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Precancerous conditions of the stomach - Coggle Diagram
Precancerous conditions of the stomach
Screening
Every 2-3 years in high risk (> 20 per 100'000 person-years)
Every 5 years in intermediate risk (10-20 per 100'000 person-years)
Not in low risk (< 10 per 100'000 person-years)
Discontinue over 80 years of age
Upper endoscopy
White-light endoscopy (WLE)
always Virtual Chromoendoscopy (VCE)
No other imaging is recommended for baseline
Endoscopic screening if first-degree relative with gastric cancer from 45 years on or 10 years before age of diagnosis
Low pepsinogen levels and/or low pepsinogen I/II ratio (indicating advanced atrophic gastritis)
Therapy/Prevention
ESD if dysplastic/intramucosal carcinom with minimal mucosal invasion (any size or < 31mm if ulcerated)
EMR only for Paris 0-IIa, <11 mm
H. pylori-Eradication if present (after endoscopical treatment if needed)
Also for patients aged 20-30 years with first-degree relatives with gastric cancer (non-invasive testing)
Smoking cessation
Low-dose daily aspirin for patients with high cardiovascular risk for prevention of gastric cancer
Staging
curative/low risk
R0 resection, no lymphovascular invasion AND pT1b, differentiated, with =< 500 um invasion and size =< 30 mm OR pT1a, undifferentiated, size =< 20 mm
No further treatment, full staging + tumorboard (LMN < 3%)
Local-risk resection
Piecemeal resection, tumor-positive horizontal margin, and meeting the criteria of either curative very low risk or low risk
see above + endoscopic surveillance and/or re-treatment
Curative/very low risk
R0 resection, pT1a/dysplastic, no lymphovascular invasion, size =< 30 mm if ulcerated
No staging (lymph node metastasis risk = LMN < 0.5%)
High-risk resection (non-curative)
Any of the following: positive vertical margin, lymphovascular invasion, mucosal invasion > 500 um, poorly differentiated if ulcerated or size > 20 mm, pT1b with size > 30 mm, intramucosal ulcerative lesion > 30 mm
Full staging, tumorboard, strong recommendation for additional treatment
Diagnosis
Endoscopy
Validated classifications for atrophy or metaplasia
Atrophy: Kimura-Takemoto
Metaplasia: Endoscopic Grading of Gastric Intestinal Metaplasia (EGGIM)
Biopsies
Minimum 2 biopsies from 2 different sites in 2 vials, optional Sidney protocol (biopsy from antrum small and large curvature, incisura, corpus small and large curvature)
2 biopsies from lesions identified with VCE
Lesions
Description (size, morphology with Paris-class, location, vascular/mucosal pattern)
Photodocumentation
H. pylori-Testing
Surveillance
Extensive endoscopic changes (Kimura C3+, EGGIM 5+)
every 3 years
1-2 years if first-degree relative with gastric cancer
Advanced histological stages (severe atrophic gastritis, intestinal metaplasia, OLGA/OLGIM III/IV)
every 3 years (no need for random biopsy if no lesion identified)
1-2 years if first-degree relative with gastric cancer
Mild to moderate atrophy
None of the above met and no risk (FA, incomplete metaplasia, persistent HP)
No surveillance
3 years if first-degree relative with gastric cancer or incomplete metaplasia or persistent H. pylori gastritis)
Intestinal metaplasia restricted to antrum
None of the above met and no risk (FA, incomplete metaplasia, persistent HP)
No surveillance
every 3 years if first-degree relative with gastric cancer or incomplete metaplasia or persistent H. pylori gastritis)
Dysplasia/Indefinite for dysplasia AND no lesions identified
repeat high-quality endoscopy as soon as possible
If still no lesion = repeat endoscopy in 6 month for high-grade dysplasia OR 12 months for low-grade dysplasia
Indefinite for dysplasia AND lesion identified
Referral for endoscopic evaluation of biopsy/resection
Following resection
Endoscopy at 3-6 months if curative/very low risk or curative/low risk
See Staging