Risk of gastric carcinoma in patients with mucosal dysplasia associated with atrophic gastritis: a follow up study

Pathology and Clinical Relevance of Gastric Epithelial Dysplasia

Gastric dysplasia is defined as an unequivocally neoplastic epithelium. Dysplastic lesions are characterized by cellular atypia reflective of abnormal differentiation and disorganized glandular architecture. The last few years have been marked by a refinement of the prognosis and risk of progression of gastric dysplasia and the recognition of novel morphologic patterns of dysplasia. Determination of the correct diagnosis and grade of dysplasia are critical steps since it will be predicting the risk of malignant transformation and help tailor appropriate surveillance strategy. This review describes the morphologic characteristics of conventional dysplasia and nonconventional gastric dysplasia that have been more recently characterized.

Incidence and Predictors of Gastric Neoplastic Lesions in Corpus-Restricted Atrophic Gastritis: A Single-Center Cohort Study

INTRODUCTION

Corpus-restricted atrophic gastritis is a chronic inflammatory disorder leading to possible development of type 1 neuroendocrine tumors (T1gNET), intraepithelial neoplasia (IEN), and gastric cancer (GC). We aimed to assess occurrence and predictors of gastric neoplastic lesions in patients with corpus-restricted atrophic gastritis at long-term follow-up.

METHODS

A prospective single-center cohort of patients with corpus-restricted atrophic gastritis adhering to endoscopic-histological surveillance was considered. Follow-up gastroscopies were scheduled according to the management of epithelial precancerous conditions and lesions of the stomach guidelines. In case of new/worsening of known symptoms, gastroscopy was anticipated. Cox regression analyses and Kaplan-Meier survival curves were obtained.

RESULTS

Two hundred seventy-five patients with corpus-restricted atrophic gastritis (72.0% female, median age 61 [23-84] years) were included. At a median follow-up of 5 (1-17) years, the annual incidence rate person-year was 0.5%, 0.6%, 2.8%, and 3.9% for GC/high-grade IEN, low-grade IEN, T1gNET, and all gastric neoplastic lesions, respectively. All patients showed at baseline operative link for gastritis assessment (OLGA)-2, except 2 low-grade (LG) IEN patients and 1 T1gNET patient with OLGA-1. Age older than 60 years (hazard ratio [HR] 4.7), intestinal metaplasia without pseudopyloric metaplasia (HR 4.3), and pernicious anemia (HR 4.3) were associated with higher risk for GC/HG-IEN or LG-IEN development and shorter mean survival time for progression (13.4, 13.2, and 11.1, respectively, vs 14.7 years, P = 0.01). Pernicious anemia was an independent risk factor for T1gNET (HR 2.2) and associated with a shorter mean survival time for progression (11.7 vs 13.6 years, P = 0.04) as well as severe corpus atrophy (12.8 vs 13.6 years, P = 0.03).

DISCUSSION

Patients with corpus-restricted atrophic gastritis are at increased risk for GC and T1gNET despite low-risk OLGA scores, and those aged older than 60 years with corpus intestinal metaplasia or pernicious anemia seem to display a high-risk scenario.

Endoscopic resection of gastric low-grade dysplasia with high risk factors is associated with decreased advanced neoplasia: a single-center retrospective cohort study

BACKGROUND

The natural course of gastric low-grade dysplasia (LGD) remains unclear, and there are inconsistent management recommendations among guidelines and consensus.

OBJECTIVE

This study aimed to investigate the incidence of advanced neoplasia in patients with gastric LGD and identify the related risk factors.

METHODS

Cases of biopsy demonstrated LGD (BD-LGD) at our center from 2010 to 2021 were reviewed retrospectively. Risk factors related to histological progression were identified, and outcomes of patients based on risk stratification were evaluated.

RESULTS

Ninety-seven (23.0%) of 421 included BD-LGD lesions were diagnosed as advanced neoplasia. Among 409 superficial BD-LGD lesions, lesion in the upper third of the stomach, H. pylori infection, larger size, and narrow band imaging (NBI)-positive findings were independent risk factors of progression. NBI-positive lesions and NBI-negative lesions with or without other risk factors had 44.7%, 1.7%, and 0.0% risk of advanced neoplasia, respectively. Invisible lesions, visible lesions (VLs) without a clear margin, and VLs with a clear margin and size ≤ 10 mm, or > 10 mm had 4.8%, 7.9%, 16.7%, and 55.7% risk of advanced neoplasia, respectively. In addition, endoscopic resection decreased the risk of cancer (P < 0.001) and advanced neoplasia (P < 0.001) in patients with NBI-positive lesions, but not in NBI-negative patients. Similar results were found in patients with VLs with clear margin and size > 10 mm. Moreover, NBI-positive lesions had higher sensitivity and lower specificity for predicting advanced neoplasia than VLs with a clear margin and size > 10 mm determined by white-light endoscopy (97.6% vs. 62.7%, P < 0.001; and 63.0% vs. 85.6%, P < 0.001, respectively).

CONCLUSION

Progression of superficial BD-LGD is associated with NBI-positive lesions, as well as with VLs with a clear margin (size > 10 mm) if NBI is unavailable, and selective resection of those lesions offers benefits for patients by decreasing the risk of advanced neoplasia.

Incidence and natural history of gastric high-grade dysplasia in patients with familial adenomatous polyposis syndrome

BACKGROUND AND AIMS

Familial adenomatous polyposis (FAP) is characterized by high risks of colonic and extracolonic tumors. Recent studies have suggested a rising risk for gastric cancer (GC). We sought to define the spectrum of premalignant gastric polyps in FAP, focusing on high-grade dysplasia (HGD).

METHODS

The gastric phenotypes of 118 patients diagnosed with FAP or attenuated FAP in our Hereditary Gastrointestinal Cancer Registry were retrospectively reviewed. To analyze the clinical features associated with the diagnosis of HGD, we established an age- and sex-matched control group of FAP patients from our cohort without gastric HGD in a 4:1 ratio.

RESULTS

The spectrum and frequency of gastric polyps in individuals with FAP included fundic gland polyps (67.9%), hyperplastic polyps/foveolar hyperplasia (19.6%), tubular adenomas (15.2%), foveolar adenomas (10.7%), and pyloric gland adenomas (6.3%). Ten patients (8.9%) exhibited gastric HGD at a mean age of 55 ± 13 years, and HGD was seen in all polyp types. When compared with control subjects, HGD was associated with a high diversity of gastric polyp histology, prior low-grade dysplasia, severe gastric polyposis, and prior Whipple surgery (P = 2.0E-5, .003, .024, and .04, respectively). Two patients (1.7%) with HGD were diagnosed with GC. However, the remaining 8 patients with HGD have been under surveillance for an average of 5.8 ± 4.5 years without progression to GC.

CONCLUSIONS

Gastric HGD in FAP may be more common than previously appreciated. The natural history of HGD is variable, and most patients with HGD do not appear to progress to GC.

Long-Term Outcome of Gastric Mild-Moderate Dysplasia: A Real-World Clinical Experience

BACKGROUND & AIMS

The natural course of gastric mild-moderate dysplasia in a country with high incidence of gastric cancer (GC) is relatively unknown. We aimed to determine the long-term cumulative incidence of and risk factors for advanced neoplasia in patients with gastric dysplasia.

METHODS

This was a single-center observational study including all consecutive patients diagnosed with gastric mild-moderate dysplasia between 2000 and 2017. Follow-up data were collected until December 2019. We determined the cumulative incidence of advanced neoplasia and identified risk factors with Cox regression.

RESULTS

A total of 3489 consecutive participants were followed for a median of 4.19 years from initial mild-moderate dysplasia diagnosis. The median surveillance interval between index endoscopy and next follow-up endoscopy was 1.08 years, and more than half of patients had at least 3 surveillance gastroscopies. During the study period, the majority of participants did not show disease progression, either with dysplasia not detected (51.4%) or with persistent dysplasia (46.1%). There were 88 (2.9%) patients (5.13 per 1000 patient-years) who progressed to advanced neoplasia within a median of 4.3 years. The annual incidence of advanced neoplasia and GC were 0.43% and 0.26%, respectively, within 5 years of mild-moderate dysplasia diagnosis. Increasing age, male sex, moderate dysplasia, dysplasia detected in fundus or cardia at index endoscopy, and persistent Helicobacter pylori infection during follow-up were independent risk factors for developing advanced neoplasia.

CONCLUSIONS

Even in a country with high incidence of GC, the majority of patients with gastric mild-moderate dysplasia did not experience disease progression in the long term. Intensified surveillance during the first 5 years after mild-moderate dysplasia detection is suggested.

Effect and cost-effectiveness of national gastric cancer screening in Japan: a microsimulation modeling study

BACKGROUND

A national endoscopic screening program for gastric cancer was rolled out in Japan in 2015. We used a microsimulation model to estimate the cost-effectiveness of current screening guidelines and alternative screening strategies in Japan.

METHODS

We developed a microsimulation model that simulated a virtual population corresponding to the Japanese population in risk factor profile and life expectancy. We evaluated 15 endoscopic screening scenarios with various starting ages, stopping ages, and screening intervals. The primary outcomes were quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratio. Cost-effective screening strategies were determined using a willingness-to-pay threshold of $50,000 per QALY gained. One-way sensitivity and probabilistic sensitivity analyses were done to explore model uncertainty.

RESULTS

Using the threshold of $50,000 per QALY, a triennial screening program for individuals aged 50 to 75 years was the cost-effective strategy, with an incremental cost-effectiveness ratio of $45,665. Compared with no endoscopic screening, this strategy is predicted to prevent 63% of gastric cancer mortality and confer 27.2 QALYs gained per 1000 individuals over a lifetime period. Current screening guidelines were not on the cost-effectiveness efficient frontier. The results were robust on one-way sensitivity analyses and probabilistic sensitivity analysis.

CONCLUSIONS

This modeling study suggests that the endoscopic screening program in Japan would be cost-effective when implemented between age 50 and 75 years, with the screening repeated every 3 years. These findings underscore the need for further evaluation of the current gastric cancer screening recommendations.

Establishment and validation of a model to determine the progression risk of low grade intraepithelial neoplasia

Objective

To establish and validate a model to determine the progression risk of gastric low-grade intraepithelial neoplasia (LGIN).

Methods

A total of 705 patients with gastric LGIN at the endoscopy center of Jiangsu Provincial People's Hospital during January 2010 and August 2017 were retrospectively reviewed. Basic clinical and pathological information were recorded. According to the time sequence of the initial examination, the first 605 patients were enrolled in the derivation group, and the remaining 100 patients were used in the validation group. SPSS 19 software was used as statistical analysis to determine independent risk factors for progression of LGIN of the stomach and to establish a risk model. The ROC was used to verify the application value of the predictive model.

Results

Univariate and multivariate analysis suggested that sex, multiple location, congestion, ulceration and form were independent risk factors for prolonged or advanced progression in patients with LGIN. Based on this, a predictive model is constructed: P = ex/(1 + ex) X = − 10.399 + 0.922 × Sex + 1.934 × Multiple Location + 1.382 × Congestion + 0.797 × Ulceration + 0.525 × Form. The higher of the P value means the higher risk of progression. The AUC of the derivation group and validation group were 0.784 and 0.766, respectively.

Conclusion

Sex, multi-site, hyperemia, ulcer and morphology are independent risk factors for the prolongation or progression of patients with gastric LGIN. These factors are objective and easy to obtain data. Based on this, a predictive model is constructed, which can be used in management of patients. The model can be used to identify high-risk groups in patients with LGIN that may progress to gastric cancer. Strengthening follow-up or endoscopic treatment to improve the detection rate of early cancer or reduce the incidence of gastric cancer can provide a reliable basis for the treatment of LGIN.

The Mexican consensus on the detection and treatment of early gastric cancer

Gastric cancer is one of the most frequent neoplasias in the digestive tract and is the result of premalignant lesion progression in the majority of cases. Opportune detection of those lesions is relevant, given that timely treatment offers the possibility of cure. There is no consensus in Mexico on the early detection of gastric cancer, and therefore, the Asociación Mexicana de Gastroenterología brought together a group of experts and produced the "Mexican consensus on the detection and treatment of early gastric cancer" to establish useful recommendations for the medical community. The Delphi methodology was employed, and 38 recommendations related to early gastric cancer were formulated. The consensus defines early gastric cancer as that which at diagnosis is limited to the mucosa and submucosa, irrespective of lymph node metástasis. In Mexico, as in other parts of the world, factors associated with early gastric cancer include Helicobacter pylori infection, a family history of the disease, smoking, and diet. Chromoendoscopy, magnification endoscopy, and equipment-based image-enhanced endoscopy are recommended for making the diagnosis, and accurate histopathologic diagnosis is invaluable for making therapeutic decisions. The endoscopic treatment of early gastric cancer, whether dissection or resection of the mucosa, should be preferred to surgical management, when similar oncologic cure results can be obtained. Endoscopic surveillance should be individualized.

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

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

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.

Identifying high-risk individuals for gastric cancer surveillance from western and eastern perspectives: Lessons to learn and possibility to develop an integrated approach for daily practice

Current evidence shows that individuals with gastric dysplasia, severe and extensive gastric atrophy, extensive gastric intestinal metaplasia and the incomplete subtype of intestinal metaplasia are at high risk for gastric cancer (GC) development. There are several approaches to identifying these subjects, including noninvasive methods, esophagogastroduodenoscopy and histology. The main approach in Western countries is histology-based while that in Eastern countries with a high prevalence of GC is endoscopy-based. Regarding asymptomatic individuals, the key issues in selecting applicable approaches are the ability to reduce GC mortality and the cost-effectiveness of the approach. At present, population-based screening programs have only been applied in a few Asian countries with a high risk of GC. Pre-endoscopic risk assessment based on demographic and clinical features, such as ethnicity, age, gender, smoking and Helicobacter pylori status, is helpful for identifying subjects with high pre-test probability for a possibly cost-effective approach, especially in intermediate- and low-risk countries. Regarding symptomatic patients with indications for esophagogastroduodenoscopy, the importance of opportunistic screening should be emphasized. The combination of endoscopic and histological approaches should always be considered as endoscopy provides a real-time assessment of the patient’s risk level. In addition, imaging enhanced endoscopy (IEE) has been shown to facilitate targeted biopsies resulting in better correlation between endoscopic and histological findings. Currently, the use of IEE is recommended for endoscopic examinations, and the Operative Link for Gastric Intestinal Metaplasia or Operative Link on Gastritis Assessment grading systems are recommended for histological examinations whenever available. However, resource limitations are an important barrier in many regions worldwide. Thus, for an approach to be applicable in real-life practice, it should be not only evidence-based but also resource-sensitive. In this review, we discuss the current understanding and approaches to identifying high-risk individuals from western and eastern perspectives, as well as the possibility of an integrated, resource-sensitive approach.

Type 1 Gastric Neuroendocrine Tumor Found on Endoscopic Polypectomy

Gastric neuroendocrine tumors (GNET) are rare gastric neoplasms accounting for <1% of all gastric neoplasms. The World Health Organization (WHO) categorized these neoplasms as types 1-3 to help predict malignant potential and long-term survival and guide management. Improved outcomes have been shown with endoscopic resections, but further studies are needed to confirm the best approach. We present a case of a 56-year-old woman who demonstrated the classic features of type one GNET with mucosal and submucosal involvement in the setting of primary atrophic gastritis, secondary hypergastrinemia, and underlying pernicious anemia. In general, standardizing treatment has been difficult due to a variable presentation.

Long-term gastric cancer risk in male smokers with atrophic corpus gastritis

OBJECTIVES

The aim of this study was to evaluate long-term gastric cancer risk in male smokers with and without atrophic gastritis.

MATERIALS AND METHODS

A total of 22,346 elderly male smokers participated in the Helsinki Gastritis Study between the years 1989 and 1993. Serum pepsinogen I (PGI) was measured for the men, and 2,132 men with low PGI (<25 µg/L; a marker of atrophic corpus gastritis) were invited to undergo gastroscopy because of increased gastric cancer risk. Endoscopy was performed to 1,327 men, who were followed up for a median of 13.6 years and a maximum of 25.3 years thereafter. In addition, the gastric cancer risk of men with low PGI was compared to that of the men with normal PGI and to the general Finnish male population of the same age.

RESULTS

Thirty-five cases of gastric cancer were diagnosed in men with gastroscopy during the follow-up. The incidence rate was 1.94 per 1000 patient years. The men with a history of gastric surgery (n = 180) due to a benign cause had even higher gastric cancer incidence (3.2 per 1000 patient-years). Gastric cancer risk was highest in men with marked intestinal metaplasia in primary biopsies. Compared to the general Finnish male population of the same age, the cancer risk was 1.13 times higher in male smokers with normal serum PGI, and 2.43 times higher in men with low serum PGI.

CONCLUSION

In male smokers, atrophic gastritis and intestinal metaplasia increase the risk of gastric cancer.

Use of DNA flow cytometry in the diagnosis, risk stratification, and management of gastric epithelial dysplasia

The natural history of gastric epithelial dysplasia and the consequential surveillance strategies are not well defined in the West. To date, the diagnosis relies on morphology, and no reliable adjunct methods, either immunohistochemical or molecular, have reproducibly been able to confirm the diagnosis and/or risk stratify gastric epithelial dysplasia. Yet, such a tool would be useful in confirming the diagnosis, and developing objective and rational surveillance guidelines. DNA flow cytometry was performed using formalin-fixed paraffin-embedded gastric tissue from 23 cases of high-grade dysplasia and 38 cases of low-grade dysplasia. Twenty-four benign background mucosal samples from the same cohort (20 biopsies and 4 surgical resections from 16 low- and 8 high-grade dysplasia cases) were utilized as controls. The presence of DNA content abnormality (aneuploidy or elevated 4N fraction) correlated with increasing levels of dysplasia, as DNA content abnormality was detected in 18 (78%) of 23 high-grade dysplasia, 5 (13%) of 38 low-grade dysplasia, and none of 24 non-dysplastic samples. 1 and 4-year detection rates of high-grade dysplasia or gastric adenocarcinoma in low-grade dysplasia patients with DNA content abnormality were 80% (p = 0.003) and 100% (p = 0.005), respectively, whereas patients with low-grade dysplasia but with normal DNA content had 1, 4, and 12-year detection rates of 23, 32, and 54%, respectively. The univariate hazard ratio (HR) for subsequent detection of high-grade dysplasia or gastric adenocarcinoma in low-grade dysplasia patients with DNA content abnormality was 6.9 (p = 0.001). Older patients (HR = 1.1, p = 0.005) and those with familial adenomatous polyposis (HR = 9.7, p = 0.029) also had an increased risk for developing high-grade dysplasia or gastric adenocarcinoma in the univariate analysis, but only DNA content abnormality demonstrated a significantly elevated HR of 5.9 in the multivariate analysis (p = 0.005). While older age showed a minimally elevated risk (HR = 1.1, p = 0.013), no other potential risk factors, including male gender, ethnicity, polypoid endoscopic appearance, Helicobacter pylori infection, and intestinal metaplasia, were significantly associated with subsequent detection of high-grade dysplasia or gastric adenocarcinoma in the multivariate analysis. Among the 18 high-grade dysplasia cases with DNA content abnormality, 13 cases (72%) developed gastric adenocarcinoma within a mean follow-up time of 9 months, conferring a HR of 2.5; however, this did not reach statistical significance. In conclusion, the presence of DNA content abnormality can identify a subset of low-grade dysplasia patients who are at increased risk for subsequent detection of high-grade dysplasia or gastric adenocarcinoma. It can also provide confirmatory evidence to a morphologic impression or suspicion of high-grade dysplasia. The majority of gastric epithelial dysplasia patients with DNA content abnormality developed high-grade dysplasia or gastric adenocarcinoma within a year and thus may benefit from more thorough and rigorous endoscopic surveillance.

Long-term follow-up study of gastric adenoma; tumor-associated macrophages are associated to carcinoma development in gastric adenoma

BACKGROUND

Some gastric adenomas may progress to adenocarcinoma in a short time, but others remain as adenoma for a long time.

METHODS

Among 1138 cases diagnosed as adenoma by biopsy at Kure Medical Association Hospital between 1990 and 2010, 51 adenomas were enrolled. Of these, 28 adenomas (group A) were followed for 60 months or longer with no progression to adenocarcinoma within 60 months, and the other 23 adenomas (group B) were upgraded to carcinoma by consecutive biopsies performed within 1 year after the first biopsy. These adenomas were compared clinicopathologically and immunohistochemically.

RESULTS

Macroscopically, the mean size of group B adenomas was significantly larger than that of group A adenomas (18.6 vs. 9.9 mm) at the first biopsy. The frequency of a depressed area in the adenoma was significantly higher in group B than group A. Microscopically none of group A but 7 (30.4%) of 23 group B adenomas showed severe atypia. Each of a highly proliferative gland measured by Ki-67 labeling, cellular atypical grade, gastric phenotype defined by MUC5AC and MUC6 and CD204-positive tumor-associated macrophage (TAM) was a significant risk factor for adenocarcinoma development in gastric adenoma by univariate analysis. Only moderate or severe atypia of adenoma cells and the TAM number in the stroma of adenomas were independent risk factors by multivariate analysis.

CONCLUSIONS

As independent risk factors, cellular atypia may reconfirm the importance of morphological analysis, and the TAM number may indicate the significance of TAM function in gastric adenoma.

[Endoscopic Treatment of Gastric Adenoma]

Gastric adenoma (dysplasia) is a precancerous lesion. Therefore, managements of gastric adenomas are important for preventing the development of gastric cancers and for detecting gastric cancers at earlier stages. The Vienna classification divides gastric adenomas into two categories: high-grade dysplasia and low-grade dysplasia. Generally, endoscopic resection is performed for adenoma with high-grade dysplasia due to the coexistence of carcinoma and the potential of progression to carcinomas. However, the treatments of adenoma with low-grade dysplasia remain controversial. Currently two treatment strategies for the low-grade type have been suggested; First is the 'wait and see' strategy; Second is endoscopic treatment (e.g., endoscopic mucosal resection, endoscopic submucosal dissection, or argon plasma coagulation). In this review, we discuss the current optimal strategies for endoscopic management of gastric adenoma.

Diagnosis and management of gastric dysplasia

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

Somatostatin analogs for gastric carcinoids: For many, but not all

Gastric carcinoids (GCs) are classified as: type I, related to hypergastrinemia due to chronic atrophic gastritis (CAG), type II, associated with Zollinger-Ellison syndrome in multiple endocrine neoplasia type 1, and type III, which is normogastrinemic. The management of type-I gastric carcinoids (GC1s) is still debated, because of their relatively benign course. According to the European Neuroendocrine Tumor Society guidelines endoscopic resection is indicated whenever possible; however, it is not often feasible because of the presence of a multifocal disease, large lesions, submucosal invasion or, rarely, lymph node involvement. Therefore, somatostatin analogs (SSAs) have been proposed as treatment for GC1s in view of their antisecretive, antiproliferative and antiangiogenic effects. However, in view of the high cost of this therapy, its possible side effects and the relatively benign course of the disease, SSAs should be reserved to specific subsets of “high risk patients”, i.e., those patients with multifocal or recurrent GCs. Indeed, it is reasonable that, after the development of a gastric neuroendocrine neoplasm in patients with a chronic predisposing condition (such as CAG), other enterochromaffin-like cells can undergo neoplastic proliferation, being chronically stimulated by hypergastrinemia. Therefore, definite indications to SSAs treatment should be established in order to avoid the undertreatment or overtreatment of GCs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Progression risk assessments of individual non-invasive gastric neoplasms by genomic copy-number profile and mucin phenotype

Background

Early detection and treatment of non-invasive neoplasms can effectively reduce the incidence of advanced gastric carcinoma (GC), but only when the lineage is continuous between non-invasive and advanced tumours. Although a fraction of non-invasive neoplasms progress to invasive GC, it is difficult to identify individual progression-prone non-invasive neoplasms. To classify non-invasive gland-forming gastric neoplasms into clusters of different levels of progression risk, we applied mucin phenotyping and genomic DNA microarray analyses to intramucosal gland-forming gastric neoplasms.

Methods

Formalin-fixed, paraffin-embedded tissues from 19 non-invasive and 24 invasive gland-forming neoplasms were obtained via endoscopic submucosal dissection or surgical excision. According to the Vienna classification, intramucosal neoplasms were classified as low-grade or high-grade non-invasive neoplasms (LGNs [category 3] and HGNs [category 4], respectively) or invasive carcinomas (intramucosal GCs and mucosal parts of submucosal or deeper GCs [category 5]). Neoplastic lesions were characterized by mucin phenotypes determined using monoclonal antibodies against MUC2, MUC5AC, MUC6, and CD10. Genomic DNA samples from mucosal neoplasms were subjected to array-based comparative genomic hybridization and subsequent unsupervised, hierarchical clustering with selected large-sized genes.

Results

There was no significant difference in mucin phenotype between HGNs/LGNs and invasive carcinomas. The clustering classified samples into stable, unstable, and intermediate. The histological tumour grade or mucin phenotype of non-invasive neoplasms did not correlate with the clustering results. Each cluster may represent an independent lineage of different outcome because the size distribution of non-invasive tumours among the 3 clusters almost overlapped. In contrast, the unstable cluster alone included invasive carcinomas.

Conclusions

These findings suggest that the outcome of individual tumours is not stochastically determined but can be predicted from the genomic copy-number profile even at the non-invasive stage. Non-invasive neoplasms of the unstable clusters, which accounted for 21% of non-invasive neoplasms, may progress to invasive carcinomas, whereas those of stable cluster may not.

Electronic supplementary material

The online version of this article (doi:10.1186/s12920-015-0080-6) contains supplementary material, which is available to authorized users.

What is the next step for gastric atypical epithelium on histological findings of endoscopic forceps biopsy?

BACKGROUND

Gastric atypical epithelium on endoscopic biopsy is borderline lesions between benign and malignant. Definitive management of this lesion remains debatable.

AIMS

We aimed to analyze the final histological diagnosis for atypical epithelium on endoscopic biopsy and to examine the discrepancy rate between the final histological diagnosis and the initial endoscopic assessment.

METHODS

This retrospective study finally enrolled 24 cases proven atypical epithelium on initial histology of an endoscopic biopsy. Of 24 cases, endoscopic submucosal dissection (n = 22), operation (n = 1) and follow-up biopsy without endoscopic submucosal dissection (n = 1) were performed.

RESULTS

Of the 24 cases, early gastric cancer (n = 15, 62%) and adenoma (n = 7, 30%) lesions were finally diagnosed in 22 cases. Age, sex, endoscopic results and number of biopsy did not significantly influence the result of final outcome. Between the initial endoscopic assessment and the final histological diagnosis, 12 cases (50%) showed a concordant diagnosis, but eight (33%) and four cases (17%) showed upgraded and downgraded diagnoses, respectively.

CONCLUSIONS

Of atypical epithelium cases, the rate of malignant and premalignant lesions was 92% and it was difficult to distinguish between malignant and benign lesions using the initial endoscopic findings. Therefore, endoscopic submucosal dissection can be considered in patients with atypical epithelium on endoscopic biopsy.

Is endoscopic mucosal resection a sufficient treatment for low-grade gastric epithelial dysplasia?

Background/Aims

The rate of diagnosis of gastric adenoma has increased because esophagogastroduodenoscopy is being performed at an increasingly greater frequency. However, there are no treatment guidelines for low-grade dysplasia (LGD). To determine the appropriate treatment for LGD, we evaluated the risk factors associated with the categorical upgrade from LGD to high grade dysplasia (HGD)/early gastric cancer (EGC) and the risk factors for recurrence after endoscopic treatment.

Methods

We compared the complication rates, recurrence rates, and remnant lesions in 196 and 56 patients treated with endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR), respectively, by histologically confi rming low-grade gastric epithelial dysplasia.

Results

The en bloc resection rate was significantly lower in the EMR group (31.1%) compared with the ESD group (75.0%) (p<0.001). However, no significant difference was observed in the prevalence of remnant lesions or recurrence rate (p=0.911) of gastric adenoma. The progression of LGD to HGD or EGC caused an increase in the incidence of tumor lesions >1 cm with surface redness and depressions.

Conclusions

For the treatment of LGD, EMR resulted in a higher incidence of uncertain resection margins and a lower en bloc resection rate than ESD. However, there was no signifi cant difference in recurrence rate.

Precancerous lesions of gastric cancer: Research progress and preventive strategies

The development of precancerous lesions of gastric cancer is a critical stage of the evolution of gastric cancer. Early detection and intervention for these lesions are of considerable significance in reducing the morbidity of gastric cancer. The development of precancerous lesions of gastric cancer is controlled by multiple factors such as Helicobacter priori infection, DNA methylation, microsatellite instability, and p53 status. Because of high malignancy and unclear etiology of gastric cancer, there are certain difficulties in carrying out successful primary prevention. This review aims to review the recent advances in understanding the pathogenesis of and preventive strategies for gastric precancerous lesions.

Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED)

Atrophic gastritis, intestinal metaplasia, and epithelial dysplasia of the stomach are common and are associated with an increased risk for gastric cancer. In the absence of guidelines, there is wide disparity in the management of patients with these premalignant conditions. The European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter Study Group (EHSG), the European Society of Pathology (ESP) and the Sociedade Portuguesa de Endoscopia Digestiva (SPED) have therefore combined efforts to develop evidence-based guidelines on the management of patients with precancerous conditions and lesions of the stomach (termed MAPS). A multidisciplinary group of 63 experts from 24 countries developed these recommendations by means of repeat online voting and a meeting in June 2011 in Porto, Portugal. The recommendations emphasize the increased cancer risk in patients with gastric atrophy and metaplasia, and the need for adequate staging in the case of high grade dysplasia, and they focus on treatment and surveillance indications and methods.

Gastric intraepithelial neoplasia in a Western population

BACKGROUND AND STUDY AIMS

Descriptions of the natural history and endoscopic appearances of gastric dysplasia/intraepithelial neoplasia (IEN) that originate mainly from Europe. Currently, there are no Australian data available. We aimed to document endoscopic appearances and progression rates of gastric IEN and to determine the significance of indefinite for IEN.

PATIENTS AND METHODS

This is a retrospective study, in which cases diagnosed with gastric IEN were identified between 2000 and 2009. Endoscopic appearances, progression rates to more advanced IEN or cancer, and long-term outcomes were recorded.

RESULTS

A total of 160 cases with IEN (26.9% high grade, 57.5% low grade, 15.6% indefinite) were identified. The mean age was 67.8 years and 53.8% were men. Endoscopic lesions were polypoid in 29.4% and nonpolypoid in 70.6%. The most common location was the antrum (58.7%). Forty patients had an intervention and 76 underwent endoscopic follow-up only. Twenty-two cancers were diagnosed; three who had an intervention were diagnosed within 12 months, one with low-grade intraepithelial neoplasia developing a cancer after 9.9 years, and 13 undergoing surveillance only, were diagnosed with cancer within 12 months of index endoscopy. Five cases had cancer after a mean of 2.6 years. Forty-seven cases initially labelled as indefinite; following rereview 25 remained unchanged, 11 reclassified as negative for IEN, 10 as low grade, and one as high grade. Three of these cases developed cancer over the study period.

CONCLUSION

We concluded that (a) majority of gastric IEN are associated with endoscopic lesions, (b) high rate of early cancer diagnosis was observed (c) rates of progression to cancer were lower than reported rates, and (d) indefinite for IEN is not innocuous requiring an expert pathologist's review.

Treatment strategy for gastric non-invasive intraepithelial neoplasia diagnosed by endoscopic biopsy

Treatment strategies, whether as follow-up or “total incisional biopsy” for gastric noninvasive intraepithelial neoplasia diagnosed by examination of an endoscopic forceps biopsy specimen, are controversial due to problems associated with the diagnostic accuracy of endoscopic forceps biopsy and questions about the safety and efficacy of endoscopic treatment. Based on the histological findings of the biopsy specimen, it is difficult to differentiate between reactive or regenerative changes, inflammation and neoplastic changes, intraepithelial and invasive tumors. Therefore, gastric neoplasia diagnosed as noninvasive intraepithelial often develop into invasive carcinoma during follow-up. Recent advances in endoscopic modalities and treatment devices, such as image-enhanced endoscopy and high-frequency generators, may make endoscopic treatment, such as endoscopic submucosal dissection (ESD), a therapeutic option for gastric intraepithelial neoplasia, including low-grade neoplasms. Future studies are required to evaluate whether ESD is a valid strategy for gastric intraepithelial neoplasm with regard to safety and cost effectiveness.

Intestinal metaplasia, intraepithelial neoplasia and gastric carcinogenesis

Gastric cancer is a common disease that greatly endangers people's health. The mechanism of gastric carcinogenesis is still unknown. Gastric carcinogenesis is a long-term multistep process, during which a series of precancerous lesions develop sequentially. Intraepithelial dysplasia and intestinal metaplasia are two types of gastric precancerous lesions. Because of high malignancy and unclear etiology of gastric cancer, there are some difficulties in carrying out successful primary prevention. Here, we give an overview of the definitions and classification of gastric intraepithelial neoplasia and intestinal metaplasia, and elaborate the relationship among Helicobacter pylori infection, atrophic gastritis, intestinal metaplasia and gastric carcinoma.

The severity of endoscopic gastric atrophy could help to predict Operative Link on Gastritis Assessment gastritis stage

BACKGROUND AND AIMS

The aims of the present study were to evaluate the role of moderate-to-severe endoscopic gastric atrophy (EGA) on predicting Operative Link on Gastritis Assessment (OLGA) gastritis stage, and to assess the association of high-stage OLGA gastritis with gastric neoplasia in patients with non-ulcer dyspepsia.

METHODS

A cross-sectional study was carried out on 280 dyspeptic outpatients. EGA was assessed according to the Kimura-Takemoto classification. Gastritis stage was established according to the OLGA staging system and gastric neoplasia was assessed according to the Vienna classification. The pathologists who read the specimens were kept blind to the endoscopic results.

RESULTS

The mean age of patients was 46.1 years (range 20-78 years) with a male-to-female ratio of 1:1. High-stage gastritis (e.g. stage III or IV) was confirmed in 13 (4.6%) patients. All of these patients were more than 40 years-of-age (P = 0.01), had Helicobacter pylori infection (P = 0.0006) and moderate-to-severe EGA (P < 0.001). Low-grade dysplasia was found in seven patients: 4/13 (30.7%) with high-stage gastritis versus 3/267 (1.1%) with low-stage gastritis (P < 0.001). Six of these patients had moderate-to-severe EGA (P = 0.048). The sensitivity, specificity, positive predictive value and negative predictive value of this endoscopic finding in high-stage gastritis diagnosis were 100%, 57.7%, 10.3% and 100%, respectively.

CONCLUSIONS

OLGA high-stage gastritis was associated with gastric dysplasia and was mostly diagnosed in patients with moderate-to-severe EGA. The absence of this endoscopic finding could effectively rule out the possibility of having high-stage gastritis.

The diagnostic accuracy of endoscopic biopsy for gastric dysplasia

Purpose

There is controversy over the treatment for low grade dysplasia, while resection is recommended for high grade dysplasia. But the concordance of the grade of dysplasia between pre- and post-resection is low because of sampling errors with endoscopic biopsy. We attempted to establish a clearer direction for the treatment of dysplasia by clarifying the discrepancy between the pre- and post-resection diagnoses.

Materials and Methods

We performed a retrospective review of 126 patients who had undergone resection with the diagnosis of dysplasia on biopsy at Bundang CHA Hospital from 1999 to 2009.

Results

Seventy patients were diagnosed with low grade dysplasia and 56 patients were diagnosed with high grade dysplasia. Among the 33 patients who received gastrectomy with lymph node dissection, 30 patients were revealed to have invasive cancers and 4 patients showed lymph node metastasis. Discordance between the diagnoses from biopsy and resection occurred in 55 patients (44%). There was no correlation on the comparative analysis between the size, location or gross type of lesion and the grade of dysplasia.

Conclusions

The rate of discordance between the diagnoses of endoscopic biopsy and the post resection pathologic report was as high as 44%. Endoscopic mucosal resection was not sufficient for some patients who were diagnosed with dysplasia on biopsy due to the presence of lymph node metastasis. It is necessary to be prudent when determining the follow-up and treatment based solely on the result of the biopsy.

Confocal laser endomicroscopy for in vivo diagnosis of gastric intraepithelial neoplasia: a feasibility study

BACKGROUND

Confocal laser endomicroscopy (CLE) is a novel endoscopic modality that allows subsurface analysis of the gastric mucosa during ongoing endoscopy. Several studies have reported that this technique is of value in the diagnosis of premalignant lesions in the GI tract, but as yet no investigations have reported its application in the analysis of gastric intraepithelial neoplasia (GIN).

OBJECTIVE

To assess the feasibility of CLE for the identification and grading of GIN.

DESIGN

Prospective double-blind feasibility study.

SETTING

Qilu Hospital, Shandong University, Jinan, China.

PATIENTS

CLE images of 33 patients were first evaluated to establish the diagnostic criteria for gastric lesions. Eligible patients were then prospectively investigated by CLE using the newly established criteria.

INTERVENTIONS

All endoscopically suspicious lesions were examined by CLE, and CLE diagnoses were compared with corresponding histopathologic results.

MAIN OUTCOME MEASUREMENTS

Sensitivity, specificity, and positive and negative likelihood ratios of CLE diagnosis of biopsy-proven intraepithelial neoplasia by per-lesion analysis.

RESULTS

The sensitivity, specificity, and positive and negative likelihood ratios of CLE diagnosis of GIN were 77.8%, 81.8%, 4.28, and 0.27, respectively. The mean κ value for interobserver agreement for the diagnosis of GIN was 0.70 among endoscopists and 0.71 between endoscopist and GI pathologist. Intraepithelial neoplasia score ≥5 differentiated high-grade from low-grade intraepithelial neoplasia with a sensitivity of 66.7% and a specificity of 88.0%.

LIMITATIONS

Nonrandomized single-center study, limited number of patients.

CONCLUSIONS

CLE is an acceptable and potentially useful technology for the identification and grading of GIN in vivo. The diagnostic accuracy needs to be improved.

Endoscopic management of gastric dysplasia: Cutting edge technology needs a new paradigm

There has been tremendous progress in endoscopic techniques for the management of premalignant or malignant gastric lesions. Gastric cancer remains the second most common cause of cancer related mortality worldwide. This means that there is a need for early detection and diagnosis of premalignant lesions or early cancer in clinical practice. Despite substantial development of endoscopic resection techniques, the management of gastric premalignant lesions is controversial because of the lack of consensus and accurate risk stratification. Future study of various aspects would clarify these issues but in the meantime we should reconsider the current algorithm approach for the management of gastric low grade dysplasia.

Genomic profiling of gastric carcinoma in situ and adenomas by array-based comparative genomic hybridization

Although genomic copy number aberrations (CNAs) of gastric carcinoma at the advanced stage have already been extensively characterized by array comparative genomic hybridization (array CGH) analysis, those of gastric carcinoma in situ (CIS) are still poorly understood. Furthermore, no reports have demonstrated correlations between CNAs and histopathological features of gastric adenoma. In this study, we investigated CNAs of 20 gastric CISs (Vienna category 4.2) and 20 adenomas including seven low-grade adenomas (LGA; Vienna category 3) and 13 high-grade adenomas (HGA; Vienna category 4.1), using oligonucleotide-based array CGH. The most frequent aberrations in CIS were gains at 8q (85%) and 20q (50%), and losses at 5q (50%) and 17p (50%), suggesting that these CNAs are involved in the development of CIS. We found that the pattern of CNAs in HGA was quite different from that in LGA. The most frequent CNAs in HGA were gains at 8q (62%) and 7pq (54%), whereas those in LGA were gain at 7q21.3-q22.1 (57%) and loss at 5q (43%). Interestingly, gains at 8q and 7pq, both of which occurred most frequently in HGA, were not detected in any cases of LGA. Of note, 8q gain was detected most frequently in both HGA and CIS but was undetected in LGA. Since HGA is believed to have a higher risk of progression to invasive carcinoma than LGA, these data suggest that 8q gain is important for the malignant transformation of gastric adenoma.

Oct4, a novel marker for human gastric cancer

BACKGROUND AND OBJECTIVE

Octamer-4 (Oct4), a transcription factor involved in regulating human embryonic stem cells (ESCs), may play a role in tumorigenesis. Since little is known about the efficacy of Oct4 as a potential biomarker for gastric cancer (GC), we investigated its expression in GC tissues and its relationship to various clinicopathological parameters.

METHODS

Primary tumor tissues and matching, adjacent non-cancerous tissues were obtained from 62 GC patients, and Oct4 expression was examined by reverse transcription-PCR (RT-PCR) and real-time PCR. Twenty biopsy specimens of atrophic gastritis and gastric ulcer individually were collected as control. To detect Oct4 expression in the paired GC and non-cancerous tissues at the protein level, Western blotting and immunohistochemistry (IHC) were employed. Correlation analyses were conducted to assess the relationship between Oct4 expression and clinicopathological parameters.

RESULTS

Oct4 expression levels were higher in GC tissues compared to matching, adjacent non-cancerous tissues, atrophic gastritis and gastric ulcer tissues. Additionally, Oct4 expression in GC tumors correlated with their differentiation status, but not with patient age or gender, tumor size, TNM stage, depth of invasion, or the presence of lymph node metastasis.

CONCLUSIONS

Oct4 may be a potential biomarker for the initiation, progression, and differentiation of human GC.

Endoscopic features predictive of gastric cancer in superficial lesions with biopsy-proven high grade intraepithelial neoplasia

AIM

To investigate the macroscopic and clinico-pathologic features of gastric cancer in patients with biopsy-suggested high grade intraepithelial neoplasia.

METHODS

Patients with biopsy-confirmed gastric high grade intraepithelial neoplasia were reviewed from January 2001 to March 2008. Pathologic sections were re-evaluated by two senior pathologists. Patients with an en-bloc resection of the lesion within two months after the diagnosis of high grade intraepithelial neoplasia were enrolled in the study. Clinical manifestations, endoscopic features, biopsy and surgical pathology of all patients were collected and analyzed. The data acquired were subjected to univariate and multivariate analysis.

RESULTS

Seventy-two superficial gastric lesions with a pathologic diagnosis of high grade intraepithelial neoplasia based on biopsy specimens were enrolled. True high grade intraepithelial neoplasia was finally proved in 16 lesions and gastric cancer in the rest 56 lesions, most of which (96.4%) were differentiated carcinomas. The result of univariate analysis indicated that the size and the presence of marked ulcer plaque or scar in a superficial lesion were independently associated with gastric cancer (P<0.05), when high grade intraepithelial neoplasia was diagnosed by biopsy pathology. The results of multivariate analysis revealed the size greater than 1.5 cm [odds ratio (OR) 18.400, P<0.001] and the presence of 5-odd mm ulcer plaque or scar (OR 10.000, P=0.044) were associated with gastric cancer. Accordingly, the sensitivity, specificity and negative predictive value of multivariate analysis for predicting "true high grade intraepithelial neoplasia" was 87.5%, 89.3% and 96.2%, respectively.

CONCLUSION

Macroscopic findings are of value in differentiation between high grade intraepithelial neoplasia and superficial gastric cancer. This may simplify patient work-up and save costs for patients and healthcare system.

Long-term follow-up study of gastric intraepithelial neoplasias: progression from low-grade dysplasia to invasive carcinoma

BACKGROUND AND STUDY AIMS

A gastric intraepithelial neoplasia (IEN) is usually regarded as a precancerous lesion; however, the natural history of the gastric IEN has not been clarified. We aimed to evaluate the progression of dysplasia in gastric IENs.

PATIENTS AND METHODS

As a retrospective study, we reviewed 26 gastric adenomas with low-grade dysplasia (LGD) and one with high-grade dysplasia (HGD) from 18 patients. The patients were followed up for a median of 66 months from 1996 to 2004 (mean 58 months, 20-112 months) in Kyungpook National University Hospital. The histological diagnosis was classified according to the Vienna classification. We reviewed clinical (age and sex), morphological (size, color, shape, location in stomach, surface nodularity, and presence of the erosion), and histological (histological diagnosis, infection with Helicobacter pylori, infiltration of inflammatory cells, atrophy, intestinal metaplasia, microscopic erosions, and glandular appearance) characteristics with regard to progression of dysplasia.

RESULTS

We found eight IENs of progressive dysplasia (29.6%). One IEN with HGD and three IENs with LGD progressed to invasive adenocarcinoma (category 5). Four gastric IENs with LGD progressed to HGD (category 4). The clinical, morphological, and histological characteristics did not reveal any distinguishable features for progressive dysplasia.

CONCLUSION

For the potential risk of progressive dysplasia, gastric IENs should be treated actively using the recently advanced therapeutic endoscopic techniques, regardless of the degrees of dysplasia.

Gastric epithelial dysplasia: the Western perspective

The need for early diagnosis of gastric cancer is emphasized by the fact that gastric cancer remains the second most common cause of cancer related deaths worldwide. The aggressive surveillance and definite therapy for low and high-grade dysplasia, which can be achieved endoscopic means, remains the cornerstone of clinical management. Although the precursor status of dysplasia is not contested, its classification is controversial and fraught with marked inter-observer variations. Most cases of gastric dysplasia have an "intestinal" phenotype referred to as adenomatous dysplasia. Hyperplastic (type II dysplasia) is another less common variant. The progression of dysplasia to carcinoma is paralleled by a stepwise accumulation of multiple, but yet uncertain, genetic abnormalities. There are no immunohistochemical or molecular assays that can stratify with certainty the risk of progression to cancer. Given the low rate of transformation of low-grade dysplasia, annual endoscopic surveillance with re-biopsy is advocated. A diagnosis of indefinite for dysplasia should also prompt endoscopic surveillance. A diagnosis of high-grade dysplasia is more ominous, since it progress to cancer in most cases. However, the novel imaging and endoscopic modalities have modified management strategies with mucosal lesions amenable to endoscopic resection, while surgical resection is reserved to invasive adenocarcinoma with submucosal invasion.

Gastric cancer risk in patients with premalignant gastric lesions: a nationwide cohort study in the Netherlands

BACKGROUND & AIMS

A cascade of precursor lesions (eg, atrophic gastritis, intestinal metaplasia, and dysplasia) precedes most gastric adenocarcinomas. Quantification of gastric cancer risk in patients with premalignant gastric lesions is unclear, however. Consequently, endoscopic surveillance is controversial, especially in Western populations.

METHODS

To analyze current surveillance practice and gastric cancer risk in patients with premalignant gastric lesions, all patients with a first diagnosis between 1991 and 2004 were identified in the Dutch nationwide histopathology registry (PALGA); follow-up data were evaluated until December 2005.

RESULTS

In total, 22,365 (24%) patients were diagnosed with atrophic gastritis, 61,707 (67%) with intestinal metaplasia, 7616 (8%) with mild-to-moderate dysplasia, and 562 (0.6%) with severe dysplasia. Patients with a diagnosis of atrophic gastritis, intestinal metaplasia, or mild-to-moderate dysplasia received re-evaluation in 26%, 28%, and 38% of cases, respectively, compared with 61% after a diagnosis of severe dysplasia (P < .001). The annual incidence of gastric cancer was 0.1% for patients with atrophic gastritis, 0.25% for intestinal metaplasia, 0.6% for mild-to-moderate dysplasia, and 6% for severe dysplasia within 5 years after diagnosis. Risk factors for gastric cancer development were increasing severity of premalignant gastric lesions at initial diagnosis (eg, severe dysplasia, hazard ratio 40.14, 95% confidence interval 32.2-50.1), increased age (eg, 75-84 years, hazard ratio 3.75, 95% confidence interval 2.8-5.1), and male gender (hazard ratio 1.50, 95% CI 1.3-1.7).

CONCLUSIONS

Patients with premalignant gastric lesions are at considerable risk of gastric cancer. As current surveillance of these patients is inconsistent with their cancer risk, development of guidelines is indicated.

Gastric preneoplastic lesions and epithelial dysplasia

The incidence of gastric cancer is declining; however, it remains the second most common cause of cancer-related deaths worldwide. This article describes gastric preneoplastic lesions and epithelial dysplasia. The possible role of Helicobacter pylori infection is emphasized.

The detection, surveillance and treatment of premalignant gastric lesions related to Helicobacter pylori infection

Gastric cancer is an important worldwide health problem and causes considerable morbidity and mortality. It represents the second leading cause of cancer-related death worldwide. A cascade of recognizable precursor lesions precedes most distal gastric carcinomas. In this multistep model of gastric carcinogenesis, Helicobacter pylori causes chronic active inflammation of the gastric mucosa, which slowly progresses through the premalignant stages of atrophic gastritis, intestinal metaplasia and dysplasia to gastric carcinoma. Detection and treatment of premalignant lesions may thus provide a basis for gastric cancer prevention. However, at present, premalignant changes of the gastric mucosa are frequently disregarded in clinical practice or result in widely varying follow-up frequency or treatment. This review provides an overview of current knowledge on detection, surveillance and treatment of patients with premalignant gastric lesions, and identifies the uncertainties that require further research.

Gastric cancer among peptic ulcer patients: retrospective, long-term follow-up

BACKGROUND

Patients with duodenal ulcer are not at high risk although Helicobacter pylori infection is no doubt associated with gastric cancer development. However, little is known about the risk after long-term follow-up.

AIMS

We investigated the incidence for gastric cancer development in peptic ulcer patients in a long term.

PATIENTS AND METHODS

Between 1965 and 2004, endoscopic follow-up of more than 1 year was conducted on 1504 peptic ulcer patients in our hospital. They consisted of 978 gastric ulcer patients, 444 duodenal ulcer patients and 82 gastric and duodenal ulcer patients. Gastric and duodenal ulcer patients were excluded from the analysis because of their limited number.

RESULTS

Gastric cancers developed in 32 (3.3%) of gastric ulcer patients and 3 (0.68%) of duodenal ulcer patients. Kaplan-Meier analysis showed that the incidence of gastric cancer in duodenal ulcer patients was significantly lower than that in gastric ulcer patients (log-rank test, p=0.0059). Cox's proportional hazard model denoted the relative risk for duodenal ulcer against gastric ulcer adjusted by sex and age as 0.23 (95% CI: 0.072-0.77, p=0.016).

CONCLUSION

The risk for patients with duodenal ulcer to develop gastric cancer over the long term is significantly less than in those with gastric ulcer.

Pathology of early upper GI cancers

Local endoscopic resection techniques for early neoplasms of the gastro-intestinal tract require exact description of the depth of infiltration for the decision of endoscopic versus surgical therapy. Subdivision of mucosal neoplasms is used only in the oesophagus. Mucosal oesophageal carcinoma (squamous cell carcinoma and adenocarcinoma) can be subdivided into m1-m3 and m1-m4. Distinction of high-grade intraepithelial neoplasia and mucosal carcinoma is without clinical relevance since the diagnosis of high-grade intraepithelial neoplasia should always first lead to a (diagnostic) endoscopic resection. The final histological diagnosis could then be made on the resection specimen. Diagnosis of low-grade intraepithelial neoplasia is often confused with regenerative changes. Histological diagnoses of early neoplasms are not the same worldwide and consensus should be improved further.

Predicting the development of gastric cancer from combining Helicobacter pylori antibodies and serum pepsinogen status: a prospective endoscopic cohort study

BACKGROUND AND AIMS

Helicobacter pylori infection and gastric atrophy are both risk factors for gastric cancer. We aimed to elucidate the natural history of gastric cancer development according to H pylori infection and gastric atrophy status.

SUBJECTS AND METHODS

A total of 9293 participants in a mass health appraisal programme were candidates for inclusion in the present prospective cohort study: 6983 subjects revisited the follow up programme. Subjects were classified into four groups according to serological status at initial endoscopy. Group A (n = 3324) had "normal" pepsinogen and were negative for H pylori antibody; group B (n = 2134) had "normal" pepsinogen and were positive for H pylori antibody; group C (n = 1082) had "atrophic" pepsinogen and were positive for H pylori antibody; and group D (n = 443) had "atrophic" pepsinogen and were negative for H pylori antibody. Incidence of gastric cancer was determined by annual endoscopic examination.

RESULTS

Mean duration of follow up was 4.7 years and the average number of endoscopic examinations was 5.1. The annual incidence of gastric cancer was 0.04% (95% confidence interval (CI) 0.02-0.09), 0.06% (0.03-0.13), 0.35% (0.23-0.57), and 0.60% (0.34-1.05) in groups A, B, C, and D, respectively. Hazard ratios compared with group A were 1.1 (95% CI 0.4-3.4), 6.0 (2.4-14.5), and 8.2 (3.2-21.5) in groups B, C, and D, respectively. Age, sex, and "group" significantly served as independent valuables by multivariate analysis.

CONCLUSIONS

The combination of serum pepsinogen and anti-H pylori antibody provides a good predictive marker for the development of gastric cancer.

Cost-benefit analysis of Helicobacter pylori screening

BACKGROUND

Helicobacter pylori screening may markedly reduce mortality and morbidity in the decades ahead.

AIMS

This study explores the costs and benefits of population-based H. pylori screening in terms of health care cost taking into account all relevant H. pylori-related diseases.

MATERIAL AND METHODS

The computer-based decision analysis compared two strategies: (1) screen for H. pylori and treat those individuals who test positive, and (2) do not screen for H. pylori, and test and treat H. pylori only if related clinical symptoms appear. The model estimated the discounted H. pylori-related accumulative health care costs from screening age to death in both strategies. The baseline case estimates cost-benefit for screenees aged 15-45 years. The main outcome measure is the incremental health care cost per case in the screening compared with the no-screening alternative. The probability estimates were obtained from the Finnish Vammala H. pylori screen and treat project, including 5288 subjects in the years 1996-1998, published studies, national statistics and hospitals' internal accounts.

RESULTS

The incremental cost per case was 26 US dollars in the screening compared with the no-screening alternative. It was lowest in the group aged 45 years, where H. pylori screening showed cost savings per case.

CONCLUSIONS

H. pylori screening is more favourable in the older age cohorts. The estimated cost per screenee can be considered to be very acceptable if the current pathophysiological evidence on the potential effects of H. pylori eradication are confirmed in the future. However, there is uncertainty about the possible negative effect of eradicating H. pylori infection on gastro-esophageal reflux disease and esophageal adenocarcinoma. This could change the balance of benefits against risks of eradicating H. pylori infection.

The long term outcome of gastric non-invasive neoplasia

BACKGROUND

The cancer risk associated with gastric non-invasive neoplasia (formerly dysplasia) is debated. This prospective long term follow up study investigates the clinicopathological behaviour of non-invasive gastric neoplasia (and related lesions), focusing on the cancer risk associated with each different histological phenotype.

PATIENTS AND METHODS

A total of 118 consecutive cases (nine indefinite for non- invasive neoplasia; 90 low grade non-invasive neoplasia; 16 high grade non- invasive neoplasia; and three suspicious for invasive adenocarcinoma) with a histological follow up of more than 12 months (average 52 months; range 12-206) were prospectively followed up with a standardised protocol. Patients in whom gastric cancer was detected within 12 months from the initial diagnosis of non-invasive neoplasia were excluded, assuming that invasive carcinoma had been missed at the initial endoscopy procedure.

RESULTS

Non-invasive neoplasia was no longer detectable in 57/118 cases (48%), was unchanged in 32 (30%), and evolved into gastric cancer in 20 patients (17%). Evolution to invasive adenocarcinoma was documented in both low and high grade non-invasive neoplastic lesions (8/90 low grade; 11/16 high grade) and correlated with histological severity (low versus high grade) at baseline (p<0.001). Seventy five per cent of cancers occurring during the long term follow up were stage I.

CONCLUSIONS

The risk of invasive gastric cancer increases with the histological grade of the non-invasive neoplasia. Following up non-invasive gastric neoplasia increases the likelihood of gastric cancer being detected in its early stages.

Magnification chromoendoscopy for the diagnosis of gastric intestinal metaplasia and dysplasia

BACKGROUND

The aim of this study was to define the reproducibility and accuracy of magnification chromoendoscopy for the diagnosis of lesions associated with gastric cancer (intestinal metaplasia and dysplasia).

METHODS

A total of 136 patients with previously diagnosed lesions and 5 gastrectomy specimens were studied. Endoscopic examination was performed with a magnification endoscope after methylene blue (1%) spraying. According to differences in color and mucosal pattern, groups and subgroups of endoscopic images were defined, and biopsies taken (n = 462). Five endoscopists were asked to classify individually 2 endoscopic images per subgroup on 2 separate occasions.

RESULTS

Three groups of endoscopic images were defined: nonmetaplastic, nondysplastic mucosa (I); metaplastic mucosa (II); and dysplastic mucosa (III). Ten subgroups were defined according to pit pattern: round small (IA), round and tubular small (IB), coarse round (IC), and course round pits with a straight pit (ID); blue irregular marks (IIA), blue round and tubular pits (IIB), blue villi (IIC), and blue small pits (IID); and loss of clear pattern, with depression (IIIA) or with slight elevation (IIIB). The kappa statistic for intraobserver agreement on the classification of endoscopic images in groups was 0.86; for interobserver agreement, it was 0.74. For classification into subgroups, kappa values ranged from 0.48 to 0.78. For 85% of the areas classified endoscopically as Group I (n = 146), no mucosal lesions or gastritis was described at histologic examination; for 83% of those in Group II (n = 198), intestinal metaplasia was found. Subgroups IIA and IIB were more often associated with complete intestinal metaplasia (62%), and IIC and IID with incomplete metaplasia (67%); in Group III (n = 118), dysplasia was diagnosed histopathologically in 33%. For the diagnosis of dysplasia, specificity was 81% (95% CI [77%, 85%]) and negative predictive value 99% (95% CI [99%, 100%]).

CONCLUSIONS

Gastric endoscopic patterns with chromoendoscopy and magnification seem reproducible and valid for the diagnosis of lesions associated with gastric cancer. This procedure may improve the follow-up of individuals at high-risk of gastric cancer, at least for the exclusion of severe lesions.