Diagnosis and Management of High Risk Group for Gastric Cancer

Gastric cancer is associated with high morbidity and mortality worldwide. To reduce the socioeconomic burden related to gastric cancer, it is very important to identify and manage high risk group for gastric cancer. In this review, we describe the general risk factors for gastric cancer and define high risk group for gastric cancer. We discuss strategies for the effective management of patients for the prevention and early detection of gastric cancer. Atrophic gastritis (AG) and intestinal metaplasia (IM) are the most significant risk factors for gastric cancer. Therefore, the accurate selection of individuals with AG and IM may be a key strategy for the prevention and/or early detection of gastric cancer. Although endoscopic evaluation using enhanced technologies such as narrow band imaging-magnification, the serum pepsinogen test, Helicobacter pylori serology, and trefoil factor 3 have been evaluated, a gold standard method to accurately select individuals with AG and IM has not emerged. In terms of managing patients at high risk of gastric cancer, it remains uncertain whether H. pylori eradication reverses and/or prevents the progression of AG and IM. Although endoscopic surveillance in high risk patients is expected to be beneficial, further prospective studies in large populations are needed to determine the optimal surveillance interval.     

The Incidence and Risk Factors for Metachronous Gastric Cancer in the Remnant Stomach after Gastric Cancer Surgery

Background/AimsLess invasive surgical treatment is performed in East Asia to preserve postoperative digestive function and reduce complications such as postgastrectomy syndromes, but there is an issue of metachronous gastric cancer (GC) in the remaining stomach. This study aimed to analyze the incidence of metachronous GC and its risk factors in patients who had undergone partial gastrectomy.MethodsA total of 3,045 GC patients who had undergone curative gastric partial resection at Seoul National University Bundang Hospital were enrolled and analyzed retrospectively for risk factors, including age, sex, smoking, alcohol, Helicobacter pylori status, family history of GC, histological type, and surgical method.ResultsMetachronous GC in the remaining stomach occurred in 35 of the 3,045 patients (1.1%) 23 in the distal gastrectomy group (18 with Billroth-I anastomosis, five with Billroth-II anastomosis), seven in the proximal gastrectomy (PG) group, and five in the pylorus-preserving gastrectomy (PPG) group. Univariate and multivariate Cox regression analyses showed that age ≥60 years (p=0.005) and surgical method used (PG or PPG, p<0.001) were related risk factors for metachronous GC, while male sex and intestinal type histology were potential risk factors.ConclusionsMetachronous GC was shown to be related to older age and the surgical method used (PG or PPG). Regular and careful follow-up with endoscopy should be performed in the case of gastric partial resection, especially in patients with male sex and intestinal type histology as well as those aged ≥60 years undergoing the PG or PPG surgical method.     

Endoscopic Resection for Synchronous Esophageal Squamous Cell Carcinoma and Gastric Adenocarcinoma in Early Stage Is a Possible Alternative to Surgery

Background/Aims

We investigated the clinical outcomes according to the method of treatment in synchronous esophageal and gastric cancer.

Methods

Synchronous esophageal squamous cell carcinoma and gastric adenocarcinoma were diagnosed in 79 patients between 1996 and 2010. We divided the patients into four groups according to treatment; Group 1 received surgical resection for both cancers or surgery for gastric cancer with chemoradiotherapy for esophageal cancer (n=27); Group 2 was treated by endoscopic resection with or without additional treatment (n=14); Group 3 received chemoradiotherapy only (n=18); and Group 4 received supportive care only (n=20).

Results

The median survival times in groups 1 and 2 were 86 and 60 months, respectively. The recurrence rate and mortality were 23% and 48%, respectively, in group 1 and 21% and 4%, respectively, in group 2. The median survival time was 12 months in group 3 and 9 months in group 4. Multivariate analysis showed that age (p<0.001) and treatment group (p=0.019) were significantly associated with death. Compared with group 1, treatment in the intensive care unit (p=0.003), loss of body weight (p=0.042), and decrease in hemoglobin (p=0.033) were worse in group 1.

Conclusions

Endoscopic resection for synchronous esophageal and gastric cancer could be considered as a possible alternative to surgery for early-stage cancer.     

内镜粘膜下剥离术治疗胃浅表病变手术时长的影响因素分析

目的 探讨造成胃浅表病变内镜黏膜下剥离术（ESD）手术时间较长（大于120 min）的独立危险因素。 方法 从北京友谊医院内镜中心病历库中,收集2015年1月至2017年12月因术前诊断早期胃癌而行ESD治疗的病例资料,包括患者基本信息（年龄、性别、体重指数、合并症等）、病灶特征（大小、部位、形态等）、操作者经验、手术时间及术后病理等信息,最终纳入193例（195处病灶）。对收集到的资料先行单因素分析以寻找ESD手术时间的影响因素,对于其中有统计学差异的因素再纳入Logistic回归分析以寻找ESD手术时间大于120 min的独立危险因素。 结果 193例患者平均年龄为63.34±9.11岁,手术时间为120.00（95.00,165.00）min,病灶长轴为1.50（1.00,2.38）cm,术后病理诊断早期胃癌164例（84.10%）,其中162例（98.78%）达到整块切除,148例（90.24%）达到治愈性切除。单因素分析中,患者性别（P=0.018）、病灶部位（P＜0.001）及病灶长轴大小（r=0.209,P=0.007）与手术时间相关,而年龄、体重指数、美国麻醉医师协会分级（ASA分级）、病灶表面是否粗糙、有无白苔、有无溃疡、病变浸润深度、手术时期、病灶大体形状、分化程度及操作者年资均不是手术时间的影响因素（P＞0.05）。患者性别、病灶部位、病灶长轴纳入多因素Logistic回归分析发现,病灶位于贲门/胃底（OR=5.656,95%CI：2.291～13.964,P＜0.001）、胃体（OR=2.667,95%CI：1.048～6.785,P=0.040）及病灶长轴＞2 cm（OR=2.761,95%CI：1.229～6.205,P=0.014）是手术时间超过120 min的独立危险因素。 结论 胃浅表病变行ESD治疗时,病灶位于贲门/胃底、胃体及病灶长轴＞2 cm者易发生手术时间较长（大于120 min）的情况。     

Endoscopic and Oncologic Outcomes of Endoscopic Resection for Superficial Esophageal Neoplasm

Background/Aims

Endoscopic resection (ER) of superficial esophageal neoplasm (SEN) is a technically difficult procedure. We investigated the clinical outcomes of ER for SEN to determine its feasibility and effectiveness.

Methods

Subjects who underwent ER for SEN at Asan Medical Center between December 1996 and December 2010 were eligible. The clinical features of patients and tumors, histopathological characteristics, adverse events, ER results and survival were investigated.

Results

A total of 129 patients underwent ER for 147 SENs. En bloc resection (EnR) was performed in 118 lesions (80.3%). Complete resection (CR) was accomplished in 128 lesions (86.5%), and curative resection (CuR) was performed in 118 lesions (79.7%). The EnR, CR, and CuR rates were significantly greater in the endoscopic submucosal dissection group when compared to those in the endoscopic resection group. Adverse events occurred in 22 patients (17.1%), including bleeding (n=2, 1.6%), perforation (n=12, 9.3%), and stricture (n=8, 6.2%). Local tumor recurrence occurred in 2.0% of patients during a median follow-up of 34.8 months. The 5-year overall and disease-specific survival rates were 94.0% and 97.5%, respectively.

Conclusions

ER is a feasible and effective method for the treatment of SEN as indicated by favorable clinical outcomes.     

Detection of Metachronous Neoplasms in Colorectal Cancer Patients: Identification of Risk Factors

Purpose Patients with colorectal cancer have a high risk of developing metachronous neoplasms. Identification of predictive factors associated with such conditions would allow individualized follow-up strategies in these patients. This study was designed to identify individual and familial factors associated with the development of metachronous colorectal neoplasms in patients with colorectal cancer. Methods In the context of a prospective, multicenter, general population-based study—the EPICOLON project—all patients with colorectal cancer attended in ten Spanish hospitals during a one-year period were included. Patients with familial adenomatous polyposis or inflammatory bowel disease were excluded. All patients were monitored by colonoscopy within two years of the diagnoses. Demographic, clinical, pathologic, molecular (microsatellite instability status and immunohistochemistry for MSH2 and MLH1), and familial characteristics (fulfillment of Amsterdam I or II criteria, and revised Bethesda guidelines) were analyzed. Results A total of 353 patients were included in the study. At two years of follow-up, colonoscopy revealed the presence of adenomas in 89 (25 percent) patients and colorectal cancer in 14 (3.9 percent) patients, in 7 cases restricted to anastomosis. Univariate analysis demonstrated that development of metachronous neoplasm (adenoma or colorectal cancer) was associated with personal history of previous colorectal cancer (odds ratio, 5.58; 95 percent confidence interval, 1.01–31.01), and presence of previous or synchronous adenomas (odds ratio, 1.77; 95 percent confidence interval, 1.21–3.17). Although nonstatistical significance was achieved, metachronisms were associated with gender (P < 0.09) and differentiation degree (P < 0.08). Multivariate analysis identified previous or synchronous adenomas (odds ratio, 1.98; 95 percent confidence interval, 1.16–3.38) as independent predictive factor. Neither presence of tumor DNA microsatellite instability nor family history correlated with the presence of metachronous neoplasms. Conclusions Patients with previous or synchronous colorectal adenoma have an increased risk of developing metachronous colorectal neoplasms. Accordingly, this subgroup of patients may benefit from specific surveillance strategies. Supported by grants from the Red Nacional de Investigación en Hepatología y Gastroenterología (Instituto de Salud Carlos III, C03/02) and from Fondo de Investigaciones Sanitarias (FIS PI061384). Xavier Llor is a recipient of a Ramon y Cajal grant form Ministerio de Ciencia y Tecnología of the Spanish government Presented at the meeting of the United European Gastroenterology, Copenhagen, Denmark, October 15 to 19, 2005.     

Microsatellite Instability of Gastric and Colorectal Cancers as a Predictor of Synchronous Gastric or Colorectal Neoplasms

Background/Aims

Microsatellite instability (MSI) plays a crucial role in gastrointestinal carcinogenesis. The aim of this study was to clarify whether MSI is a useful marker for predicting synchronous gastric and colorectal neoplasms.

Methods

Consecutive patients who underwent both esophagogastroduodenoscopy and colonoscopy before the resection of gastric or colorectal cancers were included. MSI was analyzed using two mononucleotide and three dinucleotide markers.

Results

In total, 434 gastric cancers (372 microsatellite stability [MSS], 21 low incidence of MSI [MSI-L], and 41 high incidence of MSI [MSI-H]) and 162 colorectal cancers (138 MSS, 9 MSI-L, and 15 MSI-H) were included. Patients with MSI gastric cancer had a higher prevalence of synchronous colorectal cancer, colorectal adenoma, and gastric adenoma than those with MSS gastric cancers (4.8% vs 0.5%, p=0.023; 11.3% vs 3.2%, p=0.011; 3.2% vs 1.2%, p=0.00, respectively). The prevalence of synchronous colorectal adenomas was highest in MSI-L gastric cancers (19.0%), compared with MSI-H (7.3%) or MSS (3.2%) gastric cancers (p=0.002). In addition, there were no significant differences in the prevalence rates of synchronous colorectal adenoma among the MSI-H (13.3%), MSI-L (11.1%), and MSS (12.3%) colorectal cancers (p=0.987).

Conclusions

The presence of MSI in gastric cancer may be a predictor of synchronous gastric and colorectal neoplasms, whereas MSI in colorectal cancer is not a predictor of synchronous colorectal adenoma.     

胃黏膜褪色病灶诊断肿瘤的危险因素分析

目的　分析胃黏膜褪色病灶诊断为肿瘤的相关危险因素，为内镜下早期诊断提供依据。方法　收集2020年1月—2021年5月在中国人民解放军总医院第七医学中心消化内科行胃镜检查发现胃黏膜褪色病灶并行活检的402例患者资料进行回顾性分析。总结归纳患者性别，年龄，胃黏膜萎缩程度，病灶边界、大小、部位、形态、窄带光成像放大内镜下表现及组织病理学结果等资料，采用多因素Logistic回归分析胃黏膜褪色病灶诊断为肿瘤的相关危险因素。结果　402例胃黏膜褪色病灶中，肿瘤性病变共33例（8.2%），其中高危上皮肿瘤（高级别异型增生和早期胃癌） 23例（5.7%）。患者年龄、胃黏膜萎缩程度、病灶大小、病灶表面凹陷、病灶窄带光成像放大内镜阳性征、病灶表面微血管和表面微结构均与胃黏膜褪色病灶诊断为肿瘤性病变相关（P<0.05），而患者年龄、胃黏膜萎缩程度、病灶大小、病灶表面凹陷、病灶表面微结构与胃黏膜褪色病灶诊断为高危上皮肿瘤相关（P<0.05）。多因素Logistic回归分析显示，病灶长径<20 mm（OR=4.487，95%CI：1.776~11.332，P=0.001）、窄带光成像放大内镜阳性征（OR=40.510，95%CI：1.610~1 019.456，P=0.024）是胃黏膜褪色病灶诊断为肿瘤性病变的独立危险因素；病灶表面微结构异常是胃黏膜褪色病灶诊断为高危上皮肿瘤的独立危险因素（OR=0.003，95%CI：0.000~1.587，P<0.001）。结论　表面微结构异常、病灶大小和窄带光成像放大内镜阳性征是胃黏膜褪色病灶诊断为肿瘤的危险因素。     

Low Pepsinogen I Level Predicts Multiple Gastric Epithelial Neoplasias for Endoscopic Resection

Background/Aims

Synchronous/metachronous gastric epithelial neoplasias (GENs) in the remaining lesion can develop at sites other than the site of endoscopic resection. In the present study, we aimed to investigate the predictive value of serum pepsinogen for detecting multiple GENs in patients who underwent endoscopic resection.

Methods

In total, 228 patients with GEN who underwent endoscopic resection and blood collection for pepsinogen I and II determination were evaluated retrospectively.

Results

The mean period of endoscopic follow-up was 748.8±34.7 days. Synchronous GENs developed in 46 of 228 (20.1%) and metachronous GENs in 27 of 228 (10.6%) patients during the follow-up period. Multiple GENs were associated with the presence of pepsinogen I <30 ng/mL (p<0.001). Synchronous GENs were associated with the presence of pepsinogen I <30 ng/mL (p<0.001).

Conclusions

Low pepsinogen I levels predict multiple GENs after endoscopic resection, especially synchronous GENs. Cautious endoscopic examination prior to endoscopic resection to detect multiple GENs should be performed for these patients.     

早期胃癌内镜下形态学危险因素的研究

胃癌的预后与疾病分期显著相关,早期诊断胃癌是延长患者生存期的关键。目前胃镜检查结合黏膜活检是临床上最常用的检测早期胃癌的重要手段,但检出率较低,因此要求内镜医师掌握早期胃癌的内镜下形态学特点,及时发现可疑癌灶并取活检。本文就内镜下早期胃癌的形态学危险因素作一综述,以期为内镜医师诊断早期胃癌提供参考。     

Long-term Outcomes of Additional Endoscopic Treatments for Patients with Positive Lateral Margins after Endoscopic Submucosal Dissection for Early Gastric Cancer

Background/AimsIt is uncertain whether additional endoscopic treatment may be chosen over surgery in patients with positive lateral margins (pLMs) as the only non-curative factor after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). We aimed to compare the long-term outcomes of additional endoscopic treatments in such patients with those of surgery and elucidate the clinicopathological factors that could influence the treatment selection.MethodsA total of 99 patients with 101 EGC lesions undergoing additional treatment after non-curative ESD with pLMs as the only non-curative factor were analyzed. Among them, 25 (27 lesions) underwent ESD, 29 (29 lesions) underwent argon plasma coagulation (APC), and 45 (45 lesions) underwent surgery. Clinicopathological characteristics and long-term outcomes were compared.ResultsResidual tumor was found in 73.6% of cases. The presence of multiple pLMs was associated with higher risk of residual tumor (p=0.046). During a median follow-up of 58.9 months, recurrent or residual lesions after additional ESD and APC were found in 4% (1/25) and 6.8% (2/29) of patients, respectively. However, all were completely cured with surgery or repeated ESD. There were no extragastric recurrences after additional endoscopic treatment. Lymph node metastasis was identified after additional surgery in one (2.2%) patient with an EGC showing histological heterogeneity.ConclusionsGiven the favorable long-term outcomes, additional ESD or APC may be an acceptable choice for patients with pLMs as the only non-curative factor after ESD for EGC. However, clincopathological characteristics such as multiple pLMs and histological heterogeneity should be considered in the treatment selection.     

Synchronous and Metachronous Extrapancreatic Malignant Neoplasms in Patients with Intraductal Papillary-Mucinous Neoplasm of the Pancreas

Background/Aims: Patients with intraductal papillary-mucinous neoplasm (IPMN) of the pancreas are likely to have a better prognosis than those with conventional pancreatic ductal adenocarcinoma. Recently there have been some reports on extrapancreatic malignant neoplasms (EPM) occurring in patients with IPMN. The purpose of this study was to discover the characteristic features of IPMN with EPM compared with IPMN without EPM. Methods: 61 patients with IPMN who underwent surgery at Tohoku University Hospital between 1988 and 2006 were retrospectively analyzed. Results: The 61 patients with IPMN in this study comprised 25 with intraductal papillary-mucinous adenomas (IPMA) and 36 with intraductal papillary-mucinous carcinomas (IPMC) including 6 with invasive carcinomas. Synchronous and metachronous EPM were observed in 15 out of the 61 patients (24.6%). Three of these patients, including 2 with IPMA and 1 with invasive carcinoma associated with IPMC, died of the EPM. None of the features, including sex, age, smoking, family history, macroscopic types (main duct type or branch duct type), histological types (gastric, intestinal, pancreatobiliary or oncocytic), and aberrant expression of molecules including CDKN2A, TP53, SMAD4 and DUSP6, except for the histological diagnoses were associated with the occurrence of EPM, i.e., the EPM occurred more often in patients with IPMA (10 out of 25) than in those with IPMC (5 out of 36) in our series (p = 0.0199 by the χ² test, p = 0.0330 by Fisher's exact probability test, p = 0.0422 by Yates' correction). Conclusion: Patients with IPMA were more likely to have EPM than those with IPMC. Patients with IPMA are usually expected to have a fair prognosis but EPM could be fatal in some of them, so it must be noted during follow-up.     

住院患者静脉血栓栓塞危险因素的分析

目的 通过对住院期间发生静脉血栓栓塞症（Venous thromboembolism，VTE）患者危险因素的分析，探讨VTE发生的高危因素。探索应用Caprini风险评估模型评估住院患者VTE发生风险的有效性。方法 对2012年1月1日至2012年12月31日在煤炭总院及朝阳医院确诊为VTE的住院患者进行研究。287例符合入选条件的被纳入研究。收集患者的一般资料、VTE危险因素、相关实验室检查及影像学检查结果等。分析VTE与各危险因素之间的关系。应用Caprini风险评估模型患者进行VTE风险评估。随访患者出院后VTE复发情况及生存状态。结果 1.287例患者中，92例（32.1％）患者仅患有DVT，93例（32.4％）患者仅患有PTE，102例（35.5％）患者同时患有DVT及PTE。155例为内科患者，132例为外科患者。2.VTE患者危险因素排在前五位的依次是：BMI>25 kg/m2（63.2％），蛋白C或蛋白S缺乏（52.4%），血清同型半胱氨酸升高（50%），长期卧床136例（47.4％），严重肺部疾病132例（46.0％）。3.与内科患者相比，Caprini模型评估外科患者VTE发生风险更为有效，且差异有统计学意义（风险评估分值在内科患者6.68±3.27，外科患者7.84±3.45，P=0.004）。4. 随访中，48例患者复发性VTE，复发率为18.5%。其中极高危患者的复发率最高（29.0％），其次为高危患者（6.5％），低中危患者无VTE复发。生存曲线显示极高危患者VTE复发风险最高，且差异有统计学意义（P=0.021）。结论 1.住院患者VTE的高危因素包括：BMI>25kg/m2，蛋白C或蛋白S缺乏，血清同型半胱氨酸升高，长期卧床，严重肺部疾病。2. Caprini模型评估外科患者VTE发生风险较内科患者更为有效，并且为预测VTE复发风险提供参考。     

Long-term Outcomes of Undifferentiated-Type Early Gastric Cancer with Positive Horizontal Margins after Endoscopic Resection

Background/AimsThis study examined the long-term outcomes of undifferentiated-type early gastric cancer (UD EGC) with positive horizontal margins (HMs) after endoscopic resection (ER) and compared them between additional surgery and nonsurgical management.MethodsFrom 2005 to 2015, a total of 1,124 patients with UD EGC underwent ER at 18 tertiary hospitals in Korea. Of them, 92 patients with positive HMs as the only noncurative factor (n=25) or with both positive HMs and tumor size >2 cm (n=67) were included. These patients underwent additional surgery (n=40), underwent additional endoscopic treatment (n=6), or were followed up without further treatment (n=46).ResultsNo lymph node (LN) metastasis was found in patients who underwent additional surgery. During a median follow-up of 57.7 months (interquartile range, 27.6 to 68.8 months), no LN or distant metastases or gastric cancer-related deaths occurred in the overall cohort. At baseline, the residual cancer rate was 57.8% (26/45) after additional surgery or ER. The 5-year local recurrence rate was 33.6% among patients who were followed up without additional treatment. The 5-year overall survival rates were 95.0% and 87.8% after additional surgery and nonsurgical management (endoscopic treatment or close follow-up), respectively (log-rank p=0.224). In the multivariate Cox regression analysis, nonsurgical management was not associated with an increased risk of mortality.ConclusionsUD EGC with positive HMs after ER may have favorable long-term outcomes and a very low risk of LN metastasis. Nonsurgical management may be suggested as an alternative, particularly for patients with old age or chronic illness. (Gut Liver 2021;15-731)     

Systematic Endoscopic Approach to Early Gastric Cancer in Clinical Practice

Early gastric cancers (EGCs) are defined as gastric cancers confined to the mucosa or submucosa, regardless of regional lymph node metastasis. The proportion of EGCs has been increasing due to the increase in screening endoscopy for gastric cancers; therefore, the paradigm shift from surgical resection to endoscopic resection as a treatment modality for selected EGCs is accelerating. For successful endoscopic resection of EGCs, it is important to detect EGCs at an early stage and to accurately predict the histological type, depth of invasion, and horizontal margins of the tumor. The diagnostic process of EGCs can be divided into three steps: presence diagnosis, qualitative diagnosis, and quantitative diagnosis. The presence diagnosis of EGCs is mainly based on two endoscopic findings: a well-demarcated lesion and irregularity in the color/surface pattern. Qualitative diagnosis refers to the prediction of histological type, which is mainly possible based on the macroscopic shape and color of the lesion. Quantitative diagnosis of EGCs consists of predicting the depth of invasion by detailed examination of the macroscopic morphology and determining horizontal margins using chromoendoscopy. Although advanced diagnostic modalities, such as endosonography or magnifying endoscopy, are helpful for the qualitative and quantitative diagnosis of EGCs, these modalities are not available in most hospitals. Therefore, it is still very important to evaluate EGCs systematically during conventional endoscopy for successful endoscopic treatment.     

预测老年早期胃癌患者内镜黏膜下剥离术后复发风险的列线图模型

目的 探讨个体化预测老年早期胃癌(EGC)患者内镜黏膜下剥离术(ESD)后复发风险的列线图模型构建.方法 回顾性队列研究.我院消化科2000年1月至2016年12月共收治行ESD治疗的老年EGC患者3 987例,选择临床病理资料和随访资料完整的28例复发患者作为复发组,276例未复发患者作为对照组.调取所有患者一般资料...