Julie A. Simonson

Erratum: 3-Yr Follow-Up of Topical Corticosteroid Treatment for Eosinophilic Esophagitis in Adults

BACKGROUND:Eosinophilic esophagitis (EE) is a clinicopathologic syndrome comprising isolated eosinophilic inflammation of the esophagus, with symptoms of dysphagia, and possibly, reflux. It was initially described in children, and in recent years, there is a heightened awareness in adults. The etiology is not completely understood. The treatments include dietary manipulation, topical corticosteroids, systemic corticosteroids, Montelukast, and endoscopic dilation. In adults, there are no randomized trials demonstrating the efficacy of any particular treatment, and no prospective studies describing the natural history of the disease following treatment.METHODS:We performed an interval follow-up of patients treated with a swallowed corticosteroid inhaler. We contacted 51 adult patients who were diagnosed with EE and treated with a swallowed corticosteroid inhaler between September 1, 1999, and May 31, 2003. All patients had received 6 wk of treatment with fluticasone 220 mEq/puff, four puffs swallowed twice daily for 6 wk.RESULTS:Thirty-two patients replied (63%) with a mean follow-up duration of 3.3 yr. Ninety-one percent of patients reported recurrent symptoms; a mean of 8.8 months after treatment was completed. Sixty-nine percent of patients repeated treatment with the steroid inhaler at least once.CONCLUSIONS:It appears that EE is a chronic remitting disorder that requires more than one topical steroid treatment course.

A Stable Isotope Breath Test with a Standard Meal for Abnormal Gastric Emptying of Solids in the Clinic and in Research

BACKGROUND & AIMS The aim of this study was to validate a [13C]-Spirulina platensis gastric emptying (GE) breath test (GEBT) with a standardized meal. METHODS Thirty-eight healthy volunteers and 129 patients with clinically suspected delayed GE underwent measurements at 45, 90, 120, 150, 180, and 240 minutes after a 238 kcal meal labeled test with 100 mg [13C]-S platensis and 0.5 mCi 99mTc. We established normal ranges for scintigraphy with this test meal, intraindividual and interindividual coefficients of variation (COVs), and the ability of the [13C] GEBT breath percent dose excreted *1000 values to predict scintigraphic half-life and to categorize GE as delayed, normal, or accelerated. RESULTS In health, the 10th and 90th percentiles of half-life for scintigraphic GE with this meal were 52 and 86 minutes; intraindividual COVs for scintigraphy and the GEBT were, respectively, 31% and 27% at 45 minutes, 17% and 21% at 90 minutes, 13% and 16% at 120 minutes, 10% and 13% at 150 minutes, and 8% and 12% at 180 minutes. Interindividual COVs at each time for the [13C] GEBT and scintigraphy were typically approximately 1%-4% lower than intraindividual COVs. Individual breath samples at 45, 150, and 180 minutes predicted GE category; at 80% specificity, 45- and 180-minute samples combined were 93% sensitive to identify accelerated GE, and 150- and 180-minute combined were 89% sensitive for delayed GE. CONCLUSIONS [13C]-S platensis GEBT is as reproducible as scintigraphy; imprecision with both tests reflects physiologic variation. With 4 breath samples, this method with an off-the-shelf meal is valid to assess GE in clinic and in research.

Factors That Predict Relief From Upper Abdominal Pain After Cholecystectomy

BACKGROUND & AIMS Upper abdominal pain (UAP) in patients with gallstones is often treated by cholecystectomy but it frequently persists. We aimed to identify symptoms associated with relief. METHODS We followed 1008 patients who received cholecystectomy for gallstones and UAP at the Mayo Clinic (Rochester, Minnesota) or Kaiser Permanente (San Diego, California) for 12 months. A validated, self-completed biliary symptoms questionnaire identified features of UAP, gastroesophageal reflux disease (GERD), and irritable bowel syndrome (IBS); the questionnaire was given initially and 3 and 12 months after cholecystectomy, to identify features that predicted sustained relief of UAP. RESULTS Five hundred ninety-four patients (59%) reported relief from UAP. Factors associated univariately (P < .05) with relief included frequency of UAP ≤1 per month, onset ≤1 year preoperatively, usual duration (30 minutes to 24 hours, most often in the evening or night), and severity >5/10. Compared to no features, multiple predictive features of UAP (frequency, onset, duration, or timing) were associated with increasing odds ratios (95% confidence interval) for relief: 1, 2, or 3 features (4.2 [1.1-16]; P = .03) and 4 features (6.3 [1.6-25]; P = .008). Negative univariate associations included lower abdominal pain (LAP), usual bowel pattern, nausea ≥1 per week, often feeling bloated or burpy, GERD, and/or IBS. There was an inverse association between relief and somatization; relief was not associated with postprandial UAP. Multivariable logistic regression analysis revealed independent associations (P < .05) with UAP frequency, onset, and nocturnal awakening, but inverse associations with lower abdominal pain, abnormal bowel pattern, and frequent bloated or burpy feelings. CONCLUSIONS UAP features and concomitant GERD, IBS, and somatization determine the odds for relief from UAP after cholecystectomy.

T2036 Pan-Detection of Gastrointestinal Neoplasms By Stool DNA Testing: Establishment of Feasibility

Non-apoptotic human DNA (long DNA) in stool is a discriminant marker for colorectal cancer (Gastroenterology 2000; 119:1219). Fecal long DNA may originate from either the exfoliation of dysplastic cells or from the luminal hemorrhage or exudation of leukocytes. The contribution of these potential sources long DNA in stool has not been examined. If leukocytes are the major source, then fecal human DNA and occult blood levels should correlate. If exfoliation is the major source, then fecal human DNA and occult blood should be complementary markers for colorectal cancer. AIM: To quantify and correlate human DNA and hemoglobin in stools from patients with colorectal neoplasia, and to consider a simple stool assay for cancer screening. METHODS: Subjects comprised 74 patients with colorectal cancer, 27 with adenomas >1cm, and 100 with normal colonoscopy. One stool per subject was collected in stabilization buffer before or > 1 week after colonoscopy. Fecal long DNA and occult blood were quantified in blinded fashion by real-time Alu PCR (CEBP 2006 15:1115) and the HemoQuant assay (Mayo Medical Laboratories), respectively. HemoQuant assay results are not affected by fecal storage (Ann Intern Med 1984;101:297) and could be reliably applied to archival specimens for this study. RESULTS: Fecal long DNA and occult blood showed no correlation (R2=0). At 90% specificities, long DNA testing detected 70% of colorectal cancers and 46% of adenomas while occult blood testing detected 50% and 12%, respectively. Combining these tests detected 80% colorectal cancers and 46% of adenomas at 90% specificity. For detection of colorectal cancer, AUC values were 0.82, 0.78, and 0.90 for fecal long DNA, occult blood, and combination testing, respectively (p<0.05, long DNA or occult blood vs combination). The median (range) fecal long DNA level was 181 ng/g stool (0-7120 ng/g) with stage 1-2 cancers and 910 ng/g (0-19140 ng/ g) with stage 3-4 cancers, p<0.05. The median fecal hemoglobin level was 7.0 mg Hb/g (0.2-26.4 mg/g) with proximal cancers and 2.5 mg/g (0.1-36.1 mg/g) with distal ones, p<0.05. Median size was 4.0 cm (1.0-15.0) for neoplasms detected by the combined tests and 3.7 cm (1.0-7.0) for neoplasms missed, p=0.02. Neoplasm detection rates by combined tests were affected by neither tumor site nor stage. CONCLUSIONS: Long DNA and occult blood in stools are complementary stool markers for detection of colorectal cancer, and combined assay of these markers provides higher sensitivity for cancer than assay of either alone. The combined assay offers a simple and inexpensive screening approach that warrants further evaluation.

Tu1189 An Optimized Multi-Marker Stool Test for Colorectal Cancer Screening: Initial Clinical Appraisal

Background: Organized colorectal cancer screening program in the Czech Republic (10.5 million inhabitants, 3.8 million aged over 50) was introduced in year 2000, based on guaiac fecal occult blood test (FOBT). In 2009, new program design was launched. To asymptomatic individuals aged 50 54, annual guaiac or immunochemical FOBT has been offered, followed by screening colonoscopy, if positive. In age of 55, there is a choice of either FOBT biannually or primary screening colonoscopy in 10 years interval. Methods: Early performance indicators (European guidelines 2010) were used to assess the efficacy of the program Results: The coverage of target population has been rising since the program introduction, reaching 23% in 2010. The overall FOBT positivity of 6.1% has been recorded. Since the beginning of on-line individual data management in year 2006, until November 2011, there were 59,320 screening colonoscopies (FOBT+) and 8,493 primary screening colonoscopies performed (basic result included in the table). A trend for earlier stage cancer detection was observed (42.7% in stage I). Average ADR and CIR were 31.2% and 94.2% respectively. In years 2006 2010, there were reported 45 cases of perforations (0.08% of all colonoscopies). Conclusion: The Czech national Colorectal Cancer Screening program is growing in performance and influential. Introduction of the new program design increases the target population coverage. Main findings on (primary) screening colonoscopies

T2037 Quantitative Stool DNA Testing for Detection of Both Colorectal Cancer and Advanced Adenoma

Non-apoptotic human DNA (long DNA) in stool is a discriminant marker for colorectal cancer (Gastroenterology 2000; 119:1219). Fecal long DNA may originate from either the exfoliation of dysplastic cells or from the luminal hemorrhage or exudation of leukocytes. The contribution of these potential sources long DNA in stool has not been examined. If leukocytes are the major source, then fecal human DNA and occult blood levels should correlate. If exfoliation is the major source, then fecal human DNA and occult blood should be complementary markers for colorectal cancer. AIM: To quantify and correlate human DNA and hemoglobin in stools from patients with colorectal neoplasia, and to consider a simple stool assay for cancer screening. METHODS: Subjects comprised 74 patients with colorectal cancer, 27 with adenomas >1cm, and 100 with normal colonoscopy. One stool per subject was collected in stabilization buffer before or > 1 week after colonoscopy. Fecal long DNA and occult blood were quantified in blinded fashion by real-time Alu PCR (CEBP 2006 15:1115) and the HemoQuant assay (Mayo Medical Laboratories), respectively. HemoQuant assay results are not affected by fecal storage (Ann Intern Med 1984;101:297) and could be reliably applied to archival specimens for this study. RESULTS: Fecal long DNA and occult blood showed no correlation (R2=0). At 90% specificities, long DNA testing detected 70% of colorectal cancers and 46% of adenomas while occult blood testing detected 50% and 12%, respectively. Combining these tests detected 80% colorectal cancers and 46% of adenomas at 90% specificity. For detection of colorectal cancer, AUC values were 0.82, 0.78, and 0.90 for fecal long DNA, occult blood, and combination testing, respectively (p<0.05, long DNA or occult blood vs combination). The median (range) fecal long DNA level was 181 ng/g stool (0-7120 ng/g) with stage 1-2 cancers and 910 ng/g (0-19140 ng/ g) with stage 3-4 cancers, p<0.05. The median fecal hemoglobin level was 7.0 mg Hb/g (0.2-26.4 mg/g) with proximal cancers and 2.5 mg/g (0.1-36.1 mg/g) with distal ones, p<0.05. Median size was 4.0 cm (1.0-15.0) for neoplasms detected by the combined tests and 3.7 cm (1.0-7.0) for neoplasms missed, p=0.02. Neoplasm detection rates by combined tests were affected by neither tumor site nor stage. CONCLUSIONS: Long DNA and occult blood in stools are complementary stool markers for detection of colorectal cancer, and combined assay of these markers provides higher sensitivity for cancer than assay of either alone. The combined assay offers a simple and inexpensive screening approach that warrants further evaluation.

Long-term Follow-up of Patients Having False-Positive Multitarget Stool DNA Tests after Negative Screening Colonoscopy: The LONG-HAUL Cohort Study

Background: Studies of colorectal cancer screening by multitarget stool DNA (MT-sDNA) show false-positive (FP) rates of 7% to 13%. It is unclear whether FP patients are at increased long-term risk of adverse outcomes. Methods: We compared subsequent clinical events among patients with apparent FP MT-sDNA with those in patients reported as true negative (TN). This was a retrospective cohort study of participants in pre-FDA approval MT-sDNA studies having nonadvanced or negative baseline colonoscopy findings from a single referral center. Per-protocol and calibrated cutoffs defined FP and TN groups. From the time of stool collection, we measured differences between FP and TN groups in time to death, subsequent cancer diagnosis, and onset of alarm symptoms. Results: Of 1,050 eligible patients, only 6 were lost to follow-up. Median age was 65.6 years [interquartile range (IQR), 56.8–72.3]; 54% were female. Median follow-up time was 4 years (IQR, 3.5–5.3). Eight aerodigestive (lung and gastrointestinal tract) cancers occurred. FP status by calibrated, but not per-protocol, cutoffs was associated with subsequent aerodigestive cancer; however, cumulative incidence did not exceed SEER expectations from the general population. By any cutoff method, FP status was not associated with mortality or alarm symptoms. Conclusions: Although FP status was associated with long-term aerodigestive cancers, new cases were not temporally related and did not exceed incidence estimates from general population. Impact: These observations do not justify aggressive follow-up evaluation for patients with FP MT-sDNA at this time. Larger studies are needed to confirm these early findings. Cancer Epidemiol Biomarkers Prev; 26(4); 614–21. ©2016 AACR.

T2034 Stool DNA and Occult Blood for Detection of Colorectal Cancer: Complementary Markers

Non-apoptotic human DNA (long DNA) in stool is a discriminant marker for colorectal cancer (Gastroenterology 2000; 119:1219). Fecal long DNA may originate from either the exfoliation of dysplastic cells or from the luminal hemorrhage or exudation of leukocytes. The contribution of these potential sources long DNA in stool has not been examined. If leukocytes are the major source, then fecal human DNA and occult blood levels should correlate. If exfoliation is the major source, then fecal human DNA and occult blood should be complementary markers for colorectal cancer. AIM: To quantify and correlate human DNA and hemoglobin in stools from patients with colorectal neoplasia, and to consider a simple stool assay for cancer screening. METHODS: Subjects comprised 74 patients with colorectal cancer, 27 with adenomas >1cm, and 100 with normal colonoscopy. One stool per subject was collected in stabilization buffer before or > 1 week after colonoscopy. Fecal long DNA and occult blood were quantified in blinded fashion by real-time Alu PCR (CEBP 2006 15:1115) and the HemoQuant assay (Mayo Medical Laboratories), respectively. HemoQuant assay results are not affected by fecal storage (Ann Intern Med 1984;101:297) and could be reliably applied to archival specimens for this study. RESULTS: Fecal long DNA and occult blood showed no correlation (R2=0). At 90% specificities, long DNA testing detected 70% of colorectal cancers and 46% of adenomas while occult blood testing detected 50% and 12%, respectively. Combining these tests detected 80% colorectal cancers and 46% of adenomas at 90% specificity. For detection of colorectal cancer, AUC values were 0.82, 0.78, and 0.90 for fecal long DNA, occult blood, and combination testing, respectively (p<0.05, long DNA or occult blood vs combination). The median (range) fecal long DNA level was 181 ng/g stool (0-7120 ng/g) with stage 1-2 cancers and 910 ng/g (0-19140 ng/ g) with stage 3-4 cancers, p<0.05. The median fecal hemoglobin level was 7.0 mg Hb/g (0.2-26.4 mg/g) with proximal cancers and 2.5 mg/g (0.1-36.1 mg/g) with distal ones, p<0.05. Median size was 4.0 cm (1.0-15.0) for neoplasms detected by the combined tests and 3.7 cm (1.0-7.0) for neoplasms missed, p=0.02. Neoplasm detection rates by combined tests were affected by neither tumor site nor stage. CONCLUSIONS: Long DNA and occult blood in stools are complementary stool markers for detection of colorectal cancer, and combined assay of these markers provides higher sensitivity for cancer than assay of either alone. The combined assay offers a simple and inexpensive screening approach that warrants further evaluation.

Highly Discriminant Methylated DNA Markers for the Non-endoscopic Detection of Barrett’s Esophagus

BACKGROUND: Minimally invasive methods have been described to detect Barretts esophagus (BE), but are limited by subjectivity and suboptimal accuracy. We identified methylated DNA markers (MDMs) for BE in tissue and assessed their accuracy on whole esophagus brushings and capsule sponge samples. METHODS: Step 1: Unbiased whole methylome sequencing was performed on DNA from BE and normal squamous esophagus (SE) tissue. Discriminant MDM candidates were validated on an independent patient cohort (62 BE cases, 30 controls) by quantitative methylation specific PCR (qMSP). Step 2: Selected MDMs were further evaluated on whole esophageal brushings (49 BE cases, 36 controls). 35 previously sequenced esophageal adenocarcinoma (EAC) MDMs were also evaluated. Step 3: 20 BE cases and 20 controls were randomized to swallow capsules sponges (25 mm, 10 pores or 20 pores per inch (ppi)) followed endoscopy. DNA yield, tolerability, and mucosal injury were compared. Best MDM assays were performed on this cohort. RESULTS: Step 1: 19 MDMs with areas under the ROC curve (AUCs) >0.85 were carried forward. Step 2: On whole esophageal brushings, 80% of individual MDM candidates showed high accuracy for BE (AUCs 0.84‐0.94). Step 3: The capsule sponge was swallowed and withdrawn in 98% of subjects. Tolerability was superior with the 10 ppi sponge with minimal mucosal injury and abundant DNA yield. A 2‐marker panel (VAV3 + ZNF682) yielded excellent BE discrimination (AUC = 1). CONCLUSIONS: Identified MDMs discriminate BE with high accuracy. BE detection appears safe and feasible with a capsule sponge. Corroboration in larger studies is warranted. ClinicalTrials.gov number NCT02560623.

Abstract B12: An optimized molecular stool test for colorectal cancer screening: Evaluation of an automated analytic platform and logistic algorithm

We have demonstrated that colorectal cancer (CRC) and advanced pre-cancers can be detected non-invasively by a manual multi-target stool DNA-based test (sDNA-MT) comprising exfoliated DNA markers (methylated BMP3 and NDRG4, mutant KRAS (7 mutations, codons 12, 13), plus β-actin) and fecal hemoglobin (Hb) (Lidgard, Gastroenterology 2012;142(5);S-770). We now report the clinical performance of this sDNA-MT test using an optimized automated analytic platform and logistic algorithm. This platform could facilitate the routine performance of sDNA-MT for CRC screening by molecular diagnostics capable clinical laboratories. Method: Stool samples were collected from 1003 subjects at 36 study sites after informed consent and prior to colonoscopy bowel preparation from those presenting for average risk CRC screening (283) or surveillance (176) at 2 sites. From referred subjects with CRC, Advanced Adenoma (AA) or Sessile Serrate Adenoma ≥ 1 cm, (SSA) stool was collected at least 7 days post-colonoscopy and prior to surgery or chemo-radiation (135; 21 sites) and similarly for subjects with no neoplastic findings on colonoscopy (Neg) (409; 13 sites). The study population included: cases (207), 58% male, median age 65 yrs. (38-87), CRC (93), AA (84), SSA ≥ 1 cm (30) and controls (796), 42% male, median age 65 yrs. (50-84), Neg (641) and non-advanced adenomas (NA) (155). Stool sample collection and DNA isolation were previously described. Automated methylation, mutation and actin assays were performed with a Hamilton STARlet fluid handler (Hamilton Robotics, Reno NV), and QuARTS (Quantitative Allele-specific Real-time Target and Signal amplification) run on an ABI 7500 FastDx real time thermal cycler (Applied Biosystems, Foster City, CA). Fecal Hb (ng/ml buffer) analysis was performed by automated sandwich ELISA. A “Positive” or “Negative” result was determined with an algorithm that included the methylation and mutation results and a logistic regression score, which combines DNA marker results with Hb and actin results. Algorithm results exceeding a threshold were called “Positive”. The algorithm provided good discriminative ability, stability, sensitivity and specificity. Robustness was tested with computer simulations and statistical techniques (leave-one-out and 10-fold cross validation). Results: At a 90% nominal specificity, sDNA-MT sensitivity was 98% for CRC (91/93) [Stage: I, 95% (20/21), II, 100% (23/23), III 96% (26/27), IV 100% (7/7) and I-III combined 97% (69/71)], 57% (65/114) for precursors ≥1 cm (AA, SSA), and 86% (12/14) for precursors with high grade dysplasia. CRC patients were typically referred to colonoscopy for symptoms and test sensitivity may be elevated relative to that seen with screening. Conclusion: With this study using a novel automated sDNA-MT analytic platform with logistic algorithm, we corroborate our earlier findings using a manual process and demonstrate a platform that allows testing to be performed routinely by molecular diagnostic capable laboratories. The high sensitivity of sDNA-MT for CRC across all stages and for advanced precursors with high-grade dysplasia could lead to improved non-invasive CRC screening performance with wide accessibility to patients. A large multi-site pivotal CRC screening study (DeeP-C study clinicaltrials.gov, NCT01397747) to support such use is underway. Citation Format: Graham P. Lidgard, Michael J. Domanico, Janelle J. Bruinsma, James Light, Zubin D. Gagrat, Rebecca L. Oldham-Haltom, Keith D. Fourrier, Hatim Allawi, Tracy C. Yab, Julie A. Simonson, Mary Devens, Russell I. Heigh, David A. Ahlquist, Barry M. Berger. An optimized molecular stool test for colorectal cancer screening: Evaluation of an automated analytic platform and logistic algorithm. [abstract]. In: Proceedings of the Eleventh Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2012 Oct 16-19; Anaheim, CA. Philadelphia (PA): AACR; Cancer Prev Res 2012;5(11 Suppl):Abstract nr B12.