Helicobacter pylori Eradication Prevents Metachronous Gastric Neoplasms after Endoscopic Resection of Gastric Dysplasia

Cortactin Facilitates Malignant Transformation of Dysplastic Cells in Gastric Cancer Development

BACKGROUND & AIMS

Epithelial cancer onset occurs through sequential stages of cell lineage conversion and functional dysregulation. Dysplasia is a precancerous lesion defined as a direct precursor to cancer and is histologically defined as a transition stage between pre-cancer and cancer, but molecular and biological mechanisms controlling its transformation to malignancy are underdetermined. Here, we discover the crucial role of the actin stabilization and exosome secretion-regulatory protein cortactin in dysplastic cell transformation to adenocarcinoma.

METHODS

We engineered a CRISPR/Cas9-based cortactin knock-out (KO) dysplasia organoid model established from dysplastic tissue and examined malignant roles of cortactin during gastric cancer development in vitro and in vivo.

RESULTS

Although dysplastic cell identity remained unchanged, the cortactin KO organoids exhibited a decrease in cellular organization and multicellular protrusions, which are considered aggressive features when observed in vitro. When injected into the flank of nude mice, cortactin KO cells failed malignant transformation into adenocarcinoma and solid tumor formation with reduced recruitment of fibroblasts and macrophages. In addition, cortactin KO cells showed diminished exosome secretion levels, and adenocarcinoma development was impaired when exosome secretion was inhibited in cortactin wild-type dysplastic cells.

CONCLUSIONS

These data suggest that cortactin is a functional element of membrane dynamics, malignant changes, and exosome secretion in dysplastic cells, and solid gastric tumor formation associated with alteration of the tumor microenvironment.

Helicobacter pylori eradication following endoscopic resection might prevent metachronous gastric cancer: a systematic review and meta-analysis of studies from Japan and Korea

OBJECTIVES

A systematic review and meta-analysis was performed to evaluate the preventive effectiveness of Helicobacter pylori eradication against metachronous gastric cancer (MGC) or dysplasia following endoscopic resection (ER) for early gastric cancer (EGC) or dysplasia.

METHODS

PubMed, Cochrane Library, MEDLINE, and EMBASE were searched until 31 October 2023, and randomized controlled trials or cohort studies were peer-reviewed. The incidence of metachronous gastric lesions (MGLs) including MGC or dysplasia was compared between Helicobacter pylori persistent and negative groups, eradicated and negative groups, and eradicated and persistent groups.

RESULTS

Totally, 21 eligible studies including 82,256 observations were analyzed. Compared to those never infected, Helicobacter pylori persistent group (RR = 1.58, 95% CI = 0.98-2.53) trended to have a higher risk of MGLs and significantly in partial subgroups, while the post-ER eradicated group (RR = 0.79, 95% CI = 0.43-1.45) did not increase the risk of MGLs. Moreover, successful post-ER eradication could significantly decrease the risk of MGLs (RR = 0.54, 95% CI = 0.44-0.65) compared to those persistently infected. Sensitivity analysis obtained generally consistent results, and no significant publication bias was found.

CONCLUSION

The persistent Helicobacter pylori infection trends to increase the post-ER incidence of MGC or dysplasia, but post-ER eradication can decrease the risk correspondingly. Post-ER screening and eradication of Helicobacter pylori have preventive effectiveness on MGC, and the protocol should be recommended to all the post-ER patients.Systematic review registration: The PROSPERO registration identification was CRD42024512101.

Helicobacter pylori Treatment and Gastric Cancer Risk After Endoscopic Resection of Dysplasia: A Nationwide Cohort Study

BACKGROUND & AIMS

The study investigated the association between Helicobacter pylori treatment and the risk of gastric cancer after endoscopic resection of gastric dysplasia.

METHODS

Patients who received endoscopic resection for gastric dysplasia between 2010 and 2020 from Korean nationwide insurance data were included. We verified the occurrence of new-onset gastric cancer and metachronous gastric neoplasm, which encompasses both cancer and dysplasia, >1 year after the index endoscopic resection. Newly diagnosed gastric cancer ≥3 years and ≥5 years was regarded as late-onset gastric cancer. A multivariable Cox regression model with H pylori treatment status as a time-dependent covariate was used to determine the risk of gastric cancer and metachronous gastric neoplasms.

RESULTS

Gastric dysplasia in 69,722 patients was treated with endoscopy, and 49.5% were administered H pylori therapy. During the median 5.6 years of follow-up, gastric cancer developed in 2406 patients and metachronous gastric neoplasms developed in 3342 patients. Receiving H pylori therapy was closely related to lower gastric cancer risk (adjusted hazard ratio [aHR], 0.88; 95% confidence interval [CI], 0.80-0.96). H pylori treatment also significantly decreased metachronous gastric neoplasm development (aHR, 0.76; 95% CI, 0.70-0.82). Furthermore, H pylori therapy showed a prominent protective effect for late-onset gastric cancer development at ≥3 years (aHR, 0.84; 95% CI, 0.75-0.94) and ≥5 years (aHR, 0.80; 95% CI, 0.68-0.95).

CONCLUSIONS

In this nationwide cohort, H pylori therapy after endoscopic resection of gastric dysplasia was associated with a reduced risk of gastric cancer and metachronous gastric neoplasm occurrence.

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

BACKGROUND/AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of Helicobacter pylori Eradication Treatment on Metachronous Gastric Neoplasm Prevention Following Endoscopic Submucosal Dissection for Gastric Adenoma

The long-term effect of Helicobacter pylori eradication on metachronous gastric neoplasm prevention after endoscopic submucosal dissection (ESD) of gastric adenoma is unclear. This study included patients with confirmed H. pylori infection after ESD with curative resection for gastric adenoma. Patients were divided based on the success of H. pylori eradication treatment into two groups: eradication and non-eradication. Patients with any newly detected lesion within 1 year after ESD and recurrence at the ESD site were excluded from the analysis. Further, 1:1 propensity score matching was also performed to eliminate baseline differences between the two groups. H. pylori eradication treatment was administered to 673 patients after ESD (163 in the successful eradication group and 510 in the non-eradication group). During the median follow-up periods of 25 and 39 months in the eradication and non-eradication groups, metachronous gastric neoplasm was identified in 6 (3.7%) and 22 patients (4.3%), respectively. Adjusted Cox analysis revealed that H. pylori eradication was not associated with increased risk of metachronous gastric neoplasm after ESD. Kaplan-Meier analysis in the matched population yielded similar findings (p = 0.546). H. pylori eradication treatment was not associated with metachronous gastric neoplasm after ESD with curative resection for gastric adenoma.

Kyoto classification of gastritis, virtual chromoendoscopy and artificial intelligence: Where are we going? What do we need?

Chronic gastritis (CG) is a widespread and frequent disease, mainly caused by Helicobacter pylori infection, which is associated with an increased risk of gastric cancer. Virtual chromoendoscopy improves the endoscopic diagnostic efficacy, which is essential to establish the most appropriate therapy and to enable cancer prevention. Artificial intelligence provides algorithms for the diagnosis of gastritis and, in particular, early gastric cancer, but it is not yet used in practice. Thus, technological innovation, through image resolution and processing, optimizes the diagnosis and management of CG and gastric cancer. The endoscopic Kyoto classification of gastritis improves the diagnosis and management of this disease, but through the analysis of the most recent literature, new algorithms can be proposed.

Gastric Cancer: Emerging Trends in Prevention, Diagnosis, and Treatment

Gastric adenocarcinoma (GC) is the fourth leading cause of global cancer mortality, and the leading infection-associated cancer. Helicobacter pylori is the dominant risk factor for GC and classified as an IARC class I carcinogen. Surveillance of gastric premalignant conditions is now indicated in high-risk patients. Upper endoscopy is the gold standard for GC diagnosis, and image-enhanced endoscopy increases the detection of gastric premalignant conditions and early gastric cancer (EGC). Clinical staging is crucial for treatment approach, defining early gastric cancer, operable locoregional disease, and advanced GC. Endoscopic submucosal dissection is the treatment of choice for most EGC. Targeted therapies are rapidly evolving, based on biomarkers including MSI/dMMR, HER2, and PD-L1. These advancements in surveillance, diagnostic and therapeutic strategies are expected to improve GC survival rates in the near term.

Two Distinct Etiologies of Gastric Cancer: Infection and Autoimmunity

Gastric cancer is a leading cause of mortality worldwide. The risk of developing gastric adenocarcinoma, which comprises >90% of gastric cancers, is multifactorial, but most associated with Helicobacter pylori infection. Autoimmune gastritis is a chronic autoinflammatory syndrome where self-reactive immune cells are activated by gastric epithelial cell autoantigens. This cause of gastritis is more so associated with the development of neuroendocrine tumors. However, in both autoimmune and infection-induced gastritis, high risk metaplastic lesions develop within the gastric mucosa. This warrants concern for carcinogenesis in both inflammatory settings. There are many similarities and differences in disease progression between these two etiologies of chronic gastritis. Both diseases have an increased risk of gastric adenocarcinoma development, but each have their own unique comorbidities. Autoimmune gastritis is a primary cause of pernicious anemia, whereas chronic infection typically causes gastrointestinal ulceration. Both immune responses are driven by T cells, primarily CD4⁺ T cells of the IFN-γ producing, Th1 phenotype. Neutrophilic infiltrates help clear H. pylori infection, but neutrophils are not necessarily recruited in the autoimmune setting. There have also been hypotheses that infection with H. pylori initiates autoimmune gastritis, but the literature is far from definitive with evidence of infection-independent autoimmune gastric disease. Gastric cancer incidence is increasing among young women in the United States, a population at higher risk of developing autoimmune disease, and H. pylori infection rates are falling. Therefore, a better understanding of these two chronic inflammatory diseases is needed to identify their roles in initiating gastric cancer.

Helicobacter pylori Eradication and Gastric Cancer Prevention

Since Warren and Marshall demonstrated Helicobacter pylori (H. pylori) as a cause of gastritis in the early 1980s, H. pylori has been associated with various gastric diseases, including gastric ulcer, gastric mucosa-associated lymphoid tissue (MALT) lymphoma, gastric adenoma, gastric adenocarcinoma, and hyperplastic gastric polyps. H. pylori eradication therapy can treat some associated diseases, including low-grade gastric MALT lymphoma, and significantly reduce the risk of peptic ulcer recurrence or progression of atrophic gastritis and intestinal metaplasia. In East Asia, where H. pylori and gastric cancer are prevalent, several studies have been conducted to prove whether the risk of gastric cancer development is reduced through H. pylori eradication therapy. Early studies failed to show the benefits of H. pylori eradication therapy in gastric cancer prevention. However, recent studies with extended follow-up periods have reported reduced risks of gastric cancer after treatment of H. pylori infection. H. pylori eradication therapy effectively prevents gastric cancer even in patients who were treated for early gastric cancer, and can be used in treating hyperplastic gastric polyps. Herein, we reviewed current evidence supporting the benefits of H. pylori eradication therapy to help clinicians understand its impact on gastric cancer prevention and hyperplastic polyp treatment.

Evidence based guidelines for the treatment of Helicobacter pylori infection in Korea 2020

Helicobacter pylori infection is one of the most common infectious diseases worldwide. H. pylori is responsible for substantial gastrointestinal morbidity with a high disease burden. Since the revision of the H. pylori Clinical Practice Guidelines in 2013 in Korea, the eradication rate of H. pylori has gradually decreased with the use of a clarithromycin based triple therapy. According to a nationwide randomized controlled study by the Korean College of Helicobacter and Upper Gastrointestinal Research released in 2018, the intention-to-treat eradication rate was only 63.9%, which was mostly due to increased antimicrobial resistance to clarithromycin. The clinical practice guidelines for treatment of H. pylori were updated based on evidence-based medicine from a meta-analysis conducted on a target group receiving the latest level of eradication therapy. The draft recommendations developed based on the meta-analysis were finalized after expert consensus on three recommendations regarding the indication for treatment and eight recommendations on the treatment itself. These guidelines were designed to provide clinical evidence for the treatment of H. pylori to patients, nurses, medical school students, policymakers, and clinicians. These may differ from current medical insurance standards, and will be revised if more evidence emerges in the future.

Evidence-Based Guidelines for the Treatment of Helicobacter pylori Infection in Korea 2020

Helicobacter pylori infection is one of the most common infectious diseases worldwide. Although the prevalence of H. pylori is gradually decreasing, approximately half of the world's population still becomes infected with this disease. H. pylori is responsible for substantial gastrointestinal morbidity worldwide, with a high disease burden. It is the most common cause of gastric and duodenal ulcers and gastric cancer. Since the revision of the H. pylori clinical practice guidelines in 2013 in Korea, the eradication rate of H. pylori has gradually decreased with the use of a clarithromycin-based triple therapy for 7 days. According to a nationwide randomized controlled study conducted by the Korean College of Helicobacter and Upper Gastrointestinal Research released in 2018, the intention-to-treat eradication rate was only 63.9%, which was mostly due to increased antimicrobial resistance, especially from clarithromycin. The clinical practice guidelines for the treatment of H. pylori were updated according to evidence-based medicine from a meta-analysis conducted on a target group receiving the latest level of eradication therapy. The draft recommendations developed based on the meta-analysis were finalized after an expert consensus on three recommendations regarding the indication for treatment and eight recommendations for the treatment itself. These guidelines were designed to provide clinical evidence for the treatment (including primary care treatment) of H. pylori infection to patients, nurses, medical school students, policymakers, and clinicians. These may differ from current medical insurance standards and will be revised if more evidence emerges in the future.

Evidence-based Guidelines for the Treatment of Helicobacter pylori Infection in Korea: 2020 Revised Edition

Helicobacter pylori (H. pylori) infection is one of the most common infectious diseases worldwide. Although its incidence is gradually decreasing, about half of the world's population still get infected. H. pylori infection is responsible for substantial gastrointestinal morbidity worldwide. It is the most common cause of gastric and duodenal ulcers as well as gastric cancer. Since the revision of the H. pylori Clinical Practice Guidelines in 2013, the eradication rate of H. pylori has gradually decreased with the use of classical triple therapy, wherein amoxicillin, clarithromycin, and proton pump inhibitors are administered, for 7 days. According to a nationwide randomized controlled study conducted by the Korean College of Helicobacter and Upper Gastrointestinal Research released in 2018, the intention-to-treat eradication rate was only 63.9%, which was due to increased antimicrobial resistance induced by the use of antibiotics, especially clarithromycin. The update of clinical practice guideline for treatment of H. pylori was developed based on evidence-based medicine by conducting a meta-analysis. The draft recommendations were finalized after expert consensus on three recommendations regarding the indication for treatment and eight recommendations on the treatment itself. These guidelines are designed to provide patients, nurses, medical school students, policymakers, and clinicians with clinical evidence to guide primary care and treatment of H. pylori infection. These may differ from current medical insurance standards and will be revised further, if necessary, based on research-based evidence.

Long-term natural history after endoscopic resection for gastric dysplasia

BACKGROUND AND STUDY AIMS

Natural history after endoscopic resection (ER) for gastric dysplasia is still unclear. The aim of this study was to evaluate the long-term clinical outcomes and risk factors after ER for gastric dysplasia between control and cases with synchronous or metachronous gastric neoplasm.

METHODS

A total of 1090 patients who had undergone ER for gastric dysplasia and been followed up for at least one year from December 2002 to December 2013 were finally analyzed. Risk factors affecting the development of synchronous or metachronous neoplasm (SMN) and long-term clinical outcomes after ER for gastric dysplasia were evaluated.

RESULTS

Synchronous and metachronous neoplasms had developed in 126 (11.6%) and 133 patients (12.2%) during the mean follow-up duration of 63.6 months, respectively. Five-year and 10-year risk of metachronous neoplasm were 9.8% and 27.2%, respectively. Median duration to the development of metachronous neoplasm was 103.1 months. While age (P < 0.001) and mucosal atrophy (P = 0.09) of index cases were associated with the development of synchronous neoplasm, age (P = 0.017), incomplete resection (P = 0.025), and intestinal metaplasia (P = 0.017) of background mucosa of index cases were significantly related to the development of metachronous neoplasm in multivariate analysis. Cumulative incidence of SMN was not significantly different among H. pylori negative, eradicated, and persistent group.

CONCLUSIONS

Age, incomplete ER, and background intestinal metaplasia of index gastric dysplasia were significantly associated with metachronous recurrence. Endoscopic surveillance for metachronous recurrence after ER for gastric dysplasia is mandatory for longer than 10 years.

Statins and metachronous recurrence after endoscopic resection of early gastric cancer: a nationwide Korean cohort study

BACKGROUND

Statins have shown to reduce the risk of various cancers. However, their effects on metachronous recurrence (MR) after endoscopic resection (ER) for early gastric cancer (EGC) are unknown. We evaluate their effects on MR development after ER for EGC.

METHODS

We selected 11,568 patients who received ER for EGC from 2002 to 2011 from the Korean National Health Insurance database and classified into 2 groups: control and statins using propensity score matching. Metachronous recurrence was defined as the second ER or gastrectomy performed 6 months after the first ER.

RESULTS

Mean follow-up period was 8.8 ± 3.1 years. Statins showed a significantly lower incidence of MR than the control group (12.5% vs 2.2%, respectively, P < 0.01). After conducting competing risk analyses and time-dependent cox regression analysis considering immortal time bias, statins still showed a lower incidence rate of MR compared to that observed in the control group. For the multivariate analysis, statins remained significant (HR 0.17; 95% CI 0.13-0.24, P < 0.01). In the dose-response analysis, an inverse dose-response relationship was identified between MR and statins (P < 0.01).

CONCLUSION

Statins was significantly associated with a reduced risk of MR after ER for EGC with an inverse dose-response relationship.

Risk of metachronous gastric neoplasm occurrence during intermediate-term follow-up period after endoscopic submucosal dissection for gastric dysplasia

After endoscopic resection (ER) of gastric dysplasia, metachronous gastric neoplasm (MGN) appears to have an incidence rate similar to that detected after ER of early gastric cancer (EGC). We investigated whether the risk of MGN after ER for gastric dysplasia is different between patients with low-grade dysplasia (LGD) and high-grade dysplasia (HGD). Between March 2011 and December 2016, 198 patients with LGD (LGD group) and 46 patients with HGD (HGD group) who underwent ER were included in the study. During a median follow-up of 2.5 years, MGNs developed in 21 patients (10.6%) in the LGD group and in 6 patients (13.0%) in the HGD group. Hazard ratios (HRs) for MGNs (HR, 1.45; P = 0.425) and for metachronous HGD or gastric cancer (HR, 2.41; P = 0.214) in the HGD group were not different than those of the LGD group. However, considering patients without Helicobacter pylori infection, those in the HGD group had a significantly increased risk of metachronous HGD or gastric cancer compared to those in the LGD group (HR in HGD-group, 5.23; P = 0.044). These results indicate that meticulous surveillance endoscopy is needed to detect MGNs after ER of gastric dysplasia, especially in patients with HGD, including those without H. pylori infection.

Does Helicobacter pylori Eradication Reduce the Incidence of Metachronous Gastric Cancer After Curative Endoscopic Resection of Early Gastric Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Whether Helicobacter pylori eradication could reduce the risk of metachronous gastric cancer remain controversial. In the present study, we performed a systematic review and meta-analysis to evaluate the preventive effect of H. pylori eradication on the occurrence of metachronous gastric cancer after curative endoscopic resection of early gastric cancer.

METHODS

The related studies were identified by searching PubMed and Embase databases. According to the H. pylori infection status and subsequent treatment, all patients were classified into H. pylori negative group, H. pylori eradication group and noneradication group. The relevant data were extracted and pooled effect size was assessed using a fixed effect model or a random effect model.

RESULTS

A total of 11 retrospective cohort studies and 3 randomized controlled trials were included in this meta-analysis. The results based on the cohort studies indicated that the risk of metachronous gastric cancer was significantly lower in H. pylori eradication group than in noneradication group (hazard ratios: 0.65, 95% confidence interval: 0.50-0.86, P=0.002; I=0%). The pooled result of 2 randomized controlled trials demonstrated that the patients receiving anti-H. pylori treatment had a lower risk of metachronous gastric cancer than those who did not receive H. pylori eradication treatment (hazard ratios: 0.43, 95% confidence interval: 0.26-0.70, P=0.001; I=0%). In addition, the occurrence of metachronous gastric cancer in H. pylori eradication group was not significantly different from that in H. pylori negative group.

CONCLUSIONS

Successful H. pylori eradication may be useful for the prevention of metachronous gastric cancer after curative endoscopic resection of early gastric cancer. Thus, anti-H. pylori treatment should be considered for those patients with H. pylori infection after curative endoscopic resection.

Effects of eradicating Helicobacter pylori on metachronous gastric cancer prevention: A systematic review and meta-analysis

BACKGROUND

Helicobacter pylori (H pylori) infection is closely associated with the incidence of gastric cancer. However, whether H pylori eradication prevents metachronous gastric cancer remains uncertain. The aim of our study is to assess how eradicating H pylori influences metachronous gastric cancer onset following treatment of early stage gastric cancer via endoscopic resective surgery.

PATIENTS AND METHODS

We performed a systematic review and meta-analysis by searching PubMed, Embase, Web of Science, and the Cochrane Library. Cohort studies and randomized controlled trials that compared individuals receiving H pylori eradication with individuals receiving placebo/nontreatment and evaluated the subsequent onset of metachronous gastric cancer as the main outcome were eligible for our study. Two authors reviewed articles and extracted data independently. Integrated results for all data were presented as risk ratio.

RESULTS

Thirteen studies containing 3863 patients were consistent with study inclusion criteria. Of the 2480 individuals in whom H pylori was successfully eradicated, 163 (6.57%) developed metachronous gastric cancer, as compared with 176 (12.73%) out of 1383 persistently infected individuals. The pooled risk ratio of metachronous gastric cancer for these studies was 0.46 (95% CI, 0.37-0.57, P < .001), providing support for the therapeutic elimination of H pylori. Subgroup analyses yielded similar results.

CONCLUSION

Eradicating H pylori via therapeutic treatment can effectively reduce rates of metachronous gastric cancer, and as such, it should be implemented in H pylori-infected individuals recently treated for early stage gastric cancers via endoscopic resection.

[Characteristics analysis of early gastric cancer under white light endoscopy]

OBJECTIVE

To investigate endoscopic features of early gastric cancer and clinical features of the patients, which may be helpful to provide reasonable suggestions for physicians to diagnose early gastric cancer during preliminary screening of white light gastroscopy.

METHODS

A total of 271 patients who received endoscopic submucosal dissection or surgical operation to confirm early gastric cancer in Peking University Third Hospital from Apr. 2009 to Jun. 2017 were included for the retrospective review. Clinical information was collected, including gender, age, symptoms, family history and physical examination. The endoscopic characteristics of lesions under white light endoscopy were analyzed, including endoscopic long diameter, location, texture, spontaneous bleeding, mucosal color and morphology. The pathologic long diameter, infiltration depth and differentiation degree of early gastric cancer were also summarized.

RESULTS

The study included 271 patients and 279 lesions. Among the 271 cases, 190 were male, 81 were female, average age was (63.7±12.4) years. There were 88 cases (32.5%) and 61 cases (22.5%) with the symptom of abdominal pain and discomfort respectively. The patients with family history of gastric cancer were 20 (7.4%). Abdominal physical examinations of the patients were mostly normal, accounting for 86.0% (233/271). Total detection rate of helicobacter pylori (HP) was 34.2% (79/231), with the highest rate 45.5% (10/22) in 2011 and the lowest rate 28.1% (9/32) in 2014. Among the 279 lesions, the mean endoscopic long diameter was (2.01±1.20) cm. The lesions were mainly single, accounting for 97.0% (263/271). There were 114 cases (40.9%), 62 cases (22.2%), 54 cases (19.4%) in the antrum, angular sulcus and cardia of stomach respectively. The lesions were mostly fragile, accounting for 45.5% (56/123). Most lesions had spontaneous bleeding, accounting for 52.3% (146/279). The mucosal color was mostly normal, accounting for 72.8% (203/279). The most common macroscopic morphology was IIa+IIc type (100 cases, 35.8%) and the lesions usually had mucous membrane damage like erosion and shallow ulcer (127 cases,45.5%). Among the 279 lesions, the mean pathologic long diameter was (2.05±1.48) cm. Intramucosal carcinoma accounted for 61.6% (172/279) and moderate differentiated gastric cancers accounted for 52.8% (131/248).

CONCLUSION

In order to improve diagnosis of early gastric cancer,superficial elevation and depression of flat lesions as well as mucous membrane damage under white light endoscopy should be taken notice.

Efficacy and safety of Helicobacter pylori eradication therapy immediately after endoscopic submucosal dissection

BACKGROUND AND AIMS

In the treatment of patients after endoscopic submucosal dissection (ESD), there is no consensus on the optimum time to start Helicobacter pylori eradication therapy or on whether eradication therapy improves ulcer healing rate after ESD. The aim of this study was to examine the effect of immediate eradication of H. pylori on ulcer healing after ESD in patients with early gastric neoplasms.

METHODS

A total of 330 patients who underwent ESD for early gastric neoplasms were enrolled. Patients were assigned to either H. pylori eradication group (Group A: H. pylori eradication + proton pump inhibitor 7 weeks) or non-eradication group (Group B: proton pump inhibitor 8 weeks). The primary end point was gastric ulcer healing rate (Group A vs Group B) determined on week 8 after ESD.

RESULTS

Patients in Group A failed to meet non-inferiority criteria for ulcer scarring rate after ESD compared with that in Group B (83.0% vs 86.5%, P for non-inferiority = 0.0599, 95% confidence interval: -11.7% to 4.7%). There were, however, neither large differences between the two groups in the ulcer scarring rate nor the safety profile.

CONCLUSIONS

This study failed to demonstrate the non-inferiority of immediate H. pylori eradication therapy after ESD to the non-eradication therapy in the healing rate of ESD-caused ulcers. However, because the failure is likely to attribute to small number of patients enrolled, immediate eradication therapy may be a treatment option for patients after ESD without adverse effects on eradication therapy in comparison with the standard therapy.

Occurrence of metachronous or synchronous lesions after endoscopic treatment of gastric epithelia dysplasia- impact of histologic features of background mucosa

AIMS

Endoscopic resection is a safe and effective method to treat gastric epithelia dysplasia (GED). However, the development of metachronous and synchronous lesions after treatment has become a major concern. In this study, we investigated clinicopathologic features of 105 GED lesions from endoscopic resections between January 2008 and December 2009. Our goal is to find histologic factors that predict synchronous and metachronous lesions after ESD treatment. We assessed the degree of intestinal metaplasia (IM) and atrophy, type of IM, presence of gastritis cystica profunda, and crypt dysplasia in the adjacent mucosa.

METHODS AND RESULTS

We divided 105 GED lesions into three groups: a single group without metachronous or synchronous GED or adenocarcinoma (n=35); a multiple synchronous group (n=30, group with synchronous occurrence of GED or adenocarcinoma after treatment); and a multiple metachronous group (n=40, group with metachronous occurrence of GED or adenocarcinoma after treatment). The multiple metachronous and synchronous groups showed larger sizes (p=0.003) and higher grades (p=0.021) as compared with the single group. Furthermore, marked IM and atrophy in adjacent mucosa were more easily seen in the multiple metachronous and synchronous groups as compared with the single group (p<0.0001). Interestingly, the presence of incomplete type of IM (p=0.025) and crypt dysplasia (p<0.0001) in background mucosa was associated with occurrence of metachronous and synchronous lesions following endoscopic resection of GED.

CONCLUSIONS

The histological features of background mucosa, such as intestinal metaplasia, atrophy, and crypt dysplasia could be used as indicators of occurrence of metachronous and synchronous lesions after endoscopic treatment of GED.

Risk factors for metachronous gastric carcinoma development after endoscopic resection of gastric dysplasia: Retrospective, single-center study

AIM

To determine the gastric adenocarcinoma (GAC) occurrence rate and related factors, we evaluated the follow-up results of patients confirmed to have gastric dysplasia after endoscopic resection (ER).

METHODS

We retrospectively analyzed the medical records, endoscopic examination records, endoscopic procedure records, and histological records of 667 cases from 641 patients who were followed-up for at least 12 mo, from among 1273 patients who were conformed to have gastric dysplasia after Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) of gastric mucosal lesions between January 2007 and August 2013 at the Chungnam National University Hospital.

RESULTS

The mean follow-up period was 33.8 mo, and the median follow-up period was 29 mo (range: 12-87). During the follow-up period, the occurrence of metachronous GAC was 4.0% (27/667). The mean and median interval periods between the occurrence of metachronous GAC and endoscopic treatment of gastric dysplasia were 36.3 and 34 mo, respectively (range: 16-71). The factors related to metachronous GAC occurrence after ER for gastric dysplasia were male sex (5.3% vs 1.0%), open-type atrophic gastritis (9.5% vs 3.4%), intestinal metaplasia (6.8% vs 2.4%), and high-grade dysplasia (HGD; 8.4% vs 3.2%). Among them, male sex [OR: 5.05 (1.18-21.68), P = 0.029], intestinal metaplasia [OR: 2.78 (1.24-6.23), P = 0.013], and HGD [OR: 2.70 (1.16-6.26), P = 0.021] were independent related factors in multivariate analysis. Furthermore, 24 of 27 GAC cases (88.9%) occurred at sites other than the previous resection sites, and 3 (11.1%) occurred at the same site as the previous resection site.

CONCLUSION

Male sex, intestinal metaplasia, and HGD were significantly related to the occurrence of metachronous GAC after ER of gastric dysplasia, and most GACs occurred at sites other than the previous resection sites.

Screening endoscopy finds high prevalence of Helicobacter pylori and intestinal metaplasia in Korean American with limited access to health care

BACKGROUND

Gastric cancer (GC) is the leading cause of cancer death among Korean Americans. Prevention and early detection is improved by screening.

METHODS

Between September 2013 and March 2015, ethnic Koreans age 40 or older without history or symptoms of GC and without upper endoscopy (UE) during previous 3 years were enrolled. Participants were offered screening with GC risk assessment followed by UE with biopsies.

RESULTS

Risk assessment was provided to 146 participants (age 55.6 ± 8.3 years; 52.1% female; 92.5% uninsured), of whom 99 (67.8%) returned for UE. Undergoing UE was independently associated with family history of GC (OR 12.33, 95% CI:1.52-100.17), being a former smoker (6.68,1.42-31.32), and Hp-negative status (0.25,0.11-0.57). Among UE recipients, half (49.5%) had intestinal metaplasia (IM) only (n = 24), Hp only (n = 12), or both (n = 13). No case of GC was found. Adjusted for age, IM was independently associated with male sex (2.89,1.12-7.42), current Hp (2.90,0.99-8.51), unmarried status (single or divorced) (4.23,1.23-14.56).

CONCLUSIONS

High prevalence of risk factors associated with gastric carcinogenesis including Hp infection and IM exists in Korean Americans who underwent upper endoscopic screening. Acceptance of GC screening is informed by personal risk factors. These findings support the need to improve access to screening UE among KAs.

Risk Factors for Metachronous Recurrence after Endoscopic Submucosal Dissection of Early Gastric Cancer

Although endoscopic submucosal dissection (ESD) is widely accepted as a curative treatment method for early gastric cancer (EGC) worldwide, metachronous recurrence often occurs after ESD for EGC. However, there are insufficient data about the role of Helicobacter pylori (H. pylori) infection and other risk factors for recurrence. We aimed to compare the metachronous lesion in the H. pylori persistent group and the eradicated group, and to identify risk factors for metachronous lesion. We retrospectively analyzed 782 patients who underwent ESD between January 2008 and December 2013. We excluded patients with dysplasia or patients who were not tested for H. pylori infection. One hundred eighty-five patients were enrolled. We studied risk factors for recurrence, and used survival analysis to test. There were 24 patients with metachronous recurrence after ESD for EGC among the group. The incidence of metachronous gastric lesions after ESD for EGC developed more in the over 70-year-old group (P = 0.025) and more in the H. pylori persistent group (P = 0.008). In conclusion, H. pylori infection and old age are independent risk factors for metachronous gastric lesions after ESD in EGC.

Gastric Cancer: How Can We Reduce the Incidence of this Disease?

Gastric cancer remains a prevalent disease worldwide with a poor prognosis. Helicobacter pylori plays a major role in gastric carcinogenesis. H. pylori colonization leads to chronic gastritis, which predisposes to atrophic gastritis, intestinal metaplasia, dysplasia, and eventually gastric cancer. Screening, treatment, and prevention of H. pylori colonization can reduce the incidence of gastric cancer. Other interventions that may yield a similar effect, although of smaller magnitude, include promotion of a healthy lifestyle including dietary measures, non-smoking, low alcohol intake, and sufficient physical activity. This chapter reviews interventions that can lead to a decline in gastric cancer incidence in high and low incidence countries.

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.