γH2AX and p53 Immunohistochemistry predict the incidence risk of esophageal squamous precancerous lesions

BACKGROUND: Current screening practices for esophageal squamous cell carcinoma (ESCC) subject to both over- and under-surveillance of precancerous lesions. This study aims to evaluate potential immunohistochemical (IHC) markers associated with the incidence of ESCC and to establish an IHC-based panel for surveillance. METHODS: Tissue microarrays were constructed using 946 formalin-fixed, paraffin-embedded (FFPE) samples from 883 participants with baseline Lugol-unstained lesions (LULs) enrolled in a population-based screening trial. Candidate IHC markers were identified from literature and our previous findings. IHC results (H-scores) were quantified via HALO software, and optimal cut-offs were set by X-tile. Incident esophageal malignancy identified during a median follow-up of 11.76 years served as the outcome. Cox regression models were applied to identify predictive markers. RESULTS: =3.57 (2.40-5.30)]. The IHC score, combining the expression of γH2AX and p53, demonstrated strong predictive accuracy (C-index = 0.705) with AUCs of 0.894 (3-year), 0.909 (5-year), and 0.733 (10-year). Compared with the current surveillance strategy, 5.06% of the previous low-risk group with non-dysplastic LULs changed to the high-risk group (both γH2AX and p53 positive) with a cumulative incidence of HGIN and above (HGINA) of 44.7% (17/38). while 29.17% of individuals in the previous high-risk group with low-grade intraepithelial neoplasia > 1 cm changed to the low-risk group (neither γH2AX nor p53 positive) with no incident of HGINA (0/7). CONCLUSIONS: γH2AX, a novel incidence-warning IHC marker for esophageal squamous precancerous lesions, combined with p53, showed robust and durable predictive performance for incident malignancy after one-time screening. Integrating IHC testing could help refine risk stratification and mitigate over- and under-surveillance within current ESCC screening protocol.