High-risk population for gastric cancer development based on serum pepsinogen status and lifestyle factors

Glucocorticoids and Androgens Protect From Gastric Metaplasia by Suppressing Group 2 Innate Lymphoid Cell Activation

BACKGROUND & AIMS

The immune compartment is critical for maintaining tissue homeostasis. A weak immune response increases susceptibility to infection, but immune hyperactivation causes tissue damage, and chronic inflammation may lead to cancer development. In the stomach, inflammation damages the gastric glands and drives the development of potentially preneoplastic metaplasia. Glucocorticoids are potent anti-inflammatory steroid hormones that are required to suppress gastric inflammation and metaplasia. However, these hormones function differently in males and females. Here, we investigate the impact of sex on the regulation of gastric inflammation.

METHODS

Endogenous glucocorticoids and male sex hormones were removed from mice using adrenalectomy and castration, respectively. Mice were treated with 5α-dihydrotestosterone (DHT) to test the effects of androgens on regulating gastric inflammation. Single-cell RNA sequencing of gastric leukocytes was used to identify the leukocyte populations that were the direct targets of androgen signaling. Type 2 innate lymphoid cells (ILC2s) were depleted by treatment with CD90.2 antibodies.

RESULTS

We show that adrenalectomized female mice develop spontaneous gastric inflammation and spasmolytic polypeptide-expressing metaplasia (SPEM) but that the stomachs of adrenalectomized male mice remain quantitatively normal. Simultaneous depletion of glucocorticoids and sex hormones abolished the male-protective effects and triggered spontaneous pathogenic gastric inflammation and SPEM. Treatment of female mice with DHT prevented gastric inflammation and SPEM development when administered concurrent with adrenalectomy and also reversed the pathology when administered after disease onset. Single-cell RNAseq of gastric leukocytes revealed that ILC2s expressed abundant levels of both the glucocorticoid receptor (Gr) and androgen receptor (Ar). We demonstrated that DHT treatment potently suppressed the expression of the proinflammatory cytokines Il13 and Csf2 by ILC2s. Moreover, ILC2 depletion protected the stomach from SPEM development.

CONCLUSIONS

Here, we report a novel mechanism by which glucocorticoids and androgens exert overlapping effects to regulate gastric inflammation. Androgen signaling within ILC2s prevents their pathogenic activation by suppressing the transcription of proinflammatory cytokines. This work revealed a critical role for sex hormones in regulating gastric inflammation and metaplasia.

The Impact of Whole Grain Intake on Gastrointestinal Tumors: A Focus on Colorectal, Gastric, and Esophageal Cancers

Cereals are one of staple foods in human diet, mainly consumed as refined grains. Nonetheless, epidemiological data indicate that whole grain (WG) intake is inversely related to risk of type 2 diabetes, cardiovascular disease, and several cancer types, as well as to all-cause mortality. Particularly responsive to WG positive action is the gastrointestinal tract, daily exposed to bioactive food components. Herein, we shall provide an up-to-date overview on relationship between WG intake and prevention of gastrointestinal tumors, with a particular focus on colorectal, stomach, and esophagus cancers. Unlike refined counterparts, WG consumption is inversely associated with risk of these gastrointestinal cancers, most consistently with the risk of colorectal tumor. Some WG effects may be mediated by beneficial constituents (such as fiber and polyphenols) that are reduced/lost during milling process. Beside health-promoting action, WGs are still under-consumed in most countries; therefore, World Health Organization and other public/private stakeholders should cooperate to implement WG consumption in the whole population, in order to reach nutritionally effective intakes.

Previous Helicobacter pylori infection-induced atrophic gastritis: A distinct disease entity in an understudied population without a history of eradication

Individuals with chronic atrophic gastritis who are negative for active H. pylori infection with no history of eradication therapy have been identified in clinical practice. By excluding false-negative and autoimmune gastritis cases, it can be surmised that most of these patients have experienced unintentional eradication of H. pylori after antibiotic treatment for other infectious disease, unreported successful eradication, or H. pylori that spontaneously disappeared. These patients are considered to have previous H. pylori infection-induced atrophic gastritis. In this work, we define these cases based on the following criteria: absence of previous H. pylori eradication; atrophic changes on endoscopy or histologic confirmation of glandular atrophy; negative for a current H. pylori infection diagnosed in the absence of proton-pump inhibitors or antibiotics; and absence of localized corpus atrophy, positivity for autoantibodies, or characteristic histologic findings suggestive of autoimmune gastritis. The risk of developing gastric cancer depends on the atrophic grade. The reported rate of developing gastric cancer is 0.31%-0.62% per year for successfully eradicated severely atrophic cases (pathophysiologically equal to unintentionally eradicated cases and unreported eradicated cases), and 0.53%-0.87% per year for spontaneously resolved cases due to severe atrophy. Therefore, for previous H. pylori infection-induced atrophic gastritis cases, we recommend endoscopic surveillance every 3 years for high-risk patients, including those with endoscopically severe atrophy or intestinal metaplasia. Because of the difficulty involved in the endoscopic diagnosis of gastric cancer in cases of previous infection, appropriate monitoring of the high-risk subgroup of this understudied population is especially important.

Preventable lifestyle and eating habits associated with gastric adenocarcinoma: A case-control study

Background: Besides the well-established risk factors for gastric adenocarcinoma (GaC), many other etiological factors remain largely unexplored. This large comprehensive case-control study aimed to investigate the preventable lifestyle and eating habits associated with GaC.

Methods: Consecutive patients with primary microscopically-confirmed GaC diagnosed in 2016-2018 were matched by sex, age, height, and socioeconomic status at a 1:1 ratio with healthy controls. Association of GaC versus control with investigated factors was assessed using the multivariable-adjusted conditional logistic regression for paired samples.

Results: Together 302 GaC patients and 302 healthy controls were investigated. Participants receiving higher education and those eating majorly vegetables had less frequently GaC. The majorly frying cooking habit was associated with a higher incidence of GaC. People complaining about poor sleep quality had more often GaC. The more often one smoked, the more often he/she had GaC. A higher frequency for having pickled food was associated with more frequent GaC, while having more frequently vegetables/fruit, beans, or kelps was associated with less often GaC. A greater preference for sour or bitter taste was associated with less frequent GaC. The frequencies of thin liquid intake after meal, swallowing hot food without adequate cooling, doing other things while eating, eating overnight food, and eating midnight snack were all positively associated with GaC, while going to bed regularly was associated with less often GaC.

Conclusions: Education level, sleep quality, smoking, the frequencies of use of several foods and seasonings, the preference for specific tastes, and various eating and living habits were associated with GaC. The findings offer important hints for further prospective investigations and for easy effective GaC-preventative strategy-making.

Prediction of Chronic Atrophic Gastritis and Gastric Neoplasms by Serum Pepsinogen Assay: A Systematic Review and Meta-Analysis of Diagnostic Test Accuracy

Serum pepsinogen assay (sPGA), which reveals serum pepsinogen (PG) I concentration and the PG I/PG II ratio, is a non-invasive test for predicting chronic atrophic gastritis (CAG) and gastric neoplasms. Although various cut-off values have been suggested, PG I ≤70 ng/mL and a PG I/PG II ratio of ≤3 have been proposed. However, previous meta-analyses reported insufficient systematic reviews and only pooled outcomes, which cannot determine the diagnostic validity of sPGA with a cut-off value of PG I ≤70 ng/mL and/or PG I/PG II ratio ≤3. We searched the core databases (MEDLINE, Cochrane Library, and Embase) from their inception to April 2018. Fourteen and 43 studies were identified and analyzed for the diagnostic performance in CAG and gastric neoplasms, respectively. Values for sensitivity, specificity, diagnostic odds ratio, and area under the curve with a cut-off value of PG I ≤70 ng/mL and PG I/PG II ratio ≤3 to diagnose CAG were 0.59, 0.89, 12, and 0.81, respectively and for diagnosis of gastric cancer (GC) these values were 0.59, 0.73, 4, and 0.7, respectively. Methodological quality and ethnicity of enrolled studies were found to be the reason for the heterogeneity in CAG diagnosis. Considering the high specificity, non-invasiveness, and easily interpretable characteristics, sPGA has potential for screening of CAG or GC.

Endoscopic gastric atrophy is strongly associated with gastric cancer development after Helicobacter pylori eradication

Background

Risk factors for gastric cancer during continuous infection with Helicobacter pylori have been well documented; however, little has been reported on the risk factors for primary gastric cancer after H. pylori eradication. We conducted a retrospective, endoscopy-based, long-term, large-cohort study to clarify the risk factors for gastric cancer following H. pylori eradication.

Methods

Patients who achieved successful H. pylori eradication and periodically underwent esophagogastroduodenoscopy surveillance thereafter at Toyoshima Endoscopy Clinic were enrolled. The primary endpoint was the development of gastric cancer. Statistical analysis was performed using the Kaplan–Meier method and Cox’s proportional hazards models.

Results

Gastric cancer developed in 15 of 1232 patients. The cumulative incidence rates were 1.0 % at 2 years, 2.6 % at 5 years, and 6.8 % at 10 years. Histology showed that all gastric cancers (17 lesions) in the 15 patients were of the intestinal type, within the mucosal layer, and <20 mm in diameter. Based on univariate analysis, older age and higher endoscopic grade of gastric atrophy were significantly associated with gastric cancer development after eradication of H. pylori, and gastric ulcers were marginally associated. Multivariate analysis identified higher grade of gastric atrophy (hazard ratio 1.77; 95 % confidence interval 1.12–2.78; P = 0.01) as the only independently associated parameter.

Conclusions

Endoscopic gastric atrophy is a major risk factor for gastric cancer development after H. pylori eradication. Further long-term studies are required to determine whether H. pylori eradication leads to regression of H. pylori-related gastritis and reduces the risk of gastric cancer.

Association Between Colorectal Cancer and Atherosclerotic Diseases: A Study Using a National Inpatient Database in Japan

BACKGROUND

Both colorectal neoplasms and atherosclerosis can be induced by common visceral fat accumulation. However, the association between these diseases at the advanced stage, colorectal cancer and cardiovascular/cerebrovascular diseases, has not been elucidated.

AIMS

This study aimed to investigate the association between colorectal cancer and vascular diseases in relation to obesity and metabolic disorders, using a nationwide database of hospitalized patients in Japan. We used non-cardiac gastric cancer patients as a reference, because they were considered to be neutral for obesity or metabolic disorders.

METHODS

We identified 54,591 patients with colorectal cancer and 19,565 patients with gastric cancer from the Diagnosis Procedure Combination database. The data collected included: sex; age; body mass index (BMI); smoking status; comorbidity; and medication data, comprising hypertension, diabetes, hyperlipidemia, coronary artery disease, and stroke. We compared these data in a cross-sectional setting by multivariate analyses.

RESULTS

Multivariate logistic regression analyses showed that female sex, increased BMI, hypertension [odds ratio (OR) 1.11; 95 % confidence interval (CI) 1.07-1.15; P < 0.0001], and diabetes (OR 1.17; 95 % CI 1.12-1.23; P < 0.0001) were more associated with colorectal cancer than with gastric cancer. Smoking, aspirin use (OR 0.85; 95 % CI 0.79-0.92; P < 0.0001), and coronary artery disease (OR 0.90; 95 % CI 0.86-0.95; P = 0.0001) were inversely associated with colorectal cancer.

CONCLUSIONS

Obesity and metabolic disorders were more associated with colorectal cancer than with non-cardiac gastric cancer, while coronary artery disease (CAD) was inversely associated. Some mechanisms involving separate populations of colorectal cancer and CAD under visceral fat accumulation might be suggested.

Guidelines for the management of Helicobacter pylori infection in Italy: The III Working Group Consensus Report 2015

Knowledge on the role of Helicobacter pylori (HP) infection is continually evolving, and treatment is becoming more challenging due to increasing bacterial resistance. Since the management of HP infection is changing, an update of the national Italian guidelines delivered in 2007 was needed. In the III Working Group Consensus Report 2015, a panel of 17 experts from several Italian regions reviewed current evidence on different topics relating to HP infection. Four working groups examined the following topics: (1) "open questions" on HP diagnosis and treatment (focusing on dyspepsia, gastro-oesophageal reflux disease, non-steroidal anti-inflammatory drugs or aspirin use and extra-gastric diseases); (2) non-invasive and invasive diagnostic tests; (3) treatment of HP infection; (4) role of HP in the prevention of gastric cancer. Statements and recommendations were discussed and a consensus reached in a final plenary session held in February 2015 in Bologna. Recommendations are based on the best current evidence to help physicians manage HP infection in Italy. The guidelines have been endorsed by the Italian Society of Gastroenterology and the Italian Society of Digestive Endoscopy.

Helicobacter pylori Antibody Titer and Gastric Cancer Screening

The "ABC method" is a serum gastric cancer screening method, and the subjects were divided based on H. pylori serology and atrophic gastritis as detected by serum pepsinogen (PG): Group A [H. pylori (-) PG (-)], Group B [H. pylori (+) PG (-)], Group C [H. pylori (+) PG (+)], and Group D [H. pylori (-) PG (+)]. The risk of gastric cancer is highest in Group D, followed by Groups C, B, and A. Groups B, C, and D are advised to undergo endoscopy, and the recommended surveillance is every three years, every two years, and annually, respectively. In this report, the reported results with respect to further risk stratification by anti-H. pylori antibody titer in each subgroup are reviewed: (1) high-negative antibody titer subjects in Group A, representing posteradicated individuals with high risk for intestinal-type cancer; (2) high-positive antibody titer subjects in Group B, representing active inflammation with high risk for diffuse-type cancer; and (3) low-positive antibody titer subjects in Group C, representing advanced atrophy with increased risk for intestinal-type cancer. In these subjects, careful follow-up with intervals of surveillance of every three years in (1), every two years in (2), and annually in (3) should be considered.

Age-Specific Gastric Cancer Risk Indicated by the Combination of Helicobacter pylori Sero-Status and Serum Pepsinogen Levels

BACKGROUND

Serologic screening of gastric cancer (GC) by serum pepsinogens (sPG) levels and Helicobacter pylori (Hp) sero-status, though highly informative, has provided heterogeneous results. Here, we have evaluated the modifying effects of demographic factors on the risk impact of Hp sero-status/sPG levels in gastric cancer, with particular emphasis on age.

METHODS

A cross-sectional study was carried out on 1341 individuals (GC = 578, healthy = 763), who were stratified into two age groups: 35-59 years (middle-aged, n = 830) and ≥ 60 years (60 years-plus, n = 511). Demographic factors and serological states (Hp sero-staus and sPG levels) were recorded by subject interview and serum ELISAs, respectively. Covariate-specific odds ratios were calculated by multivariable logistic regression.

RESULTS

Hp infection was consistently associated with increased sPGI and sPGII levels in the 60 year-plus, but not the middle-aged group. The joint examination of the variable states of the three serum biomarkers (Hp serology, sPGI, and sPGI/II ratio), in the 60 year-plus age group, demonstrated a stepwise escalation of risk from the single (sPGI low; OR = 2.6), to double (sPGI low/sPGI/II low; OR = 3.55, and Hp positive/sPGI low; OR = 5.0) and ultimately triple (Hp positive/PGI low/PGI/II low; OR = 10.48) positive states, in reference to the triple negatives. However, this pattern was not exhibited in the middle-aged subjects.

CONCLUSION

Age was clearly identified as a modifying factor on the risk projection of the combined states of Hp serology and sPG levels in gastric cancer screening, reflected by the augmented (~10.5 fold) risk of GC in the triple positive (Hp positive/sPGI low/sPGI/II low) 60 year-plus subjects, which was not evident in the middle-aged group.

Overview of methodological quality of systematic reviews about gastric cancer risk and protective factors

BACKGROUND AND OBJECTIVE

A comprehensive overall review of gastric cancer (GC) risk and protective factors is a high priority, so we conducted the present study.

METHODS

Systematic searches in common medical electronic databases along with reference tracking were conducted to include all kinds of systematic reviews (SRs) about GC risk and protective factors. Two authors independently selected studies, extracted data, and evaluated the methodological qualities and the quality of evidence using R-AMSTAR and GRADE approaches.

RESULTS

Beta- carotene below 20 mg/day, fruit, vegetables, non-fermented soy-foods, whole-grain, and dairy product were GC protective factors, while beta-carotene 20 mg/day or above, pickled vegetables, fermented soy-foods, processed meat 30 g/d or above, or salty foods, exposure to alcohol or smoking, occupational exposure to Pb, overweight and obesity, helicobacter pylori infection were GC risk factors. So we suggested screening and treating H. pylori infection, limiting the amount of food containing risk factors (processed meat consumption, beta-carotene, pickled vegetables, fermented soy-foods, salty foods, alcohol), stopping smoking, avoiding excessive weight gain, avoidance of Pb, and increasing the quantity of food containing protective components (fresh fruit and vegetables, non-fermented soy-foods, whole-grain, dairy products).

CONCLUSIONS

The conclusions and recommendations of our study were limited by including SRs with poor methodological bases and low quality of evidence, so that more research applying checklists about assessing the methodological qualities and reporting are needed for the future.

Serum pepsinogen II is a better diagnostic marker in gastric cancer

AIM

To investigate screening makers for gastric cancer, we assessed the association between gastric cancer and serum pepsinogens (PGs).

METHODS

The subjects comprised 450 patients with gastric cancer, 111 individuals with gastric atrophy, and 961 healthy controls. Serum anti-Helicobacter pylori (H. pylori) immunoglobulin G (IgG), PGI and PG II were detected by enzyme-linked immunosorbent assay. Gastric atrophy and gastric cancer were diagnosed by endoscopy and histopathological examinations. Odds ratios and 95%CIs were calculated using multivariate logistic regression.

RESULTS

Rates of H. pylori infection remained high in Northeastern China. Rates of H. pylori IgG positivity were greater in the gastric cancer and gastric atrophy groups compared to the control group (69.1% and 75.7% vs 49.7%, P < 0.001). Higher levels of PG II (15.9 μg/L and 13.9 μg/L vs 11.5 μg/L, P < 0.001) and lower PGI/PG II ratio (5.4 and 4.6 vs 8.4, P < 0.001) were found in patients with gastric cancer or gastric atrophy compared to healthy controls, whereas no correlation was found between the plasma PGI concentration and risk of gastric cancer (P = 0.537). In addition, multivariate logistic analysis indicated that H. pylori infection and atrophic gastritis were independent risk factors for gastric cancer. Lower plasma PGI/PG II ratio was associated with higher risks of atrophy and gastric cancer. Furthermore, plasma PG II level significantly correlated with H. pylori-infected gastric cancer.

CONCLUSION

Serum PG II concentration and PGI/PG II ratio are potential biomarkers for H. pylori-infected gastric disease. PG II is independently associated with risk of gastric cancer.

Diagnostic yield of capsule endoscopy for gastric diseases

BACKGROUND AND AIM

Capsule endoscopy (CE) for the stomach has not yet been in practical use. Likewise as in colon, CE for colorectal cancer screening, the less invasive nature of CE may be suitable for gastric screening. The aim of this study is to estimate a diagnostic yield of CE for gastric diseases.

METHODS

This study involved 55 patients who participated in other clinical studies regarding obscure overt gastrointestinal bleeding or iron deficiency anemia. All patients underwent esophagogastroduodenoscopy and CE within 2 weeks. Sensitivity and specificity of CE for diffuse and localized gastric lesions were calculated, respectively.

RESULTS

Gastroscopy revealed 38 diffuse lesions (14 antral gastritis, 19 pangastritis, and 5 diffuse antral vascular ectasia) and 25 localized lesions (14 erosions, 2 cancers, and 9 polyps). CE had a higher sensitivity for gastric diffuse lesions compared with localized lesions. For diffuse lesions, sensitivity and specificity of CE were 70% and 82%, respectively. For localized lesions, sensitivity and specificity of CE were 28% and 63%, respectively. All cancers could not be detected by CE.

CONCLUSIONS

Currently, the diagnostic yield of CE for gastric diseases is not high enough for gastric screening. Additional improvements including preparations, position change, or the invention of new technologies are required.

Diverse H. pylori strains, IL-10 promoter polymorphisms with high morbidity of gastric cancer in Hexi area of Gansu Province, China

In Hexi area of Gansu Province, people have a higher susceptibility of gastric cancer than people in the rest area of China. There is substantial geographic variation in the incidence of gastric cancer. In this article, the present author explored the roles of H. pylori infection and IL-10 promoter polymorphisms in development of gastric cancer in this area. A total of 304 participants were admitted to our study, and they were divided into two groups: control group and case group. Blood samples from all subjects were collected for gene extraction using DNA extraction kits. IL-10 polymorphisms were determined by SNaPshot Multiplex. To test H. pylori infection and its typing H. pylori antibody Immunoblotting Kits were used. This research suggested that environmental factor played an important role in the pathogenesis of gastric carcinoma in the area, H. pylori infection increased the risk of gastric cancer (OR = 2.612, 95% CI 1.636-4.170) and subject with H. pylori I-type positive was at significantly higher risk for progression to gastric cancer (OR = 4.712, 95% CI 2.656-8.537). For subjects with the ATA/GCC or GCC/GCC haplotype of the IL-10-1082/-819/-592 polymorphism relative to the ATA/ATA haplotype group, the risk of gastric cancer development was significantly increased. It has been demonstrated that the presence of IL-10-819 C alleles and IL-10-592 C alleles was associated with an increased risk for gastric cancer development in H. pylori-infected patients and IL-10 promoter polymorphisms and H. pylori have a synergistic effect on gastric cancer in Hexi population.

Clinical aspects of gastric cancer and Helicobacter pylori--screening, prevention, and treatment

Gastric cancer still represents a global health care burden, and in the absence of strategies implemented for early detection, the disease continues to have a dismal prognosis. Patients presenting with clinical manifestations of gastric cancer have limited options for cure. Thus, early detection and prevention play a key role in the fight against gastric cancer. Serologic-based test methods have the potential to detect a subset of patients at high risk of gastric cancer that require a close clinical and endoscopic follow-up. More data have been produced to support Helicobacter pylori eradication as an efficient strategy to prevent gastric cancer. Treatment options for patients with an advanced disease are still limited, but the introduction of new agents opens a more optimistic perspective for the future.

Corpus predominant gastritis: what does it mean?

PURPOSE OF REVIEW

To summarize this year's relevant literature on the causes and mechanisms of autoimmune gastritis.

RECENT FINDINGS

It is increasingly recognized that parietal cell antibodies, previously assumed exclusive to autoimmune gastritis, are associated with Helicobacter pylori infection. Successful H. pylori eradication with antibiotic treatment decreases antiparietal cell antibodies. Interestingly, vitamin B(12) deficiency, previously associated with autoimmune gastritis, is increasingly described in the elderly, irrespective of H. pylori status. Autoimmune gastritis that mostly affects patients of Scandinavian descent, was reported this year from China, and corpus predominant gastritis (autoimmune associated) was reported from Japan. It is difficult to evaluate the role played by genetics, increased use of proton pump inhibitors, and H. pylori infection, as current patient work-up does not regularly include screening for parietal cell and intrinsic-factor antibodies. As these clinicopathologic changes are seen in both H. pylori-positive patients, and in H. pylori-naïve patients, the debate continues for mechanisms involved in H. pylori-naïve patients.

SUMMARY

The clinical features commonly associated with autoimmune gastritis are increasingly seen in the elderly, irrespective of H. pylori status. Though some patients are genetically predisposed, long-term proton pump inhibitor use increases the prevalence of clinicopathologic features irrespective of genetic tendency.