Prolonged achlorhydria and gastric neoplasia: is there a causal relationship?

The role of cuproptosis in gastric cancer

As a biologically essential transition metal, copper is widely involved in various enzymatic reactions and crucial biological processes in the body. It plays an increasingly important role in maintaining normal cellular metabolism and supporting the growth and development of the human body. As a trace element, copper maintains the dynamic balance of its concentration in body fluids through active homeostatic mechanisms. Both excess and deficiency of copper ions can impair cell function, ultimately leading to cell damage and death. Cuproptosis is a novel form of cell death where copper ions cause cell death by directly binding to the lipoylated components of the citric acid cycle (CAC) in mitochondrial respiration and interfering with the levels of iron-sulfur cluster (Fe-S cluster) proteins, ultimately causing protein toxic stress. Its primary characteristics are Cu2+ concentration dependence and high expression in mitochondrial respiratory cells. Recent research has revealed that, compared to other forms of programmed cell death such as apoptosis, necrosis, and autophagy, cuproptosis has unique morphological and biochemical features. Cuproptosis is associated with the occurrence and development of various diseases, including cancer, neurodegenerative diseases, and cardiovascular diseases. This article focuses on a review of the relevance of cuproptosis in gastric cancer (GC).

Gastric cancer-Epidemiology, modifiable and non-modifiable risk factors, challenges and opportunities: An updated review

Gastric cancer represents a significant global health challenge due to its high mortality and incidence rates, particularly in Eastern Asia, Eastern Europe, and South America. This comprehensive review synthesizes the latest epidemiological data and explores both modifiable and non-modifiable risk factors associated with gastric cancer, aiming to delineate the multifactorial etiology of this disease. Modifiable risk factors include Helicobacter pylori infection, obesity, dietary habits, smoking and alcohol consumption, whereas nonmodifiable factors comprise genetic predispositions, age, family history and male gender. The interplay of these factors significantly impacts the risk and progression of gastric cancer, suggesting potential preventive strategies. The challenges in treating gastric cancer are considerable, largely because of the late-stage diagnosis and the heterogeneity of the disease, which complicate effective treatment regimens. Current treatment strategies involve a combination of surgery, chemotherapy, radiotherapy, and targeted therapies. The FLOT regimen (5-FU, Leucovorin, Oxaliplatin and Docetaxel) is now a standard for resectable cases in Europe and the US, showing superior survival and response rates over ECF and ECX regimens. For HER2-positive gastric cancer, trastuzumab combined with chemotherapy improves overall survival, as demonstrated by the ToGA trial. Additionally, immune checkpoint inhibitors like pembrolizumab and nivolumab offer promising results. However, the five-year survival rate remains low, underscoring the urgency for improved therapeutic approaches. Recent advancements in molecular biology and cancer genomics have begun to pave the way for personalized medicine in gastric cancer care, focusing on molecular targeted therapies and immunotherapy. This review also highlights the critical need for better screening methods that could facilitate early detection and treatment, potentially improving the prognosis. By integrating epidemiological insights with new therapeutic strategies, this article aims to thoroughly understand of gastric cancer's dynamics and outline a framework for future research and clinical management, advocating for a multidisciplinary approach to tackle this formidable disease.

Clinical investigation on coexisting of duodenal ulcer and gastric cancer in China

The aim of this study was to investigate the prevalence of coexistent duodenal ulcer and gastric cancer in China, then to explore the features of clinical manifestations, endoscopy, pathology and possible pathogenesis. A retrospective analysis has been made on medical records in Remin Hospital, Wuhan University, Hubei Province, China from January 1991 to December 2002. 37 cases of coexistent duodenal ulcer and gastric cancer were found. 24.3% (9/37) had previous history of duodenal ulcer. 81.0% (30/37) of them lack alarm symptoms or signs and 87.1% (27/31) had alleviation in abdominal pain by acid inhibitor. Duodenal ulcer was single in all cases with seven in A1 stage, three in A2 stage, one in H1 stage, one in H2 stage, seven in S1 stage and 18 in S2 stage. 89.2% (33/37) of concurrent gastric cancer were in the corpus and antrum, with 78.1% (29/37) of them belonging to Bormann type II and 87.1% (27/37) being moderately differentiated adenocarcinoma. 83.7% of patients (31/37) had positive rapid urease test. The coexisting gastric cancer in patients with duodenal ulcer is infrequent but not rare. Gastroscopy screening and routine follow-up are necessary for patients with duodenal ulcer. Helicobacter pylori may be important pathogen for it. Helicobacter pylori eradication is recommended in patients with duodenal ulcer to reduce the risk of contaminant gastric cancer.

Helicobacter pylori strain and the pattern of gastritis among first-degree relatives of patients with gastric carcinoma

BACKGROUND

Relatives of gastric cancer patients have an increased risk of gastric cancer, possibly related to genetically-related strains of Helicobacter pylori or a common environment.

METHODS

The pattern of gastritis and H. pylori from gastric cancer patients and their first-degree relatives were compared using detailed DNA fingerprints and vacA, cagA, and iceA genotyping.

RESULTS

Sixteen index cases from Korea, the US, or Colombia and their 38 first-degree relatives (brothers, sisters, sons and daughters) were studied. No definite, or consistent, relationship between the pattern of gastritis and the relatedness of the H. pylori strain was observed (i.e. relatives could have an identical or a totally different pattern of gastritis regardless if they were infected with identical or highly similar organisms). For example, three elderly siblings of an index case with atrophic pangastritis had identical H. pylori isolates and environments in childhood and yet two had antral predominant nonatrophic gastritis, which is typically associated with duodenal ulcer instead of gastric cancer.

CONCLUSIONS

The results of this study are not consistent with the hypothesis that specific virulence factors or similar H. pylori strains correlate with a specific histologic pattern or outcome even among those sharing the same environment in childhood.

Gastric intestinal metaplasia: subtypes and natural history

BACKGROUND

It has been suggested that the subtyping of intestinal metaplasia in the stomach is useful in stratifying patients with regard to risk of developing gastric cancer.

AIM

To determine whether subtyping intestinal metaplasia provided useful information regarding the natural history of intestinal metaplasia.

METHODS

The study used large cup gastric biopsy specimens from predetermined locations (gastric mapping). Follow up biopsies were obtained at one, two, and/or nine years. Biopsies with intestinal metaplasia were stained with high iron diamine/Alcian blue (HID/AB) to determine whether they expressed neutral mucins, sialomucins, or sulphomucins.

RESULTS

Seventy nine patients with intestinal metaplasia were studied and characterised with regard to the most advanced subtype of intestinal metaplasia. The most severe type of intestinal metaplasia was type II in 33 patients and type III in 34 patients. Helicobacter pylori was cured in 67 patients. Follow up showed that changes in type of metaplasia (apparent regression or progression) occurred in both directions and were independent of H pylori status. For example, biopsy sites with "loss" of metaplasia at a follow up visit might have it "reappear" at a subsequent visit. During follow up, no patient developed gastric dysplasia or died from gastric cancer.

CONCLUSION

HID subtyping did not provide useful information to the clinician or the pathologist. The data are consistent with the notion that the pattern, extent, and severity of atrophy with/without intestinal metaplasia is a far more important predictor of increased cancer risk than intestinal metaplasia subtype.

Alterations in intragastric nitrite and vitamin C levels during acid inhibitory therapy

Most nitrite entering the healthy acid-secreting stomach is derived from dietary nitrate. The latter is absorbed from the small intestine, 25% then being secreted by the salivary glands into the mouth. Buccal organisms subsequently convert 20% of this nitrate to nitrite. When this nitrite is swallowed, the ascorbic acid in the acidic gastric juice reduces it to nitric oxide, which is absorbed by the mucosa. In the process, the ascorbic acid is oxidized to dehydroascorbic acid. When the intragastric pH is elevated by powerful anti-secretory agents, this gastric chemistry is profoundly modified. At a neutral pH, the swallowed nitrite does not react with ascorbic acid but accumulates in the stomach. The level of nitrite in the gastric juice during treatment with anti-secretory medication is particularly high after a nitrate-containing meal. Powerful anti-secretory medication also lowers the intragastric concentration of ascorbic acid and total vitamin C, probably because of the relative instability of the vitamin at a higher pH. These changes in the intragastric concentrations of nitrite and ascorbic acid are most marked in Helicobacter pylori -infected subjects on proton pump inhibitor therapy. It is recognized that an elevated nitrite-to-ascorbic acid ratio predisposes to the formation of potentially carcinogenic N -nitroso compounds. It is, however, unclear at present whether such compounds are formed within the human stomach.

Glycans as legislators of host-microbial interactions: spanning the spectrum from symbiosis to pathogenicity

The number of microbes associated with our gut likely exceeds our total number of somatic and germ cells. Despite their numbers, almost nothing is known about the molecular mechanisms that determine whether the interaction between a microbial species and its host will be beneficial. Recent results obtained from in vivo models have revealed critical roles for glycoconjugates in helping define the outcome of two such host-microbial relationships. In one case, attachment of Helicobacter pylori to fucosylated or sialylated glycans produced by various gastric epithelial lineages and their progenitors skews the destiny of colonization toward pathogenicity. In the second case, a molecular dissection of how Bacteroides thetaiotaomicron, a normal inhabitant of the distal small intestine, is able to communicate with intestinal epithelial cells has revealed a novel role for host fucosylated glycans in forging a mutually beneficial relationship. These observations lend support to the hypothesis that the capacity to synthesize diverse carbohydrate structures may have arisen in part from our need to both evade pathogenic relationships and to coevolve symbiotic relationships with our nonpathogenic resident microbes.

Omeprazole, Helicobacter pylori status, and alterations in the intragastric milieu facilitating bacterial N-nitrosation

BACKGROUND & AIMS

Omeprazole produces greater acid inhibition in Helicobacter pylori-positive than -negative subjects. We investigated whether this is accompanied by more profound changes in the intragastric milieu that facilitates bacterial synthesis of N-nitroso compounds.

METHODS

Gastric juice pH; nitrite, ascorbic acid, and total vitamin C concentrations; and colonization by other bacteria were examined before and during omeprazole treatment in subjects with and without H. pylori infection. Studies were performed in the fasting state and after consumption of 2 mmol nitrate (equivalent to a salad meal).

RESULTS

Before omeprazole, H. pylori-positive and -negative subjects were similar for all parameters. During omeprazole, H. pylori-positive subjects had a higher intragastric pH (7.8 vs. 3.0; P < 0.00001) and greater colonization with non-H. pylori species (5 x 10(7) vs. 5 x 10(5) CFU/mL; P < 0.05). These bacteria included nitrosating species. During omeprazole treatment, H. pylori-positive subjects had higher intragastric nitrite levels after the nitrate meal (median area under the concentration/time curve, 12,450 vs. 4708 micromol/L. min; P = 0.04). Omeprazole lowered intragastric vitamin C levels in H. pylori-positive but not -negative subjects (1.8 vs. 3.4 microg/mL, respectively; P = 0.02).

CONCLUSIONS

In H. pylori-positive subjects, omeprazole produces disturbances in intragastric nitrite, vitamin C, and bacterial colonization that facilitate bacterial N-nitrosation. This may place them at increased risk of mutagenesis and carcinogenesis.

Review article: potential gastrointestinal effects of long-term acid suppression with proton pump inhibitors

This review examines the evidence for the development of adverse effects due to prolonged gastric acid suppression with proton pump inhibitors. Potential areas of concern regarding long-term proton pump inhibitor use have included: carcinoid formation; development of gastric adenocarcinoma (especially in patients with Helicobacter pylori infection); bacterial overgrowth; enteric infections; and malabsorption of fat, minerals, and vitamins. Prolonged proton pump inhibitor use may lead to enterochromaffin-like cell hyperplasia, but has not been demonstrated to increase the risk of carcinoid formation. Long-term proton pump inhibitor treatment has not been documented to hasten the development or the progression of atrophic gastritis to intestinal metaplasia and gastric cancer, although long-term studies are required to allow definitive conclusions. At present, we do not recommend that patients be tested routinely for H. pylori infection when using proton pump inhibitors for prolonged periods. Gastric bacterial overgrowth does increase with acid suppression, but important clinical sequelae, such a higher rate of gastric adenocarcinoma, have not been seen. The risk of enteric infection may increase with acid suppression, although this does not seem to be a common clinical problem with prolonged proton pump inhibitor use. The absorption of fats and minerals does not appear to be significantly impaired with chronic acid suppression. However, vitamin B12 concentration may be decreased when gastric acid is markedly suppressed for prolonged periods (e.g. Zolllinger-Ellison syndrome), and vitamin B12 levels should probably be assessed in patients taking high-dose proton pump inhibitors for many years. Thus, current evidence suggests that prolonged gastric acid suppression with proton pump inhibitors rarely, if ever, produces adverse events. Nevertheless, continued follow-up of patients taking proton pump inhibitors for extended periods will provide greater experience regarding the potential gastrointestinal adverse effects of long-term acid suppression.

Omeprazole and dietary nitrate independently affect levels of vitamin C and nitrite in gastric juice

BACKGROUND & AIMS

Hypochlorhydria is associated with an increased risk of gastric cancer. We have studied the effect of pharmacologically induced hypochlorhydria on the gastric juice ascorbate/nitrite ratio, which regulates the synthesis of potentially carcinogenic N-nitroso compounds.

METHODS

Saliva, gastric juice, and serum from 20 healthy volunteers (9 positive for Helicobacter pylori), with a mean age of 30 years (range, 20-47 years), were analyzed for nitrite, ascorbic acid, and total vitamin C before and for 2 hours after ingestion of 2 mmol [corrected] nitrate (nitrate content of a standard salad meal). This was repeated after 4 weeks of treatment with omeprazole, 40 mg daily.

RESULTS

Before omeprazole treatment, the nitrate meal lowered gastric ascorbic acid levels from 3.8 to 0.9 microg/mL (P < 0.05) and increased median salivary nitrite levels from 44 to 262 micromol/L (P < 0.001); gastric nitrite concentration remained undetected in 10 subjects. Omeprazole increased median fasting gastric nitrite levels from 0 to 13 micromol/L (P = 0.001) and decreased fasting gastric ascorbic acid levels from 3.8 to 0.7 microg/mL (P < 0.001). With omeprazole treatment, gastric nitrite levels after the nitrate meal were markedly increased at 154 micromol/L (range, 49-384 micromol/L; P < 0.001). In H. pylori-infected subjects, omeprazole also decreased total vitamin C levels in both gastric juice and serum.

CONCLUSIONS

Omeprazole and dietary nitrate independently decrease the ascorbate/nitrite ratio. This may lead to an increased risk of gastric cancer.

Ethnic variations in the occurrence of gastroesophageal cancers

Cancers of the esophagus, gastroesophageal junction (including the gastric cardia), and stomach represent three separate diseases with marked epidemiologic variations. The Department of Veterans Affairs computerized database records the ethnicity of all hospitalized patients throughout the United States, which provides an opportunity to study the influence of ethnicity on cancer rates in a uniform health-care system. All hospitalized patients, from 1980 through 1995, with a diagnosis of upper gastrointestinal cancer were identified. For each ethnic group and cancer type, hospitalization was expressed as an age-adjusted proportional rate per 10,000 hospitalizations from all causes. Hospitalization with gastric cancer was most frequent among Asians (48.4 per 10,000 hospitalizations) followed by blacks (33.3), Hispanics (28.7), American Indians (20.3), and whites (12.0). Adenocarcinoma of the gastroesophageal junction accounted for 5.9 per 10,000 hospitalizations among Asians, 4.5 among whites, and 4.5 among Hispanics. Gastroesophageal junction cancer was lowest among blacks (2.9) and American Indians (2.4). Finally, squamous cell carcinoma of the esophagus was frequent among blacks, 68.2 per 10,000, followed by Hispanics (36.4) and Asians (27.8), and was low among whites 24.0 and American Indians (21.5). Esophageal cancer rates remained stable in all ethnic groups from 1980 through 1995; gastroesophageal junction cancer rates increased particularly among whites, whereas gastric cancer rates declined in whites and blacks but not in Hispanics. There were significant ethnic differences in the occurrence of gastroesophageal malignancies among US military veterans. Environmental factors may explain some of these differences. Differential rates of Helicobacter pylori infection with resultant gastric atrophy and reduced acid output led to a greater risk for gastric cancer, but a reduced risk for reflux disease and cardiac cancer.

Co-existing gastric cancer and duodenal ulcer disease: role of Helicobacter pylori infection

BACKGROUND

The association of gastric cancer and chronic duodenal ulcer disease is considered rare. In fact duodenal ulcer disease is believed to somehow "protect" against the development of gastric cancer. Helicobacter pylori infection is an important factor in the development of gastric cancer. No detailed investigation on the prevalence of H. pylori in coexistence of gastric cancer and duodenal ulcer disease has been performed. We evaluated the frequency of H. pylori infection in the patients with co-existence of gastric cancer and duodenal ulcer disease.

MATERIALS AND METHODS

During the period March 1994 to February 1995, we collected data from 3,652 patients in whom esophagogastroduodenoscopy was done. During this period, when the cancerous or ulcerative lesions in stomach or duodenum were found, rapid urease tests were performed.

RESULTS

Six patients had concurrent gastric carcinoma and duodenal ulcer disease. Three of the cases had early gastric carcinoma; 2 had active duodenal ulcers and one had a duodenal ulcer scar; all 3 had positive rapid urease tests. The patients with early gastric cancer were younger than the individuals with advanced gastric cancer.

CONCLUSIONS

The co-existence of both diseases may be higher than reported from Western countries or from Peru which may either reflect the high prevalence of circulation of H. pylori ulcer and cancer strains in Korea and the co-infection with both types of organism in some individuals.

Gastric cancer distal to the cardia--prevention or cure?

Adenocarcinoma of the stomach distal to the cardia remains one of the most common cancers in the world. The interest in the aetiology of this disease has been rekindled because of recent epidemiological and molecular studies linking this cancer to H. pylori and certain dietary factors. The authors provide an updated review of the aetiology of gastric cancer. This review seeks to summarize the disease, to propose pathways of carcinogenesis and to suggest ways in which the "traditional" risk factors may be interpreted on the basis of evolving knowledge.

The risk of stomach cancer in patients with gastric or duodenal ulcer disease

BACKGROUND

Helicobacter pylori infection, now considered to be a cause of gastric cancer, is also strongly associated with gastric and duodenal ulcer disease. The discovery of these relations has brought the long-controversial connection between peptic ulcers and gastric cancer into focus.

METHODS

We estimated the risk of stomach cancer in a large cohort of hospitalized patients with gastric or duodenal ulcers, as recorded in the Swedish Inpatient Register between 1965 and 1983. Altogether, 57,936 patients were followed through 1989, for an average of 9.1 years. The standardized incidence ratio--the ratio of the observed number of cancers to the number expected on the basis of the incidence in the Swedish population at large--was used as a measure of relative risk.

RESULTS

After peaking in the first 3 years of follow-up, the standardized incidence ratio for gastric cancer among 29,287 patients with gastric ulcers leveled off at 1.8 (95 percent confidence interval, 1.6 to 2.0) and remained significantly increased throughout follow-up, which was as long as 24 years for some patients. Prepyloric ulcer, diagnosed in 8646 patients, was not associated with a significant excess risk (standardized incidence ratio, 1.2; 95 percent confidence interval, 0.8 to 1.6). In the cohort of patients with duodenal ulcers (24,456 patients), the incidence of gastric cancer was significantly lower than expected. After the second year of follow-up, the standardized incidence ratio was only 0.6 (95 percent confidence interval, 0.4 to 0.7) and remained stable thereafter.

CONCLUSIONS

Gastric ulcer disease and gastric cancer have etiologic factors in common. A likely cause of both is atrophic gastritis induced by H. pylori. By contrast, there appear to be factors associated with duodenal ulcer disease that protect against gastric cancer.

The role of Helicobacter pylori in pathogenesis: the spectrum of clinical outcomes

Helicobacter pylori is probably the commonest bacterial infection worldwide and is now accepted as the cause of chronic active type B gastritis. Most patients continue through life with a chronic superficial gastritis while some develop either duodenal or gastric ulcer. In a very small proportion the lymphoid reaction to H. pylori infection appears to progress to become a mucosal associated lymphoid tissue (MALT) lymphoma, while in others the evidence suggests that chronic superficial gastritis progresses to atrophy, the loss of gastric acid secretory capacity and the development of gastric cancer. The mechanisms involving H. pylori infection in peptic ulceration are increasingly well understood and H. pylori is now accepted as having a critical role in duodenal ulcer, where the prevalence of infection is 90 to 95%. More important is the dramatic reduction in duodenal ulcer recurrence after successful eradication of the organism to about 4% in a year compared to recurrences of up to 80% in those who ulcers have been healed but in whom the infection persists. There is also increasing evidence for the involvement of H. pylori in gastric ulcer, where infection is seen in between 60 and 80%, and there is a similar dramatic reduction in recurrence following cure of H. pylori infection. The progression of H. pylori gastritis from the acute infection to chronic superficial gastritis, predominantly antral gastritis or a pangastritis with increasing atrophy appears to be associated with the differing outcomes seen in this disease. Moreover, there is increasing data on the roles played by bacterial heterogeneity and the virulence of the organism, host factors such as the HLA genotype and immune response, environmental factors and the age of acquisition of infection play in determining these clinical outcomes of the disease.

Omeprazole inhibits growth of cancer cell line of colonic origin

The direct effects of omeprazole on colonic cells has not been evaluated. Controversy exists regarding the potential adverse effects of omeprazole on cell proliferation. In order to mimic the in vivo situation in the patient treated with omeprazole, proliferation cell culture experiments were performed, monitoring directly the effects of gastrin and omeprazole both alone and in combination. Three colonic cancer cell lines were used, two with neuroendocrine features (NCI-H716, LCC-18) and one (DLD-1) not known to have these features. In these in vitro proliferation experiments, only the NCI-H716 colorectal cancer cell line responded to omeprazole by decreased proliferation (P < 0.05). The effect was concentration dependent shown for all doses of omeprazole used. Gastrin had a statistically significant effect on increasing proliferation in the NCS-H716 cell line alone but only at the highest concentration (10(-6) M). Omeprazole has a cytostatic effect on one of three colorectal cancer cell lines but the mechanism for this effect of omeprazole and its potential role in treatment awaits elucidation.

Pathophysiological effects of long-term acid suppression in man

A critical evaluation has been made of the available evidence in man of the effects of prolonged low acid states on the structure and function of the stomach. Various human models have been examined. 1. Ageing does not affect acid output from the normal male stomach, and there may be an increase in women. With progressive atrophy of the corpus mucosa, which is more frequent and rapid in patients with gastric ulcer, there is an associated loss of secretory function. Chronic gastritis and atrophy are the most important age-related changes, which in many cultures are hypothesized to develop via a prior Helicobacter pylori-related gastritis. However, H. pylori colonization of the mucosa decreases with increasing grades of gastric atrophy probably because intestinal metaplasia provides a hostile environment. Atrophy and intestinal metaplasia are associated with precancerous lesions and gastric cancer. Apparent hyperplasia of the gastric argyrophil endocrine cells is a common and spontaneous phenomenon in patients with atrophic gastritis, which in part may be related to the preferential loss of nonendocrine cells. 2. Pernicious anemia is associated with a complete lack of acid production, marked hypergastrinemia, and endocrine cell hyperplasia in the majority of patients. ECL-cell carcinoids and gastric cancer occur with a prevalence of 3-7%, and endoscopic surveillance in routine clinical practice is not warranted. 3. Gastric ECL-cell carcinoids are rare events that have been described in association with two diseases in man, pernicious anemia and Zollinger-Ellison syndrome as part of multiple endocrine neoplasia syndrome type I, and usually relate to marked hypergastrinemia and the presence of chronic atrophic gastritis with gastric antibodies or a genetic defect rather than the presence or absence of acid. Regression or disappearance of ECL-cell carcinoids, either spontaneously or after removal of the gastrin drive, has been recorded. Lymph node, and rarely hepatic, metastases are documented but death in these cases has been anecdotal. 4. Therapy with H2 antagonists may result in up to a twofold rise in serum gastrin levels but in man no endocrine cell hyperplasia has been recorded. However, the data for H2 antagonists on these aspects are very limited. There is no drug-related risk of gastric or esophageal cancer, although the incidence of the latter may be raised. Long-term treatment with omeprazole is associated with a two- to fourfold increase in gastrin levels over baseline values in one third of patients and apparent endocrine cell hyperplasia in 7% of cases overall.(ABSTRACT TRUNCATED AT 400 WORDS)

Precursors of gastric carcinoma: a critical review with a brief description of early (curable) gastric cancer

Gastric adenocarcinoma is among the most common malignancies worldwide. Its etiopathogenesis is complex and, as yet, incompletely understood; however, diet, infection with Helicobacter pylori, and genetic factors are involved. It may be classified into two main types, intestinal and diffuse. The intestinal type has decreased in incidence, whereas the diffuse tumors as well as those confined to the cardia are increasing. Numerous conditions, such as gastritis, gastric atrophy, and intestinal metaplasia (IM), are associated with intestinal type gastric cancer in retrospective studies, but only epithelial dysplasia has a positive predictive value for malignancy. These precursor conditions and lesions are analyzed for their clinicopathological significance in this review, which concludes with a brief summary of curable (early) forms of gastric cancer.