Review for 10.1186/s12876-022-02381-z (2022)

Title: Identification of Helicobacter pylori-Related Gastric Cancer Risk Using Serological
Gastritis Markers and Endoscopic Findings: A Large-Scale Retrospective Cohort Study
Version: 1 Date: 29 Apr 2022
Reviewer's report:
MANUSCRIPT TITLE:
Identification of Gastric Cancer Risk Using Serological Gastritis Markers and Endoscopic
Findings: A Large-Scale Retrospective Cohort Study
By: Naoko Nagasaki, Masanori Ito, Tomoyuki Boda, Takahiro Kotachi, Hidehiko Takigawa,
Shiro Oka, Shinji Tanaka
GENERAL COMMENTS.
This interesting study aims to evaluate the usefulness of serum markers (PGI, PGII, anti-Hp-Ab)
either alone or in combination (serum markers plus endoscopy) for effective risk stratification
of gastric cancer (GC).
The tested hypothesis of the usefulness of serum markers, either alone or in combination with
endoscopy, in the assessment of GC risk, is not entirely novel. However, this study is basically
well done and includes some new data to the currently available information.
The GC risk is calculated by comparing patients at very low risk (patients with high PG levels,
negative Hp-Ab, and no endoscopy atrophy (GROUP A), with subjects with:
- high PG levels and positive Hp-Ab into GROUP B,
- low PG levels and positive Hp-Ab into GROUP C,
- with low PG levels and negative Hp-Ab into GROUP D.
Group A was subdivided into two sub-groups: true A (without endoscopic atrophic gastritis)
and pseudo-A (with endoscopic atrophy).
The study finally included 1,507 patients. All subjects underwent endoscopy, and, among them,
24 developed GC.
No “true” group A subjects developed gastric cancer (the author also wrote:  “… the incidence
rate was significantly lower than in the other groups”… which is confounding writing)
The Authors conclude: “The combination of serum markers and endoscopic findings is essential
for the risk stratification of gastric cancer.”
Note: the GC number/prevalence among “Pseudo-group A” (GC= 2/87; 2.3% is comparable to
that of Group D [GC=3/114; 2.6%].
SPECIFIC COMMENTS:
- The authors do not provide information on the Kimura & Takenomo (K&T) endoscopic
patterns (closed versus open) among the atrophic patients. (Pseudo-A= 87 (approximately 25%
of the patients); B= 518; C=15; D= 114).
In particular:
• 87/1507 subjects atrophic (with high PG levels) and Hp-Ab negative (group pseudo-A)
• 114/1507 subjects were atrophic (at least in the antrum) and Hp-Ab negative (group D).
Because the exclusion criteria involved Hp-eradication, it would be interesting to know the stage
of K&T atrophy among these 87 + 114 patients (see what the Authors wrote on page 8, “The
development of gastric cancer in patients without H. pylori infection is very rare in Japan.”
- In table 1:
• location should be replaced by “gastric location.”
• the meaning of the last line of “histological type (i.e.: “18/2” is bewildering)
- In table 2: within the table, please consider expressing the follow-up time at least in months
(instead of days)
- Within Discussion, the Authors wrote, “Therefore, it cannot be concluded that endoscopic
follow-up is unnecessary in the true A group.”
Within the Abstract, the authors wrote, “The combination of serum markers and endoscopic
findings is essential for the risk stratification of gastric cancer”.
Moreover, as for the discriminant value of Hp-Ab, among 360 +114/1,507 subjects negative for
Hp-Ab, they have 5/24 cancers (it means more than one-fifth).
A question arises: why did the authors not also consider the histological impact in any
GC prevention effort? Gastritis staging performed well in both prospective and population-
based studies. While the Western world should pay more attention to the Eastern serological/
endoscopic preventive approaches, the Eastern strategies should more carefully consider the
impact of histology (at least in patients who undergo endoscopy).
In conclusion. some too optimistic statements should be attenuated.
English editing should be reconsidered.