Gastric epithelial dysplasia: the Western perspective

Well-differentiated Adenocarcinoma Arising from Gastric Cystica Profunda Treated by Endoscopic Submucosal Dissection: A case report and literature review

Gastritis cystica profunda (GCP) is a rare disease that is often observed at the stoma site of patients undergoing gastric surgery. Specific symptoms are often lacking, making it difficult to diagnose. GCP may develop into cancer. Endoscopic resection is a good method to reduce surgical injury, and the therapeutic effect depends on the status of the primary disease.The patient was a 77-year-old male who was admitted to the hospital for repeated epigastric distention. The man had never undergone gastric surgery and did not have Helicobacter pylori infection. Physical and laboratory tests showed no abnormality. Computed tomography showed no significant abnormality. Endoscopy revealed multiple ulcers on the posterior wall of the gastric body, but biopsy showed no evidence of malignancy. The patient subsequently underwent ESD surgery with a lesion of 1.5 cm×2.3 cm. Pathological results showed the cystic dilatation of gastric glands in the submucosa, with some well-differentiated adenocarcinoma. The final diagnosis was GCP with well-differentiated gastric adenocarcinoma.Herein, we describe a case of ESD therapy for GCP with well-differentiated gastric adenocarcinoma. When gastric mucosal lesions are difficult to diagnose, further treatment and diagnosis with EMR or ESD can be considered. For patients with early gastric cancer, long-term postoperative monitoring should be carried out.

Systematic inference of super-resolution cell spatial profiles from histology images

Inferring cell spatial profiles from histology images is critical for cancer diagnosis and treatment in clinical settings. In this study, we report a weakly-supervised deep-learning method, HistoCell, to directly infer super-resolution cell spatial profiles consisting of cell types, cell states and their spatial network from histology images at the single-nucleus-level. Benchmark analysis demonstrates that HistoCell robustly achieves state-of-the-art performance in terms of cell type/states prediction solely from histology images across multiple cancer tissues. HistoCell can significantly enhance the deconvolution accuracy for the spatial transcriptomics data and enable accurate annotation of subtle cancer tissue architectures. Moreover, HistoCell is applied to de novo discovery of clinically relevant spatial organization indicators, including prognosis and drug response biomarkers, across diverse cancer types. HistoCell also enable image-based screening of cell populations that drives phenotype of interest, and is applied to discover the cell population and corresponding spatial organization indicators associated with gastric malignant transformation risk. Overall, HistoCell emerges as a powerful and versatile tool for cancer studies in histology image-only cohorts.

Long-term outcomes after endoscopic submucosal dissection for relative indication early gastric cancer in nonsurgical candidates

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is effective in treating early gastric cancer (EGC). Its role in patients with comorbidities along with more advanced disease is unknown. We sought to evaluate this in a large Western cohort.

METHODS

Consecutive patients who underwent ESD for EGC in a single tertiary Western endoscopy center over 10 years were prospectively analyzed. The primary outcomes were long-term overall survival (OS) and disease-free survival (DFS) up to 5 years. Secondary outcomes were efficacy and serious adverse events (SAEs).

RESULTS

ESD for 157 cases of EGC in 149 patients was performed in an elderly and comorbid cohort with a mean age of 73.7 years and age-adjusted Charlson Comorbidity Index of 4.2. Over a median follow-up of 51.6 months, no significant differences were found in 5-year OS (88.9% vs 77.9%, P = .290) and DFS (83.2% vs 75.1%, P = .593) between absolute indication EGC and relative indication (RI) EGC. The absolute indication EGC cohort achieved higher en bloc (96.3% vs 87.5%, P = .069) and R0 resection rates (93.6% vs 62.5%, P < .001) when compared with RI EGC. No significant differences were found in SAEs (7.3% vs 12.5%, P = .363). No mortality or surgical resection ensued from adverse events from ESD.

CONCLUSIONS

ESD safely confers DFS in poor surgical candidates with RI EGC in a large Western cohort. Patients who are elderly and/or with comorbidities or who decline surgical resection may benefit from ESD and avoid the risks of surgery and its long-term sequelae. (Clinical trial registration number: NCT02306707.).

Oncogenic Fatty Acid Metabolism Rewires Energy Supply Chain in Gastric Carcinogenesis

BACKGROUND & AIMS

Gastric carcinogenesis develops within a sequential carcinogenic cascade from precancerous metaplasia to dysplasia and adenocarcinoma, and oncogenic gene activation can drive the process. Metabolic reprogramming is considered a key mechanism for cancer cell growth and proliferation. However, how metabolic changes contribute to the progression of metaplasia to dysplasia remains unclear. We have examined metabolic dynamics during gastric carcinogenesis using a novel mouse model that induces Kras activation in zymogen-secreting chief cells.

METHODS

We generated a Gif-rtTA;TetO-Cre;KrasG12D (GCK) mouse model that continuously induces active Kras expression in chief cells after doxycycline treatment. Histologic examination and imaging mass spectrometry were performed in the GCK mouse stomachs at 2 to 14 weeks after doxycycline treatment. Mouse and human gastric organoids were used for metabolic enzyme inhibitor treatment. The GCK mice were treated with a stearoyl- coenzyme A desaturase (SCD) inhibitor to inhibit the fatty acid desaturation. Tissue microarrays were used to assess the SCD expression in human gastrointestinal cancers.

RESULTS

The GCK mice developed metaplasia and high-grade dysplasia within 4 months. Metabolic reprogramming from glycolysis to fatty acid metabolism occurred during metaplasia progression to dysplasia. Altered fatty acid desaturation through SCD produces a novel eicosenoic acid, which fuels dysplastic cell hyperproliferation and survival. The SCD inhibitor killed both mouse and human dysplastic organoids and selectively targeted dysplastic cells in vivo. SCD was up-regulated during carcinogenesis in human gastrointestinal cancers.

CONCLUSIONS

Active Kras expression only in gastric chief cells drives the full spectrum of gastric carcinogenesis. Also, oncogenic metabolic rewiring is an essential adaptation for high-energy demand in dysplastic cells.

The features of gastric epithelial reactive hyperplastic lesions under magnifying endoscopy combined with narrow-band imaging

BACKGROUND AND PURPOSE

Gastric reactive hyperplasia (RH) is a common benign lesion of the gastric mucosa that can be resolved by conservative treatment without endoscopic intervention. Some RH lesions are indistinguishable from low-grade intraepithelial neoplasia (LGIN) lesions of gastric mucosa under endoscopy. The aim of this study was to investigate the morphological features of RH lesions under magnifying endoscopy combined with narrow-band imaging (ME-NBI).

METHODS

A retrospective study of 653 patients with superficial suspicious lesions of gastric mucosa was performed. According to the pathological results of biopsies, the final included lesions were divided into the RH group (n = 88) and LGIN group (n = 138). We analysed the microvascular and microsurface patterns of these lesions under ME-NBI, extracted the most significant combination of endoscopic features of RH lesions, and evaluated their diagnostic performance.

RESULTS

ME-NBI characteristics that could distinguish RH lesions from LGIN lesions after univariate analysis were included in multivariate logistic regression. The results showed that ten characteristics, including intervening part (IP) length homogeneity, type III gastric pit pattern and homogeneity of marginal crypt epithelium (MCE), were statistically significant. Receiver operating characteristic (ROC) analysis showed that the triad of these features was the best combination for diagnosing RH lesions with an AUC of 0.886 (95% confidence interval; 0.842-0.929), the sensitivity of 85.5% and specificity of 79.5%.

CONCLUSIONS

The triad of IP length homogeneity, type III pit pattern and MCE homogeneity under ME-NBI helps endoscopists to identify gastric RH lesions, thereby avoiding unnecessary biopsy and repeat endoscopy due to misjudgment of neoplastic lesions.

Clinical value of serum Mg7-Ag detection combined with magnifying endoscopy with narrow-band imaging in diagnosis of high-risk gastric low-grade intraepithelial neoplasia

BACKGROUND

Human gastric cancer associated antigen (Mg7-Ag) can be highly expressed in gastric cancer cell lines, and is closely related to gastric cancer progression. Magnifying endoscopy with narrow-band imaging (ME-NBI) has high sensitivity and specificity in the diagnosis of early gastric cancer, especially for differentiated gastric cancer. This study assessed the clinical diagnostic value of serum Mg7-Ag detection combined with ME-NBI for high-risk low grade intraepithelial neoplasia (LGIN).

AIM

To evaluate the clinical value of serum Mg7-Ag detection combined with ME-NBI in judging whether there is pathological upgrading of gastric LGIN after endoscopic dissection (ESD).

METHODS

Patients who were diagnosed with LGIN at our hospital from January 2019 to December 2022 and underwent diagnostic ESD within 1 mo were selected and divided into a high-risk group (pathologically upgraded), a low-risk group (pathologically not upgraded), and an inflammation group (pathologically downgraded) according to the differences in pathological results after ESD and preoperative endoscopic biopsy. Serum Mg7-Ag levels were detected in all cases within 1 week before ESD, and gastroscopic ME-NBI screening was performed. The levels of serum Mg7-Ag, the number of Mg7-Ag (+) and Mg7-Ag (-) patients, and the number of ME-NBI (+) and ME-NBI (-) patients in the three groups were recorded. The sensitivity, specificity, accuracy, and positive likelihood ratio of serum Mg7-Ag and ME-NBI, alone and in combination, for predicting pathological upgrading after ESD of LGIN lesions were calculated and analyzed.

RESULTS

A total of 125 patients with gastric LGIN who underwent diagnostic ESD were included in this study, including 37 in the high-risk group, 76 in the low-risk group, and 12 in the inflammation group. Serum Mg7-Ag levels were significantly different among the three groups (P < 0.05), and Mg7-Ag levels in the high-risk group were significantly higher than those in the low-risk group and the inflammation group (P < 0.05). The positive rate of ME-NBI in the inflammation group was significantly lower than those in the other two groups (P < 0.05), and the rate in the high-risk group was higher than that in the low-risk group (P < 0.05). There was no significant difference in the sensitivity, specificity, accuracy, and positive likelihood ratio of Mg7-Ag and ME-NB alone in predicting the pathological upgrading of LGIN (P > 0.05). The sensitivity of combined Mg7-Ag detection and ME-NBI in predicting high-risk LGIN was slightly lower than that of either of them alone; the specificity was 90.5%, the accuracy was 84.0%, and the positive likelihood ratio was 2.417, all of which were significantly higher than those of single tests (P < 0.05). When Mg7-Ag + ME-NBI results were negative, the accuracy and positive likelihood for cases in the inflammation group were significantly higher than those of single tests (P < 0.05).

CONCLUSION

Combined serum Mg7-Ag detection and ME-NBI screening has important clinical value in judging whether gastric LGIN lesions will undergo pathological upgrading.

Ginsenoside Rg3 induces apoptosis and inhibits proliferation by down-regulating TIGAR in rats with gastric precancerous lesions

BACKGROUND

Ginsenoside Rg3 (GRg3) is one of the main active ingredients in Chinese ginseng extract and has various biological effects, such as immune-enhancing, antitumour, antiangiogenic, immunomodulatory and anti-inflammatory effects. This study aimed to investigate the therapeutic effect of GRg3 on gastric precancerous lesion (GPL) induced by N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) and the potential mechanism of action.

METHODS

The MNNG-ammonia composite modelling method was used to establish a rat model of GPL. Histopathological changes in the rat gastric mucosa were observed by pathological analysis using haematoxylin-eosin staining to assess the success rate of the composite modelling method. Alcian blue-periodic acid Schiff staining was used to observe intestinal metaplasia in the rat gastric mucosa. Apoptosis was detected in rat gastric mucosal cells by terminal deoxynucleotidyl transferase-mediated dUTP nick end labelling staining. The production level of reactive oxygen species (ROS) was determined by the dihydroethidium fluorescent probe method, and that of TP53-induced glycolysis and apoptosis regulator (TIGAR) protein was determined by immunohistochemical staining and western blotting. The production levels of nicotinamide adenine dinucleotide phosphate (NADP) and glucose-6-phosphate dehydrogenase (G6PDH) were determined by an enzyme-linked immunosorbent assay, and that of glutathione (GSH) was determined by microanalysis.

RESULTS

GRg3 significantly alleviated the structural disorganization and cellular heteromorphism in the form of epithelial glands in the gastric mucosa of rats with GPL and retarded the progression of the disease. Overexpression of TIGAR and overproduction of NADP, GSH and G6PDH occurred in the gastric mucosal epithelium of rats with GPL, which in turn led to an increase in the ROS concentration. After treatment with GRg3, the expression of TIGAR and production of NADP, GSH G6PDH decreased, causing a further increase in the concentration of ROS in the gastric mucosal epithelium, which in turn induced apoptosis and played a role in inhibiting the abnormal proliferation and differentiation of gastric mucosal epithelial cells.

CONCLUSION

Grg3 can induce apoptosis and inhibit cell proliferation in MNNG-induced GPL rats. The mechanism may be related to down-regulating the expression levels of TIGAR and production levels of GSH, NADP and G6PD, and up-regulating the concentration of ROS.

Comparison of Endoscopic Radiofrequency Ablation and Argon Plasma Coagulation in Patients with Gastric Low-Grade Intraepithelial Neoplasia: A Large-Scale Retrospective Study

BACKGROUND

Gastric low-grade intraepithelial neoplasia (LGIN) is a precancerous lesion of gastric cancer. Endoscopic therapies represented by radiofrequency ablation (RFA) and argon plasma coagulation (APC) have been applied to treat gastric LGIN in recent years. However, no comparative study examining the effectiveness and safety profiles of RFA and APC has been reported.

METHODS

A single-center, large-scale, retrospective study, including 73 and 50 patients treated with RFA and APC, respectively, was conducted in the First Medical Center of Chinese PLA General Hospital from October 2015 to October 2020, with a two-year follow-up. Effectiveness, complications, operative factors, and other data were assessed.

RESULTS

At 2 years of follow-up, cure, relapse, recurrence, and progression rates were 90.4%, 9.6%, 9.6%, and 2.7% in the RFA group, respectively, versus 90%, 10%, 12%, and 4% in the APC group, respectively, with no statistically significant differences between the two groups (all p > 0.05). However, the mean lesion size was significantly larger in the RFA group (2.6 ± 1.0 cm) than in the APC group (1.5 ± 0.6 cm) (p < 0.001); there was also a significant difference in the composition ratio of large lesions between the two groups (p < 0.001). No serious postoperative complications showed in either group, and the abdominal pain was the most common symptom in the short term after surgery.

CONCLUSIONS

RFA and APC are both safe and effective destructive therapies for gastric LGIN. RFA is more suitable for flat and large lesions, while APC is more suitable for small lesions, especially those with slight local uplift or depression. An intraoperative submucosal injection is expected to be an effective method for relieving postoperative abdominal pain.

Methylglyoxal Levels in Human Colorectal Precancer and Cancer: Analysis of Tumor and Peritumor Tissue

Colorectal cancer (CRC) is one of the most common cancers worldwide and its incidence is increasing; therefore, an understanding of its oncogenic mechanisms is critical for improving its treatment and management. Methylglyoxal (MGO) has a highly reactive aldehyde group and has been suggested to play a role in oncogenesis. However, no standardized data are currently available on MGO levels in colorectal precancerous and cancerous lesions. We collected 40 matched colorectal tumor and peritumor tissues from patients with low-grade dysplasia (LGD), high-grade dysplasia (HGD), and invasive cancer (IC). MGO levels increased between LGD, HGD, and IC tumor tissues (215.25 ± 39.69, 267.45 ± 100.61, and 587.36 ± 123.19 μg/g protein, respectively; p = 0.014). The MGO levels in peritumor tissue increased and were significantly higher than MGO levels in tumor tissue (197.99 ± 49.40, 738.09 ± 247.87, 933.41 ± 164.83 μg/g protein, respectively; p = 0.002). Tumor tissue MGO levels did not correlate with age, sex, underlying disease, or smoking status. These results suggest that MGO levels fluctuate in progression of CRC and warrants further research into its underlying mechanisms and function in tumor biology.

Alterations of Gastric Microbiota in Gastric Cancer and Precancerous Stages

Objective

Microbial infections have been shown to contribute to gastric carcinogenesis, the knowledge of gastric microbiota alteration in this process may provide help in early diagnosis of gastric cancer. The aim of this study was to characterize the microbial changes and identify taxonomic biomarkers across stages of gastric carcinogenesis.

Methods

The gastric microbiota was investigated by 16S rRNA gene analysis in gastric mucosal specimens from 47 patients including superficial gastritis (SG), atrophic gastritis (AG), gastric intraepithelial neoplasia (GIN), and gastric cancer (GC). Differences in microbial composition across the disease stages, especially in GIN and GC were assessed using linear discriminant analysis effect size.

Results

There was no gradual changing trend in the richness or diversity of the gastric microbiota across stages of gastric carcinogenesis. The relative abundance of dominant taxa at phylum and genus levels didn’t show a gradual shift pattern, and the only four taxa that continuously enriched from SG to GC were Slackia, Selenomonas, Bergeyella, and Capnocytophaga, all of which were oral bacteria. The most representative taxa which were enriched in GC patients were oral bacteria including Parvimonas, Eikenella and Prevotella-2, and environmental bacteria including Kroppenstedtia, Lentibacillus, and Oceanobacillus. The gastric microbiota in GIN patients were characterized by enrichment of intestinal commensals including Romboutsia, Fusicatenibacter, Prevotellaceae-Ga6A1-group, and Intestinimonas. Gastric cardia cancer and non-cardia cancer patients had significantly different microbiota profiles characterized by a higher abundance of Helicobacter in the cardia cancer patients.

Conclusions

Our results provide insights on potential taxonomic biomarkers for gastric cancer and precancerous stages, and suggest that gastric microbiota might play different roles in the carcinogenesis of cardia cancer and non-cardia cancer.

A Systematic Review of the Mechanisms Underlying Treatment of Gastric Precancerous Lesions by Traditional Chinese Medicine

Gastric precancerous lesions (GPLs) are an essential precursor in the occurrence and development of gastric cancer, known to be one of the most common and lethal cancers worldwide. Traditional Chinese medicine (TCM) has a positive prospect for the prevention and therapy of GPL owing to several advantages including a definite curative effect, fewer side effects compared to other treatments, multiple components, and holistic regulation. Despite these characteristic advantages, the mechanisms of TCM in treating GPL have not been fully elucidated. In this review, we summarize the current knowledge with respect to herbal formulations and the therapeutic mechanisms of TCM active ingredients for GPL. This paper elaborates on the mechanisms of TCM underlying the prevention and treatment of GPL, specifically those that are linked to anti-H. pylori, anti-inflammation, antiproliferation, proapoptotic, antioxidation, antiglycolytic, and antiangiogenesis effects.

Endoscopic submucosal dissection for suspected early gastric cancer: absolute versus expanded criteria in a large Western cohort (with video)

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is an effective, minimally invasive, surgery-sparing technique for the treatment of early gastric cancer (EGC). It is not well established whether EGC within the Japanese expanded criteria can be safely and effectively treated using ESD in the West. We describe the outcomes of ESD for endoscopically suspected, biopsy specimen-confirmed EGC and its adenomatous precursor lesions (pEGC) using the Vienna classification of dysplasia in a Western cohort.

METHODS

Prospective data were collected on all pEGCs undergoing ESD at a single expert endoscopy center. Outcomes were compared among pEGC, satisfying the Japanese absolute and expanded criteria, those outside criteria, and those specimens that contained low-grade dysplasia (LGD) only. Specialist GI pathologists reviewed and classified all ESD specimens. Patients were followed up at 6 and 12 months.

RESULTS

Over 71 months, 135 pEGCs in 121 patients (mean age, 72.0 years; 61.2% men) underwent ESD. Median pEGC size was 20 mm (interquartile range, 15-30), and 62 (45.9%) satisfied the expanded clinical criteria. Perforation occurred in 1.5% and postprocedural bleeding in 5.2%. Forty-two pEGCs (31.1%) contained LGD only. Rates of en bloc and R0 resection were 94.8% and 86.7%, respectively. One hundred seven pEGCs (79.2%) met the absolute or expanded criteria for endoscopic cure. Two pEGCs recurred during follow-up. Ten of 26 patients with pEGC (38.5%) outside criteria for cure underwent surgery after ESD with residual tumor detected in 3 specimens. Fifteen patients with outside criteria for pEGCs did not undergo surgery because of frailty or their expressed wish. Eleven of 15 patients have so far undergone first surveillance with 1 of 11 experiencing endoscopic and histologic recurrence.

CONCLUSIONS

ESD is a safe and effective treatment for pEGCs in a Western context. Patients who either decline or are too frail for surgery, with outside criteria resections, may benefit from ESD for local disease control. Large Western studies of ESD for pEGCs are required to define long-term patient outcomes and surveillance guidelines, particularly where pathology shows LGD or high-grade dysplasia only. (Clinical trial registration number: NCT02306707.).

Initial and crucial genetic events in intestinal-type gastric intramucosal neoplasia

Gastric cancer (GC) is one of the most common and life-threatening malignancies. The course of disease and tumor aggressiveness vary among GCs, although how early fate is determined and by what factors remains elusive. To solve this question, we collected 43 gastric intramucosal neoplasias (GINs), comprising dysplasia/intraepithelial neoplasia (D/IEN; a premalignant lesion) and minute GC (miGC; ≤10 mm) of intestinal histotype and performed targeted deep DNA sequencing of 67 GC-related genes derived from large-scale data. Gastric D/IEN was classified into low or high grade (LG-D/IEN or HG-D/IEN). The most frequent mutations in D/IENs included APC (19/25; 76%), ARID2 (6/25; 24%) and MUC6 (5/25; 20%). All LG-D/IENs had APC mutation (12/12) and APC hotspot mutations affecting R1450 and E1554 were noted in both LG-D/IEN and HG-D/IEN. ARID2 mutation always co-occurred with APC mutation, whose tumor variant allele frequency (TVAF) was higher than that of ARID2 in D/IEN. APC and TP53 mutations were mutually exclusive in D/IEN (p = 0.031 [main cohort], p = 0.025 [expanding cohort]) and TP53-mutated D/IEN was exclusively HG-D/IEN (4/4). TP53 mutations were highly recurrent (11/14; 79%) in MLH1-positive miGCs and were detected even in two microscopic lesions measuring 1 and 3 mm, respectively. Furthermore, TVAF analyses suggested that TP53 mutation is the initial event in the TP53-mutated miGCs. In contrast, TP53 mutation was absent (0/4) in MLH1-negative small intramucosal carcinoma (8-24 mm). Advanced GC data suggested that early mutations (APC and TP53) may affect the potential of cancerous progression from D/IEN. This study revealed somatic mutational landscape and initial mutations of GINs, and we report for the first time that TP53 mutations precede other mutations in intestinal-type GC. Our results also indicate that molecular subtyping based on APC/TP53 mutations would be a high-priority approach for determining and predicting the malignant potential of GIN, including D/IEN. Copyright © 2018 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Use of DNA flow cytometry in the diagnosis, risk stratification, and management of gastric epithelial dysplasia

The natural history of gastric epithelial dysplasia and the consequential surveillance strategies are not well defined in the West. To date, the diagnosis relies on morphology, and no reliable adjunct methods, either immunohistochemical or molecular, have reproducibly been able to confirm the diagnosis and/or risk stratify gastric epithelial dysplasia. Yet, such a tool would be useful in confirming the diagnosis, and developing objective and rational surveillance guidelines. DNA flow cytometry was performed using formalin-fixed paraffin-embedded gastric tissue from 23 cases of high-grade dysplasia and 38 cases of low-grade dysplasia. Twenty-four benign background mucosal samples from the same cohort (20 biopsies and 4 surgical resections from 16 low- and 8 high-grade dysplasia cases) were utilized as controls. The presence of DNA content abnormality (aneuploidy or elevated 4N fraction) correlated with increasing levels of dysplasia, as DNA content abnormality was detected in 18 (78%) of 23 high-grade dysplasia, 5 (13%) of 38 low-grade dysplasia, and none of 24 non-dysplastic samples. 1 and 4-year detection rates of high-grade dysplasia or gastric adenocarcinoma in low-grade dysplasia patients with DNA content abnormality were 80% (p = 0.003) and 100% (p = 0.005), respectively, whereas patients with low-grade dysplasia but with normal DNA content had 1, 4, and 12-year detection rates of 23, 32, and 54%, respectively. The univariate hazard ratio (HR) for subsequent detection of high-grade dysplasia or gastric adenocarcinoma in low-grade dysplasia patients with DNA content abnormality was 6.9 (p = 0.001). Older patients (HR = 1.1, p = 0.005) and those with familial adenomatous polyposis (HR = 9.7, p = 0.029) also had an increased risk for developing high-grade dysplasia or gastric adenocarcinoma in the univariate analysis, but only DNA content abnormality demonstrated a significantly elevated HR of 5.9 in the multivariate analysis (p = 0.005). While older age showed a minimally elevated risk (HR = 1.1, p = 0.013), no other potential risk factors, including male gender, ethnicity, polypoid endoscopic appearance, Helicobacter pylori infection, and intestinal metaplasia, were significantly associated with subsequent detection of high-grade dysplasia or gastric adenocarcinoma in the multivariate analysis. Among the 18 high-grade dysplasia cases with DNA content abnormality, 13 cases (72%) developed gastric adenocarcinoma within a mean follow-up time of 9 months, conferring a HR of 2.5; however, this did not reach statistical significance. In conclusion, the presence of DNA content abnormality can identify a subset of low-grade dysplasia patients who are at increased risk for subsequent detection of high-grade dysplasia or gastric adenocarcinoma. It can also provide confirmatory evidence to a morphologic impression or suspicion of high-grade dysplasia. The majority of gastric epithelial dysplasia patients with DNA content abnormality developed high-grade dysplasia or gastric adenocarcinoma within a year and thus may benefit from more thorough and rigorous endoscopic surveillance.

Weipixiao attenuate early angiogenesis in rats with gastric precancerous lesions

BACKGROUND

Angiogenesis is a pathobiological hallmark of gastric cancer. However, rare studies focus on angiogenesis in gastric precancerous lesions (GPL). Weipixiao (WPX), a Chinese herbal preparation, is proved clinically effective in treating GPL. Here, we evaluated WPX's anti-angiogenic potential for GPL, and also investigated the possibility of its anti-angiogenic mechanisms.

METHODS

HPLC analysis was applied to screen the major chemical components of WPX. After modeling N-methyl-N'-nitro-N-nitrosoguanidine (MNNG)-induced GPL in male Sprague-Dawley rats, different doses of WPX were administrated orally for 10 weeks. Next, we performed histopathological examination using routine H&E staining and HID-AB-PAS staining. In parallel, we assessed angiogenesis revealed by microvessel density (MVD) using CD34 immunostaining, and subsequently observe microvessel ultrastructure in gastric mucosa under Transmission Electron Microscope. Finally, we detect expression of angiogenesis-associated markers VEGF and HIF-1α using immunohistochemistry. Moreover, mRNA expressions of ERK1, ERK2, Cylin D1 as well as HIF-1α in gastric mucosa were determined by quantitative real-time reverse transcription- polymerase chain reaction.

RESULTS

We observed the appearance of active angiogenesis in GPL rats, and demonstrated that WPX could reduce microvascular abnormalities and attenuate early angiogenesis in most of GPL specimens with a concomitant regression of most intestinal metaplasia (IM) and a portion of gastric epithelial dysplasia (GED). In parallel, WPX could suppress HIF-1α mRNA expression (P < 0.01) as well as protein expression (although without statistical significance), and could markedly inhibit VEGF protein expression in GPL rats. Mechanistically, WPX intervention, especially at low dose, caused a significant decrease in the ERK1 and Cylin D1 mRNA levels. However, WPX might probably have no regulatory effect on ERK2 amplification.

CONCLUSIONS

WPX could attenuate early angiogenesis and temper microvascular abnormalities in GPL rats. This might be partly achieved by inhibiting on the angiogenesis-associated markers HIF-1α and VEGF, and on the ERK1/Cylin D1 aberrant activation.

Well-differentiated adenocarcinoma may be misdiagnosed as gastritis cystica profunda

Gastric cancer (GC) is one of the most common malignant tumors in China. The low detection rate of early GC is one of the reasons for its high mortality rate. Thanks to the application of new gastroscopy technology, the detection rate of early GC has increased. Highly differentiated adenocarcinoma accounts for about 70% of all early GC cases; however, well-differentiated adenocarcinoma is difficult to diagnose because of its non-significant structural abnormality and cellular atypia. Gastritis cystica profunda is a rare disease characterized by the presence of the gastric intrinsic gland in the muscularis mucosa and/or submucosa, which is easily confused with highly differentiated adenocarcinoma. Therefore, attention should be paid to the identification of these two different entities in the clinical work.

[Endoscopic Treatment of Gastric Adenoma]

Gastric adenoma (dysplasia) is a precancerous lesion. Therefore, managements of gastric adenomas are important for preventing the development of gastric cancers and for detecting gastric cancers at earlier stages. The Vienna classification divides gastric adenomas into two categories: high-grade dysplasia and low-grade dysplasia. Generally, endoscopic resection is performed for adenoma with high-grade dysplasia due to the coexistence of carcinoma and the potential of progression to carcinomas. However, the treatments of adenoma with low-grade dysplasia remain controversial. Currently two treatment strategies for the low-grade type have been suggested; First is the 'wait and see' strategy; Second is endoscopic treatment (e.g., endoscopic mucosal resection, endoscopic submucosal dissection, or argon plasma coagulation). In this review, we discuss the current optimal strategies for endoscopic management of gastric adenoma.

Diagnosis and management of gastric dysplasia

Gastric dysplasia is a neoplastic lesion and a precursor of gastric cancer. The Padova, Vienna, and World Health Organization classifications were developed to overcome the discrepancies between Western and Japanese pathologic diagnoses and to provide a universally accepted classification of gastric epithelial neoplasia. At present, the natural history of gastric dysplasia is unclear. Much evidence suggests that patients with high-grade dysplasia are at high risk of progression to carcinoma or synchronous carcinoma. Therefore, endoscopic resection is required. Although patients with low-grade dysplasia have been reported to be at low risk of progression to carcinoma, due to the marked histologic discrepancies between forceps biopsy and endoscopic specimens, endoscopic resection for this lesion is recommended, particularly in the presence of other risk factors (large size; depressed gross type; surface erythema, unevenness, ulcer, or erosion; and tubulovillous or villous histology). Helicobacter pylori eradication in patients with dysplasia after endoscopic resection appear to reduce the incidence of metachronous lesions.

Efficacy of endoscopic mucosal resections for the management of small gastric adenomas with low-grade dysplasia

OBJECTIVE

Gastric adenoma with low-grade dysplasia (LGD) can progress to gastric cancer; however, the optimal therapeutic modality for LGD has not been established. The aim of this study was to assess the efficacy, safety of and local recurrence following endoscopic mucosal resection (EMR) for LGD. Specifically, we compared EMR with circumferential precutting (EMR-P) and EMR using a dual-channel endoscope (EMR-D) for the treatment of LGD ≤2 cm.

MATERIALS AND METHODS

A total of 158 lesions from 147 patients with LGD treated by EMR were retrospectively analyzed. The en bloc resection rate, complete resection rate, procedure time, complication rate and local recurrence rate were compared between EMR-P and EMR-D.

RESULTS

The en bloc resection and complete resection rates of EMR were 91.1% and 90.5%, respectively. The bleeding and perforation rates were 1.3% and 1.3%, respectively. The local recurrence rate following EMR was 2.2%. The en bloc resection and complete resection rates did not differ between EMR-P and EMR-D (88.2% vs. 92.5%, p = not significant (NS); and 90.2% vs. 90.7%, p = NS, respectively). The procedure time was significantly longer for EMR-P compared with EMR-D (16 (5-141) vs. 7 (2-48) min, p < 0.001), and the complication rate was significantly higher for EMR-P (7.8% vs. 0.0%, p = 0.010). Local recurrence was not found in EMR-P, whereas the recurrence rate was 3.2% in EMR-D.

CONCLUSION

EMR is an effective method for the treatment of LGD ≤2 cm. Compared with EMR-P, EMR-D appears to be the more effective, technically simple and safer method.

Similarly up-regulated microRNA-106a in matched formalin-fixed paraffin-embedded and fresh frozen samples and the dynamic changes during gastric carcinogenesis and development

Evidence increasingly suggests that miR-106a is always elevated in gastric cancer; however, little is known about the expression trend and clinical significance in the whole process of gastric carcinogenesis and development. To investigate the dynamic changes of miR-106a in each stage during gastric carcinogenesis, we used formalin-fixed, paraffin-embedded (FFPE) tissues which had been reported to have valuable information for miRNA research in our previous studies. Here, we compared the expression of miR-106a in FFPE and fresh frozen tissues using real-time polymerase chain reaction. On the basis of the high correlation of miR-106a quantitative data from the two resources, FFPE samples were subsequently performed to elucidate the location and expression of miR-106a using in situ hybridization in sequential tissues, including normal gastric mucosa, chronic atrophic gastritis combined with various degrees of dysplasia, early and advanced gastric cancer. Finally, we found that miR-106a was similarly up-regulated in gastric cancer regardless of sample types although fragmentation existed inevitably in FFPE tissues. Notably, the frequency and extent of miR-106a expression gradually increased during the transition from atypical hyperplasia to advanced carcinoma and had already had positive signals in early precancerous lesions but negative signals in normal gastric mucosal epithelial cells. Our research, according to these results, indicated that FFPE samples can serve as an important research tool for miRNA field, and the early changes of miR-106a detected in such samples may have clinical application as a potential biomarker for the discovery and diagnosis of gastric cancer.

The risk factors for discrepancy after endoscopic submucosal dissection of gastric category 3 lesion (low grade dysplasia)

BACKGROUND

Treatment with endoscopic submucosal dissection (ESD) for gastric category 3 lesion (low grade dysplasia, LGD) diagnosed by endoscopic forceps biopsy (EFB) is controversial.

AIMS

The purpose of the present study was to validate the use of ESD for gastric LGD diagnosed by EFB and to evaluate predictable factors for pathologic upgrade diagnosis to category 4 (high grade dysplasia, HGD) or 5 (early gastric cancer, EGC) lesions.

METHODS

Between November 2008 and October 2011, a retrospective analysis of a prospective database was conducted at a single tertiary referral center. A total of 218 ESD procedures were carried out for gastric LGD lesions identified by EFB. The under-diagnosis rate by EFB and the predictable factors for upgrade diagnosis to category 4 or 5 lesions were analyzed.

RESULTS

Pathologic discrepancy between EFB and surgical resection was 20.1 % (44/218). Thirty eight lesions (17.4 %) were diagnosed HGD or EGC by ESD. Gastric HGD lesions were 14 cases (6.4 %) and EGC lesions were 24 cases (23 mucosal and 1 submucosal cancer) (11.0 %). Multivariate analysis revealed that lesion diameter more than 1 cm (OR 3.496 [95 % CI 1.375-8.849]), surface redness (OR 6.493 [95 % CI 2.557-16.666]) and nodular surface (OR 2.762 [95 % CI 1.237-6.172]) were significant risk factors.

CONCLUSIONS

Endoscopic resection can be recommended if a LGD lesion has risk factors such as a size of 1 cm or greater, surface redness or surface nodulariy. For lesions without the risk factors, follow-up endoscopy may be recommended.

Pathology of gastric cancer and its precursor lesions

Gastric cancers are a histologically heterogenous group of neoplasms arising from unique epidemiologic and molecular backgrounds. There is accumulating evidence that the intestinal type of gastric adenocarcinoma develops through a multistep process beginning with chronic gastritis triggered primarily by Helicobacter pylori and progressing through atrophy, intestinal metaplasia, and dysplasia (intraepithelial neoplasia) to carcinoma. Loss of E-cadherin expression resulting from CDH1 gene alterations is the primary carcinogenetic event in hereditary diffuse gastric cancer. Proximal gastric adenocarcinomas likely result from either gastroesophageal reflux or H pylori gastritis. This article provides an update of the histologic, immunohistochemical, and molecular pathways of gastric cancer and its precursors.

Precancerous lesions in the stomach: from biology to clinical patient management

Gastric cancer is the final step in a multi-stage cascade triggered by long-standing inflammatory conditions (particularly Helicobacter pylori infection) resulting in atrophic gastritis and intestinal metaplasia: these lesions represent the cancerization field in which (intestinal-type) gastric cancer develops. Intraepithelial neoplasia is consistently recognized as the phenotypic bridge between atrophic/metaplastic lesions and invasive cancer. This paper addresses the epidemiology, pathology, molecular profiling, and clinical management of advanced precancerous gastric lesions.

The diagnostic role of endoscopic submucosal dissection for gastric lesions with indefinite pathology

OBJECTIVE

Endoscopic forceps biopsy is a fundamental modality for the histologic diagnosis of gastric neoplasms. However, the pathologic findings are not always concordant with the endoscopic interpretations. Currently, repeat endoscopic biopsy is the only way to manage lesion of indefinite pathology such as Category 2 according to the revised Vienna classification. We aimed to elucidate the role of endoscopic submucosal dissection (ESD) in clarifying the final pathologic diagnosis.

METHOD

Among the 2304 gastric ESD cases, a total of consecutive 30 patients with 31 lesions (1.3%) that had a forceps biopsy with indefinite pathology discrepant from the endoscopic findings underwent endoscopic submucosal dissection (ESD) for confirmative diagnosis and treatment.

RESULTS

The final pathologic diagnoses of the ESD specimens were as follows: low-grade dysplasia in 3 patients (9.7%); high-grade dysplasia in 2 patients (6.5%); adenocarcinoma in 15 patients (48.4%); and a benign lesion in 11 patients (35.5%). Cases with adenocarcinoma included nine well-differentiated lesions, four moderately differentiated lesions, and two lesions with signet ring cell carcinoma. The complete en bloc resection rate for neoplastic lesions was 95.0%, and the incidence rates of ESD-related bleeding and perforation were 5.0% and 5.0%, respectively.

CONCLUSION

ESD can be considered an effective and safe alternative therapeutic and diagnostic tool for gastric lesions in cases where the forceps biopsy pathology is discrepant from the endoscopic findings. The overall final neoplastic diagnosis rate after ESD was 64.5%, and ESD should be performed for lesions with red coloration and friability.

Barrett's Esophagus: Emerging Knowledge and Management Strategies

The incidence of esophageal adenocarcinoma (EAC) has increased exponentially in the last 3 decades. Barrett's esophagus (BE) is the only known precursor of EAC. Patients with BE have a greater than 40 folds higher risk of EAC compared with the general population. Recent years have witnessed a revolution in the clinical and molecular research related to BE. However, several aspects of this condition remain controversial. Data regarding the true prevalence of BE have varied widely. Recent studies have suggested a lower incidence of EAC in nondysplastic BE (NDBE) than previously reported. There is paucity of prospective data showing a survival benefit of screening or surveillance for BE. Furthermore, the ever-increasing emphasis on healthcare cost containment has called for reexamination of the screening and surveillance strategies for BE. There is a need for identification of reliable clinical predictors or molecular biomarkers to risk-stratify patients who might benefit the most from screening or surveillance for BE. Finally, new therapies have emerged for the management of dysplastic BE. In this paper, we highlight the key areas of controversy and uncertainty surrounding BE. The paper discusses, in detail, the current literature about the molecular pathogenesis, biomarkers, histopathological diagnosis, and management strategies for BE.

Lesions indefinite for intraepithelial neoplasia and OLGA staging for gastric atrophy

Gastric intraepithelial neoplasia (IEN; formerly dysplasia) is an advanced precancerous lesion. Lesions indefinite for IEN mimic the IEN phenotype but lack some morphologic attributes of IEN. Indefinite for IEN lesions may arise in native foveolae (atypical foveolar hyperproliferation [aFH]) or intestinalized glands (hyperproliferative intestinal metaplasia [HIM]). The clinicopathologic outcome of such lesions is debated. We retrospectively studied the clinicopathologic behavior of 129 consecutive indefinite for IEN lesions (HIM, 98; aFH, 31; median follow-up, 31 months) and correlated outcome with the extent and topography of mucosal atrophy (assessed by OLGA staging) at the initial endoscopy/biopsy. At enrollment, aFH never coexisted with severe/extensive atrophy (all cases were in low-risk OLGA stages [0-II]), whereas HIM was associated with low- and high-risk OLGA stages (0-II, 73; III-IV, 25). At follow-up, IEN was never documented among cases enrolled as aFH, while follow-up endoscopy/biopsy documented 6 neoplastic intraepithelial lesions among 98 cases of HIM (6%, all had high-risk OLGA stages at initial biopsy). OLGA staging can stratify indefinite for IEN lesions into different risk classes, potentially contributing to decisions for a patient-specific follow-up strategy.

[Clinical aspects of premalignant lesions of the upper gastrointestinal tract]

A variety of somatic genetic and epigenetic aberrations are discussed in the multistep carcinogenesis of tumors of the upper gastrointestinal tract but specific genetic changes are still unknown. Primary prevention of cancer is important and includes the control of causal endo- and exogenous factors. Screening endoscopies to detect premalignant lesions or early carcinoma cannot be recommended in the Western world. The incidence of preinvasive neoplasia, above all the high-grade intraepithelial neoplasia, in Barrett's esophagus or stomach is as low as 4.0 or 0.6%, respectively. Secondary prevention of cancer after changes of the mucosa should be performed by endoscopic diagnosis and treatment performing biopsies or resection of the lesion. After histological diagnosis of a high-grade intraepithelial neoplasia, complete resection of these lesions including complete ablation of Barrett's mucosa should be carried out. On the basis of an exact pathological report, close cooperation between endoscopist and surgeon seems to be necessary to find out the best individual therapy with curative intent.

Upgrade of Lesions Initially Diagnosed as Low-Grade Gastric Dysplasia upon Forceps Biopsy Following Endoscopic Resection

Background/Aims

Gastric dysplasia is generally accepted to be the precursor lesion of gastric carcinoma. Approximately 25% to 35% of histological diagnoses based on endoscopic forcep biopsies for gastric dysplastic lesions change following endoscopic resection (ER). The aim of this study was to determine the predictive endoscopic features of high-grade gastric dysplasia (HGD) or early gastric cancer (EGC) following ER for lesions initially diagnosed as low-grade dysplasia (LGD) by a forceps biopsy.

Methods

To determine predictive variables for upgraded histology (LGD to HGD or EGC). The lesion size, gross endoscopic appearance, location, and surface nodularity or redness as well as the presence of a depressed portion, Helicobacter pylori infection, and intestinal metaplasia were retrospectively investigated.

Results

Among 251 LGDs diagnosed by an initial forceps biopsy, the diagnoses of 100 lesions (39.8%) changed following the ER; 56 of 251 LGDs (22.3%) were diagnosed as HGD, 39 (15.5%) as adenocarcinoma, and 5 (2.0%) as chronic gastritis. In a univariate analysis, large lesions (>15 mm), those with a depressed portion, and those with surface nodularity were significantly correlated with a upgraded histology classification following ER. In a multivariate analysis, a large size (>15 mm; odds ratio [OR], 2.8; 95% confidence interval [CI], 1.46 to 5.43) and a depressed portion in the lesion (OR, 2.7; 95% CI, 1.44 to 5.03) were predictive factors for upgraded histology following ER.

Conclusions

Our study shows that a substantial proportion of diagnoses of low-grade gastric dysplasias based on forceps biopsies were not representative of the entire lesion. We recommend ER for lesions with a depressed portion and for those larger than 15 mm.

Loss of cell polarity protein Lgl2 in foveolar-type gastric dysplasia: correlation with expression of the apical marker aPKC-zeta

Recognition of gastric epithelial dysplasia, although a key to cancer prevention, can be challenging. In this study, we evaluated whether Lgl2 can serve as a marker of gastric foveolar-type dysplasia. Since atypical protein kinase C (aPKC) is a partner of Lgl2 in the control of apical-basal polarity we also investigated whether aPKC-zeta can compliment Lgl2 as a marker of dysplasia. Routinely processed specimens included 64 normal mucosa, 35 reactive gastropathies, 31 chronic gastritides, 65 gastric dysplasias (25 foveolar; 40 adenomatous), and 34 gastric adenocarcinomas. Twenty (80%) foveolar-type dysplasias showed absence of Lgl2 immunoreactivity, while normal basolateral expression of Lgl2 was consistently seen in normal gastric epithelium (n=20) and chronic gastritis (n=22; p<0.00001). Loss of Lgl2 was similar in the groups with low-grade and high-grade foveolar-type dysplasia, 79% and 83%, respectively. Linear apical anti-aPKC-zeta immunoreactivity was consistently present in the normal epithelium and was preserved in 91% of reactive gastropathies and 87% of chronic gastritides. In contrast, loss of apical aPKC-zeta staining was observed in 47% and 65% of low-grade dysplasias of foveolar and adenomatous types, respectively (p<0.005) and in nonsignificantly higher percentage of high-grade dysplasias. Apical aPKC-zeta staining was lost in 97% of gastric adenocarcinomas. Our data suggest a role of Lgl2 immunohistochemistry as an adjunct in the diagnosis of foveolar-type gastric dysplasia. aPKC-zeta had moderate sensitivity as a marker of gastric dysplasia and additional studies are needed to establish its role in the diagnosis of dysplasia.

Endoscopic management of gastric dysplasia: Cutting edge technology needs a new paradigm

There has been tremendous progress in endoscopic techniques for the management of premalignant or malignant gastric lesions. Gastric cancer remains the second most common cause of cancer related mortality worldwide. This means that there is a need for early detection and diagnosis of premalignant lesions or early cancer in clinical practice. Despite substantial development of endoscopic resection techniques, the management of gastric premalignant lesions is controversial because of the lack of consensus and accurate risk stratification. Future study of various aspects would clarify these issues but in the meantime we should reconsider the current algorithm approach for the management of gastric low grade dysplasia.

Expression of VEGF, EGFR, and IL-6 in gastric adenomas and adenocarcinomas by endoscopic submucosal dissection

BACKGROUND

The degree of intratumoral microvascular density is thought to affect tumor metastasis and prognosis in various human cancers, including gastric cancer. Despite recent medical advancements, gastric adenoma or adenocarcinoma remains a considerable therapeutic challenge. Endoscopic submucosal dissection (ESD) is a more recent approach that is now commonly used for radical resection of gastric adenoma and adenocarcinoma.

AIM AND METHODS

The expression of vascular endothelial growth factor (VEGF), epidermal growth factor receptor (EGFR), and interleukin-6 (IL-6) are related to the prognosis of gastric adenocarcinoma. However, the expression of these factors in gastric adenoma/adenocarcinoma following ESD has not been clearly evaluated. Here, we report on our study of the expression of VEGF, EGFR, and IL-6 by immunohistochemical staining in extracted tissue from adenoma or adenocarcinoma of the stomach by ESD and subsequent evaluation of the correlation of VEGF, EGFR, and IL-6 with other clinicopathological parameters. The patient cohort consisted of 102 patients with adenoma or adenocarcinoma of the stomach.

RESULTS

Immunohistochemical staining for VEGF and IL-6 was significantly higher in both high grade dysplasia and adenocarcinoma than in low grade dysplasia (P < 0.05). There was significant correlation between histological grade and intensity of immunohistochemical staining of VEGF (P = 0.039). Histological differentiation of adenocarcinoma was related to IL-6 expression (P = 0.028). The immunoreactivity of VEGF and IL-6 increased significantly in lesions >2 cm compared to lesions <2 cm (P < 0.05).

CONCLUSION

The immunohistochemical expression of IL-6 and VEGF can be considered to be useful for clinical diagnosis and follow-up of adenoma or adenocarcinoma of the stomach.

Genomic profiling of gastric carcinoma in situ and adenomas by array-based comparative genomic hybridization

Although genomic copy number aberrations (CNAs) of gastric carcinoma at the advanced stage have already been extensively characterized by array comparative genomic hybridization (array CGH) analysis, those of gastric carcinoma in situ (CIS) are still poorly understood. Furthermore, no reports have demonstrated correlations between CNAs and histopathological features of gastric adenoma. In this study, we investigated CNAs of 20 gastric CISs (Vienna category 4.2) and 20 adenomas including seven low-grade adenomas (LGA; Vienna category 3) and 13 high-grade adenomas (HGA; Vienna category 4.1), using oligonucleotide-based array CGH. The most frequent aberrations in CIS were gains at 8q (85%) and 20q (50%), and losses at 5q (50%) and 17p (50%), suggesting that these CNAs are involved in the development of CIS. We found that the pattern of CNAs in HGA was quite different from that in LGA. The most frequent CNAs in HGA were gains at 8q (62%) and 7pq (54%), whereas those in LGA were gain at 7q21.3-q22.1 (57%) and loss at 5q (43%). Interestingly, gains at 8q and 7pq, both of which occurred most frequently in HGA, were not detected in any cases of LGA. Of note, 8q gain was detected most frequently in both HGA and CIS but was undetected in LGA. Since HGA is believed to have a higher risk of progression to invasive carcinoma than LGA, these data suggest that 8q gain is important for the malignant transformation of gastric adenoma.

Grading of gastric foveolar-type dysplasia in Barrett's esophagus

Dysplasia is the gold standard biomarker of cancer risk in Barrett's esophagus, but its diagnosis remains difficult. This is due in part to its multitude of histological appearances. One aspect receiving little attention concerns gastric-type Barrett's dysplasia, which is distinctly different from the well-established intestinal variant. Recognition of gastric-type dysplasia and development of separate grading criteria are required. The prevalence, diagnostic criteria, and natural history of gastric-type Barrett's dysplasia were systematically evaluated in 1854 endoscopic biopsies from a cohort of 200 consecutive Barrett's dysplasia patients. Goblet cells were present in all cases, confirming the utility of this defining feature of Barrett's esophagus. The prevalence of Barrett's gastric-type dysplasia was 15% at the patient level (30 of 200 patients) and 20% at the biopsy level (166 of 852 dysplastic biopsies). Gastric-type dysplasia uniformly showed non-stratified, basally oriented nuclei as the major criterion for distinguishing it from intestinal-type Barrett's dysplasia. As such, loss of nuclear polarity, as the most objective criterion to distinguish intestinal-type low- and high-grade dysplasia, cannot be applied to gastric-type dysplasia. Rather, discriminatory features included increased nuclear size with a high-grade dysplasia cutoff by receiver operating characteristic (ROC) analysis approximating 3-4 times the size of a mature lymphocyte, providing an optimal sensitivity, specificity, and area under the curve of 0.78, 0.90, and 0.90 (95% CI: (0.87, 0.93)), respectively. Crowded, irregular glandular architecture (P<0.001) was more common in high-grade lesions (P<0.001), as was eosinophilic and oncocytic cytoplasm relative to the mucinous cytoplasm (P<0.001), prominent nucleoli (P<0.001), mild nuclear pleomorphism (P<0.001), and villiform architecture (P<0.001). During follow-up, 64% (7 of 11) of patients with pure gastric and 26% (5 of 19) with mixed gastric and intestinal dysplasia underwent neoplastic progression. The recognition of Barrett's gastric-type dysplasia and use of the proposed grading criteria should promote better diagnostic classification of the Barrett's neoplastic spectrum.