The Sydney System for the classification of gastritis emphasized the importance of combining topographical, morphological, and etiological information into a schema that would help to generate reproducible and clinically useful diagnoses. To reappraise the Sydney System 4 years after its introduction, a group of gastrointestinal pathologists from various parts of the world met in Houston, Texas, in September 1994. The aims of the workshop were (a) to establish an agreed terminology of gastritis; (b) to identify, define, and attempt to resolve some of the problems associated with the Sydney System. This article introduces the Sydney System as it was revised at the Houston Gastritis Workshop and represents the consensus of the participants. Overall, the principles and grading of the Sydney System were only slightly modified, the grading being aided by the provision of a visual analogue scale. The terminology of the final classification has been improved to emphasize the distinction between the atrophic and nonatrophic stomach; the names used for each entity were selected because they are generally acceptable to both pathologists and gastroenterologists. In addition to the main categories and atrophic and nonatrophic gastritis, the special or distinctive forms are described and their respective diagnostic criteria are provided. The article includes practical guidelines for optimal biopsy sampling of the stomach, for the use of the visual analogue scales for grading the histopathologic features, and for the formulation of a comprehensive standardized diagnosis. A glossary of gastritis-related terms as used in this article is provided.

Classification and grading of gastritis.The updated Sydney system

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Pathology and genetics of tumours of the digestive system

Background: Previous research has identified a high risk of gastric carcinoma as well as a high prevalence of cancer precursor lesions in rural populations living in the province of Narino, Colombia, in the Andes Mountains. Methods: A randomized, controlled chemoprevention trial was con- ducted in subjects with confirmed histologic diagnoses of multifocal nonmetaplastic atrophy and/or intestinal meta- plasia, two precancerous lesions. Individuals were assigned to receive anti-Helicobacter pylori triple therapy and/or di- etary supplementation with ascorbic acid, -carotene, or their corresponding placebos. Gastric biopsy specimens taken at baseline were compared with those taken at 72 months. Relative risks of progression, no change, and regres- sion from multifocal nonmetaplastic atrophy and intestinal metaplasia were analyzed with multivariate polytomous lo- gistic regression models to estimate treatment effects. All statistical tests were two-sided. Results: All three basic inter- ventions resulted in statistically significant increases in the rates of regression: Relative risks were 4.8 (95% confidence interval (CI) = 1.6-14.2) for anti-H. pylori treatment, 5.1 (95% CI = 1.7-15.0) for -carotene treatment, and 5.0 (95% CI = 1.7-14.4) for ascorbic acid treatment in subjects with atrophy. Corresponding relative risks of regression in sub- jects with intestinal metaplasia were 3.1 (95% CI = 1.0-9.3), 3.4 (95% CI = 1.1-9.8), and 3.3 (95% CI = 1.1-9.5). Combi- nations of treatments did not statistically significantly in- crease the regression rates. Curing the H. pylori infection (which occurred in 74% of the treated subjects) produced a marked and statistically significant increase in the rate of regression of the precursor lesions (relative risks = 8.7 (95% CI = 2.7-28.2) for subjects with atrophy and 5.4 (95% CI = 1.7-17.6) for subjects with intestinal metaplasia). Con- clusions: In the very high-risk population studied, effective anti-H. pylori treatment and dietary supplementation with antioxidant micronutrients may interfere with the precan- cerous process, mostly by increasing the rate of regression of cancer precursor lesions, and may be an effective strategy to prevent gastric carcinoma. (J Natl Cancer Inst 2000;92: 1881-8)

Chemoprevention of Gastric Dysplasia: Randomized Trial of Antioxidant Supplements and Anti-Helicobacter pylori Therapy

Pathology and genetics: Tumours of the digestive system

Invasive gastric carcinoma is preceded by a cascade of precancerous lesions. The first recognized histologic change is active chronic inflammation, which may persist as such: non-atrophic chronic gastritis (no gland loss), or advance to multifocal atrophic gastritis (MAG), the first real step in the precancerous cascade. The following steps are: intestinal metaplasia (first “complete” and then “incomplete”); dysplasia, first low grade and then high grade (equivalent to “carcinoma in situ”). The following step is invasive carcinoma, which is thought to be associated with degradation of the intercellular matrix.

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The gastric precancerous cascade

Between 1967 and 1976, 1,525 Slovenian patients with a histological diagnosis of intestinal metaplasia (IM) were classified according to subtype of IM based on morphology and mucin staining; 518 cases were diagnosed with type I, 197 with type II and 275 with type III, but in 291 the diagnosis of IM was not confirmed. Patients who had developed cancer or died up to 1986 were identified by record linkage at the Slovenia Cancer Registry and the Central Population Registry in Slovenia. A total of 34 incident cases of gastric cancer occurring at least 6 months after the diagnosis of IM were identified. The standardised incidence ratio (SIR) for stomach cancer was 2.23 in the whole cohort. It was highest for IM type III, followed by type II and IM-unconfirmed, but not increased for type I. The relative risk (RR) of developing gastric cancer based on Cox's proportional hazards model was 2.14 for type II and 4.58 for type III, compared with type I. The RR was especially increased for a subgroup of type III secreting sulphomucins in their goblet cells in comparison with types I-II negative to sulphomucins. Our results confirm that subtyping of IM is useful for identifying individuals at high risk for gastric cancer. © 1994 Wiley-Liss, Inc.

Albert Jutersek

Papers

Intestinal metaplasia types and the risk of gastric cancer: a cohort study in slovenia