Single-bite versus double-bite technique for mapping biopsies during endoscopic surveillance for hereditary diffuse gastric cancer: a single-center, randomized trial

Abstract

Background Endoscopic surveillance is recommended in patients with hereditary diffuse gastric cancer (HDGC) who refuse or want to delay surgery. Because early signet-ring cell carcinoma (SRCC) can be inconspicuous, the current surveillance endoscopy protocol entails 30 random biopsies, which are time-consuming. This study aimed to compare single-bite and double-bite techniques in HDGC surveillance.

Methods Between October 2017 and December 2018, consecutive patients referred for HDGC surveillance were prospectively randomized to the single- or double-bite arm. The primary outcome was the diagnostic yield for SRCC foci. Secondary outcomes were: procedural time for random biopsies; comfort score; biopsy size; and quality of specimens, the latter assessed by the presence of muscularis mucosa, crush artifact, and proportion usable for diagnostic assessment.

Results 25 patients were randomized to the single-bite arm and 23 to the double-bite arm. SRCC foci were detected in three and four patients in the single- and double-bite arms, respectively (P = 0.70). The procedural time for the double-bite arm (12 minutes, interquartile range [IQR] 4) was significantly shorter than for the single-bite arm (15 minute, IQR 6; P = 0.01), but comfort scores were similar. The size of the biopsies in the double-bite arm was significantly smaller than in single-bite arm (2.5 mm vs. 3.0 mm; P < 0.001) but this did not affect the presence of muscularis mucosa (P = 0.73), artifact level (P = 0.11), and diagnostic utility (P = 0.051).

Conclusion For patients undergoing HDGC surveillance, the double-bite technique is significantly faster than the single-bite technique. The diagnostic yield for SRCC and the biopsy quality were similar across both groups.

^* Joint first authors

Publication History

Received: 03 September 2019

Accepted: 26 May 2020

Article published online:
17 July 2020

• References

• 1 Fitzgerald RC, Caldas C. Clinical implications of E-cadherin associated hereditary diffuse gastric cancer. Gut 2004; 53: 775-778
• 2 Hansford S, Kaurah P, Li-Chang H. et al. Hereditary diffuse gastric cancer syndrome: CDH1 mutations and beyond. JAMA Oncol 2015; 1: 23-32
• 3 Blair VR, McLeod M, Carneiro F. et al. Hereditary Diffuse Gastric Cancer: Updated Clinical Practice Guidelines. Lancet Oncol; 2020 (in press)
• 4 Pharoah PD, Guilford P, Caldas C. et al. Incidence of gastric cancer and breast cancer in CDH1 (E-cadherin) mutation carriers from hereditary diffuse gastric cancer families. Gastroenterology 2001; 121: 1348-1353
• 5 Fitzgerald RC, Hardwick R, Huntsman D. et al. Hereditary diffuse gastric cancer: updated consensus guidelines for clinical management and directions for future research. J Med Genet 2010; 47: 436-444
• 6 Mastoraki A, Danias N, Arkadopoulos N. et al. Prophylactic total gastrectomy for hereditary diffuse gastric cancer. Review of the literature. Surg Oncol 2011; 20: e223-e226
• 7 Hallowell N, Badger S, Richardson S. et al. An investigation of the factors effecting high-risk individualsʼ decision-making about prophylactic total gastrectomy and surveillance for hereditary diffuse gastric cancer (HDGC). Fam Cancer 2016; 15: 665-676
• 8 Mi EZ, Mi EZ, di Pietro M. et al. Comparative study of endoscopic surveillance in hereditary diffuse gastric cancer according to CDH1 mutation status. Gastrointest Endosc 2018; 87: 408-418
• 9 Lim YC, di Pietro M, O'Donovan M. et al. Prospective cohort study assessing outcomes of patients from families fulfilling criteria for hereditary diffuse gastric cancer undergoing endoscopic surveillance. Gastrointest Endosc 2014; 80: 78-87
• 10 Shaw D, Blair V, Framp A. et al. Chromoendoscopic surveillance in hereditary diffuse gastric cancer: an alternative to prophylactic gastrectomy?. Gut 2005; 54: 461-468
• 11 van der Post RS, van Dieren J, Grelack A. et al. Outcomes of screening gastroscopy in first-degree relatives of patients fulfilling hereditary diffuse gastric cancer criteria. Gastrointest Endosc 2018; 87: 397-404.e392
• 12 Fantin AC, Neuweiler J, Binek JS. et al. Diagnostic quality of biopsy specimens: comparison between a conventional biopsy forceps and multibite forceps. Gastrointest Endosc 2001; 54: 600-604
• 13 Padda S, Shah I, Ramirez FC. Adequacy of mucosal sampling with the "two-bite" forceps technique: a prospective, randomized, blinded study. Gastrointest Endosc 2003; 57: 170-173
• 14 Bae MH, Kim MH, Lee JH. et al. Study of mucosal sampling for Helicobacter pylori using ‘two-bite’ technique in relation to time-saving. Korean J Gastrointest Endosc 2004; 29: 1-5
• 15 Hookey LC, Hurlbut DJ, Day AG. et al. One bite or two? A prospective trial comparing colonoscopy biopsy technique in patients with chronic ulcerative colitis. Can J Gastroenterol 2007; 21: 164-168
• 16 Latorre M, Lagana SM, Freedberg DE. et al. Endoscopic biopsy technique in the diagnosis of celiac disease: one bite or two?. Gastrointest Endosc 2015; 81: 1228-1233