How to manage gastric low-grade dysplasia?

Management of Gastric Low-Grade Dysplasia

For patients with gastric low-grade dysplasia (LGD), endoscopic resection should be considered as the primary management approach, particularly when risk factors for progression to malignancy are present, such as large lesion size, depressed morphology, surface erythema, or ulceration. 1

Diagnostic Confirmation

• The diagnosis of gastric LGD must be confirmed by an expert gastrointestinal pathologist due to significant interobserver variability 1
• A second expert pathologist review is recommended for all cases of suspected dysplasia to ensure accurate diagnosis 2
• Pathologists should document the presence or absence of H. pylori infection, severity of atrophy/metaplasia, and histologic subtyping to inform clinical decision making 2

Risk Stratification

• Risk factors that warrant more aggressive management of gastric LGD include:
  • Large lesion size 1, 3
  • Depressed gross morphology 1, 3
  • Surface erythema, unevenness, ulceration, or erosion 1
  • Tubulovillous or villous histology 1
  • Multifocal or incomplete gastric intestinal metaplasia 2

Management Algorithm

Initial Approach

1. Confirm diagnosis with expert GI pathologist review 2
2. Perform high-definition/high-resolution endoscopy to detect any visible abnormalities 2
3. Treat H. pylori infection if present, as eradication appears to reduce the incidence of metachronous lesions 1

For Visible Lesions

• Endoscopic resection is recommended for all visible lesions, as these should be considered potentially malignant until proven otherwise 2, 3
• Endoscopic submucosal dissection (ESD) is preferred over endoscopic mucosal resection due to superior diagnostic and therapeutic outcomes 3

For Non-Visible (Flat) Dysplasia

• Endoscopic resection should be considered, particularly in the presence of risk factors for progression 1, 3
• If surveillance is chosen instead of immediate resection, perform endoscopy every 6 months for the first year, then annually if no progression is observed 2

Surveillance Protocol

• For patients undergoing surveillance rather than immediate endoscopic resection:

  • Perform endoscopy every 6 months for the first year, then annually 2
  • Obtain 4-quadrant biopsies every 1-2 cm with target biopsies of any visible lesions 2
  • Continue surveillance indefinitely unless there is progression to higher-grade dysplasia or regression to non-dysplastic mucosa 2

• For patients who have undergone successful endoscopic resection:

  • Perform surveillance endoscopy every year for the first 2-3 years 2
  • Extend intervals to every 3 years thereafter if no recurrence 2

Important Considerations and Pitfalls

• The natural history of gastric LGD is not fully understood, but evidence suggests a risk of progression to carcinoma or synchronous carcinoma 1, 4
• There is marked histologic discrepancy between forceps biopsy and endoscopic resection specimens, with high rates of upgraded diagnosis after resection 3
• Endoscopic resection serves both therapeutic and diagnostic purposes by providing a more accurate histologic assessment than biopsy alone 3, 4
• Referral to centers with expertise in managing gastric neoplasia is recommended for optimal outcomes 2
• Surveillance should only be continued in patients who are fit for potential endoscopic or surgical intervention 2

By following this structured approach to managing gastric LGD, the risk of progression to invasive cancer can be minimized while avoiding unnecessary interventions in low-risk cases.