BSG Guidelines on Gastric Adenocarcinoma Risk Diagnosis & Management 2019 PDF

Guidelines British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of...

Guidelines British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of Gut: first published as 10.1136/gutjnl-2018-318126 on 5 July 2019. Downloaded from http://gut.bmj.com/ on 15 July 2019 by guest. Protected by copyright. gastric adenocarcinoma Matthew Banks, 1,2 David Graham,1,3 Marnix Jansen, 4 Takuji Gotoda,5 Sergio Coda,6 Massimiliano di Pietro,7,8 Noriya Uedo,9 Pradeep Bhandari,10 D Mark Pritchard,11 Ernst J Kuipers,12 Manuel Rodriguez-Justo,4 Marco R Novelli,4 Krish Ragunath,13 Neil Shepherd,14 Mario Dinis-Ribeiro15 For numbered affiliations see Abstract greatest risk and intervene with recognised effi- end of article. Gastric adenocarcinoma carries a poor prognosis, in part cacious treatments, including endoscopic resec- due to the late stage of diagnosis. Risk factors include tion,before cancer is established. The British Society Correspondence to Helicobacter pylori infection, family history of gastric of Gastroenterology (BSG) endoscopy committee Dr Matthew Banks, University College London Hospital, cancer—in particular, hereditary diffuse gastric cancer agreed to create a guideline to provide statements University College London and pernicious anaemia. The stages in the progression and recommendations on the prevalence, risks, Hospitals NHS Foundation Trust, to cancer include chronic gastritis, gastric atrophy diagnosis, treatment, surveillance and screening of London NW12PG, UK; (GA), gastric intestinal metaplasia (GIM) and dysplasia. gastric premalignant and early gastric malignant ​matthew.​banks2@​nhs.​net The key to early detection of cancer and improved lesions. The principal patient group are those found Received 16 December 2018 survival is to non-invasively identify those at risk before to have GA, GIM, gastric epithelial dysplasia or Revised 6 May 2019 endoscopy. However, although biomarkers may help in early gastric adenocarcinoma limited to the mucosal Accepted 17 May 2019 the detection of patients with chronic atrophic gastritis, or superficial submucosal layers. The target users there is insufficient evidence to support their use for include gastroenterologists, GI surgeons, pathol- population screening. High-quality endoscopy with full ogists, endoscopists and general practitioners. We mucosal visualisation is an important part of improving followed the Appraisal of Guidelines for Research early detection. Image-enhanced endoscopy combined and Evaluation (AGREE II) instrument, and the with biopsy sampling for histopathology is the best quality of the evidence was assessed according to approach to detect and accurately risk-stratify GA and the Grading of Recommendations Assessment, GIM. Biopsies following the Sydney protocol from the Development and Evaluation (GRADE) system. antrum, incisura, lesser and greater curvature allow A series of statements, recommendations and both diagnostic confirmation and risk stratification suggestions are proposed to ensure that there is for progression to cancer. Ideally biopsies should be consistency of practice, such that patients with directed to areas of GA or GIM visualised by high-quality gastric premalignant and early gastric malignant endoscopy. There is insufficient evidence to support lesions are provided with optimal care. These screening in a low-risk population (undergoing routine recommendations are listed below: diagnostic oesophagogastroduodenoscopy) such as the 1. We recommend H. pylori eradication to reduce UK, but endoscopic surveillance every 3 years should be the risk of gastric adenocarcinoma development offered to patients with extensive GA or GIM. Endoscopic in patients who have GA (evidence level: high mucosal resection or endoscopic submucosal dissection quality; grade of recommendation: high; level of visible gastric dysplasia and early cancer has been of agreement: 100%). shown to be efficacious with a high success rate and low 2. We suggest that H. pylori eradication may be rate of recurrence, providing that specific quality criteria of some benefit to reduce the risk of developing are met. gastric adenocarcinoma in those who already have H. pylori-associated GIM, dysplasia or cancer (evidence level: high quality; grade of Executive summary recommendation: weak; level of agreement: Gastric adenocarcinoma continues to be a frequent 100%). © Author(s) (or their cause of death in the world and is the 16th most 3. We do not recommend the use of biomarkers as employer(s)) 2019. Re-use common cancer in the UK. The most common a screening tool in areas with a low incidence permitted under CC BY-NC. No stages in the progression to gastric adenocarci- of gastric adenocarcinoma, such as the UK (ev- commercial re-use. See rights idence level: low quality; grade of recommen- and permissions. Published noma are gastric atrophy (GA) and gastric intestinal by BMJ. metaplasia (GIM), which are collectively known as dation: weak; level of agreement: 93%). chronic atrophic gastritis (CAG). These conditions 4. We recommend that patients at higher risk for To cite: Banks M, Graham D, gastric adenocarcinoma, including GA and are principally caused by Helicobacter pylori infec- Jansen M, et al. Gut Epub ahead of print: [please tion and less commonly by autoimmune gastritis. GIM, should undergo a full systematic endos- include Day Month Year]. The key to having a significant impact on the prog- copy protocol of the stomach with clear pho- doi:10.1136/ nosis of gastric adenocarcinoma and its economic tographic documentation of gastric regions and gutjnl-2018-318126 burden is to accurately identify individuals at pathology. We suggest a minimum examination Banks M, et al. Gut 2019;0:1–31. doi:10.1136/gutjnl-2018-318126    1 Guidelines time of 7 min (evidence level: moderate quality; grade of enhanced imaging and extensive biopsy sampling, followed recommendation: strong; level of agreement: 100%). by a repeat endoscopy within 1 year if no visible neoplasia is 5. GAand GIM may be detectable by white light endosco- detected. If there is persistent, non-visible LGD, endoscopy py (WLE); however, the accuracy is poor. Therefore, we do should be repeated annually thereafter (evidence level: low Gut: first published as 10.1136/gutjnl-2018-318126 on 5 July 2019. Downloaded from http://gut.bmj.com/ on 15 July 2019 by guest. Protected by copyright. not recommend establishing a diagnosis or risk stratification quality; grade of recommendation: strong; level of agree- using WLE alone (evidence level: moderate quality; grade of ment: 100%). recommendation: strong; level of agreement: 93%). 16. We recommend that patients with non-visible, high-grade 6. We recommend image-enhanced endoscopy (IEE) as the best dysplasia (HGD) should undergo an immediate second imaging modality to accurately detect and risk-stratify GA endoscopy with enhanced imaging and extensive biopsy and GIM (evidence level: moderate quality; grade of recom- sampling. We recommend ongoing surveillance at 6-monthly mendation: strong; level of agreement: 100%). intervals for persistent, non-visible HGD. HGD should be 7. We recommend that endoscopic appearances on WLE sugges- discussed at the regional upper GI cancer multidisciplinary tive of GA or GIM require escalation to high-resolution IEE team and referred to a clinician with the appropriate exper- and, where available, magnification endoscopy (evidence tise (evidence level: low quality; grade of recommendation: level: low quality; grade of recommendation: strong; level strong; level of agreement: 100%). of agreement: 100%). 17. We recommend that all gastric dysplasia and early gastric 8. We recommend that the location and extent of GA and GIM adenocarcinoma should be resected en bloc (an endoscopic should be clearly documented with photographic evidence. mucosal resection (EMR) technique can achieve en bloc Endoscopic grading should be documented as distal gastric excision for lesions ≤10 mm in size, but only an endoscopic (affecting antrum or incisura—low risk) or proximal gastric submucosal dissection (ESD) technique can ensure en bloc (affecting the corpus with or without the antrum and incisu- excision for lesions >10 mm in size) (evidence level: high ra—high risk) (evidence level: low quality; grade of recom- quality; grade of recommendation: strong; level of agree- mendation: strong; level of agreement: 93%). ment: 100%). 9. We recommend that endoscopic appearances on WLE of gas- 18. We recommend that complete (R0) endoscopic resection of tric dysplasia and early gastric cancer (differences in colour, gastric dysplasia and early gastric adenocarcinoma with the loss of vascularity, slight elevation or depression, nodularity, following features should be considered as curative: thickening, and abnormal convergence or flattening of folds) 1. LGD. require escalation to IEE and, where available, magnifica- 2. HGD. tion endoscopy (evidence level: low quality; grade of recom- 3. Well or moderately differentiated intramucosal adeno- mendation: strong; level of agreement: 100%). carcinoma, irrespective of size and without ulceration. 10. We recommend IEE as the best imaging modality to accu- 4. Well or moderately differentiated intramucosal adeno- rately diagnose and stage gastric dysplasia and early gastric carcinoma,