Clinical and Endoscopic Characteristics Associated With Post-Endoscopy Upper Gastrointestinal Cancers: A Systematic Review and Meta-analysis

Intravenous sedation during esophagogastroduodenoscopy is associated with a reduced risk of missed gastric cancer

PURPOSE

Esophagogastroduodenoscopy (EGD) is an effective technique for diagnosing gastric cancer (GC). However, it is estimated that 10% of GCs are unnoticed, constituting missed gastric cancer (MGC). To analyse the incidence of MGC in our area, the characteristics of GC and factors related to MGC were evaluated.

MATERIALS AND METHODS

This was a retrospective study of patients diagnosed with GC at a single centre between October 2003 and December 2018. MGC was defined as GC undetected in a EGD performed 3 to 36 months before diagnosis.

RESULTS

A total of 333 patients with GC were identified, 6% of whom had MGC. MGC was more frequently located at anastomotic site of a previous surgery (p = 0.001), and fewer patients with MGC experienced alarm symptoms (p = 0.001). Using fewer biopsies (p = 0.001) and performing the procedure without sedation were associated to MGC. According to multivariate analysis, the factors associated with MGC were the absence of sedation [OR 3.2 (95% CI 1-10.4)] and localization in the anastomosis of previous surgery [OR 11.5 (95% CI 1.8-72.8)]. Moreover, there were no differences in 5-year survival between patients with MGC and patients without MGC.

CONCLUSIONS

The MGC percentage was 6%. When an EGD is indicated, regardless of the symptoms, IV sedation is recommended to reduce the risk of MGC. In addition, biopsies of the anastomosis from previous surgery should be considered even in the absence of clear suspicious lesions.

The Significance of Screening Endoscopy at 2-Year Interval for Detecting Pharyngeal and Esophageal Cancer in the Japanese General Population

PURPOSE

We previously identified examination time and 2-year interval as effective quality indicators for detecting upper gastrointestinal cancer during screening esophagogastroduodenoscopy (EGD). We evaluated the significance of biennial endoscopy in detecting pharyngeal and esophageal cancer.

METHODS

Individuals who underwent multiple EGD examinations as health checkups at our center between August 2012 and January 2022 were included. Endoscopists were categorized into two groups based on their mean examination time for normal EGD findings, using a threshold of 5 min. The associations between cancer detection rate and these indicators were analyzed using multivariable analyses.

RESULTS

Twelve endoscopists performed more than 1000 examinations each, for a total of 28,842 examinations, detecting all (6 pharyngeal and 26 esophageal) cancers. Intervals between endoscopies were classified into three groups: ≤ 1 year (Group 1), 1 to ≤ 2 years (Group 2), and > 2 years (Group 3). This cancer detection rate did not differ significantly between Groups 1 and 2 (p = 0.761) but was significantly higher in Group 3 than in Group 2 (OR = 4.356, 95% CI = 1.161-16.333, p = 0.029). When Groups 1 and 2 were combined (≤ 2 years) and compared with Group 3, an interval of > 2 years was significantly associated with a higher detection rate, including cases not curable by endoscopic resection (OR, 4.710; 95% CI, 1.806-12.282; p = 0.002). Examination time was not associated with the cancer detection rate (p = 0.944).

CONCLUSIONS

These findings support the significance of biennial endoscopy in detecting pharyngeal and esophageal cancer as well.

Post-endoscopy esophageal squamous cell carcinoma with invasion of the muscularis mucosa or deeper detected in surveillance endoscopy after esophageal endoscopic resection

BACKGROUND

Surveillance endoscopy is recommended after endoscopic resection of esophageal squamous cell carcinomas (ESCCs). However, surveillance endoscopy sometimes detects advanced subsequent ESCCs with invasion of the muscularis mucosa (MM) or deeper. We aimed to clarify the clinicopathological features of these advanced subsequent ESCCs.

METHODS

This single-center retrospective study identified subsequent ESCCs detected during surveillance endoscopy. ESCCs that invaded the MM or deeper and were detected within 24 months after the previous endoscopy were defined as post-endoscopy esophageal advanced lesions (PEEALs), while the first ESCC detected in the patient was defined as the primary lesion. Study 1 compared the clinicopathological characteristics of PEEALs versus non-advanced lesions. Study 2 compared the endoscopic features of pT1a-MM PEEALs versus pT1a-MM primary lesions.

RESULTS

A total of 307 subsequent ESCCs were analyzed in Study 1. Of these, 20 were PEEALs and 287 were non-advanced lesions (pT1a-EP/LPM). The median intervals from the previous endoscopy for PEEALs and non-advanced lesions were 6.1 months and 6.7 months, respectively (P = 0.283). The morphological feature of marginal elevation was seen in 60% of PEEALs. In Study 2, 15 pT1a-MM PEEALs were compared with 149 pT1a-MM primary lesions. Compared with primary lesions, pT1a-MM PEEALs were smaller (median 10 mm vs. 30 mm, P < 0.001) and had a higher prevalence of marginal elevation morphology (53.3% vs. 10.1%, P < 0.001).

CONCLUSIONS

The specific feature of PEEALs was marginal elevation. Surveillance endoscopy with careful observation for these lesions is recommended after endoscopic resection of ESCCs.

ACG Clinical Guideline: Diagnosis and Management of Gastric Premalignant Conditions

Gastric premalignant conditions (GPMC) are common and include atrophic gastritis, gastric intestinal metaplasia, dysplasia, and certain gastric epithelial polyps. GPMC have an increased risk of progression to gastric adenocarcinoma. Gastric cancer (GC) in the United States represents an important cancer disparity because incidence rates are 2- to 13-fold greater in non-White individuals, particularly early-generation immigrants from regions of high GC incidence. The US 5-year survival rate for GC is 36%, which falls short of global standards and is driven by the fact that only a small percentage of GC in the US is diagnosed in the early, curable stage. This document represents the first iteration of American College of Gastroenterology guidelines on this topic and encompasses endoscopic surveillance for high-risk patients with GPMC, the performance of high-quality endoscopy and image-enhanced endoscopy for diagnosis and surveillance, GPMC histology criteria and reporting, endoscopic treatment of dysplasia, the role of Helicobacter pylori eradication, general risk reduction measures, and the management of autoimmune gastritis and gastric epithelial polyps. There is insufficient evidence to make a recommendation on upper endoscopic screening for GC/GPMC detection in US populations deemed high-risk for GC. Surveillance endoscopy is recommended for individuals at high risk for GPMC progression, as defined by endoscopic, histologic, and demographic factors, typically every 3 years, but an individualized interval may be warranted. H. pylori testing, treatment, and eradication confirmation are recommended in all individuals with GPMC. Extensive high-quality data from US populations regarding GPMC management are lacking, but continue to accrue, and the quality of evidence for the recommendations presented herein should be interpreted with this dynamic context in mind. The GPMC research and education agendas are broad and include high-quality prospective studies evaluating opportunistic endoscopic screening for GC/GPMC, refined delineation of what constitutes "high-risk" populations, development of novel biomarkers, alignment of best practices, implementation of training programs for improved GPMC/GC detection, and evaluation of the impact of these interventions on GC incidence and mortality in the US.

Role of Artificial Intelligence in the Detection and Management of Premalignant and Malignant Lesions of the Esophagus and Stomach

The advent of artificial intelligence (AI) and deep learning algorithms, particularly convolutional neural networks, promises to address pitfalls, bridging the care for patients at high risk with improved detection (computer-aided detection [CADe]) and characterization (computer-aided diagnosis [CADx]) of lesions. This review describes the available artificial intelligence (AI) technology and the current data on AI tools for screening esophageal squamous cell cancer, Barret's esophagus-related neoplasia, and gastric cancer. These tools outperformed endoscopists in many situations. Recent randomized controlled trials have demonstrated the successful application of AI tools in clinical practice with improved outcomes.

Gastric Cancer Screening in the United States: A Review of Current Evidence, Challenges, and Future Perspectives

Gastric cancer remains a leading cause of cancer-related mortality worldwide. In the United States, gastric cancer incidence and mortality are substantially higher among non-White racial and ethnic groups and new immigrants from high-incidence countries. This is in large part related to the higher prevalence of Helicobacter pylori -associated gastric premalignant changes in these populations. Apart from primary prevention, early detection of gastric cancer is the principal strategy to reduce gastric cancer mortality and improve survival. Extensive evidence in Asian countries has demonstrated the benefits of endoscopic screening in detecting early-stage gastric cancer and reducing gastric cancer-related mortality. By contrast, direct, high-quality US-based data, such as from large clinical trials or observational studies, on important outcomes of gastric cancer screening are still lacking. In this review, we evaluate and summarize the latest global evidence on the epidemiology and predisposing factors of gastric cancer as well as the efficacy, benefits vs. risks, and cost-effectiveness of gastric cancer screening. We further discuss the critical knowledge gaps and challenges in promoting gastric cancer screening in the United States. Dedicated research is urgently needed to enrich the US-based data on gastric cancer primary and secondary prevention to inform clinical practice and reduce gastric cancer-related morbidity and mortality in a cost and resource efficient manner.

The variation in post-endoscopy upper gastrointestinal cancer rates among endoscopy providers in England and associated factors: a population-based study

BACKGROUND

Post-endoscopy upper gastrointestinal cancer (PEUGIC) is an important key performance indicator for endoscopy quality. We examined variation in PEUGIC rates among endoscopy providers in England and explored associated factors.

METHODS

The was a population-based, retrospective, case-control study, examining data from National Cancer Registration and Analysis Service and Hospital Episode Statistics databases for esophageal and gastric cancers diagnosed between 2009 and 2018 in England. PEUGIC were cancers diagnosed 6 to 36 months after an endoscopy that did not diagnose cancer. Associated factors were identified using multivariable logistic regression analyses.

RESULTS

The national PEUGIC rate was 8.5%, varying from 5% to 13% among endoscopy providers. Factors associated with PEUGIC included: female sex (odds ratio [OR] 1.29 [95%CI 1.23-1.36]); younger age (age >80 years, OR 0.52 [0.48-0.56], compared with ≤60 years); increasing comorbidity (Charlson score >4, OR 5.06 [4.45-5.76]); history of esophageal ulcer (OR 3.30 [3.11-3.50]), Barrett's esophagus (OR 3.21 [3.02-3.42]), esophageal stricture (OR 1.28 [1.20-1.37]), or gastric ulcer (OR 1.55 [1.44-1.66]); squamous cell carcinoma (OR 1.50 [1.39-1.61]); and UK national endoscopy accreditation status - providers requiring improvement (OR 1.10 [1.01-1.20]), providers never assessed (OR 1.24 [1.04-1.47]).

CONCLUSION

PEUGIC rates varied threefold among endoscopy providers, suggesting unwarranted differences in endoscopy quality. PEUGIC was associated with endoscopy findings known to be associated with upper gastrointestinal cancer and a lack of national endoscopy provider accreditation. PEUGIC variations suggest an opportunity to raise performance standards to detect upper gastrointestinal cancers earlier and improve outcomes.

Non-invasive early-stage cancer detection: current methods and future perspectives

This review paper explores the realm of non-invasive methods for early cancer detection. Early identification is crucial for effective therapeutic intervention, and non-invasive techniques have emerged as promising tools to enhance diagnostic accuracy and improve patient outcomes. The paper thoroughly examines the advantages, limitations, and prospects of various non-invasive approaches, including blood tests, non-blood-based tests, and diverse imaging modalities. It discusses the biomarkers found in blood for early-stage cancer detection, specifying the types of cancer associated with each biomarker. The non-blood-based tests focus on components in saliva, urine, and breath for cancer detection, alongside current studies and future perspectives on various cancers. Optical imaging methods covered in this review include fluorescence imaging in the near-infrared (NIR) region, bioluminescence imaging, and Raman spectroscopy for early-stage cancer detection. The review also highlights the pros and cons of ultrasound imaging in early-stage cancer detection. Additionally, the clinical implications of using AI for cancer detection, both present and future, are explored. This paper provides valuable insights for researchers and clinicians working in the field of non-invasive early-stage cancer detection.

The endoscopic model for gastric carcinogenesis and Helicobacter pylori infection: A potential visual mind-map during gastroscopy examination

Helicobacter pylori (Hp) is the main trigger of chronic gastric atrophy and the main leading cause of gastric cancer. Hp infects the normal gastric mucosa and can lead to chronic inflammation, glandular atrophy, intestinal metaplasia, dysplasia and finally adenocarcinoma. Chronic inflammation and gastric atrophy associated with Hp infection appear initially in the distal part of the stomach (the antrum) before progressing to the proximal part (the corpus-fundus). In recent years, endoscopic developments have allowed for the characterization of various gastric conditions including the normal mucosa (pyloric/fundic gland pattern and regular arrangement of collecting venules), Hp-related gastritis (Kyoto classification), glandular atrophy (Kimura-Takemoto classification), intestinal metaplasia (Endoscopic Grading of Gastric Intestinal Metaplasia), and dysplasia/adenocarcinoma (Vessel plus Surface classification). Despite being independent classifications, all these scales can be integrated into a single model: the endoscopic model for gastric carcinogenesis. This model would assist endoscopists in comprehending the process of gastric carcinogenesis and conducting a systematic examination during gastroscopy. Having this model in mind would enable endoscopists to promptly recognize the implications of Hp infection and the potential patient's risk of developing gastric cancer.

Association between anesthesia assistance and precancerous lesions and early cancer detection during diagnostic esophagogastroduodenoscopy: a propensity score-matched retrospective study

Background

Esophagogastroduodenoscopy (EGD) is a fundamental procedure for early detection of upper gastrointestinal (UGI) cancer. However, limited research has been conducted on the impact of sedation during EGD on the identification of precancerous lesions and early cancer (EC). This retrospective study aims to evaluate whether sedation during EGD can improve the detection rates of precancerous lesions and EC.

Methods

In this propensity score-matched retrospective study, we examined medical records from outpatients who underwent diagnostic EGD at a large tertiary center between January 2023 and December 2023. Data on endoscopic findings and histology biopsies were obtained from an endoscopy quality-control system. The primary objective was to compare the rates of detecting precancerous lesions and EC in patients who received sedation during EGD vs. those who did not receive sedation. Additionally, we aimed to identify factors influencing these detection rates using binary logistic regression analysis.

Results

Following propensity score matching, a total of 17,862 patients who underwent diagnostic EGD with or without propofol sedation were identified. The group that received sedation exhibited a higher detection rate of precancerous lesions and EC in comparison to the non-sedated group (1.04 vs. 0.75%; p = 0.039). Additionally, within the sedated group, there was an increased likelihood of identifying precancerous lesions and EC specifically at the gastric antrum (0.60 vs. 0.32%, p = 0.006). Binary logistic regression analysis demonstrated that independent risk factors influencing the detection rates included age, gender, observation time, and number of biopsies conducted during the procedure.

Conclusion

Anesthesia assistance during EGD screening proved advantageous in detecting EC as well as precancerous lesions. It is crucial for endoscopists to consider these factors when performing EGD screening procedures.

Mechanisms and clinical landscape of N6-methyladenosine (m6A) RNA modification in gastrointestinal tract cancers

Epigenetics encompasses reversible and heritable chemical modifications of non-nuclear DNA sequences, including DNA and RNA methylation, histone modifications, non-coding RNA modifications, and chromatin rearrangements. In addition to well-studied DNA and histone methylation, RNA methylation has emerged as a hot topic in biological sciences over the past decade. N6-methyladenosine (m6A) is the most common and abundant modification in eukaryotic mRNA, affecting all RNA stages, including transcription, translation, and degradation. Advances in high-throughput sequencing technologies made it feasible to identify the chemical basis and biological functions of m6A RNA. Dysregulation of m6A levels and associated modifying proteins can both inhibit and promote cancer, highlighting the importance of the tumor microenvironment in diverse biological processes. Gastrointestinal tract cancers, including gastric, colorectal, and pancreatic cancers, are among the most common and deadly malignancies in humans. Growing evidence suggests a close association between m6A levels and the progression of gastrointestinal tumors. Global m6A modification levels are substantially modified in gastrointestinal tumor tissues and cell lines compared to healthy tissues and cells, possibly influencing various biological behaviors such as tumor cell proliferation, invasion, metastasis, and drug resistance. Exploring the diagnostic and therapeutic potential of m6A-related proteins is critical from a clinical standpoint. Developing more specific and effective m6A modulators offers new options for treating these tumors and deeper insights into gastrointestinal tract cancers.

Optimal number of images and 2-year interval affect cancer detection in screening esophagogastroduodenoscopy: An observational study

We aimed to identify quality indicator for esophagogastroduodenoscopy for detecting upper gastrointestinal (UGI) cancer. Data from 43,526 consecutive health checkups from August 2012 to January 2022 were retrospectively collected. The study ultimately analyzed 42,387 examinations by 12 endoscopists who performed more than 1000 examinations, including all cancers detected. These endoscopists were classified either into fast/slow group based on their mean examination time for a normal finding of esophagogastroduodenoscopy during their first year of the examination, or small/large group based on number of endoscopic images, respectively. The association between UGI cancer detection rate and examination time or the number of images was analyzed, using 5 minutes or 50 images as cutoff values. The detection rate of overall (8 pharyngeal, 39 esophageal, 69 gastric) cancers in the fast, slow, small, and large groups were 0.17%, 0.32%, 0.21%, and 0.31%, respectively. On multivariable analysis, endoscopists in the fast group or the small group were less likely to detect overall UGI cancer (OR: 0.596, 95% CI: 0.373-0.952, P = .030; OR: 0.652, 95% CI: 0.434-0.979, P = .039). Additionally, repeated endoscopy within 2 years had a higher overall cancer detection rate, compared with repeated screening after 2 years. In a sub-analysis, a significant negative relationship was found between the detection rate of gastric cancer and the number of gastric images < 35 (OR: 0.305, 95% CI: 0.189-0.492, P = .000). There was also a negative correlation trend between the detection rate of pharyngeal and esophageal cancers and the number of esophageal images < 11 (OR: 0.395, 95% CI: 0.156-1.001, P = .050). The optimal number of images and screening 2-year interval are considered useful quality indicators for detecting UGI cancer. This study also suggests that a total of 50 images, or 35 images of the stomach are suitable for detecting UGI cancer, or gastric cancer, during screening endoscopy.

Risk factors of missed early gastric cancer in endoscopic resected population: a retrospective, case-control study

BACKGROUND

Missed early gastric cancer (MEGC) is prevalent during esophagogastroduodenoscopy (EGD), which is the first-line recommended strategy for detecting early gastric cancer (EGC). Hence, we explored the risk factors for MEGC and different types of MEGC, based on the endoscopic resected population.

METHODS

This retrospective, case-control study was conducted at Nanjing Drum Tower Hospital (NJDTH). We included patients who were diagnosed with EGC during screening EGD, underwent endoscopic resection, and were confirmed by postoperative pathology at the NJDTH from January 2014 to December 2021, and classified them into different types according to the different root causes of misses. Univariable, multivariable, subgroup and propensity score analyses were used to explore the risk factors for MEGC and different types of MEGC.

RESULTS

A total of 447 patients, comprising 345 with initially detected early gastric cancer (IDEGC) and 102 with MEGC, were included in this study. Larger size (≥ 1 cm) (OR 0.45, 95% CI 0.27-0.74, P = 0.002) and invasion depth of submucosa (OR 0.26, 95% CI 0.10-0.69, P = 0.007) were negatively associated with MEGC. Use of sedation (OR 0.32, 95% CI 0.20-0.52, P < 0.001) and longer observation time (OR 0.60, 95% CI 0.37-0.96, P = 0.034) exhibited protective effect on MEGC.

CONCLUSIONS

Smaller and more superficial EGC lesions are more susceptible to misdiagnosis. The use of sedation and prolonged observation time during EGD could help reduce the occurrence of MEGC.

Road map to small bowel endoscopy quality indicators

PURPOSE OF REVIEW

Quality indicators for upper and lower gastrointestinal endoscopy are well established and linked to patient outcomes. However, there is a perceived gap in the development and implementation of quality indicators for small bowel endoscopy. In this review, we aimed to discuss the development of quality indicators in small bowel endoscopy and their implementation in clinical practice.

RECENT FINDINGS

The proposed quality indicators for small bowel endoscopy focus on process measures, which mainly evaluate the procedural aspects, rather than the outcomes or the overall patient experience. These quality indicators have rarely been studied in clinical practice, leading to a limited understanding of their applicability and impact on patient outcomes and experience.

SUMMARY

Real-world studies evaluating the quality indicators of small bowel endoscopy are warranted to establish an evidence-based framework for their practical application and effectiveness. Linking these indicators to relevant patient outcomes is crucial for their broader acceptance and implementation.

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.

Helicobacter pylori Eradication Does Not Adversely Affect the Clinical Course of Gastric Cancer: A Multicenter Study on Screening Endoscopic Examination in Japan

BACKGROUND

Since gastric cancers (GCs) detected after Helicobacter pylori (HP) eradication present with different morphological characteristics from conventional HP-positive GCs, delayed detection of early-stage GCs may be observed. This study aimed to investigate the clinical impact of HP eradication on diagnosing GC during screening endoscopy.

METHODS

Eleven health checkup institutions in Japan participated in the present study. All GC cases newly diagnosed by screening endoscopy between January 2016 and December 2020 were included. After propensity score matching, multivariable regression analysis was performed to estimate the effect of HP eradication on deep tumor invasion among HP-eradicated and HP-positive GC cases.

RESULTS

A total of 231 patients with GCs (134 HP-eradicated and 97 HP-positive cases) were enrolled. After propensity score matching, there were 81 cases in each group. The distribution of the depth of tumor invasion (pT1a, pT1b1, pT1b2, and pT2) between the HP-eradicated group and HP-positive group was similar (p = 0.82). In the propensity analysis, with HP-positive as the reference value, HP eradication was not significantly associated with T1b-T4-GCs and T1b2-T4-GCs, with odds ratios (95% confidence intervals) of 1.16 (0.48-2.81) and 1.16 (0.42-3.19), respectively.

CONCLUSIONS

HP eradication does not adversely affect the clinical course of GCs, supporting the recommendation of HP eradication in screening programs to reduce the total number of GC cases without delaying diagnosis.

Curative criteria for endoscopic treatment of gastric cancer

Endoscopic treatment, particularly endoscopic submucosal dissection, has become the primary treatment for early gastric cancer. A comprehensive optical assessment, including white light endoscopy, image-enhanced endoscopy, and magnification, are the cornerstones for clinical staging and determining the resectability of lesions. This paper discusses factors that influence the indication for endoscopic resection and the likelihood of achieving a curative resection. Our review stresses the critical need for interpreting the histopathological report in accordance with clinical guidelines and the imperative of tailoring decisions based on the patients' and lesions' characteristics and preferences. Moreover, we offer guidance on managing complex scenarios, such as those involving non-curative resection. Finally, we identify future research avenues, including the role of artificial intelligence in estimating the depth of invasion and the urgent need to refine predictive scores for lymph node metastasis and metachronous lesions.

Gastric cancer specific drug delivery with hydrophilic peptide probe conjugation

Cancer-specific diagnosis is challenging. Phage display is an approach that could contribute to finding new specific biomarkers. In this study, we developed a new peptide probe specific for gastric cancer and validated it for gastric cancer-specific theranostics. We isolated linear peptides by screening a combinatorial phage library for a cancer stem cell marker, LGR5 protein. Among these, peptides with high selectivity against gastric cancer cells were selected and examined for therapeutic poteintial in vitro as well as in vivo. Through leucine-rich G protein-coupled receptor 5 (LGR5) protein-based phage display, we obtained a hydrophilic 7-mer peptide sequence (STCTRSR, named STC). Both the STC-peptide-conjugated fluorescent dye and chlorin e6 (Ce6) displayed a significantly higher intensity in gastric cancer cells compared to that in healthy cells. In mice with gastric cancer, the fluorescence in the tumors was 3.4× more intense when treated with the Ce6-STC conjugate compared to that with free Ce6 and conferred higher phototoxicity after single laser irradiation. Repeated photodynamic therapy could further reduce the tumor volume after treating these mice with the Ce6-STC conjugate. The treatment with the Ce6-STC conjugate exhibited a significantly lower fluorescence in the liver than that with free Ce6. In conclusion, we confirmed that the STC peptide is a gastric cancer-specific probe that could be useful in gastric cancer theranostics. In conclusion, considering its targeting ability and hydrophilicity, various hydrophobic chemotherapeutic agents could be revisited for gastric cancer treatment in combination with the probe described in this study.

Current status of quality control in screening esophagogastroduodenoscopy and the emerging role of artificial intelligence

Esophagogastroduodenoscopy (EGD) screening is being implemented in countries with a high incidence of upper gastrointestinal (UGI) cancer. High-quality EGD screening ensures the yield of early diagnosis and prevents suffering from advanced UGI cancer and minimal operational-related discomfort. However, performance varied dramatically among endoscopists, and quality control for EGD screening remains suboptimal. Guidelines have recommended potential measures for endoscopy quality improvement and research has been conducted for evidence. Moreover, artificial intelligence offers a promising solution for computer-aided diagnosis and quality control during EGD examinations. In this review, we summarized the key points for quality assurance in EGD screening based on current guidelines and evidence. We also outline the latest evidence, limitations, and future prospects of the emerging role of artificial intelligence in EGD quality control, aiming to provide a foundation for improving the quality of EGD screening.

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.

Magnitude and Time-Trends of Post-Endoscopy Esophageal Adenocarcinoma and Post-Endoscopy Esophageal Neoplasia in a Population-Based Cohort Study: The Nordic Barrett's Esophagus Study

BACKGROUND & AIMS

Post-endoscopy esophageal adenocarcinoma (PEEC) and post-endoscopy esophageal neoplasia (PEEN) undermine early cancer detection in Barrett's esophagus (BE). We aimed to assess the magnitude and conduct time-trend analysis of PEEC and PEEN among patients with newly diagnosed BE.

METHODS

This population-based cohort study was conducted in Denmark, Finland, and Sweden between 2006 and 2020 and included 20,588 patients with newly diagnosed BE. PEEC and PEEN were defined as esophageal adenocarcinoma (EAC) or high-grade dysplasia (HGD)/EAC, respectively, diagnosed 30-365 days from BE diagnosis (index endoscopy). HGD/EAC diagnosed from 0-29 days and HGD/EAC diagnosed >365 days from BE diagnosis (incident HGD/EAC) were assessed. Patients were followed up until HGD/EAC, death, or end of study period. Incidence rates (IR) per 100,000 person-years with 95% confidence interval (95% CI) were calculated using Poisson regression.

RESULTS

Among 293 patients diagnosed with EAC, 69 (23.5%) were categorized as PEEC, 43 (14.7%) as index EAC, and 181 (61.8%) as incident EAC. The IRs/100,000 person-years for PEEC and incident EAC were 392 (95% CI, 309-496), and 208 (95% CI, 180-241), respectively. Among 279 patients diagnosed with HGD/EAC (Sweden only), 17.2% were categorized as PEEN, 14.6% as index HGD/EAC, and 68.1% as incident HGD/EAC. IRs/100,000 person-years for PEEN, and incident HGD/EAC were 421 (95% CI, 317-558), and 285 (95% CI, 247-328), respectively. Sensitivity analyses that varied time interval for occurrence of PEEC/PEEN demonstrated similar results. A time-trend analysis for IRs demonstrated rising incidence rates of PEEC/PEEN.

CONCLUSIONS

Almost a quarter of all EACs are detected within a year after an ostensibly negative upper endoscopy in patients with newly diagnosed BE. Interventions to improve detection may reduce PEEC/PEEN rates.

Real-world implementation of non-endoscopic triage testing for Barrett's oesophagus during COVID-19

BACKGROUND

The Coronavirus pandemic (COVID-19) curtailed endoscopy services, adding to diagnostic backlogs. Building on trial evidence for a non-endoscopic oesophageal cell collection device coupled with biomarkers (Cytosponge), an implementation pilot was launched for patients on waiting lists for reflux and Barrett's oesophagus surveillance.

AIMS

(i) To review reflux referral patterns and Barrett's surveillance practices. (ii) To evaluate the range of Cytosponge findings and impact on endoscopy services.

DESIGN AND METHODS

Cytosponge data from centralized laboratory processing (trefoil factor 3 (TFF3) for intestinal metaplasia (IM), haematoxylin & eosin for cellular atypia and p53 for dysplasia) over a 2-year period were included.

RESULTS

A total of 10 577 procedures were performed in 61 hospitals in England and Scotland, of which 92.5% (N = 9784/10 577) were sufficient for analysis. In the reflux cohort (N = 4074 with gastro-oesophageal junction sampling), 14.7% had one or more positive biomarkers (TFF3: 13.6% (N = 550/4056), p53: 0.5% (21/3974), atypia: 1.5% (N = 63/4071)), requiring endoscopy. Among samples from individuals undergoing Barrett's surveillance (N = 5710 with sufficient gland groups), TFF3-positivity increased with segment length (odds ratio = 1.37 per cm (95% confidence interval: 1.33-1.41, P < 0.001)). Some surveillance referrals (21.5%, N = 1175/5471) had ≤1 cm segment length, of which 65.9% (707/1073) were TFF3 negative. Of all surveillance procedures, 8.3% had dysplastic biomarkers (4.0% (N = 225/5630) for p53 and 7.6% (N = 430/5694) for atypia), increasing to 11.8% (N = 420/3552) in TFF3+ cases with confirmed IM and 19.7% (N = 58/294) in ultra-long segments.

CONCLUSIONS

Cytosponge-biomarker tests enabled targeting of endoscopy services to higher-risk individuals, whereas those with TFF3 negative ultra-short segments could be reconsidered regarding their Barrett's oesophagus status and surveillance requirements. Long-term follow-up will be important in these cohorts.

Adequacy of endoscopic recognition and surveillance of gastric intestinal metaplasia and atrophic gastritis: A multicentre retrospective study in low incidence countries

BACKGROUND

Gastric atrophy (GA) and gastric intestinal metaplasia (GIM) are precursor conditions to gastric adenocarcinoma (GAC) and should be monitored endoscopically in selected individuals. However, little is known about adherence to recommendations in clinical practice in low-risk countries.

OBJECTIVE

The aim of this study was to evaluate endoscopic recognition and adequacy of surveillance for GA and GIM in countries with low GAC prevalence.

METHODS

We retrospectively analysed patients diagnosed with GIM or GA in three centers in The Netherlands and UK between 2012 and 2019. Cases with GIM and/or GA diagnosis at index endoscopy were retrieved through systematic search of pathology databases using 'gastric' and 'intestinal metaplasia' or 'atrophy' keywords. Endoscopy reports were analysed to ascertain accuracy of endoscopic diagnoses. Adequacy of surveillance was assessed following histological diagnosis at the index endoscopy based on ESGE guidelines published in 2012.

RESULTS

We included 396 patients with a median follow-up of 57.2 months. Mean age was 66 years and the rates of antrum-predominant versus extensive GIM were comparable (37% vs 38%). Endoscopic recognition rates were 48.5% for GA and 16.3% for GIM. Surveillance was adequately carried out in 215 of 396 patients (54.3%).

CONCLUSION

In countries with a low incidence of GAC, the rate of endoscopic recognition of gastric pre-cancerous lesions and adherence to surveillance recommendation are low. Substantial improvement is required in endoscopic training and awareness of guidelines recommendation in order to optimise detection and management of pre-malignant gastric conditions.

Quality indicators in the endoscopic detection of gastric cancer

Gastroscopy is the reference standard for the diagnosis of gastric cancer, but it is operator-dependent and associated with missed gastric cancer. The proliferation of gastroscopic examinations, increasingly for the screening and detection of subtle premalignant lesions, has motivated scrutiny of quality in gastroscopy. The concept of a high-quality endoscopic examination for the detection of superficial gastric neoplasia has been defined by expert guidelines to improve mucosal visualization, engender a systematic examination process and detect superficial neoplasia. This review discusses the evidence supporting the components of a high-quality diagnostic gastroscopic examination in relation to the detection of gastric cancer, and their potential role as procedural quality indicators to drive a structured improvement in clinically meaningful outcomes.

A root cause analysis system to establish the most plausible explanation for post-endoscopy upper gastrointestinal cancer

BACKGROUND : Missing upper gastrointestinal cancer (UGIC) at endoscopy may prevent curative treatment. We have developed a root cause analysis system for potentially missed UGICs at endoscopy (post-endoscopy UGIC [PEUGIC]) to establish the most plausible explanations. METHODS : The electronic records of patients with UGIC at two National Health Service providers were examined. PEUGICs were defined as UGICs diagnosed 6-36 months after an endoscopy that did not diagnose cancer. An algorithm based on the World Endoscopy Organization post-colonoscopy colorectal cancer algorithm was developed to categorize and identify potentially avoidable PEUGICs. RESULTS : Of 1327 UGICs studied, 89 (6.7 %) were PEUGICs (patient median [IQR] age at endoscopy 73.5 (63.5-81.0); 60.7 % men). Of the PEUGICs, 40 % were diagnosed in patients with Barrett's esophagus. PEUGICs were categorized as: A - lesion detected, adequate assessment and decision-making, but PEUGIC occurred (16.9 %); B - lesion detected, inadequate assessment or decision-making (34.8 %); C - possible missed lesion, endoscopy and decision-making adequate (8.9 %); D - possible missed lesion, endoscopy or decision-making inadequate (33.7 %); E - deviated from management pathway but appropriate (5.6 %); F - deviated inappropriately from management pathway (3.4 %). The majority of PEUGICs (71 %) were potentially avoidable and in 45 % the cancer outcome could have been different if it had been diagnosed on the initial endoscopy. There was a negative correlation between endoscopists' mean annual number of endoscopies and the technically attributable PEUGIC rate (correlation coefficient -0.57; P = 0.004). CONCLUSION : Missed opportunities to avoid PEUGIC were identified in 71 % of cases. Root cause analysis can standardize future investigation of PEUGIC and guide quality improvement efforts.

A Global Perspective on Gastric Cancer Screening: Which Concepts Are Feasible, and When?

BACKGROUND

Gastric cancer (GC) remains the fifth most common cancer and the third most common cause of cancer-related death globally. In 2022, GC fell into the scope of the updated EU recommendations for targeted cancer screening. Given the growing awareness of the GC burden, we aimed to review the existing screening strategies for GC in high-risk regions and discuss potentially applicable modalities in countries with low-to-intermediate incidence.

METHODS

The references for this Review article were identified through searches of PubMed with the search terms "gastric cancer", "stomach cancer", "Helicobacter pylori", and "screening" over the period from 1995 until August 2022.

RESULTS

As Helicobacter pylori (H. pylori)-induced gastritis is the primary step in the development of GC, the focus on GC prevention may be directed toward testing for and treating this infection. Such a strategy may be appealing in countries with low- and intermediate- GC incidence. Other biomarker-based approaches to identify at-risk individuals in such regions are being evaluated. Within high-incidence areas, both primary endoscopic screening and population-based H. pylori "test-and-treat" strategies represent cost-effective models.

CONCLUSIONS

Given the significant variations in GC incidence and healthcare resources around the globe, screening strategies for GC should be adjusted to the actual conditions in each region. While several proven tools exist for accurate GC diagnosis, a universal modality for the screening of GC populations remains elusive.

Quality performance measures in upper gastrointestinal endoscopy for lesion detection: Italian AIGO-SIED-SIGE joint position statement

Esophagogastroduodenoscopy (EGD) plays a crucial role in the management of gastroduodenal diseases by allowing a direct and accurate evaluation of the mucosa and the execution of several operative maneuvers. Despite a constant development of new imaging tools and operative devices, the widespread use of EGD has not resulted in a significant reduction of mortality for patients affected by esophageal/gastric cancer during the last three decades in Western countries. Evidence indicates that this disheartening scenario derives from a high variability of execution of EGD which determines its quality and diagnostic yield, delaying the diagnosis of neoplastic diseases. Based on this evidence, in recent years many scientific societies have produced different position papers aimed at defining quality performance measures in EGD. Thus, the Italian Association of Gastroenterologists and Endoscopists, the Italian Society of Digestive Endoscopy and the Italian Society of Gastroenterology have produced this joint document based on the review of ASGE, ACG, BSG, ESGE and Asian Consensus EGD position papers with the aim of indicating the quality standards of EGD (pre-, intra- and post-procedure) focused on lesion detection to be adopted in the Italian context.

Interval Advanced Gastric Cancer After Negative Endoscopy

BACKGROUND & AIMS

Esophagogastroduodenoscopy (EGD) is effective in reducing gastric cancer mortality through detection of early-stage cancer in areas with a high prevalence of gastric cancer. Although the risk of post-endoscopy advanced gastric cancer (AGC) is low, interval AGC remains a concern. We investigated the characteristics and predictors of interval AGC after negative EGD.

METHODS

We included 1257 patients with gastric cancer within 6 to 36 months of a "cancer-negative" index EGD between 2005 and 2021 at a tertiary university hospital in South Korea. Observation time on the index EGD was used as a quality indicator. We compared the clinical and endoscopic characteristics and quality indicators between interval AGC and screen-detected early gastric cancer (EGC).

RESULTS

Within 6 to 36 months of negative EGD, 102 AGCs (8.1%) and 1155 EGCs (91.9%) were identified. The percentage of patients with shorter observation time (<3 minutes) in the index EGD was higher in the interval AGC group than in the detected EGC group (P = .002). A multivariable analysis comparing screen-detected EGD and interval AGC was adjusted for age, sex, family history of gastric cancer, H. pylori status, endoscopic findings, and endoscopy-related factors including gastric observation time and interval time. A shorter observation time (<3 minutes) (odds ratio, 2.27; 95% confidence interval, 1.20-4.30), and interval time >2 years (odds ratio, 1.84; 95% confidence interval, 1.04-3.24) were associated with an increased risk of interval AGC.

CONCLUSION

A shorter observation time during index EGD is an important predictor of interval AGC. Further, withdrawal time longer than 3 minutes may be a quality indicator for screening EGD.