Gastric biopsies: increasing the yield

Endoscopic multiple biopsy and rapid diagnosis by in situ fixation and histopathologic processing

BACKGROUND AND AIMS

Endoscopic forceps biopsy and fixation are laborious and prolong the procedure and anesthesia. Multiple biopsy overcomes these shortcomings with a single endoscope pass that cuts, like a needle biopsy, up to 25 biopsy samples of uniform size and depth during endoscope withdrawal. Biopsy specimens are collected in acquisition order and stored in a perforated plastic storage chamber within the perforated metal tip. The tip is cut off, immersed in fixative, and sent to pathology. A formatted log identifies each biopsy specimen by site and position. In pathology, the plastic storage cylinder, designed for processing and microtomy with biopsy specimens in situ, supports rapid diagnosis by frozen section and microwave or routine paraffin processing.

METHODS

After a 10-patient Institutional Review Board safety study and US Food and Drug Administration registration, biopsies were performed in 57 patients during colonoscopy, upper GI endoscopy, and ERCP. A blinded retrospective study compared colon surveillance biopsies in 15 patients who underwent multiple biopsy with 15 patients who underwent forceps biopsies performed by anonymous physicians on the same day. Patient information was removed from slides, and forceps biopsies were oriented manually for blinding.

RESULTS

Multiple biopsy specimens fixed and processed in situ were not significantly different from batched processed forceps biopsy specimens for depth, orientation, fixation, artifacts, and diagnostic information. Multiple biopsy colonic specimens were significantly (26%) smaller with better epithelial preservation than forceps specimens. Each biopsy saves 61 seconds during withdrawal.

CONCLUSIONS

Single-pass multiple biopsy reduces biopsy time with less specimen damage, work, workplace risk, and soiling. Diagnostic quality is equal to forceps biopsy with better epithelial preservation, although 26% smaller. In pathology, in situ processing and microtomy reduce work and workplace risk. Grossing and manual orientation are unnecessary. Rapid diagnosis by frozen section and microwave or paraffin processing are facilitated. Multiple biopsy speeds diagnosis and improves productivity in endoscopic biopsy and histopathologic processing.

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

BACKGROUND AND AIMS

Gastric atypical cell (GAC), an indefinite pathologic finding, often requires repeated biopsy or other diagnostic treatments, such as endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), or operation (OP). The aim of this study was to analyze the initial endoscopic and histologic findings of GAC and to discuss the necessity of EMR/ESD at establishing a correct diagnosis.

METHODS

This retrospective study enrolled 96 patients proven as GAC on index forceps biopsy. ESD (17/96, 17.7%), EMR (5/96, 5.2%), OP (20/96, 20.8%), and other treatment or follow-up (54/96, 56.3%) were performed. We analyzed the initial endoscopic and histologic characteristics of GAC lesions, predictive of neoplasm.

RESULTS

After diagnostic modalities, the final pathologic diagnoses were cancer (36/96, 37.6%), dysplasia (9/96, 9.4%), and non-neoplasm (51/96, 53.0%). In univariate analysis, age [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.07], lesion size of 10 mm or greater (OR 3.94, 95% CI 1.61-9.61), lesion with depressed type (OR 2.50, 95% CI 1.09-5.72), and presence of H. pylori (OR 2.83, 95% CI 1.11-7.25) were risk factors for neoplasm. In multivariate analysis, lesion size of 10 mm or greater (OR 3.63, 95% CI 1.23-10.66), lesion with depressed type (OR 2.86, 95% CI 1.11-7.38) were independent risk factors for cancer.

CONCLUSION

Considering the neoplastic risk of GAC, which could be missed on biopsy, more comprehensive tissue sampling via EMR/ESD might be necessary to establish a definite diagnosis.

Is lesion size an independent indication for endoscopic resection of biopsy-proven low-grade gastric dysplasia?

BACKGROUND/AIM

The standard treatment for patients with gastric low-grade dysplasia (LGD) remains controversial, even though diagnosis of LGD is increasingly common as esophagogastrodeuodenoscopy becomes more available. The aim of this study was to identify a lesion size cut-off as an indication for endoscopic resection (ER) for patients with LGD.

RESULTS

We retrospectively reviewed 285 lesions initially diagnosed as LGD by endoscopic forceps biopsies (EFB) from 2007 to 2010 in Kyung Hee University Hospital, Seoul, Korea. All patients underwent ER. A total of 285 lesions from 257 patients were assessed. After ER, 239 LGD (83.9 %) showed histological concordance and the remaining 46 (16.1 %) cases revealed an upgraded histology [22 high-grade dysplasia (7.7 %), and 24 differentiated adenocarcinoma (8.4 %)]. Univariate analyses demonstrated that lesion size, erythema, depression, and erosion were significant predictors of upgraded LGD (P < 0.001). Multivariate analysis showed that a lesion size ≥2 cm, erythema, and a depressed-type lesion were independent predictors of upgraded histology (P = 0.014, odds ratio 3.27, 95 % confidence interval 1.28-8.39).

CONCLUSIONS

Our data suggest that a substantial number of LGD diagnoses based on EFB were not representative of the entire lesion. We recommend ER if gastric LGD has at least one of the following risk factors: surface erythema and a depressed type regardless of size, or ≥2 cm size regardless of abnormal surface configuration.