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74 Guideline Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED) Authors M. Dinis-Ribeiro*, 1,5, M. Areia2, 5, A. C. de Vries3, R. Marcos-Pinto4, 6, M. Monteiro-Soares5,A.O’Connor7, C. Pereira8, P. Pimentel-Nunes1, R. Correia5, A. Ensari†,9, J. M. Dumonceau‡,10, J. C. Machado11, G. Macedo§,12, P. Malfertheiner13, T. Matysiak-Budnik14, F. Megraud15, K. Miki16,C.O’Morain7, R. M. Peek17, T. Ponchon18, A. Ristimaki19, 20, B. Rembacken21, F. Carneiro¶,11, 22, E. J. Kuipers3 on behalf of MAPS Participants** (see below and Appendix) Institutions Institutions are listed at the end of article. Submitted: 4. August 2011 Atrophic gastritis, intestinal metaplasia, and epi- patients with precancerous conditions and le- Accepted after revision: thelial dysplasia of the stomach are common and sions of the stomach (termed MAPS). A multidis- 12. October 2011 are associated with an increased risk for gastric ciplinary group of 63 experts from 24 countries cancer. In the absence of guidelines, there is wide developed these recommendations by means of Bibliography disparity in the management of patients with repeat online voting and a meeting in June 2011 DOI http://dx.doi.org/ these premalignant conditions. The European So- in Porto, Portugal. The recommendations empha- 10.1055/s-0031-1291491 ciety of Gastrointestinal Endoscopy (ESGE), the size the increased cancer risk in patients with – Endoscopy 2012; 44: 74 94 European Helicobacter Study Group (EHSG), the gastric atrophy and metaplasia, and the need for © Georg Thieme Verlag KG European Society of Pathology (ESP) and the Soci- adequate staging in the case of high grade dyspla- Stuttgart · New York ISSN 0013-726X edade Portuguesa de Endoscopia Digestiva (SPED) sia, and they focus on treatment and surveillance have therefore combined efforts to develop evi- indications and methods. Corresponding author dence-based guidelines on the management of M. Dinis-Ribeiro, MD PhD Gastroenterology Department Portuguese Oncology Institute 1.INTRODUCTION though such lesions are commonly found in ev- ! of Porto eryday practice, there are no international recom- Rua Dr. Bernardino de Almeida Gastric cancer remains a major problem world- mendations to guide clinicians in their care of in- 4200–072 Porto wide. The intestinal type of gastric cancer devel- dividuals with these changes. This leads to wide Portugal ops through a cascade of well-defined and recog- heterogeneity of practice and to failure to diag- – – Fax: +351 22 5084055 nizable precursors (inflammation –metaplasia– nose patients with curable forms of cancer. Stan- [email protected] dysplasia – carcinoma sequence) [1]. It has been dardization of management is likely to benefit pa- argued that the identification and surveillance of tients, and may also be cost-effective by focusing patients with such precursor conditions and le- resources on patients with the greatest risk. sions may lead to early diagnosis of gastric cancer. This consensus project aimed to summarize cur- Indeed, this may be an important measure for rent evidence on the management of patients prevention of death due to gastric cancer both in with precancerous conditions and lesions, and to Western and Asian countries. However, even propose guidelines for the diagnosis and manage- ment of individuals with chronic gastritis, atro- phy, intestinal metaplasia, or dysplasia. * Chairman, ESGE Educational Committee, and Chairman, This Guideline does not address methodologies SPED Research Committee for screening these lesions in general populations, † Chairperson, ESP Digestive Pathology Working Group or the assessment and management of patients ‡ Chairman, ESGE Guidelines Committee with other precancerous conditions, such as per- § President, Portuguese Society of Digestive Endoscopy nicious anemia, Ménétrier disease, or gastric ¶ ESP Digestive Pathology Working Group stump, or treatment for gastric adenocarcinoma. ** Including: Cathomas G (Switzerland), Fedorov ED (Rus- sia), Figueiredo P (Portugal), Goldis A (Romania), Leja M (Latvia), Moehler M (Germany), Plesea E (Romania), Scope and key questions Bergman J (The Netherlands), Hamoudi W (Jordan), Al- We addressed the management, that is, the diag- meida R, Annibale B, Lobo LA, Balaban YH, Boeriu A, Bur- nostic assessment, treatment and follow-up, of ette A, Mallet AC, David L, Delchier J-C, Dobru ED, Fer- individuals with atrophic gastritis, or intestinal nandes C, Kahaleh M, Kashin S, Lomba-Viana R, Lunet N, metaplasia or dysplasia of the gastric mucosa. Marakhouski K, Moreira-Dias L, Ferreira CF, Pais TP, Roll- án A, Sadio A, Santos C, Chu K-M, D'Ambra G, Ellul P, van Specific issues were included: What is the opti- Grieken N, Lamarque D, Najeeb AA mal diagnostic approach for patients with gastric Dinis-Ribeiro M et al. Management of precancerous conditions and lesions in the stomach (MAPS)… Endoscopy 2012; 44: 74–94 Guideline 75 Table 1 Panel subgroups according to key questions. Key questions Working group Which are the precancerous lesions in the stomach? Fátima Carneiro, Ernst Kuipers, Mário Dinis Ribeiro Which outcomes to prevent/avoid? Is there evidence to use endoscopic methods to improve Miguel Areia, Pedro Pimentel Nunes, AnneMarie de Vries, Bjorn Rembacken, Ernst Kuipers, Mário diagnosis? Dinis Ribeiro, Whichcareshouldbetakenonbiopsies(numberand Ricardo Marcos Pinto, Bjorn Rembacken, Kazumasa Miki, José Carlos Machado, Fátima Carneiro, sites) for a correct diagnosis and staging? Ernst Kuipers, Mário Dinis Ribeiro, Should other sources of data be added for staging? Ricardo Marcos Pinto, Carina Pereira, José Carlos Machado, Miguel Areia, AnneMarie de Vries, Fátima Carneiro, Ernst Kuipers, Mário Dinis Ribeiro, Thierry Ponchon, Bjorn Rembacken, Kazu- masa Miki Is there evidence to use non-invasive methods to Miguel Areia, Ernst Kuipers, Mário Dinis Ribeiro, Kazumasa Miki, improve diagnosis? Should these patients be followed up? AnneMarie de Vries, Ernst Kuipers, Mário Dinis Ribeiro, Ricardo Marcos Pinto, Carina Pereira Does the type, the severity and the extension of the AnneMarie de Vries, Ernst Kuipers, Mário Dinis Ribeiro, Thierry Ponchon, Bjorn Rembacken, lesion influence the prognosis of these patients? Kazumasa Miki, José Carlos Machado, Ricardo Marcos Pinto, Carina Pereira, Fátima Carneiro Is there a role for Helicobacter pylori eradication? Anthony O’Connor, Pedro Pimentel-Nunes, Ernst Kuipers, Mário Dinis Ribeiro, Peter Malfertheiner, Tamara Matysiak-Budnik, Francis Megraud, Carina Pereira, Ari Ristimaki Is there a role for other therapies? Anthony O’Connor, Carina Pereira, Ernst Kuipers, Mário Dinis Ribeiro, Peter Malfertheiner, Tamara Matysiak-Budnik, Francis Megraud, Pedro Pimentel-Nunes May it/these strategies be cost-effective? Miguel Areia, Richard Peek, Jean-Marc Dumonceau, Ernst Kuipers, Mário Dinis Ribeiro precancerous conditions/lesions? Which patients are at higher cieties were represented (Germany, Jordan, Latvia, Portugal, Ro- risk and would benefit from surveillance to detect early-stage mania, Russia, Slovakia, Switzerland and The Netherlands). cancer? Should they receive pharmacological interventions to re- duce the risk of developing cancer? If so, are such measures cost- 2.2 Literature search effective? A literature search using PubMed up to November 2010 was car- ried out. A small working group from the panel dealt with each question and each string/query, and identified key references 2.METHODS which were supplied to the entire panel and participants. ! These recommendations were developed according to the pro- 2.3 Grading of evidence cess described by the Appraisal of Guidelines for Research and Each working group rated the quality level of the available evi- Evaluation (AGREE) Collaboration [2]. dence and the strength of recommendations by using both the Grading of Recommendations, Assessment, Development, and 2.1 Selection of Working Panel Evaluation (GRADE) process [3, 4] and the system of the Scottish In May 2010, three authors (M.D.R., E.J.K., and F.C.), on behalf of Intercollegiate Guidelines Network (SIGN) [5]. Researchers prior- the European Society of Gastrointestinal Endoscopy (ESGE), the itized data from randomized clinical trials (RCTs) when available, Sociedade Portuguesa de Endoscopia Digestiva (SPED), the Euro- and performed meta-analyses when applicable. Each paper was pean Helicobacter Study Group (EHSG), and the European Society individually assessed by two investigators using a methodologi- of Pathology (ESP), assembled a panel of European gastroenterol- cal tool that was identical for all topics reviewed in the guide- ogists and pathologists, including clinical experts and young re- lines. Discrepant assessment results were discussed by the full searchers trained in literature search and evidence-based medi- working group. Tables with the assessment of individual manu- cine (see Appendix). scripts are available upon request. This panel met in October 2010 in Barcelona, and agreed on the For each question the working group summarized the quantity, methodology to be applied, and on a set of key questions and pre- quality, and consistency of evidence, and they discussed the ex- liminary statements to guide a literature search. The panel fur- ternal validity of studies and whether the study conclusions ther worked in subgroups (●" Table1)
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