Within‐patient phylogenetic reconstruction reveals early events in Barrett’s Esophagus

Barrett's Esophagus is a neoplastic condition which progresses to esophageal adenocarcinoma in 5% of cases. Key events affecting the outcome likely occur before diagnosis of Barrett's and cannot be directly observed; we use phylogenetic analysis to infer such past events. We performed whole‐genome sequencing on 4–6 samples from 40 cancer outcome and 40 noncancer outcome patients with Barrett's Esophagus, and inferred within‐patient phylogenies of deconvoluted clonal lineages. Spatially proximate lineages clustered in the phylogenies, but temporally proximate ones did not. Lineages with inferred loss‐of‐function mutations in both copies of TP53 and CDKN2A showed enhanced spatial spread, whereas lineages with loss‐of‐function mutations in other frequently mutated loci did not. We propose a two‐phase model with expansions of TP53 and CKDN2A mutant lineages during initial growth of the segment, followed by relative stasis. Subsequent to initial expansion, mutations in these loci as well as ARID1A and SMARCA4 may show a local selective advantage but do not expand far: The spatial structure of the Barrett's segment remains stable during surveillance even in patients who go on to cancer. We conclude that the cancer/noncancer outcome is strongly affected by early steps in formation of the Barrett's segment.