Introduction
Gastric cancer is one of the most common and lethal malignancies worldwide1. A recognized independent risk factor for the development of this neoplasm is the presence of moderate-to-severe chronic atrophic gastritis (OLGA stage III-IV)2,3.
In Italy regions with varying epidemiology for gastric cancer coexist. Notably, the Po Valley area, encompassing the provinces of Cremona and Mantua, is a high-risk region, with a standardized incidence rate of 32.2 cases per 100,000 men and 15.9 cases per 100,000 women4.
Aims & Methods
The present single-center retrospective observational study aims to evaluate the correlation between the incidence, over a period of approximately 10 years, of dysplastic and neoplastic lesions amenable to endoscopic resection and OLGA staging and other recognized risk factors for gastric cancer in this high-risk population.
We retrospectively analyzed all mucosal resections (EMR), submucosal dissections (ESD), and hybrid resections (Hybrid EMR/ESD) performed at our hospital between December 2014 and September 2024 for visible gastric lesions identified as low-grade dysplasia (LGD) or high-grade dysplasia (HGD) in pre-resection biopsies. For each patient, we collected demographic data, information on risk factors for gastric neoplasia, pre- and post-resection histology and details related to the endoscopic resection procedure. High Definition Chromo-Endoscopy (HD-CE) with at least 5 guided biopsies from antrum, incisura and corpus were performed concurrently with biopsy sampling of visible lesions and all specimens underwent to a second-look pathological examination.
Results
A total of 66 patients (36 males and 30 females) with a mean age of 74.7 years were included in the study. Pre-resection biopsies revealed low-grade dysplasia (LGD) in 62% of cases and high-grade dysplasia (HGD) in the remaining 38%. Forty-two patients underwent ESD, 14 EMR and 10 Hybrid EMR/ESD. However, in 3 patients the ESD procedure was discontinued due to massive intra-procedural bleeding, perforation and evidence of deep infiltration involving the muscularis propria. Examination of the resected specimens identified 29 lesions as LGD (44%), 17 as HGD (26%), 2 as intramucosal adenocarcinomas (3%), 14 as pT1a adenocarcinomas (21%), and 4 as pT1b adenocarcinomas (6%). Regarding risk factors: 9 patients (14%) had a first-degree family history of gastric neoplasia, while 16 patients (24%) were affected by Helicobacter pylori at the time the lesion was identified. The more interesting finding comes from the pre-resection OLGA staging: 4 patients had no gastric mucosal atrophy (OLGA 0), and 35 patients had early-stage chronic atrophic gastritis (15 OLGA I and 20 OLGA II). Among the remaining patients, 23 presented with OLGA stage III, and 4 with OLGA stage IV. Therefore, 59% of patients had an OLGA staging of II or lower at the time of the onset of the dysplastic or neoplastic lesion.
Conclusion
Our experience confirms what has already been observed in Asian countries: traditional risk factors for gastric neoplasia are insufficient in high-risk areas to identify the population that might benefit from short-term endoscopic follow-up.
These findings further support the statement included in the recently published update of the ESGE guidelines on the management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III), highlighting the need for periodic screening in high-risk populations regardless of additional risk factors5.
References
1. Smyth EC, Nilsson M, Grabsch HI, van Grieken NC, Lordick F. Gastric cancer. Lancet. 2020;396(10251):635-648. doi:10.1016/S0140-6736(20)31288-5
2. Rugge M, de Boni M, Pennelli G, et al. Gastritis OLGA-staging and gastric cancer risk: a twelve-year clinico-pathological follow-up study. Aliment Pharmacol Ther. 2010;31(10):1104-1111. doi:10.1111/j.1365-2036.2010.04277.x
3. Yue H, Shan L, Bin L. The significance of OLGA and OLGIM staging systems in the risk assessment of gastric cancer: a systematic review and meta-analysis. Gastric Cancer. 2018;21(4):579-587. doi:10.1007/s10120-018-0812-3
4. Val Padana Cancer Registry, ATS (Health Protection Agency) Val Padana, https://www.ats-valpadana.it/documents/1654672/64558781/Stomaco.pdf/3a88e15f-a32e-9344-a748-fdfa71f138ea
5. Dinis-Ribeiro M, Libânio D, Uchima H, et al. Management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG) and European Society of Pathology (ESP) Guideline update 2025. Endoscopy. 2025;57(5):504-554. doi:10.1055/a-2529-5025
