Endoscopic and histological risk stratification for gastric cancer using gastric intestinal metaplasia.

BACKGROUND AND AIM: Intestinal metaplasia (IM) of the gastric mucosa is strongly associated with the risk of gastric cancer (GC). This study was performed to investigate the usefulness of endoscopic and histological risk stratification for GC using IM. METHODS: This was a post-hoc analysis of a multicenter prospective study involving 10 Japanese facilities (UMINCTR000027023). The ridge/tubulovillous pattern, light blue crest (LBC), white opaque substance (WOS), endoscopic grading of gastric IM (EGGIM) score using non-magnifying image-enhanced endoscopy, and operative link on gastric IM assessment (OLGIM) were evaluated for their associations with GC risk in all patients. RESULTS: In total, 380 patients (115 with GC and 265 without GC) were analyzed. The presence of an LBC (limited to antrum: odds ratio [OR] 2.4 [95% confidence interval 1.1-5.0], extended to corpus: OR 3.6 [2.1-6.3]), the presence of WOS (limited to antrum: OR 3.0 [1.7-5.3], extended to corpus: OR 4.2 [2.1-8.2]), and histological IM (limited to antrum: OR 3.2 [1.4-7.4], extended to corpus: OR 8.5 [4.5-16.0]) were significantly associated with GC risk. Additionally, the EGGIM score (5-8 points: OR 8.8 [4.4-16.0]) and OLGIM (stage III/IV: OR 12.5 [6.1-25.8]) were useful for stratification of GC risk. The area under the receiver operating characteristic curve value for GC risk was 0.740 for OLGIM and 0.706 for EGGIM. CONCLUSIONS: The LBC, WOS, EGGIM, and OLGIM were strongly associated with GC risk in Japanese patients. This finding can be useful for GC risk assessment in daily clinical practice.

A deep learning model based on magnifying endoscopy with narrow-band imaging to evaluate intestinal metaplasia grading and OLGIM staging: A multicenter study.

BACKGROUND AND PURPOSE: Patients with stage III or IV of operative link for gastric intestinal metaplasia assessment (OLGIM) are at a higher risk of gastric cancer (GC). We aimed to construct a deep learning (DL) model based on magnifying endoscopy with narrow-band imaging (ME-NBI) to evaluate OLGIM staging. METHODS: This study included 4473 ME-NBI images obtained from 803 patients at three endoscopy centres. The endoscopic expert marked intestinal metaplasia (IM) regions on endoscopic images of the target biopsy sites. Faster Region-Convolutional Neural Network model was used to grade IM lesions and predict OLGIM staging. RESULTS: The diagnostic performance of the model for IM grading in internal and external validation sets, as measured by the area under the curve (AUC), was 0.872 and 0.803, respectively. The accuracy of this model in predicting the high-risk stage of OLGIM was 84.0%, which was not statistically different from that of three junior (71.3%, p = 0.148) and three senior endoscopists (75.3%, p = 0.317) specially trained in endoscopic images corresponding to pathological IM grade, but higher than that of three untrained junior endoscopists (64.0%, p = 0.023). CONCLUSION: This DL model can assist endoscopists in predicting OLGIM staging using ME-NBI without biopsy, thereby facilitating screening high-risk patients for GC.

Carbon footprint and cost reduction by endoscopic grading of gastric intestinal metaplasia using narrow-band imaging.

BACKGROUND AND AIM: Gastric intestinal metaplasia (GIM) is a high-risk factor for the development of gastric cancer. Narrow-band imaging (NBI) enables endoscopic grading of GIM (EGGIM). In the era of climate change, gastrointestinal endoscopists are expected to reduce greenhouse gas emissions and medical waste. Based on the diagnostic performance of NBI endoscopy, this study measured the environmental impact and reduced cost of implementing EGGIM during gastroscopy. METHODS: Using NBI endoscopy in 242 patients, EGGIM classification and operative link on GIM (OLGIM) staging were prospectively performed in five different areas (lesser and greater curvatures of the corpus and antrum, and the incisura angularis). We estimated the environmental impact and cost reduction of the biopsy procedures and pathological processing if EGGIM were used instead of OLGIM. RESULTS: The diagnostic accuracy of NBI endoscopy for GIM was 93.0-97.1% depending on the gastric area. When a high EGGIM score ≥ 5 was the cut-off value for predicting OLGIM stages III-IV, the area under the curve was 0.862, sensitivity was 81.9%, and specificity was 90.4%. The reduction in the carbon footprint by EGGIM was -0.4059 kg carbon dioxide equivalents per patient, equivalent to 1 mile driven by a gasoline-powered car. The cost savings were calculated to be $47.36 per patient. CONCLUSIONS: EGGIM is a reliable method for identifying high-risk gastric cancer patients, thereby reducing the carbon footprint and medical costs in endoscopy practice.

A spatially mapped gene expression signature for intestinal stem-like cells identifies high-risk precursors of gastric cancer.

Objective: Gastric intestinal metaplasia (GIM) is a precancerous lesion that increases gastric cancer (GC) risk. The Operative Link on GIM (OLGIM) is a combined clinical-histopathologic system to risk-stratify patients with GIM. The identification of molecular biomarkers that are indicators for advanced OLGIM lesions may improve cancer prevention efforts. Methods: This study was based on clinical and genomic data from four cohorts: 1) GAPS, a GIM cohort with detailed OLGIM severity scoring (N=303 samples); 2) the Cancer Genome Atlas (N=198); 3) a collation of in-house and publicly available scRNA-seq data (N=40), and 4) a spatial validation cohort (N=5) consisting of annotated histology slides of patients with either GC or advanced GIM. We used a multi-omics pipeline to identify, validate and sequentially parse a highly-refined signature of 26 genes which characterize high-risk GIM. Results: Using standard RNA-seq, we analyzed two separate, non-overlapping discovery (N=88) and validation (N=215) sets of GIM. In the discovery phase, we identified 105 upregulated genes specific for high-risk GIM (defined as OLGIM III-IV), of which 100 genes were independently confirmed in the validation set. Spatial transcriptomic profiling revealed 36 of these 100 genes to be expressed in metaplastic foci in GIM. Comparison with bulk GC sequencing data revealed 26 of these genes to be expressed in intestinal-type GC. Single-cell profiling resolved the 26-gene signature to both mature intestinal lineages (goblet cells, enterocytes) and immature intestinal lineages (stem-like cells). A subset of these genes was further validated using single-molecule multiplex fluorescence in situ hybridization. We found certain genes (TFF3 and ANPEP) to mark differentiated intestinal lineages, whereas others (OLFM4 and CPS1) localized to immature cells in the isthmic/crypt region of metaplastic glands, consistent with the findings from scRNAseq analysis. Conclusions: using an integrated multi-omics approach, we identified a novel 26-gene expression signature for high-OLGIM precursors at increased risk for GC. We found this signature localizes to aberrant intestinal stem-like cells within the metaplastic microenvironment. These findings hold important translational significance for future prevention and early detection efforts.

Histopathological Evaluation of Gastric Mucosal Atrophy for Predicting Gastric Cancer Risk: Problems and Solutions.

Patients suffering from chronic gastritis and developing gastric mucosa atrophy are at increased risk of the development of gastric cancer. The diagnosis of chronic atrophic gastritis (CAG) is a complex procedure involving a detailed history taking, a thorough physical examination and the use of laboratory and instrumental diagnostic methods among which the endoscopy of the upper digestive tract is the cornerstone because it allows the assessment of the topography of gastritis and identification of erosions and areas of intestinal metaplasia with the use of NBI endoscopy. However, the diagnosis of CAG requires morphological examination of the gastric mucosa. So, in addition to assessing macroscopic changes in the gastric mucosa, it is necessary to take biopsy specimens in accordance with the protocols for their morphological and immunohistochemical examination. In the absence of specific diagnostic stigmas of CAG, close cooperation between a clinician, endoscopist and pathologist is necessary. The article presents systematized data on the histopathological assessment of the gastric mucosa atrophy to predict the risk of gastric cancer.

Endoscopic grading of gastric atrophy and histological gastritis staging on risk assessment for early gastric cancer: A case-control study.

OBJECTIVES: To assess the predictive value of endoscopic grading of gastric atrophy using Kimura-Takemoto classification, histological grading systems of operative link on gastritis assessment (OLGA) and operative link on gastric intestinal metaplasia (OLGIM) on risk stratification for early gastric cancer (EGC) and other potential risk factors of EGC. METHODS: A single-center, case-control study was retrospectively conducted including 68 patients with EGC treated with endoscopic submucosal dissection and 68 age- and sex-matched control subjects. Kimura-Takemoto classification, OLGA and OLGIM systems, and other potential risk factors were evaluated between the two groups. RESULTS: Of the 68 EGC lesions, 22 (32.4%) were well differentiated, 38 (55.9%) were moderately differentiated, and 8 (11.8%) were poorly differentiated, respectively. Multivariate analysis revealed O-type Kimura-Takemoto classification (adjusted odds ratio [AOR] 3.282, 95% confidence interval [CI] 1.106-9.744, P = 0.032) and OLGIM stage III/IV (AOR 17.939, 95% CI 1.874-171.722, P = 0.012) were significantly related to a higher risk of EGC. Especially, O-type Kimura-Takemoto classification within 6-12 months before EGC diagnosis (AOR 4.780, 95% CI 1.650-13.845, P = 0.004) was independently associated with EGC risk. Areas under the receiver operating characteristic curve of the three systems for EGC were comparable. CONCLUSIONS: Endoscopic Kimura-Takemoto classification and histological OLGIM stage III/IV are independent risk factors for EGC, which may reduce the need for biopsies in risk stratification of EGC. Further multicenter prospective studies of large sizes are needed.

Role of pre-existing incomplete intestinal metaplasia in gastric adenocarcinoma: A retrospective case series analysis.

BACKGROUND: Risk stratification for patients with gastric precancerous lesions for endoscopic surveillance remains controversial. AIM: To analysis of patients having developed gastric adenocarcinoma during the period of follow-up. METHODS: We conducted a retrospective study on patients having undergone upper endoscopy prior to the development of gastric adenocarcinoma. The presence and stage of precancerous lesions as well as subtype of intestinal metaplasia at the baseline endoscopy got evaluated. Literature mini-review was performed. RESULTS: Out of 1681 subjects in the Biobank, gastric adenocarcinoma was detected in five cases in whom previous endoscopy data with biopsies either from the corpus or antral part were available. All of the patients had incomplete intestinal metaplasia during the baseline endoscopy; all three subjects in whom intestinal metaplasia subtyping was performed according to Filipe et al, had Type III intestinal metaplasia. Two of the five cases had low Operative Link on Gastritis Assessment (OLGA) and Operative Link on Gastritis Intestinal Metaplasia Assessment (OLGIM) stages (I-II) at the baseline. CONCLUSION: The presence of incomplete intestinal metaplasia, in particular, that of Type III is a better predictor for gastric adenocarcinoma development than OLGA/OLGIM staging system. Subtyping of intestinal metaplasia have an important role in the risk stratification for surveillance decisions.

The OLGA-OLGIM staging and the interobserver agreement for gastritis and preneoplastic lesion screening: a cross-sectional study.

Stomach cancer (SC) incidence and mortality are relevant public health issues worldwide. In Colombia, screening for preneoplastic lesions (PNL) and the presence of H. pylori is not routinely performed. Therefore, the aim of this study was to evaluate OLGA-OLGIM staging and the interobserver agreement in gastritis and preneoplastic lesions in patients with gastroduodenal symptoms from Colombia. A cross-sectional study was conducted in 272 patients with gastroduodenal symptoms. Gastric biopsies were taken following the Updated Sydney System with the OLGA-OLGIM classification, and the results were evaluated by two pathologists. Chronic gastritis and PNL were reported in 76% and 24% of the patients, respectively. Furthermore, 25% of the patients with PNL displayed gastric atrophy (GA) and 75% intestinal metaplasia (IM). Agreement in the histopathological reading for IM was good, whereas for OLGA was variable, and for the H. pylori quantity was poor. OLGA-OLGIM stages 0-II were the most frequent (96%), while stage III (4%) and SC (4%) were the least frequent. Age and coffee consumption were associated with a higher prevalence of PNL. This work determined that 4% of the population is at high risk of developing SC and would benefit from follow-up studies. Reinforcement of training programs to improve the agreement in histopathology readings is required.

High-risk individuals for gastric cancer would be missed for surveillance without subtyping of intestinal metaplasia.

The use of Operative Link on Gastritis Assessment (OLGA) and Operative Link on Gastritis Assessment based on Intestinal Metaplasia (OLGIM) staging system is recommended for identifying subjects at risk for developing gastric cancer; usually high-risk lesions are considered only as stages III and IV. Accumulating evidence suggests that incomplete intestinal metaplasia (IM) is important in the development of gastric cancer. Our aim has been to identify the prevalence of incomplete IM in patients with low-risk OLGA/OLGIM stages among a high-risk general population. Healthy adult volunteers aged 40-64 years were invited to undergo upper endoscopy within a regional GISTAR pilot study in Kazakhstan (n = 166). Gastric lesions were staged according to OLGA/OLGIM staging system. High iron diamine-alcian blue (HID-AB) was used for subtyping IM. IM prevalence overall was 45.8%. Incomplete IM was present in 52.6% (type II in 30.3% and type III in 22.3%), whereas complete IM was found in 47.4% individuals. The prevalence of OLGIM I and II stage were 39.8 and 4.8%, respectively, whereas OLGIM III was observed in 1.2%. The prevalence of incomplete IM in patients stratified to OLGIM I was 54.5% (type II in 31.8% and type III in 22.7%). High prevalence of incomplete IM was detected not only in subjects with extensive IM, but in those stratified as at the OLGIM I stage. Without IM subtyping, patients with high risk of gastric cancer development would be missed for surveillance.

Correlations of OLGIM Stage With Gastric Mucosal Serology and Helicobacter pylori Infection in Patients With Chronic Gastritis / 胃肠病学

Background: The OLGIM (operative link on gastric intestinal metaplasia assessment) staging system is important for the prediction of gastric cancer risk in patients with chronic gastritis. However, there are few studies focusing on the correlations of OLGIM stage with gastric mucosal serology and Helicobacter pylori ( Hp) infection. Aims: To investigate the correlations between OLGIM stage and serum pepsinogens (PGs) , gastrin-17 (G-17) , and Hp infection in patients with chronic gastritis. Methods: Individuals undergoing health examination and upper GI endoscopy in the Affiliated Provincial Hospital of Anhui Medical University from May 2015 to December 2017 were enrolled consecutively in this retrospective study. Information on demography, gastric mucosal serology, endoscopy, biopsy pathology and Hp infection was collected. The severity, topography and extension of intestinal metaplasia were assessed by OLGIM staging system. The clinical features of chronic gastritis patients with different OLGIM stages were compared; the risk factors for OLGIM stage HI-IV and the predictive performance of PG I to PG II ratio (PGR) for OLGIM stage HI -TV were analyzed. Results: A total of 1 112 health examination subjects were included in this study. The Hp infection rate was 49. 1%. The serum levels of PG I , PGII , and G-17 were higher, whereas the PGR was lower in Hp-positive subjects than those in Hp-negative ones (all P <0. 05). With the increasing of OLGIM stage, the serum levels of PG II and G-17 were increased, and the PGR was decreased ( all P < 0. 05 ). Meanwhile, the Hp infection rate and the proportion of family history of GI tumors were increased in patients with higher OLGIM stages (all P < 0. 05). In multivariate Logistic regression analysis, age was identified as the independent risk factor for OLGIM stage IH -IV ( OR = 1. 032 , 95% CI: 1. 002-1. 063 , P = 0. 035 ) , while higher PGR was a protective factor ( OR = 0. 837, 95% CI: 0. 754-0. 928 , P = 0. 001) . The optimal cut-off value of PGR for predicting OLGIM stage HI -IV was 8. 065 , with the sensitivity and specificity of 73. 8% and 69. 4% , respectively. Conclusions: Older age and lower PGR are independent risk factors for OLGIM stage HI-IV- PGR can be used as an indicator for screening OLGIM stage HI -IV individuals.

Gastric intestinal metaplasia assessment between linked color imaging based on endoscopy and pathology.

OBJECTIVE: Cumulative evidence suggests that linked color imaging (LCI) can be used to identify gastric intestinal metaplasia (GIM). We aimed to develop endoscopic grading for GIM (EGGIM) with LCI. METHODS: Two hundred and seventy-seven patients who underwent high-resolution white-light gastroscopy followed by LCI for EGGIM estimation were included. LCI was performed for the entire mucosa, and images of five areas each were recorded from the lesser and greater curvatures of the antrum and corpus, and for the incisura. For each area, scores of 0 (no GIM), 1 (focal GIM, ≤30% of the area), and 2 (extensive GIM, >30% of the area) were attributed for 10 points. If GIM was suspected based on endoscopy findings, targeted biopsies were performed; if GIM was not evident, random biopsies were performed according to the Sydney system to estimate the operative link on GIM (OLGIM). RESULTS: GIM was staged as OLGIM 0, I, II, III, and IV in 136, 70, 37, 28, and 6 patients, respectively. For OLGIM III/IV diagnosis, the area under the receiver operating curve was 0.949 (95% CI 0.916-0.972). EGGIM of 4, with sensitivity and specificity of 94.12% (95% CI 80.3%-99.3%) and 86.42% (95% CI 81.5%-90.5%), respectively, was determined the best cut-off value for identifying OLGIM III/IV patients. CONCLUSIONS: Our findings demonstrated the ability of EGGIM for diagnosing the extent of intestinal metaplasia and showed that EGGIM is related to OLGIM staging. EGGIM of 4 was the best cut-off value for identifying OLGIM III/IV patients.

Pathological Changes and Influencing Factors of Lamb's Tripe Extract and Vitamin B12 Capsule in Treatment of Chronic Atrophic Gastritis With Intestinal Metaplasia / 胃肠病学

Background: Chronic atrophic gastritis with intestinal metaplasia is closely related to the development of gastric cancer. Studies have showed that Lamb's Tripe Extract and Vitamin B12 capsule (LTEVB12) may reverse atrophy and intestinal metaplasia by promoting gastric mucosal gland proliferation, inhibiting gland apoptosis and inhibiting oxidative stress response in rats.Aims: To explore the pathological changes and influencing factors of LTEVB12 in treatment of chronic atrophic gastritis with intestinal metaplasia. Methods: A total of 173 patients with chronic atrophic gastritis with intestinal metathesis from June 2018 to June 2019 at Xijing Hospital were enrolled. All patients were treated with LTEVB12 (2 capsules tid). Gastroscopy and gastric mucosal biopsies were performed at 6 months and 12 months after treatment. The therapeutic effect of the drug was evaluated according to the changes of OLGA staging and OLGIM staging before and after treatment. The influencing factors were analyzed by univariate analysis and multivariate analysis. Results: After 6 months of treatment, the effective rates on OLGA staging and OLGIM staging were 49.7% and 32.9%, respectively. After 12 months of treatment, the effective rates on OLGA staging and OLGIM staging were 56.4% and 41.8%, respectively. The total effective rates of 6 months and 12 months treatment were 64.7% and 70.9%, respectively. Univariate analysis showed that education, fried food, statins and antibiotics were correlated with OLGA staging, while age was correlated with OLGIM staging. Multivariate analysis showed that education, fried food and antibiotics were independent factors of OLGA staging. Conclusions: LTEVB12 can significantly reduce the OLGA staging and OLGIM staging in patients with chronic atrophic gastritis with intestinal metaplasia, which suggests that LTEVB12 has the potential to reduce risk of gastric cancer and has the prospects of clinical application in prevention of gastric cancer.

Reliability and accuracy of blue light imaging for staging of intestinal metaplasia in the stomach.

Background and aims: An endoscopic grading system (EGGIM) using narrow-band-imaging (NBI) has shown to accurately identify patients with extensive gastric intestinal metaplasia (GIM). However, description with alternative systems such as blue-light-imaging (BLI) is limited. The aim of this study is to determine the reliability and accuracy of BLI-bright regarding diagnosis and staging of GIM.Methods: Reliability of WLE (white-light-endoscopy) and BLI among 6 observers was assessed using a standard classification based on endoscopic images. Afterward, 37 patients were submitted to gastroscopy using FujifilmEG-760Z and endoscopists had to determine EGGIM score using BLI-bright and to perform gastric biopsies for operative-link-of-gastric-intestinal-metaplasia (OLGIM) calculation. BLI-bright accuracy was determined by comparing results with prior EGGIM scores with NBI and current OLGIM.Results: Compared with WLE, the interobserver reliability between observers was substantially better with BLI (Weighted Kappa: 0.8 vs 0.41). There was an 84% agreement between BLI and NBI assessing EGGIM intervals (EGGIM 0-4vs5-10). The area under the ROC curve was 0.90 (95%CI: 0.79-1.0) using the cut-off of EGGIM > 4 to determine advanced GIM, with a sensitivity of 100% (95%CI: 88-100%).Discussion: BLI-bright is reliable for the diagnosis of gastric intestinal metaplasia and agrees significantly with NBI evaluation. Preliminary data suggests high sensitivity for identifying patients with increased risk of gastric cancer.

A single vial is enough in the absence of endoscopic suspected intestinal metaplasia - less is more!

Background: For the correct staging of chronic atrophic gastritis (AG) and gastric intestinal metaplasia (GIM) at least 4 biopsies are recommended: 2 from the antrum/incisura and 2 from the body sent in two different vials. As virtual chromoendoscopy with narrow-band-imaging (NBI) is valid both in the diagnosis and staging of GIM, it is reasonable to question the need to separate biopsy samples in all procedures. Aims: To evaluate if biopsy samples can be placed in the same vial without implications in the diagnosis and follow-up of the patient, if during gastroscopy no typical endoscopic pattern of GIM with NBI is observed. Methods: Multicentre prospective study of a consecutive sample of patients (n = 183) submitted to gastroscopy using NBI with no superficial neoplastic lesions and no suggestive areas of GIM. Biopsies of both antrum/incisure and body were performed in all patients and samples were placed in the same vial for histologic assessment [according to OLGA (operative link for gastritis assessment) and OLGIM (operative link for gastric intestinal metaplasia)], blinded to endoscopic features. Results: In all patients, OLGA and OLGIM calculation was possible as the pathologists could distinguish biopsy samples from antrum/incisure from those of gastric body. The negative predictive value was 100% for advanced stages of GIM or AG as 179 (98%) patients presented OLGIM 0 and only 4 (2%) presented OLGIM I. Regarding AG, 150 (82%) presented OLGA 0, 23 (13%) OLGA I and 10 (6%) OLGA II. Conclusion: In the absence of a typical endoscopic pattern of GIM using NBI, it is effective to place biopsies' specimens in the same vial (for Helicobacter pylori diagnosis) or even to abstain from biopsies as no single patient with significant changes seems to be missed. This change in clinical practice can have a significant impact on endoscopy costs.

The changing face of chronic autoimmune atrophic gastritis: an updated comprehensive perspective.

Chronic autoimmune atrophic gastritis (CAAG) is an organ-specific autoimmune disease, which affects the corpus-fundus gastric mucosa. Although it has been described for several years, the real pathophysiological mechanisms, the natural history and the possible neoplastic complications are not completely known. Atrophy of the gastric mucosa is the endpoint of the chronic processes, with the loss of glandular cells and their replacement by intestinal-type epithelium, pyloric-type glands, and fibrous tissue. As a consequence, hydrochloric acid, pepsin and intrinsic-factor is impaired resulting in pernicious anemia. The exact causal agent is not yet known, but both genetic and environmental factors seem to play a decisive role. Moreover, the clinical onset may assume different characteristics; differently from what previously observed, recent evidence has reported the onset of CAAG at a younger age, frequently with iron deficiency anemia or upper gastro-intestinal symptoms. The diagnosis of CAAG might be challenging and usually requires the combination of clinical, serological and histopathologic data; moreover, CAAG patients are often misdiagnosed as refractory to HP eradication therapy, probably because achlorhydria might allow urease-positive bacteria other than H pylori to colonize the stomach, causing positive 13C-urea breath test results. However, biopsy is the most reliable method to evaluate the presence of metaplastic atrophic gastritis. In order to assess the severity of gastric atrophy and intestinal metaplasia, OLGA and OLGIM staging systems have been proposed and seem to correlate with the risk of developing gastric adenocarcinoma. Indeed, CAAG represents a pre-neoplastic condition, as patients with CAAG are very likely to develop either type-1 gastric neuroendocrine tumors and gastric adenocarcinomas, as well as several other neoplastic diseases. To date, the need, the intervals and cost-effectiveness of endoscopic/histological surveillance for patients with CAAG/pernicious anemia are yet to be established.

Surveillance of premalignant gastric lesions: a multicentre prospective cohort study from low incidence regions.

OBJECTIVE: International guidelines recommend endoscopic surveillance of premalignant gastric lesions. However, the diagnostic yield and preventive effect require further study. We therefore aimed to assess the incidence of neoplastic progression and to assess the ability of various tests to identify patients most at risk for progression. DESIGN: Patients from the Netherlands and Norway with a previous diagnosis of atrophic gastritis (AG), intestinal metaplasia (IM) or dysplasia were offered endoscopic surveillance. All histological specimens were assessed according to the updated Sydney classification and the operative link on gastric intestinal metaplasia (OLGIM) system. In addition, we measured serum pepsinogens (PG) and gastrin-17. RESULTS: 279 (mean age 57.9 years, SD 11.4, male/female 137/142) patients were included and underwent at least one surveillance endoscopy during follow-up. The mean follow-up time was 57 months (SD 36). Four subjects (1.4%) were diagnosed with high-grade adenoma/dysplasia or invasive neoplasia (ie, gastric cancer) during follow-up. Two of these patients were successfully treated with endoscopic submucosal dissection, while the other two underwent a total gastrectomy. Compared with patients with extended AG/IM (PGI/II≤3 and/or OGLIM stage III-IV), patients with limited AG/IM (PG I/II>3 and OLGIM stage 0-II) did not develop high-grade adenoma/dysplasia or invasive neoplasia during follow-up (p=0.02). CONCLUSION: In a low gastric cancer incidence area, a surveillance programme can detect gastric cancer at an early curable stage with an overall risk of neoplastic progression of 0.3% per year. Use of serological markers in endoscopic surveillance programmes may improve risk stratification.

Dynamics of Helicobacter pylori infection as a determinant of progression of gastric precancerous lesions: 16-year follow-up of an eradication trial.

OBJECTIVE: To evaluate the long-term effect of cumulative time exposed to Helicobacter pylori infection on the progression of gastric lesions. DESIGN: 795 adults with precancerous gastric lesions were randomised to receive anti-H. pylori treatment at baseline. Gastric biopsies were obtained at baseline and at 3, 6, 12 and 16 years. A total of 456 individuals attended the 16-year visit. Cumulative time of H. pylori exposure was calculated as the number of years infected during follow-up. Multivariable logistic regression models were used to estimate the risk of progression to a more advanced diagnosis (versus no change/regression) as well as gastric cancer risk by intestinal metaplasia (IM) subtype. For a more detailed analysis of progression, we also used a histopathology score assessing both severity and extension of the gastric lesions (range 1-6). The score difference between baseline and 16 years was modelled by generalised linear models. RESULTS: Individuals who were continuously infected with H. pylori for 16 years had a higher probability of progression to a more advanced diagnosis than those who cleared the infection and remained negative after baseline (p=0.001). Incomplete-type IM was associated with higher risk of progression to cancer than complete-type (OR, 11.3; 95% CI 1.4 to 91.4). The average histopathology score increased by 0.20 units/year (95% CI 0.12 to 0.28) among individuals continuously infected with H. pylori. The effect of cumulative time of infection on progression in the histopathology score was significantly higher for individuals with atrophy (without IM) than for individuals with IM (p<0.001). CONCLUSIONS: Long-term exposure to H. pylori infection was associated with progression of precancerous lesions. Individuals infected with H. pylori with these lesions may benefit from eradication, particularly those with atrophic gastritis without IM. Incomplete-type IM may be a useful marker for the identification of individuals at higher risk for cancer.

Comparison of the accuracy of staging in the combination of different endoscopic biopsy sites, operative link for gastritis assessment and operative link for gastric intestinal metaplasia assessment / 中华消化杂志

Objective To analyze the accuracy of staging among the combination of endoscopic biopsy sites,operative link for gastritis assessment (OLGA) and operative link for gastric intestinal metaplasia assessment (OLGIM) with five different biopsy sites.Methods From January 2014 to September 2015,patients with functional dyspepsia and undergoing gastroendoscopy examination were enrolled.According to update Sydney system,a total of five biopsy pieces were obtained from lesser curvature of gastric body,larger curvature of gastric body,gastric angle,larger curvature of antrum and lesser curvature of antrum.The degrees of atrophy and intestinal metaplasia were determined and staged according to OLGA and OLGIM.Kappa test and chi-square test were performed for the statistical analysis.Results A total of 268 patients were enrolled.The incidences of atrophy and intestinal metaplasia in different sites were as follow:30.4％ (113/372) and 31.0％ (111/358) in lesser curvature of antrum;26.1％(97/372) and 25.1％(90/358) in gastric angle;20.2％(75/372) and 15.4％(56/358) in larger curvature of antrum;14.8％(55/372) and 15.4％(55/358) in lesser curvature of gastric body;8.6％(32/372) and 8.1％(29/358) in larger curvature of gastric body.The incidences of atrophy and intestinal metaplasia of lesser curvature of antrum were significantly higher than those of larger curvature of gastric body,lesser curvature of gastric body and larger curvature of antrum (x2 =45.248,48.029,20.024,18.892,7.681 and 7.848;all P＜＜0.05).The incidences of atrophy and intestinal metaplasia of gastric angle were significantly higher than those of lesser curvature and larger curvature of gastric body(x2 =32.752,31.269,11.605 and 8.448;all P＜0.05).The incidences of atrophy and intestinal metaplasia of the lesser curvature of gastric body and larger curvature of antrum were higher than those of larger curvature of gastric body,and the differences were statistically significant (x2 =6.080,8.048,17.280,18.980,all P＜0.05).The incidences of mild atrophy and intestinal metaplasia of the lesser curvature of antrum were 20.2 ％ (75/ 372) and 21.2％ (76/358),respectively,which were higher than those of larger curvature of antrum (12.9％,48/372 and 12.8％,46/358),and the differences were statistically significant (x2 =5.927 and 7.377,both P＜0.05).The incidence of severe atrophy of lesser curvature of antrum was 2.4％ (9/372),respectively,which was higher than that of larger curvature of antrum (0.8％,3/372),and the difference was statistically significant (x2 =3.000,P =0.015).The incidences of mild atrophy and intestinal metaplasia of the lesser curvature of gastric body were 10.5％ (39/372) and 11.2％ (40/358),respectively,which were higher than those of larger curvature of gastric body (5.4 ％,20/372 and 5.9 ％,21/358),and the differences were statistically significant (x2 =6.119 and 5.918,both P＜0.05).The consistency of staging by three biopsy sites (lesser curvature of gastric body,gastric angle and lesser curvature of antrum) and five biopsy sites with OLGA and OLGIM was 94.0 ％ (95 ％ confidence interval (CI) =91.2％ to 96.9％,Kappa value=0.912,P＜0.01) and 92.9％ (95％CI:89.8％ to 96.0％,Kappa value=0.893,P＜0.01).Conclusion Three biopsy sites (lesser curvature of gastric body,gastric angle and lesser curvature of antrum) could accurately reflect gastric mucosa lesions with less biopsy tissues and it is worthy of clinical popularization and application.

Severe gastritis decreases success rate of Helicobacter pylori eradication.

BACKGROUND: In several studies, different risk factors other than antibiotic resistance have been documented with Helicobacter pylori eradication failure. We aimed in this study to investigate the relationship of gastric density of H. pylori, the occurrence/degree of gastric atrophy, and intestinal metaplasia (IM) with success rate of H. pylori eradication. METHODS: Two hundred consecutive treatment naive patients who received bismuth containing standart quadruple treatment due to H. pylori infection documented by histopathological examination of two antral or two corpal biopsies entered this retrospective study. The updated Sydney system was used to grade the activity of gastritis, density of H. pylori colonization, atrophy, and IM. Stages III and IV of operative link for gastritis assessment (OLGA) or the operative link on gastric intestinal metaplasia assessment (OLGIM) stages was considered as severe gastritis. H. pylori eradication was determined via stool H. pylori antigen test performed 4 weeks after the end of therapy. RESULTS: The presence of gastric atrophy and IM was significantly higher in patients with eradication failure (p = 0.001 and 0.01, respectively). Severe gastritis (OLGA III-IV and OLGIM III-IV) rates were higher in eradication failure group. A multiple linear regression analysis showed that OLGA and OLGIM stages were to be independent risk factors for eradication failure (p = 0.03 and 0.01, respectively). CONCLUSION: Our results suggested that histopathologically severe gastritis may cause H. pylori eradication failure. In addition, we found that H. pylori density was not a risk factor for treatment failure in patients who receive quadruple treatment.

OLGA- and OLGIM-based staging of gastritis using narrow-band imaging magnifying endoscopy.

BACKGROUND AND AIM: As atrophic gastritis and intestinal metaplasia as a result of Helicobacter pylori are considered risk factors for gastric cancer, it is important to assess their severity. In the West, the operative link for gastritis assessment (OLGA) and operative link for gastric intestinal metaplasia assessment (OLGIM) staging systems based on biopsy have been widely adopted. In Japan, however, narrow-band imaging (NBI)-magnifying endoscopic diagnosis of gastric mucosal inflammation, atrophy, and intestinal metaplasia has been reported to be fairly accurate. Therefore, we investigated the practicality of NBI-magnifying endoscopy (NBI-ME) for gastritis staging. METHODS: We enrolled 55 patients, in whom NBI-ME was used to score the lesser curvature of the antrum (antrum) and the lesser curvature of the lower body (corpus). The NBI-ME score classification was established from images obtained beforehand, and then biopsy specimens taken from the observed areas were scored according to histological findings. The NBI-ME and histology scores were then compared. Furthermore, we assessed the NBI-ME and histology stages using a combination of scores for the antrum and corpus, and divided the stages into two risk groups: low and high. The degree to which the stage assessed by NBI-ME approximated that assessed by histology was then ascertained. RESULTS: Degree of correspondence between the NBI-ME and histology scores was 69.1% for the antrum and 72.7% for the corpus, and that between the high- and low-risk groups was 89.1%. CONCLUSION: Staging of gastritis using NBI-ME approximates that based on histology, and would be a practical alternative to the latter.