Limited data are available on the epidemiology of gastroesophageal junction adenocarcinoma (GEJAC), particularly in comparison to esophageal adenocarcinoma (EAC). With the advent of molecular non-endoscopic Barrett’s esophagus (BE) detection tests which sample the esophagus and gastroesophageal junction, early detection of EAC and GEJAC has become a possibility and their epidemiology has gained importance. We sought to evaluate time trends in the epidemiology and survival of patients with EAC and GEJAC in a population-based cohort. EAC and GEJAC patients from 1976 to 2019 were identified using ICD 9 and 10 diagnostic codes from the Rochester Epidemiology Project (REP). Clinical data and survival status were abstracted. Poisson regression was used to calculate incidence rate ratios (IRR). Survival analysis and Cox proportional models were used to assess predictors of survival. We included 443 patients (287 EAC,156 GEJAC). The incidence of EAC and GEJAC during 1976–2019 was 1.40 (CI 1.1–1.74) and 0.83 (CI 0.61–1.11) per 100,000 people, respectively. There was an increase in the incidence of EAC (IRR = 2.45, p = 0.011) and GEJAC (IRR = 3.17, p = 0.08) from 2000 to 2004 compared to 1995–1999, plateauing in later time periods. Most patients had associated BE and presented at advanced stages, leading to high 5-year mortality rates (66

BACKGROUND & AIMS: Guidelines suggest a single screening esophagogastroduodenoscopy (EGD) in patients with multiple risk factors for Barrett's esophagus (BE). We aimed to determine BE prevalence and predictors on repeat EGD after a negative initial EGD, using 2 large national databases (GI Quality Improvement Consortium [GIQuIC] and TriNetX). METHODS: Patients who underwent at least 2 EGDs were included and those with BE or esophageal adenocarcinoma detected at initial EGD were excluded. Patient demographics and prevalence of BE on repeat EGD were collected. Multivariate logistic regression was performed to assess for independent risk factors for BE detected on the repeat EGD. RESULTS: In 214,318 and 153,445 patients undergoing at least 2 EGDs over a median follow-up of 28-35 months, the prevalence of BE on repeat EGD was 1.7% in GIQuIC and 3.4% in TriNetX, respectively (26%-45% of baseline BE prevalence). Most (89%) patients had nondysplastic BE. The prevalence of BE remained stable over time (from 1 to >5 years from negative initial EGD) but increased with increasing number of risk factors. BE prevalence in a high-risk population (gastroesophageal reflux disease plus >=;1 risk factor for BE) was 3%-4%. CONCLUSIONS: In this study of >350,000 patients, rates of BE on repeat EGD ranged from 1.7%-3.4%, and were higher in those with multiple risk factors. Most were likely missed at initial evaluation, underscoring the importance of a high-quality initial endoscopic examination. Although routine repeat endoscopic BE screening after a negative initial examination is not recommended, repeat screening may be considered in carefully selected patients with gastroesophageal reflux disease and double dagger 2 risk factors for BE, potentially using nonendoscopic tools.

INTRODUCTION:Endoscopic eradication therapy (EET) is standard of care for T1a esophageal adenocarcinoma (EAC). However, data on outcomes in high-risk T1a EAC are limited. We assessed and compared outcomes after EET of low-risk and high-risk T1a EAC, including intraluminal EAC recurrence, extraesophageal metastases, and overall survival. METHODS:Patients who underwent EET for T1a EAC at 3 referral Barrett's esophagus endotherapy units between 1996 and 2022 were included. Patients with submucosal invasion, positive deep margins, or metastases at initial diagnosis were excluded. High-risk T1a EAC was defined as T1a EAC with poor differentiation and/or lymphovascular invasion, with low-risk disease being defined without these features. All pathology was systematically assessed by expert gastrointestinal pathologists. Baseline and follow-up endoscopy and pathology data were abstracted. Time-to-event analyses were performed to compare outcomes between groups. RESULTS:One hundred eighty-eight patients with T1a EAC were included (high risk, n = 45; low risk, n = 143) with a median age of 70 years, and 84% were men. Groups were comparable for age, sex, Barrett's esophagus length, lesion size, and EET technique. Rates of delayed extraesophageal metastases (11.1% vs 1.4%) were significantly higher in the high-risk group ( P = 0.02). There was no significant difference in the rates of intraluminal EAC recurrence ( P = 0.79) and overall survival ( P = 0.73) between the 2 groups. DISCUSSION:Patients with high-risk T1a EAC undergoing successful EET had a substantially higher rate of extraesophageal metastases compared with those with low-risk T1a EAC on long-term follow-up. These data should be factored into discussions with patients while selecting treatment approaches. Additional prospective data in this area are critical.

Abstract Introduction: Barrett’s esophagus (BE) confers increased cancer risk. Endoscopic surveillance is recommended to distinguish non-dysplastic BE (NDBE), low grade dysplasia (LGD), high grade dysplasia (HGD), or adenocarcinoma (EAC) for endoscopic intervention. However, this paradigm is limited by sampling error, leading to missed/interval EAC. Herein, we aimed to classify these samples more accurately by performing whole genome methylation sequencing (WGMS) and utilizing multiple genomic features on endoscopic brush samples. Materials and methods: Endoscopic brush samples from patients with NDBE (n=18), HGD (18), EAC (18), and normal controls (18) were collected and underwent WGMS (discovery dataset). Sequence reads were processed through internal pipeline to extract CpG methylation and read level methylation ratio (alpha value). Copy number aberration (CNA) detection was performed using both CNVkit and ichorCNA. Differential methylated regions (DMRs) were identified through comparing EAC/HGD with NDBE and normal samples. Targeted methylation sequencing for selected DMRs and shallow WGMS were performed on EAC (41), HGD (26), LGD (23), NDBE (42), and normal controls (37) as validation. Ratio of the reads with alpha value>0.6 for each DMR was used for further analysis. Detected CNA segments were summarized into chromosome arm loss or gain (aneuploidy score or AS representing the number of chromosome arms gained or lost in a sample) and trimmed median absolute deviation (tMAD). Classification models were developed using the discovery set and the best performing one was applied to the validation dataset. Results: Genome-wide DNA methylation largely segregated different groups of samples as diagnosed; however, some unexpected group crossings were observed. Top 200 DMRs were identified between EAC/HGD and NDBE and normal samples. CNA changes were widespread in EAC, very common in HGD but rare in NDBE (17/18 EACs,14/18 HGDs, 5/18 NDBEs with AS>0). With tMAD > 0.015, 16/18 EACs, 8/18 HGDs but none of 18 NDBEs passed the threshold. EAC or HGD samples without detectable CNAs had very low “tumor” fraction as determined by methylation-based cell type deconvolution or ichorCNA. Similar results were found in the validation dataset. A multi-omics (AS, tMAD, estimated tumor fraction, and DMR methylation) model could predict EAC, HGD, or NDBE with 0.81 accuracy through cross validation (10X) and 0.73 in the independent dataset. This increased to 0.98 and 0.90 in separating high risk EAC/HGD from NDBE, respectively. Conclusion: Multi-omics data obtained from single WGMS allow for a comprehensive analysis of BE samples with varying dysplasia levels. Using classification modeling, these characteristics can be effectively used to accurately identify and distinguish between EAC and HGD from NDBE, suggesting their utility as adjuncts to endoscopic surveillance biopsies. Citation Format: Zhifu Sun, Caroline L. Matchett, Seth W. Slettedahl, William R. Taylor, Panwen Wang, Calise Berger, Caryn E. Anderson, Melissa A. Passe, Ramona Lansing, Collin E. Chalmers, Patrick H. Foote, Jeanette E. Eckel Passow, Doug W. Mahoney, John B. Kisiel, Prasad G. Iyer. Multi-omics cancer risk assessment of Barrett’s esophagus with DNA methylation sequencing from endoscopic brush samples [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr LB249.

Mayo Foundation for Medical Education and Research, USA.

Mayo Clinic Minnesota, USA; University Hospitals, USA; LSU Health Shreveport, USA.

Don Codipilly: NO financial relationship with a commercial interest | Erin Gibbons: NO financial relationship with a commercial interest | Ramona Lansing: NO financial relationship with a commercial interest | Dora Lam-Himlin: NO financial relationship with a commercial interest | Catherine Hagen: NO financial relationship with a commercial interest | Jason Lewis: NO financial relationship with a commercial interest | Tsung-Teh Wu: NO financial relationship with a commercial interest | Rish Pai: YES financial relationship with a commercial interest;Alimentiv inc:Consulting;Allergan :Consulting;verily:Consulting;Abbvie :Consulting;Eli Lilly Consulting | Kenneth Wang: NO financial relationship with a commercial interest | Cadman Leggett: YES financial relationship with a commercial interest;Verily Life Sciences:Consulting | Prasad Iyer: YES financial relationship with a commercial interest;Exact Sciences:Consulting;Exact Sciences:Grant/Research Support;Pentax:Grant/Research Support;Pentax:Consulting;Ambu:Consulting;Symple Surgical:Consulting;Medtronic:Consulting

Introduction: Sedated endoscopy for Barrett’s esophagus (BE) and esophageal adenocarcinoma (EAC) detection is invasive and expensive. Non-endoscopic BE/EAC detection tools have been guideline-endorsed to facilitate higher patient participation at lower cost. We previously described a promising panel of 5 methylated DNA markers (MDMs) assayed on esophageal specimens obtained by a sponge-on-a-string (SOS) cell collection device in phase II studies. We aimed to train an algorithm (establishing marker cut offs, to adjudicate samples as positive/negative) using a final MDM panel followed by testing in an independent sample set. Methods: Algorithm training samples (N=352) were prospectively collected from patients seen at 6 US medical centers. Test samples (N=125) were obtained from an independent, NIH-funded study conducted at 3 US medical centers. Cases had columnar metaplasia with intestinal metaplasia; controls had no endoscopic evidence of BE. Histology was reviewed by expert GI pathologists. The SOS device (25 mm, 10 ppi) was swallowed and withdrawn after 6-8 minutes followed by criterion standard endoscopy within 24 hours. DNA was extracted and bisulfite treated. Five MDMs were blindly assayed using the long probe quantitative amplified signal method. The algorithm was set using cross-validated logistic regression. The locked algorithm was applied to assay results from the test set. Results: Baseline characteristics of patients in training and test sets were comparable (Table). The final panel included 3 MDMs (NDRG4, VAV3, and ZNF682) and a reference marker (B3GALT6). Overall sensitivity for BE/EAC detection in the training set was 81% (95% CI 76-88%) at 90% (85-94%) specificity. Overall BE/EAC sensitivity in the test set was 88% (78-94%) at 84% (70-93%) specificity. Sensitivity for HGD and EAC was 100% in the training and test sets. Sensitivity for short segment NDBE in the test set was 63% (38-84%). Areas under the receiver operating characteristic (AUROC) curve for BE/EAC detection were 0.92 (95% CI 0.89-0.95) and 0.94 (0.90-0.98) in the training and test sets, respectively (Figure). The algorithm was not influenced by age, sex, or smoking history. 97% of participants in the training set and 85% in the test set successfully swallowed the SOS device, which was well tolerated and safe. Conclusion: A 3-MDM panel for BE/EAC detection demonstrated excellent sensitivity for high risk BE cases in multi-center case control training and test sets.Figure 1.: Area under the receiver operating characteristics curves for a 3-marker methylated DNA panel assayed from cytology specimen extracted DNA in training and test sets. Table 1. - Baseline characteristics of patients and performance characteristics of SOS test (overall sensitivity and specificity, and stratified by BE dysplasia grade) in training and test sets Variable Training Set (N=198 controls,154 cases) Test Set(N= 44 controls,81 cases) P value (comparing training and test sets) Control Case Control Case Mean (SD) age 55 (13) 65 (10) 52 (15) 65 (11) 0.312 Male Sex (%) 102 (52) 119 (77) 17 (39) 64 (79) 0.992 Mean (SD) BMI 29 (7) 30 (6) 30 (7) 30 (6) 0.283 Ever Smokers % 77 (39) 87 (56) 18 (41) 47 (58) 0.733 Mean *SD) BE length, cm - 4 (3) - 5 (3) 0.070 Long segment BE, N, (%) - 97 (63) - 56 (69) 0.426 Short segment BE, N (%) - 57 (37) - 25 (31) BE dysplasia grade, N (%) EAC - 12 (8) - 2 (2) HGD - 18 (12) - 11 (14) LGD - 7 (4) - 10 (12) IND - 18 (12) - 14 (17) NDBE (long segment) - 57 (37) - 25 (31) NDBE (short segment) - 42 (27) - 19 (24) Training Set% Positive (95% CI) Test Set% Positive (95% CI) Overall 81% (76-88%) 88 (78-94) Dysplasia grade EAC 100 (100-100) 100 (16-100) HGD 100 (100-100) 100 (72-100) LGD 71 (0-100) 90 (55-100) IND 74 (0-100) 93 (66-100%) NDBE (long segment) 91 (73-100) 96 (80-100%) NDBE (short segment) 61 (25-100) 63 (38-84%) Control (No BE) 10 (2-21) 16 (7-30)

Introduction: Current guidelines recommend single screening endoscopy in patients with multiple risk factors for Barrett’s esophagus (BE). Data suggesting a low risk of BE after a negative esophagogastroduodenoscopy (EGD) are limited by small sample size and short follow-up after initial EGD. There remains a possibility of missed or incident BE after a negative index EGD. With the advent of cost-effective, non-endoscopic BE screening tools, repeat screening may be a consideration in high-risk patients. We aimed to determine the prevalence and predictors of BE after a negative index evaluation, on repeat EGD in a large national endoscopic database. Methods: We analyzed data from the GI Quality Improvement Consortium Registry (GIQuIC), a large nationwide quality benchmarking clinical registry, from 2013-2020. We included patients who underwent at least 2 EGDs. Patients diagnosed with or with a history of BE or esophageal adenocarcinoma (EAC) at index EGD were excluded. Data on prevalence of BE/EAC on second/subsequent EGDs, and known risk factors for BE were collected. Univariate and multivariate logistic regression analyses were performed to assess association between predictors and outcome of BE/EAC on repeat EGD. Results: The prevalence of BE at index endoscopy in the GIQuIC database is 4.2%. A total of 124,223 patients underwent at least 1 EGD (mean number of repeat EGDs 1.39, range 1-63). Of these, 2,272 (1.83%, 95% CI 1.75, 1.90%) were found to have BE/EAC. Table shows the prevalence of BE/EAC stratified by risk factors. Risk factors associated with BE/EAC on repeat endoscopy included GERD (OR: 3.36, p < 0.01), male sex (OR: 1.85, p< 0.01), White race (OR: 1.76, p< 0.01), age 50-80 years (OR: 1.53, p< 0.01), and obesity (OR: 1.20, p=0.04). In patients with GERD and an additional risk factor, the prevalence of BE/EAC was higher at 3.4% at a mean (SD) time interval of 13.1 (14.1) months after a negative index EGD. The prevalence of BE/EAC increased with increasing number of risk factors (Figure). Conclusion: The prevalence of BE/EAC after an initial negative index EGD was approximately 2% (44% of baseline BE prevalence in GIQuIC), with most cases diagnosed within 5 years. In patients with two or more risk factors, the prevalence was two fold higher. Repeat evaluation for BE, particularly with non-endoscopic techniques, may be considered in patients with multiple risk factors, 1-5 years after initial negative evaluation.Figure 1.: The distribution of BE/EAC diagnosed after initial negative endoscopy stratified by the number of risk factors present per patient and GERD. Table 1. - Baseline characteristics of patients with and without BE/EAC on follow-up EGD after negative index EGD Characteristic No BE/EAC (N = 121,951, 98.17%) BE/EAC (N = 2,272, 1.83%) p-value Age (years) < 0.0001 < 50 27,466 (22.8%) 411 (18.1%) 50-80 85,262 (69.9%) 1,762 (77.6%) >80 8,890 (7.3%) 99 (4.4%) Male sex 48,224 (39.5%) 1,247 (54.9%) < 0.0001 White race 82,8384 (82.8%) 1,663 (90.0%) < 0.0001 GERD* 39,035 (32.0%) 1,346 (59.2%) < 0.0001 Obesity (BMI >30) 6,600 (35.5%) 217 (40.3%) 0.0204 Time interval between EGDs < 0.0001 < 1year 69,485 (57.0%) 1,475 (64.9%) 1 to < 3 years 41,828 (34.3%) 617 (27.2%) v3 to < 5 years 10,134 (8.3%) 174 (7.7%) >=5 years 504 (0.4%) 6 (0.3%) Indication for second EGD Screening for BE 1,218 (1.0%) 130 (5.7%) < 0.0001 Reflux 39,035 (32.0%) 1,346 (59.2%) < 0.0001 Ulcer 15,071 (12.4%0 264 (11.6%) 0.2890 Weight loss 2,493 (2.0%0 19 (0.8%) < 0.0001 Dysphagia 41,391 (33.9%) 547 (24.1%) < 0.0001 Esophagitis 11,607 (9.5%) 570 (25.1%) < 0.0001 GI bleeding/anemia 25,296 (20.7%) 227 (10.0%) < 0.0001 Vomiting 6,657 (5.5%) 84 (3.7%) 0.0002 Other 12,346 (10.1%) 185 (8.1%) 0.0019 *Based on indication of 2nd EGD

BACKGROUND & AIMS:Recommended surveillance intervals after complete eradication of intestinal metaplasia (CE-IM) after endoscopic eradication therapy (EET) are largely not evidence-based. Using recurrence rates in a multicenter international Barrett's esophagus (BE) CE-IM cohort, we aimed to generate optimal intervals for surveillance.METHODS:Patients with dysplastic BE undergoing EET and achieving CE-IM from prospectively maintained databases at 5 tertiary-care centers in the United States and the United Kingdom were included. The cumulative incidence of recurrence was estimated, accounting for the unknown date of actual recurrence that lies between the dates of current and previous endoscopy. This cumulative incidence of recurrence subsequently was used to estimate the proportion of patients with undetected recurrence for various surveillance intervals over 5 years. Intervals were selected that minimized recurrences remaining undetected for more than 6 months. Actual patterns of post-CE-IM follow-up evaluation are described.RESULTS:A total of 498 patients (with baseline low-grade dysplasia, 115 patients; high-grade dysplasia [HGD], 288 patients; and intramucosal adenocarcinoma [IMCa], 95 patients) were included. Any recurrence occurred in 27.1% and dysplastic recurrence occurred in 8.4% over a median of 2.6 years of follow-up evaluation. For pre-ablation HGD/IMCa, intervals of 6, 12, 18, and 24 months, and then annually, resulted in no patients with dysplastic recurrence undetected for more than 6 months, comparable with current guideline recommendations despite a 33% reduction in the number of surveillance endoscopies. For pre-ablation low-grade dysplasia, intervals of 1, 2, and 4 years balanced endoscopic burden and undetected recurrence risk.CONCLUSIONS:Lengthening post-CE-IM surveillance intervals would reduce the endoscopic burden after CE-IM with comparable rates of recurrent HGD/IMCa. Future guidelines should consider reduced surveillance frequency.

Introduction: Barrett’s esophagus (BE) is the only known precursor lesion of esophageal adenocarcinoma (EAC), a malignancy with poor 5-year survival. Screening for BE is endorsed in those with risk factors. Assessing BE/EAC risk remains challenging. The Kunzmann score is a tool to identify patients at risk of BE/EAC. We assessed the ability of this tool to predict BE/EAC risk 5 years prior to BE/EAC diagnosis in a large population-based database. Methods: The Rochester Epidemiology Project contains medical records of over 90% of SE Minnesota residents since 1977. Utilizing appropriate ICD-9 and 10 codes, we identified all BE/EAC patients from 1977-2020. Endoscopic evidence of at least 1 cm of salmon colored mucosa in the tubular esophagus and presence of intestinal metaplasia on endoscopic biopsies were assessed to confirm BE diagnosis. We also identified non-BE/EAC controls, and endoscopic reports were reviewed to exclude BE/EAC in these patients. The Kunzmann score is a composite score based on age, gender, smoking history, presence of esophageal conditions (such as heartburn), and BMI. It has previously been reported to have a sensitivity and specificity for EAC of 77.5% and 70.5%, respectively, utilizing a cut off score of 8. We compared risk prediction scores between BE patients and non-BE controls at datapoints obtained 5 (±1) years prior to BE diagnosis. (Table) Results: Data to calculate the Kunzmann score were abstracted from 916 cases (684 BE,232 EAC) 5 years prior to diagnosis and from 100 endoscopy negative controls. The mean Kunzmann score 5 years prior to diagnosis was significantly higher in the EAC group (10.6; SD: 2.0) compared to those with baseline BE (9.7; SD: 2.5) and controls (10.2; SD: 2.5; p < 0.01). Furthermore, the percentage of patients with a Kunzmann score greater than 8 at 5 years prior to diagnosis was highest in the EAC group (90.9%) compared to the baseline BE (78.8%) and control (83.0%; p< 0.01) groups. Utilizing a cut-off score of 8, the Kunzmann score at 5-years prior to diagnosis demonstrated a sensitivity of 84.0% and specificity of 18.1% for the diagnosis of BE/EAC, and demonstrated a sensitivity of 79.5% and specificity of 9.1% for the diagnosis of EAC alone. Conclusion: In this large population-based database, the Kunzmann score demonstrated reasonable sensitivity but low specificity to predict BE/EAC at 5 years prior to diagnosis. Its utility for predicting BE/EAC risk needs to be further evaluated. Table 1. - Baseline characteristics and Distributions of Kunzmann Score in BE cases, EAC cases and Endoscopy Negative Controls in a Population Based Cohort BE (N=684) EAC (N=232) Endoscopy Negative Controls (N=100) Mean (SD) age 61.8 (13.7) 65.6 (11.7)* 65.9 (13.8) < 0.01 Male, N (%) 490 (71.6%) 201 (86.6%) 66 (66.0%) < 0.01 White, N (%) 620 (90.6%) 211 (90.9%) 96 (96.0%) 0.5 Mean (SD) BMI 30.3 (6.0) 30.3 (6.2) 30.3 (6.1) 1.0 Never smokers, N (%) 248 (36.5%) 61 (26.3%)* 40 (40.0%) 0.04 Baseline BE grade, N (%) NDBE 570 (83.3%) - - - LGD 37 (5.4%) - - - IND 52 (7.6%) - - - HGD 25 (3.7%) - - - EAC - 232 (100.0%) - - Baseline mean (SD) BE length, cm 4.0 (3.3) 5.4 (3.1)* - Presence of Hiatal hernia, N (%) 459 (67.1%) 68 (29.3%) 55 (55.0%) < 0.01 History of GERD, N (%) 304 (44.4%) 85 (50.3%) 100 (100.0%) - Mean (SD) Kunzmann Score 9.7 (2.5) 10.6 (2.0)* 10.0 (2.4) < 0.01 Kunzmann score greater than 8 539 (78.8%) 211 (90.9%) 84 (84.0%) < 0.01