Mistakes in ... 2021 - 28

ueg education
Mistakes in... 2021
Mistake 6 Missing synchronous lesions
All gastric polyps, except FGPs and rare
inflammatory fibroid polyps, are associated with
an increased risk of cancer. There is a strong
association between gastric adenomas and
synchronous gastric cancer (figure 3), with
coexistent cancer being found in up to 30% of
patients.16
A review of the natural history of
gastric dysplasia suggests that once high-grade
dysplasia has been detected, the risk of
progression to cancer or the development of a
synchronous malignancy is 60-85% within
4-48 months.17
Detection of gastric dysplasia and early gastric
cancer is especially difficult at endoscopy, with
insufflation and careful mucosal washing
essential to ensure adequate views. Subtle
features include loss of vascular or pit patterns,
flattening or abnormal convergence of folds and
mucosal depression, as well as ulceration or
nodularity.18
Synchronous dysplasia can be
present throughout the stomach; however, there
is a slight predominance in the antrum, lesser
curve and incisura.
Mistake 7 Not assessing the background
stomach
If gastric adenomas or hyperplastic polyps are
present, the background mucosa should also
be carefully assessed for the presence of
precancerous lesions that might predict future
cancer risk. This includes CAG and gastric
intestinal metaplasia (GIM) (figure 3).
Atrophy is readily identifiable by mucosal
pallor, increased visibility of vessels, loss of rugal
folds and the presence of an atrophic border.
However, a complete assessment should include
the use of image enhancement for delineating
the presence of GIM, which is often visible as
elevated pink patches or plaques-an elongated
'groove type' pit pattern in the body and the light
Figure 4 | Endoscopic appearance of the atrophic border and modified Kimura-Takemoto classification system.
a and b | Low power view of atrophic gastritis at white light endoscopy. The abrupt transition at the atrophic
border is clearly seen (dotted line) with loss of rugal folds, mucosal pallor and increased visibility of vessels.
In this example, the atrophic border is located at the transition between the lesser and greater curve. Using
the modified Kimura-Takemoto scoring system, this patient would be staged 'C3, corpus dominant atrophy'.
c | Appearance of the atrophic border at enhanced imaging (Olympus, NBI), to the right of the dotted line the
normal body pit pattern is lost and the mucosa appears paler (asterisk). d and e | Depicted is the stomach
opened up along the greater curvature (d) and in traditional coronal view (e). This schematic representation
demonstrates the modified Kimura-Takemoto classification system; antral (C1); antral predominant (C2);
corpus predominant (C3) and panatrophy; numbers 1-5 correspond to the location of gastric biopsies, which
should be taken according to the updated Sydney system: antrum greater and lesser curve, incisura, corpus
greater and lesser curve. a-c reproduced from Waddingham W, Nieuwenburg SAV, Carlson S, et al. Frontline
Gastroenterol doi: 10.1136/flgastro-2018-101089. © Waddingham W et al. (2020). d and e reproduced from
Waddingham W, Graham D, Banks M et al. F1000Research 2018; 7 (F1000 Faculty Rev): 715. © Waddingham W
et al. (2018). Re-use permitted under CC BY-NC 4.0 license [http://creativecommons.org/licenses/by-nc/4.0/].
blue crest seen on NBI are both highly specific
signs of GIM.19
When either CAG or GIM is present the
extent should be estimated using the modified
Kimura staging system16
and biopsy samples
taken according to the Sydney protocol
a
b
After resection of gastric adenomas all patients
should undergo a follow-up endoscopy in
6-12 months, followed by yearly endoscopies if
appropriate.5
Mistake 8 Failing to consider the need for
surveillance
(antrum 1 & 2, incisura, lesser curve, greater
curve) (figure 4).5,6
a
b
c
d
e
The endoscopy interval depends on
the highest grade of dysplasia detected and the
number and size of polyps resected.
The cancer risk of the background stomach
should also be considered-if CAG and or GIM are
present they may warrant ongoing surveillance
depending on their extent. Patients who have
extensive CAG or GIM, meaning it extends into the
body of the stomach, should generally be offered
ongoing 3-yearly surveillance, while those who
have CAG with a history of dysplasia should be
offered yearly surveillance.5
The surveillance
Figure 3 | Chronic atrophic gastritis with high-risk gastric lesions. a | A sessile polyp (Paris Is) seen in the antrum
of a patient with extensive chronic atrophic gastritis (CAG), patches of gastric intestinal metaplasia (GIM) can be
seen in the background mucosa. b | A synchronous early gastric cancer (Paris IIa+c) is seen in the same patient-
the depressed central component of this lesion is worrying for high-grade neoplasia and intramucosal gastric
cancer was confirmed after endoscopic submucosal dissection (ESD).
16
strategies are discussed in the BSG and ESGE
guidelines and are based upon the risk of
progression of CAG.5,6
Estimates of cancer risk for
premaligant lesions varies, with studies from

http://www.creativecommons.org/licenses/by-nc/4.0/

Mistakes in ... 2021

Table of Contents for the Digital Edition of Mistakes in ... 2021