Gastric ulcers: malignancy yield and risk stratification for follow-up endoscopy

Abstract

Background and study aim: Malignant change can occur in gastric ulcer but guideline recommendations for follow-endoscopy (FU-OGD) are conflicting. This study aims to determine rate of malignancy and need for follow-up for gastric ulcers. Patients and methods: Patients with a first diagnosis of gastric ulcer between January 2012 and September 2013 were studied by analyzing endoscopic assessments, dysplasia, and malignancy yield and the influence of risk factors on the likelihood of benign disease. Results: In a cohort of 432 patients with gastric ulcer (53 % male, mean age 65 years) dysplasia or neoplasia were found in 27 (19 adenocarcinomas, 2 cases of dysplasia, 5 lymphomas, 1 melanoma; malignancy yield 6 %). Twenty-five (93 %) cases were diagnosed on first biopsy. The cancer yield of FU-OGD after initially benign biopsy was 0.9 %. Binary logistic regression analysis revealed that endoscopically benign appearance (odds ratio 0.004 95 % CI 0 – 0.576; P = 0.029), benign histology on first biopsy (odds ratio 0 95 % CI 0 – 0.39; P = 0.011) and lower number of ulcers (odds ratio 0.22 (95 % CI 0.05 – 0.99); P = 0.049) were independent predictors of benign disease. All dysplastic and neoplastic cases would have been identified by a combination of initial biopsies plus repeat endoscopy with further biopsies for endoscopically suspicious appearances. Conclusions: In this large cohort 6 % of gastric ulcers were found to be malignant, highlighting the need for all gastric ulcers to be biopsied. The cancer yield of FU-OGD after benign biopsies was low. We have demonstrated that the combination of benign index histology and no endoscopic suspicion of malignancy can predict benign disease. We recommend that all gastric ulcers to be biopsied. Risk stratification could potentially reduce need for FU-OGD.

Quality standards in upper gastrointestinal endoscopy: a position statement of the British Society of Gastroenterology (BSG) and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS)

“…Where a gastric ulcer is seen during an OGD, this should be fully assessed, including a description of the size and location. 145 146 Helicobacter pylori status should be assessed by a rapid urease test or gastric biopsies, and if appropriate, eradication therapy should be prescribed. 147 A repeat OGD to ensure that the ulcer has healed should be performed 6–8 weeks after the index OGD.…”

Giant gastric ulcers: Malignancy yield and predictors from a 10‐year retrospective single centre cohort

“…Previous studies looking at giant gastric ulcers have been principally case series 10,13 reporting a much lower risk of cancer. 7,8 We analysed predictors for malignancy using logistic regression analysis to improve the accuracy for predicting malignancy. Independence of variables that looked to predict malignancy in our cohort of patients included ulcer location (fundal or incisura) and age of the patient (>60), whilst if the ulcer looked endoscopically 'non-suspicious' then it was less likely to be malignant.…”

“…Previous studies looking at giant gastric ulcers have been principally case series 10 , 13 reporting a much lower risk of cancer 7 , 8 . We analysed predictors for malignancy using logistic regression analysis to improve the accuracy for predicting malignancy.…”

“…6 A recent study at Leeds Hospitals looked at malignancy yield in all size gastric ulcers from January 2012 to September 2013. 7 A malignancy/ dysplasia yield of 6% was reported, and smaller ulcer size was found to be a predictor for benign disease. Historically it has been thought that the increasing size of gastric ulcers may predict malignancy, 6,[8][9][10][11] though data have been conflicting.…”

“…Giant gastric ulcers have arbitrarily been classified as being equal to or greater than 3 cm (see Figure 1 for photograph) in size; in old literature this is about the size of half a dollar 6 . A recent study at Leeds Hospitals looked at malignancy yield in all size gastric ulcers from January 2012 to September 2013 7 . A malignancy/dysplasia yield of 6% was reported, and smaller ulcer size was found to be a predictor for benign disease.…”