The role of endoscopy in the management of premalignant and malignant conditions of the stomach

The Role of Screening and Early Detection in Upper Gastrointestinal Cancers

Upper gastrointestinal cancers are among the leading causes of cancer deaths worldwide with exceptionally poor prognosis, which is largely attributable to frequently delayed diagnosis. Although effective screening is critical for early detection, the highly variable incidence of upper gastrointestinal cancers presents challenges, rendering universal screening programs suboptimal in most populations globally. Optimal strategies in regions of modest incidence, such as the United States, require a targeted approach, focused on high-risk individuals based on demographic, familial, and clinicopathologic risk factors. Assessment of underlying precancerous lesions has key implications for risk stratification and informing clinical decisions to improve patient outcomes.

Hotspots and trends of risk factors in gastric cancer: A visualization and bibliometric analysis

BACKGROUND

The lack of specific symptoms of gastric cancer (GC) causes great challenges in its early diagnosis. Thus it is essential to identify the risk factors for early diagnosis and treatment of GC and to improve the survival rates.

AIM

To assist physicians in identifying changes in the output of publications and research hotspots related to risk factors for GC, constructing a list of key risk factors, and providing a reference for early identification of patients at high risk for GC.

METHODS

Research articles on risk factors for GC were searched in the Web of Science core collection, and relevant information was extracted after screening. The literature was analyzed using Microsoft Excel 2019, CiteSpace V, and VOSviewer 1.6.18.

RESULTS

A total of 2514 papers from 72 countries and 2507 research institutions were retrieved. China (n = 1061), National Cancer Center (n = 138), and Shoichiro Tsugane (n = 36) were the most productive country, institution, or author, respectively. The research hotspots in the study of risk factors for GC are summarized in four areas, namely: Helicobacter pylori (H. pylori) infection, single nucleotide polymorphism, bio-diagnostic markers, and GC risk prediction models.

CONCLUSION

In this study, we found that H. pylori infection is the most significant risk factor for GC; single-nucleotide polymorphism (SNP) is the most dominant genetic factor for GC; bio-diagnostic markers are the most promising diagnostic modality for GC. GC risk prediction models are the latest current research hotspot. We conclude that the most important risk factors for the development of GC are H. pylori infection, SNP, smoking, diet, and alcohol.

Enhancing endoscopic measurement: validating a quantitative method for polyp size and location estimation in upper gastrointestinal endoscopy

BACKGROUND

Accurate measurement of polyps size is crucial in predicting malignancy, planning relevant intervention strategies and surveillance schedules. Endoscopists' visual estimations can lack precision. This study builds on our prior research, with the aim to evaluate a recently developed quantitative method to measure the polyp size and location accurately during a simulated endoscopy session.

METHODS

The quantitative method merges information about endoscopic positions obtained from an electromagnetic tracking sensor, with corresponding points on the images of the segmented polyp border. This yields real-scale 3D coordinates of the border of the polyp. By utilising the sensor, positions of any anatomical landmarks are attainable, enabling the estimation of a polyp's location relative to them. To verify the method's reliability and accuracy, simulated endoscopies were conducted in pig stomachs, where polyps were artificially created and assessed in a test-retest manner. The polyp measurements were subsequently compared against clipper measurements.

RESULTS

The average size of the fifteen polyps evaluated was approximately 12 ± 4.3 mm, ranging from 5 to 20 mm. The test-retest reliability, measured by the Intraclass Correlation Coefficient (ICC) for polyp size estimation, demonstrated an absolute agreement of 0.991 (95% CI 0.973-0.997, p < 0.05). Bland & Altman analysis revealed a mean estimation difference of - 0.17 mm (- 2.03%) for polyp size and, a mean difference of - 0.4 mm (- 0.21%) for polyp location. Both differences were statistically non-significant (p > 0.05). When comparing the proposed method with calliper measurements, the Bland & Altman plots showed 95% of size estimation differences between - 1.4 and 1.8 mm (- 13 to 17.4%) which was not significant (p > 0.05).

CONCLUSIONS

The proposed method of measurements of polyp size and location was found to be highly accurate, offering great potential for clinical implementation to improve polyp assessment. This level of performance represents a notable improvement over visual estimation technique used in clinical practice.

AGA Clinical Practice Update on High-Quality Upper Endoscopy: Expert Review

DESCRIPTION

The purpose of this Clinical Practice Update (CPU) Expert Review is to provide clinicians with guidance on best practices for performing a high-quality upper endoscopic exam.

METHODS

The best practice advice statements presented herein were developed from a combination of available evidence from published literature, guidelines, and consensus-based expert opinion. No formal rating of the strength or quality of the evidence was carried out, which aligns with standard processes for American Gastroenterological Association (AGA) Institute CPUs. These statements are meant to provide practical, timely advice to clinicians practicing in the United States. This Expert Review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates (CPU) Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology & Hepatology. BEST PRACTICE ADVICE 1: Endoscopists should ensure that upper endoscopy is being performed for an appropriate indication and that informed consent clearly explaining the risks, benefits, alternatives, sedation plan, and potential diagnostic and therapeutic interventions is obtained. These elements should be documented by the endoscopist before the procedure. BEST PRACTICE ADVICE 2: Endoscopists should ensure that adequate visualization of the upper gastrointestinal mucosa, using mucosal cleansing and insufflation as necessary, is achieved and documented. BEST PRACTICE ADVICE 3: A high-definition white-light endoscopy system should be used for upper endoscopy instead of a standard-definition white-light endoscopy system whenever possible. The endoscope used for the procedure should be documented in the procedure note. BEST PRACTICE ADVICE 4: Image enhancement technologies should be used during the upper endoscopic examination to improve the diagnostic yield for preneoplasia and neoplasia. Suspicious areas should be clearly described, photodocumented, and biopsied separately. BEST PRACTICE ADVICE 5: Endoscopists should spend sufficient time carefully inspecting the foregut mucosa in an anterograde and retroflexed view to improve the detection and characterization of abnormalities. BEST PRACTICE ADVICE 6: Endoscopists should document any abnormalities noted on upper endoscopy using established classifications and standard terminology whenever possible. BEST PRACTICE ADVICE 7: Endoscopists should perform biopsies for the evaluation and management of foregut conditions using standardized biopsy protocols. BEST PRACTICE ADVICE 8: Endoscopists should provide patients with management recommendations based on the specific endoscopic findings (eg, peptic ulcer disease, erosive esophagitis), and this should be documented in the medical record. If recommendations are contingent upon histopathology results (eg, H pylori infection, Barrett's esophagus), then endoscopists should document that appropriate guidance will be provided after results are available. BEST PRACTICE ADVICE 9: Endoscopists should document whether subsequent surveillance endoscopy is indicated and, if so, provide appropriate surveillance intervals. If the determination of surveillance is contingent on histopathology results, then endoscopists should document that surveillance intervals will be suggested after results are available.

Automatically optimized radiomics modeling system for small gastric submucosal tumor (<2 cm) discrimination based on EUS images

BACKGROUND AND AIMS

The clinical management of small gastric submucosal tumors (SMTs) (<2 cm) faces a non-negligible challenge because of the lack of guideline consensus and effective diagnostic tools. This article develops an automatically optimized radiomics modeling system (AORMS) based on EUS images to diagnose and evaluate SMTs.

METHODS

A total of 205 patients with EUS images of small gastric SMTs (<2 cm) were retrospectively enrolled in the development phase of AORMS for the diagnosis and the risk stratification of GI stromal tumor (GIST). A total of 178 patients with images from different centers were prospectively enrolled in the independent testing phase. The performance of AORMS was compared to that of endoscopists in the development set and evaluated in the independent testing set.

RESULTS

AORMS demonstrated an area under the curve (AUC) of 0.762 for the diagnosis of GIST and 0.734 for the risk stratification of GIST, respectively. In the independent testing set, AORMS achieved an AUC of 0.770 and 0.750 for the diagnosis and risk stratification of small GISTs, respectively. In comparison, the AUCs of 5 experienced endoscopists ranged from 0.501 to 0.608 for diagnosing GIST and from 0.562 to 0.748 for risk stratification. AORMS outperformed experienced endoscopists by more than 20% in diagnosing GIST.

CONCLUSIONS

AORMS implements automatic parameter selection, which enhances its robustness and clinical applicability. It has demonstrated good performance in the diagnosis and risk stratification of GISTs, which could aid endoscopists in the diagnosis of small gastric SMTs (<2 cm).

Population-based evaluation of disparities in stomach cancer by nativity among Asian and Hispanic populations in California, 2011-2015

BACKGROUND

Stomach cancer incidence presents significant racial/ethnic disparities among racial/ethnic minority groups in the United States, particularly among Asian and Hispanic immigrant populations. However, population-based evaluation of disparities by nativity has been scarce because of the lack of nativity-specific population denominators, especially for disaggregated Asian subgroups. Population-based stomach cancer incidence and tumor characteristics by detailed race/ethnicity and nativity were examined.

METHODS

Annual age-adjusted incidence rates were calculated by race/ethnicity, sex, and nativity and tumor characteristics, such as stage and anatomic subsite, were evaluated using the 2011-2015 California Cancer Registry data. For Hispanic and Asian populations, nativity-specific population counts were estimated using the US Census and the American Community Survey Public Use Microdata Sample data.

RESULTS

During 2011-2015 in California, 14,198 patients were diagnosed with stomach cancer. Annual age-adjusted incidence rates were higher among foreign-born individuals than their US-born counterparts. The difference was modest among Hispanics (∼1.3-fold) but larger (∼2- to 3-fold) among Chinese, Japanese, and Korean Americans. The highest incidence was observed for foreign-born Korean and Japanese Americans (33 and 33 per 100,000 for men; 15 and 12 per 100,000 for women, respectively). The proportion of localized stage disease was highest among foreign-born Korean Americans (44%); a similar proportion was observed among US-born Korean Americans, although numbers were limited. For other Asians and Hispanics, the localized stage proportion was generally lower among foreign-born than US-born individuals and lowest among foreign-born Japanese Americans (23%).

CONCLUSIONS

Nativity-specific investigation with disaggregated racial/ethnic groups identified substantial stomach cancer disparities among foreign-born immigrant populations.

Autoimmune Atrophic Gastritis: A Clinical Review

Autoimmune atrophic gastritis (AAG) is a chronic condition characterized by the presence of atrophy in the oxyntic mucosa due to anti-parietal cell antibodies. This review provides a comprehensive and up-to-date overview of autoimmune atrophic gastritis, reporting recent evidence on epidemiology, pathogenesis, diagnosis, clinical presentation, risk of malignancies, and management. The prevalence of AAG has been estimated at between 0.3% and 2.7% in the general population. The diagnosis of AAG is based on a combination of the serologic profile and the histological examination of gastric biopsies. Patients with AAG are often asymptomatic but can also have dyspeptic or reflux symptoms. The atrophy of the oxyntic mucosa leads to iron and vitamin B12 malabsorption, which may result in anemia and neurological affections. Autoimmune atrophic gastritis is associated with an increased risk of type I neuroendocrine tumors (NETs) and gastric cancer, with an incidence rate of 2.8% and 0.5% per person/year, respectively. Management is directed to reinstate vitamins and iron and to prevent malignancies with endoscopic surveillance. In conclusion, atrophic autoimmune gastritis is an infrequent condition, often asymptomatic and misdiagnosed, that requires an early diagnosis for appropriate vitamin supplementation and endoscopic follow-up for the early diagnosis of NETs and gastric cancer.

Detection of high-risk polyps at screening colonoscopy indicates risk for liver and biliary cancer death

BACKGROUND

Hepatobiliary cancers share risk factors with colorectal cancer (CRC), but there are no combined screening programs for these conditions.

AIMS

The aim of this study was to assess whether patients with high-risk colonic polyps are more likely to die from liver related tumors than patients with a negative colonoscopy.

METHODS

In this retrospective analysis of mortality data, Austrian screening participants were included. The absolute risk for hepatobiliary cancer death was calculated using the cumulative incidence method. We aimed to identify an association with time to death of hepatobiliary cancer by Cox proportional hazards model.

RESULTS

343,838 colonoscopies performed between 01/2007 and 12/2020 were included in the analysis, of which 17,678 (5.14%) revealed high-risk polyps. Overall hepatobiliary cancer mortality was more than twice as high in patients with high risk polyps (cumulative incidence 0.39%, 95% CI 0.37-0.41%) compared to patients with a negative colonoscopy (cumulative incidence 0.17%, 95% CI 0.17-0.17%). When adjusting for age and sex, having high-risk polyps at screening colonoscopy was significantly associated with hepatobiliary cancer death (HR 1.83, 95% CI 1.29- 2.59, p < 0.001).

CONCLUSIONS

Patients with certain colonic polyp characteristics are at increased risk for mortality of liver malignancies. Further studies are needed to determine whether a structured additional screening for liver diseases and consecutive malignancies might be beneficial in these patients.

Gastric Cancer Risk Factors in a Veteran Population

INTRODUCTION

Risk factors for gastric cancer in the United States are not well understood, especially in populations with a low proportion of immigrants. We conducted a matched case-control study in a Veteran Affairs Medical Center to identify risk factors for gastric cancer.

MATERIALS AND METHODS

Gastric cancer patients and age- and sex-matched controls were identified in a 1:4 ratio from January 1, 1997 to October 31, 2018. Demographic, medical, endoscopic, and histologic data were extracted. We performed conditional logistic regression to estimate odds ratios and 95% CIs for associations between potential risk factors and gastric cancer.

RESULTS

Most gastric cancer cases were diagnosed on initial endoscopy (71.4%). Of these, the most common presenting stage was stage IV (40.8%). Risk factors for gastric cancer included Black and Asian race and never or current (compared to former) drinkers, although Helicobacter pylori eradication and pernicious anemia were associated with decreased risk.

CONCLUSIONS

The high proportion of late-stage gastric cancer diagnoses highlights the need for improved risk stratification as well as screening and surveillance protocols in the U.S. population. Racial disparities among veterans in an equal-access system necessitate further investigation into the etiology of these disparities.

A study on the improvement in the ability of endoscopists to diagnose gastric neoplasms using an artificial intelligence system

Background

Artificial intelligence-assisted gastroscopy (AIAG) based on deep learning has been validated in various scenarios, but there is a lack of studies regarding diagnosing neoplasms under white light endoscopy. This study explored the potential role of AIAG systems in enhancing the ability of endoscopists to diagnose gastric tumor lesions under white light.

Methods

A total of 251 patients with complete pathological information regarding electronic gastroscopy, biopsy, or ESD surgery in Xi'an Gaoxin Hospital were retrospectively collected and comprised 64 patients with neoplasm lesions (excluding advanced cancer) and 187 patients with non-neoplasm lesions. The diagnosis competence of endoscopists with intermediate experience and experts was compared for gastric neoplasms with or without the assistance of AIAG, which was developed based on ResNet-50.

Results

For the 251 patients with difficult clinical diagnoses included in the study, compared with endoscopists with intermediate experience, AIAG's diagnostic competence was much higher, with a sensitivity of 79.69% (79.69% vs. 72.50%, p = 0.012) and a specificity of 73.26% (73.26% vs. 52.62%, p < 0.001). With the help of AIAG, the endoscopists with intermediate experience (<8 years) demonstrated a relatively higher specificity (59.79% vs. 52.62%, p < 0.001). Experts (≥8 years) had similar results with or without AI assistance (with AI vs. without AI; sensitivities, 70.31% vs. 67.81%, p = 0.358; specificities, 83.85% vs. 85.88%, p = 0.116).

Conclusion

With the assistance of artificial intelligence (AI) systems, the ability of endoscopists with intermediate experience to diagnose gastric neoplasms is significantly improved, but AI systems have little effect on experts.

Gastric Cancer Incidence and Mortality After Endoscopic Resection of Gastric Adenoma: A Nationwide Cohort Study

INTRODUCTION

Gastric adenoma is a precursor lesion of gastric cancer. We investigated whether the removal of gastric adenoma prevented gastric cancer incidence and its mortality.

METHODS

Using the linkage of nationwide databases, we assessed gastric cancer incidence and mortality among patients who had gastric adenomas removed between 2011 and 2013 in Korea. These outcomes were compared primarily with those of the Korean general population by estimating the standardized incidence and mortality ratio and secondarily with internal control subjects who did not have gastric neoplasm after esophagogastroduodenoscopy and were matched for age, sex, and calendar year by calculating hazard ratios (HR) with the Cox proportional hazards model.

RESULTS

We identified 44,405 adenoma removal patients. During a median follow-up of 8.4 years, 1,038 (2.34%) of them were given a diagnosis of gastric cancer and a total of 524 gastric cancers were expected for a standard incidence ratio of 1.98 (95% confidence interval [CI], 1.84-2.13). A total of 199 deaths from gastric cancer were expected and 99 were observed for a standard mortality ratio of 0.50 (95% CI, 0.40-0.60). Compared with the nonadenoma cohort (n = 39,826), the adenoma removal patients had a higher risk of gastric cancer (HR, 2.84; 95% CI, 2.51-3.21) and associated mortality (HR, 1.66; 95% CI, 1.19-2.31).

DISCUSSION

Removal of gastric adenoma resulted in lower-than-expected mortality but higher-than-expected incidence due to gastric cancer than that in the general population. Our analyses indicated the importance of follow-up strategy after removal of gastric adenoma.

Pyloric Gastric Adenoma: Endoscopic Detection, Removal, and Echoendosonographic Characterization

Pyloric gland adenomas (PGAs) are rare neoplasms found not only in the gastrointestinal tract but also in other extragastrointestinal organs. They have potential for malignant conversion, and early detection and removal is imperative to prevent invasive disease. PGAs prove difficult in management and surveillance given their rarity. However, increasing familiarity with histological appearance and use of advanced tools such as echoendosonography can bring greater understanding of their clinical history. We describe a unique case of a PGA detected within a hiatal hernia sac characterized with echoendosonography and highlight the need to develop surveillance protocols for these types of lesions.

Impact of Autoimmune Gastritis on Occurrence of Metachronous Gastric Neoplasms after Endoscopic Resection for Gastric Neoplasms

Gastric cancer is the fifth most common cancer and the third leading cause of cancer-related deaths worldwide. Autoimmune gastritis (AIG) is characterized by antibody production against the gastric parietal cells, reducing the number of functional parietal cells. It is also associated with an increased susceptibility to gastric neuroendocrine tumors and gastric cancer. Endoscopic resection (ER) is an effective treatment for early gastric cancer; however, metachronous gastric neoplasms (MGN) can develop. This study aimed to evaluate the clinical effect of AIG on the occurrence of MGN after ER for gastric neoplasms. We retrospectively analyzed patients who underwent ER for gastric neoplasms. Patients with multiple lesions, recurrent lesions, or a history of partial gastrectomy were excluded. The presence of AIG was determined using anti-parietal cell antibody (APCA) testing. Follow-up endoscopy and metachronous tumor occurrence rates were compared between the AIG and non-AIG groups. Of the 569 patients, 282 underwent APCA testing and 20 (7.1%) were diagnosed with AIG. The incidence of MGN was significantly higher in the AIG group than in the non-AIG group (45.0% vs. 18.3%); however, the MGN occurrence pattern was similar between the two groups. Multivariate analysis revealed that AIG (HR 3.32, 95% CI 1.55-7.10, p = 0.002) and a higher body mass index (HR 1.16, 95% CI 1.06-1.27, p = 0.002) were independent factors significantly associated with the occurrence of MGN. Patients with AIG have a higher risk of metachronous lesion occurrence after ER for gastric neoplasms. Positive results of APCA testing have independent clinical implications for predicting MGN. Proper monitoring and management are essential for early detection and treatment of recurrent lesions in patients with AIG.

Impact of Tumor Size and Management on Survival in Small Gastric Gastrointestinal Stromal Tumors

BACKGROUND

Society guidelines remain inconsistent on the role of endoscopic and radiographic surveillance as an alternative to surgical resection of small gastric gastrointestinal stromal tumors (GISTs). Herein, we aimed to assess survival among patients with gastric GISTs undergoing observation versus surgical resection, stratified by tumor size.

METHODS

The National Cancer Database (NCDB) was queried for gastric GISTs < 2 cm diagnosed from 2010-2017. Patients were stratified by management strategy-observation vs surgical resection. The primary outcome, overall survival (OS), was examined with Kaplan-Meier and multivariable Cox proportional hazard methods. Subgroup analyses were conducted on tumors < 1 cm and 1-2 cm in size.

RESULTS

Altogether, 1208 patients were identified: 439 (36.3%) undergoing observation and 769 (63.7%) receiving surgical resection. In the overall cohort, patients undergoing surgical resection demonstrated improved survival (93.6 vs. 88.8% 5-year OS, p=0.02). In multivariable analysis, upfront surgical resection was not associated with a reduction in mortality; however, there was a significant interaction with tumor size. For patients with tumors < 1 cm, there was no difference in survival based on management strategy. However, resection of tumors 1-2 cm was associated with improved survival relative to surveillance.

CONCLUSIONS

While surgical resection and surveillance were associated with similar survival for patients with gastric GISTs < 1 cm, this NCDB analysis suggests that patients with tumor size ≥ 1 cm may benefit from upfront surgical resection. Prospective studies comparing these two approaches and their impact on recurrence-free and disease-specific survival are needed to better align consensus guidelines and recommendations.

Risk factors associated with recurrence of gastric hyperplastic polyps: a single-center, long-term, retrospective cohort study

BACKGROUND

The likelihood of recurrence of gastric hyperplastic polyps (GHPs) following endoscopic resection and the need for long-term follow-up remain unknown. We, therefore, aimed to investigate the factors associated with the recurrence and cumulative incidence of GHPs over a 10-year period.

METHODS

Between May 1995 and December 2020, 1,018 GHPs > 1 cm were endoscopically resected from 869 patients. Medical records of these patients were retrospectively reviewed and their clinical features and outcomes were assessed. Groups of GHPs with recurrence and those without recurrence group were compared, and univariate and multivariable analyses were performed to identify the potential risk factors for GHP recurrence.

RESULTS

A total of 104 (12.0%) patients who underwent endoscopic removal of GHPs experienced recurrence. Compared to patients without recurrent GHPs, those with recurrent GHPs showed considerably larger median polyp size (28 mm vs. 14 mm, P < 0.001), a higher proportion of multiple polyps (41.3% vs. 29.3%, P = 0.020), polyps with lobulation (63.5% vs. 40.3%, P = 0.001), and exudate (63.5% vs. 46.8%, P = 0.001). Compared to the local recurrence (n = 52) group, the metachronous recurrence (n = 52) group had larger median polyp size (20 mm vs. 16 mm, P = 0.006) as well as higher rates of polyp lobulation (86.5% vs. 40.4%, P < 0.001) and exudate (82.7% vs. 44.4%, P = 0.001). After primary GHP excision, the cumulative incidence of recurrence was 7.2%, 12.7%, and 19.6% at 2 years, 5 years, and 10 years, respectively.

CONCLUSION

The incidence of GHP recurrence following endoscopic excision increased as the follow-up period increased, especially in patients whose GHPs were large-sized, multiple, or characterized by surface exudates/lobulations.

ROLE OF INCISURA ANGULARIS BIOPSY IN GASTRITIS STAGING AND RISK ASSESSMENT OF GASTRIC CÂNCER

BACKGROUND

Gastric atrophy (GA) and intestinal metaplasia (IM) are early stages in the development of gastric cancer. Evaluations are based on the Updated Sydney System, which includes a biopsy of the incisura angularis (IA), and the Operative Link on Gastritis Assessment (OLGA) and Operative Link on Gastritis Assessment using Intestinal Metaplasia (OLGIM) gastric cancer risk staging systems.

OBJECTIVE

To compare the OLGA and OLGIM classifications with and without IA biopsy. In addition, to determine the prevalence of Helicobacter pylori (HP) and pre-neoplastic changes (GA and IM) in different biopsied regions and to identify the exclusive findings of IA.

METHODS

Observational, prospective, descriptive, unicentric study with 350 patients without a diagnosis of gastric cancer, who underwent upper digestive endoscopy with biopsies at Gastroclínica Itajaí, from March 2020 to May 2022. The histopathological classification of gastritis followed the Updated Sydney System, and the gastric cancer risk assessment followed the OLGA and OLGIM systems. The methodology applied evaluated the scores of the OLGA and OLGIM systems with and without the assessment of the IA biopsy. Statistical analysis was performed using descriptive measures (frequencies, percentages, mean, standard deviation, 95% confidence interval). Ranks were compared using the Kruskal-Wallis or Wilcoxon tests. To analyze the relationship between the frequencies, the bilateral Fisher’s exact test was used. Wilson’s score with continuity correction was applied to the confidence interval.

RESULTS

The median age was 54.7 years, with 52.57% female and 47.43% male patients. The comparison between the used biopsies protocol (corpus + antrum [CA] vs corpus + antrum + incisura angularis [CAI]) and the OLGA and OLGIM stages showed a significant decrease in both staging systems when the biopsy protocol restricted to the corpus and antrum was applied (OLGA CAI vs CA; P=0.008 / OLGIM CAI vs CA; P=0.002). The prevalence of pre-malignant lesions (GA, IM and dysplasia) of the gastric mucosa was (33.4%, 34% and 1.1%, respectively) in the total sample. The antrum region exhibited significantly higher numbers of alteration (P<0.001), except for HP infection, which was present in 24.8% of the patients.

CONCLUSION

Incisura angularis biopsy is important because it increased the number of cases diagnosed in more advanced stages of intestinal metaplasia and atrophy. The study had limitations, with the main one being the relatively small sample size, consisting mostly of healthy individuals, although mostly elderly.

Gastric squamous cell carcinoma: A rare malignancy, literature review and management recommendations (Review)

Gastric cancer serves a major role in the global cancer burden, being the fourth most frequent cause of mortality among all types of cancer. Gastric squamous cell carcinoma (GSCC) is a rare histological variant accounting for 0.04-0.5% of all gastric cancer cases. Diagnostic work-up of GSCC is essential and involves multiple criteria: i) Tumour not located in the cardia, ii) no oesophageal extension of the tumour, and iii) no evidence of SCC in any other part of the body. Little is known about this rare variant in terms of pathogenesis, risk factors or evolution. Consequently, neither the European Society of Medical Oncology nor the National Comprehensive Cancer Network societies have published recommendations for GSCC. The aim of the present review is to provide an in-depth analysis of the current literature on this pathology, from pathophysiological hypothesis and clinical presentation to diagnostic work-up and treatment trends, in order to establish a possible management algorithm.

[Peptic ulcer]

Peptic ulcer disease is a frequent pathology; although the incidence has decreased in recent years, it continues to be an important cause of morbidity and mortality associated with high healthcare costs. The most important risk factors are Helicobacter pylori(H. pylori) infection and the use of non-steroidal anti-inflammatory drugs. Most patients with peptic ulcer disease remain asymptomatic, with dyspepsia being the most frequent and often characteristic symptom. It can also debut with complications such as upper gastrointestinal bleeding, perforation or stenosis. The diagnostic technique of choice is upper gastrointestinal endoscopy. Treatment with proton pump inhibitors, eradication of H. pylori and avoiding the use of non-steroidal anti-inflammatory drugs are the basis of treatment. However, prevention is the best strategy, it includes an adequate indication of proton pump inhibitors, investigation and treatment of H. pylori, avoiding non-steroidal anti-inflammatory drugs or using those that are less gastrolesive.

Artificial intelligence in endoscopy: Overview, applications, and future directions

Since the emergence of artificial intelligence (AI) in medicine, endoscopy applications in gastroenterology have been at the forefront of innovations. The ever-increasing number of studies necessitates the need to organize and classify applications in a useful way. Separating AI capabilities by computer aided detection (CADe), diagnosis (CADx), and quality assessment (CADq) allows for a systematic evaluation of each application. CADe studies have shown promise in accurate detection of esophageal, gastric and colonic neoplasia as well as identifying sources of bleeding and Crohn's disease in the small bowel. While more advanced CADx applications employ optical biopsies to give further information to characterize neoplasia and grade inflammatory disease, diverse CADq applications ensure quality and increase the efficiency of procedures. Future applications show promise in advanced therapeutic modalities and integrated systems that provide multimodal capabilities. AI is set to revolutionize clinical decision making and performance of endoscopy.

Soluble HLA-G (sHLA-G) measurement might be useful as an early diagnostic biomarker and screening test for gastric cancer

Gastric cancer (GC) is the fifth most frequent malignancy worldwide and has a high mortality rate related to late diagnosis. Although the gold standard for the GC diagnosis is endoscopy with biopsy, nonetheless, it is not cost-effective and is invasive for the patient. The Human leukocyte antigen G (HLA-G) molecule is a checkpoint of the immune response. Its overexpression in cancer is associated with immune evasion, metastasis, poor prognosis, and lower overall survival. We evaluate the plasma levels of soluble HLA-G, (sHLA-G) in patients with GC and benign gastric pathologies using an ELISA test. A higher concentration of sHLA-G in patients with GC than in those with benign pathologies, higher levels of plasma sHLA-G in women with GC compared with men and significant differences in the sHLA-G levels between the benign gastric pathologies evaluated, was our main findings. As no significant differences were found between the GC assessed stages in our study population, we suggest that sHLA-G is not an adequate marker for staging GC, but it does have diagnostic potential. In addition to providing information on the potential of sHLA-G as a diagnostic marker for GC, our study demonstrate that HLA-G molecules can be found in the membrane of exosomes, which highlights the need to perform studies with a larger number of samples to explore the functional implications of HLA-G positive exosomes in the context of gastric cancer, and to determine the clinical significance and possible applications of these findings in the development of non-invasive diagnostic methods.

Gastric cancer after Bariatric Bypass Surgery. Do they relate? (A Systematic Review)

Bariatric bypass surgery has been an effective treatment for morbid obesity. However, there is an increasing number of reported cases of gastric cancer after bypass surgery. Our systematic review showed an increasing trend of gastric cancer cases after bariatric bypass surgery in the last decade, mostly located in the excluded stomach (77%) and diagnosed in an advanced stage. In addition to known risk factors such as tobacco smoking (17%), H. pylori infection (6%), and family history of gastric cancer (3%), bile reflux, a recently proposed cancer-promoting factor, was also estimated in 18% of the cases. Our data suggest that gastric cancer risk assessment should be considered before gastric bypass surgery, and further investigations are needed to determine the value of post-operative gastric cancer surveillance.

Clinical epidemiology and outcomes of patients with gastric intestinal metaplasia in the Los Angeles County System

BACKGROUND

Gastric intestinal metaplasia (GIM) is a precursor to gastric adenocarcinoma (GAC). In the United States, there is no consensus on the utility of surveillance for GIM, and minority populations most affected by GAC are understudied. Our aims were to define clinical and endoscopic features, surveillance practices, and outcomes in patients with GIM in a multicenter safety-net system.

METHODS

We identified patients with biopsy-proven GIM between 2016-2020 at the three medical centers comprising Los Angeles County Department of Health Services. Demographics, findings at index esophagogastroduodenoscopy (EGD) first showing GIM, recommended interval for repeat EGD, and findings at repeat EGD were abstracted. Descriptive statistics were performed to characterize our cohort. T-tests and chi-squared (χ²) tests were used to compare patients with and without multifocal GIM.

RESULTS

There were 342 patients with newly-diagnosed biopsy-proven GIM, 18 (5.2%) of whom had GAC at index EGD. Hispanic patients comprised 71.8% of patients. For most patients (59%), repeat EGD was not recommended. If recommended, 2-3 years was the most common interval. During a median time to repeat EGD of 13 months and cumulative follow-up of 119 patient-years, 29.5% of patients underwent at least one repeat EGD, of whom 14% had multifocal GIM not previously detected. Progression to dysplasia or GAC was not detected in any patients.

CONCLUSION

In a predominantly minority population with biopsy-proven GIM, there was a 5% incidence of GAC on index EGD. Though progression to neither dysplasia nor GAC was detected, there was significant variability in endoscopic sampling and surveillance practices.

Recent advances in endoscopic management of gastric neoplasms

The development and clinical application of new diagnostic endoscopic technologies such as endoscopic ultrasonography with biopsy, magnification endoscopy, and narrow-band imaging, more recently supplemented by artificial intelligence, have enabled wider recognition and detection of various gastric neoplasms including early gastric cancer (EGC) and subepithelial tumors, such as gastrointestinal stromal tumors and neuroendocrine tumors. Over the last decade, the evolution of novel advanced therapeutic endoscopic techniques, such as endoscopic mucosal resection, endoscopic submucosal dissection, endoscopic full-thickness resection, and submucosal tunneling endoscopic resection, along with the advent of a broad array of endoscopic accessories, has provided a promising and yet less invasive strategy for treating gastric neoplasms with the advantage of a reduced need for gastric surgery. Thus, the management algorithms of various gastric tumors in a defined subset of the patient population at low risk of lymph node metastasis and amenable to endoscopic resection, may require revision considering upcoming data given the high success rate of en bloc resection by experienced endoscopists. Moreover, endoscopic surveillance protocols for precancerous gastric lesions will continue to be refined by systematic reviews and meta-analyses of further research. However, the lack of familiarity with subtle endoscopic changes associated with EGC, as well as longer procedural time, evolving resection techniques and tools, a steep learning curve of such high-risk procedures, and lack of coding are issues that do not appeal to many gastroenterologists in the field. This review summarizes recent advances in the endoscopic management of gastric neoplasms, with special emphasis on diagnostic and therapeutic methods and their future prospects.

Gastric villous adenoma: a case report and review of the literature

BACKGROUND

Villous adenoma is the one subtype of adenomatous polyp that is very uncommon in the stomach. Data regarding clinical characteristics, natural history, and prognosis were scarce.

CASE PRESENTATION

This report presented an 87-year-old Thai woman with a large gastric villous adenoma incidentally revealed in a computed tomography of chest for the evaluation of right pleural effusion. The esophagogastroduodenoscopy demonstrated a huge, glossy, proliferative polypoid mass involving gastric cardia, fundus, and a lesser curve of the upper body. The pathological report confirmed villous adenoma with low grade dysplasia. Although surgical resection was suggested, the patient denied any treatment due to advanced age and multiple comorbidities. She was generally well after 12 months of clinical and radiologic surveillance.

CONCLUSION

From literature review, only 14 cases of gastric villous adenoma were reported to date. Most of the lesions were large and symptomatic. Malignancy presented in 43% of the cases. Nevertheless, our patient remained asymptomatic without surgical removal following a 12-month period.

Endoscopic Imaging for the Diagnosis of Neoplastic and Pre-Neoplastic Conditions of the Stomach

Gastric cancer is an aggressive disease with low long-term survival rates. An early diagnosis is essential to offer a better prognosis and curative treatment. Upper gastrointestinal endoscopy is the main tool for the screening and diagnosis of patients with gastric pre-neoplastic conditions and early lesions. Image-enhanced techniques such as conventional chromoendoscopy, virtual chromoendoscopy, magnifying imaging, and artificial intelligence improve the diagnosis and the characterization of early neoplastic lesions. In this review, we provide a summary of the currently available recommendations for the screening, surveillance, and diagnosis of gastric cancer, focusing on novel endoscopy imaging technologies.

Controlling Gastric Cancer in a World of Heterogeneous Risk

Gastric cancer (GC) is a leading cause of global mortality but also a cancer whose footprint is highly unequal. This review aims to define global disease epidemiology, critically appraise strategies of prevention and disease attenuation, and assess how these strategies could be applied to improve outcomes from GC in a world of variable risk and disease burden. Strategies of primary prevention focus on improving the detection and eradication of the main environmental risk factor, Helicobacter pylori. In certain countries of high incidence, endoscopic or radiographic screening of the asymptomatic general population has been adopted as a means of secondary prevention. By contrast, identification and targeted surveillance of individuals with precancerous lesions (such as intestinal metaplasia) is being increasingly embraced in nations of low incidence. This review also highlights existing knowledge gaps in GC prevention as well as the role of emerging technologies for early detection and risk stratification.

Magnifying endoscopy is superior at detecting easy-missed neoplastic lesions on the upper gastrointestinal tract

Magnifying endoscopy is advantageous in detecting precancerous lesions. Our study aimed to clarify its ability to detect easily missed neoplastic lesions on the upper gastrointestinal tract. A retrospective analysis of clinical, endoscopic, and pathological data of cases undergoing gastroscopy was performed using magnifying and routine endoscopy. The detection rates of overall lesions, the ability to identify flat-type neoplastic lesions, and the easily missed neoplastic lesions were compared between the two groups. Endoscopic data from 32,367 patients was analyzed in this study. The use of magnifying endoscopy was an independent factor in identifying flat lesions (OR 2.236, 95% CI 1.969-2.540, p < 0.001), particularly type IIb lesions (OR 3.117, 95% CI 2.333-4.165, p < 0.001). For neoplastic lesions, magnifying endoscopy was also identified as having better sensitivity than routine endoscopy (sensitivity, 90.4% vs. 78.9%, p < 0.001). Similarly, magnifying endoscopy was an independent factor for identifying flat lesions (OR 2.927, 95% CI 2.365-3.621, p < 0.001), especially type IIc lesions (OR 4.415, 95% CI 3.076-6.339, p < 0.001). Magnifying endoscopy was also identified as having superior sensitivity (44.7% vs. 13.3%, p = 0.034) for early cancerous lesions. Compared to routine endoscopy, magnification endoscopy is advantageous in detecting and identifying neoplastic lesions in the upper gastrointestinal tract, especially flat neoplastic lesions and early cancers.

Surveillance for Colorectal Neoplasia in Inflammatory Bowel Disease: When to Stop

Patients with chronic ulcerative and Crohn's colitis are at increased risk for colorectal neoplasia(CRN [dysplasia and cancer]) compared to the general population. Risk factors for CRN include extent of colitis, cumulative inflammatory burden, family history of colorectal cancer, and primary sclerosing cholangitis. Best practices to prevent CRN include control of colonic inflammation, high quality surveillance colonoscopy with or without enhanced imaging techniques, resection of visible dysplasia if possible, and colectomy in patients with unresectable dysplasia, invisible multifocal low grade dysplasia, or invisible high grade dysplasia. Cessation of dysplasia surveillance is individualized and should involve shared decision making based on factors including but not limited to chronologic age, frailty, co-morbid conditions, life expectancy, results of prior surveillance exams, and risk factors for CRN.

Helicobacter pylori eradication reduces risk for recurrence of gastric hyperplastic polyp after endoscopic resection

BACKGROUND/AIMS

Little is known about the effect of Helicobacter pylori eradication on the recurrence of gastric hyperplastic polyps after endoscopic resection. Thus, we evaluated the recurrence rate of gastric hyperplastic polyps based on H. pylori eradication following endoscopic resection.

METHODS

We retrospectively reviewed the medical records of 201 patients with H. pylori infection who underwent endoscopic resection for gastric hyperplastic polyps at six medical centers. H. pylori status was assessed by histological analysis and a rapid urease test. A total of 149 patients underwent successful H. pylori eradication (eradication group), whereas 52 patients had persistent H. pylori infections (non-eradication group). The recurrence rate of gastric hyperplastic polyps and the risk factors according to H. pylori status were analyzed.

RESULTS

During the mean follow-up period of 18.3 months, recurrent gastric polyps developed after endoscopic resection in 10 patients (19.2% [10/52]) in the non-eradication group and 12 patients (8.1% [12/149]) in the eradication group. The cumulative incidence of recurrent gastric hyperplastic polyps was significantly higher in the non-eradication group than in the eradication group (p = 0.041, log-rank test). In the adjusted analysis, H. pylori eradication reduced the recurrence of gastric hyperplastic polyps (hazard ratio [HR], 0.42; 95% confidence interval [CI], 0.18 to 0.99), whereas anticoagulation therapy increased the risk of recurrence of gastric hyperplastic polyps (HR, 4.91; 95% CI, 1.39 to 17.28).

CONCLUSION

Successful eradication of H. pylori may reduce the recurrence of gastric hyperplastic polyps in patients after endoscopic mucosal resection.

Single-cell sequencing of ascites fluid illustrates heterogeneity and therapy-induced evolution during gastric cancer peritoneal metastasis

Peritoneal metastasis is the leading cause of death for gastrointestinal cancers. The native and therapy-induced ascites ecosystems are not fully understood. Here, we characterize single-cell transcriptomes of 191,987 ascites cancer/immune cells from 35 patients with/without gastric cancer peritoneal metastasis (GCPM). During GCPM progression, an increase is seen of monocyte-like dendritic cells (DCs) that are pro-angiogenic with reduced antigen-presenting capacity and correlate with poor gastric cancer (GC) prognosis. We also describe the evolution of monocyte-like DCs and regulatory and proliferative T cells following therapy. Moreover, we track GC evolution, identifying high-plasticity GC clusters that exhibit a propensity to shift to a high-proliferative phenotype. Transitions occur via the recently described, autophagy-dependent plasticity program, paligenosis. Two autophagy-related genes (MARCKS and TXNIP) mark high-plasticity GC with poorer prognosis, and autophagy inhibitors induce apoptosis in patient-derived organoids. Our findings provide insights into the developmental trajectories of cancer/immune cells underlying GCPM progression and therapy resistance.

Establishing machine learning models to predict the early risk of gastric cancer based on lifestyle factors

BACKGROUND

Gastric cancer is one of the leading causes of death worldwide. Screening for gastric cancer greatly relies on endoscopy and pathology biopsy, which are invasive and pose financial burdens. Thus, the prevention of the disease by modifying lifestyle-related behaviors and dietary habits or even the prevention of risk factor formation is of great importance. This study aimed to construct an inexpensive, non-invasive, fast, and high-precision diagnostic model using six machine learning (ML) algorithms to classify patients at high or low risk of developing gastric cancer by analyzing individual lifestyle factors.

METHODS

This retrospective study used the data of 2029 individuals from the gastric cancer database of Ayatollah Taleghani Hospital in Abadan City, Iran. The data were randomly separated into training and test sets (ratio 0.7:0.3). Six  ML methods, including multilayer perceptron (MLP), support vector machine (SVM) (linear kernel), SVM (RBF kernel), k-nearest neighbors (KNN) (K = 1, 3, 7, 9), random forest (RF), and eXtreme Gradient Boosting (XGBoost), were trained to construct prognostic models before and after performing the relief feature selection method. Finally, to evaluate the models' performance, the metrics derived from the confusion matrix were calculated via a test split and cross-validation.

RESULTS

This study found 11 important influence factors for the risk of gastric cancer, such as Helicobacter pylori infection, high salt intake, and chronic atrophic gastritis, among other factors. Comparisons indicated that the XGBoost had the best performance for the risk prediction of gastric cancer.

CONCLUSIONS

The results suggest that based on simple baseline patient data, the ML techniques have the potential to start the prescreening of gastric cancer and identify high-risk individuals who should proceed with invasive examinations. Our model could also considerably lessen the number of cases that need endoscopic surveillance. Future studies are required to validate the efficacy of the models in a larger and multicenter population.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Approach to Performance of Quality Upper Endoscopy in Lynch Syndrome (QUELS): An International Expert Statement

Strong evidence demonstrates the protective benefit of frequent colonoscopy surveillance for colorectal cancer prevention in Lynch Syndrome (LS) and is endorsed by many guidelines. Until recently, the evidence supporting the utility of upper endoscopy [esophagogastroduodenoscopy (EGD)] for upper gastrointestinal (UGI) cancer surveillance was limited. Over the last 3 years, multiple studies have demonstrated that EGD surveillance in LS is associated with the detection of both precancerous lesions and early-stage UGI cancers. On the basis of the emerging favorable evidence derived from EGD surveillance programs, the 2022 National Comprehensive Cancer Network (NCCN) Guidelines for LS recommend UGI surveillance with EGD starting between age 30 and 40 years with repeat EGDs every 2 to 4 years, preferably in conjunction with colonoscopy, in all patients with a germline pathogenic variant (PV) in MLH1, MSH2, EPCAM, and MSH6 and, because of the lack of data, consideration in PMS2. Standardization of the approach to performing EGD surveillance in LS and reporting clinically actionable findings is requisite for both improving quality and understanding the cost efficiency and outcomes of patients undergoing EGD as a surveillance tool. Accordingly, the primary objective of this Quality of Upper Endoscopy in Lynch Syndrome (QUELS) statement is to articulate a framework for standardizing the approach to performing and reporting EGD findings in patients with LS by introducing emerging quality metrics. The recommendations presented herein were developed from available evidence and consensus-based expert opinion and provide a practical approach for clinicians applying EGD surveillance in accordance with the most recent and existing LS guidelines.

Interventional gastroenterology in oncology

Cancer is one of the foremost health problems worldwide and is among the leading causes of death in the United States. Gastrointestinal tract cancers account for almost one third of the cancer-related mortality globally, making it one of the deadliest groups of cancers. Early diagnosis and prompt management are key to preventing cancer-related morbidity and mortality. With advancements in technology and endoscopic techniques, endoscopy has become the core in diagnosis and management of gastrointestinal tract cancers. In this extensive review, the authors discuss the role endoscopy plays in early detection, diagnosis, and management of esophageal, gastric, colorectal, pancreatic, ampullary, biliary tract, and small intestinal cancers.

Endoscopic Surveillance and Treatment of Upper GI Tract Lesions in Patients with Familial Adenomatous Polyposis-A New Perspective on an Old Disease

Familial adenomatous polyposis (FAP) is an autosomal dominant disease caused by a germline mutation in the adenomatous polyposis coli (APC) gene. Patients with FAP develop up to thousands of colorectal adenomas as well as lesions in the upper GI tract. In FAP, the upper digestive lesions include gastric fundic gland polyps (FGPs), antrum adenomas, duodenal or small intestinal adenomas, and carcinoma. Patients, after colectomy, are still at significant risk for extracolonic malignancies. Advances in endoscope resolution and optical enhancement technologies allow endoscopists to provide assessments of benign and malignant polyps. For this reason, in the past decades, endoscopic resection techniques have become the first line of treatment in patients with polyps in the upper GI, whereby polyps and even early cancers can be successfully cured. In FAP patients, endoscopic ampullectomy appears to be a safe and effective way of treating patients with ampullary tumors. According to current indications, endoscopic retrograde cholangiopancreatography (ERCP) and stenting of the main pancreatic duct follow ampullectomy.

Establishment and Validation of a Pathologic Upgrade Prediction Nomogram Model for Gastric Low-Grade Intraepithelial Neoplasia Patients After the Eradication of Helicobacter pylori

BACKGROUND

As yet, there is no unified method of treatment for the evaluation and management of gastric low-grade intraepithelial neoplasia (LGIN) worldwide.

METHODS

Patients with gastric LGIN who had been treated with Helicobacter pylori eradication were gathered retrospectively. Based on several relevant characteristics described and analyzed by LASSO regression analysis and multivariable logistic regression, a prediction nomogram model was established. C-index, the area under the receiver operating characteristic curve (AUC), calibration plot, and decision curve analysis (DCA) were adopted to evaluate the accuracy and reliability of the model.

RESULTS

A total of 309 patients with LGIN were randomly divided into the training groups and the validation groups. LASSO regression analysis and multivariable logistic regression identified that 6 variables including gender, size, location, borderline, number, and erosion were independent risk factors. The nomogram model displayed good discrimination with a C-index of .765 (95% confidence interval: .702-.828). The accuracy and reliability of the model were also verified by an AUC of .764 in the training group and .757 in the validation group. Meanwhile, the calibration curve and the DCA suggested that the predictive nomogram had promising accuracy and clinical utility.

CONCLUSIONS

A predictive nomogram model was constructed and proved to be clinically applicable to identify high-risk groups with possible pathologic upgrade in patients with gastric LGIN. Since it is regarded that strengthening follow-up or endoscopic treatment of high-risk patients may contribute to improving the detection rate or reducing the incidence of gastric cancer, the predictive nomogram model provides a reliable basis for the treatment of LGIN.

Clinical characteristics and risk factors for upgraded pathology in patients with gastric intraepithelial neoplasia after endoscopic submucosal dissection

BACKGROUND AND AIMS

The pathological results of endoscopic forceps biopsy (EFB) are frequently inconsistent with those after endoscopic submucosal dissection (ESD) in patients with gastric intraepithelial neoplasia (GIN). The aim of this study was to explore the risk factors for upgraded pathology after ESD in the Wannan region of Anhui Province, in order to guide the best clinical treatment of GIN.

METHODS

A retrospective analysis was performed at the First Affiliated Hospital of Wannan Medical College. Univariate analysis and multivariate analysis were used to investigate the independent risk factors for pathology upgrade between EFB and ESD.

RESULTS

In total, 215 patients who were initially diagnosed with GIN from EFB and subsequently received treatment with ESD were eventually selected for analysis. Age >60 years, a lesion located in upper 2/3 of the stomach, a lesion size of >2 cm, a lesion surface with redness and nodules and a lesion with irregular or absent microglands were significantly associated with the upgraded group after ESD. Multivariate analysis suggested that a lesion size of >2 cm (odds ratio [OR], 1.499; 95% confidence interval [CI], 1.222-1.909; P=0.026), a lesion surface with redness (OR, 1.508; 95%CI, 1.260-1.993; P=0.048) and nodules (OR, 1.390; 95%CI, 1.195-1.778; P=0.008) were independent predictors for the upgraded group.

CONCLUSIONS

For patients with suspected GIN by EFB, a lesion size of >2 cm, a lesion surface with redness and nodules should be taken into account before deciding on the ESD.

Clinical and endoscopic predictors of gastric precancerous conditions: a large population case control study

BACKGROUND

Atrophic gastritis (AG) and gastric intestinal metaplasia (GIM) are well defined intermediate precancerous conditions (PCCs) in the gastric cancer cascade. The diagnosis of PCCs may be suspected based on endoscopic findings but is established by histology. Estimates of the global prevalence of PCCs vary widely but simple clinical or endoscopic predictors of their diagnosis are ill defined. We aimed to evaluate the prevalence of gastric PCCs in our practice and to identify predictors for its diagnosis.

METHODS

We analyzed electronic reports of patients referred for gastroscopy procedures over a 5-year period and included those for whom gastric biopsies were performed. We investigated demographic, clinical, and endoscopic findings to identify possible association with histologic detection of gastric PCCs and performed multivariate analysis to identify predictors of its diagnosis.

RESULTS

A total of 4930 patients with full endoscopic and histologic data were included for the final analysis. Of these, 806 (16.3%) patients had a histologic diagnosis of gastric PCCs. Demographic and clinical variables including male sex (51.4% vs. 45.7%; P=0.003), age over 60 (69.8% vs. 45.2%; P<0.001), and anemia indication for gastroscopy (17.6% vs. 14.8%; P=0.04) were significantly associated with gastric PCCs diagnosis. Likewise, endoscopic findings of Barret's esophagus (2.6% vs. 1.3%; P=0.006), atrophic gastritis according to endoscopist's judgment (12.9% vs. 3.5%; P<0.01) and corpus predominant gastritis (22.5% vs. 14.7%; P=0.02) were significantly associated with gastric PCCs. In multivariate analysis, age>60 (please explain all acronyms HR 2.51, 95% CI 2.12-2.96), male sex (HR 1.235, 95% CI 1.05-1.44), corpus predominant (HR 1.284, 95% CI 1.04-1.57), and atrophic gastritis (HR 4, 95% CI 3.07-5.21) were independent predictors for PCCs diagnosis.

CONCLUSIONS

Not uncommonly encountered in our practice, a judicious performance of gastric biopsies to detect gastric PCCs should be adopted especially in older, male patients with endoscopic findings of corpus predominant and/or gastric atrophy.

Natural compounds targeting glycolysis as promising therapeutics for gastric cancer: A review

Gastric cancer, a common malignant disease, seriously endangers human health and life. The high mortality rate due to gastric cancer can be attributed to a lack of effective therapeutic drugs. Cancer cells utilize the glycolytic pathway to produce energy even under aerobic conditions, commonly referred to as the Warburg effect, which is a characteristic of gastric cancer. The identification of new targets based on the glycolytic pathway for the treatment of gastric cancer is a viable option, and accumulating evidence has shown that phytochemicals have extensive anti-glycolytic properties. We reviewed the effects and mechanisms of action of phytochemicals on aerobic glycolysis in gastric cancer cells. Phytochemicals can effectively inhibit aerobic glycolysis in gastric cancer cells, suppress cell proliferation and migration, and promote apoptosis, via the PI3K/Akt, c-Myc, p53, and other signaling pathways. These pathways affect the expressions of HIF-1α, HK2, LDH, and other glycolysis-related proteins. This review further assesses the potential of using plant-derived compounds for the treatment of gastric cancer and sheds insight into the development of new drugs.

Learning curve of endoscopic submucosal dissection (ESD) with prevalence-based indication in unsupervised Western settings: a retrospective multicenter analysis

BACKGROUND AND AIMS

As there is still no consensus about the adequate training strategy for ESD in Western countries, we evaluated unsupervised prevalence-based learning curves including detailed organ-specific subgroup analysis.

METHODS

The first 120 ESDs of four operators (n = 480) were divided into three groups (1: ESD 1-40, 2: ESD 41-80, 3: ESD 81-120). Outcome parameters were rates of technical success, en bloc and R0 resection, the resection speed, rates of conversion to EMR, curative resection, adverse events, surgery due to adverse events, and recurrence. In addition, we analyzed the achievement of quality benchmarks indicating levels of expertise.

RESULTS

After exclusion of pretreated lesions, 438 procedures were enrolled in the final analysis. Technical success rates were > 96% with significant improvements regarding rate of en bloc resection (from 82.6 to 91.2%), resection speed (from 4.54 to 7.63 cm²/h), and rate of conversion to EMR (from 22.0 to 8.1%). No significant differences could be observed for rates of R0 resection (65.9 vs. 69.6%), curative resection (55.8 vs. 55.7%), adverse events (16.3 vs. 11.7%), surgery due to adverse events (1.5 vs. 1.3%), and recurrence (12.5 vs. 4.5%). Subgroup and benchmark analysis revealed an improvement in esophageal, gastric, and rectal ESD with achievement of competence levels for the esophagus and stomach within 80 and most of the benchmarks for proficiency level within 120 procedures. Some of the benchmarks could also be achieved in rectal ESD.

CONCLUSIONS

This trial confirms safety and feasibility of unsupervised ESD along the initial learning curve with prevalence-based indication and exclusion of colonic cases.

Dysplastic Stem Cell Plasticity Functions as a Driving Force for Neoplastic Transformation of Precancerous Gastric Mucosa

BACKGROUND & AIMS

Dysplasia carries a high risk of cancer development; however, the cellular mechanisms for dysplasia evolution to cancer are obscure. We have previously identified 2 putative dysplastic stem cell (DSC) populations, CD44v6neg/CD133+/CD166+ (double positive [DP]) and CD44v6+/CD133+/CD166+ (triple positive [TP]), which may contribute to cellular heterogeneity of gastric dysplasia. Here, we investigated functional roles and cell plasticity of noncancerous Trop2+/CD133+/CD166+ DSCs initially developed in the transition from precancerous metaplasia to dysplasia in the stomach.

METHODS

Dysplastic organoids established from active Kras-induced mouse stomachs were used for transcriptome analysis, in vitro differentiation, and in vivo tumorigenicity assessments of DSCs. Cell heterogeneity and genetic alterations during clonal evolution of DSCs were examined by next-generation sequencing. Tissue microarrays were used to identify DSCs in human dysplasia. We additionally evaluated the effect of casein kinase 1 alpha (CK1α) regulation on the DSC activities using both mouse and human dysplastic organoids.

RESULTS

We identified a high similarity of molecular profiles between DP- and TP-DSCs, but more dynamic activities of DP-DSCs in differentiation and survival for maintaining dysplastic cell lineages through Wnt ligand-independent CK1α/β-catenin signaling. Xenograft studies demonstrated that the DP-DSCs clonally evolve toward multiple types of gastric adenocarcinomas and promote cancer cell heterogeneity by acquiring additional genetic mutations and recruiting the tumor microenvironment. Last, growth and survival of both mouse and human dysplastic organoids were controlled by targeting CK1α.

CONCLUSIONS

These findings indicate that the DSCs are de novo gastric cancer-initiating cells responsible for neoplastic transformation and a promising target for intervention in early induction of gastric cancer.

Endoscopic submucosal resection: a technique using novel devices for incision and resection of neoplastic lesions

BACKGROUND

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are established techniques for treatment of superficial gastrointestinal neoplasia. Limitations of EMR are low en bloc resection rates for larger lesions, resulting in frequent recurrences. Major disadvantages of ESD are technical difficulty and long procedure times. We evaluated technical feasibility and safety of newly designed devices for en bloc resection of lesions measuring 20-40 mm in a technique called endoscopic submucosal resection (ESR).

METHODS

This case series included 93 lesions from different locations (11 stomach, 25 colon, 57 rectum) with a median size of 29 mm (range 10-70). ESR was performed using two novel instruments for circumferential mucosal incision and deep submucosal resection, respectively.

RESULTS

Resection by ESR was feasible in all cases. En bloc and R0 rates were insufficient when ESR was attempted without prior circumferential mucosal incision, but were 70 % and 63 %, respectively, when mucosal incision was done before application of the submucosal resection device. We observed three complications (two delayed bleedings, one microperforation) but no cases of emergency surgery or 30-day mortality.

CONCLUSIONS

Results demonstrated feasibility and excellent safety of ESR using two novel devices for en bloc resection of early gastrointestinal neoplasia. The technique offered relative technical ease and high efficacy.

Preoperative evaluation of endoscopic submucosal dissection for early gastric cancer

OBJECTIVE

To retrospectively analyze the preoperative endoscopic evaluation of the size, nature, and depth of lesions in endoscopic submucosal dissection (ESD) for early gastric cancer and precancerous lesions, determine whether the lesions can be completely resected, and reduce the risk of additional surgery after ESD.

METHODS

A total of 114 patients with high-grade intraepithelial neoplasia(HGIN) and early gastric cancer treated with ESD in Hebei General Hospital from January 2016 to April 2021 were enrolled in this study. The lesions were evaluated preoperatively according to the endoscopic findings of white light, magnifying endoscopy, endoscopic features of narrow band imaging, and preoperative pathology. Lesion size, positive resection margin, lesion depth, and vascular invasion of postoperative pathology were used as criteria.

RESULTS

There were 121lesions in 114 patients. The coincidence rates of preoperative and postoperative pathology were 87.21% (75/86) for HGIN and 92.1% (35/38) for adenocarcinoma. There was no significant difference in the coincidence rate between preoperative pathological evaluation and postoperative pathology among the 3 lesions (χ2 = 10.614, P = .005). The type and malignancy of the lesion were not related to its location or size. Magnifying endoscopy combined with narrow-band imaging showed that HGIN and early gastric cancer had clear borders, irregular microvessels, and irregular surface microarchitecture on endoscopic features. Lesions > 3 cm, surface ulcers and spontaneous bleeding may be risk factors for deeper lesions.

CONCLUSION

ESD is not only a method for the treatment of early gastric cancer and precancerous lesions, but is also an important method for definite pathological diagnosis. Accurate preoperative assessment of lesion type, lesion extent and depth of invasion is helpful to improve the complete resection rate of ESD and reduce the risk of additional surgery.

Cancer in Inflammatory Bowel Disease

Inflammatory bowel diseases (IBD), including Crohn disease and ulcerative colitis, are chronic inflammatory conditions of the gastrointestinal tract. Individuals with IBD are at increased risk for several malignancies originating in the intestine, such as colorectal cancer, small bowel adenocarcinoma, intestinal lymphoma, and anal cancer. There are also several extraintestinal malignancies associated with IBD and IBD therapies, including cholangiocarcinoma, skin cancer, hematologic malignancies, genitourinary cancer, cervical cancer, and prostate cancer. The authors summarize the risk of cancer in patients with IBD, diagnosis and management of colorectal neoplasia in IBD, and management of patients with IBD and active or recent cancer.

A Gastroenterologist's Approach to the Diagnosis and Management of Gastrointestinal Stromal Tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal (GI) tract. These tumors have been shown to harbor oncogenic mutations of the c-kit tyrosine kinase receptor or platelet-derived growth factor receptor alpha (PDGFRA). Immunohistochemical analysis of GISTs allows for the differentiation of these tumors from other mesenchymal tumors of the GI tract such as leiomyomas and leiomyosarcomas. All GISTs have the potential to behave in a malignant fashion. Tumor location, size, and mitotic index are factors used to predict the risk of malignant behavior. Endoscopy and endoscopic ultrasound play a critical role in the diagnosis of GISTs and can yield important information to further risk-stratify tumors and determine management. This article provides a gastroenterologist's perspective on the diagnosis and management of GISTs.