Endoscopic resection as a first therapy for gastric epithelial atypia: is it reasonable?

Management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG) and European Society of Pathology (ESP) Guideline update 2025

At a population level, the European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter and Microbiota Study Group (EHMSG), and the European Society of Pathology (ESP) suggest endoscopic screening for gastric cancer (and precancerous conditions) in high-risk regions (age-standardized rate [ASR] > 20 per 100 000 person-years) every 2 to 3 years or, if cost-effectiveness has been proven, in intermediate risk regions (ASR 10-20 per 100 000 person-years) every 5 years, but not in low-risk regions (ASR < 10).ESGE/EHMSG/ESP recommend that irrespective of country of origin, individual gastric risk assessment and stratification of precancerous conditions is recommended for first-time gastroscopy. ESGE/EHMSG/ESP suggest that gastric cancer screening or surveillance in asymptomatic individuals over 80 should be discontinued or not started, and that patients' comorbidities should be considered when treatment of superficial lesions is planned.ESGE/EHMSG/ESP recommend that a high quality endoscopy including the use of virtual chromoendoscopy (VCE), after proper training, is performed for screening, diagnosis, and staging of precancerous conditions (atrophy and intestinal metaplasia) and lesions (dysplasia or cancer), as well as after endoscopic therapy. VCE should be used to guide the sampling site for biopsies in the case of suspected neoplastic lesions as well as to guide biopsies for diagnosis and staging of gastric precancerous conditions, with random biopsies to be taken in the absence of endoscopically suspected changes. When there is a suspected early gastric neoplastic lesion, it should be properly described (location, size, Paris classification, vascular and mucosal pattern), photodocumented, and two targeted biopsies taken.ESGE/EHMSG/ESP do 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 unless there are signs of deep submucosal invasion or if the lesion is not considered suitable for endoscopic resection.ESGE/EHMSG/ESP recommend endoscopic submucosal dissection (ESD) for differentiated gastric lesions clinically staged as dysplastic (low grade and high grade) or as intramucosal carcinoma (of any size if not ulcerated or ≤ 30 mm if ulcerated), with EMR being an alternative for Paris 0-IIa lesions of size ≤ 10 mm with low likelihood of malignancy.ESGE/EHMSG/ESP suggest that a decision about ESD can be considered for malignant lesions clinically staged as having minimal submucosal invasion if differentiated and ≤ 30 mm; or for malignant lesions clinically staged as intramucosal, undifferentiated and ≤ 20 mm; and in both cases with no ulcerative findings.ESGE/EHMSG/ESP recommends patient management based on the following histological risk after endoscopic resection: Curative/very low-risk resection (lymph node metastasis [LNM] risk < 0.5 %-1 %): en bloc R0 resection; dysplastic/pT1a, differentiated lesion, no lymphovascular invasion, independent of size if no ulceration and ≤ 30 mm if ulcerated. No further staging procedure or treatment is recommended.Curative/low-risk resection (LNM risk < 3 %): en bloc R0 resection; lesion with no lymphovascular invasion and: a) pT1b, invasion ≤ 500 µm, differentiated, size ≤ 30 mm; or b) pT1a, undifferentiated, size ≤ 20 mm and no ulceration. Staging should be completed, and further treatment is generally not necessary, but a multidisciplinary discussion is required. Local-risk resection (very low risk of LNM but increased risk of local persistence/recurrence): Piecemeal resection or tumor-positive horizontal margin of a lesion otherwise meeting curative/very low-risk criteria (or meeting low-risk criteria provided that there is no submucosal invasive tumor at the resection margin in the case of piecemeal resection or tumor-positive horizontal margin for pT1b lesions [invasion ≤ 500 µm; well-differentiated; size ≤ 30 mm, and VM0]). Endoscopic surveillance/re-treatment is recommended rather than other additional treatment. High-risk resection (noncurative): Any lesion with any of the following: (a) a positive vertical margin (if carcinoma) or lymphovascular invasion or deep submucosal invasion (> 500 µm from the muscularis mucosae); (b) poorly differentiated lesions if ulceration or size > 20 mm; (c) pT1b differentiated lesions with submucosal invasion ≤ 500 µm with size > 30 mm; or (d) intramucosal ulcerative lesion with size > 30 mm. Complete staging and strong consideration for additional treatments (surgery) in multidisciplinary discussion.ESGE/EHMSG/ESP suggest the use of validated endoscopic classifications of atrophy (e. g. Kimura-Takemoto) or intestinal metaplasia (e. g. endoscopic grading of gastric intestinal metaplasia [EGGIM]) to endoscopically stage precancerous conditions and stratify the risk for gastric cancer.ESGE/EHMSG/ESP recommend that biopsies should be taken from at least two topographic sites (2 biopsies from the antrum/incisura and 2 from the corpus, guided by VCE) in two separate, clearly labeled vials. Additional biopsy from the incisura is optional.ESGE/EHMSG/ESP recommend that patients with extensive endoscopic changes (Kimura C3 + or EGGIM 5 +) or advanced histological stages of atrophic gastritis (severe atrophic changes or intestinal metaplasia, or changes in both antrum and corpus, operative link on gastritis assessment/operative link on gastric intestinal metaplasia [OLGA/OLGIM] III/IV) should be followed up with high quality endoscopy every 3 years, irrespective of the individual's country of origin.ESGE/EHMSG/ESP recommend that no surveillance is proposed for patients with mild to moderate atrophy or intestinal metaplasia restricted to the antrum, in the absence of endoscopic signs of extensive lesions or other risk factors (family history, incomplete intestinal metaplasia, persistent H. pylori infection). This group constitutes most individuals found in clinical practice.ESGE/EHMSG/ESP recommend H. pylori eradication for patients with precancerous conditions and after endoscopic or surgical therapy.ESGE/EHMSG/ESP recommend that patients should be advised to stop smoking and low-dose daily aspirin use may be considered for the prevention of gastric cancer in selected individuals with high risk for cardiovascular events.

Chinese integrated guideline on the management of gastric precancerous conditions and lesions

The standardized diagnosis and management of gastric precancerous conditions and lesions are important to prevent gastric cancer. This guideline, created by 5 traditional Chinese medicine and Western medicine associations, based on the current morbidity and diagnosis and treatment of gastric precancerous conditions and lesions, provides specific key points and strategies for diagnosis and treatment in the following five aspects: definition and epidemiology, diagnosis and stage, surveillance, treatment and efficacy evaluation. It is hoped that these aspects, assessed by integrating Western medicine and traditional Chinese medicine and involving multidisciplinary participation, will play a guiding role in clinical diagnosis and treatment and achieve effective secondary prevention of gastric cancer.

Risk stratification of patients with gastric lesions indefinite for dysplasia

BACKGROUND/AIMS

There are no definite guidelines for the management of gastric lesions diagnosed as indefinite for dysplasia (IND) by endoscopic forceps biopsy (EFB). Therefore, this study aimed to evaluate the clinical outcomes of gastric IND and predictive factors for gastric neoplasm.

METHODS

This study included 457 patients with a first diagnosis of gastric IND by EFB between January 2005 and December 2013. Patient characteristics and endoscopic and pathological data were reviewed and compared.

RESULTS

Of the 457 gastric IND patients, 128 (28%) were diagnosed with invasive carcinoma, 21 (4.6%) with high-grade dysplasia, 31 (6.8%) with low-grade dysplasia, and 277 (60.6%) as negative for dysplasia. Of lesions observed, 180 (39.4%) showed upgraded histology. Multivariate analysis revealed that surface erythema (odds ratio [OR], 2.804; 95% confidence interval [CI], 1.741 to 4.516), spontaneous bleeding (OR, 2.618; 95% CI, 1.298 to 5.279), lesion size ≥ 1 cm (OR, 5.762; 95% CI, 3.459 to 9.597), and depressed morphology (OR, 2.183; 95% CI, 1.155 to 4.124) were significant risk factors for high-grade dysplasia or adenocarcinoma. The ORs associated with 2 and ≥ 3 risk factors were 7.131 and 34.86, respectively.

CONCLUSION

Precautions should be taken in the management of gastric IND patients, especially when risk factors, including surface erythema, spontaneous bleeding, lesion size ≥ 1 cm, and depressed morphology are present. Considering the combined effect of the presence of multiple risk factors on the incidence of high-grade dysplasia or adenocarcinoma, endoscopic resection should be recommended if a gastric IND patient has at two or more of these factors.

Novel Pathologic Factors for Risk Stratification of Gastric "Indefinite for Dysplasia" Lesions

Methods

In total, 123 IND cases with final diagnoses of cancer (29.3%), high-grade dysplasia (6.5%), low-grade dysplasia (11.4%), and nonneoplasm (52.8%) were randomly divided into test set (n = 27) and validation set (n = 96). By the image analysis, size, pleomorphism, hyperchromasia, irregularity of nuclei, and ratios of structural atypia area (SAA) to total IND area were measured in the test set. Using the validation set, consensus meetings were held for the evaluation of pathologic factors that predict the final diagnosis.

Results

By image analysis, the only ratio of SAA to total IND area was associated with the final diagnosis (p < 0.001). In the consensus meeting for validation, the nuclear factors, except loss of nuclear polarity (p = 0.004–0.026), could not predict the final diagnosis. Conversely, most structural factors could predict the final diagnosis. In particular, SAA > 25% was the most powerful predictive factor. We proposed criteria of risk stratification by using SAA > 25%, loss of surface maturation (LOSM), and loss of nuclear polarity (LONP) (Malignancy rate; Category 0: SAA ≤ 25% without LOSM and LONP; 0%, Category 1: SAA ≤ 25% with any of LOSM or LONP; 15.2%–16.7%, Category 2: SAA > 25% without LOSM and LONP; 44.4%–50.0%, Category 3: SAA > 25% with any of LOSM or LONP 54.5%–55.6%).

Conclusions

Structural atypia was more helpful than nuclear atypia and SAA > 25% was the most powerful predictor for the diagnosis of INDs of the stomach. We propose shortening the follow-up period to six months for Category 1, endoscopic resection for Category 2 and 3, postresection follow-up periods of one year for Category 2, and six months for Category 3.

Effect of Helicobacter pylori infection and its eradication on gastric regenerating atypia in 22 133 subjects

BACKGROUND AND AIM

The aim of this study was to identify factors affecting persistent gastric regenerating atypia and determine the effect of Helicobacter pylori eradication on the course of this lesion.

METHODS

In cross-sectional setting, comprehensive health check-up subjects who underwent both endoscopy and H. pylori test from 2001 to 2009 were included. The association between H. pylori and gastric regenerating atypia was evaluated. In cohort setting, patients with regenerating atypia who underwent H. pylori test from 2001 to 2013 were included. Factors affecting positive pathology (persistent regenerating atypia or new development of neoplasm) in patients with regenerating atypia at baseline were investigated.

RESULTS

In cross-sectional setting, regenerating atypia was observed in 1.1% (241/22 133). H. pylori infection was associated with gastric regenerating atypia (adjusted odds ratio, 1.47; 95% confidence interval [CI], 1.12-1.91). In cohort setting, 310 patients with regenerating atypia were finally eligible. Positive pathology rate during follow up was 16.1% (15/93) in the persistent infection group, 2.8% (3/106) in successful eradication group, and 4.5% (5/111) in baseline H. pylori-negative group. Persistent H. pylori infection increased the risk of positive pathology (adjusted risk ratio [RR], 7.18; 95% CI, 1.95-26.48) compared to H. pylori eradication group. Persistent H. pylori infection increased the risk of regenerative atypia (adjusted RR, 5.70; 95% CI, 1.46-22.17) and new neoplasm (adjusted RR, 10.74; 95% CI, 1.10-105.17) compared to baseline negative H. pylori.

CONCLUSIONS

H. pylori infection is an independent risk factor for gastric regenerating atypia. Eradication of H. pylori seems helpful for regression of regenerating atypia.

Endoscopic submucosal dissection for gastric indefinite for neoplasia: which lesions should be resected?

BACKGROUND AND STUDY AIMS

The management plan for gastric indefinite for neoplasia is undetermined, and endoscopic forceps biopsy might be inconclusive in ascertaining whether a resection is required. This study aimed to evaluate the clinical outcomes of endoscopic submucosal dissection (ESD) for gastric indefinite for neoplasia and to identify the factors highly predictive of true neoplasia.

PATIENTS AND METHODS

This retrospective study was conducted in a single, tertiary, referral hospital between November 2008 and December 2015. A total of 109 gastric indefinite for neoplasia lesions from endoscopic forceps biopsy that were resected by ESD were included in the study. The clinical outcomes and endoscopic factors for prediction of true neoplasia were analyzed.

RESULTS

A total of 99 patients (90.8%) were diagnosed with definite neoplasia after ESD and were classified as category 3 (n = 42), category 4 (n = 50), and category 5 (n = 7) according to the revised Vienna classification. The mean age of the patients was 65.8 ± 9.8 years. The mean lesion size was 10.7 ± 6.1 mm. The patient population predominantly consisted of male patients (70.6%). The en bloc and complete endoscopic resection rates were 98.2% and 94.5%, respectively. Factors associated with true neoplastic lesions were male sex (odds ratio [OR] 8.596, p = 0.008) and lesion size ≥ 5 mm (OR 11.355, p = 0.003). Factors associated with category 4-5 were male sex (OR 3.165, p = 0.021) and erosive change (OR 2.841, p = 0.031).

CONCLUSIONS

Endoscopic resection for indefinite for neoplasia with larger lesions size and erosive changes, especially in males, should be considered when possible.

Treatment for gastric ‘indefinite for neoplasm/dysplasia’ lesions based on predictive factors

BACKGROUND

Gastric ‘indefinite for neoplasm/dysplasia’ (IFND) is a borderline lesion that is difficult to diagnose as either regenerative or neoplastic. There is a need for guidance in the identification of a subset of patients, who have an IFND lesion with a higher risk of malignant potential, to enable risk stratification and optimal management.

AIM

To determine the clinical and pathologic factors for the accurate diagnosis of gastric IFND lesions.

METHODS

In total, 461 gastric lesions diagnosed via biopsy as IFND lesions were retrospectively evaluated. Endoscopic resection (n = 134), surgery (n = 22), and follow-up endoscopic biopsy (n = 305) were performed to confirm the diagnosis. The time interval from initial biopsy to cancer diagnosis was measured, and diagnostic delays were categorized as > 2 wk, > 2 mo, > 6 mo, and > 1 year. The IFND lesions presenting as regenerating atypia (60%) or atypical epithelia (40%) at initial biopsy were adenocarcinomas in 22.6%, adenomas in 8.9%, and gastritis in 68.5% of the cases.

RESULTS

Four clinical factors [age ≥ 60 years (2.445, 95%CI: 1.305-4.580, P = 0.005), endoscopic size ≥ 10 mm (3.519, 95%CI: 1.891-6.548, P < 0.001), single lesion (5.702, 95%CI: 2.212-14.696, P < 0.001), and spontaneous bleeding (4.056, 95%CI: 1.792-9.180, P = 0.001)], and two pathologic factors [atypical epithelium (25.575, 95%CI: 11.537-56.695, P < 0.001], and repeated IFND diagnosis [6.022, 95%CI: 1.822-19.909, P = 0.003)] were independent risk factors for gastric cancer. With two or more clinical factors, the sensitivity and specificity for carcinoma were 91.3% and 54.9%, respectively. Ten undifferentiated carcinomas were initially diagnosed as IFND. In the subgroup analysis, fold change (5.594, 95%CI: 1.458-21.462, P = 0.012) predicted undifferentiated or invasive carcinoma in the submucosal layers or deeper. Diagnostic delays shorter than 1 year were not associated with worse prognoses. Extremely well-differentiated adenocarcinomas accounted for half of the repeated IFND cases and resulted in low diagnostic accuracy even on retrospective blinded review.

CONCLUSION

More than two clinical and pathologic factors each had significant cut-off values for gastric carcinoma diagnosis; in such cases, endoscopic resection should be considered.