Patients diagnosed with premalignant gastric lesions are at significant risk of gastric cancer, according to results of a nationwide cohort study in the Netherlands.

"As current surveillance of these patients is inconsistent with their cancer risk, development of guidelines is indicated," the study team concludes in a report in the April issue of Gastroenterology.

Studies evaluating the progression of premalignant gastric lesions to gastric cancer have produced conflicting results and, as a result, have contributed to a lack of clear guidelines on appropriate follow-up in these patients, Dr. AnneMarie C. DeVries of Erasmus MC University Medical Center, Rotterdam, and colleagues note in their report.

They used the Dutch nationwide histopathology registry to investigate surveillance practices and gastric cancer risk in all patients with a first diagnosis of premalignant gastric lesions between 1991 and 2004.

In total, 22,365 (24 per cent) patients were diagnosed with atrophic gastritis, 61,707 (67 per cent) with intestinal metaplasia, 7616 (eight per cent) with mild-to-moderate dysplasia, and 562 (0.6 per cent) with severe dysplasia.

The investigators found that 26 per cent of patients with a diagnosis of gastric atrophy and 28 per cent with a diagnosis of intestinal metaplasia received at least one re-evaluation with upper GI endoscopy with histological examination, compared with 38 per cent of patients with mild or moderate dysplasia and 61 per cent of those with severe dysplasia (p < 0.001).

It thus appears that in Dutch clinical practice, "which is likely to be representative for many Western countries, surveillance of these patients is regularly omitted, even in patients with overt dysplasia," the team notes.

Within five years of diagnosis, the annual incidence of gastric cancer in patients with gastric atrophy, intestinal metaplasia, mild-to-moderate dysplasia, and severe dysplasia was 0.1 per cent, 0.25 per cent, 0.6 per cent, and six per cent, respectively.

Age over 75 years, male gender, and increasing severity of premalignant gastric lesions at initial diagnosis were strong risk factors for progression to gastric cancer.

Dr. DeVries and colleagues make the point that the risk of gastric cancer "is comparable or even higher in patients with premalignant gastric lesions than in patients with other premalignant gastrointestinal conditions, which are routinely monitored."

"Therefore, follow-up should also be seriously considered in patients with premalignant gastric lesions," they conclude. "Our data show that routine endoscopic surveillance at short intervals is warranted in patients with gastric dysplasia, whereas surveillance at longer intervals should be considered for patients with atrophic gastritis and intestinal metaplasia."


Gastroenterology 2008;134:945-952.