Published online Jan 28, 2019. doi: 10.3748/wjg.v25.i4.469
Peer-review started: October 29, 2018
First decision: November 29, 2018
Revised: December 31, 2018
Accepted: January 9, 2019
Article in press: January 10, 2019
Published online: January 28, 2019
Gastric ‘indefinite for neoplasm/dysplasia’ (IFND) is a borderline lesion that is difficult to diagnose as either regenerative or neoplastic. There is a need for guidance in the identification of a subset of patients, who have an IFND lesion with a higher risk of malignant potential, to enable risk stratification and optimal management.
To determine the clinical and pathologic factors for the accurate diagnosis of gastric IFND lesions.
In total, 461 gastric lesions diagnosed via biopsy as IFND lesions were retrospectively evaluated. Endoscopic resection (n = 134), surgery (n = 22), and follow-up endoscopic biopsy (n = 305) were performed to confirm the diagnosis. The time interval from initial biopsy to cancer diagnosis was measured, and diagnostic delays were categorized as > 2 wk, > 2 mo, > 6 mo, and > 1 year. The IFND lesions presenting as regenerating atypia (60%) or atypical epithelia (40%) at initial biopsy were adenocarcinomas in 22.6%, adenomas in 8.9%, and gastritis in 68.5% of the cases.
Four clinical factors [age ≥ 60 years (2.445, 95%CI: 1.305-4.580, P = 0.005), endoscopic size ≥ 10 mm (3.519, 95%CI: 1.891-6.548, P < 0.001), single lesion (5.702, 95%CI: 2.212-14.696, P < 0.001), and spontaneous bleeding (4.056, 95%CI: 1.792-9.180, P = 0.001)], and two pathologic factors [atypical epithelium (25.575, 95%CI: 11.537-56.695, P < 0.001], and repeated IFND diagnosis [6.022, 95%CI: 1.822-19.909, P = 0.003)] were independent risk factors for gastric cancer. With two or more clinical factors, the sensitivity and specificity for carcinoma were 91.3% and 54.9%, respectively. Ten undifferentiated carcinomas were initially diagnosed as IFND. In the subgroup analysis, fold change (5.594, 95%CI: 1.458-21.462, P = 0.012) predicted undifferentiated or invasive carcinoma in the submucosal layers or deeper. Diagnostic delays shorter than 1 year were not associated with worse prognoses. Extremely well-differentiated adenocarcinomas accounted for half of the repeated IFND cases and resulted in low diagnostic accuracy even on retrospective blinded review.
More than two clinical and pathologic factors each had significant cut-off values for gastric carcinoma diagnosis; in such cases, endoscopic resection should be considered.
Core tip: At initial biopsy, ‘indefinite for neoplasm/dysplasia’ (IFND) lesions proved to be adenocarcinomas (22.6%). Independent risk factors for gastric IFND cancer were age (≥ 60 years), endoscopic size (≥ 10 mm), single lesion, spontaneous bleeding, atypical epithelia, and repeated IFND diagnosis. Additionally, fold change predicted undifferentiated or invasive carcinoma in the submucosal layers or deeper. However, diagnostic delays shorter than 1 year were not associated with worse prognoses. In summary, for IFND lesions with these features, endoscopic resection may be a better option than repeated endoscopic biopsy. In the absence of associated risk factors, accurate diagnosis through follow-up within 1 year is recommended.