Podcast
Questions and Answers
What is one of the main risk factors for gastric adenocarcinoma?
What is one of the main risk factors for gastric adenocarcinoma?
What is a significant challenge in the prognosis of gastric adenocarcinoma?
What is a significant challenge in the prognosis of gastric adenocarcinoma?
Which condition is characterized by the presence of gastric intestinal metaplasia (GIM)?
Which condition is characterized by the presence of gastric intestinal metaplasia (GIM)?
What is the role of the British Society of Gastroenterology (BSG) endoscopy committee concerning gastric adenocarcinoma?
What is the role of the British Society of Gastroenterology (BSG) endoscopy committee concerning gastric adenocarcinoma?
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Which is a prerequisite condition leading to gastric adenocarcinoma?
Which is a prerequisite condition leading to gastric adenocarcinoma?
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What is considered an efficacious treatment to intervene in the progression of gastric cancer?
What is considered an efficacious treatment to intervene in the progression of gastric cancer?
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Which hereditary condition is mentioned as a risk factor for gastric cancer?
Which hereditary condition is mentioned as a risk factor for gastric cancer?
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What is a consequence of the late-stage diagnosis of gastric adenocarcinoma?
What is a consequence of the late-stage diagnosis of gastric adenocarcinoma?
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What are the primary conditions associated with gastric adenocarcinoma?
What are the primary conditions associated with gastric adenocarcinoma?
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What is a common cause of chronic atrophic gastritis (CAG)?
What is a common cause of chronic atrophic gastritis (CAG)?
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Which procedure is recommended for patients at higher risk of gastric adenocarcinoma?
Which procedure is recommended for patients at higher risk of gastric adenocarcinoma?
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What is the suggested follow-up for patients after an endoscopy if no visible neoplasia is detected?
What is the suggested follow-up for patients after an endoscopy if no visible neoplasia is detected?
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What is the reported accuracy of detecting GA and GIM using white light endoscopy (WLE)?
What is the reported accuracy of detecting GA and GIM using white light endoscopy (WLE)?
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What action should be taken if persistent, non-visible low-grade dysplasia (LGD) is found during endoscopy?
What action should be taken if persistent, non-visible low-grade dysplasia (LGD) is found during endoscopy?
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How often should enhanced imaging and extensive biopsy sampling be conducted according to the recommendation?
How often should enhanced imaging and extensive biopsy sampling be conducted according to the recommendation?
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What is the level of agreement regarding the recommended protocol for endoscopy in at-risk patients?
What is the level of agreement regarding the recommended protocol for endoscopy in at-risk patients?
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What is the recommended imaging modality for accurately detecting and risk-stratifying GA and GIM?
What is the recommended imaging modality for accurately detecting and risk-stratifying GA and GIM?
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What is the recommended action for patients with non-visible, high-grade dysplasia (HGD)?
What is the recommended action for patients with non-visible, high-grade dysplasia (HGD)?
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Which technique is specifically recommended for ensuring en bloc excision of lesions greater than 10 mm?
Which technique is specifically recommended for ensuring en bloc excision of lesions greater than 10 mm?
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What should be discussed at the regional upper GI cancer multidisciplinary team for endoscopic appearances suggestive of GA or GIM?
What should be discussed at the regional upper GI cancer multidisciplinary team for endoscopic appearances suggestive of GA or GIM?
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How should gastric dysplasia and early gastric adenocarcinoma be treated?
How should gastric dysplasia and early gastric adenocarcinoma be treated?
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What is the principal patient group targeted for non-invasive identification before endoscopy?
What is the principal patient group targeted for non-invasive identification before endoscopy?
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What type of endoscopic grading should be documented for GA and GIM?
What type of endoscopic grading should be documented for GA and GIM?
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Which method is emphasized for the best detection and risk stratification of gastric adenocarcinoma?
Which method is emphasized for the best detection and risk stratification of gastric adenocarcinoma?
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What is the level of agreement for recommending ongoing surveillance at 6-month intervals for persistent, non-visible HGD?
What is the level of agreement for recommending ongoing surveillance at 6-month intervals for persistent, non-visible HGD?
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What does the Sydney protocol guide regarding biopsies?
What does the Sydney protocol guide regarding biopsies?
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How is endoscopic grading classified based on location for gastric lesions?
How is endoscopic grading classified based on location for gastric lesions?
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What is the stance on using biomarkers for population screening of gastric conditions?
What is the stance on using biomarkers for population screening of gastric conditions?
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Which group of professionals are the target users for the guidelines discussed?
Which group of professionals are the target users for the guidelines discussed?
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What is stated about screening in a low-risk population undergoing routine diagnostic procedures?
What is stated about screening in a low-risk population undergoing routine diagnostic procedures?
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Which approach is deemed important for improving early detection of gastric conditions?
Which approach is deemed important for improving early detection of gastric conditions?
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What quality assessment tool was followed to evaluate the evidence provided in the guidelines?
What quality assessment tool was followed to evaluate the evidence provided in the guidelines?
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What is the suggested method of surveillance for patients with extensive gastric adenocarcinoma or gastric intestinal metaplasia?
What is the suggested method of surveillance for patients with extensive gastric adenocarcinoma or gastric intestinal metaplasia?
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What is the evidence level for the efficacy of endoscopic mucosal resection or endoscopic submucosal dissection in treating visible gastric dysplasia and early cancer?
What is the evidence level for the efficacy of endoscopic mucosal resection or endoscopic submucosal dissection in treating visible gastric dysplasia and early cancer?
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What is the grade of recommendation for H.pylori eradication to reduce the risk of gastric adenocarcinoma development?
What is the grade of recommendation for H.pylori eradication to reduce the risk of gastric adenocarcinoma development?
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What is the risk associated with gastric adenocarcinoma globally?
What is the risk associated with gastric adenocarcinoma globally?
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What is the recommendation regarding the use of biomarkers as a screening tool in areas with low incidence?
What is the recommendation regarding the use of biomarkers as a screening tool in areas with low incidence?
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Which factor enhances the benefit of H.pylori eradication in reducing gastric adenocarcinoma risk?
Which factor enhances the benefit of H.pylori eradication in reducing gastric adenocarcinoma risk?
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What is the overall success rate of endoscopic mucosal resection when quality criteria are met?
What is the overall success rate of endoscopic mucosal resection when quality criteria are met?
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What recommendation level denotes the agreement for the benefits of H.pylori eradication in reducing the risk of gastric adenocarcinoma?
What recommendation level denotes the agreement for the benefits of H.pylori eradication in reducing the risk of gastric adenocarcinoma?
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Study Notes
British Society of Gastroenterology Guidelines on Gastric Adenocarcinoma
- Gastric adenocarcinoma has a poor prognosis, often diagnosed late
- Risk factors include H. pylori infection, family history (especially hereditary diffuse gastric cancer), and pernicious anaemia
- Progression to cancer involves chronic gastritis, gastric atrophy, gastric intestinal metaplasia (GIM), and dysplasia
- Early detection is key for improved survival
- Biomarkers have insufficient evidence for population screening
- High-quality endoscopy with full mucosal visualization is crucial for early detection
- Image-enhanced endoscopy (IEE) with biopsy sampling (Sydney protocol) is the best approach. Biopsy samples from the antrum, incisura, lesser and greater curvatures help diagnose and stratify risk
- Endoscopic surveillance every 3 years is suggested for patients with extensive gastric atrophy or GIM, but not low risk
- Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) of visible dysplasia/early cancer is effective
- H. pylori eradication is recommended for patients with gastric atrophy (GA) – high quality evidence, high recommendation.
- H. pylori eradication may be of some benefit for those with H. pylori-associated GIM, dysplasia, or cancer - high quality evidence, weak recommendation
- Biomarkers are not recommended for screening in areas with low incidence of gastric adenocarcinoma (like the UK) – low quality evidence, weak recommendation
- Patients with high risk (e.g., GA and GIM) need a full stomach endoscopy protocol with clear photographic documentation
Diagnosis and Management of Gastric Precancerous Lesions
- Image-enhanced endoscopy (IEE) is the best method to detect and risk-stratify GA and GIM
- IEE may need to be escalated to high-resolution IEE or magnification endoscopy for suspicious areas
- Documentation of location and extent of GA and GIM with photos is essential
- Distal (low risk) and proximal (high risk) gastric locations should be differentiated
- All gastric dysplasia and early gastric adenocarcinoma must be resected en bloc- using EMR(lesions ≤10mm) or ESD (lesions >10mm)
- Complete endoscopic resection (RO) is considered curative for specific conditions (e.g., low-grade dysplasia (LGD), high-grade dysplasia (HGD), specific types and sizes of adenocarcinoma).
- Features suggestive of higher lymph node metastasis (LNM) risk after endoscopic resection include poorly differentiated submucosal cancer, signet ring cancer, lymphovascular invasion, and submucosal invasion ≥500 µm.
- NSAIDs and antioxidants are not recommended for reducing gastric precancerous lesion progression.
- Endoscopic surveillance every 3 years is recommended for patients with extensive GA or GIM; this should be 3 yearly unless other factors raise risk (e.g., family history of gastric cancer or persistent H. pylori infection)
- Patients with non-visible LGD should undergo a repeat endoscopy with image enhancement and biopsy within a year; and subsequently annually if needed
- Non-visible HGD needs immediate repeat endoscopy with image enhancement and biopsy. Ongoing 6-monthly surveillance is recommended.
- Consult with an expert regional upper GI cancer MDT if HGD is present
- Considering Age, multiple risk factors, and family history when assessing the need for screening
Surveillance
- Endoscopic surveillance every 3 years is recommended for patients with extensive GA or GIM, affecting the antrum and body
- Surveillance is not recommended for those with GA or GIM limited to the antrum, unless additional risk factors (e.g., strong family history of gastric cancer or persistent H. pylori infection) are present
- Surveillance interval should be adjusted based on the severity and extent of the premalignant conditions
- The GDG did not agree whether using OLGA or OLGIM routinely in practice, as there is not enough expertise/capacity.
Biopsies and Biomarker use
- Biopsies should assess mucosal sites in the Sydney protocol areas if IEE visualization suggests GIM
- Biopsies should be labelled appropriately (e.g., "directed" or "random")
- Biopsy should be considered in those aged ≥50 years with laboratory evidence (vitamin B12) deficiency & antibody tests suggesting pernicious anemia
- Patients whose conditions are not clear need a review by an expert pathologist and repeat image enhanced endoscopy
Treatment
- All gastric dysplasia and early gastric adenocarcinoma should be resected en bloc using EMR or ESD
- Complete (RO) endoscopic resection (using EMR or ESD) is considered curative for certain types of gastric dysplasia and early-stage cancers
- Patients with ambiguous findings need MDT discussion, and possible referral to an expert center prior to any active treatment
- Recommendations for treatment are mainly based on the intestinal type of gastric cancer
- Use ESD over EMR for larger lesions, due to superior resection success rates
- Surgery should be considered only if endoscopic resection isn't curative or if the patient prefers surgery
Risk Factors
- H.pylori infection, family history, pernicious anemia, non-white origin, gastric surgery (for benign conditions) longer than 15 years, age older than 45, high salt intake and smoking are risks for gastric cancer
- Risk factors should be considered individually when assessing risk
- Family history of gastric cancer is a strong risk factor.
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Description
Test your knowledge on gastric adenocarcinoma, its risk factors, and prognosis challenges. This quiz covers important aspects such as hereditary conditions, treatment options, and the role of endoscopy in managing gastric cancer. Delve into the pathophysiology and management strategies associated with this significant health issue.
