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Gastrointestinal intraepithelial neoplasia

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Gastrointestinal intraepithelial neoplasia (GIN or GIIN) is also known as gastrointestinal dysplasia. Gastrointestinal dysplasia refers to abnormal growth of the epithelial tissue lining the gastrointestinal tract including the esophagus, stomach, and colon. Pancreatic, biliary, and rectal Intraepithelial Neoplasia are discussed separately. The regions of abnormal growth are confined by the basement membrane adjacent to the epithelial tissue and are thought to represent pre-cancerous lesions.  

In the GI tract, tumor progression is thought to occur in a series of steps.[1] It begins with normal tissue and long-term inflammation causes the cells to undergo atrophy, metaplasia, dysplasia, and finally, becomes an adenoma or carcinoma.[2] Given this progression, these lesions represent a potentially cancerous growths and an important opportunity to prevent gastrointestinal cancer.

Epidemiology

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Cancers of the GI tract (esophageal, gastric, and colorectal) are on the rise. Over the last 30 years there has been an increase in incidence of adenocarcinoma of the esophagus, gastroesophageal junction, and gastric cardia.[3] Gastric cancer is the fourth most common malignant tumor and third most common cause of cancer related death. When gastric cancer is caught early, the five year survival rate is estimated to be around 90%.[4][5] However when diagnosed at an advanced stage, survival falls to less than 30%. Colorectal cancer has demonstrated an increasing incidence in younger populations with the US lifetime risk estimated to be about 4%.[6] Colorectal cancer is the second most common cause of cancer related deaths with the highest burden found in Australia, New Zealand, Europe, and North America.[7][8]  

Signs and symptoms

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Signs and symptoms vary based on the location of the tumor and as this is a pre-cancerous stage, many patients are asymptomatic. Symptoms associated with all types of GI cancers include weight loss, abdominal pain, and anemia. Specific symptoms include:

Esophageal lesion:

  • trouble swallowing (dysphagia)
  • painful swallowing (odynophagia)
  • regurgitation of food
  • aspiration of food
  • hoarseness
  • cough[9][10]

Gastric lesion:

  • early satiety
  • nausea
  • vomiting.

Colorectal lesions:

  • change in bowel movements[11]
  • darkly colored stool (melena)
  • rectal bleeding[8]

Risk factors

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Risk factors also vary significantly based on the location and type of tumor. Risk factors for esophageal cancer include GERD, obesity, excessive alcohol use, and smoking. Other risks identified include high temperature foods, exposure to polycyclic aromatic hydrocarbons, and esophageal dysbiosis.[3][12][13][14]

Risks for gastric cancer include chronic gastritis or inflammation. This can be caused by H. pylori infection, autoimmune gastritis,[15]  high salt diet, and smoking.[16]

Colorectal cancer risk increases with increased consumption of red meat, low fiber diet, alcohol use, and obesity. A number of conditions may also increase your risk of colorectal cancer such as irritable bowel disease, familial adenomatous polyposis, lynch syndrome, and cystic fibrosis.[3]

Diagnosis

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Diagnosis of these lesions is made through histologic examination of tissue samples obtained via endoscopic biopsy. When examining the samples, the histologist looks for evidence of dysplasia which is defined as “unequivocal neoplastic epithelium confined to the basement membrane”.[17]

According to the WHO classification of Digestive System Tumors, these lesions are classified based on a two tier system.[18] The two tiers or classifications are low or high grade dysplasia. Low grade dysplasia means that the tissue maintains the glandular structure, cellular variance (pleomorphism) is mild or absent, nuclei maintain basal polarity and mitotic activity is not markedly increased. Where as high grade dysplasia includes features such as complex glandular architecture, marked deviation from the cells typical appearance (unusually large nuclei with prominent nucleoli), loss of typical cellular structure, and frequent mitotic figures.

Classification/grading

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Paris Classification

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The Paris Classification system, established in 2002, is used to classify superficial neoplastic lesions of the gastrointestinal tract based on their endoscopic appearance. This system of classification is clinically significant as it enables estimation of the depth of tumor invasion.[19]

Type Description Subclasses
1 Polypoid p: protruded, pedunculated

s: sessile

2 Nonpolypoid a: slightly elevated

b: flat

c: slightly depressed

3 Excavated

Stomach

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Vienna Classification

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The Vienna classification of gastrointestinal neoplasia was published in 2000 in an attempt to resolve differences in diagnoses between Eastern and Western trained pathologists. This system utilizes cytology, depth of invasion, and architectural severity.[20]

Category Classification Subclasses
1 Negative for neoplasia/dysplasia
2 Indefinite for neoplasia/dysplasia
3 Non-invasive low grade neoplasia (low grade adenoma/dysplasia)
4 Non-invasive high-grade neoplasia Category 4
  1. High grade adenoma
  2. Non-invasive carcinoma
  3. Suspicion of invasive carcinoma
5 Invasive neoplasia Category 5
  1. intramucosal carcinoma
  2. Submucosal carcinoma

Japanese Society for Gastroenterological Endoscopy classification

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The classification system commonly used to classify early gastric cancers was established in 1998 in Japan. This system utilizes visual and endoscopic features for classification and was developed to better assess which lesions were at higher risk of invasion.[21]

Type Type Subclasses
1 Polypoid/protuberant 1p: pedunculated

1ps/sp: Subpedunculated

1s: sessile

2 Flat 2a: superficial elevated

2b: flat

2c: flat depressed

3 Ulcerated
4 Lateral spreading tumor

References

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  1. ^ Correa P. Human gastric carcinogenesis: a multistep and multifactorial process--First American Cancer Society Award Lecture on Cancer Epidemiology and Prevention. Cancer Res. 1992;52(24):6735-6740.
  2. ^ Fearon, Eric R.; Vogelstein, Bert (June 1990). "A genetic model for colorectal tumorigenesis". Cell. 61 (5): 759–767. doi:10.1016/0092-8674(90)90186-I. PMID 2188735. S2CID 22975880.
  3. ^ a b c Napier, Kyle J (2014). "Esophageal cancer: A Review of epidemiology, pathogenesis, staging workup and treatment modalities". World Journal of Gastrointestinal Oncology. 6 (5): 112–120. doi:10.4251/wjgo.v6.i5.112. ISSN 1948-5204. PMC 4021327. PMID 24834141.
  4. ^ Ferlay, Jacques; Shin, Hai-Rim; Bray, Freddie; Forman, David; Mathers, Colin; Parkin, Donald Maxwell (2010-06-17). "Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008". International Journal of Cancer. 127 (12). Wiley: 2893–2917. doi:10.1002/ijc.25516. ISSN 0020-7136. PMID 21351269.
  5. ^ Kamangar, Farin; Dores, Graça M.; Anderson, William F. (2006-05-10). "Patterns of Cancer Incidence, Mortality, and Prevalence Across Five Continents: Defining Priorities to Reduce Cancer Disparities in Different Geographic Regions of the World". Journal of Clinical Oncology. 24 (14). American Society of Clinical Oncology (ASCO): 2137–2150. doi:10.1200/jco.2005.05.2308. ISSN 0732-183X. PMID 16682732.
  6. ^ Global Burden of Disease 2019 Cancer Collaboration; et al. (2022-03-01). "Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life Years for 29 Cancer Groups From 2010 to 2019: A Systematic Analysis for the Global Burden of Disease Study 2019". JAMA Oncology. 8 (3): 420–444. doi:10.1001/jamaoncol.2021.6987. ISSN 2374-2437. PMC 8719276. PMID 34967848.{{cite journal}}: CS1 maint: numeric names: authors list (link)
  7. ^ Siegel, Rebecca L.; Miller, Kimberly D.; Wagle, Nikita Sandeep; Jemal, Ahmedin (2023). "Cancer statistics, 2023". CA: A Cancer Journal for Clinicians. 73 (1). Wiley: 17–48. doi:10.3322/caac.21763. ISSN 0007-9235. PMID 36633525.
  8. ^ a b Siegel, Rebecca L.; Miller, Kimberly D.; Goding Sauer, Ann; Fedewa, Stacey A.; Butterly, Lynn F.; Anderson, Joseph C.; Cercek, Andrea; Smith, Robert A.; Jemal, Ahmedin (2020-03-05). "Colorectal cancer statistics, 2020". CA: A Cancer Journal for Clinicians. 70 (3). Wiley: 145–164. doi:10.3322/caac.21601. ISSN 0007-9235. PMID 32133645.
  9. ^ Obermannová, R.; Alsina, M.; Cervantes, A.; Leong, T.; Lordick, F.; Nilsson, M.; van Grieken, N.C.T.; Vogel, A.; Smyth, E.C. (2022). "Oesophageal cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up". Annals of Oncology. 33 (10): 992–1004. doi:10.1016/j.annonc.2022.07.003. PMID 35914638.
  10. ^ Cavallin, Francesco; Scarpa, Marco; Cagol, Matteo; Alfieri, Rita; Ruol, Alberto; Sileni, Vanna Chiarion; Ancona, Ermanno; Castoro, Carlo (2018). "Esophageal Cancer Clinical Presentation: Trends in the Last 3 Decades in a Large Italian Series". Annals of Surgery. 267 (1): 99–104. doi:10.1097/SLA.0000000000002048. ISSN 0003-4932. PMID 27759616.
  11. ^ Thompson, M R; O'Leary, D P; Flashman, K; Asiimwe, A; Ellis, B G; Senapati, A (2017-08-07). "Clinical assessment to determine the risk of bowel cancer using Symptoms, Age, Mass and Iron deficiency anaemia (SAMI)". British Journal of Surgery. 104 (10): 1393–1404. doi:10.1002/bjs.10573. ISSN 0007-1323. PMID 28634990.
  12. ^ Abnet, Christian C.; Arnold, Melina; Wei, Wen-Qiang (2018). "Epidemiology of Esophageal Squamous Cell Carcinoma". Gastroenterology. 154 (2): 360–373. doi:10.1053/j.gastro.2017.08.023. PMC 5836473. PMID 28823862.
  13. ^ Pandeya, Nirmala; Williams, Gail; Green, Adèle C.; Webb, Penelope M.; Whiteman, David C. (2009). "Alcohol Consumption and the Risks of Adenocarcinoma and Squamous Cell Carcinoma of the Esophagus". Gastroenterology. 136 (4): 1215–1224.e2. doi:10.1053/j.gastro.2008.12.052. PMID 19250648.
  14. ^ Muszyński, Damian; Kudra, Anna; Sobocki, Bartosz Kamil; Folwarski, Marcin; Vitale, Ermanno; Filetti, Veronica; Dudzic, Wojciech; Kaźmierczak-Siedlecka, Karolina; Połom, Karol (2022-11-16). "Esophageal cancer and bacterial part of gut microbiota – A multidisciplinary point of view". Frontiers in Cellular and Infection Microbiology. 12. doi:10.3389/fcimb.2022.1057668. ISSN 2235-2988. PMC 9709273. PMID 36467733.
  15. ^ Rawla, Prashanth; Barsouk, Adam (2019). "Epidemiology of gastric cancer: global trends, risk factors and prevention". Gastroenterology Review. 14 (1): 26–38. doi:10.5114/pg.2018.80001. ISSN 1895-5770. PMC 6444111. PMID 30944675.
  16. ^ Mantziari, Styliani; St Amour, Penelope; Abboretti, Francesco; Teixeira-Farinha, Hugo; Gaspar Figueiredo, Sergio; Gronnier, Caroline; Schizas, Dimitrios; Demartines, Nicolas; Schäfer, Markus (2023-03-06). "A Comprehensive Review of Prognostic Factors in Patients with Gastric Adenocarcinoma". Cancers. 15 (5): 1628. doi:10.3390/cancers15051628. ISSN 2072-6694. PMC 10000968. PMID 36900419.
  17. ^ Riddell, Robert H.; Goldman, Harvey; Ransohoff, David F.; Appelman, Henry D.; Fenoglio, Cecilia M.; Haggitt, Rodger C.; hren, Christer; Correa, Pelayo; Hamilton, Stanley R.; Morson, Basil C.; Sommers, Sheldon C.; Yardley, John H. (1983). "Dysplasia in inflammatory bowel disease: Standardized classification with provisional clinical applications". Human Pathology. 14 (11). Elsevier BV: 931–968. doi:10.1016/s0046-8177(83)80175-0. ISSN 0046-8177. PMID 6629368.
  18. ^ Nagtegaal, Iris D; Odze, Robert D; Klimstra, David; Paradis, Valerie; Rugge, Massimo; Schirmacher, Peter; Washington, Kay M; Carneiro, Fatima; Cree, Ian A; the WHO Classification of Tumours Editorial Board (2020). "The 2019 WHO classification of tumours of the digestive system". Histopathology. 76 (2): 182–188. doi:10.1111/his.13975. ISSN 0309-0167. PMC 7003895. PMID 31433515.
  19. ^ Participants in the Paris Workshop (December 2003). "The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon". Gastrointestinal Endoscopy. 58 (6): S3–S43. doi:10.1016/s0016-5107(03)02159-x. (subscription required)
  20. ^ Schlemper, R J (1 August 2000). "The Vienna classification of gastrointestinal epithelial neoplasia". Gut. 47 (2): 251–255. doi:10.1136/gut.47.2.251.
  21. ^ None, Japanese Gastric Cancer Association (1998). "Japanese Classification of Gastric Carcinoma". Gastric Cancer. 1 (1): 10–24. doi:10.1007/s101209800016. ISSN 1436-3305. PMID 11957040. Retrieved 2024-06-22.
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