Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED)

Abstract

Atrophic gastritis, intestinal metaplasia, and epithelial dysplasia of the stomach are common and are associated with an increased risk for gastric cancer. In the absence of guidelines, there is wide disparity in the management of patients with these premalignant conditions. The European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter Study Group (EHSG), the European Society of Pathology (ESP) and the Sociedade Portuguesa de Endoscopia Digestiva (SPED) have therefore combined efforts to develop evidence-based guidelines on the management of patients with precancerous conditions and lesions of the stomach (termed MAPS). A multidisciplinary group of 63 experts from 24 countries developed these recommendations by means of repeat online voting and a meeting in June 2011 in Porto, Portugal. The recommendations emphasize the increased cancer risk in patients with gastric atrophy and metaplasia, and the need for adequate staging in the case of high grade dysplasia, and they focus on treatment and surveillance indications and methods.

Fig.1

Summary of proposed management for patients with atrophic gastritis, gastric intestinal metaplasia and gastric epithelial dysplasia. *The further management is not covered by this guideline.

Fig.2

Morphologic changes in gastric mucosa during gastric carcinogenesis. a,b Non-atrophic gastritis, without gland atrophy and/or intestinal metaplasia: (a) antrum (hematoxylin and eosin [H&E], ×40); (b) corpus (H&E, ×100). c,d Moderate atrophy of deep antral glands (gland loss between 30% and 60%), without intestinal metaplasia: (c) H&E staining, ×40; (d) Periodic acid–Schiff (PAS) – alcian blue staining, ×40, highlighting gland loss and a single focus of intestinal metaplasia in the superficial part of the gastric mucosa. e,f Severe atrophy of antral mucosa, with loss of more than 60% of original mucous-secreting glands, replaced by intestinal metaplasia: (e) H&E, ×40; (f) PAS– alcian blue, ×40. g,h Dysplasia and intramucosal carcinoma: (g) low grade (left) and high grade (right) dysplasia (H&E, ×100); (h) intramucosal carcinoma (H&E, ×200).