See "Intracellular, Intercellular, and stromal invasion of gastric mucosa, preneoplastic lesions, and cancer by Helicobacter pylori" by Necchi V, Candusso ME, Tava F, Luinetti O, Ventura U, Fiocca R, Ricci V, and Solcia E on page 1009-1023.It has been more than 20 years since Warren and Marshall demonstrated that the human stomach can be colonized by a spiral bacterium, now called Helicobacter pylori, and that there is a strong association between the presence of H pylori and gastric and duodenal ulcer. 1 This observation was initially received with skepticism, but the impetus was given for many laboratories to investigate the pathogenic role of H pylori in gastric diseases. The results of these studies progressively convinced the medical community that the infection was present in a majority of patients with peptic ulcer disease and that the ulcer disease condition was cured if H pylori was eradicated by antibiotics. 2 Soon after the discovery of H pylori, several groups demonstrated an association between H pylori and gastric adenocarcinoma, 3,4 confirming an earlier prediction that one or several environmental factors may play a role in gastric carcinogenesis. 5 The association between gastric adenocarcinoma and H pylori was confirmed by many subsequent investigations, leading to the consensus that the bacterium is a class I carcinogen. 6However, even today, we do not know why about 80% of H pylori-infected subjects do not have peptic ulcer disease or gastric cancer and, as a corollary, how H pylori colonization of the antrum produces gastroduodenal ulceration or gastric adenocarcinoma in the remaining subjects. In an attempt to explain this conundrum, the role of bacterial virulence and of host predisposition to the disease was explored. First and foremost, peptic ulcer disease and gastric adenocarcinoma appear to be present preferentially in subjects infected by virulent strains carrying genes such as the vacuolating cytotoxin vacA and the cytotoxin-associated pathogenicity island (cag PAI). 7 In addition, persons with cytokine gene polymorphisms and/ or low pepsinogen I levels may be at a higher risk of developing gastric ademocarcinoma. 8, 9 Unexpectedly, early studies showed that H pylori was not detected in the gastric lumen of patients with precancerous and cancerous lesions, indicating that persistence of the infection was not necessary to promote the late stages of cancerization. However, as discussed below, more recent studies 10 have demonstrated that this hypothesis needs to be revised. In addition, H pylori is generally present in patients with early gastric carcinoma, and eradication of H pylori infection may prevent relapse following mucosal resection in these patients. 11To understand H pylori pathogenicity, it is useful to detail the process of gastric colonization by the bacterium. The majority of H pylori are located in the gastric lumen and mucus where Address requests for reprints to: