Optimal management of biopsy-proven low-grade gastric dysplasia

Abstract

Gastric adenocarcinoma generally culminates via the inflammation-metaplasia-dysplasia-carcinoma sequence progression. The prevalence of gastric adenomas shows marked geographic variation. Recently, the rate of diagnosis of low-grade dysplasia (LGD) has increased due to increased use of upper endoscopy. Many investigators have reported that gastric high-grade dysplasia has high potential for malignancy and should be removed; however, the treatment for gastric LGD remains controversial. Although the risk of LGD progression to invasive carcinoma has been reported to be inconsistent, progression has been observed during follow-up. Additionally, the rate of upgraded diagnosis in biopsy-proven LGD is high. Therefore, endoscopic resection (ER) may be useful in the treatment and diagnosis of LGD, especially if lesions are found to have risk factors for upgraded histology after ER, such as large size, surface erythema or depressed morphology. Fatal complications in endoscopic submucosal dissection (ESD) are extremely low and its therapeutic and diagnostic outcomes are excellent. Therefore, ESD should be applied preferentially instead of endoscopic mucosal resection.

Keywords: Adenoma; Endoscopic resection; Endoscopic submucosal dissection; Intraepithelial neoplasia; Low-grade dysplasia.

Figure 1

A lesion with a histologic upgraded from extended low-grade dysplasia to adenocarcinoma following endoscopic submucosal dissection. A: White light endoscopy reveals a large elevated mucosal lesion with nodularity in the lesser curvature side of the body. This lesion was diagnosed as LGD by the endoscopic forceps biopsy; B: This lesion is removed by ESD; C: A large mucosal defect is noted over the gastric body after ESD; D: Mapping of the resected specimen. The tumor size is 75 mm, focal cancer lesions (red bar) mixed with LGD are evident. The lateral and vertical margins are free from tumor. LGD: Low-grade dysplasia; ESD: Endoscopic submucosal dissection.

Figure 2

Endoscopic images of biopsy-proven low-grade dysplasia. A-C: lesion size > 2 cm (A), surface erythema (B), and depressed appearance (C) are endoscopic risk factors for an upgraded histology after endoscopic resection; D: In contrast, the presence of whitish discoloration was a negative factor.