Detection of early gastric cancer: misunderstanding the role of mass screening

Gastric cancer detection rates using GI endoscopy with serologic risk stratification: a randomized controlled trial

BACKGROUND AND AIMS

Efforts have been made to develop an endoscopic screening system incorporating serologic gastric cancer (GC) risk stratification (ABC classification) alongside annual population-based GC screening using barium. We conducted a randomized controlled trial (RCT) to compare GC detection rates between the Ba-Endo group, which underwent annual barium tests for primary screening followed by detailed endoscopic examinations, and the ABC-Endo group, where endoscopy intervals were determined based on individual gastric cancer risk in the ABC classification.

METHODS

In total, 1206 individuals from Yurihonjo and Nikaho City, Akita Prefecture, were randomized through the minimization method using sex and age as allocation factors. The intervention study was conducted for both groups over 5 years. The Ba-Endo group received annual barium tests, and the ABC-Endo group underwent EGD at different intervals: group A, EGD only at entry; group B, EGD once every 3 years; group C, EGD once every 2 years; and group D, EGD every year.

RESULTS

There were 24 detected GC lesions, with a GC detection rate of 1.9%. GC detection rates in the Ba-Endo and ABC-Endo groups were 2.0% and 1.8%, respectively, with no significant differences between groups (P = 1.0). However, the rate of GC cured by endoscopic resection alone was 41.6% in the Ba-Endo group and was significantly higher at 90.9% in the ABC-Endo group (P = .02).

CONCLUSIONS

There were no differences between the Ba-Endo and ABC-Endo groups in GC detection rates. However, the rate of detected GCs that could be cured by endoscopic resection alone was significantly higher in the ABC-Endo group. (Clinical trial registration number: UMIN000005962.).

Willingness to Undergo Gastroscopy for Early Gastric Cancer Screening and Its Associated Factors During the COVID-19 Pandemic - A Nationwide Cross-Sectional Study in China

PURPOSE

This study aimed to investigate the willingness of Chinese adults aged 40 years and older to undergo gastroscopy for gastric cancer (GC) screening during the COVID-19 pandemic in 2020. The secondary purpose was to identify factors influencing willingness to undergo gastroscopy.

METHODS

A cross-sectional questionnaire survey was conducted in selected cities and counties from nine provinces in China using a multi-stage sampling approach. A multivariate logistic regression model was used to determine the independent predictors of willingness to undergo gastroscopy.

RESULTS

This study included 1900 participants, and 1462 (76.95%) responded that they would undergo gastroscopy for GC screening. Participants of younger age, from the eastern region, living in an urban area, with higher educational levels, with Helicobacter pylori (H. pylori) infection, or with precancerous stomach lesions, were more willing to undergo gastroscopy. The top four reasons to reject gastroscopy were fear of pain or discomfort, worry about a possible devastating test result, no symptoms in self-feeling, and concern about the high expense. Of all those who would reject gastroscopy for GC screening, 36.76% (161/438) would be willing to accept painless gastroscopy, while 24.89% (109/438) would be willing to undergo gastroscopy screening if higher medical reimbursement rates were available. Participants considered that gastroscopy was a relatively fearful and unknown procedure, accompanied by high risks and benefits compared to all other life events.

CONCLUSION

In general, 76.95% of participants over 40 years old were willing to undergo gastroscopy for GC screening in China during the COVID-19 pandemic. Participants' willingness to undergo GC screening increased due to medical resource constraints and increased interest in their health. Individuals with H. pylori infection are more likely to undergo gastroscopy, whereas old age individuals, those with lower educational levels, and those living in rural areas are more likely to reject gastroscopy.

Late complication after gastrectomy for clinical stage I cancer: supplementary analysis of JCOG0912

BACKGROUND

Late complications following gastric cancer surgery, including postgastrectomy syndromes, are complex problems requiring a solution. Reported risk factors for developing late complications include surgery-related factors, such as the surgical approach and the extent of resection and reconstruction. However, this has not been assessed in a prospective study with a large sample size. Therefore, this study aimed to evaluate associations between surgery-related factors and the development of late complications. Data from the JCOG0912 trial were used. It compared laparoscopy-assisted distal gastrectomy (LADG) to open distal gastrectomy (ODG) in clinical stage I gastric cancer patients.

METHODS

This study included 881/921 patients enrolled in the JCOG0912 trial. The incidence of late complications was compared between the ODG and the LADG arms. In addition, associations between surgery-related factors and the development of late complications were assessed by multivariable analyses using the proportional odds model to identify relevant risk factors.

RESULTS

There was no difference in the type or number of patients with late complications between the LADG and the ODG arms. The multivariable analysis for each late complication revealed that the Billroth-I reconstruction (vs. R-en-Y or Billroth-II) had a lower risk of cholecystitis [odds ratio (OR) 0.187, 95% confidence interval (CI) 0.039-0.905, P = 0.037] or ileus (OR 0.116, 95%CI 0.033-0.406, P < 0.001), and pylorus-preserving gastrectomy (vs. R-en-Y or Billroth-II) had a higher risk of reflux esophagitis (OR 3.348, 95% CI 1.371-8.176, P = 0.008). The surgical approach was not a risk factor for any late complications.

CONCLUSION

Differences in surgical approaches did not constitute a risk for developing late complications after gastrectomy. Billroth-I reconstruction reduced the risk of ileus and cholecystitis, but pylorus-preserving gastrectomy carried a risk for reflux esophagitis.

Applicability of endoscopic submucosal dissection for patients with early gastric cancer beyond the expanded indication for endoscopic submucosal dissection

BACKGROUND

Endoscopic submucosal dissection (ESD) application for patients with tumors beyond the expanded indication for ESD is inconclusive. This study aimed to identify the preoperative clinical features that can be curatively treated with ESD in patients with early gastric cancer (EGC) beyond the indication of ESD.

METHODS

From 2006 to 2016, 673 patients who underwent gastrectomy for EGC beyond the expanded indication for ESD based on preoperative assessments were retrospectively reviewed. We identified tumors curatively resected by ESD based on the postoperative pathologic findings. We also analyzed the clinical and pre-treatment features to determine the risk factors associated with curative resection of ESD.

RESULTS

39% of the patients (263/673) who had undergone gastrectomy had tumors of endoscopic curability A or B (eCuraA/B) that could be treated by ESD alone. In multivariate analysis, tumor size ≤ 10 mm (OR 0.240; 95% CI = 0.12-0.46), no ulceration (OR 0.500; 95% CI = 0.29-0.87), differentiated histology (OR 0.599; 95% CI = 0.43-0.84), and location in the distal two-thirds of the stomach (OR 0.499; 95% CI = 0.28-0.88) in pre-treatment assessment were identified as independent predictors of eCuraA/B. Considering the risk factors, 63.6% (7/11)/61.3% (19/31) of patients with a differentiated/undifferentiated tumor size ≤ 10 mm located in distal two-third of the stomach without ulceration were deemed as eCuraA/B.

CONCLUSIONS

This study suggests that patients with EGC indicated for surgery can be treated by ESD by adding tumor locations in the indication for ESD. Thus, ESD can be applied for patients with a tumor size ≤ 10 mm located in the lower/middle stomach without ulceration.

Chinese and global burdens of gastric cancer from 1990 to 2019

BACKGROUND

Gastric cancer is a common cancer in China. This project investigated the disease burden of gastric cancer from 1990 to 2019 in China and globally.

METHODS

The global age-standardized rates (ASRs) were extracted from the Global Burden of Disease. Moreover, the estimated annual percentage changes (eAPCs) in the ASRs of incidence (ASIR), mortality (ASMR), and disability-adjusted life-years (DALYs) were calculated to determine the trends by countries and regions.

RESULTS

In China, the ASIR declined from 37.56 to 30.64 per 100,000 and the ASMR declined from 37.73 to 21.72 per 100,000. The global ASIR decreased from 22.44 to 15.59 and the ASMR declined from 20.48 to 11.88 per 100,000 persons from 1990 to 2019. The ASIR was the lowest in Malawi (3.28 per 100,000) and the highest in Mongolia (43.7 per 100,000), whereas the ASMR was the lowest in the United States of America (3.40 per 100,000) and the highest in Mongolia (40.04 per 100,000) in 2019. The incidence of early-onset gastric cancer increased in China. The DALYs attributed to gastric cancer presented a slight decrease during the period. China had a higher mortality/incidence ratio (0.845) and 5-year prevalence (27.6/100,000) than most developed countries.

CONCLUSION

China presented a steady decline in the incidence and mortality rates for gastric cancer. The global ASIR, ASMR, and DALYs showed a slight rise decrease. Different patterns of gastric cancer rates and temporal trends have been identified in different geographical regions, indicating that specific strategies are needed to prevent the increase in some countries.

Cytokine-induced killer cell/dendritic cell combined with cytokine-induced killer cell immunotherapy for treating advanced gastrointestinal cancer

Background

This study aimed to investigate the efficacy and safety of cytokine-induced killer (CIK)/dendritic cell combined with CIK (DC–CIK) cell therapy in advanced gastrointestinal cancer (GIC).

Methods

The PubMed, Cochrane library, and Embase were searched to conduct a meta-analysis of clinical controlled trials to evaluate the efficacy and safety of CIK/DC–CIK cell therapy in advanced GIC. The pooled risk ratios (RRs) or weighted mean difference (WMD) with 95% confidence intervals (95% CIs) were calculated.

Results

A total of nine studies with 1113 patients were identified. The overall survival (RR = 1.84, 95% CI = 1.41–2.40, P_{heterogeneity} = 0.654, I² = 0%), progression-free survival (RR = 1.99, 95% CI = 1.52–2.60, P_{heterogeneity} = 0.727, I² = 0%), and quality of life (WMD = 16.09, 95% CI = 1.66–30.52, P_{heterogeneity} < 0.001, I² = 98.8%) were significantly improved in patients who received chemotherapy combined with CIK/DC–CIK cells, and no severe adverse events were reported.

Conclusion

This meta-analysis suggested that the combination of CIK/DC–CIK immunotherapy and chemotherapy was safe and applicable for patients with advanced GIC. It is a feasible choice to prolong survival and improve quality of life.

Analysis of Long Non-Coding RNA Expression Profile and Functional Study of LOC389332 in Early Gastric Cancer

Background

Long non-coding RNAs (LncRNAs) could potentially function as diagnostic markers for gastric carcinoma. Nevertheless, the expression profile and biological feature of LncRNAs in early gastric cancer (EGC) remains to be explored.

Material/Methods

LncRNA expression microarray analysis was performed on 6 paired EGC tissues. One deregulated LncRNA, LOC389332, was validated using a quantitative reverse-transcription polymerase chain reaction (qRT-PCR) assay using independent tissue samples and cell lines. The Cell Counting Kit-8 (CCK-8) assay and wound healing assay were conducted to evaluate its influences on the proliferation and migration of gastric cancer cells. LncRNA expression microarray and gene ontology (GO) analysis were also performed on the LOC389332 knockdown cell line model to explore the molecular feature of LOC389332 in gastric carcinoma.

Results

The LncRNA expression profiling showed that 72 LncRNAs were significantly differentially expressed in EGC tissues. The results in the validation phase revealed that LOC389332 was remarkably overexpressed in gastric carcinoma tissues, precancerous lesions, and gastric cancer cells. Functional study showed that knockdown of LOC389332 expression could inhibit cell proliferation and migration. LncRNA expression microarray on the LOC389332 knockdown cell line model revealed that 393 mRNAs were differentially expressed. The GO enrichment analysis indicated that the downregulated genes were mainly associated with cell membrane function, signal transmission process, and cell adhesion process.

Conclusions

The LncRNA expression profile between EGC and gastritis tissues was significantly different. LOC389332 was potential non-coding oncogenes in gastric cancer, and it may perform its function through altering cell membrane function, signal transmission, and cell adhesion.

Ginsenoside Rg3 (Shenyi Capsule) Combined with Chemotherapy for Digestive System Cancer in China: A Meta-Analysis and Systematic Review

Objective

In China, ginsenoside Rg3 is often used in combination with chemotherapy to treat digestive system cancer. We here performed a meta-analysis and systematic review to provide a much needed high-quality evaluation of the efficacy and safety of ginsenoside Rg3 combined with chemotherapy in these cancers.

Materials and Methods

The PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang, and Weipu (VIP) databases were searched. All randomized controlled trials (RCTs) concerning ginsenoside Rg3 combined with chemotherapy for digestive system cancer were selected. Dichotomous data were expressed as odds ratios (ORs) with 95% confidence intervals (CI). The methodological quality of the included studies was evaluated according to the Cochrane evidence-based medicine system, and the statistical analyses were performed with Review Manager 5.3 and STATA 12.0 software. In addition, the Grades of Recommendation Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of the evidence. Trial sequential analysis (TSA) was used to evaluate information size and treatment benefits.

Results

A total of 18 trials comprising 1531 patients were included in this study. The results revealed that the trials were of sufficient standard to draw reliable conclusions that ginsenoside Rg3 combined with chemotherapy could improve the objective response rate (ORR; OR 2.17, 95% CI 1.72–2.73), disease control rate (DCR; OR 2.83, 95% CI 2.02–3.96), 1-year survival rate (SR; OR = 2.33, 95% CI = 1.24–4.37), Karnofsky Performance Scale (KPS; OR 2.67, 95% CI 1.76–4.03), gastrointestinal dysfunction (OR 0.44, 95% CI 0.31–0.61), and the decline of leucocyte count (OR 0.28, 95% CI 0.21–0.38).

Conclusion

Ginsenoside Rg3 combined with chemotherapy can improve the clinical efficacy and alleviate treatment-induced side effects for digestive system cancer.

Utility of a standardized training program for endoscopic diagnosis of early gastrointestinal neoplasia

Background and study aims  Image enhanced endoscopy (IEE) allows endoscopists to improve recognition and characterization of gastrointestinal neoplasia. The Asian Novel Bio-Imaging and Intervention Group (ANBIG) conducted a standardized training program in endoscopic diagnosis and treatment of early gastrointestinal cancers in Asia. We embarked on a study to investigate the effect of this module on endoscopic diagnosis of early gastrointestinal neoplasia. Methods  This prospectively collected database was from workshops conducted on training for endoscopic diagnosis of early gastrointestinal neoplasia. All workshops were conducted in a standardized format, which included a pretest, a learning phase consisting of didactic lectures, case discussion, and live demonstration followed by a post-test to assess knowledge gained. The pretest and post-training tests were standardized questions addressing four domains, including basic knowledge of imaging and diagnosis of esophageal, gastric, and colonic neoplasia. Results  From November 2013 to November 2016, 41 ANBIG workshops were conducted in 13 countries. A total of 1863 delegates and 40 faculty participated in these workshops. Of the delegates, 627 completed both tests. There was a significant improvement after training in all domains of the tests. There was a trend in general lack of knowledge across all domains for delegates from "low" healthcare cost countries before training. All delegates demonstrated significant improvement in knowledge of all domains after the workshop irrespective of whether they were from "high" or "low" healthcare cost per capita countries. Conclusion  A standardized teaching program on IEE improved the diagnostic ability and quality of endoscopists in recognizing early gastrointestinal neoplasia in Asia.

Prognostic Value of Long Noncoding RNAs in Patients with Gastrointestinal Cancer: A Systematic Review and Meta-Analysis

Gastrointestinal cancers (GICs) are a huge threat to human health, which mainly include esophageal, gastric, and colorectal cancers. The purpose of this study was to clarify the prognostic value of long noncoding RNAs (lncRNAs) in GICs. A total of 111 articles were included, and 13103 patients (3123 with esophageal cancer, 4972 with gastric cancer, and 5008 with colorectal cancer) were enrolled in this study. The pooled hazard ratio (HR) values and corresponding 95% confidence interval (95% CI) of overall survival (OS) related to different lncRNA expressions in esophageal, gastric, colorectal, and gastrointestinal cancer patients were 1.92 (1.70–2.16), 1.96 (1.77–2.16), 2.10 (1.87–2.36), and 2.00 (1.87–2.13), respectively. We have identified 74 lncRNAs which were associated closely with poor prognosis of GIC patients, including 58 significantly upregulated lncRNA expression and 16 significantly downregulated lncRNA expression. In addition, 47 of the included studies revealed relative mechanisms and 12 of them investigated the correlation between lncRNAs and microRNAs. Taken together, this meta-analysis supports that specific lncRNAs are significantly related to the prognosis of GIC patients and may serve as novel markers for predicting the prognosis of GIC patients. Furthermore, lncRNAs may have a promising contribution to lncRNA-based targeted therapy and clinical decision-making in the future.

Gastric Cancer Screening by Combined Determination of Serum Helicobacter pylori Antibody and Pepsinogen Concentrations: ABC Method for Gastric Cancer Screening

Objective:

Gastroscopy combined with gastric mucosa biopsies is currently regarded as a gold standard for diagnosis of gastric cancer. However, its application is restricted in clinical practice due to its invasive property. A new noninvasive population screening process combining the assay of anti-Helicobacter pylori antibody and serum pepsinogen (PG) (ABC method) is adopted to recognize the high-risk patients for further endoscopy examination, avoiding the unnecessary gastroscopy for most population and saving the cost consumption for mass screening annually. Nevertheless, controversies exist for the grouping of ABC method and the intervals of gastroscopy surveillance for each group. In this review, we summarized these popular concerned topics for providing useful references to the healthcare practitioner in clinical practice.

Data Sources:

The PubMed databases were systematically searched from the inception dates to November 22, 2017, using the keywords “Helicobacter pylori,” “Pepsinogens,” and “Stomach Neoplasms.”

Study Selection:

Original articles and reviews on the topics were selected.

Results:

Anti-H. pylori antibody and serum PG concentration showed significant changes under the different status of H. pylori infection and the progression of atrophic gastritis, which can be used for risk stratification of gastric cancer in clinic. In addition, anti-H. pylori antibody titer can be used for further risk stratification of gastric cancer contributing to determine better endoscopy surveillance interval.

Conclusions:

The early detection and diagnosis of gastric cancer benefit from the risk stratification, but the cutoff values for H. pylori antibody and serum PG concentration require further modification.

Incidence and mortality of stomach cancer in China, 2014

OBJECTIVE

In this study, we aimed to estimate the updated incidence and mortality rate of stomach cancer based on the cancer registration data in 2014, collected by the National Central Cancer Registry of China (NCCRC).

METHODS

In 2017, 339 registries' data were qualified based on the criteria of data quality control of the NCCRC. Cases of stomach cancer were retrieved from the national database. We estimated numbers of stomach cancer cases and deaths in China using age-specific rates and corresponding national population stratified by area, sex, age-group (0, 1-4, 5-9, 10-14, …, 85+). Chinese standard population in 2000 and Segi's world population were applied for age-standardized incidence and mortality rates.

RESULTS

In 2014, 410,400 new stomach cancer cases and 293,800 cancer-associated deaths were estimated to have occurred in China. The crude incidence rate of stomach cancer was 30.00/100,000, age-standardized incidence rates by Chinese standard population (ASIRC) and by world standard population (ASIRW) were 19.62/100,000 and 19.51/100,000, respectively. The crude mortality rate of stomach cancer was 21.48/100,000, age-standardized mortality rates by Chinese (ASMRC) and by world standard population (ASMRW) were 13.44/100,000 and 13.30/100,000, respectively. Incidence and mortality rates in rural areas were both higher than that in urban areas. Stomach cancer has a strong relationship with gender and age. The disease has occurred more frequently among men than women with a male to female ratio of 2.4 for ASIRC. After age group of 40-44 years, incidence rates are substantially higher in men than in women, same pattern was seen for age-specific mortality rates.

CONCLUSIONS

There is still a heavy burden of stomach cancer in China. The incidence and mortality patterns of stomach cancer show substantial gender and regional disparities. Great effort is needed to provide more accessible health services, sufficient financial resources, and adequate cancer-care infrastructure for the Chinese population, especially for people living in rural areas.

Feasibility of colorectal endoscopic submucosal dissection (ESD) carried out by endoscopists with no or little experience in gastric ESD

BACKGROUND AND AIM

Colorectal endoscopic submucosal dissection (ESD) is recommended to be carried out only by endoscopists with sufficient experience in gastric ESD. However, early gastric carcinoma is less common in Western countries than in Japan, and endoscopic maneuverability differs between the stomach and colorectum. We assessed the feasibility of colorectal ESD carried out by endoscopists with no or little experience in gastric ESD.

METHODS

We analyzed en bloc resection, R0 resection and perforation rates in 180 consecutive colorectal ESD carried out by three endoscopists who had no or <5 cases of experience in gastric ESD. We also identified factors associated with R0 resection failure.

RESULTS

Overall en bloc and R0 resection rates were 93.3% (168/180) and 82.2% (148/180), respectively. All 11 cases with perforation were treated endoscopically. Dividing 180 cases into three learning phases (early, middle, or late phases), the en bloc and R0 resection rates increased from 88.3% and 75.0% in the early phase to 98.3% and 88.3% in the late phase, respectively. Perforation rate also improved from 10.0% to 3.3%. Factors associated with R0 resection failure were location at junctions (odds ratio: 6.8, 95% CI: 1.9-27.5), preoperative factors reflecting fibrosis (5.8, 1.9-19.0), and late phase (0.2, 0.1-0.7).

CONCLUSION

Endoscopists without experience in gastric ESD carried out colorectal ESD safely. In the early and middle phases (≤40 cases), they should treat mainly rectal lesions but may also resect lesions in the colon avoiding flexures. Lesions located at junctions and those with preoperative factors reflecting fibrosis should be resected after completing 40 procedures.

The Safety of Appropriate Use of Over-the-Counter Proton Pump Inhibitors: An Evidence-Based Review and Delphi Consensus

The availability of over-the-counter (OTC) proton pump inhibitors (PPIs) for the short-term (2 weeks) management of frequent heartburn (≥2 days/week) has increased markedly, yet evidence-based recommendations have not been developed. A panel of nine international experts in gastroesophageal reflux disease developed consensus statements regarding the risks and benefits of OTC PPIs using a modified Delphi process. Consensus (based on ≥80% approval) was reached through multiple rounds of remote voting and a final round of live voting. To identify relevant data, the available literature was searched and summarized. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system terminology was used to rate the quality of evidence and strength of recommendations; consensus was based on ≥2/3 agreement. After 4 rounds of review, consensus was achieved for 18 statements. Notably, the available data did not directly reflect OTC use, but instead, prescription use; therefore, extrapolations to the OTC setting were often necessary. This limitation is regrettable, but it justifies performing this exercise to provide evidence-based expert opinion on a widely used class of drugs. The panel determined that using OTC PPIs according to label instructions is unlikely to mask the symptoms of esophageal or gastric cancer or adversely impact the natural history of related precursor conditions. OTC PPIs are not expected to substantially affect micronutrient absorption or bone mineral density or cause community-acquired pneumonia, Clostridium difficile infection, or cardiovascular adverse events. However, OTC PPI use may be associated with slightly increased risks for infectious diarrhea, certain idiosyncratic reactions, and cirrhosis-related spontaneous bacterial peritonitis. The available evidence does not suggest that OTC PPI use consistent with label instructions is associated with substantial health risks. To minimize potential risks, healthcare professionals and consumers must actively participate in decision making when managing reflux-related symptoms in the self-care setting.

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.

Differences in routine esophagogastroduodenoscopy between Japanese and international facilities: A questionnaire survey

BACKGROUND AND AIM

The mortality rate of gastric cancer (GC) is close to the incidence rate worldwide. However, in Korea and Japan, the mortality rate of GC is less than half of the incidence rate. We hypothesized that good-quality routine esophagogastroduodenoscopy (EGD) contributes to a high detection rate for early GC (EGC) and improves mortality in these countries.

METHODS

To clarify the differences in routine EGD, a questionnaire survey was conducted in 98 Japanese and 53 international institutions.

RESULTS

Prevalence of screening examination among routine EGD was higher in Japanese than in international institutions. Japanese endoscopists noted that endoscopic mucosal atrophy was the most significant risk factor for GC, whereas international endoscopists paid more attention to clinical information such as age, symptoms and family history. Antispasmodics, mucolytics and defoaming agents were used more frequently in Japanese institutions. The examination time was similar (mostly 5-10 min) between Japanese and international institutions. Japanese endoscopists took more pictures (>20 in almost all institutions) than international endoscopists (≤20 in two-thirds of institutions). In Japanese institutions, biopsy specimens were more frequently taken from areas of mucosal discoloration, unevenness or spontaneous bleeding rather than from obvious endoscopic lesions such as ulceration or polyps. In most Japanese institutions, one or two biopsy specimens were taken per lesion, compared with ≥three in international institutions.

CONCLUSION

There were some discrepancies between Japanese and international institutions for routine EGD. Thus, standardization is required for adequate risk assessment, proper techniques, and knowledge of endoscopic diagnosis of EGC.

The Japanese Viewpoint on the Histopathology of Early Gastric Cancer

Japanese histopathologists have traditionally had greater opportunity to study the histology and clinical course of early gastric cancer because of technological developments including double contrast radiography and endoscopy systems, combined with the higher incidence of gastric cancer in the general population in Japan. Endoscopic resection is now considered best practice for treatment of early gastric cancers with a negligible risk of lymph node metastasis. Histopathologic evaluation plays a critical role in assessing the likelihood of lymph node metastasis on endoscopically resected specimens. There remains disparity between Western and Japanese histopathologists in the conceptual approach to the histopathologic evaluation of neoplastic lesions in the upper gastrointestinal tract, in particular regarding lesions straddling the borderline between noninvasive and invasive disease. Although in routine practice, the clinical impact of these conceptual differences is small, this disparity does complicate international exchange of datasets and the development of globally applicable formal definitions. Here we review the current practice in histological diagnosis of early gastric cancer in Japan and discuss some of the conceptual differences between Japanese and Western histopathological assessment of lesions in the neoplastic stomach.

Aberrant metastatic behavior and particular features of early gastric cancer

In this paper, we have focused on the metastatic behavior of EGC and its particularities. The main factors that are currently considered as predictors of the metastatic behavior and that are used in the therapeutic decision (endoscopic resection vs surgical removal) are the tumor size (upper or bellow 2 cm), depth of infiltration, angiolymphatic invasion, the presence or absence of ulceration, and histologic type (undifferentiated vs differentiated carcinomas). However, most of the metastatic cases were published as case reports or case series. This is the reason why a proper estimation of metastatic risk in EGC is not well known. To date, 79 cases presenting bone metastases, three reports of brain metastases, and one EGC that was associated with skin metastasis were published. However, occult metastasis, lymph node micrometastasis, and skip metastasis can also occur and should be identified. Making a synthesis of the literature data that is correlated with our experience, we finally proposed the inclusion of the six Japanese subgrouping system, tumor size, angiolymphatic invasion, and micrometastasis as components of the pTNM staging system, which should be particularly adapted for EGC.

Screening of gastric cancer in Asia

In North-Eastern Asian countries, where incidence and mortality of gastric cancer remain very high, population-based gastric cancer screenings have been conducted under governmental subsidy in Japan and Korea. Reduction of gastric cancer mortality by the screening was documented in Japan, but the Japanese gastric cancer screening with the X-ray photofluorography is criticized for its high cost and a low uptake rate. Although the Korean program seems to achieve a high-rate of uptake with increasing use of endoscopy, the work load is substantial. In the meantime, more attention in the world turns to primary prevention through eradication of Helicobacter pylori. Indeed, fairly large-scale studies to examine the feasibility of mass-eradication to prevent gastric cancer are underway in China and Taiwan. In the future, gastric cancer screening should incorporate 'screen to treat' of H. pylori infection at younger age followed by endoscopic surveillance for subjects at risk.

Colorectal endoscopic submucosal dissection (ESD) performed by experienced endoscopists with limited experience in gastric ESD

PURPOSE

Since colorectal endoscopic submucosal dissection (ESD) requires higher-level skills than endoscopic mucosal resection (EMR), it is recommended to acquire sufficient experience in gastric ESD prior to attempting colorectal ESD. We evaluated the ability of experienced endoscopists with limited experience in gastric ESD to perform colorectal ESD.

METHODS

We retrospectively reviewed 120 colorectal ESDs performed by two endoscopists who had expertise in colonoscopy and colorectal EMR but experience of fewer than five gastric ESDs. Main outcomes were the en bloc resection rate with tumor-free margins (R0 resection rate) and adverse events rate. Using only clinical characteristics prior to ESD, we also identified factors affecting outcomes.

RESULTS

A total of 113 patients (94.2 %) received en bloc resection, and the R0 resection rate was 80.0 % (96/120). Perforation and postoperative hemorrhage occurred in eight (6.7 %) and two (1.7 %) patients, respectively. Dividing the 120 cases into three learning phases, R0 resection and perforation rates improved from 77.5 % (31/40) and 12.5 % (5/40) in phase 1 to 85.0 % (34/40) and 2.5 % (1/40) in phase 3, respectively. Multivariate analysis revealed that lesions at junctions (dentate line, sigmoid-descending junction, splenic flexure, hepatic flexure, ileocecal valve) and lesions with factors reflecting fibrosis in the submucosal layer (based on endoscopic findings before ESD) were significantly correlated with R0 resection failure, with adjusted odds ratios of 10.5 (95 % CI 2.1-67.6) and 10.4 (2.7-48.6), respectively.

CONCLUSIONS

Colorectal ESD is feasible for experienced endoscopists with limited experience in gastric ESD. Novices should avoid lesions at junctions or those with factors reflecting fibrosis.

Optimizing early upper gastrointestinal cancer detection at endoscopy

Survival rates for upper gastrointestinal cancers are poor and oesophageal cancer incidence is increasing. Upper gastrointestinal cancer is also often missed during examinations; a predicament that has not yet been sufficiently addressed. Improvements in the detection of premalignant lesions, early oesophageal and gastric cancers will enable organ-preserving endoscopic therapy, potentially reducing the number of advanced upper gastrointestinal cancers and resulting in improved prognosis. Japan is a world leader in high-quality diagnostic upper gastrointestinal endoscopy and the clinical routine in this country differs substantially from Western practice. In this Perspectives article, we review lessons learnt from Japanese gastroscopy technique, training and screening for risk stratification. We suggest a key performance indicator for upper gastrointestinal endoscopy with a minimum total procedure time of 8 min, and examine how quality assurance concepts in bowel cancer screening in the UK could be applied to upper gastrointestinal endoscopy and improve clinical practice.

The stomach in health and disease

The stomach is traditionally regarded as a hollow muscular sac that initiates the second phase of digestion. Yet this simple view ignores the fact that it is the most sophisticated endocrine organ with unique physiology, biochemistry, immunology and microbiology. All ingested materials, including our nutrition, have to negotiate this organ first, and as such, the stomach is arguably the most important segment within the GI tract. The unique biological function of gastric acid secretion not only initiates the digestive process but also acts as a first line of defence against food-borne microbes. Normal gastric physiology and morphology may be disrupted by Helicobacter pylori infection, the most common chronic bacterial infection in the world and the aetiological agent for most peptic ulcers and gastric cancer. In this state-of-the-art review, the most relevant new aspects of the stomach in health and disease are addressed. Topics include gastric physiology and the role of gastric dysmotility in dyspepsia and gastroparesis; the stomach in appetite control and obesity; there is an update on the immunology of the stomach and the emerging field of the gastric microbiome. H. pylori-induced gastritis and its associated diseases including peptic ulcers and gastric cancer are addressed together with advances in diagnosis. The conclusions provide a future approach to gastric diseases underpinned by the concept that a healthy stomach is the gateway to a healthy and balanced host. This philosophy should reinforce any public health efforts designed to eradicate major gastric diseases, including stomach cancer.

Hereditary diffuse gastric cancer--An overview

The incidence of gastric cancer varies by up to ten fold throughout the world, and the geographic distribution of hereditary cases is not well explored. Familial clustering is seen in 10% of cases, and approximately 3% of all gastric cancers develop due to hereditary diffuse gastric cancer (HDGC). In this review, the characteristics of HDGC are presented according to molecular particularities, geographic distribution, and other parameters. Based on our experience and the data from the literature, we discuss the possibility of applying a mutation signature (spectrum) study and adductomic approaches to a comparative carcinogenesis of HDGC. We also provide a comprehensive, up-to-date review of genetic counseling and criteria for screening and surveillance of eligible families.

Randomized controlled trial comparing gastric cancer screening by gastrointestinal X-ray with serology for Helicobacter pylori and pepsinogens followed by gastrointestinal endoscopy

BACKGROUND

Based on the results of several case-control and cohort studies gastrointestinal X-ray (GI X-ray) has been recommended for use in the nationwide screening program for gastric cancer.. Although this was the only effective screening program when almost all of the Japanese population were Helicobacter pylori (H. pylori) positive, there has been concern whether an alternative effective screening system should be established for the future H. pylori-negative generation. We therefore conducted the first randomized controlled trial (RCT) comparing GI X-ray and gastrointestinal endoscopy (GIE) scheduled according to results of serological testing (ST); this was done to determine the potential for an alternative screening method.

METHODS

Subjects who fulfilled the inclusion criteria were residents between the ages of 30 and 74 and who were able to receive gastric cancer screening in the Yurihonjo area. Participants were assigned to the GI X-ray group or the GIE-ST group by computer randomization. Subjects in each group were further subdivided into 4 categories according to their different risks for gastric cancer. The feasibility of stratified randomization was serologically assessed and detection rates of gastric cancer at entry by the different screening methods were also compared.

RESULTS

Of the 2,962 subjects invited, 1,206 individuals (41 percent) were included in the first stage of this stratified RCT, and 604 and 602 individuals were assigned to the GI X-ray group and the GIE-ST group, respectively. There were no statistically significant differences in sex, age, height, body weight, smoking, alcohol intake and family history of cancer between the 2 groups. During ST the GI X-ray group showed a distribution that was not statistically different from that of the GIE-ST group. Although 3 cases of gastric cancer were detected in the GIE-ST group, there was no statistically significant difference between the 2 groups. One complication found was barium aspiration during the examination in the X-ray group.

CONCLUSION

We confirmed that baseline demographic features of the 2 groups were well balanced. We are now organizing the first RCT to compare the existing screening method and the alternative method (Clinical trial registration number: UMIN000005962).

Risk factors of developing interval early gastric cancer after negative endoscopy

BACKGROUND

New or missed gastric cancer rates after negative endoscopy are high. However, the clinicopathologic characteristics of missed or interval early gastric cancer (EGC) are not well known. The aim of this study was to evaluate clinicopathologic and endoscopic characteristics of missed or interval EGC after negative endoscopy.

METHODS

We retrospectively analyzed 1,055 patients with EGC confirmed by endoscopic resection or surgery between June 2006 and July 2013. Referred patients with diagnosed or suspected gastric neoplasms were excluded (n = 771). Interval EGC was defined as gastric cancer diagnosed within 2 years of negative endoscopy. Clinicopathologic characteristics of patients with initially detected and interval EGC and risk factors for interval EGC were investigated.

RESULTS

Of 284 patients, 52 had interval EGC (18.3 %; mean age 65.4 years; average interval between diagnosis and previous endoscopy, 12.6 months). Tumors were significantly smaller (1.3 vs. 1.8 cm, P < 0.001), and the incidence of metaplasia was significantly higher (90.4 vs. 65.9 %, P < 0.001) for interval EGC than for initially detected EGC. And no symptoms (50 vs. 17.7 %, P < 0.001) were significantly associated with interval EGC. However, tumor location, differentiation, gross morphology, and Helicobacter pylori infection status did not differ significantly.

CONCLUSIONS

Subtle mucosal lesions with surrounding intestinal metaplasia were associated with interval EGC. Careful endoscopic screening for patients with intestinal metaplasia at short-term interval would be beneficial for decreasing interval EGC rates.

Gastric cancer screening uptake trends in Korea: results for the National Cancer Screening Program from 2002 to 2011: a prospective cross-sectional study

Although the effectiveness of mass screening for gastric cancer remains controversial, several countries with a high prevalence of gastric cancer have implemented nationwide gastric cancer screening programs. This study was conducted to assess trends in the use of either upper gastrointestinal series (UGIS) or endoscopy to screen for gastric cancer, as well as to assess factors strongly associated with changes therein, over a 10-year period. Data were obtained from the National Cancer Screening Program (NCSP) database from 2002 to 2011 in Korea. The NCSP provides biennial gastric cancer screening with either UGIS or endoscopy for men and women aged ≥40 years. Using the NCSP database, overall screening rates for gastric cancer and percentages of endoscopy use among participants were analyzed from 2002 to 2011. To estimate changes in participation rates and endoscopy use over time, we assessed the average annual percentage change (APC) by comparing the rates from 2002 and 2011 as relative rates. Participation rates for gastric cancer screening increased 4.33% annually from 2002 to 2011. In terms of screening method, a substantial increase in endoscopy use was noted among the gastric cancer screening participants over the 10-year period. The percentage of participants who had undergone endoscopy test increased from 31.15% in 2002 to 72.55% in 2011, whereas the percentage of participants who underwent UGIS decreased tremendously. Increased endoscopy test use was greatest among participants aged 40 to 49 (APC = 4.83%) and Medical Aid Program recipients (APC = 5.73%). Overall, men, participants of ages 40 to 49 years, and National Health Insurance beneficiaries of higher socioeconomic status were more likely to undergo screening via endoscopy. This study of nationwide empirical data from 2002 to 2011 showed that endoscopy is increasingly being used for gastric cancer screening in Korea, compared with UGIS. Nevertheless, further study of the impact of endoscopy on gastric cancer mortality is needed, and future evaluations of screening methods should take into account both cost and any associated reduction in gastric cancer mortality.

Implementation of gastric cancer screening - the global experience

Gastric cancer (GC) is still an important global healthcare problem, and in absolute figures it is going to remain at the present level in foreseeable future. In general, survival of patients with GC is poor mainly due to advanced-stage diagnosis. Early-stage GC can be cured by endoscopic resection or less invasive surgical treatment. Unfortunately, there is no appropriate screening strategy available for global application. This article provides a description of established national and regional GC screening programs and the screening modalities used. This review also summarizes current approaches to develop cancer-screening biomarkers. Although candidates with initial promising results have been suggested, moving discovery into clinical practice is still a major challenge. Well-designed biomarker studies, with systematic validation steps, are needed to decrease the burden of this fatal disease.

Circulating microRNAs as a novel class of diagnostic biomarkers in gastrointestinal tumors detection: a meta-analysis based on 42 articles

OBJECTIVE

MicroRNAs (miRNAs) have become the focus of most recent efforts in cancer research. However, there have been inconsistencies in the literature regarding the suitability of circulating miRNAs for early detection of gastrointestinal cancers. This study aims to assess the diagnostic performance of circulating miRNAs in detection of gastrointestinal cancer through a meta-analysis.

METHODS

Eligible studies were selected by conducting a systematic literature search of public databases. The sensitivity and specificity were used to plot the summary receiver operator characteristic (SROC) curve and calculate the area under the SROC curve (AUC). The between-study heterogeneity was evaluated by Q test and I2 statistics. Subgroup analyses and meta-regression were further performed to explore the potential sources of heterogeneity. All analyses were performed using the STATA 12.0 software.

RESULTS

A total of 107 studies from 42 articles were included for the meta-analysis according to the inclusion criteria. The overall analysis of all gastrointestinal cancers showed that circulating miRNAs have a relatively good diagnostic performance in gastrointestinal cancers, with a sensitivity of 0.75, a specificity of 0.81 and an AUC of 0.85. In addition, subgroup analyses based on different type of miRNA assay suggested that single-miRNA assay displayed a relatively low diagnostic performance with the AUC values of 0.84 for gastric cancer (GC) and 0.79 for colorectal cancer (CRC), while multiple-miRNAs assay significantly improved the diagnosing accuracy with AUC rising to 0.92 for GC and 0.89 for CRC. Another interesting finding was that plasma-based miRNA assay reach a higher accuracy compared with serum-based one for GC, while opposite conclusion was drawn for CRC.

CONCLUSIONS

In conclusion, circulating miRNAs, particularly the combination of multiple miRNAs, may present as promising biomarkers for the diagnosis of gastrointestinal cancers. Further large-scale prospective studies are necessary to validate their potential applicability in human cancer diagnosis.

Potential prognostic, diagnostic and therapeutic markers for human gastric cancer

The high incidence of gastric cancer (GC) and its consequent mortality rate severely threaten human health. GC is frequently not diagnosed until a relatively advanced stage. Surgery is the only potentially curative treatment. Thus, early screening and diagnosis are critical for improving prognoses in patients with GC. Gastroscopy with biopsy is an appropriate method capable of aiding the diagnosis of specific early GC tumor types; however, the stress caused by this method together with it being excessively expensive makes it difficult to use it as a routine method for screening for GC on a population basis. The currently used tumor marker assays for detecting GC are simple and rapid, but their use is limited by their low sensitivity and specificity. In recent years, several markers have been identified and tested for their clinical relevance in the management of GC. Here, we review the serum-based tumor markers for GC and their clinical significance, focusing on discoveries from microarray/proteomics research. We also review tissue-based GC tumor markers and their clinical application, focusing on discoveries from immunohistochemical research. This review provides a brief description of various tumor markers for the purposes of diagnosis, prognosis and therapeutics, and we include markers already in clinical practice and various forthcoming biomarkers.

Surgical treatment of non-early gastric remnant carcinoma developing after distal gastrectomy for gastric cancer

BACKGROUND AND OBJECTIVES

The optimal surgical procedure for gastric remnant carcinoma (GRC) remains debatable. The aim of this study was to retrospectively evaluate the surgical treatments for T2-4 GRC developing after distal gastrectomy for gastric cancer.

METHODS

Between 1970 and 2012, a total of 50 patients underwent R0 resection for T2-4 GRC. The clinicopathologic features, therapeutic methods, and follow-up data of these patients were reviewed.

RESULTS

The tumor was located at a non-anastomotic site of the remnant stomach in 43 of the 50 patients. Total gastrectomy was performed in 48 patients and partial gastrectomy was in two patients. Lymph node metastasis was found in 19 patients. Major postoperative complications occurred in 16 patients. The overall 1-, 3-, and 5-year survival rates of the 50 patients were 90%, 66%, and 44%, respectively. Presence of small intestinal or esophageal infiltration and postoperative complications was independently associated with poorer survival. Dissection of the perigastric and splenic hilar/artery nodes was found to have potential therapeutic benefit.

CONCLUSIONS

Surgical resection for T2-4 GRC developing after distal gastrectomy for gastric cancer can be invasive, but is feasible and effective. Total gastrectomy with splenectomy is one of the recommendable procedures for this disease.

Progress in diagnosis and treatment of precancerous lesions and early gastric cancer

Gastric cancer is the fourth most prevalent cancer worldwide and the second cause of cancer-related death. The 5-year survival rate for early gastric cancer after treatment is 84%-99%. Early detection and treatment of precancerous lesions are pivotal to improved patient survival. The development of various endoscopic (e.g., endoscopic ultrasound, narrowband imaging, magnifying endoscopy and chromoendoscopy), imaging and laboratory technologies has significantly improved the rate of diagnosis of early cancer and precancerous lesions. In addition, endoscopic techniques (e.g., endoscopic submucosal dissection) and minimally invasive surgery (e.g., laparoscopy) make the therapy of early cancer and precancerous lesions better and less invasive, reduce the incidence of postoperative complications, and improve the quality of life of patients after surgery.

Assessment, origin, and implementation of breath volatile cancer markers

A new non-invasive and potentially inexpensive frontier in the diagnosis of cancer relies on the detection of volatile organic compounds (VOCs) in exhaled breath samples. Breath can be sampled and analyzed in real-time, leading to fascinating and cost-effective clinical diagnostic procedures. Nevertheless, breath analysis is a very young field of research and faces challenges, mainly because the biochemical mechanisms behind the cancer-related VOCs are largely unknown. In this review, we present a list of 115 validated cancer-related VOCs published in the literature during the past decade, and classify them with respect to their "fat-to-blood" and "blood-to-air" partition coefficients. These partition coefficients provide an estimation of the relative concentrations of VOCs in alveolar breath, in blood and in the fat compartments of the human body. Additionally, we try to clarify controversial issues concerning possible experimental malpractice in the field, and propose ways to translate the basic science results as well as the mechanistic understanding to tools (sensors) that could serve as point-of-care diagnostics of cancer. We end this review with a conclusion and a future perspective.

A nanomaterial-based breath test for distinguishing gastric cancer from benign gastric conditions

Background:

Upper digestive endoscopy with biopsy and histopathological evaluation of the biopsy material is the standard method for diagnosing gastric cancer (GC). However, this procedure may not be widely available for screening in the developing world, whereas in developed countries endoscopy is frequently used without major clinical gain. There is a high demand for a simple and non-invasive test for selecting the individuals at increased risk that should undergo the endoscopic examination. Here, we studied the feasibility of a nanomaterial-based breath test for identifying GC among patients with gastric complaints.

Methods:

Alveolar exhaled breath samples from 130 patients with gastric complaints (37 GC/32 ulcers / 61 less severe conditions) that underwent endoscopy/biopsy were analyzed using nanomaterial-based sensors. Predictive models were built employing discriminant factor analysis (DFA) pattern recognition, and their stability against possible confounding factors (alcohol/tobacco consumption; Helicobacter pylori) was tested. Classification success was determined (i) using leave-one-out cross-validation and (ii) by randomly blinding 25% of the samples as a validation set. Complementary chemical analysis of the breath samples was performed using gas chromatography coupled with mass spectrometry.

Results:

Three DFA models were developed that achieved excellent discrimination between the subpopulations: (i) GC vs benign gastric conditions, among all the patients (89% sensitivity; 90% specificity); (ii) early stage GC (I and II) vs late stage (III and IV), among GC patients (89% sensitivity; 94% specificity); and (iii) ulcer vs less severe, among benign conditions (84% sensitivity; 87% specificity). The models were insensitive against the tested confounding factors. Chemical analysis found that five volatile organic compounds (2-propenenitrile, 2-butoxy-ethanol, furfural, 6-methyl-5-hepten-2-one and isoprene) were significantly elevated in patients with GC and/or peptic ulcer, as compared with less severe gastric conditions. The concentrations both in the room air and in the breath samples were in the single p.p.b._v range, except in the case of isoprene.

Conclusion:

The preliminary results of this pilot study could open a new and promising avenue to diagnose GC and distinguish it from other gastric diseases. It should be noted that the applied methods are complementary and the potential marker compounds identified by gas-chromatography/mass spectrometry are not necessarily responsible for the differences in the sensor responses. Although this pilot study does not allow drawing far-reaching conclusions, the encouraging preliminary results presented here have initiated a large multicentre clinical trial to confirm the observed patterns for GC and benign gastric conditions.

D1 versus D2 lymphadenectomy for gastric cancer

Significant variability exists throughout the world in the extent of lymphadenectomy that is performed for gastric adenocarcinoma. D2 lymphadenectomy is the standard lymphadenectomy performed in high incidence countries such as Japan and South Korea, and less extensive lymphadenectomies are often performed in lower incidence countries such as the Unites States. This article reviews the evidence on the extent of lymphadenectomy that should be performed for gastric adenocarcinoma.

Stepwise training in rectal and colonic endoscopic submucosal dissection with differentiated learning curves

BACKGROUND

Endoscopic submucosal dissection (ESD) has revolutionized the resection of GI superficial neoplasms, but adoption in Western countries is significantly delayed.

OBJECTIVE

To evaluate a stepwise colorectal endoscopic submucosal dissection (ESD) learning and operative training protocol.

DESIGN

Prospective study in the Western setting.

SETTING

This study took place in a nonacademic hospital with one endoscopist expert in therapeutic endoscopy but novice in ESD.

PATIENTS

Indications for ESD were superficial neoplasms 20 mm and larger without ulcerations or fibrosis.

INTERVENTION

Training consisted of 5 unsupervised ESDs on isolated stomach, an observation period at an ESD expert Japanese center, 1 supervised ESD on isolated stomach, and retraining on 1 rectal ESD under supervision. The operative training on patients was performed without supervision moving from the rectum to the colon according to the competence achieved.

MAIN OUTCOME MEASUREMENTS

Competence was defined as an 80% en bloc resection rate plus a statistically significant reduction in operating time per square centimeter. Learning curves were calculated based on consecutive blocks of 5 procedures.

RESULTS

From February 2009 to February 2012, 30 rectal and 30 colonic ESDs were performed. The rectal ESD learning curve showed that the en bloc resection rate was 80% after 5 procedures (P = not significant); the operating time per square centimeter significantly decreased after 20 procedures (P = .0079); perforation occurred in 1 patient. The colonic ESD learning curve showed that the en bloc resection rate was 80% after 20 procedures (P = not significant); the operating time per square centimeter significantly decreased after 20 procedures (P = .031); perforations occurred in 2 patients.

LIMITATIONS

Single-center design.

CONCLUSIONS

A minimal intensive training seems sufficient for endoscopists expert in therapeutic procedures to take up ESD in a not overly arduous incremental method with separate and sequential learning curves for the rectum and colon.

Asian consensus report on functional dyspepsia

BACKGROUND AND AIM

Environmental factors such as food, lifestyle and prevalence of Helicobacter pylori infection are widely different in Asian countries compared with the West, and physiological functions and genetic factors of Asians may also be different from those of Westerners. Establishing an Asian consensus for functional dyspepsia is crucial in order to attract attention to such data from Asian countries, to articulate the experience and views of Asian experts, and to provide a relevant guide on management of functional dyspepsia for primary care physicians working in Asia.

METHODS

Consensus team members were selected from Asian experts and consensus development was carried out by using a modified Delphi method. Consensus teams collected published papers on functional dyspepsia especially from Asia and developed candidate consensus statements based on the generated clinical questions. At the first face-to-face meeting, each statement was reviewed and e-mail voting was done twice. At the second face-to-face meeting, final voting on each statement was done using a keypad voting system. A grade of evidence and strength of recommendation were applied to each statement according to the method of the GRADE Working Group.

RESULTS

Twenty-nine consensus statements were finalized, including seven for definition and diagnosis, five for epidemiology, nine for pathophysiology, and eight for management. Algorithms for diagnosis and management of functional dyspepsia were added.

CONCLUSIONS

  This consensus developed by Asian experts shows distinctive features of functional dyspepsia in Asia and will provide a guide to the diagnosis and management of functional dyspepsia for Asian primary care physicians.

Asian consensus report on functional dyspepsia

BACKGROUND/AIMS

Environmental factors such as food, lifestyle and prevalence of Helicobacter pylori infection are widely different in Asian countries compared to the West, and physiological functions and genetic factors of Asians may also be different from those of Westerners. Establishing an Asian consensus for functional dyspepsia is crucial in order to attract attention to such data from Asian countries, to articulate the experience and views of Asian experts, and to provide a relevant guide on management of functional dyspepsia for primary care physicians working in Asia.

METHODS

Consensus team members were selected from Asian experts and consensus development was carried out using a modified Delphi method. Consensus teams collected published papers on functional dyspepsia especially from Asia and developed candidate consensus statements based on the generated clinical questions. At the first face-to-face meeting, each statement was reviewed and e-mail voting was done twice. At the second face-to-face meeting, final voting on each statement was done using keypad voting system. A grade of evidence and a strength of recommendation were applied to each statement according to the method of the GRADE Working Group.

RESULTS

Twenty-nine consensus statements were finalized, including 7 for definition and diagnosis, 5 for epidemiology, 9 for pathophysiology and 8 for management. Algorithms for diagnosis and management of functional dyspepsia were added.

CONCLUSIONS

This consensus developed by Asian experts shows distinctive features of functional dyspepsia in Asia and will provide a guide to the diagnosis and management of functional dyspepsia for Asian primary care physicians.

[Endoscopic submucosal dissection: only for expert endoscopists?]

Endoscopic submucosal dissection (ESD) can be applied to early gastrointestinal cancers. This technique was developed to achieve radical curative resection and to reduce unnecessary surgical interventions. ESD was designed in eastern countries and is not widely used in the West. Although ESD represents a major therapeutic advance in endoscopy and is performed with curative intent, the complication rate (hemorrhage, perforation) is higher than reported in other techniques, requiring from endoscopists the acquirement of technical skill and experience through a structured and progressive training program to reduce the morbidity associated with this technique and increase its potential benefits. Although there is substantial published evidence on the applications and results of ESD, there are few publications on training in this technique and a standardized training program is lacking. The current article aims to describe the various proposals for training, as well as the basic principles of the technique, its indications, and the results obtained, since theoretical knowledge that would guide endoscopists during the clinical application of ESD is advisable before training begins. Training in an endoscopic technique has a little value without knowledge of the technique's aims, the situations in which it should be applied, and the results that can be expected.

Advances in research and diagnosis of early gastric cancer

The overall prognosis of gastric cancer is generally poor due to late presentation and diagnosis. When detected early, the prognosis of gastric cancer is excellent, and curative endoscopic resection may be possible, without the need for surgery. Careful endoscopic examination is important so as to avoid missed lesions. Besides the endoscopic screening for gastric cancer, other screening methods are also used in different countries and areas. This also provides us different avenues for the diagnosis of early gastric cancer.

Gastric adenocarcinoma surgery and adjuvant therapy

Gastric adenocarcinoma is one of the most common causes of death worldwide. Surgical resection remains the mainstay of therapy, offering the only chance for complete cure. Resection is based on the principles of obtaining adequate margins, with the extent of lymphadenectomy remaining controversial. Neoadjuvant and adjuvant therapies are used to reduce local recurrence and improve long-term survival. This article reviews the literature and provides a summary of surgical management options and neoadjuvant/adjuvant therapies for gastric adenocarcinoma.

Pilot study on clinical effectiveness of autofluorescence imaging for early gastric cancer diagnosis by less experienced endoscopists

This study aimed to assess and compare effectiveness of Autofluorescence imaging (AFI) in diagnosis of early gastric cancer (EGC) between experienced and less experienced endoscopists. Fifty selected images (20 neoplastic lesions and 30 benign lesions/areas) of both white light endoscopy (WLE) and AFI were blindly reviewed by two groups; first consisted of five experienced endoscopists and second included five less experienced endoscopists. Sensitivity, specificity, and accuracy were 70%, 78%, and 75%, respectively, for AFI and 81%, 76%, and 78%, respectively, for WLE in the experienced group. In the less experienced group, sensitivity, specificity and accuracy were 80%, 81% and 80%, respectively, for AFI and 65%, 77%, and 72%, respectively, for WLE. Interobserver variability for the less experienced group was better with AFI than WLE. AFI improved sensitivity of endoscopic diagnosis of neoplastic lesions by less experienced endoscopists, and its use could beneficially enhance the clinical effectiveness of EGC screening.

An evidence-based review of the surgical treatment of gastric adenocarcinoma

The management of gastric adenocarcinoma continues to evolve. Chemotherapy is being increasingly used in both the neoadjuvant and adjuvant setting. Surgical resection of the stomach and regional lymph nodes remains the mainstay of potentially curative therapy, but significant regional differences persist in the surgical management. This review provides an update on the current literature regarding the preoperative evaluation and staging, extent of gastric resection, extent of lymph node resection, and adjuvant therapy for patients with gastric adenocarcinoma.

Gastric Cancer Working Group report

EPIDEMIOLOGY

Gastric cancer is the second most common cancer in Asia, more than half of the world's gastric cancer cases arise in Eastern Asia, and the majority of Asia's cases still occur in the distal part of the stomach.

ETIOLOGY AND PREVENTION

The etiology of gastric cancer consists of genetic susceptibility, Helicobacter pylori infection and environmental risk factors. Helicobacter pylori eradication treatment, consumption of fresh vegetables and fruits and use of aspirin and non-steroidal anti-inflammatory drugs seem to reduce the risk of gastric cancer.

ENDOSCOPY AND DIAGNOSIS

Screening for gastric cancer is cost-effective in countries with high incidence. Risk stratification may increase the cost-effectiveness of screening in populations at moderate risk. Endoscopic resection is curative in a subset of patients with early cancer.

SURGERY AND ADJUVANT TREATMENT

R0 resection with D2 lymph node dissection has produced the best survival data. Some kind of post-operative adjuvant chemotherapy including S-1 is recommended after D2 surgery.

CHEMOTHERAPY FOR ADVANCED GASTRIC CANCER

As chemotherapy for gastric cancer, fluorouracils plus platinum are the most widely accepted first-line regimens, whereas taxanes or irinotecan are mostly used in second- and third-line settings. Differences in the approval and medical insurance systems may influence the status of these regimens. Trastuzumab in combination with fluorouracils/platinum will be a standard regimen for HER2-positive gastric cancer. Many new targeting agents are currently under investigation, and Asian countries are playing important roles in investigation and development of new and better treatments for this malignancy.

Comparing upper gastrointestinal X-ray and endoscopy for gastric cancer diagnosis in Korea

AIM: To compare the cost and accuracy of upper gastrointestinal (GI) X-ray and upper endoscopy for diagnosis of gastric cancer using data from the 2002-2004 Korean National Cancer Screening Program (NCSP).

METHODS: The study population included 1 503 646 participants in the 2002-2004 stomach cancer screening program who underwent upper GI X-ray or endoscopy. The accuracy of screening was defined as the probability of detecting gastric cancer. We calculated the probability by merging data from the NCSP and the Korea Central Cancer Registry. We estimated the direct costs of the medical examination and the tests for upper GI X-ray, upper endoscopy, and biopsy.

RESULTS: The probability of detecting gastric cancer via upper endoscopy was 2.9-fold higher than via upper GI X-ray. The unit costs of screening using upper GI X-ray and upper endoscopy were $32.67 and $34.89, respectively. In 2008, the estimated cost of identifying one case of gastric cancer was $53 094.64 using upper GI X-ray and $16 900.43 using upper endoscopy. The cost to detect one case of gastric cancer was the same for upper GI X-ray and upper endoscopy at a cost ratio of 1:3.7.

CONCLUSION: Upper endoscopy is slightly more costly to perform, but the cost to detect one case of gastric cancer is lower.