Gastric Dysplasia
Summary: A worldwide-accepted
histologic, classification of the gastric carcinomatous and
precancerous lesions is a prerequisite for a consistent recording
of epidemiologic data and for both developing and evaluating
primary and secondary preventive efforts. Different nomenclatures
have been proposed for gastric precancerous lesions in eastern
countries and in Japan. This article presents a classification of
gastric precancerous lesions resulting from an international
consensus conference involving pathologists of different
countries. Five main diagnostic categories are identified. To
allow comparisons with the nomenclature proposed by the Japanese
Research Society for Gastric Cancer, each category was also
assigned a numeric identification: 1 = normal, 2 = indefinite for
dysplasia, 3 = noninvasive neoplasia, 4 = suspicious for invasive
cancer, and 5 = cancer. The interobserver reproducibility of the
histologic classification was tested in a series of 46 cases. By
collapsing benign alterations (categories 1+2) versus noninvasive
neoplasia (category 3) versus suspicious for invasive cancer and
fully appearing carcinomatous lesions (categories 4+5), the
general agreement value was 77.7%, whereas kappa coefficient was
0.63. By examining gastric precancerous lesions from diverse
populations, the authors agreed that the gastric precancerous
process is universal and the differences in nomenclatures are
merely semantics. The international Padova classification of the
gastric precancerous lesions is submitted to the attention of the
international scientific community, which is invited to test and
to improve on it.
Comment: In
order to reach a consensus on the definition and diagnostic
criteria of gastric precancerous lesions between that defined by
Japanese and western (North American and European) pathologists,
a group of pathologist from these countries gathered in Padova,
Italy in the spring of 1998. Their main objectives were:
They have proposed a classification based on a five-tired scheme; categories one to five with subdivisions for each category.
There are three distinctive features in this proposal:
It is true that the pathological criteria lie at the foundation for classification of many diseases, but there are considerable differences in the interpretation of such criteria.
Looking at the definition of dysplasia, there are different views for such nomenclature.
Japanese pathologists believed that all dysplasia as neoplasia even cancer. Many other pathologists in the world do not accept such definition. They believe that dysplasia is a multiple step of changes from normal, reactive alteration to intermediate and finally neoplastic changes. Even in the last nomenclature they are still hesitating to put neoplastic dysplasia under frank carcinoma.
One of the most important questions is whether these limited cases entered in the study are truly representative of all gastric lesions from "normal" (category one) to "invasive adenocarcinoma" (category 5).
There are cases of gastric atrophy, atrophic gastric and reactive changes which have not truly agreed definition by all pathologists and is not mentioned in this proposal. Inadequate specimens from endoscopic procedures sometimes causes a lot of limitation for interpretation. Another point of concern is to find out whether the cure of Helicobacter pylori is an effective preventive measure against gastric cancer and to what extent the mucosal damages are irreversible. There is a special problem in our country Iran, in which patients consult physician in the advanced stages of their disease. Above all, we believe the effort of this international group in clarifying the extent and the morphological criteria of changes of gastric mucosa in preneoplastic conditions. The Pavoda Classification of Gastric Precancerous Lesions could be a useful tool for evaluation the mucosal changes of the stomach in adequately prepared endoscopic biopsies. The main goal and benefit of this classification is to find out and eradicate the early gastric cancer, as it was the achievement of the Japanese group. We shall hopefully test this classification in our future studies.
Moslem Bahadori, MD, FCCP
Consultant Pathologist, NRITLD, Tehran.
Source: Rugge M, Correa P, Dixon MF, et al. Am
J Surg Pathol. 2000; 24 (2): 167-76.
Role of maintenance treatment in opioid dependence
Summary: Methadone maintenance treatment (MMT) involves the daily administration of the oral opioid agonist methadone as a treatment for opioid dependence-a persistent disorder with a substantial risk of premature death. MMT improves health and reduces illicit heroin use, infectious-disease transmission, and overdose death. However, its effectiveness is compromised if low maintenance doses of methadone (<60 mg) are used and patients are pressured to become prematurely abstinent from methadone. Pregnancy and psychiatric comorbidity are not contraindications for MMT. As an alternative to MMT, other oral opioid agents (eg, naltrexone, buprenorphine) may increase patient choice and avoid some of the more unpleasant aspects of MMT. The public-health challenge for the future is to develop and continue to deliver safe and effective forms of opioid maintenance treatment to as many opioid-dependent individuals as can benefit from them.
Comment: Methadone maintenance is gaining worldwide approval in the treatment of opioid dependence and is constantly recommended as a means of harm reduction and improving the general health and well-being of former illicit substance abusers. The National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction strongly intonates the implementation of MMT in opioid dependent individuals.1 Currently despite increasing opioid dependence in Iran, there is no agonist maintenance program available in this country. Apparently fear of uncurbed release of methadone and clandestine access of people especially adolescents to this drug has created an air of suspicion and doubt in introducing this treatment modality in Iran. The same concern applies to buprenorphine as well. MMT needs a well developed infrastructure for patient assessment, selection, follow up and surveillance and strict monitoring on the distribution of the drug which is lacking at present. Besides, careless introduction of methadone to the market may abort any simultaneous attempts for establishing abstinence oriented treatments in the nation.
During the recent years the number of Iranian opium abusers has inflated disproportionately and the psychiatric profile and demographic features show that the average Iranian opium abuser is somewhat different from his counterparts in well industrialized nations. He is employed, married, has started opium after 20 years of age and shows lower comorbidity. There is also a barrier between opium and heroin abuse and most of the former do not end up as heroin abusers. Although this statement needs corroboration by meticulous scientific methodology but apparently the average Iranian opium abuser is more similar to softcore drug users in industrialized societies.2,3 This difference might render the Iranian patients more responsive to abstinence oriented treatments such as naltrexone maintenance, currently being introduced as a part of a national research program by the Welfare Organization. It is proposed that before implementing nation-wide MMT programs, a large scale trial of antagonist maintenance program is warranted. Abstinence oriented programs along with social and political revisions concerning drug abuse might offer promising results and considerably diminish the number of opiate abusers.
1-Effective medical treatment of opiate addiction. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. JAMA 1998 Dec 9;280(22):1936-43
2-Westermeyer JJ, Schneekloth TD, Course of substance abuse in patients with and without schizophrenia. Am J Addict. 1999 Winter;8(1):55-64.
3-Westermeyer JJ Substance use disorders among young minority refugees: common themes in a clinical sample. NIDA Res Monogr. 1993;130:308-20.
Azarakhsh Mokri MD, Addiction
Clinic, Rouzbeh Hospital, Tehran, Iran
Source: Ward J, Hall W, Mattick. Lancet 1999
Jan 16;353(9148):221-6