What is the management approach for patients with pre-malignant gastric lesions identified on biopsy?

Management of Pre-malignant Gastric Lesions on Biopsy

Complete surgical or endoscopic resection is recommended for pre-malignant gastric lesions, particularly those with high-grade dysplasia or concerning features, to prevent progression to gastric cancer. 1

Classification and Risk Assessment

Pre-malignant gastric lesions typically follow a stepwise progression:

• Atrophic gastritis (AG)
• Intestinal metaplasia (IM)
• Low-grade dysplasia (LGD)
• High-grade dysplasia (HGD)
• Invasive carcinoma

Risk Stratification

The risk of progression to gastric cancer depends on:

1. Histological grade:

   • High-grade dysplasia: Highest risk (requires immediate intervention)
   • Low-grade dysplasia: Moderate risk
   • Intestinal metaplasia: Lower risk
   • Atrophic gastritis: Lowest risk among pre-malignant lesions

2. Endoscopic features:

   • Size (lesions >3 cm have higher risk)
   • Presence of ulceration
   • Irregular borders
   • Nodularity or depression

3. Extent of lesions:

   • Extensive intestinal metaplasia involving the cardia carries higher risk 2
   • OLGIM staging system (Operative Link on Gastric Intestinal Metaplasia) - stages III-IV indicate higher risk 3

Management Algorithm

1. High-Grade Dysplasia

• Immediate complete resection is mandatory
• Options include:
  • Endoscopic resection (preferred for accessible lesions <2 cm without concerning features)
  • Surgical resection for larger lesions or those with concerning features 1

2. Low-Grade Dysplasia

• Endoscopic resection is recommended when technically feasible
• For lesions not amenable to endoscopic resection, consider surgical options
• If patient has excessive operative risk, close surveillance may be considered with thorough discussion of risks 1

3. Intestinal Metaplasia

• Management depends on extent and risk factors:
  • Extensive IM (OLGIM III-IV): Consider endoscopic resection if focal lesions present
  • Limited IM (OLGIM I-II): Surveillance is appropriate 3
• H. pylori eradication if infection is present 4

4. Atrophic Gastritis

• H. pylori eradication if infection is present
• Surveillance with endoscopy and biopsies

Surveillance Protocols

Recommended Surveillance Intervals:

• High-grade dysplasia (if not resected): Every 3-6 months
• Low-grade dysplasia: Every 6-12 months
• Extensive intestinal metaplasia: Every 1-3 years
• Limited intestinal metaplasia: Every 3-5 years
• Atrophic gastritis: Every 3-5 years

Biopsy Protocol for Surveillance:

• Targeted biopsies from any visible lesions (essential for detecting high-grade dysplasia) 2
• Non-targeted biopsies using the Sydney protocol:
  • At least 2 biopsies from antrum
  • At least 2 biopsies from angulus
  • At least 2 biopsies from corpus (lesser curvature)
  • At least 2 biopsies from corpus (greater curvature)
  • At least 2 biopsies from cardia
  • Minimum of 12 biopsies total 2

The angulus (40%), antrum (35%), and lesser curvature of the corpus (33%) show the highest prevalence of pre-malignant conditions and should be carefully sampled 2.

Advanced Diagnostic Techniques

• Endoscopic ultrasound (EUS): Helpful for assessing depth of invasion in suspicious lesions
• Narrow-band imaging (NBI) or chromoendoscopy: Improves detection of subtle mucosal abnormalities
• Serum pepsinogen testing: PG I/II ratio ≤3 indicates extensive atrophy/intestinal metaplasia and higher risk 3

Pitfalls and Caveats

1. Sampling error: Pre-malignant lesions can be patchy and missed with inadequate sampling. Always follow the standardized biopsy protocol.

2. Underestimation of dysplasia: Endoscopic biopsies may underestimate the degree of dysplasia. When low-grade dysplasia is found, consider the possibility that high-grade dysplasia may be present elsewhere.

3. Surveillance compliance: Emphasize the importance of adherence to surveillance schedules, as progression to cancer can occur during gaps in follow-up.

4. Risk of progression: While the overall annual risk of progression to gastric cancer is approximately 0.3% in low-incidence regions 3, individual risk varies significantly based on histology, extent, and location of lesions.

5. Surveillance in elderly or comorbid patients: Consider life expectancy and comorbidities when determining surveillance intervals and intervention strategies.

By following this structured approach to management, pre-malignant gastric lesions can be appropriately treated or monitored to prevent progression to gastric cancer or detect malignancy at an early, curable stage.