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ASGE Releases New Guideline on Endoscopic Management of Premalignant, Malignant Stomach Conditions
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The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy has released a new guideline on the role of endoscopy in the management of premalignant and malignant conditions of the stomach. A revision of a previous guideline published in 2006, this document was updated based on a critical review of data from medical literature published from January 1980 through March 2014.
“Multiple updated recommendations were made in the recent ASGE Standards of Practice Committee guideline on the endoscopic management of premalignant and malignant conditions of the stomach,” committee chair Brooks D. Cash, MD, from the Digestive Health Center at University of South Alabama Health System, and member of the Healio Gastroenterology Peer Perspective Board, said in an interview. “The suggestions and recommendations contained in this document represent a careful evaluation of the available literature.”
Brooks D. Cash
Premalignant conditions
According to Cash, the new guideline includes “an aggressive approach to gastric polyps,” with a strong recommendation that solitary gastric polyps be biopsied or resected when possible. The committee also suggests that fundic gland polyps 1 cm or larger, hyperplastic polyps 0.5 cm or larger and adenomatous gastric polyps of any size should be resected, “and patients who undergo resection of gastric adenomas should undergo surveillance endoscopy in 1 year,” Cash said.
When multiple polyps are present, biopsy or resection of the largest polyps and representative biopsy specimens from others is recommended, “with additional sampling of the surrounding gastric mucosa in the setting of multiple hyperplastic or adenomatous gastric polyps,” Cash said.
For patients with familial adenomatous polyposis syndrome (FAP), the committee suggests sampling and, if feasible, polypectomy for large gastric polyps to confirm histology and detect dysplasia.
For patients with gastric intestinal metaplasia (GIM) with increased risk for gastric cancer based on ethnic or family background, surveillance endoscopy is suggested, and for patients with GIM and high-grade dysplasia, endoscopic resection and surveillance endoscopy is recommended.
For patients with pernicious anemia, endoscopy within 6 months of diagnosis or development of upper GI symptoms is suggested.
For local staging of gastric carcinoids, the committee recommends endoscopic ultrasonography (EUS). For small type 1 and type 2 gastric carcinoids without aggressive features, endoscopic resection and endoscopic surveillance every 1 to 2 years is suggested. For type 3 and 4 gastric carcinoids, endoscopic removal is suggested.
Malignant conditions
EUS and, when applicable, EUS-FNA (fine needle aspiration) is recommended for locally staging gastric cancer, and EUS with or without FNA is recommended for evaluating gastric submucosal lesions. Annual EUS surveillance of gastrointestinal stromal tumors smaller than 2 cm is suggested if surgical resection is not performed to assess for changes in size or echo features.
“In the case of gastric ulcers suspicious for malignancy, the committee reiterated the importance of multiple tissue biopsies (at least seven) to maximize diagnostic yield,” Cash said. “The committee also … underscored the important role that endoscopic ultrasound (± FNA) plays in the diagnosis and staging of gastric neoplasia.”
Finally, the committee recommends endoscopic stent placement for palliation of malignant gastric outlet obstructions related to gastric cancer in patients with poor performance status or nonoperable anatomy. – by Adam Leitenberger
Disclosure: Cash reports no relevant financial disclosures. Please see the guideline for a full list of all other authors’ relevant financial disclosures.
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