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. Thus, due to the possibility of dysplasia or carcinoma, follow-up evaluation according to the Vienna classification is recommended for gastric IFND cases. However, in clinical settings, no clear guideline exists that indicates the exact cut-off time for additional biopsy or endoscopic resection; additionally, there is no subsequent plan for endoscopists in dealing with more than two pathologic reports of IFND lesions at the follow-up biopsy.
There is a critical need for guidance in the identification of a subset of patients through forceps biopsy, who have an IFND lesion with a higher risk of malignant potential, to enable risk stratification and optimal management.
Our study aimed to establish the correct diagnosis for gastric IFND lesions by evaluating a series of IFND lesions in detail and determining the key clinical and pathologic predictive factors for gastric cancer. The findings of this study may be useful in informing the decision to either perform biopsy repeatedly or resect gastric IFND lesions.
Medical records and pathologic reports of patients who underwent gastric endoscopic biopsy from January 2007 to December 2016 were reviewed, and a total 461 IFND lesions were enrolled in this study. Two gastrointestinal pathologists confirmed all cases as IFND lesions according to standard guidelines (the Korean pathologic grading system for gastric epithelial proliferative disease, the classification of the Japanese Gastric Cancer Association, and the Vienna classification), and IFND lesions were divided into two subgroups: ‘atypical epithelia’ and ‘regenerating atypia. To assess the possible risk factors for diagnostic delays, the time interval from the onset of the first biopsy to the establishment of cancer diagnosis was measured.
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. Diagnostic delays shorter than 1 year were not associated with worse prognoses in our study. However, there may be a selection bias enrolled in a single, tertiary medical center located at the gastric cancer-endemic country.
More than two clinical and pathologic factors each had significant cut-off values for gastric carcinoma diagnosis; in such cases, endoscopic resection would be a better option than repeated endoscopic biopsy. Otherwise, without any associated risk factors, accurate diagnosis through follow-up endoscopic biopsy within 1 year is recommended and will likely not worsen long-term outcomes.
As a result of this study, our institute established a guideline. And we will use this guideline to conduct future prospective studies to reduce selection bias.