Endoscopic Characteristics And Related Factors Of Gastric Low-grade Intraepithellal Neoplasia

In recent years,the morbidity and mortality of gastric cancer have shown a certain declining trend all over the world.However,gastric cancer remains still one of the most common cancers.The gastric cancer progressing model was first proposed in the early 1970s,which has been modified two times by far.Now the general process is regarded with the following steps:normal gastric mucosa→chronic non-atrophic gastritis→chronic multifocal atrophic gastritis→intestinal epithelial metaplasia→low-grade intraepithelial neoplasia(LGIN)→high-grade intraepithelial neoplasia(HGIN)→gastric cancer.It has been well documented that timely intervention for early gastric malignant tumors can lead to a 90%of the five-year survival rate.Nevertheless,the five-year survival rate for advanced gastric malignancies is less than 15%due to the lack of early intervention.Early detection and treatment of gastric cancer can effectively reduce the death rate,improve the quality of life,and enhance the survival rate of patients with gastric cancer.Hence,the research on early gastric cancer plays an important role in the prevention and treatment of gastric cancer.LGIN of the gastric mucosa belongs to a precancerous lesion of gastric cancer.Though LGIN has a low probability of developing into gastric cancer,it is still one of the main targets of clinical monitoring and internal medical treatment.For LGIN,international guidelines recommend regular follow-up through endoscopy during the time of drug treatment,and endoscopic surgical intervention can be performed if necessary.In this paper,the clinicopathological features and related factors of low grade intraepithelial neoplasia under endoscopy will be discussed in detail.Part I Clinical and Pathological Analysis of LGINOBJECTIVE:To assess the general clinical characteristics,endoscopic morphology and related pathological features of gastric LGIN,and further to focus on the specific features,so as to provide certain enlightenment for clinic.METHODS:Totally,466 clinical cases were collected retrospectively from January 2017 to February 2019 in the endoscopy center of the First Affiliated Hospital of Guangxi Medical University which were diagnosed as LGIN for the first time by pathological biopsies.According to the age,the patients were divided into three groups:low age group(L-Y group,100 cases,45 years old or younger),middle age group(M-Ygroup,180 cases,45～60 years old),high age group(H-Ygroup,186 cases,60 or older).Pathological examination and data statistical analysis of gastric LGIN were carried out,including clinicopathological characteristics;clinical baseline data;location of the lesions;macroscopic morphological analysis under endoscope;status of combined intestinal metastasis;status of combined atrophy;status of Hp infection,Statistical analysis of ME-NBI diagnostic efficacy;ME-NBI and pathological diagnosis difference analysis;Multivariate regression analysis of gastric mucosa low-grade intraepithelial neoplasia with atrophy;multivariate regression analysis of gastric mucosa low-grade intraepithelial neoplasia with intestinal metastasis;Statistical analyses,including endoscopic treatment complications;outcome of gastric LGIN via pathological follow-up,were further performed.RESULTS:(1)Analysis of the basic clinical characteristics of gastric LGIN:There was no significant difference in sex ratio among all the three groups(χ~2=2.031,P=0.362).In pathological classification(mild,mild-moderate,moderate),the differences among the groups were statistically significant(χ~2=13.167,P=0.000).In terms of combined underlying diseases,the differences among the groups were statistically significant(χ~2=10.276,P=0.000).Site analysis:there was no significant difference in patients with LGIN in gastric antrum,gastric body,gastric angle and gastric fundus in each group(χ~2=0.090,0.292,0.369,0.704,P=0.956,0.864,0.832,0.703);Endoscopic macroscopic morphological analysis:No significant lesions,rough erosive lesions,hyperplastic uplift lesions,and ulcer depression lesions were found in LGIN patients(χ~2=0.014,1.576,0.175,4.919,P=0.993,0.455,0.916,0.085);Analysis of LGIN combined with intestinal metaplasia:the difference in gross morphology of LGIN patients in each group was statistically significant(χ~2=16.176,P=0.013);the difference in gastric antrum of LGIN patients in each group was statistically significant(χ~2=15.209,P=0.019);The difference of LGIN combined with atrophy among all groups was statistically significant(χ~2=19.165,P=0.004),and the difference in the affected parts was statistically significant(χ~2=17.896,P=0.006);The LGIN data analysis and comparison among all three groups was:LY group<MY group<HY group,the difference was statistically significant(P<0.05);the analysis of Hp infection in LGIN patients:positive Hp infection,combined intestinal metaplasia,and combined atrophy were statistically significan(χ~2=42.218,38.233,66.176,P=0.000);Statistical analysis of ME-NBI diagnostic efficacy:through pearson correlation analysis,there was no significant difference in sensitivity,specificity,and accuracy of LGIN patients in each group(P=0.118,0.123,0.090);Analysis of the difference between ME-NBI and pathological diagnosis:patient age(P=0.060),lesion surface color(P=0.059),lesion surface morphology(P=0.068),lesion diameter(P=0.063),lesion macroscopic morphology(P=0.070),the differences were not statistically significant(P>0.05);There was no statistically significant difference in the patient’s lesion secretion(P=0.013),lesion location(P=0.042)and Hp infection(P=0.009)(P>0.05)(2)Multivariate analysis of gastric LGIN with intestinal metaplasia and atrophy;Logistic regression analysis of multi-factorial LGIN with intestinal metaplasia patient age(P=0.035)and gross morphology(P=0.009、0.014、0.024),stomach sinus(P=0.019),stomach angle(P=0.040),and gastric fundus(P=0.013),the difference was statistically significant(P<0.05);Multivariate Logistic regression analysis of LGIN combined with atrophy:patient age(P=0.015),gross morphology(P=0.020、0.025、0.019),diseased site(P=0.090、0.023、0.010),and Hp infection(P=0.002),the difference had statistical significance(P<0.05).CONCLUSIONS:(1)The morphology of LGIN endoscopic lesions was mainly rough erosion type and hyperplastic bulge type,and the distribution of lesions was mainly gastric antrum,followed by gastric body and gastric angle,and the gastric fundus of cardia was the least.(2)The rate of Hp infection in patients with LGIN with atrophy and intestinal metaplasia is higher than those without.(3)ME-NBI can clearly detect the relevant information of LGIN with accurate positioning,high accuracy and specificity.Lesion secretions,lesion sites and Hp infection are all key factors for the difference between ME-NBI and postoperative pathological diagnosis.(4)Multivariate logistic regression analysis found that age,macroscopic morphology,lesion site and Hp infection are risk factors for LGIN associated with atrophy and intestinal mealtimes.Part II Endoscopic Clinical Manifestations and Characteristics of LGIN Diagnosed as Cancer Within 1 YearOBJECTIVE:To summarize and analyze the regression characteristics of LGIN in early gastric cancer based on the work of Part I,so as to improve the clinical detection rate of early gastric cancer.METHODS:See information of Part I.After pathological examination and data statistical analysis of patients with LGIN of the gastric mucosa,relevant items were analyzed,including:statistical analysis of endoscopic treatment complications;Outcome analysis of patients with LGIN:pathological follow-up and outcome statistical analysis;Statistical analysis of cancer rate in different sites;Endoscopic clinical manifestations and factors of cancer diagnosed within 1year of gastric LGIN:Endoscopic clinical manifestations and characteristics;Multi-factor analysis;Comparison of sensitivity,specificity,accuracy and positive/negative predictive values,Statistics,draw conclusions.RESULTS:Pathological follow-up and outcome:mild(P=0.750),mild-moderate(P=0.340),moderate(P=0.214),HGIN(P=0.270),and advanced gastric cancer(P=0.085),differences No statistical significance(P>0.05);The disappearance(P=0.001),early gastric cancer(P=0.017)in each group’s outcome ratio trend was L-Y group<M-Y group<H-Y group,the difference was statistically significant(P<0.05);ME-NBI performance characteristics and diagnostic efficacy:ME-NBI performance characteristics:DL pathological boundary(P=0.000),MSP gastric micro-surface structure(P=0.009),MVP gastric microvascular structure(P=0.012),the difference has Statistical significance(P<0.05);ME-NBI diagnostic efficacy:ME-NBI detected the sensitivity(P=0.123),specificity(P=0.119)and accuracy(P=0.180)of LGIN patients in each group,and the difference was not statistically significant(P>0.05);The pathological features of patients diagnosed with cancer lesions within 1year:LGIN patients with active inflammation(P=0.727)and intestinal metaplasia(P=0.606),the difference was not statistically significant(P>0.05);the difference between LGIN and atrophy was statistically significant(P=P=0.042);Statistical analysis of the canceration rate of different parts:the gastric antrum(P=0.067),gastric body(P=0.254),gastric angle(P=0.396)and gastric fundus(P=0.792)of the LGIN patients(P>0.05);Postoperative pathological manifestations and complications of ESD:54.55%of 55 cases of LGIN remained unchanged,32.72%were upgraded to HGIN,and 7 cases were cancerous;the pathological upgrade of gastric antrum,gastric body,gastric horn,and cardiac fundus was not statistically significant Obvious statistical significance(P>0.05);0 cases of bleeding after ESD,2 cases of perforation(3.63%)but no serious complications;Statistics of different macroscopic morphological distributions:no obvious lesions(P=0.470),rough erosion type(P=0.056),hyperplastic uplift(P=0.764)and ulcer depression type(P=0.102),the difference was not statistically significant(P>0.05);Logistic regression analysis of influencing factors of LGIN cancer:patient age(P=0.049),intestinal metaplasia(P=0.040),atrophy(P=0.043),degree of dysplasia(P=0.005),Hp infection(P=0.009)The diseased part(P=0.018)and endoscopic gross morphology(P=0.030),the difference was statistically significant(P<0.05).CONCLUSIONS:(1)Most of the LGIN disappeared or remained unchanged during the follow-up process,but a small portion still progressed to HGIN or gastric cancer,suggesting that clinical attention should be paid.(2)ME-NBI can clearly observe the internal micro-vessel and micro-surface structures with high accuracy and specificity.For the suspected cancerous lesions under ME-NBI,it is recommended to actively adopt ESD and other methods to obtain whole lesion specimens to confirm the diagnosis.(3)This study suggests that age,intestinal metaplasia,atrophy,degree of dysplasia,Hp infection,diseased site,and endoscopic macroscopic morphology are all key factors that cause cancer for LGIN patients within 1 year.