Follow-up of intestinal metaplasia in the stomach: When, how and why

Gastric cancer remains the second most frequent cause of cancer-related mortality in the world. Screening programs in some Asian countries are impractical in the majority of other countries worldwide. Therefore, follow-up of precancerous lesions is advisable for secondary gastric cancer prevention. Intestinal metaplasia (IM) is recognized as a precancerous lesion for gastric cancer, increasing the risk by 6-fold. IM is highly prevalent in the general population, being detected in nearly 1 of every 4 patients undergoing upper endoscopy. The IM prevalence rate is significantly higher in patients with Helicobacter pylori (H. pylori) infection, in first-degree relatives of gastric cancer patients, in smokers and it increases with patient age. IM is the "breaking point" in the gastric carcinogenesis cascade and does not appear to regress following H. pylori eradication, although the cure of infection may slow its progression. Gastric cancer risk is higher in patients with incomplete-type IM, in those with both antral and gastric body involvement, and the risk significantly increases with IM extension over 20% of the gastric mucosa. Scheduled endoscopic control could be cost-effective in IM patients, depending on the yearly incidence of gastric cancer in IM patients, the stage of gastric cancer at diagnosis discovered at surveillance, and the cost of endoscopy. As a pragmatic behavior, yearly endoscopic control would appear justified in all IM patients with at least one of these conditions: (1) IM extension > 20%; (2) the presence of incomplete type IM; (3) first-degree relative of gastric cancer patients; and (4) smokers. In the remaining IM patients, a less intensive (2-3 years) could be proposed.

Current approach in the treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common malignant hepatobiliary disease; it is responsible for about 1 million deaths per year. Risk factors include hepatitis B and C, hepatic cirrhosis, including alcohol related hepatitis, metabolic and nutritional hepatic damage. The main modality of diffusion is intrahepatic in the natural course of the disease. There are two leading types of treatment: local and systemic. Surgical resection and liver transplantation constitute the most appropriate local treatments and are considered the only real possibility for recovery. Other local approaches include: radiofrequency ablation, percutaneous ethanol ablation, hepatic endoarterial chemoembolization and intrahepatic radiotherapy (SIRT: selective internal radiation therapy). These last treatments are used to control the disease when surgery or transplantation is not achievable; in some cases they are able to prolong survival while theyconstitute mainly a palliative treatment. Systemic treatments include: chemotherapy, immunological and hormonal therapies and, more recently, the introduction of new specific molecular target drugs. At the moment, in this group, the only drug that has given positive results during phase trials (SHARP study) is Sorafenib.Sorafenib represents the only primary systemic therapy that has demonstrated, unlike the other treatments previously described, an increase in survival rate in patients affected with advanced HCC. Currently, other studies are taking place that are further developing the potential of this drug. These studies, including phase trials, aredirected in order to test the activity and safety of new emerging drugs with targeted activity. Examples of these new agents are: Sunitinib, Gef itinib, Cetuximab, Bevacizumab and Erlotinib.

Helicobacter pylori and functional dyspepsia: An unsolved issue?

Patients with Helicobacter pylori (H. pylori) infection may complain of dyspeptic symptoms without presence of macroscopic lesions on gastroduodenal mucosa. Such a condition is usually recognized as functional dyspepsia, and different pathogenetic mechanisms are involved. The role of H. pylori in these patients is controversial. Several trials assessed the potential role of H. pylori eradication in improving dyspeptic symptoms, and data of some meta-analyses demonstrated that cure of infection is associated with a small (10%), but significant therapeutic gain as compared to placebo. The reason for which dyspeptic symptoms regress in some patients following bacterial eradication, but persist in others remains unclear. Regrettably, trials included in the meta-analyses are somewhat different for study design, definition of symptoms, assessment of symptoms changes, and some may be flawed by potential pitfalls. Consequently, the information could be not consistent. We critically reviewed the main available trials, attempting to address future research in this field

Colorectal cancer metastatic to the breast:A case report

BACKGROUND Breast metastases from colorectal cancer(CRC)are very uncommon.There is no unanimous consensus regarding the best treatment for this rare condition,and management is,especially in elderly patients,limited to diagnosis and palliative care.Capecitabine,an oral fluoropyrimidine derivative,might be helpful in controlling the disease and may be a treatment option for patients unable to receive more aggressive chemotherapy.CASE SUMMARY We report a case of synchronous massive breast metastasis from CRC in an 85 year old patient who came to the hospital presenting a huge mass originating from the axillary extension of the right breast.A whole body computed tomography also showed a mass in the right colon.The patient underwent a simple right mastectomy along with right hemicolectomy.The resected breast showed massive metastasis from CRC with intense and homogeneous nuclear CDX2 staining,while the colon specimen revealed poorly differentiated adenocarcinoma stage pT4a pN0 pM1(breast)(Tumor Node Metastasis 2017).Three months later she developed a subcutaneous mass at the site of the previous mastectomy.An ultrasound guided biopsy was carried out again and revealed a metastasis from CRC.The patient then started treatment with capecitabine plus bevacizumab,obtaining stable disease(RECIST criteria)and a clinical benefit after 3 mo of therapy.CONCLUSION In our experience,capecitabine and bevacizumab may be a useful treatment option for breast metastases from primary CRC in elderly patients.

Relationship between p-catenin expression and epithelial cell proliferation in gastric mucosa with intestinal metaplasia

AIM： To investigate β-catenin expression in patients with intestinal metaplasia, and to look for a possible relationship between β-catenin expression and either epithelial proliferation values or Helicobacter pylori （ H pylori） infection.METHODS： Twenty patients with complete type intestinal metaplasia were studied. β-Catenin expression and epithelial cell proliferation in antral mucosa were assessed using an immunohistochemical analysis. H pylori infection was detected by histology and a rapid urease test.RESULTS： Reduced β-catenin expression on the surface of metaplastic cells was detected in 13 （65%） out of 20 patients. Moreover, in eight （40%） patients intranuclear expression of β-catenin was found. When patients were analyzed according to H pylori infection, the prevalence of both β-catenin reduction at the cell surface and its intranuclear localization did not significantly differ between infected and uninfected patients. Cell proliferation was higher in patients with intranuclear β-catenin expression as compared to the remaining patients, although the difference failed to reach the statistical significance （36±8.9 vs 27.2±11.4, P= 0.06）. On the contrary, a similar cell proliferation value was observed between patients with reduced expression of β-catenin on cell surface and those with a normal expression （28.1±11.8 vs 26.1±8.8, P= 0.7）.H pylori infection significantly increased cell proliferation （33.3±10.2% vs 24.6±7.4% , respectively, P= 0.04）.CONCLUSION： Both cell surface reduction and intranuclear accumulation of β-catenin were detected in intestinal metaplasia. The intranuclear localization of β-catenin increases cell proliferation. H pylori infection does not seem to play a direct role in β-catenin alterations, whilst it significantly increases cell proliferation.