Why does Japan have a high incidence of gastric cancer? Comparison of gastritis between UK and Japanese patients

Global incidence and prevalence of gastritis and duodenitis from 1990 to 2019: A systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND AND AIM

Gastritis and duodenitis, prevalent diseases of the digestive system, impose a significant global burden. This study aimed to examine their incidence and prevalence patterns worldwide, including changes over the past 30 years.

METHODS

The age-standardized incidence rate (ASIR) and age-standardized prevalence rate (ASPR) of gastritis and duodenitis, stratified by age, sex, geographical region, and sociodemographic index (SDI), were obtained from the Global Burden of Disease 2019. The dynamic trends were captured by calculating the average annual percentage changes (AAPC).

RESULTS

In 2019, the global ASIR and ASPR of gastritis and duodenitis were 379.88/100 000 (95% uncertainty interval [UI]: 312.42/100 000-448.12/100 000) and 518.11/100 000 (95% UI: 420.62/100 000-631.66/100 000), respectively. The highest rates were observed among the 50-69 age group (ASIR: 856.48/100 000; ASPR: 1158.04/100 000) and in low SDI regions (ASIR: 443.33/100 000; ASPR: 631.22/100 000). From 1990 to 2019, there was a significant decrease in global ASIR (AAPC = -0.34%, 95% confidence interval [CI]: -0.36% to -0.31%) and ASPR (AAPC = -0.34%, 95% CI: -0.37% to -0.31%) of gastritis and duodenitis. However, ASIR (AAPC = 0.47%, 95% CI: 0.42%-0.52%) and ASPR (AAPC = 0.51%, 95% CI: 0.47%-0.52%) of gastritis and duodenitis experienced a significant increase in low SDI regions.

CONCLUSIONS

Despite a significant decrease in the global incidence and prevalence of gastritis and duodenitis, these conditions continue to impose a burden on individuals aged 50-69 years and low SDI regions. Targeted interventions for those specific populations and regions are necessary.

The role of gastric microecological dysbiosis in gastric carcinogenesis

Gastric cancer (GC) is the leading cause of cancer-related death worldwide, and reducing its mortality has become an urgent public health issue. Gastric microecological dysbiosis (including bacteria, fungi, viruses, acid suppressants, antibiotics, and surgery) can lead to gastric immune dysfunction or result in a decrease in dominant bacteria and an increase in the number and virulence of pathogenic microorganisms, which in turn promotes development of GC. This review analyzes the relationship between gastric microecological dysbiosis and GC, elucidates dynamic alterations of the microbiota in Correa's cascade, and identifies certain specific microorganisms as potential biomarkers of GC to aid in early screening and diagnosis. In addition, this paper presents the potential of gastric microbiota transplantation as a therapeutic target for gastric cancer, providing a new direction for future research in this field.

Histopathologic findings in laparoscopic sleeve gastrectomy: is routine full pathologic evaluation indicated?

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is the most commonly performed bariatric surgery. The resected gastric segment is routinely sent for pathology evaluation. No formal national recommendation exists that mandates pathology review. We proposed to study the largest histopathologic series in SG patients yet reported.

OBJECTIVE

The primary objective of our study was to determine whether a subgroup of patients who underwent bariatric surgery in the northeastern Unites States is more susceptible to having clinically significant pathologic findings that may benefit from routine histopathologic evaluation of the gastric sleeve specimen.

SETTING

University hospital.

METHODS

A retrospective electronic chart review of patients who underwent SG at a single large academic institution was performed. Patient demographics, body mass index, and histopathologic reports of the gastric specimens obtained during SG were analyzed.

RESULTS

The records of 3543 patients were reviewed. A total of 1076 patients had abnormal pathologies, including gastritis (938), follicular gastritis (98), intestinal metaplasia (25), gastrointestinal stromal tumor (12), leiomyoma (1), lymphoma (1), and other malignancy (1). Black and Hispanic patients had a higher incidence of developing gastrointestinal stromal tumor and intestinal metaplasia. A higher incidence of Helicobacter pylori infection among specimens with abnormal pathologies was noted.

CONCLUSIONS

The findings of this study call into question the routine use of pathology workup in gastric specimens after SG. Our data suggest that such analysis may be warranted in certain subtypes of patients such as older Black and Hispanic patients in the northeastern United States.

Development of a modified ABC method among Helicobacter pylori infected but serum pepsinogen test-negative individuals

BACKGROUND

Although the ABC method for gastric cancer (GC) screening has been widely adopted in Japan, it may not be suitable for other countries due to population heterogeneity and different tumor histology. We aim to develop a modified ABC method to improve GC screening performance, especially among Helicobacter pylori (Hp) infected but serum pepsinogen (sPG) test-negative individuals.

METHODS

A total of 4745 participants were recruited from Tianjin, China, and were classified into four groups by combined assay for Hp infection and sPG concentrations: Group A (Hp [-], PG [-]), Group B (Hp [+], PG [-]), Group C (Hp [+], PG [+]), and Group D (Hp [-], PG [+]). We used receiver-operating characteristic (ROC) curves analysis and minimum p value method to determine the optimal cutoff point for PG II in Group B. We performed logistic regressions to examine the risk of GC across different subgroups. In addition to the derivation set, the performance of the modified ABC method was also evaluated in an external set involving 16,292 participants from Liaoning, China.

RESULTS

In the modified ABC method, we further classified Group B as low-risk (Group B1) and high-risk subgroups (Group B2) using optimal sPG II cutoff point (20.0 ng/mL) by ROC curves analysis and minimum p value method. Compared with Group B1, Group B2 had a significantly higher risk of GC (adjusted OR = 2.54, 95% CI = 1.94-3.33). The modified ABC method showed good discrimination for GC (AUC = 0.61, 95% CI = 0.59-0.63) and improved risk reclassification (NRI = 0.11, p < .01). Similar results were observed in the validation dataset.

CONCLUSIONS

The modified ABC method can effectively identify high-risk population for GC among Hp-infected but sPG test-negative participants in China.

Effects of Helicobacter pylori eradication on esophageal motility, esophageal acid exposure, and gastroesophageal reflux disease symptoms

Background

The effects of Helicobacter pylori (HP) eradication on gastroesophageal reflux disease (GERD) are yet to be fully elucidated. Few studies have investigated the mechanisms underlying the correlations between HP and GERD with prospective methods. The objective of this prospective clinical study was to explore the effects of HP eradication on GERD.

Methods

Patients diagnosed with both GERD and HP were included. High-resolution esophageal manometry (HRM), 24-h esophageal pH monitoring, and the Gastroesophageal Reflux Disease Questionnaire (GerdQ) were performed before and after the successful eradication of HP, and the data were compared using statistical analysis.

Results

Sixty-eight patients diagnosed with both GERD and HP were included. The After HP eradication group showed significantly decreased median distal contractile integral (DCI) [610.40 (847.45) vs. 444.90 (559.60)] and significantly increased median inefficient esophageal motility (IEM) [36.00 (50.00) vs. 60.00 (57.00)] in the HRM compared with those of the Before HP eradication group, indicating that HP eradication reduced esophageal peristalsis. The 24-h esophageal pH monitoring showed that the longest reflux event, the percentage of time that the pH was &lt;4, the number of reflux episodes, and the DeMeester score were all significantly different between the Before and After HP eradication groups (P &lt; 0.05), suggesting that HP eradication increased esophageal acid exposure. The After HP eradication group also had a significantly higher GerdQ score than that of the Before HP eradication group (P &lt; 0.05).

Conclusions

HP eradication reduced esophageal peristalsis, enhanced esophageal acid exposure, and aggravated GERD symptoms, suggesting that HP infection may be a protective factor for GERD.

The Health and Clinical Benefits of Medicinal Fungi

The human uses of mushrooms and cultured mycelium products for nutrition and medicine are detailed and supported by available human studies, which in many cases are clinical trials published in peer-reviewed journals. The major medically active immunomodulating compounds in the cell walls-chitin, beta-glucans, and glycoproteins, as well as lower weight molecules-nitrogen-containing compounds, phenolics, and terpenes-are discussed in relation to their current clinical uses. The nutritional content and foods derived from mushrooms, particularly related to their medical benefits, are discussed. High-quality major nutrients such as the high amounts of complete protein and prebiotic fibers found in edible and medicinal fungi and their products are presented. Mushrooms contain the highest amount of valuable medicinal fiber, while dried fruiting bodies of some fungi have up to 80% prebiotic fiber. These fibers are particularly complex and are not broken down in the upper gut, so they can diversify the microbiome and increase the most beneficial species, leading to better immune regulation and increasing normalizing levels of crucial neurotransmitters like serotonin and dopamine. Since the growth of medicinal mushroom products is expanding rapidly worldwide, attention is placed on reviewing important aspects of mushroom and mycelium cultivation and quality issues relating to adulteration, substitution, and purity and for maximizing medicinal potency. Common questions surrounding medicinal mushroom products in the marketplace, particularly the healing potential of fungal mycelium compared with fruiting bodies, extraction methods, and the use of fillers in products, are all explored, and many points are supported by the literature.

Determination of gastric atrophy with artificial intelligence compared to the assessments of the modified Kyoto and OLGA classifications

Background and Aim

Gastric atrophy is a precancerous lesion. We aimed to clarify whether gastric atrophy determined by artificial intelligence (AI) correlates with the diagnosis made by expert endoscopists using several endoscopic classifications, the Operative Link on Gastritis Assessment (OLGA) classification based on histological findings, and genotypes associated with gastric atrophy and cancer.

Methods

Two hundred seventy Helicobacter pylori‐positive outpatients were enrolled. All patients' endoscopy data were retrospectively evaluated based on the Kimura‐Takemoto, modified Kyoto, and OLGA classifications. The AI‐trained neural network generated a continuous number between 0 and 1 for gastric atrophy. Nucleotide variance of some candidate genes was confirmed or selectively assessed for a variety of genotypes, including the COX‐21195, IL‐1β 511, and mPGES‐1 genotypes.

Results

There were significant correlations between determinations of gastric atrophy by AI and by expert endoscopists using not only the Kimura‐Takemoto classification (P < 0.001), but also the modified Kyoto classification (P = 0.046 and P < 0.001 for the two criteria). Moreover, there was a significant correlation with the OLGA classification (P = 0.009). Nucleotide variance of the COX‐2, IL‐1β, and mPGES‐1genes was not significantly associated with gastric atrophy determined by AI. The area under the curve values of the combinations of AI and the modified Kyoto classification (0.746) and AI and the OLGA classification (0.675) were higher than in AI alone (0.665).

Conclusion

Combinations of AI and the modified Kyoto classification or of AI and the OLGA classification could be useful tools for evaluating gastric atrophy in patients with H. pylori infection as the risk of gastric cancer.

Duodenal-type follicular lymphoma more than 10 years after treatment intervention: A retrospective single-center analysis

BACKGROUND

Duodenal-type follicular lymphoma (D-FL) has been recognized as a rare entity that accounts for approximately 4% of primary gastrointestinal lymphomas. D-FL follows an indolent clinical course compared with common nodal FL and is generally considered to have a better prognosis. Therefore, the “watch and wait” approach is frequently adopted as the treatment method. Alternatively, there is an option to actively intervene in D-FL. However, the long-term outcomes of such cases are poorly understood.

AIM

To clarify the clinical outcomes after long-term follow-up in cases of D-FL with treatment intervention.

METHODS

We retrospectively analyzed patients who met the following criteria: the lesion was confirmed by endoscopy, the diagnosis of D-FL was confirmed histopathologically, and the patient was followed-up for more than 10 years after the intervention at our center.

RESULTS

We identified 5 cases of D-FL. Two patients showed a small amount of bone marrow involvement (Stage IV). Rituximab was used as a treatment for remission in all 5 patients. It was also used in combination with chemotherapy in 2 Stage IV patients as well as for maintenance treatment. Radiation therapy was performed in 2 cases, which was followed by complete remission (CR). Eventually, all 5 patients achieved CR and survived for more than 10 years. However, 3 patients experienced recurrence. One patient achieved a second CR by retreatment, and in another case, the lesion showed spontaneous disappearance. The remaining patient had systemic widespread recurrence 13 years after the first CR. Biopsy results suggested that the FL lesions were transformed into diffuse large B-cell lymphoma. The patient died 4 years later despite receiving various chemotherapies.

CONCLUSION

In this study, the treatment for patients of D-FL in Stage IV was successful. In the future, criteria for how to treat “advanced” D-FL should be established based on additional cases. This study of patients with D-FL indicates that whole-body follow-up examinations should continue for a long time due to a fatal recurrence 13 years after reaching CR.

The JMJD Family Histone Demethylases in Crosstalk Between Inflammation and Cancer

Inflammation has emerged as a key player in regulating cancer initiation, progression, and therapeutics, acting as a double edged sword either facilitating cancer progression and therapeutic resistance or inducing anti-tumor immune responses. Accumulating evidence has linked the epigenetic modifications of histones to inflammation and cancer, and histone modifications-based strategies have shown promising therapeutic potentials against cancer. The jumonji C domain-containing (JMJD) family histone demethylases have exhibited multiple regulator functions in inflammatory processes and cancer development, and a number of therapeutic strategies targeting JMJD histone demethylases to modulate inflammatory cells and their products have been successfully evaluated in clinical or preclinical tumor models. This review summarizes current understanding of the functional roles and mechanisms of JMJD histone demethylases in crosstalk between inflammation and cancer, and highlights recent clinical and preclinical progress on harnessing the JMJD histone demethylases to regulate cancer-related inflammation for future cancer therapeutics.

Consistency between the endoscopic Kyoto classification and pathological updated Sydney system for gastritis: A cross-sectional study

BACKGROUND

Two methods are used to evaluate gastritis: the updated Sydney system (USS) with pathology and Kyoto classification, a new endoscopy-based diagnostic criterion for which evidence is accumulating. However, the consistency of their results is unclear. This study investigated the consistency of their results.

METHODS

Patients who underwent esophagogastroduodenoscopy and were evaluated for Helicobacter pylori infection for the first time were eligible. The association between corpus and antral USS scores (neutrophil activity, chronic inflammation, atrophy, and intestinal metaplasia) and Kyoto classification scores (atrophy, intestinal metaplasia, enlarged folds, nodularity, and diffuse redness) was assessed.

RESULTS

Seven-hundred-seventeen patients (mean age, 49.2 years; female sex, 57.9%; 450 H. pylori-positive and 267 H. pylori-negative patients) were enrolled. All endoscopic gastritis cases in the Kyoto classification were associated with high corpus and antral USS scores for neutrophil activity and chronic inflammation. A subanalysis was performed for H. pylori-positive patients. Regarding atrophy and intestinal metaplasia, endoscopic findings were associated with USS scores. Enlarged folds, nodularity, and diffuse redness were associated with high corpus USS scores for neutrophil activity and chronic inflammation, but with low antral USS scores for atrophy and intestinal metaplasia. The Kyoto classification scores were also associated with the pathological topographic distribution of neutrophil activity and intestinal metaplasia.

CONCLUSIONS

Among H. pylori-positive individuals, endoscopic and pathological diagnoses were consistent with atrophy and intestinal metaplasia. Enlarged folds, nodularity, and diffuse redness were associated with pathological inflammation (neutrophil activity and chronic inflammation) of the corpus; however, they were inversely associated with pathological atrophy and intestinal metaplasia. The endoscopy-based Kyoto classification of gastritis partially reflects pathology.

Pathophysiology of Pediatric Gastroesophageal Reflux Disease: Similarities and Differences With Adults

Gastroesophageal reflux (GOR) is defined as "the passage of gastric contents into the esophagus with or without regurgitation and vomiting" and gastroesophageal reflux disease (GORD) is defined "when GOR leads to troublesome symptoms affecting the daily functioning and/or complications." This definition was first developed in 2006 by the Montreal consensus group (1) and later on adopted by pediatric gastroenterology societies such as ESPGHAN and NASPGHAN in 2009 (2). The definition of gastroesophageal reflux reveals little about its pathophysiology and is focused on symptomatology. In this way, it acts as an umbrella term for the multifactorial causes of the disease and the various phenotypes encountered; from functional heartburn to hypersensitive esophagus and nonerosive reflux disease, to erosive esophagitis and Barrett's esophagus. This article is devoted to the pathophysiology of pediatric GORD in comparison to adult GORD and is divided in 2 parts. In the first part, we will systematically describe the different mechanisms for the generation and clearance of reflux events, while on the second part we will discuss the mechanisms involved in symptoms generation. Finally, we will discuss the similarities and differences between pediatric and adult GORD.

Review of Standardized Incidence Ratios (SIR) of non-lymphoid de novo malignancies after liver transplantation: Structured analysis of global differences

INTRODUCTION

De Novo malignancy after liver transplantation (LTx) is the second most common cause of death in adult LTx recipients. The current report identifies differences in Standardized Incidence Ratios (SIR) for various non-lymphoid de novo malignancies by comparing and analyzing post LTx SIR for non-lymphoid de novo malignancies.

MATERIAL AND METHODS

A thorough search of PubMed and Web of Science databases was conducted; 25 publications describing de novo malignancies post-LTx with SIR were identified.

RESULTS

Overall SIR varied from 1.4 to 11.6 (median 2.4). Oropharyngeal/larynx (OPL), lung, colo-rectal, and kidney malignancies were more prevalent with higher SIR (median = 4.4, 1.9, 2.67, 2.5, respectively). Breast and prostate malignancies were also more prevalent with lower SIR (median = 0.9, 1.0, respectively). Pancreatic, central nervous system (CNS), melanoma, rare cancers and Kaposi's sarcoma were less prevalent (except in Italy and Sweden) but had much higher SIR (median = 2.6, 2.4, 2.02, 22.5 and 53.6, respectively). The overall higher SIR values are related to the age of the recipient, length of follow-up, the grouping of different organ systems, inclusion or exclusion of epidermal non-malacotic skin cancers, lymphoid malignancy, and occurrence of rare malignancies including Kaposi's sarcoma.

CONCLUSION

OPL, lung, gastrointestinal, kidney, and bladder malignancies were more prevalent with higher SIR. Breast and prostate cancers were more prevalent with lower SIR. Pancreatic, CNS, melanoma, rare cancers and Kaposi's sarcoma were less prevalent with higher SIR. Age of the recipients, length of follow-up, and rare cancer types influence overall SIR values with some global differences.

Role of Helicobacter pylori and Other Environmental Factors in the Development of Gastric Dysbiosis

Microbiomes are defined as complex microbial communities, which are mainly composed of bacteria, fungi, and viruses residing in diverse regions of the human body. The human stomach consists of a unique and heterogeneous habitat of microbial communities owing to its anatomical and functional characteristics, that allow the optimal growth of characteristic bacteria in this environment. Gastric dysbiosis, which is defined as compositional and functional alterations of the gastric microbiota, can be induced by multiple environmental factors, such as age, diet, multiple antibiotic therapies, proton pump inhibitor abuse, H. pylori status, among others. Although H. pylori colonization has been reported across the world, chronic H. pylori infection may lead to serious consequences; therefore, the infection must be treated. Multiple antibiotic therapy improvements are not always successful because of the lack of adherence to the prescribed antibiotic treatment. However, the abuse of eradication treatments can generate gastric dysbiotic states. Dysbiosis of the gastric microenvironment induces microbial resilience, due to the loss of relevant commensal bacteria and simultaneous colonization by other pathobiont bacteria, which can generate metabolic and physiological changes or even initiate and develop other gastric disorders by non-H. pylori bacteria. This systematic review opens a discussion on the effects of multiple environmental factors on gastric microbial communities.

Sentinel-Lymph-Node Multicenter Trials

Well executed multicenter clinical trials often provide significant evidence and support for, or against, foundational aspects of clinical procedures perceived to improve clinical management of a medical condition. In this review, discussed are reports of multicenter clinical trials designed to investigate sentinel lymph node biopsy procedures in seven types of cancer: breast, melanoma, head and neck, gastric, colon, uterine, and vulvar-with focus on the most recent reports of the hypotheses, objectives, parameters, data, results, implications, and impacts of the included trials. Such trials generally enroll more subjects, in shorter time periods, than do single-center studies. Such studies generally also have greater diversities among investigator practitioners and investigative environments than do single-center studies. The greater number of subjects provides more power to statistical analyses performed in such studies. The more rapid accrual usually results in data being more consistently acquired. The diversities of practitioners and environments may produce results that are more conservative than might be obtained from more "focused" studies; however, diversities in a study often identify implicitly results that are more robust-that is results applicable by more practitioners and applicable in more environments.

Memories of a friend and colleague - Takashi Sugimura

Takashi Sugimura, M.D., Honorary President of the National Cancer Center in Tokyo, and former President of The Japan Academy, is regarded by many as a pre-eminent contributor to the field of environmental genotoxicology. His pioneering spirit led to many key discoveries over a long and distinguished scientific career, including the first preclinical models for gastric cancer, identification of novel mutagens from cooked food, and the development of fundamental concepts in environmental chemical carcinogenesis. With his passing on September 6, 2020, many will reflect on the loss of an astute and engaging "Scientific Giant," who with warmth and good humor maintained lasting friendships both at home and abroad, beyond his many important scientific contributions.

Endoscopy for Gastric Cancer Screening Is Cost Effective for Asian Americans in the United States

BACKGROUND & AIMS

Endoscopic screening for gastric cancer is routine in some countries with high incidence and is associated with reduced gastric cancer-related mortality. Immigrants from countries of high incidence to low incidence of gastric cancer retain their elevated risk, but no screening recommendations have been made for these groups in the United States. We aimed to determine the cost effectiveness of different endoscopic screening strategies for noncardia gastric cancer, compared with no screening, among Chinese, Filipino, Southeast Asian, Vietnamese, Korean, and Japanese Americans.

METHODS

We generated a decision-analytic Markov model to simulate a cohort of asymptomatic 50-year-old Asian Americans. The cost effectiveness of 2 distinct strategies for endoscopic gastric cancer screening was compared with no screening for each group, stratified by sex. Outcome measures were reported in incremental cost-effectiveness ratios (ICERs), with a willingness-to-pay threshold of $100,000/quality-adjusted life-year (QALY). Extensive sensitivity analyses were performed.

RESULTS

Compared with performing no endoscopic gastric cancer screening, performing a 1-time upper endoscopy with biopsies, with continued endoscopic surveillance if gastric intestinal metaplasia was identified, was cost effective, whereas performing ongoing biennial endoscopies, even for patients with normal findings from endoscopy and histopathology, was not. The lowest ICERs were observed for Chinese, Japanese, and Korean Americans (all <$73,748/QALY).

CONCLUSIONS

Endoscopic screening for gastric cancer with ongoing surveillance of gastric preneoplasia is cost effective for Asian Americans ages 50 years or older in the United States. The lowest ICERs were for Chinese, Japanese, and Korean Americans (all <$73,748/QALY).

Gastroesophageal reflux disease: key messages for clinicians

Gastroesophageal reflux disease (GERD) is a chronic common disorder for which patients often refer to specialists. In the last decades, numerous studies helped to clarify the pathophysiology and the natural history of this disease. Currently, in the clinical setting, GERD is defined by the presence of symptoms that, when endoscopic investigation is required, permit to distinguish between cases with or without associated esophageal mucosal injuries. These conditions are called erosive reflux disease and non-erosive reflux disease (NERD), respectively. The latter is the most common manifestation of GERD. Symptoms are defined typical, as heartburn and regurgitation, and atypical (also called extra-esophageal), as coughing and/or wheezing, hoarseness, sore throat, otitis media, and dental manifestations. In this context, it is crucial for clinicians to investigate the presence of features of suspected malignancy, as unexplained weight loss, anemia, dysphagia, persistent vomiting, familiar history of cancer, long history of GERD, and beginning of GERD symptoms after the age of 50 years. The presence of these risk factors should induce to perform an endoscopic examination. Particular attention should be given to functional conditions that can mimic GERD, such as functional heartburn and hypersensitive esophagus as well as, more rarely, eosinophilic esophagitis. The former ones have different pathophysiology and this explains the frequent non-response to proton pump inhibitor drugs. This narrative review provides to clinicians a useful and practical overview of the state-of-the-art on advancements in the knowledge of GERD.

Pepsinogen Serology and Gastritis OLGA Staging in Mucosal Atrophy Assessment: A Cross-Sectional Study Involving East China Endoscopy Population

The histological gastric stage (OLGA) plays an important role in evaluating gastric atrophy, a symptom which suggests a risk of gastric cancer (GC). However, gastroscopy is an invasive examination, which has limited application in populations undergoing physical examination. Serum pepsinogen (PG) and gastin-17 (G-17) levels are noninvasive indexes which are recommended when screening for GC. We aim to explore the correlation between PG/G-17 and OLGA stage, in order to provide reliable indexes for GC screening. The study included 453 asymptomatic individuals from East China undergoing physical examination, who then underwent endoscopy including collection of biopsy samples. Assays for serum PG, G-17, and Helicobacter pylori (Hp) were performed. Atrophy of gastric mucosa was graded according to OLGA for each individual. 453 participants, average age 52.46 ± 10.30 years, 253 male and 200 female, were included. In the asymptomatic physical examination population, serum PGI, PGII, and PGR levels decreased with increasing OLGA scores. PGI and PGR were inversely correlated with increasing OLGA stage in both Hp-positive and Hp-negative groups. The levels of serum PGI, PGII, and G-17 in the Hp-positive group were higher than those in the Hp-negative group; conversely, the PGR levels were lower. Furthermore, OLGA scores increased with age in the Hp-positive group. In conclusion, there is a significant correlation between OLGA stage and serum PG in populations from East China undergoing physical examination. Serum PG and G-17 combined with Hp test plays an important role in evaluating gastric atrophy.

Use of endoscopic assessment of gastric atrophy for gastric cancer risk stratification to reduce the need for gastric mapping

Background/Aims: Stratification for gastric cancer risk typically involves histologic grading of gastric biopsies. This study aimed to compare endoscopic assessment of gastric atrophy and histologic gastric mapping for gastric cancer risk stratification in a region with relatively high risk of gastric cancer.Methods: Endoscopic and histologic gastric cancer risk stratification were compared in Vietnamese patients with functional dyspepsia. Endoscopic gastric atrophy was graded according to the Kimura-Takemoto classification. High-risk histologic lesions were defined as gastric dysplasia, Operative Link on Gastritis Assessment (OLGA) gastritis stage III/IV, intestinal metaplasia in both the antrum and the corpus or incomplete intestinal subtype at any site. Two experienced pathologists, blinded to endoscopic information, jointly examined all specimens and reached a consensus. The presence of high-risk histologic lesions was compared among patients with different endoscopic grades of gastric atrophy.Results: There were 280 subjects (mean age, 46.1 ± 10 years, and male, 50%). The numbers of patients with moderate/severe grade of endoscopic gastric atrophy and high-risk histologic lesions were 126 (45.0%) and 46 (16.4%), respectively. The sensitivity, specificity, positive and negative likelihood ratios of moderate/severe endoscopic atrophic grade for detecting high-risk histologic lesions were 93% (95% CI 86%-100%), 65% (95% CI 58%-71%), 2.64 (95% CI 2.18 - 3.18) and 0.10 (95% CI 0.03 - 0.30), respectively.Conclusions: Gastric cancer risk assessment using endoscopic or histologic methods provided similar results such that the absence or a mild grade of endoscopic gastric atrophy would preclude the need for histologic mapping.

Endoscopic Kyoto classification of Helicobacter pylori infection and gastric cancer risk diagnosis

Recent advances in endoscopic technology allow detailed observation of the gastric mucosa. Today, endoscopy is used in the diagnosis of gastritis to determine the presence/absence of Helicobacter pylori (H. pylori) infection and evaluate gastric cancer risk. In 2013, the Japan Gastroenterological Endoscopy Society advocated the Kyoto classification, a new grading system for endoscopic gastritis. The Kyoto classification organized endoscopic findings related to H. pylori infection. The Kyoto classification score is the sum of scores for five endoscopic findings (atrophy, intestinal metaplasia, enlarged folds, nodularity, and diffuse redness with or without regular arrangement of collecting venules) and ranges from 0 to 8. Atrophy, intestinal metaplasia, enlarged folds, and nodularity contribute to gastric cancer risk. Diffuse redness and regular arrangement of collecting venules are related to H. pylori infection status. In subjects without a history of H. pylori eradication, the infection rates in those with Kyoto scores of 0, 1, and ≥ 2 were 1.5%, 45%, and 82%, respectively. A Kyoto classification score of 0 indicates no H. pylori infection. A Kyoto classification score of 2 or more indicates H. pylori infection. Kyoto classification scores of patients with and without gastric cancer were 4.8 and 3.8, respectively. A Kyoto classification score of 4 or more might indicate gastric cancer risk.

British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma

Gastric adenocarcinoma carries a poor prognosis, in part due to the late stage of diagnosis. Risk factors include Helicobacter pylori infection, family history of gastric cancer-in particular, hereditary diffuse gastric cancer and pernicious anaemia. The stages in the progression to cancer include chronic gastritis, gastric atrophy (GA), gastric intestinal metaplasia (GIM) and dysplasia. The key to early detection of cancer and improved survival is to non-invasively identify those at risk before endoscopy. However, although biomarkers may help in the detection of patients with chronic atrophic gastritis, there is insufficient evidence to support their use for population screening. High-quality endoscopy with full mucosal visualisation is an important part of improving early detection. Image-enhanced endoscopy combined with biopsy sampling for histopathology is the best approach to detect and accurately risk-stratify GA and GIM. Biopsies following the Sydney protocol from the antrum, incisura, lesser and greater curvature allow both diagnostic confirmation and risk stratification for progression to cancer. Ideally biopsies should be directed to areas of GA or GIM visualised by high-quality endoscopy. There is insufficient evidence to support screening in a low-risk population (undergoing routine diagnostic oesophagogastroduodenoscopy) such as the UK, but endoscopic surveillance every 3 years should be offered to patients with extensive GA or GIM. Endoscopic mucosal resection or endoscopic submucosal dissection of visible gastric dysplasia and early cancer has been shown to be efficacious with a high success rate and low rate of recurrence, providing that specific quality criteria are met.

Analysis of risks of gastric cancer by gastric mucosa among Indonesian ethnic groups

Indonesia is a big country with multiethnic populations whose gastric cancer risks have not been elucidated. We performed a nationwide survey and obtained histological specimens from 1053 individuals in 19 cities across the country. We examined the gastric mucosa, the topography, the atrophic gastritis risk factors, and the gastric cancer risk scores. Almost half (46.1%) of the patients with dyspeptic symptoms had histological abnormalities; chronic (36.3%) and atrophic gastritis (28.9%) being the most frequent. Individuals of the Timor ethnicity had the highest prevalence of acute (52.6%) and chronic gastritis (68.4%), even those negative for H. pylori. Our topographic analysis showed the majority of patients had predominantly antral acute and chronic gastritis. A multivariate logistic regression model showed age (Odds ratio [OR], 1.107), Timor ethnicity (OR, 8.531), and H. pylori infection (OR, 22.643) as independent risk factors for presence of atrophic gastritis. In addition, the gastric cancer risk score was highest in those from Timor, Papuan, and Bugis ethnic populations. Overall, Indonesia is a low-risk gastric cancer country. However, several ethnic groups displayed severe gastric mucosa symptoms suggesting policy makers should focus on those ethnic groups to perform gastric cancer screenings and to eradicate H. pylori.

Clinical characteristics and prognostic analysis of multiple primary malignant neoplasms in patients with lung cancer

Retrospective analysis of data from 14,528 lung cancer patients with multiple primary malignant neoplasm (MPMN) revealed that 2.5% (364/14,528) were MPMN cases and 96.2% (350/364) were diagnosed with two primary malignancies, 3.6% (13/364) with three primary malignancies, and 0.3% (1/364) with four primary malignancies. Among 350 lung cancer patients diagnosed with two primary malignancies, 26.6% (93/350) had lung cancer diagnosed first (LCF) and 73.4% (257/350) had other cancers diagnosed initially (OCF), whereas synchronous MPMN (SMPMN) accounted for 21.1% (74/350) and metachronous MPMN (MMPMN) accounted for 78.9% (276/350) of the cases. Detection of first primary neoplasms were at an early stage for LCF patients and the age of the first lung cancer diagnosis was 59.3 years vs. 55.4 years in the OCF group (P = 0.008), whereas the onset age of second primary neoplasm diagnosis was similar in both groups (62.5 and 61.6 years, P = 0.544). Median survival times of MMPMN and SMPMN patients in the LCF group were 6.83 and 2.42 years and in the OCF group 8.67 years and 2.25 years, respectively. Multivariate analysis showed that SMPMN, LCF and the age of the primary cancer diagnosed first ( ≥ 60 years) and NSCL staging  > II were significant independent factors for inferior prognosis of patients.

New metastatic lymph node classification for early gastric cancer should differ from those for advanced gastric adenocarcinoma: Results based on the SEER database

AIM

To establish an appropriate N classification system for early gastric cancer (EGC).

METHODS

Data from 10714 patients who underwent radical gastrectomy between 1988 and 2011 were retrieved from the National Cancer Institute’s Surveillance, Epidemiology, and End Result database. The overall survival (OS) based on the eighth edition and new tumor lymph node metastasis (TNM) staging systems were compared, and the analysis was repeated in an external validation set from the Fujian Medical University Union Hospital database.

RESULTS

There were no significant differences in OS between N1 and N2 cancers or between N3a and N3b cancers in cases of EGC. The X-tile program identified that the new staging system for EGC consisted of T1N0, T1N1’ [1-6 metastatic lymph nodes (LNs)], and T1N2’ ( ≥ 7 metastatic LNs). Compared with the eighth edition of the TNM staging system, the OS of patients in T1N1’ stage was similar to that of patients with stage IIA disease, whereas the OS of patients in T1N2’ stage was similar to that of patients with stage IIB disease. The new TNM staging system exhibited a slightly lower Akaike Information Criterion value and higher χ² and c-statistic compared with the eighth edition of the TNM classification system. Similar results were found in the external validation dataset from the external validation set.

CONCLUSION

We have developed an optional new TNM staging system with a better predictive ability that can be used to accurately predict the 5-year OS of patients with EGC.

Is the AJCC TNM staging system still appropriate for gastric cancer patients survival after 5 years?

PURPOSE

The aim of this study was to evaluate the prognostic value of the eighth AJCC TNM staging classification for patients with gastric cancer who had already survived for 5 years.

PATIENTS AND METHODS

Patients who underwent radical gastrectomy at a large eastern center were considered. The prognostic value of staging systems were assessed and compared. Additional external validation was performed using a dataset from the Surveillance, Epidemiology, and End Result (SEER) database.

RESULTS

The 5-year overall survival (OS) rate for patients in the training set was 59.4%. With the prolongation of the survival time after surgery, the 5-year OS improved significantly (P < 0.05). However, there were no significant differences in survival curves among patients who have survived 5 years after surgery. The AUC and χ2 of the eighth AJCC classification for predicting of 5-year OS decreased gradually after surgery and appeared stable after 5 years. For patients who survived 5 years after surgery, we constructed a new TNM staging system (nTNM) according to the survival curves of T stage and N stage. A 2-step multivariate analysis showed that nTNM, age and sex were independent prognostic factors. The nTNM demonstrated superior prognostic stratification, with higher c-statistic and likelihood ratio chi-square scores and lower AIC values than those of the AJCC classification. Similar results were observed in the external validation set.

CONCLUSION

The nTNM predicted an additional survival more accurately than did the AJCC classification for patients who have survived 5 years after surgery; this may guide decisions regarding surveillance.

Assessment of Gastritis and Gastric Cancer Risk in the Chilean Population Using the OLGA System

Gastric cancer (GC) is the first cancer-related cause of death in Chile; however, no plan for GC early detection has been implemented in this country. The OLGA system characterizes gastritis from stages 0 to IV according to the risk of developing GC based on H. pylori infection, atrophy, metaplasia and GC. In this study, the performance of the OLGA system was evaluated in 485 Chilean patients receiving routine endoscopy to improve the detection of early GC or preneoplastic lesions. The results showed that OLGA scores, atrophy, metaplasia and GC increased significantly with age (p < 0.001). Conversely, H. pylori infection was higher in younger groups (p < 0.05). All gastric lesions were more frequent in men than women. The majority of patients with atrophy also had metaplasia (99%, p < 0.0001). Patients with H. pylori infection had more gastric atrophy and metaplasia than those without infection (p < 0.05). Of the 485 patients, 21 (4.3%) had GC, being 2.3 times more frequent among men than women and about 2/3 (14) were in OLGA stage ≥2. In addition, 19 (90%) GC patients had atrophy and 18 (85%) had metaplasia (p < 0.001). In conclusion, the OLGA system facilitated the evaluation of GC precursor lesions particularly in patients with an OLGA score > 2 between 45 and 56 years old, because this group showed atrophy and intestinal metaplasia more frequently. Therefore, biennial endoscopic surveillance of patients with an OLGA >2 can be an important health policy in Chile for diagnosing GC in its early stages and reducing mortality over the next two decades.

Increased risk of non-AIDS-defining cancers in Asian HIV-infected patients: a long-term cohort study

BACKGROUND

Data on the long-term risks of non-AIDS defining cancers (NADCs) are limited, especially in Asians. The incidence of NADCs may correlate with the epidemiological trend of cancers or oncogenic infection in each country, and thus the target cancers would be different between Western and Asian countries. We aimed to elucidate the incidence of NADCs and its predictive factors in Asian HIV-infected patients.

METHODS

Subjects were HIV-infected patients (n = 1001) periodically followed-up for 9 years on average. NADCs were diagnosed by histopathology and/ or imaging findings. Standardized incidence ratios (SIR) were calculated as the ratio of the observed to expected number of NADCs for comparison with an age-and sex-matched general population. Cox's proportional hazards model was used to estimate hazard ratios (HR).

RESULTS

During the median follow-up of 9 years, the 10-year cumulative incidence of NADCs was 6.4%.At NADC diagnosis, half of patients presented at age 40-59 years and with advanced tumor stage. Compared with the age-and sex-matched general population, HIV-infected patients are at increased risk for liver cancer (SIR, 4.7), colon cancer (SIR, 2.1), and stomach cancer (SIR, 1.8). In multivariate analysis, a predictive model for NADCs was developed that included age group (40-49, 50-59, 60-69, and ≥ 70 years), smoker, HIV infection through blood transmission, and injection drug use (IDU), and HBV co-infection. The c-statistic for the NADCs predictive model was 0.8 (95%CI, 0.8-0.9, P < 0.001). The higher 10-year incidence rate of NADCs was associated with increasing prediction score.

CONCLUSIONS

Liver and colon cancer risk was elevated in Asian HIV-infected individuals, similar to in Western populations, whereas stomach cancer risk was characteristically elevated in Asian populations. Half of Asian NADC patients were aged 40-59 years and had advanced-stage disease at diagnosis. Periodic cancer screening may be warranted for high-risk subpopulations with smoking habit, HIV infection through blood transmission or IDU, and HBV co-infection, and screening should be started over 40 years of age.

Which staging system better predicts 10-year survival for gastric cancer? A study using an international multicenter database

PURPOSE

Our aim was to evaluate the prognostic performance of the 8th edition AJCC staging system for gastric cancer survival after 10 years or more.

PATIENTS AND METHODS

An international multicenter database was constructed (total n = 4537) by combining gastric cancer cases from the SEER database (n = 3066) and the database (n = 1471) of the Department of Gastric Surgery, Fujian Medical University Union Hospital. The relative discriminatory abilities were assessed using the likelihood ratio chi-square test, Akaike's Information Criterion (AIC) and Harrell's concordance index (c-statistic).

RESULTS

The 10-year overall survival rate for all the patients was 32.2%. A 2-step multivariate analysis showed that the 8th edition staging system was an independent factor for long-term overall survival. It also had higher likelihood ratio chi-square score, c-statistic and smaller AIC values compared with the 7th edition. However, stages IB and IIA of the TNM staging system showed a similar prognosis (both P > 0.05). Based on the survival data, we revised the 8th edition by merging stages IB and IIA into 1 category in the training set. The modified staging system demonstrated superior prognostic stratification with a higher c-statistic, likelihood ratio chi-square score and smaller AIC values compared to the 8th edition. Similar results were observed in the external validation set.

CONCLUSION

The 8th edition AJCC TNM classification predicts the 10-year survival of gastric cancer patients more accurately than the 7th edition. However, by merging stages IB and IIA into 1 category, we propose a revised TNM stage system that provides an optimal prognosis.

Efficacy of Rebamipide in Organic and Functional Dyspepsia: A Systematic Review and Meta-Analysis

OBJECTIVE

The role of gastritis in dyspepsia remains controversial. We aimed to examine the efficacy of rebamipide, a gastric mucosal protective agent, in both organic and functional dyspepsia.

DESIGN

A systematic review and meta-analysis was performed. The following databases were searched using the keywords ("rebamipide" OR "gastroprotective agent*" OR "mucosta") AND ("dyspepsia" OR "indigestion" OR "gastrointestinal symptoms"): PubMed, Wed of Science, Embase, CINAHL, Cochrane Clinical Trials Register. The primary outcome was dyspepsia or upper GI symptom score improvement. Pooled analysis of the main outcome data were presented as risk ratio (RR) for dichotomous data and standardized mean difference (SMD) for continuous data.

RESULTS

From an initial 248 records, 17 randomised controlled trial (RCT) publications involving 2170 subjects (1224 rebamipide, 946 placebo/control) were included in the final analysis. Twelve RCTs were conducted in subjects with organic dyspepsia (peptic ulcer disease, reflux esophagitis or NSAID-induced gastropathy) and five RCTs were conducted in patients with functional dyspepsia (FD). Overall, dyspepsia symptom improvement was significantly better with rebamipide compared to placebo/control drug (RR 0.77, 95% CI = 0.64-0.93; SMD -0.46, 95% CI = -0.83 to -0.09). Significant symptom improvement was observed both in pooled RR and SMD in subjects with organic dyspepsia (RR 0.72, 95% CI = 0.61-0.86; SMD -0.23, 95% CI = -0.4 to -0.07), while symptom improvement in FD was observed in pooled SMD but not RR (SMD -0.62, 95% CI = -1.16 to -0.08; RR 1.01, 95% CI = 0.71-1.45).

CONCLUSION

Rebamipide is effective in organic dyspepsia and may improve symptoms in functional dyspepsia.

World trends for H. pylori eradication therapy and gastric cancer prevention strategy by H. pylori test-and-treat

Helicobacter pylori-associated gastritis leads to the development of gastric cancer. Kyoto global consensus report on H. pylori gastritis recommended H. pylori eradication therapy to prevent gastric cancer. To manage H. pylori infection, it is important to choose the appropriate regimen considering regional differences in resistance to clarithromycin and metronidazole. Quinolones and rifabutin-containing regimens are useful as third- and fourth-line rescue therapies.

Hematological parameters, serum iron and vitamin B12 levels in hospitalized Palestinian adult patients infected with Helicobacter pylori: a case-control study

Objective

This study aimed to investigate the relationship between hematological parameters, serum iron, and vitamin B₁₂ levels in adult hospitalized Palestinian patients infected with Helicobacter pylori.

Methods

This case–control study included 150 adult (18–50 years old) patients infected with H. pylori and 150 healthy adults. A complete blood count was performed, and serum iron and vitamin B₁₂ levels of the patients were measured, statistically analyzed and compared with the control group. All parameters in cases were reassessed after the triple treatment of omeprazole 20 mg b.i.d., amoxicillin 1 g b.i.d., and clarithromycin 500 mg b.i.d. for 14 successive days. The triple treatment was the same for males and females.

Results

The results revealed that the mean levels of hemoglobin, red cell count, white cell count and hematocrit were significantly lower and the red blood cell distribution width significantly higher in cases compared to controls, while no significant differences were found for mean corpuscular volume, mean corpuscular hemoglobin and platelet count. Serum vitamin B₁₂ and iron levels were significantly lower in cases compared to controls (262.5 ± 100.0 vs. 378.2 ± 160.6 pg/mL and 71.6 ± 24.8 vs. 80.1 ± 20.7 μg/dL, respectively). Vitamin B₁₂ and serum iron increased significantly and was restored to close to normal levels after medical treatment.

Conclusions

H. pylori infection appears to cause decreases in vitamin B₁₂, iron levels and some hematological parameters. However, these were almost normalized after treatment with omeprazole, amoxicillin and clarithromycin. H. pylori is associated with vitamin B₁₂ and iron deficiency, thus, this may be a useful marker and a possible therapeutic agent of anemic patients with gastritis.

Deep learning analyzes Helicobacter pylori infection by upper gastrointestinal endoscopy images

BACKGROUND AND STUDY AIMS

Helicobacter pylori (HP)-associated chronic gastritis can cause mucosal atrophy and intestinal metaplasia, both of which increase the risk of gastric cancer. The accurate diagnosis of HP infection during routine medical checks is important. We aimed to develop a convolutional neural network (CNN), which is a machine-learning algorithm similar to deep learning, capable of recognizing specific features of gastric endoscopy images. The goal behind developing such a system was to detect HP infection early, thus preventing gastric cancer.

PATIENTS AND METHODS

 For the development of the CNN, we used 179 upper gastrointestinal endoscopy images obtained from 139 patients (65 were HP-positive: ≥ 10 U/mL and 74 were HP-negative: < 3 U/mL on HP IgG antibody assessment). Of the 179 images, 149 were used as training images, and the remaining 30 (15 from HP-negative patients and 15 from HP-positive patients) were set aside to be used as test images. The 149 training images were subjected to data augmentation, which yielded 596 images. We used the CNN to create a learning tool that would recognize HP infection and assessed the decision accuracy of the CNN with the 30 test images by calculating the sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve (AUC).

RESULTS

 The sensitivity and specificity of the CNN for the detection of HP infection were 86.7 % and 86.7 %, respectively, and the AUC was 0.956.

CONCLUSIONS

 CNN-aided diagnosis of HP infection seems feasible and is expected to facilitate and improve diagnosis during health check-ups.

Correlation of endoscopic images and histological findings of a high grade dysplasia developed in a gastric xanthoma

Gastric neoplasia developed in a xanthoma is very rare. We herein report a high grade dysplasia (HGD) arising in a gastric xanthoma removed by endoscopic submucosal dissection (ESD). A 57-year-old man was referred to our hospital for removal of rectal polyps. During surveillance esophago-gastro-duodenoendoscopy before polypectomy, an irregularly shaped gastric xanthoma with unusual color was found in the stomach. Although, magnifying narrow band imaging showed no typical neoplastic vessel or surface pattern on the surface and endoscopic biopsies revealed no tumor, diagnostic ESD was performed because of its irregular shape and unusual color for a commonly seen xanthoma. Histologically, a high grade dysplasia, 6 mm×6 mm in size, was detected within a gastric xanthoma. This is the first report of correlation of endoscopic images and histological findings of a HGD in a gastric xanthoma.

Presentation and Epidemiology of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is the most prevalent gastrointestinal disorder in the United States, and leads to substantial morbidity, though associated mortality is rare. The prevalence of GERD symptoms appeared to increase until 1999. Risk factors for complications of GERD include advanced age, male sex, white race, abdominal obesity, and tobacco use. Most patients with GERD present with heartburn and effortless regurgitation. Coexistent dysphagia is considered an alarm symptom, prompting evaluation. There is substantial overlap between symptoms of GERD and those of eosinophilic esophagitis, functional dyspepsia, and gastroparesis, posing a challenge for patient management.

Russian Caucasians have a higher risk of erosive reflux disease compared with East Asians: A direct endoscopic comparison

BACKGROUND

Erosive reflux disease (ERD) is prevalent in the West, and its incidence is increasing in the East. The differences between the West and East, especially in body composition, have not been investigated thoroughly.

METHODS

Subjects who underwent esophagogastroduodenoscopy and body composition analysis during health screening were analyzed retrospectively. Russian Caucasians who visited Korea were propensity matched with native Koreans. Endoscopy results were analyzed to identify ERD and gastroesophageal flap valve (GEFV) status. Body composition and laboratory results were compared to identify risk factors for ERD.

KEY RESULTS

32 279 subjects underwent health screening with 1496 Russian Caucasians propensity matched with 1496 Koreans. ERD prevalence was 20.2% for Caucasians and 9.8% for Koreans (P<.001). Caucasians had significantly greater body mass index (BMI) and were more sarcopenic. Significant risk factors for ERD were Caucasian ethnicity (OR 1.629, 95% CI 1.265-2.099, P<.001), male gender (OR 2.374, 95% CI 1.883-2.993, P<.001), greater BMI (OR 1.067, 95% CI 1.041-1.093, P<.001), and abnormal GEFV (OR 2.730, 95% CI 2.194-3.397, P<.001). H. pylori seropositivity (OR 0.614, 95% CI 0.488-0.774, P<.001) and atrophic gastritis (OR 0.547, 95% CI 0.411-0.728, P<.001) were significantly preventive.

CONCLUSIONS & INFERENCES

Caucasian ethnicity is a significant risk factor for ERD. Greater BMI, male gender and abnormal GEFV are associated with ERD, and H. pylori seropositivity and atrophic gastritis are preventive. Further studies are needed to assess the differences in ERD between Caucasians and East Asians.

New opportunities for the prevention of gastric cancer

The approvals and provisions of the Management of Helicobacter pylori infection-the Maastricht V/ Florence Consensus Report and those of the Kyoto Global Consensus Conference on H. pylori-associated gastritis, concerning with the primary and secondary prevention of gastric cancer (GC), unambiguously suggest that H. pylori infection is the most important risk factor of GC. Accordingly, the basis for the primary and secondary prevention of GC is the optimization of H. pylori eradication therapy. The clear direct relationship of the risk of GC to the severity and extent of atrophic gastritis, intestinal metaplasia and dysplasia and no reversal of intestinal metaplasia and dysplasia in the presence of H. pylori eradication presume that gastroprotective agents should be used for primary and secondary prevention. Experimental and clinical findings can lead to the conclusion that rebamipide is a highly effective and safe agent for the primary and secondary prevention of GC in patients with and without H. pylori infection, by optimizing anti-Helicobacter therapy, its anti-inflammatory effect and ability to restore the cellular structure of the gastric epithelium.

Gastrin and Gastric Cancer

Gastric cancer although occurring in reduced frequency is still an important disease, partly because of the bad prognosis when occurring in western countries. This decline in occurrence may mainly be due to the reduced prevalence of Helicobacter pylori (Hp) infection, which is the most important cause of gastric cancer. There exist many different pathological classifications of gastric carcinomas, but the most useful seems to be the one by Lauren into intestinal and diffuse types since these types seldom transform into the other and also have different epidemiology. During the nearly 30 years that have passed since the groundbreaking description of Hp as the cause of gastritis and gastric cancer, a continuous search for the mechanism by which Hp infection causes gastric cancer has been done. Interestingly, it is mainly atrophic gastritis of the oxyntic mucosa that predisposes to gastric cancer possibly by inducing hypoacidity and hypergastrinemia. There are many arguments in favor of an important role of gastrin and its target cell, the enterochromaffin-like cell, in gastric carcinogenesis. The role of gastrin in gastric carcinogenesis implies caution in the long-term treatment with inhibitors of gastric acid secretion inducing secondary hypergastrinemia, in a common disease like gastroesophageal reflux disease.

Apparent diffusion coefficient by diffusion-weighted magnetic resonance imaging as a sole biomarker for staging and prognosis of gastric cancer

Objective

To investigate the role of apparent diffusion coefficient (ADC) from diffusion-weighted magnetic resonance imaging (DW-MRI) when applied to the 7th TNM classification in the staging and prognosis of gastric cancer (GC).

Methods

Between October 2009 and May 2014, a total of 89 patients with non-metastatic, biopsy proven GC underwent 1.5T DW-MRI, and then treated with radical surgery. Tumor ADC was measured retrospectively and compared with final histology following the 7th TNM staging (local invasion, nodal involvement and according to the different groups — stage I, II and III). Kaplan-Meier curves were also generated. The follow-up period is updated to May 2016.

Results

Median follow-up period was 33 months and 45/89 (51%) deaths from GC were observed. ADC was significantly different both for local invasion and nodal involvement (P<0.001). Considering final histology as the reference standard, a preoperative ADC cut-off of 1.80×10^–3 mm²/s could distinguish between stages I and II and an ADC value of ≤1.36×10^–3 mm²/s was associated with stage III (P<0.001). Kaplan-Meier curves demonstrated that the survival rates for the three prognostic groups were significantly different according to final histology and ADC cut-offs (P<0.001).

Conclusions

ADC is different according to local invasion, nodal involvement and the 7th TNM stage groups for GC, representing a potential, additional prognostic biomarker. The addition of DW-MRI could aid in the staging and risk stratification of GC.

Association of Endoscopic Features of Gastric Mucosa with Helicobacter pylori Infection in Chinese Patients

The aim of this study is to identify and consolidate reliable endoscopic features associated with H. pylori infection in gastric mucosa, which is one of the major causes of gastric cancer. A total of 256 Chinese patients with symptomatic stomach disturbances were enrolled. Pathological examination was conducted using a light microscope and biopsy specimens stained with hematoxylin-eosin. Endoscopic examination was performed using a high resolution video endoscope. The association between endoscopic features and pathological H. pylori diagnosis was compared, and endoscopic features significantly associated with H. pylori infection were identified. A total of 14 endoscopic features were observed. Six of the 14 endoscopic features, including mucus on the gastric mucosa, diffuse redness, spotty redness of fundic mucosa, enlarged fold, mucosal edema, and RAC (type D and type I), were highly associated with H. pylori infection and were significantly sensitive and specific predictors for H. pylori diagnosis. The type R RAC was not significantly associated with H. pylori diagnosis. Our results indicate that conventional endoscopy features can be used to diagnose H. pylori in Chinese patients and can help determine the risk factor for gastric cancer.

Gastric ulcers: malignancy yield and risk stratification for follow-up endoscopy

BACKGROUND AND STUDY AIM

Malignant change can occur in gastric ulcer but guideline recommendations for follow-endoscopy (FU-OGD) are conflicting. This study aims to determine rate of malignancy and need for follow-up for gastric ulcers.

PATIENTS AND METHODS

Patients with a first diagnosis of gastric ulcer between January 2012 and September 2013 were studied by analyzing endoscopic assessments, dysplasia, and malignancy yield and the influence of risk factors on the likelihood of benign disease.

RESULTS

In a cohort of 432 patients with gastric ulcer (53 % male, mean age 65 years) dysplasia or neoplasia were found in 27 (19 adenocarcinomas, 2 cases of dysplasia, 5 lymphomas, 1 melanoma; malignancy yield 6 %). Twenty-five (93 %) cases were diagnosed on first biopsy. The cancer yield of FU-OGD after initially benign biopsy was 0.9 %. Binary logistic regression analysis revealed that endoscopically benign appearance (odds ratio 0.004 95 % CI 0 - 0.576; P = 0.029), benign histology on first biopsy (odds ratio 0 95 % CI 0 - 0.39; P = 0.011) and lower number of ulcers (odds ratio 0.22 (95 % CI 0.05 - 0.99); P = 0.049) were independent predictors of benign disease. All dysplastic and neoplastic cases would have been identified by a combination of initial biopsies plus repeat endoscopy with further biopsies for endoscopically suspicious appearances.

CONCLUSIONS

In this large cohort 6 % of gastric ulcers were found to be malignant, highlighting the need for all gastric ulcers to be biopsied. The cancer yield of FU-OGD after benign biopsies was low. We have demonstrated that the combination of benign index histology and no endoscopic suspicion of malignancy can predict benign disease. We recommend that all gastric ulcers to be biopsied. Risk stratification could potentially reduce need for FU-OGD.

Different Pathophysiology of Gastritis between East and West? An Asian Perspective

Background

The incidence of gastric cancer in Asia is higher than that in Europe and Northern America. Helicobacter pylori infection is the most important factor for the development of atrophic gastritis and gastric cancer. The geographical distribution of the prevalence and virulence factors of H. pylori are important to understand the difference between gastritis in the East and West.

Summary

Articles comparing gastritis cases between eastern and western countries showed that the severity of gastritis is closely related to the risk of gastric cancer, and the severity of gastritis is more advanced in East Asia. Although the prevalence of H. pylori infection is closely associated with the incidence of gastric cancer in European countries, the severity of gastritis and the high incidence of gastric cancer in East Asia are not dependent only on the prevalence of H. pylori infection itself. From the viewpoint of the virulence factors of H. pylori, the East Asian CagA-positive strain (EPIYA motif ABD type) is peculiar in East Asia. Considering comprehensively the geographical distribution of H. pylori subtypes is the most important factor among all prospected risk factors for the incidence of gastric cancer and the rate of development of gastritis. While eating habits, such as salty foods, vegetables and fruits, might influence the progression of gastritis, such factors might be responsible for the geographic heterogeneity of gastritis.

Key Message

East Asian CagA-positive H. pylori is the strongest risk factor for gastric carcinogenesis and the development of gastritis.

Different Pathophysiology of Gastritis in East and West? A Western Perspective

Background

Gastritis results from multifactorial gastric mucosal injury. Helicobacter pylori (Hp) is the main cause, and associated diseases have typical underlying patterns of gastritis. Gastric ulcer and gastric cancer (GC) develop from chronic atrophic corpus gastritis (CAG) which therefore represents the most important pattern. GC incidences in East Asia are substantially higher than elsewhere, and this should be also reflected by higher prevalences of CAG and characteristic differences in pathophysiology compared to the West.

Summary

The few available comparative studies of gastritis in Eastern and Western patients are summarized. The main pathogenic factors of gastritis are discussed together with their limitations to explain local differences in disease outcome. Emphasis was put to also include less well-established pathogenic host and environmental factors of possible impact.

Conclusions

CAG is more prevalent in East Asian areas with high GC incidences than the West. Geographic heterogeneity of associated diseases is due to differences in Hp prevalence and virulence as well as modulating host and environmental factors. The following may contribute to the higher burden of CAG in the East: ABD type of CagA with vacA s1 and babA2 alleles of Hp, host Lewis(b) expression in sej/sej nonsecretors, H. heilmannii, low parietal cell mass, high sodium and nitrate intake, preferences in vegetable and fruit consumption, cigarette smoking, air pollution, alcohol. Conversely, green tea, nonfermented soy products and rice may confer protective effects. Hp is on the decline, but also in a world cleared from this bacterium, differences in host genetics will continue to modify gastric disease outcome together with maintained customs as part of cultural diversity.

Basic principles and practice of gastric cancer screening using high-definition white-light gastroscopy: Eyes can only see what the brain knows

Endoscopic diagnosis of gastrointestinal tumors consists of the following processes: (i) detection; (ii) differential diagnosis; and (iii) quantitative diagnosis (size and depth) of a lesion. Although detection is the first step to make a diagnosis of the tumor, the lesion can be overlooked if an endoscopist has no knowledge of what an early-stage 'superficial lesion' looks like. In recent years, image-enhanced endoscopy has become common, but white-light endoscopy (WLI) is still the first step for detection and characterization of lesions in general clinical practice. Settings and practice of routine esophagogastroduodenoscopy (EGD) such as use of antispasmodics, number of endoscopic images taken, and observational procedure are customarily decided in each facility in each country and are not well standardized. Therefore, in the present article, we attempted to outline currently available evidence and actual Japanese practice on gastric cancer screening using WLI, and provide tips for detecting EGC during routine EGD which could become the basis of future research.

A Lymph Node Staging System for Gastric Cancer: A Hybrid Type Based on Topographic and Numeric Systems

Although changing a lymph node staging system from an anatomically based system to a numerically based system in gastric cancer offers better prognostic performance, several problems can arise: it does not offer information on the anatomical extent of disease and cannot represent the extent of lymph node dissection. The purpose of this study was to discover an alternative lymph node staging system for gastric cancer. Data from 6025 patients who underwent gastrectomy for primary gastric cancer between January 2000 and December 2010 were reviewed. The lymph node groups were reclassified into lesser-curvature, greater-curvature, and extra-perigastric groups. Presence of any metastatic lymph node in one group was considered positive. Lymph node groups were further stratified into four (new N0–new N3) according to the number of positive lymph node groups. Survival outcomes with this new N staging were compared with those of the current TNM system. For validation, two centers in Japan (large center, n = 3443; medium center, n = 560) were invited. Even among the same pN stages, the more advanced new N stage showed worse prognosis, indicating that the anatomical extent of metastatic lymph nodes is important. The prognostic performance of the new staging system was as good as that of the current TNM system for overall advanced gastric cancer as well as lymph node—positive gastric cancer (Harrell C-index was 0.799, 0.726, and 0.703 in current TNM and 0.799, 0.727, and 0.703 in new TNM stage). Validation sets supported these outcomes. The new N staging system demonstrated prognostic performance equal to that of the current TNM system and could thus be used as an alternative.

Clinical and epidemiological differences in functional dyspepsia between the East and the West

BACKGROUND

Functional dyspepsia (FD) is a common condition, affecting adults in both Western (North America and Europe) and Eastern (Asian) parts of the globe. The prevalence has been reported to range from 5% to 40%, largely due to variation from definition criteria and geographical location. Recent published reports in Western and Eastern populations separately indicate that differences in the epidemiology and clinical patterns of FD may exist. Such differences will have implications for the clinical management of and healthcare strategizing for FD at the local level.

PURPOSE

This review aims to examine the prevalence and clinical patterns of FD in specific groups, namely Western and Eastern populations, based on the Rome criteria. Further differences in the epidemiological associations of FD will be explored between population-based studies in both the East and the West. Finally, the socio-economic consequences of FD, an important measure of the impact of the disease, will be compared between the East and the West.

Antiulcer and antiproliferative properties of spent brewer's yeast peptide extracts for incorporation into foods

The main objective was to study the antiulcer and antiproliferative potential of yeast peptide extract for further incorporation into functional foods.

Helicobacter pylori Infection Synergistic with IL-1β Gene Polymorphisms Potentially Contributes to the Carcinogenesis of Gastric Cancer

Helicobacter pylori (H. pylori) infection is the most common chronic bacterial infection in the world and the etiological agent for most gastric cancer (GC). Interleukin-1β (IL-1β) is a potent proinflammatory cytokine, and its deregulation is closely associated with the tumorigenesis of several cancers. Recent studies have revealed that the IL-1β-31 and -511T alleles are closely associated with gastric carcinogenesis due to their roles in the induction of gastric precancerous lesions and hypochlorhydria. Furthermore, H. pylori infection has a synergistic effect on the development of GC with IL-1β gene polymorphisms, and the highest prevalence of severe gastric abnormalities are found in patients with both host and bacterial high-risk genotypes (cagA(+)/vacAs1(+)/IL-1β-511T). Therefore, these recent advances demonstrate that H. pylori synergistic with IL-1β gene polymorphisms contribute to the gastric carcinogenesis by their involvement in precancerous gastric lesions and low gastric acid secretion.