Observational Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Sep 16, 2021; 13(9): 426-436
Published online Sep 16, 2021. doi: 10.4253/wjge.v13.i9.426
Enlarged folds on endoscopic gastritis as a predictor for submucosal invasion of gastric cancers
Osamu Toyoshima, Shuntaro Yoshida, Toshihiro Nishizawa, Akira Toyoshima, Kosuke Sakitani, Tatsuya Matsuno, Tomoharu Yamada, Takashi Matsuo, Hayato Nakagawa, Kazuhiko Koike
Osamu Toyoshima, Shuntaro Yoshida, Toshihiro Nishizawa, Kosuke Sakitani, Tatsuya Matsuno, Tomoharu Yamada, Department of Gastroenterology, Toyoshima Endoscopy Clinic, Setagaya-ku 157-0066, Tokyo, Japan
Toshihiro Nishizawa, Department of Gastroenterology and Hepatology, International University of Health and Welfare, Narita Hospital, Narita 286-8520, Chiba, Japan
Akira Toyoshima, Department of Colorectal Surgery, Japanese Red Cross Medical Center, Shibuya-ku 150-8935, Tokyo, Japan
Kosuke Sakitani, Department of Gastroenterology, Sakitani Endoscopy Clinic, Narashino 275-0026, Chiba, Japan
Tatsuya Matsuno, Tomoharu Yamada, Hayato Nakagawa, Kazuhiko Koike, Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku 113-8655, Tokyo, Japan
Takashi Matsuo, Department of Internal Medicine, Sakura Internal Medicine Clinic, Setagaya-ku 157-0071, Tokyo, Japan
Author contributions: Toyoshima O designed the study, recruited patients, analyzed the data, and wrote the manuscript; Nishizawa T designed the study, recruited patients, edited, and revised the manuscript; Yoshida S recruited patients and revised the manuscript; Toyoshima A, Matsuno T, Yamada T, Matsuo T, Nakagawa H, and Koike K revised the manuscript; Sakitani K reviewed endoscopic images and revised the manuscript.
Institutional review board statement: This retrospective study was approved by Certificated Review Board, Hattori Clinic on September 4, 2020 (approval No. S2009-U04).
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: Authors declare no conflict of interests for this article.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (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: Toshihiro Nishizawa, MD, PhD, Professor, Department of Gastroenterology and Hepatology, International University of Health and Welfare, Narita Hospital, 852 Hatakeda, Narita 286-8520, Chiba, Japan. nisizawa@kf7.so-net.ne.jp
Received: May 29, 2021
Peer-review started: May 29, 2021
First decision: June 11, 2021
Revised: June 12, 2021
Accepted: July 6, 2021
Article in press: July 6, 2021
Published online: September 16, 2021
Abstract
BACKGROUND

Accurate diagnosis of the depth of gastric cancer invasion is crucial in clinical practice. The diagnosis of gastric cancer depth is often made using endoscopic characteristics of the tumor and its margins; however, evaluating invasion depth based on endoscopic background gastritis remains unclear.

AIM

To investigate predicting submucosal invasion using the endoscopy-based Kyoto classification of gastritis.

METHODS

Patients with gastric cancer detected on esophagogastroduodenoscopy at Toyoshima Endoscopy Clinic were enrolled. We analyzed the effects of patient and tumor characteristics, including age, sex, body mass index, surveillance endoscopy within 2 years, current Helicobacter pylori infection, the Kyoto classification, and Lauren’s tumor type, on submucosal tumor invasion and curative endoscopic resection. The Kyoto classification included atrophy, intestinal metaplasia, enlarged folds, nodularity, and diffuse redness. Atrophy was characterized by non-reddish and low mucosa. Intestinal metaplasia was detected as patchy whitish or grayish-white flat elevations, forming an irregular uneven surface. An enlarged fold referred to a fold width ≥ 5 mm in the greater curvature of the corpus. Nodularity was characterized by goosebump-like multiple nodules in the antrum. Diffuse redness was characterized by uniform reddish non-atrophic mucosa in the greater curvature of the corpus.

RESULTS

A total of 266 gastric cancer patients (mean age, 66.7 years; male sex, 58.6%; mean body mass index, 22.8 kg/m2) were enrolled. Ninety-three patients underwent esophagogastroduodenoscopy for surveillance within 2 years, and 140 had current Helicobacter pylori infection. The mean Kyoto score was 4.54. Fifty-eight cancers were diffuse-type, and 87 cancers had invaded the submucosa. Multivariate analysis revealed that low body mass index (odds ratio 0.88, P = 0.02), no surveillance esophagogastroduodenoscopy within 2 years (odds ratio 0.15, P < 0.001), endoscopic enlarged folds of gastritis (odds ratio 3.39, P = 0.001), and Lauren’s diffuse-type (odds ratio 5.09, P < 0.001) were independently associated with submucosal invasion. Similar results were obtained with curative endoscopic resection. Among cancer patients with enlarged folds, severely enlarged folds (width ≥ 10 mm) were more related to submucosal invasion than mildly enlarged folds (width 5-9 mm, P < 0.001).

CONCLUSION

Enlarged folds of gastritis were associated with submucosal invasion. Endoscopic observation of background gastritis as well as the lesion itself may help diagnose the depth of cancer invasion.

Keywords: Gastric cancer, Gastritis, Enlarged fold, Endoscopy, Kyoto classification

Core Tip: We investigated predicting submucosal invasion using the endoscopy-based Kyoto classification of gastritis. We analyzed the effects of patient and tumor characteristics, including the Kyoto classification, on submucosal tumor invasion. Two hundred sixty-six gastric cancer patients were enrolled. Multivariate analysis revealed that low body mass index, no surveillance esophagogastroduodenoscopy within 2 years, endoscopic enlarged folds of gastritis, and Lauren’s diffuse-type were independently associated with submucosal invasion. Among cancer patients with enlarged folds, severely enlarged folds (width ≥ 10 mm) were more related to submucosal invasion than mildly enlarged folds (width 5-9 mm). Enlarged folds of gastritis were associated with submucosal invasion.