Follow-up in gastric dysplasia patients

Incidence Rate of Gastric Cancer Adenocarcinoma in Patients With Gastric Dysplasia: A Systematic Review and Meta-Analysis

Several studies have reported the risk of progression to gastric adenocarcinoma (GAC) in patients with gastric dysplasia (GD); however, the findings are controversial. We performed a systematic review and meta-analysis to study the incidence rate of GAC among patients with GD. Using a comprehensive search strategy, we systematically searched online databases including PubMed, Scopus, EMBASE, Cochrane Library, and Web of Science databases for identifying all relevant original articles through inception until July 2018. Cochran Q and I tests were used to assess heterogeneities between included studies. The incidence rates of GAC and their corresponding 95% confidence intervals (CIs) were pooled using random-effect or fixed-effect models. Of the 1980 retrieved records, 30 eligible articles (61 studies) were included. The overall pooled incidence rate of GAC was 40.36 (95% CI, 27.08-55.71; I, 96.0%) cases per 1000 person-years in patients with GD. Subgroup analysis according to the type of GD indicated the highest incidence rate of GAC was 186.40 (95% CI, 106.63-285.60; I, 94.6%) per 1000 person-years among patients with high-grade dysplasia (HGD) lesions. Although the incidence rates of GAC in low-grade dysplasia (LGD) lesions and in nonclassified lesions were 11.25 (95% CI, 3.91-21.22; I, 89.3%), and 1.40 (95% CI, 0.00-9.71; I, 78.8%), respectively. Compared with patients with LGD lesions, progression rate from GD to GAC was roughly 16 times greater in patients with HGD lesions. As the majority of patients with GAC are diagnosed in an advanced stage our study suggests strict management of HGD lesions to prevent GAC.

Clinical and experimental study of therapeutic effect of Weixibaonizhuan pills on gastric precancerous lesions

AIM:To observe the therapeutic effect of Wei-xibaonizhuan pills on gastric precancerous lesions.METHODS: Thirty patients with gastric precancerous lesions were treated with Weixibaonizhuan pills for 3 months. Of the 36 cases, 13 (36.1%) were mild atrophic gastritis, 14 (38.9%) moderate atrophic gastritis and 9 (25.0%) severe atrophic gastritis; among them 22 (61.1%) and 27 cases (75.0%) were accompanied with intestinal metaplasia (IM) and dysplasia (DYS) respectively. Of the 36 patients, 20 were men and 16 women, aged from 30-60 years and those aged 30-59 years accounted for 61.1%. The course of disease ranged from 3 months to 21 years, and 20 (55.6%) of them had a course of 5-10 years. The clinical manifestations were fullness of the abdomen (31 cases),abdominalgia (27 cases), anorexia (30 cases), gas eructation (26 cases), acid regurgitation (6 cases) and loose stool (9 cases). When treatment ended, the improvement of patients' clinical symptoms, atrophy of gastric mucosa, IM and DYS were analysed.RESULTS: After 3 months' treatment with Wei-xibaonizhuan pills,7 cases recovered, 11 cases were much improved, 13 cases showed some improvement, and 5 cases were ineffective; the total rate of symptomatic improvement was 86.1%. Of the 13 cases with mild atrophic gastritis, 11 cases changed into superficial gastritis, and 2 cases had no changes. Of the 14 cases of moderate atrophic gastritis, 4 cases changed into superficial gastritis, 7 cases changed into mild atrophic gastritis, and 3 cases had no changes. Five of 9 cases of severe atrophic gastritis were reduced to moderate atrophic gastritis, and 4 cases had no changes. The total effective rate was 77.8% in chronic atrophic gastritis. Of the 9 cases with mild IM, IM disappeared in 6 cases and 3 showed no change. Of the 10 cases with moderate IM, it disappeared in 2 cases, 5 cases changed to ild IM, and 3 cases had no change. One of the 4 cases of severe IM changed to moderate IM and 3 had no change. The total effective rate was 63.6% in IM. Of the 16 cases of mild DYS, 11 cases showed disappearance of DYS and 5 had no change. In 9 cases of moderate DYS, 2 showed disappearance, 5 changed to mild DYS and 2 had no change. Two cases of severe DYS, both showed no change. The total effective rate was 66.7% in DYS. Before treatment, the I, II, III and IV degree positive expressions of CEA were present in 13, 12, 9 and 2 cases, respectively, whereas after treatment, the positive expressions were present in 25, 7, 3 and 1, respectively. Before treatment, the I, II, III and IV degree positive expressions of PCNA were present in 16, 11, 10 and 4 respectively, but after treatment, they were present in 21, 9, 5 and 1 respectively. In short, the positive expressions of CEA and PCNA of gastric mucosa were significantly decreased after treatment (P < 0.01).CONCLUSION: Weixibaonizhuan pill has a therapeutic effect in gastric precancerous lesions.

Gastric epithelial dysplasia and adenoma: historical review and histological criteria for grading

Gastric epithelial dysplasia (GED) hypothetically is a straight-forward concept: dysplastic epithelium replacing the normal gastric epithelium of the stomach. However, since its inception several decades ago, the term GED has become progressively complex and confusing because of differences in definitions and nomenclature that have been based on cytological, microscopic, endoscopic, or gross features. This has resulted in the terms "dysplasia," "adenoma," "flat adenoma," and "depressed adenoma." Some authors have also included reactive changes under the term "dysplasia."

Gastric epithelial dysplasia. How clinicopathologic background relates to management

BACKGROUND

Gastric epithelial dysplasia (GED) in metaplastic mucosa is considered the most advanced preinvasive lesion in the multistep morphogenesis of intestinal-type gastric cancer (GC). The rate of GED's evolution into GC is still under debate and probably is related to pathologic and clinical parameters other than the dysplasia itself. The aim of this study was to evaluate whether clinical aspects (sex and age) and/or morphologic variables (GED grade, coexisting atrophic gastritis) are relevant to the outcome of dysplasia, with a view toward initiating the establishment of a rational follow-up protocol for practical GED management.

METHODS

Ninety-three patients harboring GED (G1: 56, G2:34, G3:18) were followed for more than 12 months according to a previously-agreed protocol. Regression, progression, or evolution into GC were detected for each grade of GED. Multivariate analysis was used to check the independence of clinical and pathologic variables in the progression of GED into more severe dysplastic lesions and/or as risk factors for evolution into GC.

RESULTS

Age, male sex, GED grade and grade of coexisting atrophic gastritis proved independent risk factors for GED progression, with no significant interactions. Only GED grade (G2 and G3) was significantly associated with carcinomatous evolution. In G1-GED, age and the grade of coexisting atrophy proved to be independent risk factors for carcinomatous evolution.

CONCLUSIONS

In G1-GED, more stringent follow-up should be recommended for older patients with coexisting high grade atrophic gastritis; stringent follow-up is always mandatory for G2-GED; and a surgical approach is justified in G3-GED.

Gastric epithelial dysplasia in the natural history of gastric cancer: a multicenter prospective follow-up study. Interdisciplinary Group on Gastric Epithelial Dysplasia

BACKGROUND/AIMS

Because the precancerous significance of gastric epithelial dysplasia (GED) is still under debate, this study attempts to ascertain whether a prospective follow-up of GED can contribute to clarifying its clinical and pathological relationships with gastric cancer (GC).

METHODS

One hundred twelve patients with mild (G1), moderate (G2), and severe (G3) GED or diagnosed as indefinite for dysplasia were prospectively followed up with a standardized endoscopic and bioptic protocol.

RESULTS

Evaluation of GED outcome refers only to 93 patients with a follow-up period longer than 12 months. Regression of dysplasia was documented in 36%, 27%, and 0% of G1, G2, and G3 GED cases, respectively. Progression to more severe dysplasia or evolution into GC was detected in 21%, 33%, and 57% of G1, G2, and G3 GED cases, respectively. Evolution into GC was documented for all grades of dysplasia and correlated significantly with high-grade atrophic gastritis. A high prevalence of early GC (86.9%) was also observed.

CONCLUSIONS

GED is a pre-invasive lesion, and carcinomatous evolution increases proportionally with its histological grade. Bioptical follow-up is mandatory for all histological grades of GED and significantly increases the likelihood of GC being detected in its early stages.

Epithelial dysplasia of the gastric mucosa. A morphometric and ploidy pattern study

60 cases of gastric dysplasia (20 mild, 20 moderate and 20 severe) were quantitatively studied and compared with cases of hyperplastic polyp (No 10), intestinal metaplasia (No 20), peptic ulcer (No 10) and invasive adenocarcinoma (No 20). In each case the area, the perimeter and the integrated optical density of 100 nuclei were measured in Feulgen stained tissue sections by means of a Leitz TAS. The stepwise discriminant analysis demonstrates that severe dysplasia and adenocarcinoma can be well distinguished from mild and moderate dysplasia. The ploidy pattern study demonstrates that the presence of severe dysplastic changes corresponds to a sharp increase in the degree of aneuploidy. In peptic ulcer, intermediate values between "benign" and "malignant" lesions were found.

Gastric epithelial dysplasia: a prospective multicenter follow-up study from the Interdisciplinary Group on Gastric Epithelial Dysplasia

To assess the evolution of gastric epithelial dysplasia (GED), a prospective multicenter study was based on a protocol of repeated endoscopies and biopsies. To date, 134 cases (0.4% of all patients endoscopically examined in the same period) have been diagnosed as having GED and 80 of those have had an "adequate" follow-up (at least three endoscopies). Mean follow-up time was 18 months. Gastric epithelial dysplasia was mild in 59% of cases, moderate in 25%, and severe in 10%. Six percent of the patients had lesions that were "indefinite for dysplasia." Chronic atrophic gastritis (40%), gastric ulcer (32%), gastrectomy (10%), and polyps (9%) were the most frequently associated lesions. The term "regression" was adopted for GED no longer detectable during follow-up and the term "progression" was used when more severe changes or cancer was detected. Mild GED regressed in 66% of cases, persisted in 15%, and progressed in 19% (three cases to moderate, one to severe, and five to cancer). Moderate GED regressed in 30% of patients, persisted in 30%, and progressed in 40% (one to severe GED and seven to cancer). Severe GED regressed in 12.5% of patients, persisted in 12.5%, and progressed to cancer in 75%. Of the five patients with lesions indefinite for dysplasia, two had no dysplastic changes at follow-up and three had cancer diagnosed. Ten of 21 cases of cancer (48%) were at the early stage. The diagnosis was reached within the first year of follow-up in 14 cases and after 1 year in seven (13 to 39 months). Fifteen of 21 cases of cancer were diagnosed in gastric ulcer patients. In conclusion, GED is an infrequent finding and its biologically neoplastic significance is confirmed by the results of the follow-up study: (1) in its mild form, it tends to regress but adequate subsequent check-ups are mandatory as it may associate with or evolve as cancer; (2) patients with moderate GED require strict follow-up since the lesion shows a higher cancer risk; (3) surgery is indicated for severe GED because gastric cancer develops in 75% of cases; and (4) patients with lesions indefinite for dysplasia should immediately undergo repeat endoscopy and biopsy. Such an approach allows gastric cancer to be detected at an early stage in a much higher percentage of cases than may be expected.

Risk of cancer in patients with gastric dysplasia. Follow-up study of 67 patients

This work is based on the follow-up evaluation of 67 moderate (MD) or severe gastric dysplasias (SD) diagnosed by endoscopic biopsy. Forty-one patients had moderate gastric dysplasia, 22 (53.65%) had regression of MD, 14 patients (34.4%) had persistence, three (7.31%) had progression to SD, and two (4.87%) had transformation in gastric adenocarcinoma. Twenty-six patients were diagnosed with severe gastric dysplasia: in 12 patients (46.15%) gastric lesions regressed to normality (five cases), mild (six cases) or moderate dysplasia (one case); six patients (23.07%) showed persistent histologic changes of SD in the subsequent biopsy specimens; eight patients (30.7%) presented progression of lesions to gastric adenocarcinoma after 1 to 79 months of follow-up evaluation. The authors conclude that moderate and severe gastric dysplasias are preneoplastic lesions and a valuable marker of gastric cancer risk; the risk of gastric cancer after moderate or severe dysplasia is of 9.52%, excluding those cases with short follow-up. The authors claim that these patients may receive a conservative clinical treatment with frequent endoscopic studies until the appearance of either early carcinoma to indicate gastrectomy, or no dysplasia at all or mild dysplasia in specimens from at least two consecutive biopsies.

Gastric dysplasia: inter-observer variation, sulphomucin staining and nucleolar organizer region counting

Gastric dysplasia is regarded as a pre-neoplastic lesion and is generally believed to have higher potential for malignant transformation with increasing grade. To obtain consistency in diagnosis and management, reproducible diagnostic criteria are needed. We have used the classification system of the International Study Group on Gastric Cancer--ISGGC and investigated the interobserver variation in histological diagnosis. A Kappa statistic of 0.579, which reflects moderate agreement, was obtained for variation between two experienced pathologists. The prevalence of type III intestinal metaplasia was studied and found to occur in 55% of dysplastic areas, but in only 9% of hyperplastic areas (P less than 0.01). In addition, the correlation of mean nucleolar organizer region (AgNOR) counts with diagnostic categorization was investigated. A significant inter-observer variation was found between an experienced pathologist and a postgraduate student and only one of the observers obtained statistically significant separation of mean AgNOR counts between the categories of high-grade dysplasia, low-grade dysplasia, atypical hyperplasia, simple hyperplasia and normal.