Guideline - ESGE

1 GuidelineManagement of epithelial precancerous conditions and lesions inthe stomach (MAPS II): European Society of GastrointestinalEndoscopy (ESGE), EuropeanHelicobacterand Microbiota StudyGroup (EHMSG), European Society of Pathology (ESP), andSociedade Portuguesa de Endoscopia Digestiva (SPED) guidelineupdate 2019 AuthorsPedro Pimentel-Nunes1,2,3, Diogo Lib nio1,2, Ricardo Marcos-Pinto2,4, Miguel Areia2,5,MarcisLeja6,Gianluca Esposito7, Monica Garrido4, Ilze Kikuste6, Francis Megraud8, Tamara Matysiak-Budnik9, Bruno Annibale7,Jean-Marc Dumonceau10, Rita Barros11,12,Jean-Fran oisFl jou13, F tima Carneiro11,12,14, Jeanin E.

2 Van Hooft15,Ernst J. Kuipers16, Mario Dinis-Ribeiro1,2 Institutions1 Gastroenterology Department, Portuguese OncologyInstitute of Porto, Portugal2 Center for Research in Health Technologies andInformation Systems (CINTESIS), Faculty of Medicine,Porto, Portugal3 Surgery and Physiology Department, Faculty ofMedicine of the University of Porto, Porto, Portugal,4 Department of Gastroenterology, Porto UniversityHospital Centre, Institute of Biomedical Sciences,University of Porto (ICBAS/UP), Portugal5 Gastroenterology Department, Portuguese OncologyInstitute of Coimbra, Portugal6 Institute of Clinical and Preventive Medicine, Universityof Latvia, Digestive Diseases Center, GASTRO, Riga,Latvia7 Department of Medicine, Surgery and TranslationalMedicine University Hospital Sant Andrea, UniversitySapienza Roma, Rome, Italy8 INSERM U1053, Universit de Bordeaux and CHUP ellegrin, Laboratoire de Bacteriologie, Bordeaux,France9 IMAD, Hepato-Gastroenterology and DigestiveOncology, CHU de Nantes.

3 University of Nantes, France10 Gedyt Endoscopy Center, Buenos Aires, Argentina11 Institute of Molecular Pathology and Immunology atthe University of Porto (Ipatimup), Porto, Portugal12 Instituto de Investiga o e Inova o em Sa de (i3S),University of Porto, Porto, Portugal13 Service d Anatomie Pathologique, H pital Saint-Antoine, AP-HP, Facult de M decine SorbonneUniversit , Paris, France14 Pathology Department, Centro Hospitalar de S o Jo oand Faculty of Medicine, Porto, Portugal15 Department of Gastroenterology and Hepatology,AmsterdamUMC,UniversityofAmst erdam,TheNetherlands16 Department of Gastroenterology and Hepatology,Erasmus MC University Medical Center, Rotterdam,The online: | Endoscopy 2019.

4 51: 365 388 Georg Thieme Verlag KG Stuttgart New YorkISSN 0013-726 XCorresponding authorPedro Pimentel-Nunes, MD PhD, GastroenterologyDepartment, Portuguese Oncology Institute of Porto, RuaDr. Bernardino de Almeida, 4200-072 Porto, PortugalFax: materialOnline content viewable at: Pedro et al. MAPS II .. Endoscopy 2019; 511 IntroductionGastric cancer is still a major world problem, ranking fifth forincidence and third for cancer-related mortality worldwide inthe latest published global cancer statistics [1]. Even thoughearly recognition and treatment is possible, most cases are di-agnosed at a late stage and thus most patients with a diagnosisof gastric cancer die of the disease [1].

5 Screening and surveil-lance of people at risk may decrease gastric cancer mortalityby allowing early detection and treatment, often by endoscopyinstead of more invasive surgery, and have therefore been re-commended [2,3].In 2012, the European Society of Gastrointestinal Endoscopy(ESGE), the Sociedade Portuguesa de Endoscopia Digestiva(SPED), the European Helicobacter and Microbiota Study Group(EHMSG), and the European Society of Pathology (ESP) pro-duced the first international Guideline on the management ofprecancerous conditions and lesions in the stomach (MAPS) [4,5].

6 Its recommendations were then presented in various coun-tries, ,theMAPS Guideline was incorporated into ESGE guidelines on qual-ity parameters for upper gastrointestinal (GI) endoscopy [6].This document aims to update the first MAPS Guideline (re-ferred to here as MAPS I) and to summarize current evidence onthe management of patients with precancerous conditions andlesions, focusing on the evidence published after RECOMMENDATIONSP atients with chronic atrophic gastritis or intestinal meta-plasia (IM) are at risk for gastric adenocarcinoma.

7 Thisunderscores the importance of diagnosis and risk stratifica-tion for these patients. High definition endoscopy withchromoendoscopy (CE) is better than high definitionwhite-light endoscopy alone for this purpose. Virtual CEcan guide biopsies for staging atrophic and metaplasticchanges and can target neoplastic lesions. Biopsies shouldbe taken from at least two topographic sites (antrum andcorpus) and labelled in two separate vials. For patientswith mild to moderate atrophy restricted to the antrumthere is no evidence to recommend surveillance.

8 In patientswith IM at a single location but with a family history of gas-tric cancer, incomplete IM, or persistentHelicobacter pylorigastritis, endoscopic surveillance with CE and guided biop-sies may be considered in 3 years. Patients with advancedstages of atrophic gastritis should be followed up with ahigh quality endoscopy every 3 years. In patients with dys-plasia, in the absence of an endoscopically defined lesion,immediate high quality endoscopic reassessment with CEis recommended. Patients with an endoscopically visible le-sion harboring low or high grade dysplasia or carcinomashould undergo staging and pylorieradicationheals nonatrophic chronic gastritis, may lead to regressionof atrophic gastritis, and reduces the risk of gastric cancerin patients with these conditions, and it is pylorieradication is also recommended for patients withneoplasia after endoscopic therapy.

9 In intermediate to highrisk regions, identification and surveillance of patients withprecancerous gastric conditions is AND SCOPEThis Guideline is an official statement of the EuropeanSociety of Gastrointestinal Endoscopy (ESGE), the Euro-pean Helicobacter and Microbiota Study Group (EHMSG),the European Society of Pathology (ESP), and the Socie-dade Portuguesa de Endoscopia Digestiva (SPED). Basedon new evidence, it makes recommendations on the diag-nostic assessment and management of individuals withatrophic gastritis, intestinal metaplasia and dysplasia ofthe stomach.

10 Updating the 2012 MAPS of Guidelines for Research andEvaluationAUCarea under the curveCEchromoendoscopyCIconfidence intervalCOXcyclo-oxygenaseEGCearly gastric cancerEHMSGE uropeanHelicobacterand Microbiota StudyGroupESDendoscopic submucosal dissectionESGEE uropean Society of GastrointestinalEndoscopyESPE uropean Society of PathologyGIgastrointestinalGRADEG rading of Recommendations Assessment,Development, and EvaluationHD-WLEhigh definition white-light endoscopyHGDhigh grade dysplasiaHRhazard ratioIMintestinal metaplasiaLGDlow grade dysplasiaMAPSM anagement of precancerous conditions andlesions in stomachNBInarrow-band imagingNSAID nonsteroidal anti-inflammatory drugOLGAO perative Link on Gastritis AssessmentOLGIMO perative Link on Gastritis Assessment basedon Intestinal MetaplasiaORodds ratioRCTrandomized controlled trialRRrelative riskSIRstandardized incidence ratioSPEDS ociedade Portuguesa de