Retrospective Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 28, 2019; 25(4): 469-484
Published online Jan 28, 2019. doi: 10.3748/wjg.v25.i4.469
Treatment for gastric ‘indefinite for neoplasm/dysplasia’ lesions based on predictive factors
Mi Jung Kwon, Ho Suk Kang, Hyeon Tae Kim, Jin Woo Choo, Bo Hyun Lee, Sung Eun Hong, Kun Ha Park, Dong Min Jung, Hyun Lim, Jae Seung Soh, Sung Hoon Moon, Jong Hyeok Kim, Hye-Rim Park, Soo Kee Min, Jin won Seo, Ji-Young Choe
Mi Jung Kwon, Hye-Rim Park, Soo Kee Min, Jin won Seo, Ji-Young Choe, Department of Pathology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang 14068, South Korea
Ho Suk Kang, Hyeon Tae Kim, Jin Woo Choo, Bo Hyun Lee, Sung Eun Hong, Kun Ha Park, Dong Min Jung, Hyun Lim, Jae Seung Soh, Sung Hoon Moon, Jong Hyeok Kim, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang-si 431-796, South Korea
Author contributions: Kwon MJ and Kang HS designed the study, analyzed the data and drafted the manuscript; Kim HT, Choo JW, Lee BH, Hong SE, Park KH, Jung DM collected the data; Soh JS and Lim H revised the manuscript for important intellectual content; Park HR, Min SK, Seo JW, Choe JW and Kwon MJ reviewed the pathologic slides; Moon SH and Kim JH supervised the study; all authors have read and approved the final version of the manuscript to be published.
Institutional review board statement: This study was conducted with the approval of the ethics committee of Hallym University Sacred Heart Hospital in Anyang, South Korea. IRB No. HALLYM 2018-01-003-001.
Conflict-of-interest statement: All authors declare no conflicts of interest related to this article.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Ho Suk Kang, MD, Assistant Professor, Division of Gastroenterology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, 22, Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang-si 431-796, South Korea. hskang76@hallym.or.kr
Telephone: +82-31-3803707 Fax: +82-31-3803701
Received: October 27, 2018
Peer-review started: October 29, 2018
First decision: November 29, 2018
Revised: December 31, 2018
Accepted: January 9, 2019
Article in press: January 10, 2019
Published online: January 28, 2019
Processing time: 92 Days and 2.2 Hours
ARTICLE HIGHLIGHTS
Research background

Gastric ‘indefinite for neoplasm/dysplasia’ (IFND) is a borderline lesion that is difficult to diagnose as either regenerative or neoplastic. Thus, due to the possibility of dysplasia or carcinoma, follow-up evaluation according to the Vienna classification is recommended for gastric IFND cases. However, in clinical settings, no clear guideline exists that indicates the exact cut-off time for additional biopsy or endoscopic resection; additionally, there is no subsequent plan for endoscopists in dealing with more than two pathologic reports of IFND lesions at the follow-up biopsy.

Research motivation

There is a critical need for guidance in the identification of a subset of patients through forceps biopsy, who have an IFND lesion with a higher risk of malignant potential, to enable risk stratification and optimal management.

Research objectives

Our study aimed to establish the correct diagnosis for gastric IFND lesions by evaluating a series of IFND lesions in detail and determining the key clinical and pathologic predictive factors for gastric cancer. The findings of this study may be useful in informing the decision to either perform biopsy repeatedly or resect gastric IFND lesions.

Research methods

Medical records and pathologic reports of patients who underwent gastric endoscopic biopsy from January 2007 to December 2016 were reviewed, and a total 461 IFND lesions were enrolled in this study. Two gastrointestinal pathologists confirmed all cases as IFND lesions according to standard guidelines (the Korean pathologic grading system for gastric epithelial proliferative disease, the classification of the Japanese Gastric Cancer Association, and the Vienna classification), and IFND lesions were divided into two subgroups: ‘atypical epithelia’ and ‘regenerating atypia. To assess the possible risk factors for diagnostic delays, the time interval from the onset of the first biopsy to the establishment of cancer diagnosis was measured.

Research results

At initial biopsy, ‘indefinite for neoplasm/dysplasia’ (IFND) lesions proved to be adenocarcinomas (22.6%). Independent risk factors for gastric IFND cancer were age (≥ 60 years), endoscopic size (≥ 10 mm), single lesion, spontaneous bleeding, atypical epithelia, and repeated IFND diagnosis. Additionally, fold change predicted undifferentiated or invasive carcinoma in the submucosal layers or deeper. Diagnostic delays shorter than 1 year were not associated with worse prognoses in our study. However, there may be a selection bias enrolled in a single, tertiary medical center located at the gastric cancer-endemic country.

Research conclusions

More than two clinical and pathologic factors each had significant cut-off values for gastric carcinoma diagnosis; in such cases, endoscopic resection would be a better option than repeated endoscopic biopsy. Otherwise, without any associated risk factors, accurate diagnosis through follow-up endoscopic biopsy within 1 year is recommended and will likely not worsen long-term outcomes.

Research perspectives

As a result of this study, our institute established a guideline. And we will use this guideline to conduct future prospective studies to reduce selection bias.