Clinicopathologic Characteristics of Patients with Gastric Superficial Neoplasia and Risk Factors for Multiple Lesions after Endoscopic Submucosal Dissection in a Western Country

The Impact of Tobacco Smoking and Alcohol Consumption on the Development of Gastric Cancers

Chronic infection of Helicobacter pylori is considered the principal cause of gastric cancers, but evidence has accumulated regarding the impact of tobacco smoking and alcohol consumption on the development of gastric cancers. Several possible mechanisms, including the activation of nicotinic acetylcholine receptors, have been proposed for smoking-induced gastric carcinogenesis. On the other hand, local acetaldehyde exposure and ethanol-induced mucosal inflammation have been proposed as the mechanisms involved in the development of gastric cancers in heavy alcohol drinkers. In addition, genetic polymorphisms are also considered to play a pivotal role in smoking-related and alcohol-related gastric carcinogenesis. In this review, we will discuss the molecular mechanisms involved in the development of gastric cancers in relation to tobacco smoking and alcohol consumption.

Endoscopic Resection of Malignancies in the Upper GI Tract: A Clinical Algorithm

Background

Malignancies in the upper gastrointestinal tract are amenable to endoscopic resection at an early stage. Achieving a curative resection is the most stringent quality criterion, but post-resection risk assessment and aftercare are also part of a comprehensive quality program.

Summary

Various factors influence the achievement of curative resection. These include endoscopic assessment prior to resection using chromoendoscopy and HD technology. If resectability is possible, it is particularly important to delineate the lateral resection margins as precisely as possible before resection. Furthermore, the correct choice of resection technique depending on the lesion must be taken into account. Endoscopic submucosal dissection is the standard for esophageal squamous cell carcinoma and gastric carcinoma. In Western countries, it is becoming increasingly popular to treat Barrett's neoplasia over 2 cm in size and/or with suspected submucosal infiltration with en bloc resection instead of piece meal resection. After resection, risk assessment based on the histopathological resection determines the patient's individual risk of lymph node metastases, particularly in the case of high-risk lesions. This is categorized according to the current literature.

Key Messages

This review presents clinical algorithms for endoscopic resection of esophageal SCC, Barrett's neoplasia, and gastric neoplasia. The algorithms include the pre-resection assessment of the lesion and the resection margins, the adequate resection technique for the respective lesion, as well as the post-resection risk assessment with an evidence-based recommendation for follow-up therapy and surveillance.

Characteristics of multiple early gastric cancer and gastric high-grade intraepithelial neoplasia

This study evaluated the clinical characteristics of multiple early gastric cancer (MEGC) and high-grade intraepithelial neoplasia (HGIN) treated by endoscopic submucosal dissection. The clinical profiles of 23 patients with MEGC treated by endoscopic submucosal dissection from January 2008 to June 2019 at the Fujian Provincial Hospital or Fujian Provincial Hospital South Branch were analyzed. The following information was extracted from clinical records: general data, preoperative conditions, and pathological data of each lesion after surgery. In total, 23 patients with MEGC or HGIN were evaluated (average age 64 ± 6 years, 17 (73.9%) males). MEGC and HGIN accounted for 4.9 percent of all cases, in which 19 (4.1%) were synchronous multiple cancers and 4 (0.8%) cases were metachronous multiple cancers. Lesions of synchronous and metachronous MEGC groups did not differ in age, sex, smoking history, alcohol consumption, family history of tumors, Helicobacter pylori infection, mucosal background atrophy, or intestinal metaplasia (P > .05). The vertical locations of primary and secondary lesions of MEGC were correlated (R = 0.395, P = .034). The primary and secondary lesions of MEGC shared the same macroscopic subtype (R = 0.590, P = .015), infiltration depth (R = 0.455, P = .014), and pathological subtype (R = 0.736, P < .001). MEGC and HGIN were located in close proximity. Pathologic types tended to be low-grade malignancies. The macroscopic type, histology type, and infiltration depth of the 2 lesions were significantly correlated. When detecting early gastric cancer, we should inspect the stomach and carefully consider the pathological characteristics, to improve the diagnosis of MEGC.

Metachronous lesions after gastric endoscopic submucosal dissection: first assessment of the FAMISH prediction score

BACKGROUND

Surveillance after gastric endoscopic submucosal dissection (ESD) is recommended for all patients owing to the persistent risk of metachronous gastric lesions (MGLs). We developed and validated a prediction score to estimate MGL risk after ESD for early neoplastic gastric lesions, to define an individualized and cost-saving approach.

METHODS

Clinical predictors and a risk score were derived from meta-analysis data. A retrospective, single-center, cohort study including patients with ≥ 3 years of standardized surveillance after ESD was conducted for score validation. Predictive accuracy of the score by the area under the receiver operating characteristic curve (AUC) was assessed and cumulative probabilities of MGL were estimated.

RESULTS

The risk score (0-9 points) included six clinical predictors (scored 0-3): positive family history of gastric cancer, older age, male sex, corpus intestinal metaplasia, synchronous gastric lesions, and persistent Helicobacter pylori infection (FAMISH). The study population included 263 patients. The MGL rate was 16 %. The score diagnostic accuracy for predicting MGL at 3 years' follow-up, measured by the AUC, was 0.704 (95 %CI 0.603-0.806). At 3 years and a cutoff < 2, the score achieved maximal sensitivity and negative predictive value; 15 % of patients could be assigned to a low-risk group, in which the progression to MGL was significantly lower than for the high-risk group (P = 0.04).

CONCLUSION

The FAMISH score might be a useful tool to accurately identify patients with low-to-intermediate risk for MGL at 3 years of follow-up who could have surveillance intervals extended to reduce the burden of care.

Risk assessment of metachronous gastric cancer development using OLGA and OLGIM systems after endoscopic submucosal dissection for early gastric cancer: a long-term follow-up study

BACKGROUND

Metachronous gastric cancer (MGC) may develop in patients undergoing curative endoscopic submucosal dissection for early gastric cancer. As gastritis and intestinal metaplasia are notable precursors to gastric cancer, we assessed MGC risk using the Operative Link on Gastritis Assessment (OLGA) and Operative Link on Gastric Intestinal Metaplasia assessment (OLGIM) systems.

METHODS

This retrospective cohort study classified the OLGA and OLGIM stages for 916 patients who had undergone endoscopic submucosal dissection for early gastric cancer between 2005 and 2015. MGC development was followed up until 2020 and risk factors were evaluated using the Cox proportional hazards regression analysis.

RESULTS

During a median follow-up of 94 months, MGC developed in 120 subjects. OLGA stages II ~ IV were significantly associated with increased MGC risk (hazard ratio [HR] 1.83, 95% confidence interval [CI] 1.05-3.19; HR 2.31, 95% CI 1.22-4.38; HR 2.36, 95% CI 1.16-4.78) in multivariable analysis, even after adjusting for the well-known positive predictor of Helicobacter pylori eradication. OLGIM stages II ~ IV also showed significant association (HR 2.86, 95% CI 1.29-6.54; HR 2.94, 95% CI 1.34-6.95; HR 3.64, 95% CI 1.60-8.29). 5-year cumulative incidence increased with each stage. Helicobacter pylori-eradicated patients with OLGIM stages 0 ~ II had significantly less MGC than non-eradicated patients (4.5% vs 11.8%, p = 0.022), which was not observed with OLGIM stages III ~ IV.

CONCLUSIONS

High OLGA and OLGIM stages are independent risk factors for metachronous gastric cancer, with the OLGIM staging system being a better predictor. Patients with OLGIM stages 0 ~ II are a subgroup that may benefit more from Helicobacter pylori eradication.

Gastric submucosal mass lesions

PURPOSE OF REVIEW

Gastric submucosal mass lesions are a collection of tumours that arise in the stomach and are deep to the mucosal layer. Distinct from gastric epithelial carcinomas, these tumours are generally more indolent. They are often found incidentally on upper endoscopy. Most often they present as smooth protuberant masses covered by normal intact gastric mucosa. The majority are asymptomatic. Endoscopic ultrasound (EUS) is frequently employed to further characterize the lesions. EUS can be diagnostic of some lesions, such as lipomas, and can be used to guide fine needle aspiration to diagnose others. Adding to the traditional management approaches of observation and surgical resection, numerous new and emerging endoscopic therapies are now being used to resect these gastric tumours.

RECENT FINDINGS

This review focuses on evolving strategies in the diagnosis and management of submucosal mass lesions. Although surgical intervention was once the lone option for intervention, there are an increasing number of endoscopic therapies. There have also been advancements in neoadjuvant therapies and in distinguishing the malignant potential of submucosal mass lesions.

SUMMARY

Gastric submucosal lesions are common. EUS is frequently indicated in the evaluation and diagnosis. For tumours for which observation is not recommended, novel endoscopic therapies may offer less invasive management options.

Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022

ESGE recommends that the evaluation of superficial gastrointestinal (GI) lesions should be made by an experienced endoscopist, using high definition white-light and chromoendoscopy (virtual or dye-based).ESGE does not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection.ESGE recommends endoscopic submucosal dissection (ESD) as the treatment of choice for most superficial esophageal squamous cell and superficial gastric lesions.For Barrett's esophagus (BE)-associated lesions, ESGE suggests the use of ESD for lesions suspicious of submucosal invasion (Paris type 0-Is, 0-IIc), for malignant lesions > 20 mm, and for lesions in scarred/fibrotic areas.ESGE does not recommend routine use of ESD for duodenal or small-bowel lesions.ESGE suggests that ESD should be considered for en bloc resection of colorectal (but particularly rectal) lesions with suspicion of limited submucosal invasion (demarcated depressed area with irregular surface pattern or a large protruding or bulky component, particularly if the lesions are larger than 20 mm) or for lesions that otherwise cannot be completely removed by snare-based techniques.ESGE recommends that an en bloc R0 resection of a superficial GI lesion with histology no more advanced than intramucosal cancer (no more than m2 in esophageal squamous cell carcinoma), well to moderately differentiated, with no lymphovascular invasion or ulceration, should be considered a very low risk (curative) resection, and no further staging procedure or treatment is generally recommended.ESGE recommends that the following should be considered to be a low risk (curative) resection and no further treatment is generally recommended: an en bloc R0 resection of a superficial GI lesion with superficial submucosal invasion (sm1), that is well to moderately differentiated, with no lymphovascular invasion, of size ≤ 20 mm for an esophageal squamous cell carcinoma or ≤ 30 mm for a stomach lesion or of any size for a BE-related or colorectal lesion, and with no lymphovascular invasion, and no budding grade 2 or 3 for colorectal lesions.ESGE recommends that, after an endoscopically complete resection, if there is a positive horizontal margin or if resection is piecemeal, but there is no submucosal invasion and no other high risk criteria are met, this should be considered a local-risk resection and endoscopic surveillance or re-treatment is recommended rather than surgery or other additional treatment.ESGE recommends that when there is a diagnosis of lymphovascular invasion, or deeper infiltration than sm1, or positive vertical margins, or undifferentiated tumor, or, for colorectal lesions, budding grade 2 or 3, this should be considered a high risk (noncurative) resection, and complete staging and strong consideration for additional treatments should be considered on an individual basis in a multidisciplinary discussion.ESGE recommends scheduled endoscopic surveillance with high definition white-light and chromoendoscopy (virtual or dye-based) with biopsies of only the suspicious areas after a curative ESD.

From part to whole, operative link on to endoscopic grading of gastric intestinal metaplasia, pathology to endoscopy: gastric intestinal metaplasia graded by endoscopy

Objective: To conduct a systematic review and meta-analysis on the prediction of severity of gastric intestinal metaplasia (GIM) in localized and entire gastric mucosa using endoscopy. Methods: The authors searched Web of Science, PubMed, Embase and Cochrane Central Register of Controlled Trials and performed systematic searches on endoscopic grading of GIM of the entire stomach using Meta-DiSc and Stata. Results: Sensitivity and specificity for the stratified prediction of overall GIM were 0.91 (95% CI: 0.85-0.95) and 0.91 (95% CI: 0.88-0.93), respectively. Sensitivity in predicting the different grades of GIM was higher in operative link on GIM assessment grades 0, III and IV but lower in grades I and II. Conclusion: Digital chromoendoscopy is well suited to predicting the severity of localized and overall GIM.

Gastric microbiome profile throughout gastric carcinogenesis: beyond helicobacter

BACKGROUND

Gastric dysbiosis has been hinted as a potential cause of gastric cancer. However, changes in microbiome throughout the major stages of gastric carcinogenesis remain mostly unknown.

OBJECTIVE

To describe gastric microbiome at different stages, analysing for the first time dysbiosis specifically in patients with early gastric cancer (EGC).

METHODS

Cross-sectional study including patients (n = 77) with endoscopically and histologically confirmed normal stomachs (controls; n = 25), advanced atrophic gastritis with intestinal metaplasia (IM; n = 18) and EGC (n = 34). Endoscopic biopsies from antrum and corpus (n = 154) were analyzed. Next-generation sequencing was performed characterizing microbial communities down to the species level based on full-length 16SrRNA gene profiling.

RESULTS

Significant differences were found in the microbiome profile between the groups. Firmicutes were more frequent (p = .012) and Proteobacteria were less frequent (p = .04) both in the IM and EGC when comparing to controls. Relative frequency of Helicobacter pylori, when present, was much higher in the controls (83%) when comparing to the other groups (IM 1%, EGC 27%; p = .006), being the dominant bacteria only in the controls. Dysbiosis was present already and more significantly at the IM stage, with two bacteria progressively increasing from controls to IM then to cancer: Gemella from 1.48 to 3.9% (p = .014); and Streptococcus from 19.3 to 33.7% (p = .04), being the EGC dominant bacteria.

CONCLUSIONS

Our results confirm Helicobacter pylori dominancy in non-atrophic stomachs and progressive dysbiosis throughout gastric carcinogenesis. Gemella but particularly Streptococcus is significantly increased in patients with EGC. Specific modulation of these bacteria may change gastric cancer risk.

A novel method of grading gastric intestinal metaplasia based on the combination of subtype and distribution

Background

Studies have shown the value of subtypes and distribution of gastric intestinal metaplasia (GIM) for prediction of gastric cancer. We aim to combine GIM subtypes and distribution to form a new scoring system for GIM.

Methods

This was a cross-sectional study. No GIM, type I, II, and III GIM of gastric antrum and corpus scored 0–3 points respectively. Then the severity of the whole stomach was calculated in two ways: 1. The gastric antrum and corpus scores were added together, with a score ranging from 0 to 6, which named “Subtype Distribution Score of Gastric Intestinal Metaplasia (SDSGIM)”. 2. Direct classification according to a table corresponding to that of OLGIM. We compared the SDSGIM among benign lesions, dysplasia, and cancer and drew receiver operating characteristic (ROC) curve to determine the optimal cut-off value. According to the cut-off value and the classification from the table, the predictive ability of these two methods were calculated.

Results

227 patients were included. For SDSGIM, benign lesion group was significantly different from dysplasia or cancer group. Area under curve of ROC curve was 0.889 ± 0.023. The optimal cut-off value was 3. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of SDSGIM for malignancy were 89.5%, 78.0%, 74.6%, 91.2% and 82.8%. And those for the second classification method were 84.2%, 82.6%, 77.7%, 87.9%, and 83.3% respectively.

Conclusions

This study firstly combined GIM subtypes with its distribution forming a novel scoring system, which showed high prediction accuracy for malignant lesions.