Risk of high-grade dysplasia or carcinoma in gastric biopsy-proven low-grade dysplasia: an analysis using the Vienna classification

Role of submucosal injection in radiofrequency ablation of gastric low-grade dysplasia: Effects on symptoms and outcomes

BACKGROUND

To date, there is still a lack of standardized management strategies for gastric low-grade dysplasia (LGD), which is a direct neoplastic precancerous lesion and requires specifically superficial destruction. Radiofrequency ablation (RFA) is expected to be an effective method for gastric LGD, but post-RFA pain may affect patients' satisfaction and compliance. The current study aimed to evaluate the value of a submucosal injection prior to RFA (SI-RFA) for postoperative pain and treatment outcomes.

METHODS

Between October 2014 and July 2021, gastric LGDs without risk factors (size >2 cm, unclear boundary, and abnormal microsurface and microvascularity) undergoing regular RFA and SI-RFA were retrospectively analyzed. Postoperative pain scores, wound healing, and clinical efficacy were compared. Propensity score matching, stratified analysis, and multivariable logistic regression were performed to control the confounding variables.

RESULTS

One hundred and ninety-seven gastric LGDs in 151 patients received regular RFA. Forty-nine gastric LGDs in 36 patients received SI-RFA. Thirty-six pairs of patients were selected for the assessment of postoperative pain by propensity score matching. Compared to regular RFA, SI-RFA significantly decreased the degree and duration of postoperative pain (OR, 0.32; 95% CI, 0.13-0.84; P = 0.020), improved wound healing rate (80.0% [36/45] vs. 58.9% [89/151], P = 0.012), increased the complete ablation rate (91.8% [45/49] vs. 86.3% [170/197], χ2 = 1.094, P = 0.295), but correlated with higher rates of local recurrence and progression (25.6% [10/39] vs. 13.2% [18/136], χ2 = 3.471, P = 0.062; 8.3% [3/36] vs. 0.9% [1/116], P = 0.042). The multivariable logistic regression model confirmed that submucosal injection was associated with local recurrence (OR, 2.93; 95% CI, 1.13-7.58; P = 0.027).

CONCLUSIONS

Submucosal injections prior to RFA may reduce postoperative pain and scar formation while ensuring complete ablation of gastric LGD. However, local recurrence and progression should be considered seriously.

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.

Clinical features of gastric adenoma detected within 3 years after negative screening endoscopy in Korea

Background

Early detection and management of gastric adenoma are important for preventing gastric cancer. The present study aimed to evaluate the predictors of missed gastric adenoma on screening endoscopy in Korea and identify the risk factors associated with interval precancerous gastric lesions.

Methods

All cases of gastric adenomas diagnosed via screening endoscopy between 2007 and 2019 were reviewed. Among them, those who had undergone endoscopy within 3 years were included in the present study. Missed gastric adenoma was defined as gastric adenoma diagnosed within 3 years after negative screening endoscopy.

Results

In total, 295 cases of gastric adenoma were identified. Of these, 95 (32.2%) were missed gastric adenoma cases (mean age, 60.6 years; average interval between final and index endoscopies, 12.6 months); the remaining 200 (67.8%) were newly detected adenoma cases. Univariate analysis revealed that male sex, endoscopist experience, observation time, and presence of gastric intestinal metaplasia (pathologically proven) were associated with missed gastric adenoma. Multivariate analysis revealed that gastric intestinal metaplasia (odds ratio [OR], 2.736; 95% confidence interval [CI], 1.320-5.667; P = 0.007) and shorter observation time of the index screening endoscopy (B, -0.011; OR, 0.990; 95% CI, 0.986-0.993; P < 0.001) were independent risk factors for missed gastric adenoma. The optimal cut-off for the observation time for detecting gastric adenoma was 3.53 minutes (area under curve, 0.738; 95% CI, 0.677-0.799; P < 0.001).

Conclusions

Gastric intestinal metaplasia is an indication of missed gastric adenoma. Therefore, careful inspection of gastric mucosa with gastric intestinal metaplasia and proper observation time can lower the possibility of missing the gastric adenoma during screening.

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic resection of gastric low-grade dysplasia with high risk factors is associated with decreased advanced neoplasia: a single-center retrospective cohort study

BACKGROUND

The natural course of gastric low-grade dysplasia (LGD) remains unclear, and there are inconsistent management recommendations among guidelines and consensus.

OBJECTIVE

This study aimed to investigate the incidence of advanced neoplasia in patients with gastric LGD and identify the related risk factors.

METHODS

Cases of biopsy demonstrated LGD (BD-LGD) at our center from 2010 to 2021 were reviewed retrospectively. Risk factors related to histological progression were identified, and outcomes of patients based on risk stratification were evaluated.

RESULTS

Ninety-seven (23.0%) of 421 included BD-LGD lesions were diagnosed as advanced neoplasia. Among 409 superficial BD-LGD lesions, lesion in the upper third of the stomach, H. pylori infection, larger size, and narrow band imaging (NBI)-positive findings were independent risk factors of progression. NBI-positive lesions and NBI-negative lesions with or without other risk factors had 44.7%, 1.7%, and 0.0% risk of advanced neoplasia, respectively. Invisible lesions, visible lesions (VLs) without a clear margin, and VLs with a clear margin and size ≤ 10 mm, or > 10 mm had 4.8%, 7.9%, 16.7%, and 55.7% risk of advanced neoplasia, respectively. In addition, endoscopic resection decreased the risk of cancer (P < 0.001) and advanced neoplasia (P < 0.001) in patients with NBI-positive lesions, but not in NBI-negative patients. Similar results were found in patients with VLs with clear margin and size > 10 mm. Moreover, NBI-positive lesions had higher sensitivity and lower specificity for predicting advanced neoplasia than VLs with a clear margin and size > 10 mm determined by white-light endoscopy (97.6% vs. 62.7%, P < 0.001; and 63.0% vs. 85.6%, P < 0.001, respectively).

CONCLUSION

Progression of superficial BD-LGD is associated with NBI-positive lesions, as well as with VLs with a clear margin (size > 10 mm) if NBI is unavailable, and selective resection of those lesions offers benefits for patients by decreasing the risk of advanced neoplasia.

A Prediction Model Based on the Risk Factors Associated with Pathological Upgrading in Patients with Early-Stage Gastric Neoplasms Diagnosed by Endoscopic Forceps Biopsy

Background/Aims

The discrepancies between the diagnosis of preoperative endoscopic forceps biopsy (EFB) and endoscopic submucosal dissection (ESD) in patients with early gastric neoplasm (EGN) exist objectively. Among them, pathological upgrading directly influences the accuracy and appropriateness of clinical decisions. The aims of this study were to investigate the risk factors for the discrepancies, with a particular focus on pathological upgrading and to establish a prediction model for estimating the risk of pathological upgrading after EFB.

Methods

We retrospectively collected the records of 978 patients who underwent ESD from December 1, 2017 to July 31, 2021 and who had a final histopathology determination of EGN. A nomogram to predict the risk of pathological upgrading was constructed after analyzing subgroup differences among the 901 lesions enrolled.

Results

The ratio of pathological upgrading was 510 of 953 (53.5%). Clinical, laboratorial and endoscopic characteristics were analyzed using univariable and binary multivariable logistic regression analyses. A nomogram was constructed by including age, history of chronic atrophic gastritis, symptoms of digestive system, blood high density lipoprotein concentration, macroscopic type, pathological diagnosis of EFB, uneven surface, remarkable redness, and lesion size. The C-statistics were 0.804 (95% confidence interval, 0.774 to 0.834) and 0.748 (95% confidence interval, 0.664 to 0.832) in the training and validation set, respectively. We also built an online webserver based on the proposed nomogram for convenient clinical use.

Conclusions

The clinical value of identifying the preoperative diagnosis of EGN lesions is limited when using EFB separately. We have developed a nomogram that can predict the probability of pathological upgrading with good calibration and discrimination value.

Tumor heterogeneity and carcinoma in resected specimens of gastric low-grade dysplasia: A retrospective single center study

Lesions diagnosed as gastric low-grade dysplasia (LGD) may be pathologically upgraded to early gastric cancer (EGC) or high-grade dysplasia (HGD) after endoscopic resection (ER). In this study, we investigated the risk factors for pathological upgrades after ER and assessed the reason for these upgrades by retrospectively analyzing ER data between January 1999 and December 2019. We enrolled patients with LGD confirmed by forceps biopsy; the patients were classified into pathologically concordant (LGD) and upgraded (HGD and EGC) groups according to the pathology of their resected specimen. To determine the risk factors for upgrade, we compared the endoscopic findings of the concordant and upgraded groups via 1:1 matched case-control design. To find the reasons for discordance, all upgraded cases were pathologically re-evaluated. Among 1,643 cases of LGD, pathological upgrades were observed in 423 (25.7%) resected specimens and EGC was found in 111 (6.7%) lesions. After matching the upgraded and concordant cases, lesion sizes exceeding 1.5 cm (odds ratio (OR): 1.8; 95% CI: 1.1-3.0), mucosal nodularity (OR: 10.8; 95% CI: 5.6-21.0), heterogeneous color (OR: 3.0; 95% CI: 1.7-5.3), presence of erosion (OR: 2.7; 95% CI: 1.8-5.3), and open-type gastric atrophy (OR: 2.9; 95% CI: 1.7-4.9) were noted to be significantly associated with upgraded pathology to EGC. Among the EGC cases, 99 (89.2%) were found to have pre-existing dysplasia. In conclusion, endoscopic evaluations should be performed because of possible pathological upgrades and co-existence of carcinomas in LGDs, especially when they exhibit surface nodularity, erosion, heterogeneous color, and large size.

Endoscopic or Follow-up Treatment for Gastric Indeterminate Tumors Is the Preferred Method of Management

Background

Endoscopic forceps biopsy (EFB) lacks precision in diagnosing indeterminate tumors. When the presence of early gastric cancer (EGC) is macroscopically suspected, but biopsy pathology fails to give a diagnosis of neoplasia, it causes problems in clinical management. The purpose of this study was to discuss the outcome of gastric indeterminate tumors and the clinical factors associated with predicting EGC.

Methods

The medical records of 209 patients diagnosed with gastric indeterminate neoplasia by biopsy forceps were retrospectively studied. Initial endoscopic findings were analyzed and predictors of EGC were evaluated.

Results

The final pathological diagnosis in 209 patients included adenocarcinoma (n = 7), high-grade intraepithelial neoplasia (n = 11), low-grade intraepithelial neoplasia (n = 21), and non-neoplastic lesion (n = 170). Multivariate analysis showed that older age (OR = 1.78; 95% CI = 1.17–2.71; p = 0.008), patients undergoing narrow band imaging (NBI) (OR = 3.40; 95% CI = 1.37–8.43; p = 0.008), and surface erosion (OR = 3.53; 95% CI = 1.41–8.84; p = 0.007) were associated with the upgraded group, and were significantly associated with risk. Univariate logistic regression analysis showed that among patients with NBI, the presence of demarcation line (DL) (OR = 24.00; 95% CI = 4.99–115.36; p < 0.0001), microvascular (MV) pattern irregularity (OR = 9.129; 95% CI = 2.36–35.34; p = 0.001), and the presence of white opaque substance (WOS) (OR = 10.77; 95% CI = 1.14–101.72; p = 0.038) were significant risk factors.

Conclusions

For gastric indeterminate tumors, older patient age, lesion surface with erosion, clear DL visible under NBI observation, presence of WOS, and irregular MV pattern are suggestive of the high possibility of neoplasia and need to be focused on and may benefit more from endoscopic resection treatment as opposed to simple endoscopic follow-up.

Magnifying endoscopy with narrow-band imaging is useful in differentiating gastric cancer from matched adenoma in white light imaging

This study assessed the effect of magnifying endoscopy with narrow-band imaging (M-NBI) on the endoscopic differential diagnosis between intramucosal gastric carcinomas and adenomas with matched characteristics. Associations between magnified endoscopic findings and pathological high-grade cellular and architectural atypia were also investigated. In total, the records of 50 adenomas and 50 intramucosal well-differentiated adenocarcinomas matched by tumor size (≥ 20 mm or < 20 mm), shape (depression or non-depression), and color (red or non-red) were extracted. Fourteen endoscopists diagnosed adenoma or cancer in the 100 cases with conventional white light imaging (C-WLI), then did the same with C-WLI + M-NBI.The cancer diagnostic sensitivity, specificity, and accuracy were assessed. The sensitivity of C-WLI + M-NBI for cancer diagnosis was 79.9% compared to 71.6% with C-WLI (p < 0.001). There were no significant differences in specificity (40.1% vs. 36.3%, p = 0.296) and accuracy (55.9% vs. 58.1%, p = 0.163). High-grade cytological or architectural atypia was diagnosed more often with irregular microvascular pattern (IMVP) or microsurface pattern (IMSP), respectively, than the low-grade forms. In conclusion, IMVP and IMSP correlate with high-grade cytological and architectural atypia. M-NBI is useful in differentiating intramucosal carcinoma from adenoma and can reduce underdiagnosis of cancer.

Discrepancy Between Forceps Biopsy and Resection in Colorectal Polyps: A 1686 Paired Screening-Therapeutic Colonoscopic Finding

Purpose

To identify pathology discrepancy between forceps biopsies and polypectomy specimens in colorectal polyps, as well as the reliability of biopsy-based treatment strategy.

Methods

All endoscopic polypectomy cases with forceps biopsies performed within 6 months were included in the study. The biopsies were compared with polypectomy specimens in terms of concordance of histological diagnosis. A logistic regression model was used to investigate the independent predictors of upgrade in histological diagnosis compared with concordance in histological diagnosis.

Results

A total of 1686 paired screening-therapeutic colonoscopies and 1739 paired biopsy-polypectomy specimens were enrolled in the study. The grade of dysplasia in 84.5% of biopsy specimens were concordant to polypectomy specimens, but this proportion decreased to 75.4% when the specimens were classified using tubular or villousness structure. 10.1% and 5.4% of biopsy specimens were upgraded and downgraded in assessing grade of dysplasia, respectively, while 14.3% and 10.3% of biopsy specimens were upgraded and downgraded in assessing tubular or villousness structure, respectively. In subgroup analysis stratified by size of polyps, 9.0% and 10.6% of biopsies obtained from polyps smaller than 10 mm were upgraded in assessing dysplasia and tubular or villousness structure, respectively. This proportion increased to 10.7% and 21.3%, respectively, in biopsies obtained from polyps larger than 10 mm. Larger size of polyps and pedunculated polyps were associated with a higher incidence of upgrade in histological diagnosis. Nearly 25% of biopsy specimens with high-grade dysplasia were identified as adenocarcinoma in polypectomy specimens.

Conclusion

The concordance between biopsy and polypectomy specimens is not adequate. The biopsy-based treatment strategy is not reliable and should not be considered as an indicator for further treatment, particularly in large or pedunculated polyps.

Endoscopic characteristics in predicting prognosis of biopsy-diagnosed gastric low-grade intraepithelial neoplasia

BACKGROUND

Endoscopic biopsy can underestimate gastric malignancies as low-grade intraepithelial neoplasia (LGIN). Definitively diagnosed LGIN would progress. This study aimed to evaluate predictive factors to identify malignancies misdiagnosed as LGIN by biopsy and LGIN at high risk of progression.

METHODS

The clinical records of patients diagnosed with gastric LGIN by endoscopic biopsy who underwent at least two endoscopies during the first year of follow-up between 2007 and 2017 were retrospectively collected. Three endoscopists reviewed photographs of the initial endoscopy, described lesion characteristics, and made endoscopic diagnoses. Logistic regression was used to analyze predictors to identify malignancies underestimated as LGIN. A receiver operating characteristic curve was used to evaluate the diagnostic accuracy of these predictors. Patient clinical outcomes of follow-up >1 year were collected. Kaplan-Meier estimates with log-rank tests and Cox proportional hazards regression were used to analyze predictors of progression.

RESULTS

Overall, 48 of 182 (26.4%) patients were proven to have malignancies. A single lesion, a large lesion size, and marked intestinal metaplasia (IM) were independent predictors of initially misdiagnosed malignancies. The area under the curve of these predictors was 0.871, with a sensitivity of 68.7% and specificity of 92.5%. Twelve of 98 patients (12.2%) progressed during the 33-month median follow-up period. A whitish appearance, irregular margins, marked IM, and histological diagnosis of LGIN more than twice within the first year were predictors for progression.

CONCLUSIONS

Lesions diagnosed as LGIN by biopsy with marked IM and other predictors above should be prudently treated for high potential to be malignancies or progress. Endoscopic follow-up with repeated biopsies within the first year is recommended.

Risk factors for the histologic discrepancy of gastric adenomatous lesions and long-term outcome

Although endoscopic forceps biopsies (EFB) have a significant role in diagnosing gastric adenoma, there are still discrepancies between EFBs and finalized pathology results.Therefore, the objective of this study was to find the risk factors that cause this discrepancy and to analyze the effects of this discrepancy on the long-term outcome.In this study patients that had received endoscopic resection due to low-grade gastric adenoma diagnosis from EFB between January of 2011 and January of 2018 at the Chungnam National University Hospital were retrospectively analyzed. According to whether there was histological discrepancy the cumulative incidence of the metachronous lesions were analyzed.A total of 745 lesions diagnosed as low-grade gastric adenoma at EFB were enrolled, and the final pathology results were confirmed to be non-neoplastic (n = 19), low-grade adenoma (n = 614), High-grade adenoma (n = 63), and carcinoma (n = 49), and with the exception of non-neoplastic lesion, the results confirmed 84.6% (n = 614) for the concordant group and 15.4% (n = 112) for the discordant. The results of the multivariate analysis confirmed that depressed lesion (odds ratio [OR]: 2.056; 95% confidence interval [CI]: 1.130-3.451; P = .011), erythema (OR: 2.546; 95% CI: 1.604-4.030; P = .004), and a size >1.5 cm (OR: 1.903; 95% CI: 1.102-3.172; P = .018) were risk factors for discrepancy. The results also confirmed that for the average observation period of (SD) 39.12 (12.31) months, the cumulative incidence of metachronous neoplasm had a higher significance (P = 0.001) in the discordant group when compared to that of the concordant group.The factors related to the histologic discrepancy of low-grade gastric adenoma were depressed lesion, erythema and size >1.5 cm. In the groups with histological discrepancy, the cumulative incidence of the metachronous neoplasm was significantly higher and therefore closer observation of such patients after performing endoscopic resection is necessary.

Mucosal microbial microenvironment in early gastric neoplasia and non-neoplastic gastric disease

BACKGROUND AND AIM

The biological characterization of microbial environment in early gastric cancer (EGC), other than Helicobacter pylori, is limited. This study aimed to explore the microbial microenvironment in chronic gastritis (CG), fundic gland polyps (FGPs), low-grade intraepithelial neoplasia (LGIN), and EGC.

METHODS

16S-rRNA gene sequencing and bioinformatic analysis were performed on 63 individuals with 252 mucosal biopsies or endoscopic submucosal dissection margin samples from endoscopy.

RESULTS

The microbiota in gastric LGIN functions analogously to EGC in terms of functional prediction. Neoplastic lesions showed a significant difference to CG or FGPs in beta diversity of the microbiota. Bacteria genera including Paracoccus, Blautia, Barnesiella, Lactobacillus, Thauera, Collinsella were significantly enriched in gastric neoplastic mucosa (LGIN and EGC) compared with non-neoplastic tissues (CG and FGPs). While Pseudomonas and Kingella were depleted in neoplastic tissues. FGPs showed a distinctive microbial network system that negatively interacted with Helicobacter.

CONCLUSIONS

In terms of the mucosal microbial microenvironment, gastric LGIN and EGC showed no significant difference as early neoplastic lesions. We observed a coordinated microbial microenvironment that correlated negatively with Helicobacter.

Risk stratification of patients with gastric lesions indefinite for dysplasia

BACKGROUND/AIMS

There are no definite guidelines for the management of gastric lesions diagnosed as indefinite for dysplasia (IND) by endoscopic forceps biopsy (EFB). Therefore, this study aimed to evaluate the clinical outcomes of gastric IND and predictive factors for gastric neoplasm.

METHODS

This study included 457 patients with a first diagnosis of gastric IND by EFB between January 2005 and December 2013. Patient characteristics and endoscopic and pathological data were reviewed and compared.

RESULTS

Of the 457 gastric IND patients, 128 (28%) were diagnosed with invasive carcinoma, 21 (4.6%) with high-grade dysplasia, 31 (6.8%) with low-grade dysplasia, and 277 (60.6%) as negative for dysplasia. Of lesions observed, 180 (39.4%) showed upgraded histology. Multivariate analysis revealed that surface erythema (odds ratio [OR], 2.804; 95% confidence interval [CI], 1.741 to 4.516), spontaneous bleeding (OR, 2.618; 95% CI, 1.298 to 5.279), lesion size ≥ 1 cm (OR, 5.762; 95% CI, 3.459 to 9.597), and depressed morphology (OR, 2.183; 95% CI, 1.155 to 4.124) were significant risk factors for high-grade dysplasia or adenocarcinoma. The ORs associated with 2 and ≥ 3 risk factors were 7.131 and 34.86, respectively.

CONCLUSION

Precautions should be taken in the management of gastric IND patients, especially when risk factors, including surface erythema, spontaneous bleeding, lesion size ≥ 1 cm, and depressed morphology are present. Considering the combined effect of the presence of multiple risk factors on the incidence of high-grade dysplasia or adenocarcinoma, endoscopic resection should be recommended if a gastric IND patient has at two or more of these factors.

Clinical Outcomes of Endoscopic Resection for Low-Grade Dysplasia and High-Grade Dysplasia on Gastric Pretreatment Biopsy: Korea ESD Study Group

Background/Aims

Some cases of gastric low-grade dysplasia (LGD) and high-grade dysplasia (HGD) on forceps biopsy (FB) are diagnosed as gastric cancer (GC) after endoscopic resection (ER). This study aims to evaluate the clinical outcomes of ER for gastric LGD and HGD on pretreatment FB and to identify the factors that predict pathologic upstaging to GC.

Methods

Patients who underwent ER for LGD and HGD on pretreatment FB from March 2005 to February 2018 in 14 hospitals in South Korea were enrolled, and the patients’ medical records were reviewed retrospectively.

Results

This study included 2,150 cases of LGD and 1,534 cases of HGD diagnosed by pretreatment FB. In total, 589 of 2,150 LGDs (27.4%) were diagnosed as GC after ER. Helicobacterpylori infection, smoking history, tumor location in the lower third of the stomach, tumor size >10 mm, depressed lesion, and ulceration significantly predicted GC. A total of 1,115 out of 1,534 HGDs (72.7%) were diagnosed with GC after ER. Previous history of GC, H. pylori infection, smoking history, tumor location in the lower third of the stomach, tumor size >10 mm, depressed lesion, and ulceration were significantly associated with GC. As the number of risk factors predicting GC increased in both LGD and HGD on pretreatment FB, the rate of upstaging to GC after ER increased.

Conclusions

A substantial proportion of LGDs and HGDs on pretreatment FB were diagnosed as GC after ER. Accurate ER procedures such as endoscopic submucosal dissection should be recommended in cases of LGD and HGD with factors predicting pathologic upstaging to GC.

Comparative analysis of differences between preoperative endoscopic biopsy and postoperative pathological examination for diagnosis of gastric intraepithelial neoplasia

OBJECTIVE

This study was performed to compare the differences between preoperative endoscopic biopsy (PEB) and postoperative pathological examination (PPE) for diagnosis of gastric intraepithelial neoplasia (GIN).

METHODS

From September 2016 to July 2019, 188 consecutive patients with GIN at Yuyao People's Hospital were retrospectively analyzed. The 188 patients had 218 GIN lesions. All patients underwent PEB and either endoscopic submucosal dissection or surgical treatment. PPE was performed on pathological tissues that had been surgically removed.

RESULTS

Among 138 cases of low-grade dysplasia (LGD) diagnosed by PEB, 46 were upgraded to high-grade dysplasia (HGD), 20 were upgraded to early gastric cancer (EGC), and 2 were downgraded to inflammation after PPE. Among 42 cases of HGD, 23 were upgraded to EGC, 2 were downgraded to LGD, and 2 were downgraded to inflammation after PPE. Among 38 cases of EGC, 1 was downgraded to HGD and 2 were downgraded to LGD after PPE. The original diagnosis was maintained after the operation in 120 cases of GIN.

CONCLUSION

Biopsy did not fully reflect the lesions of GIN. Biopsy review should be actively performed, and the lesions should be clarified by endoscopic submucosal dissection or surgery.

Clinical applicability of gastroscopy with narrow-band imaging for the diagnosis of Helicobacter pylori gastritis, precancerous gastric lesion, and neoplasia

Premalignant gastric lesions such as atrophic gastritis and intestinal metaplasia frequently occur in subjects with long-term Helicobacter pylori (H. pylori) infection. The regular arrangement of collecting venules (RAC) is seen in the normal gastric corpus, whereas mucosal swelling and redness without RAC are observed in H. pylori-infected mucosa. Despite successful H. pylori eradication, the presence of atrophic gastritis and/or gastric intestinal metaplasia (GIM) is a risk factor for gastric cancer. With the development of advanced imaging technologies, recent studies have reported the usefulness of narrow-band imaging (NBI) for endoscopic diagnosis of atrophic gastritis and GIM. Using NBI endoscopy with magnification (M-NBI), atrophic gastritis is presented as irregular coiled microvessels and loss of gastric pits. Typical M-NBI endoscopic findings of GIM are a light blue crest and a white opaque substance. Based on the microvascular patterns, fine network, core vascular, and unclear patterns are useful for predicting gastric dysplasia in polypoid lesions. For diagnosis of early gastric cancer (EGC), a systematic classification using M-NBI endoscopy has been proposed on the basis of the presence of a demarcation line and an irregular microvascular/microsurface pattern. Furthermore, M-NBI endoscopy has been found to be more accurate for determining the horizontal margin of EGC compared to conventional endoscopy. In this review, we present up-to-date results on the clinical usefulness of gastroscopy with NBI for the diagnosis of H. pylori gastritis, precancerous gastric lesion, and neoplasia.

Predictive Model of Nonneoplastic Pathology after Endoscopic Resection of Gastric Epithelial Neoplasia

Background/Aims

The rate of nonneoplastic pathology (NNP) after endoscopic resection (ER) of gastric epithelial neoplasia (GEN) has been reported to be 3%–7%. However, to date, the associations of pretreatment characteristics with NNP have not been identified. The aim of this study was to develop a predictive model for NNP after ER.

Methods

Among 817 patients who underwent ER for GEN, factors associated with NNP were identified by univariate and multivariate analyses. Weighted points considering the β coefficient were allocated to each variable that was significant in the multivariate analysis. The predictive score was calculated by the total points. The area under the receiver operating characteristic curve (AUROC) was calculated for the predictive score.

Results

The rate of NNP was 8.8%. After multivariate analysis, poor demarcation from the background, no ulceration, a flat appearance, and low-grade dysplasia were significant factors predictive of NNP. One point each was allocated for no ulcer, flat appearance, and low-grade dysplasia. Two points were allocated for poor demarcation from the background. The predictive score ranged from 0 to 5 points. Patients were categorized as being at low risk (0, 1, or 2 points) or high risk (3, 4, or 5 points) for NNP. The AUROC was 0.82 (95% confidence interval, 0.77 to 0.88; p<0.01). With a cutoff value of 2.5, the sensitivity and specificity of the score for predicting NNP were 0.72 and 0.84, respectively.

Conclusions

We developed a model to predict NNP after ER. Endoscopic re-biopsy or re-evaluation by pathologists is strongly recommended for the high-risk group.

Long-term outcomes of patients with gastric adenoma in Korea: A retrospective observational study

New endoscopic resection techniques are constantly being developed for gastric adenoma, which can be classified as low or high grade according to the Vienna classification. However, long-term data on gastric adenoma (e.g., removal or follow-up after resection via endoscopy) remain lacking.We retrospectively analyzed 133 cases with gastric adenoma that underwent endoscopic resection from January 2010 to November 2018. We analyzed the risk factors and frequency of patients with synchronous and metachronous lesions after endoscopic resection for gastric adenoma and followed them for more than 2 years.One hundred six (79.7%) and 27 patients (20.3%) received endoscopic resection (ER) once and more than twice, respectively. Compared with the initial endoscopic biopsy pathological results, the upgraded and downgraded histological discrepancy rates were 10.5% (n = 14) and 3.0% (n = 4) after resection, respectively. The mean time to synchronous/metachronous recurrence was 2.23 years. The average lesion size at first procedure was larger in the multiple ER group than in the single ER group (2.00 vs 1.10 cm; P = .040). Eleven (8.3%) and 16 patients (12.0%) had recurred synchronous and metachronous lesions, respectively. In the multivariate Cox analysis of the recurrence group, intestinal metaplasia (hazard ratio, 2.761; 95% confidence interval, 1.117-6.820; P = .028) and lesion size (hazard ratio, 1.607; 95% confidence interval, 1.082-2.385; P = .019) were independent factors for receiving endoscopic resection more than twice.If patients have severe intestinal metaplasia or large size of lesion at endoscopic resection for gastric adenoma, periodic observation is necessary.

Incidence Rate of Gastric Cancer Adenocarcinoma in Patients With Gastric Dysplasia: A Systematic Review and Meta-Analysis

Several studies have reported the risk of progression to gastric adenocarcinoma (GAC) in patients with gastric dysplasia (GD); however, the findings are controversial. We performed a systematic review and meta-analysis to study the incidence rate of GAC among patients with GD. Using a comprehensive search strategy, we systematically searched online databases including PubMed, Scopus, EMBASE, Cochrane Library, and Web of Science databases for identifying all relevant original articles through inception until July 2018. Cochran Q and I tests were used to assess heterogeneities between included studies. The incidence rates of GAC and their corresponding 95% confidence intervals (CIs) were pooled using random-effect or fixed-effect models. Of the 1980 retrieved records, 30 eligible articles (61 studies) were included. The overall pooled incidence rate of GAC was 40.36 (95% CI, 27.08-55.71; I, 96.0%) cases per 1000 person-years in patients with GD. Subgroup analysis according to the type of GD indicated the highest incidence rate of GAC was 186.40 (95% CI, 106.63-285.60; I, 94.6%) per 1000 person-years among patients with high-grade dysplasia (HGD) lesions. Although the incidence rates of GAC in low-grade dysplasia (LGD) lesions and in nonclassified lesions were 11.25 (95% CI, 3.91-21.22; I, 89.3%), and 1.40 (95% CI, 0.00-9.71; I, 78.8%), respectively. Compared with patients with LGD lesions, progression rate from GD to GAC was roughly 16 times greater in patients with HGD lesions. As the majority of patients with GAC are diagnosed in an advanced stage our study suggests strict management of HGD lesions to prevent GAC.

Forceps Biopsies Are Not Reliable in the Workup of Large Colorectal Lesions Referred for Endoscopic Resection: Should They Be Abandoned?

BACKGROUND

Biopsies are routinely obtained in the workup of large colorectal polyps before endoscopic resection.

OBJECTIVE

This study aimed to examine how reliable biopsies are in terms of reflecting the true histopathology of large colorectal polyps, in the clinical routine.

DESIGN

This is a retrospective study.

SETTINGS

Data from patients undergoing polypectomy of large colorectal polyps at the endoscopy unit, Skåne University Hospital Malmö, between January 2014 and December 2016 were scrutinized.

PATIENTS

A total of 485 colorectal lesions were biopsied within 1 year before complete endoscopic removal. Biopsy-obtained specimens were compared with completely resected specimens in terms of concordance and discordance and if the final result was upgraded or downgraded.

MAIN OUTCOME MEASURES

The primary outcome measured was the concordance between biopsy-obtained specimens and completely resected specimens.

RESULTS

Median lesion size was 3 cm (range 1-11). In 189 cases (39%), biopsies did not provide a correct dysplastic grade compared with final pathology after complete resection. One hundred forty-three cases (29%) and 46 cases (9%) were upgraded and downgraded. The percentage of cases with discordant biopsy results was 40% in cases with 1 biopsy taken and 38% in cases where multiple biopsies had been sampled. Time from biopsy to complete resection did not influence the erroneous outcome of biopsies. Notably, the percentage of discordant biopsy results was 37% and 35% in lesions measuring 1 to 2 cm and 2 to 4 cm. However, this percentage increased to 48% in colorectal lesions larger than 4 cm.

LIMITATIONS

This study was designed to reflect the clinical routine, the number of biopsies obtained and forceps technique were hence not standardized, which constitutes a limitation.

CONCLUSIONS

This study demonstrates that cancer-negative forceps biopsies of large colorectal polyps, referred for endoscopic resection, are not reliable. Considering that endoscopic resection of lesions containing superficial cancer is plausible, the clinical value of forceps biopsies in lesions suitable for endoscopic resection is questionable. See Video Abstract at http://links.lww.com/DCR/A984. LAS BIOPSIAS CON FÓRCEPS NO SON CONFIABLES EN EL ESTUDIO DE LAS LESIONES COLORRECTALES GRANDES REFERIDAS PARA RESECCIÓN ENDOSCÓPICA: ¿DEBERÍAN ABANDONARSE?: Las biopsias se obtienen de forma rutinaria en el estudio de pólipos colorrectales grandes previo a resección endoscópica.

OBJETIVO

Analizar que tan confiables son las biopsias en cuanto a reflejar la verdadera histopatología de los pólipos colorrectales grandes, en la rutina clínica. DISEÑO:: Este es un estudio retrospectivo.

AJUSTES

Los datos de pacientes sometidos a polipectomía de pólipos colorrectales grandes en la unidad de endoscopia, en Skåne University Hospital Malmö, entre enero de 2014 y diciembre de 2016 fueron examinados.

PACIENTES

Un total de 485 lesiones colorrectales se biopsiaron dentro de un año antes de la resección endoscópica completa. Las muestras obtenidas mediante biopsia se compararon con las muestras completas resecadas en términos de concordancia y discordancia, y si el resultado final ascendió o disminuyó de categoría.

PRINCIPALES MEDIDAS DE RESULTADO

Concordancia entre muestras obtenidas mediante biopsia y muestras completamente resecadas.

RESULTADOS

La mediana de tamaño de lesiones fue de 3 cm (rango 1-11). En 189 casos (39%) las biopsias no proporcionaron un grado de displasia correcto en comparación con la patología final después de la resección completa. 143 casos (29%) y 46 casos (9%) ascendieron y descendieron de categoría, respectivamente. El porcentaje de casos con resultados de biopsia discordantes fue del 40% en los casos con una sola biopsia tomada y del 38% en los casos en los que se tomaron múltiples biopsias. El tiempo desde la biopsia hasta la resección completa no influyó en el resultado erróneo de las biopsias. Notablemente, el porcentaje de resultados de biopsia discordantes fue de 37% y 35% en lesiones que midieron 1-2 cm y 2-4 cm, respectivamente. Sin embargo, este porcentaje aumentó a 48% en lesiones colorrectales mayores de 4 cm.

LIMITACIONES

Este estudio se diseñó para reflejar la rutina clínica, el número de biopsias obtenidas y la técnica de fórceps no fueron estandarizadas, lo que constituye una limitación.

CONCLUSIONES

Este estudio demuestra que las biopsias con fórceps negativas a cáncer, de pólipos colorrectales grandes referidas para resección endoscópica, no son confiables. Teniendo en cuenta que la resección endoscópica de lesiones que contienen cáncer superficial es posible, el valor clínico de las biopsias con fórceps en lesiones aptas para la resección endoscópica es cuestionable. Vea el Resumen en video en http://links.lww.com/DCR/A984.

Clinical outcomes of endoscopic treatment for gastric epithelial neoplasm in remnant stomach after distal gastrectomy

BACKGROUNDS/AIM

We aimed to evaluate the feasibility of endoscopic treatment for gastric epithelial neoplasm in the remnant stomach after distal gastrectomy and compared the clinical outcomes by tumor location and endoscopic treatment modality.

METHODS

We reviewed the data of patients who underwent endoscopic treatment for gastric epithelial neoplasms in the remnant stomach after distal gastrectomy between January 1996 and August 2013. The treatments included endoscopic resection or argon plasma coagulation.

RESULTS

Herein, 107 patients (median age, 65.1 years; 92 men) encompassing 117 cases of gastric neoplasms in the remnant stomach after distal gastrectomy were endoscopically treated. Forty of these lesions were located at anastomotic sites; they were treated with endoscopic resection in 29 cases (72.5%) and argon plasma coagulation in 11 cases (27.5%). For 77 lesions located on the non-anastomotic site, endoscopic resection was performed in 68 cases (88.4%) and argon plasma coagulation was performed in nine cases (11.7%; p = 0.031). The mean endoscopic resection duration was significantly longer in the anastomotic site group than in the non-anastomotic site group (43.6 vs. 26.3 min, p = 0.018). Recurrence was observed in five (12.8%) patients in the former and in one (1.3%) in the latter (p = 0.015); all the patients were successfully retreated with endoscopic resection or APC.

CONCLUSIONS

Endoscopic treatment for gastric epithelial neoplasm in a remnant stomach after distal gastrectomy is effective and safe. However, closely monitoring for recurrence should be conducted, particularly when the tumor is located at the anastomotic site.

Endoscopic submucosal dissection for gastric indefinite for neoplasia: which lesions should be resected?

BACKGROUND AND STUDY AIMS

The management plan for gastric indefinite for neoplasia is undetermined, and endoscopic forceps biopsy might be inconclusive in ascertaining whether a resection is required. This study aimed to evaluate the clinical outcomes of endoscopic submucosal dissection (ESD) for gastric indefinite for neoplasia and to identify the factors highly predictive of true neoplasia.

PATIENTS AND METHODS

This retrospective study was conducted in a single, tertiary, referral hospital between November 2008 and December 2015. A total of 109 gastric indefinite for neoplasia lesions from endoscopic forceps biopsy that were resected by ESD were included in the study. The clinical outcomes and endoscopic factors for prediction of true neoplasia were analyzed.

RESULTS

A total of 99 patients (90.8%) were diagnosed with definite neoplasia after ESD and were classified as category 3 (n = 42), category 4 (n = 50), and category 5 (n = 7) according to the revised Vienna classification. The mean age of the patients was 65.8 ± 9.8 years. The mean lesion size was 10.7 ± 6.1 mm. The patient population predominantly consisted of male patients (70.6%). The en bloc and complete endoscopic resection rates were 98.2% and 94.5%, respectively. Factors associated with true neoplastic lesions were male sex (odds ratio [OR] 8.596, p = 0.008) and lesion size ≥ 5 mm (OR 11.355, p = 0.003). Factors associated with category 4-5 were male sex (OR 3.165, p = 0.021) and erosive change (OR 2.841, p = 0.031).

CONCLUSIONS

Endoscopic resection for indefinite for neoplasia with larger lesions size and erosive changes, especially in males, should be considered when possible.

Clinical Implication and Risk Factors for Malignancy of Atypical Gastric Gland during Forceps Biopsy

Background/Aims

Although forceps biopsy is performed for suspicious gastric tumors during endoscopy, it is difficult to determine treatment strategies for atypical gastric glands due to uncertainty of the diagnosis. The aim of this study was to investigate clinical implications and risk factors for predicting malignancy in atypical gastric glands during forceps biopsy.

Methods

We retrospectively reviewed medical records of 252 patients with a diagnosis of atypical gastric gland during forceps biopsy. Predictors of malignancy were analyzed using initial endoscopic findings and clinical data.

Results

The final diagnosis for 252 consecutive patients was gastric cancer in 189 (75%), adenoma in 26 (10.3%), and gastritis in 37 (14.7%). In the multivariate analysis, lesion sizes of more than 10 mm (odds ratio [OR], 3.021; 95% confidence interval [CI], 1.480 to 6.165; p=0.002), depressed morphology (OR, 3.181; 95% CI, 1.579 to 6.406, p=0.001), and surface nodularity (OR, 3.432; 95% CI, 1.667 to 7.064, p=0.001) were significant risk factors for malignancy.

Conclusions

Further evaluation and treatment should be considered for atypical gastric gland during forceps biopsy if there is a large-sized (>10 mm) lesion, depressed morphology, or surface nodularity.

Endoscopic Indication of Endoscopic Submucosal Dissection for Early Gastric Cancer Is Not Compatible with Pathologic Criteria in Clinical Practice

BACKGROUND

The inappropriate selection of patients with early gastric cancer (EGC) for endoscopic submucosal dissection (ESD) may lead to additional surgery because of a non-curative resection. This study was performed to assess the accuracy of clinical decisions in ESD for EGC.

METHODS

A total of 607 cases of EGC treated by ESD were prospectively enrolled from January 2011 to June 2014 at a single academic hospital. The 607 EGCs were divided into three groups (overestimated, same-estimated, and underestimated) based on pre-procedure endoscopic findings (indication) and pathological diagnosis after ESD (criteria). We evaluated the discrepancy rates between pre-procedure indication and pathological criteria, and then analyzed the pre-procedure factors that could influence the occurrence of the discrepancies.

RESULTS

The absolute, expanded, and beyond the expanded indication has its accuracy on curability criteria in 87%, 77.6%, and 55.6% of cases, respectively. The ratio of overall indication-criteria discrepancies was 250/607 (41.2%). The curability was significantly lower in the underestimated group compared to the overestimated and same-estimated groups (41.6% vs. 94.6%, 94.4%, p < 0.001). In multivariate analysis examining the predictive factors for discrepancies in the 598 EGCs with absolute/expanded indications, the endoscopic size ≥ 20 mm [odds ratio (OR) 2.493, confidence interval (CI) 1.546-4.022, p < 0.001], presence of ulcers (OR 1.712, CI 1.070-2.738, p = 0.025), patient age < 60 years (OR 1.689, CI 1.044-2.733, p = 0.033), and undifferentiated type EGC on forceps biopsy (OR 5.397, CI 2.027-14.369, p = 0.001) were all associated with discrepancies.

CONCLUSIONS

Indication judged by pre-procedural endoscopy is not sufficiently accurate to be used as a good measurement for post-procedural criteria.

Analysis of endoscopic features for histologic discrepancies between biopsy and endoscopic submucosal dissection in gastric neoplasms: 10-year results

BACKGROUND AND AIM

The histologic discrepancies between preoperative endoscopic forceps biopsy (EFB) and endoscopic submucosal dissection (ESD) specimens sometimes confuse the endoscope operator. This study aimed to analyze the limitation of the biopsy-based diagnosis before ESD and to evaluate which factors affect the discordant pathologic results between EFB and ESD.

METHODS

A total of 1427 patients, who were diagnosed with gastric adenoma by EFB, were enrolled. Cancer confirmed on EFB was excluded (n = 513). We retrospectively reviewed cases and compared histologic diagnoses in the biopsy sample with the final diagnosis in the endoscopically resected specimen.

RESULTS

The diagnosis was upgraded (from low-grade dysplasia to high-grade dysplasia or adenocarcinoma, or from high-grade dysplasia to adenocarcinoma) in 328 cases (23.0%), concordant in 944 (66.1%), and downgraded (from high-grade dysplasia to low-grade dysplasia or non-neoplasia, or from low-grade dysplasia to non-neoplasia) in 155 (10.9%). Multivariate logistic regression analysis showed that surface ulceration and depressed lesions were associated with significant risk factors for upgrading. Age younger than 60 years and size <1 cm were associated with significant factors for downgrading.

CONCLUSIONS

Careful endoscopic observation should consider size, ulceration, and depression to ensure accurate diagnosis when a gastric neoplasm is suspected.

Risk factors associated with histological upgrade of gastric low-grade dysplasia on pretreatment biopsy

OBJECTIVES

Histological discrepancies between biopsy and resection specimens are common. In this study, we aimed to analyze the risk factors predicting histological upgrade or downgrade of biopsy-diagnosed gastric low-grade dysplasia (LGD).

METHODS

The medical records of patients with 104 biopsy-diagnosed gastric LGD from January 2011 to December 2017 were collected. The association of endoscopic characteristics with histological discrepancies between the biopsy and resection specimens was analyzed. The risk factors for histological upgrade were studied using the multivariate analysis.

RESULTS

Among the 104 lesions, 88 were removed by endoscopic resection and 16 were monitored. The upgrade and downgrade rates of the pathological diagnosis were 48.9% and 12.5%, respectively. Lesion size >20 mm, surface redness and positive results in magnifying endoscopy with narrow band imaging (ME-NBI) were risk factors for histological upgrade. Compared with the negative ME-NBI group, the positive ME-NBI group had a higher upgrade rate (56.8% vs 7.1%) but a lower downgrade rate (2.7% vs 64.3%). In addition, 11 of the 16 the gastric LGD with negative ME-NBI findings were monitored, and all 11 lesions regressed to gastritis during follow-up.

CONCLUSIONS

Endoscopic resection should be recommended in cases of LGD showing surface redness, with a lesion size of >20 mm or positive ME-NBI result, whereas regular follow-up may be an option for LGD with negative ME-NBI result.

Gastric Cancer Caused by Adenoma: Predictive Factors Associated with Lesions Other Than the Expanded Indications

Background/Aims

We aimed to investigate whether the current indications for curative endoscopic resection (ER) of gastric cancer (GC) can be applied to GC caused by adenoma. Additionally, we attempted to identify factors predictive of lesions subsequently found in addition to the expanded indications for ER.

Methods

We retrospectively analyzed 342 patients diagnosed with GC caused by adenoma who underwent ER at a single tertiary center between February 2011 and December 2014. The gross whole tumor size was measured using the endoscopically resected specimen. The microscopic whole tumor size was measured using mapping paper. The estimated cancer size was calculated using the microscopic whole tumor size and the square root of the carcinoma component.

Results

A gross whole tumor size ≥3 cm, carcinoma component ≥35%, and gross ulceration were predictive of lesions other than the expanded indications for ER. The overall rate of lymph node metastasis was 0.3% (1/327), which only occurred in one patient with a lesion other than the expanded indications (4.5%, 1/22).

Conclusions

The current indications for curative ER in GC can be applied to GC caused by adenoma. In cases suspected of having lesions other than the expanded indications, patients should be cautiously selected for ER to reduce the risk of an inappropriate procedure.

Cost-effectiveness and short-term clinical outcomes of argon plasma coagulation compared with endoscopic submucosal dissection in the treatment of gastric low-grade dysplasia

Endoscopic treatment such as endoscopic submucosal dissection (ESD) or argon plasma coagulation (APC) is widely performed to treat gastric low-grade dysplasia (LGD). We aimed to evaluate the clinical efficacy of APC versus ESD for gastric LGD in terms of cost-effectiveness. This was a retrospective review of patients with gastric LGD who were treated with endoscopic intervention (APC or ESD) between March 2011 to December 2015. Fifty-nine patients treated with APC and 124 patients treated with ESD were included. Patients in the APC group were significantly older (mean age, 67.68 vs 63.90 years, respectively, P < .01), had an increased rate of Helicobacter pylori infection (27.1 vs 10.5%, respectively, P < .01), and had a higher mean Charlson Comorbidity Index score (2.32 vs 0.38, respectively, P < .01) than those in the ESD group. The 2 groups did not differ in tumor size, location, macroscopic morphology, or surface configuration. The procedure time (11.31 vs56.44 minutes, respectively, P < .01), and hospital stay (3.2 vs 5.6 days, respectively, P < .01) were significantly, shorter in the APC group than in the ESD group. Additionally, the cost incurred was significantly, lower in the APC group than in the ESD group (962.03 vs 2,534.80 dollars, respectively, P < .01). APC has many advantages related to safety, and cost-effectiveness compared with ESD. Therefore, APC can be considered an alternative treatment option for gastric LGD.

Incidence of gastric adenocarcinoma among lesions diagnosed as low-grade adenoma/dysplasia on endoscopic biopsy: A multicenter, prospective, observational study

BACKGROUND AND AIM

Differentiation between gastric adenocarcinoma and low-grade adenoma/dysplasia (LGA) on endoscopic forceps biopsy is difficult. We aim to clarify the incidence of carcinoma in specimens, obtained by endoscopic resection (ER), from cases that had been diagnosed as LGA (Vienna category 3) on endoscopic biopsy.

METHODS

In this multicenter, prospective, observational study, patients with gastric adenoma (Vienna category 3 or 4.1) diagnosed on endoscopic forceps biopsy were enrolled. All the specimens were subjected to histopathological central review. Primary endpoint was the incidence of carcinoma (Vienna category 4.2 or over) among the biopsy-proven gastric LGA. Secondary endpoints were the histological findings of resected specimens, clinicopathological features of carcinoma, and short-term outcomes of all ER cases.

RESULTS

Ninety-five patients with 104 lesions diagnosed as gastric adenoma were enrolled. After central review of the biopsy specimens, 47 lesions were diagnosed as LGA and seven lesions (15%) as adenocarcinoma (95% confidence interval, 7.6-28%). Carcinoma was detected in lesions that had a minimum size of 6 mm; the incidence of carcinoma was higher in the larger lesions. There was a histological discrepancy between biopsy and ER material in more than 60% of the cases.

CONCLUSIONS

A substantial proportion of biopsy-proven gastric LGA specimens were diagnosed as adenocarcinoma after ER. This indicated histological discrepancy between biopsy-proven gastric LGA and histology of the resected material.

Endoscopic submucosal dissection of gastric neoplasms using a snare tip

BACKGROUND

Endoscopic submucosal dissection (ESD) enables the complete removal of gastric lesions regardless of tumor size. ESD is typically performed using one of several available electrocautery knives and endoscopic mucosal resection (EMR) is performed using a diathermic snare. We aimed to investigate the clinical outcomes and complications in patients in whom a snare tip was used for ESD.

MATERIALS AND METHODS

We retrospectively evaluated the medical records of 30 patients who underwent removal of a gastric lesion using a snare tip by ESD or hybrid ESD (ESD with snaring). For hybrid ESD, snaring was performed after an adequate submucosal dissection. The clinical outcomes according to the endoscopic procedure performed were evaluated.

RESULTS

ESD was performed in 12 patients and hybrid ESD was performed in 26 patients. Overall en-bloc and complete resection rates were both 97.4%. There was one case where piece-meal resection was performed in the hybrid ESD group. There were no procedure related complications such as perforation or bleeding. The mean specimen size was 2.8 ± 0.6 cm in the ESD group and 2.3 ± 0.5 cm in the hybrid ESD group (p = .031). The mean procedure time did not differ between the two methods (12.8 min in ESD and 9.7 min in hybrid ESD, p = .060).

CONCLUSIONS

The snare tip can be used as an electrocautery knife to incise the mucosa and dissect the submucosa during removal of a gastric lesion.

Predictors of upstage diagnosis after endoscopic resection of gastric low-grade dysplasia

BACKGROUND

The optimal management of precursor lesions such as gastric low-grade dysplasia is crucial in order to improve gastric cancer-related mortality. However, there are no universally accepted management guidelines regarding which lesions should be resected or should be monitored by follow-up visits.

PATIENTS AND METHODS

We retrospectively analyzed data from 1006 gastric low-grade dysplasia lesions that had been resected via endoscopic submucosal dissection. We also evaluated the endoscopic risk factors associated with upstage diagnosis from low-grade dysplasia to high-grade dysplasia or gastric cancer.

RESULTS

The mean age of our patients was 63.7 ± 9.1 years and 70.3% of our study population included men. The predominant location and gross type of lesions was the lower third of the stomach (78.6%) and the elevated type (57.8%), respectively. The rates of pathological concordance, upstage, and downstage diagnosis were 85.3, 12.1, and 2.6%, respectively. Multivariate analysis, after adjusting for age and sex, showed that a lesion size ≥ 10 mm (Odds ratio [OR] 2.231; p = 0.003), erythema (OR 7.315; p < 0.001), nodularity (OR 5.589; p < 0.001), depression (OR 3.024; p = 0.002), and erosion (OR 7.680; p < 0.001) were all factors significantly associated with upstage diagnosis. Furthermore, an increasing number of risk factors was associated with an increasing frequency of upstage diagnosis; if there were no risk factors, then there was no upstage diagnosis.

CONCLUSIONS

This study identified several risk factors that were significantly associated with the upstage diagnosis of gastric low-grade dysplasia: lesion size ≥ 10 mm and a variety of surface changes (erythema, nodularity, depression, and erosion). Our data indicate that if there is no evidence of these endoscopic risk factors, then regular follow-up may be considered, according to the patient's combined comorbid conditions.

[Endoscopic Treatment of Gastric Adenoma]

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

Gastric superficial neoplasia: high miss rate but slow progression

BACKGROUND AND AIMS

 Gastric superficial neoplasia (GSN) is often overlooked at endoscopy because of difficulty in identifying it. The miss rate of GSN at endoscopy and the impact on clinical outcome of the missed GSN have not been fully elucidated. In this study, we investigated these issues.

METHODS

 Among 1462 endoscopically and pathologically diagnosed gastric cancers in our hospital from January 2011 to December 2014, previous records of esophagogastroduodenoscopy (EGD) were available for 198 lesions (index lesions) and were reviewed retrospectively. Among those, 157 lesions, which were diagnosed as GSN on the basis of their EGD findings at initial endoscopy, were analyzed. Progression was defined as advanced cancer in the index lesion.

RESULTS

 Among the 157 GSNs, 118 (75.2 %) had not been recorded in the previous EGD report but were evident upon review of endoscopic photographs for this study. Progression to advanced cancer was observed in only 13 (8.3 %) of the 157 GSNs during a mean interval of 41 months and as long as 96 months, and the rate of progression was similar in missed and not-missed lesions (8.5 % and 7.7 %, respectively). Cumulative incidence rates of progression of missed GSNs to advanced cancer were 0.8 %, 1.7 %, 4.2 %, and 7.6 % at 36, 48, 60, and 72 months after the initial EGD, respectively.

CONCLUSIONS

 Our findings illustrate that GSNs are often missed at endoscopy but progress slowly in most cases. Even though the rate of progression to cancer is relatively low, rigorous attempts should be made to reduce the miss rate of GSNs at EGD.

Atrophic and Metaplastic Progression in the Background Mucosa of Patients with Gastric Adenoma

BACKGROUND

In patients with adenoma, assessing premalignant changes in the surrounding mucosa is important for surveillance. This study evaluated atrophic and metaplastic progression in the background mucosa of adenoma or early gastric cancer (EGC) cases.

METHODS

Among 146 consecutive patients who underwent endoscopic resection for intestinal-type gastric neoplasia, the adenoma group included 56 patients with low-grade dysplasia and the ECG group included 90 patients with high-grade dysplasia or invasive carcinoma. For histology, 3 paired biopsies were obtained from the antrum, corpus lesser curvature (CLC), and corpus greater curvature (CGC). Serological atrophy was determined based on pepsinogen A (PGA), progastricsin (PGC), gastrin-17, and total ghrelin levels. Topographic progression of atrophy and/or metaplasia was staged using the operative link on gastritis assessment (OLGA) and operative link on gastric intestinal metaplasia assessment (OLGIM) systems.

RESULTS

Rates of moderate-to-marked histological atrophy/metaplasia in patients with adenoma were 52.7%/78.2% at the antrum (vs. 58.8%/76.4% in EGC group), 63.5%/75.0% at the CLC (vs. 60.2%/69.7% in EGC group), and 10.9%/17.9% at the CGC (vs. 5.6%/7.8% in EGC group). Serological atrophy indicated by PGA and PGC occurred in 23.2% and 15.6% of cases in the adenoma and ECG groups, respectively (p = 0.25). Mean serum gastrin-17 concentrations of the adenoma group and EGC group were 10.4 and 9.0 pmol/L, respectively (p = 0.54). Mean serum total ghrelin levels were 216.6 and 209.5 pg/mL, respectively (p = 0.71). Additionally, between group rates of stage III-IV OLGA and OLGIM were similar (25.9% vs. 25.0%, p = 0.90; 41.8% vs. 44.9%, p = 0.71, respectively).

CONCLUSIONS

Atrophic and metaplastic progression is extensive and severe in gastric adenoma patients. A surveillance strategy for metachronous tumors should be applied similarly for patients with adenoma or EGC.

Clinical features of negative pathologic results after gastric endoscopic submucosal dissection

BACKGROUND

Endoscopic submucosal dissection (ESD) is widely used for the treatment of gastric superficial neoplasms. Negative pathologic results after ESD can confuse the endoscopists and patients. The aim of this study was to evaluate the reasons for and the factors associated with negative pathologic results after ESD.

PATIENTS AND METHODS

From December 2008 to July 2015, a total of 1379 lesions diagnosed as definite dysplasia or adenocarcinoma by endoscopic forceps biopsy (EFB) were removed with an ESD procedure. The initial endoscopic and pathologic findings were analyzed.

RESULTS

The incidence of negative pathology after ESD was 2.0 % (28/1379). Compared with positive pathologic lesions, negative pathologic lesions were smaller and had less surface area (P < 0.001). The reasons for negative pathologic lesions after ESD were complete removal by EFB (n = 20), over-estimations of the EFB specimen (n = 5), and different ESD site (n = 3).

CONCLUSION

Small tumor size and surface area are associated with negative pathologic results after ESD. When negative pathologic results are reported after ESD, we should review the previous endoscopic biopsy tissue specimen and compare the previous EFB site to the ESD site. Thereafter, regular endoscopic examination of the lesion is needed.

Retrospective study: The diagnostic accuracy of conventional forceps biopsy of gastric epithelial compared to endoscopic submucosal dissection (STROBE compliant)

Conventional forceps biopsy (CFB) is the most popular way to screen for gastric epithelial neoplasia (GEN) and adenocarcinoma of gastric epithelium. The aim of this study was to compare the diagnostic accuracy between conventional forceps biopsy and endoscopic submucosal dissection (ESD).Four hundred forty-four patients who finally undertook ESD in our hospital were enrolled from Jan 1, 2009 to Sep 1, 2015. We retrospectively assessed the characteristics of pathological results of CFB and ESD.The concordance rate between CFB and ESD specimens was 68.92% (306/444). Men showed a lower concordance rate (63.61% vs 79.33%; P = 0.001) and concordance patients were younger (P = 0.048). In multivariate analysis, men significantly had a lower concordance rate (coefficient -0.730, P = 0.002) and a higher rate of pathological upgrade (coefficient -0.648, P = 0.015). Locations of CFB did not influence the concordance rate statistically.The concordance rate was relatively high in our hospital. According to our analysis, old men plus gastric fundus or antrum of CFB were strongly suggested to perform ESD if precancerous lesions were found. And young women with low-grade intraepithelial neoplasia could select regular follow-up.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Diagnosis and management of gastric dysplasia

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

Predicting pre- and post-resectional histologic discrepancies in gastric low-grade dysplasia: A comparison of white-light and magnifying endoscopy

BACKGROUND AND AIM

The aim of this study was to evaluate the validity of the parameters of conventional white-light endoscopy and magnifying endoscopy with narrow-band imaging (MENBI) for the prediction of discrepancies between pre- and post-resectional histology in cases of gastric adenoma with low-grade dysplasia (LGD) that were diagnosed based on endoscopically biopsied specimens.

METHODS

The medical records of 266 lesions with gastric LGD that were diagnosed by endoscopic forceps biopsies were retrospectively reviewed. The Vienna classification was used for histologic diagnosis. These patients all underwent MENBI examinations followed by analyses of the incidence of histologic discrepancies and histologic heterogeneity. The relationship between white-light endoscopic/MENBI parameters and the presence of histologic discrepancies was also analyzed.

RESULTS

Discrepancies between the pre- and post-resectional histologies were found in 74 cases (27.9%). Among those cases, the histology was upgraded in 71 cases, whereas the histology was downgraded in three cases. The presence of erythema and positive MENBI findings were independent factors for the prediction of upgraded histologic discrepancies (P-values = 0.008, < 0.001, respectively). A positive MENBI finding yielded the highest predictive value, with a multivariate adjusted odds ratio of 42.46. Histologic heterogeneity in post-resectional specimens was found in 40.8% of cases with upgraded histologic discrepancies.

CONCLUSIONS

MENBI can provide more accurate information than white-light endoscopy for the prediction of pre- and post-resectional histologic discrepancies in biopsy-proven gastric LGD. Endoscopic resection is strongly recommended in cases with surface erythema on conventional white-light endoscopy or positive MENBI, irrespective of the lesion size.

Diagnosis and therapies for gastric non-invasive neoplasia

There has been a great discrepancy of pathological diagnosis for gastric non-invasive neoplasia/dysplasia between Japanese and western pathologists. In Japan, lesions that most western pathologists diagnose as dysplasia are often considered adenocarcinoma based on nuclear and structural atypia regardless of the presence of invasion. In the Vienna classification, gastric non-invasive intraepithelial neoplasia (NIN) were divided into low grade and high grade (including intra-mucosal cancer of Japanese criteria). The diagnosis by both endoscopy and pathology of biopsy specimen is difficult. Recent advances of diagnostic modality such as magnified endoscopy and imaged enhanced endoscopy is expected to improve the diagnostic yield for NIN. There are two treatment strategies for NIN, observation and diagnostic therapy by endoscopic resection (ER). ER is acceptable because of its less invasiveness and high local control rate, on the other hand, cancer-developing rate of low-grade NIN is reported to be low. Therefore there is controversy for the treatment of gastric NIN. Prospective study based on unified pathological definition is required in the future.

How Commonly Is the Diagnosis of Gastric Low Grade Dysplasia Upgraded following Endoscopic Resection? A Meta-Analysis

Gastric dysplasia is a well-known precancerous lesion. Though the diagnosis of gastric low grade dysplasia (LGD) is generally made from endoscopic forceps biopsy (EFB), the accuracy is doubtful after numerous EFB-proven gastric LGD were upgraded to gastric high grade dysplasia (HGD) or even carcinoma (CA) by further diagnostic test with the procedure of endoscopic resection (ER). We aimed to evaluate the upgraded diagnosis rate (UDR) and the risk factors by ER in EFB-proven gastric LGD lesions. Two investigators independently searched studies reporting the UDR by ER in EFB-proven gastric LGD lesions from databases and analyzed the overall UDR, HGD-UDR and CA-UDR. The pooled UDR by ER in EFB-proven gastric LGD lesions was 25.0% (95% CI, 20.2%-29.8%), made up of HGD-UDR and CA-UDR by rates of 16.7% (95% CI, 12.8%-20.6%) and 6.9% (95% CI, 4.2%-9.6%) respectively. Lesion size larger than 2 cm, surface with depression and nodularity under endoscopic examinations were the major risk factors associated with UDR. In conclusion, one quarter of EFB-proven gastric LGD lesions will be diagnosed as advanced lesions, including gastric HGD (16.7%) and gastric CA (6.9%) by ER. The diagnosis of those LGD lesions with an endoscopic diameter larger than 2cm, and depressed or nodular surface are more likely to be upgraded after ER.

Low Discrepancy Between Tissue Biopsy Plus Magnifying Endoscopy With Narrow-Band Imaging and Endoscopic Resection in the Diagnosis of Gastric Epithelial Neoplasia (STROBE)

Tissue biopsy is often not very accurate for the diagnosis of gastric epithelial neoplasia (GEN), and the results differ notably from endoscopic resection (ER) in terms of the pathological diagnosis. The aims of this study were to evaluate the diagnostic performances of biopsy, magnifying endoscopy with narrow-band imaging (ME-NBI), and biopsy plus ME-NBI for GEN.This study retrospectively analyzed 101 cases diagnosed as GEN using ER samples. The discrepancies between biopsy and ER, as well as between biopsy plus ME-NBI and ER in the diagnosis of GEN were evaluated. Factors that contributed to such discrepancies were analyzed. The sensitivity and specificity of biopsy and ME-NBI for the diagnosis of high-grade neoplasia (HGN) were determined.The discrepancy in the pathological diagnosis between biopsy and ER was 39.6% for GEN and 54.2% for HGN. The discrepancy between biopsy combined with ME-NBI and ER was 15.9% for GEN and 10.2% for HGN. Factors that undermined the diagnostic accuracy of biopsy included the lesion size (≤10 mm, odds ratio [OR] 1; 10-20 mm, OR 0.2, 95% confidence interval [CI] 0.1-0.7; >20 mm, OR 0.5, 95% CI 0.1-2.1, P = 0.03) and the number of biopsy fragments (OR 0.6, 95% CI 0.5-0.8, P = 0.001). The sensitivity and specificity for HGN were 45.8% (33.7%-58.3%) and 100% (87.5%-100%) for biopsy, and 88.1% (77.5%-94.1%) and 92.9% (81.0%-97.5%) for ME-NBI, respectively.In conclusion, biopsy-based diagnoses for GEN should be interpreted with caution. Biopsy combined with ME-NBI can contribute to the diagnosis of GEN, which improves diagnostic consistency with pathological result of ER specimens.

Clinical outcomes of no residual disease in the specimen after endoscopic resection for gastric neoplasms

BACKGROUND

No residual disease (NRD) can be found in the specimen after endoscopic resection (ER) of biopsy-proven gastric neoplasm. This study aimed to evaluate the endoscopic and pathologic characteristics of patients with NRD and identify the cause and long-term prognosis.

METHODS

Medical records of patients who underwent ER for biopsy-proven gastric neoplasms at a single tertiary hospital between January 2005 and November 2014 were retrospectively reviewed. Patients whose post-ER histology was revealed as NRD were included. Overall incidence, clinicopathologic characteristics, cause, and long-term prognosis were analyzed.

RESULTS

NRD was detected in 143 (3.2%) of 4401 cases of gastric neoplasms treated with ER. Mean endoscopic size of the initial lesion was 8.15 ± 6.64 mm; in 93 cases (65.0%), the lesion was located in the lower third of the stomach. Initial pathologic diagnosis was as follows: adenoma (n = 110), carcinoma (n = 29), and atypical gland (n = 4). The causes of NRD were minute lesions removed by biopsy in 140 patients, pathologic misdiagnoses in two, and localization error in one. Local recurrence was detected in five patients (3.6%) with minute lesions during follow-up and treated with argon plasma coagulation (n = 4) or re-ER (n = 1). Synchronous (n = 5, 3.6%) and metachronous gastric lesions (n = 6, 4.3%) were also detected during follow-up.

CONCLUSIONS

The main cause of NRD was minute lesions which might be completely removed by initial diagnostic biopsy. These cases showed a minimal rate of local recurrence and synchronous or metachronous gastric neoplasms. Careful follow-up is also mandatory for detection of residual disease.

Risk factors associated with diagnostic discrepancy of gastric indefinite neoplasia: Who need en bloc resection?

BACKGROUND

Endoscopic forceps biopsy is insufficient for a definitive diagnosis of dysplastic lesions. It is difficult to decide clinical management of gastric indefinite neoplasia diagnosed by endoscopic forceps biopsy when early gastric cancer (EGC) is macroscopically suspected. The aim of this study was to discuss the final results of gastric indefinite neoplasia and associated clinical factors predictive of early gastric cancer.

METHODS

The medical records of 119 patients who were diagnosed with gastric indefinite neoplasia by index forceps biopsy were retrospectively reviewed. The initial endoscopic findings were analyzed, and predictive factors of EGC were evaluated.

RESULTS

The final pathologic diagnoses of 119 patients included early gastric cancer (n = 26, 21.8%), adenoma (n = 6, 5.0%) and non-neoplasm (n = 87, 73.1%). Univariate analysis showed that lesion size greater than 10 mm, surface nodularity and surface redness were associated risk factors. In the multivariate analysis, lesions diameter (p = 0.021, OR 11.401, 95% CI 1.432-90.759) and surface redness (p = 0.014, OR 3.777, 95% CI 1.306-10.923) were significant risk factors.

CONCLUSIONS

Patients with gastric indefinite neoplasia with larger size (≥10 mm) and surface redness might need further diagnostic investigation rather than simple follow-up endoscopy.

Optimal management of biopsy-proven low-grade gastric dysplasia

Gastric adenocarcinoma generally culminates via the inflammation-metaplasia-dysplasia-carcinoma sequence progression. The prevalence of gastric adenomas shows marked geographic variation. Recently, the rate of diagnosis of low-grade dysplasia (LGD) has increased due to increased use of upper endoscopy. Many investigators have reported that gastric high-grade dysplasia has high potential for malignancy and should be removed; however, the treatment for gastric LGD remains controversial. Although the risk of LGD progression to invasive carcinoma has been reported to be inconsistent, progression has been observed during follow-up. Additionally, the rate of upgraded diagnosis in biopsy-proven LGD is high. Therefore, endoscopic resection (ER) may be useful in the treatment and diagnosis of LGD, especially if lesions are found to have risk factors for upgraded histology after ER, such as large size, surface erythema or depressed morphology. Fatal complications in endoscopic submucosal dissection (ESD) are extremely low and its therapeutic and diagnostic outcomes are excellent. Therefore, ESD should be applied preferentially instead of endoscopic mucosal resection.

Combination of Paris and Vienna classifications may optimize follow-up of gastric epithelial neoplasia patients

Background

The aim of this study was to evaluate the efficiency of the combination of Paris and Vienna classifications in a follow-up study of gastric epithelial neoplasia (GEN) patients.

Material/Methods

This study was conducted between January 2003 and September 2010, during which 170 biopsy-proven GEN patients were followed up by gastroenterologists and pathologists according to our follow-up regimen (modified Vienna classification).

Results

In total, 161 patients with low-grade neoplasia (LGN) and 9 patients with high-grade neoplasia (HGN) were randomly enrolled in our study. Eighteen patients with depressed appearance were observed, of which 9 patients had HGN and 9 patients had low-grade dysplasia (LGD). Three patients with type 0-IIa were observed with low-grade adenoma (LGA), and type 0–I was observed in 2 patients with LGN. Endoscopic or surgical treatments were performed to avoid potential malignancy or bleeding. Two patients with ulcer lesions, 2 patients with non-depressed type 0 appearance, and 3 patients without visible lesions were shown to have higher-grade lesions during follow-up. The misdiagnosis rate of forceps biopsy – 62.07% – was determined by comparing pre- and post-resection diagnoses of 29 patients.

Conclusions

The combination of the Paris and Vienna classifications for GEN may optimize the follow-up routines for patients with suspicious precancerous lesions and may significantly improve the detection of early gastric cancer (EGC) while helping gastroenterologists select the best therapy option.