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Aim: The incidence of Helicobacter pylori‐negative gastric cancer (HPNGC) is increasing worldwide. Recently, metabolic dysfunction‐associated fatty liver disease (MAFLD) has been reported to be associated with various cancers, but its association with HPNGC has not been reported. We aimed to identify important independent factors associated with HPNGC, including MAFLD. Methods: This multicenter observational cohort study enrolled patients with gastric cancer (n = 1078) and health checkup examinees (n = 17 408). We analyzed patients with HPNGC (n = 26) and healthy participants with no H. pylori infection or any abnormal findings on upper gastrointestinal endoscopy (n = 1130). A logistic regression model was used to identify independent factors associated with HPNGC. The priority of the factors associated with HPNGC was evaluated using a decision‐tree algorithm and random forest analysis. Results: Among all patients with gastric cancer, 2.4% (26/1078) were diagnosed with HPNGC (mean age, 64 years; male/female, 13/13). In the logistic regression analysis, age, smoking, and MAFLD (odds ratio, 6.5359; 95% confidence interval, 2.5451–16.7841; p < 0.0001) were identified as independent factors associated with HPNGC. Metabolic dysfunction‐associated fatty liver disease was also identified as the most important classifier for the presence of HPNGC in decision‐tree analyses. Helicobacter pylori‐negative gastric cancer was observed in 5.2% of patients with MAFLD and 0.8% of patients without MAFLD. In the random forest analysis of the HPNGC, MAFLD was identified as the distinguishing factor with the highest variable importance (0.32). Conclusions: Metabolic dysfunction‐associated fatty liver disease was the most influential independent factor associated with HPNGC. These findings suggest that fatty liver and metabolic dysfunction could be involved in the pathogenesis of HPNGC. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to evaluate the feasibility of a simple method named aspiration and coagulation (AC) for reducing the risk of postoperative bleeding after gastric endoscopic submucosal dissection (ESD). Methods: Data were retrospectively reviewed and collected from the medical records and endoscopic and pathologic reports about consecutive patients who underwent ESD for early gastric cancer or precancerous lesions or gastric submucosal lesions from January 2016 to December 2021 at the Seventh Medical Center of Chinese PLA General Hospital. Enrolled patients who underwent the AC method during ESD were included in the AC group, and the others were included in the control group. Propensity score (PS) matching (1:1 match) was used to compensate for the differences that might affect post‐ESD bleeding. Massive hemorrhage and overall delayed bleeding events after gastric ESD were compared between the two groups. Results: Propensity score matching analysis created 242 matched pairs in the study. Characteristics of the subjects such as age and use of antithrombotic drugs were all similar between the two groups after PS matching. The rate of massive hemorrhage and overall delayed bleeding was both significantly lower in the AC group than in the control (0.4% vs. 3.3% for massive hemorrhage, P = 0.037, and 1.2% vs. 5.0% for overall delayed bleeding, P = 0.032), predominantly in mucosal lesions (0.6% vs. 4.4% for massive hemorrhage, P = 0.032, and 1.2% vs. 5.6% for overall delayed bleeding, P = 0.031). Conclusions: Our study demonstrated that the AC method effectively decreased delayed bleeding events after ESD. [ABSTRACT FROM AUTHOR]

Aim: Gastrectomy is recommended for patients with early gastric cancer (EGC) because the possibility of lymph node metastasis (LNM) cannot be completely denied. The aim of this study was to develop a discrimination model to select patients who do not require surgery using machine learning. Methods: Data from 382 patients who received gastrectomy for gastric cancer and who were diagnosed with pT1b were extracted for developing a discrimination model. For the validation of this discrimination model, data from 140 consecutive patients who underwent endoscopic resection followed by gastrectomy, with a diagnosis of pT1b EGC, were extracted. We applied XGBoost to develop a discrimination model for clinical and pathological variables. The performance of the discrimination model was evaluated based on the number of cases classified as true negatives for LNM, with no false negatives for LNM allowed. Results: Lymph node metastasis was observed in 95 patients (25%) in the development cohort and 11 patients (8%) in the validation cohort. The discrimination model was developed to identify 27 (7%) patients with no indications for additional surgery due to the prediction of an LNM‐negative status with no false negatives. In the validation cohort, 13 (9%) patients were identified as having no indications for additional surgery and no patients with LNM were classified into this group. Conclusion: The discrimination model using XGBoost algorithms could select patients with no risk of LNM from patients with pT1b EGC. This discrimination model was considered promising for clinical decision‐making in relation to patients with EGC. [ABSTRACT FROM AUTHOR]

The dynamic changes of key biological characteristics from gastric low‐grade intraepithelial neoplasia (LGIN) to high‐grade intraepithelial neoplasia (HGIN) to early gastric cancer (EGC) are still unclear, which greatly affect the accurate diagnosis and treatment of EGC and prognosis evaluation of gastric cancer (GC). In this study, bioinformatics methods/tools are applied to quantitatively analyze molecular characteristics evolution of GC progression, and a prognosis model is constructed. This study finds that some dysregulated differentially expressed mRNAs (DEmRNAs) in the LGIN stage may continue to promote the occurrence and development of EGC. Among the LGIN, HGIN, and EGC stages, there are differences and relevance in the transcription expression patterns of DEmRNAs, and the activation related to immune cells is very different. The biological functions continuously changed during the progression from LGIN to HGIN to EGC. The COX model constructed based on the three EGC‐related DEmRNAs has GC prognostic risk prediction ability. The evolution of biological characteristics during the development of EGC mined by the authors provides new insight into understanding the molecular mechanism of EGC occurrence and development. The three‐gene prognostic risk model provides a new method for assisting GC clinical treatment decisions. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

With the development of blue laser endoscopy (BLE) technique, it's often used to diagnose early gastric cancer (EGC) by the morphological changes of blood vessels through BLE. However, EGC is still not obvious to identify, resulting in a high rate of missed diagnosis. Molecular imaging can show the changes in early tumors at molecular level, which provides a possibility for diagnosing EGC. Therefore, developing a probe that visually monitors blood vessels of EGC under BLE is particularly necessary. Herein, a bis‐pyrene (BP) based nanoprobe (BP‐FFVLK‐(PEG)‐RGD, M1) is designed, which can target angiogenesis and self‐assemble into fibers in situ, resulting in stable and long‐term retention in tumor. Moreover, M1 probe can emit yellow‐green fluorescence for imaging under BLE. M1 probe is confirmed to steadily remain in tumor for up to 96 hours in mice transplanted subcutaneously. In addition, the M1 probe is able to target angiogenesis for molecular imaging of isolated human gastric cancer tissue under BLE. Finally, M1 probe i.v. injected into primary gastric cancer model rabbits successfully highlighted the tumor site under BLE, which is confirmed by pathological analysis. It's the first time to develop a probe for diagnosing EGC by visualizing angiogenesis under BLE, showing great clinical significance. [ABSTRACT FROM AUTHOR]

Gastric cancer (GC) is one of the most serious health problems worldwide. Chronic atrophic gastritis (CAG) is most commonly caused by Helicobacter pylori (H. pylori) infection. Currently, endoscopic detection of early gastric cancer (EGC) and CAG remains challenging for endoscopists, and the diagnostic accuracy of H. pylori infection by endoscopy is approximately 70%. Artificial intelligence (AI) can assist endoscopic diagnosis including detection, prediction of depth of invasion, boundary delineation, and anatomical location of EGC, and has achievable diagnostic ability even comparable to experienced endoscopists. In this review we summarized various AI‐assisted systems in the diagnosis of EGC, CAG, and H. pylori infection. [ABSTRACT FROM AUTHOR]

Objective: To clarify the endoscopic, clinicopathological, and growth characteristics of minute gastric cancer (MGC) and to improve its detection rate. Methods: Patients with early gastric cancer who underwent endoscopic submucosal dissection from July 2012 to September 2021 were retrospectively reviewed. MGC was defined as gastric cancer of 5 mm or less in size. Preoperative and postoperative endoscopic and pathological data were collected and analyzed. Follow‐up information was collected until 9 April 2022. Results: Eighty patients were enrolled, with 82 lesions observed under endoscopy and 87 diagnosed histopathologically. All patients received en bloc and curative resection. Compared with the time point when the last endoscopic examiniation prior to lesion deteciton was performed (t0), 64.29% of patients with MGC had disease progression at lesion detection (t1). However, 21.43% showed normal or only atrophic changes under white‐light endoscopy, and their lesions were diagnosed accidentally by random biopsy. The majority of MGC lesions presented as type IIc and reddish, and 95.00% of cases had well‐differentiated tubular adenocarcinoma. The mean growth rate of MGC was 0.0071 mm/day, and it took an average of 3.42 years to grow to 5 mm. There was no significant difference in the depth of invasion between the low cellular atypia group and the high cellular atypia group. Conclusions: Type IIc and reddish appearance are main endoscopic features of MGC. For cases with no obvious endoscopic changes, multipoint biopsy is helpful. MGC is mostly well differentiated and grows relatively slowly; therefore, MGC can still have a chance to be identified and resected curatively if it is missed diagnosed. [ABSTRACT FROM AUTHOR]

Background and Aim: Despite the widespread use of endoscopic submucosal dissection (ESD) for early gastric cancer, post‐ESD bleeding remains a significant problem. Intragastric pH plays an important role in intragastric bleeding. Because gastric acid secretion contributes to intragastric pH, both the presence or absence of Helicobacter pylori infection and the degree of gastric mucosal atrophy may affect bleeding. The present study aimed to clarify the relationship between post‐ESD bleeding and the degree of gastric mucosal atrophy based on H. pylori infection status. Methods: We included 8170 patients who underwent ESD for early gastric cancer at 33 hospitals in Japan from November 2013 to October 2016. We analyzed the risk factors contributing to post‐ESD bleeding. Results: There were 3935 H. pylori‐positive patients and 4235 H. pylori‐negative patients. A nonsevere degree of gastric mucosal atrophy was an independent risk factor for post‐ESD bleeding in H. pylori‐negative patients (odds ratio: 1.51, P = 0.007), but not in H. pylori‐positive patients (odds ratio: 0.91, P = 0.600). Further, in H. pylori‐negative, but not H. pylori‐positive, patients, the rate of post‐ESD bleeding increased in a stepwise manner for patients continuing antithrombotic drug use, patients who withdrew antithrombotic drug use, and antithrombotic drug nonusers. Conclusions: Nonsevere gastric mucosal atrophy was a risk factor for post‐ESD bleeding in early gastric cancer in H. pylori‐negative patients but not in H. pylori‐positive patients. [ABSTRACT FROM AUTHOR]

Screening endoscopy improves detection and prognosis of patients with gastric cancer. However, even expert endoscopists can miss early gastric cancer under standard white light imaging. Texture and color enhancement imaging (TXI) is an image‐enhanced endoscopy that enhances brightness, surface irregularities such elevation or depression, and subtle color changes. A few image‐oriented studies have compared the gastric color differences between neoplastic and peripheral areas under both white light imaging and TXI. The results not only suggested that the overall color differences to be more pronounced in TXI, but also that TXI mode 1 was superior to white light imaging in the visibility of early gastric cancer. Despite the promising results in these initial studies, it is unclear whether the superiority of the image‐enhanced endoscopy will translate into an improvement in early gastric cancer detection in real practice. Therefore, large‐scale prospective studies are necessary to investigate the efficacy of this new technology in the evaluation of patients undergoing screening endoscopy. [ABSTRACT FROM AUTHOR]

Background and Aim: Endoscopic submucosal dissection (ESD) is performed as one of standard treatments for patients with early gastric cancer (EGC) and superficial esophageal squamous cancer (SESCC). A prototype of a flexible endoscope with a 3‐D system has been recently developed. This study aimed to investigate the safety and feasibility of ESD using a 3‐D flexible endoscope (3‐D ESD) for EGC and SESCC. Methods: This single‐center, prospective, observational study enrolled patients who underwent planned 3‐D ESD. The clinical outcomes, including the incidence of adverse events and treatment results, were analyzed. Visibility and manipulation during 3‐D ESD were evaluated using a visual analog scale (VAS). We also evaluated the effect of the 3‐D system on the endoscopist using VAS and the critical flicker fusion frequency (CFFF). Results: We analyzed 47 EGC and 20 SESCC cases. There are no bleeding cases that required transfusion and perforation during 3‐D ESD in both EGC and SESCC patients. However, the incidence of delayed bleeding and delayed perforation was 1.5% (one case) each. The mean VAS scores for recognizing the submucosal layer during the submucosal dissection, visual perception of blood vessel, and depth perception were 72.7 ± 22.2, 74.7 ± 21.8, and 78.2 ± 19.9, respectively. In contrast, the mean VAS score for manipulation was 25.4 ± 19.7. Among endoscopists, there was no significant difference in the VAS of eyestrain and headache before and after ESD, and there was no significant difference in the CFFF. Conclusion: The safety and feasibility of 3‐D ESD for EGC and SESCC are acceptable in both patients and endoscopists. [ABSTRACT FROM AUTHOR]

Background and Aim: Recently, artificial intelligence (AI) has been used in endoscopic examination and is expected to help in endoscopic diagnosis. We evaluated the feasibility of AI using convolutional neural network (CNN) systems for evaluating the depth of invasion of early gastric cancer (EGC), based on endoscopic images. Methods: This study used a deep CNN model, ResNet152. From patients who underwent treatment for EGC at our hospital between January 2012 and December 2016, we selected 100 consecutive patients with mucosal (M) cancers and 100 consecutive patients with cancers invading the submucosa (SM cancers). A total of 3508 non‐magnifying endoscopic images of EGCs, including white‐light imaging, linked color imaging, blue laser imaging‐bright, and indigo‐carmine dye contrast imaging, were included in this study. A total of 2288 images from 132 patients served as the development dataset, and 1220 images from 68 patients served as the testing dataset. Invasion depth was evaluated for each image and lesion. The majority vote was applied to lesion‐based evaluation. Results: The sensitivity, specificity, and accuracy for diagnosing M cancer were 84.9% (95% confidence interval [CI] 82.3%–87.5%), 70.7% (95% CI 66.8%–74.6%), and 78.9% (95% CI 76.6%–81.2%), respectively, for image‐based evaluation, and 85.3% (95% CI 73.4%–97.2%), 82.4% (95% CI 69.5%–95.2%), and 83.8% (95% CI 75.1%–92.6%), respectively, for lesion‐based evaluation. Conclusions: The application of AI using CNN to evaluate the depth of invasion of EGCs based on endoscopic images is feasible, and it is worth investing more effort to put this new technology into practical use. [ABSTRACT FROM AUTHOR]

Objectives: Predicting the depth of invasion for early gastric cancer (EGC) with ulcerative findings may prove difficult. The purpose of this study was to evaluate the extent of ulcer healing and clinical effectiveness of proton pump inhibitor (PPI) administration for ulcerative differentiated EGC prior to endoscopic submucosal dissection (ESD). Methods: A total of 214 patients with ulcerative differentiated EGC who were treated by ESD were retrospectively analyzed, among whom 129 had been administered a PPI prior to ESD and 85 patients had not. The degree of ulcer healing following administration of PPI and the clinical outcome were compared between the PPI and non‐PPI groups. Results: The ulcer healing rate (80.7 vs. 30.6%, P < 0.001) and complete ulcer healing rate (45.0 vs. 16.5%, P < 0.001) differed significantly between the PPI and non‐PPI groups, respectively. The ESD procedure time was 86.0 (73) vs. 100.0 (68.0) min (P = 0.044). However, no significant differences were observed in the en bloc resection rate, complete resection rate, or the incidence of adverse events. Based on the multivariate regression analysis, PPI administration [odds ratio (OR) = 4.909, 95% confidence interval (CI) 2.459–9.799, P < 0.001] and mucosal cancer (OR = 9.336, 95% CI 2.693–32.362, P < 0.001) were independent predictive factors for complete ulcer healing. Partial or complete ulcer healing following PPI administration had a better predictive ability than EUS for mucosal invasion (kappa value 0.553 vs. 0.101; Youden index 0.553 vs. 0.132). Conclusions: Partial or complete ulcer healing following PPI administration predicts differentiated EGC that is confined to the mucosa. [ABSTRACT FROM AUTHOR]

Splenic artery aneurysm (SAA) is a relatively rare disease. Most patients with SAA have no symptoms, and detection is incidental detection. The incidence of rupture is not particularly high, but the mortality rate of ruptured SAAs is high. The main treatment for gastric cancer is gastrectomy with lymph node dissection, with dissection around the celiac artery suggested to be the most important. A 68‐year‐old woman with early gastric cancer in the lesser curvature of the lower gastric corpus was referred to our hospital. CT showed no remarkable findings except for a saccular SAA (diameter, 1.5 cm). We planned laparoscopic distal gastrectomy. However, because the SAA was close to the surgical field and its saccular shape created a rupture risk, we performed interventional radiology for SAA before surgery. One month later, laparoscopic distal gastrectomy with D1+ was performed successfully. The patient has remained disease‐free in the 51 months since the operation. [ABSTRACT FROM AUTHOR]

Background and Aim: Magnifying endoscopy (ME) diagnostic algorithm for early gastric cancer (EGC) relies on qualitative features such as microvascular (MV) architecture and microsurface structure; however, it is a "static" diagnostic algorithm that uses still images. ME can visualize red blood cell flow within subepithelial microvessels in real time. Here, we evaluated the utility of using the MV blood flow rate in combination with ME for the diagnosis of EGC as a retrospective study. Methods: Patients with differentiated‐type EGC (n = 10) or patchy redness (n = 10) underwent ME with blue laser imaging. The mean MV blood flow rates of EGC, patchy redness, and background mucosa were calculated by the mean movement distance of one tagging red blood cell using split images of ME with blue laser imaging videos. We compared the mean MV blood flow rate between EGC, patchy redness, and background mucosa and also calculated the MV blood flow imaging ratio (inside lesion/background mucosa) between EGC and patchy redness. Results: Mean MV blood flow rate was significantly lower in EGC (1481 μm/s; range 1057–1762) than in patchy redness (3859 μm/s; 2435–5899) or background mucosa (4140.6 μm/s; 2820–6247) (P < 0.01). The MV blood flow imaging ratio was significantly lower in EGC (0.39; 0.27–0.62) than in patchy redness (0.90; 0.78–1.1) (P < 0.01). Conclusions: Dynamic diagnosis with MV blood flow rate using ME may be useful for the differential diagnosis of EGC and patchy redness. Endoscopic assessment of dynamic processes within the gastric mucosa may facilitate the diagnosis of EGC. [ABSTRACT FROM AUTHOR]

Background and Aims: A deep convolutional neural network (CNN) was used to achieve fast and accurate artificial intelligence (AI)‐assisted diagnosis of early gastric cancer (GC) and other gastric lesions based on endoscopic images. Methods: A CNN‐based diagnostic system based on a ResNet34 residual network structure and a DeepLabv3 structure was constructed and trained using 21,217 gastroendoscopic images of five gastric conditions, peptic ulcer (PU), early gastric cancer (EGC) and high‐grade intraepithelial neoplasia (HGIN), advanced gastric cancer (AGC), gastric submucosal tumors (SMTs), and normal gastric mucosa without lesions. The trained CNN was evaluated using a test dataset of 1091 images. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the CNN were calculated. The CNN diagnosis was compared with those of 10 endoscopists with over 8 years of experience in endoscopic diagnosis. Results: The diagnostic specificity and PPV of the CNN were higher than that of the endoscopists for the EGC and HGIN images (specificity: 91.2% vs. 86.7%, by 4.5%, 95% CI 2.8–7.2%; PPV: 55.4% vs. 41.7%, by 13.7%, 95% CI 11.2–16.8%) and the diagnostic accuracy of the CNN was close to those of the endoscopists for the lesion‐free, EGC and HGIN, PU, AGC, and SMTs images. The CNN had image recognition time of 42 s for all the test set images. Conclusion: The constructed CNN system could be used as a rapid auxiliary diagnostic instrument to detect EGC and HGIN, as well as other gastric lesions, to reduce the workload of endoscopists. [ABSTRACT FROM AUTHOR]

Gastric cancer is a heterogenous disease with different phenotypes, genotypes, and clinical outcomes, including sensitivity to treatments and prognoses. Recent medical advances have enabled the classification of this heterogenous disease into several groups and the consequent analysis of their clinicopathological characteristics. Gastric cancer associated with Epstein–Barr virus (EBV) and microsatellite‐unstable tumors are considered to be the two major subtypes as they are clearly defined by well‐established methodologies, such as in situ hybridization and polymerase chain reaction‐based analyses, respectively. However, discrepancies in the histological diagnosis of gastric neoplasms remain problematic, and international harmonization should be performed to improve our understanding of gastric carcinogenesis. We re‐evaluated Japanese cases of early gastric cancer according to the current World Health Organization (WHO) criteria and classified them into genomic subtypes based on microsatellite instability (MSI) and EBV positivity to determine the initial genetic events in gastric carcinogenesis. A total of 113 Japanese early gastric cancers (including low‐ and high‐grade dysplasias) treated with endoscopic resection over 5 years were archived in our hospital. A histological re‐evaluation according to the WHO criteria revealed 54 adenocarcinomas, which were divided into 6 EBV‐positive (11.1%), 7 MSI‐high (MSI‐H, 13.0%), and 41 microsatellite stable cases (75.9%). MSI‐H adenocarcinoma was confirmed by an immunohistochemistry assay of mismatch repair proteins. Programmed death‐ligand 1 immunostaining with two antibodies (E1L3N and SP263) was positive in tumor cells of one MSI‐H adenocarcinoma case (1/7, 14.3%). The proportion of stained cells was higher with clone SP263 than with E1L3N. Histologically, EBV‐positive carcinomas were poorly differentiated (83.8%), and MSI‐H cancers were frequent in well to moderately differentiated adenocarcinoma (85.7%), indicating that the EBV‐positive subtype presented with high‐grade morphology even when an early lesion. Our study indicates that the WHO criteria are useful for subdividing Japanese early gastric cancers, and this subdivision may be useful for comparative analysis of precursor lesions and early carcinoma. [ABSTRACT FROM AUTHOR]

Background and Aims: Laser endoscopy involves blue laser imaging in bright mode (BLI‐bright). Linked color imaging (LCI) is superior to white light imaging (WLI) for detecting gastric cancers. This study aimed to detect gastric cancers on screening endoscopy using not only WLI but also BLI‐bright and LCI in patients with atrophic gastritis. Patients and Methods: A total of 500 patients with atrophic gastritis undergoing screening esophagogastroduodenoscopy were included. The gastric lumen was observed in the WLI mode, followed by the LCI and BLI‐bright modes. When gastric neoplasms were suspected, the mode was changed to WLI, and we sprayed indigo carmine. Finally, biopsy specimens were taken for those lesions and pathological diagnosis was made. We compared the size, morphology, and color of gastric neoplasms found by the first WLI mode and those detected by only the LCI mode or BLI‐bright mode. Results: We detected 16 gastric neoplasms (3.2%), of which 13 were early gastric cancers (EGCs) and three were gastric adenomas. Ten EGCs and two gastric adenomas (75%) were detected by the first WLI mode; three EGCs and one gastric adenoma (25%) were missed by the first WLI mode and were detected by the LCI mode or BLI‐bright mode. All were less than 1 cm in diameter and were reddish. Mean diameter of the lesions was significantly less for LCI‐detected or BLI‐bright‐detected lesions than for WLI‐detected lesions (7.8 vs 21.2 mm). Conclusions: Laser endoscopy is useful for detecting EGCs by LCI for patients with atrophic gastritis. [ABSTRACT FROM AUTHOR]

A 79‐year‐old woman with a history of invasive lobular breast cancer presented with a lesion that was endoscopically and histopathologically consistent with poorly differentiated early gastric adenocarcinoma. Endoscopic submucosal dissection was performed, and histopathological examination using additional immunohistochemistry determined that the lesion was metastatic breast cancer. Even if a lesion suspicious of gastric cancer is found on endoscopy in a patient with a history of breast cancer, the possibility of metastasis should be considered and clinicians should inform the pathologists of the possibility. [ABSTRACT FROM AUTHOR]

Background and Aim: Magnifying endoscopy with narrow‐band imaging (ME‐NBI) has made a huge contribution to clinical practice. However, acquiring skill at ME‐NBI diagnosis of early gastric cancer (EGC) requires considerable expertise and experience. Recently, artificial intelligence (AI), using deep learning and a convolutional neural network (CNN), has made remarkable progress in various medical fields. Here, we constructed an AI‐assisted CNN computer‐aided diagnosis (CAD) system, based on ME‐NBI images, to diagnose EGC and evaluated the diagnostic accuracy of the AI‐assisted CNN‐CAD system. Methods: The AI‐assisted CNN‐CAD system (ResNet50) was trained and validated on a dataset of 5574 ME‐NBI images (3797 EGCs, 1777 non‐cancerous mucosa and lesions). To evaluate the diagnostic accuracy, a separate test dataset of 2300 ME‐NBI images (1430 EGCs, 870 non‐cancerous mucosa and lesions) was assessed using the AI‐assisted CNN‐CAD system. Results: The AI‐assisted CNN‐CAD system required 60 s to analyze 2300 test images. The overall accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of the CNN were 98.7%, 98%, 100%, 100%, and 96.8%, respectively. All misdiagnosed images of EGCs were of low‐quality or of superficially depressed and intestinal‐type intramucosal cancers that were difficult to distinguish from gastritis, even by experienced endoscopists. Conclusions: The AI‐assisted CNN‐CAD system for ME‐NBI diagnosis of EGC could process many stored ME‐NBI images in a short period of time and had a high diagnostic ability. This system may have great potential for future application to real clinical settings, which could facilitate ME‐NBI diagnosis of EGC in practice. [ABSTRACT FROM AUTHOR]

In response to the rapid and wide acceptance and use of endoscopic treatments for early gastric cancer, the Japan Gastroenterological Endoscopy Society, in collaboration with the Japanese Gastric Cancer Association, produced "Guidelines for Endoscopic Submucosal Dissection and Endoscopic Mucosal Resection for Early Gastric Cancer" in 2014, as a set of basic guidelines in accordance with the principles of evidence‐based medicine. At the time, a number of statements had to be established by consensus (the lowest evidence level), as evidence levels remained low for many specific areas in this field. However, in recent years, the number of well‐designed clinical studies has been increasing. Based on new findings, we have issued the revised second edition of the above guidelines that cover the present state of knowledge. These guidelines are divided into the following seven categories: indications, preoperative diagnosis, techniques, evaluation of curability, complications, long‐term postoperative surveillance, and histology. [ABSTRACT FROM AUTHOR]

Background and Aim: At present, there is no recognized diagnostic criteria for gastric low‐grade intraepithelial neoplasia (LGIN). The purpose of this study was to determine whether an "endoscopic acanthosis nigricans appearance (EANA)" could be a useful endoscopic marker for distinguishing LGIN lesions from peripheral non‐neoplastic tissues. Methods: A retrospective study was conducted on 638 cases of suspected superficial lesions with endoscopic images from white light endoscopy and magnifying endoscopy combined with narrow band imaging. According to the pathological results of accurate biopsies, those lesions were divided into three groups: a control group, an LGIN group, and an early gastric cancer (EGC) group. Results: According to the presence of EANAs, the sensitivity, specificity, positive predictive value, and negative predictive value for differentiating between the LGIN and control groups were 24.8%, 97.3%, 78.3%, and 76.6%, respectively. The sensitivity (84.1%) and negative predictive value (92.4%) were significantly improved by combining EANA with types IV–VI pit pattern. The intervening part and mean gray value of glands, representing microsurface features and microvascular variation, were significantly larger or higher in EANA lesions than in the surrounding non‐neoplastic mucosa. LGIN with EANA was more likely to be present in lesions of type 0‐IIa. In addition, the prevalence of EANAs in EGC was 16.7%. Conclusion: An EANA could be used as an auxiliary indicator for a diagnosis of LGIN in suspected lesions. It could also play a potential assistive role in the diagnosis of EGC lesions. [ABSTRACT FROM AUTHOR]

Intestinal‐type gastric cancer (IGC) has a clear and multistep histological evolution. No studies have comprehensively explored gastric tumorigenesis from inflammation through low‐grade intraepithelial neoplasia (LGIN) and high‐grade intraepithelial neoplasia (HGIN) to early gastric cancer (EGC). We sought to investigate the characteristics participating in IGC tumorigenesis and identify related prognostic information within the process. RNA expression profiles of 94 gastroscopic biopsies from 47 patients, including gastric precancerous lesions (GPL: LGIN and HGIN), EGC, and paired controls, were detected by Agilent Microarray. During IGC tumorigenesis from LGIN through HGIN to EGC, the number of activity‐changed tumor hallmarks increased. LGIN and HGIN had similar expression profiles when compared to EGC. We observed an increase in the stemness of gastric epithelial cells in LGIN, HGIN, and EGC, and we found 27 consistent genes that might contribute to dedifferentiation, including five driver genes. Remarkably, we perceived that the immune microenvironment was more active in EGC than in GPL, especially in the infiltration of lymphocytes and macrophages. We identified a five‐gene signature from the gastric tumorigenesis process that could independently predict the overall survival and disease‐free survival of GC patients (log‐rank test: p < 0.0001), and the robustness was verified in an independent cohort (n > 300) and by comparing with two established prognostic signatures in GC. In conclusion, during IGC tumorigenesis, cancer‐like changes occur in LGIN and accumulate in HGIN and EGC. The immune microenvironment is more active in EGC than in LGIN and HGIN. The identified signature from the tumorigenesis process has robust prognostic significance for GC patients. © 2020 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland. [ABSTRACT FROM AUTHOR]

Introduction: In laparoscopic gastrectomy, a method to locate the margin of an early‐stage cancerous lesion that is invisible from the serosal surface and impalpable during laparoscopic procedures is needed to determine an appropriate transection line. We conducted a prospective study to develop a new marking method using preoperative submucosal injection of indocyanine green (ICG). Methods: Patients undergoing laparoscopic gastrectomy for T1 gastric cancer were recruited. The first 11 patients comprised the learning set and the subsequent 18 patients the validation set. ICG was endoscopically injected in the submucosal layer of the stomach approximately 1 cm away from the tumor edge 1 or 3 days before surgery. The diameters of the visualized ICG were compared with those of a conventional marking method using India ink in 10 historical controls. Results: In the learning set, the optimal amount of ICG was determined to be 0.1 mL at a concentration of 0.5 mg/mL. In the validation set, the same procedure was repeated. No technical problems or adverse reactions related to ICG injection were observed. In all cases, ICG was successfully detected, and negative surgical margins were pathologically confirmed. The mean long diameter of the visualized ICG fluorescence measured at the mucosal surface of the stomach was significantly smaller in the current study than in the historical controls in whom India ink was used (21 vs 52 mm, P < 0.0001). Conclusions: The preoperative submucosal ICG marking was safely performed and successfully detected without excessive blurring during laparoscopic gastrectomy. [ABSTRACT FROM AUTHOR]

Epstein‐Barr virus‐positive gastric cancer (EBVGC) comprises approximately 9% of all gastric cancers and is associated with a low prevalence of lymph node metastasis (LNM). Given that limited data concerning LNM in EBV‐related early GC are available, EBV status is not considered an indicator for endoscopic submucosal dissection (ESD). In this review, we focused on pT1 EBVGC and on gastric carcinoma with lymphoid stroma (GCLS), and discuss expanded ESD indications and curative resection criteria. In pT1b EBVGC, the incidence of LNM was low (6/180 patients, 3.3%; 95% confidence interval [CI] 1.2–7.1), especially in lymphovascular invasion‐negative EBVGC (1/109 patients, 0.9%). No patients with pT1a EBVGC had LNM (0/38 patients, 0%; 95% CI 0–7.6), even those who did not meet the current curative ESD criteria. Although the frequency of LNM in GCLS was low (5.0–10.6%), the incidence of LNM in non‐EBV GCLS was relatively high (10.0–20.0%); therefore, EBV status can be considered a more important factor than GCLS. In summary, the clinicopathological characteristics of EBVGC differ from those of conventional GC, and EBV negativity is a risk factor for LNM in early GC. Therefore, patients in this group are likely to be promising candidates for ESD, and we recommend that EBV status evaluation be included in early GC treatment guidelines. [ABSTRACT FROM AUTHOR]

Japanese guidelines for gastric cancer treatment were first published in 2001 for the purpose of showing the appropriate indication for each treatment method, thereby reducing differences in the therapeutic approach among institutions, and so on. With the accumulation of evidence and the development and prevalence of endoscopic submucosal dissection (ESD), the criteria for the indication and curability of endoscopic resection (ER) for early gastric cancer (EGC) have expanded. However, several problems still remain. Although a risk‐scoring system (eCura system) for predicting lymph node metastasis (LNM) may help treatment decision in patients who do not meet the curative criteria for ER of EGC, which is referred to as eCura C‐2 in the latest guidelines, additional gastrectomy with lymphadenectomy may be excessive for many patients, even those at high risk for LNM. Less‐invasive function‐preserving surgery, such as non‐exposed endoscopic wall‐inversion surgery with laparoscopic sentinel node sampling, may overcome this problem. In addition, further less‐invasive treatment, such as ER with chemotherapy, should be established for patients who prefer not to undergo additional gastrectomy. [ABSTRACT FROM AUTHOR]

Objectives: The pathological diagnosis of endoscopically resected early gastric cancer (EGC) is performed by evaluating a few representative sections from the specimen. We aimed to determine whether evaluating twice as many sections as usual by essentially cutting the original sections in half could improve the pathological diagnosis of EGC. Methods: We retrospectively investigated 85 EGC in 82 patients who had undergone endoscopic resection at our hospital from August 2008 to October 2012. EGC without indications of curative resection were excluded. We re‐examined the original paraffin blocks after shaving away approximately half their original thickness, and evaluated whether the pathological diagnoses were affected. This technique essentially doubled the number of sections examined. Results: Ten pathological diagnoses of 68 EGC (14.7%) were changed from curative resection to non‐curative resection when we evaluated twice as many sections as in the standard method. The median tumor size was 25 mm in the changed diagnosis group versus 14.5 mm in the no change group (P = 0.03). The univariate analysis also showed that tumor size was a significant predictor of changed diagnosis (P = 0.015). Both the changed diagnosis group and no change group had no recurrence during follow up. Conclusions: Histological evaluation of twice as many sections as usual changed the initial pathological diagnosis of EGC, although the clinical implication of an additional deeper section was controversial because there was no recurrence. Our analysis also emphasized the importance of detailed histological evaluation to confirm a radical cure in endoscopic resection, especially in the case of larger EGC. [ABSTRACT FROM AUTHOR]

With the wide application of endoscopic resection for early gastric cancer (EGC) by not only Asian endoscopists but also those from Western countries, reviews on standardized treatment processes before and after endoscopic resection are nevertheless lacking. In this article we provide a narrative review of studies on the selection of appropriate EGC for endoscopic resection and the follow‐up strategies for those with histologically confirmed EGC after endoscopic resection. EGC should be comprehensively assessed before endoscopic resection, including its exact margin, invasive depth and risk of lymph node metastasis (LNM). While the curative resection status of EGC may be evaluated after endoscopic resection based on the newly developed eCura system, although this needs to be further verified. Surveillance with endoscopy and computed tomography scan is necessary for patients with an EGC level A or B. An additional endoscopic resection is recommended for patients with a level‐C1 EGC. For patients with a level‐C2 EGC, close follow‐up is suggested for low‐risk tumors of level C2 and additional surgery for those at high risks. Further postoperative strategy is suggested based on comprehensive assessment of the risk of LNM, patient's quality of life and wishes. [ABSTRACT FROM AUTHOR]

Endoscopic submucosal dissection (ESD) is technically challenging as a result of a lack of depth perception. The present article investigated the 3‐D endoscope for carrying out ESD and translated the technique from bench to clinical use. In a preclinical porcine experiment, ESD using a 3‐D endoscope was compared between an experienced and a novice endoscopist. All ESD were completed without perforation. Median operative time per surface area was significantly lower for the experienced endoscopist than for the novice (197.9 s/cm2vs 434.7 s/cm2; P = 0.05). The second part was a prospective clinical experience to evaluate use of the 3‐D endoscope for carrying out ESD. Ten patients received ESD using the 3‐D endoscope. Four patients had gastric ESD, two had duodenal ESD and four had sigmoid and rectal ESD. There were no complications, whereas ESD failed in one patient who had gastric neoplasia at anastomosis. Mean operative time was 99.4 min, and operative time per surface area resection was 391 s/cm2. The operating endoscopist did not complain of motion sickness, whereas the assistants had some dizziness upon prolonged ESD procedure. This study showed that carrying out ESD was safe and effective using a 3‐D endoscope with an excellent 3‐D view enhancing depth perception. Future study should be conducted to compare 3‐D against 2‐D endoscopes for ESD. [ABSTRACT FROM AUTHOR]

Objectives: A Japanese multicenter prospective cohort study examining endoscopic resection (ER) for early gastric cancer (EGC) has been conducted using a Web registry developed to determine the short‐term and long‐term outcomes based on absolute and expanded indications. We hereby present the short‐term outcomes of this study. Methods: All consecutive patients with EGC or suspected EGC undergoing ER at 41 participating institutions between July 2010 and June 2012 were enrolled and prospectively registered into the Web registry. The baseline characteristics were entered before ER, and the short‐term outcomes were collected at 6 months following ER. Results: Nine thousand six hundred and sixteen patients with 10 821 lesions underwent ER (endoscopic submucosal dissection [ESD]: 99.4%). The median procedure time was 76 min, and R0 resections were achieved for 91.6% of the lesions. Postoperative bleeding and intraoperative perforation occurred in 4.4% and 2.3% of the patients, respectively. Significant independent factors correlated with a longer procedure time (120 min or longer) were as follows: tumor size >20 mm, upper‐third location, middle‐third location, local recurrent lesion, ulcer findings, gastric tube, male gender, and submucosa. Histopathologically, 10 031 lesions were identified as common‐type gastric cancers. The median tumor size was 15 mm. Noncurative resections were diagnosed for 18.3% of the lesions. Additional surgery was performed for 48.6% (824 lesions) of the 1695 noncurative ER lesions with a possible risk of lymph node (LN) metastasis. Among them, 64 (7.8%) exhibited LN metastasis. Conclusions: This multicenter prospective study showed favorable short‐term outcomes for gastric ESD. [ABSTRACT FROM AUTHOR]

Gastric cancer is common in China. At present, early detection with prompt resection of early gastric carcinoma (EGC) is crucial for improving patient's survival. Because of high heterogeneity of EGC in Chinese patients we reviewed recent clinicopathological and molecular evidence and proposed a grouping EGC in three subgroups according to their location for appropriate management. In group 1 (cardia), most patients with EGC in this small location were elderly men. The tumors originated in the cardiac mucosa with a high proportion of cases with slightly elevated gross patterns and intestinal adenocarcinoma histology with moderate to well differentiation. Poorly cohesive carcinoma was infrequent. As the risk for lymph node metastasis in this kind of tumor was significantly lower than that in the distal stomach, endoscopic therapy is preferred. Group 2 (fundus‐corpus), many patients with EGC in this large location were young women. The EGCs originated in the oxyntic mucosa with pure and mixed poorly cohesive carcinomas that are more commonly present in this area than in any other. Most tumors were poorly differentiated with a high risk for lymph node metastasis. Thus, endoscopic therapy may be appropriate for intramucosal, but not for submucosal, carcinoma. Group 3 (antrum‐pylorus). EGC tumors arose from the antral mucosa, primarily because of Helicobacter pylori infection, following the Correa gastric cancer tumorigenetic pathway. Erosive and ulcerated gross patterns were most frequently observed. While most EGCs in this location were mainly intestinal adenocarcinomas, poorly differentiated EGCs were substantial in number. Because the risk of lymph node metastasis remains to be illustrated, clinical management requires an individualized approach. This preliminary observation requires verification in large nationwide multicenter studies. [ABSTRACT FROM AUTHOR]

Chronic gastritis caused by Helicobacter pylori (H. pylori) infection could lead to the development of gastric cancer. The finding that multiple gastric cancers can develop synchronously and/or metachronously suggests the development of field cancerization in chronically inflamed, H. pylori‐infected gastric mucosa. The genetic basis of multiple tumorigenesis in the inflamed stomach, however, is not well understood. In this study, we analyzed the microsatellite instability (MSI) status and copy number aberrations (CNAs) of 41 multiple intramucosal early gastric cancers that synchronously or metachronously developed in 19 patients with H. pylori infection. Among the 41 intramucosal gastric carcinomas, 9 (22%) exhibited MSI, and the remaining 32 (78%) exhibited the microsatellite stable (MSS) phenotype. Metachronous multiple intramucosal gastric carcinoma exhibit inter‐tumor heterogeneity by individually acquiring genetic aberrations. All synchronous multiple intramucosal gastric carcinoma pairs shared a common MSI/MSS profile, and CNA analysis revealed that synchronous multiple intramucosal gastric carcinoma pairs with the MSS phenotype shared common aberrations of representative tumor‐suppressor genes, including focal deletion of APC, TP53, CDKN2A, and CDKN2B. Multiregional CNA analysis revealed that heterogeneous gene amplifications/deletions, including PDL1 amplification, evolved under the presence of shared “trunk” genetic alterations in a subpopulation of individual intramucosal gastric carcinomas. These data suggest that multiple gastric carcinomas develop in a multicentric/multifocal manner exhibiting features of inter‐ and intra‐tumor heterogeneity in H. pylori‐infected gastric mucosa, whereas synchronous multiple intramucosal gastric carcinomas could share partially common genetic alterations, possibly via common oncogenic pathways. [ABSTRACT FROM AUTHOR]

Background and Aim: With the aging of society, comorbidities or nutritional status are assessed prior to endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). However, it is uncertain which factors are important for predicting prognosis in EGC patients after ESD. Thus, we aimed to evaluate clinical outcomes of ESD for EGC, with respect to comorbidities or nutritional status. Methods: We carried out a retrospective study involving 708 EGC in 585 patients who were enrolled between April 2007 and March 2012. They were classified into two groups; an elderly (≥80 years) and non‐elderly (<80 years) group. Short‐ and long‐term outcomes were evaluated between the groups. Results: There were no significant differences regarding short‐term outcomes. Overall survival (OS) rates in the elderly group were significantly lower than those in the non‐elderly group (P = 0.001). OS rates in patients with a low (≤2) Charlson comorbidity index (CCI) were significantly higher than those in patients with a high (≥3) CCI, regardless of age. OS rates in patients with a high (≥47.7) prognostic nutritional index (PNI) were significantly higher than those in patients with a low (<47.7) PNI, regardless of age. In multivariate analysis, an Eastern Cooperative Oncology Group performance status (PS) ≥2 (hazard ratio [HR], 95% confidence interval: 3.23, 1.54–6.75), CCI ≥3 (HR 7.88, 4.50–13.80) and PNI <47.7 (HR 3.44, 2.00–5.90) were significantly associated with OS rate (P < 0.01). Conclusion: CCI and PNI can be prognostic indicators for non‐elderly and elderly patients with EGC after ESD. [ABSTRACT FROM AUTHOR]

Endoscopic submucosal dissection (ESD) was first conceptually described almost 30 years ago in Japan and is now widely practiced throughout East Asia. ESD expands the boundaries of endoscopic resection (ER) by allowing en bloc resection of large early neoplastic lesions within the gastrointestinal tract (GIT). This offers advantages over other ER techniques by facilitating definitive histological staging and curative treatment of early cancer in selected cases. Indeed, the experience of ESD in Eastern countries is significant, and excellent outcomes from high‐volume centers are reported. The potential benefits of ESD are recognized by Western endoscopists, but its adoption has been limited. A number of factors contribute to this, including epidemiological differences in GIT neoplasia between Western and Eastern populations and limitations in training opportunities. In this review, we discuss the role of ESD, its current status and the future in Western endoscopic practice. [ABSTRACT FROM AUTHOR]

Background Less invasive surgery is widely used in the treatment of early gastric cancer; however, no definite guidelines exist regarding indications for less invasive surgery to treat early gastric cancer with signet ring cell histology. The aim of this study was to identify risk factors for lymph node metastasis ( LNM) in early signet ring cell carcinoma ( SRC). An extensive search of PubMed, Embase and the Cochrane library was performed for pertinent articles involving early SRC and LNM. Methods Eligible data (gender, depth of invasion, lymphovascular invasion, size, ulceration, macroscopic type and location) were extracted from the included studies and systematically reviewed via a meta-analysis. Review Manager version 5.3 was used to perform the data processing. The Newcastle-Ottawa Scale was utilized to evaluate the quality of the included articles. Results Fourteen studies were included in the final analysis. After meta-analysis, female gender, submucosal invasion, lymphovascular invasion and size >20 mm were associated with LNM in early SRC. Conclusion Four variables were identified as risk factors for LNM in early SRC. The significance of the results of the present study should be further confirmed in more early SRC patients for future clinical use. [ABSTRACT FROM AUTHOR]

Background/Aim The authors aimed to determine the clinical value of colonoscopy by evaluating the frequency of colorectal neoplasm ( CRN) detection in patients with early gastric cancer ( EGC) as compared with healthy controls and analysed the risk factors of advanced CRN in patients with EGC. Methods The medical records of 201 patients diagnosed as EGC and age- and gender-matched healthy controls were retrospectively reviewed. Frequencies and clinical features of colorectal polyps of patients and controls were compared. Risk factors of advanced CRN in patients with EGC were also analysed. Results Frequencies of CRN in patients and controls were 49.8 and 49.3% respectively ( P = 0.90). They were more common in the right colon in patients ( P < 0.05). Advanced CRN were found in 10.3% of patients and in 3% of controls ( P < 0.05). Multivariate analysis revealed that old age and smoking history were risk factors of an advanced CRN in patients with EGC. Conclusion The prevalence of a coexisting advanced CRN was higher in EGC patients. The study shows colonoscopy plays an important role with respect to the detection of synchronous advanced CRN in patients with EGC. [ABSTRACT FROM AUTHOR]

Background and Aim: We evaluated probe-based confocal laser endomicroscopy (pCLE) in the margin delineation of early gastric cancer (EGC) for endoscopic submucosal dissection in comparison with white-light imaging with chromoendoscopy (CE). Methods: We conducted a prospective, randomized controlled study from November 2013 to October 2014 in a tertiary referral hospital. A total of 101 patients scheduled for endoscopic submucosal dissection due to differentiated EGC were randomized into pCLE and CE groups (pCLE 51, CE 50). Markings were made by electrocautery at the proximal and distal tumor margins, as determined by either pCLE or CE. The distance from the marking to the tumor margin was measured in the resected specimen histopathologically and was compared between the two groups by a linear mixed model. Results: Among 104 lesions, 80 lesions with 149 markings (pCLE 68, CE 81) were analyzed after excluding undifferentiated EGCs (n = 8) and unidentifiable markings (n = 13). Although the complete resection rate showed no difference between the groups (94.6% vs 93.2%, P = 1.000), the median distance from the marking to the margin was shorter in the pCLE group (1.3 vs 1.8 mm, P = 0.525) and the proportion of the distance <1 mm was higher (43.9% vs 27.6%, P = 0.023) in the pCLE group. Finally, subgroup analysis with superficial flat lesions (18 lesions, 31 marking dots) showed a significantly decreased distance in the pCLE group (0.5 vs 3.1 mm, P = 0.007). Conclusions: Among EGCs with superficial flat morphology, in which the accurate evaluation of lateral extent is difficult with CE, pCLE would be useful for more precise margin delineation. [ABSTRACT FROM AUTHOR]

Evaluating the prevalence and severity of gastritis by endoscopy is useful for estimating the risk of gastric cancer (GC). Moreover, understanding the endoscopic appearances of gastritis is important for diagnosing GC due to the fact that superficial mucosal lesions mimicing gastritis (gastritis-like lesions) are quite difficult to be detected even with optimum preparation and the best technique, and in such cases tissue biopsy is often not very accurate for the diagnosis of gastric epithelial neoplasia. Magnifying endoscopy is a highly accurate technique for the detection of early gastric cancer (EGC). Recent reports have described that various novel endoscopic markers which, visualized by magnifying endoscopy with image-enhanced system (ME-IEE), can predict specific histopathological findings. Using ME-IEE with vessels and surface classification system (VSCS) may represent an excellent diagnostic performance with high confidence and good reproducibility to the endoscopists if performed under consistent conditions, including observation under maximal magnification. The aim of this review was to discuss how to identify high-risk groups for GC by endoscopy, and how to detect effectively signs of suspicious lesions by conventional white light imaging (C-WLI) or chromoendoscopy (CE). Furthermore, to characterize suspicious lesions using ME-IEE using the criteria and classification of EGC based upon VSCS. [ABSTRACT FROM AUTHOR]

Background and Aim Chromoendoscopy (CE) is widely used in the diagnosis of early gastric cancer (EGC) and premalignant gastric lesions (PGLs). We conducted a meta-analysis to evaluate the diagnostic efficacy of CE for EGC and PGLs. Methods We searched PubMed/MEDLINE, EMBASE, and the Cochrane library to identify all eligible studies according to inclusion and exclusion standards. Publication bias was tested using Funnel plots and Egger's test. The possible sources of the heterogeneity were explored by performing a meta-regression analysis. Heterogeneity was assessed by the Q test and I2 statistic. Results Ten studies met the inclusion standards, including a total of 699 patients and 902 lesions. The pooled sensitivity, specificity, and area under the curve of CE were 0.90 (95% confidence interval, 0.87-0.92), 0.82 (95% confidence interval, 0.79-0.86), and 0.9464, respectively. In subgroup analysis of diagnostic accuracy, CE showed higher accuracy versus standard white light endoscopy for EGC ( P = 0.005) and PGLs ( P = 0.001). Conclusion Chromoendoscopy seems to have a high diagnostic efficacy and improve the detection of EGC and PGLs compared with standard white light endoscopy. [ABSTRACT FROM AUTHOR]

Background and Aim Although follow-up endoscopy is routinely performed after endoscopic resection (ER) for early gastric cancer (EGC), it remains unclear whether resection scar biopsies should also be taken. This study sought to predict local recurrence at the ER scar on the basis of endoscopic criteria after margin-negative EGC resection and to determine the necessity of taking scar biopsies. Methods All consecutive patients with EGC who underwent margin-negative ER in June 1995 to December 2011 and developed recurrence at the scar were identified. Each case was matched by four controls with EGC and margin-negative ER but without local recurrence for age, sex, and en-bloc resectability (en-bloc vs. piecemeal resection). Endoscopic data were reviewed by consensus of two endoscopists. Key endoscopic criteria were gross morphology (evenly elevated, unevenly elevated, and flat), hyperemic change, mucosal defect, and spontaneous bleeding. Results Of 3037 cases, which underwent margin-negative ER, 22 developed local recurrence (mean age, 63.8 years; 72.9% male). En-bloc resection was achieved in 20 of the 22 (90.9%). Flat endoscopic morphology without hyperemic changes predicted non-recurrence at the scar with a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 95.5%, 68.2%, 2.6%, 99.94%, and 73.6%, respectively. For patients who underwent en-bloc resection for differentiated EGC, these values were 100%, 71.4%, 3.0%, 100%, and 75.8%, respectively. Conclusions Routine follow-up biopsies may be unnecessary when follow-up endoscopy reveals flat mucosa without hyperemic changes at the scar, especially for en-bloc resected and differentiated EGCs. [ABSTRACT FROM AUTHOR]

Objectives Endoscopic resection (ER) is becoming an increasingly used treatment option for early gastric cancer (EGC); however, data comparing the long-term outcomes of ER and surgery are limited. Accordingly, we here aimed to perform a meta-analysis to clarify the long-term outcomes and safety of ER and surgery for EGC. Methods Literature on the direct comparison of ER and surgery for EGC was retrieved from the Medline, PubMed and Scopus databases. We selected the eligible studies, extracted data, and assessed the quality scores according to the guidelines. The overall survival (OS), recurrence-free survival (RFS), and adverse event rates were investigated, and the pooled hazard ratio (HR), odds ratio (OR), and 95% confidence interval (CI) were estimated. Results Nine retrospective studies were identified, including 973 and 1190 participants undergoing ER and surgery, respectively. There were no significant differences regarding the OS (HR: 0.995, 95% CI: 0.836-1.185; P = 0.959) and adverse event rates (OR: 0.50, 95% CI: 0.20-1.28, P = 0.148) between ER and gastrectomy. However, patients undergoing ER had significantly shorter RFS (HR: 7.226, 95% CI: 1.718-30.400, P = 0.007) than those undergoing gastrectomy. Conclusions Despite the limitations of this review, including the retrospective nature of all included studies, our results suggest that ER might be a feasible and safe treatment strategy compared to that of gastrectomy for EGC; however, careful endoscopic surveillance is needed for ensuring favorable outcomes. These findings should be confirmed in further large-scale, prospective, randomized, controlled trials from different countries. [ABSTRACT FROM AUTHOR]

The relevance of the clinicopathological and molecular features of early gastric cancers (EGCs) having the microsatellite instability (MSI)-high phenotype has not been clearly defined in sporadic gastric carcinogenesis. Here, we examined the clinicopathological and molecular characteristics of EGC according to MSI status in 330 patients with EGC (intestinal-type adenocarcinoma). Tumors were classified as MSI-high (45 cases), MSI-low (9 cases), or microsatellite stable (MSS; 276 cases). The specimens were examined using a combination of polymerase chain reaction (PCR)-microsatellite assays and PCR-pyrosequencing to detect chromosomal allelic imbalances in multiple cancer-related chromosomal loci, MSI, gene mutations ( KRAS and BRAF) and methylation status [high methylation epigenome (HME), intermediate methylation epigenome and low methylation epigenome]. In addition, the expression levels of various target proteins were examined using immunohistochemistry. Interestingly, EGC with the MSI phenotype showed distinct papillary features. The expression of gastric mucin was more frequent in EGC with the MSI phenotype, while p53 overexpression was common in EGCs, irrespective of MSI status. The frequency of HME was significantly higher in EGCs with the MSI phenotype than in EGCs with the MSS phenotype. Although there was a low frequency of allelic imbalance in EGCs with the MSI phenotype, some markers of allelic imbalance were more frequently detected in EGCs with the MSI-high phenotype than in EGCs with the MSS phenotype. KRAS and BRAF mutations were rare in EGCs. Thus, the MSI phenotype in EGC is a major precursor lesion in gastric cancer and is characterized by distinct clinicopathological and molecular features. [ABSTRACT FROM AUTHOR]

In response to the rapid and wide acceptance and use of endoscopic treatments for early gastric cancer, the Japan Gastroenterological Endoscopy Society (JGES), in collaboration with the Japanese Gastric Cancer Association (JGCA), has produced 'Guidelines for ESD and EMR for Early Gastric Cancer', as a set of basic guidelines in accordance with the principles of evidence-based medicine. These Guidelines cover the present state of knowledge and are divided into the following seven categories: Indications, Preoperative diagnosis, Techniques, Evaluation of curability, Complications, Long-term postoperative surveillance, and Histology. Twenty-three statements were finally accepted as guidelines, and the majority of these were obtained from descriptive studies with lower evidence levels. A number of statements had to be created by consensus (the lowest evidence level), as evidence levels remain low for many specific areas in this field. [ABSTRACT FROM AUTHOR]

Background and Aim: Endoscopic ultrasonography (EUS) is a widely used imaging modality for detecting the depth of early gastric cancer (EGC) invasion. However, the studies pertaining to EUS for staging early gastric cancer have reported widely varied sensitivities and specificities. This study was conducted to estimate the overall diagnostic accuracy of EUS for staging the depth in EGCs. Methods: The literatures were identified by searching in PubMed, Embase, and Web of Knowledge databases. Two reviewers independently extracted the information from the literatures for constructing 2 × 2 table. A random-effect model or a fixed-effect model was used to estimate the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio. A summary receiver operating characteristic curve also was constructed. Meta-regression and subgroup analysis were used to explore the sources of heterogeneity. Results: The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of EUS for M staging were 76% (95% confidence interval [CI], 74-78%), 72% (95% CI, 69-75%), 3.67 (95% CI, 2.48-5.44), and 0.31 (95% CI, 0.24-0.40), respectively. For SM staging, these results were 62% (95% CI, 59-66%), 78% (95% CI, 76-80%), 2.99 (95% CI, 2.26-3.96), and 0.43 (95% CI, 0.32-0.57), respectively. For M/SM1 staging, they were 90% (95% CI, 88-92%), 67% (95% CI, 61-72%), 3.14 (95% CI, 2.08-4.73), and 0.12 (95% CI, 0.07-0.22), respectively. The area under the curve for mucosal, submucosal, and mucosal/minimal submucosal invasion staging were 0.85, 0.82, and 0.81, respectively. Conclusions: Endoscopic ultrasonography only has a relatively low accuracy for staging the depth of invasion in EGCs. Accordingly, EUS may be not indispensable in the staging of EGCs. [ABSTRACT FROM AUTHOR]

Gastric cancer (GC) is the fifth most common cancer and the third leading cause of cancer-related deaths in the world. The prognosis of GC is clearly associated with the tumor stage, with a 5-year overall survival rate for early gastric cancer (EGC) exceeding 90%, which is significantly higher than that of advanced gastric cancer. Endoscopic resection, including endoscopic mucosal resection and endoscopic submucosal dissection, has been adopted in recent decades as the first treatment option of EGC in many countries for its minimal invasion and high curative rate. However, the horizontal and vertical margins are related to the curative resection of EGC and the prognosis of patients. Thus the accurate prediction of the tumor boundary and its invasive depth before treatment counts for much in planning the most appropriate treatment strategy and promising curative resection. To date, various endoscopic techniques have been identified to play a role in pretreatment evaluation, such as white light endoscopy, chromoendoscopy, narrow band imaging and endoscopic ultrasonography. This article aimed to summarize the diagnostic methods, applications and limitations of these different endoscopic techniques for identifying tumor horizontal and vertical margins in EGC, helping to increase preoperative evaluation of capabilities and to improve the curative resection rate of EGC. [ABSTRACT FROM AUTHOR]

Background and Aims The clinical significance and prognosis of mixed adenocarcinoma in early gastric cancer ( EGC) are incompletely understood. The aim of this study was to evaluate the clinicopathological characteristics and long-term outcomes of mixed adenocarcinoma diagnosed as EGC after endoscopic submucosal dissection ( ESD). Methods There were 430 EGCs histologically proven by ESD in 395 patients. The clinicopathological characteristics and long-term outcomes, including the rates of local recurrence, were evaluated according to histological type in EGC treated with ESD. Results In total, 430 EGCs were classified as 362 (84.4%) tubular adenocarcinomas, 41 (9.5%) poorly cohesive carcinomas ( PCCs), 26 (6.0%) mixed adenocarcinomas, and 1 (0.2%) papillary adenocarcinoma according to the World Health Organization classification. Although the en bloc resection rate was acceptable (92.3%) for mixed adenocarcinoma, the complete resection rate was lower (53.8%) than those in other types ( P < 0.01). Local recurrence occurred in 5 (19.2%) of 26 mixed adenocarcinomas after ESD. In a multivariate analysis, mixed adenocarcinoma was an independent risk factor predicting local recurrence after ESD for EGC (hazard ratio, 7.039; P < 0.01). Conclusion Mixed adenocarcinoma is more aggressive than other histological types of EGC based on clinical outcomes. Moreover, it is an independent prognostic factor for local recurrence after ESD for EGC. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Current guidelines for treating early gastric cancer (EGC) with endoscopic submucosal dissection (ESD) are being developed with broader criteria. This systematic review and meta-analysis aimed to assess the application of expanded indications (EIN) by comparing outcomes between conventional indication (CIN) and EIN groups. METHODS: Literature databases were searched. Short-term outcomes, including endoscopic resection rates, complications and local recurrence, and longterm outcomes including gastric cancer-specific mortality and overall mortality were compared in the two groups. RESULTS: In all, 13 studies were identified and evaluated. The EIN group had lower rates of en bloc (93.6% vs 97.0%, P < 0.0001), complete (87.8% vs 95.8%, P < 0.00001) and curative resection (82.4% vs 94.0%, P < 0.00001) than the CIN group. The rates of delayed bleeding and perforation were both significantly higher in the EIN group (3.9% vs 2.8%, P = 0.04 and 3.9% vs 1.8%, P < 0.0001). Local recurrence rates were 0.6% in the CIN group and 1.5% in the EIN group (P = 0.03). There were no significant differences between the two groups in the gastric-cancer specific mortality (P = 0.22) and the overall mortality (P = 0.37). CONCLUSIONS: Long-term mortality in the EIN group did not significantly differ from those in the CIN group, although the EIN group was associated with more unfavorable short-term outcomes. Thus, ESD could be recommended as an effective therapy for EGC of EIN. [ABSTRACT FROM AUTHOR]

Background and Aim We have focused on sodium alginate ( SA) solution as a potential submucosal injection material for endoscopic submucosal dissection ( ESD). A previous SA solution had high viscosity and problems such as difficult handling. After its properties were adjusted, SA solution was examined in vitro and its clinical safety was evaluated. Methods With 0.4% sodium hyaluronate ( SH) solution as a control, catheter injectability and mucosa-elevating capacity of 0.3-0.8% SA solutions were evaluated. Next, 0.6% SA solution was used for ESD in 10 patients with early gastric cancer in a prospective clinical study. Results Compared with 0.4% SH solution, 0.6% SA solution exhibited no significant difference in catheter injectability but significant superiority in mucosa-elevating capacity. In the clinical study, no adverse events were observed in any patient. Conclusion The safety of 0.6% SA solution as a submucosal injection material was confirmed and it is suggested that its efficacy should be investigated in a larger number of cases. [ABSTRACT FROM AUTHOR]

Background and Aim There are a number of published reports on long-term outcomes of endoscopic submucosal dissection ( ESD) for early gastric cancer ( EGC), but most reports are from single centers with median follow-up periods shorter than 5 years. This questionnaire study investigated long-term outcomes of curative ESD for EGC at six Japanese institutions with follow-up rates of at least 90% over a minimum 5-year period. Methods All consecutive patients with initial-onset EGC who underwent ESD through December 2006 at the six institutions were included in our study. The questionnaire covered pathological curability and long-term outcomes of patients with curative resections or curative resections for expanded indications over follow-up periods of at least 5 years. Results There were 3788 patients with initial-onset EGC including 1710 (45.1%) patients with curative resections and 1289 (34.0%) patients with curative resections for expanded indications. The remaining 789 (20.8%) patients had non-curativeresections. Altogether, 1601 (93.6%) patients with curative resections and 1205 (93.5%) patients with curative resections for expanded indications were successfully followed up for at least 5 years. No recurrences were reported in any of the 1601 patients with curative resections whereas three recurrences (0.2%) were reported in the 1205 patients with curative resections for expanded indications. Gastric cancer-related deaths occurred in seven (0.2%) of the 2806 patients with curative resections or curative resections for expanded indications including six patients with metachronous gastric cancer-related deaths. Conclusion This questionnaire study's results indicated favorable long-term outcomes for patients with curative resections or curative resections for expanded indications. [ABSTRACT FROM AUTHOR]

With the ever-increasing concern regarding morbidity and mortality associated with diseases of the gastrointestinal tract, the importance of an effective and efficient diagnostic tool cannot be overstated. The standard of care currently is an examination using conventional white light endoscopy. This approach may occasionally overlook areas exhibiting a premalignant change. Numerous image-enhanced modalities have been recently introduced. Narrow band imaging ( NBI) appears to be the most prominent of these and perhaps the most commonly used. Thepresent review will focus on some of the newer studies on NBI and its utility in the diagnosis of malignant, pre-malignant and chronic inflammatory conditions of the upper gastrointestinal tract. [ABSTRACT FROM AUTHOR]