Is endoscopic forceps biopsy enough for a definitive diagnosis of gastric epithelial neoplasia?

The long-term outcome and risk factors of histologic discrepancy between forceps biopsies and endoscopic resections in early gastric cancer: An observational study

Although endoscopic forceps biopsy is the gold standard for early gastric cancer (EGC) diagnosis, the method can cause endoscopic resection of specimens and histological discrepancies. This study aims to examine the risk factors for histological discrepancies in EGC and long-term clinical outcomes. This retrospective study included patients diagnosed with differentiated-type EGC using forceps biopsy. Patients without histological discrepancies and with undifferentiated types in endoscopic resection histology were categorized into the concordant and discordant groups, respectively. Clinical characteristics and long-term outcomes related to histological discrepancies were analyzed. A total of 957 lesions from 936 patients were enrolled. An overall discrepancy rate of 8.7% was confirmed, with an undifferentiated-type discrepancy of 5.5%. The discordant group showed a higher tendency for lesions to be located in the upper third region, to have whitish discoloration, and to undergo a greater number of biopsies compared with the concordant group. Multivariate analysis confirmed that lesion location in the upper third region (odds ratio [OR]: 2.125; 95% confidence interval [CI]: 1.032-5.277; P = .041) and whitish surface discoloration (OR: 13.615; 95% CI: 6.028-28.728; P = .001) were significantly correlated with histologic discrepancy. Compared with the concordant group, the discordant group had a lower curative resection rate, but no differences were observed in complications, local recurrence, or survival rates. Upper third location and whitish discoloration were risk factors for the histologic discrepancy between differentiated and undifferentiated types in patients with EGC. For curative resections performed in patients with EGC and histologic discrepancies and without additional treatment, careful follow-up is possible.

Application of artificial intelligence for diagnosis of early gastric cancer based on magnifying endoscopy with narrow-band imaging

Although magnifying endoscopy with narrow-band imaging is the standard diagnostic test for gastric cancer, diagnosing gastric cancer using this technology requires considerable skill. Artificial intelligence has superior image recognition, and its usefulness in endoscopic image diagnosis has been reported in many cases. The diagnostic performance (accuracy, sensitivity, and specificity) of artificial intelligence using magnifying endoscopy with narrow band still images and videos for gastric cancer was higher than that of expert endoscopists, suggesting the usefulness of artificial intelligence in diagnosing gastric cancer. Histological diagnosis of gastric cancer using artificial intelligence is also promising. However, previous studies on the use of artificial intelligence to diagnose gastric cancer were small-scale; thus, large-scale studies are necessary to examine whether a high diagnostic performance can be achieved. In addition, the diagnosis of gastric cancer using artificial intelligence has not yet become widespread in clinical practice, and further research is necessary. Therefore, in the future, artificial intelligence must be further developed as an instrument, and its diagnostic performance is expected to improve with the accumulation of numerous cases nationwide.

Long-term outcomes and clinical safety of expanded indication early gastric cancer treated with endoscopic submucosal dissection versus surgical resection: a meta-analysis

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) remains an investigational issue for early gastric cancer (EGC) with expanded indications owing to the risk of lymph node metastasis. In this study, we aimed to evaluate the clinical outcomes and safety of ESD versus surgical resection (SR) for EGC with expanded indications.

METHODS

The systematic review selected studies from PubMed, Embase, Cochrane and Web of Science databases from 2010 to 2020, and compared survival and clinical safety data of ESD with those of surgical resection for EGC with expanded indications. The fixed-effects or random-effects model was used to calculate the differences between the two groups. To assess the validity of the eligible studies, risk of bias was measured using the Newcastle-Ottawa Quality Assessment Scale.

RESULTS

Nine retrospective studies were used to calculate the differences in survival and clinical safety data between the two groups for EGC with expanded indications. Differences were not significant between the groups in terms of age, sex, tumour size, tumour histology or lesion morphology. Regarding tumour site, tumours located in the L area (the lower third of the stomach) were more likely to be found in the ESD group. With regard to metachronous and synchronous carcinomas, there was a significant difference favouring SR treatment (metachronous: OR=0.12, 95% CI=0.05 to 0.25, p<0.00001; synchronous: OR=0.11, 95% CI=0.02 to 0.46, p=0.003). Adverse event data were identified in six studies showing a significant difference favouring ESD treatment (ESD vs SR, OR=0.49, 95% CI=0.34 to 0.72. p=0.002). Additionally, six studies evaluating 5-year overall survival showed no significant differences between the two groups (HR=1.22, 95% CI=0.66 to 2.25, p=0.53). With regard to 5-year disease-free survival, patients with expanded indication EGC undergoing SR showed better survival (ESD vs SR, HR=3.29, 95% CI=1.60 to 6.76, p=0.001).

CONCLUSION

ESD provided favourable results for patients with EGC with expanded indications regarding clinical outcomes and safety in retrospective studies. Further, to detect synchronous or metachronous lesions, endoscopic surveillance should be performed following ESD. However, the included studies were observational, some did not have adequate adjustment for confounding factors and their results lacked generalisability due to their origin. Thus, further related randomised controlled trials are urgently encouraged.

PROSPERO REGISTRATION NUMBER

CRD42021251068.

Targeted labeling with tissue marking dyes guided by magnifying endoscopy of endoscopic submucosal dissection specimen improves the accuracy of endoscopic and histopathological diagnosis of early gastric cancer: a before–after study

BACKGROUND

Although histopathological evaluation after endoscopic submucosal dissection (ESD) is critical to assess the accuracy of endoscopic diagnosis, it is still challenging to perform precise endoscopic to pathological evaluation. We evaluated the importance of tissue marking dye (TMD)-targeted marking for post-ESD specimen guided by magnificent endoscope on histopathological accuracy and endoscopic-to-histopathological reconstruction.

STUDY DESIGN

A total of 81 specimens resected by ESD [43 without TMD marking (N-TMD group), and 38 specimens with TMD-targeted cancerous areas marking guided by post-procedural magnifying endoscopy on resected specimens (TMD group)] between January 31, 2019, and January 31, 2022 at the Renmin Hospital of Wuhan University were included in the study. The baseline characteristics of patients, discrepancies between endoscopic and histopathological diagnosis, and the impact of TMD on histopathological diagnosis and reconstruction were analyzed.

RESULTS

Discrepancies between endoscopic (pre-ESD) and histopathological (post-ESD) diagnosis increased significantly in TMD group (68.4% (26/38) for tumor areas, 26.3% (10/38) for tumor margins, and 26.3% (10/38) for tumor differentiations) when compared with N-TMD group (p < 0.0001). Deeper sections were achieved in all TMD-marked resected lesions and 27.9% (12/43) lesions in the N-TMD group (p < 0.001). More pathological evaluations in TMD group were changed from curative resection to non-curative resection [6/38(15.8%) vs 1/43(2.3%)] compared with N-TMD group (p < 0.0001). TMD-targeted marking also improved the efficiency of histopathological reconstruction on pre-procedural endoscopic images and benefit endoscopists training.

CONCLUSION

TMD-targeted labeling on resected specimens could improve precise endoscopic-to-pathological diagnosis, reconstruction by point-to-point marking and benefit endoscopists training.

Endoscopic or Follow-up Treatment for Gastric Indeterminate Tumors Is the Preferred Method of Management

Background

Endoscopic forceps biopsy (EFB) lacks precision in diagnosing indeterminate tumors. When the presence of early gastric cancer (EGC) is macroscopically suspected, but biopsy pathology fails to give a diagnosis of neoplasia, it causes problems in clinical management. The purpose of this study was to discuss the outcome of gastric indeterminate tumors and the clinical factors associated with predicting EGC.

Methods

The medical records of 209 patients diagnosed with gastric indeterminate neoplasia by biopsy forceps were retrospectively studied. Initial endoscopic findings were analyzed and predictors of EGC were evaluated.

Results

The final pathological diagnosis in 209 patients included adenocarcinoma (n = 7), high-grade intraepithelial neoplasia (n = 11), low-grade intraepithelial neoplasia (n = 21), and non-neoplastic lesion (n = 170). Multivariate analysis showed that older age (OR = 1.78; 95% CI = 1.17–2.71; p = 0.008), patients undergoing narrow band imaging (NBI) (OR = 3.40; 95% CI = 1.37–8.43; p = 0.008), and surface erosion (OR = 3.53; 95% CI = 1.41–8.84; p = 0.007) were associated with the upgraded group, and were significantly associated with risk. Univariate logistic regression analysis showed that among patients with NBI, the presence of demarcation line (DL) (OR = 24.00; 95% CI = 4.99–115.36; p < 0.0001), microvascular (MV) pattern irregularity (OR = 9.129; 95% CI = 2.36–35.34; p = 0.001), and the presence of white opaque substance (WOS) (OR = 10.77; 95% CI = 1.14–101.72; p = 0.038) were significant risk factors.

Conclusions

For gastric indeterminate tumors, older patient age, lesion surface with erosion, clear DL visible under NBI observation, presence of WOS, and irregular MV pattern are suggestive of the high possibility of neoplasia and need to be focused on and may benefit more from endoscopic resection treatment as opposed to simple endoscopic follow-up.

Successful endoscopic diagnosis of angiosarcoma of the small intestine: A case report

A 51-year-old man had hematochezia, anemia, and an intraabdominal mass. Gastroscopy and colonoscopy showed no significant lesions with intraluminal bleeding, while radiological examinations showed bulky swelling of the lymph nodes around the abdominal aorta and a tumor in the left ischial bone. Small intestine endoscopy detected a dark purpuric protruding tumor of the jejunum and its biopsy specimen brought a definitive diagnosis of primary jejunal epithelioid angiosarcoma from positive staining of AE1/AE3, CD31, and erythroblast transformation specific related gene in immunohistochemical studies. The patient underwent surgical resection with adjuvant chemotherapy but died of progression of metastases 7 months after the diagnosis. Epithelioid angiosarcoma of the gastrointestinal tract is an extremely rare malignancy with poor prognosis and it is challenging to distinguish from undifferentiated carcinoma or melanoma. Immunohistochemistry is necessary for a definitive diagnosis. Sufficient biopsy specimen may aid a prompt diagnosis of this disease of the small intestine, which may present as obscure gastrointestinal bleeding.

Risk factors for the histologic discrepancy of gastric adenomatous lesions and long-term outcome

Although endoscopic forceps biopsies (EFB) have a significant role in diagnosing gastric adenoma, there are still discrepancies between EFBs and finalized pathology results.Therefore, the objective of this study was to find the risk factors that cause this discrepancy and to analyze the effects of this discrepancy on the long-term outcome.In this study patients that had received endoscopic resection due to low-grade gastric adenoma diagnosis from EFB between January of 2011 and January of 2018 at the Chungnam National University Hospital were retrospectively analyzed. According to whether there was histological discrepancy the cumulative incidence of the metachronous lesions were analyzed.A total of 745 lesions diagnosed as low-grade gastric adenoma at EFB were enrolled, and the final pathology results were confirmed to be non-neoplastic (n = 19), low-grade adenoma (n = 614), High-grade adenoma (n = 63), and carcinoma (n = 49), and with the exception of non-neoplastic lesion, the results confirmed 84.6% (n = 614) for the concordant group and 15.4% (n = 112) for the discordant. The results of the multivariate analysis confirmed that depressed lesion (odds ratio [OR]: 2.056; 95% confidence interval [CI]: 1.130-3.451; P = .011), erythema (OR: 2.546; 95% CI: 1.604-4.030; P = .004), and a size >1.5 cm (OR: 1.903; 95% CI: 1.102-3.172; P = .018) were risk factors for discrepancy. The results also confirmed that for the average observation period of (SD) 39.12 (12.31) months, the cumulative incidence of metachronous neoplasm had a higher significance (P = 0.001) in the discordant group when compared to that of the concordant group.The factors related to the histologic discrepancy of low-grade gastric adenoma were depressed lesion, erythema and size >1.5 cm. In the groups with histological discrepancy, the cumulative incidence of the metachronous neoplasm was significantly higher and therefore closer observation of such patients after performing endoscopic resection is necessary.

Risk stratification of patients with gastric lesions indefinite for dysplasia

BACKGROUND/AIMS

There are no definite guidelines for the management of gastric lesions diagnosed as indefinite for dysplasia (IND) by endoscopic forceps biopsy (EFB). Therefore, this study aimed to evaluate the clinical outcomes of gastric IND and predictive factors for gastric neoplasm.

METHODS

This study included 457 patients with a first diagnosis of gastric IND by EFB between January 2005 and December 2013. Patient characteristics and endoscopic and pathological data were reviewed and compared.

RESULTS

Of the 457 gastric IND patients, 128 (28%) were diagnosed with invasive carcinoma, 21 (4.6%) with high-grade dysplasia, 31 (6.8%) with low-grade dysplasia, and 277 (60.6%) as negative for dysplasia. Of lesions observed, 180 (39.4%) showed upgraded histology. Multivariate analysis revealed that surface erythema (odds ratio [OR], 2.804; 95% confidence interval [CI], 1.741 to 4.516), spontaneous bleeding (OR, 2.618; 95% CI, 1.298 to 5.279), lesion size ≥ 1 cm (OR, 5.762; 95% CI, 3.459 to 9.597), and depressed morphology (OR, 2.183; 95% CI, 1.155 to 4.124) were significant risk factors for high-grade dysplasia or adenocarcinoma. The ORs associated with 2 and ≥ 3 risk factors were 7.131 and 34.86, respectively.

CONCLUSION

Precautions should be taken in the management of gastric IND patients, especially when risk factors, including surface erythema, spontaneous bleeding, lesion size ≥ 1 cm, and depressed morphology are present. Considering the combined effect of the presence of multiple risk factors on the incidence of high-grade dysplasia or adenocarcinoma, endoscopic resection should be recommended if a gastric IND patient has at two or more of these factors.

A deep learning-based system for identifying differentiation status and delineating the margins of early gastric cancer in magnifying narrow-band imaging endoscopy

BACKGROUND : Accurate identification of the differentiation status and margins for early gastric cancer (EGC) is critical for determining the surgical strategy and achieving curative resection in EGC patients. The aim of this study was to develop a real-time system to accurately identify differentiation status and delineate the margins of EGC on magnifying narrow-band imaging (ME-NBI) endoscopy. METHODS : 2217 images from 145 EGC patients and 1870 images from 139 EGC patients were retrospectively collected to train and test the first convolutional neural network (CNN1) to identify EGC differentiation status. The performance of CNN1 was then compared with that of experts using 882 images from 58 EGC patients. Finally, 928 images from 132 EGC patients and 742 images from 87 EGC patients were used to train and test CNN2 to delineate the EGC margins. RESULTS : The system correctly predicted the differentiation status of EGCs with an accuracy of 83.3 % (95 % confidence interval [CI] 81.5 % - 84.9 %) in the testing dataset. In the man - machine contest, CNN1 performed significantly better than the five experts (86.2 %, 95 %CI 75.1 % - 92.8 % vs. 69.7 %, 95 %CI 64.1 % - 74.7 %). For delineating EGC margins, the system achieved an accuracy of 82.7 % (95 %CI 78.6 % - 86.1 %) in differentiated EGC and 88.1 % (95 %CI 84.2 % - 91.1 %) in undifferentiated EGC under an overlap ratio of 0.80. In unprocessed EGC videos, the system achieved real-time diagnosis of EGC differentiation status and EGC margin delineation in ME-NBI endoscopy. CONCLUSION : We developed a deep learning-based system to accurately identify differentiation status and delineate the margins of EGC in ME-NBI endoscopy. This system achieved superior performance when compared with experts and was successfully tested in real EGC videos.

Comparative analysis of differences between preoperative endoscopic biopsy and postoperative pathological examination for diagnosis of gastric intraepithelial neoplasia

OBJECTIVE

This study was performed to compare the differences between preoperative endoscopic biopsy (PEB) and postoperative pathological examination (PPE) for diagnosis of gastric intraepithelial neoplasia (GIN).

METHODS

From September 2016 to July 2019, 188 consecutive patients with GIN at Yuyao People's Hospital were retrospectively analyzed. The 188 patients had 218 GIN lesions. All patients underwent PEB and either endoscopic submucosal dissection or surgical treatment. PPE was performed on pathological tissues that had been surgically removed.

RESULTS

Among 138 cases of low-grade dysplasia (LGD) diagnosed by PEB, 46 were upgraded to high-grade dysplasia (HGD), 20 were upgraded to early gastric cancer (EGC), and 2 were downgraded to inflammation after PPE. Among 42 cases of HGD, 23 were upgraded to EGC, 2 were downgraded to LGD, and 2 were downgraded to inflammation after PPE. Among 38 cases of EGC, 1 was downgraded to HGD and 2 were downgraded to LGD after PPE. The original diagnosis was maintained after the operation in 120 cases of GIN.

CONCLUSION

Biopsy did not fully reflect the lesions of GIN. Biopsy review should be actively performed, and the lesions should be clarified by endoscopic submucosal dissection or surgery.

Multifocal gastrointestinal epithelioid angiosarcomas diagnosed by endoscopic mucosal resection: A case report

BACKGROUND

Epithelioid angiosarcoma is a vascular neoplasm that is among the most aggressive subtypes of sarcomas. Its involvement in the gastrointestinal tract is rare. We here report a case of multifocal gastrointestinal epithelioid angiosarcomas presenting with gastrointestinal bleeding.

CASE SUMMARY

A 77-year-old woman was admitted because of melena and dizziness for three months. Gastroscopy and colonoscopy were performed, revealing a centrally ulcerated hemorrhagic polypoid lesion in the gastric body and multiple polypoid lesions with blood clots and hemorrhagic tendency in the colon. Histopathological examination of routine endoscopic biopsy samples showed inflammation in the gastric mucosa and tubular adenomas in the colon. The polypoid lesions were removed by endoscopic mucosal resection. Immunohistochemistry suggested a final diagnosis of epithelioid angiosarcomas. The patient refused chemotherapy and died after three months.

CONCLUSION

Epithelioid angiosarcomas are characterized by highly vascular nature and tendency to cause gastrointestinal bleeding. Efforts to obtain histological findings using endoscopic mucosal resection are of great importance.

Predictive Model of Nonneoplastic Pathology after Endoscopic Resection of Gastric Epithelial Neoplasia

Background/Aims

The rate of nonneoplastic pathology (NNP) after endoscopic resection (ER) of gastric epithelial neoplasia (GEN) has been reported to be 3%–7%. However, to date, the associations of pretreatment characteristics with NNP have not been identified. The aim of this study was to develop a predictive model for NNP after ER.

Methods

Among 817 patients who underwent ER for GEN, factors associated with NNP were identified by univariate and multivariate analyses. Weighted points considering the β coefficient were allocated to each variable that was significant in the multivariate analysis. The predictive score was calculated by the total points. The area under the receiver operating characteristic curve (AUROC) was calculated for the predictive score.

Results

The rate of NNP was 8.8%. After multivariate analysis, poor demarcation from the background, no ulceration, a flat appearance, and low-grade dysplasia were significant factors predictive of NNP. One point each was allocated for no ulcer, flat appearance, and low-grade dysplasia. Two points were allocated for poor demarcation from the background. The predictive score ranged from 0 to 5 points. Patients were categorized as being at low risk (0, 1, or 2 points) or high risk (3, 4, or 5 points) for NNP. The AUROC was 0.82 (95% confidence interval, 0.77 to 0.88; p<0.01). With a cutoff value of 2.5, the sensitivity and specificity of the score for predicting NNP were 0.72 and 0.84, respectively.

Conclusions

We developed a model to predict NNP after ER. Endoscopic re-biopsy or re-evaluation by pathologists is strongly recommended for the high-risk group.

Clinical outcomes of endoscopic treatment for gastric epithelial neoplasm in remnant stomach after distal gastrectomy

BACKGROUNDS/AIM

We aimed to evaluate the feasibility of endoscopic treatment for gastric epithelial neoplasm in the remnant stomach after distal gastrectomy and compared the clinical outcomes by tumor location and endoscopic treatment modality.

METHODS

We reviewed the data of patients who underwent endoscopic treatment for gastric epithelial neoplasms in the remnant stomach after distal gastrectomy between January 1996 and August 2013. The treatments included endoscopic resection or argon plasma coagulation.

RESULTS

Herein, 107 patients (median age, 65.1 years; 92 men) encompassing 117 cases of gastric neoplasms in the remnant stomach after distal gastrectomy were endoscopically treated. Forty of these lesions were located at anastomotic sites; they were treated with endoscopic resection in 29 cases (72.5%) and argon plasma coagulation in 11 cases (27.5%). For 77 lesions located on the non-anastomotic site, endoscopic resection was performed in 68 cases (88.4%) and argon plasma coagulation was performed in nine cases (11.7%; p = 0.031). The mean endoscopic resection duration was significantly longer in the anastomotic site group than in the non-anastomotic site group (43.6 vs. 26.3 min, p = 0.018). Recurrence was observed in five (12.8%) patients in the former and in one (1.3%) in the latter (p = 0.015); all the patients were successfully retreated with endoscopic resection or APC.

CONCLUSIONS

Endoscopic treatment for gastric epithelial neoplasm in a remnant stomach after distal gastrectomy is effective and safe. However, closely monitoring for recurrence should be conducted, particularly when the tumor is located at the anastomotic site.

Endoscopic management of patients with early gastric cancer before and after endoscopic resection: A review

With the wide application of endoscopic resection for early gastric cancer (EGC) by not only Asian endoscopists but also those from Western countries, reviews on standardized treatment processes before and after endoscopic resection are nevertheless lacking. In this article we provide a narrative review of studies on the selection of appropriate EGC for endoscopic resection and the follow-up strategies for those with histologically confirmed EGC after endoscopic resection. EGC should be comprehensively assessed before endoscopic resection, including its exact margin, invasive depth and risk of lymph node metastasis (LNM). While the curative resection status of EGC may be evaluated after endoscopic resection based on the newly developed eCura system, although this needs to be further verified. Surveillance with endoscopy and computed tomography scan is necessary for patients with an EGC level A or B. An additional endoscopic resection is recommended for patients with a level-C1 EGC. For patients with a level-C2 EGC, close follow-up is suggested for low-risk tumors of level C2 and additional surgery for those at high risks. Further postoperative strategy is suggested based on comprehensive assessment of the risk of LNM, patient's quality of life and wishes.

A robust qualitative transcriptional signature for the correct pathological diagnosis of gastric cancer

BACKGROUND

Currently, pathological examination of gastroscopy biopsy specimens is the gold standard for gastric cancer (GC) diagnosis. However, it has a false-negative rate of 10-20% due to inaccurate sampling locations and/or insufficient sampling amount. A signature should be developed to aid the early diagnosis of GC using biopsy specimens even when they are sampled from inaccurate locations.

METHODS

We extracted a robust qualitative transcriptional signature, based on the within-sample relative expression orderings (REOs) of gene pairs, to discriminate both GC tissues and adjacent-normal tissues from non-GC gastritis, intestinal metaplasia and normal gastric tissues.

RESULTS

A signature consisting of two gene pairs for GC diagnosis was identified and validated in data of both biopsy specimens and surgical resection specimens pooled from publicly available datasets measured by different laboratories with different platforms. For gastroscopy biopsy specimens, 96.20% of 79 non-GC tissues were correctly identified as non-GC, and 96.84% of 158 GC tissues and six of seven adjacent-normal tissues were correctly identified as GC. For surgical resection specimens, 98.37% of 2560 GC tissues and 97.28% of 221 adjacent-normal tissues were correctly identified as GC. Especially, 97.67% of the 257 GC patients at stage I were exactly diagnosed as GC. We additionally measured 21 GC tissues from seven different GC patients, each with three specimens sampled from three tumor locations with different proportions of the tumor epithelial cell. All these GC tissues were correctly identified as GC, even when the proportion of the tumor epithelial cell was as low as 14%.

CONCLUSIONS

The qualitative transcriptional signature can distinguish both GC and adjacent-normal tissues from normal, gastritis and intestinal metaplasia tissues of non-GC patients even using inaccurately sampled biopsy specimens, which can be applied robustly at the individual level to aid the early GC diagnosis.

Analysis of endoscopic features for histologic discrepancies between biopsy and endoscopic submucosal dissection in gastric neoplasms: 10-year results

BACKGROUND AND AIM

The histologic discrepancies between preoperative endoscopic forceps biopsy (EFB) and endoscopic submucosal dissection (ESD) specimens sometimes confuse the endoscope operator. This study aimed to analyze the limitation of the biopsy-based diagnosis before ESD and to evaluate which factors affect the discordant pathologic results between EFB and ESD.

METHODS

A total of 1427 patients, who were diagnosed with gastric adenoma by EFB, were enrolled. Cancer confirmed on EFB was excluded (n = 513). We retrospectively reviewed cases and compared histologic diagnoses in the biopsy sample with the final diagnosis in the endoscopically resected specimen.

RESULTS

The diagnosis was upgraded (from low-grade dysplasia to high-grade dysplasia or adenocarcinoma, or from high-grade dysplasia to adenocarcinoma) in 328 cases (23.0%), concordant in 944 (66.1%), and downgraded (from high-grade dysplasia to low-grade dysplasia or non-neoplasia, or from low-grade dysplasia to non-neoplasia) in 155 (10.9%). Multivariate logistic regression analysis showed that surface ulceration and depressed lesions were associated with significant risk factors for upgrading. Age younger than 60 years and size <1 cm were associated with significant factors for downgrading.

CONCLUSIONS

Careful endoscopic observation should consider size, ulceration, and depression to ensure accurate diagnosis when a gastric neoplasm is suspected.

Gastric Cancer Caused by Adenoma: Predictive Factors Associated with Lesions Other Than the Expanded Indications

Background/Aims

We aimed to investigate whether the current indications for curative endoscopic resection (ER) of gastric cancer (GC) can be applied to GC caused by adenoma. Additionally, we attempted to identify factors predictive of lesions subsequently found in addition to the expanded indications for ER.

Methods

We retrospectively analyzed 342 patients diagnosed with GC caused by adenoma who underwent ER at a single tertiary center between February 2011 and December 2014. The gross whole tumor size was measured using the endoscopically resected specimen. The microscopic whole tumor size was measured using mapping paper. The estimated cancer size was calculated using the microscopic whole tumor size and the square root of the carcinoma component.

Results

A gross whole tumor size ≥3 cm, carcinoma component ≥35%, and gross ulceration were predictive of lesions other than the expanded indications for ER. The overall rate of lymph node metastasis was 0.3% (1/327), which only occurred in one patient with a lesion other than the expanded indications (4.5%, 1/22).

Conclusions

The current indications for curative ER in GC can be applied to GC caused by adenoma. In cases suspected of having lesions other than the expanded indications, patients should be cautiously selected for ER to reduce the risk of an inappropriate procedure.

Clinical predictors of histologic type of gastric cancer

BACKGROUND AND AIMS

Gastric cancer is classified into differentiated and undifferentiated types according to the degree of glandular differentiation. Undifferentiated-type early gastric cancer (EGC) carries a higher risk of lymph-node metastasis than differentiated type, and therefore the indication criteria for endoscopic resection differ. This study aimed to clarify the ability of clinical predictors to distinguish between differentiated-type and undifferentiated-type EGCs.

METHODS

This was a post hoc study of a multicenter prospective trial carried out in 5 Japanese hospitals, including 343 patients with cT1 EGC of ≥10 mm. According to the protocol, age, sex, and endoscopic findings of cancer (diameter, location, macroscopic type, and invasion depth) were evaluated, and the final diagnosis was confirmed from resected specimens. We evaluated the associations between these clinical factors and the histologic type of cancer and calculated the ability of the factors to diagnose differentiated-type EGC. The diagnostic ability of forceps biopsy was also calculated as a reference.

RESULTS

Multivariate analysis identified older age (≥72 years), male sex, larger tumor size (>30 mm), elevated type, and shallower invasion depth (cT1a) as independent significant predictors for differentiated-type EGC, with elevated type showing the highest positive likelihood ratio. The sensitivity, specificity, accuracy, and positive and negative likelihood ratios of elevated type for differentiated-type EGC were 24%, 99%, 38%, 15.7, and 0.77, respectively, compared with 96%, 86%, 95%, 7.0, and 0.04 for forceps biopsy.

CONCLUSIONS

Endoscopic elevated type is a significant predictor for differentiated-type EGC and may exclude undifferentiated-type EGC without the need for forceps biopsy.

Endoscopic submucosal dissection for undifferentiated-type early gastric cancer: short- and long-term outcomes

BACKGROUND AND AIMS

Application of endoscopic submucosal dissection (ESD) for undifferentiated-type early gastric cancers (EGCs) remains controversial owing to limited data regarding long-term outcomes. We aimed to evaluate the feasibility of ESD for undifferentiated-type EGCs that meet the expanded criteria (EC).

METHODS

We performed a retrospective analysis of 66 patients who underwent ESD for undifferentiated-type EGC between January 2005 and December 2014. We evaluated the rates of en bloc, complete, and curative resections along with overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS).

RESULTS

Of the 66 patients, the EC group included 38 patients and the beyond-EC group included 28 patients. The overall rates of en bloc, complete, and curative resection of the 66 lesions were 92.4% (61/66), 65.2% (43/66), and 48.5% (32/66), respectively. Of the 34 patients with non-curative resection, 18 underwent additional surgery. Local remnant cancer was detected in 1 patient (1/18, 5.6%), and none of the 18 patients had lymph node metastasis. On multivariate analysis, tumors > 2 cm [odd ratio (OR) 6.183, 95% confidence interval (CI) 1.279-29.880, p = 0.023) and submucosal invasion depth (OR 6.226, 95% CI 1.881-20.606, p = 0.003) were independent predictors of incomplete resection. All 26 patients with more than 1 year of follow-up after curative resection survived without any evidence of local or distant recurrences over a median follow-up period of 36 months. The OS, DSS, and RFS rates of patients with curative ESD were 93.8, 100, and 100%, respectively.

CONCLUSIONS

ESD may have favorable long-term outcomes in patients with undifferentiated-type EGC after curative resection.

Does the discrepancy in histologic differentiation between a forceps biopsy and an endoscopic specimen necessitate additional surgery in early gastric cancer?

AIM

To investigate the clinicopathological variables in early gastric cancer (EGC) patients in relation to differentiation discrepancy.

METHODS

The data of 265 specimens from 240 patients with EGC, who had undergone radical operation at Hallym University Sacred Heart Hospital from 2010 to 2015, were retrospectively analyzed. We evaluated clinical, endoscopic, and histopathological data according to histological discrepancy.

RESULTS

Clinically significant discrepancy rate showed the difference in differentiated type (well and moderately differentiated) and undifferentiated type (poorly differentiated and signet ring cell) between endoscopic biopsies and postoperative specimens was 9.4% (25/265). There were no differences in tumor location, size, gross pattern, and number of biopsies. Specimens having histological discrepancy showed more submucosal invasion (72.0% vs 49.6%, P = 0.033) and lymph node involvement (24.0% vs 7.9%, P = 0.009) than specimens having non-discrepancy. The rate of a positive epidermal growth factor receptor status was higher in specimens having discrepancy than in specimens having non-discrepancy (81.0% vs 55.4%, P = 0.035).

CONCLUSION

The discordance of histologic differentiation is associated with higher submucosal invasion and lymph node metastases in EGC. Patients have histological discrepancy may require additional surgical treatments.

Long-Term Outcome After Endoscopic Submucosal Dissection for Early Gastric Cancer in Non-neoplastic Pathology Results

BACKGROUND

After endoscopic submucosal dissection (ESD) for early gastric cancer (EGC), negative pathological findings cause concern about the adequacy of the procedure and local recurrence after ESD.

AIM

To investigate the incidence of local recurrence in cases with negative pathological findings after ESD for EGC and pathologically complete resection (CR) during long-term follow-up.

METHODS

We reviewed 453 patients who underwent ESD for ECG from January 2007 to December 2010, respectively. Of these patients, in 17 cases the pathology results confirmed no residual tumor (NRT), and in 421 cases they showed CR in the ESD specimen. Finally, 17 NRT and 358 CR cases were followed up during surveillance. Patient characteristics, endoscopic and pathological data were analyzed for risk factors of local recurrence. We also re-evaluated the pathology of the NRT group to identify hidden malignant cells in the previous ESD specimens.

RESULTS

There was no difference between the two groups in terms of recurrence during follow-up surveillance (median 55.7 months). Late local recurrence of EGC was found in two cases (11.8%) in the NRT group, and three early local recurrences (5.6%) were found in the CR group. A review of the pathology in the NRT group revealed hidden malignant cells in five patients (29.4%).

CONCLUSIONS

Even when the pathological report indicates NRT after ESD, it might be necessary to re-evaluate ESD specimens with a width <2 mm, and long-term endoscopic surveillance should be routinely used for detecting local EGC recurrence after ESD.

Role of targeted biopsy under magnifying endoscopy with narrow band imaging may be not necessary: a prospective diagnostic accuracy study

BACKGROUND AND AIMS

Targeted biopsy under the guidance of magnifying endoscopy with narrow band imaging (ME-NBI) has higher accuracy than endoscopic forceps biopsy (EFB) in the differential diagnosis of cancerous lesions from noncancerous lesions. The aims of this study were to validate diagnostic efficacy of targeted biopsy under the guidance of ME-NBI (MNTB) and further evaluate whether it is necessary to perform MNTB when combined with ME-NBI.

METHODS

This study prospectively analyzed 211 gastric lesions of suspected cancerous tissues. The sensitivity, specificity, positive predictive value, and negative predictive value of EFB, ME-NBI, MNTB, EFB plus ME-NBI, and MNTB plus ME-NBI for the diagnosis of cancerous lesions were determined, respectively. The accuracy, sensitivity, specificity of EFB and MNTB, EFB plus ME-NBI, and MNTB plus ME-NBI were also compared, respectively.

RESULTS

The accuracy, sensitivity, and specificity with 95% confidence intervals were 68.2% (61.4-74.4%), 62.3% (54.1-69.9%), 84.2% (71.6-92.1%) for EFB, 75.4% (68.9-80.9%), 72.7% (64.9-79.4%), 82.5% (69.6-90.8%) for MNTB, 76.8% (70.4-82.2%), 73.4% (65.5-80.0%), 86.0% (73.7-93.3%) for ME-NBI, 82.0% (76.0-86.8%), 85.7% (79.0-90.6%), 71.9% (58.3-82.6%) for EFB plus ME-NBI, 84.8% (79.1-89.3%), 89.6% (83.4-93.8%), and 71.9% (58.3-82.6%) for MNTB plus ME-NBI, respectively. The sensitivity of MNTB was significantly higher than that of EFB (P=0.048). There was no significant difference in the sensitivity (P=0.307), specificity (P=1.000), and accuracy (P=0.337) between EFB plus ME-NBI and MNTB plus ME-NBI.

CONCLUSION

Although MNTB has a higher diagnostic efficacy than EFB in the diagnosis of cancerous lesions, it may be not necessary to perform MNTB when combined with ME-NBI.

Practical Points in Gastric Pathology

CONTEXT

-The diagnosis of gastric epithelial lesions is difficult in clinical practice, even with the recent developments and advances in endoscopic modalities, owing to the diverse morphologic features of the lesions, lack of standardized diagnostic criteria, and the high intraobserver and interobserver variabilities in the nonneoplastic (regenerative)-neoplastic spectrum.

OBJECTIVE

-To provide an overview of the current concepts and unresolved issues surrounding the diagnosis of diseases in the nonneoplastic-neoplastic spectrum, and to discuss some noteworthy properties and histologic features of gastric epithelial lesions.

DATA SOURCES

-A comprehensive assessment of the medical literature on gastric epithelial lesions was performed; we also interjected our own experiences into the discussion. Sources included original studies, review articles, and textbooks related to the field.

CONCLUSIONS

-Our literature review revealed that clear cell changes and micropapillary carcinoma components in gastric carcinomas are associated with poor clinical outcomes and should hence be included in pathologic reports. Moreover, we suggest a stepwise biopsy-endoscopic resection modality for the diagnosis of borderline neoplasia-nonneoplasia cases.

Atrophic and Metaplastic Progression in the Background Mucosa of Patients with Gastric Adenoma

BACKGROUND

In patients with adenoma, assessing premalignant changes in the surrounding mucosa is important for surveillance. This study evaluated atrophic and metaplastic progression in the background mucosa of adenoma or early gastric cancer (EGC) cases.

METHODS

Among 146 consecutive patients who underwent endoscopic resection for intestinal-type gastric neoplasia, the adenoma group included 56 patients with low-grade dysplasia and the ECG group included 90 patients with high-grade dysplasia or invasive carcinoma. For histology, 3 paired biopsies were obtained from the antrum, corpus lesser curvature (CLC), and corpus greater curvature (CGC). Serological atrophy was determined based on pepsinogen A (PGA), progastricsin (PGC), gastrin-17, and total ghrelin levels. Topographic progression of atrophy and/or metaplasia was staged using the operative link on gastritis assessment (OLGA) and operative link on gastric intestinal metaplasia assessment (OLGIM) systems.

RESULTS

Rates of moderate-to-marked histological atrophy/metaplasia in patients with adenoma were 52.7%/78.2% at the antrum (vs. 58.8%/76.4% in EGC group), 63.5%/75.0% at the CLC (vs. 60.2%/69.7% in EGC group), and 10.9%/17.9% at the CGC (vs. 5.6%/7.8% in EGC group). Serological atrophy indicated by PGA and PGC occurred in 23.2% and 15.6% of cases in the adenoma and ECG groups, respectively (p = 0.25). Mean serum gastrin-17 concentrations of the adenoma group and EGC group were 10.4 and 9.0 pmol/L, respectively (p = 0.54). Mean serum total ghrelin levels were 216.6 and 209.5 pg/mL, respectively (p = 0.71). Additionally, between group rates of stage III-IV OLGA and OLGIM were similar (25.9% vs. 25.0%, p = 0.90; 41.8% vs. 44.9%, p = 0.71, respectively).

CONCLUSIONS

Atrophic and metaplastic progression is extensive and severe in gastric adenoma patients. A surveillance strategy for metachronous tumors should be applied similarly for patients with adenoma or EGC.

Diagnosis and management of gastric dysplasia

Gastric dysplasia is a neoplastic lesion and a precursor of gastric cancer. The Padova, Vienna, and World Health Organization classifications were developed to overcome the discrepancies between Western and Japanese pathologic diagnoses and to provide a universally accepted classification of gastric epithelial neoplasia. At present, the natural history of gastric dysplasia is unclear. Much evidence suggests that patients with high-grade dysplasia are at high risk of progression to carcinoma or synchronous carcinoma. Therefore, endoscopic resection is required. Although patients with low-grade dysplasia have been reported to be at low risk of progression to carcinoma, due to the marked histologic discrepancies between forceps biopsy and endoscopic specimens, endoscopic resection for this lesion is recommended, particularly in the presence of other risk factors (large size; depressed gross type; surface erythema, unevenness, ulcer, or erosion; and tubulovillous or villous histology). Helicobacter pylori eradication in patients with dysplasia after endoscopic resection appear to reduce the incidence of metachronous lesions.

Predicting pre- and post-resectional histologic discrepancies in gastric low-grade dysplasia: A comparison of white-light and magnifying endoscopy

BACKGROUND AND AIM

The aim of this study was to evaluate the validity of the parameters of conventional white-light endoscopy and magnifying endoscopy with narrow-band imaging (MENBI) for the prediction of discrepancies between pre- and post-resectional histology in cases of gastric adenoma with low-grade dysplasia (LGD) that were diagnosed based on endoscopically biopsied specimens.

METHODS

The medical records of 266 lesions with gastric LGD that were diagnosed by endoscopic forceps biopsies were retrospectively reviewed. The Vienna classification was used for histologic diagnosis. These patients all underwent MENBI examinations followed by analyses of the incidence of histologic discrepancies and histologic heterogeneity. The relationship between white-light endoscopic/MENBI parameters and the presence of histologic discrepancies was also analyzed.

RESULTS

Discrepancies between the pre- and post-resectional histologies were found in 74 cases (27.9%). Among those cases, the histology was upgraded in 71 cases, whereas the histology was downgraded in three cases. The presence of erythema and positive MENBI findings were independent factors for the prediction of upgraded histologic discrepancies (P-values = 0.008, < 0.001, respectively). A positive MENBI finding yielded the highest predictive value, with a multivariate adjusted odds ratio of 42.46. Histologic heterogeneity in post-resectional specimens was found in 40.8% of cases with upgraded histologic discrepancies.

CONCLUSIONS

MENBI can provide more accurate information than white-light endoscopy for the prediction of pre- and post-resectional histologic discrepancies in biopsy-proven gastric LGD. Endoscopic resection is strongly recommended in cases with surface erythema on conventional white-light endoscopy or positive MENBI, irrespective of the lesion size.

Endoscopy vs surgery in the treatment of early gastric cancer: Systematic review

AIM: To report a systematic review, establishing the available data to an unpublished 2a strength of evidence, better handling clinical practice.

METHODS: A systematic review was performed using MEDLINE, EMBASE, Cochrane, LILACS, Scopus and CINAHL databases. Information of the selected studies was extracted on characteristics of trial participants, inclusion and exclusion criteria, interventions (mainly, mucosal resection and submucosal dissection vs surgical approach) and outcomes (adverse events, different survival rates, mortality, recurrence and complete resection rates). To ascertain the validity of eligible studies, the risk of bias was measured using the Newcastle-Ottawa Quality Assessment Scale. The analysis of the absolute risk of the outcomes was performed using the software RevMan, by computing risk differences (RD) of dichotomous variables. Data on RD and 95%CIs for each outcome were calculated using the Mantel-Haenszel test and inconsistency was qualified and reported in χ² and the Higgins method (I²). Sensitivity analysis was performed when heterogeneity was higher than 50%, a subsequent assay was done and other findings were compiled.

RESULTS: Eleven retrospective cohort studies were selected. The included records involved 2654 patients with early gastric cancer that filled the absolute or expanded indications for endoscopic resection. Three-year survival data were available for six studies (n = 1197). There were no risk differences (RD) after endoscopic and surgical treatment (RD = 0.01, 95%CI: -0.02-0.05, P = 0.51). Five-year survival data (n = 2310) showed no difference between the two groups (RD = 0.01, 95%CI: -0.01-0.03, P = 0.46). Recurrence data were analized in five studies (1331 patients) and there was no difference between the approaches (RD = 0.01, 95%CI: -0.00-0.02, P = 0.09). Adverse event data were identified in eight studies (n = 2439). A significant difference was detected (RD = -0.08, 95%CI: -0.10--0.05, P < 0.05), demonstrating better results with endoscopy. Mortality data were obtained in four studies (n = 1107). There was no difference between the groups (RD = -0.01, 95%CI: -0.02-0.00, P = 0.22).

CONCLUSION: Three-, 5-year survival, recurrence and mortality are similar for both groups. Considering complication, endoscopy is better and, analyzing complete resection data, it is worse than surgery.

Difficulty of predicting the presence of lymph node metastases in patients with clinical early stage gastric cancer: a case control study

BACKGROUND

The relationship between pathological factors and lymph node metastasis of pathological stage early gastric cancer has been extensively investigated. By contrast, the relationship between preoperative factors and lymph node metastasis of clinical stage early gastric cancer has not been investigated. The present study was to investigate discrepancies between preoperative and postoperative values.

METHODS

From January 2011 to December 2013, 1042 patients with clinical stage early gastric cancer who underwent gastrectomy with lymphadenectomy were enrolled. Preoperative and postoperative values were collected for subsequent analysis. Receiver operating characteristics curves were computed using independent predictive factors.

RESULTS

Several discrepancies were observed between preoperative and postoperative values, including existence of ulcer, gross type, and histology (all McNemar p-values were <0.001). Multivariate analyses identified the following independent predictive factors for lymph node metastasis: postoperative values including age (p = 0.002), tumor size (p < 0.001), and tumor depth (p < 0.001); preoperative values including age (p = 0.017), existence of ulcer (p = 0.037), tumor size (p = 0.009), and prediction of the presence of lymph node metastasis in computed tomography scans (p = 0.002). These postoperative and preoperative independent predictive factors produced areas under the receiver operating characteristics curves of 0.824 and 0.660, respectively.

CONCLUSIONS

Surgeons need to be aware of limitations in preoperative predictions of the presence of lymph node metastasis for clinical stage early gastric cancer.

Diagnosis and therapies for gastric non-invasive neoplasia

There has been a great discrepancy of pathological diagnosis for gastric non-invasive neoplasia/dysplasia between Japanese and western pathologists. In Japan, lesions that most western pathologists diagnose as dysplasia are often considered adenocarcinoma based on nuclear and structural atypia regardless of the presence of invasion. In the Vienna classification, gastric non-invasive intraepithelial neoplasia (NIN) were divided into low grade and high grade (including intra-mucosal cancer of Japanese criteria). The diagnosis by both endoscopy and pathology of biopsy specimen is difficult. Recent advances of diagnostic modality such as magnified endoscopy and imaged enhanced endoscopy is expected to improve the diagnostic yield for NIN. There are two treatment strategies for NIN, observation and diagnostic therapy by endoscopic resection (ER). ER is acceptable because of its less invasiveness and high local control rate, on the other hand, cancer-developing rate of low-grade NIN is reported to be low. Therefore there is controversy for the treatment of gastric NIN. Prospective study based on unified pathological definition is required in the future.

Is screening and surveillance for early detection of gastric cancer needed in Korean Americans?

The incidence rate of gastric cancer in Korean Americans is over five times higher than that in non-Hispanic whites, and is similar to the incidence of colorectal cancer in the overall United States population. In Korea, the National Cancer Screening Program recommends endoscopy or upper gastrointestinal series for people aged 40 years and older every 2 years. However, the benefit of gastric cancer screening in Korean Americans has not been evaluated. Based on epidemiologic studies, Korean Americans appear to have more similar gastric cancer risk factors to Koreans as opposed to Americans of European descent, though the risk of gastric cancer appears to decrease for subsequent generations. Therefore, in accordance with recent recommendations regarding screening for gastric cancer in Korea, endoscopic screening for gastric cancer in Korean Americans should be considered, especially in those with known atrophic gastritis/intestinal metaplasia or a family history of gastric cancer. In the future, additional studies will needed to assess whether a screening program for gastric cancer in Korean Americans will result in a survival benefit.

Risk factors for under-diagnosis of gastric intraepithelial neoplasia and early gastric carcinoma in endoscopic forceps biopsy in comparison with endoscopic submucosal dissection in Chinese patients

Differences in pathologic diagnosis between endoscopic forceps biopsy (EFB) and endoscopic submucosal dissection (ESD) for gastric intraepithelial neoplasia (GIN) and early gastric carcinoma (EGC) in Chinese patients remain unknown. The aim of the study was to investigate risk factors for under-diagnosed pathology in initial EFB, compared to final ESD. We reviewed endoscopic and histopathologic findings for tumor location, size, macroscopic pattern, nodularity, erythema, erosion, GIN (low and high grade), and EGC diagnosed with the WHO criteria. Differences in those features between EFB and ESD were compared and risk factors for under-diagnosis by EFB were analyzed. Although concordant in most (74.9 %) cases between EFBs and ESDs, pathological diagnoses in 57 (25.1 %) cases were upgraded in ESDs. Compared to the concordant group, the lesion size ≥2 cm, and depressed and excavated patterns were significantly more frequent in the upgraded group. Further multivariate regression analysis demonstrated the depressed pattern and lesion size ≥2 cm as independent risk factors for upgraded pathology with the odds ratio of 5.778 (95 % confidence interval 2.893-11.542) and 2.535 (95 % confidence interval 1.257-5.111), respectively. Lesion size ≥2.0 cm and the depressed pattern at initial EFB were independent risk factors for pathologic upgrade to advanced diseases in ESD. Therefore, these endoscopic characteristics should be considered together with the initial EFB diagnosis to guide the optimal clinical management of patients with GIN and EGC.

How Commonly Is the Diagnosis of Gastric Low Grade Dysplasia Upgraded following Endoscopic Resection? A Meta-Analysis

Gastric dysplasia is a well-known precancerous lesion. Though the diagnosis of gastric low grade dysplasia (LGD) is generally made from endoscopic forceps biopsy (EFB), the accuracy is doubtful after numerous EFB-proven gastric LGD were upgraded to gastric high grade dysplasia (HGD) or even carcinoma (CA) by further diagnostic test with the procedure of endoscopic resection (ER). We aimed to evaluate the upgraded diagnosis rate (UDR) and the risk factors by ER in EFB-proven gastric LGD lesions. Two investigators independently searched studies reporting the UDR by ER in EFB-proven gastric LGD lesions from databases and analyzed the overall UDR, HGD-UDR and CA-UDR. The pooled UDR by ER in EFB-proven gastric LGD lesions was 25.0% (95% CI, 20.2%-29.8%), made up of HGD-UDR and CA-UDR by rates of 16.7% (95% CI, 12.8%-20.6%) and 6.9% (95% CI, 4.2%-9.6%) respectively. Lesion size larger than 2 cm, surface with depression and nodularity under endoscopic examinations were the major risk factors associated with UDR. In conclusion, one quarter of EFB-proven gastric LGD lesions will be diagnosed as advanced lesions, including gastric HGD (16.7%) and gastric CA (6.9%) by ER. The diagnosis of those LGD lesions with an endoscopic diameter larger than 2cm, and depressed or nodular surface are more likely to be upgraded after ER.

Low Discrepancy Between Tissue Biopsy Plus Magnifying Endoscopy With Narrow-Band Imaging and Endoscopic Resection in the Diagnosis of Gastric Epithelial Neoplasia (STROBE)

Tissue biopsy is often not very accurate for the diagnosis of gastric epithelial neoplasia (GEN), and the results differ notably from endoscopic resection (ER) in terms of the pathological diagnosis. The aims of this study were to evaluate the diagnostic performances of biopsy, magnifying endoscopy with narrow-band imaging (ME-NBI), and biopsy plus ME-NBI for GEN.This study retrospectively analyzed 101 cases diagnosed as GEN using ER samples. The discrepancies between biopsy and ER, as well as between biopsy plus ME-NBI and ER in the diagnosis of GEN were evaluated. Factors that contributed to such discrepancies were analyzed. The sensitivity and specificity of biopsy and ME-NBI for the diagnosis of high-grade neoplasia (HGN) were determined.The discrepancy in the pathological diagnosis between biopsy and ER was 39.6% for GEN and 54.2% for HGN. The discrepancy between biopsy combined with ME-NBI and ER was 15.9% for GEN and 10.2% for HGN. Factors that undermined the diagnostic accuracy of biopsy included the lesion size (≤10 mm, odds ratio [OR] 1; 10-20 mm, OR 0.2, 95% confidence interval [CI] 0.1-0.7; >20 mm, OR 0.5, 95% CI 0.1-2.1, P = 0.03) and the number of biopsy fragments (OR 0.6, 95% CI 0.5-0.8, P = 0.001). The sensitivity and specificity for HGN were 45.8% (33.7%-58.3%) and 100% (87.5%-100%) for biopsy, and 88.1% (77.5%-94.1%) and 92.9% (81.0%-97.5%) for ME-NBI, respectively.In conclusion, biopsy-based diagnoses for GEN should be interpreted with caution. Biopsy combined with ME-NBI can contribute to the diagnosis of GEN, which improves diagnostic consistency with pathological result of ER specimens.

Combination of Paris and Vienna classifications may optimize follow-up of gastric epithelial neoplasia patients

Background

The aim of this study was to evaluate the efficiency of the combination of Paris and Vienna classifications in a follow-up study of gastric epithelial neoplasia (GEN) patients.

Material/Methods

This study was conducted between January 2003 and September 2010, during which 170 biopsy-proven GEN patients were followed up by gastroenterologists and pathologists according to our follow-up regimen (modified Vienna classification).

Results

In total, 161 patients with low-grade neoplasia (LGN) and 9 patients with high-grade neoplasia (HGN) were randomly enrolled in our study. Eighteen patients with depressed appearance were observed, of which 9 patients had HGN and 9 patients had low-grade dysplasia (LGD). Three patients with type 0-IIa were observed with low-grade adenoma (LGA), and type 0–I was observed in 2 patients with LGN. Endoscopic or surgical treatments were performed to avoid potential malignancy or bleeding. Two patients with ulcer lesions, 2 patients with non-depressed type 0 appearance, and 3 patients without visible lesions were shown to have higher-grade lesions during follow-up. The misdiagnosis rate of forceps biopsy – 62.07% – was determined by comparing pre- and post-resection diagnoses of 29 patients.

Conclusions

The combination of the Paris and Vienna classifications for GEN may optimize the follow-up routines for patients with suspicious precancerous lesions and may significantly improve the detection of early gastric cancer (EGC) while helping gastroenterologists select the best therapy option.

Comparative study of Western and Japanese criteria for biopsy-based diagnosis of gastric epithelial neoplasia

BACKGROUND

In Western countries, gastric cancer (GC) is diagnosed when there is histological evidence of invasion into the lamina propria or beyond the submucosa. In Japan and some other countries, however, diagnosis of GC is based on the degree of structural and cytological abnormality of tumor glands. The aim of the present study was to compare the accuracy of the Western and Japanese criteria for diagnosis of GC.

METHODS

The study included 233 consecutive patients with a postoperative diagnosis of submucosal invasive GC who underwent gastrectomy or endoscopic submucosal dissection. All pretreatment biopsy specimens were independently reviewed by two experts in gastrointestinal pathology employing both the Western and Japanese diagnostic criteria. Diagnostic agreement between pretreatment biopsy specimens and the corresponding resected specimens was evaluated, together with the interobserver agreement for each of the criteria.

RESULTS

On the basis of the Western and Japanese criteria, the pretreatment biopsy diagnosis was noncancerous (including dysplasia) in 44 lesions and 1 lesion, respectively. Diagnostic accuracy based on biopsy was 81.1% for the Western criteria and 99.5% for the Japanese criteria (P < 0.001). Interobserver agreement based on the Western and Japanese criteria was 73.8% and 96.5%, respectively (P < 0.001). Invasion into the submucosa was detected by biopsy in only 25 cases.

CONCLUSIONS

The Japanese criteria are significantly more accurate for pretreatment biopsy diagnosis of GC. The Western criteria could lead to underdiagnosis of a lesion as high-grade dysplasia, even if submucosal invasive cancer is present.

Progress in research of gastric intraepithelial neoplasia

Gastric carcinoma is one of the most common malignant tumors in the world, and the accurate diagnosis of precancerous lesions plays an important role in gastric cancer prevention. Intraepithelial neoplasia is a form of precancerous lesion of gastric cancer, and many efforts have been done to explore the relationship between gastric cancer and dysplasia. Recently, there has been much progress in the research of intraepithelial neoplasia, including genetic changes at the molecular level, the eradication of Helicobacter pylori (H. pylori), regular follow-up and endoscopic therapy. All of these will play an important role in clinical management of this condition. However, the etiological mechanism, influencing factors and malignant transformation of GIN are still unclear. Hence, further multi-center and long-term prospective studies are needed to solve these problems.

Endoscopic predictors for undifferentiated histology in differentiated gastric neoplasms prior to endoscopic resection

BACKGROUND

There is often a discrepancy between results from endoscopic forceps biopsy and resected specimen. We aimed to identify endoscopic predictors for undifferentiated histology in differentiated gastric neoplasms prior to endoscopic resection.

METHODS

Medical records of the patients who underwent endoscopic submucosal dissection (ESD) for biopsy-proven differentiated gastric neoplasms at Seoul National University Hospital between July 2005 and July 2014 were retrospectively reviewed. The lesions were divided into two groups based on the final histologic result of ESD: differentiated adenocarcinoma (DA group) and undifferentiated histology (UDH group). The discordant rate, clinicopathologic characteristics, and endoscopic factors were analyzed.

RESULTS

A total of 1641 early gastric cancers from 1615 patients were included. Of these, 1556 (94.8%) were diagnosed as DA and 85 (5.2%) as UDH. The mean age was significantly lower, and number of women was higher in the UDH group than in the DA group. On multivariate analysis, age <65 years [odds ratio (OR) 1.75, 95 % confidence interval (CI) 1.10-2.80], female sex (OR 3.19, 95% CI 2.00-5.08), endoscopic size >10 mm (OR 1.81, 95% CI 1.12-2.92), depressed type (OR 2.85, 95% CI 1.56-5.21), nodularity (OR 2.83, 95% CI 1.59-5.05), and whitish discoloration (OR 19.64, 95% CI 6.98-55.25) were independent predictors.

CONCLUSIONS

Female sex, age <65 years, large endoscopic size, depressed morphology, surface nodularity, and whitish discoloration were predictors for UDH. Meticulous attention should be paid to the lesions with these endoscopic predictors for determining the risk of UDH prior to endoscopic resection.

Endoscopic resection as a first therapy for gastric epithelial atypia: is it reasonable?

BACKGROUND AND AIMS

Gastric atypical cell (GAC), an indefinite pathologic finding, often requires repeated biopsy or other diagnostic treatments, such as endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), or operation (OP). The aim of this study was to analyze the initial endoscopic and histologic findings of GAC and to discuss the necessity of EMR/ESD at establishing a correct diagnosis.

METHODS

This retrospective study enrolled 96 patients proven as GAC on index forceps biopsy. ESD (17/96, 17.7%), EMR (5/96, 5.2%), OP (20/96, 20.8%), and other treatment or follow-up (54/96, 56.3%) were performed. We analyzed the initial endoscopic and histologic characteristics of GAC lesions, predictive of neoplasm.

RESULTS

After diagnostic modalities, the final pathologic diagnoses were cancer (36/96, 37.6%), dysplasia (9/96, 9.4%), and non-neoplasm (51/96, 53.0%). In univariate analysis, age [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.07], lesion size of 10 mm or greater (OR 3.94, 95% CI 1.61-9.61), lesion with depressed type (OR 2.50, 95% CI 1.09-5.72), and presence of H. pylori (OR 2.83, 95% CI 1.11-7.25) were risk factors for neoplasm. In multivariate analysis, lesion size of 10 mm or greater (OR 3.63, 95% CI 1.23-10.66), lesion with depressed type (OR 2.86, 95% CI 1.11-7.38) were independent risk factors for cancer.

CONCLUSION

Considering the neoplastic risk of GAC, which could be missed on biopsy, more comprehensive tissue sampling via EMR/ESD might be necessary to establish a definite diagnosis.

Clinical safety of endoscopic submucosal dissection compared with surgery in elderly patients with early gastric cancer: a propensity-matched analysis

BACKGROUND

Little is known about the clinical and oncologic outcomes of endoscopic submucosal dissection (ESD) compared with surgery in elderly patients with early gastric cancer (EGC).

OBJECTIVE

To evaluate the clinical and oncologic outcomes of ESD compared with surgery in elderly patients with EGC of an expanded indication.

DESIGN

Retrospective study with propensity-matched analysis.

SETTING

University-affiliated tertiary-care hospital, Seoul, South Korea.

PATIENTS

A total of 518 patients 70 years of age or older with initial-onset EGC.

INTERVENTIONS

ESD and surgery.

MAIN OUTCOME MEASUREMENTS

Clinical outcomes, disease-free survival, and overall survival.

RESULTS

In a propensity-matched analysis of 132 pairs, the length of hospital stay of the ESD group was shorter than that of the surgery group (median [interquartile range], 4 [3-4] vs 9 [7-11] days; P < .001). Intensive care unit admission occurred in the surgery group only (7 patients [5.3%]). Two surgery-related deaths occurred in the surgery group (1 splenic artery bleeding and 1 anastomosis site leakage). During follow-up, metachronous lesions developed more often in the ESD group than in the surgery group (12 vs 2 lesions, P = .004). All recurred lesions were successfully treated endoscopically except for 3 patients who refused additional treatment. Overall survival did not differ between the 2 groups (P = .280).

LIMITATIONS

Nonrandomized, retrospective study.

CONCLUSIONS

ESD is a safe procedure in elderly patients with EGC. Although the risk of metachronous lesions is higher in patients who undergo ESD than in those who undergo surgery, overall survival did not differ between the patients who undergo ESD and surgery.

Endoscopic resection for undifferentiated early gastric cancer: focusing on histologic discrepancies between forceps biopsy-based and endoscopic resection specimen-based diagnosis

BACKGROUND

Before endoscopic resection (ER), a considerable number of undifferentiated early gastric cancer (UD-EGC) cases were initially diagnosed as atypical glands, dysplasia, or differentiated EGC (D-EGC) based on forceps biopsy specimens. As UD-EGC carries a high risk of resection margin involvement, identifying the predictive factors for UD-EGC cases with histologic discrepancy (HD) is of clinical importance.

AIMS

To investigate the outcomes of ER for UD-EGC and to identify the predictive factors for UD-EGC with HD.

METHODS

Among 2,194 EGC lesions treated by ER, 59 lesions were finally diagnosed as UD-EGC and 50 UD-EGC cases showed HD. The demographic and endoscopic characteristics were compared between D-EGC and UD-EGC with HD, and the predictive factors for the latter were investigated among cases of forceps biopsy-based diagnosis of atypical glands, dysplasia, or D-EGC.

RESULTS

UD-EGC showed significantly higher rate of lateral margin involvement compared to D-EGC (18.6 vs. 3.4%). Among the UD-EGC cases meeting the expanded criteria and not involving additional surgery, no local or extragastric tumor recurrence was observed during the median follow-up of 27.5 months. Multivariate analysis demonstrated that age (≤60 years), female gender, gastric body, flat or depressed type, and tumor size (>2 cm) were independent predictive factors for UD-EGC with HD among cases of forceps biopsy-based diagnosis of atypical glands, dysplasia, or D-EGC.

CONCLUSIONS

For lesions with predictive factors for UD-EGC with HD, a circumferential mapping biopsy before ER or wide marking during ER could be considered to avoid the potential risk of incomplete resection.

A randomized trial to determine the diagnostic accuracy of conventional vs. jumbo forceps biopsy of gastric epithelial neoplasias before endoscopic submucosal dissection; open-label study

BACKGROUND AND AIMS

Larger biopsy specimens or increasing the number of biopsies may improve the diagnostic accuracy of gastric epithelial neoplasia (GEN). The aims of this study was to compare the diagnostic accuracies between conventional and jumbo forceps biopsy of GEN before endoscopic submucosal dissection (ESD) and to confirm that increasing the number of biopsies is useful for the diagnosis of GEN.

RESULTS

The concordance rate between EFB and ESD specimens was not significantly different between the two groups [83.1 % (54/65) in JG vs. 79.1 % (53/67) in CG]. On multivariate analyses, two or four EFBs significantly increased the cumulating concordance rate [coefficients; twice: 5.1 (P = 0.01), four times: 5.9 (P = 0.02)]. But, the concordance rate was decreased in high grade dysplasia (coefficient -40.32, P = 0.006).

PATIENTS AND METHODS

One hundred and sixty GENs from 148 patients were randomized into two groups and finally 67 GENs in 61 patients and 65 GENs in 63 patients were allocated to the conventional group (CG) or jumbo group (JG), respectively. Four endoscopic forceps biopsy (EFB) specimens were obtained from each lesion with conventional (6.8 mm) forceps or jumbo (8 mm) forceps. The histological concordance rate between 4 EFB specimens and ESD specimens was investigated in the two groups.

CONCLUSIONS

Before ESD, the diagnostic accuracy of GENs was significantly increased not by the use of jumbo forceps biopsy but by increasing the number of biopsies.

Narrow band imaging: application for early-stage gastrointestinal neoplasia

Narrow-band imaging (NBI) is an imaging technique for endoscopy using optical filters to narrow the bandwidth of spectral transmittance. Through this narrow spectrum, NBI contrasts surface structure and microvascular architecture of various lesions. In this article we focus on the application of NBI for early-stage neoplasia in the esophagus, stomach and colon with a three-step strategy of endoscopic diagnosis: (i) the detection of abnormality; (ii) the differentiation between non-neoplasia and neoplasia; and (iii) staging for tumor extension and depth of invasion.

Guidance on the effective use of upper gastrointestinal histopathology

Given the ever-increasing demand for upper gastrointestinal endoscopy, for diagnosis and surveillance, there is a need to consider when it is appropriate, and when it is not appropriate, to take an endoscopic biopsy for histological evaluation. In this article, we consider this in relation to each of the anatomical compartments encountered during oesophagogastroduodenoscopy, and in relation to the common clinical scenarios and endoscopic abnormalities encountered. There are clear indications to biopsy suspicious ulceration or mass lesions and for investigation of some inflammatory conditions, such as eosinophilic oesophagitis and coeliac disease. Increasing guidance is available on optimal biopsy sites and biopsy numbers to maximise yield from histology. Outside these areas, the endoscopist should consider whether biopsy of normal or abnormal appearing mucosa is likely to contribute to patient management, to ensure effective use of limited healthcare resources.

Clinicopathologic factors and outcomes of histologic discrepancy between differentiated and undifferentiated types after endoscopic resection of early gastric cancer

BACKGROUND

Histologic discrepancies among specimens obtained by forceps biopsy and endoscopic resection (ER) between the differentiated and undifferentiated types often occur in early gastric cancer (EGC). This study aimed to evaluate the predictive clinicopathologic characteristics and clinical implications of histologic discrepancies in EGC.

METHODS

From August 2005 to March 2012, 596 lesions from 579 patients underwent ER for EGC. The lesions studied were diagnosed as the differentiated histologic type from forceps biopsy specimens. The lesions were grouped according to the occurrence of histologic discrepancy between the differentiated and undifferentiated types in specimens obtained by ER as concordant (n = 570) or discordant (n = 26). The main outcome measures were en bloc resection, complete resection, and curative resection rates.

RESULTS

The histologic discrepancy rate was 4.4% among the studied lesions. Larger size, lesion location in the mid third of the stomach, easy friability, exudates, and submucosal invasion shown on endoscopic ultrasound were significantly related to histologic discrepancy in the univariate analysis. In the multivariate analysis, lesion location in the mid third of the stomach [odds ratio (OR) 5.34, 95% confidence interval (CI) 1.59-19.13] and easy friability (OR 29.26, 95% CI 2.30 to >999.9) were significant factors associated with histologic discrepancy. The complete resection and curative resection rates were significantly lower and the additional operation rates after ER were significantly higher in the discordant group.

CONCLUSIONS

The EGCs with histologic discrepancy between the differentiated and undifferentiated types changed the therapeutic outcomes of ER. Easily friable lesions located in the mid third of the stomach carry a significant risk for histologic discrepancy in undifferentiated histology when ER of EGCs is performed.

Dense-type crypt opening seen on magnifying endoscopy with narrow-band imaging is a feature of gastric adenoma

BACKGROUND

Magnifying endoscopy with narrow-band imaging (ME-NBI) can visualize crypt openings (CO) as slit-like structures in gastric epithelial neoplasia. Visualization of numerous CO is characteristic of low-grade adenoma (LGA). The aim of the present study was to investigate whether visualization of CO by ME-NBI is useful for discriminating between LGA and early gastric cancer (EGC).

PATIENTS AND METHODS

Fifty-one superficial elevated-type gastric neoplasias (10 LGA and 41 EGC) were retrospectively evaluated. The presence of CO and the number of CO were evaluated in endoscopic photos obtained at high-power endoscopic magnification by ME-NBI. The optimal cut-off value for the number of CO visualized to discriminate between LGA and EGC was determined by receiver operating characteristic curve analysis.

RESULTS

The mean number of CO visualized was significantly larger in the LGA group than in the EGC group (31.2, 95% confidence interval [CI] 16.3-46.1 vs 6.3, 95% CI 3.6-9.0; P < 0.001). When the cut-off for the number of CO visualized was set at 20, the sensitivity, specificity, and accuracy of dense-type CO for discriminating between LGA and EGC were 90.0%, 87.8%, and 88.2%, respectively.

CONCLUSION

Determining the number of CO visualized in superficial elevated-type gastric neoplasias by ME-NBI appears to be a useful method for discriminating between LGA and EGC.

Discrepancy between endoscopic forceps biopsy and endoscopic resection in gastric epithelial neoplasia

BACKGROUND

Endoscopic forceps biopsy (EFB) is a major diagnostic procedure for gastric epithelial neoplasia (GEN). However, discrepancy between the result of EFB and endoscopic resection (ER) is not uncommon. Thus, there is controversy over whether specimens obtained by EFB are optimal for diagnosis of GEN. We investigated the discrepancy between EFB and ER in the diagnosis of GEN.

METHODS

A total of 1,850 GEN cases were histologically diagnosed with EFB, including 954 low-grade dysplasias (LGDs), 315 high-grade dysplasias (HGDs), and 581 carcinomas. Following diagnosis with EFB, all patients were treated with ER. We retrospectively reviewed the pathologic findings and patient characteristics and analyzed predictors for the discrepancy between the two procedures (largest diameter, number of biopsy fragments, number of biopsy fragments/largest diameter, location, macroscopic type, color, surface unevenness, and erosion).

RESULTS

The overall discrepancy rate between EFB and ER was 31.7 % (587/1,850). Among the discordant group, 440 (23.9 %) cases showed a higher grade of disease after ER; 229 of the 954 LGDs (24.0 %) were diagnosed as HGD or carcinoma, 166 of the 315 HGDs (52.7 %) as carcinoma, and 45 of the 581 differentiated carcinomas (7.7 %) as undifferentiated carcinoma. In the LGD group with EFB, the largest diameter (≥1.8 cm; P < 0.001), surface unevenness (P = 0.014), and depressed macroscopic type (P < 0.001) were factors associated with discrepancy. In the carcinoma group with EFB, flat macroscopic type (P = 0.043) was the only significant factor. In the HGD group with EFB, there were no significant factors for discrepancy.

CONCLUSIONS

EFB can be insufficient for diagnosing GENs, and ER can be considered not only as treatment but also as a diagnostic modality in GEN. It is especially pertinent to all cases of HGD regardless of their endoscopic features and to cases of LGDs with the largest lesion diameter ≥1.8 cm, surface unevenness, or a depressed macroscopic type.

Tissue acquisition in gastric epithelial tumor prior to endoscopic resection

Endoscopic forceps biopsy is essential before planning an endoscopic resection of upper gastrointestinal epithelial tumors. However, forceps biopsy is limited by its superficiality and frequency of sampling errors. Histologic discrepancies between endoscopic forceps biopsies and resected specimens are frequent. Factors associated with such histologic discrepancies are tumor size, macroscopic type, surface color, and the type of medical facility. Precise targeting of biopsies is recommended to achieve an accurate diagnosis, curative endoscopic resection, and a satisfactory oncologic outcome. Multiple deep forceps biopsies can induce mucosal ulceration in early gastric cancer. Endoscopic resection for early gastric cancer with ulcerative findings is associated with piecemeal resection, incomplete resection, and a risk for procedure-related complications such as bleeding and perforation. Such active ulcers caused by forceps biopsy and following submucosal fibrosis might also be mistaken as an indication for more aggressive procedures, such as gastrectomy with D2 lymph node dissection. Proton pump inhibitors might be prescribed to facilitate the healing of biopsy-induced ulcers if an active ulcer is predicted after deep biopsy. It is unknown which time interval from biopsy to endoscopic resection is appropriate for a safe procedure and a good oncologic outcome. Further investigations are needed to conclude the appropriate time interval.