Upper gastrointestinal endoscopy does not reassure patients with functional dyspepsia

BACKGROUND AND STUDY AIMS

Upper gastrointestinal endoscopy in patients with functional dyspepsia is often carried out merely to reassure patients that symptoms are not due to serious pathology. The aim of this study was to compare anxiety, depression, and health-related quality of life as proxy values for reassurance in patients with functional dyspepsia before and after upper gastrointestinal endoscopy.

PATIENTS AND METHODS

Consecutive patients referred for endoscopy between February 2002 and February 2004 were included in the study. They were asked to score anxiety and depression using the Hospital Anxiety and Depression Scale, health-related quality of life using the EuroQol-5D questionnaire, and their impression of their own general health using a visual analogue scale, 2 weeks before endoscopy and again 1 month afterwards.

RESULTS

A total of 420 patients were included, 42 % of whom were found to have an organic abnormality of some sort during upper gastrointestinal endoscopy. Neither the anxiety nor the depression frequencies differed significantly before and after endoscopy, either in patients with organic abnormalities at endoscopy or in those without. The general impression of health did not change after endoscopy either: organic abnormalities 62.7 +/- 27.4 vs. 64.9 +/- 24.2, P = 0.28; functional dyspepsia 61.0 +/- 27.9 vs. 62.8 +/- 27.2, P = 0.39. Only patients who had organic abnormalities reported a slightly improved quality of life 1 month after endoscopy: 0.74 +/- 0.15 vs. 0.78 +/- 0.12, P < 0.01.

CONCLUSION

In patients with functional dyspepsia, upper gastrointestinal endoscopy does not improve psychological well-being or health-related quality of life. In view of the invasiveness, cost, and potential harm associated with endoscopy, careful consideration should be given to whether this procedure should be carried out merely for the sake of the patient's "peace of mind".

Gain-of-function mutations in the tumor suppressor gene p53

The tumor suppressor protein p53 is a multifunctional transcription factor involved in the control of cell cycle progression, DNA integrity, and cell survival. p53 is mutated in half of all tumors and has a wide spectrum of mutation types. p53 mutants show different degrees of dominance over coexpressed wild-type p53, and loss of the wild-type p53 allele has been observed frequently. Several p53 mutants can exert oncogenic functions beyond their negative domination over the wild-type p53 tumor suppressor functions. These so-called gain-of-function effects, such as enhancement of tumorigenicity and therapy resistance, were investigated in p53-null cells. The possible mechanisms by which p53 mutants exert their gain-of-function effects are reviewed. The existence of functional gains of certain p53 mutants has important ramifications for tumor prognosis and cancer therapies.

Oral field cancerization: carcinogen-induced independent events or micrometastatic deposits?

Patients with a head and neck squamous cell carcinoma (HNSCC) often develop multiple (pre)malignant lesions. This finding led to the field cancerization theory, which hypothesizes that the entire epithelial surface of the upper aerodigestive tract has an increased risk for the development of (pre)malignant lesions because of multiple genetic abnormalities in the whole tissue region. Demonstration of alterations in histologically normal tumor-adjacent mucosa from HNSCC patients supported this hypothesis. Currently, the question has been raised whether multiple lesions develop independently from each other or from migrated malignant or progenitor cells. The majority of the mucosal alterations appear to be related to the exposure to alcohol and/or tobacco. Moreover, almost all primary remote tumors from HNSCC patients appear to be clonally unrelated. Therefore, there is more evidence that field cancerization is due to multiple independent events than to migration of genetically altered cells.

The origins of multiple squamous cell carcinomas in the aerodigestive tract

BACKGROUND

Chemoprevention and cessation of smoking and alcohol may prevent development of multiple tumors (MTs) in the aerodigestive tract if new MTs arise independently, but they are of no benefit if MTs are due to migration of an already transformed clone of tumor cells. This issue was addressed in this study by investigation of the clonality among MTs.

METHODS

Mutation analysis of the entire coding region of p53 and loss of heterozygosity (LOH) pattern analysis of microsatellite markers on chromosome arms 3p, 9p, and 17p are promising for the investigation of clonality. In the first part of this study, the authors established the variability and stability of these clonal markers by comparing primary head and neck squamous cell carcinomas (HNSCCs) with their metastases. In the second part of this study, the authors evaluated nine patients with multiple HNSCCs using these markers. In the final part, the authors illustrate the use of these clonal markers in 11 patients for whom there was diagnostic uncertainty as to whether their second squamous cell carcinoma was either a new primary tumor, a metastasis, or a recurrence.

RESULTS

Both p53 gene mutations and LOH patterns were stable during tumor progression. Furthermore, the variability of p53 gene mutations was high. More than 90% of the tumors contained a p53 mutation. A particular mutation never occurred more than twice in a total of 69 primary HNSCCs. Five of 69 cases presented a common mutation. In contrast, LOH patterns showed less variability; they were identical in 5 of 16 cases. The metachronous HNSCCs from nine patients all showed different p53 mutations, and in the three cases that were subjected to LOH analysis different patterns were observed. All 11 patients for whom there was diagnostic uncertainty about the origin of their second squamous cell carcinoma could be categorized as having multiple primary tumors, disseminated disease, or recurrent disease.

CONCLUSIONS

Metachronous HNSCCs at different locations are not clonally related and thus have not developed from the migration of tumor cells.

p53 overexpression in oral mucosa in relation to smoking

The tumour-suppressor protein p53 is mutated in many head and neck squamous cell carcinomas (HNSCCs). In this immunohistochemical study, similar numbers of p53-overexpressing cells were uniformly distributed throughout normal oral epithelium, irrespective of different smoking habits or the presence of an adjacent HNSCC. In a previous study, an increased number of proliferating cells were observed in normal oral mucosa from (ex)-smoking individuals and the present observations indicate that overexpression of p53 does not play a role in this increase. In contrast, focally overexpressed p53 occurred more frequently (p<0.05) in the tumour-adjacent normal mucosa (TAM) from smoking HNSCC patients (50 per cent) than in that from non-smoking HNSCC patients (20 per cent). This increase in focal p53 overexpression might represent an early alteration in the development of HNSCC, but it could not be detected in mucosa from healthy smokers. This indicates that besides the abuse of tobacco, other environmental and/or genetic factors must contribute to the presence of p53-positive clusters in TAM. Abuse of alcohol, an additional factor in these HNSCC patients, together with the abuse of tobacco, might play a role in the development of the p53-positive clusters.

Influence of cytotoxicity enhancers in combination with human serum on the activity of CD22-recombinant ricin A against B cell lines, chronic and acute lymphocytic leukemia cells

Despite the strong in vitro activity of some immunotoxins (ITs), clinical application did not result in complete cure. The outcome of therapy may be improved by combining ITs with IT-cytotoxicity enhancing agents. We studied the effect of various agents that influence the intracellular routing of ITs on the activity of the anti-B cell IT CD22-recombinant (rec) ricin A. In protein synthesis inhibition assays the carboxylic ionophores monensin and nigericin enhanced the activity of the IT 117- and 382-fold, respectively, against the cell line Daudi, and 81- and 318-fold, respectively, against the cell line Ramos. IT activity to Daudi and Ramos was enhanced to a lesser extent by the lysosomotropic amines chloroquine (14- and 11-fold, respectively) and NH4Cl (nine- and 10-fold, respectively). However, the combination of NH4Cl and chloroquine induced more than an additive effect (145- and 107-fold, respectively). Cytotoxicity was not influenced by brefeldin A, all-trans retinoic acid (ATRA), verapamil and perhexiline maleate. Bacitracin enhanced the IT cytotoxicity in contrast to the other protease inhibitors aprotinin, leupeptin and soybean trypsin inhibitor, albeit enhancement was weak (two-fold). The enhancers exerted only a negligible effect on bone marrow progenitor cells. We recently developed a flow cytometric cytotoxicity assay in which cell elimination can be assessed. In order to detect enhancement in this assay, we used 5 x 10(-11) M IT (approximately the 50% protein synthesis inhibiting dose (ID50)). This concentration killed 41% of the Daudi cells and 42% of the Ramos cells. In the presence of 10 nM monensin the IT killed 74% and 99% and in the presence of 10 nM nigericin 96% and 99% of the Daudi and Ramos cells, respectively. At 10(-8) M, CD22-rec ricin A eliminated malignant cells originating from three patients with B-CLL (0.42 log) and two with B-ALL (0.19 log) patients. Cytotoxicity to malignant cells was enhanced by NH4Cl, chloroquine, monensin and nigericin. The combination of NH4Cl and chloroquine enhanced the activity most effectively (up to 2.06 log). To determine the applicability of the IT in combination with enhancers in vivo we investigated the effect of human serum. Human serum inhibited IT activity which could not be restored by monensin and nigericin because of complete inhibition of these enhancers by serum. In contrast, chloroquine partially restored the activity of CD22-rec ricin A in the presence of human serum. We conclude that monensin, nigericin and the combination of NH4Cl and chloroquine can be used instead of NH4Cl to potentiate CD22-rec ricin A activity in purging autologous bone marrow transplants contaminated with malignant B cells. Chloroquine might be a promising enhancer of CD22-rec ricin A for treating patients in vivo.

Expression of p21 (Waf1/Cip1) in head and neck cancer in relation to proliferation, differentiation, p53 status and cyclin D1 expression

p21(Waf1/Cipl) is a critical downstream effector in the p53-dependent pathway of growth control and causes growth arrest through inhibition of cyclin-dependent kinases. In this study 67% of 43 head and neck squamous cell carcinoma (HNSCC) and 60% of 15 tumour-adjacent oral dysplasias overexpressed p21 by immunohistochemical staining. Overexpression of p21 in HNSCC was independent of the presence of functional p53, as assessed by analysis of mutations and loss of heterozygosity and by immunohistochemisty. Rather, the expression pattern of p21 was associated with differentiation. Furthermore, in most tumours, the p21 positive cells did not incorporate bromodeoxyuridine (BrdU), which indicates inhibition of proliferation by p21 in these cells. In some tumours, p21 was also expressed in proliferating cells. In these latter tumour cells, cyclin D1 was frequently expressed as well. Therefore, we suggest that expression of cyclin D1 might overcome the inhibitory effect of p21 in these cells.

Increased number of proliferating cells in oral epithelium from smokers and ex-smokers

To analyse initial tobacco-related cellular alterations in the upper aerodigestive tract, we investigated the proliferation state in paraffin embedded samples of tumour-adjacent histologically normal mucosa from head and neck squamous cell carcinoma (HNSCC) patients and normal buccal mucosa from healthy individuals. The proliferation index (PI) was assessed by indirect immunohistochemical staining for the proliferation marker Ki-67. Only a slight rise in PI was seen in the normal epithelium from non-smoking HNSCC patients in comparison with the epithelium from non-smoking healthy individuals. The epithelia from the smoking HNSCC patients and from the healthy smoking individuals both showed an increased PI compared with epithelia from the non-smoking HNSCC patients and healthy individuals (P = 0.001). In addition, the ex-smokers in both groups still showed a trend towards increased PI. Increased PI after cessation of smoking could indicate permanent epithelial alterations. Our findings provide new evidence for the concept of field cancerisation.

Positivity of the proliferation marker Ki-67 in noncycling cells

Ki-67 is a proliferation marker that is often used to estimate the growth fraction of tumors and other tissues. This antigen is expressed during all phases of the cell cycle but not in quiescent G0 cells. Many studies fail to indicate that the Ki-67 antigen can be expressed even when DNA synthesis is blocked. We studied the expression of the antigen Ki-67 in cycle-arrested osteosarcoma cells. We found that these cells are positive for Ki-67 even when they are arrested in G1/S or G2/M by using synchronizing inhibitors, by inducing p21(Waf1/Cip1) in a tetracycline-regulated expression system or by inducing wild type p53 and p21 after inflicting DNA damage. Our results show that not all cells containing the Ki-67 antigen are actively proliferating cells and we advise against the use of Ki-67 in studies on cells that overexpress p53 or p21.

Overexpression of c-Src in areas of hyperproliferation in head and neck cancer, premalignant lesions and benign mucosal disorders

To examine which proteins are responsible for the elevated protein tyrosine kinase (PTK) activity in human head and neck squamous cell carcinoma (HNSCC) and adjacent histologically normal epithelium, paraffin embedded sections of these tissues were stained for PTK c-Src. Using double labeling techniques and antibodies against both the proliferation marker Ki-67 and PTK c-Src, we have shown that c-Src is overexpressed in areas of hyperproliferation in HNSCC, dysplastic epithelium, benign papillomas and inflamed normal tissue. Our data indicate that c-Src is (one of) the protein(s) responsible for the increased PTK activity in HNSCC. We could not demonstrate that c-Src expression is responsible for the increased PTK activity in normal epithelium adjacent to tumour tissue. We assume that c-Src plays a role in the increased proliferation seen in (pre)malignant and benign epithelial lesions as well as in reactive inflammatory epithelial hyperplasia.

Increased expression of epidermal growth factor receptor in normal epithelium adjacent to head and neck carcinomas independent of tobacco and alcohol abuse

OBJECTIVE

In this study we examined if expression of the epidermal growth factor receptor (EGFR) in normal epithelium adjacent to head and neck squamous cell carcinomas (HNSCC) is increased and if this increase is due to the use of tobacco and alcohol.

MATERIALS AND METHODS

Cut sections of formalin-fixed and paraffin-embedded material of histologically normal epithelium adjacent to HNSCC from 25 patients who smoke excessively and abuse alcohol, and 17 HNSCC patients who do not abuse tobacco and alcohol were compared with cut sections of normal epithelium from 27 control individuals. The sections were immunohistochemically stained for the EGFR.

RESULTS

We show an elevation of the expression of the EGFR in patients who smoke and drink excessively, that could also be ascertained, to a lesser extent, in patients that do not have a history of smoking or drinking (P = 0.08). We also find that the closer the epithelium lies to the HNSCC the higher the expression of the EGFR is.

CONCLUSIONS

Expression of the EGFR is increased in tumour-adjacent epithelium and this is not only due to the use of tobacco and/or alcohol. We suggest that paracrine effects of the HNSCC and migration of tumour cells may also play a role in this increased expression.