Barrett's Metaplasia Research Articles

Esophageal cancer: new developments in prevention and therapy

Esophageal carcinomas comprise 2 entities, squamous cell carcinoma and adenocarcinoma, which differ in pathogenesis and treatment. Elimination of inflammatory influences and risk factors, such as obesity and gastroesophageal reflux that contribute to a rising incidence of adenocarcinoma, is crucial for tumor prevention. In Germany, general endoscopic screening for upper GI tumors is not recommended, whereas endoscopic surveillance is applied in the presence of Barrett's metaplasia. In the future, better prediction models will be needed to identify patients at risk who will benefit from endoscopic surveillance. Precancerous lesions and early tumor stages can be removed endoscopically using modern resection methods. In recent years, therapeutic strategies for advanced esophageal tumors have undergone significant changes. In the multimodal treatment of locally advanced stages, radiochemotherapy remains to play a key role for squamous cell carcinoma, whereas new evidence highlights the importance of perioperative chemotherapy for the optimal management of adenocarcinoma. Systemic treatment options for both tumor entities have been significantly expanded due to the successful use of immune checkpoint inhibitors in adjuvant and palliative treatment regimen. Determination of PD-L1 and MSI status has therefore become decisive for the choice of therapy. In metastatic stages of adenocarcinoma, chemotherapy can now be supplemented by multiple antibodies directed against Her2, PD1, or claudin 18.2, and the antibody-drug conjugate trastuzumab deruxtecan has become a Her2-targeted option in second line treatment.

Distal esophageal spasm and gastroesophageal reflux disease: re-examining the association.

Distal esophageal spasm (DES) is a rare motility disorder presenting with dysphagia or chest pain. Although studies suggest a link between DES and gastroesophageal reflux disease (GERD), data supporting a distinct GERD-related phenotype are limited. This study aims to investigate demographic, symptomatic, and physiologic differences between DES subjects with and without GERD. A retrospective cohort analysis of DES patients determined by high resolution manometry (HRM) was conducted between February 2020 and January 2023. Demographics, medications, symptoms, and quantitative reflux testing data were collected. DES subjects with reflux (R-DES) were defined by presence of Los Angeles Grade B/C/D esophagitis, Barrett's metaplasia, or abnormal pH testing. DES subjects without reflux (NR-DES) had normal parameters. Statistical analysis employed two-sided or Wilcoxon Rank-Sum, Chi-squared, or Fisher's exact tests, and multivariate logistic regression. Of 69 DES subjects, 32 (46.3%) had GERD. R-DES and NR-DES patients had similar demographic variables except for higher BMI in R-DES (30.41 vs. 26.88, P= 0.01). R-DES and NR-DES shared similar symptom profiles (heartburn P= 0.67, dysphagia P= 0.448, chest pain P= 0.32). Proton pump inhibitor use was similar between groups (78.1% vs. 91.9%, P= 0.202). HRM metrics were comparable except for basal LES tone (20.7mmHg vs. 32.99mmHg, P= 0.03) and median IRP 11.82mmHg versus 17.20mmHg, P= 0.017). This study found no distinguishing clinical or physiologic differences between DES patients with and without GERD, challenging the historical emphasis of GERD in DES pathogenesis. The impact of GERD management on the natural history of DES remains uncertain.

Genomic Landscape of Adenocarcinomas Across the Gastroesophageal Junction: Moving on from the Siewert Classification.

To investigate how the Siewert classification of gastroesophageal junction adenocarcinomas correlates with genomic profiles. Current staging and treatment guidelines recommend that tumors with an epicenter less than 2cm into the gastric cardia be treated as esophageal cancers, while tumors with epicenter greater than 2cm into the cardia be staged and treated as gastric cancers. To date, however, few studies have compared the genomic profiles of the 3 Siewert classification groups to validate this distinction. Using targeted tumor sequencing data on patients with adenocarcinoma of the gastroesophageal junction previously treated with surgery at our institution, we compared genomic features across Siewert classification groups. A total of 350 patients were included: 121 had Siewert type I, 170 type II, and 59 type III. Comparisons by Siewert location revealed that Siewert type I and II were primarily characterized as the chromosomal instability (CIN) molecular subtype and displayed Barrett's metaplasia and p53 and cell cycle pathway dysregulation. Siewert type III tumors, by contrast, were more heterogeneous, including higher proportions of microsatellite instability (MSI) and genomically stable (GS) tumors and more frequently displayed ARID1A and somatic CDH1 alterations, signet ring cell features, and poor differentiation. Overall, Siewert type I and II tumors demonstrated greater genomic overlap with lower esophageal tumors, while Siewert type III tumors shared genomic features with gastric tumors. Overall, our results support recent updates in treatment and staging guidelines. Ultimately, however, molecular rather than anatomic classification may prove more valuable in determining staging, treatment, and prognosis.

Use of flexible transnasal esophagogastroscopy in patients with unclear globus sensation

Globus pharyngeus is acommon symptom with considerable suffering. Globus sensation can be caused by reflux. In many places, endoscopy of the esophagus is recommended for clarification, especially when there is aquestion about the presence of ahiatal hernia as the cause of reflux. Transnasal esophagogastroscopy (TNE) represents an alternative to conventional gastroesophagoscopy. It enables aquick low-complication examination of the upper aerodigestive tract in the sitting, non-sedated patient. The aim of this work was to assess the feasibility of outpatient TNE in patients with globus sensation. Furthermore, the results of dual-probe pH monitoring were compared with the results of TNE in order to assess the value of TNE in the clarification of globus sensation and reflux. In 30patients with globus symptoms, 24-hour dual-probe pH monitoring and TNE were performed. In pH monitoring, reflux number, fraction time, reflux surface area index, and DeMeester score were evaluated as indicators of laryngopharyngeal reflux (LPR) and gastroesophageal reflux (GERD). Abnormalities of the esophageal mucosa and the gastroesophageal junction were recorded in TNE. The results were compared. The TNE could be performed without any complications. Mean examination time was 5.34 ± 0.12 min. Reflux was measured in 80% of the patients (24/30) with pH monitoring. In almost half of these patients (46%), abnormalities were detected in TNE as indirect evidence of reflux. In addition to an axial hiatal hernia, these included mucosal changes such as erosive esophagitis and Barrett's metaplasia. Patients with ahiatal hernia also suffered significantly more often from LPR than patients without ahernia (9:1). TNE is aquick and safe examination method for diagnosing patients with an unclear globus sensation. Detection of ahiatal hernia can be seen as an indication of reflux disease. Lack of evidence of ahernia does not rule out reflux. Thus, TNE is auseful addition to pH monitoring in patients with globus sensation, because reflux-related changes in the mucosa can be recognized early and adequately treated.

Abstract 6099: Identification of intrinsic precursors of Barrett's and gastric intestinal metaplasia

Abstract The origin of Barrett's esophagus (BE) and gastric intestinal metaplasia (GIM), obligate precursors of esophageal adenocarcinoma (EAC) and intestinal gastric cancer (iGC), has intrigued investigators for decades and would likely guide preemptive strategies. From endoscopic biopsies of clinically confirmed BE and GIM, we have cloned stem cells committed to intestinal metaplasia in vitro. Remarkably, the gene expression profiles of BE and GIM stem cells are highly related down to broad arrays of transcription factors compared with stem cells of the normal gastric mucosa. Using cell surface markers in common between BE and GIM stem cells, we have identified clusters of cells at the squamocolumnar junction and the distal stomach in mice and have used Fluorescence-activated cell sorting (FACS) to clone these cells from both sites. These murine clones can be differentiated in air-liquid interface cultures, and both are committed to intestinal metaplasia marked by goblet cells and Alcian blue staining. To ask whether similar cells exist in humans, we generated stem cell libraries from endoscopic biopsies taken from the gastroesophageal junction (GEJ) and the antrum-body junction (ABJ) in patients without BE or GIM. FACS sorting of these stem cell libraries using the same cell surface markers common to BE and GIM stem cells and the murine precursors, we have identified stem cells from the GEJ and ABJ that show similar gene expression profiles and share a commitment to intestinal metaplasia upon in vitro differentiation. Using identical transformation protocols involving retrovirally transduced protooncogenes, we find that these transformed intrinsic cells give rise to tumors with expression profiles similar to EAC and iGC in TCGA datasets, whereas transformed gastric mucosal stem cells yield tumors marked by signet ring cells typical of diffuse gastric cancer. Lastly, we find that drugs we have developed that target the stem cells of BE and GIM also eliminate the putative precursor cells of BE and GIM, suggesting the potential of therapeutics that might eliminate the emergence of intestinal metaplasia and the cancers derived from them. Citation Format: Wa Xian, Frank McKeon, Yusuke Yamamoto, Melika Khorrami, Melina Khorrami, Zaal Mory, Jeremy Siegelman, Amber Su, Raul Caballero Montes, Ashley Hoffman, Jaffer Ajani, Christopher Crum, William Bachovchin, Shan Wang, Matthew Vincent, Crystal Nguyen. Identification of intrinsic precursors of Barrett's and gastric intestinal metaplasia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6099.

Esophageal Cancer with Early Onset in a Patient with Cri du Chat Syndrome.

In Cri du Chat (CdC), cancer as comorbidity is extremely rare. In databases from Denmark, Spain, Australia, New Zealand, and Japan, no cancer was reported; in Italy and Germany, four cancers were identified out of 321 CdCs. In a 29-year-old CdC patient, clinical investigations following hematemesis led to the diagnosis of esophageal adenocarcinoma (EAC). A high pain threshold was also observed. Conventional and molecular cytogenetic defined the size of the deletion, and exome analysis on the trio completed the molecular work. Cytogenetic analysis showed a de novo chromosomal alteration: 46,XY,ishdel(5)(p14.3)(D5S28-) and arr[GRCh37] 5p15.33p14.3(1498180_19955760)x1. A quantitative sensory test demonstrated a high heat threshold. A 18f-fluorodeoxyglucose PET/TC scan of the brain failed to detect reduction of metabolism in the somatosensory area or insular cortex. Exome analysis in the trio (patient and parents) failed to identify variants to be interpreted as a likely risk factor for EAC. We conclude that the presence of well-known risk factors (maleness, obesity, gastroesophageal reflux, and Barrett's metaplasia) in a patient with very limited capability of expressing discomfort or referring clinical symptoms have been the main risk factors for developing EAC. At present, based on the available data, there is no evidence of any increased risk of developing cancer in CdC patients.

A Review on the Extraction Process and Therapeutic Activity of Curcumin on Diabetes Mellitus and Cancer

Abstract: Turmeric or Curcuma Longa is a natural product whose medicinal properties have been widely studied and a wide range of therapeutic effects in various diseases, including neurodegenerative, liver, kidney damage, cancer and diabetes have been linked mainly to its curcuminoid content. In recent decades Diabetes has become an alarming global health problem due to the increasing prevalence of diabetes. The people who suffer from this disease and the consequences for them are devastating. In this review article we review the current basic and clinical evidence on the potential of curcumin / curcuminoids for the treatment of diabetes mainly due to its hypoglycemic, antioxidant and anti-inflammatory properties. Action of curcumin or curcuminoids as a hypoglycemic agent or only as a healing aid improve metabolic profile and improve diabetes-related complications such as diabetes nephropathy and cardiopathy are discussed. Interactions between curcumin and conventional antidiabetic drugs could be investigated in the treatment of diabetes Curcumin has also been shown to be a mediator of chemoresistance and radioresistance. Anticancer effects have been observed in a number of clinical trials, mainly a natural chemopreventive agent in colon and pancreatic cancer, cervical neoplasia and Barrett's metaplasia. Something clinical studies in healthy volunteers have shown low bioavailability of curcumin, calling into question the use of curcumin alone food additive Our clinical experience with curcumin and the antimetabolite gemcitabine in patients with advanced pancreatic cancer resulted in an objective response in less than 10% of patients with a small effect on survival. However, the safety of this combination has been proven. The potent antiproliferative effects of curcumin, which interact with multiple intracellular signaling pathways, may enhance the antitumor effects of gemcitabine. The Preclinical data lead to various, but still few, clinical trials (some ongoing) that demonstrated the potential effectiveness of the drug. this treatment as a chemopreventive or chemotherapeutic agent. This review focuses on clinical evidence including our experience with curcumin as a chemopreventive and therapeutic agent and background results in vitro.

OGC P05 Liquid biopsy in oesophageal cancer: a systematic review of blood biomarkers for early diagnosis

Abstract Background Oesophageal cancer is the 6th leading cause of cancer death worldwide, accounting for 1 in 18 cancer-related mortality in 2020. High mortality rates with oesophagogastric cancer is largely related to late diagnosis. In England and Wales, 35% of oesophagogastric cancers are diagnosed at stage 3 and 42% at stage 4. Early detection of oesophageal cancer improves survival. Currently, the only reliable and effective modality for early diagnosis is oesophagogastroduodenoscopy (OGD). However, OGD is an invasive procedure that carries risks, such as bleeding and visceral perforation. Thus, there is no national screening programme for oesophagogastric cancer, although patients with diagnosed Barrett's oesophagus undergo endoscopic surveillance. Cytological sampling devices such as Cytosponge and EsophaCap are less invasive but still require ingestion of a medical device, and are not without risks, including detachment of device, pharyngeal bleed, and failure to swallow. The discovery and validation of blood biomarkers for the screening and diagnosis of oesophageal cancer may provide advantages of non-invasive, rapid, and cost-effective testing. Yet, currently, there is no clinically validated blood screening biomarker. In this systematic review, we aim to identify developing blood biomarkers that have been described in the literature for early diagnosis of oesophageal cancer. Methods A systematic search was conducted on EMBASE (1974-), Medline (1947-), and Web of Science (1980-) from inception to 3rd November 2021. Exploded subject headings and combinations of keywords were used. Search terms used were [oesophageal cancer or oesophageal ca or oesophageal malignancy or oesophageal neoplasm or Barrett's oesophagus or Barrett's metaplasia] AND [Tumour biomarkers or tumour markers or biological marker] AND [diagnosis or early diagnosis or screening or detection or discrimination] AND [adenocarcinoma or squamous cell carcinoma] AND [blood or serum or plasma] AND [esophagus or oesophagus]. Papers describing blood biomarkers that hold potential in screening and diagnosing oesophageal cancer were included. We focussed on adenocarcinoma, and squamous cell carcinoma affecting the oesophagus and the oesophagogastric junction. Tumour markers with a role in more than one type of cancer were included. We excluded rarer histological types. Biomarkers utilised to prognosticate outcomes of therapy were excluded, as were markers of recurrence and “Pan-cancer” biomarkers. Titles and abstracts identified by electronic search were reviewed independently by two reviewers, using Rayyan. Conflict was resolved by a third independent reviewer. Results The electronic search yielded 2619 records. After removal of duplicates 2267 records remained for screening. Following screening of titles and abstracts, 130 studies remained for full-text review. After full-text review, 53 records fulfilled the criteria for detailed analysis and reporting. 86 additional papers were identified through manual searches and review of reference lists. Studies were published from diverse populations including: USA, China, Japan, Germany, Poland, India, Australia, Ireland, South Africa, Italy, Brazil, Turkey and Netherlands. Blood biomarkers investigated in the literature comprised classical tumour markers, such as CEA, SCC-AG, CA19–9, CA-125; inflammatory markers; metabolites; peptides and glycoproteins; enzymes; cytokines; volatile organic compounds; circulating tumour cells; miRNA; circulating DNA; long non-coding RNAs; circular RNAs; peripheral blood cell DNA/RNA; antibodies and tumour-associated antigens; and spectra from Raman spectroscopy. The most widely described markers were antibodies and tumour-associated antigens (61 papers) and miRNAs (25 papers). Several other panels with combinations of different types of markers are described. The highest area under receiver operating curve (AUC) was 0.99 from two papers. One paper described a panel of serum miRNA ratios (RNU6-1/miR-16-5p, miR-25-3p/miR-320a, let-7e-5p/miR-15b-5p, miR-30a-5p/miR-324-5p, miR-17-5p/miR-194-5p). The other described a serum N-glycan with mass:charge ratio of 2244. Conclusions Several blood biomarkers with a potential role in screening or diagnosis of oesophageal cancer have been described in the literature. The results of some tests suggest promising diagnostic accuracy with two papers having AUCs of 0.99. Despite this however, no single test has come into clinical practice as a non-invasive diagnostic test. The gold standard in diagnosing oesophageal squamous cell carcinoma and oesophageal adenocarcinoma remains to be endoscopy and biopsy. Reasons for these markers not being utilised in clinical practice to date include need for further studies to validate results with larger sample size; challenges in reproducibility of studies; cost and lack of availability of techniques used in hospital; and other challenges to translate scientific studies into clinical application. There seem to be promising candidates liquid biopsy markers in oesophageal cancer, but further work is required to validate and translate the use of some promising markers into clinical practice.

AI-assisted discovery of an ethnicity-influenced driver of cell transformation in esophageal and gastroesophageal junction adenocarcinomas.

Although Barrett's metaplasia of the esophagus (BE) is the only known precursor lesion to esophageal adenocarcinomas (EACs), drivers of cellular transformation in BE remain incompletely understood. We use an artificial intelligence-guided network approach to study EAC initiation and progression. Key predictions are subsequently validated in a human organoid model, in patient-derived biopsy specimens of BE, a case-control study of genomics of BE progression, and in a cross-sectional study of 113 patients with BE and EACs. Our model classified healthy esophagus from BE and BE from EACs in several publicly available gene expression data sets (n = 932 samples). The model confirmed that all EACs must originate from BE and pinpointed a CXCL8/IL8↔neutrophil immune microenvironment as a driver of cellular transformation in EACs and gastroesophageal junction adenocarcinomas. This driver is prominent in White individuals but is notably absent in African Americans (AAs). Network-derived gene signatures, independent signatures of neutrophil processes, CXCL8/IL8 expression, and an absolute neutrophil count (ANC) are associated with risk of progression. SNPs associated with changes in ANC by ethnicity (e.g., benign ethnic neutropenia [BEN]) modify that risk. Findings define a racially influenced immunological basis for cell transformation and suggest that BEN in AAs may be a deterrent to BE→EAC progression.

An Endoscopic and Histologic Study on Healing of Radiofrequency Ablation Wounds in Patients With Barrett's Esophagus.

Radiofrequency ablation (RFA) of Barrett's esophagus (BE) inflicts a wound spanning 3 epithelial types (stratified squamous, Barrett's metaplasia, gastric epithelium), yet the esophageal injury heals almost completely with squamous epithelium. Knowledge of how this unique wound heals might elucidate mechanisms underlying esophageal metaplasia. We aimed to prospectively and systematically characterize the early endoscopic and histologic features of RFA wound healing. Patients with nondysplastic BE had endoscopy with systematic esophageal photographic mapping, biopsy, and volumetric laser endomicroscopy performed before and at 1, 2, and 4 weeks after RFA. Seven patients (6 men; mean age 56.1 ± 10.9 years) completed this study. Squamous re-epithelialization of RFA wounds did not only progress exclusively through squamous cells extending from the proximal wound edge but also progressed through islands of squamous epithelium sprouting throughout the ablated segment. Volumetric laser endomicroscopy revealed significant post-RFA increases in subepithelial glandular structures associated with the squamous islands. In 2 patients, biopsies of such islands revealed newly forming squamous epithelium contiguous with immature-appearing squamous cells arising from esophageal submucosal gland ducts. Subsquamous intestinal metaplasia (SSIM) was found in biopsies at 2 and/or 4 weeks after RFA in 6 of 7 patients. RFA wounds in BE are re-epithelialized, not just by squamous cells from the proximal wound margin but by scattered squamous islands in which esophageal submucosal gland duct cells seem to redifferentiate into the squamous progenitors that fuel squamous re-epithelialization. SSIM can be found in most patients during the healing process. We speculate that this SSIM might underlie Barrett's recurrences after apparently successful eradication.

Patient Selection in One Anastomosis/Mini Gastric Bypass-an Expert Modified Delphi Consensus.

One anastomosis/mini gastric bypass (OAGB/MGB) is up to date the third most performed obesity and metabolic procedure worldwide, which recently has been endorsed by ASMBS. The main criticisms are the risk of bile reflux, esophageal cancer, and malnutrition. Although IFSO has recognized this procedure, guidance is needed regarding selection criteria. To give clinicians a daily support in performing the right patient selection in OAGB/MGB, the aim of this paper is to generate clinical guidelines based on an expert modified Delphi consensus. A committee of 57 recognized bariatric surgeons from 24 countries created 69 statements. Modified Delphi consensus voting was performed in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was considered to indicate a consensus. Consensus was achieved for 56 statements. Remarkably, ≥ 90.0% of the experts felt that OAGB/MGB is an acceptable and suitable option "in patients with Body mass index (BMI) > 70, BMI > 60, BMI > 50kg/m2 as a one-stage procedure," "as the second stage of a two-stage bariatric surgery after Sleeve Gastrectomy for BMI > 50kg/m2 (instead of BPD/DS)," and "in patients with weight regain after restrictive procedures. No consensus was reached on the statement that OAGB/MGB is a suitable option in case of resistant Helicobacter pylori. This is likely as there is a concern that this procedure is associated with reflux and its related long-term complications including risk of cancer in the esophagus or stomach. Also no consensus reached on OAGB/MGB as conversional surgery in patients with GERD after restrictive procedures. Consensus for disagreement was predominantly achieved "in case of intestinal metaplasia of the stomach" (74.55%), "in patients with severe Gastro Esophageal Reflux Disease (GERD)(C,D)" (75.44%), "in patients with Barrett's metaplasia" (89.29%), and "in documented insulinoma" (89.47%). Patient selection in OAGB/MGB is still a point of discussion among experts. There was consensus that OAGB/MGB is a suitable option in elderly patients, patients with low BMI (30-35kg/m2) with associated metabolic problems, and patients with BMIs more than 50kg/m2 as one-stage procedure. OAGB/MGB can also be a safe procedure in vegetarian and vegan patients. Although OAGB/MGB can be a suitable procedure in patients with large hiatal hernia with concurrent hiatal hernia, it should not be offered to patients with grade C or D esophagitis or Barrett's metaplasia.

A human Barrett's esophagus organoid system reveals epithelial-mesenchymal plasticity induced by acid and bile salts.

The pathogenesis of subsquamous intestinal metaplasia (SSIM), in which glands of Barrett's esophagus (BE) are buried under esophageal squamous epithelium, is unknown. In a rat model of reflux esophagitis, we found that columnar-lined esophagus developed via a wound-healing process involving epithelial-mesenchymal plasticity (EMP) that buried glands under ulcerated squamous epithelium. To explore a role for reflux-induced EMP in BE, we established and characterized human Barrett's organoids and sought evidence of EMP after treatment with acidic bile salts (AB). We optimized media to grow human BE organoids from immortalized human Barrett's cells and from BE biopsies from seven patients, and we characterized histological, morphological, and molecular features of organoid development. Features and markers of EMP were explored following organoid exposure to AB, with and without a collagen I (COL1) matrix to simulate a wound-healing environment. All media successfully initiated organoid growth, but advanced DMEM/F12 (aDMEM) was best at sustaining organoid viability. Using aDMEM, organoids comprising nongoblet and goblet columnar cells that expressed gastric and intestinal cell markers were generated from BE biopsies of all seven patients. After AB treatment, early-stage Barrett's organoids exhibited EMP with loss of membranous E-cadherin and increased protrusive cell migration, events significantly enhanced by COL1. Using human BE biopsies, we have established Barrett's organoids that recapitulate key histological and molecular features of BE to serve as high-fidelity BE models. Our findings suggest that reflux can induce EMP in human BE, potentially enabling Barrett's cells to migrate under adjacent squamous epithelium to form SSIM.NEW & NOTEWORTHY Using Barrett's esophagus (BE) biopsies, we established organoids recapitulating key BE features. During early stages of organoid development, a GERD-like wound environment-induced features of epithelial-mesenchymal plasticity (EMP) in Barrett's progenitor cells, suggesting that reflux-induced EMP can enable Barrett's cells to migrate underneath squamous epithelium to form subsquamous intestinal metaplasia, a condition that may underlie Barrett's cancers that escape detection by endoscopic surveillance, and recurrences of Barrett's metaplasia following endoscopic eradication therapy.

Threshold evaluation for optimal number of endoscopic treatment sessions to achieve complete eradication of Barrett's metaplasia.

Endoscopic eradication therapy (EET) is the standard of care for Barrett's esophagus (BE)-associated neoplasia. Previous data suggest the mean number of EET sessions required to achieve complete eradication of intestinal metaplasia (CE-IM) is 3. This study aimed to define the threshold of EET sessions required to achieve CE-IM. The TREAT-BE Consortium is a multicenter outcomes cohort including prospectively enrolled patients with BE undergoing EET. All patients achieving CE-IM were included. Demographic, endoscopic, and histologic data were recorded at treatment onset along with treatment details and surveillance data. Kaplan-Meier analysis was performed to define a threshold of EET sessions, with 95 %CI, required to achieve CE-IM. A secondary analysis examined predictors of incomplete response to EET using multiple logistic regression and recurrence rates. 623 patients (mean age 65.2 [SD 11.6], 79.6 % male, 86.5 % Caucasian) achieved CE-IM in a mean of 2.9 (SD 1.7) EET sessions (median 2) and a median total observation period of 2.7 years (interquartile range 1.4-5.0). After three sessions, 73 % of patients achieved CE-IM (95 %CI 70 %-77 %). Age (odds ratio [OR] 1.25, 95 %CI 1.05-1.50) and length of BE (OR 1.24, 95 %CI 1.17-1.31) were significant predictors of incomplete response. The current study found that a threshold of three EET sessions would achieve CE-IM in the majority of patients. Alternative therapies and further diagnostic testing should be considered for patients who do not have significant response to EET after three sessions.

Computational pathology aids derivation of microRNA biomarker signals from Cytosponge samples.

SummaryBackgroundNon-endoscopic cell collection devices combined with biomarkers can detect Barrett's intestinal metaplasia and early oesophageal cancer. However, assays performed on multi-cellular samples lose information about the cell source of the biomarker signal. This cross-sectional study examines whether a bespoke artificial intelligence-based computational pathology tool could ascertain the cellular origin of microRNA biomarkers, to inform interpretation of the disease pathology, and confirm biomarker validity.MethodsThe microRNA expression profiles of 110 targets were assessed with a custom multiplexed panel in a cohort of 117 individuals with reflux that took a Cytosponge test. A computational pathology tool quantified the amount of columnar epithelium present in pathology slides, and results were correlated with microRNA signals. An independent cohort of 139 Cytosponges, each from an individual patient, was used to validate the findings via qPCR.FindingsSeventeen microRNAs are upregulated in BE compared to healthy squamous epithelia, of which 13 remain upregulated in dysplasia. A pathway enrichment analysis confirmed association to neoplastic and cell cycle regulation processes. Ten microRNAs positively correlated with columnar epithelium content, with miRNA-192–5p and -194–5p accurately detecting the presence of gastric cells (AUC 0.97 and 0.95). In contrast, miR-196a-5p is confirmed as a specific BE marker.InterpretationComputational pathology tools aid accurate cellular attribution of molecular signals. This innovative design with multiplex microRNA coupled with artificial intelligence has led to discovery of a quality control metric suitable for large scale application of the Cytosponge. Similar approaches could aid optimal interpretation of biomarkers for clinical use.FundingFunded by the NIHR Cambridge Biomedical Research Centre, the Medical Research Council, the Rosetrees and Stoneygate Trusts, and CRUK core grants.

Hybrid APC in Combination With Resection for the Endoscopic Treatment of Neoplastic Barrett's Esophagus: A Prospective, Multicenter Study.

INTRODUCTION:The current therapy of neoplastic Barrett's esophagus (BE) consists of endoscopic resection plus ablation, with radiofrequency ablation as the best studied technique. This prospective trial assesses a potential alternative, namely hybrid argon plasma ablation.METHODS:Consecutive patients with neoplastic BE undergoing ablation after curative endoscopic resection (89.6%) or primarily were included into this prospective trial in 9 European centers. Up to 5 ablation sessions were allowed for complete eradication of BE (initial complete eradication of intestinal metaplasia [CE-IM]), by definition including BE-associated neoplasia, documented by 1 negative endoscopy with biopsies. The main outcome was the rate of initial CE-IM in intention-to-treat (ITT) and per-protocol (PP) samples at 2 years. The secondary end points were the rate of recurrence-free cases (sustained CE-IM) documented by negative follow-up endoscopies with biopsies and immediate/delayed adverse events.RESULTS:One hundred fifty-four patients (133 men and 21 women, mean age 64 years) received a mean of 1.2 resection and 2.7 ablation sessions (range 1–5). Initial CE-IM was achieved in 87.2% of 148 cases in the PP analysis (ITT 88.4%); initial BE-associated neoplasia was 98.0%. On 2-year follow-up of the 129 successfully treated cases, 70.8% (PP) or 65.9% (ITT) showed sustained CE-IM; recurrences were mostly endoscopy-negative biopsy-proven BE epithelium and neoplasia in 3 cases. Adverse events were seen in 6.1%.DISCUSSION:Eradication and recurrence rates of Barrett's intestinal metaplasia and neoplasia by means of hybrid argon plasma coagulation at 2 years seem to be within expected ranges. Final evidence in comparison to radiofrequency ablation can only be provided by a randomized comparative trial.

Magnetic Sphincter Augmentation Outcomes in Severe Gastroesophageal Reflux Disease

Introduction: Outcomes of laparoscopic procedures for gastroesophageal reflux disease (GERD) are variable depending on surgical expertise and/or patient-related factors. Some procedures may be inadequate in patients with severe disease. Effectiveness of laparoscopic magnetic sphincter augmentation (MSA) has not been extensively tested in patients with severe disease.Methods: A prospectively collected database was analyzed to identify patients who underwent MSA at a single institution. Individuals who had previous esophago-gastric surgery were excluded. Severe GERD was defined as lower esophageal sphincter pressure <5 mmHg, distal esophageal amplitude <30 mmHg, Barrett's metaplasia, stricture or grade C-D esophagitis, and/or DeMeester score >50. Clinical characteristics and outcomes of patients with severe GERD were compared with those of patients with mild to moderate GERD who served as control group.Results: Over the study period, a total of 336 patients met the inclusion criteria, and 102 (30.4%) had severe GERD. The median follow-up was 24 months (IQR = 75) in severe GERD patients and 32 months (IQR = 84) in those with non-severe GERD. Patients with severe GERD had a higher rate of dysphagia and higher GERD-HRQL scores. After the MSA procedure, symptoms, health-related quality of life scores, and proton-pump inhibitors consumption significantly decreased in both groups (p < 0.05). No difference between groups was found in the prevalence of severe post-operative dysphagia, the need for endoscopic dilation or device removal, and the DeMeester score.Conclusion: Laparoscopic MSA is safe and effective in reducing symptoms, PPI use, and esophageal acid exposure also in patients with severe GERD.

Abstract 2671: SMAD4 as a potential gatekeeper for genomic instability and mTOR-mediated tumorigenesis in esophageal adenocarcinoma

Abstract Esophageal cancer is the 8th most common cancer worldwide and has the 6th highest mortality rate of all cancers. The 5-year survival rate following esophageal adenocarcinoma (EAC) diagnosis is dismal at less than 15 percent, indicating a dire need for improved therapeutic strategies and early detection. EAC develops stepwise following exposure to chronic gastric reflux: From pre-malignant Barrett's metaplasia, through stages of low- and high-grade dysplasia until developing into invasive cancer. Mutation or loss of common tumor suppressor genes TP53 and SMAD4 act as markers for cancer progression, occurring in high-grade dysplastic tissue and invasive EAC, respectively. Our novel in vivo tumorigenesis model demonstrates progression of Barrett's metaplasia to EAC, in which SMAD4-deficient Barrett's metaplasia cells form tumors in immunodeficient mice after a period of latency and in a dose-dependent manner. This delayed tumor growth onset suggests further drivers are required for oncogenesis, and these SMAD4-deficient cells and tumors display a greater degree of genomic instability than wildtype-SMAD4 controls. A genome-wide CRISPR-Cas9 knockout screen unveiled a synthetic lethal relationship between SMAD4-deficiency and cell cycle checkpoint inhibition, suggesting a role for SMAD4 in maintaining genomic stability and a potential novel therapeutic avenue for SMAD4-deficient EAC. Additionally, a concurrent in vivo CRISPR-Cas9 tumorigenesis screen produced tumors 4-fold faster than the previous model and identified regulators of mTOR signaling as co-operative drivers of tumorigenesis in EAC. Wildtype-SMAD4 cells failed to generate tumors despite undergoing the same genetic perturbations, indicating a potential gatekeeping effect of SMAD4 in mTOR-mediated EAC tumorigenesis. In sum, loss of SMAD4 acts as a double-edged sword, increasing genomic instability and thereby rendering EAC cells sensitive to cell cycle checkpoint inhibition, whilst simultaneously co-operating with modulated mTOR signaling to promote tumorigenesis in EAC xenograft models. Citation Format: Julia V. Milne, Jovana R. Gotovac, Kenji M. Fujihara, Cuong P. Duong, Wayne A. Phillips, Nicholas J. Clemons. SMAD4 as a potential gatekeeper for genomic instability and mTOR-mediated tumorigenesis in esophageal adenocarcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2671.

Hybrid Stomach-Intestinal Chromatin States Underlie Human Barrett’s Metaplasia

Tissue metaplasia is uncommon in adults because established cis-element programs resist rewiring. In Barrett's esophagus, the distal esophageal mucosa acquires a predominantly intestinal character, with notable gastric features, and is predisposed to developing invasive cancers. We sought to understand the chromatin underpinnings of Barrett's metaplasia and why it commonly displays simultaneous gastric and intestinal properties. We profiled cis-regulatory elements with active histone modifications in primary human biopsy materials using chromatin immunoprecipitation followed by DNA sequencing. Mutations in Barrett's esophagus were examined in relation to tissue-specific enhancer landscapes using a random forest machine-learning algorithm. We also profiled open chromatin at single-cell resolution in primary Barrett's biopsy specimens using the assay for transposase-accessible chromatin. We used 1- and 2-color immunohistochemistry to examine protein expression of tissue-restricted genes. Barrett's esophagus bears epigenome fingerprints of human stomach and intestinal columnar, but not esophageal squamous, epithelia. Mutational patterns were best explained as arising on the epigenome background of active gastric cis-elements, supporting the view that adjoining stomach epithelium is a likely tissue source. Individual cells in Barrett's metaplasia coexpress gastric and intestinal genes, reflecting concomitant chromatin access at enhancers ordinarily restricted to one or the other epithelium. Protein expression of stomach-specific mucins; CLDN18; and a novel gastric marker, ANXA10, showed extensive tissue and subclonal heterogeneity of dual stomach-intestinal cell states. These findings reveal mixed and dynamic tissue-restricted chromatin states and phenotypic heterogeneity in Barrett's esophagus. Pervasive intragland variation argues against stem-cell governance of this phenotype.

Forkhead box F1 induces columnar phenotype and epithelial-to-mesenchymal transition in esophageal squamous cells to initiate Barrett's like metaplasia

Multiple genome-wide association studies (GWAS) have linked Forkhead Box F1 (FOXF1) to Barrett's esophagus (BE). Understanding whether FOXF1 is involved in initiation of Barrett's metaplasia could allow FOXF1 to be used for risk stratification and for therapy. Two-dimensional cell cultures and three-dimensional organoid cultures and well-annotated human biopsies were used to determine the role of FOXF1 in BE pathogenesis. Multiple established esophageal squamous and BE cell lines were tested in gain- and loss-of-function studies. Initiation of a BE-like metaplastic change was evaluated by measuring characteristic cytokeratins and global gene expression profiling and by culturing organoids. Epithelial–mesenchymal transition (EMT) was evaluated by immunostaining for E-cadherin, vimentin and Snail, and by cell motility assay. Columnar esophageal epithelium of BE patients exhibited higher expression of FOXF1 compared to normal squamous esophageal epithelium of GERD patients (P < 0.001). Acidic bile salts induced nuclear FOXF1 in esophageal squamous cells. FOXF1 overexpression in normal esophageal squamous cells: (a) increased columnar cytokeratins and decreased squamous cytokeratins, (b) converted squamous organoids to glandular organoids, and (c) switched global gene profiles to resemble that of human BE epithelium (P = 2.1685e − 06 for upregulated genes and P = 8.3378e − 09 for downregulated genes). FOXF1 inhibition in BE cell lines led to loss of BE differentiation markers, CK7, and mucin 2. Also, FOXF1 induced EMT and promoted cell motility in normal esophageal squamous epithelial cells. FOXF1-induced genes mapped to pathways such as Cancer, Cellular Assembly and Organization, DNA Replication, Recombination, and Repair. In conclusion, FOXF1 promotes a BE-like columnar phenotype and cell motility in esophageal squamous epithelial cells, which may have a critical role in BE development. FOXF1 should be studied further as a biomarker for BE and as a target for BE treatment.

How extent of Barrett's metaplasia influences the risk of esophageal adenocarcinoma.

This review will focus on how the extent of Barrett's metaplasia influences the risk of esophageal adenocarcinoma (EAC). More specifically, this review will discuss the concepts of long and short-segment Barrett's metaplasia and irregular Z line as they relate to EAC risk. The Prague classification can standardize reporting of Barrett's metaplasia. Recent literature has found significant associations between the length of Barrett's metaplasia and increased progression risk to EAC in multiple geographically distinct populations. Length of Barrett's metaplasia has been incorporated into the Progression of Barrett's esophagus (PIB) model that can predict individualized life-time risks of progression. The risk of malignant transformation appears to be very low in patients with irregular Z line. Length of Barrett's metaplasia has emerged as an important predictor that can influence the risk of EAC and should be reported using the Prague classification. The PIB model, if further validated, could help a practicing gastroenterologist to inform patients with Barrett's metaplasia about their personal risk of progression to tailor surveillance intervals. Current guidelines do not recommend surveillance in patients with irregular Z line, but careful examination is recommended.