Endoscopic Tumor Diagnosis and Treatment

Epidemiology and Screening

The most effective method of screening for malignancy is to follow up those patients who may be expected to have malignant tumor. At the Digestive Diseases Week (DDW) in San Diego, there were many presentations concerning risk factors in esophagogastric malignancy - such as obesity in young adults, chronic gastritis, aging, the pepsinogen A and C ratio, “alarm symptoms,” vagotomy, etc. Cheng et al. [1] presented an interesting study in which obesity in young adults and low consumption of fruit were found to be important risk factors in women with esophageal adenocarcinoma, while women who breast-fed were found to have protection against it. The authors carried out a population-based case-control study including 74 women under 75 years of age in whom adenocarcinoma had been confirmed by histology, and 74 women matched for age who were randomly selected from primary care registers. The body mass index (BMI) at age 20, total fruit consumption (TFC, items per week), and breast-feeding (BF) were correlated with the odds ratio (OR) for esophageal adenocarcinoma. A BMI of < 19.5 was associated with an OR of 1, < 21 with 0.86, < 23 with 4.90, and > 23 with 6.04. A TFC of < 12 was associated with an OR of 1, < 18 with 0.42, < 26 with 0.37, and > 26 with 0.08. With regard to breast-feeding, having no child was associated with an OR of 1, never having breast-fed with 0.66, having up to six months of breast-feeding with 0.30, and breast-feeding for over six months with 0.13, respectively (poster data). The incidence of adenocarcinoma as a percentage of esophageal tumors has been steadily rising, from 10 % in 1973 to 50 % in 1995 in the USA [2], and possibly in Europe as well.

It is widely believed that gastric cancer is associated with chronic atrophic gastritis (CAG), intestinal metaplasia (IM), gastric epithelial dysplasia (GED), and Helicobacter pylori infection. However, according to an Italian cross-sectional study by Bersani et al. [3] including 2792 patients, CAG, IM, and GED were significantly more frequent in older patients (over 60) compared with younger ones: 25.8 % versus 10.8 % for CAG, 58 % versus 25 % for IM, 8 % versus 2.8 % for GED. H. pylori infection did not play a clear role in the etiology or pathogenesis of these diseases.

It was also reported that the ratio between pepsinogen A (PGA) and pepsinogen C (PGC) and a gastrin index are useful predictors of chronic atrophic gastritis and gastric cancer. Bona et al. [4] studied the efficacy of PGA, PGC, and gastrin for screening for gastric malignancy in 186 subjects. They concluded that PGA and the PGA/PGC ration showed good sensitivity and specificity, with a high negative predictive value (NPV). Despite a low positive predictive value (PPV), most of the patients at high risk showed a pattern of gastritis that might require follow-up. Even using this method, it may be difficult to reduce the amount of endoscopic screening required.

Numans et al. [5] reported that four symptoms - weight loss, obstruction, being free of pain at night, and an absence of heartburn - predicted malignancy with an area under the curve (AUC) of 0.90 in the study population (1153 patients). Thorough evaluation of these “alarm symptoms” in dyspeptic patients might help minimize unnecessary gastroscopies requested by general practitioners.

It is well known that a prior partial gastrectomy, particularly a Billroth II operation, is a risk factor for gastric cancer. Duncan et al. [6] reviewed 1992 patients who underwent surgery for peptic ulcer. Medical records identified all patients who subsequently developed malignant diseases during the follow-up period (median 26 years). The observed number of malignancies was compared with the expected number of cancers, calculated by multiplying the person-years at risk by the prevailing incidence rates during the follow-up period. The authors concluded that - like gastrectomy - vagotomy also represents an increased risk factor for the subsequent development of gastric cancer.

References

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