MANAGEMENT OF PREMALIGNANT
LESIONS OF GASTRIC CANCER
A SURVEY OF EUROPEAN GASTROENTEROLOGISTS
Porto, 2008/2009
Professor Doutor Altamiro da Costa Pereira
Class 16
Authors: Ana Silva, Andreia Carvalho, Carlos Laranja, Cláudia Leite, Daniel Oliveira, Francisco Silva, Henrique Sousa, Joana
Matos, João Cardoso, Luís Vale, Mariana Santiago, Pedro Morais, Renato Ramos, Rui Loureiro, Tatiana Salazar;
Supervisors: Prof. Doutor Mário Ribeiro e Dr. Ricardo Santos
Management of premalignant lesions of
gastric cancer
INTRODUCTION
RESEARCH QUESTION
AIMS
PARTICIPANTS
AND METHODS
RESULTS
DISCUSSION
REFERENCES
Management of premalignant lesions of
gastric cancer
INTRODUCTION
Gastric
Cancer
Worldwide
incidence
Premalignant
lesions
Lack of
practical
recommendations
High
mortality
and
morbidity
Management of premalignant lesions of
gastric cancer
INTRODUCTION
Premalignant lesions
Atrophic chronic gastritis (ACG)
Intestinal metaplasia (IM)
Dysplasia (Dys)
Management of premalignant lesions of
gastric cancer
RESEARCH QUESTION
Which are the main options concerning
diagnosis, monitoring and treatment of
premalignant lesions of gastric cancer
that are being taken by European
Gastroenterologists?
Management of premalignant lesions of
gastric cancer
AIMS
To assess the clinical practice in terms of diagnosis,
monitoring and treatment of premalignant lesions of
gastric cancer
To compile these management options into a
database
Management of premalignant lesions of
gastric cancer
PARTICIPANTS
AND METHODS
Type of study
Observational
Cross-sectional
Quantitative
Management of premalignant lesions of
gastric cancer
PARTICIPANTS
AND METHODS
Participants’ selection
Non-randomized
sampling
Target Population:
Gastroenterologists
performing research in this
field
Articles search
Authors’ contacts
database
Management of premalignant lesions of
gastric cancer
PARTICIPANTS
AND METHODS
Inclusion Criteria
European Author/Centre (when in doubt
where included)
Published between 2007 – 2009
Keywords: intestinal neoplasm,
precancerous conditions, adenocarcinoma,
atrophic gastritis, metaplasia
Management of premalignant lesions of
gastric cancer
PARTICIPANTS
AND METHODS
Data collection
Online Questionnaire
Closed-ended questions
Open-ended questions
Link sent by E-mail
Management of premalignant lesions of
gastric cancer
PARTICIPANTS
AND METHODS
Variables description
• Dependent variables:
– Management options taken
• Independent variables:
–
–
–
–
–
–
–
Type of lesions
Author/Department
Place of work
Time of follow-up
How frequently techniques are applied
Diagnosis of H.P.
Eradication of H.P.
Management of premalignant lesions of
gastric cancer
RESULTS
E-mails sent
1st time
sent
2nd time
sent
Researchers who
E-mails not
couldn’t answer the
delivered
questionnaire
Responses to
the
questionnaire
Response
Rate
132
0
2
14
10,6%
120
14
3
2
1,6%
16
12,2%
Table1: E-mails response
Management of premalignant lesions of
gastric cancer
RESULTS – Participants description
0 - Do your answers reflect your own practice or your department(s)?
Frequency
60%
50%
40%
30%
20%
10%
0%
My own
Department
Graph1
Management of premalignant lesions of
gastric cancer
RESULTS – Participants description
Place of Work
14
12
10
8
6
4
2
0
Public
Private
University
Graph 2
Hospital
Other
Management of premalignant lesions of
gastric cancer
RESULTS
Do you, in your everyday practice, use any
protocol for the detection and management of
patients with atrophic chronic gastritis (ACG),
intestinal metaplasia (IM) or dysplasia (Dys)?
If yes, which case?
42.9
7
57.1
6
5
Yes
No
4
If yes, which case?
3
2
Graph 3
1
0
ACG
IM
Graph 4
Dys
Management of premalignant lesions of
gastric cancer
RESULTS
Does your hospital have any protocol for
the detection and management of patients
with atrophic chronic gastritis (ACG),
intestinal metaplasia (IM) or dysplasia
(Dys)?
18.8
If yes, which case?
3.5
Yes
81.3
No
3
2.5
2
1.5
1
Graph 5
0.5
0
ACG
IM
Graph 6
Dys
Management of premalignant lesions of
gastric cancer
RESULTS
Conserning biopsies, which is your usual procedure
for the study of these patients?
7
6
5
4
3
2
1
0
Random Biopsies
Random Biopsies in
predefined cases
Targeted Biopsies
Graph 7
Other
Management of premalignant lesions of
gastric cancer
RESULTS
H. Pylori Diagnosis
100%
8.3
90%
80%
8.3
38.5
70%
60%
50%
30%
100
91.7
40%
91.7
61.5
20%
10%
0%
ACG
IM
Low grade
High grade
Dys
Graph 8
No
Yes
Management of premalignant lesions of
gastric cancer
RESULTS
Sort of Follow-up
100%
90%
23.1
8.3
70%
14.3
20
80%
25
15.4
60%
50%
40%
46.2
50
30%
None
80
85.7
20%
10%
15.4
End. Follow-up sym.
16.7
Other
0%
ACG
End. Follow-up asy.
IM
Low grade
High grade
Dys
Graph 9
Management of premalignant lesions of
gastric cancer
RESULTS
Follow-up time for endoscopies when the patient is
asymptomatic
100%
90%
16.7
16.7
18.2
18.2
80%
70%
60%
9.1
50
50%
24m
50
54.5
12m
40%
54.5
30%
20%
33.3
10%
48m
6m
3m
33.3
1m
27.3
0%
18.2
ACG
IM
Low grade
High grade
Dys
Graph 10
Management of premalignant lesions of
gastric cancer
RESULTS
Eradication of H. Pylori
100%
90%
9.1
25
80%
70%
60%
50%
40%
90.9
100
100
75
No
Yes
30%
20%
10%
0%
ACG
IM
Low grade
High grade
Dys
Graph 11
Management of premalignant lesions of
gastric cancer
Problems and limitations
• Low response rate
we have 12.12% of response
• Not all questions were answered (missing)
• Possible Selection Bias
-
Only sent our questionnaire to practitioners who
published papers
Low significance/precision
DISCUSSION
Hard to make generalizations - Results
don’t allow for guidelines to be created
Management of premalignant lesions of
gastric cancer
DISCUSSION
Results of this study reflect some lack of consensus:
•disagreement about what is the best sort of followup for patients with IM or ACG
•techniques that should be used for the diagnosis of
these lesions
Management of premalignant lesions of
gastric cancer
DISCUSSION
However, some tendencies can be identified:
• diagnose H. pylori in patients with IM, ACG and Dys
• eradicate the bacteria when it is diagnosed
• for patients with dysplasia (both low and high grade)
is to perform periodical endoscopies even if the
patient is asymptomatic.
Management of premalignant lesions of
gastric cancer
RESULTS
1. Contacts database
2. Answers to questionnaire
3. Management options database
4. Online publication
- Build webpage
- Software: MS Frontpage
Management of premalignant lesions of
gastric cancer
REFERENCES
[1] Lockead P, El-Omar EM. Gastric Cancer. Br Med Bull. 2008;85:87-100.
[2] Parkin DM, Bray F, Ferlay J, Pisani P..Global cancer statistics, 2002. CA Cancer J Clin. 2005 Mar-Apr;55(2):74108.
[3] Stomach (Gastric) Cancer [Internet]. Bethesda: National Cancer Institute. Estimated new cases and deaths
from stomach cancer in the United States in 2008; [cited 2008 November 1]; [1 screen]. Available from:
http://www.cancer.gov/cancertopics/types/stomach
4] Plano Nacional de Prevenção e Controlo das Doenças Oncológicas 2007/2010, Dezembro 2007.
[5] Sugiyama T, Asaka M. Helicobacter pylori infection and gastric cancer. Med Electron Microsc. 2004
Sep;37(3):149-57.
[6] Menaker RJ, Sharaf AA, Jones NL. Helicobacter pylori infection and gastric cancer: host, bug, environment,
or all three?. Curr Gastroenterol Rep. 2004 Dec;6(6):429-35.
[7] de Vries AC, Haringsma J, Kuipers EJ. The detection, surveillance and treatment of premalignat gastric
lesions related to Helicobacter pylori infection. Helicobacter 2007; 12: 1-15.
[8] Bowles MJ, Benjamin IS. ABC of the upper gastrointestinal tract. Cancer of the stomach and pancreas. BMJ
2001;323:1413–6
[9] Witold Bartnik. Clinical aspects of Helicobacter pylori infection. Pol Arch Med Wewn, 2008; 118 (7-8): 426430
[10] M Dinis-Ribeiro, A Costa-Pereira, C Lopes, L Moreira-Dias. Guidelines for surveillance of patients with
atrophic chronic gastritis and intestinal metaplasia in stomach would be welcome! Helicobacter . 2007
Feb;12(1):1-15
Management of premalignant lesions of
gastric cancer
ACKNOWLEDGEMENTS
Eng.º Jorge Jácome
Prof. Doutor Altamiro da Costa Pereira
Prof. Doutor Mário Dinis Ribeiro
Dr. Ricardo Santos