Association of gastroesophageal reflux disease and laryngeal cancer

Pepsin Inhibitors Prevent Inflammation and Loss of Laryngeal Barrier Function in Mice with Gastroesophageal Reflux

OBJECTIVE

This study aimed to evaluate the role of pepsin inhibitors in the inflammatory response and their effects on laryngeal mucosal integrity during gastroesophageal reflux (GERD) under in vivo conditions.

METHODS

A surgical model of GERD was used, in which mice were treated with pepstatin (0.3 mg/kg) or darunavir (8.6 mg/kg) for 3 days. On the third day after the experimental protocol, the laryngeal samples were collected to assess the severity of inflammation (wet weight and myeloperoxidase activity) and mucosal integrity (transepithelial electrical resistance and paracellular epithelial permeability to fluorescein).

RESULTS

The surgical GERD model was reproduced. It showed features of inflammation and loss of barrier function in the laryngeal mucosa. Pepstatin and darunavir administration suppressed laryngeal inflammation and preserved laryngeal mucosal integrity.

CONCLUSION

Pepsin inhibition by the administration of pepstatin and darunavir improved inflammation and protected the laryngeal mucosa in a mouse experimental model of GERD.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:3080-3085, 2024.

HPV and head and neck cancers: Towards early diagnosis and prevention

Head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer worldwide with an increasing trend of its incidence. Alcohol consumption, smoking, and viral infections, such as the mucosal high-risk (HR) human papillomaviruses (HPVs) are major risk factors for HNSCC development. In particular, HR HPVs are mainly associated with a subset of oropharyngeal squamous cell carcinoma (OPSCC), while other head and neck sites are marginally affected by HPV infection. HPV16 is the most frequently HR HPV type associated with HNSCC. In contrast to the cervix, no screening programs or identifiable pre-malignant lesions have been characterized for HPV-related HNSCC. Therefore, identification of general diagnostic algorithms and HPV biomarkers that could facilitate the early diagnosis, disease evolution and recurrence for HPV-driven HNSCCs are urgently needed. We herein review the role of HPV in HNSCC with a focus on epidemiology, biology, applied diagnostic algorithms and available biomarkers in body fluids as early diagnostic tools in HPV-driven HNSCCs.

The role of Glut-1 and H+/K+-ATPase expression in hyperplasia of mice laryngeal epithelium induced by pepsin

Purpose

To explore the role played by Glut-1 and H⁺/K⁺-ATPase in pepsin-induced, mouse laryngeal epithelial proliferation, growth, and development.

Methods

We established a mouse model of laryngopharyngeal reflux and measured Glut-1 and H⁺/K⁺-ATPase expression levels in mouse laryngeal epithelium treated with artificial gastric juice containing pepsin.

Results

Artificial pepsin-containing gastric juice induced significant hyperplastic changes in mouse laryngeal epithelium compared to control mice at 15, 30, and 45 days. Inhibition of Glut-1 expression by 2-DG significantly suppressed such hyperplasia compared to mice exposed to artificial gastric juice containing pepsin at 15, 30, and 45 days. After treatment with pepsin-containing artificial gastric juice, RT-PCR and Western blotting showed that the levels of Glut-1 and H⁺/K⁺-ATPase α, β increased significantly.

Conclusions

Pepsin-containing artificial gastric juice promoted mouse laryngeal epithelial hyperplasia associated with abnormal expression of Glut-1 and H⁺/K⁺-ATPase α, β.

Alarming triad of progressive hoarseness in a male smoker

Hoarseness accounts for 1% of all consultations in primary care. Suspicion of malignancy should be considered in individuals with risk factors presenting with unexplained hoarseness lasting more than two weeks. A significant number of patients with laryngeal cancer present at an advanced stage due to lack of awareness regarding vocal health. It is important to educate both the public and primary care health providers concerning laryngeal cancer. We present the case of an 81-year- old male smoker who presented to us with a six-month history of progressive hoarseness. He was initially treated in two primary and one secondary care centres, where a diagnosis of laryngeal cancer was not considered. Careful assessment in our centre managed to determine a diagnosis of T3N0M0 glottic carcinoma. We will discuss this alarming triad of progressive hoarseness in a male smoker to help primary care physicians streamline their thoughts and identify red flags in a hoarse patient.

Role and mechanism of Glut-1 and H+/K+-ATPase expression in pepsin-induced development of vocal cord leukoplakia

PURPOSE

We investigated the role of Glut-1 and H⁺/K⁺-ATPase expression in pepsin-induced development of human vocal cord leukoplakia cells (HVCLCs). Next, we analyzed the relationship between Glut-1 and H⁺/K⁺-ATPase expression with the clinicopathological features of laryngeal carcinoma.

METHODS

Glut-1 and H⁺/K⁺-ATPase expression levels in HVCLCs were determined after treatment with artificial gastric juice containing pepsin and laryngeal carcinoma tissues.

RESULTS

Exposure to pepsin-containing artificial gastric juice significantly enhanced the migration and proliferation of VSCLCs in a time-dependent manner. The apoptotic rate of VSCLCs decreased over time after exposure to pepsin and reached a nadir on day 7 (p < 0.01). With increasing duration of exposure to pepsin, the proportion of VSCLCs in G0/G1 phase decreased and the proportions in the S and G2/M phases significantly increased (p < 0.05). After treatment with pepsin-containing artificial gastric juice, RT-PCR and Western blotting showed that the expression of Glut-1 and H⁺/K⁺-ATPase α, β significantly increased in HVCLCs compared to in the absence of pepsin (p < 0.05). The expression of Glut-1 and H⁺/K⁺-ATPase α, β gradually increased from vocal cord leukoplakia (VLC) to laryngeal carcinoma (p < 0.05). Lentivirus-mediated inhibition of Glut-1 expression in VCL significantly inhibited the cells' migration and proliferation (p < 0.05) but enhanced their apoptosis (p < 0.05). Also, inhibition of Glut-1 expression resulted in an increased proportion of cells in G0/G1 phase and a significantly decreased proportion in G2/M phase (p < 0.05).

CONCLUSIONS

Elevated Glut-1 expression may promote the development of VCL by upregulating laryngeal H⁺/K⁺-ATPase expression to reactivate absorbed pepsin, thus damaging the laryngeal mucosa.

Associations between gastro-oesophageal reflux disease and a range of diseases: an umbrella review of systematic reviews and meta-analyses

OBJECTIVE

Numerous meta-analyses have revealed the association between gastro-oesophageal reflux disease (GORD) and a range of diseases; however, the certainty of the evidence remains unclear. This study aimed to summarise and assess the certainty of evidence derived from meta-analyses.

METHODS

Embase, PubMed, Web of Science, Cochrane Databases of Systematic Reviews, CNKI and Wangfang databases from their inception to 22 February 2020 were queried for systematic reviews and meta-analyses on the association between GORD and various diseases. The methodological quality of the included studies was assessed using A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2), and evidence certainty was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Statistical analysis was conducted using Stata V.15.

RESULTS

Ten publications with associations between GORD and different types of diseases were included. There was high heterogeneity (I² >75%) among seven independent meta-analyses. Evidence for publication bias in two independent meta-analyses was also observed. According to the AMSTAR 2 approach, the methodological quality was high for 20% of meta-analyses, moderate for 10%, low for 40% and critically low for 30%. Based on GRADE approach, the certainty of evidence was high for the association between GORD and higher risk of chronic obstructive pulmonary disease (COPD) exacerbation (OR 5.37; 95% CI 2.71 to 10.64) and higher prevalence of oesophageal adenocarcinoma (OR 4.57; 95% CI 3.89 to 5.36), and it was moderate for the association between GORD and higher chronic rhinosinusitis prevalence (OR 2.16; 95% CI 1.37 to 3.48).

CONCLUSION

The association between GORD and a range of diseases was extensively studied, and our findings revealed a high certainty of evidence of the association between GORD and an increased risk of COPD exacerbation as well as increased prevalence of oesophageal adenocarcinoma. Further investigations using systematic reviews and meta-analyses of high methodological quality that include prospective large cohort studies and adjusted confounders are warranted.

PROSPERO REGISTRATION NUMBER

CRD42019122264.

Association between ambient air pollution and laryngeal neoplasms incidence in twelve major Chinese cities, 2006-2013

Epidemiological evidence has suggested that ambient air pollution is an increasingly important risk factor for respiratory diseases without assessing its influence on laryngeal neoplasms incidence in China. We constructed two-way fixed effect models and Poisson regression models to explore the effects of ambient air pollutants including nitrogen dioxide (NO₂), sulfur dioxide (SO₂), and particulate matter less than or equal to 10 μm in aerodynamic diameter (PM₁₀) on incidence of laryngeal neoplasms in twelve major cities in China over the period 2006-2013. The annual average concentration for PM₁₀, SO₂, and NO₂ was 107.22 μg/m³, 44.07 μg/m³, and 46.71 μg/m³ with standard deviations of 24.84 μg/m³, 13.68 μg/m³, and 9.19 μg/m³, respectively. We observed that ambient air pollutants were significantly positively correlated with the incidence of laryngeal neoplasms, especially for NO₂. The relative risks of overall incidence of laryngeal neoplasms in the current period were 1.20, 1.04, and 1.00 for NO₂, SO₂, and PM₁₀, with 95% confidence intervals (CIs) of 1.01-1.43, 0.93-1.16, and 0.96-1.05, respectively. Moreover, this deleterious impact was stronger in the male than in the female, likely due to genetic predisposition caused by longer exposure to more serious air pollution for men. Our findings complement the epidemiological evidence of laryngeal neoplasms due to ambient air pollution and reinforce the necessity of policy efforts to control the noxious air pollution emissions.

Gastroesophageal reflux disease and head and neck cancers: A systematic review and meta-analysis

PURPOSE

Gastroesophageal reflux disease (GERD) has been associated with head and neck cancer (HNC), including laryngeal and pharyngeal anatomical sites. A systematic review and meta-analysis was performed to examine these associations.

METHODS

Articles were retrieved from the Medline, Web of Science, Scopus, and Embase databases using keywords "gastroesophageal reflux disease", "laryngopharyngeal reflux", "head and neck cancer", and associated variants. Inclusion criteria were English language publications, human subjects, and controlled studies with described development of head and neck cancer among individuals with GERD. 13 studies with a total of 39,824 patients were included.

RESULTS

Overall, presence of GERD was associated with an increased risk of developing HNC (OR = 1.86, 95% Confidence Interval [CI] = 1.27-2.74). This association remained significant with laryngeal cancers (OR = 1.95, 95% CI = 1.33-2.86), but not pharyngeal cancers (OR = 1.56, 95% CI = 0.86-2.83). Subgroup analyses of hypopharyngeal (OR = 2.26, 95% CI = 0.67-7.68) and oropharyngeal subsites (OR = 1.39, 95% CI = 0.51-3.84) were not statistically significant. Meta-analysis of studies that objectively assessed reflux, such as pH monitor placement, showed statistical significance (OR = 2.81, 95% CI = 1.36-5.81), while studies that used subjective reporting or chart review of GERD were not significant (OR = 1.46, 95% CI = 0.89-2.40). Association between H. pylori infection and head and neck cancers was not statistically significant (OR = 2.66, 95% CI = 0.59-11.97).

CONCLUSION

A diagnosis of GERD is associated with a later diagnosis of HNC, but this association is not significant for pharyngeal cancers. Associations of GERD with HNC may be specific to laryngeal cancers.

LEVEL OF EVIDENCE

Systematic review and meta-analysis of case control studies (3a).

Incidence and survival for oropharynx and non-oropharynx head and neck cancers among veterans living with HIV

Background

People living with HIV/AIDS (PLWH) have an excess risk for head and neck squamous cell carcinoma (HNSCC) compared to the general U.S. population, but little is known about HIV‐specific risk factors associated with the incidence and outcomes HNSCC. We aim to identify clinical and HIV‐specific risk factors associated with oropharyngeal and non‐oropharyngeal HNSCC incidence and outcomes separately.

Methods

We constructed a retrospective cohort study of 45,052 PLWH aged 18 or above from the national Veteran Affairs (VA) Corporate Data from 1999 to 2015. We extracted demographic data and risk factor information, including history of alcohol abuse, smoking, CD4 count (cells/μl), and percent of follow‐up time with undetectable HIV viral load as time‐updated variables. We calculated the age‐standardized incidence rates of oropharyngeal and non‐oropharyngeal HNSCC and estimated adjusted hazard ratios (HR). We also examined overall survival using Kaplan–Meier curves and adjusted HR.

Results

The standardized incidence rate of oropharyngeal and non‐oropharyngeal HNSCC in this veteran cohort of PLWH is 23.0 (95% confidence intervals (CIs): 17.1‐28.9) and 55.4 (95% CI: 46.5‐64.3) per 100,000 person‐years, respectively. Nadir CD4 count ≤200 was associated with an increased risk of non‐oropharyngeal HNSCC (HR: 1.78; 95% CI: 1.31‐2.30 vs >200). Five‐year overall survival of OPSCC (37.0%) was significantly lower than non‐oropharyngeal HNSCC (49.1%).

Conclusions

PLWH who receive care in the VA had higher age‐adjusted HNSCC incidence rates than reported in the general population, suggesting that HIV and immunosuppression play a role. Additional studies should be conducted to study the interaction between HPV and HIV.

Analysis of reflux as the aetiology of laryngeal dysplasia progression through a matched case-control study

OBJECTIVES

Laryngeal dysplasia (LD) is a precancerous lesion of the larynx. In this study, the laryngeal tissue of patients with laryngeal dysplasia was taken as the research object, and the aetiology of reflux was analysed.

METHOD

Patients with laryngeal dysplasia after surgery were selected as our subjects. The levels of pepsin, enterokinase and bilirubin in laryngeal tissue samples of the two groups were detected by immunohistochemical method.

RESULTS

The OR values (95% CI) of pepsin, enterokinase and bilirubin were 0.67 (0.19-2.36), 0.80 (0.22-2.98) and 1.33 (0.30-5.96), respectively, in the univariate analysis. Besides, in the multivariate analysis, the OR values (95% CI) of pepsin, enterokinase and bilirubin were 0.57 (0.14-2.30), 0.73 (0.18-2.92) and 1.40 (0.30-6.53), respectively.

CONCLUSION

Larger sample size should be applied to prospective studies on whether reflux is a risk factor for laryngeal cancer.

Pepsin and Laryngeal and Hypopharyngeal Carcinomas

Laryngeal and hypopharyngeal carcinomas are common malignant tumors of the head and neck, and the incidence of both is increasing. Laryngopharyngeal reflux refers to the retrograde flow of gastric contents into the larynx, oropharynx, and/or nasopharynx. It remains controversial whether laryngopharyngeal reflux is a risk factor for laryngeal and hypopharyngeal cancers. The refluxing substances mainly include hydrochloric acid, pepsin, and occasionally bile acids and bile salts, as well as bacteria that colonize the gastrointestinal tract. Loss of epithelium in the mucous membrane of the larynx and hypopharynx is thought to be caused by pepsin. Here, we review the relationships between laryngopharyngeal reflux and both laryngeal and hypopharyngeal carcinomas, as well as the significance of pepsin, methods of clinical detection, and the mechanism of carcinogenesis.

Assessment and Diagnostic Accuracy Evaluation of the Reflux Symptom Index (RSI) Scale: Psychometric Properties using Optimal Scaling Techniques

OBJECTIVES

To investigate the psychometric properties of the reflux symptom index (RSI) as short screening approach for the diagnostic of laryngopharyngeal reflux (LPR) in patients with confirmed diagnosed regarding the 24-hour multichannel intraluminal impedance-pH monitoring (MII-pH).

METHODS

From January 2017 to December 2018, 56 patients with LPR symptoms and 71 healthy individuals (control group) were prospectively enrolled. The LPR diagnosis was confirmed through MII-pH results. All subjects (n = 127) fulfilled RSI and the Reflux Finding Score (RFS) was performed through flexible fiberoptic endoscopy. The sensitivity and the specificity of RSI was assessed by ROC (Receiver Operating Characteristic) analysis.

RESULTS

A total of 15 LPR patients (26.8%) of the clinical group met MII-pH diagnostic criteria. Among subjects classified as positive for MII- pH diagnoses, RSI and RFS mean scores were respectively 20 (SD ± 10.5) and 7.1 (SD ± 2.5), values not significantly different compared to the negative MII-pH group. The metric analysis of the items led to the realization of a binary recoding of the score. Both versions had similar psychometric properties, α was 0.840 for RSI original version and 0.836 for RSI binary version. High and comparable area under curve (AUC) values indicate a good ability of both scales to discriminate between individuals with and without LPR pathology diagnosis. Based on balanced sensitivity and specificity, the optimal cut-off scores for LPR pathology were ≥ 5 for RSI binary version and ≥ 15 for RSI original version. Both version overestimated LPR prevalence. The original version had more sensitivity and the RSI Binary version had more specificity.

CONCLUSIONS

It would be necessary to think about modifying the original RSI in order to improve its sensitivity and specificity (RSI binary version, adding or changing some items), or to introduce new scores in order to better frame the probably affected of LPR patient.

OGFOD1 negatively regulated by miR-1224-5p promotes proliferation in human papillomavirus-infected laryngeal papillomas

Laryngeal papillomas (LP) is a difficult disease to manage due to its frequent recurrence, airway compromise, and risk of cancer. Recently, growing evidence indicates the aberrant expression of OGFPD1, a stress granule protein, links closely to the development of tumorigenesis; however, little is known about its role in LP progression. Here, we investigated the tumor promoting action of OGFOD1 in LP. The transcriptional and translational levels of OGFOD1 were significantly up-regulated in LP tissues and cells. Moreover, OGFOD1 promoted viability and proliferation, and inhibited LP cells apoptosis. We further revealed that OGFOD1 was directly targeted by miR-1224-5p, which was significantly down-regulated in LP. Overexpression of the miR-1224-5p suppressed OGFOD1-induced cell proliferation and viability, and promoted apoptosis of LP. In accordance, knockdown of miR-1224-5p inversed the inhibitory effects. In confederation of the central involvement of OGFOD1 in LP progression, targeting the miR-1224-5p/OGFOD1 pathway might provide a novel strategy for LP treatment.