Final presentation given by Ileana Lulic and Ivor Kovic at the end of Scientific research in gastro-intestinal & liver diseases Sunday, July 8 - Friday, August 3, 2007 Amsterdam, Academisch Medisch Centrum

1. Identification of Barrett’s
esophagus patients at higher risk
for adenocarcinoma development
Ileana Lulic, Ivor Kovic

2. Definition
“... a change in the esophageal epithelium of any length
that can be recognized at endoscopy and is confirmed
to have intestinal metaplasia by biopsy ...”
American College of Gastroenterology

3. Characteristics
• Caucasian males – middle age
• Rapidly rising incidence in Western countries
• Around 150x higher risk of esophageal adenocarcinoma
compared to general population
• 0.5% of BE patients will develop EAC
• Overall survival rate of EAC = 20-25%

4. Progression
Squamous esophageal epithelium
Intestinal metaplasia
Dysplasia
Esophageal adenocarcinoma

5. Progression
Squamous esophageal epithelium
GERD
Intestinal metaplasia
Dysplasia
Esophageal adenocarcinoma

6. Progression
Squamous esophageal epithelium
Obesity
Diet
?
GERD Tobacco
Alcohol
Bacteria
Intestinal metaplasia
Dysplasia
Esophageal adenocarcinoma

7. Progression
Squamous esophageal epithelium
Obesity
Diet
?
GERD Tobacco
Alcohol
Bacteria
Intestinal metaplasia
Dysplasia
Low grade
High grade
Esophageal adenocarcinoma

8. Diagnosis
Normal Metaplasia Adenocarcinoma
Endoscopy
Pathology

9. Diagnosis
Normal Metaplasia Adenocarcinoma
Endoscopy
Pathology
http://www.gastrointestinalatlas.com/

10. Diagnosis
Normal Metaplasia Adenocarcinoma
Endoscopy
Pathology

11. Surveillance problems
Endoscopy Pathology
• • Intra-observer variability
Difficulty of identifying
early neoplastic lesions
• Inter-observer variability
• Sampling errors
• Expensive and time
consuming

12. Surveillance problems
Endoscopy Pathology
• • Intra-observer variability
Difficulty of identifying
early neoplastic lesions
• Inter-observer variability
• Sampling errors
• Expensive and time
consuming
Questionable cost-effectiveness

13. Potential of genetic markers
• Prediction of risk for disease progression in endoscopic
surveillance program
• Early detection of high grade dysplasia and invasive
adenocarcinoma
• Staging and prognosis
• Prediction of chemosensitivity
• Novel targets for anticancer therapies

14. Genetic markers
p16/9p-loss
p53/17p-loss
Y chromosome loss
Aneuploidy/tetraploidy
Losses - 3p, 4p, 7q, 12q,17q
Gains – 2p, 8q, 20q

15. Genetic markers
p16/9p-loss No dysplasia
p53/17p-loss
Low grade dysplasia
Y chromosome loss
Aneuploidy/tetraploidy
High grade dysplasia
Losses - 3p, 4p, 7q, 12q,17q
Esophageal adenocarcinoma
Gains – 2p, 8q, 20q

16. Genetic markers
p16/9p-loss
p53/17p-loss
Y chromosome loss
Aneuploidy/tetraploidy
Losses - 3p, 4p, 7q, 12q,17q
Gains – 2p, 8q, 20q

17. Genetic markers
p16/9p-loss Fluorescent in situ hybridization
p53/17p-loss
Y chromosome loss
Image cytometry
Aneuploidy/tetraploidy
Losses - 3p, 4p, 7q, 12q,17q
Gains – 2p, 8q, 20q

18. Procedure
Image cytometry
Brush cytology Slides preparation
FISH

19. FISH
• Fluorescent probe
• Fluorescent microscopy

20. FISH
• Numerical chromosomal
changes: aneuploidy
• Locus specific losses: tumor
suppressor genes
• Amplifications: oncogenes
and growth factor

21. Image cytometry
• DNA ploidy analysis
• Aneuploidy – from 2N to 4N, DNA index
• Measurement of optical density

22. FISH results
Cep1 p16 p53
Patient Hystology
loss gain loss gain loss gain
+ +
1 LGD
+
2 LGD
+ + +
3 HGD
+ +
4 HGD
+ + +
5 HGD
+ +
6 HGD
Total 2 3 5 0 3 0

23. Image cytometry results

24. Image cytometry results

25. Results
LGD HGD
6
5
4
3
2
1
0
Cep 1 gain p16 loss p53 loss

26. Results from 151 patients
(n=114)
(n=24)
(n=13)

27. Conclusion
• p53 loss and aneuploidy are promising markers for
dysplasia development in BE
• Ongoing follow up study to demonstrate the true
predictive value of these markers

29. Agnieszka Rygiel
Francesca Milano
Sheila Krishnadath
Wendy Bruins
Willemijn van Dop