304 research outputs found
Accuracy of endoscopic staging and targeted biopsies for routine gastric intestinal metaplasia and gastric atrophy evaluation study protocol of a prospective, cohort study: the estimate study
Introduction Patients with chronic atrophic gastritis (CAG)
and intestinal metaplasia (IM) are at risk of developing
gastric adenocarcinoma. Their diagnosis and management
currently rely on histopathological guidance after random
endoscopic biopsy sampling (Sydney biopsy strategy). This
approach has significant flaws such as under-diagnosis,
poor reproducibility and poor correlation between
endoscopy and histology. This prospective, international
multicentre study aims to establish whether endoscopyled risk stratification accurately and reproducibly predicts
CAG and IM extent and disease stage.
Methods and analysis Patients with CAG and/or
IM on standard white light endoscopy (WLE) will be
prospectively identified and invited to undergo a second
endoscopy performed by an expert endoscopist using
enhanced endoscopic imaging techniques with virtual
chromoendoscopy. Extent of CAG/IM will be endoscopically
staged with enhanced imaging and compared with standard
WLE. Histopathological risk stratification through targeted
biopsies will be compared with endoscopic disease staging
and to random biopsy staging on WLE as a reference. At
least 234 patients are required to show a 10% difference
in sensitivity and accuracy between enhanced imaging
endoscopy-led staging and the current biopsy-led staging
protocol of gastric atrophy with a power (beta) of 80% and a
0.05 probability of a type I error (alpha).
Ethics and dissemination The study was approved by the
respective Institutional Review Boards (Netherlands: MEC2018-078; UK: 19/LO/0089). The findings will be published in
peer-reviewed journals and presented at scientific meetings
Recent advances in the detection and management of early gastric cancer and its precursors
Despite declines in incidence, gastric cancer remains a disease with a poor prognosis and limited treatment options due to its often late stage of diagnosis. In contrast, early gastric cancer has a good to excellent prognosis, with 5-year survival rates as high as 92.6% after endoscopic resection. There remains an East-West divide for this disease, with high incidence countries such as Japan seeing earlier diagnoses and reduced mortality, in part thanks to the success of a national screening programme. With missed cancers still prevalent at upper endoscopy in the West, and variable approaches to assessment of the high-risk stomach, the quality of endoscopy we provide must be a focus for improvement, with particular attention paid to the minority of patients at increased cancer risk. High-definition endoscopy with virtual chromoendoscopy is superior to white light endoscopy alone. These enhanced imaging modalities allow the experienced endoscopist to accurately and robustly detect high-risk lesions in the stomach. An endoscopy-led staging strategy would mean biopsies could be targeted to histologically confirm the endoscopic impression of premalignant lesions including atrophic gastritis, gastric intestinal metaplasia, dysplasia and early cancer. This approach to quality improvement will reduce missed diagnoses and, combined with the latest endoscopic resection techniques performed at expert centres, will improve early detection and ultimately patient outcomes. In this review, we outline the latest evidence relating to diagnosis, staging and treatment of early gastric cancer and its precursor lesions
Colorectal cancer risk after removal of polyps in fecal immunochemical test based screening
Background: Colonoscopy surveillance intervals are based on the predicted risk of metachronous colorectal cancer (CRC) after polyp removal. However, risk estimation per polyp subtype is difficult due to the fact that many patients have multiple polyps. To enable risk estimation per polyp subtypes we examined the metachronous CRC risk of subgroups based on presence or absence of co-occurring findings. Methods: Using high-quality screening colonoscopies performed after a positive fecal immunochemical test between 2014 and 2020 within the Dutch CRC screening program, we applied Cox regression analysis to evaluate the association between findings at baseline colonoscopy and metachronous CRCs. For our primary outcome, we appointed each patient to unique subgroups based on removed polyp subtypes that were present or absent at baseline colonoscopy and used the groups without polyps as reference. High-risk subgroups were individuals with high-risk serrated polyps, defined as serrated polyp â„10 mm, sessile serrated lesions with dysplasia, or traditional serrated adenomas, as well as high-risk adenomas, defined as adenoma â„10 mm or containing high-grade dysplasia. Findings: In total 253,833 colonoscopies were included. Over a median follow-up of 36 months (IQR, 21â57), we identified 504 metachronous CRCs. Hazard ratios for metachronous CRC was 1.70 (95% CI, 1.07â2.69) for individuals with high-risk serrated polyps without high-risk adenomas, 1.22 (0.96â1.55) for individuals with high-risk adenomas without high-risk serrated polyps, and 2.00 (1.19â3.39) for individuals with high-risk serrated polyps and high-risk adenomas, compared to patients without polyps. Interpretation: Accounting for co-occurring findings, we observed an increased metachronous CRC risk for individuals that had high-risk serrated polyps with the presence of high-risk adenomas, or individuals with high-risk serrated polyps without high-risk adenomas. These findings could provide more evidence to support post-polypectomy surveillance guidelines. Funding: None.</p
Multisegmented esophageal fully covered self-expandable metal stent for palliation of malignant dysphagia:a prospective, multicenter feasibility and safety study
Background and Aims: A novel multisegmented esophageal fully covered self-expandable metal stent (FCSEMS) was designed to reduce stent migration, which is seen in up to 30% of patients. The goal of this study was to evaluate the safety and efficacy of the multisegmented FCSEMS. Methods: This multicenter prospective study aimed to include 30 patients undergoing palliative stent placement. Efficacy, defined as technically successful stent placement and dysphagia scores, and safety, defined as the number of adverse events (AEs) and serious AEs (SAEs), were measured. Results: The study was prematurely terminated due to safety concerns after including 23 patients (mean ± standard deviation age, 72 ± 10 years; 78% male). Stent placement was technically successful in 21 patients (91%), and dysphagia scores had improved in all patients with successful stent placement. SAEs were reported in 16 (70%) patients. Stent-related mortality occurred in 3 patients (13%). Conclusions: The multisegmented FCSEMS successfully treated malignant dysphagia. The study was prematurely terminated, however, because stent placement was associated with a relatively high SAE rate. (Clinical trial registration number: NCT04415463.)</p
Four cycles of BEP versus an alternating regime of PVB and BEP in patients with poor-prognosis metastatic testicular non-seminoma; a randomised study of the EORTC Genitourinary Tract Cancer Cooperative Group.
We have investigated whether an alternating induction chemotherapy regimen of PVB/BEP is superior to BEP in patients with poor-prognosis testicular non-seminoma. A total of 234 eligible patients were randomised to receive an alternating schedule of PVB/BEP for a total of four cycles or four cycles of BEP. Poor prognosis was defined as any of the following: lymph node metastases larger than 5 cm, lung metastases more than four in number or larger than 2 cm, haematogenic spread outside the lungs, such as in liver and bone, human chorionic gonadotrophin > 10,000 IU l-1 or alphafetoprotein > 1000 IU l-1. The complete response (CR) rates to PVB/BEP and BEP were similar, 76% and 72% respectively (P = 0.58). In addition, there was no significant difference in relapse rate, disease-free and overall survival at an average follow-up of 6 years. The 5-year progression-free and survival rates in both treatment groups were approximately 80%. The PVB/BEP regime was more toxic with regard to bone marrow function; the frequencies of leucocytes below 1000 microliters-1, leucocytopenic fever and platelets below 25,000 microliters-1, throughout four cycles were 28% vs 5% (P < 0.001), 16% vs 5% (P = 0.006), and 10% vs 1% (P = 0.001) respectively. Neuropathy also occurred more often in the PVB/BEP arm: 47% vs 25% (P = 0.001). This study shows that an alternating regimen of PVB/BEP is not superior to BEP and that it is more myelo- and neurotoxic
Constitutive programmed death ligand 1 expression protects gastric G-cells from Helicobacter pyloriâinduced inflammation
INTRODUCTION: Gastric intestinal metaplasia (GIM) is a premalignant lesion, highly associated with Helicobacter pylori infection. Previous studies have shown that H. pylori is able to induce the expression of programmed death ligand 1 (PDâL1), an inhibitory immune modulator, in gastric cells. Our aim was to investigate whether tissues from GIM patients may exploit PDâL1 expression upon H. pylori infection to evade immunosurveillance. METHODS: Immunohistochemistry was performed for PDâL1 and enteroendocrine markers somatostatin and gastrin on samples derived from a cohort of patients with known GIM, both before and after H. pylori eradication. To determine the identity of any observed PDâL1âpositive cells, we performed multiplex immunofluorescent staining and analysis of singleâcell sequencing data. RESULTS: GIM tissue was rarely positive for PDâL1. In normal glands from GIM patients, PDâL1 was mainly expressed by gastrinâpositive Gâcells. While the Dâcell and Gâcell compartments were both diminished 2âfold (p = .015 and p = .01, respectively) during H. pylori infection in the normal antral tissue of GIM patients, they were restored 1âyear after eradication. The total number of PDâL1âpositive cells was not affected by H. pylori, but the percentage of PDâL1âpositive Gâcells was 30% higher in infected subjects (p = .011), suggesting that these cells are preferentially rescued from destruction. CONCLUSIONS: Antral Gâcells frequently express PDâL1 during homeostasis. Gâcells seem to be protected from H. pyloriâinduced immune destruction by PDâL1 expression. GIM itself does not express PDâL1 and is unlikely to escape immunosurveillance via expression of PDâL1
- âŠ