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54 1 UPPER GASTROINTESTINAL CANCER
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on magnifying advanced imaging are indicative of gastric
intestinal metaplasia (Banks et al. 2019; Kohoutova et al. 2021)
(see Figure 2). Expert recommendations for optimal endoscopic
practice include (Kohoutova et al. 2021):
1
Combined use of high-resolution white-light endoscopy and
magnifying NBI
2 Application of mucolytic/defoaming agents to achieve
optimal mucosal visualization
3
A minimum inspection time of seven minutes
Procurement of endoscopic images after careful inspection
4
Multiple gastric biopsies if there is a suspicion of atrophic
5
gastritis and intestinal metaplasia.
Two serologic screening procedures for gastric cancer that have
been explored clinically are H. pylori serology and serum pepsinogen (PG). The role of H. pylori serology as a stand-alone screen-
ing test is limited due to its low sensitivity and inability to detect
precursor lesions. An H. pylori infection has a strong link with the
development of gastric cancer. However, previous studies have
shown that the gastric cancer risk is actually higher in
H. pylori-negative patients. This paradox probably can be
explained by the spontaneous disappearance of H. pylori as the
chronic gastritis progresses to AG and IM, making the gastric
microenvironment nonconducive (Yoon and Kim 2015). There
are two types of PG, PG I (produced by the chief and mucous
neck cells) and PG II (also additionally secreted by the pyloric and
Brunner’s glands) (Choi et al. 2012). As the severity of atrophic
gastritis increases, the PG I level decreases but the PG II level
remains stable (Park and Kim 2015). As a result, a PG I value of <70
ng/mL and a PGI/II ratio of <3 have been used as cut-offs for
gastric cancer screening, with a sensitivity and specificity of 84.6%
and 73.5%, respectively (Kitahara et al. 1999; Sugano K. 2015).
Multiple Japanese studies have evaluated the combination of
H. pylori serology and serum PG as a non-invasive screening
test. This strategy is known as the ABC method (implemented
in Nishitokyo city since 2011) (Yamaguchi et al. 2016). Patients
are stratified into four groups according to the positivity/negativity of the H. pylori serology and PG I with PGI/II ratio values.
In the negative group, no further testing is required. In the
other three groups, H. pylori eradication therapy is recom-
mended, followed by surveillance endoscopy every three years
(H. pylori-positive, PG-negative group), two years (H. pyloripositive, PG-positive group), or annually (H. pylori-negative,
PG-positive group). These surveillance intervals vary according
to the gastric cancer risk, as shown by HR of 1.1 to 4.2, 6.0 to
11.23, and 8.2 to 14.81, respectively (Kishikawa et al. 2015).
Biomarkers for Gastric Cancer
Early detection of gastric cancer is challenging, mainly due to
either individuals’ lack of symptoms or the presence of non-specific
gastrointestinal symptoms. Therefore, many studies have been
conducted to identify novel biomarkers that could aid in the
screening and surveillance of precursor lesions/early gastric cancer, as well as in prognostication and predicting treatment
response. A recent systematic review has identified a total of 185
novel biomarkers for gastric cancer that have been sufficiently
validated but need further evaluation in the low-prevalence
population. In terms of the type of biomarkers in gastric cancer,
the most commonly studied category is microRNA and other
RNAs (n = 80), followed by autoantibodies and other immunological markers (n = 52), proteins (n = 44), and circulating tumor
DNA (n = 7). Apart from serum PG, other biomarkers are yet to
be used in clinical practice and certainly need further evaluation
and validation (Calanzani et al. 2021).
Figure 2 Using image-enhanced and magnification endoscopy, features
of gastric intestinal metaplasia include light blue crest and marginal turbid
band (Kohoutova et al. 2021/ MDPI/CC BY 4.0).
Surveillance
Regarding endoscopic surveillance intervals for AG and IM, the
Japanese and Koreans do not specifically recommend any surveillance intervals, except for the existing intervals of screening for
gastric cancer every two years (either with radiography or endoscopy) and conducting endoscopy surveillance at three-, two-, and
one-year intervals according to the ABC method. Nevertheless,
other major gastrointestinal societies, such as AGA (Gupta
et al. 2020; Shah et al. 2021), BSG (Banks et al. 2019), and the
European Society of Gastroenterology (ESGE) (Pimentel-Nunes
et al. 2019), do provide recommendations on the surveillance of
these neoplastic precursor lesions, albeit with slight variations
among them. In general, adherence to the Sydney biopsy protocol
3 SCREENING, SURVEILLANCE, AND PREVENTION OF ESOPHAGEAL AND GASTRIC CANCERS 55
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is recommended; two biopsies from the gastric antrum, two from
the body (at the lesser and greater curvatures), and one from
the incisura. In addition, all individuals undergoing endoscopy
should be tested for H. pylori infection and treated if positive, with
subsequent testing to confirm eradication.
Individuals with extensive AG/IM, defined as the involvement of antrum and corpus, are recommended to undergo
endoscopic surveillance every three years. Surveillance is not
recommended if the finding is only limited to the antrum.
However, with any additional risk factors, such as a family history of gastric cancer, an incomplete subtype of intestinal metaplasia, and persistent H. pylori infection, such individuals are
advised to undergo surveillance every three years as well, given
the perceived high risk for gastric cancer. ESGE, along with
other European Societies, in 2019 guidelines (Pimentel-Nunes
et al. 2019), further recommends a shorter surveillance interval
(1–2 years) in individuals with extensive AG/IM and the
presence of a family history of gastric cancer. In individuals
with non-visible dysplasia, BSG recommends an immediate
repeat endoscopy for extensive gastric mapping with biopsy
(Banks et al. 2019). If persistent dysplasia is detected, both BSG
and European guidelines recommend surveillance in 1 year
and 6 months for low-grade and high-grade dysplasia, respectively. BSG further recommends a multidisciplinary team
discussion in the case of non-visible, high-grade dysplasia.
An expert review by AGA additionally provides a few best
practices for autoimmune atrophic gastritis. Individuals with
the clinical suspicion of pernicious anemia should undergo
endoscopy with multiple biopsies to establish the diagnosis of
corpus-predominant atrophic gastritis. As part of the endoscopic screening for AG/IM/dysplasia, they should also be
endoscopically screened for type 1 neuroendocrine tumors. No
clear-cut endoscopic surveillance interval for autoimmune
atrophic gastritis has been suggested and, therefore, the frequency of endoscopy should be based on shared decision-making with the patients. However, if a small endocrine tumor (<1
cm) is detected, it should be resected and endoscopic surveillance performed every 1–2 years (Shah et al. 2021).
Prevention
The most important primary prevention step for gastric cancer is
the treatment of H. pylori infection and the subsequent confirma-
tion of its eradication. A meta-analysis of seven randomized trials
(6695 participants) showed a larger proportion of gastric cancer
cases in untreated individuals vs. treated individuals (56/3307
(1.7%) vs. 37/3388 (1.1%)). The risk of gastric cancer was also
reduced in H. pylori-treated individuals, with a relative risk of 0.65
(4- to 10-year follow-up) (Fuccio et al. 2009). One randomized
placebo-controlled trial was performed in China involving 1630
healthy carriers of H. pylori infection (988 participants had precancerous lesions). Overall, no significant difference was detected
in the incidence of gastric cancer in both groups after a mean follow-up of 7.5 years: 7 cases in the treatment group vs. 11 cases in
the placebo group, p = 0.33. However, in a subgroup analysis after
excluding the participants with precancerous lesions, eradication
of H. pylori significantly decreased the development of gastric
cancer, that is, 0 cases in the treatment group vs. 6 cases in the
placebo group, p = 0.02 (Wong et al. 2004).
Another randomized controlled trial (the Shandong
Intervention Trial) in a high-risk region in China (Linqu
County) has shown a significant reduction in gastric cancer, by
39%, with the H. pylori treatment during the follow-up period
of 15 years (Ma et al. 2012). In the treatment group, the H. pylori
eradication rate was reported as 72.9%. This trial also demonstrated the feasibility of conducting a large-community-based
H. pylori screening and eradication program. In this trial, 53.1%
of the county’s eligible population (total of 347,811 individuals
aged 25–54 years) participated, indicating a good acceptance
among the residents (Pan et al. 2016). Another important study
was recently conducted by the Taiwanese group on a high-risk
population dwelling on Matsu Islands. In this cohort study, a
very good coverage for mass screening and eradication had
been achieved (85.5%), with a subsequent fall in the prevalence
rate of H. pylori to 15% from 64.2%. The long-term benefits
included a reduction in gastric cancer incidence by 53%, a
reduction in gastric cancer mortality by 25%, and a significant
decline in prevalence rates of premalignant gastric lesions, that
is, atrophic gastritis and intestinal metaplasia, from 7.1% to 0
and from 11.8% to 1.8%, respectively. Interestingly, when the
decreasing trends were extrapolated, a greater reduction of 68%
in gastric cancer incidence and of 39% in mortality rate, would
be expected by 2025 (Chiang et al. 2021).
Currently, in the majority of the countries, H. pylori screen-
ing strategy is mainly opportunistic based. In some high-risk
gastric cancer regions, community-based H. pylori screening
and eradication programs have already been launched (Chiang
et al. 2021; Lee et al. 2013; Pan et al. 2016). In an ideal situation,
a vaccine against H. pylori probably is the best option to ensure
mass H. pylori eradication. However, the progress of such vac-
cines is slow and still uncertain, with most of the vaccines currently being developed are still in the preclinical stage (Sutton
and Boag 2019).
Since cigarette smoking, alcohol consumption, obesity, and
dietary factors have been associated with gastric cancer to some
extent, individuals should be advised to practice a healthy lifestyle, although the evidence for these preventive measures is
still lacking. The role of aspirin, NSAIDs, and statin as chemoprevention in gastric cancer has also been explored in multiple
observational and case-control studies. Most studies showed a
risk reduction of 30 – 50% (Zakko et al. 2017). However, due to
the heterogenicity of these studies, lack of robust study design,
and an unclear benefit/risk profile, their sole usage as gastric
cancer chemoprevention is not recommended for now.
56 1 UPPER GASTROINTESTINAL CANCER
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Summary
Upper GI malignancies are among the most prevalent cancers
globally and have high disease burden with significant negative
impacts on public health. As the first step toward tackling their
rising incidence, it is critical to recognize the potential associated risk factors, such as chronic GERD symptoms, obesity,
high intake of salty/pickled foods, and H. pylori infection, and
take subsequent preventive measures. More robust, high-quality study designs are needed to evaluate the efficacy and cost-effectiveness of existing screening and surveillance programs for
BE, ESCC, and gastric cancer. Similarly, more evidence and
systematic guidelines are needed for the screening and surveillance strategy in high-risk groups in the low- and intermediateincidence population. Endoscopy is a great screening tool, and
with the emergence of advanced imaging technologies, it will
definitely improve the detection rate of precursor lesions/early
cancers. Nevertheless, less invasive tools and non-invasive biomarkers are needed for a better screening/surveillance
approach for accurate risk stratification so that a well-informed
prognosis can be offered to the patients.
Key Take Home Messages
• Majority of gastrointestinal societies in the West advocate the
endoscopic screening for Barrett’s esophagus in high-risk individuals;
having chronic GERD symptoms with ≥3 of the following risk factors:
male, ≥50 years, Caucasian, smoking, obesity, and family history of
Barrett’s esophagus or esophageal adenocarcinoma.
• Mass screening for esophageal squamous cell carcinoma and gastric
cancer are limited to high-incidence countries/regions. Screening for
esophageal squamous cell carcinoma is implemented in certain regions in
China, while for gastric cancer, screening program has been established
in Japan, South Korea, and certain regions in China.
• Optimal endoscopic practices are very important when conducting
surveillance endoscopy. For Barrett’s esophagus surveillance,
endoscopists are required to adhere to Seattle’s biopsy protocol and
recommended to apply chromoendoscopy (dye or virtual) to enhance
dysplasia detection. For atrophic gastritis/intestinal metaplasia,
Sydney biopsy protocol is recommended while maintaining maximum
mucosa visualization by applying magnifying narrow band imaging,
usage of defoaming agent, and adequate inspection time.
• Tackling the modifiable risk factors forms the important step in
preventing upper gastrointestinal cancers. Treating the obesity and
gastroesophageal reflux disease would reduce the incidence of
esophageal adenocarcinoma while adopting healthier lifestyle such as
stopping tobacco smoking, high fruits/vegetables consumption and
low pickled foods/hot drinks intake might prevent the occurrence of
esophageal squamous cell carcinoma. In addition, individuals should
be screened for Helicobacter pylori infection and offered eradication
therapy in order to prevent gastric cancer.
Areas for Further Research
• Novel biomarkers for screening, surveillance, and prognostication
of upper gastrointestinal precursor lesions/cancers are in dire need. To
date, multiple biomarkers have been explored, but lack of clinical
validation.
• More randomized trials are needed in regard to the application of
image enhanced endoscopy incorporating an artificial intelligence for
early detection of pre-cancerous upper gastrointestinal lesions.
• More studies are needed to evaluate the efficacy and strategy of
cancers screening among high-risk individuals/groups in low and
moderate-incidence regions/countries.
• More studies are needed to provide the best evidence-base
recommendation on the surveillance intervals for gastric cancer
precursor lesions, that is, atrophic gastritis and gastric intestinal
metaplasia.
Trusted Websites for Further Reading
• National Cancer Institute Website:
https://www.cancer.gov/types/esophageal/hp
https://www.cancer.gov/types/stomach/hp
• Medscape Website:
https://emedicine.medscape.com/article/277930-overview
https://emedicine.medscape.com/article/278744-overview
• StatPearls (NCBI Bookshelf):
https://www.ncbi.nlm.nih.gov/books/NBK459267/
https://www.ncbi.nlm.nih.gov/books/NBK459142/
• MSD Manual (Professional version):
https://www.msdmanuals.com/professional/gastrointestinal-disorders/
tumors-of-the-gastrointestinal-tract/esophageal-cancer
https://www.msdmanuals.com/professional/gastrointestinal-disorders/
tumors-of-the-gastrointestinal-tract/stomach-cancer
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4 Management of Esophageal Dysplasia
https://t.me/medicina_free
and Esophageal Adenocarcinoma
Prithwish Ghosh1, Luis F. Tapias2, Tsung-Teh Wu3, D. Chamil Codipilly4,
5
Hans Prenen
1
Division of Gastroenterology and Hepatology, Mayo Clinic, SW Rochester, MN, USA
2
Division of Thoracic Surgery, Mayo Clinic, SW Rochester, MN, USA
3
Division of Anatomical Pathology, Mayo Clinic, SW Rochester, MN, USA
4
Division of Gastroenterology and Hepatology, Mayo Clinic, SW Rochester, MN, USA
5
University Hospital Antwerp, Belgium
6
Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
7
Division of Gastroenterology and Hepatology, Mayo Clinic, SW Rochester, MN, USA
[Aspects of the management of esophageal squamous cancer, especially surgery are also covered in Chapter 5].
[Aspects of relevant colorectal date are covered in Chapter 11].
, Bas P.L. Wijnhoven6 & Kenneth K. Wang
7
Epidemiology
Esophageal cancer is the seventh most common incident cancer, and is the sixth most common cause of mortality worldwide, disproportionately affecting men (Sung et al. 2021). In
the United States alone, it is estimated that in 2022 there will be
over 20,000 new cases of esophageal cancer resulting in over
16,000 deaths (Siegel et al. 2022).
Esophageal cancer has two major histologic subtypes:
squamous cell carcinoma (ESCC), which is prevalent in East
Asia, Central Asia, and Sub-Saharan Africa, and adenocarcinoma (EAC), which is found mainly in North America,
Western Europe, and Australia (Arnold et al. 2020). EAC is
more prevalent among those of Caucasian race (Then et al.
2020). EAC primarily affects males in the sixth or seventh
decade of life. Furthermore, the incidence of EAC has increased
over time beginning in the 1970s (Codipilly et al. 2021).
Barrett’s esophagus (BE) is the single most important risk
factor for EAC, and the risk of EAC increases depending on the
degree of dysplasia within BE, ranging from 3.3/1,000 person
years for those with non-dysplastic BE to 8/100 person years in
those with high grade dysplasia (HGD) (Shaheen et al. 2016).
The main risk factors for BE include male gender, age over 50
years, central obesity (waist circumference >102 cm or waist to
hip ratio >0.9), current or past history of smoking, and family
history of BE and/or EAC in a first-degree relative.
Gastrointestinal Oncology: A Critical Multidisciplinary Team Approach,
Second Edition. Edited by Janusz A. Z. Jankowski.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
Pathological Features
Barrett esophagus is characterized by the normal squamous epithelium replaced by metaplastic columnar epithelium including
goblet cell, paneth cells, and gastric foveolar cells and glands
(both cardiac and oxyntic types) corresponding to the region of
salmon colored appearance identified endoscopically in esophagus (Figure 1). In the United States, identification of intestinal
metaplasia (goblet cells) is required for the histological diagnosis
of Barrett esophagus (Shaheen NJ, Am J Gastroenterology 2016)
based on the evidence only metaplastic columnar epithelium
with presence of intestinal metaplasia is with increased risk of
neoplastic progression. This presence of intestinal metaplasia is
not required in Europe, only the histologically confirmed metaplastic columnar epithelium endoscopically visibly above the
GEJ is sufficient for diagnosis of Barrett esophagus by British
Society of Gastroenterology (Bennett C et al 2012, 2015). In fact,
intestinal metaplasia can occur in the stomach whereas deep
oesophageal gland ducts with metaplasia above and the mosaic
of metaplasias only seen in Barrett’s are diagnostic. Multilayered
epithelium contains columnar epithelium with acidic mucin
lying on top of a layer of stratified squamous cells and is thought
to possibly representing a precursor or intermediate step in the
development of Barrett esophagus (Glickman JN, AJSP 2001). It is
often identified at the squamocolumnar junction in patients with
gastroesophageal reflux of Barrett esophagus, the identification
of multilayered epithelium of alone is not sufficient for diagnosis
of Barrett esophagus.
Duplication of muscularis mucosae and fibromuscular
anomaly with prolapse-type change can be seen in Barrett
esophagus. Duplicated muscularis mucosae can be patchy or
63
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