Abstract
Methods In total, 123 IND cases with final diagnoses of cancer (29.3%), high-grade dysplasia (6.5%), low-grade dysplasia (11.4%), and nonneoplasm (52.8%) were randomly divided into test set (n = 27) and validation set (n = 96). By the image analysis, size, pleomorphism, hyperchromasia, irregularity of nuclei, and ratios of structural atypia area (SAA) to total IND area were measured in the test set. Using the validation set, consensus meetings were held for the evaluation of pathologic factors that predict the final diagnosis. Results By image analysis, the only ratio of SAA to total IND area was associated with the final diagnosis (p < 0.001). In the consensus meeting for validation, the nuclear factors, except loss of nuclear polarity (p = 0.004–0.026), could not predict the final diagnosis. Conversely, most structural factors could predict the final diagnosis. In particular, SAA > 25% was the most powerful predictive factor. We proposed criteria of risk stratification by using SAA > 25%, loss of surface maturation (LOSM), and loss of nuclear polarity (LONP) (Malignancy rate; Category 0: SAA ≤ 25% without LOSM and LONP; 0%, Category 1: SAA ≤ 25% with any of LOSM or LONP; 15.2%–16.7%, Category 2: SAA > 25% without LOSM and LONP; 44.4%–50.0%, Category 3: SAA > 25% with any of LOSM or LONP 54.5%–55.6%). Conclusions Structural atypia was more helpful than nuclear atypia and SAA > 25% was the most powerful predictor for the diagnosis of INDs of the stomach. We propose shortening the follow-up period to six months for Category 1, endoscopic resection for Category 2 and 3, postresection follow-up periods of one year for Category 2, and six months for Category 3.
Highlights
Pathologic evaluations are the gold standard for the diagnosis of gastric cancer; it is not always possible to distinguish between malignancy and benign conditions when architectural distortion or nuclear atypia is present [1,2,3]
The international consensus meeting held in Vienna suggested to designating this indefinite histology as a distinct category, i.e., indefinite for dysplasia (IND) [6, 7]
The reason for gastrectomy after a diagnosis of IND in six patients was the presence of coexisting lesions in distant sites of the stomach (The final diagnoses were carcinomas in four patients and nonneoplasms in two)
Summary
Pathologic evaluations are the gold standard for the diagnosis of gastric cancer; it is not always possible to distinguish between malignancy and benign conditions when architectural distortion or nuclear atypia is present [1,2,3]. With regard to the management of the IND, no definite criteria for selecting follow-up methods have been established. Current guidelines advise follow-up biopsy for IND areas, a few endoscopists insist that endoscopic resection (ER) be used as a follow-up method because malignancy rates in IND areas are high (22.6%–75.0%) [8,9,10,11,12]. Architectural features such as loss of surface maturation (LOSM), margination, glandular cribriform patterns, glandular branching/budding, glandular arrangement, and glandular crowding are relatively more associated with tumorous conditions [4, 13]
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