium that is confined to the basement membrane, without invasion into the lamina propria. Unfortunately, unlike in UC, only a few studies have evaluated the pathologic features and biologic characteristics of dysplasia and carcinoma in CD specifically. As a result, this article focuses mainly on the pathologic features, adjunctive diagnostic methods, and differential diagnosis of dysplasia in UC.

Epithelial cell proliferation of the colonic mucosa in different degrees of colonic diverticular disease

GOAL

This study assesses the epithelial cell proliferation in different degrees of diverticular disease and compares this with two different control groups.

BACKGROUND

Hyperproliferation of the colonic mucosa has been recently described in diverticular disease (DD), but it is unknown whether this finding is present in every degree of DD.

PATIENTS AND METHODS

Thirty consecutive patients with a new endoscopic diagnosis of DD (10 with asymptomatic diverticulosis, 10 with symptomatic uncomplicated DD, and 10 with acute uncomplicated diverticulitis) were enrolled. Ten matched healthy people and 10 patients with ulcerative colitis (UC) (5 with UC in remission and 5 with active UC) were enrolled as control groups. The Ki-67 antigen index of the whole crypt and the upper third was separately evaluated.

RESULTS

Ki-67 index of the whole crypt and the upper third of the crypt was significantly higher in all degrees of DD compared with the healthy control group. In particular, asymptomatic diverticulosis showed a threefold higher Ki-67 index compared with that of the healthy control group (5.4% and 5.6% vs. 1.6% and 1.8%, respectively, P = 0.005), and similar to that of UC in remission (5.4% and 5.6% vs. 5.9% and 5.8%, respectively, P = not significant).

CONCLUSIONS

We found an upward shifting of cellular proliferation of the colonic mucosa in patients with different degrees of DD. In particular, asymptomatic diverticulosis seems to show the same risk for colonic carcinoma as that of UC.

Bottom-up cell proliferation with cyclin A and p27Kip1 expression in ulcerative colitis-associated dysplasia

To analyze the cell kinetics of ulcerative colitis (UC)-associated dysplasia, cyclin A, cyclin D1, cyclin E, cdk2, cdk4, p21(Waf1), and p27(Kip1) were immunohistochemically examined, in comparison with sporadic tubular adenomas. Immunohistochemical labeling indices for each marker in formalin-fixed paraffin-embedded tissue sections were assessed in a total of 23 low-grade dysplasias, 27 high-grade dysplasias, and 14 invasive adenocarcinomas associated with UC. For comparison, 21 sporadic tubular adenomas with low-grade dysplasia, 33 with high-grade dysplasia, and 21 invasive adenocarcinomas were also examined. In UC-associated dysplasias, cyclin A and p27(Kip1) were located in the lower parts of the crypts and p21(Waf1) in the upper regions. In tubular adenomas, cyclin A, cdk4, p27(Kip1), and p21(Waf1) were all expressed in the upper parts of the crypts. The expression levels of cyclin D1, cyclin E, and cdk2 were low. The cell proliferation zone in UC-associated dysplasia is located towards the bases of the crypts with the strong expression of cyclin A and p27(Kip1), in contrast to tubular adenomas, which have their cell proliferation zone in the upper parts of neoplastic crypts. It is considered that tumorigenesis with UC-associated dysplasia is of the bottom-up type, related to altered expression of cyclin A and p27(Kip1).

Chronic inflammation promotes retinoblastoma protein hyperphosphorylation and E2F1 activation

Chronic inflammation contributes to tumorigenesis. The retinoblastoma protein (pRb), in its hyperphosphorylated form, releases E2 promoter binding factor-1 (E2F1), which drives cell proliferation. Here, we show that pRb is hyperphosphorylated in both mouse and human colitis. In turn, pRb hyperphosphorylation is associated with release of E2F1 from pRb, resulting in the activation of E2F1 target molecules involved in proliferation and apoptosis. These observations provide insight into the in vivo mechanisms associated with chronic colon inflammation and increased colon cancer risk.

Insulin-like growth factor binding protein 3 in inflammatory bowel disease

Epithelial cell growth regulation has been reported to be altered in inflammatory bowel disease (IBD) patients. The cell growth regulatory factor, insulin-like growth factor binding protein 3 (IGFBP-3), may be partly responsible for this phenomenon. So far, IGFBP-3 levels have been assessed as values of total protein, which is a sum of bioactive intact 43- to 45-kDa protein and its inactive proteolytic cleavage fragments. We aimed to assess the levels of intact IGFBP-3 and its cleaving protease MMP-9 in IBD. Patients with IBD and controls were included. Total plasma IGFBP-3 concentration was measured in ELISA. Western blot analysis, which distinguishes between intact and cleaved IGFBP-3, was performed in order to determine the ratio of intact to total protein; this ratio was used to calculate the concentration of intact IGFBP-3. The profile of plasma proteases was evaluated in zymography and MMP-9 levels were determined in ELISA. The concentration of intact IGFBP-3 was significantly decreased in patients with moderate to severe IBD activity compared to those in remission or controls. Of note, a dramatic depletion of intact IGFBP-3 was found in 7.4% of patients with IBD. Zymography revealed that the dominant gelatinase was the pro-form of MMP-9. However, no differences in MMP-9 levels were noted between those with active disease and controls. The level of intact IGFBP-3 is decreased in IBD patients with moderate to severe disease activity. This decrease may be linked to altered IGFBP-3 production or to increased cleavage by proteases other than MMP-9.

CD4+ CD25+ regulatory T lymphocytes inhibit microbially induced colon cancer in Rag2-deficient mice

Inflammatory bowel diseases, including ulcerative colitis and Crohn's disease, increase the risk of colorectal cancer in humans. It has been recently shown in humans and animal models that intestinal microbiota and host immunity are integral in the progression of large bowel diseases. Lymphocytes are widely believed to prevent bacterially induced inflammation in the bowel, and lymphocytes are also critical in protecting against primary tumors of intestinal epithelia in mice. Taken together, this raises the possibility that lymphocytes may inhibit colon carcinogenesis by reducing bacterially driven inflammation. To examine the role of bacteria, lymphocytes, and inflammatory bowel disease in the development of colon cancer, 129/SvEv Rag-2-deficient and congenic wild-type mice were orally inoculated with a widespread enteric mouse bacterial pathogen, Helicobacter hepaticus, or sham-dosed with media only. H. hepaticus-infected Rag2-/-, but not sham-dosed Rag2-/- mice, rapidly developed colitis and large bowel carcinoma. This demonstrated a link between microbially driven inflammation and cancer in the lower bowel and suggested that innate immune dysregulation may have an important role in inflammatory bowel disease and progression to cancer. H. hepaticus-infected wild-type mice did not develop inflammation or carcinoma showing that lymphocytes were required to prevent bacterially induced cancer at this site. Adoptive transfer with CD4+ CD45RBlo CD25+ regulatory T cells into Rag-deficient hosts significantly inhibited H. hepaticus-induced inflammation and development of cancer. These results suggested that the ability of CD4+ T cells to protect against intestinal cancer was correlated with their ability to reduce bacterially induced inflammatory bowel disease. Further, regulatory T cells may act directly on the innate immune system to reduce or prevent disease. These roles for T cells in protection against colon carcinoma may have implications for new modes of prevention and treatment of cancer in humans.

Diverse p53 alterations in ulcerative colitis-associated low-grade dysplasia: full-length gene sequencing in microdissected single crypts

In long-standing ulcerative colitis (UC), p53 mutations have been shown to occur by indirect detection methods such as PCR-SSCP. To clarify whether p53 gene mutations are early events in UC-associated neoplasia and to analyse clonality within dysplasia-associated lesions or masses (DALMs), the entire coding region of the p53 gene was analysed in DNA of microdissected single crypts by the polymerase chain reaction (PCR)-direct sequencing method. With a novel microdissection method using serial histological sections, the p53 gene (exons 2-11) was analysed in a total of 11 regenerative crypts and 76 single crypts within seven DALMs selected from three colectomy specimens of long-standing UC patients. Although p53 point mutations were found in at least one crypt in each DALM, heterogeneity in terms of the presence and the type of genetic change was marked, except in one carcinoma. As early events, p53 gene mutations were apparent even in some regenerative crypts (8/12 crypts). Some were of silent type. Altered p53 protein expression was confirmed in only 14/32 mutated crypts and was also evident in 24 other non-mutated examples by immunostaining of serial sections. Polyclonal p53 gene mutations were found in regenerative (REG) crypts and low-grade dysplasia (LGD), but monoclonal changes were noted in high-grade dysplasia (HGD) or carcinoma (Ca) in long-standing UC. At the single crypt level, however, p53 point mutations were not always linked to p53 overexpression, indicating a discrepancy between gene alteration and protein accumulation in LGD.

Histologic precursors of gastrointestinal tract malignancy

Precursor lesions in the GIT include flat dysplasias, adenomas, dysplasia superimposed on nonneoplastic polyps, endocrine cell dysplasia, ACF, and condyloma accuminatum. Interobserver variability can be a problem in reporting dysplasia, and ancillary techniques including flow cytometry, image analysis, proliferation markers, and examination for p53 expression can help in this task. Squamous dysplasia seen in the esophagus and anus is graded on either a two-tiered or three-tiered system largely based on the extent of mucosal involvement. Glandular dysplasia is morphologically similar whether seen as an adenomatous polyp or within the setting of Barrett's esophagus, atrophic gastritis, or idiopathic inflammatory bowel disease. The distinction between LGD and HGD in glandular mucosa is based on the severity of cytologic and architectural distortion. Type I dysplasia is the classic adenomatous pattern seen most commonly and recognized by the presence of elongate hyperchromatic stratified nuclei. Type II, the nonadenomatous variant, contains vesicular nuclei and alteration in nuclear size and shape. Nonantral endocrine dysplasia in the stomach is seen in the setting of corporal predominant atrophic chronic gastritis and Zollinger-Ellison syndrome with Multiple Endocrine Neoplasia syndrome type I. Condyloma accuminatum is a HPV-related lesion most commonly seen in men practicing anal intercourse. Superimposed squamous dysplasia can be seen with HGD most frequently in the HIV-positive population. Recognition of the different classification systems of dysplasia, the most frequent settings in which these lesions are found, and their natural history is important for all practicing gastroenterologists and pathologists.

Inhibition of epithelial chloride secretion by butyrate: role of reduced adenylyl cyclase expression and activity

Butyrate and other short-chain fatty acids (SCFAs) are found at high concentrations in the colonic lumen and affect multiple epithelial cell functions. To better understand how SCFAs regulate ion transport, we investigated the effects of SCFAs on Cl(-) secretion in human colonic epithelial cell line T(84). Butyrate inhibited Cl(-) secretory responses to prostaglandin E(2), forskolin, and cholera toxin. Other SCFAs were less effective or inactive. Reduced secretion was associated with decreased synthesis of the second messenger cAMP rather than increased degradation. Expression and activity of adenylyl cyclase were decreased by butyrate, whereas phosphodiesterase activity was unaffected and phosphodiesterase inhibition did not reverse the effects of butyrate on Cl(-) secretion. Furthermore, butyrate decreased expression of the basolateral Na-K-2Cl cotransporter, indicating that it might modulate the secretory capacity of the cells. However, butyrate did not affect secretory responses to the calcium-dependent secretagogue carbachol, cAMP analogs, or uroguanylin, indicating that normal secretory responses to adequate levels of second messengers in butyrate-treated T(84) cells are possible. These results show that butyrate affects several aspects of epithelial Cl(-) secretion, including second messenger generation and expression of key ion transporters. However, these effects may not all be equally important in determining Cl(-) secretion in response to physiologically relevant secretagogues.

Mutations of p53 in morphologically non-neoplastic mucosa of long-standing ulcerative colitis

Two cases of ulcerative colitis (UC)-associated carcinoma or dysplasia and morphologically non-neoplastic mucosa with p53 protein overexpression (MNNM-p53OE) were selected. DNA was extracted from the paraffin blocks of these lesions and exons 5 - 8 of the p53 gene were analyzed by PCR and direct sequencing. In addition, mutations in K-ras codon 12 were analyzed by PCR-RFLP methods. MNNM-p53OE was located surrounding and adjoining a coexisting carcinoma and / or dysplasia. A p53 mutation was detected in 12 / 22 (54.5%) MNNM-p53OE samples, 4 / 8 (50%) dysplasia samples and 8 / 8 (100%) carcinoma samples. The p53 mutations detected in MNNM-p53OE were identical to those demonstrated in the adjoining carcinoma and / or dysplasia. No K-ras codon 12 mutation was detected in any of the samples. These results indicate that MNNM-p53OE may share an identical clonal linkage with a coexisting carcinoma and / or dysplasia, and may be an initial and submorphological form of UC-associated neoplasia. Recognition of MNNM-p53OE in biopsy specimens may help to identify patients with UC at risk of developing colorectal carcinoma.

High proliferative activity is associated with dysplasia in ulcerative colitis

PURPOSE

Ulcerative colitis is associated with an increased risk of colorectal neoplasia. Markers of proliferation are reported to be valuable in the diagnosis of dysplasia in ulcerative colitis. However, it is not known whether dysplastic change or proliferative change occurs first. Whether abnormal proliferation is present in normal-seeming mucosa in ulcerative colitis was investigated.

METHODS

Eighteen cancer or high-grade dysplasia specimens and 9 low-grade dysplasia specimens from 5 patients and 51 specimens from 31 patients without neoplasia were studied. Immunostaining with anti-Ki 67 antibody was used to evaluate proliferative activity. Labeling index (in the superficial one-half of crypt) was calculated. Crypts with labeling index more than 0.3 were determined to have abnormal proliferation.

RESULTS

The mean +/- standard error of the mean labeling index in specimens negative for dysplasia (0.056+/-0.004) was significantly lower than that in low-grade dysplasia specimens (0.418+/-0.024) and that in high-grade dysplasia specimens (0.503+/-0.027; P < 0.0001). In specimens negative for dysplasia, only 4 (4 cases) of 339 (1.2 percent) crypts had abnormal proliferation, whereas the ratio of crypts with abnormal proliferation was 76 percent (54/71) in low-grade dysplasia and 92.1 percent (35/38) in high-grade dysplasia. The labeling index in background mucosa was 0.139+/-0.009, which was significantly higher than that in specimens negative for dysplasia (P < 0.001). In background mucosa 15.7 percent of crypts showed abnormal proliferation. A follow-up study revealed that two of four cases developed cancer or high-grade dysplasia one and seven years after proliferative abnormality was detected in nondysplastic specimens.

CONCLUSION

Ki-67 immunostaining can be an aid in the diagnosis of dysplasia. High proliferating activity in background mucosa suggests that proliferating activity change precedes dysplasia detected with hematoxylin-and-eosin staining.

Immunohistochemical assessment of Ki67 and p53 expression assists the diagnosis and grading of ulcerative colitis-related dysplasia

AIMS

To assess whether Ki67 and p53 immunostaining may assist the diagnosis and grading of ulcerative colitis-related dysplasia.

METHODS AND RESULTS

Location of Ki67 staining and location and intensity of p53 staining were assessed in ulcerative colitis (UC) cases showing the features of high-grade dysplasia (HGD, n = 14), low-grade dysplasia (LGD, n = 22), 'indefinite for dysplasia' (n = 12), or regenerative atypia (RA, n = 22). Good intra- and inter-observer reproducibilities were demonstrated in the performance of these assessments. All the dysplasia cases showed extension of Ki67 staining above the basal third of the crypt. Moderate intensity p53 staining was seen in 10/22 RA cases, but strong intensity p53 staining was seen only in cases of dysplasia. All the cases of HGD showed extension of Ki67 and p53 staining above the basal two thirds of the crypt.

CONCLUSIONS

Restriction of Ki67 staining to the basal third of the crypt appears to exclude a diagnosis of dysplasia whereas strong intensity p53 staining suggests a diagnosis of dysplasia. Restriction of Ki67 or p53 staining to the basal two-thirds of the crypt appears to exclude a diagnosis of HGD.

Prognostic factors in colorectal cancer. College of American Pathologists Consensus Statement 1999

BACKGROUND

Under the auspices of the College of American Pathologists, the current state of knowledge regarding pathologic prognostic factors (factors linked to outcome) and predictive factors (factors predicting response to therapy) in colorectal carcinoma was evaluated. A multidisciplinary group of clinical (including the disciplines of medical oncology, surgical oncology, and radiation oncology), pathologic, and statistical experts in colorectal cancer reviewed all relevant medical literature and stratified the reported prognostic factors into categories that reflected the strength of the published evidence demonstrating their prognostic value. Accordingly, the following categories of prognostic factors were defined. Category I includes factors definitively proven to be of prognostic import based on evidence from multiple statistically robust published trials and generally used in patient management. Category IIA includes factors extensively studied biologically and/or clinically and repeatedly shown to have prognostic value for outcome and/or predictive value for therapy that is of sufficient import to be included in the pathology report but that remains to be validated in statistically robust studies. Category IIB includes factors shown to be promising in multiple studies but lacking sufficient data for inclusion in category I or IIA. Category III includes factors not yet sufficiently studied to determine their prognostic value. Category IV includes factors well studied and shown to have no prognostic significance.

MATERIALS AND METHODS

The medical literature was critically reviewed, and the analysis revealed specific points of variability in approach that prevented direct comparisons among published studies and compromised the quality of the collective data. Categories of variability recognized included the following: (1) methods of analysis, (2) interpretation of findings, (3) reporting of data, and (4) statistical evaluation. Additional points of variability within these categories were defined from the collective experience of the group. Reasons for the assignment of an individual prognostic factor to category I, II, III, or IV (categories defined by the level of scientific validation) were outlined with reference to the specific types of variability associated with the supportive data. For each factor and category of variability related to that factor, detailed recommendations for improvement were made. The recommendations were based on the following aims: (1) to increase the uniformity and completeness of pathologic evaluation of tumor specimens, (2) to enhance the quality of the data needed for definitive evaluation of the prognostic value of individual prognostic factors, and (3) ultimately, to improve patient care.

RESULTS AND CONCLUSIONS

Factors that were determined to merit inclusion in category I were as follows: the local extent of tumor assessed pathologically (the pT category of the TNM staging system of the American Joint Committee on Cancer and the Union Internationale Contre le Cancer [AJCC/UICC]); regional lymph node metastasis (the pN category of the TNM staging system); blood or lymphatic vessel invasion; residual tumor following surgery with curative intent (the R classification of the AJCC/UICC staging system), especially as it relates to positive surgical margins; and preoperative elevation of carcinoembryonic antigen elevation (a factor established by laboratory medicine methods rather than anatomic pathology). Factors in category IIA included the following: tumor grade, radial margin status (for resection specimens with nonperitonealized surfaces), and residual tumor in the resection specimen following neoadjuvant therapy (the ypTNM category of the TNM staging system of the AJCC/UICC). (ABSTRACT TRUNCATED)

American Joint Committee on Cancer Prognostic Factors Consensus Conference: Colorectal Working Group

BACKGROUND

The American Joint Committee on Cancer (AJCC), which regularly reviews TNM staging systems, established a working party to develop recommendations for colorectal carcinoma.

METHODS

A multidisciplinary consensus conference using published literature developed an arbitrary classification system of prognostic marker value (Category I, IIA, IIB, III, and IV), which forms the framework for this report.

RESULTS

The working party concluded that several T categories should be subdivided: pTis into intraepithelial carcinoma (pTie) and intramucosal carcinoma (pTim); pT1 into pT1a and pT1b corresponding to the absence or presence of blood or lymphatic vessel invasion, respectively; and pT4 into pT4a and pT4b according to the absence or presence of tumor involving the surface of the specimen, respectively. The working party also recommended that TNM groups be stratified based on the presence or absence of elevated serum levels of carcinoembryonic antigen (CEA) (>/= 5 ng/mL) on preoperative clinical examination. In addition, the working party also concluded that carcinoma of the appendix should be excluded from the colorectal carcinoma staging system because of fundamental differences in natural history.

CONCLUSIONS

The TNM categories and stage groupings for colorectal carcinoma published in the current AJCC manual have clinical and academic value. However, a few categories require subdivision to provide increasing discrimination for individual patients. The serum marker CEA should be added to the staging system, whereas multiple other factors should be recorded as part of good clinical practice. Although many molecular and oncogenic markers show promise to supplement or modify the current staging systems eventually, to the authors' knowledge none have yet been evaluated sufficiently to recommend their inclusion in the TNM system.

Dysplasia in Chronic Ulcerative Colitis: A Molecular Approach to Its Differential Diagnosis

Ulcerative colitis-related epithelial dysplasia represents a premalignant lesion, which may lead to the development of ulcerative colitis-related adenocarcinoma. The proper management of this condition requires proctocolectomy before the acquisition of the invasive phenotype. Patients with chronic ulcerative colitis, however, like the general population, may develop sporadic colorectal adenomas not related to the presence of the inflammatory bowel disease. These adenomas are also characterized by epithelial dysplasia, but their detection carries very different clinical implications. It is therefore essential to distinguish between chronic ulcerative colitis-related dysplasia and sporadic colorectal adenomas. The gross and histologic features do not provide a definite distinction between these two different types of dysplasia of the colonic epithelium. Recent developments in the molecular genetics may provide the necessary means. Int J Surg Pathol 8(1):11-16, 2000

Misplacement of dysplastic epithelium in Peutz-Jeghers Polyps: the ultimate diagnostic pitfall?

Peutz-Jeghers syndrome is characterized by multiple polyps throughout the gastrointestinal tract in association with mucocutaneous pigmentation. Small bowel polyps in the syndrome may exhibit epithelial misplacement, into the submucosa, the muscularis propria, and even the subserosa. The authors demonstrate two patients in whom there is also misplacement of dysplastic epithelium into the submucosa and muscularis propria of the small bowel. Epithelial misplacement is recognized to mimic invasive malignancy. Such mimicry is heightened substantially when the misplaced epithelium is dysplastic. Correct interpretation of the histologic changes is aided by the use of special stains, which demonstrate the associated lamina propria and the lack of a desmoplastic response, and immunohistochemistry, which shows that the misplaced dysplastic epithelium is accompanied by non-neoplastic mucosa. There is an increased prevalence of gastrointestinal malignancy in Peutz-Jeghers syndrome. However, the presence of perplexing histologic features, caused by epithelial misplacement, especially when some of that epithelium is dysplastic, in small bowel polyps at least has the potential for the overdiagnosis of malignancy in the syndrome.

Ki-67: a useful marker for the evaluation of dysplasia in ulcerative colitis

AIMS

Evaluation of dysplasia in long standing ulcerative colitis is a difficult and often subjective task. Therefore, the aim of this study was to search for a more objective parameter to help distinguish regenerative changes from epithelial dysplasia.

METHODS

A total of 97 sections from colectomy specimens from 12 patients with ulcerative colitis of more than 10 years duration were stained immunohistochemically with MIB 1 to detect differences in the frequency and pattern of nuclei positive for the proliferation marker Ki-67. All patients had epithelial dysplasia in one or more areas (high grade dysplasia, n = 16; low grade dysplasia, n = 15; indefinite for dysplasia, n = 16), and three patients had additional adenocarcinoma (one Dukes's C multifocal, mucinous carcinoma; one Dukes's C adenocarcinoma in the sigmoid; and one Dukes's A adenocarcinoma in the caecum). Two patients had adenomas--one had an 8 cm villous adenoma with intramucosal carcinoma, and the other had a 4 cm tubulovillous adenoma with high grade dysplasia.

RESULTS

There were highly significant differences between the percentages of Ki-67 immunopositive cells in low grade and high grade dysplasia and carcinoma compared with regenerative epithelium. In high grade dysplasia and carcinoma, the distribution of Ki-67 positive cells was diffuse throughout the full length of the crypt, whereas low grade dysplasia and epithelium indefinite for dysplasia, as well as regenerative epithelium, showed an expanded basal zone.

CONCLUSIONS

Assessment of the number of Ki-67 immunostained cells is of additional value in deciding whether the mucosa is regenerative or dysplastic, and the MIB 1 staining pattern is characteristic for most lesions with high grade dysplasia and carcinoma. Therefore, this technique could be combined with routine histological evaluation of colorectal epithelium being examined for dysplasia.

Multifocal neoplasia involving the colon and appendix in ulcerative colitis: pathological and molecular features

A patient with ulcerative colitis, extensive dysplasia, multifocal colon cancer, and an appendiceal cystadenoma is described. A 48-year-old man with a 26-year history of ulcerative colitis (UC) had extensive dysplasia involving nearly the entire colon and four dysplasia-associated mass lesions (DALMs). Four invasive adenocarcinomas were present. This case is the first documentation of a DALM (mucinous cystadenoma) arising in the appendix in the setting of UC. The genetic alterations present in the various lesions were analyzed. The molecular profiles of the neoplastic lesions differed. Mutations were found in p53 and ras genes, and one site showed microsatellite instability in a single genetic locus. These molecular abnormalities develop before invasive cancer develops, and may undergo clonal expansion to create large mucosal patches containing certain cells with genetic alterations. The diversity of the early changes suggests that the recurrent inflammation characteristic of long-standing UC randomly damages genes known to participate in colon carcinogenesis and that it affects multiple target genes. The findings also support a multiclonal origin of synchronous tumors because the molecular phenotypes of the preinvasive lesions differed at various sites.

Proliferative epithelial changes in ectopic gastric mucosa of Meckel's diverticula

Twenty-one Meckel's diverticula containing an adequate amount of assessable heterotopic gastric mucosa were investigated for epithelial changes. Marked or moderate foveolar hyperplasia was present in 52% and 29% of the cases, respectively. Four cases displayed an excessive epithelial proliferation indefinite for dysplasia. It is pointed out that reflux type gastritis or gastropathy, which is the most common lesion in the ectopic gastric mucosa of Meckel's diverticulum, can be associated with the same confusing epithelial proliferation as reflux gastritis in the stomach, but these lesions are best regarded as representing atypia of repair. Distinguishing features from dysplasia are maturation towards the surface, lack of hyperchromatism and abscence of atypical mitoses. Negative p53 immunostaining and localization of the Ki-67 positivity to the expanded neck region could be additive clues that can help to classify lesions indefinite for dysplasia as negative for dysplasia. On the basis of the similarities of the ectopic and ortotopic gastric mucosa, it is suggested that these additive clues previously used in other parts of the digestive tract could also apply for the stomach.