GERD—Barrett—Adenocarcinoma: Do We Have Suitable Prognostic and Predictive Molecular Markers?

Table 1

Summary of investigated and published biomarkers in the GERD-BE-EAC axis. The categorization is based on four groups according to their potential usage as A = Diagnostic Biomarker indicates the presence of disease, B = Progression Biomarker indicates the risk of developing cancer—progression in BE to EAC, C = Predictive Biomarker predicts response to therapy (CTX, RTX, photodynamic therapy), or D = Prognostic Biomarker indicates overall survival—prognostic in EAC (survival, recurrence).

	Biomarker	Method	Remarks/findings	OR/RR/𝑃 value	Refs
A = Diagnostic Biomarker	TFF3		novel nonendoscopic screening modality in a prospective cohort study	𝑃=0.02 (for maximal length of BE); 𝑃=0.009 (for circumferential length of BE)	[48]
	TFF3	IHC, esophageal cytosponge samples for BE combined with IHC for TFF3	biomarker to screen asymptomatic patients for BE; TFF3 protein was expressed at the luminal surface of BE (not at normal esophageal or gastric mucosa)	𝑃<0.0001	[49]
	Chromosomes 7 and 17 (copy number changes)	ICDA & FISH	chromosomal gains in early stages of BE; valuable adjunct to conventional cytology to detect dysplasia or EAC	IND/LGD: 75% sensitivity, (76% specificity); HGD/EAC: 85% sensitivity,; (84% specificity)	[50]
	8q24 (C-MYC), 17q12 (HER2), and 20q13 (copy number changes)	FISH	chromosomal gains in early stages of BE; represents a valuable adjunct to conventional cytology to detect dysplasia or EAC	LGD (50% sensitivity); HGD (82% sensitivity); EAC (100% sensitivity)	[51]
	17q11.2 (ERBB2)	Southern blotting, microarray analysis	amplified copies of the ERBB2 gene in EAC	10-fold amplification in 3 of 25 (12%) tumors	[52]
	Serum proteomic pattern analysis	mass spectrometry	several limitations due to applied technology	identified 10 of 11 normal’s; and 42 of 43 EAC’s correctly	[53]
B = Progression Biomarkers	P53 positivity	IHC	limited efficacy as a single progression biomarker	OR 11.7 (95% CI: 1.93–71.4)	[54]
	P53 positivity	IHC	positive in 4/31 that regressed, 3/12 that persisted, and 3/5 that progressed to HGD or EAC	RR not available	[55]
	DNA content abnormalities	flow cytometry	higher relative risk for EAC in patients with tetraploidy (4N) or aneuploidy (>6%)	tetraploidy: RR 7.5 (95% CI: 4–14) (𝑃<0.001); aneuploidy: RR 5.0 (95% CI: 2.7–9.4) (𝑃<0.001)	[56]
			4N fraction cut point of 6% for cancer risk	RR 11.7 ( 95% CI: 6.2–22)
			aneuploid DNA contents of 2.7N were predictive of higher cancer risk	RR 9.5 (95% CI: 4.9–18)
	DNA content abnormalities	flow cytometry	presence of both 4N fraction of 6% and aneuploid DNA content of 2.7N is highly predictive for progression	RR 23 (95% CI: 10–50)	[57]
			17p(p53) LOH associated with higher risk of progression to HGD + EAC	HGD: RR 3.6 (𝑃=0.02)
		flow cytometry, PCR		EAC: RR 16 (𝑃<0.001)	[58]
			combined LOH of 17p and 9p and DNA content abnormalities can best predict progression to EAC	RR 38.7 (95% CI: 10.8–138.5) not clinical applicable
	LOH of 157p and 9p and DNA content abnormalities		LOH of 17p alone	RR 10.6 (95% CI: 5.2–21.3)
		flow cytometry, PCR	LOH of 9p alone	RR 2.6 (95% CI: 1.1–6.0)
			Aneuploidy alone	RR 8.5 (95% CI: 4.3–17.0)	[59]
			Tetraploidy alone	RR 8.8 (95% CI: 4.3–17.7)
	mutations of p16 and p53 loci (clonal diversity measurements)	flow cytometry, PCR	significant predictors for EAC progression, not clinical applicable	𝑃=0.001	[60]
	EGFR	IHC	overexpression in HGD/EAC	35% of HGD/80% of EAC specimens	[61]
	MCM2	IHC	correlation between degree of dysplasia and level of ectopic luminal surface MCM2 expression	MCM2-positive; staining in 42% (19/45) of BE samples	[62]
	Cyclin A	IHC	surface expression of cyclin A in BE samples correlates with the degree of dysplasia	OR 7.5 (95% CI: 1.8–30.7) (𝑃=0.016)	[63]
	Cyclin D1	IHC	association with increased risk of EAC	OR 6.85 (95% CI: 1.57–29.91)	[64]
	hypermethylation of p16 (CDKI2A)		association with increased risk of progression to HGD/EAC	OR 1.74 (95% CI: 1.33–2.2)
	hypermethylation of RUNX3		association with increased risk of progression to HGD/EAC	OR 1.80 (95% CI: 1.08–2.81)
	hypermethylation of HPP1	RT-PCR	association with increased risk of progression to HGD/EAC	OR 1.77 (95% CI: 1.06–2.81)	[41]
	hypermethylation of p16 and APC	PCR	predictor of progression to HGD/EAC	OR 14.97 (95% CI: 1.73–inf.)	[65]
	8 gene methylation panel	RT-PCR	age dependent; predicts 60.7% of progression to HGD/EAC within 2 yrs	RR not available (90% specificity)	[66]
	Gene expression profile	microarray analysis	64 genes up regulated; 110 genes down regulated in EAC	𝑃=0.05	[67]
	Cathepsin D, AKR1B10, and AKR1C2 mRNA levels	Western blotting, qRT-PCR	dysregulation predicts progression to HGD/EAC	AKR1C2: ↑ levels in BE (𝑃<0.05) but ↓ levels in EA (𝑃<0.05)	[68]
		ICDA	aneuploidy predicts progression to EAC	60% with LGD; 73% with HGD, and 100% with EAC (total number of samples = 56)	[69]
	DNA abnormalities	ACIS	frequency and severity of aneuploidy predicts progression to EAC	unstable aneuploidy in 95% with EAC	[70]
		DICM	relationship between DICM status and progression to HGD/EAC	𝑃<0.0001	[71]
	SNP-based genotyping in BE/EAC specimens	flow cytometry, 33K SNP array	copy gains, losses, and LOH increased in frequency and size between early and late stage of disease	𝑃<0.001 (BE)	[72]
C = Predictive Biomarkers	p16 allelic loss	FISH	decreased response to photodynamic therapy	OR 0.32 (95% CI: 0.10–0.96)	[73]
	DNA ploidy abnormalities	ICDA	DNA ploidy as a covariate value for recurrence	HR 6.3 (1.7–23.4) (𝑃<0.0015)	[74]
	HSP27	IHC	association between low HSP27 expression and no response to neoadjuvante chemotherapy	𝑃=0.049 and 𝑃=0.032	[75]
	Ephrin B3 receptor	microarray	response prediction in EAC in patients with Ephrin B3 receptor positive versus Ephrin B3 receptor negative	Response rate <50%: 3 (15.8) versus 16 (84.2) (𝑃<0.001)	[76]
	Genetic polymorphisms	qRT-PCR	association between individual single nucleotide polymorphisms; and clinical outcomes	comprehensive panel of genetic polymorphisms on clinical outcomes in 210 esophageal cancer patients	[77]
	P21	IHC	alteration in expression correlated with better CTX-response	𝑃=0.011	[78]
	P53	IHC	alteration in expression correlated with better CTX-response	𝑃=0.011	[79]
	ERCC1	IHC	ERCC1-positivity predicts CTX-resistance and poor outcome	𝑃<0.001	[80]
D = Prognostic Biomarkers	DCK; PAPSS2; SIRT2; TRIM44	RT-PCR,; IHC	prognostic 4-gene signature in EAC predicts 5-year survival	0/4 genes dysregulated: 58%; (95% CI: 36%–80%); 1-2/4 genes dysregulated: 26%; (95% CI: 20%–32%); 3-4/4 genes dysregulated: 14%; (95% CI: 4%–24%); (𝑃=0.001)	[81]
	p16 loss; C-MYC gain	FISH	association between therapy response status and FISH positivity	𝑃=0.04	[82]
	ASS expression	microarrays	low expression correlates with lymph node metastasis	𝑃=0.048	[83]
	microRNA expression profiles	miRNA microarray, qRT-PCR	association with prognosis (e.g. low levels of mir-375 in EAC → worse prognosis)	HR = 0.31 (95% CI: 0.15–0.67) (𝑃<0.005)	[84]
	Genomic alterations	MLPA	reverse association between survival and DNA copy number alterations (>12 aberrations → low mean survival)	𝑃=0.003	[85]
	Cyclin D1	FISH, IHC	2 of 3 genotypes confers to ↓ survival	𝑃=0.0003	[86]
		IHC	expression = ↓ survival	𝑃=0.07	[87]
	EGFR	IHC	↓ expression = ↓ survival	𝑃=0.034	[88]
	Ki-67	IHC	low levels of staining (<10%); = ↓ survival	𝑃=0.02	[89]
	Her2/neu	FISH	amplification = ↓ survival	𝑃=0.03	[90, 91]
		IHC	low levels = ↓ survival	𝑃=0.03	[92]
	TGF-α	IHC, ISH	high levels = tumor progression and lymph node metastasis	𝑃=0.025 and 𝑃<0.05	[93]
		qRT-PCR	overexpression = ↓ survival	𝑃=0.0255	[94]
	TGF-β1	ELISA	high plasma levels = ↓ survival	𝑃=0.0317	[95]
	APC	RT-PCR	high plasma levels of methylation; = ↓ survival	𝑃=0.016	[96]
	Bcl-2	IHC	expression = ↓ survival	𝑃=0.03	[97]
		IHC, RT-PCR	↑ expression = ↓ survival, ↑ TN-stage, and recurrence	𝑃<0.001,; 𝑃=0.008/0.049, and; 𝑃=0.01	[98]
		IHC	strong staining = ↓ survival	𝑃=0.03	[99]
	COX-2	IHC	strong staining = ↓ survival, distant metastasis, and recurrence	𝑃=0.002, 𝑃=0.02, and 𝑃=0.05	[100]
	NF-κB	IHC	activated NF-κB = ↓ survival, and; ↓ disease free survival	𝑃=0.015 and 𝑃=0.010	[101]
	Telomerase	Southern blot analysis, RT-PCR	higher telomere-length ratio; = ↓ survival	RR of death: 3.4; (CI: 1.3–8.9) (𝑃<0.02)	[102]
			expression = ↓ survival,	𝑃<0.01
	CD105		angiolymphatic invasion	𝑃<0.05
			↑ lymph node metastasis	𝑃<0.01
			↑ T-stage	𝑃<0.001
		IHC	↑ distant metastasis	𝑃<0.01	[103]
			↑ expression = ↓ survival,	𝑃<0.01
	VEGF		angiolymphatic invasion	𝑃<0.05
			↑ lymph node metastasis	𝑃<0.01
			↑ T-stage	𝑃<0.01
			↑ distant metastasis	𝑃<0.01
	Cadherin	IHC	↓ level = ↓ survival	𝑃=0.05	[89]
	uPA	ELISA	↑ uPA = ↓ survival	𝑃=0.0002	[104]
	TIMP	IHC, RT-PCR	↓ expression = ↓ survival, and ↑ disease stage	𝑃=0.007 and 𝑃=0.046	[105]
	Promoter hypermethylation of multiple genes	IHC, methylation specific PCR	if >50% of gene profile methylated; = ↓ survival, and earlier recurrence	𝑃=0.05 and 𝑃=0.04	[106]
	MGMT hypermethylation	IHC, methylation specific PCR	correlation with higher tumor differentiation	𝑃=0.0079	[107]

ACIS: automated cellular imaging system; ASS: argininosuccinate synthase; APC: adenomatous polyposis coli; BE: barrett’s esophagus; COX: cyclooxygenase; DCK: deoxycytidine kinase; DICM: digital image cytometry; EAC: esophageal adenocarcinoma; EGFR: epidermal growth factor receptor; ELISA: enzyme-linked immunosorbent assay; FISH: fluorescence in-situ-hybridization; ICDA: image cytometric DNA analysis; HSP27: Heat-shock protein 27; IHC: immunohistochemistry; LOH: loss of heterozygosity; PAPSS2: 3′-phosphoadenosine 5′-phosphosulfate synthase 2; PCR: polymerase chain reaction; qRT: quantitative reverse transcriptase; MLPA: multiplex ligation dependent probe amplification; NF-κB: nuclear factor kappa B; SIRT2: Sirtuin 2; SNP: single nucleotide polymorphism; TFF3: Trefoil factor 3; TGF: transforming growth factor; TIMP: tissue inhibitors of metalloproteinases; TRIM44: Tripartite motif-containing 44; uPA: urokinase-type plasminogen activator; VEGF: vascular endothelial growth factor.